The time was not yet ripe for public action on a large scale in
matters of Hygiene. Pringle, Lind, and Percival had, however, their
humanitarian parallels among prison reformers. Scientific attempts to
improve the ventilation and sanitation of prisons had been instituted
by the Rev. Stephen Hales (pp. 146-7). None brought greater devotion
to the task than John Howard (1726-90), a native of London who spent
his vigorous powers in investigating the prison system. His researches
extended to the hospital, quarantine and prison systems of France,
Flanders, Holland, Germany, Italy, Greece and Turkey (Fig. 88). His
reports were directly instrumental in the improvement of the hygiene
both of prisons and hospitals, as well as in the institution of
special fever hospitals in many countries. Some aspects of Howard’s
work were carried on by the great Quaker philanthropist Elizabeth Fry
(1780-1845), others came within the field of activity of Southwood
Smith and Chadwick (pp. 193-5).
The eighteenth-century humanitarian movement was active and had many
able representatives in the United States. Foremost among them was
Benjamin Franklin (1706-90), while in the ranks of Medicine none takes
a higher place than Benjamin Rush of Philadelphia (1745-1813). Rush
was particularly revolted by public punishments, to the abolition of
which he devoted much energy. In matters of Hygiene Rush was ahead of
his time. He wrote on the hygiene of troops and laid special stress
on fresh air and cleanliness of body and mind as an aid to health. He
had a peculiar horror and repulsion for alcoholic intemperance. He
was responsible for the first systematic work on insanity published
in America. He left a fine account of a Yellow Fever epidemic at
Philadelphia, and he approached the truth in his view that the disease
arose in Philadelphia itself and was not brought as an infection from
without.
[Illustration: FIG. 88. AN EIGHTEENTH-CENTURY QUARANTINE STATION
(Naples).
From John Howard’s _An Account of the principal Lazarettos in Europe_,
Warrington, 1789.]
§ 11. _The Industrial Revolution._
During the eighteenth century the character of English civilization
became modified by a factor which has since profoundly influenced all
civilized countries. There was a rapid increase in the number and size
of the towns. The main cause of this was the transformation of Industry
by the use of mechanical power. The change that resulted in the life
and outlook of the people was very profound. These changes and the
causes that gave rise to them are usually spoken of as the ‘Industrial
Revolution’. That revolution had effects that were both wider and
deeper than followed any other such single upheaval in history. With
the mechanical elements that were at the back of the Industrial
Revolution, such as the improvements in transport, the invention of
industrial machinery (Fig. 90), the enclosure of common land, the new
position of agriculture, we are not here directly concerned. What does
affect our story is the increasing urbanization of the population,
which began early in the eighteenth century, increased rapidly soon
after the middle of the eighteenth century, and has progressed
continuously ever since. In this matter England is but a type,
for all other civilized countries followed in her wake, though at a
somewhat later date.
Along with the growth of towns and the increased population there was
an increased demand for food. The country became better cultivated and
better drained, and there were many improvements in agriculture. Thus,
certain diseases began to diminish, notably Malaria, essentially a
disease of undrained and ill-cultivated lands. The expulsion of this
disease, as of Typhus, was the work of the nineteenth century (p. 283).
It is often assumed that the physical evils of life became accentuated
by the rise of the great towns. Nevertheless, investigation shows
that the opposite has been the case. During the eighteenth century
men and women began to crowd into the great towns from the country.
They were, in fact, right in their choice, for their chances of life
there were greater than upon the land. In the rural districts infamous
housing conditions, an overcrowding beyond anything which we now
encounter, exposure to weather, uncertainty and fluctuation in the
prices of commodities, low wages, unpassability of roads in winter
time, inaccessibility of medical aids, combined to render life, and
especially child life, more precarious than in urban areas.
[Illustration:
FIGS. 89 and 90 illustrate the passage of the textile trade from home
industry to factory work with the consequent break-up of the family as
the labor unit. Textiles were the first important articles of commerce
to be thus affected, but others rapidly followed. The pictures are
typical of the Industrial Revolution.
