[Dr. Billings is a surgeon and administrator of the first
rank. He is now a director of the New York Public Library.
Among his many published works are "Principles of Ventilation
and Heating," issued by the _Engineering Record_, New York.
The essay which follows appeared in the _Evening Post_, New
York. January 12, 1901, copyrighted. It is reprinted in a
volume entitled "The Nineteenth Century: a Review of Progress
During the Past One Hundred Years," published by G. P.
Putnam's Sons, New York, 1901, copyrighted. It is presented
here by the kind permission of Dr. Billings, the publisher of
the _Evening Post_, and G. P. Putnam's Sons.]
The word "medicine," as used in the title of this paper, includes all
branches of the art of prevention and treatment of disease and injuries;
all discoveries of methods of diminishing physical pain and of
prolonging life, and also that part of modern science which is concerned
with accurate knowledge of the structure and functions, normal and
abnormal, of the human body, and of the causes of diseases. In other
words, it includes not only therapeutics, medical and surgical, but also
physiology, pathology, and hygiene.
In all these branches of medicine greater progress has been made during
the last century than had been made during the previous two thousand
years. This progress has been largely due to improvements in methods of
investigation and diagnosis, resulting from increase of knowledge in
chemistry and physics; to better microscopes and new instruments of
precision; to experimental work in laboratories and to the application
of scientific method and system in the observation and recording of
cases of disease and of the results of different modes of treatment. The
introduction of statistical methods in the study of cases of disease and
of causes of death; the discovery of general anæsthetics; the adoption
of antiseptic [excluding microbes] and aseptic [uninfective] methods in
surgery, and the development of modern bacteriology--each marks a point
in the history of medicine in the nineteenth century.
The scientific demonstration that some diseases are due to the growth
and development of certain specific micro-organisms in the human body
dates from about twenty years ago, although the theory of such causal
relation is much older. Since 1880 it has been proved that anthrax,
Asiatic cholera, cerebro-spinal meningitis, diphtheria, one form of
dysentery, erysipelas, glanders, gonorrhoea, influenza, certain
epidemics of meat-poisoning, pyæmia and suppuration in general,
pneumonia, tetanus, relapsing fever, tuberculosis, bubonic plague, and
typhoid fever are due to minute vegetable organisms known as bacteria;
that malarial fevers, Texas cattle fever, and certain forms of
dysentery are due to forms of microscopic animal organisms known as
microzoa; and for most of these diseases the mode of development and
means of introduction of the micro-organism into the body are fairly
well understood. To the information thus obtained we owe the triumphs of
antiseptic and aseptic surgery, a great increase of precision in
diagnosis, the use of specific antitoxins [antidotes to organic
infection] as remedies and as preventives, and some of the best
practical work in public hygiene.
The evidence as to the increased powers of medicine to give relief from
suffering and to prolong life is most clear and direct in the records of
modern surgery--particularly in some of its special branches. In a large
proportion of certain cases in which the surgeon now operates with a
fair chance of success, such as calculus in the kidney or gall-bladder,
shot-wounds of the abdomen, and tumours of various kinds, there was no
hope in the year 1800, and the unhappy sufferer could only expect a
certain, though often a lingering and painful, death. In cases of cancer
of the face, tongue, breast, or uterus, the persistent pain, extreme
disfigurement, and offensive odors which attended them made death a boon
to be prayed for, if not deliberately sought, while now such cases, if
brought in time to the surgeon, can often be entirely relieved. The
knowledge of this fact has become general with the public, and patients
no longer defer an operation as long as possible, as was their custom
in days of old. Instead of having to look forward to the torture of
incisions, manipulations, and stitching, with but small hope of
surviving the exhausting suppuration and blood-poisoning which were such
common results, the patient now knows that he will inhale a little sweet
vapour, and sleep unconscious of the strokes of the surgeon's knife or
the pricks of his needle. He may dream wondrous dreams, but he will soon
awake to find himself in his bed staring at the trained nurse standing
by his side, and wondering vaguely why the operation has not begun. He
does not have to look forward to weeks and even months of daily
dressings. The surgeon will glance at his temperature record and at the
outside of his bandages, but will probably not touch them for a week;
and when he does remove them nothing will be seen but a narrow red line
without a trace of suppuration. These improved methods not only preserve
the mother for her children, and the bread-winner for the family, but
they greatly contribute to the public good by shortening the period of
enforced idleness and unproductivity after operations.
