The Medicine Book

THE SCIENTIFIC BODY 101 virulent doses of his rabbit-spine developed to combat each one – How vaccination concoction. It worked, and the boy those vulnerable to winter flu need works recovered. Pasteur insisted that to get a new vaccination every his method would also be called autumn to protect them against When the body is exposed to “vaccination”, in honour of Jenner, that year’s version. Other diseases, a pathogen (a disease-causing and the name has stuck. such as HIV, are very hard to create organism), it reacts by releasing an effective vaccine for, since HIV floods of antibodies targeted Inspired by Pasteur’s success, attacks a person’s immune system. against that specific germ. It scientists around the world began takes a while to produce the to look for other “live, attenuated Vaccination has saved hundreds right antibodies, and the body vaccines”, believing that in this of millions of lives. Smallpox has may suffer the symptoms of way, they could find a vaccine for, been entirely eradicated, and many disease before the immune and eradicate, every single disease. other infectious diseases are in system mounts its counter- Live vaccines have since been decline. In the US, for instance, attack. Eventually, if the found for tuberculosis, yellow fever, diphtheria declined from 206,939 person survives, the germs are measles, mumps, and rubella, cases in 1921 to just two cases beaten and the body recovers. among other diseases. between 2004 and 2017; whooping cough declined from 265,269 cases The next time the body Getting it right in 1934 to 15,609 in 2018; and encounters the germ, however, The challenge with vaccinations is measles has fallen from 894,134 the antibodies are ready to to find the right vaccine. A vaccine cases in 1941 to just 372 in 2019. eliminate it before the disease has to trigger the production of develops. Vaccination primes the right antibodies, but it clearly New diseases are being fought the immune system by should not make the patient ill. successfully all the time. Since the exposing it to weakened, Medical scientists have no doubt haemophilus influenzae type b (Hib) dead, or partial versions of the that the best way of combating vaccine was introduced in the 1990s, germ. These “safe” pathogens most infectious diseases is to find for example, the incidence of the trigger antibody production, a vaccine. With some diseases, disease Hib meningitis, which once but do not cause the disease. one vaccine seems enough to give killed tens of thousands of children, With some diseases, a single long-term immunity. With others, has declined in Europe by 90 per exposure is enough. With such as influenza, new variations cent and in the US by 99 per cent. others, immunity needs to of the virus are appearing all the But globalization has brought new be built up gradually with time, and a new vaccine has to be threats, and in 2020, the race to find a series of vaccinations, or a vaccine for COVID-19 began. ■ restored with a “booster” jab. 12 MILLION 1995 2000 2005 2010 2017 Vaccination has greatly improved 10 MILLION the global life expectancy of children under five. The height of each bar shows 8 MILLION the total number of deaths, and the 6 MILLION coloured sections represent deaths that 4 MILLION could have been prevented by vaccines. 2 MILLION Key: Causes of death 0 1990 Causes of death that are preventable by vaccines: 1. Tetanus 2. Whooping cough 3. Measles Causes of death that are partly preventable by vaccines: 1. Meningitis and encephalitis 2. Diarrhoeal diseases 3. Acute respiratory infections Other causes (not preventable by vaccines)

102 LLCIIUKKREEES HOMEOPATHY IN CONTEXT G erman physician Samuel The system still has many Hahnemann first proposed adherents, but conventional medicine BEFORE the system of “like cures warns that there is no reliable c. 400 bce Hippocrates writes like” medicine in his 1796 Essay on evidence to support homeopathy, that plants resembling a body a New Principle for Ascertaining and it should never be used to treat part affected by disease can the Curative Power of Drugs. After chronic or serious conditions. As help to treat the disorder. translating Scottish physician some homeopathic products react William Cullen’s 1781 Lectures on with conventional medicines, those c. 1530s Paracelsus proposes the Materia Medica into German, considering homeopathy should that colour and other attributes Hahnemann had tested Cullen’s consult a doctor first. While many of plants and minerals indicate observation that taking cinchona users report positive results, these which disorder they can treat. bark powder (later isolated as are probably a placebo effect, quinine) produced symptoms that largely due to the holistic approach 1760s Austrian physician were similar to those of malaria, of homeopathic practitioners. ■ Anton von Störck advocates the disease it was known to treat. the use of poisons, such as Hahnemann also experienced … homeopathic products hemlock, in minute quantities malarial symptoms, which led him perform no better to treat incurable diseases. to the “like cures like” principle. This than placebos. is the key doctrine of homeopathy, a Science and AFTER term Hahnemann coined in 1807. 1834 Austrian physician Technology Committee Johann Martin Honigberger Hahnemann would prescribe uses a mix of conventional and highly diluted solutions of a remedy, British House of Commons, 2010 homeopathic medicine, and as he believed that the lower the takes homeopathy to India. dose, the greater its potency. In Britain, Europe, and the US, 2017 The US FDA proposes homeopathy soon became a new, risk-based scrutiny of popular alternative to conventional homeopathic products. The UK therapies such as purging and halts their public funding, and bloodletting; by 1900, there were Spain (2018) and France (2019) 15,000 homeopathists in the US. resolve to end funding, too. See also: Ayurvedic medicine 22–25 ■ Greek medicine 28–29 ■ Herbal medicine 36–37 ■ Medieval medical schools and surgery 50–51 ■ Pharmacy 54–59

THE SCIENTIFIC BODY 103 OTTHOFETHHBEEEAARHTEINARGT THE STETHOSCOPE IN CONTEXT I n 1816, French physician A 19th-century engraving reveals René Laënnec invented the how little the form of stethoscopes has BEFORE stethoscope. He had found the changed. In hospitals, doctors now also 17th century bce Egyptian earlier practice of pressing his ear use pocket-sized ultrasound scanners. papyri mention that signs of to a patient’s chest to listen to the disease can be heard within heart and lungs both inefficient Improvements made after Laënnec’s the body. and embarrassing – especially death in 1826 included a flexible when examining women. Laënnec tube, two earpieces, and a dual-head c. 375 bce Hippocrates discovered that a piece of paper version to press against the back and suggests shaking patients and rolled into a cylinder and pressed chest (a hollow bell to detect low- pressing an ear against their against the chest or back made frequency sounds and a diaphragm chest to listen for abnormalities. the sounds more clearly audible. to pick up high-frequency sounds). His first instrument was a hollow American professor David Littman 1616 William Harvey notes wooden tube 3.5 cm (11/3 in) in developed a lighter stethoscope with that blood pulsing through the diameter and 25 cm (93/4 in) long better acoustics in the early 1960s, heart “can be heard within with a small earpiece attached at and in 2015, Palestinian doctor Tarek the chest”. one end. He called it a stethoscope, Loubani remedied a shortage by from the Greek words stethos creating the first 3D-printed model. ■ AFTER (“chest”) and skopein (“to observe”). 1852 American physician George P. Cammann perfects Widespread use his design of a flexible binaural In 1819, Laënnec published (two-earpiece) stethoscope. On mediate auscultation, which discussed how the sounds of 1895 In France, obstetrician possible heart and lung diseases Adolphe Pinard develops a and defects could be heard through stethoscope that detects foetal a stethoscope. This work aroused activity in the womb. great interest, and encouraged widespread use of the instrument 1998 3M in the US launches a over the next 30 years. new Littman stethoscope that electronically amplifies sounds See also: Blood circulation 68–73 ■ Case history 80–81 ■ Electrocardiography that might go undetected. 188–89 ■ Ultrasound 244 ■ Pacemakers 255

MCEICLRLOSBAE 1820–1890

NSD

106 INTRODUCTION British obstetrician American dentist Realizing that all In the Crimean War, James Blundell reports William Morton tissues are made of Florence Nightingale demonstrates the cells, which develop nurses the wounded at a successful blood successful use of ether from other cells, Albert transfusion for a as an anaesthetic von Kölliker publishes Scutari. Her 1859 mother with severe during an operation. his Handbook of Human Notes on Nursing bleeding after childbirth, Histology, founding that but the process involves initiates modern many serious risks. field of medicine. nursing care. 1829 1846 1852 1854 1843 1846–60 1854 1858 In the US, physician Originating in India, the British physician John Rudolf Virchow’s Oliver Holmes presents third and worst of six Snow traces the causes of Cellular Pathology evidence showing that cholera pandemics in a severe cholera outbreak shows how medicine puerperal (childbed) the 19th century spreads fever is contagious to Asia, Europe, North in Soho, London, to a should examine and can be prevented America, and Africa, water pump, laying the individual cells to foundations for the medical by strict hygiene. killing millions. field of epidemiology. find the causes of disease. D uring the 19th century, anatomy) to understanding illness organisms – germs – were causing huge medical progress with his Cellular Pathology in 1858. the problems, rather than chemical was made possible by the Causes of disease, diagnosis, and changes or spontaneous generation. light microscope. Improvements progress of treatment could all be increased magnifications to many achieved by the scrutiny of cells. By Progress and challenges hundreds of times, with far greater now, age-old theories such as the Pasteur began to focus on animal clarity. As researchers delved deeper spontaneous generation of life from diseases, including a blight of into the body’s minuscule secrets, non-living matter were fading. In silkworms, and cholera and anthrax new levels of detail came into focus. their place came cell theory, with in farmyard birds and livestock. His In Switzerland, and then Germany, its three key elements: all living microscope-based investigations Swiss anatomist Albert von Kölliker organisms are composed of one or were inventive and thorough, and studied a vast range of animal more cells; the cell is the basic he considered that these harmful materials and moved onto human structural unit of life; and cells arise microorganisms could also cause samples. He observed almost every from pre-existing cells. many human diseases. Gradually type of tissue: skin, bones, muscles, he conceived the notion we now nerves, blood, and guts. His first In France and Germany, further call germ theory. great work, Handbook of Human microscopic studies were looking not Histology, of 1852, quickly became just at the body’s own cells, but at Around this time, German recommended reading across invaders from outside. In the 1850s, microbiologist Robert Koch also biology and medicine. French microbiologist Louis Pasteur gained prominence. In 1875, he began to help the local beer and identified the germ that causes Just six years later, German wine industries, whose products anthrax, Bacillus anthracis, followed pathologist Rudolf Virchow applied suffered from spoiling and souring. by those for TB and cholera. Pasteur histology (the study of microscopic Pasteur concluded that tiny and Koch also strove to develop

CELLS AND MICROBES 107 French scientist French physician Claude Joseph Lister reports Russian researcher Élie Louis Pasteur publishes Bernard describes his extremely positive Metchnikoff suggests concept of a milieu results of using that white blood cells his germ theory. He intérieur (constancy carbolic acid as an are part of the body’s suspects that many of the internal antiseptic during defence mechanism, diseases are caused by operations. rather than actually tiny organisms that environment), which is spread in various ways. key to the development spreading disease. of physiology. 1861 1865 1867 1882 1884 1865 1865 1870s Austrian monk Gregor Elizabeth Garrett-Anderson Rivals Louis Pasteur and French physician Mendel creates the basis is the first woman to Robert Koch announce Alphonse Laveran discoveries identifying first proposes that of genetics with qualify as a doctor in the the causes of diseases the parasite that Experiments in Plant UK. In 1874, with Elizabeth including anthrax and causes malaria Hybridization. Its value Blackwell, she inaugurates cholera, thereby is carried by is not recognized the London School of verifying germ theory. mosquitoes. until 1900. Medicine for Women. vaccines for the diseases they had anomaly to register for a medical restricted by conscious patients unravelled. Pasteur successfully degree. She was soon followed by screaming in agony and struggling developed one for anthrax in 1881. other pioneering women. under the knife, and they had to work quickly. The first operations Away from the microscope, Sanitation and surgery under nitrous oxide, and then ether doctors were facing new challenges In 1854, British reformer Florence anaesthetic, occurred in the US in and had to respond to the continuing Nightingale and her team of nurses the 1840s. The techniques rapidly effects of industrialization, which and carers had travelled to Scutari, spread to Europe, with chloroform brought urbanization, and crowded, Turkey, to tend the wounded during as the chemical of choice. Surgeons insanitary conditions in cities and the Crimean War. Conditions in the no longer had to rush and could factories. Disease patterns were crowded, unsanitary hospital wards develop more complex procedures. changing as a result, with cholera, were horrific: up to ten times more typhoid, and dysentery all more men succumbed to disease than to Despite this, post-operative prominent. Medical organizations their war wounds. Nightingale’s infections were still a common were being set up with regulations efforts reduced this tally dramatically. hazard of surgery. In the 1860s, to govern standards of practice and On her return to Britain, she British surgeon Joseph Lister began care. Britain’s Royal College of continued to lobby for change, and to use carbolic acid as an antiseptic Surgeons became active in 1800, in 1859 penned Notes on Nursing, against invading micropathogens. and in 1808 the University of France generally regarded as the basis of His work showed that infections numbered medicine among its six modern nursing practices. were drastically reduced, yet even faculties. Yet these professions this clear evidence was rejected by were hugely dominated by men. In A further field of 19th-century some in the medical establishment, 1847 in the US, Elizabeth Blackwell progress was anaesthesia. For where dogma continued to hold back seized on a college admissions centuries, surgeons had been progressive practices in medicine. ■

