A Concise History of Medicine By Sir. William Osler, M. D. F. R. S. Ml Regius Professor of Medicine in the University of Oxford PublisKecToy permission of the Encyclopaedia Americana Publishing Co. The Medical Standard Book Co. Baltimore, Md. Copyright 1919 by the Encyclopaedia Americana Publishing Co. HISTORY OF MEDICINE 7 HISTORY OF MEDICINE. Within the past three centuries the average working life of English-speaking men has doubled. A few lived as long as now, and some strong or favored ones had efficient working powers as long; but the common life was worn out in what is now middle age. In Shapespeare's time the 50's were venerable: "Old John of Gaunt, time-honored Lancaster/' was 58 when supposedly so addressed; and Ad- miral Coligny, murdered at 53, is de- scribed by bis contemporary biographer as a very old man. Now, when we hear of a death in the 60 s, we instinctively feel it an untimely cutting off, in what should be still fresh and vigorous age, and even at 80 it seems but just fair ripe- ness for the sickle. The three factors which have wrought this change are ad- vanced physical comfort, medicine and its handmaid hygiene, and surgery. And in the mitigation of the frightful mass of 8 HISTORY OF MEDICINE actual pain, of physical torment which has racked every age down to the pres- ent, and which has scarcely even been alleviated til>the past century, medicine stands incomparably first. Some good foundations hive been laid, it is true, in the century previous, and men were at work in the true scientific spirit. Great masters had stimulated their successors to study in the essential pre- liminary subjects, the constitution and functions of the body. The mighty Boer- haave of Holland (1668-1738) had revo- lutionized clinical observation; Morgagni of Italy (1682-1771) had "introduced an7 atomical thinking into medicine'' (Vir- chow), and had done something, the same service for pathology which Haller of Germany (1708-77) did a generation later for physiology; while John Hunter (1728- 93) had not only introduced capital im- provements into operative surgery, but had set the pace in research into anatomi- cal and physiological problems. But the HISTORY OF MEDICINE 9 influence of old theories, founded on guesses and imperfectly interpreted ob- servation, still lay heavy on the body of practitioners. The chief general theories in the 18th century were those of Wil- liam Cullen (1710-90) and his pupil and assistant, John Brown (1736-88), of the University of Edinburgh; the former- a great advance on the older theory of "humors/' and on the right track-made the nervous system the seat of diseases; the latter divided all diseases into two classes-the sthenic, resulting from over- excitation and treated by depletion, and the asthenic, resulting from under-excita- tion and treated by stimulation. On the Continent, Hahnemann (1755-1S43), his great theory propounded at Leipsic (1796- 1810), soon after took adverse ground in his "homeopathy-a very different thing from what later passed under the name, though the latter retained the underlying basis. Besides his "law of similars" which Hippocrates had formulated before him, he rejected theory utterly, declaring that 10 HISTORY OF MEDICINE it was impossible to know anything about pathological changes out of sight; that we can only know symptoms, and if those are removed it indicates of necessity that the disease which produced them must be gone, also. He also alleged that the fact of a given dose causing certain symp- toms in a healthy person was obvious proof that it must be too large for a sick one; further, that to possess healing power the dose must be too small for recognition by the senses or chemical analysis; and that trituration, or dilution and shaking of minute doses caused molecular changes which infinitely in- creased their power-"dynamization," he termed it. The exaggeration of symp- tomatics and empirics was a reaction against the current reliance on unbased theories; the paradox of infinitesimal doses, against the monstrous boluses and draughts with which patients were often gravely injured; there was usefulness in both reactions, but he went so far as to HISTORY OF MEDICINE 11 declare that a child could be cured while asleep by holding the pellets near it. But the reign both of guesswork theo- rizing and of groping empirics, as exclu- sive methods, was coming to an end, and the first great blow was delivered in the first year of the century. France now came to the front where other countries had thronged. Bichat, a genius, who wore himself out at 31, as did Clifford at 34, published the year before his death (1801) a work on general anatomy, in which he remade the entire science by showing that the different organs have membranes and tissues in common, and, therefore, that the seat ot disease was in the constituent tissues and not in the organs as such. This not only simplified anatomy and physiology in much the same way that the alphabet simplified hieroglyphics, but threw the investiga- tion of pathological changes into an en- tirely new channel. Parallel with this work, the followers in the footsteps of 12 HISTORY OF MEDICINE Morgagni were carrying on his work in studying morbid anatomy, the appear- ances of diseased organs; this, too, was remodeled on Bichat's discoveries. In 1808 and 1816 Broussais of Paris (1772- 1838) published valuable works whose theory is merely the sthenic and asthenic idea of Brown, but which led to renewed research in pathological anatomy and local ailments. Percussion had been de- vised by Auenbrugger of Vienna (1722- 1809) in 1761, and Corvisart of Paris (1755-1821) revived it; but a greater ef- fect was created by the introduction of auscultation (1816-19) by the Breton Laennec (1781-1826) at Paris, where he was Corvisart's pupil. He invented the stethoscope to diagnose diseases of the lungs, heart and abdominal organs, by means of alteration in the normal sounds of their action; and his own use of it, and observations on the diseases of these organs, were the greatest advance made in clinics since Boerhaave, and may be HISTORY OF MEDICINE 13 said to have founded modern clinical sci- ence. In 1827, Richard Bright at Lon- don (1789-1858) first published his recog- nition of the true nature of the kidney- disease since called by his name, and of the general characteristics of renal com- plaints, the foundation of our knowledge of them. A special branch of investigation and analysis in the first half of the century was in discriminating the continued fevers; one of the most active and anxious battle-grounds for practitioners and the- orists since modern medicine took its rise, though eruptive and malarial fevers were well differentiated. The first to be dis- criminated was typhoid, by Louis of Paris (1787-1872). His American pupils, W. W. Gerhard (1809-72- and Alfred Stille (1803), with C. W. Pennock (1799- 1867), all of Philadelphia, and George B. Shattuck, of Boston, proved that typhoid and typhus, theretofore loosely classed together, were independent diseases. 14 HISTORY OF MEDICINE though generated by similar causes. This was confirmed by the work of A. P. Stewart at Glasgow and Sir William Jen- ner at London. Dengue or break-bone fever, yellow and relapsing fevers, and their kind, were carefully studied. Among the other names associated with this labor are R. J. Graves (1797-1853) and William Stokes (1804-78) of Dublin, George Budd (1803-82) of London, and Daniel Drake (1785-1852), S. H. Dickson (1798-1872), and Austin Flint (1812-86) in America. This work was soundly based by 1860 in regard to fever clinics. Development in the United States.