Some of the greatest triumphs of modern surgery are obtained in cases of
disease or injury of the abdominal organs. The removal of ovarian and
uterine tumours is now so common and successful that it is not easy to
realize that a hundred years ago there was practically no help or hope
for such cases. In former days, the lists of deaths contained many
cases reported as inflammation or obstruction of the bowels, or as
peritonitis. It is now well understood that most of these cases are due
to disease of a little worm-like appendix connected with the large
intestine on the right side of the lower part of the abdomen,
inflammation of which, known as appendicitis, causes excruciating pain,
and often produces internal abscesses and death. An operation for the
removal of such a diseased appendix is now common, and in most cases
successful. The operation for the removal of calculus, or stone, from
the urinary bladder dates from over twenty-five hundred years ago, and
no one knows who first performed it. Within the last century it has been
largely superseded by an operation which crushes the stone to powder
within the bladder, and removes this powder without the use of the
knife. The removal of calculi from the kidney or from the gall bladder,
and the removal of a diseased kidney, are new operations, made possible
by improved means of diagnosis, anæsthesia, and antisepsis [determining
disease, causing insensibility, and excluding microbes]. Wounds of the
intestines were formerly thought to be almost necessarily fatal, and
nothing was done for them except to stupify the patient with opium. Now
in such cases the abdomen is opened, the lacerations of the bowel are
closed, the effused blood and other matters are removed, and in many
cases life has thus been preserved.
By increase of knowledge of the anatomy of the brain, and of the
distribution of nerves connected with it, it has become possible in a
certain number of cases to determine what part of the brain is suffering
from irritation or pressure, and to operate for the removal of the
tumour or other substance causing the trouble, with considerable hope of
giving permanent relief. A branch of surgery which has developed into an
important specialty during the last century is that known as plastic and
orthopædic surgery [ameliorating deformities]. The replacing of a lost
nose by engrafting other tissue in its place is a very old triumph of
surgical art, but operations of this kind have been greatly extended and
perfected within the last hundred years, and much can now be done to
mitigate the deformity and weakness due to club feet, bandy legs,
contracted joints, etc., which formerly were considered to be beyond
remedy.
Many of the diseases peculiar to women have been deprived of much of
their terrors within a hundred years. In 1800, for every thousand
children born, from ten to twenty mothers died. Puerperal fever occurred
in epidemics, following certain physicians and nurses, but nothing was
known as to its causes or nature. To-day puerperal fever is almost
unknown in the hospitals or in the practice of a skilled physician. The
death-rate of mothers is less than five per thousand births, and the
mechanical obstructions which a century ago would almost certainly have
brought about the death of both mother and child, are now so dealt with
that more than half of both mothers and children are saved.
The study of the diseases of the eye has greatly developed another
specialty during the century, viz., ophthalmology. The investigations of
Helmholtz in physiological optics, with his invention of the
ophthalmoscope in 1852, effected a revolution in this branch of medical
science and art, and have added greatly to human comfort and happiness.
A hundred years ago, when the physician saw the eyelids of a new-born
babe redden, and swell, and yellow matter ooze from between them, he
knew that in a few days or weeks the child would be partially or wholly
blind, but he knew nothing of the simple means by which the skilled
physician can now prevent such a calamity. It is unfortunately true that
this knowledge is not even now sufficiently widely diffused, and that
our blind asylums must, for some time to come, continue to receive those
that have been deprived of sight during the first months of their life
through the ignorance or neglect of those who should have properly cared
for them.
While it is certain that the death-rates in the last century were
greater than those of the present day, it is not possible to make
precise comparisons. The record of deaths in the city of New York
begins with 1804, and was necessarily very imperfect until the law of
1851, which required the registration of all deaths; but it shows a
death-rate of 30.2 per 1,000 in 1805, which means that the true
death-rate must have been between 35 and 40. At present, for a series of
five years, it would be about 20, having been below 19 in 1899, so that
the death-rate has been diminished by at least one-third. How much of
this is due to improved sanitary conditions it is impossible to say. A
comparison of the list of causes of death in 1805 with the list of
causes for 1900 shows great differences, but much of this is due to
changes in name and to more accurate diagnosis.
"Malignant sore throat" and "croup" were well known to anxious parents
in 1800, but "diphtheria" caused no anxiety. "Inflammation of the
bowels" was common and fatal, but "appendicitis" had not been heard of.
"Nervous fever," "continued fever," and "low fever" were on the lists,
but not typhoid, which was not clearly distinguished as a special form
of disease until 1837, when Dr. Gerhard, an American physician, pointed
out the differences between it and typhus, which also prevailed at the
commencement of the century.
