in Medicine or in any other department of Science, we shall find
certain philosophical tendencies at work of which the modern man of
Science is the heir, though often the unconscious and sometimes the
ungrateful and even the misunderstanding heir. Neither men of Science
nor medical men are always philosophers, or at least not always
consciously so. Nevertheless, they are as surely influenced by the
streams of thought of their time as they are by their heredity and
their physical environment. The general tendencies of Medicine in this
or in any other age cannot be interpreted without some reference to
the intellectual atmosphere in which it has arisen and in which it has
flourished.
The intellectual atmosphere in which scientific specialism arose was
that of the so-called ‘Utilitarian Philosophy’. Many of the dicta
of that school, which came into prominence toward the end of the
eighteenth century, are still used as part of the language of men of
Science and others. ‘The greatest happiness of the greatest number’
is a formula launched upon our common speech by Joseph Priestley
(1733-1804, p. 154). The pursuit of such happiness as the main object
of human activity is taught by the ‘Utilitarian’ philosophy, a word
coined by the English political and social thinker, Jeremy Bentham
(1748-1832). To Bentham, the founder of that philosophy, we owe such
useful additions to our language as ‘codification’ and ‘international’,
and these, together with ‘utilitarian’, give us some clue to the
character and mode of his thought. It is probable that no thinker had a
larger share than Bentham in ushering in the era of the subdivision of
the sciences.
Bentham made a sustained attempt to draw a parallel between the
physical and the social sciences, and this gave him a special
influence over medical thinkers and especially over those that dealt
with the public health. His pupil, John Stuart Mill (1806-73), speaks
of his master’s mode of working as ‘the chemical method’. It is
thus not remarkable that Bentham should exert a profound influence
on Medicine, both directly and indirectly. The peculiarly logical,
uncompromising and perhaps un-English character of his mind, while it
prevented him, fortunately for himself, from taking an active share in
the task of government, did not prevent him from influencing those who
did. Specifically, he is the direct begetter of our modern system of
organization of the Science of Preventive Medicine.
[Illustration:
FIG. 95. A CARTOON OF THE EARLY NINETEENTH CENTURY illustrating the
condition of children in the factories of the time. A bale is directed
to Sir Robert Peel. This is the first Baronet (1750-1830), father of
the statesman. Peel the elder was a cotton-spinner who imported from
the London workhouses deserted children whom he treated well, but used
to work his factories in Lancashire. He was a Member of Parliament
and in 1802 carried the Act which was the forerunner of all factory
legislation, _An Act for the Preservation of the Health and Morals of
Apprentices and others, employed in Cotton and other Mills_.
]
§ 2. _The Revolution in Preventive Medicine._
Of all the many changes in Medicine and Medical thought that the
Period of Scientific Subdivision has witnessed, none have been
more revolutionary than those in the department which deals with
Preventive Medicine. Great and important reforms were introduced
during the course of the eighteenth century. These, however, even
when the result of legislation, were the outcome of the effort of
individuals, or were concerned with the Army and Navy (p. 169). In the
period that follows, the Public Health becomes a general political,
legislative, and administrative matter, and ‘Prevention’ becomes its
watchword. The public consciousness--moralists will call it the public
_conscience_--had been aroused, and has never again entirely slept. The
chief agent in the awakening process, the intellectual force at its
back, was and is Jeremy Bentham.
Rational Medicine has, in general, no national frontiers. To it men
of all the national units have made important contributions. But the
care of the Public Health in the period on which we now enter, being
an affair of legislation and administration, has developed along
national lines and it is difficult to discuss it save on a national
basis. It is a source of justifiable national pride that Britain has,
from the first and throughout, been the leader of the Public Health
movement. But while we lose little and gain much by telling the story
from the British point of view, it has still to be remembered that,
just as Rational Medicine has, fortunately, no spiritual frontiers,
so, unfortunately, sickness and suffering have no physical frontiers.
