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I CONTRIBUTIONS TO
MEDICAL AND BIO^
LOGICAL RESEARCH

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CONTRIBUTIONS TO

MEDICAL & BIOLOGICAL

RESEARCH

VOLUME TWO

CONTRIBUTIONS

TO MEDICAL AND BIOLOGICAL
RESEARCH

DEDICATED TO

iiR William Osler

Bart., m. d., f. r. s.

IN HONOUR OF HIS

SEVENTIETH BIRTHDAY

July la, 1919

HIS PUPILS AND CO-WORKERS

VOLUME TWO

NEW YORK

PAUL B. HOEBER

M CM XIX

>V';

CoP'i'RIGHT, I919,

By PAUL B. HOEBER

///

0 75'

Printed in the United States oj America

CONTENTS

VOLUME TWO

Rehabilitation of the Disabled . . Frank Billijigs .

The Choice and Training of Medi-
cal Officers for the Air Forces.

Personality and Disease ....

Medical Examination of Men for
Military Service: Some of Its
Problems, Lessons, and Results .

American Red Cross Child Welfare
Work in France

Military Morale

Phases of War Surgery. Extensive,
Highly Disfiguring Wounds of
THE Face

A Psychotic Episode in Roman
History

The Schematic Drawing of the Eye
in Its Historic Development . .

Physicians' Letters

Homage to Sir William Osler. . .

Epidemics of Influenza in 1647,
1789-90 AND 1807

VoTUM Medici

Sir William Osler and the Johns
Hopkins Hospital

An Appreciation of Hermann
Weber

Edward Jenner, a Student of Medi-
cine, as Illustrated in His Letters

Thomas R. Boggs . .
Frederic J. Farnell . .

Sir James Galloway

J. H. Mason Knox, Jr.
Edward L. Munson

Charles A. Powers

Charles L. Dana

Mortimer Frank
Fielding H. Garrison
Arpad G. Gerster

Guy Hinsdale
Bayard Holmes .

Henry M. Hurd

A. Jacobi . . .

Henry Barton Jaco

The Influence of Osler on Ameri-
can Medicine ........

Servetus Notes .

George M. Kober
Leonard L. Mackall

PACE
651

655
659

665
680

688

694
697

708

712
720

721
731

732

736

740

756

767

CONTENTS

A Simple Keyword System for In-
dexing AND Classifying Clinical
Case Histories and Current Med-
ical Literature

Prothymia: Note on the Morale-
Concept IN Xenophon's "Cyro-
pedia"

The Medical History of Two
Crusades

A Souvenir of the Macartney
Museum

William H. Mercur

E. E. Southard .

James J. Walsh

J. Collins Warren

Influence of English Medicine
upon American Medicine in Its
Formative Period

HE Eyes of the Burrowing Owl .

The Regulation of the Red Blood-
Cell Supply

William H. Welch .
Casey A. Wood . .

C. H. Bunting . .

^ The Action of Adrenalin on the
Leucocytes and Erythrocytes . .

Studies on Blood Sugar

Influence of Fat on Calcium Metab-
olism

On Contra-lateral Representation
IN THE Cerebral Cortex of the
Peripheral Blood Vessels . . .

David Murray Cowie
Louis Hamman . .

B. Raymond Hoobler

Colloid Chemistry and Medicine .

A Few Thoughts on the Vis Medica-
TRix Nature

Sources of Intellectual Power . .

The Psychology of Anticipation and
OF Dreams

Clinical and Developmental Study
OF a Case of Ruptured Aneurysm
OF the Right Anterior Aortic
Sinus of Valsalva ...<,..

Detection of Abnormal Tissues
within the Lungs

The Conditions Presented in the
Heart and Kidneys of Old People.

5. P. Kraw.er . . .
Jacques Loeb . . .

Robert Dawson Rudolph
William Browning . .

Frederick Peterson . .

Maude E. Abbott . .
C. R. Bardeen . . .
W. T. Councilman . .

778

786
796
806

811

818

824

829
845

853

857
861

873
880

892

899
915
918

CONTENTS

Epidemiology of Poliomyelitis . . Simon Flexner

PAGE

929

942

Hemangioendothelioma of the Liver

in the Infant, and So-called

Angiosarcoma John Foote . . • • 935

The Production of an Antihemol- f ur-n- n/ c- 1

YSIN FOR THE HEMOLYSIN OF ^^ ^"^"^ ^^;.^°;^ „,.,,.

Bacterium Welchii \ George Huntington Williams

Symptomless Obliteration of the

Superior Vena Cava Thomas B. Futcber 946

The Study of Morbid Anatomy . Alexander G. Gibson . .951

Leucocytes AND Protozoa . . . ■{ ^ f; ^rS Goodrich } 958

Further Observations on the
Effects of Roentgenization and
Splenectomy on Antibody Produc-
tion Ludvig Hektoen . . . 973

The Importance of Recording the

Weight at Death Elliott P. Joslin . . . 983

The Tumor in Syphilis of the Liver . Thomas McCrae . . . 985

Splenic Anemia W. J. Mayo . . . .991

Tumor Formation with Peptic

Ulcer Charles G. Stockton . . 1002

Aneurysm of the Middle Cerebral
Artery in a Child Nine and One-
Half Years Old Fritz B. Talbot . . .1004

Observations on Congenital Hyper-
trophy of the Pylorus .... John Thomson . . .1010

The Cardiovascular Defective . . Louis M . Warfield . .1031

A Case of Ayerza's Disease . . . Aldred Scott Warthin . .1042

Description of a Minute Sarcoma,
Necessitating Removal of the
Eyeball, with Histological
Findings John E. Weeks . . . 1060

Intoxication of Intestinal Ob-
struction G.H. Whipple . . . 1065

Some Experiences and Observations
IN THE Treatment of Arterioven-
ous Aneurysms Rudolph Matas . . .1074

Exstrophy of the Bladder . . . C. H. Mayo . . . . i C9

CONTENTS

Some Notes on Achylia Gastrica . Thomas R. Brown

Epidemic Pneumonia W. G. MacCallum

A Psycho-therapeutic Clinic in the

Jura Mountains C. F. Martin . .

The Life Chart and the Obligation
of Specifying Positive Data in
Psychopathological Diagnosis . . Adolf Meyer .

Pneumonia and Empyema at Camp

Dodge, Iowa Jos. L. Miller .

Clinical Observations on the Late

Pulmonary Effects of Gassing . Roger S. Morris .

The Diagnosis of Traumatic

Hemothorax Geo. W. Norris

The Peritoneal Syndrome in

Malaria H. C. Parsons

Studies on the Potency of Digitalis

Leaves from Various Sources . . Joseph H. Pratt .

Epidemic Influenza in Children . John Ruhrdh .

An Unusual Complication of Mumps Joseph Sailer .

Segmental Cerebral Monoplegia . William G. Spiller

The Relation of Thyroid Secretion
TO the Condition of the Skin — and
Incidentally to Old Age . . . M. Allen Starr

Relation of Acute Infection to
Diabetes Alfred Stengel .

The Significance of Rickettsia in

Relation to Disease .... Richard P. Strong

The Relative Infrequency of Can-
cer OF the Uterus in Women of
the Hebrew Race Hiram N. Vineberg .

The Contribution of Modern Psy-
chiatry TO General Medicine . . William A. White

The Tolerance of Freshly Deliv-
ered Women to Excessive Loss of
Blood J. Whitbridge Williams

Intratracheal Pulmonary Irriga- f M. C. Winternitz
TioN \G.H. Smith

Envoi: Sir William Osler and the
American Medical Officer . . Francis A. Winter

PAGE

. nil
. III5

. 1 123

. 1 128

. II34
. 1 138

. "43

. 1 149

• 1155
. 1 168
. 1172
. 1 175

. 1 184
. 1 186
. 1205

. 1217
. 1226

. 1238
. 1255

. 1267

ILLUSTRATIONS

Illustrating Phases of War Surgery (Seven Plates) Facing Page 694
Hermann Weber " " -,35

Reproduction of Copperplate Engraving of Ser-

VETUS. By C. Van Sichem (1607) " " y68

The Fundus Oculi of the Burrowing Owl (Colored) " " 820

Photograph of Gelatin Treated with Silver Ni-
trate " " 868

Aneurysm of Right Aortic Sinus of Valsalva,

Rupturing into Right Ventricle at Level of " " i 9oo
Pulmonary Valves (Two Plates) 19^2

Model of Heart of Human Embryo (Two Plates) . " " -f ^^^

1903
Heart of Alligator Mississippiensis " " 903

Illustrating Hemangioendothelioma of the Liver
IN THE Infant (Seven Plates) " " 936

Illustrating Symptomless Obliteration of the Su-
perior Vena Cava " " 946

Leucocytes and Protozoa " " 964

Illustrating Tumor Formation with Peptic Ulcer

(Three Plates) " " 1002

Illustrating Congenital Hypertrophy of the Py-
lorus (Two Plates) , " " 1012

Illustrating Case of Ayerza's Disease (Seven
Plates) " " 1050

Illustration of Case of Minute Sarcoma ..." " 1064

Illustrating Treatment of Arteriovenous Aneu-
rysms (Seventeen Plates) " " 1082

Illustrating Exstrophy of the Bladder (Five .; .< (1102

Plates) I 1 104

Rickettsia Bodies in the Excrement of Normal
Lice " " i^io

CONTRIBUTIONS TO

MEDICAL & BIOLOGICAL

RESEARCH

I^^p^

m^m

r^^

p^V^SSkvI

REHABILITATION OF THE DISABLED
By Frank Billings, M.D., Washington, D. C

HE World War has aroused an universal
interest in the physical and mental rehabil-
itation of disabled soldiers. The instru-
ments of destruction of modern warfare
sacrificed so many lives and disabled such
a multitude of men that it became necessary
to utilize all possible measures to conserve
man power. There was urgent need to
hasten and to make more certain the res-
toration of the soldier disabled by illness or wounds so that he
could return to mihtary duty.

Modern mihtary medicine and surgery is a development of the
World War. It is efficient. Phenomenal technical surgical skill
and wise and rational medical management contemplate functional as
well as physical restoration. The armamentarium of the mihtary
medical officer embraces in addition to the knife and drugs, hydro-,
electro-, and thermo-therapy; passive and active exercise in the form
of massage; of curative work both manual and mental in wards,
shops, gardens, and fields; of drill, cahsthenics, and physical culture,
and of sports and pastimes in and out of doors.

These measures hasten and make more certain the recovery of
the disabled soldier. Their appHcation maintains the constant interest
of the medical officers, nurses, and enhsted personnel in the wel-
fare of the patient. It diverts the mind of the disabled man from the
contemplation of his present suffering and future fate; the morale
of the hospital corps and the patients is kept at a high standard.

651

652 REHABILITATION OF THE DISABLED

Based upon available statistics, from 80 to 85 per cent of combat-
injured soldiers of the allied armies returned to combat duty. From
5 to 10 per cent of combat-disabled soldiers, unfit for full military
service, returned to special or limited duty. Of the remainder, unfit
for all mifitary service, continued treatment was carried to the fullest
degree of restoration possible when the nature of the disability is
considered. These disabled men unfit for all mifitary service include
the bfind, the deaf, the dismembered, the severely gassed, the in-
sane, and others. Among these must be classed also those disabled
by illness, including tuberculosis, meningitis, chronic nephritis, or-
ganic heart disease, epilepsy, insanity, and other morbid conditions.

Practically all of the countries engaged in the war have en-
deavored, with more or less success, to extend the attempt at physical
and functional restoration of the disabled soldier no longer fit for
military duty, beyond the period of the needed hospital care. This
involves a program of education and training to overcome the
permanent physical handicap and to fit them to become self-
sustaining economic factors in civil life.

The blind are no longer left to brood and lament to the degree
of mental degeneracy. The remarkably efficient school for the blind
at St. Dunstan's, organized and directed by Sir Arthur Pearson, has
set an example which will hereafter force all civilized governments
properly to educate and train the adult population blinded in industrial
occupations or by disease. Under the Medical Department of the U.
S. Army, a school for the blinded soldiers and sailors modeled upon St.
Dunstan's is maintained at U. S. General Hospital No. 7, Baltimore.

In like manner deaf soldiers are taught lip reading, and speech
defects are corrected by proper training. Coincidentally, the dis-
abled soldier is educated and trained better to qualify him for his
old occupation or for a new and gainful trade or profession.

The soldier who suffers from an improvable type of tuberculosis
is given a form of curative work, either manual or mental, which will
divert him and aid in the avoidance of hospitalization. The conva-
lescent tuberculosis patient is especially benefited by work in the open
air, on a protected porch, or in garden or field. Intelligent medical
supervision as to the dosage of work and a common-sense choice of
practical forms of curative work are essential in the treatment of
the tuberculosis patient.

REHABILITATION OF THE DISABLED 653

The object of the training and education of dismembered patients
is two-fold. First, the training of the brain and of the muscles of
the remaining hmb or Hmbs is for the purpose of making the one limb
perform the function of two. The left upper extremity may be trained
to do all and more than the lost right arm did. Properly fitted
artificial legs may become, with supervised and regulated rational
practice, almost as useful as the natural ones. Second, training or
education for life employment, which may be carried on coinciden-
tally with the efforts to restore control of a member or to attain
what may be termed vicarious function.

One may not contemplate the physical and mental rehabilitation
of disabled soldiers without a consideration of the past and present
neglect of the disabled men in the great industrial armies of the
world. It has been stated that 750,000 people are injured annually in
the industrial occupations of eighteen of the United States of
America. That 35,000 of these individuals are permanently disabled.
It is also stated that of people engaged in industrial occupations,
80,000 are permanentl}'^ disabled annually in the whole United
States. Of these, 2000 are totally disabled. This enormous crippling
or entire loss annually of the industrial workers must be met by a
policy of conservation and a rational program of rehabilitation of the
disabled. The experience of the allied countries associated in
the World War in the rehabilitation of disabled soldiers should be
applied to the disabled of the industrial army.

The policy of rehabilitation of the disabled should be the same
as that applied in military organizations, but the program should be
modified to meet civilian demands and conditions. During the
conflict disabled soldiers were kept in the hospital or in convalescent
training centers until fit for military service. The military authority
trained and educated the disabled soldier, no longer fit for combat
service, for special or limited military duty. Then it was necessary
to organize educational and trade-training facilities at the military hos-
pital, which was, necessarily, more or less an educational institution.

In civil life, the chief function of the hospital is to afford the
patients the most efficient methods of medical and surgical care
and the most certain and rapid physical and functional restoration
with due consideration of the nature of the disability. To facilitate
the physical Sind Junctional restoration of the patients, the hospital

654 REHABILITATION OF THE DISABLED

must furnish efficient, medical, surgical, and nursing care, adequate
facilities for physiotherapy, for occupational therapy, and for play
and other amusements. Occupational therapy must be applied
primarily for the purpose of functional cure, but the rational choice
of forms of curative work, at the bedside, in shop, or elsewhere, may
be essentially pre-vocational, or even the primary steps of vocational
training. The more nearly curative work approaches occupational
training, the greater the therapeutic value, because of the gain in
useful knowledge and the consequent interest the patient takes in
the work as a rule.

Many disabled industrial workers will need training and educa-
tion to overcome the handicap of a permanent disability. This
training and education is not a function of the hospital. The hospital
has discharged its responsibility when the treatment of the patient
has reached the stage of the completed physical and functional
restoration consistent with the nature of the disabihty. But the
disabled industrial worker should have the opportunity for this
training and education. If he takes advantage of the opportunity,
the training and education will neutrahze the handicap due to the dis-
abihty. He may then return to his old or to a new job an efficient
economic factor in the industrial world, instead of an unhappy
dependent of the government or state.

The pohcy of rehabihtation of the disabled and, by the practice
of it, the conservation of man power and of individual and com.mu-
nity self-respect and happiness, is imperatively demanded. Provision
for its universal efficient apphcation must be made by the govern-
ment, either Federal, State or Municipal, or by all co-operatively.

Pensions and disabihty compensation are just measures for the re-
Hef of permanently disabled soldiers and injured industrial workmen.
These measures of financial rehef should be continued as additional
aids in the attempt to provide efficient rehabihtation of permanently
disabled victims of war and of accidents due to industrial activities.

The efficient apphcation of the complete rehabihtation of per-
manently disabled soldiers and men and women of the industrial
army will materially lessen the inmates of soldiers' homes and of
almshouses. Only those soldiers and civihans whose disabihties
are total will seek refuge therein.

THE CHOICE AND TRAINING OF MEDICAL
OFFICERS FOR THE AIR FORCES

By Thomas R. Boggs, M.D., Baltimore, Md.,

Colonel Med. Corps, U. S, A., (Temp.) Medical Consultant, Air Service, A. E. F.

FROM the most ancient times medical men have been interested
in the theoretical and speculative aspects of flying, and now
that the development of modern warfare has brought hundreds
of doctors into contact with what is for them an unexplored field of
professional activity, and practically forced the evolution of a new
specialty, it may seem not altogether inappropriate to discuss
briefly some points bearing on the selection and education of medical
men for this duty, in a volume prepared in honor of one who, with
all his versatihty, is perhaps most eminent as a teacher and molder
of ideals in the medical profession.

Change and adaptation to new conditions has been the lot of the
doctor since medicine emerged from its enslavement to the doctrines
of Galen, and the profession has had many more difficult adjustments
to make than those involved in taking up the problems of the flying
men; in fact, until the Great War gave such impetus to the develop-
ment of aeronautics, very few of the profession at large had realized
that there were any such problems. It is not remarkable, then,
that at the beginning the assignment of medical officers to air ser-
vice units was more or less fortuitous, nor that the characters most
desirable in the squadron medical officer were arrived at empirically.
Only the test of time brought out the pecuHar importance and
responsibility of the squadron doctor, and made apparent the
diff"erences between the successful and the mediocre, so that a type
was defined by a process of gradual ehmination.

At the first glance these men may seem to have httle in common
in their previous training and professional activities. One was in civil
life an ophthalmologist, another an obstetrician, a third a country
practitioner, the next a neurologist or a laboratory worker. In age
they vary from twenty-five to nearly fifty, though it is less common

655

6^6 TRAINING FOR AIR FORCES

for the very young men to make good in this field. Let us, then,
consider the factors, environmental and personal, which have
brought about this development.

The basal unit of the Air Service is the Squadron, which is
relatively small, but must be self-contained, as the exigencies of the
service may require it to be very much isolated. The proportion of
officers in this group is very large, much larger than in any other
branch of the service. Again, the average age of the officers is very
low; they are hardly more than boys, and still have many of the
boy's characteristics. These young officers are engaged in a service
fraught with many dangers other than those incurred in fighting,
and with factors of isolation, personal responsibihty, and strain,
which are specially difficult for the very young. Furthermore these
fliers are relatively highly paid, and they have been encouraged
to consider themselves as a corps d' elite, set apart and different from
the rest of the world. There yet remains from the earfier and more
perilous days of aviation the idea that these are enjants perdus, who
should be excused for hving vividly while Hfe is theirs. Women
particularly seek them out and shower their favors upon them.
Lastly, they have been given Httle discipfinary training, in deference
to the highly technical character of the duty they perform. It is
hardly strange, then, that, while these young men are essentially
normal, they have none the less presented special problems for the
medical man. We can make no adequate approach to the medical
aspects of aviation without keeping in mind these factors and their
physical and psychological bearing.

With these facts in mind it is easy to understand that the doctor
with youth in his heart, tact, sympathy, insight, abihty to five with
and as the others without sacrificing their respect, franknese,
courage, and a background of sport, has stood pre-eminent. Such
traits have made of the medical officer the familiar friend and coun-
selor, and it is to such men that these boys have come with their
worries, physical, social, moral, or spiritual, and have not gone away
uncomforted.

To reach the necessary degree of understanding and acquire
the flier's respect, the aviation medical man must fly, at least as a
passenger. Only in this way can he understand the air man's language
and think his thoughts or enter into his experiences. In no other way

TRAINING FOR AIR FORCES 657

can the doctor learn what it means to loop, spin, dive, or make a
landing. Without these experiences in common the doctor is kept at
arm's length. In brief, the squadron medical officer's success is
proportional to his humanness and practical psychology.

In order to measure up fully to his responsibihties, however, the
doctor in the Air Service must have special training in applied
physiology, somatic and psychic, for the laboratory has made great
strides in the study of flying fitness, the causes and nature of flying
stress and fatigue, the recognition of their early symptoms, and the
measures for their prevention and treatment. The medical ofiicer
should be able to apply the simpler tests in the field, and to decide
whether it is necessary to send the flier to a laboratory for more
complete examination.

The aviation medical laboratory is an institute of appHed
physiology, which has already proved itself indispensable to the
development of maximal efficiency in aeronautics. It has a threefold
function — the routine apphcation of special methods of examination
to the individual flier in order to determine his fitness or the nature
of any disabihty, the instruction of medical officers for field and
laboratory service with the air forces, and the prosecution of
researches into every phase of physiology, psychology, and medicine
which may affect man's adaptation to life in the air.

In the medical organization of the air forces, then, we must
provide for two groups of officers with rather different duties, the
field officers or "FHght Surgeons" and the laboratory workers.
The fines may not be too sharply drawn, however, as there should
be every opportunity for the interchange of duties. Indeed, the
laboratory examinations and the research into aviation problems
can be carried on much better by men who have had some field
experience as well, or at least have made flights as passengers.

It follows from the foregoing that the aviation medical service
must be separated, at least so far as the personnel is concerned,
from the other branches. For it is not economy to give the medical
officer months of special technical training only to have him trans-
ferred to some service to which this training is inappHcable.

With regard to the future in peace times, it seems probable that
there will be httle difficulty in supplying the laboratories with
staffs sufficient to carry on the work, because of the opportunities

658 TRAINING FOR AIR FORCES

for research. But the field surgeons present a rather different prob-
lem, as it is unlikely that the narrow prospects of an army medical
career will attract the highly gifted man we desire. Perhaps this
contingency could be met by hmited periods of active service in a
special reserve corps, and the offering of training in aviation medicine
in our best-equipped medical schools. In countries where a form of
national service prevails it should be relatively simple to have a
reserve of trained doctors of the best type.

The development of civil and commercial aviation may create in
time ample scope for an interesting professional branch. But what-
ever the difficulties to be surmounted as time goes on we must
recognize now a sturdy neophyte in the Temple of Hippocrates, the
"Fhght Surgeon," at once a foster-son of Dsedalus, a disciple of
Leonardo, and a votary of St. Ehas.

PERSONALITY AND DISEASE
By Frederic J. Farnell, M.D., Providence, R. I.

Psychiatrist to Providence Public Schools; Director of School Psychiatric Clinic; Neuro-

Psychiatrist, Providence City Hospital; Sero- Pathologist, State Hospital for

Mental Diseases; Consulting Psychiatrist, St. Joseph's Hospital

and Sophia Little Home for Delinquent Girls, etc.

"^^ YNOPTIC man is one who sees the verities of life in their

^^true relations, properly co-ordinated and subordinated, and

^,^ who, in particular pursuits, however absorbing, does not ignore

the unity of the whole, nor overlook the universal aspect of even

the commonplaces of hfe."

I wish to express my great appreciation to the committee for
the comphment they have given me in asking me to contribute
to the Osier Anniversary Volume. In what I have to say I shall
endeavor to study conciseness and brevity:

A French scientist once said, " In scientific research be extremely
careful for fear you may find exactly what you are looking for."
In the field of medicine such words could be no more true, either in
behalf of the patient who may enumerate innumerable symptoms,
or the physician who consciously or unconsciously observes only
the apparent symptoms. How often the internist will base his com-
plete diagnosis upon a complex of defensive or reactionary symptoms
and avoid or even neglect the actual setting of those signs, especially
so with regard to the interrelation or finking together of the systemic
organs, either through the nervous system or through the vascular
system, with its vast quantity of blood and its complex biochemical
formulae I

Except within the study of neuroses and psychoses the problem
of individuafity or makeup is rarely examined, and yet without it
the full value of the organic or even functional disorder is far from
complete. Self-preservation is man's uppermost wish, and hence
his adaptative mechanism must meet fairly and squarely not only
the preservation of its species, but also its social attributes and their
environmental adjustment. It is here that motive and conduct

659

66o PERSONALITY AND DISEASE

reaction, with either its corresponding instinctive demands or its
emotional evaluation, largely is manifest, offering complex settings
and transitory as well as variable symptom-complexes. Thus one
may readily observe that oftentimes a far greater number of symp-
tom indicators arise from origins that have no apparent direct rela-
tion to the organ involved, and develop in a region one may never
suspect disturbed. It has always been the tendency to take man
at his own valuation, and then to assume that the most sure way of
finding out how such and such a symptom developed is simply to
ask him, not recognizing the fact that defensive reactions are obsta-
cles in way of a final interpretation as well as a recovery. These
defensive reactions serve as excitants and irritants in the connecting
chain of neuro-physical and neuro-psychical components, disturbing
now the vegetative mechanism, again an emotional, still again the
instinctive, adding many symptoms quite foreign to the initial
disturbance, and often cloaking the actual difficulty. For example:
a woman of forty years was treated for hemorrhages from the bowels,
said to be due to sclerosis of her intestinal vessels. Sclerosis imme-
diately roused an emotional activity, and environmental maladjust-
ment arose. Her behavior towards this maladjustment naturally
took on an apparent preservative coloring, whereas in reality her
emotional factors and her instinctive demands in turn disturbed her
vegetative system, with the result that cardiac, gastro-intestinal,
and general vasomotor symptoms became quite obvious, destructive
rather than preservative. Then, again, with total disregard of this
growing neuro-psychophysical complex, she is quietly informed and
courageously accepts from the internist the statement of "non-
compensating chronic heart." (How close one still is to the initial
vascular sclerosis.) All phenomena are now involved, body and mind,
vegetative system, instinct, emotion, and personahty. What a phght
the family, as well as the patient, now face, for with each rise or
fall in the threshold of feeling in the patient there was a correspond-
ing modification in the emotional and instinctive fife of the immedi-
ate family.

When approached, at this time, by the psychopathologist, who
observed the entire problem from the standpoint of maladaptation
towards self and environment, it was quite obvious that the initial
hemorrhages were traumatic, from "marble" stools incident to

PERSONALITY AND DISEASE 66i

spastic constipation of autonomic origin. Hence one might infer
that her autonomic system was "conditioned," and probably so
determined by the fact that her makeup for years prior to her
primary disorder was neuropathic (vagotonic). Conflicting, emo-
tional trends broke down this "conditioned" system and added more
cardio-vascular signs. They were, however, signs of vegetative
disharmony, a loss of tone rather than a destruction of tone. A return
to society was soon acquired by the breaking down of her emotional
defenses, strengthening her instinctive demands and readjusting her
vagus tone.

The complexity of this problem is far reaching and, at times,
discouraging. In systemic disease processes of the spinal cord, where
toxic substances or biochemical changes in the blood are utilized
as indicators of the disease and its activity, due consideration should
be given to the makeup of the individual, and his response to emo-
tional stimuli and instinctive demands, before relegating some of his
symptoms to the pigeonhole of imagination. It may not be a surmise
to state that such toxines or biochemical phenomena as produce the
cord lesion might produce a lesion in the ganghonated cord of the
sympathetic chain, or it (the toxine) may so "condition" the auto-
nomic system as to select the organic lesion. The personahty factor,
the behavioristic response, is quite manifest in syphilis of the nervous
system, and interest should he in not only striving for a cure, but
so stabiHzing the makeup as to lessen the possiblHties of late syphilis
manifesting itself in personality changes. For example: a man with
a manic makeup developing meningo-encephaHtis might, presuma-
bly, be grandiose in his psychic sphere. His readjustment should not
only be remedial as far as his organic process is concerned, but also
his "ego," his self, and his relation to society require adjustment.
May there not be a close relation between the disease process (histo-
pathological) and the personahty with its behavioristic and emo-
tional components (psychological) in such a case? But still more
marked is the ever-present fear and those horrible anticipatory
imaginings of the tabetic and his pains. Even after, treatment with
subsidence of the actual neuritic pains, should a non-tabetic pain
occur the pain-stimulus undoubtedly reproduces in kind and often
in degree the original pain-stimulus. The emotional experiences
and activities in these patients are alert, quick, and instantly

662 PERSONALITY AND DISEASE

responsive, with the result that the fear probably influences the
autonomic system.

There are patients, also, whose autonomic system not infrequently
causes a phenomenon not unlike intermittent claudication. For ex-
ample: a man of fifty, whose makeup was quick and active, whose
emotion was swayed by the rise and fall of luck, and one whose sex
Hfe was never subjected to a normal control, develops at forty-three
the tabetic syndrome. His remorse for a poorly spent sex life and
his regret at not maintaining an economic grip upon himself led to
depressive thoughts and later physical neglect. Examination not
only revealed an organic disorder of the tabetic type, but also a
distinct vegetative disturbance of the cardio-vascular type and a
modified instinctive reaction with emotional instabihty. Environ-
ment might exaggerate one or all. Specific treatment caused the
abatement of his organic subjective symptoms. Yet with this much
under control he continued in morbid fear of the return of his pains,
and whereas primarily the anxiety reaction accompanied the organic
reaction, it was manifest alone. His autonomic difficulty was of the
sympatheticotonic type, and treatment directed accordingly at the
time adjusted that phase. There still remained the anxiety dis-
turbance and his modified instinctive demands. Environmental
adaptation in the latter, and a gradual eradication of his fear with
the actual disappearance of his real pains and the creation of a
dream-like memory of those true pains, the patient soon became
quite comfortable and adjusted himself to society. It would appear
that the patient's cardio-vascular system was "conditioned"
through an autonomic sensitization, and that his emotional reaction
was brought out not only by a stimulus which did not originally
call it up, but also that a fingering emotion might have continued
and produced recall even after the actual subsidence of true
symptoms.

McDougall states that the idea of self and the self-regarding
sentiment are essentially social products, that their development
is effected by a constant interplay between personafities, between
self and society, and its conception must be always of one's self
in relation to other selves. That is, one must often give up pleasure-
winning ways of satisfying one's self and adapt himself to any new
condition arising. This self-sacrifice may bring about a conflict

PERSONALITY AND DISEASE 663

between the pleasure-pain and reality motives, and in so doing
return to the infantile, with a complete destruction of one's ideal,
and maybe a progressive separation of his personahty from the
community in general. In the compulsion neuroses there is a regres-
sion of the sex craving to its earher stage, with the development of
an OEdipus mechanism.