108 IN CONTEXT ILBSNELITCTOOKOHTDMEHAALELNETAHPY BEFORE 1628 William Harvey publishes BLOOD TRANSFUSION De Motu Cordis et Sanguinis, AND BLOOD GROUPS in which he describes the circulation of blood. 1665 Richard Lower attempts blood transfusion between two dogs. 1667 Jean-Baptiste Denis transfuses blood from a lamb into a human. AFTER 1914 Adolph Hustin develops long-term anticoagulants. 1916 US Army medic Oswald Robertson creates “blood depots” during World War I. 1939 Karl Landsteiner and Alexander Weiner discover the Rh blood group system. T here are about five litres (11 pints) of blood in an adult human body. Severe blood loss leads to weakness, organ damage, and death. It is a major cause of death from injury, and for centuries was a common reason for maternal death in childbirth. The concept of transfusion – replacing lost blood with blood from another person, as British obstetrician James Blundell did in 1829 – seemed like an obvious remedy, but the means to do this safely proved elusive until Austrian physician Karl Landsteiner named three blood groups in 1901. Early experiments Physicians had long written of blood’s vital powers, but the first documented blood transfusion was carried out by English physician Richard Lower in 1665. Lower drained the blood of a dog “until its

CELLS AND MICROBES 109 See also: Bloodletting and leeches 52 ■ Battlefield medicine 53 ■ Blood circulation 68–73 ■ The immune system 154–61 ■ Transplant surgery 246–53 ■ Monoclonal antibodies 282–83 Many injuries result in Replacing blood will people losing blood. aid recovery. However, some But blood transfusions blood transfusions between only work if the donor and recipient are the members of the same species also fail. same species. In an early blood transfusion from Transfusions fail because there are lamb to man, blood from the carotid different blood types. Blood types must be artery in the neck of the lamb is transferred into a vein in the man’s compatible for transfusion to take place. inner elbow. strength was nearly gone” and then John Henry Leacock, a plantation dogs were less successful: five of revived it by introducing blood from owner’s son from Barbados, carried the dogs in his experiment died a second dog. The first dog recovered out experiments on dogs and and only one recovered. Blundell’s but the donor dog died. Following cats in Edinburgh, Scotland, and experiments also differed from Lower’s experiment, physicians in established that the donor and Leacock’s in that he transfused England and France were eager to recipient of a blood transfusion had venous blood, ratherthan arterial ❯❯ try the procedure on humans. Given to be the same species. Leacock that the outcome for any donor was also created a cross-circulation … the blood of one sort likely to be fatal, blood from animals between two dogs, modifying the of animal cannot, with was used instead. The results were rate of blood flow and observing impunity, be substituted … inconclusive, and reports of death the effects of impeding and then in large quantities for that of following transfusion emerged. re-establishing the dual circulation. another sort of animal. He also recommended human blood French physician Jean-Baptiste transfusion to treat haemorrhage, James Blundell Denis faced a murder charge in however, whether he actually 1668, when a patient died after he carried out any human transfers Researches physiological and was given lamb’s blood. Many is unknown. pathological, 1825 doctors condemned the practice and the Royal Society in London James Blundell was aware of banned it the following year. Leacock’s experiments, but he took them a stage further. He discovered Leacock and Blundell that dogs bled to “apparent death” Early in the 19th century, physicians could be revived by transfusions began to re-examine the possibility of blood from other dogs. Attempts of human blood transfusion. In 1816, to use human blood to revive the

110 BLOOD TRANSFUSION AND BLOOD GROUPS blood and transferred blood with RECIPIENT BLOOD TYPE DONOR BLOOD TYPE a syringe instead of connecting the donor and recipient using a O+ O- A+ A- B+ B- AB+ AB- tube. Blundell calculated the time O+ it took for blood to coagulate in his O- transfusion method, concluding A+ that blood must not be allowed to A- remain in the syringe for more than B+ a few seconds. B- AB+ Human to human AB- The first documented human-to- human blood transfusion was This chart shows which blood groups are compatible. Key: carried out by Blundell in 1818. Type O- is known as the universal donor – it can be given to Compatible Aided by surgeon Henry Cline, anyone. However, people with O- can receive blood only from Blundell gave a transfusion to a other people with O- blood type. People with type AB+ are Incompatible patient suffering from a gastric universal recipients – they can receive blood from anyone. carcinoma, injecting around 400 ml (0.7 pints) of blood from various severe postpartum haemorrhage While a few patients responded donors in small amounts at five- after receiving around 250 ml positively to the treatment, others minute intervals. The patient (0.4 pints) of blood drawn from her died within days. showed an initial improvement, husband’s arm during the course but died two days later, although of a three-hour procedure. Realizing Blood groups that may have been because he the serious risks involved, Blundell Physicians did not understand the had already been close to death. advocated transfusion only in the reason for the different responses treatment of desperately ill patients. to blood transfusions until the Over the next decade, Blundell Other physicians who attempted beginning of the 20th century. and his colleagues performed transfusions on patients also They had observed that when several more transfusions, with reported distressing failure rates. blood from different people was limited success. Only four out of ten patients treated survived. The first successful transfusion, reported in The Lancet in 1829, was of a woman who recovered from Karl Landsteiner Born in Vienna, Austria, in 1868, the immune response of blood Karl Landsteiner was the son serum. After discovering blood of a well-known journalist and groups in 1901, he went on to newspaper publisher who died identify the bacterium that when Karl was only six. Brought caused syphilis, as well as the up by his mother, Landsteiner disease agent that caused studied medicine at the University polio as a virus. In 1930, he of Vienna, graduating in 1891. was awarded the Nobel Prize He then spent five years working in Physiology or Medicine. Still in laboratories to further his working at the age of 75, knowledge of biochemistry, before Landsteiner died of heart going on to practise medicine at failure in 1943. Vienna General Hospital. Key work In 1896, Landsteiner became an assistant to bacteriologist Max 1928 “On Individual Differences von Gruber at Vienna’s Institute in Human Blood” of Hygiene, where he researched

CELLS AND MICROBES 111 mixed in test tubes, the red blood attack the alien blood cells, causing Blood banks cells sometimes clumped together. them to burst. Accumulated burst It was largely assumed that this cells then created clumps that Building on Landsteiner’s was caused by disease and it was clogged up the recipient’s blood work, further initiatives soon not seriously investigated. In 1900, vessels, potentially leading to death. facilitated the safe storage of Austrian physician Karl Landsteiner blood for transfusion. In 1914, decided to see what happened Landsteiner identified three Belgian physician Adolph when healthy blood was combined. different blood types: A, B, and C Hustin found that adding He took samples from himself and (the C blood type was later renamed small amounts of sodium five of his colleagues and recorded O). In 1902, one of Landsteiner’s citrate to blood stopped it what happened when he mixed students identified a fourth type, from clotting. Two years later, them together. AB, and in 1939, Landsteiner and Peyton Rous and Joseph Alexander Weiner discovered Turner at the Rockefeller Publishing his results in 1901, the Rh blood group system. Rh+ Institute in New York City Landsteiner classified human blood (Rhesus positive) or Rh- (Rhesus discovered that blood could into three types. He had found that negative) denotes the presence be safely stored for 14 days if antigens – protein markers on the or absence of an inherited protein dextrose (a sugar) was added outside of cells – differed according on the surface of red blood cells, to the sodium citrate. to the blood type and that blood which affects blood compatibility. clumped when the donated red In 1916, Oswald Robertson, blood cells were of a different type New possibilities a medical officer in the US from the recipient’s red blood cells. Landsteiner’s discoveries made Army, set up the first blood If blood from one blood group was safe blood transfusions the norm. bank. Using the method of introduced into the body of The first successful transfusion Rous and Turner, he created a someone with an incompatible based on Landsteiner’s blood type supply of blood types in order blood group, it would trigger an theory was carried out by Reuben to perform operations on the immunological reaction: the Ottenberg, a physician and battlefields of World War I. recipient’s immune system would haematologist at Mount Sinai Hospital, New York City, in 1907. The world’s first blood Blood donors in Indonesia give Knowledge of blood groups paved donor service – a bank of blood during the COVID-19 pandemic. the way for organ transplants, volunteer donors – was set Antibody-rich blood plasma from which are also dependent on up in 1921 by British Red people who had overcome COVID-19 the donor and recipient having Cross worker Percy Oliver. was given to patients fighting the virus. compatible blood types. ■ The term “blood bank” was coined by Dr Bernard Fantus when he set up one in Chicago’s Cook County Hospital in 1937. Modern blood banks allow blood to be stored for several weeks after donation. Blood plasma can be stored for up to three years.

QSOUOIETTHIINNGG,, AND DELIGHTFUL BEYOND MEASURE ANAESTHESIA



114 ANAESTHESIA T he use of some form of paper describing both nitrous sedation during surgical oxide’s euphoric effects and its IN CONTEXT operations dates back ability to reduce pain – a property several millennia. Physicians he tested on his own erupting BEFORE employed a range of narcotic wisdom tooth. Davy suggested the 6th century bce In the substances derived from plants, possible use of the gas in surgery. Sushruta Samhita, the Indian including the mandrake, from His assistant, scientist Michael physician Sushruta advocates whose effects the Greek physician Faraday, also studied the effects cannabis and wine to sedate Dioscorides coined the term of inhaling ether, whose sedative patients during surgery. anaesthesia, meaning “absence powers were already known. of sensation”, in the 1st century ce. 2nd century ce Chinese However, for most patients Recreational anaesthetics physician Hua Tuo uses an undergoing surgery in Europe, Laughing gas parties and “ether anaesthetic containing opium. there was little effective pain frolics” became the latest trend relief until the mid-19th century. among Victorian luminaries, often c.1275 In Spain, physician British novelist Fanny Burney’s in Davy’s own drawing room. Raymundus Lullius discovers harrowing description of her Participants, who breathed in puffs ether, calling it “sweet vitriol”. unanaesthetized mastectomy in of the gas, reported feelings of 1811 – “suffering so acute that was intense joy. Lexicographer and AFTER hardly supportable” – reveals how physician Peter Mark Roget, the 1940s To combat spinal tortuous such operations were. creator of Roget’s Thesaurus, wrote fractures in patients receiving of a feeling of weightlessness and electroconvulsive shock In the early 1800s, a new sinking, while poet Samuel Taylor therapy (ECT), American anaesthetic agent was emerging in Coleridge described a sensation like neuropsychiatrist A.E. Bennett Britain but was not yet in clinical returning from a walk in the snow uses curare, a muscle relaxant. use. In 1798, the young chemist into a warm room. Yet the leap from Humphry Davy – later known for party gas to surgical anaesthetic 1960–80 Ketamine and his discoveries of chlorine and was not immediate, probably due to etomidate replace earlier iodine, and his invention of the the dosages being difficult to control. barbiturates that could have Davy lamp – had been tasked with Faraday reported in 1818 that one dangerous cardiac side effects. investigating the effectiveness of participant anaesthetized with the laughing gas nitrous oxide, ether did not wake up for 24 hours. 1990s Sevoflurane, a safe and discovered by Joseph Priestley effective inhaled anaesthetic, 26 years earlier. Davy published a In the US around the same time, becomes widely used. American medical students and young intellectuals began to engage in the same frolics as those enjoyed by London’s society figures. Crawford Long, a physician in Jefferson, Georgia, would inhale ether with friends in the evening and observe the results. The next morning, Long would find new bruises on himself, but he had no memory of the antics that had caused them, nor of the pain they Laughing gas (nitrous oxide) is given to a “scolding wife” in a satirical British engraving from 1830. At that time, the anaesthetic’s main claim to fame was the euphoria it induced when inhaled.