]
The improvement of hygienic conditions in the towns began in England
soon after the middle of the eighteenth century. Westminster obtained
an Improvement Act in 1762, Birmingham in 1765, the City of London in
1766, Manchester in 1776, and most of the other provincial towns soon
followed. As a result of such Acts noisome streams which were but open
drains were covered in, the streets were paved and lighted, and the
sewers improved. There were still many glaring defects of sanitation
which have occupied and still occupy reformers, but by the end of the
eighteenth century the general appearance of a street in one of the
more advanced cities was much what it now is. The change from the
medieval conditions of a century before was at least as great as the
changes that have since taken place.
[Illustration:
FIG. 91 shows how the population of England and Wales started to
increase rapidly about 1750, with the beginning of the Industrial
Revolution. The chart covers a period in which statistics were not
exact. The figures for it have had to be estimated, but they are
probably accurate as round numbers. The census returns are available
from 1801.
]
[Illustration:
1910-12
_Age_ 1730-9 1740-9 1750-9 1760-9 1770-9 1780-9 1790-9 _Males_ _Females_
10 36·9 37·0 37·3 36·9 36·7 37·5 38·2 -- --
20 29·1 28·9 29·2 29·3 29·4 29·9 28·4 42·35 46·71
30 23·7 23·5 23·8 24·1 24·1 24·9 24·4 33·87 37·94
40 19·6 19·2 19·4 19·6 19·5 19·5 19·5 26·03 29·67
50 16·1 15·8 15·7 16·1 15·9 15·7 15·8 19·09 22·17
60 12·2 12·4 12·1 11·9 11·9 12·0 11·9 13·09 15·39
70 9·4 8·6 8·7 8·5 8·3 8·7 8·5 8·17 9·57
80 5·9 5·7 5·7 5·7 5·7 6·3 6·2 4·79 5·39
Showing the expectations of life in London for each decade from
1730-1800, with recent data for comparison.
_Age_ 1730-9 1740-9 1750-9 1760-9 1770-9 1780-9 1790-9 1911-12
10-20 6·5 5·9 5·9 7·1 8·2 7·1 6·5 --
20-30 17·5 17·6 17·2 17·9 17·3 16·4 15·1 3·7
30-40 27·1 26·3 26·1 25·2 25·0 23·9 23·7 6·2
40-50 36·6 38·6 35·9 36·3 35·5 35·4 34·3 11·7
50-60 45·5 47·9 45·7 42·1 45·0 44·7 44·6 21·1
60-70 61·4 63·4 63·7 64·4 62·8 64·7 64·1 40·3
70-80 83·7 98·3 96·4 101·8 105·0 101·7 104·4 87·3
80-90 143·1 150·4 151·0 153·0 152·7 153·0 155·1 181·9
Showing the death-rates at Age groups in London for each decade from
1730-1800, with recent data for comparison.
FIG. 91A. TABLES showing that vital conditions in the eighteenth
century did not deteriorate but improved with the Industrial
Revolution. ]
But if the streets had improved there was much under and around them
which would horrify us now. Water-supply, as in London, was usually
drawn mainly from surface wells and rivers. In most towns a continuous
water-supply was unknown. Even when water mains existed, the supply
to the houses was limited. Thus, even in the early nineteenth century
London houses had a water-supply only three times a week, and then only
for a few hours at a time. The water mains were often defective, and
there was not always that clear distinction between a water main and a
sewer that we now regard as desirable. Floods were a constant trouble
in all riverside towns. Cesspools were in use even in London as late as
the middle of the nineteenth century, and water-closets did not become
general, even in the better houses, until about 1828. The methods of
disposal of sewage hardly bear relation. In London the sewage simply
polluted the rivers.
The improvement of such conditions as these could only be made by State
action. The eighteenth century did well where individual activity
was concerned. It was reserved for Southwood Smith (p. 193) and
Chadwick (p. 194) to introduce into the sphere of practical political
action the truth, set forth by Bentham (pp. 190-2), that all factors
which influence the health of the country must be the concern of the
Legislature.
We gladly pass from this darker picture to the Hospital and Dispensary
Movement which took its rise about the middle of the eighteenth
century. Many of the great hospitals both in England and in Continental
countries were either founded or rebuilt about this time. Thus, the
London Hospital was rebuilt in 1752, St. Bartholomew’s in 1730-53.
