has been enhanced quite as much as general surgery by the employment of
Listerism. The process of childbirth, although a perfectly natural one,
almost necessarily carries with it a certain amount of laceration, and,
through the wound surfaces thus produced, absorption of poisonous
material was formerly so frequent that puerperal fever figured
prominently in mortality reports. It was Oliver Wendell Holmes--a
graduate in medicine and a professor in the Harvard Medical School,
though we are accustomed to think of him only as a delightful
writer--who first declared that puerperal fever was the product of
infection from without the body, and Semmelweis demonstrated the truth
of the proposition. Holmes was a teacher of physiology, and his study of
that branch of medical science was in itself enough to convince him of
the doctrine which he inculcated.
Listerism must be credited, not only with having added immensely to the
safety of the major operations of surgery, but also with having led to
great improvement of their technics by reason of the greatly increased
frequency with which it has come to be thought justifiable to practise
them; what we do again and again we are apt in the end to do well,
whereas that which we turn to only in despair and as rarely as possible,
we do clumsily and imperfectly. Listerism has been unjustly alleged by
a few to be unworthy of the appreciation in which it is held by the
great majority of medical men of all countries; simple cleanliness, it
has been urged, is quite as efficient as the full Listerian precautions.
This is begging the question, for simple cleanliness, "chemical
cleanliness," is all that Listerism purports to accomplish. The use of
antiseptics has been decried in the interest of asepticism, as if the
whole purpose of antisepticism were not to secure asepsis. Lord Lister
is entitled to the full credit of establishing the aseptic surgery of
the present day, in spite of the facts that his doctrine followed rather
than preceded his early improvements, that aseptic procedures have been
brought nearer perfection elsewhere than in his own country, and that
the whole system rests on foundations laid by Pasteur.
While it is quite true that to the Listerian theory and practice are
almost wholly to be ascribed the favorable results of the major surgery
of the present day, we must not forget the immeasurable benefits to the
diseased, the injured, and the crippled that have arisen from patient
efforts and occasional brilliant intuition that have had no connection
with the germ theory of infection. Take the case of a broken leg, for
example, an injury that formerly condemned the victim to weeks and weeks
of confinement to bed, together with the suffering and danger almost
inseparable from the old methods of the long straight splint and tight
bandaging. At the present time he who has met with such a misfortune is
commonly able to be about on crutches within a few days, and his broken
bone mends while he is cultivating his appetite and indulging in
pleasant intercourse with his fellow-men. This great change has been
made possible by one device after another, invented by different men.
Josiah Crosby introduced the use of sticking-plaster for extension,
instead of the chafing bands previously employed; Gurdon Buck
substituted elastic extension by means of a weight and pulley for the
rude and arbitrary traction in vogue before; James L. Little devised the
plaster-of-Paris splint, whereby broken bones were immobilized with
hardly appreciable discomfort; and Henry B. Sands established the safety
and practicability of applying the plaster-of-Paris splint almost
immediately after the reduction ("setting") of the fracture. In the
meantime Nathan R. Smith and John T. Hodgen had demonstrated the
advantages of suspending a fractured limb from above. All these men were
Americans; surely our country has contributed powerfully to the
well-being of the subjects of fracture. Other Americans, notably Lewis
A. Sayre, have enabled sufferers with joint disease, including the
dreaded hip disease, to run about and gain health and strength, instead
of languishing in bed. Sayre, too, by his suspension treatment and the
plaster-of-Paris jacket, set the hunchback on his feet at a stage in his
disease in which before he had been forced to prolonged and painful
recumbency.
Although men professing special skill in certain operations, and
doubtless possessing it, flourished in old times, and left more or less
of their impress on the surgery of the present day, for that matter, it
was not until the second half of the Nineteenth Century that regional
surgery (which is what specialism virtually amounts to) was
systematically cultivated. Now there is hardly a portion of the body to
which practitioners who make its ailments a specialty do not direct
their searching methods of examination or on which they do not practise
their ingenious devices in the way of treatment. Specialism has always
been decried by a large section of the medical profession. On the other
hand, it has been and is still overrated by the laity. The true estimate
lies between the two. The specialists have advanced surgery immensely,
but, with many honorable exceptions, they have laid too much stress on
their several specialties, making too wide a range of ailments fall
within them. As for the community at large, their shortcoming lies in
the fact that most of them would seek for a specialist in mumps in case
that painful but transitory infliction were to come upon them, and in
their underrating of the family physician.
To change for a moment to a topic akin to the germ theory of disease,
the reader may be reminded that the antitoxine treatment of infectious
disease involves in almost every instance the use of some product
contained in the serum (that is to say, the watery part of the blood).
