According to Porter, public health initiatives were stimulated in the 19th century by epidemics of cholera and yellow fever, and war. What arguments and evidence does he provide to show that it was...

According to Porter, public health initiatives were stimulated in the 19th century by epidemics of cholera and yellow fever, and war. What arguments and evidence does he provide to show that it was the effectiveness of the public health movement, not antibiotics, that is the reason for declining mortality rates in the 19th century?

Roy Porter, The Greatest Benefit of Mankind, p. 397-492

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Chapter XII of Roy Porter’s history of medicine and medical care, The Greatest Benefit to Mankind: A Medical History of Humanity, is titled “Nineteenth-Century Medical Care.”  While Porter’s history includes a great deal of useful information regarding the development of medical practices over many centuries, it is this chapter that discusses the single greatest advances in the provision of medical care.  While the question specified pages 397-492, with emphasis on Porter’s discussion of cholera and yellow fever, one would be remiss to begin any essay on the effects of antiseptics, the development of the theory of which preceded the development of antibiotics by many decades, without reference to Porter’s discussion earlier in Chapter XII on the trials of Joseph Lister (1827-1912), a British physician considered the father of modern surgical techniques with regard to the use of antiseptics to kill bacteria responsible for post-operative infections.  Porter provides a detailed history of Lister’s efforts at both understanding the relationship between invisible-to-the-naked-eye germs and alarmingly high mortality rates among patients who underwent surgical procedures.  On page 372 of Porter’s text, he includes data on Lister’s success rate in bringing down mortality figures in surgical patients through the application of cleanliness processes, citing Lister’s data that showed that, from 1864-1866, there was a mortality rate of 45.7 percent among surgical patients without the use of antiseptics to clean both the wound or surgical incision and the surrounding operating facility, and then contrasting those numbers with data for the period of 1867-70, during which the mortality rate dropped to 15 percent when antiseptics were used.  Porter notes that Lister’s emphasis on sterilizing instruments, wounds and surrounding environments met with remarkable success, stating that “[a] new operation he had developed on tuberculosis changes in the wrist had good results, Lister found, so long as the wound remained infection free . . .”

Lister was not, of course, without his critics. Skepticism among colleagues who couldn’t visibly see bacteria, so denied its existence, was wide-spread. Quoting John Hughes Bennett, a professor in Edinburgh, as derisively asking with respect to Lister’s focus on microscopic bacteria, “Where are these little beasts?  Show them to us, and we shall believe in them.  Has anyone seen them yet?”  Such skepticism aside – and critics of Lister’s theories were responsible for many unnecessary deaths – his emphasis on sterilization was obviously correct.

Moving on to the specific discussions of cholera and yellow fever, then, Porter focuses on the continued struggle among public health experts and officials in Europe to come to terms with those same microscopic bacteria and their efforts at understanding the spread of infectious diseases, especially in relation to local sanitary practices.  It is in these section of his book that Porter introduces the reader to Edwin Chadwick (1800-1900), an English social reformer and follower of the theories of Jeremy Bentham and the school of Utilitarianism.  Chadwick and others recognized the relationship between public sewage systems, especially those upon which the poor were dependent, and the spread of deadly diseases.   Porter notes the prevalence of riots among the economically destitute who were suspicious of the efforts of the upper classes to isolate them and create cordons between them, when the wealthy were trying to insulate themselves from the spread of cholera.  Porter briefly relates one example:

“In Britain isolation of victims in workhouse infirmaries caused riots among those accusing the medical profession of using the [cholera] epidemic as a body-snatching opportunity for dissection.”

Such fears among the millions of poor in France – and much of these developments occurred within the historical context of the French Revolution – compelled the Utilitarians among the educated to focus on public health initiatives more than had previously been the case.  As Porter writes, “The social costs of sickness thus converted Chadwick to ‘the sanitary idea’: that is, prevention.”  Thus, as Porter’s history of the nineteenth-century continues, the relationship between proper sanitation requirements and the spread of infectious diseases gains increasing acceptance among those in power, and the need for adequate public health systems were recognized.

Similarly, in his subsection on yellow fever, Porter discusses the efforts among some, mainly John Crawford (1746-1813), Josiah Nott (1804-73), and Louis Beauperthuy (1807-71), to identify the causes of yellow fever, a deadly viral disease, and the processes by which it was spread.  Identifying mosquitos as the source of yellow fever’s spread, these individuals led the efforts to contain the disease through improvements in public sewage and water treatment systems.  By correctly identifying the role of mosquitos and the conditions under which mosquitos thrive, public health analysts were able to suggest corrective measures – all of which were recognized before the advent of antibiotics.

In conclusion, Porter’s chapter on nineteenth-century medical practices and theories all demonstrated conclusively the relationship between personal and public hygiene and mortality rates.