CELLS AND MICROBES 115 See also: Plastic surgery 26–27 ■ Traditional Chinese medicine 30–35 ■ Herbal medicine 36–37 ■ Antiseptics in surgery 148–51 ■ Minimally invasive surgery 298 ■ Nanomedicine 304 ■ Robotics and telesurgery 305 Before the advent of anaesthesia, surgeons operate at dangerous speed, and terrified patients often die of shock from pain or post-surgical infections. Victorian scientists explore the anaesthetic properties of nitrous oxide and ether, using both recreationally. Ether was first used as an anaesthetic American physician Crawford Long inhales ether for fun in a Paris operation in 1846. Early basic and later notes his bruises but recalls no pain. masks were soon replaced by more effective models, such as this one, from a 19th-century French medical manual. might have induced. He concluded In the US, William Morton publicly demonstrates the that ether might prove an excellent pain-numbing effects of ether, which helps to convince agent for eliminating pain during an operation and soon found an physicians of its viability in surgical operations. opportunity to test his theory. Early medical use of ether British surgeons begin to use ether, In 1842, a young man approached and Queen Victoria inhales “blessed chloroform” Long to ask whether he could to sedate her during childbirth. Her approval encourages remove an unsightly sebaceous cyst from his neck. Long anaesthetized the wider use of anaesthetics. his patient with ether and was overjoyed with its success. He watching a demonstration of their There, in front of an audience, a began to use it in other operations effects. To test it on himself, he medical student agreed to have a but did not report his findings breathed in nitrous oxide before a tooth extracted. Wells administered until 1849. By this time, others had fellow dentist extracted his tooth – the gas, but the student screamed introduced the effects of the new he experienced no pain. Both he out in pain as soon as the operation anaesthetics to a wider audience, and his business partner William began; whether this response was and Long lost a subsequent legal T.G. Morton began to use the gas simple theatrics or because Wells bid to be declared the discoverer at his practice. By 1845, Wells felt used too little nitrous oxide is of ether anaesthesia. confident enough to demonstrate unknown. The episode sank Wells’s the gas at Harvard Medical School. career and his reputation. ❯❯ Horace Wells, a little-known dentist from Hartford, Connecticut, also recognized the potential of nitrous oxide and ether after

116 ANAESTHESIA Different types of anaesthesia A general anaesthetic Drugs are injected A peripheral Local anaesthesia is given via an inhaler, or into the lower nerve block is is often used for a an intravenous injection back to numb the often used in minor skin or dental of anaesthetic drugs, or body from the shoulder surgery. procedure. The both, to sedate the whole waist down. anaesthetic is body and render the Spinal Peripheral injected at the site patient unconscious Regional anaesthesia nerve block to temporarily throughout the surgery. (there are three types) numbs numb the area. part of the body. Drugs are Drugs to numb injected close to nerves that the lower body link the relevant area to are injected via a the brain to stop them catheter (tube) so transmitting pain signals. that repeat doses can be given. Epidural In October 1846, Wells’s colleague himself. There is no evidence that Jackson’s already fragile mental Morton gave another demonstration, Jackson was involved in these health that he spent his last seven this time at Massachusetts General ether trials, although Morton years in an asylum for the insane. Hospital, Boston. He administered almost certainly discussed his ether to a patient so that the work with him. As ether anaesthesia Further anaesthetic agents attending surgeon John Warren became more widely used in News of the American use of could remove a tumour on his neck. surgery, the two men’s one-time anaesthesia soon spread. In The patient remained unconscious friendship dissolved into a bitter December 1846, Scottish surgeon throughout the procedure, which fight over who discovered ether’s Robert Liston became the first Warren completed without incident. anaesthetic effects. It is said that doctor in Britain to operate on According to legend, Warren turned seeing Morton’s tombstone, which an anaesthetized patient. After triumphantly to his audience and read, “Inventor and Revealer of amputating the patient’s leg, he declared, “Gentlemen, this is no Anesthetic Inhalation”, so affected declared, “This Yankee dodge beats humbug!” This demonstration of mesmerism [the popular use of safe, effective pain relief during I am inclined to hypnotism] hollow!” Liston also surgery proved a landmark event. look upon the new found chloroform to be a useful application of ether as anaesthetic. In 1853, royal surgeon Battling for recognition the most valuable discovery John Snow first administered Morton had studied medicine at in medical science chloroform to Queen Victoria during Harvard after giving up his dentistry since that of vaccination. the birth of Prince Leopold. Her work with Horace Wells. It was with approval (she used it during eight Wells that Morton had first seen John Snow confinements, finding it “delightful proof of the pain-relieving qualities beyond measure”) silenced earlier of nitrous oxide, and, after learning On the Inhalation of the objections by some sceptical about the properties of ether from Vapour of Ether, 1847 physicians and instilled public his chemistry professor Charles confidence in anaesthesia. Jackson, he wondered if it might prove equally effective. As anaesthesia became more accepted, surgeons began to use Morton began his ether trials several different gases together – soon after completing his medical heralding modern medicine’s training, testing its effects on combination of drugs – rather than insects, fish, his dog, and finally a potentially more toxic dose of a

CELLS AND MICROBES 117 single drug. They also experimented task is to select the appropriate William T.G. Morton with local anaesthetics, applied anaesthetic agents, to carefully to smaller areas of the body, and monitor the patient, and to ensure Born in 1819, in Charlton, initially used the South American throughout the surgery that the Massachusetts, William alkaloid cocaine. patient remains oblivious to pain. Thomas Green Morton worked as a labourer, salesman, and In 1942, Canadian doctor Harold Modern drugs have long since store owner before training as Griffith discovered that curare – a replaced ether, but nitrous oxide is a dentist. He set up a dental poison South American Indigenous still used for dental and other minor practice with Horace Wells peoples used on the tips of hunting operations. Those undergoing long, in 1842, but during his darts – was an effective muscle major operations may receive a engagement to Elizabeth relaxant. His finding revolutionized general anaesthetic, but regional Whitman, he decided to anaesthesiology because it allowed anaesthesia can now numb large retrain as a doctor. He learned surgeons safe access to the thorax areas of the body rather than induce about the effects of ether and abdomen. Before the use of total unconsciousness. Key during the chemistry lectures curare, physicians relaxed these innovations, such as anaesthetic of Charles Thomas Jackson. areas with high doses of general machines to induce and maintain a anaesthetic before surgery, which continuous flow of anaesthetic, and A year after Wells’s failed depressed patients’ respiration and computer-controlled monitors that attempt to demonstrate the blood circulation, causing high display information about a patient’s anaesthetic effects of nitrous mortality rates. An injection of breathing and heartbeat, have made oxide, Morton staged the first curare relaxed muscles sufficiently anaesthesia and the surgery successful demonstration of for a breathing tube to be inserted performed much safer for patients. ether’s anaesthetic effects, into the trachea (intubation), so Nanotechnology and ever more which led to its much wider that breathing could be controlled rapid automation look set to make use in surgery. However, artificially during an operation. future anaesthesiology even safer Morton then spent the next and more effective than it is now. ■ 21 years of his life in a costly A specialism emerges bid to gain official recognition By the mid-20th century, the In general anaesthesia, the patient as the discoverer of ether increasing sophistication of surgery receives an intravenous injection of a anaesthesia, an honour finally required skilful anaesthetists, and drug to cause loss of consciousness, accorded to Horace Wells anaesthesiology became a specialist then an inhaled anaesthetic to induce and the rural Georgia doctor area of medicine. The anaesthetist’s or maintain anaesthesia. Crawford Long. Morton died in 1868, after suffering a stroke. Key work 1847 Remarks on the proper mode of administering sulphuric ether by inhalation

118 HWAANSDHSYOUR HYGIENE IN CONTEXT A ncient texts that mention in Austria, and Oliver Wendell frequent bathing and Holmes in the US – recognized the BEFORE shaving the head to link between poor hygiene and 14th–13th century bce The prevent lice indicate that the contagious diseases. prophet Moses sets down laws Egyptians, Greeks, and Romans for the Israelites regarding were well aware that good hygiene The quest to save lives personal cleanliness for health mattered, but its crucial health In 1846, Semmelweis began work and religious purification. significance was not appreciated as an assistant in obstetrics at a for a further 2,000 years. Public teaching hospital in Vienna. At the c. 400 bce Hippocrates states health suffered as towns and cities time, puerperal fever (also known the importance of hygiene. became more populous from the as childbed fever), an infection of medieval era onwards; successive the reproductive organs, killed c. 1012 In The Canon of waves of plague killed millions of many women within days of Medicine, Ibn Sina associates people. Finally, in the 1840s, two childbirth. People attributed it hygiene and cleanliness with perceptive physicians – Ignaz to a “putrid effluvium” in the air, good health throughout life. Semmelweis, a Hungarian working overcrowded neighbourhoods, or the poor diet and fatigue that often AFTER accompanies poverty. Yet hygiene 1858 While studying at the hospital was minimal. Few fermentation, Louis Pasteur surgeons scrubbed up before links bacteria to decaying operating or washed their hands organic matter. between patients. 1865 Joseph Lister uses Semmelweis observed that the carbolic acid (phenol) to mortality rate was two or three cleanse wounds and later times higher in one clinic where reports his successful results physicians and medical students in The Lancet. examined women and delivered their babies than in a second where 1980s The UK and US issue the first national hand hygiene A statue of Semmelweis, erected guidelines for health workers. outside the Medical University in Vienna to commemorate the 200th anniversary of his birth, wears a face mask during the COVID-19 pandemic.

CELLS AND MICROBES 119 See also: Hospitals 82–83 ■ Epidemiology 124–27 ■ Nursing and sanitation 128–33 ■ Germ theory 138–45 ■ Antiseptics in surgery 148–51 ■ Pandemics 306–13 midwives helped women give birth. The disease guidelines for physicians, such as He noted that, unlike the midwives, known as puerperal fever “thorough ablution” and a complete the doctors and students carried change of clothes after attending out autopsies, often handling the is so far contagious autopsies, and waiting “some corpses of puerperal fever victims as to be frequently carried weeks” after any contact with then attending to pregnant women. puerperal fever sufferers before This, he concluded, was how the patient to patient delivering a child. disease spread. by physicians and nurses. Oliver Wendell Holmes A lesson finally learnt When Semmelweis introduced Both Holmes and Semmelweis were a regime of handwashing in a “The Contagiousness of unsung heroes in their time. Their solution of chlorinated lime for his Puerperal Fever”, 1843 suggestion that physicians with students and junior doctors in 1847, unwashed hands were responsible the mortality rate for the women they It outlines case after case of women for so many women’s deaths upset attended fell sharply. Despite the contracting and dying of puerperal their colleagues. Holmes’s paper evidence, he failed to persuade his fever when midwives or doctors went largely unnoticed until it was senior colleagues that the reduced had previously attended puerperal republished in 1855 and, for two deaths were due to handwashing. fever victims or had conducted decades, medical experts in Vienna His superior attributed it to a new autopsies of victims, and includes refused to acknowledge what ventilation system. accounts from a few physicians Semmelweis had clearly shown. that strict adherence to hygiene A few years earlier, Oliver had prevented the disease’s spread. As the work of microbiologists Wendell Holmes, a brilliant young In his conclusion, Holmes lays down Louis Pasteur in France, Robert American physician who studied Koch in Germany, and Joseph Lister medicine at Harvard and in Paris, in Britain advanced knowledge and began to research puerperal fever the acceptance of germ theory and after hearing of a doctor who died antiseptic techniques, the value of a week after performing an autopsy handwashing was at last accepted. on a fever victim. In his 1843 paper, Its importance in limiting the spread “The Contagiousness of Puerperal of a highly contagious pandemic Fever”, Holmes sets down the disease remains paramount today. ■ considerable evidence he amassed. Ignaz Semmelweis Born in 1818 in Buda (later part taking part in events linked to of Budapest), Hungary, Ignaz a failed nationalist uprising in Semmelweis was the fifth of eight Hungary. Back in Pest, as head children. On his father’s advice, of obstetrics at the university, he studied law at the University Semmelweis continued to of Vienna in 1837, but he returned promote his handwashing to Hungary to study medicine at regime. In later life, he suffered the University of Pest in 1838. mental health problems and was confined to an asylum in 1865, Semmelweis graduated in where he died the same year. 1844, and specialized in obstetrics. As assistant to Professor Johann Key works Klein, he worked in the Vienna General Hospital maternity ward, 1849 “The Origin of Puerperal where in 1846 he made the crucial Fever” link between poor hygiene and 1861 The Etiology, Concept, and puerperal fever. However, he lost Prophylaxis of Childbed Fever his post in Vienna in 1848 after

