6) Filth, Pus and Germs

The Cholera Years

During the 19th century, putrefaction was a key concept in understanding disease. In the increasingly crowded cities of Europe and North America, disease was understood to be caused by the accumulation of decaying organic matter. This supposedly gave rise to corrupt and corrupting vapours, which could result in contagious epidemics. This was particularly evident in the cholera epidemics during the 1830s and '40s. This was the correlation they saw, thus making them believe this to be the cause.

Cholera was a previously unknown disease. British social reformers, like Edwin Chadwick (Poor Law Commissioner, 1834), viewed the unsanitary conditions of the poor and working classes as its cause. He believed that reform of urban life was needed to prevent the occurence of disease, as well as the transformation of the medical profession: Medical Officers of Health as salaried public employees, interested in the health of the body politic, rather than the illnesses of single individuals. The miasmatic theory of disease also underwent considerable changes.

John Snow rejected the miasmatic theory of disease by identifying a single drinking fountain on Broad Street as the centre of the cholera epidemic of 1854 by using statistics, and microscopic and chemical analysis, to identify specific causes of epidemic disease. His discovery wasn't very detailed, but was a start. Edward Frankland used ideas from Liebig in 1867 to detect bacteria using chemicals and took up the issue with water companies. But, they weren't happy.

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If Snow moved towards the identification of specific casues of disease, like other Medical Officers of Health, he argued that the situation could only be remedied by reorganising and improving urban water supplies. But, this entailed public spending on sewers and the regulation of water suppliers, which were very difficult to promote in a liberal political context that was averse to taxation and public interference with the market.

The first sewers were put into the centre of cities and towns, but later in the century they spread to all towns. Later, flushing toilets and piped water supplies began to spread. But, rumours began that sewers were causing cholera. In the heat of debates calling for reform, sewers could be seen as causes of disease, just as much as the reformers viewed them as solutions to the problem. What is a cause?

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Hospital Fevers

A similar problem confronted sanitary reformers when they sought to tackle the hospital, the other great source of miasma and contagious epidemics. As a result of their inability to stem the toll of cholera, the Board of Health and Medical Officers were objects of much ridicule. But, for reformers like Thomas Wakley, John Roberton and Florence Nightingale, hospitals were as much the cause as a remedy because they reproduced all the problems plaguing the crowded city. For example, in 1849, in a private hospice in Tooting paid by the parish, 200 children died as a result of an outbreak of cholera. Wakely's investigation concluded that poor diet, overcrowding and impure air had hastened the spread of the disease. Morality in the hospital, according to the reformers, was due to unsanitary and decrepit conditions, where the miasmas produced by 1 decaying body could result in a contagious epidemic within the ward: hospital fevers. They now understood that sharing air with sick people could make you sick.

Eradicating hospital fevers meant improving the cleanliness of the hospital and care of patients, and rebuilding the hospital. Hospitals removed from contact with the miasmatic atmosphere of the city would be much more conducive to restoring health, and they should be built to slow the spread of contagions. But, these problems amounted to a call for interference in the physicians' domain. Physicians fought back arguing that, to stop hospital fever, new reforms would be needed, but that should be left to them. Their own answer to the problem was to emphasise that it should rest on the revision of treatment rather than the transformation of medical architecture.

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From Pasteur to Koch

Physicians' approach could be secured against the reformers' criticism by emphasising that contagious diseases of hospitals weren't due to miasmatic atmosphere, but by the failure to ensure that airborne agents of putrefaction had been properly excluded from wounds, leading to sepsis and gangrene. Joseph Lister's antiseptic theory addressed this which included chloroform in increasingly invasive surgery, heavy bandaging, draining and carbolic antiseptics. He argued that diseases were actually caused by the treatments as, if putrefying materials were left in the wound, sepsis and gangrene etc would develop. It took until the 1890s before surgeons stopped wearing day clothes in surgery.

Lister sought to further prevent the sanitarian approach by turning to Pasteur's theory of fermentation (1860s), which attributed fermentation to invisible, living organisms: germs. But, while lending scientific legitimacy to antiseptic procedure, his analogy between putrefaction and fermentation didn't pursuade many of his contemporaries as, in many cases, fevers weren't accompanied by any putrefaction. The miasmatic theory wasn't dislodged so easily.

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Robert Koch's theory of specific infection (1880s) stated that there was a specific and causal germ for each disease which could invade open wounds and sores. This provided a more pursuasive account of post-op complications, and an answer to the reformers' criticism of the hospital. Koch's germ theory of disease, especially after the development of vaccines and specific chemical therapeutics that it enabled (tuberculin test, diptheria anti-toxin and arsenicals for syphilis), increasinlgy privileged the hospital and its new allies (the laboratory and the pharmaceutical industry) to become the model for medical intervention. It basically meant that it was important to have operations in the hospital, linking hospitals with bio-medical labs.

Koch's theory can be seen as enabling a compromise between clinical medicine and the sanitarian principles of public health.

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