Epidemics pass the most scientifically constructed boundaries upon the
surface of the map, and without a passport. In our time this evident
proposition has obtained, at least, formal recognition. International
health legislation has at last appeared. A future historian of Rational
Medicine will be able to write his chapter on the Public Health
from the point of view of Humanity at large. The historian who has
the misfortune to be born too early must still content himself with
treating the subject along national lines.
(a) _Preventive Medicine in Britain._
If Bentham be the spiritual father of Public Health legislation, the
protagonists whose names must be associated with the development of the
movement along practical lines in England are Thomas Southwood Smith
(1788-1861) and Edwin Chadwick (1800-90).
Thomas Southwood Smith was a Unitarian minister, and long combined this
office with that of physician. Settling in London in 1820 he came under
the influence of Bentham. By his essay on _The Use of the Dead to the
Living_ he did something to remove the odium attached to dissection.
The scandals of the time and the common sense of the ‘utilitarians’
(p. 190) led to the passing of the Anatomy Act of 1832. Thus by a
proper legal process bodies became available for dissection by medical
students. Bentham died just before this Act became law and by his will
left his body to Southwood Smith to be the subject of dissection and
of an anatomical lecture.
Southwood Smith’s services to the spread of interest in Public Health
were very numerous. He circulated a simple and popular _Philosophy of
Health_ (1835). He served on a board of inquiry as to the condition
of children in factories (1832, cp. Fig. 191), and he was especially
useful to the Poor Law Commissioners by reason of his exceptional
knowledge of fevers. He was the founder of a ‘Health of Towns
Association’ (1840), and of another association for ‘improving the
Dwellings of the Industrial Classes’ (1842). In 1848 he became a member
of a new government department, the ‘General Board of Health’ (p. 195).
His official reports on Quarantine (1845), Cholera (1850), Yellow Fever
(1852), and on the results of sanitary improvement (1854), were of
world-wide use.
Edwin Chadwick (1800-90), who was not a medical man, introduced to
public notice what he called the ‘sanitary idea’, a conception that
colored the whole of his extraordinarily active life. He sat on
Government Commissions on Poor Law, on Police, and on the investigation
of the condition of factory children. One of his Reports (1833), issued
while he and the century were both in the early thirties, recommended a
system of inspection with a view to limiting children’s hours of work.
The current system of pensions and of trade instruction to soldiers and
sailors is the descendant of a scheme of Chadwick’s devising. An item
in the evidence attached to one of his Reports is the public provision
of open spaces for recreation, a topic of current interest at the
moment of writing.
At the time of the accession of Queen Victoria in 1837 Chadwick was
agitating for the appointment of a Sanitary Commission. Two years
later, as a result of a grave epidemical outbreak in London, the
Commission was appointed. Its reports, which drew wide attention at
the time, have had a large share in determining the general course of
health legislation in the ninety years that have since elapsed. The
scientific basis of health legislation can only be determined if proper
vital statistics be available. The Registration Act of 1838, under
a developed form of which we still live and die, was in essence his
work. If we search into the history of any department of the scientific
treatment of the Public Health, we shall always ultimately work back
either to Southwood Smith or to Chadwick and through them to Bentham.
Among the most important documents for which Chadwick was responsible
was the _Parliamentary General Report on the Sanitary Condition of the
Labouring Population of Great Britain_ (1842). It came to fruit in 1848
with the _Public Health Act_, which established a new governmental
department, the ‘General Board of Health’ (p. 196). The same year saw
the passage of the _Nuisances Removal and Diseases Prevention Act_,
by which summary action in such matters was rendered possible on the
complaint of specially authorized local authorities. Just as the Board
came into action there was an outbreak of Cholera in England, of which
54,000 persons died. The statistics available under the new system made
possible the deduction that the infection is conveyed by drinking-water
and led to suitable precautions. This is one of the many instances in
which the practice of prevention of a germ-borne disease preceded
any knowledge of its organic cause, or indeed any direct knowledge of
disease germs at all.