One can but feel the great value of this mechanism as seen in
many cases of so-called "chronic invahdism," especially true in the
fifth and sixth decade in women. It usually manifests itself at the
stage of menopause, and gradually becomes a fixed state of both
mental and physical destruction. Since all love has as its funda-
mental object the preservation of species, either in self or through
self, then that failure in one's eagerness to reach an ideal may not
only warp the personahty of the patient, but also destroy the per-
sonahty of the child, and both the neurosis in the former and the
psychosis in the latter will undoubtedly take on the (Edipus-incest
complex with poor chance for readjustment. These patients fre-
quently complain for years of vague and poorly recognized physical
complaints which rather often symboHze unsatisfied cravings. For
instance, one young man has tried all sorts of doctors, quacks, etc.,
to obtain a permanent removal of hair from his face. An absence of
a secondary sex character would enhance his feminine characteristics
and complete a more or less cloaked female conduct reaction. This
young man was left at two years of age with his mother by the
sudden death of the father. The mother brought him up under the
most strict and yet good environment. They schooled together, read
together, had the same interests in music, hterature, and poetry.
The boy became proficient in music, became an art and poetry
critic, and worked well under guidance. When he reached the age of
fifteen his mother, then forty-seven, had an accident, and evidently
developed a "traumatic spine," with the result that she has grown
less and less adaptable to herself or her environment. This physical
incapacity upon the part of the mother caused the son to attach
himself more strongly to his mother, and both gradually became
crippled in such a way as to leave them inadequately equipped to
deal with reality, the mother frequently enumerating what might
have resulted "if" such and such a thing had not occurred, and
her son might have been a "big chemist" or a "poet of the highest

664 PERSONALITY AND DISEASE

order" if such a thing had not happened; the son in turn emphasizing
trivial occurrences and indicating his regrets accordingly. At this
time the mother is an invahd, with gastro-intestinal and urinary
disturbance, the former manifest by spastic constipation and peri-
odical diarrheas, and the latter by frequency (organic examination
negative). The son has marked insomnia, indigestion, and "ner-
vousness."

Presumably there is a distinct unconscious conflict related to
success both in the mind of the mother and the son. Emancipation
of the son has not taken place. The mother is incapable farther of
idealizing in reahty. Destruction of omnipotence in hfe and love is
an admission of actual loss of species preservation. Truthfully to
meet the reaction would mean a social insult of a severe type. To
build a defense reaction means to separate one's self from his social
hfe with the complete collapse of social values, and a substitution in
both mental and physical symptoms of such psycho-sexual activities
as conversion of the all-powerfulness of thought into autoerotic and
incestuous symbols.

The extent to which investigations into personahty and its
relation to all disease process is of value can be reached only by
making such an examination a part of the history of all patients.
Many times patients are treated for "local" symptoms when their
greatest diflficulty is their makeup and its adjustment. Man is first
of all a social animal, and the strugghng desire for hfe's existence and
for a rational fulfillment of it is becoming more and more a struggle
between self from a psychological viewpoint and society from its
social aspect, and from such he must be so considered and treated.

Bergson says, "When a shell bursts, the particular way it
breaks is explained both by the explosive force of the powder
it contains and by the resistance of the metal. So of the way hfe
breaks into individuals and species. It depends, we think, on two
series of causes, the resistance hfe meets from inert matter, and the
explosive force, due to an unstable balance of tendencies which hfe
bears within itself."

MEDICAL EXAMINATION OF MEN FOR MILITARY
SERVICE: SOME OF ITS PROBLEMS, LESSONS
AND RESULTS

By Sir JaxMes Galloway, K.B.E., C.B., M.D., LL.D. (Aberd.),
F.R.C.S. (Eng.), F.R.CP. (Lond.)

Chief Commissioner of Medical Services, Ministry of National Service; Colonel, Army

Medical Service; late Consulting Physician I. and II. Armies, B. E. F.; Senior

Physician, Charing Cross Hospital

IN Other circumstances it would have been the wish of the writer
to contribute a paper giving the result of clinical observation,
as an expression of regard to an acknowledged master of clinical
medicine, but my old Chief well knows the urgent circumstances that
for a period of time obliged me to rehnquish my work as a clinician
in order to undertake duties involving direction of, rather than per-
sonal participation in, medical practice.

I hope that the following account of some of the more directly
medical aspects of the work done may not be devoid of interest.

Before the Great War the medical examination of recruits for
the army was carried out by medical officers, retired or on the
active list, and by civihan medical practitioners. The standard used
was that laid down in Army Medical Service Regulations, and the
men were passed as "fit" or "unfit." No attempt was made to
place them in grades or categories. This system did not lend itself
to accurate investigation and record of the physical condition of the
men, and gave partial and misleading information as to the health
and physical state of the population.

At the beginning of the war, when the first great voluntary
rush to the colours was witnessed, the same system of recruiting was
pursued, but under new and greatly increased difficulty, owing to
urgent pressure of time and want of suitable accommodation for
medical inspection.

On October 20, 19 15, the scheme of recruiting associated with the
name of Lord Derby came into operation and caused a further great
flocking of recruits to the colours. The medical examination of these

665

666 EXAMINATION FOR MILITARY SERVICE

men, which was carried out under great difficulties, caused so much
unfavourable public criticism that the War Office made a complete
change in the procedure of medical examination. Fortunately for the
country, the medical administration of the War Department at
home was then in the hands of Sir Alfred Keogh.

On December 24, 19 15, the War Office ordered the formation
of Medical Boards to replace the system of examination by single
medical officials previously in practice. These boards were designed
to consist of a president and three or four members. The examining
members in many cases were civilians, but the president of the
board was a mihtary medical officer, usually holding the rank of
Lieutenant-Colonel or Major. In a few cases these officers were still
on the active list, but usually they had retired from the army be-
fore the war.

These boards were instructed to place the recruits in categories.
The first Army Council Instruction dealing with this important
matter was issued in January, 19 16, and laid down the following
categories of fitness :

1 . For general service.

2. For field service at home.

3. For garrison service, (a) abroad, (b) at home.

4. For (o) labour (road making, entrenching work, etc.)
For (6) sedentary work (clerks, etc.)

It was expected that each board should be able to examine 200
men daily.

It will be noted that even at this date the system of categorisation
involved two conceptions: the first derived from purely medical
data — the man's physical condition and state of health at the time of
examination; the second involving administrative considerations,
indicating the form of service for which he was presumed to be fitted
on entering the army. The task of combining these two ideas was one
of the main difficulties to be faced by the boards, most of whom
were largely civilian in composition ; this difficulty increased as time
went on until in 191 7 the attempt had to be abandoned. The
attempt to solve the problem at one decision of the board gave rise
to much confusion, and ultimately much unrest in the minds of the
public — a trouble that was never satisfactorily dispelled.

In April, 191 6, a classification certificate was issued for the

EXAMINATION FOR MILITARY SERVICE 667

first time to men who had been medically examined. This document
became of much importance in the recruiting system and developed
ultimately into the grade card of the Ministry of National Service.
On May 19, 1916, Army Council Instruction 1023 was issued,
which divided men into five categories:

(A) Fit for general service.

(B) Fit for service abroad.

(D) Temporarily unfit for service in A, B, C, but Hkely to become

fit in six months, and meanwhile either

(E) Unfit for service in A, B, C, and not hkely to become fit

in six months; or awaiting discharge or reclassification.

Classes A, B, C, and D were further subdivided into three
categories.

This Army Council Instruction was for use not only by Recruit-
ing Medical Boards, but also by regimental officers and all others
within the army. There were at least thirteen categories in which
men could be placed. These details are given to show how completely
classification to aid administrative requirements overshadowed
classification on purely medical grounds.

During 19 16 recruiting, which had now become compulsory for
certain sections of the adult male population, was carried on more
intensively, owing to the ever increasing demands for men. As an
inevitable result, the recruiting machinery and methods came under
pubhc criticism. It is in the medical board and at the hands of the
medical men working on these boards that the recruit first feels the
actual touch of compulsory mihtary service — his medical examina-
tion is his initiation into mihtary methods. It is only to be expected,
therefore, that the pubhc will watch critically the methods employed
by the boards and examining medical officers. The medical boards —
their medical administration and organisation — had to bear the
brunt of this criticism, much of it badly informed and far from
helpful, much of it influenced by pohtical prejudice. Later the
administration of recruiting under the Mihtary Service Acts was
given over to a special department of the War Office and placed
under the control of Brigadier-General, now Sir, Auckland Geddes.

At the end of 1916 it was found necessary to institute more
close supervision of the medical boards with a view to reorganisa-

668 EXAMINATION FOR MILITARY SERVICE

tion, and a special medical department was formed to undertake
this work.

In December, 191 6, and early in 19 17, the writer inspected nearly
every recruiting centre throughout the country in order to obtain
information as to the methods used and the quality of the medical
work. It was manifestly clear that as the war progressed recruiting
would bear still more hardly on the population, interfering more and
more with trades and occupations, until at length only the essential
industries could be permitted to continue. With this prospect in
view, it became necessary to arrange the medical machinery to be
not only efficient, but to give as little offence as possible. The days of
voluntary recruiting had passed; recruiting and medical examination
now concerned every effective man in the community.

Reorganisation was brought about just in time, for on April 5,
19 1 7, the Military Service (Review of Exceptions) Act came into
operation. This Act provided for the calling up for medical examina-
tion of large numbers of men who had previously been excepted
from the operation of the Military Service Acts. It will be remem-
bered how difficult it was to put the provisions of this Act into
operation and how in course of time the operation of the Act produced
acute political disturbance. The intensity of feeling against the
operation of the Act manifested itself largely by embittered criticism
of the working of the medical organisation of the Recruiting Depart-
ment of the army. After an anxious period marked by much dis-
turbance, a Select Committee of the House of Commons was
estabhshed to enquire into the administration of the Act, which
made the following amongst other recommendations :

"The Committee recommends that the whole organisation of Recruit-
ing Medical Boards and of the medical examinations and re-examinations
should be removed from the War Office and placed under civilian control."

In consequence of this recommendation Sir Auckland Geddes was
appointed Minister of National Service, and the previously existing
Department was thoroughly reconstituted. The Recruiting Depart-
ment of the Adjutant-Generafs Office, including the Medical Sec-
tion, was transferred to the Ministry of National Service, and
henceforth recruiting for the army with all its medical organisation
passed into what proved to be the last stage of development. After

EXAMINATION FOR MILITARY SERVICE 669

a strenuous period of preparation the reconstituted Ministry of
National Service commenced as from midnight, October 31, 19 17.

During the year 19 16 the experience gained of the work of
recruiting medical boards under the army had been gradually
collated, with the result that during this year the organisation,
the personnel, and administrative methods of the boards underwent
a gradual change. In the latter part of the summer the boards had
gradually been placed on a new basis, so that when the great
change took place from military to civihan administration, no
noticeable jar to the machinery occurred. The organisation and ad-
ministration proceeded on the methods which had been previously
thought out, and which had now the opportunity of becoming fully
developed.

It had become increasingly obvious that the attempt to super-
impose a classification adapted to assist the administrative side of
the army on work done by medical boards, now largely civihan,
could not be continued, both for reasons of efficiency and on account
of the social and political difficulties which such a method of classifi-
cation inevitably brought in its train. The old army categories w^re
guides to posting officers, based only partly on the result of medical
examination. Classification of a man in one of the existing categories
was therefore clearly the function of the army, and not of a board of
a civihan ministry.

It was necessary for the new recruiting organisation to estabhsh
certain broad principles of classification of the men supplied to
the army, for it would be useless to supply 1000 men fit only for
employment as clerks when the demands of the army were for 1000
fighting men. Classification was therefore essential, but the medical
and administrative aspects of the classification had to be sharply
diff'erentiated — relegated to civihan medical boards on the one hand,
and to the miHtary medical organisation within the army on the
other.

Experience had shown that men of mihtary age can be classified
by medical examination into four great groups, determined by
physical considerations alone:

I. Men free from serious defects or organic disease, of good muscular
development, actual or potential, the movements of their joints unimpaired,
their special senses acute, of good intelligence and at the time of being

670 EXAMINATION FOR MILITARY SERVICE

handed over to the army, free from such infectious and contagious dis-
eases as are not transient or rapidly curable.

2. Men fulfilling the above conditions, but whose special senses,
e.g., eyesight — may be below the normal standard, but nevertheless suffi-
ciently good for all ordinary purposes. Men in these two groups are capable
of active service.

3. Men with defects which do not interfere with their vocation in
civil life or with organic disease not likely to be incapacitating for a
considerable period of years. These men must possess fair intelligence and
be able to perform the duties allotted to them regularly. Men in this
group are required to perform the multifarious auxiliary services required
for a modern army.

4. Men whose defects or disabilities, physical or mental, are of such a
nature or of so severe a degree as to render them unfit for service in the
army.

It was on these considerations that the four well-known grades
of the National Service Medical Boards were established, and from
the time that the National Service Ministry undertook medical
examination for recruiting the grading of men was carried out on the
principles indicated.

During this period of reconstruction the actual organisation of
the boards themselves had undergone changes. The fully developed
National Service Medical Board consisted of a president and four
members. The examination of the men was conducted on a sectional
method. Experience had shown that the best results in medical
examination from the point of view both of accuracy and of standard
results were obtained if the candidate was examined by the members
of the board in turn, each examiner in addition to a general view
of the recruit paying attention especially to certain sections of the
examination. The president of the board co-ordinated the work of
the examiners, collated the results in every case, arranged for more
formal consultation of examiners in diflficult cases, and always
pronounced the final grading of the recruit. The methods of the
National Service Medical Boards are given fully in the instruction
which was issued at the commencement of the work of the Min-
istry, the last edition of which was published in December, 1918
(M.N.S.R., 88).

The National Service Medical Boards, constituted on this basis
and composed of the best available practitioners left in the country.

EXAMINATION FOR MILITARY SERVICE 671

by degrees developed into a very efficient organisation for the
estimation of physical fitness. The quality of their work naturally
improved with time, and now the members of these boards, to the
number of 3000 to 4000, have acquired special knowledge of methods
of examination, of the conditions underlying physical fitness, and
aptitude in the recognition of what makes a man fit or unfit which
will be of great service to the State in the future. The work reacted
beneficially on the profession itself; it brought medical colleagues
together in all parts of the country; they worked together, and got
to know each other well. The work developed in some respects in
the nature of a post-graduate course of training. These good results
were much appreciated and favourable opinions were expressed to
the writer on many occasions.

To give an indication of the work done, it may be stated that
from November, i, 19 17, to October 31, 1918, 2,425,184 medical
examinations were carried out by the boards; in May the numbers
reached 456,599, and in June, 475,416.

The Development of a Standard for Estimating the Fitness oj
Groups of Men. At an early stage of the work, before the boards
developed their final phase, it became clear that there was an op-
portunity of obtaining an intimate knowledge of the health of the
community, especially of the conditions producing deviations from
the normal, degeneration, and disease, and particularly the effects
of the habits and occupations of the people.

It soon became desirable to obtain an index of the condition of
groups of the population as compared with what might be consid-
ered the normal standard. After some consideration, the following
rough indication was arrived at, and has proved to be a serviceable
guide.

The suggestion as to the method of obtaining such an index
is due to Professor Arthur Keith, of the Royal College of Surgeons.
Taking the results of the medical examination of 1000 young men
who may fairly be considered to have been reared under good
conditions, it was found that seven companies of 100 men should be
in Grade I; two companies in Grade II; and of the remaining
company of 100, three platoons of 25 in Grade III, and one platoon'
of 25 in Grade IV. In other words, 1000 young men drawn from a
normally healthy section of the population should yield seven

672 EXAMINATION FOR MILITARY SERVICE

companies of Grade I men; two companies of Grade II; three-
fourths of a company of Grade III, and one-fourth of a company of
Grade IV. Quoting Professor Keith's words in a very helpful letter
addressed to the writer:

"We cannot get a better method of giving a concrete expression to the
degree of fitness than that, yet the method is too clumsy for ready use.
We need a more concise method of estimating and expressing the degree of
fitness — a figure which will give us the relative degree of fitness in any batch
of men examined by a medical board. The method I would propose is one
used in anthropological work. Let us suppose the board has just examined
1000 men with the following result:

700 are placed in Grade I.
200 are placed in Grade II.

75 are placed in Grade III.

25 are placed in Grade IV.

Each Grade I man has his full unit of fitness 700 units

Each Grade II man we will assess at -|, or 75 per cent of a

unit. The 200 men have amongst them 200 x |-. . . . 150 units

Each Grade III man, assessed at ^ unit, gives us 75 x y-- 37-5 units

Each Grade IV man, assessed at ^ unit, gives us 25 x ^. , , 6.25 units

893 -75

That is to say, in this artificial but yet approximately accurate method,
the battahon of men just examined had 893.75 units of fitness — or cutting
the expression short — the amount of fitness was 89.375 per cent of the
total possible. The index of fitness of that group of men may be expressed
as 89.3."

This index, which we speak of as "Keith's index," has been
employed from time to time in our work, and has proved useful in
forming an estimate of the relative value of man-power in different
parts of the country and in different groups of the population.

For instance, the following table gives an idea of the quality
of the men obtained for mihtary service in a large section of the
country, including populations occupied in agricultural pursuits, in
mining, in the steel and iron trades, and in textile factories.

Example of Wide Divergence in Physique of Population in Neigh-
bouring Areas. Extract from the report of a National Service visitor

EXAMINATION FOR MILITARY SERVICE

673

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674 EXAMINATION FOR MILITARY SERVICE

after visitation of Emergency Boards in a manufacturing area to
enquire into the reason for the relatively high percentage of men
placed in Grade III:

(A) Emergency Board, dealing with recruiting of colliers. April 5, 6,
8 and 9, 1918; 412 men examined and graded.

Grade I II III IV

319 39 50 3

77.4% 9.4% 12.1% .9%

(B) Emergency Board, dealing with the recruiting of colhers. April
5, 6, 8, and 9, 1918; 306 men examined and graded.

Grade I II III IV

221 53 25 7

72% 17.3% 8.1% 2.2%

(C) Emergency Board, deahng with munition area reserved occupa-
tions and colhers. April 5, 6, 8, and 9, 1918; 314 men examined and graded.

Grade I II III IV

257 27 29 I

81.8% 8.5% 9.2% .3%

Combined average gradings of all Emergency Boards in this region
deahng with this class of men, mainly colhers:

Grade I II III IV

70.6% 12.4% 13.2% 3-4%

(D), (E) Emergency Boards dealt with cotton operatives, weavers
and spinners, working in factories instead of colhers and munition area
reserved occupations. The population examined was in a neighbouring
portion of the country to the areas dealt with by Boards A, B, and C.

The visitor remarks:

"The difference is marked even in the waiting room, and becomes
striking in the examination hall. Age for age the colhers strip much better
than the cotton-mih operatives, and are as a class muscular and well
developed. The difference is revealed in a more exact manner by the
returns."

(D) Emergency Board. During March, 19 18, 40.95 per cent of the men
examined were placed in Grade III and 16.8 per cent in Grade IV;
combined, 57.5 per cent. During April 5, 6, 8 and 9, 1918, 184 men were
examined and graded and 106 postponed, as the Deputy Commissioner
of Medical Services considered they would obviously fall within Grades
III and IV.

EXAMINATION FOR MILITARY SERVICE 675

The 184 examined and graded were distributed as follows:
Grade I II IH jy

SI 64 56 7

30.9% 34-7% 30.1% 3.8%

If the 106 cases postponed, presumed to be Grades III or IV, are
added, we get the following figures:

Grade I II HI jy

SI 64 169

19.6% 22% 58.2%

The visitor records his opinion that the grading by the board
was in general correct, and adds that the Deputy Commissioner of
Medical Services is of opinion that work in the moist and overheated
atmosphere of the cotton mills has a profound effect upon the
physique and health of the operatives when extended over long
periods, so that they age quickly.

(E) Emergency Board. During the month of March, 191 8, the men
examined by this board consisted almost entirely of cotton-mill operatives,
and the returns show a daily average of 51.35 per cent of Grade III and
8.5 per cent of Grade IV. Daily combined average, 59.85 per cent.

On April 5, 6, 8 and 9, 19 18, there was a considerable admixture of
colliers — 126 were examined and graded.

Grade I II III IV

53 27 36 10

42% 21% 28.5% 7.9%

These figures, though eminently unsatisfactory when compared
with the returns of a purely miner "comb-out," give a percentage
of 36.4 per cent of Grade III and IV men, as compared with the
59.85 per cent of the cotton operatives in the previous month.

For purposes of comparison the following table is added :

TABLE II

Grade I

Grade II

Grade III

Grade IV

Combined average gradings of boards
examining mainly colliers in the
region

70-6

12-4

13-2

3 -4=-- 16 6

Combined average grading of all men
examined throughout a wide area of
the country in April, 1918

55-9

19-8

19-2

51.= 24-3

Grading of 290 cotton operatives ex-
amined by Board D, on April 5th,
6th, 8th and 9th

19-6

58-2

d-jd EXAMINATION FOR MILITARY SERVICE

A medical official in this area made the following commentary:

"The average man is an old man before he reaches the age of forty.
. . . The folk of his part of the country are hardworking and industrious,
and from an early age absorbed in industry; youths on being questioned
frequently say they have no time for any games; they begin work young,
work long hours, and too often think they are fully compensated if they
make big wages. Thus the growing boy gets no chance of healthy outdoor
exercise to develop his frame — he is too tired at the end of a hard day's
work to trouble about physical culture. He is not troubled by his physical
condition, he accepts it with dull contentment — after all he is only like
his fellows. He works in a mill which has to be kept at a high temperature.
He comes out in the evening weary, heated, and debilitated. The climate
is damp and cold, he readily contracts rheumatic and bronchitic affections.
Rheumatism affects his heart; hernia is easily produced when the muscles
are poor and flabby, especially when there is frequent cough or when the
work is really beyond his strength. Varix and flat foot are natural results
of long hours of standing, when the muscles are flabby, anaemic, and
weary."

Report upon Condition of 2gg4 Men between Forty-three and Fijty-

one Years, Examined in Neighbouring Areas of Boards D and E.

The following table is of interest, as it indicates the physical state of

a number of the older men examined in areas in which the population

is employed in work of practically the same nature as in the areas

of Boards D and E. All these areas are in the same part of the

country.

TABLE III

Diseased Conditions

Number

Per Cent

Varicose veins.

602

Heart affections.

462

Hernia.

374

Rheumatic affections.

315

Deformed toes.

308

Emphysema and bronchitis.

268

Varicocele.

234

Haemorrhoids.

235

Deafness and otitis.

214

Flat feet.

172

Arterial degeneration.

124

No disability of any kind noted.

The preceding report throws light on the effect of occupation on
the physique of a population inhabiting a well-defined section. The

EXAMINATION FOR MILITARY SERVICE 677

reports that follow reflect the influence of race, environment, and
occupation on the physique of a definite group. The statistics of the
examination of ahens are derived from boards in London.

TABLE IV

Causes of Rejection among Aliens of Jewish Race Examined in London between
September 20 and November, 1917, with Corresponding Figures from
Scotland.

Race

Number
Examined

Rejected

Percentage
Rejected

Percentage Rejected for
Pulmonary Tuberculosis

Russian Jews.

495

135

27-2

91 Add to the 135 re-
jected 23 relegated
to the reserve, dis-
ability not stated,
158, or 32.1 per
cent.

Scots.

10,000

440

4-4

Details of Causes of Rejection

Pulmonary tuberculosis 45

Valvular disease of the heart . . 17

Bronchitis 12

Trachoma 8

Disease not stated 7

Disordered action of the heart 5

Emphysema 4

Epilepsy 4

Poor physique 2

Defective vision 3

Mentally defective 3

Albuminuria 2

Duodenal ulcer 2

Varicose veins 2

Sycosis

Ascites

Curvature of spine

Nasal caries

Gunshot wound head and leg.

Otorrhoea

Scar after appendicitis

Fracture right leg

Deafness

Chronic mediastinitis. .

Glaucoma

Disseminated sclerosis .
Rheumatoid arthritis. . ,

Corneal nebula

Kyphosis

Withered right arm . . . .
Oto-sclerosis, incurable.

Old choroiditis

Sciatica

135
Relegated to reserve (disabihty
not stated) 23

158
Ages.

Between 18-25 24

Between 26-30 30

Between 31-35 35

Between 36-41 46

135

678

EXAMINATION FOR MILITARY SERVICE

TABLE V

Comparative Frequency of Common Disabilities in 1100 British and 1370
Aliens of Jewish Race, London

Disability

Percentage among
British

Percentage among
Russian Jews

Pulmonary tuberculosis.

•1

Other diseases of lungs.

•0

• 5

Eye diseases.

•7

Ear diseases.

• 2

Diseases of throat and nose.

Diseases of heart.

Mental diseases.

Gastric diseases.

Syphilis.

Gonorrhoea.

Epilepsy.

Obesity.

5 feet 6 inches and under.

Defective feet. |

Defective teeth. |

Illiterates. |

TABLE VI

Percentage of Grading of British Youths of Eighteen and Aliens of Jewish
Race Respectively, London

Grade

British

Russian Jews

72-1

67-5

15 1

16-2

III

7-2

100

2-5

3-8

Deferred

2.5

The Deputy Commissioner of Medical Services reports as fol-
lows on the above table:

"Two thousand British youths were examined and eighty Russian
Jews of this age — no more appeared for examination at this date. They
were all born in the Russian Ghettos, nearly all of German extraction,
brought to England in early hfe and passed through our schools.

"On these figures their grading corresponds very closely to that of
the British youths, and presents a very marked difference to that of
adult Russian Jews; the inference appears to be that the Russian Jew
deteriorates and becomes diseased chiefly during early manhood."

The above description and notes partly explain the way in which
the work was done and give some indication of the results obtained.

EXAMINATION FOR MILITARY SERVICE 679

The writer acknowledges the arduous service and good work of his
colleagues and assistants.

For many years it has been the wish of those interested in social
and racial progress to have a mass of information based on sufficiently
accurate observations to estimate the physical condition of the people
at the time, and to serve as a datum line from which progress or
retrogression in the future could be judged. More than one effort
has been made to study the problems influencing the health of the
people, but have been fruitless because sufficiently accurate data
have hitherto been wanting. There is now available much informa-
tion giving many of the data required, some of which is now in the
process of analysis and collation.

In addition to information concerning the men of miHtary age,
facts are being collected by degrees from various sources respecting
the health of infants, children, young persons of school age, and
women. The opportunity, therefore, is at hand for making an
extensive medical survey of the population, but in order to make
the foundations for future opinions complete and firm, arrangements
must be made to obtain information comparable to that obtained
respecting the adult population of mihtary age during the past four
years. The state of our manhood at the beginning of Hfe's work
should be under survey continuously, and at intervals thereafter
the state of the population should be investigated. It is only by
methods such as these that matters of such vital importance as the
effects of occupation on our workers of all classes and the results of
measures intended to improve the public health can be estimated.
Without this information, plans for the improvement of our racial
stock will be badly made and progress must be at random. The
medical profession, now awakening to the sense of its responsibility
for the health of the community and not merely for the ill-health
of the individual, must obtain information of such importance.
But the signs of the times indicate that now is the opportunity to
secure what we require. Let us not forget the words of a very wise
and friendly adviser:

"Dimidium facti qui coepit habet; sapere aude:
incipe: qui recte vivendi prorogat horam,
rusticus exspectat dum defluat amnis: at ille
labitur et labetur in omne volubihs aevum."

AMERICAN RED CROSS CHILD WELFARE WORK

IN FRANCE

By J. H. Mason Knox, Jr., M.D., Baltimore, Md.

Lately Associate and Acting Chief of Children's Bureau, American Red Cross, France;
Associate in Clinical Pediatrics, The Johns Hopkins University.

I VENTURE to offer for this commemorative volume a brief
account of the American Red Cross activities in behalf of
French children during the latter part of the war period. I do
this with some confidence, because Sir WilKam Osier's great interest
in all that pertains to child life is well known, and it was my privilege
to hear this interest expressed when I reported to him in person at
Oxford last July on the doings of the Children's Bureau. Moreover,
it is becoming increasingly apparent that medical research cannot
be confined to the laboratory or even to the ward, but must extend
also to deahngs with people in social groups, to the investigation
of the causes of their common miseries and to the application of
adequate methods of relief. Progress in these broader fields requires
methods of research not unhke those of the cHnic.

France during the latter months of the war offered a peculiarly
promising field for child welfare work for the following reasons :

(i) The importance of better work for the children of the nation
had been sounded throughout the land and was recognized by all
inteUigent citizens.

(2) The birth-rate of France, the lowest in Europe before the
war, had sunk to less than half its usual figure — to about 8 per 1000
— a reduction which, if continued, would of itself destroy the nation.
It could be claimed, for example, that in comparison to America,
every infant life in France was at least twice as valuable.

(3) France had already in operation many activities tending to
reduce infant mortality and to foster child Kfe. Methods that have
been proven successful in England and America owed their origin
to France, notably the Consultation de Nourissons, founded by
Budin in 1892, and the Goutte de kit by Dufour two years later.

680

RED CROSS CHILD WELFARE WORK 68i

An older mutual benefit organization widespread in France is the
Mutualite maternelle, with its many branches, which for a small
sum of money assures to all members competent obstetrical service
and an allocation permitting the mothers to rest for some weeks
after confinement. This society is said to have lowered infant
mortality 7 per cent.

(4) France has enacted two laws which have far-reaching pos-
sibihties in the protection of early childhood. By the Loi Roussel
every child under two years confided to a woman other than its
mother for its care becomes automatically under government super-
vision. It insists that factories employing women provide chambres
d' allaitement for nursing mothers and creches for older children.
The Loi Strauss, passed just before the war, 191 3-14, allows an
allocation of one franc a day for the mother, one month before the
birth of her child, and one and a half francs per day for four weeks
afterwards if she remains home and cares for it.

Unfortunately the exigencies of the great conflict interfered
greatly with the enforcement of these beneficent regulations.

In normal times about five thousand women in France are em-
ployed in factories; during the war, the number exceeded a million
— at once a partial explanation of a low birth and a high infant mor-
tality rate. These facts, briefly stated, indicate that the French nation
was fully alive to the need of conserving its children and had led the
world in devising methods to accompfish this end. With the war and
the taxing of all the resources of the country for immediate measures
of defense many of the activities on behalf of mothers, infants, and
young children had to be curtailed or discontinued. Nearly all the
nurses and physicians under fifty-five years were called for military
service, and many civilian hospitals were turned over to the army or
closed.

