Department of english language and literature

2.2. The Nineteenth Century

Although medicine had become a more exact science by the nineteenth century, there remained many deficiencies in medical care and hygiene. Many people died because of squalid conditions in the towns and cities, which were overcrowded and unhealthy. There was dangerous filth and squalor everywhere and what was worse, it was tolerated. There was an effort to introduce some elementary steps of sanitary reform but unfortunately, the Commons and local authorities refused to accept it. Poor people could not afford proper drainage systems or clean a water supply. In the tightly packed and filthy slums where the poor lived there was very little air or light either. Therefore, many different kinds of diseases flourished.

2.2.1. Cholera and Precautions against the Disease

One of the feared diseases during that time was cholera. It was a disease in which germs would spread by dirty water or by contact with excrement. It killed about 31,000 people in 1832.¹⁰ People started to suffer from violent stomach pains and vomiting, their bodies became cold and their skin turned blue. It did not last long; they sometimes died within only two hours. Medical science was almost totally helpless against cholera, which could spread with terrifying rapidity especially in slums where there was no drainage or clean water supply.

There was little knowledge about infections and disease in general. The germ theory had existed previously, but it was supported only by very few scientists.

‘ The most popular explanation was that infection was carried through the atmosphere, hanging in the air like an invisible mist, and was therefore most prevalent amid the filth in the courtyards and back streets of the great cities.’¹¹

This explanation was called “miasma theory of disease” which referred to the mentioned mist, filled with particles – miasmas- which smelt foul and caused illness.

The reformers reacted to this interpretation by sweeping the sewage into nearby rivers. It was absolutely the wrong remedy; their efforts to clean the towns brought only faster transmission of disease. Fortunately, in 1832 the Cholera Prevention Act was passed. On the one hand, the Act gave local authorities the right to require elementary sanitary precautions; on the other hand, it was practically useless because the authorities did not have any means of enforcing the right.

Other diseases such as typhus, tuberculosis, smallpox, typhoid and scarlet fever were always present and the situation was rapidly deteriorating. Wood claims that “in Glasgow a death rate of twenty-eight per thousand in 1821 had risen to thirty-eight per thousand by 1838, and to forty per thousand in 1843”¹¹. Living conditions were improved towards the middle of the century. Health officers started to provide proper drainage and clean water which led to the reduction of mortal diseases.

In 1842, Edwin Chadwick, an English social reformer, played an important role in the beneficial improvement of public health. He wrote Report on the Sanitary Condition of the Laboring Population, in which he required the appointment of local medical officers. He wanted each house to be supplied with pure water for drinking and for the operation of a water closet as well; all waste matter was to be drained off through small egg-shaped sewerage pipes to remote country districts, where it could be utilized as mature. (See Appendix 1 below.)

Finally in 1848 the Liberal Government, under Prime Minister Lord John Russell, passed the Public Health Act. It was passed particularly in response to urges by Edwin Chadwick. The object of the Act was to improve the sanitary conditions (as Chadwick demanded) in towns and other places in England and Wales where many people lived. The improvement covered the supply of water, sewage, drainage, cleansing and paving, all under a single local body. It did not affect the City of London and some other areas in the Metropolis because they were already under the control of sewer commissioners.

Moreover, the act laid down the first boards of health. The central authority was the General Board of Health but its life was limited to only five years. However, during the time of its existence the Board consisted of a chairman and two Commissioners. It was created to advise Parliament and to support urban authorities to organize their own Local Boards, sometimes called Local Boards of Health. These Local Boards were established on the grounds of cholera epidemics and their responsibilities were to control sewers, clean the streets and ensure the proper supply of water to their districts. They also undertook many other activities which helped introduce more sanitary conditions. Due to Chadwick and Ashley’s admirable effort, 182 local boards were set up by 1853.¹² These local boards either merged with the corporation of municipal boroughs in 1873 or they became urban districts in 1894.¹³

The fresh wave of cholera, which was sweeping into Europe from the East, reached cities in England and Wales in the summer months of 1848 and 1849; more than

72, 000¹⁴ people died of cholera. Cholera returned again in 1853 but because of the success of the General Board of Health, the death rate was much lower. Regardless of such success, in 1854 the Board was doomed to failure because there were 65 votes for and 74 against the preservation of the Board in the House of Commons and a Board of Ministers took the place of the Board of Health.¹⁴

In spite of all the above mentioned efforts, a report from 1869 showed that some towns remained as dirty and unhealthy as they had been in 1830s.¹⁵
In the nineteenth century, there lived another man, who helped in the fight against cholera. His name was John Snow.