- When the 19th century opened there were only three medical schools in the United States, and only two of importance- those connected with Harvard College and the University of Pennsylvania-and only two general hospitals. Medical edu- cation was somewhat on a footing with divinity education; physicians took ap- prentices for some years, and clergymen HISTORY OF MEDICINE 15 took private pupils in divinity. Those who wished and could afford a more system- atic medical education went to London or Edinburgh. The literature of the pro- fession was English and (translated) French almost wholly; Rush and a few others had published books, but not of moment, and there were only two or three medical journals. There were but two medical libraries, except in private h^nds-those at the New York and the Pennsylvania Hospitals. The physicians of most reputation were Benjamin Rush and Philip S. Physick, of Philadelphia; David Hosack and Samuel L. Mitchill, of New York, and James Jackson and John C. Warren, of Boston. The smaller places did not lack for able men, though of less wide-spread repute, such as Daniel Drake, of Cincinnati, and Nathan Smith, founder of the medical schools both of Dartmouth and of Yale. But the great repute of the French medical investiga- tors in the first quarter of the century- Bichat, Corvisart, Laennec, Louis, etc.- 16 HISTORY OF MEDICINE took an increasing number of American students there, and the new spirit they brought back revolutionized American practice for a time. The enormous in- crease in American population, however, enlarged the demand upon its stock of medical knowledge far faster than that could be legitimately developed; educated physicians could not be turned out so fast as the thronging populace needed them, and it was the golden age of the half-educated. Perhaps, too, the masses had the same ideas of the needlessness of training in medicine as in public life. The machinery was multiplied indefi- nitely, and the product turned out de- preciated in proportion. Up to about 1870 the medical schools sprung up every- where, both public and private, and their competition for pupils degraded the stand- ard very low indeed. Diplomas were given for two years' work, and short sessions at that; and the instructors were sometimes as incapable of giving competent educa- tion as the authorities were unwilling to history of medicine 17 enforce severe study or careful experi- ment. The first place to exact a new and much higher standard was Harvard, about 1870. The rapidity with which the rest of the country, in the better institu- tions, followed its lead showed that there was a large instructed upper class which appreciated the need of thorough educa- tion in this as in other departments of knowledge, and understood that medicine was a great science as well as a delicate craft. As always, the rich were glad to give when they knew where to give in- telligently, and endowed generously both study laboratories and general and special hospitals. It would be a grateful task to enumerate these, did space permit; here can be mentioned only such names as Pierpont Morgan and Andrew Carne- gie, Johns Hopkins and Vanderbilt, Sims, Strathcona, Mount-Stephen, Payne and Lane. Methods of Investigation.-The last century, of course, did not invent experi- 18 HISTORY OF MEDICINE ment in medicine or physiology; the method was recognized by the great Greek and Latin physicians, used by the two great Bacons, Roger and Francis, fully developed by Harvey, and utilized with superb skill by Hunter. But though these great men did not lack sound ideas, they lacked tools and the mass of labora- tory facilities gradually built up in our age. The research laboratory is the de- velopment of the 19th century, and well along toward the middle of it. The work- ers in it experiment along three main lines -the condition and functions of the organs in a state of health; the nature of the functional changes produced by dis- ease, and the causes of the changes; and the prophylactic or curative agencies which can neutralize the disturbing agents. The results of these studies have created a new knowledge, which is to that of even 1800 like the relation of an adult to a baby. The physiological and pathological revelations have not merely left the knowledge accumulated in the HISTORY OF MEDICINE 19 previous centuries possessed of a merely archeological interest, but they have weaned us from the sway of any author- ity whatever; recognizing that even the seemingly soundest conclusions of the present are but working hypotheses, which may have to be abandoned at any time on fresh evidence-the true scientific spirit. No part of life has been left as it was, the digestive and assimilative, circu- latory, respiratory and excretory, repro- ductive and directive functions have all been illuminated by a flood of light. Es- pecially has this been wonderful in the study of the brain, whose functions not only are so intangible and elusive, but apparently so impossible of experimenta- tion without destroying the subject of experiment. Not only have we penetrated deep into the secrets of the paths and operations of sensory and motor impulses, the localization of functions, and the me- chanical implements of thought and mem- ory, but we have been enabled to apply with great success a number of curative 20 HISTORY OF MEDICINE measures not before dreamed of, or even if so, not deemed possible of use. Another marked feature of the age is the development of specialism, in which we have to set off a lack of co-ordination and breadth of knowledge or judgment against an extension of knowledge not possible by any other method. Scientifi- cally no other means has been so potent in extending and deepening the realm of demonstrated fact. Practically no other has been so effective in developing cura- tive processes. This specialism must not be confounded with that of the "lung doctors'' and "fever doctors'' of former days, mere guesswork empiricism of un- educated practitioners; it rests on a basis of competent general medical knowledge and thorough education in the specialty besides. The physicians who give their time and thought to one limited field- diseases of women, of children, of eyes and ears, of throat, of teeth, of the brain, or who, though less eclusively, choose HISTORY OF MEDICINE 21 diseases of the heart or the liver or other organs for their preferred field-have won for the profession some of its most signal triumphs. American physicians especially have stood at the very head of those who have perfected dentistry and opthalmol- ogy, as well as gynaecology or diseases of women. In this branch the blessings they have conferred not only on women in ordinary disease, but on both them, their male relatives, and their children, by the saving of life and health, in the special diseases of the sex, cannot be estimated. One of the finest branches of this spe- cializing is that of alienism, and the change in the mental attitude of the pub- lic toward it in consequence of that study has been most remarkable and