Was there a Bacteriological Revolution in late nineteenth-century medicine?

Abstract

That there was a ‘Bacteriological Revolution’ in medicine in the late nineteenth-century, associated with the development of germ theories of disease, is widely assumed by historians; however, the notion has not been defined, discussed or defended. In this article a characterisation is offered in terms of four linked rapid and radical changes: (i) a series of discoveries of the specific causal agents of infectious diseases and the introduction of Koch’s Postulates; (ii) a reductionist and contagionist turn in medical knowledge and practice; (iii) greater authority for experimental laboratory methods in medicine; (iv) the introduction and success of immunological products. These features are then tested against developments in four important but previously neglected diseases: syphilis, leprosy, gonorrhoea and rabies. From these case-studies I conclude that the case for a Bacteriological Revolution in late nineteenth-century medicine in Britain remains unproven. I suggest that historians have read into the 1880s changes that occurred over a much longer period, and that while there were significant shifts in ideas and practices over the decade, the balance of continuities and changes was quite uneven across medicine. My argument is only for Britain; in other countries the rate and extent of change may have been different.

Introduction

Revolutions are out of fashion in history.¹ In recent decades historians have increasingly abandoned the notion, so while terms like the ‘Scientific Revolution’ and ‘Industrial Revolution’ continue to be used in popular histories and as a shorthand, they no longer have much currency in academic discourses.² In comparison to the history of science, which once upon time had many revolutions—the Copernican, Chemical and Darwinian immediately come to mind—medical history has been relatively devoid of them.³ The main candidate has been the Bacteriological Revolution, in which historians have claimed that the germ theory of disease and its associated practices ‘transformed every aspect of medicine’.⁴ In The greatest benefit to mankind, Roy Porter refers to ‘one of medicine’s few true revolutions—bacteriology’.⁵ In my book Spreading germs I argued against there having been a Bacteriological Revolution, specifically with regard to Britain and with the hope the question would be re-examined in other countries.⁶ My conclusion has been generally accepted, perhaps unsurprisingly as it goes with the flow of historiographical fashion, though some, for example David Barnes, have argued that I underestimated the epistemological impact of Koch’s postulates which ‘forever changed the nature of medical knowledge’.⁷ This and similar responses have led me to reflect again on my argument and to discuss the historiography of medical bacteriology in the last quarter of the nineteenth–century more systematically. In this article I set out further reflections, based on my own new work on germs and other recently published studies. In order to make it clear where all this is heading, I should say straightaway that my answer to the question in my title remains the same—there was no Bacteriological Revolution in late nineteenth-century medicine in Britain.⁸

A useful starting point would be a definition of the Bacteriological Revolution, but this proves to be a most elusive notion. Despite its currency, I have been unable to find an explicit characterisation in the literature, nor is the term used in the any of the texts that are routinely cited to support it: for example, Bulloch’s History of bacteriology, Stevenson on critiques of bacteriology, Brock’s writing on Koch, or Dubos’s biography of Pasteur.⁹ Nor is it mentioned in the recent writings of Bill Bynum, Gerry Geison, Nancy Tomes and John Harley Warner.¹⁰ To be fair, Brock refers to Koch as a ‘one of the true scientific revolutionaries’ and many French historians write of a ‘Pasteurian Revolution’, but a Bacteriological Revolution is usually taken to mean something much wider—not just the establishment of bacteriology as a scientific discipline and medical specialism with its own knowledge claims, methods and institutions, but rapid and radical changes across medicine.¹¹

As far as I can tell, the term Bacteriological Revolution first came into use in the 1970s, seemingly in the wake of Thomas Kuhn’s work when it became common for any and every branch of science to have its ‘revolution’ or ‘revolutions’.¹² Bacteriology was said to have wrought a paradigm shift in medicine, symbolised by radically new ideas and practices; for example, in public health where attempts to combat elusive aerial miasmas were replaced by measures targeted at demonstrable disease-germs spread directly by interpersonal contact or indirectly by water; and in surgery where best practice was reversed, from leaving healing wounds open to ensure that healing processes were well supplied with oxygen, to covering them with elaborate antiseptic dressings. In the 1970s, there was in fact a claim for nothing less than a ‘scientific revolution’ in late Victorian medicine, where progress in bacteriology was linked with changes in physiology, surgery, therapeutics and professional developments.¹³ Another common phrase was George Rosen’s notion of ‘Era’ or ‘Golden Age of Bacteriology’, though to me this implies less a rapid turning point than an extended period of innovation and influence around the new subject.¹⁴ Latterly in the 1990s, historians tended to absorb the coming of bacteriology into discussions of a ‘laboratory revolution’ in medicine, an alleged radical shift of the locus of medical education, research and authority from the clinic to the laboratory.¹⁵