120 MMEEDNIACNINDEWNEOEMDESN WOMEN IN MEDICINE IN CONTEXT I n the 1840s, there was no from an American medical school. provision for women to This paved the way for the right of BEFORE attend medical school and women to become doctors. 1540 King Henry VIII of qualify as doctors. Elizabeth England grants a charter Blackwell decided to buck this Closed to women establishing the Company trend by applying to numerous Ablaze with scientific discoveries, of Barber-Surgeons, from medical schools in the US. After the 19th century was regarded as which women are barred. countless rejections, she tried a new era of modern medicine, but Geneva Medical College in rural the profession was still closed to 1754 Dorothea Erxleben is New York. The college put the women. Some doctors maintained the first woman in Germany idea to the all-male student body, that higher education might to earn a medical degree, but assuming it would reject it abnormally expand women’s brains, dies just eight years later. outright. However, as a joke, the while others thought that female students voted “yes” and Blackwell doctors would not be able to take AFTER was able to start her studies in the sight of blood. In 1862, the 1866 The Women’s Medical 1847. Two years later she became British Medical Journal stated, College of Pennsylvania is the the first woman to receive a degree “It is high time that this unnatural first medical school to appoint and preposterous attempt … to a female dean. establish a race of feminine doctors should be exploded.” Women such 1876 A British Act of as Blackwell strongly disagreed. Parliament allows women to train as doctors. If the present arrangements Challenging the system of society will not admit of Blackwell found a loophole in the 1960 The Pill is introduced. woman’s free development, British 1858 Medical Registration Over the next two decades, Act that did not expressly prohibit the Women’s Liberation then society must women with foreign medical degrees Movement campaigns for be remodelled … practising in the UK. She became women’s rights in all aspects Elizabeth Blackwell the first woman to be officially of healthcare and society. registered by the General Medical Letter to Emily Collins, 1848 Council (GMC) soon afterwards. 2019 Women make up 50.5 per cent of graduates Back in the US, Blackwell opened from US medical schools. the New York Infirmary for Women and Children in 1857 and, in 1868,

CELLS AND MICROBES 121 See also: Midwifery 76–77 ■ Hospitals 82–83 ■ Nursing and sanitation 128–33 ■ Birth control 214–15 ■ Hormonal contraception 258 Women practise medicine informally as healers, herbalists, and midwives but are barred from the professional medical bodies that emerge during the medieval and Renaissance period. Women begin to exploit loopholes in legislation to Elizabeth Blackwell gain access to medical education during the 19th century. Born in 1821 in Bristol, UK, Pioneers such as Elizabeth Blackwell qualify as Elizabeth Blackwell emigrated doctors and establish the concept that women have to the US with her family in 1832. When her father died, an equal place with men in medicine. leaving the family penniless, Blackwell, aged 17, became a a medical college for women next years later, Sophia Jex-Blake and teacher. However, the death door. This offered a four-year degree six other women (known as the of a friend swayed Blackwell with a higher level of clinical training “Edinburgh Seven”) became the in her career choice, and she than at existing colleges for men. first female students at any British decided instead to substitute university when they were accepted medicine for teaching. British women soon followed to study medicine at Edinburgh. Blackwell’s lead. Elizabeth Garrett- Headstrong in all that she Anderson became the first female In 1874, Garrett-Anderson, Jex- did, Blackwell became the first doctor in the UK when she used a Blake, and Blackwell – now back in American woman to graduate loophole in the Charter of the Society England – set up the London School from medical school in 1849. of Apothecaries to gain a licence to of Medicine for Women, which She would continue to fight practise medicine in 1865. Four became the first British institution against gender discrimination that allowed women to study and for the rest of her life, on both practise medicine. This led to a sides of the Atlantic, working steady increase in the numbers of with other pioneering women women doctors: in 1881 there were in medicine including Sophia only 25 in Britain, but by 1911 this Jex-Blake, Elizabeth Garrett- had risen to 495. Anderson, Marie Zakrzewska, and her sister Emily Blackwell. Blackwell retired from medicine In 1907, Blackwell was left in 1877, but remained an active disabled after falling down campaigner for reform in women’s stairs. She died of a stroke rights, family planning, medical three years later. ethics, and preventative medicine. ■ Key works Women attend a class at the Women’s Medical College of Pennsylvania, US, 1856 An Appeal in Behalf of in 1911. Founded in 1850, it was one of the Medical Education the earliest institutions authorized to of Women train women as doctors. 1895 Pioneer Work in Opening the Medical Profession to Women

122 CCALEOLLMLCESEFLRLOSM HISTOLOGY IN CONTEXT H istology, the study of the produced distorted images, but microscopic structure of advanced again with improved BEFORE tissues, has its origins lenses in the 1830s. 1660s Marcello Malpighi in the 17th century, when Italian, uses a magnifying lens to English, and Dutch scientists It was when Swiss anatomist study chickens’ embryos and Marcello Malpighi, Robert Hooke, Albert von Kölliker published his frogs’ lungs. and Antonie van Leeuwenhoek used Handbook of Human Histology in primitive microscopes to examine 1852 that histology really came 1676 Cells and bacteria are plant and animal tissues. The of age. Kölliker was one of the first documented by Antonie nascent science stalled for more scientists to realize that all tissues van Leeuwenhoek, using a than a century because of the poor are made up of cells, which do not homemade microscope. quality of microscope lenses, which develop spontaneously, but from other cells. His research placed 1830 British opticist Joseph Jackson Lister presents his A fresh specimen of A fixative is applied new design for a compound tissue is extracted. to preserve the tissue. microscope lens almost free of image distortion. Coloured staining A thin section of tissue is applied to visualize is cut for microscopic AFTER 1873 Camillo Golgi invents cells of interest. analysis. a silver staining method that allows nerve cells to be A cellular diagnosis can be conducted. studied under a microscope. 1931 A prototype electron microscope is unveiled by German physicist Ernst Ruska. 1990s The development of optical coherence tomography (OCT) enables microscopic imaging of cells in situ, without the need for a tissue biopsy.

CELLS AND MICROBES 123 See also: Cellular pathology 134–35 ■ The nervous system 190–95 ■ Cancer screening 226–27 ■ Evidence-based medicine 276–77 ■ Nanomedicine 304 microscopic anatomy at the centre of Kölliker’s 1852 handbook, with 1858, German anatomist Joseph von medical understanding, and also fed its hand-drawn illustrations of cells Gerlach achieved the differential into the new fields of histopathology observed through a microscope, staining of a cell’s nucleus and (the diagnosis of disease at cellular transformed understanding of tissue cytoplasm, and in the 1880s, level) and neuroscience. structures and the nervous system. Kölliker made use of Italian biologist Camillo Golgi’s new silver staining Perfecting procedures on a microscope slide. Modern method to study the structure of Kölliker’s handbook formalized ultramicrotomes can now prepare nerve cells. Combining the dye histological procedures, introducing sections as thin as 30 nanometres. haematoxylin with the acid scientists to the relatively new compound eosin in the 1890s also techniques of fixation, sectioning, Staining highlights important produced an effective tissue stain, and staining samples for analysis. tissue features and differentiates which is still in use today. between cell structures, as the stain Tissue samples must be “fixed” chemically binds to some substances Tied to technology to preserve their structure and to but not others. Advances in chemical By the end of the 19th century, the inhibit fungal and bacterial growth. processes and dye synthesis in availability of reliable microscopes, Danish pathologist Adolph Hannover the mid-19th century improved improvements in the processing of used chromic acid solution as a histological staining methods. In samples, and the work of scientists fixative when he made probably the such as Kölliker had initiated a first definitive description of a cancer modern age of medical histology. cell in 1843. Almost 50 years later, Further technological innovations, German pathologist Ferdinand such as the electron microscope, Blum found that formaldehyde (only allowing analysis of tiny cellular discovered in 1859) was an excellent structures; microscopes that allow fixative; it is still the most commonly 3D imaging of cells; and optical used fixing solution today. coherence tomography (OCT), which uses infrared light to generate cross- To enable light to pass through sectional images with microscopic samples, they must be very thin. resolution, continue to advance In 1770, Scottish inventor Alexander the field. ■ Cummings built the first microtome to cut slices thin enough to be used Albert von Kölliker Born in Zurich, Switzerland, in cells that would later be 1817, Rudolph Albert von Kölliker identified as mitochondria, studied medicine at the University and demonstrated that nerve of Zurich, where he developed an fibres are elongated parts of interest in embryology. Appointed nerve cells. Continuing to professor of anatomy at Zurich conduct research into his late in 1844, he transferred to the 80s, Kölliker died in 1905. University of Würzburg, Germany, shortly afterwards. There, he Key works taught and researched for the rest of his career, making advances in 1852 Handbook of Human the microscopic study of tissues. Histology 1861 Embryology of Man and Among his many discoveries, Higher Animals Kölliker suggested that cell nuclei may carry the key to heredity, was one of the first to notice bodies within striated muscle

124 IN CONTEXT FTTOHHREEYTSMHMEIOSKFTIEOROEK BEFORE c. 400 bce Hippocrates tries to EPIDEMIOLOGY explain disease as a result of environmental factors. 1662 British statistician John Graunt publishes his landmark analysis of mortality data. 1847 Ignaz Semmelweis reduces infection significantly in maternity wards by introducing handwashing. AFTER 1866 Most of London is connected to a new sewer network devised by British engineer Joseph Bazalgette. 1870s Robert Koch’s studies suggest that specific organisms cause specific diseases. 1913 Pasteurization is shown to be effective in controlling the spread of disease. C holera is a gastrointestinal infection that is still a major global health problem today in areas with inadequate sanitation. The symptoms include diarrhoea, nausea, and vomiting, which can result in severe dehydration and death. John Snow’s systematic study of its spread in 19th-century London changed understanding about the causes of disease, how diseases are transmitted, and how best to study this process, establishing the field of epidemiology. Something in the air? The idea that disease was caused by a miasma, or “something bad in the air”, had persisted for centuries. The alleged corruption of the air was attributed to causes such as

CELLS AND MICROBES 125 See also: Roman medicine 38–43 ■ Medieval medical schools and surgery 50–51 ■ Case history 80–81 ■ Anaesthesia 112–17 ■ Hygiene 118–19 ■ Nursing and sanitation 128–33 ■ Germ theory 138–45 ■ Virology 177 ■ Pandemics 306–13 In the 19th century, New analysis of This suggests that the belief prevails that mortality data shows miasma theory disease is spread by that the first symptoms poisonous vapours of cholera victims are is incorrect. digestive problems, (miasma) due to not respiratory problems. putrefaction. Improvements in public Evidence that a cluster of cholera victims live near a health and hygiene follow, to particular water pump suggests that the disease is spread limit the spread of disease. by contaminated water and other materials. decay of waste organic matter, theory. Southwood Smith in his causes such as poor sanitation, and “exhalations” from swamps and role as physician at the London these factors could be rectified. He marshes, or ill winds bringing bad Fever Hospital was convinced that saw improving living conditions as air from other places. People noted there was a link between the slum making sound economic sense – men the coincidence of the outbreak of conditions many endured in cities who were ill could not work after all. disease with the summer months, and the contagious diseases they when smells of decomposing waste suffered from. These views were In 1838, Chadwick, assisted by were pervasive. In an attempt to echoed by Chadwick, who was a Southwood Smith among others, combat the spread of infection, close acquaintance. began work on reports for the Poor ineffective interventions were Law Commission. Southwood Smith pursued, such as lighting bonfires, Chadwick believed that there advocated fumigation and improved in the hope that the smoke would was no mystery to the origins of ventilation in buildings; others halt both plague and cholera. disease: it came from environmental pointed out the importance of removing “nuisance occupations” By the mid-19th century, bad The annual loss of life (such as slaughterhouses) from smells and the spread of disease from filth and bad ventilation residential areas and of improving were a serious public health issue drainage, sewers, and cesspools to as fast-expanding cities, unable to are greater than the loss prevent the spread of disease. properly dispose of large quantities from death or wounds of human and industrial waste, Chadwick’s Report on the used streets as open drains and in any wars … Sanitary Condition of the Labouring waterways as open sewers. Edwin Chadwick Population of Great Britain was published in 1842 to enthusiastic In Britain, debate still raged as endorsement from newspapers such to the origin of diseases such as as The Times. Detailing the cramped cholera. The sanitation reformer and insanitary living conditions Thomas Southwood Smith, public found across the country, it led to health reformer Edwin Chadwick, an urgent demand for change. and Florence Nightingale, the founder of modern nursing, were all In 1848, the government set staunch proponents of the miasma up a General Board of Health, its members including Chadwick ❯❯

126 EPIDEMIOLOGY and Southwood Smith, to tackle northeast of England in 1831, he I found that nearly all the problem. When a new cholera had attended to sufferers who the deaths had taken outbreak struck London in the worked in the Killingworth Colliery place within a short board’s first year of operation, they near Newcastle upon Tyne. He instigated emergency measures to noted that many of the miners distance of the remove waste and clean the streets. succumbed to cholera while working [Broad Street] pump. beneath the ground and wondered Tracking contagion how this squared with transmission John Snow In 1853, Thomas Wakley, editor of by miasma. He suspected that The Lancet, wrote on the subject of transmission was by a different Medical Times and Gazette, 1854 cholera: “Is it a fungus, an insect, a route. The observations he made miasma, an electrical disturbance, at this time laid the foundations for contracted cholera and died. Snow a deficiency of ozone …? We know his later work. viewed this second death as strong nothing; we are at sea in a whirlpool evidence of contagion. of conjecture.” In August 1854, a In September 1848, Snow severe outbreak of cholera hit the attempted to track the progress of As more cases developed, Snow Soho area of London. Thousands an outbreak in London to determine found that all victims reported that of people succumbed to the illness how the disease was spread. He their first symptoms were digestive and at least 600 died. John Snow, a discovered that the first victim, a problems. He believed this showed doctor working in Soho at the time merchant seaman, had arrived from that the disease must be transferred of the outbreak, began to formulate Hamburg by ship on 22 September, via polluted food or water. If miasma his own ideas about its cause. had quickly developed cholera was the vector then, he reasoned, symptoms, and had died. Snow the first symptoms should surely Snow had previous experience learned that, just a few days after have affected the respiratory system, of cholera. During an outbreak of the seaman’s death, his room was not the digestive. He suspected that the disease that spread across the rented to a second man who also the extreme diarrhoea that was a feature of the disease might be the PUMP B Locations that might be source of infection. Just a few drops expected to have a high contaminating the water supply Snow’s hypothesis that incidence of infection had the potential to spread the pump A was the source 1 had few cases because disease over a whole community. of infection is confirmed they had their own wells by the lack of cases and did not use pump A. In August 1849, Snow published around pumps B and C. a pamphlet entitled On the Mode of PUMP A Communication of Cholera, setting out his arguments and evidence to 3 support his theory. He cited the 2 case of a London street in which Key: The area around the John Snow compiled a spot map most popular local pump to log cholera cases, showing the 1. Workhouse features the highest distribution of infection. This new 2. Brewery density of cases. method of statistical disease mapping 3. Broad Street allowed Snow to compare different PUMP C groups of people and has become a key Contagious cases component of modern epidemiology.

