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Medicine in the Nineteenth Century: Part 2

Women Attempt to Enter the Profession

While women had traditionally been healers, in 1800 there were professionally excluded, not least because they were also barred from attending university! Most doctors and the elite claimed the young women were gynaecologically and psychologically unfit for higher education—”dominated by her ovaries, a woman’s place was in the home as wife and mother. Over-exercise of the brain would divert energy from the womb and lead to sterility and hysteria.” Also medicine (with its blood and guts) was simply no place for a lady!
The first woman doctor graduated in America were licensing was much less stringent. Elizabeth Blackwell graduated in 1849 at the top of her class at the Geneva Medical School in New York (she went on to found a hospital for poor women in 1857, and to organize nurses during the US Civil War).
The first women to qualify in Britain was Elizabeth Garrett who used legal loopholes to obtain a diploma of the Society of Apothecaries in 1865—thereby securing enrolment on the Medical Register. Over the next decade she built a large private practice, received a medical degree from the University of Paris, and established the London School of Medicine for Women in 1874.
One of the most interesting female medical careers of the era was that of Dr. James Barry who practiced medicine as an officer in the British Army, who was renowned as both a marksman and a surgeon, and who was only revealed to be a women when an autopsy was performed after her death!

Cartoon of Elizabeth Garrett (1836-1917) [Top Left]; Elizabeth Blackwell (1821-1910) [Top Right]; and Dr. ‘James’ Miranda Barry (1797-1865) [Image to Right]

Ladies with the Lamp: The Development of Nursing

In the early 1800s there were many groups working to improve both hospitals and the quality of nursing. In Catholic countries nurses had traditionally been members of religious orders, and this trend continued with such as the Sisters of Mercy and the Irish Sisters of Charity, founded in 1831. Both groups sent nuns to Paris to train, and the graduates served not only in Ireland, but also in Australia and throughout the British Empire. Vowed to poverty, chastity and obedience these sisterhoods won respect in society.
Protestants also trained nurses. Elizabeth Fry founded the Institute of Nursing in London in 1840, and the women called themselves the Protestant Sisters of Charity—later changed to ‘nursing sisters’.
Florence Nightingale, hailing from a wealthy, cultured family had a religious vision at the age of 16 that she was to serve mankind. At the age of 31 she finally managed to travel to Kaiserwerth in Germany for training, but she lasted only 3 months. She then went to Paris (Daughter of Charity) and in 1853 was appointed superintendent of nurses at King’s College Hospital. With the outbreak of the Crimean War in 1854 she traveled to the front and witnessed the suffering of the troops. She organized nursing for the sick, brought cleanliness to hospitals, and the result was that the death rate fell from 40% to only 2%! Her book, Notes on Nursing (1859) was a hit. Nursing became a key weapon in the hygiene war, and nursing became a honorable vocation for women!

The Lady with the Lamp (Florence Nightingale during the Crimean War, 1854-1856) [Above]; and Florence Nightingale (1820-1920) [Image to Right]

Improving Surgery: Joseph Lister and Antiseptics

Joseph Lister was from a well-off Quaker background. After studying at University College, he became assistant surgeon in Edinburgh in 1854, and in 1860 was named Regius Chair of Surgery in Glasgow.
He noted that the major problem in surgery was infection (gangrene that was associated with the process of rotting). After reading the works of Pasteur (putrefaction was a fermentation caused by air-borne bacteria, not the air itself), he became convinced that germs had to be defeated in the operating room.
He conducted experiments and concluded that bacteria were affected by carbolic acid (phenol), and that if a chemical barrier was placed on a wound that the wound would stay free of infection. He then developed an antiseptic ritual: the clotted blood was removed; the wound bathed with carbolic; carbolic-soaked lint was applied; tinfoil was then added to prevent evaporation; absorbent wool packed around the wound; and when a new dressing was needed, the foil was lifted and fresh carbolic applied. During the operation itself, the atmosphere was constantly sprayed with carbolic. This technique involved both antisepsis (killing infective agents in the wound), and asepsis (preventing bacteria from getting into the wound).
Initially surgeons mocked this new method—asking where were the ‘little beasts’ (germs). But as germ theory became accepted (and with Lister’s proven results) such techniques became common.

