Chapter XIII: Introduction (2)

_Hydrophobia._—Rabies, a remarkable, and in certain countries a widespread, disease of animals, when transmitted to a man by the bite of rabid dogs, wolves, etc., is known as hydrophobia. The specific germ is unknown, but by a series of brilliant observations Pasteur showed (1) that the poison has certain fixed and peculiar properties in connection with the nervous system; (2) that susceptible animals could be rendered refractory to the disease, or incapable of taking it, by a certain method of inoculation; and (3) that an animal unprotected and inoculated with a dose of the virus sufficient to cause the disease may, by the injection of proper anti-rabic treatment, escape. Supported by these facts, Pasteur began a system of treatment of hydrophobia in man, and a special institute was founded in Paris for the purpose. When carried out promptly the treatment is successful in an immense majority of all cases, and the mortality in persons bitten by animals proved to be rabid, who have subsequently had the anti-rabic treatment, has been reduced to less than one-half per cent. The disease may be stamped out in dogs by careful quarantine of suspected animals, and by a thoroughly carried out muzzling order.

_Malaria._—Among the most remarkable of modern discoveries is the cause of malarial fever, one of the great maladies of the world, and a prime obstacle to the settlement of Europeans in tropical regions. Until 1880 the cause was quite obscure. It was known that the disease prevailed chiefly in marshy districts, in the autumn, and that the danger of infection was greatest in the evening and at night, and that it was not directly contagious. In 1880 a French army surgeon, Laveran, discovered in the red blood-corpuscles small bodies which have proved to be the specific germ of the disease. They are not bacteria, but little animal bodies resembling the amœba—tiny little portions of protoplasm. The parasite in its earliest form is a small, clear, ring-shaped body inside the red blood-corpuscle, upon which it feeds, gradually increasing in size and forming within itself blackish grains out of the coloring matter of the corpuscle. When the little parasite reaches a certain size it begins to divide or multiply, and an enormous number of these breaking up at the same time give off poison in the blood, which causes the paroxysms of fever. During what is known as the chill, in the intermittent fever, for example, one can always find these dividing parasites. Several different forms of the parasites have been found, corresponding to different varieties of malaria. Parasites of a very similar nature exist abundantly in birds. Ross, an army surgeon in India, found that the spread of this parasite from bird to bird was effected through the intervention of the mosquito. The parasites reach maturity in certain cells of the coats of the stomach of these insects, and develop into peculiar thread-like bodies, many of which ultimately reach the salivary glands, from which, as the insect bites, they pass with the secretion of the glands into the wound. From this as a basis, numerous observers have worked out the relation of the mosquito to malaria in the human subject.

Briefly stated, the disease is transmitted chiefly by certain varieties of the mosquito, particularly the _Anopheles_. The ordinary _Culex_, which is present chiefly in the Northern States, does not convey the disease. The _Anopheles_ sucks the blood from a person infected with malaria, takes in a certain number of parasites, which undergo development in the body of the insect, the final outcome of which is numerous small, thread-like structures, which are found in numbers in the salivary glands. From this point, when the mosquito bites another individual, they pass into his blood, infect the system, and in this way the disease is transmitted. Two very striking experiments may be mentioned. The Italian observers have repeatedly shown that _Anopheles_ which have sucked blood from patients suffering from malaria, when sent to a non-malarial region, and there allowed to bite perfectly healthy persons, have transmitted the disease. But a very crucial experiment was made a short time ago. Mosquitoes which had bitten malarial patients in Italy were sent to London and there allowed to bite Mr. Manson, son of Dr. Manson, who really suggested the mosquito theory of malaria. This gentleman had not lived out of England, and there is no acute malaria in London. He had been a perfectly healthy, strong man. In a few days following the bites of the infected mosquitoes he had a typical attack of malarial fever.

The other experiment, though of a different character, is quite as convincing. In certain regions about Rome, in the Campania, malaria is so prevalent that in the autumn almost every one in the district is attacked, particularly if he is a new-comer. Dr. Sambron and a friend lived in this district from the 1st of June to the 1st of September, 1900. The test was whether they could live in this exceedingly dangerous climate for the three months without catching malaria, if they used stringent precautions against the bites of mosquitoes. For this purpose the hut in which they lived was thoroughly wired, and they slept with the greatest care under netting. Both of these gentlemen at the end of the period had escaped the disease.

The importance of these studies cannot be overestimated. They explain the relation of malaria to marshy districts, the seasonal incidence of the disease, the nocturnal infection, and many other hitherto obscure problems. More important still, they point out clearly the way by which malaria may be prevented: First, the recognition that any individual with malaria is a source of danger in a community, so that he must be thoroughly treated with quinine; secondly, the importance of the draining of marshy districts and ponds in which mosquitoes breed; and, thirdly, that even in the most infected regions persons may escape the disease by living in thoroughly protected houses, in this way escaping the bites of mosquitoes.