Between 1700 and
1825 no less than 154 hospitals and dispensaries were founded in
the British Isles. Though defective from the modern point of view,
yet under the influence of the sanitary reformers, Hales (p. 146),
Pringle (p. 169), Lind (p. 170), and Percival (pp. 170-1), these were
incomparably better equipped, better ventilated and better found than
such institutions would have been at the beginning of the eighteenth
century. The notes of the industrious Howard (p. 171) give us a very
complete picture of them, and one that is more favorable than might,
perhaps, have been expected.
A defect of the hospitals of the time was certainly the nursing.
This, however, was somewhat better in the Lying-in-Hospitals, where
the services of a higher type of woman were available and where
ladies served on the committee of management. The general state of
the hospitals remained much the same until transformed by the changes
in surgery and nursing in the second half of the nineteenth century,
though a number of special fever hospitals and pest-houses were
established.
Something must be said of the more prevalent diseases of the Industrial
Revolution. Stress is often laid on the effect of urban conditions
on child life. Yet there can be little doubt that historically the
movement has been beneficial to it. This comes out well in the
death-rates. Thus, in England in the period around 1740, before the
industrial revolution had begun, about 75 per cent. of children born
died before the age of five. In the period around 1800, when the
industrial revolution had set in, the percentage of deaths had fallen
to about 41. In the period 1915-24 it was about 14. Among the most
characteristic diseases of children is Rickets. It is very difficult
to trace the early history of this disease, but its incidence seems
to have been very high about 1700, and to have fallen progressively
throughout the eighteenth century. This fall, it has been suggested,
was due to agricultural improvements which led to better supplies of
better-fed meat. It was these improvements and better supplies that, in
their turn, made the big towns possible.
We have already spoken of Scurvy on ships. It was, however, well known
on land, especially in winter when green vegetables were not to be
had. Lind (p. 170) in 1753 found it common in the land population. The
advances in agriculture removed it altogether from the land diseases
during the eighteenth century.
[Illustration: FIG. 92. ST. BARTHOLOMEW’S HOSPITAL AT SMITHFIELD,
LONDON, in 1720.]
[Illustration: FIG. 93. A VIEW OF THE PEST HOUSE in Tothill Fields,
London, in 1796. From a print in the British Museum.]
§ 12. _Control and Recognition of Epidemic Diseases._
Over one department of public health there was State supervision
during the eighteenth century. The ports were guarded against the
introduction of Epidemic Diseases, and especially against Plague.
Throughout the eighteenth and early nineteenth century there was Plague
in the Near East which extended at times to various parts of Europe.
It was epidemic in Russia in 1709 and some 150,000 died of it. In 1719
it spread to Eastern Central Europe. One historic outbreak was at
Marseilles and Toulon in 1720, when 90,000 died. The outbreak caused
great alarm in England, but did not reach this country, nor has there
since been any outbreak here. Quarantine is now regarded as antiquated,
vexatious, inhumane, expensive, and ineffectual. It seems probable,
however, that during the eighteenth century, when drastically enforced,
as in France with the Marseilles epidemic, it had indeed the effect
of keeping the disease within bounds. Incidentally, it led to the
foundation of many plague hospitals or Lazarettos, of the conduct of
some of which Howard (p. 171 and Fig. 88) speaks well.
During the eighteenth century Small-pox was never absent from this
country. From time to time the disease became epidemic, and there
were grave and fatal outbreaks. Thus, in 1774 there was an outbreak
of small-pox at Chester. Next year an investigation was made of the
degree to which the population had suffered. It was then found that
before the outbreak there were in Chester only 15 per cent. who had
not already had the disease. The incidence on those unprotected by a
previous attack was 53 per cent., with a death-rate of about 17 per
cent. of those actually infected and of about 9 per cent. of the entire
unprotected population.
With the certainty of contracting small-pox before their eyes, men
sought a way of getting it in a mild form. Outbreaks of small-pox
varied greatly in virulence, and infection with a mild form would
lead to protection from a graver one. In the East a method of direct
inoculation of the disease from a patient suffering from a slight
attack was widely in vogue from an early date. The practice attracted
little attention in Europe until Lady Mary Wortley Montagu (1689-1762)
studied it at Constantinople. It was then soon taken up in England, and
became recognized on the Continent.