Royal College of Surgeons, London in 1800s [Above]; and Joseph Lister (1827-1912) [Image to Right]

The Industrial Revolution, Slums and Reform

The Industrial Revolution brought great changes to the lives of people in Europe and North America. Britain’s population between 1750 and 1850 tripled from 10 million to over 30 million. Not only were there more people, where and how they lived also changed. In 1785 there were only three cities in Britain with more than 50,000 people, but by 1860 there were more than 30. Rising population densities led to major urban problems, and the situation was made worse by the fact that most cities had no legal status, no real officials, no ability to raise taxes, and no legal powers to enforce regulations on factories and health and safety issues. The new industrial towns were very unhealthy. Air and water were polluted. Housing was in short supply. Wages were low, and therefore many people suffered from malnutrition, inadequate clothing, and cold and crowded housing. Life expectancy was low (around 30 years in the cities of London, Liverpool and Glasgow). Infant mortality was extremely high. Family life was deteriorating (female and child labor, combined with alcoholism, STDs and stress).
The British reformer Edwin Chadwick led the charge to change the old Poor Laws. In 1834 a new Poor Law was enacted, that ended the old workhouse system—and attempted to end pauperism. It failed, but Chadwick concluded that this was because ‘sickness bred poverty’ and has a result the British government began to assume public responsibility for the sick poor. He also sponsored studies of the living conditions in the cities and found that they were squalid (in some regions life expectancy was only 16!)—the result was more calls for prevention of disease through public sanitation and public health authorities.

‘A Poor House,’ Cartoon from Mid 1800s [Above]; and Edwin Chadwick (1800-1890) [Image to Right]

Cholera: John Snow and the Broad Street Pump

After gaining some experience with cholera during the 1831 epidemic, John Snow had established a practice in the Soho district of London where he was respected as one of the city’s leading anaesthetists. When cholera returned to the city in 1849, Snow contended that the disease could not be spread by miasmas since it affected the intestines and not the lungs. He argued that the contamination of drinking water (as fecal matter spilled into wells and rivers) was the culprit.
In August 1854 cholera arrived in Soho. In early September he investigated over 90 local deaths, and concluded that the water supply (the Broad Street Pump) was contaminated. In a nearby prison conditions were even filthier than in the city, but deaths were fewer—the prison had its own well. He asked the local parish authorities to disconnect the pump—reluctantly they did, and the number of cases plummeted.
He presented his findings to Parliament, and as a result the Metropolitan Board of Works was ordered to improve the city’s drinking water. The water-borne theory of cholera had been introduced, but still had challengers throughout the 19th century, due to opposition from colonial authorities who worried that quarantine (of ships from India) could negatively affect trade.

Map of Broad Street and Surrounding Area [Above]; and Portrait of John Snow (1813-1858) [Image to Right]

From Rabies to Milk: France’s Hero, Louis Pasteur

Louis Pasteur began his career as a chemist, but with his appointment in 1854 to a university chair in the manufacturing center of Lille, he began to study fermentation—the souring of milk, the alcoholic fermentation of wine and beer, and the forming of vinegar. He then returned to Paris where he continued his work on fermentation and he demonstrated that spontaneous generation was impossible (publicly and professionally defeating the old ideas of his rival, the biologist Felix Pouchet). He also conducted important work on anthrax and rabies—in the latter he performed public displays that led to great fame throughout France and Europe. Rabies immunization grew dramatically, and his work received huge state support as the Institut Pasteur was established in 1888 as a world-leading scientific research center.
Pasteur conducted a series of experiments in the 1860s in which he discovered that putrefaction and fermentation were mediated by living micro-organisms. He also proved that microbial life could not function in an organic medium that had been sterilized and maintained in a controlled environment. Germ theory was born and would both revolutionize our understanding of disease, and give tremendous hope that science would ultimately triumph over all illnesses.