(5) America entered the war in April, 191 7, and in the late
summer of that year the Children's Bureau was organized under
Dr. William Palmer Lucas as part of the Department of Civil
Affairs, American Red Cross. The other bureaus working in the
closest co-operation were the Bureau of Refugees, the Tuberculosis
Bureau, and the Bureau of Reconstruction in the War Zone.

It will be recalled that that fall and winter and the following
spring were very critical times for the allied arms. The balance of

682 RED CROSS CHILD WELFARE WORK

military power after the defection of Russia seemed to favor Ger-
many, and France was turning toward its sister republic across the
sea to bring to her the additional assistance needed to rescue her
from German greed.

It was during these anxious months before the fighting qualities
of America's raw troops had been tested, or the extent of our mili-
tary effort was fully appreciated, that aid was proffered by the
American Red Cross for the civilian population of France.

(6) The whole population, official and unofficial, wealthy and
poor, without regard to rehgious faith or social standing, accepted
our offers of assistance for the children with the utmost gratitude
and with every evidence of cordial co-operation.

(7) Through the generosity of the American people we had large
means at our disposal, and a constantly increasing number of care-
fully selected physicians, nurses, and others famifiar with the vari-
ous phases of child welfare work.

These, then, were the outstanding elements in the unique situa-
tion: (a) A great country fully afive to the importance of increasing
and preserving its child population, but with its means of carrying
on its plans greatly curtailed because of a great war; (6) assistance
extended to all classes of children in a sympathetic, tactful manner,
from the large resources of an alHed sister-repubfic. Such a com-
bination of favorable circumstances may never occur again, and
they offered such unusual opportunities to demonstrate certain
methods of infant welfare that it may be worth while to place them
on record.

The Children's Bureau arrived in France early in August, 191 7,
with a staff of about a dozen members. The number was increased
by nearly every boat until 100 physicians, 200 nurses, and as many
more nurses' aids and other assistants especially interested in child
welfare, were in the service of the Bureau. The effort from the first
was not to implant American methods upon the older country, but
to assist it in working out its own problems.

It is not the intention of this paper to describe the work in any
detail, but rather to mention briefly certain features of it which
have general application both at home and abroad.

Rural Dispensaries. One of the first jobs the Bureau was asked
to undertake was the medical supervision of a colony of 500 children

RED CROSS CHILD WELFARE WORK 683

gathered at a large military barracks near Toul from villages which
were subjected to gas attacks. After some months of patient effort
this large group of children was made into a model colony. In con-
nection with it was organized a dispensary and a hospital, first of a
few, later of 200 beds, which ministered to the civil population for
miles around. Soon it was learned that there were large manu-
facturing towns within reaching distance which were almost without
medical service. With the support of the American Fund for French
Wounded a dispensary service was established in perhaps a dozen
of these centers. Rooms were secured in each through the kind
offices of the officials, and twice a week at a specified hour, a phy-
sician, nurse, and one or more nurses' aids would arrive by an auto-
ambulance and hold a chnic. Simple supplies were carried in the
ambulance, which was used also to bring urgent cases to the hospital.

These ambulatory cHnics were held at various other sections, both
in France and Belgium, behind the fighting fronts. The automobile
was always hailed with pleasure. The routes were known and often
the doctor would be stopped and asked to see some special case
along the way.

The value of this method of bringing medical aid to a rural
population was abundantly proven. A similar system is appHcable
in many remote districts in other countries. Wherever the rural
mail carriers go these dispensary units could visit, ministering to
the sick and preaching the gospel of personal hygiene and child
welfare. One automobile and staff could serve eight or ten different
communities. In some towns a district nurse should remain in resi-
dence, spending her time in house-to-house visiting and in bringing
patients to cHnics.

The Detection oj Contagious Disease at Evian. The reception, care,
and distribution of the repatries at Evian, returning to France
after spending months in the hands of the enemy, was one of the
most interesting and moving experiences of the war period. It is
too well known to require more than a reference. To the Children's
Bureau was allotted the task of detecting and treating infectious
disease found among the 200 to 500 children passing through Evian
in two convoys each day. A large hotel was converted into a 200-
bed hospital, and with this and a number of detention wards and
convalescent homes many acute and chronic infections were stopped

684 RED CROSS CHILD WELFARE WORK

at the border and prevented from spreading disease throughout
France. Perhaps no better opportunity has been afforded anywhere
of studying communicable affections common in childhood.

In the admirable methods the French introduced for bathing,
delousing, clothing, feeding, and transporting these unfortunate
elderly derelicts and children to their new homes representatives of
the Children's Bureau actively co-operated. Much information was
obtained on the subject of child-placing in all its phases, in hospitals,
asylums, colonies, and private homes, through our experience with
the repatrie children.

Exhibits in Child Welfare. Exhibits as a method of propaganda
are more famihar in America and England than in France. Two
sorts of exhibits were arranged by the Children's Bureau in con-
junction with the Rockefeller Commission against Tuberculosis, in
which the subjects of Child Welfare and Tuberculosis were graphic-
ally depicted. The larger exhibits were held in several of the principal
cities of France, beginning at Lyons. They were opened with the
cordial approval and assistance of the officials and prominent citi-
zens. The story was told by means of lectures by French physi-
cians, by demonstrations of the exhibits many times each day, and
by cinema, indoor and outdoor, to enormous crowds, and for the
first time by a cleverly acted "Punch and Judy" show, the guignol,
which was first introduced at Lyons, and was now used to show to
delighted audiences of parents the bad results to the baby of in-
difi'erence and neglect, and the happy consequences that follow its
proper care. In glass booths real physical examinations of children
were conducted; babies were weighed, bathed, and clothed. The
value of nose and throat work was demonstrated on the patients
and dental work actively carried on. The attendance at Lyons in
three weeks was over 170,000, including nearly 50,000 school
children, and as a result the number of patients at the welfare cHnics
in the city were doubled.

Other smaller exhibits were arranged for in several of the de-
partments of the country. Approximately two months was spent
in a department — about a week in each of its larger cities. Similar
lectures and demonstrations, aided by lantern sHdes and cinema,
told the story of the fight against tuberculosis and the healthful
rearing of children. In each town where interest was aroused active

RED CROSS CHILD WELFARE WORK 685

"follow up" work was planned and started, if possible, through
existing organizations. Thus the enthusiasm stirred up by the
American exhibits was continued under French auspices.

Courses in Nursing. It soon became evident in our work for
children that house visiting on the part of a tactful nurse as we know
her in America was rarely done, and that if our dispensary work
both in small towns and large cities was to be really valuable, it
should be supplemented by the instructive visits of nurses in the
patients' homes. Fortunately many of our American nurses had
been trained in Social Service, and were able to instruct the French
pupil nurses in the field. Short courses in health visiting were begun
in co-operation with the Rockefeller Commission and independently,
designed to emphasize the simple rules of hygiene as apphed to child
welfare and to tuberculosis, and to lay especial stress on social ser-
vice in the home. Active assistance was given by French physicians,
who delivered the lectures and conducted the quizzes of the care-
fully prepared course. Practical work for the pupil nurses was
obtained at the hospitals and dispensaries. These courses were
given at Paris, Lyons, Marseilles, and elsewhere. They attracted
earnest women — who, as they completed their training, were sent to
assist the trained nurses on the field.

Those who are familiar with the great value of home visiting
as a part of the medical work in America will join in the hope that
this little demonstration in France will lead to its general intro-
duction in connection with every hospital and dispensary.

Supervised Play. We were fortunate in having in the Bureau the
services of a number of playground workers and recreational
experts. It was possible, therefore, in connection with all our
exhibits and in the various colonies and institutions under our
charge, to give practical instruction and demonstrations of the
value of supervised play in physical, mental, and moral training.
In the games such qualities as initiative, self-reliance, pluck, team-
play, and so forth, were stressed. The children quickly learned the
games, and it is expected that many French children who loved to
romp when shown how and to whom this kind of play was novel
will not forget it when the Americans have gone home.

Intensive Infant Welfare Work. What would happen if every
baby in a limited community received proper care? We had unusual

686 RED CROSS CHILD WELFARE WORK

opportunity to begin the answer to this question in a number
of places because of the co-operation of French officials, who
placed at our disposal the accurate statistical information of the
district. A ward in Paris and several other limited areas in town
and country were selected. Each day the names and addresses of
the babies born in these areas were sent to the Red Cross repre-
sentatives. These infants were immediately visited and, with the
aid of French agencies, adequately helped if there was need. That
is, it was made financially possible for the mother to remain home
and nurse and care for her baby, and she was encouraged to so do.
She received instruction both at her home and at a nearby welfare
station. Each case was studied individually, and the treatment
required to "save the baby" by its own mother, administered.
Thus each dependent baby in the district was given more of an
equal chance with the baby of the well to do.

A society was organized in the 14th Arrondissement, Paris,
under the patronage of Maire Ferdinand Brunot, "Patronage
Franco-American de la premiere Enfance," to begin this intensive
work there. Through this means it was hoped greatly to reduce
infant mortafity in that crowded district and to demonstrate that
babies can be saved if those care sufficiently who know and have.
We are confident that this "100 per cent work" for which this
Patronage Society stands is a distinct forward step in Infant Wel-
fare Work, and that time will demonstrate that the plan is practical
and that this method born in Paris as a war measure may prove
a model applicable in other times and places.

Co-ordination oj Child Welfare Work. With the well-known
imagination and impulsiveness of the French people and their
fondness for children it is not difficult to understand that there
are in France many kinds of organizations and societies devoted to
child care. Not a small part of the labor of the Bureau was to help
the most deserving and to co-ordinate the activities of those deal-
ing with similar problems.

Many grants made by the Red Cross to children's societies and
institutions reduced in their resources because of the war were
conditional upon the introduction of some suggested improvement
in plant or method. It seemed in many instances that this merging
of interests could be secured only through American suggestion.

RED CROSS CHILD WELFARE WORK 687

but when once brought about will be continued in the future. In
Marseilles and Lyons, for example, practically all the children's
organizations were brought for the first time into cordial affihation.
Such were a few of the more instructive attempts made by the
American Red Cross to come to the aid of French children in the
hour of their need. The occasion was unusual. In the process France
became in a sense a voluntary laboratory for the testing of many
phases of child care. It was possible, therefore, not only to bring
assistance to the present generation of children of this gifted and
industrious nation, but perhaps also to indicate some methods by
which child life may become more healthful and happy in other
countries as well.

MILITARY MORALE
By Edward L. Munson,

Brigadier General, General Staff; Colonel,- Medical Corps, U. S. A.

WHILE the above subject is one not directly related to the
practice of medicine, it still is not wholly dissociated
therefrom, as it not infrequently pertains to group states
of mind quite as abnormal and irrational as those which, in the
individual, come to the attention of the alienist. Further, it may
have a certain medical interest from the fact that, so far as the
United States were concerned, the proposal for the institution of
morale work, its successful experimental application, and its or-
ganization as a military agency, were all carried out by a member
of the Medical Department.

One of the many blunders made by Germany during the war in
its psychological estimate of other peoples was in deciding that the
United States could not put forward a disciplined army of a fighting
quality equal to the best that the Central Powers were able to
present. To-day this mistake is conceded in Berlin, for it was
American aggressiveness, quite as much as actual or potential force,
that broke the heart of German resistance and showed the enemy
not only that he could not win, but that stalemate tactics would
not be tolerated and that he was sure to lose.

The morale of the American soldier was perhaps one of the most
impressive things pertaining to his part in the war. The triple chain
of confidence, cheerfulness, and willingness to suffer any sacrifice,
so bound the troops together as to make them unbeatable. They
knew it all the time — it did not take long for the Germans to find it
out. The latter had spent generations in developing their armies to
such a degree of efficiency that their organization was proclaimed
to be the best ever upbuilt. Probably so it was, from the mechanical
aspect; but it lacked in animating spirit to have full fighting strength.
From their first contact with American troops, from Chateau

688

MILITARY MORALE 689

Thierry to Sedan, the flower of militaristic Germany was swept
back, foot by foot, yard by yard, and mile by mile, until only the
armistice saved retreat from becoming rout. These things were done
by men who, called from the farm and bench, became in a few
months an army of courageous, confident, self-sacrificing soldiers,
whose presence the enemy feared and detested.

The sudden and stupendous expansion of an army to represent
the might of an unprepared nation caused the full force of the War
Department to concentrate at first on the problems of mobihzation,
organization, and procurement of material. With these preparations
the spirit of patriotism was quickened.

It was felt, however, that morale, which with training is the
basis of discipline, was so fundamentally important a matter that
its growth should not be matter of chance. Napoleon had said, "In
war, the moral is to the physical as three is to one," and all writers
had recognized that good morale was prerequisite to military suc-
cess. But the question of how to influence morale directly was
largely unattacked.

In January, 19 17, the writer, in an editorial entitled "The
Soul of an Army," said: "There must be systematized education
and training in the psychology of the soldier and of the war. This
field is not now covered. It is a 'No Man's Land' into which neither
line nor staff" penetrate." Again on March 2, 19 18, in a memorandum
entitled, "Need for the Systematized Psychological Stimulation of
Troops in the Promotion of Fighting Efficiency," he further urged
the importance of the matter on the General Staff, with a result that
a series of conferences was held on the subject by representatives of
various organizations having to do with the prosecution of the war.
In the meantime, the writer had been transferred to Camp Green-
leaf, Georgia, and as Commanding Officer there tried out in actual
field work, on a camp of some 35,000 men, the ideas advanced in
theory. As a result of these conferences, and the successful demon-
stration of the practical value of the work at Camp Greenleaf, the
General Staff decided to authorize the work and place it on a sound
basis throughout the Army.

Accordingly, the following order was issued by the War De-
partment:

690 MILITARY MORALE

"i. There is hereby created a Morale Branch within the General
Staff. . . .

"2. The general functions of the Morale Branch relate to the improve-
ment of the efficiency of the soldier through the betterment of morale.

"3. The Morale Branch shall have cognizance and control of the fol-
lowing:

"(a) The initiation and administration of plans and measures to
stimulate and maintain the morale of troops.

"(b) The organization, training, co-ordination and direction of all
agencies, military and civil, operating within military zones, in so far as
they serve to stimulate and maintain morale in the army.

"(c) Co-operation with any morale agencies of the General Staffs
of Allied countries in connection with military morale.

"(d) The supervision, co-ordination and direction of activities in the
various departments, corps, and bureaus of the army for stimulating
morale within organizations or among producers of munitions.

"(e) The supervision, co-ordination and utilization, so far as may
properly be accomplished by military authority, of all recognized civilian
agencies which might contribute, directly or indirectly, to the enhancement
of morale. To this end, close relations will be established, through the Third
Assistant Secretary of War as Director of Civilian Relations, by the Morale
Branch, with all officially recognized agencies for the improvement of
morale in the Army or Nation. It will not give official recognition to un-
recognized voluntary agencies, though treating them with respect and
consideration."

The writer was made Chief of the new Branch, which,with its
military organization, including a number of various experts, as
psychologists, sociologists, newspaper men, artists and cartoonists,
advertising men, linguists, and others, at once set about the system-
atic stimulation of military morale.

It is not practicable at this time to go into details as to how this
was accomplished, and is being accomplished; for the task is still
uncompleted, and it is obvious that work of this sort is best accom-
plished as unobtrusively as possible. Disclosure of methods and
purposes would arouse unconscious resistance and render far less
plastic the human material which must be handled. Suffice it to
say that exact methods were worked out in relation to the psy-
chological forces which render them as relatively controllable and
intelligently directed as the similarly unseen forces of electricity or

MILITARY MORALE 691

radium, and which will later be given out when such may be done
without detriment to mihtary purposes. An organization, sensitive
down to the private in the company, was created whereby the
morale agencies could function to the lowest unit. By it, favorable
states of mind were induced and undesirable acts averted by pro-
cesses more or less analogous to the ehmination of infectious disease
and the prevention of epidemics.

Morale work has its purposes quite as much in peace as in war.
In the latter, patriotic purpose, mutual protection, and other factors
tend to hold men together. But the signing of the armistice, and
rehef from the mihtary tension along the above Hues, released a
horde of pent-up emotions which created most difficult adminis-
trative problems. These states of mind it was the duty of the Morale
Branch to handle. Perhaps it may claim a certain efficiency in this
respect, since nearly two miUion men have, at this writing, been
demobihzed and returned to civil Hfe without the shghtest disorder,
where riots and disturbances against authority have repeatedly
occurred in the troops of other nations during the same period.
Also the men have been absorbed back into civil Hfe in a good frame
of mind toward the Government and Army, untainted by pohtical
heresies.

There are many quahties expressive of mihtary morale. Some
pertain to fighting only — others are stepping stones to that end.
Disciphne imphes both training and morale. Training gives abihty
to fight, while morale is desire to fight. Both are necessary to victory.
Morale is to an army what temper is to the Damascus blade, a
"fighting edge" with a resihency no shock can crack. If morale is as
important as this, it is important enough to make every eff^ort to
cultivate it, and it thrives under such culture.

But morale is not merely enthusiasm or mental courage or the
fighting spirit. It is all these, and more. It has a sterner element. It
is that mental hardening which, in a body of troops, continues to
function after everything else has broken. It is a quahty which at
the last desperate moment continues to function after all the condi-
tions which have created it have disappeared. It is not only the will
to win, but the refusal to consider anything else as possible. Mihtary
morale accordingly is mental fitness of troops for the work of war.
It is to the mind what "condition" is to the body; good morale is

692 MILITARY MORALE

good mental "condition," bad morale is bad mental condition.
The state of good morale must be relatively lasting, for the test of
good morale is time and adversity.

In an army of a democratic government the soldier fights well
only for ideals. Money or material reward is no inducement to the
American soldier to face the bullets of the Argonne, but he seeks
out death, with a smile on his lips, as the champion of ideals. He
must know the reasons and principles of the cause for which he
fights; and besides knowing, he must beheve in them.

The morale of the army of democracy, therefore, must rest
solidly upon the basis of conviction. If the soldier does not possess
this on entering the army — and all do not — it must be given to him.
Ideals are an essential part of his equipment. It follows, therefore,
that information and education, the mainstay of democracy in
peace, must be its strength in war.

There is such a thing as morale based on sordid motives, but its
nature is comparatively temporary, and its quality is inferior.
Such was the German morale, founded on a desire and expectation
to take possession by force of the material things of this world. It
was the same morale that held together the buccaneers and free-
booters of all ages. But it could be successful only in material
success. Hence the extraordinary spectacle of the powerful German
armies, everywhere fighting in enemy territory and successful ac-
cording to the map, falling apart without cohesiveness when defini-
tively balked of their prey and finding their booty of the past snatched
from them. They had no other ideals than those of materialism to
sustain and inspire them. When these failed, morale was lost.

To these, the Allies opposed the imponderables. Their ideals
of right, truth, honor, justice, and liberty shone more brightly after
four years of adversity and became more precious as they were
threatened. The thin Allied line might give ground under the mighty
blows of the war engine; it might bend and stretch, but it never
broke, because of the flaming spirit of the ideal that made death
better than submission.

The Germans bolstered up their men with falsehood, as by the
same way they sought to undermine the fighting spirit of their foes.
They could be successful only so long as their deceit and falsehood
were not found out. When this happened, they lost confidence in

MILITARY MORALE 693

their cause, their leaders, and themselves. America, through its
morale methods, fights lies with truth. Its cause is just. It knows
that against an unholy cause "the truth is mighty and will prevail."
It knows that what it does in making a better soldier will make him
later a better citizen. Its ideals are such as stimulate its men to
victory and confound its foes. And right ideals win. Even such a
crass materialist as Bismarck said, " It is the imponderables which
weigh the most."

PHASES OF WAR SURGERY. EXTENSIVE, HIGHLY
DISFIGURING WOUNDS OF THE FACE

By Charles A. Powers, M.D., Denver, Colo.

Professor Emeritus of Surgery in the University of Colorado.
Formerly Major, M. C, U. S. Army

THE incidence of high-explosive casualties in the present war
has occasioned wounds hitherto unknown. Of these, the
severely disfiguring injuries of the face are of marked im-
portance. The carrying away of the lower part of the face may
be immediately fatal (hemorrhage, shock, closure of the glottis),
or fatality may result later through sepsis, secondary hemorrhage,
pneumonia. In a given percentage of cases, however, the wounded
soldier survives, only too often to be repulsive through his disfigure-
ment, the reduction of which to the greatest possible degree has
furnished the surgeon with difficult and perplexing problems,
problems enlisting his sympathy as well as his skill. Not only should
the soldier be made to present as comely an appearance as possible,
but he should be able (wounds of the lower part of the face) to
masticate well and to speak intelligibly. In gaining the best results,
the surgeon must have the intelligent co-operation of the dentist;
fragments of bone must be appropriately held by sphnts, dentures
must be carefully made and applied. This co-operation between
surgeon and dentist has found in this war appHcation previously
unknown.

The subjoined history and photographs are presented without
further comment.

Case. P. C, aged forty-one years, single. Regt. Adjutant 3"" Mixt.
Zouaves. Serial No. 4441. Wounded by fragments of shell while in action
May 18, 19 1 6. Admitted to the American Ambulance Hospital of Paris,
Ward 178, May 30, 19 16.

Examination. Compound, comminuted fractures of the anterior,
lower portions of both sup)erior maxillae, of both palate bones, of the
vomer and of the anterior portion of the inferior maxilla. Much loss of

694

Fig. I. Condition on Admission, May
30, 1916.

Fig. 2. Approximation of Upper Lip
AND Chin, June 6, 1916.

Fig. 3. Ji i.v 10, 1916, IJiri.K 1 ip
Formed.

Fig. 4. August 29, 1916, Formation of Fig. 5. September 2, 1916.

Lower Lip and ISIouth.

Fig. 6. April ii, 19 17.

Fig. 7. Condition on Discharge, May
2, 1917.

PHASES OF WAR SURGERY 695

bone substance, loss of all teeth excepting some upper and lower molars.
Severe laceration and much loss of substance (considerable loss of mucous
membrane) of the soft tissues of the face, especially those of upper lip,
lower lip, and chin. Severe lacerations, with considerable loss of substance,
of the tongue. All wounds septic and foul. Moderate fever. (Facial condition
on admission shown in Fig. i.)

Treatment. Hourly irrigations with permanganate solution, i-8ooo,
suitable tube feeding, attention to bowels, removal of eclats d'obus (local
anesthesia), from front of neck; sitting posture. (The patient, a very
intelligent professional soldier, co-operates with the surgeon and nurses
in every way.)

Three days after admission, June 2, 19 16, under local anesthesia, the
fragments of the upper lip and those of the soft tissues of the chin were
loosely brought together by sutures of silk- worm gut and horsehair. (Fig. 2,
picture taken June 6, 19 16.) (Note. June 10 the patient is up and about,
doing well. Slight suppurative fever.)

July 3, 1916. The upper lip drops (Note: I am of the thought that an
attempt should have been made to elevate this at the time of the opera-
tion of June 2, despite the severely septic condition of the wound. —
C. A. P.), and under local anesthesia both sides of the upper lip and the
adjacent portions of the wound are dissected free, lifted, and held up by
large, stay, suture-guys, these suture-guys running to the soft parts over
the anterior portions of the malar bones. (Guy scars shown in Fig. 3.)
In addition, the right side of the lower lip is dissected loose from the
tissues to which it had become adherent and brought up toward the upper
lip, being held in place by sutures. Tissues of chin loosened and approx-
imated as far as possible.

Note: July 7. Left side of lower lip loosened and held up by stay-
sutures.

July 10. These latter procedures have been successful. (Fig. 3, photo-
graph taken this day.) Note, July 20: The opening in the face is contracting
rapidly.

July 31. Ether. Further plastic approximation of tissues. Necrosed
bone removed from right side of inferior maxilla. (Small, loose fragments
have been taken from all fractured bones from time to time.)

August 19, 1916. Operation, ether. Complete freeing of all tissues
of the face, extensive freeing of tissues of chin well down on neck. Section
of the cheek on right side at angle of present mouth. Mucous membrane
brought to skin. Preliminary attempt at formation of lower lip. Chin tissues
brought up and fastened to lower lip.

August 26. Further plastic operation. Right cheek slit out about i J

696 PHASES OF WAR SURGERY

inches. Mucous-skin approximation. Right angle of mouth formed. Left
cheek slit out about |- inch. Remains of lower lip brought over from right
side and fastened to tissues of left side, thus forming a lower lip. Chin
tissues undermined and brought up. (Fig. 4, taken August 29, 1916, shows
formation of mouth and lower lip.)

Fig. 5, September 2, 19 16, shows the result of this procedure; at this
time (September 2d) the patient has not yet complete control of the saliva.

Small, additional plastic operations were done on September 17th,
October 9, and October 3 1 .

The patient spent the winter of 1916-17 in an annex hospital at Clichy
awaiting further plastic procedures.

April 16, 19 1 7. Ordinary Nelaton operation for the relief of the hare-lip
shown in Fig. 5 (September 2, 19 16) and Fig. 6 (April 11, 19 17). In this last
picture the smoothing out of the depressed scars and the return of a
molded facial contour may be noted. At this time the patient is able to
control the flow of saliva.

May 10, 191 7. The hare-lip has been satisfactorily corrected (Fig. 7).
The patient retains saliva well. There is firm, bony union in the fractured
mandible. The dental departm.ent (Dr. Darcissac) has provided the patient
with cleverly made, practically useful and excellent appearing artificial
teeth. He controls saliva perfectly. Small operations have freed an adherent
tongue. He speaks and eats well and presents the quite comely appearance
shown in Fig. 7. (Photograph May 2, 19 17.) His general health has been
excellent since a month after his injury.

May 25, 19 1 7. Patient discharged.

July 4, 19 1 7. The patient writes me (C. A. P.) of a recently and happily
contracted marriage.

Continued observation of a fairly large series of somewhat sim-
ilar cases serves to impress upon me the advantage of complete
military control of the given patient (fortunately these cases are
exceedingly rare outside of the casualties of battle), the importance
of deliberate and careful daily inspection, as well as the retention
of the patient in a single hospital and continued attention by a
single surgeon. Continuity of service, not often possible in war
surgery, makes for the best results. It seems trite to say that the
earlier skilled attention is afforded these distressing cases, the better
will be the results.

A PSYCHOTIC EPISODE IN ROMAN HISTORY
a study of the abnormal psychology of nations

By Charles L. Dana

I AM calling attention to a short period of human history between
50 B. c. and 44 B. c, during which time there was an extraordi-
nary upset in human affairs — the world changed hands.

I wish to show that the phenomena of that period, as ex-
hibited by certain national events, resemble a psychotic episode
in the human individual. The analogy is not altogether fanciful,
and is perhaps of more than academic interest; for it seems to me
that it is suggestive of a new line of study — that of the abnormal
psychology of races considered as units. The study is a difficult one,
and what I present may be nothing more than suggestive, but I
feel satisfied that it is worth while, for such studies may help us in
interpreting and forecasting national events and progress.

In studying the career of an individual for psychological pur-
poses, we try to learn the make-up of his character, to get at his
personafity, to find out the amount and quafity and proportions of
his mental endowments. Some persons are simply defective quanti-
tatively— they lack the mind stuff, they are imbecile or childish in
intelligence; others are lacking in some single form of endowment,
such as emotion, self-control, power of decision, or of initiative,
being otherwise perhaps brilliantly intelHgent. These are said to
have a constitutional psychopathic inferiority. Others have an abnor-
mal make-up, with overdevelopment of anti-social instincts ; they form
the criminals, the perverts, the eccentric and abnormal types. They
are said to have a psychopathic personality.

In the life history of a normal individual, the ordinary methodical
working of his thoughts, emotions, or behavior may become seriously
disordered. Then we say he has a psychosis or mental sickness. This
morbid mental condition may be slight and episodal, or it may be

697

698 A PSYCHOTIC EPISODE IN ROMAN HISTORY

persistent and lead to the loss of his health, property, personal
responsibility, and death.

The history of a race or nation may be studied, just as we study
the career of an individual. We may study its behavior for the pur-
pose of determining its normahty, or to find whether there is anything
in the racial make-up that is comparable to a psychosis, or an
inferiority, or psychopathic personahty, or a quantitative mental
defect. This is in line with the present trend, viz., that of studying
behavior as well as that of applying the results of introspection, for
the purpose of determining the condition of the mind.

As we consider the history of nations, I think we can recall in-
stances in which there have occurred some things characteristic of
the psychoses.

It is easy, for example, to conceive of a national exhaustion
psychosis. This would be characterized by a general clouding and
confusion, by indecision, by hallucination, lack of insight or fore-
sight, and a general collapse of capacity to care for the person or its
possessions. We may be seeing such things at the present time.
There was certainly a psychotic confusion in Germany after thebreak-
up of Charlemagne's empire in the ninth century. After three or four
hundred years of futile wrangling and fighting, the only result was
the estabhshment of 276 feeble independent states.

There are races which may, through partial deterioration, show
a constitutional psychic inferiority — like the present race of the
Persians, and that of certain Nyro repubhcs. Perhaps the history
of Korea illustrates this also.

Some nations seem to have what is equivalent to a psychopathic
personahty, i.e., they are abnormal in certain lines of their develop-
mental activities. This was perhaps true of the Phoenicians, whose
civihzation was characterized by ambition to gain money, and who
contributed nothing to the progress of the world in the domain of
science, art, letters, or of mechanical or agricultural invention dur-
ing the whole of their history.

A quality of constitutional inferiority may be said to characterize
the Turks — "a race," says John Fiske, "politically unteachable and
intellectually incurious, which has contributed absolutely nothing
to the common weal of mankind.'*

There are races which belong to the high grades of feeble-minded-

A PSYCHOTIC EPISODE IN ROMAN HISTORY 699

ness. These races may show some intelligence, but they have not
enough to enable them to exist nationally, except as dependents.
A primitive and undeveloped race, however, may not be a feeble-
minded one, for the test of intelligence lies in the power of living
with some degree of order and happiness through its own exertions,
like the North American Indians and Esquimaux.

The emotional state is the most unstable of the elements of
mental hfe, the most easily affected by the strains and tragedies
of Hfe, and the most easily communicated to masses. All nations are
more or less subject to emotional outbursts, to contagious obsessions,
to illusions or misinterpretations of data. When these things pass
beyond what the average intelHgence and education of the people
should correct, they come within the group of morbid mental states.
The emotional attitude of the Greeks was characterized by obsessive
passion for local and personal Hberty, not for a large community
welfare. This led to their undoing. The French had in 1870 an attack
of episodal pithiatism, developed out of the exhaustion and suffering
of previous years. They are said now by a German writer to have a
"GaHic psychopathy" characterized by a passion for revenge!