The first town in England to appoint a Medical Officer of Health was
Liverpool. The City of London followed in 1848, when Simon took office.
After Southwood Smith and Chadwick, Sir John Simon (1816-1904) was the
foremost figure in the history of the Public Health of this country. He
later became medical officer to the ‘General Board of Health’. The work
of this Board--together with its medical officer--was taken over, for
political and administrative reasons, by the Privy Council. The medical
department of the Privy Council became in 1871 part of the Local
Government Board, the medical functions of which were absorbed by the
new Ministry of Health in 1917.
To Simon are due the abolition of urban cesspits and improvement of
the system of sewers, and the institution of sanitary inspectors and
legislation concerning housing and overcrowding. One important result
of these measures was that it became possible to abandon the cruel and
wasteful system of quarantine that had been of value in the eighteenth
century. Simon’s plan, which was gradually adopted, was to trust to
the same preventive methods for foreign as for native infections. This
was, of course, only possible with an efficient sanitary service such
as he succeeded in instituting. Such measures were aided by laboratory
investigations, begun by a small staff. At first largely occupied
with examinations in connection with actual outbreaks, its scientific
functions rapidly grew. Working on a wider basis, these functions have
been performed for the nation since 1911 under the direction of the
Medical Research Council.
[Illustration: FIG. 96. ANNUAL DEATH-RATE IN LONDON PER THOUSAND LIVING
OVER A PERIOD OF 85 YEARS.
It will be seen that the curve begins definitely to take a downward
trend about 1870. It has been falling ever since. It is now less than
half of what it was sixty years ago. This fall is largely, though
not entirely, due to decrease in infant mortality. Some of the more
important epidemics are indicated. Typhus disappears as an important
cause of death in the forties and Cholera and Small-pox in the sixties.
Since then the death-rate has been considerably influenced by Influenza
outbreaks.
]
(b) _Preventive Medicine in the United States._
In the United States the history of the national Public Health Service
has been very different from that of the English system. The same
philosophical tendencies have been at the basis of the American as of
the English system. In the United States, however, the National Service
has been linked with the Army and Navy in a manner quite foreign to
British traditions. The Federal health system had its origin in the
old Marine Hospital Service, first authorized by Congress in 1798.
This enabled the President to appoint medical officers at ports and
elsewhere for the purpose of giving medical treatment to disabled
merchant seamen. The funds were obtained by a tax on those employed on
American vessels.
The first marine hospital under the Act was at Norfolk, Va., in 1800.
In 1802 a marine hospital was built for the port of Boston, and from
time to time hospitals were built at other important seaports. To
provide for the relief of seamen on inland waters Congress passed in
1837 an Act for the appointment of a board of advisory medical officers
of the Army. A number of hospitals were established on its advice.
The evolution of public health functions from this service was along
natural lines. The medical officers, in providing care for the
American merchant marine, were often the first physicians to diagnose
such diseases as Cholera, Yellow Fever, Small-pox and the like,
which were being imported into the United States. In the epidemics
of Cholera which occurred in certain ports of the United States the
marine hospitals and their medical officers were utilized for the
relief of those suffering from the disease. During the Civil War the
marine hospitals, together with the medical officers, were used by
the military authorities, both North and South, for the care of the
military forces.
Not until 1878 did Congress authorize any extensive use of the Marine
Hospital Service as a Federal Health Service. An Act of 1878 gave
broad powers to the Service to co-operate with State and local health
authorities in the control of disease, especially of Yellow Fever.
In 1890 Congress decided to utilize the Marine Hospital Service as
the Federal Health agency for the prevention of inter-State spread of
Cholera, Yellow Fever, Small-pox and Plague. In 1893 the powers of
the Marine Hospital Service in this regard were extended to cover all
infectious and contagious diseases, in co-operation with State and
local health agencies.