gratifying. From a matter of derision, as it was largely in the Middle Ages, or ineffec- tual commiseration as an act of God, or mere terror and aversion, it has come to be sympathetically studied, often relieved, 22 HISTORY OF MEDICINE and always recognized as a mere func- tional disease. Starting from the labors of our own Rush, of the English Tuke, of the German Jacobi and Hasse, and the French Pinel and Esquirol, this reform has built up a body of physicians in every civilized country not only to study mental aberration scientifically, but to introduce humane and rational methods into its care and cure. America is not behind any other in the treatment of the insane; but the curse of so many good causes in America-politics-is a blight upon this science still in too many States. Prophylactics. - "Prevention is better than cure" has reached its most brilliant exemplification in the 19th century. It is true that nations far back in antiquity have grasped some of the chief condi- tions under which diseases most prevail, and have even carried systems of public hygiene much farther than even yet we have reattained to. Thfe law of Moses furnishes a remarkable example, in its HISTORY OF MEDICINE 23 insistence on cleanliness, isolation and diet; the Greeks systematised diet and exercise and general physical training thoroughly, their ideal being "the fair mind in the fair body" (and had discov- ered that professional athletes do not make good soldiers, from lack of endur- ance) ; the Romans and Greeks made the bath almost a fetish, far beyond even the English, and the public benefactor of the day gave his city baths, not libraries. But modern science goes much farther; it dis- cerns the causes which create the disease itself, and removes or neutralizes them. In the 18th century some light had been thrown on this: Howard had seen that typhus was in direct ratio to the crowded condition of jails, Captain Cook and Sir Gilbert Blaine had perceived and removed the conditions that generate scurvy. Jen- ner had gone still farther and anticipated the methods of modem preventive medi- cine by vaccination. But all these could only be feeble and groping attempts until there was a scientific basis for them. This 24 HISTORY OF MEDICINE was furnished by bacteriology, and a few words upon that are needed to make later explanations intelligible. THE BACTERIOLOGICAL BASIS OF PREVENTIVE MEDICINE. The ancients speculated with great eagerness and sometimes acuteness on the origin of life, and had guessed that dis- ease and living germs were in some way related; and the relation of disease and putrefaction was not doubted. As soon as the first weak crude microscope was invented, it was used to investigate the organisms of decay. The Jesuit Kircher in 1671 examined the "minute worms" in putrid milk and cheese and meat; in 1675 a Dutch merchant named Leeuwenhoek improved his lenses and studied the "ani- malcula" in rainwater, saliva, intestinal fluids, and putrid substances; and the physicians of his day were quick to sus- pect and suggest that these organisms might be the cause of all diseases. In HISTORY OF MFDICINH 25 1762 the Viennese Pleincz, who had studied fluids in all conditions, gave his firm adhesion to this belief. But this was not the whole; whence came these organ- isms-were they self-generated, or simply transmitted from other bodies and multi- plied? Despite even the microscope, the theory of spontaneous generation main- tained itself tenaciously far past the mid- dle of the century. A distinguished chem- ist maintained as the result of careful experiment that germs were so generated, and even the proof that the organisms were forms already existent did not con- vince him or his followers. It was re- served for Pasteur in 1861, and finally (with Koch and Cohn) in 1876, to crush this theory forever. Following quickly on the first came the^ discovery of the anthrax germ by Pollender and Davaine in 1863; shortly afterward Lister's epoch- making researches into wound infection, making possible the triumphs of antiseptic surgery; then swiftly followed the isola- tion of the germs of relapsing fever, lep- 26 HISTORY OF MEDICINE rosy and typhoid. But towering above all, from the enormous difficulties over- come, were Robert Koch's isolations of the tuberculosis germ in 1882, and of that of Asiatic cholera in 1884. Thence on a crowd of discoveries of the germs of other diseases have left but few-unfor- tunately, some of the worst-unrevealed, diseases of animals and insects having been investigated as well as those of men. Thus much for the history of discovery; but what are these germs? The popular mind is very confused on the subject. Bacteria are generally thought of as a sort of worm. In fact, they are not mem- bers of the animal, but the vegetable king- dom ; the smallest organisms known. They are protoplasm, a jelly-like substance, en- closed in a hard membrane exactly like wood fibre. They are classified by shape in three groups: Cocci (spherical), bacilli (rod-like), and spirilla (corkscrew or un- dulatory shape). The cocci are found in pairs, fours, clusters or chains; they in- HISTORY OF MEDICINE 27 elude the smallest known organisms, some of them being as small as 1/150,000 of an inch in diameter. The bacilli are larger, but vary much, from 1/25,000 to 1/4,000 o£ an inch inlength, and 1/125,000 to 1/16,000 in diameter; some of them have organs of locomotion, called flagella. The spirilla are longest of all, sometimes 1/600 of an inch. They all increase either by fission into twTo, or by developing a spore or seed. Their rate of multiplication does not seem rapid, but that is because we for- get our old arithmetical "catches." A bacterium dividing each hour, and each division thus dividing, would obviously have increased to 8,383,608 in 24 hours, and in three days to a number beyond all verbal expression, weighing nearly 7,500 tons. Of course, this is a reductio ad absurdum, as the body they feed on would be exhausted early in the series; but outside of starvation nature has other ways of arresting their multiplication. Before discussing this point, let us look at the nature of bacteria as a whole. It 28 HISTORY OF MEDICINE is a misapprehension to think of them simply as a principle of disease and death. They are a universal principle of life as well, and the few species which cause harm are lost in the myriads which do good. But for them organic existence would perish; it has been suggested that the first organic things on earth were bacteria-organisms needing only nitro- gen for support-and life means their multiplication. They abound in air and water, in the soil to nine feet deep or so, and in the outsides and insides of all organisms; but naturally their number varies with the conditions for sustaining existence, and there are none at extreme altitudes or in glacier ice, and few in the polar regions or the deep seas. Those conditions are (1) moisture, without, which all die; (2) air, as to which there are three classes-aerobes, which must have it; anaerobes, which must not have it, and facultative anaerobes, which care nothing either way; (3) food, which must be living tissues for a few, may be dead HISTORY OF MEDICINE 29 ones for most, and can be mineral salts or atmospheric nitrogen for some; (4) temperature, which has for possibilities of their multiplication, though