It is too soon to characterize the development and spread of
Bolshevism, but it is some form of racial or national psychosis; a
great national movement based on the results of deprivation and
suffering and stimulated by delusions — as we beheve — or by mis-
interpretations of the laws of sound national development.

Thus I am sure it is safe to say that races, whether Hving under
the common arrangements of organized government or not, are
quite proper objects of studies in abnormal psychology. Such study
may help to explain the rise and fall of nations and civihzations.

Historians have in the past attempted to describe the cause of
the decHne of individual races and civihzations, but their explana-
tions have generally been based upon certain incidental conditions,
such as an excessive amount of war, the conditions of the soil, dev-
astations made by famine, epidemics, etc. These conditions all did
exist, but they persisted in a measure because of the defects in the
organization and mental quahties of the race. One-sixth of Italy
s uninhabitable on account of malarial conditions, yet these could
be removed if the people and its government wished, i. e., if it
had the mentahty to initiate reform.

700 A PSYCHOTIC EPISODE IN ROMAN HISTORY

Mr. Flinders Petrle, in his "Revolutions of Civilization," has con-
tended that civilization is an intermittent phenomenon, that the civil-
ization of certain dynasties of Egypt went through periods of develop-
ment and decline, and that the same process took place in Europe.
He puts the civihzation which began in the fifth century B.C. , and ended
in the Age of Constantine, as a seventh period of European evolution.

Professor Petrie does not attempt to explain these recurrent
phenomena, however, nor has anyone, so far as I know, attempted
it in any general way. The suggestion that it may be due to the
faulty make-up in the mentality of races is at least worth consider-
ing. We know that, given a certain personality, if it is subject to
depressing or irritant conditions, it develops a special psychosis
corresponding to the mechanism of the individual's character. So,
when a nation or race is made up on a certain pattern, it will react
to exhausting or depressing stimuh, in accordance with its mental
mechanisms.

Let us now see what was the "make-up" of the Roman race.

The members of this race were certainly not constitutionally
inferior or psychopathic. They developed, expanded, and controlled
the destinies of the world for a thousand years. But, like many
normal individuals who Hve Hves of aggression and domination,
they had some psychopathic and perilous periods, due to their natu-
ral characteristics.

The Romans started as a race of fighting farmers, and at the
beginning, waged war mainly on the defensive. In order to retain
their homes and land, they developed the sturdy virtues of disci-
phne, valor, and obedience. They were only fairly intelhgent, but
they beheved that they had superior qualities and were extremely
confident of themselves. They were not strongly individualistic like
the Greeks, but were willing to make personal sacrifice for the sake
of the whole group.

They had an un imaginative state religion, and they prayed for
their families and crops. They were not a sensitive people, not gener-
ous in spirit, were poor in emotion, with no great social gifts. They
had little ingenuity, and until later developed no art or science —
except those of war and farming.

Says Mr. Jerome in "Roman Memories," referring to the early
Romans :

A PSYCHOTIC EPISODE IN ROMAN HISTORY 701

"The Romans were a people relatively deficient in sentiment and
imagination; intellectually, they were not above mediocrity; they were
self-confident, avaricious, severe, and pitiless, but were not needlessly
cruel; they were remarkably free from envy, hatred, and malice; they had
a strong feeling for gravity and decorum, and possessed to a degree higher
than in the case of other ancient peoples the sentiment of justice.

"They had common sense, but no great mental nimbleness, nor clar-
ity of vision. They were conservative, credulous, opportunist, formahst.
These qualities were joined to their defective imagination and insight.
Their strongest characteristic was their volitional power; they were iron-
willed, energetic, determined, patient, and self-controlled. Their leaders
were not afraid to lead, and the masses were not impatient of restraint,
not disinclined to obey nor backward in facing death or pain."

Says Smith in "History of Rome":

"We may trace the superiority of the Romans, first to the strength
and firmness of their character, which endowed them with confidence in
themselves, still more with confidence in one another; to the power of
command over themselves and not less of command over others; to the
mutual sympathy and brotherly feeling nurtured by the perils they had
encountered and the triumphs they had won together, and to a conscious-
ness of natural fitness to rule and an imperial destiny to accomphsh.
The vaunted patriotism of the Romans, which was undoubtedly both sin-
cere and active, may be resolved into a sense of dependence upon one
another and an independence of all besides, which taught them to regard
their city as the center of their universe."

The Romans prospered. As they became more experienced and
realized the resources and enjoyments of a larger life, they secured,
through their primitive virtues, their intelligence and practical
training, the things that art and greater social development in other
countries could furnish. They bought art and culture and good
living. They found it easier to plunder than build, so they became
predatory in habit, and war was used to enrich their homes with
everything that the world could furnish.

They could not fight and plunder and keep their acquisitions
without retaining their discipline and all that went to make success-
ful warriors. As they had continually to fight not only to acquire
wealth, but to defend themselves against other robbers, they were
led to become efficient in constructing roads, fortresses, and buildings.

702 A PSYCHOTIC EPISODE IN ROMAN HISTORY

They retained their pride and egotism, which showed itself in
an intense desire to dominate and to fear any form of personal or
national enslavement.

For about 250 years, under the Kings, the Roman people were
busy organizing themselves and establishing their city, pursuing
agriculture, and defending themselves against their neighbors.
Then the republic began, and with it the beginnings of the Great
Addiction. Rome began to expand; it felt the desire for power, and
this gave it plunder, a great commerce, and riches. It conquered
Sicily, parts of Spain, and all of Italy. At about the same time it
destroyed Carthage and conquered Greece, and by 165 b. c. became
master of the whole Mediterranean basin. Later this people com-
pleted the conquest of Africa, Sulla, Marius, and Brutus plundered
the East and Spain, while Caesar plundered Gaul. When the latter
was assassinated he was planning to conquer the Parthians and pay
the debts of the Romans. The desire for power and territory and
money grew, as does the desire for opium. The more they possessed,
the more they needed to defend what they possessed. At first this
was an ambition of the people or nation, a group ambition, but later
it became an individual ambition. It was specialized, and the
leaders or the classes sought power and riches for themselves. This
led to civil wars: the wars of the Gracchi, of Sylla and Marius,
the wiping out of the Samnites, and the control of all Italy.

The nation was on the point of falling to pieces through the
debts and exhaustion of the state, the rivalry and ambitions of the
leaders, and the neglect and incapacity of its administration.

Here is the Roman experience from 264 b. c. to 48 b. c.

War by Hannibal, first Punic War, 264-241 b. c; second Punic War,
218-201 B. c; conquest of Greece, 200—195 b. c; conquest of Syria, Spain,
and Cisalpine Gaul, 191-178 b. c; Macedonian War, 168 b. c; final con-
quest of Greece, 148 b. c; destruction of Carthage, 146 b. c; civil wars
led by the Gracchi, 133 and 121 b. c.

Defensive and offensive war against the Teutons and Jugurtha, iio-
loi b. c; social war led by Marius, 90-86 B.C.; foreign and civil war
conducted by Sulla, 86 to 82 b. c; Gallic wars by Caesar, 57 to 48 b. c;
conquest of the East by Brutus.

The condition of Rome at this period is summed up by Fowler
somewhat as follows: There had been a sudden increase in wealth

A PSYCHOTIC EPISODE IN ROMAN HISTORY 703

which was misused and misspent, so that the nation was over-
whelmed with debt. There was an abnormal increase of badly used
slave labor; city Hfe, greatly developed, was not wisely handled;
wholesome family Hfe had decayed; there was a decadence of women
and of the old forms of state religion; the methods of education
were wrong, and there had occurred an increase of disease, due to
malaria in the country, to bad sanitary conditions in the city.

In Appian's "Roman History," Book II, Sect. 19, we are told
that the Commonwealth had for a long time been disorderly and
unmanageable. The magistrates were chosen by means of money
and factional fights. Bribery and corruption prevailed in the most
scandalous manner. The people went bought to the elections. The
Consuls could not lead armies or command in war, because they were
shut out by the Triumvirate. The RepubHc went without Consuls
for eight months. Good men would not take the task. Finally mob
violence broke out and Pompey was made Dictator, but his reforms
were short-hved. A devotion to personal or chque ambitions had
taken the place of loyalty to the government and love of the father-
land. The condition has been characterized as the beginning of na-
tional degeneracy and decHne. But the work of Rome in the next
three centuries disproves this.

It was rather a psychotic episode, precipitated by the weakening
eflFect of wars, and excited finally by the enormous opportunities
for personal self-indulgence, so that those things which should have
gone to enrich and develop the state went to demorahze and con-
fuse the people.

When addiction overwhelms an individual, there result mental
confusion, dehrium, clouding of consciousness, and a definite toxic
exhaustive psychosis, caHing for the offices of a physician or cus-
todian.

It so happens that we have a picture of the times at this period,
as accurate and vivid as if it were a product of the best kind of
modern daily journalism. This is in the letters of Cicero, covering
the period 50 to 47 b. c, in which latter year Caesar crossed the
Rubicon and later conquered Pompey at Pharsaha.

Cicero pictures the situation as hopeless if Caesar wins. Historians
agree that it would have been hopeless if he had not.

The letters show Cicero's views on the instabifity of the Republic,

704 A PSYCHOTIC EPISODE IN ROMAN HISTORY

the power of one general, the weakness of another. His letters portray
the general distrust of those in authority and a despair for the future
of the state and himself. I quote especially his references to Csesar,
as showing how keenly he feared another social war and civil disaster.
All that he apprehended did occur for a time, but after Augustus
had finished his proscriptions and restored social order, the state
revived and grew in strength and efficiency for several hundred
years.

In the year 50 b. c. Cicero had just finished his government of
Cihcia, and he was on his way home, when he first got news of
Caesar's demands — viz., to be retained as governor of Gaul, and
later to be elected consul. The Senate soon voted that if Caesar did
not resign he would be declared a pubhc enemy.

Thereupon Caesar crossed the Rubicon (49 b. c), and civil war
between him and the loyahsts, led by Pompey, began. Pompey left
Rome, fled to Brundusium, the southern seaport of Italy, and thence
crossed to Epirus. Caesar seized the government at Rome, garrisoned
Italy, went to Spain, conquered the loyahsts there; returned to
Italy; then in January, 48 b. c, he crossed to Epirus, and in August,
48 B. c, won a victory over Pompey at Pharsaha. The Roman
repubhc was ended.

Caesar began — and Augustus completed — the medical treatment
of Rome, bringing back the authority of Rome and its patriotism
and passion for domination, to the government, and not to groups
of individuals.

Speciahzation of power, without co-operation and authoritative
organization, fails in national fife as it does in personal Hfe. This is
the lesson drawn from the story of the Great Addiction.

[Many letters are omitted in order to shorten this article, such as
give the picture of Rome when CatiHne nearly succeeded, and tell
the stories of the fives of the men of that time, Dolabella, Coefius,
Curio, Antony, Clodius, Milo. There were only two real men at this
period — Cato and Caesar.]

51 B. c.
Marcus Ccelius to Cicero:

With respect to our present divisions, I foresee that the senate, together
with the whole order of judges, will declare in favor of Pompey: and that
all of those of desperate fortunes, or who are obnoxious to the laws, will

A PSYCHOTIC EPISODE IN ROMAN HISTORY 705

list themselves under the banners of Caesar. As to their armies, I am
persuaded there will be a great inequality. But I hope we shall have time
enough to consider the strength of their respective forces, and to declare
ourselves accordingly. ... In the name of all the gods, my dear
Cicero, hasten hither to enjoy the diverting spectacle of Appius sitting
in judgment on extravagance, and Drusus on debauchery! It is a sight,
believe me, well worth your expedition.

Marcus Ccelius to Cxcero: ^

Meanwhile, we are in the humor here of acquitting all criminals:
nothing, in truth, so base or so villainous can be perpetrated that is not
sure of escaping punishment. You will perceive how wondrously active
our consuls are in their office, when I tell you that they have not yet been
able to procure a single decree of the senate, except one for appointing
the Latin festivals. Even our friend Curio has not hitherto acted with
any spirit in his tribunate; as, indeed, it is impossible to describe the
general indolence that has seized us. If it were not for my contests with
the vintners and the surveyors of the public aqueducts all Rome would
appear in a profound lethargy.

^ I B C*

Cicero to Marcus Coelius:

You mentioned something of a lethargic inactivity that had seized
the republic. I rejoiced, no doubt, to hear that you were in a state of such
profound tranquillity, as well as that our spirited friend was so much
infected with this general indolence as not to be in a humor of disturbing
it. But the last paragraph of your letter, which was written, I observed,
with your own hand, changed the scene, and somewhat, indeed, dis-
composed me. Is Curio really, then, become a convert to Caesar? But,
extraordinary as this event may appear to others, believe me, it is agreeable
to what I always suspected. Good gods ! how do I long to laugh with you
at the ridiculous farce which is acting in your part of the world!

Athens, October 16, 50 b, c.
Cicero to Atticus, Greeting:

If you have at last received my letter you will know that I have yours
through our friend Acastus, and that I am in good spirits {bono animo)
because Acastus told me of your improved health. But I shivered myself
{coborruisse autem me) at your news of Caesar's legions, . . . For myself,
I seem to foresee a terrific struggle {tantam dimicationem) unless the same
god who saved us in the Parthian war take pity on the state — even so,
such a terrific struggle as there never has been before.

7o6 A PSYCHOTIC EPISODE IN ROMAN HISTORY

Cicero to Atticus, Greeting: Formic, Dec. 5, 49 b. c.

I have really no news, but it soothes me to write to you and to read
your letters. (Acquiesco enim et scribens ad te et legens tua.)

My fears about the republic are very great. I have no consolation
except the thought that if fortune bestows on Caesar the supreme power
he will not be so mad as to misuse his advantages. If he begins to run amuck
my fears are more than I dare to write. (Quodsi mere coeperit, ne ego multa
timeo quae non audeo scribere.) But whoever conquers there will come many
evils and no doubt a tyrant.

FoRMiiE, March 8, 49 b.c.

What a difficult and calamitous business! {Quern difficultem planeque
perditam.) How can Ceesar keep from a destructive policy? It is forbidden
by his character, his previous career, the nature of his present enterprise
and his associates. For what a following he has, what damned souls! what
an abandoned and desperate cause! I foresee a massacre if he conquers,
an attack on the wealth of nations, repudiation of obligations, recall of
exiles, high office for the basest men and a tyranny intolerable.

Please introduce Terentia to the bankers; and send me news of Tiro,
as you have done.

Brundusium, Nov. 26, 50 b. c.

I arrived at Brundusium Nov. 24th. Terentia, who met me in the forum,
told me that your second attack of quartan had passed ... I hope that by
your prudence and temperance your health has been restored. I have all
your letters, each more delightful than the last. . . .

Cato has treated me shamefully and spitefully. He gave me a high
character (which I did not want) but denied me a triumph, for which I
asked, and how Caesar exults over this wrong done me by Cato! . . .

I long to answer all your letters; though there is one to which I have
no answer to make, and that is the one dealing with the perils of the
republic. I am very much upset (valde eram perturbatus) . What would you
have me do?

From Letter to Tiro.

A. U. 704, 49 B. c.

But an invincible rage for war had unaccountably seized not only
the enemies, but even those who are esteemed the friends, of the common-
wealth: and it was in vain I remonstrated, that nothing was more to be
dreaded than a civil war. Caesar, in the mean time, unmindful of his former
character and honors, and driven, it should seem, by a sort of frenzy, has
taken possession of Ariminum, Pisaurum, Ancona, and Arretum.

A PSYCHOTIC EPISODE IN ROMAN HISTORY 707

From Letter XII, To Servius Sulpicius.

A. U. C. 704, 49 B. c.

The flames of war, you see, have spread themselves throughout the
whole Roman dominions, and all the world has taken up arms under our
respective chiefs. Rome, in the mean time, destitute of all rule or magis-
tracy, of all justice or control, is wretchedly abandoned to the dreadful
inroads of rapine and devastation. In this general anarchy and confusion, I
know not what to expect; I scarcely know even what to wish. . . .

From Letter XI V, Cicero to Marcus Coelius.

A. U. C. 704, 49 B.C.

The truth of it is, there is no calamity so severe to which we are not
all of us, it should seem, in this universal anarchy and confusion, equally
and unavoidably exposed. But if I could have averted this dreadful storm
from the republic at the expense of my own private and domestic enjoy-
ments, even of those, my friend, which you so emphatically recommend
to my care, I should most willingly have made the sacrifice.

THE SCHEMATIC DRAWING OF THE EYE IN ITS
HISTORIC DEVELOPMENT

(fifteenth and sixteenth centuries)

By Mortimer Frank, S.B., M.D., Chicago, III.^

THE difficulties encountered in examining an eye anatomically
in earlier times probably led every auditor to form his own
conception of that which was orally presented to him. These
concepts naturally must have been very different, and so drawings
were made for teaching purposes, some of which have been pre-
served. These have been carefully studied by Sudhoff.

Sudhoff's investigations commence with an anonymous Anatomia
oculi on the back page of a thirteenth century MS. in the Sloane
collection of the British Museum (420). The eyeball and its tunics
are shown as made up of circles and divided perpendicularly by
two straight hnes into an anterior (left) and a posterior (right) half.
Below the figure, at the left, appears pars oculi exterior; at the right,
pars oculi interior. The innermost circle, which is not divided, is
inscribed humor cristallinus, and the inscriptions from within out-
ward in the hemispheres surrounding this are for the anterior half
{pars exterior) as follows: tunica aranea, humor albugineus, tunica
vuea (uvea), tunica cornea, and tunica coniunctiva. The tunica coniunc-
tiva has been drawn like a perioscopic lens which gradually thins
out towards the poles of the eyeball, an idea which probably origi-
nated from a misunderstood drawing of the cornea. The posterior
half is inscribed, reading from within outward, as follows: humor
vitreus, rethina, secundina, tunica sclirotica. From the upper and
lower folds of the eyeball two straight Hnes lead to the right (pars
posterior) and intersect at an acute angle (the limits of the orbit?)
and at their point of intersection is written. Hie tanget cerebrum;
that is, the place of entering the brain. From the equator of the
posterior half to the point of intersection of the two straight lines is
the inscription, Nervus opticus, without any Hnear limitation.

' Dr. Mortimer Frank died suddenly April 21, 1919, in his forty-fourth year, at his
residence, 1059 Hyde Park Boulevard, Chicago, III.

708

THE SCHEMATIC DRAWING OF THE EYE 709

In another Sloane MS. (981), belonging to the second half of
the fourteenth century, there is a short text with an illustration per-
taining to ophthalmic anatomy. The figure represents a cross-
section of the entire head, in the center of which is an eye surrounded
by circles and semicircles, Hke the coats of an onion. Here, as in the
diagram above, the circles are divided by a perpendicular Hne into
an anterior and posterior part, with the same inscriptions as in the
foregoing. Behind the posterior part is a moon-shaped sector marked
Cerebrum, surrounded by three semicircular segments inscribed with
the names of the coverings of the brain.

The Vatican Library at Rome possesses the Codex Urbinus
(246), a MS. written in the second half of the fourteenth century
or the beginning of the fifteenth, including among its contents the
anatomy of Mundinus. Where the structure of the eye is discussed,
a later owner drew, on the margin of the page, a diagram of the
arrangement of the coats of the eye in the manner already described
and with the same inscriptions within the circles.

Chronologically following the preceding pictures is one in the
Codex Leipzig (1183) ascribed to the first half of the fifteenth
century. Sudhoff does not agree with Hirschberg of Berhn that this
diagram should be ascribed to the Spanish-Arabian ophthalmologist
Alcoati. This hasty pen and ink sketch of the fifteenth century
upon the margin of a page was copied from some unknown source.
The evidence is proof of the fact that, independent of Arabic tradi-
tion, a cross-section of the eyeball must have been handed down
during the Middle Ages through the Occident. He also points out
that the placing of the cornea outside the conjunctiva is directly
contrary to Alcoati. Alcoati did nothing original in ophthalmology
and surely not in his anatomy. The latter originated with the Greeks
and from them passed to the Arabs and thence to the Occident, and
to Salerno and other medical schools through many different chan-
nels, and finally also through the Latin translations from the Arabs.
The Arabs made no anatomic investigations of their own on the eye,
just as they made none on any other parts of the body. The many
rehgious restrictions made the publication of drawings representing
parts of the human body absolutely impossible or highly difficult.
But even as other diagrams and sketches of organs were made in
Alexandria, so there can be no doubt whatever that diagrammatic

710 THE SCHEMATIC DRAWING OF THE EYE

drawings of the structure of the eye were made there and found their
way during the Middle Ages to the Orient and Occident. On the other
hand, we have no proof that all the pictures of the eye which are
found in the Latin editions of Arabic authors come from Arabic
tradition. Sudhoff does not doubt that the Arabs possessed Greek
diagrams of the eye in graphic form, but no MS. of any Arabic
work during the Islamic zenith contains a drawing of the eye.

During the second half of the thirteenth century, the decline
of Islam, the Syrian Hahfa wrote a treatise on ophthalmology of
which two MSS. are known. The drawing in the Constantinople
MS. (924) of the sixteenth century illustrates the structure of the
eye and its connection, by means of the chiasm, with the brain. This
picture, published several times without text by Hirschberg, dates
from the Halifa MS. of the year 1560.

Another interesting drawing of the eye, which also shows a hori-
zontal cross-section divided into an anterior and posterior portion
by a median line, as in the Occidental models, is found in an Arabic
MS. (3008) in the Bibliotheque Nationale at Paris, written in 17 14.
This is a very late transmission if we consider that the portion on
the eye by the Syrian, Salah-Ad-din, is said to have been written
about the year 1296. The drawing was first published by Pansier
and later again by Hirschberg, but without the anatomic text which
Sudhoff gives. It illustrates the combination of two cross-sections
of the globe perpendicular to one another, and plays even to-day a
certain role in the Arabic world according to Hirschberg. Sudhoff
does not agree with Hirschberg's interpretation of the picture, which
is of no consequence in this discussion. Whether it was the original
illustration for Salah-Ad-din's text book, and as such inserted about
the year 1296, or whether it was drawn without any influence from
the Alexandrian or even Byzantine sources, Sudhoff is not prepared
to say.

Further researches might establish for these graphic representa-
tions of the structure of the eye an earlier date than the year 1300,
beyond which none of the present illustrations go. Earlier drawings
by Hobeisch of the ninth century and by Hammar of the eleventh
century have not been preserved, as far as recent researches have
gone. The assumption might also be made that all these drawings
found their models in a late Alexandrian period, which remained

THE SCHEMATIC DRAWING OF THE EYE 711

alive in the traditions of the Orient and Occident far into the
fifteenth century, if not longer, and which appear to have been not
without influence even upon Leonardo and Vesalius.

The oldest printed illustration of the structure of the eye is
found in the "Margarita Philosophica" by Gregor Reisch, published
by Kaspar Schott at Strasburg on April 17, 1504. The external view
of the eye on the same page is a revised reproduction by Johannes
Peyhgk and Magnus Hundt. The Freiburg Carthusian monk, Sud-
hoff says, undoubtedly got his drawing from tradition, as with most
of the other illustrations in his book.

With this early accessible model created in the various editions
of the "Margarita Philosophica," it found a place in other works, as,
for instance, Hieronymus Brunschwig's "Distilierbuch." Very soon
afterward it is found in many ophthalmic treatises, with alterations
and additions. Independent modifications, however, are first ob-
served in a rather similar illustration which Walther Reiff uses in
his "Anatomie" (1541). However incomplete the illustration still
is, there already appears a trace of some independent anatomic ob-
servation, some real study of nature. Reiff"'s picture of the eye had
a long fife and was reproduced by Anton Novarinus as late as 1681.

Individual conception does not come to the surface until the
pubHcation of the "Fabrica humani corporis" by Andreas Vesahus
in 1543. His drawing is not wholly true to nature, especially as
regards the crystalhne lens. Vesalius could not free himself from the
tradition that the crystalline lens had its seat in the center of the eye,
a fact which he particularly illustrates in several detailed drawings.

In some respects it must be admitted that before this, through
his own individual observations, Leonardo da Vinci had come nearer
the truth than any of his predecessors or his successors up to the
time of Vesahus. He not only treats of the anatomy of the eye, but
also considers it from the viewpoint of optics.

George Bartisch, in his treatise of 1583, employs a schematic
representation of the eye made up of seven superimposed plates,
a common device of the fugitive anatomical pictures of the period.
From this it was only a step to the models in three dimensions which
sprang up in the seventeenth and were common in the eighteenth
century. These were again abandoned for the actual eyes of dead
animals, still employed in the teaching of to-day.

PHYSICIANS' LETTERS
By Fielding H. Garrison, M.D., Washington, D. C.

ONE of the earliest modes of conveying medical information
known to physicians was by means of letters, personal or
professional. These, in a much later period, were destined
to be the originals of our medical periodicals and transactions. From
the existence of two pediatric epistles from the physician Arad-
Nana to the Assyrian king Assurbanipal (884-860 B.C.) on eye
trouble and epistaxis in the Httle prince, his son, one might almost
venture to infer the possibility of clinical correspondence between
physicians themselves, as in the old medieval Consilia (consultations
by letter). Morgagni's "De sedibus," 1761, is, of course, the most
remarkable medical treatise in which the consilium is consciously
used as a norm or mode of expression. From the days of Gentile
da Foligno and Montagnana, it is a far cry to the huge interchange
of letters between Bretonneau and his pupils Trousseau and Velpeau,
the last and latest specimens of consilia. With the letters of Gui
Patin (1601-72), things take a new turn. They are a vast gossip-
shop and school-for-scandal, replete with the anecdotage and
midisance usually associated with our profession. As we approach
our own period, with its mania for smartness and efficiency, its
multiplicity of labor-saving devices and its corresponding lack of
large leisure for anybody, physicians' letters become dryer and more
businessHke, with only a touch, here and there, of the Pepysian
quaHty. Delightful exceptions are the Billroth letters, mainly
rhapsodies about music > Only passing reference can be made to the
various collections of Tissot, Frank, Scarpa, Jenner, Astley Cooper,
von Baer, Pirogoff, Korsakoff, and others. The life and letters of
Weir Mitchell will be a stately biography, which awaits its author.
Almost every biography of recent date is eked out by means of
letters. Those of John S. BilHngs are a fair example of the modern
tendency. His youthful letters, especially those from Civil War
battlefields, are spirited and colorful; in the later period, they are

712

PHYSICIANS' LETTERS 713

the plain business statements of one who has acquired the outlook
of Stendhal's ideal philosopher — to see things as they are, with the
clear, cold vision of a banker.^

In the earlier days of the Surgeon General's Library, Billings
began to gather from his own extensive correspondence a small
library collection of autograph letters of notable physicians. This
collection has been very materially enlarged by liberal and valuable
donations from Dr. A. Jacobi, Sir Lauder Brunton, and others.
Brunton began his correspondence with the writer in the following
letter, which may be embalmed in this keepsake as affording an
interesting view of Huxley's ultimate attitude towards religion.

"May 5, 1915.
"I have been reading with great delight the charming memoir you
have written of my dear old friend Dr. John Shaw Billings. I trust you
will forgive me if I write to you in regard to a mistake you have made in
what you say regarding another dear friend of mine, the late Thomas
Henry Huxley. At page 373 you say on the questions of religion and
immortahty of the soul, Huxley's attitude was antagonistic. I knew Huxley
very well, indeed, and for a long time spent my Sunday evenings generally
at his house in Marlborough Road, where he and Mrs. Huxley had a
'high tea* every Sunday night, to which they welcomed any of their
friends who might drop in without any formal invitation. I had been
brought up in one of the straitest sects of Scotch Presbyterianism, and
the Bible being the most interesting of the four or five books which I
was permitted to read on the Sabbath, I naturally learned to know it
well — so well indeed that I have only met two men in my hfe who, I
thought, knew it better than I did, and one of these was Thomas Henry
Huxley. Some of his opponents objected to his use of Biblical phraseology,
but he used it simply because he was so steeped in the language of the
Bible that he could not help it. But it was not the language of the Bible
only that Huxley knew. He had assimilated its teachings and guided
his Hfe by them. Huxley has always appeared to me as one of the most
religious men I have ever met. He was pugnacious by nature and detested
Pharisees intensely, but I do not think that in all his writings you will
find such strong language about them as that in the Gospel of Matthew,
Chap, xxiii, 13, 14 and 15.

* Pour 6tre bon philosophe, il faut 6tre sec, clair, sans illusion. Un banquier qui a
fait fortune a une partie du caractfere requis pour faire des d6couvertes en philosophic,
c'est a. dire pour voir clair dans ce qui est." — Stendhal.

714 PHYSICIANS' LETTERS

"In 1879 I married a daughter of the late archdeacon of Meath.
Shortly after our return from our honeymoon we went together to Huxley's
one Sunday night. He took my wife a little apart and began to ask her
about herself. When she told him that she was a clergyman's daughter
he asked about me. When she said, *Dr. Brunton is a Presbyterian' he
drew himself up involuntarily and said — not without some pride, my wife
thought — 'We were all Church of England people.'

"His natural turn for argument was fostered by his father, who set
all his boys two and two at a time to argue a question. At the end of half
an hour they had to change sides and demolish the view they had at
first taken as best they could. When I tell you farther that after his death
Mrs. Huxley told me that he had been buried at his own special request
with the full Church of England service, I think you will agree with me
that his attitude regarding the questions of religion and the immortality
of the soul cannot properly be described as 'antagonistic'
"Believe me,

" Faithfully yours,

"Lauder Brunton."

Toward the end of his life, Brunton began to send to the Surgeon
General's Library many gifts of unique value, among them his
choice collection of autograph letters of notable physicians. These
were accompanied by extensive commentaries, written out by
himself. A few paragraphs, of historical and biographical interest,
are worth quoting:

September 27, 191 5.