The efforts of Lady Mary in England were reflected on the other side of
the Atlantic. The famous Puritan leaders, Increase Mather (1639-1723)
and Cotton Mather (1663-1728), turning from their exploits against
the witches, ardently urged the operation. In England the learned
Dr. Richard Mead (1673-1754), an eminent and far-seeing physician
who exercised very great influence on the medical world in his day,
published in 1747 a work in which he supported the practice of
inoculation with all the weight of his authority. During the subsequent
half-century the practice spread widely. The operation was largely in
the hands of specialists who were not always medical men.
Such was the state of affairs when the country practitioner Edward
Jenner (1749-1823) came upon the scene. In 1796 a dairymaid became
infected with a disease of the udders of cows, distantly resembling
small-pox. She developed pustules on her hand. Jenner inserted a
little of the matter from one of these into the arm of a boy of eight,
who developed typical cow-pox. Jenner next inoculated this boy with
small-pox, which, however, failed to develop. The evidence, so far as
it went, was complete. It is an entire justification of what might seem
nowadays to be a reckless experiment, that at that time inoculation
of small-pox was a normal and effective defensive procedure. The
disease of cows has since become known as Vaccinia, and the process of
inoculating it as _Vaccination_.
[Illustration:
FIG. 94. HAND OF DAIRYMAID infected with cow-pox from a cow’s udder.
From Edward Jenner, _Inquiry into the Causes and Effects of the
Variolae vaccinae, a Disease discovered in some of the Western Counties
of England, particularly Gloucestershire, and known by the name of the
Cow Pox_, London, 1798.
]
The discovery of vaccination, important though it be, is a mere
trifle compared to the train of new work and new thought that has
been opened out by it. The whole study of Immunity, which has now
become an independent science, arises from it. The work of Pasteur (p.
225), Lister (p. 239), and Koch (p. 234), and a large part of modern
therapy, are among the achievements of this movement.
Besides Plague and Small-pox, many other epidemic diseases became more
clearly understood during the period we are considering. Among these
was Scarlet Fever, the history of which is particularly interesting
for the variations which it has shown in virulence. It first became
clearly recognizable as a mild disease without prominent symptoms about
1650. Good observers in the half-century that followed considered it a
new disease. In England it continued to be of little importance till
about 1748, when it began to be associated with grave throat symptoms
and to be confused with Diphtheria. This phase continued for about ten
years. The virulence then dropped and the disease continued of slight
consequence till 1785. It then grew virulent again and remained so till
about 1808. The malignancy then fell again and remained low for about
thirty years. It rose about 1837 and from then till 1884 it was one of
the great killing diseases, especially of childhood. Since then, the
mortality from it has steadily decreased.
During most of its history Scarlet Fever has been liable to greater
or less confusion with Diphtheria. The clinical distinction was first
clearly made in 1826 by Pierre Bretonneau of Tours (1771-1862), who
gave Diphtheria its present name. The same French physician performed
the first successful tracheotomy in a case of Diphtheria. He is also
known for pioneer work in the recognition of Typhoid Fever.
VI
PERIOD OF SCIENTIFIC SUBDIVISION
(FROM ABOUT 1825 ONWARDS)
§ 1. _Origins and Implications of Scientific Specialization._
We have seen how the philosophy of Newton, with its implication, the
Reign of Law, which is the Uniformity of Nature, has come to pervade
scientific thought (p. 137). Now, before Newton as after him, there
were certain natural divisions of scientific activity corresponding,
in some degree, to the types and faculties of men. Since Science
first began there have been Mathematicians, Biologists, Physical
Experimenters, because in fact the particular powers which enable
a man to reach distinction in one of these departments are of less
value in the others. Until the period of which we are now to treat,
investigators were accustomed to explore at large within these great
departments. Such specialist professions as Actuarial Calculators,
Economic Entomologists, Physical Chemists, or, in the department
of Medicine, Medical Statisticians, Aural Surgeons, or Vaccine
Therapists--familiar to us now--were unknown and undreamt of then. This
subdivision is a new thing, and is a characteristic product of the
period of which we have now to treat. The subdivisions, unlike those
of old, are largely artificial. Thus, the Aural Surgeon who deals with
the organ of hearing cannot be separated clearly by his training, his
powers and faculties, his operative skill, nor even perhaps by his
field of work, from the Stomatologist who deals with the mouth, or
the Rhinologist who deals with the nose. Nevertheless these minute
subdivisions are convenient and beneficent in medical as in other
departments. The question of scientific specialization is so important
and characteristic that we must examine it a little farther.