_Venereal Diseases._—These continue to embarrass the social economist and to perplex and distress the profession. The misery and ill-health which they cause are incalculable, and the pity of it is that the cross is not always borne by the offender, but innocent women and children share the penalties. The gonorrhœal infection, so common, and often so little heeded, is a cause of much disease in parts other than those first affected. Syphilis claims its victims in every rank of life, at every age, and in all countries. We now treat it more thoroughly, but all attempts to check its ravages have been fruitless. Physicians have two important duties: the incessant preaching of continence to young men, and scrupulous care, in every case, that the disease may not be a source of infection to others, and that by thorough treatment the patient may be saved from the serious late nervous manifestations. We can also urge that in the interests of public health venereal diseases, like other infections, shall be subject to supervision by the State. The opposition to measures tending to the restriction of these diseases is most natural: on the one hand, from women, who feel that it is an aggravation of a shocking injustice and wrong to their sex; on the other, from those who feel the moral guilt in a legal recognition of the evil. It is appalling to contemplate the frightful train of miseries which a single diseased woman may entail, not alone on her associates, but on scores of the innocent—whose bitter cry should make the opponents of legislation feel that any measures of restriction, any measures of registration, would be preferable to the present disgraceful condition, which makes of some Christian cities open brothels and allows the purest homes to be invaded by the most loathsome of all diseases.

_Leprosy._—Since the discovery of the germ of this terrible disease systematic efforts have been made to improve the state of its victims and to promote the study of the conditions under which the disease prevails. The English Leprosy Commission has done good work in calling attention to the widespread prevalence of the disease in India and in the East. In this country leprosy has been introduced into San Francisco by the Chinese, and into the Northwestern States by the Norwegians, and there are foci of the disease in the Southern States, particularly Louisiana, and in the province of New Brunswick. The problem has an additional interest since the annexation of Hawaii and the Philippine Islands, in both of which places leprosy prevails extensively. By systematic measures of inspection and the segregation of affected individuals the disease can readily be held in check. It is not likely ever to increase among native Americans, or again gain such a foothold as it had in the Middle Ages.

_Puerperal Fever._—Perhaps one of the most striking of all victories of preventive medicine has been the almost total abolition of so-called child-bed fever from the maternity hospitals and from private practice. In many institutions the mortality after child-birth was five or six per cent., indeed sometimes as high as ten per cent., whereas to-day, owing entirely to proper antiseptic precautions, the mortality has fallen to three-tenths to four-tenths per cent. The recognition of the contagiousness of puerperal fever was the most valuable contribution to medical science made by Oliver Wendell Holmes. There had been previous suggestions by several writers, but his essay on the “Contagiousness of Puerperal Fever,” published in 1843, was the first strong, clear, logical statement of the case. Semmelweis, a few years later, added the weight of a large practical experience to the side of the contagiousness, but the full recognition of the causes of the disease was not reached until the recent antiseptic views had been put into practical effect.

THE NEW DISPENSATION IN TREATMENT

The century has witnessed a revolution in the treatment of disease, and the growth of a new school of medicine. The old schools—regular and homœopathic—put their trust in drugs, to give which was the alpha and the omega of their practice. For every symptom there were a score or more of medicines—vile, nauseous compounds in one case; bland, harmless dilutions in the other. The new school has a firm faith in a few good, well-tried drugs, little or none in the great mass of medicines still in general use. Imperative drugging—the ordering of medicine in any and every malady—is no longer regarded as the chief function of the doctor. Naturally, when the entire conception of the disease was changed, there came a corresponding change in our therapeutics. In no respect is this more strikingly shown than in our present treatment of fever—say, of the common typhoid fever. During the first quarter of the century the patients were bled, blistered, purged and vomited, and dosed with mercury, antimony, and other compounds to meet special symptoms. During the second quarter, the same, with variations in different countries. After 1850 bleeding became less frequent, and the experiments of the Paris and Vienna schools began to shake the belief in the control of fever by drugs. During the last quarter sensible doctors have reached the conclusion that typhoid fever is not a disease to be treated with medicines, but that in a large proportion of all cases diet, nursing, and bathing meet the indications. There is active, systematic, careful, watchful treatment, but not with drugs. The public has not yet been fully educated to this point, and medicines have sometimes to be ordered for the sake of the friends, and it must be confessed that there are still in the ranks _antiques_ who would insist on a dose of some kind every few hours.

The battle against poly-pharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into bodies of the action of which we know less), has not been fought to a finish. There have been two contributing factors on the side of progress—the remarkable growth of the skeptical spirit fostered by Paris, Vienna, and Boston physicians, and, above all, the valuable lesson of homœopathy, the infinitesimals of which certainly could not do harm, and quite as certainly could not do good; yet nobody has ever claimed that the mortality among homœopathic practitioners was greater than among those of the regular school. A new school of practitioners has arisen which cares nothing for homœopathy and less for so-called allopathy. It seeks to study, rationally and scientifically, the action of drugs, old and new. It is more concerned that a physician shall know how to apply the few great medicines which all have to use, such as quinine, iron, mercury, iodide of potassium, opium, and digitalis, rather than a multiplicity of remedies the action of which is extremely doubtful.

The growth of scientific pharmacology, by which we now have many active principles instead of crude drugs, and the discovery of the art of making medicines palatable, have been of enormous aid in rational practice. There is no limit to the possibility of help from the scientific investigation of the properties and action of drugs. At any day the new chemistry may give to us remedies of extraordinary potency and of as much usefulness as cocaine. There is no reason why we should not even in the vegetable world find for certain diseases specifics of virtue fully equal to that of quinine in the malarial fevers.