There was some writing on a Revolution in late nineteenth-century medicine amongst historians of medicine before the 1970s, though they tended to stress continuities. Garrison absorbed bacteriology in long-run changes in pathology, aetiology and practice, suggesting a continuous accumulation of knowledge.¹⁶ This was also the view of Richard Shryock, who, arguing against what he termed the ‘episodical’ interpretation of history, portrayed bacteriology as emerging from developments in pathology, and from work on contagia and surgical methods. However, he did write that the effects of bacteriology were ‘far-reaching’, acknowledging a ‘veritable revolution in the knowledge of disease causation’ after 1870.¹⁷ Erwin Ackerknecht was also equivocal, balancing the ‘breath-taking’ advances in the 1870s and 1880s—‘the most important [medical] development of the eventful nineteenth century and perhaps of all time’ when ‘the whole of medicine was transformed’, with the observation that ‘medical opinion was slowly to change’.¹⁸ He comments on how disease classifications changed little, it being ‘amazing how many disease units, originally isolated on purely clinical and pathological anatomical grounds, were now identified and confirmed by bacteriological discovery’.¹⁹ Oswei Temkin’s widely quoted views on how bacteriological discoveries were decisive in altering the very meaning of disease, advancing the ontological conception of disease so familiar to us today, might be read as pointing to an epistemological revolution.²⁰ However, he qualified this in his observation that the simple monocausal aetiological models and ontological assumptions of the 1880s rapidly broke down in the 1890s and 1900s with the rise of immunological knowledge and ecological perspectives. Pelling has characterised the Bacteriological Revolution as ‘chain reaction of finding in the 1870s and 1880s, set off by Koch’s methods and Postulates’.²¹ However, this claim comes at the end of a discussion of long-term shifts in ideas of contagion, germs and disease specificity, and is not elaborated upon. In his essay ‘Transforming the plague’, Andrew Cunningham makes the case for a complete discontinuity between old Plague and new ‘bacteriologic’ plague around 1894, but he accepts that for many years the new identity of the disease was only held by bacteriologists, and acceptance across medicine only came in the 1930s.²² Most recently, Andrew Mendelsohn has made a similar argument, though in different terms, arguing for two bacteriological revolutions.²³ First, the familiar revolution precipitated by the invention of bacteriology and pioneered by Pasteur and Koch in the 1870s and 1880s, followed by a revolution ‘in bacteriology’ in the 1890s and 1900s. In the latter transformation, echoing Temkin, he suggests that the relatively simple models and methods introduced earlier were complicated by new findings about bacterial variability, asymptomatic infection and the carrier state, immunological processes, and so on. Mendelsohn is more concerned with the revolution ‘in bacteriology’ and says little on why events in the 1870s and 1880s qualify to be a revolution—an assumption made somewhat problematic given his delineation of different bacteriologies, with different chronologies, in France and Germany.

