El espacio urbano como término teórico 102

Emile Roux at the Pasteur Institute pioneered immunization of horses during 1892–3, which enabled the mass production of anti-diphtheria serum. In Paris the Council of Hygiene established a municipal hygiene laboratory, and supervised the distribution of sera. This was provided free of charge by the Pasteur Institute. The bureau of public assistance, established in July 1893, formed a network for the distribution of serum.

The Paris hospitals were used for clinical trials of the serum therapy. It was fortuitous that the Pasteur Institute was only five minutes’ walk away from the Hospital for Sick Children. Alexandre Yersin, a young doctor at this hospital, had alerted Roux to the problem of diphtheria prevention, and the hospital was used for the first clinical trials from January 1894. The Assistance Publique strongly supported this. Indeed the President of the Republic attended an experimental immunization.44 _{The Assistance Publique improved}

public access to the therapy by opening new diphtheria ‘barracks’ at a cost of half a million francs in 1895 at the hospital of Aubervilliers in the banlieue.45 _{In 1896 there was an ambitious}

scheme to replace the Trousseau Hospital by three hospitals. This scheme involved the sale of the Trousseau site to the municipality for five million francs, the conversion of another hospital (L’Hôpital Herold for children) and the establishing of new hospitals in Montmartre (in the 18th arrondissement) and in the 12th arrondissement.46 _{Each hospital was to have the best modern}

facilities, including facilities for surgery and hydrotherapy, gymnasia and facilities for dental treatment, as well as wards for contagious diseases and diphtheria treatment. There were also outpatient dispensaries. Their siting was to ensure that mothers should not have too great a distance to travel. These hospitals were to have a total of 684 beds.47 _{However, the plans were too ambitious and the}

project had to be scaled down during the following year.48

Whereas the Pasteur Institute had a virtual monopoly of serum production, in Germany there was competition between the chemical manufacturers Hoechst and Schering. Because of concern that

competition would reduce standards, the state health authorities and medical researchers initially agreed that a central state institution for serum testing was necessary. In November 1894 the director of the Charité suggested the foundation of a national institute for serum research and therapy under Emil Behring in Berlin. A committee under royal patronage was to launch a massive public appeal to finance the Institute. This plan to emulate the Pasteur Institute was only to be partially realized, as an Institute for Serum Testing and Experimental Therapy was founded with joint state, municipal and private finance in Frankfurt. It represented an important model of a national medical research institute, on a charitable basis later realized for infant welfare.

During the autumn of 1892 the first experimental immunizations were conducted at Koch’s infectious diseases wards and at the children’s clinic of the Charité.49 _{In May 1894, after trials in five}

Berlin hospitals, it was established that the children treated on the first day showed the best rates of cure.50 _{At the Kaiser und Kaiserin}

Friedrich Children’s Hospital the paediatrician Baginsky conducted clinical trials for the new therapy from March 1894 for a ten-month period.51 _{The municipality financed the costs of treating sick children}

at this hospital. The new serum of Aronson—who was Virchow’s protégé—was tested here. The coincidence of Virchow’s role in the founding of the hospital and the use of serum developed by a protégé should be noted. By way of contrast the Prussian authorities supported the use at the Charité of the Behring-Ehrlich serum manufactured by Hoechst.

It was not until 1894 that serum therapy was used in Britain. At a time when there were hundreds of horses producing serum in Berlin and Paris, a single horse was immunized at the Brown Institute; when a relative of the physiologist Charles Sherrington fell ill, the serum was quickly utilized.52 _{The Local Government Board’s policy}

was essentially voluntaristic. It decided in 1894 that while prepared to monitor the spread of diphtheria, it ‘should not take any part in supplying materials for the treatment and prevention of the disease’.53

Yet during 1894 the MAB increased the number of beds available for diphtheria patients. In October 1894 the MAB began to consider provision of facilities for the antitoxin treatment, and an experimental trial period began for six months in December 1894; this ‘experimental phase’ was periodically renewed until the treatment became routine in 1897. However, medical superintendents of the MAB had found that they could not obtain sufficient antitoxin

sera.54 _{In December 1894 the MAB accepted the offer of the royal}

colleges of physicians and surgeons to supply antitoxin (using three horses). The laboratories were also to carry out routine diagnoses. The aim was that comprehensive statistical trials could be conducted by the Clinical Society in order to assess the therapy.55 _{The Board}

rejected as ‘unfair’ the suggestion that it should compare patients treated with antitoxin with patients not so treated. Instead it compared the records of patients not treated with antitoxin during 1894 with the rates of those treated in successive years.