**...! am sending you a batch of autographs : some are interesting,
others are of no particular interest.

"You have probably a very large number of Acland's letters in the
correspondence he had with Billings, because they were very fond of each
other, but the one that I send you is interesting because Acland has put
in it very shortly the dream of his life to make Oxford a University for the
advancement of learning rather than for its dissemination. For a good many
years I examined in Materia Medica in Oxford and during the period
of examination I was always his guest. On o^? occasion a curious incident
occurred which showed that Acland possessed to a very extraordinary
degree indeed the power of foreseeing other people's intentions. It almost
outdid any of Sherlock Holmes' adventures. I was going to the examination
one hot afternoon and I must have been drowsy. I looked out at Oxford
Station but did not see the name, and on the contrary saw in very large
characters the name of Reading, which I afterwards found out belonged

PHYSICIANS' LETTERS 715

to an advertisement of Reading Ales. I did not get out but at the next
station looked up and saw that I had passed Oxford and got on to Ban-
bury. I knew the students would all be waiting for me and I was much
perturbed. I found that the only way of getting back to Oxford was to
wait for two hours, which of course was far too long, or else to take a special
train back. I at once got a special train and on arriving at Oxford Station
on the up platform, to my astonishment, I found Sir Henry Acland waiting
for me. I asked him how this came about. He said, 'I knew you had left
London, for if you had not you would have sent a telegram. I knew you
had passed Oxford, because you did not get out. I knew you would find
out your mistake and take a special train back and here you are.' He said,
T told the boys that you had been detained and I kept them. They are all
waiting in the Examination Hall.' We went back to the Examination Hall,
the examination began about half an hour late but otherwise as if nothing
had happened. The special train, however, consumed almost the whole
of my salary as examiner for the year at Oxford. . . . Heidenhain's letter
refers to certain statements made by Lawson Tait. He said that Harvey
had not discovered the circulation of the blood by means of vivisection.
Harvey himself said that he had but Harvey was dead and could not con-
tradict Lawson Tait; but Lawson Tait went on quite unnecessarily to
say that this had been admitted in their evidence by Sir Henry Acland
and Dr. Lauder Brunton. Both these men were alive and promptly con-
tradicted Lawson Tait's statement. He searched the evidence but in
vain, for the statements attributed to Acland and Brunton were
not there. He then said that his informant was Mr. Jesse, secretary
of the Anti- vivisection Society. Mr. Jesse said that he had done
nothing of the kind, and Lawson Tait was left in the lurch. If Lawson
Tait had been content to limit his statements to Harvey he would have
been all right, but his memory played him false in regard to Acland and
me. Lawson Tait was not at all a deliberate liar: he simply did not know
what truth was. He could not distinguish between the products of his own
imagination and objective facts. He was a student of medicine in Edin-
burgh University when I began to study. He still remained a student when
I left, and as far as University was concerned he was never anything but
a student because he could not pass the examinations. When he went up
for examinations he gave what he believed to be the correct answer to
the questions, but unfortunately these answers were not what the ex-
aminers wanted. They told him to go back and study for several months
more. Finally he succeeded in getting a license from the College of Surgeons,
but he never got a University degree. But the same excessive, lively
imagination which was such an enemy to him at examinations befriended

7i6 PHYSICIANS* LETTERS

him most thoroughly in debating societies. At the Royal Medical Society
of which I was a member there was, on one occasion, a special discussion
in regard to tracheotomy. Some of the members who were house surgeons
had had as many as six cases. Lawson Tait was not a member of the
Society but was invited to come as a guest and take part in the discussions.
He got up and stated that he had had either 68 or 86 cases, I do not remem-
ber which, he still being a student without any license to practice at all.
Various members of the Society expressed their incredulity, but Lawson
Tait was quite equal to the occasion and proceeded to give all particulars
of cases with the same minuteness as Defoe employed in his history of
Robinson Crusoe. After he had given six or eight most vivid accounts of
his operations and success the Society thought they would take the
remainder as read. . . . There is no particular interest in Laycock's
letter, but the man was very interesting personally. He had a most
profound confidence in himself and I have heard him say 'Twenty-five
years ago, gentlemen, I wrote a book which was then half a century above
its age, but the age is now gradually beginning to appreciate it.' The odd
thing was that in saying this he understated the truth. The book was
'Nervous Diseases of Women,* and such neurologists as Ferrier and
Crichton Browne still look upon it as in advance of the age. Laycock was
really the original of Sherlock Holmes. Conan Doyle got the idea from Joe
Bell, but Joe Bell got his ideas from Laycock, who was Bell's teacher as
well as mine. He used sometimes to make very brilliant diagnoses, and at
others, great mistakes. I have known him diagnose waxy degeneration
of the capillaries of the small intestine, and post-mortem examination
proved the correctness of the diagnosis. He has also been known simply
on walking through a ward to look at a man and say 'This patient has
cancer of the pancreas. ' Again he was correct. One day he was telling the
students a great deal about a child and he said to them, 'Gentlemen, I
know all this from my observation of the mother.' 'Please, Sir,' said the
woman, 'I am only his stepmother.' Another time he was saying, 'This I
can tell, gentlemen, from the condition of the patient's teeth.' 'Please, Sir,
shall I hand them round?' said the patient, taking the teeth out. . . "

John Hunter's letters to Jenner are good examples of the
circumstantial notes of a scientific investigator, wrapped up in
his own subject. An amusing instance is the famous letter of
September 25, 1778, in which Hunter bluntly consoles Jenner for
disappointment in love, "Let her go, never mind her. I shall employ
you with hedgehogs." In the Brunton correspondence there is a
letter from Gaskell, in which we are taken into his laboratory and

PHYSICIANS' LETTERS 717

see the great physiologist at work on his monograph on the vagus
nerve.

"GrANTCH ESTER, CAMBRIDGE,

"Dear Brunton: "^P"^ 3, 1882.

"It was very good of you to think of me with respect to the tortoises.
I certainly am going on with the vagus action and have aheady made a
large number of experiments on the tortoise and a few on the snake;
every animal has its own pecuharities and affords very interesting results —
tortoises are specially good. I hope to work through all the different
kinds of beasts I can get and finally tackle the mammal. As to Meyer's
tortoise, I think I have seen the same thing to all intents and purposes
in the ordinary tortoise. I find the R nerve always has more power of
stopping or slowing than the L, while the L often has a more marked action
on the strength of the auricular contractions than the R. Also the separa-
tion of fibres that slow and fibres which diminish and increase the force
of the contractions is carried out by nature in the ordinary tortoise in a
most excellent way, for the R vagus first passes to the sinus and is in con-
nection with the ganghon cells there, then in great part leaves the heart
to run an isolated course along one of the coronary veins, which passes
from the ventricle to the sinus entirely free, so that a piece of nerve lying
between the ganglia of sinus and those in auric.-ventr. groove can be iso-
lated and stimulated. The result is that the fibres which pass to the sinus
do all the slowing; those which pass to the auric.-ventr. ganglia do the
diminution and increase of the auric, contractions. Also, other matters of
great interest have turned up, showing for instance that the sequence of
vent, upon aur. does not depend on the large nerves between sin. and
vent, but upon the auricular contractions. Some of these results I hope to
show at Cambridge and would much hke to show them to you and talk
them over.

"With kind regards to Mrs. Brunton,

"Yours ever,

"W. H. Gaskell."

A note of Lister's refers to his monograph on the cutaneous

pigmentary system of the frogs, one of his preHminary studies in

the mechanism of inflammation.

ux, T^ T^ T D "May 28, 1889.

My Dear Doctor Lauder Brunton:

"My observations on the pigment cells were published in the Pbila.

Trans, for 1859. May I ask you to accept one of the few separate copies

I have left?

7i8 PHYSICIANS* LETTERS

"The impression conveyed to me in observing the movements of the
pigment molecules was that they were free in a fluid. But we then knew
nothing about protoplasm, and I have often felt a desire to observe the
phenomena again in the light of our present knowledge.
"Believe me,

"Yours very truly,

"Joseph Lister."

There is an interesting batch of letters interchanged between Sir
Henry Acland and the late Dr. John S. Billings, which deserves to
be printed in part, if the Acland letters can ever be entirely
deciphered. The passage in the Acland note referred to by Brunton
(supra) reads as follows;

"Oxford, England,

"July 24, 1 89 1.
"... At last I can see the hope of the foundation here of a general
comparative pathology, one of my lifelong dreams for Oxford, through
good report and evil report. You must all help me to counteract the craze
here to educate numbers only for the 'M.B.,' omitting thereby all earlier
conceptions of the wider morphology and pathology which John Hunter,
one would have thought, had founded forever.

"Always yours,

"H. W. Acland."

Among the many unpublished notes of Billings is this breezy
little bit of chaffing, one of his humorous love-taps to his personal
friends:

"January 5, 1892.
" I have yours of January 4th. I do not in the least understand what
you mean by acknowledging the receipt of your 'suspension in the Surgeon
General's Department.' Who has been suspending you? What are you
suspended from? And why do you feel particularly thankful about it?
"With the compliments of the season,

"Yours very sincerely,

"John S. Billings."

The following, addressed to the Harvard physiologist. Professor
Henry P. Bowditch, deals with one of the burning questions of the
hour, namely, the centralization of public health in a governmental
bureau. It has the bold, straightforward aller droit au but which
was eminently characteristic of Billings.

PHYSICIANS' LETTERS 719

"February 27, 1892.
"My Dear Dr. Bowditch:

"Your letter of February 23d is received. I do not upon the whole
think that it is desirable to attempt to create a Cabinet officer to be
known as a 'Medical Secretary of Public Health'; or that it is expedient
for the medical profession to urge the creation of such an office. At best
it would be held but four years, and the probabilities of having it filled
by a satisfactory man are, I think, extremely small. The benefits to be
derived from it are very doubtful. It is the old scheme of Jeremy Bentham.
Such an officer, to have any practical power, must have more or less
control of the medical departments of the government, that is to say, of the
Medical Departments of the Army and of the Navy, of the Marine
Hospital Service, the Indian Bureau, the Pension Bureau, of the Army
Medical Museum and the Naval Museum of Hygiene, and so on. This is a
concentration of powers and duties which I feel very sure would not be
expedient at the present time, and it would require a man with the
qualities of an archangel to fill the position satisfactorily. I beheve that
we ought to have a National Board of Health, composed of a limited
number of men, such Board to be under the direction of the Department
of the Interior, and not of the Treasury Department. But this scheme
for a medical cabinet officer appears to me to be utterly impracticable,
and in fact hardly worth serious discussion; and I feel absolutely certain
that no influence which can be brought to bear upon the present Congress
could induce the creation of a new salaried office like this.

"With kindest regards and best wishes believe me to be,

"Very sincerely yours,

"J. S. Billings."

HOMAGE TO SIR WILLIAM OSLER
By Arpad G. Gerster, M.D., New York

XOPOE

. . . trig dv8Q8iag
Eivexa tqijtt]?,
Eirruxia yivon^ dv —

dpCOJlCp, OTl JIQ01]X0V

'Eg padi) rfig f|Xixiag,
NECOTEQOig xfiv qpxJaiv dviov
Ugdynaoi XQCori^exai
Kai oocpiaw ejtadxei.

Aristophanes, The Clouds

CHORUS

. . . virtutem

Ob hanc

Feliciter evenit huic

Homini, quod setate,

Multum provecta,

Recentioribus ingenium suum

Rebus exornat,

Et sapientfam colit.

Versio Stepbani Bergleri (1760)

CHORAL SONG

. . . for virtue's guerdon

This fate is vouchsafed now

To yonder man;

That at the age

Of mellow ripeness

His genius, through wisdom's culture,

May freshly blossom forth in works

Of all-surpassing beauty.

Paraphrase by A. G. G.
720

EPIDEMICS OF INFLUENZA IN 1647, 1789-90 AND 1807

AS RECORDED BY NOAH WEBSTER, BENJAMIN RUSH, AND

DANIEL DRAKE

By Guy Hinsdale, M.D., Hot Springs, Va.

HE earliest record of influenza in America was made by
Hubbard, whose "Manuscript"^ informs us that:

"In the year 1647 an epidemical sickness passed through the whole
country of New England both among Indians, English, French and Dutch.
It began with a cold and in many was accompanied with a light fever. Such
as bled, or used cooling drinks, generally died; such as made use of cordials,
and more strengthening, comfortable things, for the most part recovered.
"It seems to have spread through the whole coast, at least all the
English Plantations in America, for in the Island of Christophers and
Barbadoes there died 5 or 6000 in each of them. Whether it might be called
a plague or pestilential fever, physicians must determine. It was accom-
panied in those islands with a great drought, which burnt up all their
potatoes and other fruits, which brought the provisions of New England
into great request with them, who before that time had looked upon New
England as one of the poorest, most despicable, barren parts of America." *

Noah Webster, the famous lexicographer, in his "Brief History
of Epidemic and Pestilential Diseases," published in Hartford,
Conn., in 1799, in two volumes, gives in chronological order a list
of epidemics of "influenza or epidemic catarrh," dating in Europe
from A.D. 1 1 74, and in America from 1647. In this remarkable list
of 44 instances of influenza there are most interesting notes of earth-
quakes, volcanic eruptions, and comets, since it was the fashion in
those days to associate something supernatural with the outbreak
of a pestilence. So we read that the epidemic of 1 174 was "the year

1 William Hubbard's Manuscript, Massachusetts Historical Society "Collections,"
2d Series, VI, 531, 532. The author is indebted to Mr. Worthington C. Ford for the
transcript.

* There is a slight confusion here. According to Winthrop the drought preceded the
pestilence. — H.

721

722 EPIDEMICS OF INFLUENZA

before an eruption of Etna"; that of 15 lo "the same year with an
eruption in Iceland and following great earthquakes, humid air — a
comet appeared the next year"; in 1647, "First catarrh mentioned
in American annals. The same year with violent earthquakes in
South America, a comet."

In Noah Webster's view, Etna, Vesuvius, comets, and earth-
quakes loom large in etiology. He states^ in regard to the epidemics
listed :

"i. That most of them happened, after or during severe cold, or during
moist weather and in spring, winter or autumn. Some, however,
occurred in dry hot seasons, and others in mild winters.

"2. Nineteen instances occurred in years when there was a volcanic
eruption in Italy or Iceland, and eleven others, though in different
years, were within a few months of eruptions; making 30 out of the
44. Tv/o or three others happened near the time of volcanic discharges
in South America."

"3. Almost all happened in years of earthquakes, or within a few months
preceding or following them.

"4. Thirty instances occurred within the year, or a few months preceding
or following the appearance of comets.
"It is further to be observed that some of these epidemics have been

limited to the American hemisphere, at the distance of three, four or five

years from an epidemic of the same kind in Europe. Such as those of

1 647- 1 655 — which coincide in time with violent earthquakes in South

America."

It is remarkable and worthy of record that the epidemic of
influenza which ravaged the Atlantic coast shortly after the Revolu-
tion had practically all the features of the recent epidemic. There
was no better student of clinical medicine in those days than Ben-
jamin Rush, who held the chair of the Practice of Medicine and of
Chnical Practice in the University of Pennsylvania, which a cen-
tury later was graced by Prof. William Osier. Dr. Rush had the
unusual faculty and patience to set down the minute details of
cases as they came under observation. He was deeply interested in
the weather as it affected the sick and the well, and he urged his
students to make a study of meteorology; this was partly because
of the evident relation of epidemic diseases to atmospheric condi-

5 II. 33-36.

EPIDEMICS OF INFLUENZA 723

tions. Climatic influences always had for him a prominent place in
etiology.

On turning to Rush's chapter on influenza as published in his
"Inquiries and Observations," one is struck with a very remarkable
parallel between the course of the epidemic of 1789 and 1790 and
that of 1918 and 1919. In the account preserved to us by Benjamin
Rush there are many of the familiar symptoms so noticeable in the
last epidemic.

Rush noticed that the epidemic followed a cool summer and, in
the early cases, occurred in those sufl"ering from fatigue. Then fol-
lows a classic description of the extraordinary sneezing with hoarse-
ness and sore throat; a sense of weariness, chills and fever, pains in
the head, and abscesses in the frontal sinus. Rush noted the watery
eyes and the occurrence of swellings just behind the ears, now recog-
nized as the familiar mastoiditis. There was the distressing cough
which in some caseswasmoreof a tracheitis; and the final pneumonia.
He also described the abdominal form; also the fact that those
employed in out-of-door occupations, such as 'longshoremen, sur-
veyors, and the Niagara Indians, had it severely. He notes the oc-
currence of insanity consequent on influenza. We wonder if Rush
could possibly have observed the eff"ects of the streptococcus hemo-
lyticus, for he described "streams of blood" and spitting of blood
in consequence of the violence of the cough.

Dr. Rush's account is of great historic interest, revealing a
parallel between the clinical course of these two epidemics separated
by 129 years; so I am giving his account in his own words.

"an account of the influenza as it appeared in PHILADELPHIA
IN THE AUTUMN OF 1 789, IN THE SPRING OF I79O AND IN THE WINTER
OF 1 79 1, FROM 'medical INQUIRIES AND OBSERVATIONS' BY BENJAMIN
RUSH, M.D., PUBLISHED IN PHILADELPHIA, 1819.

"The latter end of the month of August, in the summer of 1789,
was so very cool that fires became agreeable. The month of September
was cool, dry, and pleasant. During the whole of this month, and for
some days before it began, and after it ended, there had been no rain.
In the beginning of October, a number of the members of the first congress,
that had assembled in New York, under the present national government,
arrived in Philadelphia, much indisposed with colds. They ascribed them
to the fatigue and night air to which they had been exposed in travelling

724 EPIDEMICS OF INFLUENZA

in the public stages; but from the number of persons who were affected,
from the uniformity of their complaints, and from the rapidity with
which it spread through our city, it soon became evident that it was the
disease so well known of late years by the name of the influenza.

"The symptoms which ushered in the disease were generally a hoarse-
ness, a sore throat, a sense of weariness, chills, and a fever. After the
disease was formed, it affected more or less the following parts of the
body. Many complained of acute pains in the head. These pains were
frequently fixed between the eye-balls, and in three cases which came under
my notice, they were terminated by abscesses in the frontal sinus, which
discharged themselves through the nose. The pain in one of these cases,
before the rupture of the abscess, was so exquisite that my patient in-
formed me that he felt as if he should lose his reason. Many complained
of a great itching in the eye-lids. In some the eye-lids were swelled. In
others, a copious effusion of water took place from the eyes; and in a few,
there was a true ophthalmia. Many complained of great pains in one
ear, and some of pains in both ears. In some, these pains terminated in
abscesses, which discharged for some days a bloody or purulent matter.
In others, there was a swelling behind each ear, without a suppuration.
. . . Sneezing was a universal symptom. In some, it occurred not less
than fifty times a day. The matter discharged from the nose was so acrid
as to inflame the nostrils and the upper lip, in such a manner as to bring
on swellings, sores, and scabs in many people. In some, the nose discharged
drops, and in a few streams of blood, to the amount in one case, of twenty
ounces. In many cases it was so much obstructed as to render breathing
through it difficult. In some, there was a total defect of taste. In others,
there was a bad taste in the mouth, which frequently continued through
the whole course of the disease. In some, there was a want of appetite.
In others, it was perfectly natural. Some complained of a soreness in their
mouths, as if they had been inflamed by holding pepper in them. Some
had swelled jaws, and many complained of tooth-ache. I saw only one
case in which the disease produced a coma.

"Many were affected with pains in the breast and sides. A difficulty
of breathing attended in some, and a cough was universal. Sometimes
this cough alternated with a pain in the head. Sometimes it preceded this
pain, and sometimes followed it. It was at all times distressing. In some
instances it resembled the chin cough. One person expired in a fit of cough-
ing, and many persons spat blood in consequence of its violence. I saw
several patients in whom the disease affected the trachea chiefly, producing
great difficulty of breathing, and, in one case, a suppression of the voice,
and I heard of another in which the disease, by the falling of the trachea,

EPIDEMICS OF INFLUENZA 725

produced a cyanche trachealis. In most of the cases which terminated
fatally, the patients died of pneumonia notha.

"The stomach was sometimes affected by nausea and vomiting; but
this was far from being a universal symptom.

"I have met with four cases in which the whole force of the disease
fell upon the bowels, and went off in a diarrhoea; but in general the bowels
were regular or costive.

"The limbs were affected with such acute pains as to be mistaken
for the rheumatism, or for the break-bone fever of 1780. The pains were
most acute in the back and thighs. Profuse sweats appeared in many
over the whole body in the beginning, but without affording any
relief.

"It affected adults of both sexes alike. A few old people escaped it.
It passed by children under eight years old with a few exceptions. Out
of five and thirty maniacs in the Pennsylvania hospital, but three were
afi"ected with it. No profession or occupation escaped it. The smell of
tar and tobacco did not preserve the persons who worked in them from
the disease, nor did the use of tobacco, in snuff, smoking or chewing,
afford a security against it.

"Even previous and existing diseases did not protect patients from
it. It insinuated into sick chambers, and blended itself with every species
of chronic complaint.

"It was remarkable that persons who worked in the open air, such as
sailors, and 'long-shore-men, (to use a mercantile epithet) had it much worse
than tradesmen who worked within doors. A body of surveyors, in the
eastern woods of Pennsylvania, suffered extremely from it. Even the
vigour of constitution which is imparted by the savage life did not mitigate
its violence. Mr. Andrew Ellicott, the geographer of the United States,
informed me that he was a witness of its affecting the Indians in the
neighborhood of Niagara with peculiar force. The cough which attended
the disease was so new and so irritating a complaint among them that
they ascribed it to witchcraft.

" It proved most fatal on the sea-shore of the United States.

"Many people who had recovered, were affected a second time with
all the symptoms of the disease. I met with a woman, who after
recovering from it in Philadelphia, took it a second time in New York
and a third time upon her return to Philadelphia.

"Many thousand people had the disease, who were not confined to
their houses, but transacted business as usual out of doors. A perpetual
coughing was heard in every street of the city. Buying and selling were
rendered tedious by the coughing of the farmer and the citizen who met

726 EPIDEMICS OF INFLUENZA

in the market places. It even rendered divine service scarcely intelligible
in the churches.

"A few persons who were exposed to the disease escaped it, and
some had it so lightly as scarcely to be sensible of it. Of the persons who
were confined to their houses not a fourth part of them kept in their beds.

" It proved fatal (with few exceptions) only to old people, and to persons
who had been previously debilitated by consumptive habits. It likewise
carried off several hard drinkers. It terminated in asthma in three persons
whose cases came under my notice, and in pulmonary consumption, in
many more. I met with an instance of a lady, who was much relieved of a
chronic complaint of her liver; and I heard of another instance of a clergy-
man whose general health was much improved by a severe attack of this
disease.

" It was not wholly confined to the human species. It affected two cats,
two house dogs and one horse within the sphere of my observations.

"In the treatment of the influenza I was governed by the state of the
system. Where inflammatory diathesis discovered itself by a full or tense
pulse, or where great difficulty of breathing occurred, and the pulse was
low and weak in the beginning of the disease, I ordered moderate bleeding.
In a few cases in which the symptoms of pneumony attended, I bled
a second time with advantage. In all these instances of inflammatory
affection, I gave the usual antiphlogistic medicines. I found that vomits
did not terminate the disease, as they often do a common catarrh, in the
course of the day or a few hours.

"The duration of this epidemic in our city was about six weeks. It
spread from New York and Philadelphia in all directions, and in the course
of a few months, pervaded every state in the union. It was carried from the
United States to several of the West India Islands. It prevailed in the
island of Grenada in the month of November, 1789, and it was heard of
in the course of the ensuing winter in the Spanish settlements in South
America.

"The following winter was unusually mild, insomuch that the naviga-
tion of the Delaware was not interrupted during the whole season, only
from the seventh to the twenty-fourth of February. The weather on the
third and fourth of March was very cold, and on the eighth and ninth
days of the same month, the mercury stood in Fahrenheit's thermometer
at 4 degrees at seven o'clock in the morning. On the tenth and eleventh,
there fell a deep snow. The weather during the remaining part of the
month was cold, rainy and variable. It continued to be variable during
the month of April. About the middle of the month there fell an unusual
quantity of rain. The showers which fell on the night of the seventeenth

EPIDEMICS OF INFLUENZA 727

will long be connected in the memories of the citizens of Philadelphia,
with the time of the death of the celebrated Dr. Franklin. In the last
week of the month the influenza made its appearance. It was brought to
the city from New England and affected, in its course, all the intermediate
states. Its symptoms were nearly the same as they were in the preceding
autumn, but in many people it put on some new appearances. Several
persons who were aff'ected by it had symptoms of madness, one of whom
destroyed himself by jumping out of the window. Some had no cough,
but very acute pains in the back and head. It was remarked that those
who had the disease chiefly in the breast the last year, complained now
chiefly of their heads, while those whose heads were aff'ected formerly,
now complained chiefly of their breasts. In many it put on the type of an
intermitting fever. Several complained of constant chills, or constant
sweats; and some were much alarmed by an uncommon blue and dark
color in their hands. I saw one case of ischuria, another of an acute pain
in the rectum, a third of anasarca, and a fourth of a palsy in the tongue and
arms; all of which appeared to be anomalous symptoms of the influenza.
Sneezing, and pains in the ears and frontal sinus, were less common now
than they were in the fall; but a pain in the eye-bafls was a universal
symptom. Some had a pain in the one eye only, and a few had sore eyes, and
sweflings in the face. In two persons whom I saw, the cough was incessant
for three days, nor could it be composed by any other remedy than plentiful
bleeding. A patient of Dr. Samuel Duffield informed me, after his recovery,
that he had had no other symptom of the disease than an efflorescence on
his skin, and a large swelling in his groin, which terminated in a tedious
abscess.

"The prisoners in the jail who had it in the autumn, escaped it this
spring.

"During the prevalence of this disease, I saw no sign of any other
epidemic.

" It declined sensibly about the first week in June, and after the twelfth
day of this month I was not cafled to a single patient.

"The remedies for it were the same as were used in the fall.

"I used bleeding in several cases on the second, third and fourth
days of the disease, where it had appeared to be improper in its first stage.
The cases which required bleeding were far from being general. I saw two
instances of syncope of an alarming nature, after the loss of ten ounces of
blood; and I heard of one instance of a boy who died in half an hour after
this evacuation.

" I remarked that purges of all kinds worked more violently than usual
in this disease.

728 EPIDEMICS OF INFLUENZA

"The convalescence from it was very slow, and a general languor
appeared to pervade the citizens for several weeks after it left the
city.

"I shall conclude this account of the influenza by the following
observations:

"i. It exists independently of the sensible qualities of the air, and in
all kinds of weather. Dr. Patrick Russel has proved the plague to be
equally independent of the influence of the sensible qualities of the
atmosphere, to a certain degree.

"2. The influenza passes with the greatest rapidity through a country,
and aff"ects the greatest number of people, in a given time, of any disease
in the world.

"3. It appears from the histories of it which are upon record, that
neither climate, nor the diff^erent states of society, have produced any
material change in the disease. This will appear from comparing the account
I have given, with the histories of it which have lately been given by
Dr. Grey, Dr. Hamilton, Dr. A. Fothergill, Mr. Chisholm, and other
modern physicians. It appears further, that even time itself has not
been able materially to change the type of the disease. This is evident,
from comparing modern accounts of it with those which have been
handed down to us by ancient physicians.

"I have hinted in a former essay at the diminutives of certain
diseases. There is a state of influenza, which is less violent and more
local, than that which has been described. It generally prevails in the
winter season. It seems to originate from a morbid matter, generated in
crowded and heated churches, and other assemblies of the people. I have
seen a cold, or influenza, frequently universal in Philadelphia, which I
have distinctly traced to this source. It would seem as if the same species
of diseases resembled pictures, and that while some of them partook of
the deep and vivid nature of mosaic work, others appeared like the feeble
and transient impression of water colours. "

A third epidemic of influenza occurred twenty-seven years after
the one described by Rush. We have a brief record by Daniel Drake
in his "Systematic Treatise on the Principal Diseases of the In-
terior Valley of North America." This work, in two volumes of
nearly a thousand pages each, was published after his death,
and is a monumental record of the history of clinical medicine,
as he and his colleagues observed it, during the first half of the
last century.

EPIDEMICS OF INFLUENZA 729

It will be noticed that Drake was acting as an army surgeon to
two regiments of militia in camps when the influenza swept down
from the East to the frontier post in the Ohio Valley where he was
stationed. Drake describes it in these words:

"i. History. The cause of this malady is as utterly unknown, as the
place where any one of its invasions commenced. I am unable to say
how often it has traversed our Interior Valley, for its vast uniformity of
surface leads to an extensive production of the endemic disease at the
same time, when it is generally called influenza, and the means of distin-
guishing it from that malady do not exist. It is sufficient to know that
we have been invaded by this exotic epidemic.

"The first and greatest invasion of this kind which I have had an
opportunity of witnessing, occurred in the year 1807. In the summer or
early autumn, the newspapers brought the intelhgence of its prevalence
in Europe and afterwards that it had reached our eastern cities. It was
in October, when the weather was fine and steady that it appeared in this
locahty. Two regiments of mihtia called into the field to repel from our
frontier a threatened invasion of Indians, were at the time encamped a
few miles out of town and I was then in attendance upon them. These
men were its first subjects, the people of the town still being heahhy. In
a few days, however, it reached the latter, and then sought out the scattered
inhabitants of the country. At that time there was but little communica-
tion between our settlements, yet I was able to ascertain that it 'spread
far and wide' among them.

"I need not give the history of any other prevalence, as this illus-
trates the most constant of the laws which govern influenza; first its
progressive extension from east to west; second its independence of all
sensible conditions of the atmosphere; third, its first outbreak in bodies
of men, and compact settlements.

"2. Symptoms. While the symptoms of this new visitant were sub-
stantially the same as those of catarrh, there were modifications which
deserved notice. Thus, although it often commenced in the nares alone,
it seemed at the same time to invade the whole respiratory membrane.
There was more fever, and the signs of inflammatory orgasm were often
very apparent; but the highest characteristic, not always present, was
a sense of sinking and prostration, with a serious feehng of disorder
throughout the whole system, indicating the impress of some malig-
nant agent. In subsequent epidemics, I met with cases of the same
kind; although they did not prove fatal, they suggested the idea of
danger."

730 EPIDEMICS OF INFLUENZA

Dr. Drake closes his account by noting among the sequels of
influenza the occurrence of purulent pleural eff'usions and the unusual
number of cases of pulmonary phthisis that developed.^

' The magnitude of the recent epidemic of influenza has not been fully measured,
but it seems to have exceeded any previous one of which we have a record. The London
Times has stated that the deaths in the entire world have numbered twelve millions. We
have no means of corroborating this estimate, but it is believed that the deaths in the
United States have reached over 500,000. In Canada in 1918 there were 13,880 deaths
in a total of 53,700 cases of influenza. Late reports give the mortality in India alone at
three millions.

VOTUM MEDICI

UT CONATA MEA SINE RATIONE LUCRANDI

AUT PERDENDI PERFICIAM.

UT SERVIAM SINE EXSPECTATIONE

GRATIAE FAMAEVE.

UT lUVEM MAGIS QUAM lUBEAM.

UT MAGIS CIRCUMVENIAR QUAM CIRCUMVENIAM

FIDEIQUE DESIM.