The efficiency of the Marine Hospital Corps in the control of epidemic
diseases became widely recognized. In 1889 Congress passed an Act which
made possible the further organization of the Marine Hospital Corps,
and provided that the officers be commissioned in grades similar to
those of the medical department of the United States Army. An Act
of 1875 had already provided that the Surgeon-General (supervising
surgeon) should be appointed by the President, with the consent of the
Senate.
In 1893 the Marine Hospital Service was organized into the Federal
Health Service. Congress continued to impose additional health
functions upon the Service, and in 1902 changed its name to the ‘Public
Health and Marine Hospital Service’ and made it a health service in
name as well as function. The larger part of its duties, up to this
time, had been the combating of epidemics, especially those of Yellow
Fever, which from time to time swept the country. With the threat of
Bubonic Plague in 1900 at San Francisco, the Marine Hospital Service
was placed in charge of control methods and succeeded in preventing any
extensive spread of the disease.
In addition to the quarantine and hospital functions, the activities
of the Service soon came to include research and educational work. In
1902 Congress authorized the establishment of the Hygienic Laboratory
for investigating Cholera, Yellow Fever, and other conditions.
The Laboratory grew rapidly and is now a very important research
institution, equipped for carrying on pathological, zoological,
pharmacological, bacteriological, chemical, and physiological work.
From the control of epidemics, the Public Health and Marine Hospital
Service began to develop control measures for the more common
contagious and infectious diseases, such as Typhoid Fever, Diphtheria,
and Scarlet Fever. The history of the wonderful control of Typhoid
Fever which has taken place in the United States within the past
twenty years is a part of the history of the Public Health Service in
co-operation with State and local health agencies. Typhoid fever, which
formerly took a toll of more than 50,000 lives annually, is responsible
for the death of a mere fraction of this number at the present day.
The development of health functions of the Public Health and Marine
Hospital Service continued until Congress in 1912 changed the name to
its present one, the ‘United States Public Health Service’, and at the
same time gave it broad powers to investigate the diseases of man and
the pollution of navigable streams and lakes.
During the courses of Federal development the separate States of the
Union were not devoid of protagonists of State intervention in matters
of public health. Among these was Lemuel Shattuck (1793-1859), who,
like Chadwick, was no medical man, but a student of social problems.
Under the influence of Chadwick he drafted in 1850 the _Report of
the Massachusetts Sanitary Commission_. This publication set forth a
complete scheme of Public Health organization. The formation of the
first State Board of Health in Massachusetts was, however, delayed
till 1869. In this matter Massachusetts was, in fact, anticipated by
Louisiana, which obtained a State Board of Health in 1855, and by New
York City, which obtained a Board of Health in 1866. Most of the States
followed in the seventies. The seventies and eighties were the decades
in which the general principles suggested by the work of Pasteur and
Koch were put into effect. The working hypothesis of sanitarians
of the time was that filth and ill-drainage were direct factors in
the production of epidemic disease. The view is now untenable, but
there was unquestionably an immense improvement in health conditions
resulting both directly and indirectly from the improved drainage,
water-supply, housing, and the like that the agitation had stimulated.
As the bacteriological discoveries of the time became generally
accepted, they were widely applied on American soil to the
administrative control of disease, notably by the New York Department
of Health under Hermann M. Biggs. That body, in 1892, instituted a
bacteriological laboratory, the scope of which has steadily increased.
Its work in connection with Diphtheria is elsewhere discussed (pp.
265-6).
To follow into our own time the development of factory legislation,
vital statistics, school medical service, local health authorities,
municipal laboratories and clinics, methods of food inspection, would
be to write a text-book of Public Health Administration. In all these
developments we see working the rational spirit in the peculiarly
English field of Preventive Medicine. The spirit of Rational Medicine
cannot function, however, without material upon which to work. The
basis, the elementary matter, as it were, of that material, is the
conception we form of the nature of the bodily processes. Such
a conception it is the function of Physiology to provide and to
Physiology we therefore now turn.