Pasteur Institute in Paris [Above]; and Portrait of Louis Pasteur (1822-1896) in Laboratory [Image to Right]

Germany’s Microbial Hunter: Robert Koch

Even more important than Pasteur, the German scientist Robert Koch was largely responsible for consolidating bacteriology into a scientific discipline. Koch’s first triumph was revealed on 24 March 1882 when he presented the bacillus responsible for causing tuberculosis to the Berlin Physiological Society. The next year Koch travelled to Egypt to investigate a cholera outbreak, and in Alexandria in 1883 he isolated and identified Vibrio cholerae (the comma bacillus). He continued this work in 1884 in India where he demonstrated that the bacillus lived in the human intestine and was communicated mainly by polluted water (thereby supporting the earlier claims of John Snow). He became a German icon and hero—the discoverer of the causes of both tuberculosis and cholera, two of the greatest diseases of the period. His students (following his four postulates) went on to discover the micro-organisms responsible for diphtheria, typhoid, pneumonia, gonorrhoea, meningitis, undulant fever, leprosy, plague, tetanus, syphilis, whooping cough, and various streptococcal and staphylococcal infections. Mankind now knew the names and identities of its greatest enemies.

Koch’s First Bacteriology Postgrad Class in Berlin, 1891 [Above]; and Robert Koch (1843-1910) [Image to Right]

Canada’s (the World’s) Most Famous Physician: Sir William Osler

While historians often talk of the rise of the professional society in the 19th century, this period was not particularly accommodating to the medical profession. Politicians were reluctant to pass laws regulating or reforming doctors, nor were they anxious to promote public health programs at taxpayers expense.
The greatest Canadian physician (and probably the most famous doctor in the Western world) during the late 19th and early 20th centuries was William Osler. The son of an Ontario preacher, Osler received his early education in Toronto and Montreal. After beginning his career in Montreal (at McGill University), Osler moved steadily up through the ranks of his profession—to the University of Pennsylvania, then to Johns Hopkins and finally to take the Regius Chair of Medicine at Oxford.
Osler began his career as a pathologist, but what he is best remembered for are his book, The Principles and Practice of Medicine, and his work to improve medical education in North America (primarily in the US).

Microbes Fleeing From Saint Osler [Above]; and William Osler (1849-1919) Bedside Consultation [Image to Right]

Professionalizing the ‘Noble Profession’

Negotiating the Doctor-Patient Relationship

Doctors are only doctors when their patients agree. A contract has always existed between the physician and patient, although it normally has not been in writing. The contract assumes that doctors have expert knowledge that will satisfy patient expectations. When these expectations are met, patients grant doctors the privilege of authority and professional control, which are exemplified by autonomy over examination, licensing and discipline. These privileges continue as long as both parties are satisfied.
When doctors have failed to meet the expectations of their patients there have been penalties that ranged from having their hands amputations (Code of Hammurabi), to crucifixion (Roman era), to the less drastic penalties of our time (fines, loss of license to practice medicine, and jail).
Professional authority is still a privilege—not a right. The history of the medical profession is a history of the contract between doctor and patient, and how it has been negotiated and changed over time.

Dutch Engravings from 1587. The Physician as Angel [Above] and Devil [Below]

The Doctor Idealized

In Luke Fildes’ 1891 painting, The Doctor, we see the image of a caring physician sitting beside a suffering child whose parents look in from the background. The doctor is an image of comfort; his presence alone (as he appears to be offering little in the way of medical treatment) is an excellent representation of the 19th century belief in the strength of the new professionalized medical expert.
What values are symbolized by Fildes’ doctor: patience, tenderness, wisdom, and perhaps even courage (as the physician is potentially exposing himself to disease). The older, bearded doctor appear to be wise, and he has even displaced the parents as the authority figure in the home. How has he treated the little patient—likely with mercury, antimony, bloodletting or other therapies no longer used. Whether or not the patient lives or dies, the family will owe him money.
Are these ‘ideals’ still true today? Now, a doctor may not share the religious, cultural or racial origins of the patient. The family is also more likely to have brought the sick child into a high-tech hospital emergency room. Here, there will be a good chance that the doctor will be a women, and the family will be more likely to demand information and question the treatments. Families’ expectations for a ‘cure’ are much higher than a century ago, and the likelihood of a house-call is far lower.