not of their life, extremes of 32 and 170° F.; for an average most favorable tract 60 to 104°, and for disease germs (as evolution would imply) is most favorable 98.4°, or blood heat; (5) light, of which direct sun- light is death to all, and common day- light of no importance either way to most. Their enormous number gives them a power of accomplishment seemingly al- most miraculous, and certainly far super- human. The quality of farm products and dairy products, of fatted stock or wool, of hides or horn, and many other familiar articles, is due to them; and they are the scavengers of our water supply from pollution, as well as some of them deriving powers for harm from it. Still more to our surprise, peas and beans cer- tainly, and all plants probably, gain their life from the soil through the medium of 30 HISTORY OF MEDICINE bacteria which live in their roots, decom- pose nitrogenous minerals and feed on. atmospheric nitrogen also, turning both kinds over to the plant for its nourish- ment. Hence the processes of health and dis- ease alike are functions of bacteria. What medical science has specially to do is to trace the progress and manifestations of that spread of harmful bacteria commonly called "infection," and the methods by which the system's natural tendency to starve or poison them can be reinforced. Before entering upon the phases of pre- vention and cure, we must indicate briefly how they obtain entrance, how they pro- duce their effects, and what is the reac- tion of the body thereupon. The first is naturally limited in variety; they enter by being injected from the bites of animals or insects, from wounds or abrasions, from inhaling infected air, from eating or drinking substances con- taining them. Specific cases will be con- HISTORY OF MEDICINE 31 sidered later. The action of the microbes is by generating a set of poisons known as toxins, which produce either languor, loss of appetite, and vague general dis- comfort, or more active pains, headaches, fevers, inflammations of the tissues, per- haps entire stupor. The action of the body is complex and difficult, and not thoroughly worked out; but some things are known. The normal blood and tissues have a germicidal power, varying in dif- ferent bodies even of full health, and varying still more as to specific germs, each body having its own set of germs to which it is congenial or maleficent. The struggle of the body against their multi- plication, dependent on this unfavorable- ness of soil for their propagation, is called "general resistance/' and on its strength depends the immunity against ordinary disease; and the secret of inoculation is, that if the soil favorable to the propaga- tion of a specific bacterium is eaten up, it is usually very slow in fresh growth. The disease microbe gains no lodgment 32 HISTORY OF MEDICINE because there is nothing to live on. But in addition to this passive resistance, an active one is carried on by the white cells or '"leucocytes '-the wandering cells, and those of the tissues chiefly invaded, as well as those of the spleen and lymphatic, glands; these and others seem to work among the toxins and produce a change in their chemical constitution, at last elab- orating counter-poisons or antitoxins which neutralize the first, and enable the cells to carry on the war against the dis- ease microbes till one or other is over- come; and as said, if there is recovery, a partial or complete immunity is afforded against further ravages of the same class of microbe. But it is evident that if this process can be shortened and made more certain, so that the antitoxins can perform their work before the disease microbes arrive at all, a great system of prophylactic or preventive medication can be had; and if the antitoxins are used in a case of HISTORY OF MEDICINE 33 similar disease, they will strengthen the natural power of the body to develop them, and greatly aid it in throwing off the disease. This is the new system of serum-therapy, begun by Pasteur in 1877, and continued by a set of brilliant experi- menters since. The serum of the infected blood is chosen as a medium for injection into the blood of the patient. Pasteur with fowl cholera, Raynaud with cow-pox, Salmon and Smith in this country in 1886 with hog cholera, fully proved the pos- sibility of the treatment, curing animals previously inoculated with the most viru- lent disease poisons, and rendering healthy animals immune; but these ex- cited but languid interest till Behring's announcement in 1892 of a diphtheria antitoxin, with incontestable proof of its value. Oddly, not only laymen, but phy- sicians in many cases, opposed it; partly from misunderstanding, partly from hu- manitarianism as involving experiments on animals. Most of its opponents have now been won over, from the crushing 34 HISTORY OF MEDICINE weight of evidence, and the brilliant work of its supporters. Diphtheria alone has reduced its mortality one-half since the introduction of the serum treatment little more than a decade ago. To illustrate the general methods of preparing all the serums for infectious diseases, that of diphtheria will serve as a model. The bacilli are cultivated for eight or ten days in alkaline beef broth, found to develop a peculiarly virulent poison under its work; the toxin is then isolated and its strength precisely esti- mated, then set aside in sterilized vessels. A healthy horse, found by experiment the most suitable animal, has injected under the skin of its neck or forequarters 20 cubic cm. of toxin and perhaps half that of antitoxin, three times five days apart; then it is given heavier and heavier doses of toxin alone, a week apart, till it can endure doses speedily fatal at the outset. After two months it is bled and its serum tested; if satisfactory, it is dosed as before HISTORY OF MEDICINE 35 for another month, when the maximum quality of serum is usually reached. The animal is then bled sufficiently, the blood being caught in a sterilized vessel and placed in a refrigerator. The coagulation finished, the serum is drawn off from the clot and its strength accurately deter- mined in the laboratory, an antiseptic is added to keep it, and it is bottled for use. Antitoxins for tetanus and snake bite have been similarly prepared, and the present century will see probably every infectious disease and every venom with its bac- terial antidote. SPECIFIC RESULTS OF PREVEN- TIVE TREATMENT. An abstract of the work already done in preventive medicine can best be given by a note of the great maladies of men and animals more or less controlled by it, with their bacteria. But it must be noted that of the ones cited, the bacteria of smallpox and hydrophobia (though the 36 HISTORY OF MEDICINE former has been almost exterminated by vaccination), as well as scarlet fever and measles, have not yet been isolated. The reason may be excessively small size, since that of cattle pleuro-pneumonia is barely visible under the microscope; or it may be that the organisms are not bacteria, but unknown beings. The diseases may be classified variously and some admit no special classification, but we will begin with the great scourges past, and which have owed their virulence and destructiveness, though not their di- rect origin, to filth and overcrowding and general unsanitary conditions. (1) The Great Plague, or Bubonic