[Illustration: FIG. 97. THE OLD _DREADNOUGHT_ HOSPITAL SHIP.
A ‘Seamen’s Hospital Society’ was founded in England in 1817. Its first
hospital was the _Grampus_, an old 50 gun ship moored off Greenwich.
This was succeeded in 1830 by the _Dreadnought_, 104 guns, and this
in 1857 by the _Caledonia_, 120 guns, renamed _Dreadnought_. In 1870
this last wooden _Dreadnought_ was broken up and the patients were
transferred to a building on shore close by. The darkness, damp,
ill-ventilation, noisiness and septic character of a wooden ship made
it thoroughly unsuitable for hospital purposes.
In 1899 the ‘Seamen’s Hospital Society’ established a special Hospital
and School for Tropical Diseases such as are peculiarly common among
seamen. ]
§ 3. _The Transition to a Physiological Synthesis._
Modern developments in physiological knowledge introduce an important
period in the History of Medicine, for the study of the functions of
the body is a natural portal of entry to the study of the perversions
and suspensions of those functions that we call disease. The general
character of physiological thought during the modern period may perhaps
be described as the ‘synthetic study of the animal body’. The study
has become synthetic because organs have not been studied so much in
and for themselves as in relation to other organs. There has been, in
fact, during the period, an increasing consciousness of the integration
of the organs into one organic whole, the entire process being under
the control of the nervous system, the various parts of which are
themselves integrated (p. 308). This movement has, to some extent,
mitigated the ever growing evils of scientific specialization.
(a) _Anatomy and Embryology in the Earlier Nineteenth Century._
Let us first glance at the state of anatomical knowledge in the early
and middle nineteenth century. The general structure of the animal body
was well known. Descriptive Anatomy was not far from where it now is.
Comparative Anatomy, which had made good progress, was given a fresh
impetus by the researches and by the authority of a brilliant group of
French investigators, headed by Baron Georges Cuvier (1769-1832), whose
influence spread to England, Germany, and America, where the leading
exponents were Richard Owen (1804-92), Karl Gegenbaur (1826-1903), and
E. D. Cope (1840-97). Cuvier was a biological dictator whose opinion
did much to encourage investigation, and something to discourage some
important investigators. His services to Comparative Anatomy can hardly
be overrated. There was, however, still no effective knowledge of the
anatomical differences between the races of man, while the species of
man and of allied forms, whose skeletons palaeontologists have since
described, were quite unknown.
As regards knowledge of the process of Development of the animal body,
the broad lines of Embryology were being put on a firm basis by Karl
Ernst von Baer (1792-1876), whose work was finished in 1837, though he
lived another forty years. The subject was to be given a new meaning by
the evolutionary school, which applied to new details and to particular
instances the work of Charles Darwin (1809-82). Foremost of this school
was Francis Maitland Balfour (1851-82).
(b) _Chemical Physiology in the Earlier Nineteenth Century._
The analysis of the functions and workings of the body had advanced far
less than the knowledge of its structure. The study of Respiration was
perhaps in the best position. The elementary conception of Respiration
attained by Lavoisier at the end of the eighteenth century (p. 155)
was hardly extended till E. F. W. Pflüger of Bonn (1829-1910), in
the sixties and seventies of the nineteenth century, showed that the
essential chemical changes of respiration do not occur in the blood or
in the lungs, but in the tissues.
A very important figure in the scientific world of the thirties and
forties of the nineteenth century was the German Justus von Liebig
(1803-73), professor of Chemistry at Giessen. He was a convinced
mechanist, and over the door of the University Laboratory which he
founded he had inscribed the dictum _God has ordered all His Creation
by Weight and Measure_. His great achievement was his application of
chemical knowledge to physiology. He did much to introduce laboratory
teaching, and certain apparatus which he invented is still in constant
use.