UT ONUS OFFICI SUSCIPIAM POTIUS, ET MUNERIBUS

QUAE AD ME ATQUE AD HOMINES PERTINEANT

MAXIME PERFUNGAR QUAM MIHI IPSI

COMMODUM MAGNUM CAPIAM.

UT VIRES ET SCIENTIAM AD OPUS EFFICIENDUM

HABEAM QUODCUNQUE DI MIHI DENT.

UT NIL QUERAR.

UT CONSTANS, FIDELIS AMANSQUE SIM,

UT OMNIA SORDIDA ET MALA ODERIM SINE

ACERBITATE ERGA EUM QUI PECCET.

UT FATUM INELUCTABILE FORTITER OPPETAM.

UT MINISTRATIONEM SOLITUDINIS, SILENTI ET DOLORIS

MENTE OBSTINATA ACCIPIAM.

UT MODERATE, PALAM, TEMPERANTER VIVAM

HAEC OMNIA SINT MIHI VOTA COTIDIANA.

By Bayard Holmes, M.D.,
Chicago, III.

731

SIR WILLIAM OSLER AND THE JOHNS HOPKINS

HOSPITAL

HOW SIR WILLIAM OSLER PROMOTED AND FOSTERED THE ACTIVI-
TIES OF HIS STUDENTS AT THE JOHNS HOPKINS HOSPITAL,
I 889- 1 905

By Henry M. Hurd, M.D., Baltimore, Md.

THE Johns Hopkins Hospital of Baltimore was opened in
May, 1889. Although Dr. Osier was appointed Physician-in-
Chief in 1888, he did not remove to Baltimore until the fol-
lowing year. The opening of the hospital for the reception of patients
had been much delayed because of the expectation, unfortunately not
realized, that the Medical School of the Johns Hopkins University
would be estabhshed in connection with it. An attempt had already
been made to arrange courses of study at the Johns Hopkins
University to prepare students to enter upon the study of medicine
when H. Newell Martin was appointed Professor of Biology, and
later when William H. Welch became Professor of Pathology in
1886. After spending a year abroad in special study. Dr. Welch
took up his residence in Baltimore in 1887. Laboratory accommo-
dations were thereupon provided for him in the Pathological Build-
ing of the Johns Hopkins Hospital, and the teaching of students
began there in 1888. Here he formed classes and guided the work
of special students, inaugurating laboratory instruction which
proved of great value, not alone to Baltimore, but to the country
at large, when the newer methods of bacteriology and pathology
were first presented to medical students. At the opening of the
Hospital no further effort was made at first to inaugurate systematic
instruction in medicine. In the autumn of that year, however,
largely through the initiative of President Oilman of the Johns
Hopkins University, who had co-operated in the organization of
the hospital, courses were announced and classes were established
for post-graduate students. Such classes were well attended and

732

SIR WILLIAM OSLER AND JOHNS HOPKINS 733

averaged between fifty and seventy-five students each year until
the establishment of the Medical School in 1893. They served
a useful purpose, and were among the earliest facilities afforded to
students in the United States to become familiar with bacteriology
and the modern methods of medical investigation.

Dr. Osier took up his residence at the hospital during the first
year, and was surrounded by a busy company of young medical
men, many of them recent graduates in medicine, who were eagerly
engaged in laboratory work or medical study and investigation.

In October, 1889, through the hearty co-operation of Doctors
Welch, Osier, Halsted, and Kelly a Medical Society was established
which has continued in uninterrupted operation for the past thirty
years. At the meetings of the society medical and surgical cases from
the hospital or dispensary were presented and terse and instruc-
tive comments were made upon them. Formal papers upon new
or interesting medical topics, followed by more or less formal dis-
cussions, were features of the society. The moving spirit in its
organization was Dr. Osier, who attended its meetings with great
regularity, and engaged actively in its work. The meetings were
held in the library of the hospital, and were attended not only
by members of the staff and post-graduate students, but also by
representatives of the medical profession in Baltimore. The society
soon outgrew the limited space furnished by the library and its
sessions were later transferred to the medical amphitheater. At
these meetings were presented the results of original studies in
malaria, tuberculosis, amebic dysentery, diphtheria, typhoid fever,
neuro-histology, and various branches of more special and newer
methods of laboratory work. Meetings were held twice monthly
during the university year, and proved a great source of interest
and profit to the students, as will be seen by the reports in the
Bulletin of the hospital and the papers printed in detail therein.

Soon after at Dr. Osier's suggestion, a Journal Club was estab-
lished, which met weekly in the afternoon or evening, and furnished
an opportunity for all who were interested to acquaint themselves
with the newest medical literature. Internes and students were
appointed to present summaries of the current literature in the
various branches of medicine. Papers were read sometimes in
extenso; generally, however, summaries were presented. The eftect

734 SIR WILLIAM OSLER AND JOHNS HOPKINS

upon the student body was excellent, and all students were thus
stimulated to keep themselves in touch with the current medical
journals of America and Europe. The Journal Club soon created
an appetite for medical Hterature.

In the following year, at the suggestion of Dr. Osier, the
Historical Club was estabhshed, which held a monthly meeting,
and gave an opportunity to students to become familiar with the
history of medicine. This club has held regular meetings during
the past twenty-nine years. At first, a series of formal and scholarly
papers was presented on the various aspects of the writings of
Hippocrates. Later, similar papers were read upon the writings
of Celsus and other classical writers. Largely through the initiative
of Dr. Osier, careful sketches were given of the earlier physicians
in England and America. The list of Osier's own papers is a long
one, and includes such titles as "An Alabama Student, " " Influence
of Louis on American Medicine," "John Keats, the Apothecary
Poet," "Oliver Wendell Holmes," "Thomas Dover, M.B., of
Dover's Powder, Physician and Buccaneer," and others. The
meetings of this society attracted physicians from other parts of
the United States, and many interesting papers upon historical
topics connected with medicine were thus brought before the
students: and many of them were published in the Bulletin of the
Johns Hopkins Hospital.

Another student activity which Osier initiated was the Laennec
Society, for the study of tuberculosis. This grew out of his effort
to familiarize himself with the extent of the prevalence of tubercu-
losis in the city of Baltimore. At his own expense he employed two
medical students to follow up dispensary cases of tuberculosis at
their homes, to study housing conditions, and to ascertain and to
remedy the defects existing in the home care of tuberculous patients.
The condition thus brought to his attention by the eff"orts of his
students proved to be so serious as to decide him to begin a
systematic movement in the community towards more varied and
eflfective work for the detection of tuberculosis and its relief. He
further desired to place a knowledge of the dread disease thoroughly
before the public, and to interest physicians generally in the early
detection of the disease and its prompt treatment. Hence, the
Laennec Society was established, and held regular meetings at the

SIR WILLIAM OSLER AND JOHNS HOPKINS 735

hospital during Dr. Osier's residence in Baltimore, and has con-
tinued them since his departure in 1905.

It is of special interest to recall the fact that Dr. Osier's energetic
and enthusiastic work in organizing and directing the Laennec
Society soon came to the knowledge of Mr. Henry Phipps of New
York, who, unsolicited, placed in Dr. Osier's hands a liberal fund
for the fuller prosecution of this work. The out-patient work at
the Johns Hopkins Hospital thus made possible became so useful
that Mr. Phipps eventually established the Phipps Dispensary
for the treatment of tuberculosis. This dispensary was inaugurated
first in a small building adjoining the General Dispensary; it subse-
quently was much enlarged by two generous contributions from
the same liberal donor, and has since accomplished a remarkable
work in the detection, diagnosis, and treatment of early tuberculosis
in Baltimore and its vicinity.

All of these societies have performed an important work in
leading many medical students to devote themselves to medical
research and investigation in every department of medicine.

In conclusion it should be added that beyond and above all
other influences exercised by Dr. Osier was the daily and hourly
spectacle of his tireless industry as a teacher, writer, and student
of medicine, and his boundless enthusiasm over the rapid progress
of medicine, his generous recognition of the efforts of others, his
unselfish assistance to those who were struggling to advance it,
and his unfeigned pride in their success. During the whole period
of his residence in Baltimore he was the guide, friend, and elder
brother of his students. He welcomed them to his hospitable home
and regularly gathered them in larger or smaller groups to read
with them the newer literature, to discuss the problems of medicine,
or to present some project of social betterment. He gave freely of
his time and energies to all who came under his notice, and ever
had an open hand for all who needed aid. His presence and example
were a benediction to all.

AN APPRECIATION OF HERMANN WEBER
By a. Jacobi, M.D., New York

HERMANN WEBER was a lifelong friend of mine. I knew
him first at Bonn in 1849, after having left the University of
Goettingen in 1849. My sojourn at Bonn lasted from my
sixth semester, 1 849 to 1 85 1 , where after my eighth semester I was
graduated in medicine in April, 1851.

Hermann Weber was born December 30, 1823, of a German
father and an Italian mother. His early years were spent in country
life in Bavaria and Hesse-Cassel, and he studied in Fulda until he
left for the University of Marburg. Here he met Carlyle during his
medical studies. From Marburg he changed to Bonn, where his
relations with Englishmen were still more frequent. It was here that
Sir Peregrine Maitland, Sir Henry Havelock, and Sir James Simp-
son gained an influence on the active young man. It was through
them that his studies of Shakespeare, and of Enghsh in general,
became more matured and his English future more established.

It was in Bonn that he graduated in medicine, 1848, and built
the foundation for his future greatness, his position there being that
of first assistant of the medical clinic of the university. As such,
he prepared the lectures of the professor, Friedrich Nasse, for whom
he was the superintendent of the medical clinic. In that capacity
he controlled the cHnic-dispensary work, which, under Nasse, was
quite extensive, the number of patients from the poorer classes
treated at the clinic being very large, consisting of adults and
children, both surgical and medical cases. All the advanced students
were in charge of patients, in great part responsible work. The
professor himself participated in the active work, which was
guided by the actual assistants, whose activities were many. The
students were occupied many hours every day, and their labors
did not end with the death of the patients, as our school work was
not closed until the post-mortem and epicrises were finished.

The most important factor in my labors in Bonn was the method-

736

Hermann Weber.

AN APPRECIATION OF HERMANN WEBER 737

ical teaching at the university. There was but one instructor in
Germany comparable with Nasse, namely, Krukenberg of Halle.
Indeed these two chnics were the only thorough ones in German
universities. These two professors were actually in contact with
French teaching. We students were fully aware of what was going
on in France under Laennec and Piorry, and were quite superior
in attainments to the students in Vienna, where Skoda taught and
Rokitansky demonstrated.

It is characteristic in the hfe of Hermann Weber that while he
continually studied and learned, he never ceased to teach. I early
adopted his methods, and never forgot them. I learned from him to
combine the study of the case and the obligation to the human
creature when treating a patient, and I apphed his theories in later
life when teaching. My connection with American teaching institu-
tions was of the same nature, both scientifically and humanistically.
I have been assured that my influence as a general teacher has been
the result of what was inculcated by my lifelong friend and teacher,
Hermann Weber. There should be more such friends and more
such teachers.

His first pubhc position in England was that of house physician
in the German Hospital of Dalston, a general hospital in London,
where I met him a few times after I landed in England as a refugee.
Meanwhile I felt that our paths had diverged considerably. He had
applied for admission to the Royal College of Physicians, of which,
after studying in Guy's Hospital, he became a member at the same
time as Dr William Odhng, in 1855. About that time he Joined the
"Medical Society of Observation," which attracted all the younger
men — his co-workers — of the London profession ; and from that time
dated his friendship with Addison, Edmund Parkes, Wilson Fox,
Hilton Fagge. It was in 1894 that he estabhshed the " Weber-Parkes
Prize" for the study of tuberculosis, which has been awarded five
times altogether.

"Tuberculosis," "phthisis," "consumption" were his lifelong
topics of study and close exertion. The British profession has not
failed to recognize this. On the Council of the Royal College of
Physicians he served as a censor in 1879 ^^^ 1880. The honor of
knighthood came to him in 1899. He became a consulting physician
to the Royal National Hospital for Consumptives at Ventnor; to

738 AN APPRECIATION OF HERMANN WEBER

the North London Consumption Hospital; and to the King Edward
VII Sanitarium. He was connected with a great many British and
foreign learned societies. All must have been sources of intense
satisfaction to him, but the keenest interests of the warm-hearted
man were his Kfelong sympathies with poverty, sickness, and
humanity.

A great many of Weber's pubhcations may be found mentioned
in the two series of the Index Catalogue of the Surgeon General's
Office, Vols. XVI of the ist, and XXI of the 2d series. Extensive
writings of his form part of Ziemssen's Cyclopaedia of 1880, of
Quain's Dictionary, and of Allbutt and RoIIeston's" System of Medi-
cine." His Croonian lectures before the Royal College of Physicians
in 1885 treated extensively of phthisis, Hke others of his special
studies. His "Notes on the Chmate of the Swiss Alps" (1864), his
"Treatment of Phthisis by Residence in Elevated Regions," belong
to this class.

Many results of his studies were embodied in an extensive book
pubHshed with his son. Dr. F. Parkes Weber, the last edition of
which, " Climato-therapy and Balneo-therapy," appeared in 1907.

An obituary pubhshed in the Lancet, of December 7, 19 18,
speaks of him in warm words. The claims of climatology were pub-
licly recognized owing to his knowledge of the subject, Hermann
Weber being an ardent mountain cHmber all over the Alps and
Apennines. His recommendations of Switzerland, Tyrol, and Italy,
and wintering in high altitudes were generally well known. His ad-
ventures in the Alpine Club were matters of extensive knowledge.
In his sixty-eighth year he climbed the Wetterhorn and the Jung-
frau; in his seventy-third year he still made extensive Alpine trips.
He did not give them up until he reached his eightieth year. They
made him the great judge "amongst half a dozen of British prime
ministers and a number of members of the royal Enghsh family."
One of my personal letters from him, which was burned in a fire
September 20, 19 18, speaks enthusiastically of his tour up Mount
Sinai "a few years previously."

He was medical officer to the Central office of the North British
and Mercantile Insurance Company for many years; was president
of the Life Assurance Medical Officers' Association from 1897 to
1899; and his presidential address on heredity in relation to fife

AN APPRECIATION OF HERMANN WEBER 739

assurance showed considerable prevision in respect to matters that
have since become subjects of more elaborate discussion and
arrangement.

In connection with his extensive active and scientific studies,
those on the muscular tissue are easily appreciated.

His main care was the treatment of the muscular tissue. In his
last paper ^ he referred to much of what he had taught for decades:
The principal movements ought to be those of walking, but arms
should be exercised similarly, not only of the young, but of the old,
always in relation to the different ages and conditions. Friar Roger
Bacon knew that the body heat decreased after the age of forty.

The effects of the muscular actions on different parts of the body
are pointed out, as follows:

1. Increased afflux of blood to the muscles with each contraction.

2. Increased nutrition of the muscle combined with improved
metabolism and production of body heat.

3. Increase of exchange of fluid between blood and tissues.

4. FaciHtation of the removal of waste products.

5. Preservation of the elasticity of the thorax and lungs.

6. Abundant supply of oxygen for the blood and the metabolism.

7. Maintenance of the healthy condition of the organs of cir-
culation, from the heart to the smallest arteries, capillaries, and
lymphatics.

8. Massage of the bones, keeping up the healthy condition of
the bone substance and the bone marrow, and through this the
formation of a sufficiency of blood efficient for the fight with hostile
bacteria entering it.

9. Increase of the resisting power of the body against disease.

10. Persistence of the working capacity of the brain centers,
which initiate the action of the different sets of muscles.

This last paper of his is characterized by assiduity, hke every
one of his endeavors. Even when he participated in the "Fest-
schrift in honor of A. Jacobi, M.D., LL.D.," 1900, p. 14, in his "A
Contagious Form of Pneumonic Fever in Children," he displayed
the same exactitude. Even in his last article he extended general
knowledge regarding patients ot advanced years.

Hermann Weber died November 11, 19 18.

1 "On the Influence of Muscular Exercise on Longevity," Brit. M. J., Feb. 23, 19 18.

EDWARD JENNER, A STUDENT OF MEDICINE, AS
ILLUSTRATED IN HIS LETTERS

By Henry Barton Jacobs, M.D., Baltimore

THE 17th of May, 19 19, marks the 170th anniversary of the
birthday of Edward Jenner. The great contribution to public
health and happiness which this man made has not only
stood the challenges and criticisms of time and men, but stands
to-day as the most momentous of all prophylactic measures against
disease which has yet been suggested. The magnitude of his one
great contribution so completely engrosses our thoughts of Jenner,
at least in the mind of the present generation, that all other ideas
of his personaHty or of his work are quite ecHpsed, and so it has
occurred to me that it might be appropriate in this, the 170th
returning year of his birth, to recall by quotation from a few of his
own letters some of the other medical subjects which engaged his
attention, and in which he also made distinct contributions to
medical knowledge.

Moreover, the fact that this paper is one of many others offered
as a token of esteem and affection on his birth anniversary to
another, younger by just an hundred years, and whose earliest
medical contribution also related to smallpox, seems further to make
the subject appropriate.

Space and opportunity together compel but a limited number
of quotations from those letters at hand. It is believed that some,
at least, have never before been published, and to that extent are of
particular interest.

Care has been taken to avoid as far as possible quotations
relating to the discovery of vaccination. For the sake of simplicity
the letters are arranged in chronological sequence.

In reading these extracts the state of medicine in Jenner's time
must be constantly borne in mind. He lived in the early period of
the great medical awakening at the end of the eighteenth and the
beginning of the nineteenth century. In Britain, Huxham, Cullen,
the two Hunters, Heberden, Fothergill, Lettsom, Baillie, Parry;

740

EDWARD JENNER, A STUDENT OF MEDICINE 741

in France, Corvisart, Pinel, Bayle, BIchat, Andral, Laennec, Louis,
and Piorey, together formed a group from which modern medicine
has its origin.

Jenner fortunately enjoyed in his student years the instruction,
inspiration, and friendship of John Hunter, that great investigator
and seeker after Nature's secrets. To him he owed, largely perhaps,
his love for the study of natural phenomena, though he must have
possessed an innate tendency in that direction, and a curiosity to
solve problems in Nature much greater than that which moves
most young men.

The following letter from Hunter to Jenner indicates that Jenner
had already, at an early date, undertaken investigations of his
own, and had become interested in surgical lesions which were also
of interest to the London surgeon.

Mr, Hunter to E. Jenner.^

Dear Jenner: I received your account of your experiments on the
hedge-hog, also the dog-fish, for which I thank you. I have now received
your account of the aneurismal vein with the cast, and showed it to my
pupils this evening with the description.

I hope you will be able to procure the arm when the man dies. If you
would choose to have it published, I would either give it to the Medical
Society here, or send it to Edinburgh to be published in their commen-
taries. Let me know your inclination, and I will add whatever I may think
wanting, and give it your name. I am very happy to hear that some of
you have wished to communicate your ideas to another. If I can give you
any assistance, command me; I shall always be glad to hear from you as
an individual, or as from the Society. Mrs. H. desires her compHments
to you. Have you left off fossilizing?

I am, dear Jenner,

Your much obliged and humble servant,

John Hunter.
London, April 28th.

In May, 1777, in writing to Jenner, John Hunter mentions
his own indisposition, with which he had suffered from time to
time since 1773, and in August he went to Bath for the waters,
where Jenner saw him. Jenner at once concluded that Hunter's

^ Baron's "Life of Edward Jenner," I, 47.

742 EDWARD JENNER, A STUDENT OF MEDICINE

trouble was due to the angina pectoris, the disease from which he
was to die sixteen years later.

So much impressed was Jenner with the seriousness of Hunter's
complaint that soon after he wrote to Heberden as follows:

E. Jenner, to Dr. Heberden, 1778.^

Sir: When you are acquainted with my motives, I presume you will
pardon the liberty I take in addressing you. I am prompted to it from a
knowledge of the mutual regard that subsists between you and my worthy
friend Mr. Hunter. When I had the pleasure of seeing him at Bath last
Autumn, I thought he was affected with many symptoms of the Angina
Pectoris. The dissections (as far as I have seen) of those who have died of
it, throw but little light upon the subject. Though in the course of my
practice I have seen many fall victims to this dreadful disease, yet I have
only had two opportunities of an examination after death. In the first of
these I have found no material disease of the heart, except that the coronary
artery appeared thickened.

As no notice had been taken of such a circumstance by anybody who
had written on the subject, I concluded that we must still seek for other
causes as productive of the disease: but about three weeks ago, Mr. Pay-
therus, a surgeon at Ross, in Herefordshire, desired me to examine with him
the heart of a person who had died of the Angina Pectoris a few days before.
Here we found the same appearance of the coronary arteries as in the former
case. But what I had taken to be an ossification of the vessel itself, Mr. P.
discovered to be a kind of firm fleshy tube, formed within the vessel, with
a considerable quantity of ossific matter dispersed irregularly through it.
This tube did not appear to have any vascular connection with the coats
of the artery, but seemed to lie merely in simple contact with it.

As the heart, I believe, in every subject that has died of the Angina
Pectoris, has been found extremely loaded with fat, and as these vessels
lie quite concealed in that substance, is it possible this appearance may
have been overlooked? The importance of the coronary arteries, and how
much the heart must suff"er from their not being able duly to perform their
functions (we cannot be surprised at the painful spasms) is a subject I
need not enlarge upon, therefore shall only just remark that it is possible
that all the symptoms may arise from this one circumstance.

As I frequently write to Mr. H. I have been some time in hesitation
respecting the propriety of communicating the matter to him, and should
be exceedingly thankful to you, Sir, for your advice upon the subject.
Should it be admitted that this is the cause of the disease, I fear the medical

' Baron's "Life of Edward Jenner," I, 39; I, 47.

EDWARD JENNER, A STUDENT OF MEDICINE 743

world may seek in vain for a remedy, and I am fearful (if Mr. H. should
admit this to be the cause of the disease) that it may deprive him of the
hopes of a recovery. . . .

Here, then, is the first intimation that angina pectoris, described
by Heberden in his "Commentaries on the History and Cure of
Diseases,*' is at least partially dependent upon coronary artery
disease for its occurrence.

Heberden had found only "small rudiments of ossification in the
aorta" in the one case he had examined post-mortem. In Osier's
seventeen post-mortems, recorded in the eighth edition of his
text book, thirteen presented coronary artery disease. We must
conclude, therefore, that this is the predominating lesion in angina
pectoris, and to Edward Jenner's careful observations must be
given credit for its discovery — a fact which modern medical historians
admit.

In the letter following one finds that as early as 1790 Jenner had
become interested in hydatid disease, particularly of the kidneys,
and had suggested a remedy. Full report of the case, as made before
the Gloucestershire Medical Society, July 28, 1796, is to be found in
British Medical Journal, May 23, 1896. Jenner thought the patient
improved under use of turpentine, and it was administered because
the general opinion seemed to be that hydatids were insects.

Whether or not Jenner accepted Hunter's reasoning that the
hydatid was an animal rather than an insect we are left somewhat
in doubt. We know, however, this was but the beginning of his
inquiries into the nature of this parasite, as letters to come will show.

Mr. Hunter to E. Jenner.^

Dear Jenner: I have just received the favour of yours. I have just
now forgot the case of hydatids ; but if there was any thing that struck me,
I dare say it was laid by. They are frequently in the kidneys, but I should
doubt your oil of turpentine having any merit in bringing them away. My
reason for supposing them animals is because they move after they have
been extracted. I have taken them out of the head or brain of a sheep, and
they have contracted in different parts of them when put into warm
water. I should be glad to employ you if I knew in what; but if any
thing comes across my imagination, I will think of you. The measly pork
are hydatids.

^ Baron's "Life of Edward Jenner," I, 39; I, 47; I, 98.

744 EDWARD JENNER, A STUDENT OF MEDICINE

I am afraid of your friend Mrs. L. There is a hard tumour that almost

fills the pelvis, most probably the uterus. How does Mrs. Jenner do? do

you bring her to London? What family have you got? My compliments to

Mrs. Jenner, and believe me to be, dear Sir,

Your most obedient, and

Most humble servant,

T>, I o r John Hunter.

December 8th, 1790.

The next letter from Sir Everard Home, son-in-law, executor,
and successor of John Hunter, is interesting as confirming in Hunter's
case the ideas Jenner had formed regarding angina pectoris. Such a
complete substantiation of his diagnosis, made sixteen years before,
must have been gratifying, though in the loss of his friend he was
deeply grieved.

Sir Everard Home to Dr. Jenner,*

Leicester Square, February i8th, 1794.

My dear Sir: I have sent you by the Major the numbers due to you
from the Royal Society. I am well assured that you were sincerely afflicted
at the death of your old and most valuable friend, whose death, although
we all looked for it, was more sudden than could have been imagined. It
is singular that the circumstance you mentioned to me, and was always
afraid to touch upon with Mr. Hunter, should have been a particular
part of his own complaints, as the coronary arteries of the heart were
considerably ossified.

As I am about to publish a life of Mr. Hunter, which will contain both
the symptoms of the disease, and the dissection, I shall not say more about
it at present; it will be prefixed to the work on inflammation, and we hope
to have it printed at the end of next month.

I cannot say that I have met with the ossification of these arteries so
frequently as other alterations of structure in the heart, but this case is
very much in favour of your theory. ...

Throughout his life Jenner maintained firmly that the digestive
organs, particularly the stomach, were in the animal economy the
main source of good or ill health. Here again he anticipates many
a later advocate.

The following letter puts this belief in picturesque words. It
also indicates that diseases of the eyes, "these invaluable organs,"
had claimed his thoughts.

* Baron's "Life of Edward Jenner," I, 39; I, 47; I, 98; I, 104.

EDWARD JENNER, A STUDENT OF MEDICINE 745

Cheltenham, Octob' 8th, 1797.
Wm. Peter Lunell, Esq.,^

Bristol.

My DEAR Friend: . . . The hour may come (I do not despair of its
arrival) when my stomach, where, wielding an absolute Sceptre, sits the
grand Monarque of the Constitution, may undergo some spontaneous
change, which may meliorate its present condition; and then I trust you
will find me a more orderly correspondent, and that William Shakespear
may furnish me with a better motto than that which is now, alas, too
applicable "To morrow, to morrow & to morrow." . . . And pray how
are your Eyes? — My little lecture on this subject did not sufficiently catch
your attention. I know not why; for the preservation of this invaluable
organ has occupied much of my Time, & perhaps the most intense of my
Studies have been devoted to it.

Believe me

Yf very faithfully

Edw. Jenner.

Osier says, in his article on acute endocarditis, that "Bouilland
first emphasized the association of simple endocarditis with rheu-
matic fever. Before him, however, the association had been noticed."

Bouilland, hving from 1796 to 1881, pubhshed his researches on
articular rheumatism and the coincidence of pericarditis and endo-
carditis with this disease in 1836.

The letter which follows shows that Jenner already had written
a paper on this subject prior to 1805. As a matter of fact, on July 29,
1789, "Mr. Jenner favored the Society with Remarks on a Disease
of the Heart following Acute Rheumatism, illustrated by Dissec-
tions." (Record of the Gloucestershire Medical Society.)

From the wording of the letter one would certainly infer that
the observations on the relation of the heart to rheumatism were
original ones, and that to Jenner therefore belongs the credit of
first noticing this relationship. The Fleece Medical Society was
another name for the Gloucestershire Medical Society, as it met in
the parlor of the Fleece Inn, Rodborough, Gloucestershire.

' From Dr. Jacobs' collection.

746 EDWARD JENNER, A STUDENT OF MEDICINE

Berkeley, Jan^ loth, 1805.
Dr. Parry,^

Circus, Bath.
Dear Parry: ... A neighbour of mine died yesterday from a disease of
the Heart, which followed two or three severe attacks of acute Rheumatism.
You may probably remember a paper of mine that was given into the
Fleece Med. Socy. on this subject. This & my other Papers are in your
possession. If you would be good enough to convey them to me, I should
be extremely happy in regaining them particularly that I now allude to,
as I am confident many a life is lost by not shielding the Heart at the going
off of acute Rheumatism, which not unfrequently at that time feels a
morbid determination of blood. . . .

Yrs. truly,

E. Jenner.

The next letter indicates that Jenner formed early a sane, if
perhaps radical, view of the value of medicinal baths.

William Lunell, Esq.,^
Bristol.
My dear Sir: . . . Now my good sir, what shall we do? I am almost
tempted to say, will not Miss Wait be benefitted by a change of scene, at
least by that of changing the air of Bristol — a murky City, for the aether
of Cheltenham? Our Springs too might prove salubrious. In the days of
old you know, we could reckon but on one, now we boast of eleven. Our
Chalybeate Spring rivals that of Tunbridge, and our sulphurated Spa, the
famous water of the North. It is really a very extraordinary fact that all
the medicinal waters of any celebrity in the Island are to be found concen-
trated in this little spot, Bath excepted, and to this I attach no more value
than that which flows from my Tea Kettle. . . .
Believe me.

Truly yours,

Edward Jenner.
Cheltenham, 5th Janf 18 11.

The appreciation of the value of comparative anatomy and
pathology may have come to Jenner from his master, John Hunter;
at any rate he was a believer in it, as he testifies in the two fol-
lowing letters, written only a day apart in 1813, when sixty-four
years old. They indicate how interested he still was in the hydatid
disease, and how well his enthusiasm for investigation persisted.

• From Dr. Jacobs' collection.
' Ibid.

EDWARD JENNER, A STUDENT OF MEDICINE 747

The language is poetic, but evidently the author here confuses the
two hepatic diseases, cirrhosis and hydatids. However, the desire
for greater knowledge is most praiseworthy.

The letter to "My dear young Friend" is such a beautiful one
that it is quoted in full.

I would have it noted that Jenner's mind here is surely con-
templating an active agency as the source of infection in typhus.
Reference to this will be made later on.

Berkeley, March 14, 1813.
Dr. Morgan,^

Great Russell Street,

London.

My dear Friend: ... I have not been in town since the summer of
181 1, nor much at Cheltenham, preferring, whenever I am permitted, the
enjoyment of my Cottage in this, my native Village. But don't think I
spend my time in idleness. My pursuit has lately been, when uninter-
rupted by Vaccination, the morbid changes in the Structure of the Livers
of Brutes, which has led me to some conclusions respecting the same changes
in the human, Tis hard methinks that the poor animal that is content with
what the meadows afford for his daily Bill of Fare & whose Cellar is the
Pond or the Brook, should perish from the same diseases as the Drunkard;
but so it is. There are Plants which some how or another are capable of
throwing the state of the Liver into that sort of confusion which calls
Hydatids into existence. These do not continue long in their native state,
but produce a great variety of Tubera, cartilaginous, boney masses, &c.
In other instances the disease originates in the biliary Ducts which become
astonishingly enlarged & thickened in every part of the Liver and finally
destroy it in various ways. This is the outline of my research. The Hydatid
I can call into existence in the Rabbit in about a fortnight. . . .