This leads to the subject of the use of natural and artificial serum in
the treatment of disease. To quote again from the article entitled, "The
Nineteenth Century in Medicine" ("New York Medical Journal," Dec.
29,1900): "It has been observed that the normal serum of certain animals
that are insusceptible to particular infectious diseases, if injected
into the human blood current or even into the subcutaneous tissue,
confers more or less of immunity against those diseases.... Artificial
serum seems to have been first employed by Edmund R. Peaslee as a benign
application to the peritonaeum in the operation of ovariotomy. His
conception of its mode of action is not very clear, but he was a very
successful ovariotomist, and we can only conjecture that he builded
better than he knew, like many another man. A few years ago much was
expected from transfusion of blood, but gradually the conviction has
forced itself upon us that it is wellnigh useless, and indeed that, on
the whole, it is worse than useless. It has virtually been abandoned....
But experiments in transfusion have not been fruitless; they have
culminated in demonstrating the inestimable value of infusions of
'normal,' or 'physiological,' solutions of sodium chloride, and not only
of infusions, but also of peritoneal irrigation with such solutions.
Many a life has been saved by resorting to this measure, even in
apparently desperate cases."
Within about a decade of the close of the century, Robert Koch, whose
discoveries and ingenious studies in bacteriology had brought him
world-wide renown, announced that he had produced a derivative of the
tubercle bacillus, which he termed tuberculin, that he thought might
prove curative of tuberculous disease. It was to be injected beneath the
skin. If the subject was really tuberculous, he would "react" by
manifesting a certain degree of fever, and repeated injections would
bring about elimination of the tuberculous deposits and thus effect a
cure. The world was carried away with such an announcement coming from
such a man, and it was thoroughly believed that at last "the great white
plague," consumption, was to be conquered. Tuberculin did, indeed, cure
certain minor forms of tuberculous disease, such as the skin affection
known as lupus, but it soon became evident that it was almost impotent
in the treatment of pulmonary consumption. It has, however, served to
enable the veterinarian to make out the existence of tuberculous disease
in cattle at an early stage of its course, and it is probable that by
the slaughter of cattle thus found to be tuberculous much infection of
human beings has been prevented.
Tuberculin failed of its prime purpose, but it does seem to have marked
the initiative of a campaign against consumption which has already
proved of incalculable benefit, and bids fair to put that omnipresent
disease toward the foot of the list of causes of death. We have made
substantial advances in our knowledge of the disease, and we no longer
regard it as incurable. We have learned that it is communicable from one
person to another, but also that its communication can easily be
prevented, so that there is no reason to shrink from association with
tuberculous persons. We have learned, too, that consumption in one's
progenitors, immediate or remote, hardly makes it even probable that he
himself is doomed to suffer with it; the only tuberculous heredity that
we now recognize is that of defective ability to withstand the
infection, and even this we regard as in most instances readily
surmountable. We have learned, furthermore, that pulmonary tuberculous
disease is by no means so fatal as it was formerly esteemed, for men
whose business it is to make great numbers of post-mortem examinations,
such as coroners' physicians and hospital pathologists, assure us that
in a very large percentage of cases of death from other causes they find
indubitable signs of past tuberculous disease of the lungs which had
ceased its activity--been, in fact, cured, either spontaneously or by
medical intervention. Such intervention, it has been abundantly proved,
is altogether likely to be successful if it is of the right sort and
employed early. There is, to be sure, no cure-all. Powerful as the
climatic treatment is, it must be supplemented by measures accurately
adapted to the individual case, and failure to comprehend this fact
still leads many a phthisical person to his grave. But information is
rapidly being diffused, sanatoria for such of the tuberculous as can
take advantage of them are multiplying, and those who are shut off from
their aid are growing more and more cognizant of how they should live in
order to give themselves the best chance of recovery and save their
associates from infection. The era of consumption-cures--meaning
drugs--is past; but the disease is cured in an ever-increasing
proportion of instances, and that, too, by medical though not
medicinal measures.
At almost every turn medicine has been powerfully assisted by the
sciences which should rather be termed correlative than subsidiary.
Notable among them is chemistry. The isolation of the active principles
of medicinal plants--such as morphine, quinine, strychnine, and
cocaine--has been a remarkable service rendered by chemistry to
medicine. How should we be handicapped if we still had to fight
malarial disease with the crude Peruvian bark instead of its chief
alkaloid, quinine! And how impracticable if not impossible would it be
to render the eye insensitive to pain with any extract of coca leaves,
no matter how concentrated--a purpose that we accomplish almost
instantly with cocaine! Of minor importance, perhaps, but not to be
despised, is the resulting liberation from the old slavery to bulky and
nauseous drugs. The isolation of active principles long antedated the
synthetical preparations, but the latter came at last--the marvellous
array of hypnotics, anodynes, and fever-quellers that are now at our
command, largely coal-tar products. But it is not to pure chemistry
alone that we are indebted for the elegant dosing of the present day;
progressive pharmacy, with its tablets, its coated pills, and its
capsules, has put to shame the old-time purveyor of galenicals. Right
jauntily do we now take our "soda mint" in case of slight derangement of
the stomach, happily oblivious of its vile prototype, the old rhubarb
and soda mixture. Even castor oil has been stripped of its repulsiveness
by the combinations which the soda water fountain affords.