Plague. The frightful devastations of this in the past need not be recited; it will be remembered that it was the "Black Death," which swept off from a third to a half the population of Europe in the latter part of the 13th century. Long thought almost extinct, it reappeared with HISTORY OF MEDICINE 37 fearful intensity at Hong-Kong in 1894, spread to India and had several occa- sions of violent outbreak, raged in Turkey and on some parts of the Mediterranean coast, and in small volume has shown it- self in Glasgow, South American ports, New York and San Francisco. But in Western Europe and America it has been easily put down, and serum inoculation has been fairly successful in India. Its bacillus is known to enter the body by wounds of the skin, and very largely by bites of fleas from infected rats. (2) Asiatic Cholera. This terrible plague, even in the middle of the 19th century, swept away thousands of lives in America; now it has been so thoroughly controlled that it is not feared even to the extent of disturbing commerce when it appears. It originated on the banks of the Ganges in India, where Koch found its spirillum and the means of its spread- almost entirely through drinking infected water, though very slightly by contact- 38 HISTORY OF MEDICINE so little that since 1873 the disease in Great Britain and the United States has never got farther than the port of entry. How thoroughly a city's immunity de- pends on its water supply is strikingly shown by the twin city on the Elbe in. 1892; Hamburg using the unfiltered river water, had about 18,000 cases and 8,000 deaths; Altona, with a filtration plant, had 516 cases, largely refugees from Hamburg. (3) Typhus Fever. It is hard to be- lieve that this was once so steady and frightful a curse in the West that one in- vestigator says its history would be that of Europe. In all the large cities, in camps and ships, hospitals and jails, it was almost permanent, and its rate of mortality appalling. It depended so en- tirely on filth and over-crowding that mere city sanitation and cessation of pack- ing, sewers and a good water supply, have practically exterminated it except in a few slums. The rate has been reduced in England from 1,228 per 1,000,000 in HISTORY OF MEDICINE 39 1838 (typhus and typhoid together, not then discriminated) to 137 typhoid and 3 typhus. (4) Typhoid Fever. This disease, long identified with typhus, is now not only known to be separate, but dependent on somewhat different generating conditions. It depends not so much on dirt and crowd- ing as on sewer gases and contaminated water and milk. Given pure water and perfect drainage, a city practically has no typhoid, except when its milk supply is drawn from infected sources, as often happens; while seaside resorts are notori- ous generators of the disease, from the sand-driven wells and the crowded privies draining ino them. The germ was dis- covered by Eberth in 1880, and called bacillus typhosus. The continued prev- alence of the disease in our cities is due partly to the great hardiness of the bacil- lus, which can exist in the body of a patient long after recovery, and be a means of contamination. The outbreak 40 HISTORY OF MEDICINE in the Spanish-American war seemed due to overcrowding, but more likely to the contaminations caused by it, as in the sea- side cases. In the country districts there is no mystery about it; often there is no rural sanitation, and even the wells are grossly neglected, sometimes on a slope below a barn. In the typical example at Plymouth, Pa. (about 8,000 people), the evacuations of a typhoid patient were thrown out during the winter on the banks of a stream which fed the town reservoir; the spring thaw carried them into it, and the own had a typhoid epi- demic which struck down 1,200 people. The proper precautions are the use of boiled water, and of distilled-water ice, the thorough inspection of dairy sur- roundings and water sources, and great care on the part of physicians and nurses to disinfect discharges, are the true pro- phylactics. (5) Diphtheria. This bacillus was dis- covered in 1883-4 by Klebs and Loeffler, and has been given their joint names; it HISTORY OF MEDICINE 41 enters either by inhalation or the stomach. The antitoxins thus made possible of prep- aration have reduced the mortality one- half ; the hygienic precautions have great- ly reduced the primary prevalence. The latter are isolation and disinfection, watch- fulness during convalescence, careful ex- amination of the least throat disorder, and -since the mild and often unsuspected cases where the children go about and to school freely are the worst in spreading disease, because not guarded against- regular inspection of school children's throats. Children's teeth and mouths should also be carefully attended to, and the tonsils removed where tonsilitis is frequent. (6) Yellow Fever. The germ of this has not yet been isolated. Its dependence on dirt, however, would seem almost as close as typhus, thorough sanitation hav- ing practically eradicated it in its favorite tropic home, Havana, and in the Southern cities once ravaged by it. Jamaica has been almost freed from it in the same way. 42 HISTORY OF MEDICINE (7) Smallpox. This once widespread and sometimes destructive scourge, al- most more dreaded for life than for death, has been so nearly eradicated by vaccina- tion, and vaccination alone, that the per- sistence of a strong section of the com- munity opposed to it is one of the strang- est of phenomena. The evidence is over- whelming. Wherever smallpox breaks out it is in an unvaccinated district, country, or body of people, and the fatalities are almost all among the unvaccinated and never among the re-vaccinated; where two bodies of men lie side by side under the same conditions, as the French and German armies in 1871, the vaccinated body scarcely suffers, the unvaccinated one is decimated; and in Egypt, where the natives are compulsorily vaccinated and the foreigners escape it, the fatalities are five foreigners to three natives, though the latter are far poorer, worse housed and fed and medically cared for, and would naturally be supposed the chief victims. If all the people of a country HISTORY OF MEDICINE 43 were vaccinated, and re-vaccinated at fair intervals, the disease would absolutely disappear, as it has in the German army; it is the ones who escape vaccination that maintain its existence. The ravages still among the unvaccinated French-Cana- dians are a constant example of what it has been. For instance, on April 1, 1885, there was a smallpox death in the Mont- real Hospital, the Hotel Dieu; the pa- tients who had not had it were sent home; the disease spread like wildfire, and by the end of the year 3,164 persons died of it, the city's business for the winter was destroyed, and the loss was millions. It has been proved that not above one in 100 of the vaccinated takes the disease when exposed, and almost none die; of the unvaccinated, fully 99 per cent take it and 25 to 30 die. It must be remembered, however, that there cannot be perfect se- curity without frequent re-vaccination, as the power of the cow-pox varies with dif- ferent persons and is rarely permanent, sometimes not over a year or two. With 44 HISTORY OF MEDICINE animal lymph there is no danger of the introduction of other diseases, the fear of which