Your much attach'd

Edw: Jenner.

Berkeley, March 15, 1813.

My dear young Friend: Before I received a confirmation of your
convalescence under your own hand &. seal, I had the happiness of hearing
of it thro' one of your relatives here. Be assured it was a great happiness:

' From Dr. Jacobs' collection.

748 EDWARD JENNER, A STUDENT OF MEDICINE

for had the Monster Typhus stuck one of his venom'd Fangs so deep as to
have wounded you mortally, I should have grfev'd exceedingly. What is
this Fellow — into what apartment of our Mansions does he first break in,
and how does he perform the work of havock? Let this form one of the
subjects of our conversation when next we meet. I have both seen and felt
enough of this burglarious Depredator to excite a wish to detect him in his
first hiding place where he makes his entry & think I have found him out.
I have been endeavoring to trace him by means of my old auxiliary,
analogy — but no more of this now, except a hint respecting the oxy muriatic
gas. On this as the best contrivance to stop his rambhng from place to
place, I have a very confidential reliance. Let me entreat you to keep a
watchful eye over yourself for some time to come. The activity of your
mind may outstrip the powers of your Muscles and keep up a state of
debility, which would be overcome by a due quantity of rest. Your Father's
Letter tells me how imperiously you are call'd upon to attend to this. I
should say some lounging amusement would be the thing for you. A long
journey is out of the question, otherwise, I should say, come and take it
here; at all events when you are able I shall hope to see you. I hear much
of Mrs. Ibbetson's beautiful Discoverys among vegetables with her micro-
scope. Who would have thought that the Nettle concealed for so many
ages such treasures for the Naturalist. Have you seen its spiral apparatus
for darting forward its sting when irritated by the touch? How beautifully
the God of Nature displays to us his great and grand Museum. Were all
the doors to be thrown open at once, our senses would be confused & on
recovery we sh^ be satiated, just like those (comparing small things with
great) who exhibit the Gallerys of Napoleon.

/ am still goin^ on with my inquiries into the causes and effects of the
morbid changes oj the Liver in Brutes. This has led me into some conclusions
respecting the same morbid changes in the structure of that Viscus in the
human body. How wonderful that the poor animal whose Larder is the
Meadow and whose Cellar is the brook should perish from the same
diseases as the Drunkard; but so it is. There are plants which somehow or
another are capable of throwing the Liver into that kind of confusion which
calls Hydatids into existence. These vermin do not continue long in their
natural state, but produce a great variety of Tubera in all manner of shapes
and forms. They are variously organiz'd; fleshy, boney, cartilaginous, etc.
In other instances the disease originates in the deranged state of the biliary
Tubes, from one extremity of the Liver to the other, which become as-
tonishingly enlarged in their diameter, & thickened. Hence such havoc
arises that Hydrops Pectoris is the consequence, emaciation & death.
Accept this as just an outline of my research, which from a thousand inter-

EDWARD JENNER, A STUDENT OF MEDICINE 749

ruptions, and I must confess from a dislike to application, has been con-
ducted in a very desultory way.

Pray let me hear soon how you are going on, & thank your Father for
his letter.

Believe me, my dear Henry, very truly

Yours,

«TT ^ „ Edw. Jenner.

? Henry Cline.'

It may be recalled that Mrs. Jenner for the greater part of her
married life w^as an invalid, suffering from a chronic pulmonary
complaint, with an occasional hemorrhage; that Dr. Jenner's eldest
son died of consumption, following the death, from the same disease,
of his young tutor, who had lived in the house. It is no surprise,
therefore, that Jenner should have been extremely anxious about
his younger and only remaining son. The three following extracts
relate to this boy's health. They show a keen appreciation of the
early symptoms of pulmonary tuberculosis, the insidious nature of
its onset, and the value of fresh air in its treatment — differing only
from the modern teaching in believing that its temperature should
be regulated.

Cheltenham, Dec' 2, 18 13.
Mr. R. Jenner,^*

Henley, Oxon.

My dear Robert; . . . We should have been extremely happy to have
heard by him that you were looking well but we were griev'd to hear that
you look'd pale & thin. When you left us you were stout & in good health.
Pray tell me, are you entirely free from Cough, or Complaints about your
chest of any sort or kind? Such as a sense of tightness or difficult breathing
or using any great exertion? Have you at any time a pain in your side
under the Ribs? Are your bowels got back to the old state of costiveness?
Don't fail to tell me, if you are unwell the precise feelings you experience.

I trust you diligently attend to all I have said again & again about
cold.

The Post is going out & I can only add with what anxiety & affection
I remain

Truly Yours,

E. J.

• From Dr. Jacobs' collection.
" Ibid.

750 EDWARD JENNER, A STUDENT OF MEDICINE

Mr. R. Jenner,"

Henley, Oxon.
Dear Robert: You would not have had another Letter so soon had it
not been for your telling me that your Cough still continues. In my opinion
you cannot have recourse to the remedy too soon; however, at all events
call on Dr. Routh. The sort of Cough you had when here, is sometimes
more troublesome to cure, & is apt to continue longer than when it attacks
at once with greater severity. . . .

Yr. affte. Father

E. Jenner.

Dec' 20, 1 813.
Dr. Worthington,^*
Southend

near Upton.
My dear Doctor: . . . My poor dear Robert came home from School
about ten days since with a bad Cough & looking so peculiarly ill, so like
his lost Brother, that I was almost struck dead at his appearance. Thank
God I he is already much better & his Cough nearly gone. Our sheet anchor
in threatening cases I believe is the constant breathing of air duly regulated
as to temperature. One very cheering circumstance is, his not having a
quick pulse.

Most truly Your's

Edw: Jenner.

The next letter quoted opens up fully the question of Jenner*s
conception of tubercle. In the letters describing his researches upon
hydatids in the livers of brutes he speaks of "tubera" being formed,
and here he writes of another "tubercle" bursting. It is probable
that the words relate in some sense to pathological processes,
which, to Jenner, seemed more or less identical, though we are not
to suppose that either represents the true tubercle of Laennec.
That there must have been some kind of relation between the tubera
from hydatids and the tubercle of consumption in Jenner's mind is
evident, for in a letter to the Rev. Dr. Worthington, of December
13, 1809, quoted in Baron, II, 407, Jenner says: "What dreadful
strides pulmonary consumption seems to be making over every
part of our Island. I trust some advantage may, one day or another,
be derived from my having demonstrably made out that what is
tubercle in the lungs has been hydatid."

" From Dr. Jacobs' collection. 1* Ibid.

EDWARD JENNER, A STUDENT OF MEDICINE 751

While there existed this unquestioned confusion in Jenner's
conception of the etiology of consumption, I cannot but believe
that he had a ghmmering of the truth that consumption was de-
pendent upon the introduction into the lungs of some active, living
substance, and, to this extent, he was a forerunner in thought to
all those who since have demonstrated the exact state of the case.
The former letter, relating to typhus, still further substantiates my
idea that he was searching in the right direction in his effort to
explain infection.

It may be well to remark here what Hektoen has called to
attention, namely, that in Jenner's "Inquiry," published in 1798,
he gives, in the words of Garrison, "an early reference and a clear
explanation of anaphylaxis or allergy. In Case IV, he notes that
inoculation of variolous matter in a woman who had had cowpox
thirty-one years before, produced a palish red efflorescence of the
skin, which he regards as almost a criterion of whether the infection
will be received or not, attributing the phenomenon to the dynamic
of a permanent change in the blood during Hfe."

Ch« Murrav, Esq^•» Cheltenham, Sept'. «. ,814.

Bedford Row,
London.

My dear Sir: After the accounts you must lately have heard from this
place respecting the health of poor Gen. Lyman you will not be surprised
at the doleful intelligence I now communicate. It was evident yesterday
that he was in a dying state, & this afternoon at ten minutes past one, he
expired without a groan or a struggle. The Miss Lymans bear the loss
with as much firmness as one can expect. I understand the family in Town
will be appriz'd of the event by this Post.

The General's state of health continued nearly stationary from the
time of his arrival here till the commencement of the late warm weather,
soon after which he declined rapidly & another Tubercle burst about a
week since, which discharged profusely.

Pray make my best Compt. to Mrs. Murray & yr. Family & believe

me very truly Your's ^^ t

•^ -^ Edw. Jenner.

In the letter which follows, at the age of sixty-seven, we still
find him interested in anatomy and evidently engaged in some
research involving the lymphatics.

" From Dr. Jacobs' collection.

752 EDWARD JENNER, A STUDENT OF MEDICINE

Dr. Burder/*

21 Southampton Row,

Russels Square, London.
My dear Sir: . . . You speak of your engagements — I hope they are
of a nature to afford you pleasure & that professional calls are already
occupying part of your time, as a reward for your attentions & laborious
exercises during your long residence in Scotland. I could wish you for a
moment to turn to your Notes on the Lymphatics, & just tell me whether
anything new is said of their structure — If I recollect right a lymphatic
has two Coats, the external less delicate than the internal.
Believe me, with best wishes, dear Sir

Very truly yrs.

r, T- T T r. ^ EdW. JeNNER.

Berkeley, Feb. 5th, 18 16.

Here are Jenner's views regarding wine and its effects upon the
human system — a timely subject for discussion at the present day.

r, I- T T- ris Berkeley, March 2, 1816.

R. F. Jenner, Esq.,^5

Exeter College, Oxford.

My dear Robert: Your last Letter relieved me from an anxiety

naturally felt respecting your health, for you express'd yourself more

vaguely in your Letter than in your quotation, as in the former nothing

was said about your having taken a Cold, but that you were unwell; so I

was left to guess at the nature of your indisposition. I trust you have

attended to my suggestions with regard to the Wine, & that you have

only sent for a sufficiency for present use. You will be coming home ere

long & we can talk more about the poisonous business when we meet. You

know my fixt & unalterable opinion of wine, as far as regards its deleterious

effects on the human constitution. . . .

Yr. affectionate Father

Edw*^ Jenner.

A picturesque letter in which he anticipates animal experimenta-
tion in physiology:

Berkeley 31 August 1816.
Doctor Charles Parry, M.D.^*
Gay Street, Bath.
My dear Charles: . . . with regard to Pathology.
The impression at present on my mind is that somehow or another
the milk of the mother is capable of receiving impregnations which affect
" From Dr. Jacobs* collection. '^ Ibid. " Ibid.

EDWARD JENNER, A STUDENT OF MEDICINE 753

the child. We have not yet made out all the odd things going forward in
the animal economy. Tell me how it comes to pass that if I drink a glass
of good cider my urine smells as fragrant as the bottle when just uncorked?
I don't give this as a parallel case but as a puzzle. There must be a short
cut from the stomach to the Bladder. Shall we ask Riddle about these
things? What if we were to fill the Stomach of a Puppy with Mercury first
tying up the Intestine and then give it a good squeeze? . . .

Ever yrs.

my dear F-*^

Edw^ Jenner.

This interesting letter to his friend, Dr. Parry, is quoted in full
as the finale to this paper. The freshness of mind and spirit is de-
lightful, despite his more than sixty-seven years; note, too, his
wisdom in prescribing diet to the new-born babe — anticipating
completely the modern modified milk treatment — and again recur-
ring to his doctrine that the stomach is the key to health. Note, too,
his search for truth and his rejection of terms inexpressive of true
processes, his realization of the youthfulness of scientific research,
and the great fields which yet lay ahead for investigation.

'Tis at once the letter of the young enthusiast and the resigned
expression of one who reahzes fully that his day is over, and is con-
tent to await the future whatever it may bring — with complete
Aequinimitas.

Chauntry Cottage, Berkeley, Oct. 15, 1816.
Dr. Charles Parry,^'^

Gay Street, Bath,
My dear Charles: I am happy in wTiting to you, & making /or me,
rather a quick reply to your last letter. The beauty of my God-daughter
must be secur'd at all points & I have sent her the enclos'd little present
to guard her from the spells of the Fiend that takes delight in spoiling
Ladys faces. Mr. Norman had better use the points on the arms of some
Cottage children, and having produc'd a Pustule (vesicle if it must be so)
to vaccinate from that. I mention this because the Lymph fresh from the
arm is more certain than when inspissated, even (as per experiment) tho*
It has not been dried five minutes. Emma I think had but one Pustule,
which I fancy went thro' its course undisturb'd — However, it w . do the
Lady no harm to test her from her sister's arm. The matter sent is fresh
" From Dr. Jacobs* collection.

754 EDWARD JENNER, A STUDENT OF MEDICINE

from as fine a Pustule, as ever was call'd up by Vaccine Lancet. Some
Dolts, Walker of Oxford and Shinlake of Taunton have lately been writing
some alarming stuff in the Yellow Journal declaring thro' thick and thin
that all the V. matter now in use is worn out by being work'd so long.
Pretty analogy this — "the world is young." Now the fact is, that this par
nobile had got some that was ruined from contamination by some individual
whose skin (from disease) was incapable of producing that which was
correct. This sort of decompos'd rubbish, I am sorry to say, gets into the
hands of the ignorant and produces local disgrace. "The world is in its
infancy."

The question is, respecting the stomach in the nursery, whether that
is in fault, or whether Mrs. Parrys milk is in a state fit to meet its powers
of digestion? I should think the latter, & to put the thing to issue, I w*|
have you give the little one a meal or two, from a new milk-pail. The
substitutes for milk I believe are all bad. The best deviation I have found
from the maternal milk is that of the ass — the next is the Cows diluted
with one third part of water, with a very small portion of sugar. But not
unfrequently the process of Vaccination acts like a charm in correcting
deviation in the absorbent system, & you know it is a doctrine in my
school, that the Stomach is the first — the root, the foundation, the governor
of the whole family. Away with the term Scrofula — Let us have something
expressive of morbid action, or disease of the Lymphatics. You know how
long I have been an Hydatid-Hunter & tho' Time has brought me to a
hobble, yet I scramble after my Game as hard as I can. And what do you
think? I seem to see him now popping out of a Lymphatic, A speck, or
specks (small hydatids) appear where a like portion of the Lymphatic
is lost. "The world's a Baby."

I don't take in the Institution Journal, but both the others. I must
see this paper on the Metals, because you say 'tis good. How goes on
Geology? I think I have made out something about the pebbles in our
Basaltic-amygdaloid Rock. I wish you would look at your Oolite thro' a
good magnifyer. I find — (stop — I fancy so) they are made up of con-
centric layers; the first crystaliz'd on a small atom, a fragment of stone.
You really should see, with a geological eye, the Country around this
place — the diversity it presents would delight you, and if my good old
Friend in the Circus would but accompany you, then after a day's
hunt we w . sing old Rose & burn the Bellows. I really want to sing a

swan-like ditty to him before 1 want too, to write to him; but

when I think of setting about it my head seems so full, I know not how,
and so it is put off until to morrow, to morrow & to morrow.

EDWARD JENNER, A STUDENT OF MEDICINE 755

"The world's a Fcetus." Adieu my dear Charles — Bob & Catherine desire
their best affections with myself to you, Mrs. Parry & the accomplished
Miss Emma.

Most truly yrs

Edw'^. Jenner.
P.S.

No Cheltenham for me, this
winter.

THE INFLUENCE OF OSLER ON AMERICAN
MEDICINE

By George M. Kober, M.D., LL.D., Washington, D. C.

DR. OSLER has passed his seventieth goal post. Sincere per-
sonal appreciation of the master work of this chieftain in the
art and science of medicine, gratitude for the kindly inspira-
tions experienced through his influence, and the sanguine hope that
his fair example may stimulate the younger generation to emulate
his noble achievements have prompted the writer to lay the wreath
of tribute at the feet of this most deserving of septuagenarians.

Early Lije and Student Days. Sir William Osier was born at
Broad Head, Ontario, July 12, 1849, ^^^ son of F. L. Osier, a clergy-
man of the Church of England. His were not only rare physical
and mental characteristics through parental inheritance, but, as
told him by his old and true friend, Dr. Jacobi, at the farewell
banquet tendered to him on May 2, 1905, "It is no mean felicity
to be born with the imprint of virtue."

Those familiar with the portrait of Osier as a schoolboy at
Trinity College, and those fortunate enough to have been personally
associated with him in later years, have read in that face innate
qualities which not only endeared him to his friends, but, in the
estimate of his dear old mother, "were more precious than all his
honors."

Osier's earliest school life was passed in the school of his native
village, following which he went to Port Hope for a term or two in
Trinity College School of that place, and later still he entered
Trinity University at Toronto. Devoted to his books during hours
of class, he enjoyed his play with the "playful child let loose from
school." Robust of health, his mind matured with equal pace.

On quitting Trinity College young Osier entered the office of
Dr. Bovell at Toronto as assistant, and there he inaugurated his
medical studies, later matriculating in the School of Medicine of
McGill University, Montreal, graduating in 1872.

756

INFLUENCE OF OSLER ON AMERICAN MEDICINE 757

We learn from his classmate, Professor F. J. Shepherd, that
while a conscientious worker, Osier never passed for "a grinder."
He was not particularly known for his devotion to books, nor were
his efforts entirely focused towards success in examinations, but his
main attention was directed towards the post-mortem room and to
all hospital work within reach. He was beloved because of his social
qualities, kindliness of disposition, and characteristic sense of hu-
mor. Dr. Shepherd remarks:

"While he did not graduate very high in his class, there is a note in
the convocation that a special prize was awarded for his graduation
thesis, because of the originality it displayed and the research it evinced,
and because of the collection of pathological specimens accompanying
it which were presented to the museum. In the hght of his after studies, it
is interesting to note that some of these specimens, still in the college
museum, concerned the ulcers of typhoid fever. "

As a student, Osier was deeply interested in comparative pathology,
and as teacher in subsequent years often illustrated a point in human
disease by a reference to a parallel condition in the lower animals.

How carefully he prepared himself for the practice of medicine
and the professor's chair is evinced in the fact that following his
graduation he spent two years abroad in study in the laboratory of
the physiologist, Burdon-Sanderson, and attending the clinics of
Jenner and Wilson Fox, Ringer and Bastian in medicine and the
dermatological clinics of Tilbury Fox. In 1873 he took the degree
of licentiate of the Royal College of Physicians in London. There-
upon he went to Berlin, where he studied pathology under Virchow,
physiological chemistry under Salkowsky, and clinical medicine
under Frerichs and Traube. In the early part of 1874 he continued
his studies in Vienna under Bamberger, Hebra, and other noted
clinicians.

Teacher at McGill University. Upon his return to Montreal in
1874 he was appointed, at the early age of twenty-five, professor
of the institutes of medicine at the McGill University, which in-
cluded the course of physiology and a series of twenty lectures on
pathology. In 1875-76 instruction in histology and demonstrations
in physiology were added to his work, and the following year a
summer course in pathological histology. Dr. Osier served from

758 INFLUENCE OF OSLER ON AMERICAN MEDICINE

1874-75 as Physician to the Smallpox Hospital of Montreal, and it
is chronicled that he sacrificed his salary for the purchase of micro-
scopes for his department at the University. Osier himself has said
that a man should come into internal medicine by one of three ways
— physiological chemistry, physiology, or morbid anatomy. He made
himself proficient in all three of these branches, especially in pa-
thology.

In the winter of 1875-76 his autopsy work began at the Mon-
treal General Hospital, and continued for eight years with 1000
autopsies to his credit. In 1878 he was appointed physician to this
hospital, and there began his career as a brilliant chnical teacher.
A man with such firm scientific foundations, a comprehensive
knowledge of the subject presented by him, and his personal mag-
netism, could not fail to command the respect and esteem of his
students and professional colleagues. He not only awakened interest
and enthusiasm in modern scientific medicine among his hearers,
but also among the members of the medical societies. Even before
the completion of his thirtieth year he figured as a leader, and his
influence was felt not only in Canada and the States, but merited
for him later the appointment of Regius professor of Oxford Uni-
versity. Osier's recollections of his early teaching career are charm-
ingly and modestly set forth in an address delivered at the opening
of the session of that school, September 21, 1899, twenty-five years
after the faculty, as he declared, "with some hardihood selected a
young and untried man to deliver lectures in the Institutes of
Medicine."

"My first appearance before the class filled me with tremulous uneasi-
ness and an overwhelming sense of embarrassment. I shall not forget the
nice consideration of my colleagues and the friendly greetings of the boys,
which calmed my fluttering heart. One permanent impression abides —
the awful task of the preparation of about 100 lectures. After the ten or
twelve with which I started had been exhausted, I was on the treadmill
for the remainder of the session. False pride forbade the reading of the
excellent lectures of my predecessor, Dr. Drake, which with his wonted
goodness of heart, he had offered. I reached January in an exhausted con-
dition, but relief was at hand. One day the post brought a brand new book
on physiology by a well-known German professor, and it was remarkable
with what rapidity my labors of the last half of the session were lightened.

NFLUENCE OF OSLER ON AMERICAN MEDICINE 759

AlII extraordinary improvement in the lectures was noticed, the students
jenefited, and I gained rapidly in the facility with which I could quote
the translated German. Four years later I was appointed on the visiting
staff of the Montreal General Hospital. What better fortune could a
young man desire? I left the same day for London with my dear old
friend, George Ross, and the happy days we spent together working at
clinical medicine did much to wean me from my first love. From that date I
paid more attention to pathology and practical medicine and added to my
courses, one in morbid anatomy, another in pathological histology, and
a summer class in clinical medicine. I had become a plurist of the most
abandoned sort, and by the end of two years it was difficult to say what
I did profess, and I felt like the man to whom Plato applies the words

of the poet:

'Full many a thing he knew
But knew them only badly.'

"Weakened in this way, I could not resist when temptation came
from pastures new in the fresh and narrower field of clinical medicine.
After ten years of hard work I left Montreal a rich man — rich in the
treasures of friendship and good fellowship, and those treasures of widened
experience and a fuller knowledge of men and manners which contact with
the bright minds in the profession necessarily entails. My heart, or a
good bit of it at least, has stayed with these treasures. "

University oj Pennsylvania. In the summer of 1884 Osier received
a call from the University of Pennsylvania. When the invitation
to present himself as a candidate for the position of professor of
clinical medicine at Philadelphia reached him at Leipzig, Dr. Osier
told us he was inclined to believe it a joke. Nor was he disabused
of this notion until two weeks later a cablegram reached him to
meet Dr. Weir Mitchell in London. He added with his characteristic
humor, "Boston measures men by brains, it is said, New York by
*baw-bees,' and Philadelphia by breeding." It was Mitchell's task
to test his breeding. He did so by having him eat cherry pie, and
noting how he disposed of the stones. As Osier disposed of them
discreetly, the breeding question was settled.

In 1884 Osier was elected to the Fellowship of the Royal Col-
lege of Physicians of London, and in 1885 was also chosen from
the newly elected fellows of the College to deliver the "Gulstonian
Lectures," a singular honor which he most efficiently discharged,
selecting for his subject, "Malignant Endocarditis." His lectures

76o INFLUENCE OF OSLER ON AMERICAN MEDICINE

were based on his studies and material available in Montreal. Nc
wonder that a man so highly honored by the Royal College had becL
chosen the year before to become an associate of Leidy, Pepper,
Stille, and other leading lights. Osier's advent in Philadelphia
marked a turning point in the methods of teaching medicine, not
only in Philadelphia, but in the States.

In Philadelphia, as in Montreal, as was well said by his friend,
Dr. James G. Wilson, he inspired his students with a craving for
knowledge based upon facts of the ward, of the microscope, of the
laboratory, of the post-mortem room, and also stimulated their in-
terest in medical Hterature. He demonstrated how medicine should
be learned and taught.

He also insisted with the younger generation, by precept and
example, that it is not necessary for every physician to be a prac-
titioner in the ordinary sense, but that long years of hospital and
laboratory work constitute a better equipment for the teacher and
consultant.

Johns Hopkins Medical School. In 1889, at the age of forty,
Osier was invited to Baltimore to take charge of the Medical
Clinic of the Johns Hopkins Hospital. From this time on dates
clearly his greatest activity and usefulness in professional work.

Professor William H. Welch advises us that, when Dr. Osier
came to Baltimore, the main intention of the faculty was that
the hospital should form an integral part of the medical school,
and that opportunities should be afforded for higher clinical train-
ing. It accordingly seemed expedient that students should be
made part of the hospital machinery, and to Osier is due the credit
of working out the details of the scheme. This, indeed, represents
his contribution to medical teaching in America.

Influence on Higher Medical Education. Over forty published
essays and addresses bearing upon medical education and medi-
cal history are sufficient warrant of Osier's keen interest in this
subject.

He was ever a staunch advocate of higher pre-medical education
requirements, extension of the period of professional study and the
substitution of laboratory instruction for didactic teaching. In
his "Essay on the Need of Radical Reforms in the Methods of
Teaching Senior Students" he advises teachers "to give to students

INFLUENCE OF OSLER ON AMERICAN MEDICINE 761

an education of such a character that they can become sensible
practitioners. "

Dr. Osier was convinced that it is the duty of a medical school
to see that the senior student "begins his studies with the patient,
continues them with the patient, ends them with the patient,
using books and lectures as tools, means to an end. " He persistently
maintained that the ideal hospital is one connected with a medical
school, with the professors members of the attending staff. In this
connection he writes:

"The work of an institution in which there is no teaching is rarely
first class. It is, I think, safe to say that in a hospital with students in the
wards the patients are more carefully looked after, their diseases are more
fully studied, and fewer mistakes are made."

Osier's methods of teaching clinical medicine fitted in admirably
with the general policy of the Faculty that the students should be
made a part of the machinery of the hospital. As a result the
clinical unit was maintained in the fourth year as taught by him,
but the work transferred from the out-patient department to the
wards. In Osier's judgment

" Each man should be allowed to serve for at least half of the session
in the medical wards and half in the surgical wards. He should be assigned
four or five beds, and under the supervision of the house physician, he
does all the work in connection with his own patients. One or two of the
clinical units are taken around the wards three or four times a week by
one of the teachers for a couple of hours, the cases commented upon, the
students asked questions, and the group made familiar with the progress
of the cases. In this way the student gets a familiarity with disease, a
practical knowledge of clinical medicine, and a practical knowledge of how
to treat disease. "

Though Dr. Osier disclaims any credit for his teaching method,
it is nevertheless unquestionable that, had it not been for his won-
derful personality, enthusiastic and effective leadership, American
medical education might still be fifty years in arrears of that of
Europe. It required a man of his broad vision, sound judgment,
a devotee to his profession, and a statesman in medicine to make
converts to the cause of his revolutionary ideals.

762 INFLUENCE OF OSLER ON AMERICAN MEDICINE

Dr. Osier has always felt justly proud of his connection with the
organization of the medical Clinic of the Johns Hopkins Hospital
and the introduction of the old-fashioned methods of practical
instruction, and regards this, "as by far the most useful and im-
portant work he has been called upon to do. " We who are familiar
with the beneficent effects of his individual influence upon his
students know that he never failed to do his best work and to keep
far afield in every department of medicine, but over and above
all this and his breadth of culture and broadminded attitude
towards medical problems, he possessed attributes which are rarely
found associated in any other single individual.

His was the power of encouraging and inspiring, of firing in the
youthful heart an enthusiasm for a chosen life work. The scenes
enacted with his students in the out-patient department are
fondly recalled. There he stood, surrounded by his boys, lending
them friendly advice in some puzzling case. With his arms thrown
about their shoulders, through friendly inquiry, marked with oc-
casional humorous interspersions, he guided them on to a satis-
factory solution of every difficult problem. Exact always, but never
dogmatic, he could not but be always loved, always revered.

We feel that we would be omitting an important page in the
story of Osier's activities were we to pass over in silence those
homely Saturday evening gatherings, held at the table round in his
magnificent library, or those charming essays on medical history,
which Sudhoff estimated "to contain more of the historical spirit
than many learned works of the professional historian."

These gatherings also enabled him to familiarize himself with
the individuality of each student, and in his charming way to off"er
timely and valuable suggestions as to how to solve certain intel-
lectual and moral problems. Johns Hopkins Medical School has
become known as the mother of medical teachers, and since 213
of the 483 graduates prior to 1907 were also his pupils, are or have
been connected with our medical schools, it is easy to infer the extent
of his beneficent influence.

Dr. Osier realizing, as every master mind necessarilj"^ must, the
value of example, ever inculcated on his student body esteem for
the general practitioner and old-style country doctor. Most of his
pupils will cherish gratefully the words addressed to them:

INFLUENCE OF OSLER ON AMERICAN MEDICINE 763

"Many of you have been influenced in your choice of a profession by
the example and friendship for the old family doctor or of some country
practitioner in whom you have recognized the highest type of mankind,
and whose unique position in the community has filled you with laudable
ambition. You will do well to make such a man your example, and I would
urge you to start with no higher ambition than to join the noble
band of general practitioners. They form the very sinews of the profes-
sion— generous-hearted men, with well-balanced, cool heads, not scientific
always, but learned in the wisdom of the sick room, if not in the
laboratories. "

Osier was deeply interested in the progress of American Medicine,
and proud of its achievements, as shown in his address delivered
at the opening of the Museum of the Medical Graduates College
and Polyclinic in London on July 4, 1900, in which he pointed out
the silent revolution which had taken place in medical education,
and especially in the cultivation of the scientific branches, hospital
equipment, and clinical facilities.

"The most hopeful feature is a restless discontent which, let us hope,
may not be allayed until the revolution is complete in all respects. Mean-
time, to students who wish to have the best that the world offers, let me
suggest that the lines of intellectual progress are veering strongly to the
West, and I predict that in the twentieth century the young English

physician will find his keenest inspiration in the land of the setting

>»

sun.

It is quite natural that a man with such high hopes and aspira-
tions would strongly resent any interference with the legitimate
and humane methods employed for the advancement of scientific
medicine. I shall never forget the expression of scorn in his eyes and
the words with which he rebuked the enemies of scientific progress,
who had been heard before the U. S. Senate Committee on a bill
for the further prevention of cruelty to animals.

"The blood just surged in my veins, sir, when I heard two men address
you to-day who said things which they should have been ashamed to say
of the medical profession, of men who daily give their fives for their fellows.
. . . With reference to men who train with these enemies of the pro-
fession, I say this, that I scorn them from my heart. "^

* See "Hearing on Vivisection," February 21, 1900, Government Printing Office,
Washington. The Bill failed in the Committee and no serious attempt has been made
to enact what Osier characterized as "a piece of unnecessary legislation."