CELLS AND MICROBES 127 John Snow The eldest of nine children, John was a pioneer in the field of Snow was born in York, UK, in anaesthetics. In 1853, he 1813. His father was a coal-yard attended the birth of Prince labourer, and the family home was Leopold, giving his mother, sited in one of York’s poorer areas. Queen Victoria, chloroform to Aged 14, Snow was apprenticed ease her birth pains. to a surgeon and in 1836 moved to London to begin his formal medical Snow was a vegetarian education, graduating from the and teetotaller who campaigned University of London in 1844. for temperance societies, but his chronic health problems may In 1849, Snow published his have contributed to his early ideas on cholera’s transmission, death, aged just 45, in 1858. contending that the prevailing miasma theory was wrong. He Key work backed up these claims with his study of the 1854 Soho outbreak. 1849 On the Mode of As well as epidemiology, Snow Communication of Cholera many residents on one side became cholera in this part of London except investigate incidences of cholera in cholera victims, while on the other among the persons who were in South London and linked them to side only one person succumbed. the habit of drinking the water of the the Southwark and Vauxhall water Snow reported that dirty water, above-mentioned pump well”. companies, which were supplying emptied into a channel by the mechanically pumped water from inhabitants of the first houses, got Snow took his findings to the sewage-polluted sections of the into the well from which they drew local council and convinced them Thames and delivering it to homes. their water. He believed that to to remove the handle from the pump, prevent cholera epidemics, wells making it unusable. Shortly after, the Snow’s detailed statistical and freshwater pipes would have outbreak ended. It was later found analysis proved to be a compelling to be isolated from pipes carrying that the source of the outbreak was way of demonstrating the correlation waste, but his ideas gained little the discarded soiled nappies from a between the quality of the water traction with his fellow medics. baby who had contracted cholera source and cholera cases. Shortly elsewhere, which had been dumped after the end of the outbreak, Snow The Broad Street pump in a cesspit near the pump. presented his views to the Medical As the 1854 Soho outbreak took Society of London, only to have them hold, Snow believed that the source Hand pumps like the one on rejected by leading doctors. of the infection was to be found in Broad Street were not the only the water supply. By talking to local source of water. Snow began to It would be several more years residents and using information from before the germ theory of disease local hospital and public records, would begin to find acceptance, he marked each residence where when it was proved by French cholera had occurred on a map of the chemist Louis Pasteur. Sadly, Snow area, and found that they centred on did not live to see his theories one particular water pump in Broad vindicated as he died in 1858 Street. Today, this type of map, following a stroke. It was not until showing the geographic distribution 1884 that Robert Koch identified of cases, is called a spot map. Snow the comma-shaped bacillus, Vibrio theorized that the pump was the cholerae, which causes cholera. ■ source of the epidemic. In a letter to the Medical Times and Gazette An 1866 satire on London’s polluted he wrote: “ … there has been no water supply indicates a shift from particular outbreak or prevalence of the belief that diseases are spread by airborne “miasma” to a realization that they are caused by specific organisms.

NSTAHHOHOEOUHSLSPADIIRTCDAMKOL NURSING AND SANITATION



130 NURSING AND SANITATION Unhygienic conditions and overcrowding in hospitals enable disease to spread. IN CONTEXT Mortality rates are high, and diseases contracted BEFORE in hospitals are the leading cause of death. c.390 ce The first general hospital is built in Rome. A hospital should do the sick no harm. 1633 The Daughters of Improving sanitation and general hygiene reduces Charity, a Catholic group of the spread of disease, leading to lower mortality rates. women who care for the sick poor, is established in France. AFTER 1901 New Zealand becomes the first country to have state registration, requiring nurses to have set qualifications. 1916 The world’s largest union of nurses, the Royal College of Nursing, is founded in the UK. 1948 The UK launches its public-funded National Health Service. E xactly when nursing care on a tour of Europe and Egypt with and incompetent. Nightingale, who first began is impossible to family friends that Nightingale had had been on the verge of taking up say. Caring for the sick and the opportunity to study different a post as superintendent of nurses injured is a natural part of human hospital systems. In early 1850, at King’s College Hospital, London, existence, but for a long time it was she began training at the Institute was invited to take on the role of tied up with religious beliefs, with of St Vincent de Paul in Alexandria, nursing administrator, overseeing nursing often being carried out in Egypt. This, and further training in the deployment of nurses to British Europe by members of holy orders, Germany and France, taught her military hospitals. such as nuns and monks. In the observation and organization as Islamic world, Rufaida Al-Aslamia well as nursing care. On returning Nightingale arrived in Scutari, (c. 620 ce) is thought to be the first to London in 1853, Nightingale took near Constantinople (now Istanbul), nurse who treated casualties and up the position of superintendent at in November 1854, accompanied trained other women in hygiene. Yet the Institution for Sick Gentlewomen by 38 nurses and 15 nuns. She the history of modern nursing really in Distressed Circumstances. Here, found soldiers crowded together on begins with Florence Nightingale – she honed her administrative and bare floors, with little ventilation a tireless social reformer who not nursing skills, and soon improved or food, operations carried out in only took a scientific approach to conditions at the institution. unhygienic conditions, inadequate nursing, but also saw the need for supplies of medical equipment, and medicine to be based on statistics. Lady with the lamp diseases such as cholera and typhus In March 1854, the Crimean War running rampant in the hospitals. Nursing in the mid-19th century began when Britain, France, and was not considered to be a suitable Turkey declared war on Russia. At first, the male army doctors profession for an educated woman, British military medical facilities resented the intrusion as an attack and Nightingale’s wealthy family faced harsh criticism in the press, on their professionalism. But the were opposed to her gaining any which described them as ineffective nurses soon proved their value hospital experience. It was while when, a few days after their arrival, an influx of injured soldiers from

CELLS AND MICROBES 131 See also: Battlefield medicine 53 ■ Hospitals 82–83 ■ Hygiene 118–19 ■ Women in medicine 120–21 ■ Epidemiology 124–27 ■ Germ theory 138–45 ■ Evidence-based medicine 276–77 All were swarming With Nightingale’s cooperation, life, Nightingale returned from the with vermin, huge lice the sewers were fixed and flushed Crimean War in 1856, determined crawling all about their out, toilets and washing facilities that the catastrophic loss of life persons and clothes. … upgraded, and overcrowding in the she had witnessed be prevented in Several were completely hospitals reduced. Only then did future. Backed by Queen Victoria, the appalling death rate begin to she persuaded the government to prostrated by fever drop. Mortality fell from 41 per cent establish a royal commission into and dysentery. when Nightingale first arrived to the state of health in the army. Henry Bellew just 2 per cent by the end of the war. Her experiences in the Crimea led Numbers in pictures British assistant surgeon describing Nightingale to campaign for better A talented student of mathematics Scutari hospital, January 1855 sanitation in hospitals generally from an early age, Nightingale when she returned to Britain. collected data and organized a major battles threatened to record-keeping system. Together overwhelm the hospital. Using Reports of the achievements with her friend William Farr, the funds supplied by The Times of Nightingale and her nurses in UK’s leading statistician, and newspaper, Nightingale bought combating the squalid conditions John Sutherland of the Sanitary equipment for the hospital and in the Crimea made Nightingale a Commission, she embarked on an pressed soldiers’ wives into service national celebrity. She became analysis of army mortality rates in cleaning and laundering. She known as “the lady with the lamp”, the Crimean hospitals. They addressed not only the soldiers’ a description that originated in an established that the leading cause physical needs, but also their article published in The Times: of death among the soldiers was not psychological ones, helping them “When all the medical officers have combat, but disease – often diseases to write letters and finding ways to retired for the night, and silence that could be prevented by good keep their minds off their situation. and darkness have settled down hygiene. Injured soldiers were seven upon these miles of prostrate sick, times more likely to die of infections Disease played a major role in she may be observed alone, with a caught in the hospitals than from the Crimea; in the winter of 1854–55, little lamp in her hand, making her injuries sustained on the battlefield. 23,000 troops were unfit for duty solitary rounds.” due to sickness. A Sanitary Nightingale realized that the Commission sent out by the UK Despite contracting “Crimean data was best presented visually, government to investigate conditions fever”, a debilitating condition that “to affect thro’ the eyes what we ❯❯ in 1855 found that the hospital at would affect her for the rest of her Scutari had been built over a broken sewer, and the patients were drinking contaminated water. This scene from the military hospital at Scutari during the Crimean War shows Florence Nightingale inspecting the wards at night, holding her iconic lamp.

132 NURSING AND SANITATION fail to convey to … the public In 1858, in recognition of her work, Wise and humane through their word-proof ears”. What Nightingale became the first management of the patient she came up with was the coxcomb, female member of the UK’s Royal or polar area, graph – a variation Statistical Society. During the 1860 is the best safeguard on the pie chart. The pie was split International Statistical Congress, against infection. into 12 slices, one for each month, she advocated the collection of larger or smaller according to the hospital statistics, so that outcomes Florence Nightingale number of deaths, and colour-coded could be compared by hospital, to indicate the causes of death. region, and country – the first Notes on Nursing, 1859 Nightingale’s graphs of patient model for the systematic collection mortality would influence the of hospital data. She also pressed, set up during Nightingale’s time development of epidemiology – the unsuccessfully, for questions on in the Crimea, the school aimed branch of medicine that deals with health to be added to the 1861 UK to provide nurses with practical the appearance, distribution, and population census, believing that training in hospitals specially control of epidemic diseases. this would provide an invaluable organized for that purpose. It was overview and a source of data to largely due to the foundation of the Today, the use of graphical data guide public policy on health. school that Nightingale was able to is the norm, but Nightingale was transform nursing into a respectable one of the first people to use data Training nurses and responsible career, and the visualization to influence public The Nightingale Training School school provided a model that would policy. The royal commission and Home for Nurses, based at later be adopted worldwide. The report produced from her findings London’s St Thomas’s Hospital, Nightingale Fund also financed the suggested the creation of a statistical welcomed its first 10 students in setting up of a school for midwives department to track rates of disease 1860. Financed by the Nightingale at King’s College Hospital in 1862. and mortality, identifying problems Fund, a public contributions fund so they could be dealt with promptly. When Nightingale published Notes on Hospitals and Notes June July Key: on Nursing in 1859, the UK had May Deaths from disease no health service, and private Deaths from battle wounds healthcare was beyond the means Deaths from other causes of most. She believed that everyday knowledge of sanitation was vital August in preventing the spread of disease, and Notes on Nursing was intended April September to educate the public as much in 1855 improving health standards as in caring for the sick. March 1856 October February Nightingale’s focus on sanitation and healthcare also extended to January November reforming the nursing services December offered to the poorest members of society in workhouse infirmaries. This coxcomb graph shows that in the Crimea in 1855–56, These institutions had scant more soldiers died from disease than from battle wounds or medical care of any kind, relying other causes. The larger the slice, the higher the monthly on untrained nurses who were death rate. A graph for 1854–55 showed similar results.