One of the most striking characteristics of the modern treatment of disease is the return to what used to be called the natural methods—diet, exercise, bathing, and massage. There probably never has been a period in the history of the profession when the value of _diet_ in the prevention and the cure of disease was more fully recognized. Dyspepsia, the besetting malady of this country, is largely due to improper diet, imperfectly prepared and too hastily eaten. One of the great lessons to be learned is that the preservation of health depends in great part upon food well cooked and carefully eaten. A common cause of ruined digestion, particularly in young girls, is the eating of sweets between meals and the drinking of the abominations dispensed in the chemists’ shops in the form of ice-cream sodas, etc. Another frequent cause of ruined digestion in business men is the hurried meal at the lunch-counter. And a third factor, most important of all, illustrates the old maxim, that more people are killed by over eating and drinking than by the sword. Sensible people have begun to realize that alcoholic excesses lead inevitably to impaired health. A man may take four or five drinks of whiskey a day, or even more, and thinks perhaps that he transacts his business better with that amount of stimulant; but it only too frequently happens that early in the fifth decade, just as business or political success is assured, Bacchus hands in heavy bills for payment, in the form of serious disease of the arteries or of the liver, or there is a general breakdown. With the introduction of light beer there has been not only less intemperance, but a reduction in the number of the cases of organic disease of the heart, liver, and stomach caused by alcohol. While temperance in the matter of alcoholic drinks is becoming a characteristic feature of Americans, intemperance in the quantity of food taken is almost the rule. Adults eat far too much, and physicians are beginning to recognize that the early degenerations, particularly of the arteries and of the kidneys, leading to Bright’s disease, which were formerly attributed to alcohol, are due in large part to too much food.

_Nursing._—Perhaps in no particular does nineteenth-century practice differ from that of the preceding centuries more than in the greater attention which is given to the personal comfort of the patient and to all the accessories comprised in the art of nursing. The physician has in the trained nurse an assistant who carries out his directions with a watchful care, and who is on the lookout for danger-signals, and with accurate notes enables him to estimate the progress of a critical case from hour to hour. The intelligent, devoted women who have adopted the profession of nursing, are not only in their ministrations a public benefaction, but they have lightened the anxieties which form so large a part of the load of the busy doctor.

_Massage and Hydrotherapy_ have taken their places as most important measures of relief in many chronic conditions, and the latter has been almost universally adopted as the only safe means of combating the high temperatures of the acute fevers.

Within the past quarter of a century the value of _exercise_ in the education of the young has become recognized. The increase in the means of taking wholesome out-of-door exercise is remarkable, and should show in a few years an influence in the reduction of the nervous troubles in young persons. The prophylactic benefit of systematic exercise, taken in moderation by persons of middle age, is very great. Golf and the bicycle have in the past few years materially lowered the average incomes of the doctors in this country as derived from persons under forty. From the senile contingent—those above this age—the average income has for a time been raised by these exercises, as a large number of persons have been injured by taking up sports which may be vigorously pursued with safety only by those with young arteries.

Of three departures in the art of healing, brief mention may be made. The use of the extracts of certain organs (or of the organs themselves) in disease is as old as the days of the Romans, but an extraordinary impetus has been given to the subject by the discovery of the curative powers of the extract of the thyroid gland in the diseases known as cretinism and myxœdema. The brilliancy of the results in these diseases has had no parallel in the history of modern medicine, but it cannot be said that in the use of the extracts of other organs for disease the results have fulfilled the sanguine expectations of many. There was not, in the first place, the same physiological basis, and practitioners have used these extracts too indiscriminately and without sufficient knowledge of the subject.

Secondly, as I have already mentioned, we possess a sure and certain hope that for many of the acute infections antitoxins will be found.

A third noteworthy feature in modern treatment has been a return to psychical methods of cure, in which _faith in something is suggested_ to the patient. After all, faith is the great lever of life. Without it, man can do nothing; with it, even with a fragment, as a grain of mustard-seed, all things are possible to him. Faith in us, faith in our drugs and methods, is the great stock in trade of the profession. In one pan of the balance, put the pharmacopœias of the world, all the editions from Dioscorides to the last issue of the United States Dispensatory; heap them on the scales as did Euripides his books in the celebrated contest in the “Frogs”; in the other put the simple faith with which from the days of the Pharaohs until now the children of men have swallowed the mixtures these works describe, and the bulky tomes will kick the beam. It is the _aurum potabile_, the touchstone of success in medicine. As Galen says, confidence and hope do more good than physic—“he cures most in whom most are confident.” That strange compound of charlatan and philosopher, Paracelsus, encouraged his patients “to have a good faith, a strong imagination, and they shall find the effects” (Burton). While we often overlook or are ignorant of our own faith-cures, doctors are just a wee bit too sensitive about those performed outside our ranks. They have never had, and cannot expect to have, a monopoly in this panacea, which is open to all, free as the sun, and which may make of every one in certain cases, as was the Lacedemon of Homer’s day, “a good physician out of Nature’s grace.” Faith in the gods or in the saints cures one, faith in little pills another, hypnotic suggestion a third, faith in a plain, common doctor a fourth. In all ages the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. The cures in the temples of Æsculapius, the miracles of the saints, the remarkable cures of those noble men, the Jesuit missionaries, in this country, the modern miracles at Lourdes and at St. Anne de Beaupré in Quebec, and the wonder-workings of the so-called Christian Scientists, are often genuine, and must be considered in discussing the foundations of therapeutics. We physicians use the same power every day. If a poor lass, paralyzed, apparently, helpless, bed-ridden for years, comes to me, having worn out in mind, body, and estate a devoted family; if she in a few weeks or less by faith in me, and faith alone, takes up her bed and walks, the saints of old could not have done more. St. Anne and many others can scarcely to-day do less. We enjoy, I say, no monopoly in the faith business. The faith with which we work, the faith, indeed, which is available to-day in every-day life, has its limitations. It will not raise the dead; it will not put in a new eye in place of a bad one (as it did to an Iroquois Indian boy for one of the Jesuit fathers), nor will it cure cancer or pneumonia, or knit a bone; but, in spite of these nineteenth-century restrictions, such as we find it, faith is a most precious commodity, without which we should be very badly off.