It is often thought that, since no man can compass all knowledge,
this scientific subdivision is merely an attempt to compass a part
of that growing mass of knowledge which is becoming progressively
less compassable in its entirety. The movement, however, both in
origin and development, is less simple than this, for there never
was a time when a man could know all that was known about his world.
In this respect our own age is even as other ages. Were the view
philosophically tenable--which it is not--that Science becomes yearly
less comprehensible, our outlook would be gloomy indeed. For since
there is no evidence of any increase in the mental capacity of the
human race--at least in historic time--such a view would imply a
progressive diminution in the number of those competent to treat any
wide scientific area, and a corresponding progressive separation
from each other of minds with scientific insight. Fortunately such
conditions do not prevail; the view that they do is simply due to a
gross, yet widespread, misconception of the nature of Science.
Equally fallacious is the idea, which has become diffused by the
existence of scientific specialization itself, that the progress of any
science is to be measured by the mass of observations that its votaries
have succeeded in accumulating. This is far from being the case. The
advance of a science is measured by the degree with which it succeeds
in bringing a multiplicity of observations under general laws. Judged
by this standard, we should probably rate very highly, for example,
the present state of what is called _Demography_, the study of the
life conditions of communities, while we should rank much less highly,
for example, the present state of the study of Aural Surgery. Yet, for
one publication on Demography there must be many on Aural Surgery.
In the one case, however, the accumulation of knowledge follows a
well-directed and rational scheme. In the other it is prompted and
occasioned by the immediate needs of individual sufferers. This must
not be considered as derogatory to those whose task it is to treat
the sufferers. The point is that the one department, of its nature,
exhibits the rational spirit better than does the other.
Since Rational Medicine is the subject that we treat here, we shall
select for discussion those departments which best illustrate
its spirit. This does not imply, and is not meant to imply, any
belittlement of the less fortunate departments. On the contrary, the
less any scientific department has succeeded in eliciting general laws,
the more necessary it is that those most capable for the prosecution of
such advance should devote their attention to that department. It may,
indeed, reasonably be urged that a leading defect in our scientific
organization is that men of scientific insight crowd to just those
studies where their special powers have already been best exhibited.
In previous chapters, dealing with more remote times, we have been able
to place our facts in historic perspective. Despite the enormous mass
of scientific literature dating from the seventeenth, eighteenth, and
early nineteenth centuries, there is no real obstacle to selecting
what is most important in it. True, it is beyond the power of any
one student to examine all this literature at first hand, but it has
been arranged and indexed, posterity has passed its verdict, and the
historian can find his way through the thicket. It is also true that
important advances are sometimes forgotten, as happened to Mayow’s
discovery of Oxygen in the seventeenth century (pp. 126, 151), which
was repeated by Priestley a hundred years later (p. 154). But the
fact that we know of such neglected discoveries shows that, however
unjust the fates may have been to Mayow, yet his influence has not been
underestimated by later historians. The History of Science, therefore,
can up to a certain point be written along the same lines as political
or economic history.
The face of affairs changes, however, when we pass into a period which
differs for different topics, but may be roughly defined as beginning
somewhere between about 1820 and about 1870. We then begin to encounter
the very questions with which men of Science are occupied in our own
time. Since many of these questions still remain unsettled, it is
impossible for the historian to say with certainty which are the most
fruitful lines of work. The most he can hope to do is to distinguish
the most influential and stimulating thinkers and observers from those
who have been less so, and to say something about the ideas with which
the more important schools of thought were instinct.