CELLS AND MICROBES 133 Florence Nightingale with students from the Nightingale Training School at St Thomas’s, photographed in 1866 at the home of her brother-in-law and supporter, Sir Harry Verney. themselves workhouse inmates. Thanks to Nightingale’s persistence and funding from philanthropist William Rathbone, the first attempts to staff a workhouse infirmary with trained nurses took place in 1865 in Liverpool. Twelve nurses trained at the Nightingale school, assisted by 18 probationers, were placed in the workhouse infirmary. Gradually, the nursing system was taken up by other infirmaries. Campaign for healthcare of letters and publishing some Florence Nightingale’s lasting Nightingale believed that the sick 200 books, reports, and pamphlets. legacy is the role she played in were best cared for at home, so she She advised on healthcare in India, setting nursing on the road to also advised Rathbone to start a where her reforms led to a sharp becoming a modern, professional training school and home for nurses decline in mortality among British career in the field of medicine. at Liverpool’s Royal Infirmary. soldiers as well as improved She was also key in driving Opened in 1862, the school formed sanitation in rural communities. improvements in public hygiene the basis of a district nursing She was a consultant to the US and sanitation, extending life system, where nurses went out government during the American expectancy for thousands. Medical to visit the ill in their homes. Civil War, inspiring the formation science has made huge strides of the US Sanitary Commission, since her lifetime, but her practical, Nightingale’s own poor health and acted as a mentor to Linda evidence-based approach to prevented her from practising as a Richards, who was America’s first healthcare is still relevant in nurse, but she remained a tireless professional nurse. today’s health services. ■ campaigner, writing thousands Florence Nightingale Named after the Italian city of her 1856. Although she was largely birth, Florence Nightingale was housebound from 1858 due to born in 1820, while her parents the illness she had contracted were touring Europe. Her father in the Crimea, Nightingale used took particular interest in her her fame to work on reforming education, teaching her history, health and social care in Britain. philosophy, and mathematics. She was the first woman to be From an early age, she loved to awarded Britain’s Order of Merit, collect and organize data – she and her ideas of nursing practice used lists and tables to document still underpin the profession her impressive shell collection. today. She died in 1910, aged 90. Despite some family opposition, Key works Nightingale trained as a nurse, seeing it as her calling to combat 1859 Notes on Hospitals suffering. She led a team of nurses 1859 Notes on Nursing in the Crimea during the war, returning home a celebrity in

134 LDAETISVTTEHULERBCEALNLCUELSAR CELLULAR PATHOLOGY IN CONTEXT T he study of diseases in Polish–German physiologist Robert terms of cell abnormalities, Remak three years earlier. Virchow BEFORE known as cellular pathology, went on to discover that disease 1665 In Micrographia, English is central to modern medical occurs when normal cells produce physicist Robert Hooke coins diagnosis and treatment. The field abnormal cells, leading him to the the term “cells” to describe the owes much to 19th-century German conclusion that all diseases arise at microscopic box-like units in pathologist Rudolf Virchow, who the cellular level. cork wood. insisted that science should look beyond organs and tissues, and Virchow was the first to explain 1670s Dutch scientist Antonie examine individual cells to find that cancer develops from cell van Leeuwenhoek observes the causes of disease. abnormalities, and he described single-celled “animalcules”. and named leukaemia, a potentially In 1855, Virchow popularized fatal disease in which the blood 1838–39 In Germany, the key tenet of cell theory that all produces too many leucocytes scientists Matthias Schleiden cells are derived from other cells (white blood cells). He also coined and Theodor Schwann propose (omnia cellula e cellula) as a result the terms “thrombus” (a clot of that cells are the basic building of division – an idea first posited by coagulated blood) and “embolism” blocks of all living things. (when a blood clot blocks an artery), We must endeavour to … and showed that a blood clot in the AFTER take [the cell] apart and leg could travel to the lung, causing 1857 Albert von Kölliker find out what each portion a pulmonary embolism. His 1858 describes mitochondria, which contributes to cellular function work Cellular Pathology became a release energy to the cell. and how these parts go wrong bible for pathologists for many years. 1909 In Russia, scientist in disease. Rapid scientific advances Alexander Maximow uses the Rudolf Virchow, 1898 Virchow’s groundbreaking work term “stem cell” and proposes on cells paved the way for further that all types of blood cell come progress in understanding disease from a single ancestor cell. in the late 19th and 20th centuries. Histopathology – the microscopic 1998 American researchers examination of tissue to study James Thomson and John disease – became an increasingly Gearhart isolate and culture important area of research and human embryonic stem cells. diagnosis, advanced by the use of more effective dyes to stain tissue.

CELLS AND MICROBES 135 See also: Histology 122–23 ■ Cancer therapy 168–75 ■ Targeted drug delivery 198–99 ■ Cancer screening 226–27 ■ Stem cell research 302–03 From his study of cells, Virchow’s techniques have helped scientists Rudolf Virchow distinguished pupil Friedrich von explore DNA, analyse cell nuclei, Recklinghausen explored a variety discover embryonic stem cells, and Born in Pomerania (now part of bone and blood disorders, while shed light on gene-based diseases. of Poland) in 1821, Virchow Edwin Klebs, another of Virchow’s graduated in medicine from students, uncovered links between Ever-tinier cell components the University of Berlin and bacteria and infectious disease and Today’s specialists use powerful learned much about pathology discovered the diphtheria bacillus. electron microscopes to assess while working in the city’s In 1901, in another major advance, changes in the size, shape, and Charité Hospital. In 1848, he Austrian immunologist Karl appearance of a cell’s nucleus that took part in Germany’s failed Landsteiner identified the A, B, and may indicate cancer, pre-cancer, or revolutionary uprising and O blood groups, documenting the other diseases. In tissue samples, was banished from Berlin. cellular differences between types. they study the interaction of cells He was soon offered a position and identify any abnormalities. at the University of Würzburg The cell research of Greek in Bavaria, where he shared American physician George Diagnosis is not the only goal, ideas with Swiss histologist Papanicolaou, who identified however. By studying ever-tinier Albert von Kölliker. cervical cancer cells in vaginal cell molecules, scientists can better smears in the 1920s, led to mass understand disease processes, Returning to Berlin in cervical “Pap smear” tests from the while cell therapy – the insertion of 1855, Virchow continued his 1950s onwards. Screening tests for viable cells to combat mechanisms innovative work on cellular other cancers followed. Since the that cause disease – may soon offer pathology, campaigned 1950s, increasingly advanced real hope to those suffering from vigorously for public health, diagnostic equipment and new thus far incurable disorders. ■ established the city’s water supply and sewerage system, The body is made up of many individually active, and, from 1880 to 1893, was mutually dependent parts. a member of the German Reichstag (parliament). After Every part is composed of multiple cells, jumping from a tram and the body’s basic building blocks. breaking his femur, Virchow died of an infection in 1902. In most normal cells, In some normal cells, the nucleus divides the nucleus may Key works to produce two new divide to produce 1854 Handbook on Special similar cells, creating abnormal cells, forming Pathology and Therapeutics healthy tissue. abnormal tissue. 1858 Cellular Pathology as Based upon Physiological and All diseases are disturbances at the cellular level. Pathological Histology 1863–67 Pathological Tumours

136 MMAASKTEEYROSUORFSEALNVAETSOMY GRAY’S ANATOMY IN CONTEXT B ritish surgeon Henry Gray while Carter meticulously recorded became a lecturer in anatomy every tendon, muscle, bone, and BEFORE at St George’s Hospital tissue with his pencils. The 1543 Andreas Vesalius Medical School, London, in 1853. illustrations, which emphasized the publishes De Humani Corporis Wanting to create an accurate, functionality and form of each body Fabrica, which marks the birth authoritative, low-cost textbook for part, were key to the book’s success. of modern anatomy. his students, Gray enlisted the help of a colleague, Henry Vandyke Cleverly published to coincide 1780s A rapid rise in the Carter to draw the illustrations. with the start of the academic year, number of European medical Published in 1858, the 750-page and priced below its competitors, schools increases demand for tome described the human body in Gray’s book was an instant success. detailed anatomical knowledge vast anatomical detail, using 363 Its detail, accuracy, and clarity led through dissection. “Body- images. Originally titled Anatomy: to enduring popularity, and it has snatching” from cemeteries Descriptive and Surgical, then remained the most comprehensive becomes common. Anatomy of the Human Body, the guide to anatomical knowledge book is still in print today and, since for physicians. ■ 1828 Irish anatomist Jones 1938, is known as Gray’s Anatomy. Quain publishes his three- volume Elements of Anatomy, A pioneering textbook which becomes the standard Working side by side over 18 months, textbook on anatomy. Gray and Carter conducted detailed dissections on unclaimed cadavers 1832 Parliament’s Anatomy from hospitals and workhouses. Act gives surgeons, medical Gray used his scalpel to strip back students, and anatomists the human body’s many layers, the legal right to dissect donated bodies in the UK. Gray’s book was unique in including anatomical labels within its illustrations, AFTER and in using life-sized representations 2015 The 41st edition of to aid understanding. Gray’s Anatomy is published; See also: Roman medicine 38–43 ■ Anatomy 60–63 it is the first edition to include ■ Blood circulation 68–73 ■ Physiology 152–53 additional online content.

CELLS AND MICROBES 137 ROSENCPEALRMARCUINESGTTHTIESSUE SKIN GRAFTS IN CONTEXT I n 1874, German surgeon Karl [Thiersch] possessed Thiersch published the results not only the necessary BEFORE of his experiments with skin 1663 English physician Walter grafts. His groundbreaking results firmness of eye and Charleton attempts the first showed that the best outcome was hand, but also recorded skin graft on a dog. achieved by removing granulation tissue – the new tissue that forms a sovereign calmness … 1785 Italian physiologist on the surface of a wound – before Obituary Giuseppe Baronio begins applying a razor-thin, uniform graft, researching skin grafts using using skin taken from the patient’s Popular Science Monthly, 1898 a variety of animals and own body (an autograft). Autografts proves that they are feasible. using the full thickness of skin had been attempted previously, but often 1817 British surgeon Astley failed because underlying fat and Cooper performs the first tissue layers prevented new blood documented successful skin vessels forming between the wound graft on a human. site and the graft. 1869 Jacques-Louis Reverdin Split-thickness success attachment and survival rates, and pioneers the pinch graft using Five years earlier, in 1869, Swiss produced less scar tissue at the site tiny particles of skin. surgeon Jacques-Louis Reverdin of the graft and minimal damage had shown that tiny skin fragments, at the donor site, making it possible AFTER later named “pinch grafts”, could to harvest as much skin as needed 1929 American surgeons be applied successfully to burns, for a repair. Called a “split-thickness” Vilray Blair and James Brown ulcers, and open wounds. Thiersch graft because it uses only part of improve split-thickness graft was able to build on this principle, the thickness of the skin, Thiersch’s techniques to enable grafts using new surgical instruments technique transformed outcomes of varying dermal thickness. that allowed him to harvest larger in reconstructive surgery and and thinner grafts than previously became the standard procedure for 1939 American surgeon Earl possible. These grafts had quicker repairing large expanses of skin. ■ Padgett and engineer George Hood pioneer a mechanical See also: Plastic surgery 26–27 ■ Transplant surgery 246–53 “dermatome” for accurately ■ Nanomedicine 304 ■ Face transplants 315 harvesting large skin grafts.