_Hypnotism_, introduced by Mesmer in the eighteenth century, has had several revivals as a method of treatment during the nineteenth century. The first careful study of it was made by Braid, a Manchester surgeon, who introduced the terms hypnotism, hypnotic, and nervous sleep; but at this time no very great measure of success followed its use in practice, except perhaps in the case of an Anglo-Indian surgeon, James Esdaile, who, prior to the introduction of anæsthesia, had performed two hundred and sixty-one surgical operations upon patients in a state of hypnotic unconsciousness. About 1880 the French physicians, particularly Charcot and Bernheim, took up the study, and since that time hypnotism has been extensively practised. It may be defined as a subjective psychical condition, what Braid called nervous sleep, resembling somnambulism, in which, as Shakespeare says, in the description of Lady Macbeth, the person receives at once the benefit of sleep and does the effects or acts of watching or waking. Therapeutically, the important fact is that the individual’s natural susceptibility to suggestion is increased, and this may hold after the condition of hypnosis has passed away. The condition of hypnosis is usually itself induced by suggestion, requesting the subject to close the eyes, to think of sleep, and the operator then repeats two or three times sentences suggesting sleep, and suggesting that the limbs are getting heavy and that he is feeling drowsy. During this state it has been found that the subjects are very susceptible to suggestion. Too much must not be expected of hypnotism, and the claims which have been made for it have been too often grossly exaggerated. It seems, as it has been recently well put, that hypnotism “at best permits of making suggestions more effective for good or bad than can be done upon one in his waking state.” It is found to be of very little use in organic disease. It has been helpful in some cases of hysteria, in certain functional spasmodic affections of the nervous system, in the vicious habits of childhood, and in suggesting to the victims of alcohol and drugs that they should get rid of their inordinate desires. It has been used successfully in certain cases for the relief of labor pains, and in surgical operations; but on the whole, while a valuable agent in a few cases, it has scarcely fulfilled the expectations of its advocates. It is a practice not without serious dangers, and should never be performed except in the presence of a third person, and its indiscriminate practice by ignorant persons should be prevented by law.

One mode of faith-healing in modern days, which passes under the remarkable name of Christian Science, is probably nothing more than mental suggestion under another name. “The patient is told to be calm, and is assured that all will go well; that he must try to aid the healer by believing that what is told him is true. The healer then, quietly but firmly, asserts and reiterates that there is no pain, no suffering, that it is disappearing, that relief will come, that the patient is getting well.” This is precisely the method which Bernheim used to use with such success in his hypnotic patients at Nancy, iterating and reiterating, in a most wearisome way, that the disease would disappear and the patient would feel better. As has been pointed out by a recent writer (Dr. Harry Marshall), the chief basis for the growth of Christian Science is that which underlies every popular fallacy: “Oliver Wendell Holmes outlined very clearly the factors concerned, showing (a) how easily abundant facts can be collected to prove anything whatsoever; (b) how insufficient ‘exalted wisdom, immaculate honesty, and vast general acquirements’ are to prevent an individual from having the most primitive ideas upon subjects out of his line of thought; and, finally, demonstrating ‘the boundless credulity and excitability of mankind upon subjects connected with medicine.’”

WILLIAM OSLER.

SURGERY

The end of the eighteenth century was made notable by one of the most remarkable and beneficent discoveries which has ever blessed the human race, the discovery of the means of preventing small-pox. On May 14, 1796, Dr. Edward Jenner inoculated James Phipps. When we remember that two million persons died in a single year in the Russian Empire from small-pox; that in 1707 in Iceland, out of a population of thirty thousand, sixty per cent., or eighteen thousand, died; that in Jenner’s time “an adult person who had not had small-pox was scarcely met with or heard of in the United Kingdom, and that owing to his discovery small-pox is now one of the rarest diseases,” the strong words I have used seem fully justified. But the eighteenth century was not to witness the end of progress in medicine. The advances in the nineteenth century have been even more startling and more beneficent. What these advances have been in the department of medicine has been related by Professor Osler. It is my province to speak only of surgery.

