THE BODY, MEDICINE, HEALTH AND DISEASE

THE BODY, MEDICINE, HEALTH AND DISEASE

The development of modern medicine is not a simple linear affair from a brute past to an elegant present, but is a dense field of often conflicting ideas and practices jostling for academic and popular acceptance. An account of it must situate its knowledge within particular cultural and philosophical ideas as well as day-to-day events. Nineteenth- century Europe and North America saw increased urbanization and industrialization, revolution, civil, and other wars; the downgrading of religious influence in secular matters (see RELIGION, SECULARIZATION AND THE CRISIS OF FAITH), changing concepts of death, the influence of the philosophy of René Descartes (see MAIN CURRENTS OF PHILOSOPHY), and so on. This was also a time when trade unions and colleges of education were forming to consolidate and moderate the knowledge gained by their graduates. Resistance to such academic pressure, as well as disagreement as to subject matter taught in these places, gave rise to splinter groups. Diverse theories of the human body and the nature of disease coexisted among doctors, apothecaries, herbalists, and other healers and lay people. Some clung to religious ideas

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about pain and disease, accepting them as the will of God; folk remedies, perhaps effective perhaps not, were sought by many; some, following the ancient Greek physician, Hippocrates, and Galen’s later version, insisted on understanding bodily health in terms of the balance (homeostasis) of bodily fluids (humours: blood, phlegm, yellow bile and black bile) appropriate to each person—disease or ‘fevers’ being defined as having a plethora of a single humour (relievable by blood-letting, the use of leeches, purges and enemas); other ideas current were based only on clinical observation without anatomical reference; while still others were manufactured away from actual patients, theorized without reference to bodily symptoms at all. The nosological work of Philippe Pinel (1745–1826) is an example of this. Pinel, a somewhat transitional figure in late eighteenth- and early nineteenth-century medical thought, was innovative where his psychiatric patients were concerned (he is reputed to have released them from their chains, even though this was, in fact, the work of a hospital administrator). He also wrote

a book cataloguing a large number of ‘fevers’ characterized by their visible symptoms and classified according to theoretically artificial criteria that did not take account of new methods of patient examination or discoveries that work on autopsies yielded. The nineteenth century, though, was also a time when scientific medicine began to develop as

a driving and mainstream force. Statistical analysis of symptoms; measurement of medication; experimentation on animals; the use of microscopy, using newly developed coal tar-derived staining materials (originating from the Londoner, William Perkins’s 1856 discovery of aniline dyes), to define the nature of microorganisms; diagnostic tools such as the stethoscope and, later, X-rays; the development of anaesthesia; and changes in medical education all witness to this. Changes in the hospital system and public health benefited from the development of a scientific medicine.

Cartesian thought, already influential since the eighteenth century, considered the body a very complex machine with the mind or soul separate from it. The soul, it was thought, equated with conscious rationality. It should be noted that Descartes’s claim that the soul/mind and the body belonged to distinctly different categories cut right across earlier ideas about the nature of human beings. In seventeenth-century thought, the body was the instrument of the soul. This new idea was very popular throughout Europe at the beginning of the eighteenth century, and adhered to by many throughout the nineteenth century, assimilated Newtonian philosophy where the body was seen as a machine consisting of fluids in tubes. Another dominant idea was vitalism (the idea that some- thing accounts for life other than the matter of the physical body). The seventeenth- and eighteenth-century arguments for vitalism may be traceable to Cartesian dualism via the metaphysical foundations of G.E.Stahl (1660–1734). Others tempered their vision with conjectural accounts of eugenic theory under the impulse of Darwinian evolutionary thought (see DARWIN, CHARLES). Jean-Martin Charcot (the ‘father’ of neurology) and his pupil Gilles de la Tourette (c.1887) working at the Salpêtrière Hospital of Paris, much influenced by Darwinian thought, considered the ticcing condition now known as Tourette’s Syndrome a ‘degeneracy’. Charcot based his reasoning on the supposition that people with the syndrome occupied a lower position on the human phylogenetic scale. Tourette physically suspended patients to straighten such ‘primitives’ to aid them to become modern Homo erecti.