Serum therapy came at a crucial time for the MAB. It had already begun to expand facilities for infectious diseases. A cholera epidemic—expected from Hamburg—did not materialize, but rates of infection from diphtheria were rising. The Board’s hospitals had first admitted diphtheria patients in 1888. The opening of the North Eastern Hospital in Tottenham, Fountain Hospital in Lower Tooting from 1893, the Brook Hospital in Woolwich from 1896, Park Hospital in Hither Green from 1897, and Tooting Grove from 1899, raised the number of beds for fever and diphtheria from 2,070 to 4,544.56 _{The social spectrum of those admitted broadened. As the}

MOH for Woolwich observed, ‘all classes in the borough make use of the fever hospitals, the middle class less so than the working class, but it is by no means unusual for the professional and well-to-do classes to send their children to these hospitals’.57 _{A series of MAB}

reports confirmed that the antitoxin serum was effective if promptly administered. Whereas in 1890 17.9 per cent of notified cases were admitted to Board hospitals, by 1900 72.5 per cent were so admitted.58 _{The Webbs argued that speedy and efficient}

administration of antitoxin meant a financial saving to public health authorities.59

Laboratories symbolized the new scientific approach to therapy. On 24 May 1894 the Assistance Publique agreed to a laboratory for microbiology at the Hôpital des Enfants-Malades and one was established at the Hôpital Trousseau.60 _{In 1895 the council of public}

hygiene of the 3rd arrondissement petitioned that the prefecture of police establish a central laboratory of bacteriology for the diagnosis of infectious diseases. This was sited in an annex of the town hall.61

The instituting of a municipal laboratory in Berlin was controversial as it raised the issue of whether there should be a central health office. There were also tensions within Koch’s Institute which performed routine diagnostic tests. Koch was jealous of the success of Behring, and denied him research facilities. Behring and Paul

Ehrlich rented an arch under the urban railway to stable horses. They required separate facilities for the manufacture and distribution of sera. Public appeals were made by Behring, Ehrlich and Wassermann to raise funds for serum research.62 _{Not only was Koch’s}

Institute cramped on its central site, it was overly rigid in structure when compared to the Pasteur Institute. In 1896 Virchow supported plans to relocate Koch’s Institute next to a planned fourth municipal hospital. This was seen as a ‘Condominium’ between state and municipality, increasing the utility of and services for medical research.

It was as a result of professional pressure arising from the British Institute for Public Health (representing the interests of metropolitan MOHs) in November 1894, that the MAB entered into an arrangement for the early diagnosis of diphtheria with the Royal College of Physicians (RCP) and the Royal College of Surgeons.63

The MAB’s aim remained the establishment of its own bacteriological laboratory. It argued for this on both scientific and economic grounds, as laboratory tests would provide a means of excluding cases of sore throat which were not diphtheria, and because isolating the centres of infection might reduce the spread of the disease.64 _{In November 1896 it was decided that MAB hospitals}

should conduct their own bacteriological tests. The MAB continued to fund the stables at the RCP laboratory for serum production.65

The Metropolitan Branch of the Society of Medical Officers of Health pressed for a central laboratory, but testing facilities in London continued on a decentralized basis.66 _{The MAB functioned}

independently from the MOHs as admissions came through Poor law guardians in any district. But in November 1897 it was agreed that when there was no room for a diphtheria case, supplies of the serum should be given to the MOH or a general practitioner.67