METHOD OF TEACHING

The first advance which should be mentioned is a fundamental one—namely, methods of medical teaching. At the beginning of the nineteenth century there were only three medical schools in the United States: the Medical Department of the University of Pennsylvania, established in 1765; the Medical Department of Harvard, established in 1783; and the Medical Department of Dartmouth, established in 1797. The last report of the Commissioner of Education gives a list of one hundred and fifty-five medical schools now in existence in this country, many of them still poorly equipped and struggling for existence, but a large number of them standing in the first rank, with excellent modern equipment, both in teachers, laboratories, hospitals, and other facilities. The medical curriculum then extended over only two years or less, and consisted of courses of lectures at the most by seven professors who, year after year, read the same course of lectures, without illustrations and with no practical teaching. The medical schools, even when connected with universities, were practically private corporations, the members of which took all the fees, spent what money they were compelled to spend in the maintenance of what we now should call the semblance of an education, and divided the profits. Until within about twenty years this method prevailed in all our medical schools. But the last two decades of the century have seen a remarkable awakening of the medical profession to the need of a broader and more liberal education, and that, as a prerequisite, the medical schools should be on the same basis as the department of arts in every well-regulated college. To accomplish this the boards of trustees have taken possession of the fees of students, have placed the faculties upon salaries, and have used such portion of the incomes of the institutions as was needed for a constant and yet rapid development along the most liberal lines.

COLLEGE HOSPITALS

The first step has been the establishment in connection with most schools of general hospitals in which the various teachers in the college should be the clinical instructors, and where the students would have the means not only of hearing theoretically what should be done to the sick, but of actually examining the patients under the supervision of their instructors, studying the cases so as to become skilled in reaching a diagnosis and indicating what in their opinion was necessary in the way either of hygiene, medicine, or surgical operation. More than that, in most of the advanced schools to-day the students assist the clinical faculties of the hospitals in the actual performance of operations, so that when they graduate they are skilled to a degree utterly unknown twenty years ago.

ESTABLISHMENT OF LABORATORIES

Another step which was equally important, and in some respects even more so, has been the establishment of laboratories connected with each branch of instruction. A laboratory of anatomy (the dissecting room) every medical school has always had, but all the other laboratories are recent additions. Among these may be named a laboratory of clinical medicine, a laboratory of therapeutics, in which the action of drugs is studied; a laboratory of chemistry, a laboratory of microscopy, a laboratory of pathology for the study of diseased tissues, a laboratory of embryology for the study of the development of the human body and of the embryos of animals, a laboratory of hygiene, a laboratory of bacteriology, a laboratory of pharmacy, a surgical laboratory, in which all the operations of surgery are done on the cadaver by each student, a laboratory of physiology, and in many colleges private rooms in which advanced work may be done for the discovery of new truths.

In all these laboratories, instead of simply hearing about the experiments and observations, each student is required to handle the drugs, the chemicals, the apparatus, to do all the operations, to look through the microscope, etc.; in other words, to do all that which is necessary for the proper understanding of the case in hand. In fact, it may be said that in view of the opportunities and the requirements of modern hospitals, it is undoubtedly true that a hospital patient, the poorest of the poor, often has his case more thoroughly studied and more accurately observed than the wealthy patient who is attended at his home. On the other hand, however, so many laboratories with their expensive apparatus and a large staff of assistants mean an enormous increase in the expense of a medical education, for which the student does not pay anything like an equivalent. Hence the need in all of our best modern medical schools for endowments, in order that such work may be carried on properly, and yet the student not be charged such fees as to be practically prohibitory, excepting for the rich, or at the least the well-to-do. I do not hesitate to say that at the end of the second year many a diligent student of to-day is better fitted to practise medicine than was the graduate of half a century ago.

ANATOMICAL MATERIAL

One of the most important means of the study of medicine, and especially of surgery, is a thorough acquaintance with the anatomy of the human body. No one would think of placing an engineer in charge of a complicated piece of machinery, who had never become intimately acquainted with all the parts of such a machine, so that he could take it to pieces and put it together again with ease and intelligence. Yet, until comparatively recently, this knowledge of anatomy was both required of, and yet at the same time the means of obtaining it was forbidden to, the medical student. If he performed an operation and was guilty of negligence or error, due to his want of anatomical knowledge, he was liable to a suit for malpractice. Yet his only means of becoming acquainted with the anatomy of the human body was by stealing the bodies of the dead. In England, up to 1832, this was equally true. A regular traffic in human bodies existed there as well as here, and, by reason of its perils, the cost of bodies for dissection was very great; but it was only a question of money. In his testimony before the Parliamentary Committee, Sir Astley Cooper made a shiver run down the backs of the noble lords who listened to him when he said that in order to dissect the body of any of them it was only necessary for him to pay enough. The large pecuniary profits of such business, when the supply was very small, led to the horrible atrocities of Burke and Hare in Edinburgh in 1832. They deliberately murdered a considerable number of persons, and sold the bodies to the dissecting rooms in that city. The discovery of their crimes finally led to the passage of the Anatomy Act, which has been in force in Great Britain ever since. Similar violations of graveyards in this country have led to the passage in various States of somewhat similar laws, usually giving for dissection the bodies of those who were so poor in friendship that no one would spend the money necessary for their burial. Even to-day, in a large number of our States, the former anomalous condition of affairs exists. The increase of anatomical material which has resulted from the enactment of wise and salutary laws for this purpose has given a great impetus to the study of anatomy, and has produced a far better educated class of physicians in most parts of the United States within the last few years. The enlightened sense of the community has perceived that to deny the medical schools the means of properly teaching anatomy was a fatal mistake, and resulted in an ignorance of which the community were the victims. As a result, it is possible now, by law, in most States to obtain a reasonable number of cadavers, not only for the study of anatomy, but for the performance of all the usual operations.