It was but a step, we can now realize, from the employment of isolated
vegetable principles to that of preparations of certain glandular organs
of the animal economy, but the doctrine of "internal secretions" had to
intervene, and its evolution took time; not till toward the close of the
century did the venerable Brown-Séquard lead up to it. We have not yet
come to "eye of newt and toe of frog," but what we have incorporated
into modern therapeutics in the way of animal products lends at least
some theoretical justification to the ancient use of the dried organs of
various animals. It is but a few years since the "ductless glands"--such
organs, as, for example, the thyreoid gland (an organ situated in the
front of the neck, a small affair in its normal state, but prominent and
even pendulous when by its permanent enlargement it comes to constitute
a goître)--were looked upon as puzzles, as structures destitute of any
known function. Some observers even affirmed that they had no function,
though the constancy of goître in cretins ought to have shown the
fallacy of this allegation in the case of the thyreoid. We do not now
need to be told that the thyreoid gland plays a very important part in
the economy, for we know that its surgical removal gives rise to a
special disease known as myxoedema, which, in addition to its physical
manifestations, is characterized by impairment of the mental powers.
Consequently, this ductless gland--a gland, that is to say, which has no
obvious canal by which it throws off any product of its activity--must
elaborate some material that is necessary to the health of the organism
and is imparted to the blood. That material, whatever it may be, is
termed an "internal secretion." Some of the internal secretions have
turned out to be of singular value medicinally. It is apparently not the
ductless glands alone that furnish internal secretions; the glands that
are provided with ducts and yield a definite and observable product
secrete also a substance (perhaps more than one) which they give up to
the blood.
Prominent among the therapeutic advances of the century is the direct
reduction of the high temperature of sunstroke and certain fevers by the
use of cold. Although foreshadowed by Currie early in the century by his
use of cold affusion in the treatment of scarlet fever, it did not come
into general use until the closing decades. It is employed principally
in typhoid fever, on the theory that a condition of high fever is in
itself a source of danger quite distinct from the other injurious
effects of a febrile disease. On the other hand, the employment of high
degrees of heat has of late been shown to be a potent agency in the
treatment of certain forms of disease, notably in various affections
classed as rheumatic. Applications of very hot air, provided it is
thoroughly dry, are borne without serious discomfort, and their
employment promises to be of greater service in the conditions in which
it is resorted to than that of any other agent.
A revelation in the treatment of heart disease has been effected by the
Bad Nauheim system of effervescent baths and resisted exercises. It is
not only functional disorders of the heart that are relieved, but grave
organic diseases also. Somewhat elaborate explanations of the way in
which the treatment proves beneficial have been given, but they are not
altogether satisfactory.
Thus far we have dealt chiefly with those developments of medicine that
seem to have been the outgrowth of much thought and experiment, but
there was one that can hardly be viewed as other than a happy discovery,
yet it was one that was fraught with unspeakable mitigation of human
suffering, and that wrought a boundless extension of the field of
surgery. It was that of anaesthesia. The first to discover an efficient
surgical anaesthetic was Crawford W. Long, of Georgia. It has been
established that he performed several minor operations with the patient
anaesthetized with sulphuric ether, but he did not proclaim his
discovery, and so it was reserved for William T. G. Morton, of Boston
(then a dentist, but subsequently a physician), to make the first public
demonstration of the efficiency of ether as an anaesthetic, which he did
in the operating theatre of the Massachusetts General Hospital, in
Boston, in the year 1846. The news of Morton's achievement spread
broadcast, and it was at once realized that it was destined to
revolutionize surgery. It certainly has done that, and in no less
degree than was afterward accomplished by Listerism. Ether did not long
remain the only anaesthetic known; Simpson, of Edinburgh, soon
discovered that chloroform was possessed of even more decided
anaesthetic properties. The inhalation of ether is disagreeable, and it
is slow in producing the desired effect, whereas that of chloroform is
not unpleasant, and it acts more rapidly. Consequently chloroform soon
came to be generally preferred; but abundant experience has finally
shown that ether is much the safer agent of the two, and improved
methods of administration have almost entirely done away with the
objections to its use, so that now it is looked upon as the preferable
general anaesthetic. But general anaesthesia--meaning the suspension of
sensibility in the whole organism, including unconsciousness--is not
always necessary, and sometimes it is undesirable. We have now
trustworthy local anaesthetics, the chief of which is cocaine, wherewith
we are able to anaesthetize the part to be operated on without rendering
the patient unconscious, and the co-operation that a conscious patient
may be able to render is sometimes valuable. It was not alone in the
direct saving of human suffering that anaesthetics proved a boon to the
world; they have made possible an amount of experimental work on animals
in the way of vivisection that humane investigators would otherwise have
shrunk from, necessary as it has been and still is for the advancement
of the healing art.