It seems that the term Bacteriological Revolution is, like many historical revolutions, widely used but poorly articulated. If those who use the term have not bothered to define their great moment, I will have to do if for them. Firstly, what kind of revolution was it? Historians use the term revolution in one of two ways: either for a moment of very rapid change, or a period with radical discontinuities. Needless to say, the term is least contested for revolutions that seem to qualify on both counts, for example the Russian Revolution is mostly seen to have been rapid and radical.²⁴ I will assume that Bacteriological Revolution was rapid—concentrated in the 1880s and that it was radical—it ‘transformed every aspect of medicine’.²⁵ Its equivalent of the seizure of the Winter Palace in 1917 might be said to be Robert Koch’s announcement of the Tubercle bacillus on 22 March 1882. This discovery has been said to have introduced a fundamentally new understanding of infectious diseases and to have successfully demonstrated the value of novel methods for investigating the causes and processes of disease in the laboratory.²⁶ What was critical was not just the discovery of the essential causal micro-organism of tuberculosis, though this was dramatic as the disease switched from being hereditary to communicable, but the new meanings of disease and the new ways of knowing its causes, processes and consequences. The latter have been canonised as Koch’s Postulates, though his colleague Loeffler first set them out and it arguable whether Koch himself ever held to them.²⁷ The so-called Postulates are that: (i) a specific micro-organism must be shown to be constantly present in diseased tissue; (ii) the specific organism must be grown and isolated in pure culture; (iii) the pure culture must produce the disease when inoculated into a healthy animal.²⁸ The alleged radical shift was that diseases could be and were defined aetiologically, and that the goal of medical science became that of identifying single necessary causes.²⁹ The case for a Bacteriological Revolution could be elaborated further by showing how the new ideas and methods produced more effective practices, principally through reductionism and narrowing the focus of medical interventions. This was exemplified in Lister’s focus on the entry of aerial germs to control wound infection, which though developed in the 1860s, was given new meanings by Koch’s work on wound infection in the late 1870s.³⁰ The case might be concluded by highlighting two further innovations that quickly became available: laboratory methods of diagnosis where medical investigators did not need even to meet the patient, and new ways of preventing and treating diseases with vaccines and antisera, heralded by the introduction in 1885 of a treatment for rabies and followed by diphtheria antitoxin in the early 1890s.³¹

In summary, the notion of there having been a Bacteriological Revolution seems to rest on four linked changes that were both rapid and radical, and which were concentrated in the 1880s:

• A series of discoveries of the specific causal agents of infectious diseases and the introduction of Koch’s Postulates.

• A reductionist and contagionist turn in medical knowledge and practice.

• Greater authority for experimental laboratory methods in medicine.

• The introduction and success of immunological products.

The Bacteriological Revolution is normally presented as an international phenomenon, occurring across medical science in an era when knowledge was circulating more rapidly through the proliferation and international circulation of publications and the movement of doctors and patients.³² Historiographically, it is much easier to sustain the phenomenon of a ‘revolution’ if one can pick and choose developments across countries and disciplines. However, recent work has shown the persistence and importance of sites of practice and specifically of national cultures in medicine, so if the task is to determine the extent and pace of change in medical ideas and practice, then the best level for doing this is the national, though with sensitivity to regional differences.³³ This is because there were national standards of education, national publications and above all institutions. Also, I showed in Spreading germs that British doctors and scientists were not isolated from developments in Continental Europe and North America—there was dense, two-way traffic in people, ideas and practices. By focussing on Britain, it could be argued that I am loading the dice against finding a Bacteriological Revolution, as this was the country where few discoveries were made, where there was relatively little experimental research, and where clinicians had the strongest hold on medical knowledge. However, as I have argued previously, Britain was not a bacteriological backwater.³⁴ It had spawned Listerian antisepsis and by the 1880s there was a cadre of bacteriological workers and followers, who were part of international networks, and themselves contributed to new developments. They were also close to, if not integrated into medicine and surgery, which they were able to inform, if not always to shape to their model of modern practice.

To explore the claims for there having been a Bacteriological Revolution in British medicine, I will consider each of the four characteristics set out above in turn. In doing this I draw upon new work on syphilis, leprosy, gonorrhoea and rabies. These are diseases about which there are few published medical histories, yet each was as medically and socially important as tuberculosis and cholera, the usual focus of histories of germs in the 1880s. All four were being studied by international networks and all were prime candidates for germ aetiologies and pathologies. Moreover, syphilis was the subject of intense public attention due to the Contagious Diseases Acts, which were repealed in the 1880s, while in the same decade leprosy was the subject of growing concern as a threat to the new imperialism in Asia and Africa, and threatened to be imported back into Europe.³⁵ Gonorrhoea was the most prevalent of the venereal diseases and in the 1880s was the subject of growing attention because of claims of its effects on women’s fertility and health, and the recognition that it was the largest cause of blindness in infants.³⁶ Pasteur’s rabies vaccine was, to adapt the words of Bert Hansen, the ‘world’s first medical breakthrough’, attracting press attention and direct public interest as evident in the monies raised to found Pasteur Institutes.³⁷ If the medical understanding and management of these diseases was not transformed by the new bacteriology, then the case for a Bacteriological Revolution must continue to be unproven. In the next four sections I discuss each disease with respect to one feature of my typology for a Bacteriological Revolution: germ discoveries with regard to syphilis, contagionism with regard to leprosy, the authority of the laboratory over the clinic with regard to gonorrhoea, and immunological products with regard to rabies.