As in other fields of endeavour, Romanticism (see ROMANTICISM, INDIVIDUALISM AND IDEAS OF THE SELF) and Rationalism both had adherents in

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the medical field. Medical Romanticism saw the clinician as a charismatic figure who healed by charm alone. The practice of mesmerism (following the work of the Viennese physician Franz Anton Mesmer [1734–1815]), or suggestion, began to be used in the treatment of the mentally ill; a practice that transgressed beyond medicine to entertainment. Homeopathy, developed by Samuel Hahnemann (1755–1843), is another example of Romantic medicine. The basis of Homeopathy is the belief in the ‘law of similars’ where the vibration of a substance (a much watered down version of the original substance) is administered that has the same characteristics as the disease process. Romantic medicine, though, had a valuable side: it continued to listen to the experiences of patients, where mainstream scientific medicine often failed. Experiences are, after all, not easily measurable. The psychoanalytic techniques of Sigmund Freud (1856–1939) and Carl Jung (1875–1961) incorporated the experiential aspects of this Romantic medicine, as well as the Germanic fascination for mythology.

Rationalism came to dominate the development of a scientific medicine. This medicine is scientific in the sense of incorporating the systematic collection of data, its measurement and controlled experimentation. Previously, deference to tradition, empiricism and a concentration upon symptoms ruled. The development of scientific medicine coincides with the realization that contrary to the notion of disease as a single entity, there are many diseases with many causes, many symptoms and many treatments.

The realization of the multiplicity of disease processes impacted upon an understanding of public health. The escalating industry of the nineteenth century brought more workers to towns, putting increasing pressure upon limited fresh water and sewage resources. Town councils were forced to provide inexpensive housing, schools and churches for industrial workers. Poverty became visible and social classes discernable. Diseases came to be seen as bad for the national interest and, for a time, a sign of individual irresponsibility and a failure to abide by the well understood rules of modern hygiene, though, by the late 1880s and 1890s the germ theory of disease and understanding of bacteriology had clouded the issue of individual responsibility for illness.

The formation of a scientific medicine had to fight free from religious control and dogma. This meant a cultural climate willing to let go of the past. The post-French Revolution period provided exactly this climate for change.

Old-style medical training facilities in France were abolished during the French Revolution. Learned societies were condemned as being elitist in the name of liberty and equality. Religious-run institutions had to abandon them to the state. What sprung up from the ashes were medical institutions and three schools of health in Paris, Montpellier and Strasburg, accountable to the state. Thus France, unlike other parts of Europe, could truly be scientifically independent. French, rather than the traditional Latin, became the language of discourse. Professors were appointed and paid by the state, chairs for the individual disciplines and set numbers of students were instituted.

There was a great number of innovative thinkers and medical inventions in France at this time, all contributing to a scientific medicine. Jean-Nicolas Corvisart (1755–1821)—Napoleon’s physician—recommended percussion to diagnose thoracic complaints. A student of his, Theophile-Rene Laennec (1781–1826), invented auscultation with a tube placed on the female chest. To put one’s ear to a woman’s chest was deemed lacking in decorum. This was the forerunner of the

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stethoscope. In Vienna, Karl Rokitansky (1804–78) and his pupil Josef Skoda (1805–81), both heads of medical schools, adopted this French practice of ‘listening to the chest’ by means of percussion and auscultation.

Pierre-Charles Louis (1787–1872) introduced what he called ‘the numerical method’ (a precursor of what is now called ‘medical statistics’), This was the scrupulous observation of symptoms, their repetition and frequency, from which he drew diagnostic and prognostic conclusions. In this way, the results he obtained were carefully quantified so as to ascertain their effectiveness. The results, likewise, of therapy were also quantified, this measurement determining the effectiveness of the therapy. While criticized by his contemporaries, this careful comparison of symptoms and lesions allowed doctors to associate a particular disorder with a particular sign and symptom.

François Magendi (1783–1855) argued against animism and vitalism, and urged experimentation on animals, thus causing outrage among the protectors of animals. Magendi viewed the body as a complex machine and animals as nothing more than automata. Using animals, he studied the peristalsis of the oesophagus, the formation of the image on the retina, the effect of absences in one’s diet, and did considerable work on the nervous system.