is made an excuse for refusal. (8) Tuberculosis (including "consump- tion" of the lungs), called by Holmes the "white plague" ; the most destructive sin- gle agency of death, and responsible for 120,000 deaths a year in the United States, more than all other infectious diseases to- gether, except pneumonia. Formerly be- lieved hereditary (the truth in a very slight degree), it is now known to be the product of a bacillus, isolated by Koch in 1880-2; and the hereditary conditions are mainly environment, with some tendency to anaemia. The communication, though in a few cases by infected milk, in the overwhelming mass proceeds by inhala- tion of the particles of dried sputum from other consumptives' lungs, blown about in the dust of streets or houses, or even wards of hospitals. Naturally, the great- est mortality is in places where free circu- lation of air is not possible, as jails and HISTORY OF MEDICINE 45 "institutions.'' Nature seems to have pro- vided for the largest possible distribution of them; one patient not in extremes has been known to give off from two to four thousand millions of germs in 24 hours; they are shaken from handkerchiefs, from the beard or mustache, from the furniture and other things handled oy consump- tives, beaten up from contaminated floors. So universally diffused are they that it seems probable there are few persons who have not some tuberculous lesion of some organ, for it is not confined to the lungs. The great weapons against it are, first, maintaining the standard of nutrition and cleanliness as high as possible; with care- ful protection of the chest; second, the education of the public in the dangers of the dried sputa; third, enforcement of notification and registration of cases; fourth, public sanatoriums for treatment of early cases; fifth, special hospitals for incurables. Immense progress has already been made; the rate in Massachusetts, one of the chief seats of the disease, has fallen 46 HISTORY OF MEDICINE from 42 to under 21 per 1,000 since 1853; and in New York, Glasgow, and other great cities the drop has been similar. (9) Pneumonia. Frankel in 1886 iso- lated this germ, a coccus growing in pairs and chains and entering by inhalation, and with one-fifth of healthy persons present, in the saliva. This is almost the one dis- ease which has not diminished under med- ical and hygienic science, and has appa- rently increased, ranking next to con- sumption in deadliness. It is especially a disease of languid circulation, as in the aged (their typical disease) and invalid and the intemperate; but it lays low vast numbers of the strong as well. The treat- ment has been revolutionized from the bottom, but still from one-fifth to one- fourth of all attacks are fatal. Thus far the most valuable novelties have been measures to prevent sudden heart failure. (10) Malaria. Till a generation ago this was one of the obscurest diseases on our list; it still remains one of the worst HISTORY OF MEDICINE 47 drawbacks to civilization, preventing gen- eral Caucasian settlement in the tropics. It was know to have an intimate connec- tion with wet ground, marshes or the building up and sewering of new districts; to prevail chiefly in the fall, and be caught chiefly from dusk to dawn, and to be non- contagious. But nothing more was known till M. Charles Laveran, a French surgeon who had gone to Algeria specially to study the diseases, discovered the germs in the red blood-corpuscles of patients; not bacteria, but small protoplasmic bodies which begin as transparent rings inside the corpuscle, feed and enlarge on its coloring matter and form blackish grains from it, and on attaining a certain size divide and redivide in vast multi- tude, giving off a toxin which causes the acute spasm of fever, and apparently of chill also. Each variety of the fever is caused by a special form of the parasite. It was suggested by Dr. Patrick Manson, of London, that the communicating agent might be mosquitoes, also products of wet 48 HISTORY OF MEDICINE! ground and active after dusk; and an army surgeon of India, Ross, found that mosquitoes did transmit similar parasites between birds-developing them in their stomach cells into filary bodies, which pass into the saliva and so through bites into the bodies of others. It is now thor- oughly established that this is the chief means of transmission among human be- ings. The mosquito is not the common culex of the Northern United States, but chiefly the anopheles, which develops and transfers the parasites as just described. The crucial experiments are, that these mosquitoes, allowed to bite malarial pa- tients, and subsequently healthy persons in non-malarious regions, infect the lat- ter, and that in the deadly campagna around Rome, two persons during the worst season, from June 1 to September 1, 1900, lived entirely immune by simply keeping behind tight netting after dusk, while exposing themselves freely during the daytime. The net result is, that swamps and stagnant pools should be HISTORY OF MEDICINE 49 drained, that persons having malaria should be thoroughly treated with quinine so that they may not transmit the disease if bitten by mosquitoes, and that Europeans can live in the worst districts by not being out after dusk and by thoroughly wiring their houses. (11) Venereal Diseases. These are in one respect by far the worst of all we have to mention, for they are the only ones transmitted in full virulence to inno- cent children, to fill their lives with suf- ferring, and which involve equally inno- cent wives in the misery and shame. In the victim the infection does not stop with the parts originally affected; and it has not been seriously checked, from the na- ture of its causes making it impossible for society to stamp out or much diminish the actions which involve it. Physicians and the public have each solemn duties in this matter; the former, to act as apos- tles of continence, especially with the bachelors who pretend to believe that 50 HISTORY OF MEDICINE their health needs the indulgence and will not marry, and to use every effort to pre- vent the disease being carried to others; the latter to let no scruples of delicacy or affected ignorance stand in the way of thorough public supervision. The op- position to this is natural; women feel it adding an unfair stigma to an already shameful load of injustice; decent people feel that legal recognition is legal pallia- tion and defense; and there is the real danger shown by experience, that if it is once shielded by law, the weight of the police force will be thrown on the side of protecting instead of abating houses of ill-fame, as with liquor saloons, but with far more disastrous results. But any risk is preferable to the present shocking conditions, which make city brothels a stream of contamination to what should be the purest of homes. (12) Puerperal Fever. Remembering not merely the former fatality of this dis- ease-terribly frequent in private prac- HISTORY OF MEDICINE 51 tice, and in maternity institutions rising from five even to ten per cent-but the double bereavement it usually involves, the almost entire extermination of this disease is one of the grandest triumphs of modern medicine. Its contagiousness had long been suspected, when Oliver Wendell Holmes in 1843 published a full and clear statement of the facts leading to the