Luke Fildes’ The Doctor (1891) [Above]; and Cast Photo from ER (2004) [Below]

Professionals vs Quacks

After the scientific revolution of the 16th century, religion and medicine were formally separated, and doctors began to take a more scientific approach to illness, and to make claims for their superior abilities as healers. Charters were granted to physicians and to guilds of barber-surgeons, first by cities and then by nations (and rulers). Being a professional was defined by membership in a body of practitioners who held the privilege of examining, licensing and governing their own profession. Still, most members of society were still distrustful of physicians, and many prominent writers portrayed doctors as pompous, expensive, ineffective (as likely to kill as to cure). Also physicians and surgeons still had to compete with a variety of other healers, including: wise-women, quacks, and charlatans. The slow, but steady history of medical professionalization was a shift from pluralistic health care to a monopoly of a powerful orthodoxy.
Professional societies were formed at both local and national levels to preserve and advance standards of medical knowledge through meetings, publications and licensing. In the 19th century, in North America doctors resented the financial threat and career success of unorthodox colleagues such as homeopaths and midwives. The American Medical Association was founded in 1847 partly as a professional lobby to protect the market share of doctors against homeopaths.

Early 19th Century Cartoon Against ‘Quackery’ in Britain

Professionalization in Europe & Canada

Lecture at the Royal College of Surgeons [Above]; and Johns Hopkins Medical Class, c. 1900 [Below]

Date	Authority	License Requirement
Mid 12th Century	Roger II of Sicily	Public examination of practitioners
1231	Frederick II of Sicily	Salerno masters examine students
13th Century	Montpellier	Barber-surgeon’s guild
1418	Montpellier	Barber-surgeons’ guild examinations
1518	London	Royal College of Physicians
Year	Canadian Medical School Founding	Location
1822-1892	Montreal Medical Institution (Becomes McGill)	Montreal, Quebec
1843-1891	Toronto School (merged with University of Toronto)	Toronto, Ontario
1852	University of Laval	Quebec City, Quebec
1854	Queen’s University	Kingston, Ontario
1868	Dalhousie University	Halifax, Nova Scotia
1882	University of Western Ontario	London, Ontario
1883	University of Manitoba	Winnipeg, Manitoba
1883-1895	Women’s Medical College	Kingston, Ontario
1883-1906	Women’s Medical College	Toronto, Ontario

Heroes & Specialists

In Canada, medical practice has been regulated by regional licensing bodies since the 17th century. Before Canadian medical schools were founded, a degree from an elite institution in Europe would get one a license to practice. American graduates and others would have to take an exam. In the early 19th century as Canadian schools were set up, exams before compulsory for all. Since 1911, the license of the Medical Council of Canada has been portable across all provinces.
Patient expectations began to rise in the mid-19th century with the discoveries of anesthesia and antisepsis. Diseases that previously had been fatal could now be treated. Similarly, the discovery of antibiotics in the 1930s and 1940s, resulted in patients expecting a technical quick fix for every pain and illness. Also patients, now lost much of their individual autonomy, as they acquiesced to the knowledge to the medical experts. Between 1850 and 1950 there was a succession of famous surgical and medical giants who were hailed as national treasures and institutions. Medical power and prestige increased further with the growth of specialties in the late 1800s.
In the 21st century, there has been a return to the mistrust of the medical profession, why? 1) Unnecessary or even dangerous common procedures of the past (tonsillectomy, IUDs, breast implants); 2) the side-effects of the majority of drugs, some very serious (thalidomide); 3) lawsuits and lobbyists (pharmaceutical companies); 4) medical information is increasing at a rapid pace, but not necessarily medical knowledge (can anyone know it all?); 5) hero worship is dead (at least in North America); 6) being cured is a right—failure leads to malpractice suits.

Sir (Saint) William Osler with Johns Hopkins Hospital in the Background