One hundred years ago the great topic of discussion in our cities on the
North Atlantic coast was the means of preventing yellow fever, which had
been epidemic in New York and Philadelphia for two years. Physicians
were disputing as to whether the disease was contagious and imported,
and, therefore, perhaps, preventable by quarantine and disinfection, or
was due to some occult condition of the atmosphere (which was the view
taken by Noah Webster in his "History of Epidemic and Pestilential
Diseases," a work which appeared about the middle of the year 1800,
although it is dated 1789). The discussions remind one of the remark
that a certain patented form of electric light was surrounded by a cloud
of non-luminous verbosity. For example, the Committee of the Medical
Society of the State of New York reported that yellow fever may be
produced in any country by pestilential effluvia; and Webster concluded
that typhus and nervous fevers were due to a "conversion of the
perspirable fluids of the body into septic [poisonous] matter"--all of
which means that they knew nothing about it. Even now we do not know the
cause of yellow fever, or the precise mode of its spread; but we are
sufficiently certain that it is due to a specific micro-organism to be
confident that its spread can be checked by isolation and disinfection
properly applied--and Memphis and New Orleans are witnesses to the truth
of this.
In the year 1800, the majority of persons over twenty years old were
more or less pitted by small-pox, being the survivors of a much greater
number who had suffered from this disease. Dr. Miller in New York had
just received from England a thread which had been steeped in the newly
discovered vaccine matter, and was about to begin vaccination in this
city. To-day there are many physicians who have never seen a case of
small-pox, and a face pitted with the marks of this disease is rarely
seen.
During the century there have appeared in civilized countries two
strange and unfamiliar forms of epidemic disease, namely, Asiatic
cholera and the plague, the first coming from the valley of the Ganges,
the second from the valley of the Euphrates, and each having a long
history. A really new disease was the outbreak in Paris in 1892 of a
specific contagious disease transmitted from sick parrots, and known as
psittacosis. This little epidemic affected forty-nine persons, and
caused sixteen deaths. Typhus fever has almost disappeared, while some
diseases have increased in relative frequency, in part, at least,
because of medical progress. The children who would have died of
small-pox in the eighteenth century now live to be affected with
diphtheria or scarlet fever, and the increase in the number of deaths
reported as due to cancer is partly due to the fact that a greater
proportion of people live to the age most subject to this disease.
A large part of modern progress in medicine is due to improved methods
of diagnosis, and to the use of instruments of precision for recording
the results of examinations. The use of the clinical thermometer has
effected a revolution in medical practice. Our knowledge of diseases of
the heart and lungs has been greatly expanded during the century by
auscultation [trained listening to sounds] and percussion, and
especially by the use of the stethoscope. The test-tube and the
microscope warn us of kidney troubles which formerly would not have been
suspected, and the mysterious Röntgen rays are called in to aid the
surgeon in locating foreign bodies and in determining the precise nature
of certain injuries of the bones. Bacteriological examination has become
a necessary part of the examination in cases of suspected diphtheria,
tuberculosis, or typhoid, and a minute drop of blood under the
microscope may furnish data which will enable the skilled physician to
predict the result in certain cases of anæmia [bloodlessness], or to
make a positive diagnosis as between malaria and other obscure forms of
periodic fever.
The means at the command of the physician for the relief of pain now
include, not only the general anæsthetics,--chloroform, ether, and
nitrous oxide,--but also the hypodermic use of the concentrated
alkaloids of opium, belladonna, and other narcotics, and the local use
of cocaine; and restful sleep for the weary brain may be obtained by
sulphonal, chloral, etc. Some agonizing forms of neuralgic pain are now
promptly relieved by the section or excision of a portion of the
affected nerve; or it may be forcibly stretched into a condition of
innocuous desuetude. Relief to the sufferings of thousands of neurotic
women, and of their families and friends, has been produced by the
systematic scientific application of the rest cure of Dr. Weir Mitchell.
A hundred years ago the medical advertisement which was most prominent
in New York and Philadelphia newspapers was one of a remedy for worms.
Many symptoms of nervous and digestive troubles in children were in
those days wrongly attributed to worms. Nevertheless, there is good
reason to believe that parasitic diseases derived from animals were in
those days much more prevalent in this country than they are to-day. Our
knowledge of the mode of origin and development of the tapeworm, the
_trichina spiralis_, the liver fluke, and the itch insect has been
gained during the nineteenth century. Much the same may be said with
regard to the peculiar worm known as _anchylostum_, the cause of
Egyptian chlorosis, and of the St. Gothard tunnel disease, although
prescriptions for this parasite are found in the Papyrus Ebers, written
before the time of Pharaoh.