belief; but for many years the pro- fession generally scouted it-a wit and poet could be no authority in medical science. Others gradually took his view; but it was the Lister antispectic treatment which enabled it to be fully tested. Now the mortality is but about one-third of one per cent. (13) Hydrophobia. This disease, though widely distributed among animals, is not very common among human beings in America, but excites a widespread hor- ror from the multitude of pets, any one of whom may chance to be stricken and to communicate it; in Europe it is less 52 HISTORY OF MEDICINE rare. The germ has not been isolated, but Pasteur ascertained its calculable ef- fects on the nervous system and that cer- tain inoculations could render healthy animals immune and neutralize a powerful dose of the virus. He founded an insti- tution in Paris for its treatment, and the mortality among those bitten by certainly rabid animals was reduced to less than one-half of one per cent. In dogs, quar- antine and muzzling are the only precau- tions. (14) Leprosy. This is caused by a bacillus which probably enters the body through abrasions of the skin, and prob- ably only from contact with another per- son ; even so, it is but slightly contagious, contrary to the popular notion. It was discovered by Hansen in 1879, and since then an active and very hopeful investi- gation into prophylactic conditions has been carried on. Known to be old and widespread in Asia, it is not generally known that it came into San Francisco HISTORY OF MEDICINE 53 with the Chinese, that the Norwegians have given it a considerable foothold in the Northwest, and that in Louisiana there is an endemic condition of it, and slightly in some other Southern States. It exists in New Brunswick likewise. Still more important for the United States is its great abundance in Hawaii and the Phil- ippines. It can be readily kept in check by segregation and inspection. Some other bacilli may be mentioned, of which the discovery has not as yet been followed by large results in preven- tion. The deadliest known is that of lock- jaw or tetanus, discovered by Nicolaier in 1884; it enters by wounds, and in some tropic parts all lesions tend to develop tetanus as surely as other sections do gangrene. Influenza, or "the grip/' has one of the smallest bacilli known; it is spread by dried nasal discharges, and enters by the nasal tracts. Anthrax is a disease mainly 54 HISTORY OF MEDICINE of cattle and sheep. Its bacilli were the first micro-organisms of disease to be iso- lated, and can enter either by inhalation, infected food or abrasions. Changes in Therapeutic Method.-It is only restating the same fact to say that new practice has followed on new theory, or, rather, new scientific knowledge of the nature of diseases. The only object of acquiring the knowledge was to em- body it in practice. With the discovery of the zymotic principle in disease, traced finally to bacterial action, there could not be the same or like treatment as when the body was supposed to be possessed by conflicting "humors"; or when a fever was supposed to be an abnormal increase of vital fluids needing to be drained off; or when diseases were supposed to have no relation to any function of the body ex- cept the organs furnishing the dominant symptoms; or when one school supposed them waves of some sort, to be overborne by more powerful waves of the same class, HISTORY OF MBDICINB 55 and another school refused to entertain any theoretical suppositions at all, but relied on the history of cases, printed or traditional or experimental. But it may be said that the greatest revolution in the century, or at any rate the last half of it, is in the position assigned to drugs. At the outset the old faith in bleeding still held great sway; Boerhaave himself had made almost the whole art of medi- cine consist in its proper application, and at the end of the 18th century Washing- ton had been sacrificed to it. But by the middle of the century it began to dimin- ish. Both the homeopahic and the regu- lar schools based their practice, and many still base it, on the study and adminis- tration of drugs. They differed in the size and strength of doses, from huge boluses, or powders or draughts whose efficacy was supposed to be in proportion to their nauseousness, to small bland tri- turations or dilutions; but not in the as- sumption that in them lay the one effi- cient method of dealing with disease. 56 HISTORY OF MEDICINE The advanced school of the present does not discard medicines; so far from it, it studies them with more care than ever, and values a few, well-tried and certain of quality and action, as highly as ever. It knows the mass of current medicines to be inert or worse, uncertain of action and applied to human functions of still more uncertain action; but it seeks to study thoroughly and apply scientifically the few real medicines or healing agents which must be used-quinine and digi- talis, and opium, iron and mercury and iodide of potassium, etc.-instead of a swarm of dubious and varying materials. It is significant that some of the stand- bys are extremely old; iodine, as ashes of burnt sponge, was known in classic times, and ergot impressed its peculiar action on stockraisers' minds from very early ages; even Peruvian bark is nothing new. We have not as yet made as many additions to the stock of panaceas as we might. But chemistry has done vast services for us, and will probably do far more. Aside HISTORY OF MEDICINE 57 from the discovery of new substances like cocaine, it has given us the active prin- ciples, of calculable strength and purity, in place of crude drugs of varying strength at best, and of varying purity and age; and there is no reason why we may not have new specifics as sure (and for as important diseases) as quinine. But the new school does not feel itself under obligation to give any medicines whatever, while a generation ago not only could few physicians have held their prac- tice unless they did, but few would have thought it safe or scientific. Of course, there are still many cases where the patient or the patient's friends must be humored by administering medicine or alleged medicine where it is not really needed, and indeed often where the buoy- ancy of mind, which is the real curative agent, can only be created by making him wait hopefully for the expected action of medicine; and some physicians still can- not unlearn their old training. But the 58 HISTORY OF MEDICINE change is great. The modern treatment of disease relies very greatly on the old so-called "natural" methods, diet and ex- ercise, bathing and massage-in other words, giving the natural forces the full- est scope by easy and thorough nutrition, increased flow of blood, and removal of obstructions to the excretory systems or the circulation in the tissues. One nota- ble example is typhoid fever. At the out- set of the 19th century it was treated with "remedies" of the extremest violence -bleeding and blistering, vomiting and purging, and the administration of anti- mony and mercury and plenty of other heroic remedies. Now the patient is bathed and nursed and carefully tended, but rarely given medicine. This is the result partly of the remarkable experi- ments of the Paris and Vienna schools into the action of drugs, which have shaken the stoutest faiths, and partly of