2.2.1.1. John Snow (1813 – 1858)

Snow was a British physician, who is considered to be one of the founders of epidemiology. He studied medicine at University of London and graduated in 1844. Six years later, Snow was admitted to the Royal College of Physicians.

He was a supporter of medical hygiene and usage of anesthesia in practice. In 1854 during a cholera outbreak, he observed that the disease was restricted to a small area in Soho, London. By visiting the houses where the ill people lived, he deduced that the source of cholera was in the water which came from the public water pump on Broad Street, nowadays called Broadwick Street.

Snow applied the germ theory without knowing any other details about it because it was not fully formulated until 1865. He examined the water under a microscope. Even though he observed that there was something in the water which could cause the disease, he was not able to describe it more, he did however make important steps not only towards getting rid of cholera but also towards the investigation of the micro-organism.

His other contribution to medicine was made in the field of anaesthesiology. Snow was one of the first physicians who calculated the dosage of anaesthetics such as ether and chloroform. Obstetric anaesthesia was commonly used as well. Snow was even present while Queen Victoria was giving birth to one of her children and he personally administered ether to Her Majesty.

In the nineteenth century there appeared on the scene quite a lot of university-educated physicians, who helped develop medicine as a science. Not only were medical anatomy and physiology advanced, but considerable strides were made in pharmacology too. In the first half of the century morphine, atropine, digitalin and others were beginning to be used. Moreover, there was significant progress made in the identification, classification and description of various diseases. British doctors who played important roles in such demanding and outstanding work are; Thomas Addison (1793-1860), Richard Bright (1789-1858), Thomas Hodgkin (1798-1866), John Hughlings Jackson (1835-1911), Joseph Lister (1827 – 1912), James Parkinson (1755–1824) and others. Immediately below there is mention of the work of James Parkinson only because the disease named after him is generally known, even to people uninitiated in the field of medicine. On account of the above mentioned reasons, the nineteenth century is considered to be a very remarkable time period in the development of medicine.

2.2.2. James Parkinson (1755 - 1824)

Parkinson was an English physician and a palaeontologist. He was born on April 11, 1755 in Hoxton Square, Shoreditch, in London. It is not known where he studied, nevertheless, his name was written down on the list of surgeons approved by the Corporation of London. So in 1784 he became a surgeon. Besides medicine and science, he was involved in various social and revolutionary causes and he was a member of certain secret political societies. Parkinson was interested in politics very much, but fortunately since 1799 he started to become interested in medicine more than in politics. He published several works about medicine concerning gout and the description of a perforated and gangrenous appendix with peritonitis. Moreover, he was interested in general public health and the well-being of the population and he was an advocate of legal protection for the mentally ill, as well as their families and doctors. The work for which Parkinson deserves the most profound admiration is the excellent clinical description of the disease (nowadays called Parkinson’s disease), which he described in his work called An Essay on the Shaking Palsy published in 1817. Parkinson’s disease is defined as “A degenerative disorder of the nervous system characterized by masklike facies, a fine, slowly spreading tremor, cogwheel rigidity, bradykinesia, and postural instability with a peculiar gait.“¹⁶ The name Parkinson’s disease did not come from Parkinson himself. Approximately 60 years later, French neurologist, Jean Martin Charcot, named the disease as Parkinson’s disease.

Just as Parkinson had changed his interest from politics to medicine, he soon switched from medicine to nature, so there are no other important descriptions of diseases from Parkinson. Despite little attention from his English-speaking colleagues in his time, Parkinson’s disease is one of the best known medical eponyms and his description of the disease was a great asset in the development of medicine.

2.2.3. Hospitals

In the nineteenth century poor people either had to do without medical treatment or rely on dubious home remedies, which could often be dangerous. Medical care at that time was mainly private or voluntary. Some poor workers had free access to a doctor but this was not the case for their wives and children. There were however some doctors who provided free treatment to the poorest people.

