Relaciones entre formas espaciales y procesos sociales

During the 1890s it was hoped that large-scale research institutions could have a major impact on public health. Paris and Berlin were competing as international centres of medical research. London lagged behind: science did not occupy the same importance in the medical profession, and there was less pressure to develop research institutes and teaching posts in new medical specialisms such as paediatrics. The establishment of the Pasteur Institute in 1888 represented an innovative model of a medical research institution

in a metropolitan centre. It was a private initiative, arising from the success of the anti-rabies serum, although it benefited from state and municipal grants. It was emulated in Berlin in 1891, when the Institute for Infectious Diseases was founded for Koch in order to develop his tuberculin therapy. The Institute was financed solely by the Prussian state. It was sited in the centre of Berlin, close to the Charité state hospital, whereas the Pasteur Institute was on the southern peripheries of Paris in the 15th arrondissement, owing to Pasteur’s wish for a spacious site. Koch’s Institute had clinical facilities, but the Pasteur Institute had only a public dispensary for anti-rabies serum.33

In 1889 the Lord Mayor of London chaired a fund to send cases of rabies to the Pasteur Institute (much to the horror of anti- vivisectionists who denounced Pasteur and his methods). At this time the only specialized research institute in London was the Brown Animal Welfare Institute, which had dual functions as an animal hospital and as a physiological research institute of London University. The Brown Institute was a target for anti-vivisectionists, however, as was the newly established laboratory of the Royal College of Surgeons.34 _{Plans for a privately funded British Institute}

of Preventive Medicine in 1893, to emulate the Pasteur Institute, also foundered on protests from the anti-vivisection lobby.35 _Thus,

while the Board of Trade refused to recognize it as a limited liability company, the public were reluctant to make donations.36 _Indeed

mass demonstrations by anti-vivisectionists broke out in 1894 when a donation of £25,000 was received by the Institute for a bacteriological laboratory, and production of diphtheria antitoxin. The fact that the Institute was to be sited in Chelsea hardly helped matters since there were known to be high death rates there as a result of the exploratory surgery conducted at the Chelsea Hospital for Women. Protesters stated that the Institute was liable to experiment on poor hospital patients repeating ‘the barbarities of the Pasteur Institute’.37 _{Anti-vivisection and voluntary initiatives,}

characteristics of Victorian London, hampered initiatives of medical researchers.38 _{Eventually, a site was secured in Chelsea Gardens,}

and the Institute opened in 1897—significantly later than its French or German counterparts. The next step was a private appeal for research funds—raising only £5,700 of which £5,000 were provided by Lord Iveagh of the Guinness family. The Institute only became solvent through a further donation from Lord Iveagh of £250,000 in 1903.39

EPIDEMIOLOGY

It has been important to discuss administrative structures before comparing the actual incidence of diphtheria. Reports by medical officers of health provide an uncertain indication of actual health conditions. As a notifiable disease in Berlin from 1884 and in London from 1889, there were statistics on both the incidence and the mortality from diphtheria. But notification was problematic as there was a high rate of children carrying diphtheria bacilli, but not showing any symptoms of the disease. The notion of diphtheria as a contagious disease was very much a product of nineteenth-century advances in pathology and bacteriology. The Registrar-General grouped diphtheria together with scarlet fever until 1859. Opinions differed over what constituted diphtheria and whether it was distinguishable from croup—a severe form of laryngitis. It was observed that the bacillus varied in virulence in different localities and over time. Many doctors preferred to rely for diagnosis on clinical observations rather than bacteriology. Moreover, the compulsory isolation and disinfection resulting from notification of the disease meant that there were incentives not to comply with regulations. On the other hand, the apparent rise in diphtheria occurred at a time when bacteriology and serum therapy were being introduced. Medical science created the possibilities for diagnosing diphtheria as a distinct disease and then created the possibilities of a specific ‘cure’.

Administrative structures varied. While local statistics of diphtheria mortality rates exist for London boroughs or Paris arrondissements, for Berlin there are aggregate mortality statistics by locality but no local data on specific diseases apart from those in the peripheral municipalities. Mortality rates also varied, so that contrasting trends can be discerned in different districts.40 _When

mortality in London was at a high point in 1893 with 76 per 1,000 living, in Paris deaths were plunging to an all-time low. In Paris diphtheria mortality rates fell from around 77 in 1890 to 18 in 1895.41 _{Deaths from diphtheria in Berlin reached 242 in 1883, but}

plunged to 34 in 1896.42

While there are statistics on the use of serum therapy in public hospitals, it is not always possible to find out about how soon the serum was administered and in what quantities. Patients often rushed to hospital suffering only from a mild sore throat. The antitoxin sera was administered without a diagnostic test, and numbers of

children who did not actually have diphtheria could boost the statistics of successful cures. A substantial proportion would in any case have recovered. Thus assertions as to the effectiveness of the serum therapy rightly encountered scepticism.43