MEDICAL LIBRARIES

Along with this there has been throughout this country a marked movement in favor of medical libraries. It is to the credit of the government of the United States that the whole world is debtor to us, not only for the foremost medical library in the world, that of the surgeon-general of the army in Washington, but also for the magnificent index-catalogue, not only of the books, but all the journal articles in every language in the world. No better investment of money was ever made than the establishment of this library, and its allied museum, and the publication of the index-catalogue.

EMBRYOLOGY

As a result of all these means and methods of study, and as a part of the great educational and scientific movement of the century, medical men now take a wholly different view of the normal and abnormal structures of the human body. The study of embryology has shown us that many of the deviations from the normal development of the human body are easily explained by embryology. One of the most important changes in our idea, for example, of tumors is due to the fact that the study of embryology and of the tissues of the embryo have shown us that diseased structures, which lack explanation entirely, when compared with the adult human tissues, readily find their explanation and fall into an unexpected order when compared with the tissues of the embryo. Not only, however, has the study of embryological tissues thrown a flood of light on diseased structures, but we have obtained new views of the relation of man to all creatures, lower in the scale of life. Largely owing to the doctrine of evolution, we now recognize the fact that, so far as his body is concerned, man is kindred to the brutes; that his diseases, within certain limitations, are identical with similar diseases of the lower animals; that his anatomy and physiology are, in essence, the same as the anatomy and physiology of the lower animals, even the very lowest, and that many of his diseases can be best studied in the lower animals, because upon them we can make exact experiments which would be impossible in man. While it is true that each animal has disorders which are peculiar to itself, and that it is not subject to some of the disorders to which man is a victim, and, _per contra_, that man is a victim to some disorders from which animals do not suffer, yet, taking them as a whole, the diseases of man and of animals, and the action of remedies on both, are practically identical. To this I shall have occasion to refer again.

PATHOLOGY

Among the laboratories which I mentioned, one of the most important is that of pathology and morbid anatomy, or the study of diseased tissues and organs. The first work on pathology written in this country was by one of our best-known surgeons, the late Samuel D. Gross, and one of his most important contributions to surgical progress consisted in his persistent advocacy of the need for the study of pathology as a basis for all our means of cure. This is evident, if we consider the illustration I used a moment ago of a steam-engine. Unless he knows precisely the defects of such a machine, the influence of fresh or salt water on a boiler, the influence of rust, the effect of oils, entirely apart from the mere mechanism of the engine, an engineer might make the most serious mistake, resulting in fatal damage, both to the machine and probably to life. So, surgical pathology is the study of the processes of disease, the alterations in the minute structure of tissues and organs, without which no surgeon can be fitted for his task, much less can he be called an accomplished surgeon. All of these laboratories mark the difference between the scientific and the empirical method. The old student of medicine went from case to case, heard many a good maxim, and learned many a useful trick; but, after all, it was only an empirical knowledge which he obtained. It did not go to the foundation of things, it was not scientific, as is the collegiate instruction of to-day.

Having now glanced rapidly at the improvement in medical instruction, let me turn next to a few of the principal discoveries which have made the surgery of to-day so much superior to the surgery of a hundred years ago.

ANÆSTHESIA

After vaccination, the most important medical event of the century is the discovery of anæsthesia. While there were some prior attempts at anæsthesia, practically it dates from October 16, 1846, when Dr. John C. Warren, in the Massachusetts General Hospital, first performed a major surgical operation, without inflicting the slightest pain. I cannot enter into the merits of the various claimants for the credit of first using an anæsthetic, but ether was then for the first time publicly administered by Morton, and the very sponge which was then used is now a precious trophy of the Massachusetts General Hospital. I may, perhaps, quote from an address which I delivered before the Medical and Chirurgical Faculty of the State of Maryland, at their centennial anniversary, in April, 1899, the following in relation to anæsthesia:

“The news went like wildfire, and anæsthesia was soon introduced
into every clinic and at almost every operation throughout
the civilized world. Prior to that time a surgical operation
was attended with horrors which those who live in these days
cannot appreciate. He was the best surgeon who could perform any
operation in the least possible time. The whole object of new
methods of operating was to shorten the period of frightful agony
which every patient had to endure. Every second of suffering
saved was an incalculable boon. To submit to any operation
required then a heroism and an endurance which is almost
incomprehensible to us now. All of the more modern, deliberate,
careful, painstaking operations, involving minute dissection,
amid nerves and blood-vessels, when life or death depends on the
accuracy of almost every touch of the knife, were absolutely
impossible. It was beyond human endurance quietly to submit one’s
self for an hour, for an hour and a half, for two hours, or even
longer, to such physical agony.