The limits of this article permit of but a brief reference to the
progress in preventive medicine during the century. The studies made in
England of the results of the cholera epidemic of 1849, and the
experience gained in the English army during the Crimean war, led to
some of the most important advances in sanitary science, more
especially to the demonstration of the importance of pure water
supplies, and of proper drainage and sewerage. During our Revolutionary
War, and the Napoleonic wars, the losses to the armies from disease
greatly exceeded those from wounds; and hospital fever--in other words,
typhus--was dreaded by a general almost more than the opposing forces.
During the wars of the last twenty-five years, typhus and hospital
gangrene have been unknown, but some extensive outbreaks of typhoid
fever have occurred, showing that our knowledge of the causes and mode
of transmission of this disease has not been practically applied to the
extent to which it should have been; this remark applies also to some of
the most fatal diseases in civil life. In the United States diphtheria
and typhoid fever each causes from twenty to thirty thousand deaths a
year, while more than one hundred thousand deaths are annually due to
consumption. Yet for each of these diseases we know the specific germ,
the channels through which it is usually conveyed, and the means by
which this conveyance can be to a great extent prevented. The ravages of
these diseases are, therefore, largely due to the fact that the great
mass of the people are still ignorant of these subjects. Antitoxin is
not yet used for either prevention or treatment in diphtheria to
anything like the extent which our knowledge of its powers demands.
Our better knowledge of the causes of certain infectious and contagious
diseases, and of the mode of their spread, has been of great importance
to the world from a purely commercial point of view, since it has led to
the doing away with many unnecessary obstructions to traffic and travel
which were connected with the old systems of quarantine, while the
security which has been gained from the modern method of cleansing and
disinfection is decidedly greater than that secured by the old methods.
A striking illustration of the effect of these improvements is seen in
the manner in which the news of the recent outbreak of plague in Glasgow
was received in England and throughout Europe. One hundred years ago the
city would have been almost deserted, and terror would have reigned in
all England. To-day it is well understood that the disease spreads by a
bacillus which is not conveyed through the air. No one fears a
repetition of the ghastly scenes of the Black Death in the fourteenth
century. In like manner, and for the same reasons, Asiatic cholera has
lost most of its terrors.
The benefits to the public of modern progress in medicine have been
greatly enlarged by the establishment of many small hospitals, and by
the steady increase in the employment of specially trained nurses in
private practice, even in rural districts. The results of a case of
typhoid or of pneumonia often depend as much upon the nurse as upon the
doctor; and affection cannot take the place of skill in either. For the
great mass of the people, cases of severe illness or injury, or those
requiring major surgical operations, can be treated more successfully in
well-appointed hospitals than in private houses, and as this is becoming
generally understood the old feeling against entering a hospital for
treatment is rapidly disappearing. Improvement in hospital construction
and management has kept pace with progress in medical knowledge; and in
future such institutions seem destined to play an increasingly important
part in municipal and village life.
All progress in civilization is attended with injury to some
individuals. Trained nurses have deprived some unskilled labour of
employment; hospitals have injured the business of some physicians;
pure-water supplies, good sewers, food inspection, vaccination,--in
short, all effective measures in public hygiene,--interfere with the
trade side of medical practice; but upon the whole the public at large
benefits by all these things. In one sense they seem opposed to the
general law of evolution, in that they prolong the life of the unfit;
but in a broader sense they work in accordance with this law by
increasing the power of the strong to protect and care for the weak.
All told, the most important feature in the progress of medicine during
the century has been the discovery of new methods of scientific
investigation, more especially in the fields of bacteriology and
pathology. These methods have been as yet only partially applied, and
great results are to be hoped from their extension in the near future.
They will not lead to the discovery of an elixir of life, and the
increasing feebleness of old age will continue to be the certain result
of living a long time, for the tissues and organs of each man have a
definitely limited term of duration peculiar to himself; but many of the
disorders which make life a burden in advancing years can now be
palliated, or so dealt with as to secure comparative comfort to the
patient, so that "if by reason of strength" life can be prolonged beyond
threescore years and ten it no longer necessarily involves labour and
sorrow.
Transcriber's Notes:
Punctuation and hyphenated and accented words have been standardized.
All else remains as in the original.