Pierre Bretonneau (1778–1862) identified in typhoid fever a whole range of pathological symptoms (sore throat, pink rash, joint pain, peritonitis due to the perforation of the small intestine, haemorrhaging, liver and renal and possible heart problems). Bretonneau realized that this litany of conditions had a single origin in the abnormal patches on the mucous membrane of the intestine. Bretonneau’s work contributed to a basic medical precept: specificity. The concept of specificity in medicine is this: a disease is specific in that it has a cause and seemingly unconnected symptoms that have a single prognosis. In this way, diagnosis is simple and treatment must be tailored to the disease.

A Prussian-born doctor Rudolf Virchow (1821–1902) explored particularity of medical disorder to specific organ dysfunction. He developed the science of pathological histology (the study of tissues), noting that each form of tissue has its own particular cell type and that cells belonging to the various organs are alive in their own right, are nourished by the blood and discharge waste, and are born from a similar cell. This observation built upon the earlier work of the Frenchman François-Xavier Bichat (1771– 1802). Bichat, without the use of microscope, had identified classes of tissues according to structure and function. Bichat pushed for the study of physiology—work continued by Claude Bernard (1813–78). Claude Bernard contributed much to the study of physiology, especially to knowledge of the secretions of the pancreas. He established the concept of ‘function’, that is, the role fulfilled by each tissue or organ in the human physiology to maintain life. He described the physico-chemical substance that bathes bodily tissues, inside the blood vessels and outside them, so that a change in the medium can have repercussions on a remote organ.

Medical training in France consisted of dissections and regular and compulsory visits to hospitals. The effect of this was to ensure that hospitals became places of learning and no longer ones where the sick were left to languor. Furthermore these state-run institutions ensured that health care was egalitarian. The new institutions swelled the numbers of hospitals, patients and medical students. In 1830, Paris boasted thirty hospitals with 20,000 patients, and training 5,000 medical students.

Entries A-Z 75 The progress of scientific medicine was enmeshed with changing ideas about the

nature of death and life. The development of these ideas allowed for a radical change in the way medicine was practised. This is elaborated below.

The examination of pathological anatomy essential to the kind of medical education taught in France, and later elsewhere, helped redefine the theoretical nature of disease and changed the way such disease was treated. The examination of cadavers also changed the way death was understood. No longer was death seen as a battle of life lost as was believed in previous times, but the corpse itself came to be understood as the putrefying site of different life forms. This shift in understanding life and death is reflected in the writings of Jean-Nicolas Corvisart, who considered the normal functioning of the living organism was to become increasingly and intrinsically pathogenic. Such an understanding permitted a number of valuable discoveries: two, for instance, being the nature and pathology of disease causing microorganisms in wound infection and disease process and the development of anaesthetics that could be used to induce death-like states while surgery could be performed.

Louis Pasteur (1822–95) noted that the destruction of organic materials was due to the multiplication of living creatures and life appearing in a new form. Some of his first work was on fermentation of beer, wine and vinegar. He applied the same rationale to disease processes. By use of the microscope (previously underused by medical researchers, even though already improved by Leeuwenhoek in the seventeenth century), he identified the micro-organism responsible for fowl cholera. Realizing the implications of the presence of micro-organisms, Pasteur insisted on the sterilization of surgical instruments.

Some micro-organisms were found to protect a person against more serious diseases. The important work of Edward Jenner (1749–1823) needs to be mentioned here. Through study of smallpox and cowpox (a much less serious disease), Jenner noticed the similarities between the two. He inoculated a young boy with cowpox material, demonstrating that this vaccination technique protected against smallpox.

Pasteur’s association of putrefaction and wound infection led to the germ theory of disease and to a veritable weaponry of poisonous substances introduced into the body to destroy disease. Later work by Paul Ehrlich (1854–1915) continued this technique of introducing poisonous substances into the body to combat disease. He illustrated his technique by reference to a German folktale about a Magic Bullet that when fired blindly would unerringly find its target.

An English doctor, Joseph Lister (1827–1912), introduced antiseptic surgery, which was not generally adopted until the twentieth century.

As already noted, France led medical education at least in the first half of the nineteenth century. Surgical studies and internal medicine were on the curriculum for both doctors and surgeons. Previously and elsewhere in Europe and North America, surgeons had a different education and a different life path. Practical surgery was a craft often combined with barbering learned by being apprenticed to a master and was controlled by a trade guild, though there is evidence that some surgeons were university trained as was true in Padua, Italy. Surgeons studied anatomy, dissected corpses and performed autopsies to ascertain a person’s death. The use of cadavers was generally illegal, so surgeons paid grave robbers to supply them with corpses. These disinterred putrefying corpses killed off a number of young surgeons.