“It is a striking commentary on the immediate results of
anæsthesia to learn that, in five years before the introduction
of ether, only one hundred and eighty-four persons were
willing to submit themselves to such a dreadful ordeal in the
Massachusetts General Hospital—an average of thirty-seven
operations per annum, or three per month.... During the last
year, in the same hospital—a Mecca for every surgeon the world
over—over thirty-seven hundred operations were performed. It is
not an uncommon thing at the present day for any one of the more
active surgeons of this country to do as many as four or five
hundred operations in a year. I have known as many as nineteen
operations to be done in the Jefferson Medical College Hospital
in a single day—equalling six months’ work in Boston before the
introduction of ether.”

The next year, 1847, witnessed the introduction of chloroform by Sir James Y. Simpson, of Edinburgh. Until I became acquainted with the striking figures just quoted, I had often wondered at the hospital scene in that most touching story, _Rab and His Friends_, by the late gifted and well-beloved physician, Dr. John Brown, of Edinburgh. Nowadays students do not rush into the surgical amphitheatre when they learn that an operation is to be done, but it is taken as a matter of course, for practically every day many operations are done in most of our large hospitals. But, at the time when Rab’s mistress was operated upon, an operation, as has been stated, was a very rare event. Few had the fortitude to endure its dreadful pangs. Now, thanks to the blessed sleep of anæsthesia, sufferers from even the most dreadful disorders can have long and difficult operations done, accurate and tedious dissections made, and yet feel not a twinge of pain.

Besides general anæsthesia by ether, chloroform, and a few other agents, there have been introduced several means for producing “local anæsthesia,” _i.e._, agents which destroy the sensibility of the part of the body to be operated upon while not producing unconsciousness. Freezing the part by ice and salt, or by a quickly evaporating spray of rhigolene or chloride of ethyl, are sometimes used. But cocaine and a somewhat similar substance, eucaine, have of late been more extensively used on man, after their harmlessness had been first shown by experiments on animals. In 1885 Corning, of New York, injected a solution of cocaine as near to the spinal cord as was possible, and produced insensibility of all the body below the point of injection by the effect of the cocaine upon the spinal cord. A few years ago Quincke, of Kiel, in Germany, devised a means of puncturing the spinal canal itself in the lumbar region (the lowest part of the small of the back) for the purpose of drawing off some of the fluid for examination. This suggested to Bier, then of Kiel, who was apparently ignorant of Corning’s work, that cocaine could be injected through a hollow needle inserted into the spinal canal by “lumbar puncture” and so produce anæsthesia of all the body below this point. This method was published by him in 1899, and was soon repeated in America. In France, however, it has been practised more than elsewhere, Tupper, of Paris, having successfully done over two hundred operations by “spinal anæsthesia.” All of the body below the diaphragm can thus be deprived of sensibility. The method will probably never replace ether and chloroform, but in many cases is a valuable aid to the surgeon. But it has its dangers and its inconveniences. The ideal anæsthetic is not that which destroys sensibility and yet leaves the patient perfectly conscious, as spinal anæsthesia does. A patient to whom I recently proposed it for certain special reasons rejected it, saying, with probable truth, that she could never bear the strain of lying on the table perfectly conscious of all that was being done and frightened by any surgical emergency which might easily arise in such a long, difficult, and dangerous operation. The ideal anæsthetic is that which will abolish pain and consciousness without danger to life. The twentieth century will undoubtedly see the discovery of this safe and efficient anæsthetic.

ANTISEPSIS

But the limits of surgical progress were not yet reached. Let me quote again from the address before alluded to:

“Even the introduction of anæsthesia, however, did not rid
surgery of all its terrors. The acute pain of the operation was
abolished, but the after-suffering, as I know only too well,
in my early surgical days, was something dreadful to see. The
parched lips of the poor sufferer, tossing uneasily during
sleepless nights; wounds reeking with pus, and patients dying by
scores from blood-poisoning, from erysipelas, from tetanus, from
gangrene, were only too familiar sights in the pre-antiseptic
days. Then, again, there arose one of these deliverers of the
human race whose name can never be forgotten and whose fame will
last so long as time shall endure. Jenner, Warren, and Lister
are a triumvirate of names of which any profession may well be
proud. Thank God, they all sprang from virile Anglo-Saxon loins!
No praise, no reward, no fame is too great for them. That Lord
Lister still lives to see the triumph of his marvellous services
to humanity is a joy to all of us. And when the profession arose
_en masse_, within the last few years, at the International
Congress of Berlin, and at the meeting of the British Medical
Association in Montreal, and welcomed him with cheer after cheer,
it was but a feeble expression of gratitude for benefits which no
words can express.