LIFE IS AT MTHIENMUETRCEYBOOF DTHIEESSE GERM THEORY



140 GERM THEORY IN CONTEXT The blessed gods diseases”. Later, the Roman purge all infection physician Galen described plague BEFORE from our air whilst you as being spread by “seeds of plague” 1656 Athanasius Kirchner do climate here! that are carried on the air and lodge identifies microscopic worms William Shakespeare in the body. in the blood of plague victims. The Winter’s Tale, c.1611 In the medieval era, two Islamic 1670s Under his microscope, physicians who witnessed outbreaks Antonie van Leeuwenhoek Robert Koch proved the germ theory of the Black Death in 14th-century sees bacteria or “animalcules”. beyond doubt. Since then, hundreds Andalusia drew similar conclusions of infectious diseases have been about disease. In his Kitab al-Tahsil AFTER linked to particular germs. The (Book of the Pest), Ibn Khaˉ tima 1910 Paul Ehrlich develops first priority for medical scientists suggested that plague was spread Salvarsan, the first drug to today when a new transmissible by “minute bodies”. In another be targeted at a germ, the disease emerges is to identify the treatise on the plague, Ibn al-Khatib syphilis bacterium. germ responsible. explained how such entities spread the disease through contact 1928 Alexander Fleming Early theories between people, remarking that discovers penicillin, the first Ancient physicians were aware individuals “who kept themselves in effective antibiotic. that many diseases are contagious isolation” remained in good health. and speculated over their causes. 1933 H1N1, a virus of avian More than 2,500 years ago in India, For a long time, the air itself origin, is named as the cause followers of the Jainist religion was believed to spread disease – of the 1918–19 flu pandemic. believed that minute beings called especially damp, misty air near nigoda, which were thought to ditches and swamps. This odorous 2016 Facebook founder Mark pervade the Universe, caused mist was called a miasma (ancient Zuckerberg and Priscilla Chan diseases such as leprosy. During Greek for “pollution”). The Roman launch the Chan Zuckerberg the 1st century bce, Roman scholar architect Vitruvius, writing in the Initiative – to cure, prevent, or Marcus Terentius Varro advised his 1st century bce, thought it unwise to manage all human disease by readers to take precautions in the build a city anywhere near swamps, the end of the century. neighbourhood of swamps “because saying that morning breezes would there are bred certain minute blow miasmas from the marshes, G erm theory asserts that creatures which cannot be seen by a host of diseases, from the eyes, which float in the air and smallpox to tuberculosis, enter the body through the mouth are caused by germs – minuscule and nose and there cause serious organisms, such as bacteria, that are mostly too small to be seen Doctors in the medieval era wore with the naked eye. Each disease a beaked mask filled with herbs to is linked to a particular kind of germ. protect themselves from miasmas – People get sick when the germ, or the foul odours thought to cause “pathogen”, enters the body and disease until well into the 19th century. multiplies, triggering the symptoms of the disease. French chemist Louis Pasteur published his theory that microbes might be to blame in 1861, but in the 1870s, experiments conducted by Pasteur and German physician

CELLS AND MICROBES 141 See also: Vaccination 94–101 ■ Epidemiology 124–27 ■ Antiseptics in surgery 148–51 ■ The immune system 154–61 ■ Virology 177 ■ Bacteriophages 204–05 ■ Attenuated vaccines 206–09 ■ Antibiotics 216–23 ■ Pandemics 306–13 Antonie van Leeuwenhoek uses his newly invented microscope to view the microorganisms he called “animalcules”. The single lens was a tiny glass bead held between two metal plates. along with the poisonous breath of cause plague. He outlined his germ entomologist Agostino Bassi began swamp creatures, into the city and theory in 1658 and recommended to investigate muscardine disease, make people ill. In ancient China, protocols to stop its spread: isolation, which was devastating the Italian under imperial rule from the 3rd quarantine, and the burning of and French silkworm industries. century bce onwards, prisoners and clothes worn by victims. In 1835, after 28 years of intense insubordinate officials were exiled study, Bassi published a paper to the damp and humid mountains In the 1660s, Dutch scientist showing the disease was caused of southern China in the hope that Antonie van Leeuwenhoek made by a microscopic, parasitic fungus they would fall ill and die from the a microscope that could magnify and that it was contagious. He noxious air. objects 200 times. He discovered demonstrated that the organism that clear water is not clear at all, Beauveria bassiana spread among Little worms but teeming with tiny creatures, the silkworms through contact and The microscope, invented by Dutch and that these minuscule organisms infected food. He also suggested spectacle-maker Zacharias Janssen are almost everywhere. In 1683, that microbes were the cause of around 1590, revealed a new world Leeuwenhoek viewed bacteria many other diseases in plants, of tiny organisms too small to see wriggling in plaque from the teeth animals, and humans. with the naked eye. In 1656, German of his wife and daughter. He drew priest and scholar Athanasius the shapes of the bacteria he saw: Over the next few decades, Kirchner examined the blood of round (coccus), spiral (spirillum), the germ theory gathered support. plague victims in Rome through a and rod (bacillus). This was the In 1847, Hungarian obstetrician microscope, and saw “little worms” first depiction of bacteria. Ignaz Semmelweis insisted on that he believed caused the disease. strict hygiene in labour wards, He may have seen blood cells rather Increasing evidence where puerperal (childbed) fever ❯❯ than the Yersinia pestis bacterium In spite of Leeuwenhoek’s discovery that causes plague, but he was right of bacteria, the miasma theory I now saw very distinctly to say that microscopic organisms still continued to hold sway until that these were the early 1800s, when Italian little eels or worms … the whole water seemed to be alive with the multitudinous animalcules. Antonie van Leeuwenhoek Letter to German natural philosopher Henry Oldenburg, 1676

142 GERM THEORY Louis Pasteur works in his laboratory, c. 1880. Originally a chemist before turning to biology, Pasteur was a meticulous experimenter who guarded against error. afflicted many new mothers Snow’s explanation but began to Pasteur’s interest in microbes had (although at the time his advice was make improvements to London’s begun in the 1850s, when he was largely ignored). He argued that it water supply nonetheless. studying the fermentation of wine was “cadaverous particles” spreading and beer. People had assumed the disease, transmitted from the Cholera also hit Florence, in that fermentation was a chemical autopsy room to the obstetric Italy, that year. Anatomist Filippo reaction, but Pasteur showed that wards on the hands of physicians. Pacini examined mucus lining the tiny round microbes called yeast Instituting handwashing with a guts of some of its victims and are responsible. However, it has to chloride of lime solution dramatically discovered a bacterium common be the right type of yeast: another reduced mortality rates. to all of them – Vibrio cholerae. kind that makes unwanted lactic This was the first clear link between acid ruins the wine. Pasteur found In 1854, a cholera epidemic a particular pathogen and a major that by heating the wine gently to hit London’s Soho district. British disease. Despite republishing about 60°C (140°F), he could kill the physician John Snow was not his findings several times, Pacini harmful yeast while leaving the good convinced that the miasma theory was ignored by the medical yeast undamaged. “Pasteurization” explained the outbreak, because establishment, which continued is now widely used not only in some victims were clustered in a to favour the miasma theory. the wine industry but to destroy very small area while others were potential pathogens in milk, fresh scattered far away. Pasteur’s experiments fruit juice, and other foods. Semmelweis and Snow had shown After conducting detailed that clean hands and good drains Pasteur wondered how such research, Snow demonstrated that can reduce the spread of disease, microbes appear in substances all the victims, including those and it became increasingly clear in the first place. Most people still living further afield, had drunk water that bad air was not to blame. believed in the idea of spontaneous from a particular water pump in Within a few years, Louis Pasteur generation – that maggots and Soho that had been contaminated began a series of experiments that mould simply appear out of nowhere by human excrement. The city proved germ theory conclusively. when food decays. In 1859, Pasteur authorities were unconvinced by showed that these microbes came from the air. He boiled meat broth in a flask with a bent “swan” neck, so that no air could get in, and the In the field of observation, chance favours only the prepared mind. Louis Pasteur, 1854

CELLS AND MICROBES 143 broth stayed clear. When he broke Truly there does not exist Louis Pasteur the tip of the neck, so that air could in the whole world enter the flask, the broth quickly Pasteur was born in Dôle, went cloudy; the microbes were an individual to whom the French Pyrenees, in 1822. multiplying. Crucially, Pasteur had medical science As a boy, he preferred art to demonstrated that the broth could science, but at the age of 21 be contaminated and ruined by owes more than you. he went to the École normale microbes in the air, suggesting that Joseph Lister supérieure in Paris to train as disease might well be spread in a a science teacher. A year after similar way. On Louis Pasteur, in a speech to the graduating, he delivered a Royal Society to mark Pasteur’s brilliant paper on molecular Disease prevention 70th birthday, 1892 asymmetry to the Academy A few years later, in 1876, Pasteur of Sciences, for which he won was asked to find a solution to Joseph Lister, who had read about the Légion d’honneur. pébrine disease, which was killing Pasteur’s earlier work on microbes, silkworms and devastating the silk realized that surgical operations are In 1854, aged 32, Pasteur industry of southern France. Helped much safer if wounds are cleaned was made head of science by reading Bassi’s work from 30 and dressings sterilized to destroy and professor of chemistry at years earlier, he quickly discovered microbes. With this “antiseptic” the University of Lille, where that a tiny parasite was to blame. procedure, death rates among several local distilleries asked Pasteur recommended a drastic Lister’s patients fell by two-thirds him for assistance with the solution – destroying all the infested between 1865 and 1869. process of fermentation. This worms, and the mulberry trees on formed the basis of his interest which they fed, and starting again. Germ theory proved in microbes and germ theory. The silk makers took his advice and In 1876, Robert Koch announced By 1888, Pasteur was world the industry survived. that he had identified the germs that famous, and money was raised cause the farmyard animal disease to create the Pasteur Institute By now, Pasteur was convinced anthrax. He extracted the bacteria in Paris for the further study that germs were to blame for many Bacillus anthracis from the blood of of microorganisms, diseases, infections and began to study how a sheep that had died from anthrax, and vaccines. When he died diseases spread among humans and then left them to multiply in a in 1895, Pasteur was given a and animals. In Scotland, surgeon culture dish of food – initially the state funeral and was buried liquid from an ox’s eye, but later a in Notre-Dame Cathedral. broth of agar and gelatine. Koch then injected the bacteria into a mouse. Key works The mouse died of anthrax, too, proving that the bacteria had caused 1866 Studies on Wine the disease. Pasteur immediately ❯❯ 1868 Studies on Vinegar 1878 Microbes organized, Bacillus anthracis is a rod-shaped their role in fermentation, bacterium that causes anthrax, putrefaction and contagion a serious disease that produces skin lesions, breathing difficulties, vomiting, and shock.

144 GERM THEORY Robert Koch identified four criteria, known as Koch’s postulates, to confirm the link between a germ and a disease. Association: Isolation: Inoculation: Re-isolation: the germ is present the germ can the germ taken the germ be taken from from the diseased in every case of the diseased host can be taken the disease. and grown in a host causes from the newly pure culture. the disease in a infected host. healthy organism. If these criteria are all met, the germ causes the disease. ran his own tests. He confirmed a pathogen will cause a disease, pathogenic microbes that are to Koch’s findings and also showed and not everyone’s body responds in blame for all infectious diseases. In that the germs could survive in soil the same way, but the link is clear. the 1880s, Koch provided medical for long periods, proving that healthy scientists with a series of four steps animals could pick up the disease Pasteur had proved that air can for confirming the link when they from a field that had previously been transmit microbes, and he and Koch came to investigate a disease for occupied by infected livestock. had shown that these microbes may the first time. Koch’s postulates cause disease. Koch then went on still underpin the more extensive Pasteur went on to develop a to show that there is an army of criteria used today to establish the vaccine against the disease after causes of contagious diseases. realizing that heating the bacteria produced a weakened form of the By 1882, Koch had identified the pathogen that was potent enough germ responsible for tuberculosis to provoke a defence in the body of (TB) – Mycobacterium tuberculosis, the sheep but not strong enough to or Koch’s bacillus – which is cause disease. transmitted through tiny droplets released into the air, mainly through Koch’s postulates coughing or sneezing. Next, he The bacterium that causes anthrax, turned his attention to finding the Bacillus anthracis, is a tiny rod- germ responsible for cholera, visiting shaped organism that is visible only Egypt and India to acquire samples. under a microscope. Pasteur and By 1884, he had identified the cause Koch had shown that despite its to be the comma-shaped bacterium, tiny size, Bacillus anthracis can kill animals and also people. It A US government poster from multiplies in the body, releasing a 1944 warns against the spread of toxin or interfering with the body’s germs. Flies were linked to outbreaks functions. Such an invasion is called of dysentery and other infectious an infection. Not every infection by diseases during World War II.