Encyclopedia of nineteenth-century thought 76 Doctors, on the other hand, had previously only studied philosophy and Latin. They

did not study anatomy, or physiology. Many doctors of the period never even touched their patients, merely ascertaining the disease from symptoms alone. Cadaver examination came to be seen as most valuable for the training of doctors as well. Many Americans and other foreign students travelled to Paris to study this new medicine. Gradually other medical schools similarly amalgamated the training of internal physicians and surgeons.

Women in certain parts of Europe (Paris, Zurich and Berne) were not excluded from medical study, even though they often found it difficult to practise as doctors because of prevailing gender-specific prejudice against them. The first woman university trained physician, Dorothea Christiane Erxleben-Leporin, Prussian-born, was granted her doctorate in 1754. The social conditions that allowed women to become doctors in these places, but not in England for many years, appears to be linked to the climate of Nonconformist Protestantism, their links with international anti-slave movements and feminism (see FEMINISM AND THE FEMALE FRANCHISE MOVEMENT). All medical doctorates awarded women were non-British until the 1870s. In 1876, an act was passed allowing women to sit for medical examinations. Dublin’s King and Queen’s College of Physicians was the first to admit women and seven did so in that year.

The situations of war also brought the professions of surgery and internal medicine closer together. The sheer numbers of injured meant that a common knowledge base of both professions was needed: not all limbs needed to be amputated and there were infections to deal with. It was also in war that the nursing profession came to its own through the ministrations of the British reformer, Florence Nightingale (1820–1910). Trained at an Institute for Protestant Deaconesses in Kaiserwerth, Germany (one of the first formal nursing training institutions), Nightingale became superintendent of the Hospital for Invalid Gentlewomen in London. When the Crimean War broke out, she went to the battlefield to direct nursing operations at the command of the minister of war. With thirty-eight nurses, she instigated sanitary conditions in the military camps that were otherwise antagonistic to the healing process. In this way, the mortality rate among the soldiers was greatly reduced. Though popular sentimental accounts of Florence Nightingale depict her as a gentle lady with a lamp, she was a steely administrator with reformist ambitions. When the Crimean War ended in 1860, she founded the Nightingale School and Home for Nurses at Saint Thomas’ Hospital in London. This school was the first to train nurses in a professional manner.

The changing concepts of death, plus viewing the body asleep as insensate machinery, impacted upon the development of anaesthetics for surgery. Surgeons began inducing death-like states with various substances so as to explore previously forbidden interior bodily zones such as the abdomen. Anaesthetic was generally not thought of as ameliorating pain even though Humphrey Davy (1778–1829) had already suggested that the pain and shock of surgical operations might be relieved if patients inhaled nitrous oxide.

Ether, whose starting materials are sulphuric acid and alcohol, had long been known. It was used as a sedative in the treatment of tuberculosis, asthma and whooping cough, and as a remedy for toothache. Its anaesthetic potential, though, had never been exploited and its introduction was gradual.

Entries A-Z 77 In the USA in 1846, William Morton demonstrated the surgical applications of ether,

using a hastily rigged apparatus to deliver the substance to the patient. The new technique was to revolutionize surgical practice, enabling surgeons to develop finer skills and life- saving invasive procedures.

Chloroform was introduced by James Young Simpson (1811–70), a Professor of Midwifery at Edinburgh, to replace ether with its disagreeable and persistent smell. He began using it to relieve women’s pains of childbirth and incurred the wrath of those holding to the biblical view that ‘In sorrow thou shalt bring forth children.’ After Queen Victoria chose to be anaesthetized in 1853 for the birth of Prince Leopold and again in 1857 for the birth of Princess Beatrice, the practice became common among the upper and middle classes.

By the 1880s anaesthesia, with aseptic surgical technique, was standard practice in US and European surgical theatres. Middle-class patients, used to receiving medical care at home, sought admission to hospitals for operations, and hospitals were transformed from charitable asylums for the poor into consumer-oriented service institutions. While the surgeon’s prestige and power soared, the anaesthetist was a mere assistant—a nurse, intern or medical student. The development of the independent medical speciality of anaesthesiology did not occur until the early twentieth century.