“Before Lister’s day erysipelas, tetanus, gangrene, and
blood-poisoning in its various phases were the constant
attendant of every surgeon. They were dreaded guests at almost
any operation; and when in rare cases we obtained primary union
without a drop of pus, without fever, and with but little
suffering, it was a marvellous achievement. Now it is precisely
reversed. The surgeon who does not get primary union without
a drop of pus, with no fever, and with little suffering, asks
himself—what was the fault in my technic? To open the head, the
abdomen, or the chest thirty years ago was almost equivalent to
signing the death-warrant of a patient. The early mortality of
ovariotomy was about sixty per cent.; two out of three died. Now
many a surgeon can point to a series of one hundred abdominal
operations with a fatality of only two or three per cent. When
Sir Spencer Wells recorded his first one thousand cases of
ovariotomy it was calculated that after deducting the years which
the patients who died from the operation would have lived had no
operation been done the net result of the thousand cases was an
addition of twenty thousand years to human life. One thousand
ovariotomies under antiseptic precautions at the present would
certainly add at least thirty thousand years to human life. Would
not such a guerdon be enough for any man?

“This, too, is a direct result of laborious laboratory
researches, beginning with the investigations of Liebig and
Pasteur on fermentation. Lister went still further. Even before
the discovery of the bacteria of suppuration, of tetanus, and
of erysipelas he showed us experimentally how, by surgical
cleanliness, we could avoid all infection and so banish these
pests from our hospitals and bring life and health to many who
otherwise would have perished from operations which are now
perfectly safe.

“The mortality of compound fractures in the pre-antiseptic days
was about sixty per cent. It was one of the most dreaded of
all accidents. Its mortality now is perhaps not over three per
cent., and the mortality from sepsis after such a fracture, in
the hands of well-instructed surgeons, is almost nil. Prior to
Lister’s day the mortality of major amputations varied from fifty
to sixty-three per cent. Now it is from ten to twenty per cent.
And so I might go on with operation after operation and show how
they have become so safe that one need not dread any, saving
exceptional cases.

“These two modern discoveries, anæsthesia and antisepsis, have
utterly revolutionized modern surgery. They have made possible
operations which, by reason of their length and pain and danger,
were utterly unjustifiable in former days, but are now the daily
occupation of a busy surgeon. And, far better than this, they
have enabled us to bring to homes and hearts, which otherwise
would have been broken up and wrung with sorrow, the comfort of
life restored to dear ones upon whom depended the happiness and
support of the families. Translate figures into happy hearts and
prosperous homes if you can, and then you can tell me what Warren
and Lister have done for humanity!”

The result of these two wonderful discoveries has been to separate us from the surgical past, as by a great gulf.

“Great theologians, such as a Calvin or a Jonathan Edwards,
were they recalled to life, could discourse as learnedly as
ever of predestination and free will; great preachers, as
a Beecher or a Spurgeon, could stir our souls and warm our
hearts as of old; great jurists, as a Justinian or a Marshall,
could expound the same principles of law which hold good for
all time; great forensic orators, as a Burke or a Webster,
could convince us by the same arguments and arouse us by the
same invectives or the same eloquence that made our fathers
willing captives to their silver tongues. But to-day, so rapid
has been our surgical progress, a Velpeau, a Sir William
Ferguson, or a Pancoast, all of whom have died within the
last thirty years, could not teach modern surgical principles
nor perform a modern surgical operation. Even our every-day
surgical vocabulary—staphylococcus, streptococcus, infection,
immunity, antisepsis and asepsis, toxin and antitoxin—would be
unintelligible jargon to him; and our modern operations on the
brain, the chest, the abdomen, and the pelvis would make him
wonder whether we had not lost our senses, until, seeing the
almost uniform and almost painless recoveries, he would thank God
for the magnificent progress of the last half-century, which had
vouchsafed such magical, nay, such almost divine, power to the
modern surgeon.”

THE SURGERY OF WAR

One of the immediate consequences of the introduction of the antiseptic method has been a remarkable mitigation of the horrors of war. Our recent war with Spain has proved, and the present military operations in the Philippines and of the British in South Africa will still further prove, its advantages. Witness a little book written by Professor von Esmarch, of Kiel, Germany, with the apt title, _The Fight of Humanity Against the Horrors of War_; with an appendix, entitled, “The Samaritan on the Battle-field.” One of the most valuable means for the preservation of human life is carried by every soldier in a modern civilized army as a part of his regulation outfit, a “First Aid Package” for the treatment of any wound or injury; and one of the most valuable and interesting papers read before the American Surgical Association, at its meeting in Chicago in 1899, was by Professor Senn on the “First Aid Package.” This first aid package contains an antiseptic dressing, which can be applied to all but the gravest wounds for the purpose of preventing infection, which is the principal danger to life after accident or injury. The universal testimony of our surgeons in Cuba was that by its use most wounds were prevented from becoming infected, and, therefore, inflamed, and that the number of operations was greatly diminished by reason of its use.

BACTERIOLOGY

In experimental science, two methods of progress are observed; first, in actual practice certain methods are adopted because they are found to be the most advantageous and useful, though we cannot explain why it is so—_i.e._, practice outstrips theory. Again, as a result of experimental investigation, certain facts are discovered which explain why the practical methods just alluded to are the best, and this in turn suggests further improvements in our practice—_i.e._, theory outstrips practice and enlarges its domain. Thus outstripping theory, the practical advance made by Lister was an example of the first. His striking results in turn stimulated scientific observers to make new discoveries of the greatest importance, and thus science immensely improved and widened our practical methods.