The operation of ovariotomy, first performed by Ephraim McDowell, of
Kentucky, can hardly be classed with the happy accidents; but so little
had been said about it or thought concerning it that when the news of it
reached Europe "from the wilds of America" the editor of a ponderous
English quarterly journal of medicine recorded his incredulity in the
words "_Credat Judoeus, non ego_" An ovarian tumor inevitably proves
fatal in the long run if it is not removed. In a certain percentage of
cases it is malignant and will kill whether it is removed or not, but
the general result of ovariotomy has been the saving of thousands of
women from untimely death. Bell, of Edinburgh, had imagined the
operation and had mentioned it in his lectures, but none the less to
McDowell is due the credit of demonstrating its feasibility.
Medicine bore quite its full share in the mitigation of the horrors and
hardships of war that marked the Nineteenth Century. Its work was shown
in the great reduction of pestilential disease incident to camp life, in
prompt aid to the wounded, in the establishment of salubrious field and
general hospitals, and in improved methods of transportation of the sick
and wounded. Certainly the soldier on the sick list never before had
such a fair prospect of rejoining his comrades safe and sound as he
has now.
In the care of the insane, too--care not only in the sense of humane
treatment, but in the systematic employment of measures for their
restoration to mental soundness--the century has been marked by notable
progress. This has been chiefly in the direction of preventing insanity,
and although mental disease is said to be on the increase, it may
undoubtedly be said with entire truth that its growing prevalence is not
in proportion to the heightened frequency of "the strenuous life." We
may confidently expect that a more pronounced mastery over diseases of
the mind will come when physicians in general are taught psychiatry
clinically, so that the beginnings of mental alienation may be
intelligently met by the family practitioner.
The supreme achievement of the medicine of the Nineteenth Century
undoubtedly has been the development of its preventive feature. When we
recall the fact that but a few years ago an attack of infectious disease
was interpreted as a visitation of Providence, by a perversity that even
the triumphs of vaccination did not serve to do away with; when we
contemplate the well-ordered and well-understood measures that are now
resorted to in an ever-increasing number of communities (and resorted to
not solely on the outbreak of an epidemic, but at all times), to purify
the air we breathe, the food we eat, and the water we drink; and when we
reflect upon the greatly reduced morbidity as well as mortality of most
infectious diseases--we must realize the immense service that has been
rendered by preventive medicine. No doubt we must all die some time, and
the day is yet far remote when the only causes of death will be old age
and injury; but a decided prolongation of the average lifetime, such as
the life-insurance companies recognize, is an unquestionable gain to the
human race.
A great blessing that has been brought about in great measure by medical
men has been the establishment of the profession of nursing. The work of
caring for the sick between the physician's visits is no longer, at
least in large communities and in cases of severe illness, left to
over-sympathetic and uninstructed relatives or to outsiders who traded
on mystery. An intelligent and intelligible record is now kept of all
important happenings in the sick room, remedies are administered as they
were ordered, needless alarm at something deemed by the patient to be of
ill omen is quelled, and in case of real emergency, overlooked as it
might otherwise have been, the physician is summoned to meet it. The
advent of the trained nurse marked an era in medicine.
The literature of medicine has fully kept pace in volume with the
progress of the art itself, and its quality has steadily improved. To
this the great tomes of that gigantic work, the "Index-Catalogue of the
Library of the Surgeon-General's Office, United States Army," bear
solid testimony. It is a consolidated catalogue, by subjects and by
authors' names, of practically every medical book published throughout
the world and of every article in the periodical literature of medicine.
For its existence the world is indebted to Dr. John S. Billings,
formerly a surgeon of high rank in the army and now the director of the
New York Public Library, and for its continued existence to the United
States Government, and it is to be hoped that Congress will never cease
to provide adequately for its continued publication. Its completeness
and its accuracy long ago led to its being prized everywhere.
There are some problems of which medicine has hardly yet entered upon
the solution. Prominent among them is that of cancer. Little as we now
know of the real nature of that disease, we know quite as much of it as
we knew but a few years ago concerning other diseases equally
destructive and far more prevalent, which, however, we have now
practically mastered. Who can say that we shall not triumph over cancer
while the Twentieth Century is still young? Our final triumph is
indubitable.