Medical care was pursued in hospitals as well as outside. At the very beginning of the nineteenth century the worst hospitals were in a very bad state. There was a typically unpleasant smell in hospital wards which could be found not only in England but also elsewhere. The wards were stuffy and overcrowded. Patients were not bathed so often and usually slept two to a bed. Sheeting was rarely washed and windows were not opened frequently. The people who worked there and were called nurses were ordinarily very poor women as well. They were often not clean, and were considered by the majority of the public to be of a lower class. They slept in the wards and took care of patients but they only brought them food or washed their clothes. Nurses were not supposed to do any skilled work. It was done by surgeons themselves. People did not want to be placed in such hospitals but those who did not have any relatives who could look after them had no other choice. Moreover, there was one condition to be met by the sick to be able to be admitted to the hospital. They had to have money for their burials in case they died, which they handed over upon admission to the hospital. Because of the very bad conditions of such hospitals, it was quite likely for patients to die there. Conditions there generally contributed to a worsening of the state of health rather than an improvement.

In 1828 William Marsden, a young doctor who helped people free of charge, opened London General Institution for the Gratuitous Cure of Malignant Diseases. It was a dispensary for advice and medicines which is now called the Royal Free Hospital. It was built as a hospital for poor, ill people who could not afford to pay for medical care. Free care lasted until 1920, when the institution was forced to ask patients to pay for their treatment.

Hospitals were built in urban areas. Two-thirds of the hospitals were originally built before 1891 and approximately 21 per cent before 1861¹⁷. Their physical state was very poor and besides, they lacked operating theatres, diagnostic facilities, pathology and radiology.

Treatment in hospitals was very much based on good nursing, bed rest and the giving of sedatives, especially at night. Patients were often admitted to the hospital at a very late stage of their disease. Diagnosis, prognosis and treatment were often based only on bedside observation over a period of time. In that time, there were not as many drugs available as today. Doctors frequently used salicylates for rheumatic fever, digoxin for heart disease, sulphonamides, penicillin and streptomycin for controlling pneumonias.

Essentially, all hospitals were subdivided into general medical and general surgical wards. If any maternity department or gynecology wards existed, they were separate. Children were commonly placed in adult wards. In some larger hospitals there might have been orthopedic wards.

During the nineteenth century and at the beginning of the twentieth century there were two main kinds of hospitals - voluntary hospitals and municipal hospitals.

Voluntary hospitals were the most prestigious hospitals, which were responsible only to themselves, mainly because they financed themselves. They offered considerable outpatient services which enabled the hospitals to advertise themselves. This kind of hospitals would provide care only to a limited number of patients and it tended to deal especially with serious illnesses. Voluntary hospitals admitted only limited categories of patients; people with chronic diseases and elderly people were not admitted at all. Hospitals were well controlled at large and they could afford to choose their staff. Matrons chose only the student nurses who gained a “school certificate”. Among others, the selected nurses usually came from “good families”. Discipline was very firm; if a nurse became pregnant she was dismissed. Nevertheless, despite hard working conditions and running the risk of being dismissed, there were quite a number of marriages between doctors and nurses.

Municipal hospitals were provided by the local authorities of large towns. In contrast to voluntary hospitals which were not able to keep pace with the increasing needs of the population, the municipal hospitals kept up. They provided more beds even though many of them were intended for long-term care. Better laboratories and operating theaters were slowly developing, yet outpatient departments remained elementary.

In some places hospitals co-operated with each other without hostility but there were other places where hospitals were engaged in what could only be described as open war.

Mentally ill and mentally handicapped people represented a special group of patients. Mainly at the beginning of the twentieth century there was a greater number of hospital beds for such patients than there were for patients suffering from acute symptoms of physical illness. Crowding was caused by bomb damage in the wartime.

‘Before 1946 there had been little expectation of the inclusion of these services in the NHS, and therefore little planning. The mental health sector was subsumed into the NHS with difficulty, as an unwilling and inferior partner’¹⁷ Institutions and care the mentally ill is too complex topic and it might be the subject of further investigation. Therefore, it is mentioned in this chapter only marginally.