the constant and reproachful object-les- son of homeopathy. No regular physician would ever admit that the homeopathic HISTORY OF MEDICINE 59 preparations, '"infinitesimals," could do any good as direct curative agents; and yet it was perfectly certain that homeo- paths lost no more of their patients than others. There was but one conclusion to draw-that most drugs had no effect whatever on the diseases for which they were administered. These "natural methods" have been in- dicated above; but some further analysis of the individual elements is worth while. It will be noted that this is not, as a hasty reader might assume, the discard- ing of all the results of civilization and a return to barbarism. That the natural methods are efficient is precisely because scientific knowledge and modern improve- ments in appliances, as well as the thou- sand civilized devices for comfort and cleanliness, unattainable even a genera- tion ago, have raised them to the level of first-rate therapeutic agents. Perhaps foremost in the rank is the trained nurse, who is not only a greater 60 HISTORY OF MEDICINE agent of philanthropy than many pro- fessed altruists, but sets free the physi- cian from a load of care and anxiety. In place of ignorant and stubborn, usually conceited and often superstitious women, who pride themselves on defying all the doctor's commands, these intelligent and loyal women can be relied on to carry out all his injunctions, to watch care- fully for indications of danger, and to furnish notes enabling him to view the progress and hourly changes of a critical case. The importance of diet in therapy, and indeed in the preservation of health be- fore the system becomes a subject for the physicians, has never been wholly lost sight of; but at no time has it been so thoroughly recognized, so firmly insisted on, raised to so high a place in therapeutic agencies. Too much food, improper or ill-prepared food, over-haste in eating, all have their part in the dyspepsia which is a byword among foreigners as the na- HISTORY OF MEDICINE 61 tional malady, and though much lessened, is still most formidable. Over-eating, too, is largely responsible for the prevalent Bright's disease and degeneration of the arteries. Sweetmeats and the mixtures of the drug stores, ice-cream soda and artificial flavors, are other potent causes; especially among girls is the eating of candies between meals. The business man's five-minute meal at the lunch coun- ter saves his business time often to the permanent ruin of his health. The question of alcoholic drinks is usually left to the forum of morals or politics; but it has a serious bearing on health, though not nearly so much as one or two gen- erations ago. The introduction of light beers has not only lessened drunkenness, but organic diseases of the liver, stomach, heart and arteries. Few influences on general health have been greater or more beneficial than the enormous multiplication of the means of cheap enjoyable outdoor exercise in 62 HISTORY OF MEDICINE America within the past generation. Owing to the climate, it is much harder to keep up habits of steady exercise here than in Europe, and unless there can be sociability with it, most people will not put themselves under the stress. We have not been a people addicted to sport and play, and formerly there were not suffi- cient means provided for us. Now tennis and golf, and the bicycle and their kind are improving the constitutions, espe- cially the nervous condition, of vast num- bers. Of course, there must be judgment in these matters, and probably some elderly people injure themselves by in- dulging in severe athletic sports only fit for young people with sounder tissues. Massage need only be mentioned; its aim is primarily to remove obstructions to circulation. The normal blood should be sufficient to establish normal bacterial and other conditions, and massage gives it the freest play. The essence of bath- ing, called when practiced scientifically HISTORY OF MEDICINE 63 "hydrotherapy/' is the same, save that its special function is to free the ob- structed perspiratory system. To these might be added a fourth, which in some sense is the most natural of all; for it has been practiced in ages more remote by many thousands of years than the suspicion of either of the others, and by savages almost at the bottom of the human scale; that is, some form of suggestion or hypnosia. The main diffi- culty of this sort of treatment is that so little has been done to make it utilizable in practice, or to provide any certain means of assuring a definite result. An- other is, that as with all the forms of men- tal science, its vagueness, its mystery, the impossibility of regulating its manifesta- tions, surround it with so hopeless an atmosphere of fraud and of that open- mouthed credulity which irresistibly in- vites fraud. Yet after all, the psychical method has always played an important, though largely unrecognized, part in 64 HISTORY OF MEDICINE therapeutics. It is from faith, which buoys up the spirits, sets the blood flow- ing more freely and the nerves playing their parts without disturbance, that a large part of all cures arises. Despond- ency, or lack of faith, will often sink the stoutest constitution almost to death's door; faith will enable a bread pill or a spoonful of clear water to do almost mira- cles of healing, when the best medicines have been given over in despair. The basis of the entire profession of medicine is faith in the doctor and his drugs and his methods. This is no new discovery; it was said by Galen that "he works the most cures in whom most have faith"; and the doctor-chemist-charlatan Para- celsus, who died of taking a universal panacea too poisonous even for his con- fidence, told his patients to have full faith and a strong imagination, and they would see the effects of it. The subject of hypnotism, originally called mesmerism from its 18th century HISTORY OF MEDICINE 65 describer and practicer, can only be touched upon. Different practitioners have had such varying results from its use as to suggest that here, too, the personal equation is very important. Braid of Manchester, England, who first made a scientific study and attempt at utilizing it, was not successful; while an English sur- geon in India, Esdraile, was highly suc- cessful, performing 268 operations on patients, with all the effect of anaesthetics, not then introduced. Its possibilities have been greatly exaggerated, not so much by the claims of the persons using it (ex- cept impostors) as by the eager credulity of the public. It seems not so much to create a new condition of sensitiveness to suggestion, as to increase what normally exists. In organic disease it is practically useless. Its great service has been found to be in various affections which may all be classed as of the nervous system; hys- teria, spasmodic functional complaints, children's vicious habits, and the victims of the drug and alcohol habits; occasion- 66 HISTORY OF MEDICINE ally in childbirth and surgery, but it is precarious and not free from serious dan- gers. It should no more be practiced without witnesses present than dentists give nitrous oxide, and the law should re- strict its practice to special licensees or physicians of a certain grade. WILLIAM OSLER, M. D., Regius Professor of Medicine, Oxford University.