What of the nature of surgery? As noted above, the introduction of anaesthetics allowed the surgeon to operate within the body cavity. Much of the first internal surgery was conducted on women. Indeed, gynaecological surgery led to gynaecology becoming the specialized field of medicine it is today and the development of modern surgery itself. Much of this early gynaecological surgical work was practised in the US South during the Revolutionary and Civil wars on black female slaves by the ‘father’ of gynaecology, J.Marion Sims (1813–83). Many of the women had suffered injury as a result of difficult or mismanaged births. Sims operated on these women to fix such injuries sometimes with anaesthetics, sometimes without.

Anaesthesia was not considered in terms of pain amelioration for some time. Pain was dealt with by a variety of substances: opiates, alcohol, mandrake, belladonna from the deadly nightshade and marijuana. In 1897, Felix Hoffmann discovered another compound, Acetylsalicylic acid, found naturally in willow tree bark, which also had analgesic properties. This was packaged and sold under the trade name ‘Aspirin’.

Sensitivity to pain was attributed to higher evolutionary creatures—men feeling more pain than women. Non-Europeans, following eugenic ideas, were thought of as having little capacity to feel pain. Babies were thought to have no capacity for pain, no emotions and no mind to interpret their experiences, in other words, as pre-human.

By the 1890s, physiological and medical concepts of pain, as of the body and of disease generally, had become mechanistic, localized and empirical. The experimental findings of physiologists in France, Germany and England supported mechanical models of body functions, though barely any explanation for differing perceptions of pain. The work of Charles Bell and François Magendie showed that the posterior roots of the spinal nerves responded to sensations whereas the anterior roots appeared to be associated with motor responses, thus laying the groundwork for the idea of a specific neural pathway of pain sensation, elaborated in 1839 by Johannes Müller’s theory of ‘specific nerve energies’. Further confirmation came from the work of Edouard Brown-Séquard on the pain pathway in the spinal cord; from the contributions of John Hughlings Jackson and

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others, suggesting specific locations of various function in the brain; and from the experiments of Max von Frey, who in 1896 identified ‘pain spots’ on the skin.

The insights of human anatomy learned through surgery, plus the conception of the body as an organic machine, allowed for the conceptual development of X-rays. The German scientist Wilhelm Röntgen (1845–1923) noticed that a barium platincyanide screen fluoresced whenever he passed a high electrical current through a near empty tube, demonstrating the ability of these mysterious rays to pass through metal. He took a photograph of the image of his wife’s hand complete with wedding ring. Interestingly, cinematography was developing simultaneously with X-ray technology. Building on the work of Röntgen, Marie Curie (1867–1934) and her husband, Pierre, explored the use of radium as the fluorescing element of choice in the development of X-rays. The X-ray machine proved to be a most valuable diagnostic tool and allowed access to a view of the body hitherto unimagined. X-ray technology became very popular, albeit dangerous in those early days; many technicians dying of cancer, including Marie Curie herself. Marie Curie was awarded the 1911 Nobel Prize in Chemistry for her work in discovering radium and polonium, and in isolating radium. The Curies earlier shared the 1903 Nobel Prize in Physics with the French physicist Antoine Henri Becquerel for fundamental work on radioactivity.

Reinterpreting death as continuing life in new forms and the Cartesian model of the body as machine were driving forces in the development of a scientific medicine. It allowed for the experimentation upon the body, it opened up the possibility of internal surgery, the exploration for effective anaesthetics and painkillers, and it encouraged the use of microscopy and X-ray technology for systematic examination of the body and diagnosis of disease and injury. The realization of what putrefaction meant encouraged aseptic surgery and scrupulous cleanliness in hospitals and the personal hygiene of medical staff. Understanding micro-organisms better allowed for their possible use against some disease itself. Public health became an issue to be reckoned with. Medical education for doctors and surgeons came to be recognized as absolutely essential; an education that included clinical rounds, the study of anatomy and physiology, the examination of cadavers, mathematics, physics and chemistry. The systematic education of nurses, too, became important. Scientific medicine was established and became mainstream, thus continuing to expand our understanding of the body, health and disease.