CELLS AND MICROBES 145 Vibrio cholerae, confirming Pacini’s Some ways that germs enter the body discovery 30 years earlier. Koch took his findings one stage further by linking Vibrio cholerae with contaminated water and then suggesting several measures that would prevent its spread. Find and destroy Airways Gastrointestinal Cuts in the skin Eyes By the late 19th century, many Airborne pathogens tract Pathogens can enter Rubbing eyes with scientists were actively searching for the microbes that cause disease. in evaporated Consumption of the body through hands that have It is now known that 99 per cent of droplets or dust contaminated food wounds or bites. touched infected microbes are completely harmless particles can be surfaces can transfer and many, such as those found in breathed in. They or water causes They include pathogens such as gut flora, are beneficial. However, many diseases, Clostridium tetani, cold viruses into around 1,500 have been identified include the including salmonella as pathogens, with more discovered influenza virus. which causes the body. each year. The main pathogens are and cholera. tetanus. bacteria, viruses, fungi, and protozoa (single-celled organisms that are specific microbes – stopping the diseases killed far fewer people, responsible for many diseases, disease rather than just addressing with diseases that are not including amoebic dysentery). its symptoms. infectious, notably heart disease, overtaking them. Yet infectious Knowing that diseases are From the mid-20th century, new diseases still killed 10 million caused by germs transformed the diagnostic tools and advances in people in 2017 alone – many of fight against them. It clarified the biochemistry and genetics further them in developing countries, where measures needed to prevent their transformed health in the developed poor nutrition and sanitation and spread, such as hygiene, sanitation, world. In 1900, for example, the limited access to healthcare allow and quarantining, and it quickly led infectious diseases pneumonia, avoidable and treatable diseases to an understanding of how vaccines TB, and enteritis with diarrhoea to thrive. Here, poverty-related confer immunity. It also promoted were the three leading causes of diseases, such as diarrhoea, TB, the development of drugs, such as death in the US, taking the lives and malaria, are more lethal than antibiotics and antivirals, to target of 40 per cent of children aged incurable diseases. ■ under five. A century later, these Robert Koch Born in Clausthal, in Germany’s Koch conclusively proved that Harz Mountains, in 1843, Robert Pasteur’s germ theory explained Koch studied medicine at the the cause and spread of disease. University of Göttingen. He served He became professor of hygiene as an army surgeon in the Franco- at the University of Berlin in Prussian War (1870–71) before 1885, and surgeon general in becoming district medical officer 1890. For his research on TB for Wollstein (now Wolsztyn in (which used to kill one in seven Poland) between 1872 and 1880. people in the West), he received the Nobel Prize in Physiology or Applying Louis Pasteur’s ideas Medicine in 1905. Koch died in on germ theory, Koch began his Baden-Baden in 1910. research on anthrax bacteria in a home-made laboratory in his flat. Key work This marked the start of a period of intense rivalry between the two 1878 Investigations of the men, as they vied to identify new Etiology of Wound Infections microbes and develop vaccines.

146 MA IGSEPNREINTITC INHERITANCE AND HEREDITARY CONDITIONS IN CONTEXT A ustrian monk Gregor peas with purple flowers were bred Mendel laid the basis for with white-flowered peas, the next BEFORE our understanding of generation had purple flowers. c. 400 bce Hippocrates inheritance by meticulously studying Mendel deduced that the purple suggests that hereditary traits pea plants in his monastery garden. allele for flower colour dominated occur when material from a He selectively bred thousands of the recessive white allele. For a pea parent’s body is transmitted plants between 1856 and 1863, plant to have white flowers, it must to their offspring. studying specific features or traits have two recessive alleles, one such as plant height, flower colour, inherited from each parent plant. 1859 British biologist Charles and pod shape. Mendel showed that Darwin describes how valuable these traits were not the result of Ideas rediscovered traits become more common in blending or merging, but “factors” Mendel published his research in On the Origin of Species. (later called genes) inherited from 1865, but it remained obscure until parent plants. He also noted that 1900 when it was rediscovered by AFTER each factor had different versions, three botanists: Hugo de Vries in 1879 German biologist now known as alleles. Holland, Carl Correns in Germany, Walther Flemming discovers chromosomes. Most organisms, from pea plants … [recessive traits] recede to humans, have two sets of genes, or disappear entirely 1900 Hugo de Vries, Carl one from each parent, and two alleles in the hybrids, Correns, and Erich Tschermak for each trait. Mendel devised three “rediscover” Mendel’s laws. laws that govern how these alleles but reappear unchanged are passed on. His law of segregation in their progeny … 1905 William Bateson coins states that alleles for a trait are Gregor Mendel the term “genetics” for the new allocated randomly to offspring, science of heredity. rather than in any regular pattern. Experiments in His law of independent assortment Plant Hybridization, 1865 1910 American scientist says that traits are inherited Thomas Hunt Morgan traces a separately – the allele for flower gene to a specific chromosome colour, for example, passes on for the first time, locating independently of that for pod shape. the gene that codes for eye colour on the X chromosome Mendel’s law of dominance of fruit flies. asserts that one allele, termed dominant, can override or overpower another, known as recessive. When

CELLS AND MICROBES 147 See also: Colour vision deficiency 91 ■ Cellular pathology 134–35 ■ Genetics and medicine 288–93 ■ Gene therapy 300 Recessive allele Homozygous Heterozygous Dominant allele Double Dominant Double Dominant Gregor Mendel recessive recessive recessive recessive Christened Johann, Mendel Versions of a gene, called alleles, carried on paired There is a one was born in Silesia, then part chromosomes, determine inherited traits. One allele is inherited in two chance of the Austrian Empire, in from each parent, and some alleles dominate or overpower other that a child 1822. Excelling in maths and (recessive) genes. Individuals with identical alleles are termed will inherit the physics at university, he joined homozygous; those with varying alleles are heterozygous. recessive trait. St Thomas’s Monastery in Brünn (now Brno, in the Czech and Erich Tschermak in Austria. the Y from the father. If the X Republic) as an Augustinian Their discussion of Mendel’s work chromosome carries the allele monk in 1843. Here he took had an immediate impact, and for the condition, it cannot be the name Gregor. fuelled the studies of British biologist counteracted by a dominant allele William Bateson. Bateson went on because the Y chromosome does In 1851, the monastery to republish Mendel’s original not have this gene. Women have sent Mendel to the University papers and to popularize his ideas, two X chromosomes, XX, so they of Vienna to continue his establishing the field of genetics. must receive two recessive alleles studies. He worked under to be affected, which is exceptionally Austrian physicist Christian Hereditary conditions rare. Affected women are “carriers”, Doppler, and also learned Mendel’s original ideas guided who can transmit the condition to much about the physiology of medical understanding of genetic their offspring, but they usually have plants using microscopy. After conditions, explaining why some no symptoms themselves. returning to Brünn, Mendel run in families, are sex-specific, embarked on his inheritance or skip a generation. Huntington’s Genetics is now known to be project using pea plants, and disease is due to a dominant more complex than Mendel could presented the results in 1865. mutated allele which overpowers have imagined. There are currently Two years later, he became the normal one. Cystic fibrosis is more than 5,000 known inherited the monastery’s abbot, but recessive and so needs two recessive conditions, and many traits depend still continued to devote time alleles to occur, one from each parent. not on a single “factor” or gene, but to research, studying bees and on several, even hundreds, working the weather. In his later years, Some conditions are sex-related, together. There are some alleles that Mendel suffered from a painful such as the blood-clotting disorder are neither dominant nor recessive, kidney disorder. After his haemophilia, which more commonly but co-dominant (expressed to an death in 1884, the rediscovery affects men. A recessive allele on equal degree). Yet Mendel’s pea of his ideas in 1900 led to his the X sex chromosome causes it. plants laid the foundations for a posthumous recognition as Men have two sex chromosomes, new understanding of genetics and the father of genetics. XY – the X is from the mother and inherited medical conditions. ■ Key work 1865 Experiments in Plant Hybridization

148 IN CONTEXT IPMTTAHISRIASCTTIHFACRILLEOLEFMSTAHREISES BEFORE c. 1012 Persian polymath Ibn ANTISEPTICS IN SURGERY Sina establishes early ideas about germ theory. 1850s Louis Pasteur suggests that microorganisms could cause food and drink to spoil. 1861 Pasteur publishes his germ theory of disease. AFTER 1880s Robert Koch shows that steam sterilization is as effective at killing germs as antiseptics. 1890s Gustav Neuber establishes sterilization and aseptic methods in his operating theatre. 1940s The mass use of antibiotics helps surgeons tackle infection by killing microorganisms from inside the body. O perating rooms in the mid-19th century were dirty, dangerous places where surgeons seldom washed their hands or took precautions to prevent patients’ wounds becoming infected. Unsterilized surgical instruments, made of ivory or wood, were difficult to keep clean, and operating tables were not usually wiped down between procedures. Surgeons sported blood-encrusted operating aprons and took pride in the “good old surgical stink” that surrounded them. The discovery of anaesthesia in 1846 meant that patients no longer had to be awake during operations, nor did they have to be subjected to procedures in which – to reduce

CELLS AND MICROBES 149 See also: Anaesthesia 112–17 ■ Hygiene 118–19 ■ Nursing and sanitation 128–33 ■ Germ theory 138–45 ■ Malaria 162–63 ■ Antibiotics 216–23 Joseph Lister (centre) directs an assistant who is using carbolic spray to clean the surgeons’ hands, their instruments, and the air around them during an operation. the chances of a patient dying from was placed in charge of the Male Up until that point, many in the shock or blood loss – speed was Accident Ward, one of several medical profession believed that prized over skill. Surgery was now wards in the new surgical block. disease was spread by bad air pain-free, allowing more time for It had been constructed in the (miasma), while others thought it complicated procedures. But it also hope of reducing the high death was transferred by something in led to a dramatic rise in the number rate from “hospital disease” the body (contagionism). Lister of deaths from infection caused by (today called operative sepsis: proposed that sepsis was spread unsterilized surgical conditions. the infection of blood by germs). by an airborne dust-like substance, But the newness of the building did although he did not consider that Doctors of the time were nothing to stem the tide of deaths. this dust would be living. It was unaware that the microorganisms Lister determined to discover the not until he read the work of French now known as germs should be underlying cause of the infections. bacteriologist Louis Pasteur in ❯❯ prevented from entering an open wound during surgery. Most were baffled by the high numbers of post- operative patients succumbing to infection – especially those who had had a limb amputated. Invisible killer This was the environment that young British physician Joseph Lister encountered in 1861 when he became surgeon to the Glasgow Royal Infirmary in Scotland. Lister Joseph Lister Born in 1827, in Essex, UK, Joseph 16 years, until he retired in 1893. Lister was brought up a Quaker. Despite winning numerous His father taught him how to use honours, including the Order a microscope, which Lister used of Merit, and being the first for his later trials on infected surgeon to be made a peer in human tissue. After graduating the House of Lords, Lister led from London’s University College a somewhat reclusive existence. in 1852, he became an assistant to He died in 1912, and was buried Edinburgh surgeon James Syme. in London after a funeral at In 1856, Lister married Syme’s Westminster Abbey. daughter Agnes, who also became his lifelong laboratory partner. Key work Lister worked as a surgeon in 1867 “On the Antiseptic Edinburgh and Glasgow before Principle in the Practice moving to London in 1877. He of Surgery” was professor of clinical surgery at King’s College Hospital for

150 ANTISEPTICS IN SURGERY In the early 19th-century, operations in Britain are carried out time, as the necessary surgery in filthy conditions, using unsterilized instruments. invariably led to infection. In most Nearly half of all patients die following surgery. cases, surgeons would try to offset Joseph Lister postulates that if “floating particles”, this risk by amputating the limb or microorganisms, can cause food and drink to go off, altogether, which also came with they might also be infecting patients’ wounds. great mortal risk. Lister, however, Lister uses antiseptic spray and antiseptic-soaked set the boy’s leg and applied a bandage soaked in carbolic acid to bandages during surgery to kill these microorganisms the wound. A few days later, there and prevent them from getting into open wounds. was no sign of infection, and the bone showed itself to be healing. Surgical mortality rates improve dramatically. The boy was discharged five weeks later, having made a full recovery. Lister continued his clinical work with carbolic acid and, in 1867, published his findings in the article, “On the Antiseptic Principle in the Practice of Surgery”, in the British Medical Journal. His results made for startling reading. Between 1865 and 1869, surgical mortality caused by infected wounds fell by two-thirds in Lister’s Male Accident Ward. 1865 that he began to make the open wound by creating a chemical Overcoming scepticism connection between germs and barrier between the wound and its Despite Lister’s demonstrable surgical infection. surroundings. He would later call successes, there was immediate this chemical an “antiseptic”. opposition to his theories. For many Pasteur had discovered the role surgeons, Lister’s techniques of microorganisms in disease after Carbolic acid, which was being simply slowed surgery down, which studying the fermentation of beer used to clean Scotland’s worst- improved the likelihood of death and milk. He proved that food and smelling sewers, proved to be an through blood loss. Surgeons also drink were not spoiled by oxygen effective antiseptic. Lister found in the air, but by microbes that that adding diluted carbolic acid … since the antiseptic appeared and thrived over time to infected wounds was a good treatment has been brought into within oxygen-rich environments. way to prevent the development of full operation … my wards … gangrene. He then reasoned that Blocking bacteria spraying a carbolic solution onto have completely changed Lister seized on Pasteur’s germ surgical instruments, a surgeon’s their character … theory and decided to apply it to hands, and post-operative bandages Joseph Lister surgical infections. Pasteur had would also effectively block the suggested that microorganisms transmission of germs from these Speech at the Dublin meeting of the could be eliminated through heat, objects into a patient’s wounds. British Medical Association, 1867 filtration, or exposure to chemicals. As the first two methods were In 1865, Lister was able to test unworkable for wounds, Lister began his theories on an 11-year-old boy experimenting with chemicals on who had presented at the infirmary infected human tissue under a with an open fracture, after a cart microscope. His ultimate aim was ran over his leg. Open fractures, to prevent germs from entering an where the bone had broken the skin, were often death sentences at that