764 INFLUENCE OF OSLER ON AMERICAN MEDICINE

Influence on the Profession at Large. The many invitations
extended and accepted by Dr. Osier to address medical societies
attest the savory widespread influence his career wielded over the
medical community at home and abroad. His text, "Principles and
Practice of Medicine," graces the bookshelves of well-nigh every
English-speaking physician the world over.

The medical societies, the efficient vehicle, as he took it, for the
dissemination of scholarship, ever received his heartiest encourage-
ment. Accordingly, we find him either enrolled as an active member
of these societies or fostering their foundation because, as he said
to the members and friends on the occasion of the centennial
celebration of the New Haven Medical Association, January 6, 1903,
"The Society is a school in which the scholars teach each other,
and there is no better way than by the demonstration of the more
unusual cases that happen to fall in your way." Through these
societies he awakened interest in post-mortem work, the presentation
of pathological specimens, and in hbrary equipment. Through them,
also, he emphasized what a well-equipped and properly manned
hospital in every town of 50,000 inhabitants could effect towards
the advancement of clinical medicine. Through them he felt that
America would accompHsh more for chnical medicine in five years
than Germany could in ten.

Osier was one of the most active founders of the Association of
American Physicians, organized at a meeting held in the office of
Dr. Francis Delafield, New York City, October 10, 1885. Others
present at this time were Drs. Wm. H. Draper, Wm. Pepper, James
Tyson, George L. Peabody, and Robert T. Edes.

The first scientific meeting of the Association was convened
in Washington, June 17, 1886, and from that meeting until his
departure for Oxford he was recorded absent from the meetings
but twice. Even after his departure, he attended several meetings
and was elected an honorary member in 19 12. In 1894 he was
elected President of the Association, and in his address delivered
May 30, 1895, he spoke in part as follows:

"At the opening of our Tenth Meeting the question is timely — How
far has the Association fulfilled the object it had in view? Have our
aspirations and hopes of 1885 been realized? We sought, as stated in
Article I of our Constitution, the advancement of scientific and practical

INFLUENCE OF OSLER ON AMERICAN MEDICINE 765

medicine. With this primary object we sought also, as Dr. Delafield said
in his opening remarks, 'An Association in which there will be no medical
politics, and no medical ethics; an Association in which no one will care
who are the officers and who are not, in which we will not ask from which
part of the country a man comes, but whether he had done good work,

and will do more, whether he has anything to say worth saying and can

• . > >>

say It.

Osier believed that the nine volumes of the Transactions offered
a full and satisfactory answer to the first question, and referred to
them as "the repository of very much that is best in American
medical literature." He emphasized the widespread and effective
interest which the papers of Dr. Fitz on Appendicitis and of Dr.
F. M. Draper on Pancreatic Hemorrhage had produced, and suc-
cinctly reviewed some of the topics presented for discussion, such
as typhoid fever, the parasites of malaria, tuberculosis, diseases of
the gastric intestinal tract, diseases of the heart, blood, blood ves-
sels, kidneys, etc. He boldly stated that several papers had been
presented which indicated that the readers had failed to grasp the
scope of the Association. He declared that the Association had
already shown a powerful influence on the study of pathological
and clinical medicine in this country, that there was at present an
actual scarcity of trained pathologists and bacteriologists and a
distinct need of well-trained special clinical physicians, and of such
physicians and of pathologists and bacteriologists should the Asso-
ciation in greater part be composed.

He referred to the limited membership, and with characteristic
frankness declared, "We should all understand that this is a working
society, and when any one of us ceases to attend regularly, or when
our interest grows lukewarm, we will promote best the common
welfare by quickly retiring."^

Osier was a member of the Council of the Association for a
number of years, and exercised a strict but just censorship over the
admission of members; he was doubtless the most active worker
in that body, as shown by ten original contributions and his discus-

* The membership of the association in 1886 was limited to 100, which was increased
in 1897 to 125, in 1904 to 135 active and 25 associate members, and further increased
in 19 1 2 to 160 active and 25 associate members. Active members after ten years'
service may be transferred to the list of emeritus members. Honorary membership
is limited to 25.

766 INFLUENCE OF OSLER ON AMERICAN MEDICINE

sion of sixty-four papers presented by other members. He was as
popular as a teacher among his colleagues in the Association as with
his classes in the medical school. The young and the old were at-
tracted, inspired, and improved, and men hke Jacobi and others
much older than he had told him that they were glad to sit at his
feet and listen to him. Since the majority of these men were occupy-
ing professorial chairs, the sphere of his influence has been greatly
widened. He was also an enthusiastic founder of the National Asso-
ciation for the Study and Prevention of Tuberculosis in 1904, and
has been the Honorary Vice President ever since 1905.

When Osier, well-nigh fifty years ago, stood upon the threshold
of his professional life, he stood there convinced of the dignity and
responsibilities of his lofty vocation. He stood there convinced that
if his name were to be dug deep in the marble walls of the hall of
fame, it had to be dug therein with the chisels of study, honesty,
and truth. He has now lived a hfetime of Hfe and lived it well. He
has lived a lifetime of study, as evinced by over 240 contributions
to medical literature. He has lived a lifetime of service to his fellow
man, to which bear witness his contributions to preventive medi-
cine, his active participation in the eradication of preventable
disease, his kindly ministrations to the sick poor. He has lived a
lifetime which has been an honor to his profession and a glory to
his professional brethren — a hfetime which has been rewarded with
every honor and trust at home and abroad which the medical com-
munity could possibly bestow upon him. He has hved a Hfetime of
service, and during this Hfetime he has tempered tenderness with
firmness, condescension with authority. His only protest against
cares was silence. Dignity met his responsibiHties, equanimity his
successes and griefs, sufferings and disappointments. And as our
congratulations go out to him there foUows the sincere hope that his
days of activity and bHss may stiU be many to complement this
lifetime that shall know no death.

SERVETUS NOTES
By Leonard L. Mackall, New York

WRITERS on Servetus, almost without exception, seem to
be pursued by some singular fatality leading to bib-
liographical inaccuracy — the most learned become il-
logical, and even professional bibliographers hke van der Linde
become careless for the occasion. Hence I hope that the following
informal notes, ^ as being based entirely on study of the rare original
documents and accepting nothing on mere hearsay, will prove of
value by correcting and supplementing various statements still
current.

The Portrait of Servetus. There is much uncertainty about por-
traits of Servetus. WilHs's preface states expressly that the portrait
prefixed to his book was concocted by the author's daughter, yet
it was selected for reproduction by Odhner, 1910. Bernigeroth's
engraving in Mosheim, 1748, is crude, so that Sterhng ("Some
Apostles of Physiology," 1902), Osler,^ and Garrison naturally
preferred Fritzsch's frontispiece in Allwoerden's "Historia," 1728
(not 1727, cf. Mosheim's letter, 1728, at end of most copies), which
is re-engraved anonymously in the Dutch version of 1729. AII-
woerden explains (p. I32f.):

"Imago haec eius satis accurate expressa est ex antique & nitide picto
apX^TUTTCO, quod probabile est ahquem ex Serveti amicis fieri curasse,
cum in custodia detineretur," ^

and that the original painting had belonged successively to Joh.
Crellius, Count Schwerin, Stenger, Teuber (Bishop of Halberstadt)

^ They have now become mere notes on notes! Though written solely for this
volume in honor of Sir William Osier, I have since abridged the MS. very materially
in order to make room for other contributors. However, I hope to print it later in full,
perhaps in the Annals of Medical History; and hence should greatly appreciate any
corrections or additions for such future use.

* Sir William Osier's "Servetus," Oxford, 1909, now out of print, but reprinted the
same year in the Johns Hopkins Hospital Bulletin for January, 1910; also translated
into German in the Deutsche Revue for December, 1909, but without the illustra-
tions, which had, however, been retained in the Bulletin, and reappear in Hemmeter's
interesting paper in Janus, 1915, from the original blocks, though differently combined.

767

768 SERVETUS NOTES

and then to Peter Ad. Boysen (author of the "Historia M. Serveti,"
Wittenbergae, 17 12) who lent it to Mosheim. Allwoerden quotes a
long letter from Boysen on the subject. That painting seems now
permanently lost, and Fritzsch's print is only less crude than that of
Bernigeroth. But Allwoerden, who had perhaps seen the original as
well as heard about it from Mosheim, fortunately gives us his opin-
ion of the previous engravings thus:

"Ceterum duplex alia Serveti imago nobis occurit acre satis eleganter
expressa. Altera in minori folio formae circiter octavae descripta erat:
Sed exempio, quod nobis videre hcuit, nee chalcographi nomen, nee aliud
quid adiectum erat. Alteram vero Christophorus de Sichem in patente
charta Amstelodami, adiuncta Serveti historia aut potius accusatione, anno
1607 expressit." (p. 133, cf. Mosheim, p. 24 if.)

The admirable article on Servetus in the new Encyclopaedia
Britannica by the Rev. Alex. Gordon, who has made exhaustive
researches into everything connected with the subject, states: "The
only hkeness of Servetus is a small copperplate by C. Sichem, 1607
(often reproduced)," and so he neatly reproduced this small head
in an oval as frontispieces in his privately printed "Personahty of
Servetus" (Manchester, 191 0, cf. the crude drawing in Cuthbertson,
p. $2) from the British Museum copy of the "Grouwelen der
vornaemster Hooft-Ketteren," Leyden, 1607.^ This Httle Dutch
book, consisting of short notices and portraits of select heretics, was
reprinted several times, in various languages. So much for the small
head.

The Uffenbach-Tronchin copy of the larger engraving (extending
to the waist) examined by Allwoerden (who reprints the Dutch
text below it) and Chauffepie (Nouv. Diet. Hist. IV, 227, cf. Yair's
Enghsh translation of this Life, 1771) seems to have disappeared
entirely. The Geneva Library and Tronchin's family know nothing
of it. But the British Museum and I have the " Iconica et historica

' Some copies at least of the 1607 "Grouwelen" have only eight portraits, but the
German version (Leyden, 1608) has seventeen, and so has the Latin "Apocalypsis
insignium aliquot Hseresiarcharum" by "H.S.F.D.M.D." (Leyden, 1608), and the
very similar "Speculum Anabaptisti Furoris" (Leyden, 1608). The English translation
by John Davies, "Apocalypsis: or the Revelation of certain notorious Advancers of
Heresie," was first issued as appended to the second edition (1655) of the "Pan-
sebeia, or, a View of all Religions of the World," by that polemical ubique Alex. Ross
(who had even ventured to attack the Religio Medici in his "Medicus Medicatus,"
1645). Both the Dutch and English versions were reprinted several times, in cruder
form.

\ ...

( OHFER-PI ATF EnGKAXINCV OF Sf.RVFTI'S. Bv C VAN SiCIIFM (l6()-).

From Copy in I lit- Surgeon General's I ilirarw Washington

SERVETUS NOTES 769

descriptio prsecipuorum hseresiarcharum per C. V. S. [i.e., Chris-
tofFel van Sichem] Arnheim, 1609," and I am fortunately able to
reproduce here an impression'* with German text in the Surgeon
General's Library, van Kaathoven Collection (cf. Index Cat. Ill,
289, First Series). No doubt it was taken from the "Historische
Beschreibung und Abbildung der fiirnehmbsten Haupt-Ketzer.
Durch C.V.S.A. zu Amsterdam, bey Niclauss, Buchhandler, 1608."
The plate itself is the same as in the Latin edition, and doubtless
the 1607 Dutch one also (cf. Nagler XVI, 346). It corresponds
closely to Allwoerden's frontispiece and evidently the small head of
the "Grouwelen," etc., was merely taken out of this careful engrav-
ing, which is thus our best substitute for the lost original painting
from which it was made. There is no reason why we should not,
with Menendez y Pelayo ("Hist, de los Heterodoxos Espaholes,"
II, 312, 1880), consider this portrait as at least "probablemente
autentico."

The First Two Publications of Servetus. The genuine original
editions of the 1531 and 1532 volumes on the Trinity (printed by
Johann Setzer in Hagenau near Strassburg) have for centuries
been so extremely rare that it is not surprising that Osier, Cuth-
bertson, and Hemmeter give an illustration of a counterfeit instead.
Fortunately I own the genuine Girardot de Prefond-MacCarthy-
Bohn-Thorold copy of both bound together in red morocco, bought
by the elder Quaritch personally at the Syston Park sale in 1884.
Nodier's well-known story, "Le Bibliomane" (Paris, ou le Livre
des Cent-et-un, I, 183 1), expressly mentions this very copy as sold
in the MacCarthy auction (181 7), but carelessly assumes its
identity with the Hoym-La Valhere copy. There can be no possible
doubt as to its authenticity, and both title-pages are now repro-
duced in the exact size of the originals.

There has long been great confusion as to the spurious counter-
feits of these two books. The counterfeits have a single ordinary
hyphen in the words TRINI-TATIS and DIALOGO-RUM on the
titles, instead of the two diagonals of the originals now illustrated.

* The heading, "Michael Servetus, ein Spangiard," has been cut from the upper
margin. Cf. J. K. F. Knaake — auction cat. Ill, No. 975 (21-23 Febr., 1907, Osw.
Weigel, Leipzig) and Hiersemann's cat. 346, No. 1378.

On account of its size, the text ("Michael Servetus . . . Gott wolle Richter
sein." 24 lines) and ornamental border are not reproduced in the present volume,
but they will be included if these Notes are printed in full.

770

SERVETUS NOTES

DeBure's Bibl. Instr. I, 1763, is the only direct authority for any
edition of either book with two horizontal hnes instead of one, and

he does not even mention
any edition with only one;
so that it is quite safe to
disregard his statement as
being merely inaccurate.
There seems no reason to
doubt that the usual
counterfeit with the mis-
print: CHHRSTUM, on
p. 8^b (first noted by
Ebert, then Graesse; not
mentioned in Brunet) of

DE TRINI

TATIS ERRORIBVS
LIBRI SEPTEM*

Per lAkhaekm ScruetOt4his
'B<eucs ah Aragoni4

the 153 1 book was made
for the Rev. Georg Serpi-
hus ( 1 668-1 723), a promi-
nent clergyman and
learned hymnologistof Re-
gensburg (about 1721?).
The 1532 book was evi-
dently reprinted at the
same time. The printed
catalogue of the hbrary of
Serpilius includes copies
of '*zw€yerley editiones"
of both these books, and
also of the very rare 1607
Roman Index, which he
hkewise counterfeited, ° ex-
patiating on its rarity in
his "S. S. Verzeichniiss
einiger Rarer Biicher," I
Stiick, Frankfort and
Leipzig, 1723, pp. 52-72. This is certainly very significant, and we
may well believe that he gradually sold the counterfeits as genuine

B Copies of the Index were advertised as still for sale in the Gdttingiscbe Zeitungen von
gelebrten Sacben for August 29, 1743, p. 614.

DIALOGO

RVM DE TRINITATB
LIBRI OVO*

SB IVSTICIA REGNI CHRl.
fiifCapituld Qtuituor*

PER MICHAELEM SERVBTO,

4liAS KeueSfOb Arttgom

Hif^anum*

Anno M* D. XXXir.

Facsimile of title pages of genuine original edi-
tions of the first two publications of Servetus. From
the Girardot de Prefond-MacCarthy-Syston Park
copy, now in the possession of L. L. Mackall. To be
carefully distinguished from the spurious counter-
feits.

SERVETUS NOTES 771

(with the assistance of his son), especially in view of his suspicious
letter dated June 19, 1721, to Seelen (printed in the latter's "Selecta
Litteraria," Lubecse, 1726, p. 54) stating that he then had three
copies of both the 153 1 and 1532 volumes, which he had bought in
Poland, where he could still get more but at a high price !Cf. Mosheim
p. 309f. But in behalf of Serpilius I can state at least that he owned
also the "Religio Medici, Argent, 1665."

Deschamps and G. Brunet, in their Supplement to J. C. Brunet's
famous "Manuel," assure us that at the Morante sale (1872) a
copy of the 153 1 volume, not the original, was in its original binding,
dated 1573, and that there was a similar edition of the 1532 book,
both of which must, therefore, have been printed much earlier than
J. C. Brunet intimated. This statement has hitherto proved a
puzzle, to be solved only by reading in turn the various passages
involved; and this could not be done conveniently.

Thus it now appears that Brunet did not confirm DeBure's
inaccurate statement, or intimate that there was anything unusual
about the MacCarthy counterfeit. Though he occasionally refers
to Ebert, he never mentions the misprint CHHRSTUM (cf. above),
which may have been present in both the MacCarthy counterfeit
and the problematical Bearzi-Morante copy. The Bearzi and the
Spanish Morante catalogues both record the binding of this copy
as old, but neither mentions any date on it. The former describes
the book simply as a "contrefacon" (meaning doubtless the usual
one) and Morante himself states positively that the book was a
reprint made in Germany about the middle of the eighteenth cen-
tury. So we have a right to be skeptical as to the authenticity or
significance of the alleged date, 1573, in this case — especially as the
same authorities seem equally sure about the 1532 book. For this
very Bearzi-Morante copy of the 1532 volume is now in the Hispanic
Society of America, and on examination it proves to be merely the
usual counterfeit, such as is so often bound up with the CHHRS-
TUM reprint of the 1531 volume, as in the Bransby (Sotheby,
1828) — S. M. Jackson-Union Theological Seminary (New York),
Jefferson Medical College and numerous other copies. However,
the Hispanic Society owns also a different counterfeit^ of the same

* Both these Hispanic Society books were described briefly in the Knaake auction
catalogue (III, Nos. 971 and 972, February, 1907) and then in Hiersemann's catalogue
346, Nos. 1376 and 1377, 1907).

772 SERVETUS NOTES

book, and this one has not only a flower basket and no cupid in the
N on A2, but also a head in the lower half of the P on C6b, and
further (which seems not to have been noticed hitherto), the title-
page reads "IVSTITIA" instead of "IVSTICIA," though the
latter form occurs on C6b as usual. The type is shghtly different,
e.g., the T on the title-page, and the paper is whiter and stronger.
The fly-leaves bear notes in German referring to eighteenth-century
books, and the binding (apparently German "Pappband") seems
to belong to that period also. Some specialist in typography might
be able to date it more definitely. The ornamented initials on A2
and C6b are in both reprints of this book wholly diff"erent from those
in the original edition, though its use of abbreviations in the mar-
ginal notes is copied. The CHHRSTUM reprint of the 153 1 vol-
ume attempts to copy the initial I on a2 but prints out in full the
original abbreviations in the marginal notes. Probably there are
two reprints of this volume also.

The 1^46 Servetus Manuscript in Paris. It is universally admitted
that the earhest printed account of the pulmonary circulation of the
blood is that in Servetus's "Christianismi Restitutio," 1553, p.
i69f., but it is not so generally known that the passage occurs
already in the 1546 MS. (corresponding to Christ. Rest. bks.
III-VII of De Trinitate Div.) bought by the BibHotheque Nationale
at the great La Valliere sale in 1784 (lot 912, for 240 hvres). It had
previously belonged (going backward!) to Gaignat, Hoym, and du
Fay, and was described in the catalogues of their hbraries as well
as in De Bure's " Bibhographie Instructive" I, No. 757:1763 (cf.
Allwoerden, p. 191 f., and Mosheim, p. 458f.) Chereau'^ professed
utter ignorance of its whereabouts, though it had been listed by
Dehsle, and Gordon had already printed a careful collation in the
Theological Review for July, 1878, p. 4i7f. This MS. is not in the
handwriting of Servetus, but it is a copy of an earlier draft of the

^ Chereau strangely says {Bull, de I' Acad, de Med. de Paris, 1879, P- 795): "Nous
ne Savons par qui il a ete alors (La Vall., sale 1784) achete, ni dans quel cabinet il est
passe. Tollin assure V avoir vu . . . nous I'avons, nous, cherch^ en vain" —
but the MS. had been duly included in Delisle's standard official Inventory as: "MS.
Latin 18212. Mich. Servet, de Trinitate, XVI s. [iecle]. — La Vail." (Bibl. de I'ficole des
Chartes, XXXI, 546, 1871, for 1870). Previously it was known as MS. "Fonds La
Vall. 162," as cited by Tollin in Vircbow's Arcbiv, 1885, CI, 59, from old notes. Months
ago I ordered a photograph of the circulation passage in this MS., but war conditions
have hitherto delayed it.

SERVETUS NOTES 773

"Christlanismi Restitutio," corresponding to the pages in MS.
in the Edinburgh copy of the book.

The Paris Copy of the '* Christianismi Restitutio." Much has been
written about the famous BibHotheque Nationale copy of the
"Christianismi Restitutio" bearing the name and notes of CoIIadon,
yet its history is still partly obscure. It has suffered from both fire
and moisture in the opinion of A. Laboulbene (Revue Scientifique,
November 26, 1887), whose own books had been burned a few years
before, so that he knew whereof he spoke.

The book was secured at the La Valhere sale in 1764 (lot 913)
for 412 1 livres, due to the insistence of the Abbe Desaulneys,
Van Praet's predecessor as Keeper of Printed Books.

The Due de La Valhere had acquired this book at the Gaignat
sale in 1769 for 3800 hvres, Gaignat bought it from de Cotte, who
got it from the de Boze collection and de Boze received it from Dr.
Richard Mead, in whose house Chas. Et. Jordan saw it in 1733.
(Hist, d'un Voyage Litt., La Haye, 1735, p. i69f.) Mead still had
it in 1740, but no one seems to have noted that it is already included
in de Boze's own rare quarto catalogue, 1745.

The London Reprint of the '' Christianismi Restitutio" 172^. It is
usually assumed and simply stated as a fact that the unfinished
London reprint (1723) of the "Christianismi Restitutio," was made
for Mead from the original in his possession, but there seems to be
no contemporary authority whatever for this view, or any proof
that he owned the original before 1733, when Jordan saw it. Several
years ago I carefully examined such documents on the seizure of
the reprint as could be found in the London Pubhc Record Office,
but none of them referred to Mead even indirectly.

Mosheim (p. 372f.), who was greatly interested in the matter,
beheved that the actual printing was done by George Gallet (who
had worked for the Huguetans in Lyon, and then was active as
printer-pubHsher in Amsterdam) for Peter Palmer. I agree with
Murr that Mead probably got his copies of both original and re-
print after they had been unexpectedly seized by the London
authorities on May 29, 1723, and that, just before sending the
original to de Boze, he had had a transcript of the rest appended
to his copy of the unfinished reprint, now in the Bibliotheque
Nationale.

774 SERVETUS NOTES

The Vienna Copy of the " Christianismi Restitutio" and Murr*s
Reprint 17QO. Of the Vienna copies of the original and of Murr's
reprint only a word can be said here, though I have examined them
both myself. Perhaps it was the Prefect of the Imperial Library,
Gottfried Freiherr von Swieten (the musical son of the learned
editor of Boerhaave), who induced Count Samuel Teleki von
Szek ( 1 739-1 822) to present the original to the Emperor Joseph
II, in 1786, and probably he had already tried in vain to buy the
La Valhere copy in 1784.

Even Menendez y Pelayo and the Heredia catalogue (IV, No.
4106) state that Murr's reprint was made in 1791, but the very
small date at the foot of the last page of text reads: 1790, and this
correct date is twice given in Murr's own "Adnotationes," etc.
(1805, pp. 29, 63).

I have just been so fortunate as to discover in the Harvard
Library ("C. 1346. 10.2*") what is evidently the very transcript

* In fronte huius exempli ad dextram subscriptum legitur: Danielis Mdrkos
Szent-Ivdnyi Transylvano-Hungari. Londini i66s. die 13 Maii. Hocce exemplum idem
est, de quo Samuel Crellius in limine codicis MS. olim Preussiani meminit, apud loh.
Laur. Moshemium in hist. lat. Michaelis Serveti, pag. 204 [p. 181 of usual ed.], et in
germanice 1748 pag. 344. C, T. de Murr."'

used by Murr for his reprint. It is quarto size, bound in handsome
German calf with gilt edges, and a fly-leaf bears the inscriptions:
rectOy "Summa Venerando REINHARDO^ d.d.g. de Murr d. 9
Apr. 1808," and verso, "a. 1786 Biblioth. Caesareae illato*), e Vindo-
bonensi exempio, typis excuso A. 1553, in 8. secundum seriem
paginarum, exactissime descriptus est hicce liber nitidissimus, et
editus a possessore a. 1790 in 8 mai."

* "Reinhardo" was perhaps Franz Volkmar Reinhard (1753-1812), a learned and
influential theologian and prolific preacher then living in Dresden. Like the original
book this transcript consists of 734 pages and Errata; but there are usually twenty-six
or twenty-seven full lines to a page (besides the running title and catchword) as com-
pared with thirty-three in the original, and thirty-six in the reprint. The scribe, who-
ever he was, seems to have done his work very carefully, copying even the misprints
in the original, and using similar abbreviations, which are, however, expanded in the
reprint. Murr's printed list of Errata reproduces the list in the original edition without
even allowing for the fact that the number of lines to a page is different. There is one
exception: the Harvard MS. reads p. 3: res oTm, but this "omnium" was by mistake
omitted in printing, and so this correction in the Errata applies to the reprint only.
The anonymous reviewer in the Allg. Lit. Ztg., November 20, 1792, noted that Murr's
(p. 4, I. 3): verbo cognationem should be verbo generationem, as in his (?G6ttingen) tran-
script. The Harvard MS. reads, gnatione, which abbreviation may have puzzled the
printer. The MS. agrees with the reprint in reading (p. 67, I. 25) apKrj for apxv> which
the reviewer suggested might be a misprint in the original.

•The words "et editus ... 8 mai" and signature were evidently written
later than the rest, probably at the same time with the presentation inscription, 1808.

SERVETUS NOTES 775

C. G. von Murr, who Reprinted the " Christianismi Restitutio."
Christoph Gottlieb (Theophilus) von Murr (1733-1811) of Nurem-
berg was one of the last survivors of the now extinct species Poly-
bistor. Of very varied learning, he wrote learnedly on every imagin-
able subject, was familiar with all possible languages, and cor-
responded with learned men in many countries, including England.
He translated Fielding's "Voyage to Lisbon" into German (Altona,
1764, anon.) and Thos. Pennant's "British Zoology" into Latin.
His elaborately learned "Adnotationes ad Bibhothecas Hallerianas
Botanicam, Anatomicam, Chirurgicam et Medicinse Practicse cum
Variis ad Scripta Michaelis Serveti Pertinentibus" (Eriangen, 1805,
4to) contains even a tabular "Quadrupedum Sinicorum Dispositio,
methodo Linneanse accomodata. Auct. C. T. de Murr," printed in
Chinese characters!! But it must be added that his knowledge of
medicine was learned and antiquarian rather than practical; he
was not an M.D., and his own death is said to have been immedi-
ately caused by his clumsy use of a catheter on himself!

The writer who exerted the chief influence on Murr in his youth
was none other than our old friend Sir Thomas Browne! "Prseter
ahos paternse bibHothecae hbros maxime arrisit Murrio nostro,
tredecim turn annos nato, Thomae Brownii Pseudodoxia Epidemica,
quippe quae ipsius animum ita affeceret, ut sibi proponeret, omne
quod rehquum esset vita tempus impendere vero," the preface by
Joh. Ferd. Roth to the sale catalogue of Murr's books (Nuremberg,
181 1, with portrait) tells us, and its No. 5036 is: "Brown, Th.
Pseudodoxia Epidemica, d.i. Von den Irrthiimern des gemeinen
Mannes; a. d. Engl. u. Lat. durch Christian Peganium (Knorr von
Rosenroth) mit Figg. (Nbg.) 1680 Pd." (sic\) Murr visited London
in 1757 and again in 1761-62, and thus made the acquaintance of
Birch (who took him to the Royal Society and the Soc. of Anti-
quaries), Hill, Askew, Taylor, Parsons, Wm. Hunter, Swinton,
Glover, Garrick, Hogarth, and others, with several of whom he later
corresponded.

Murr was a bibliophile, and he was particularly interested in Ser-
vetus. In 1784 he published an elaborate bibliographical essay on the
"Christianismi Restitutio" in his Journal Zur Kunstgeschichte and a
"Gesch. d. ber. span. Arztes Michael Serveto, in welcher Calvins
schandhches Verfahren gegen denselben an Tag gelegt wird. Mit

776 SERVETUS NOTES

Urkunden und einer Kupfert. gr. 80." is listed among Murr's works,
then (1805) "theils unter der Presse, theils ... in Hs. zum Drucke
bereit," but it was apparently never printed. Attention was called
to Murr's Servetus collection in the second edition of his book on
Nuremberg, and the titles are given in the auction catalogue issued
in 181 1 after his death.

Murr's chief Servetus treasure is No. 5102, in the Catalogus:
"Magistri Guidonis de Cauliaco Inventarium s. CoIIectorium partis
chirurgicahs Medicinae s. Chirurgia. Lugd. 1537. Ldr. Titulus manu
restitutus. Hoc ex. ob Mich. Serveti manum quae ad calcem libri
conspicitur, a b. Poss. magni aestimatum." I have tried in vain to
trace this book.

Unknown Works by Servetus. The unique personal item just
mentioned leads naturally to works by Servetus hitherto introuvable
or entirely unknown. Mosheim at first categorically denied (1748,
P- 73» 34 0 t>ut later (1750, p. 34, cf. 27, after d'Artigny II, 103)
admitted the existence of the " In Leonardum Fuchsium Apologia.
Autore Michaele Villnovano, 1536," though he had noted that
J. G. Schenck's "Bibha latrica," 1609, p. 410, had given the title.
Haller's "Bibl. Med. Pract." II, 34, starred the title, thus indicating
that he himself owned a copy, but Murr ("Adnot." p. 6of.) made
elaborate efforts to trace it without result. WiHis (p. 103 n.) found
the title in the printed catalogue (III, 287 : 1870) of Dr. Wilhams's
Library, London, but the book itself could not then be found. It
has, however, since then turned up again. Gordon had it photo-
graphed in 1909, and he has located another copy elsewhere. Mean-
while ToIIin had discovered extracts from it in Seb. Montuus's
"Dialexeon MedicinaHum," Lugd. 1537, and reprinted them in
Rohlfs's Deutscbes Arcbv. /. Gescb. d. Medicin, 1884, VII, 409f.

Sudhoff (whom I met at the Leipzig Book Exhibition in 19 14)
kindly informed me that a wholly unknown work: "M. Villanouanus,
Epistolae. Lutetiae 1536," had recently come to light and then disap-
peared again in the stock of a bookseller in Leipzig. Let us hope
that he will find it and turn it over to Sudhoff".

Chronology oj Servetus on tbe Circulation of the Blood. The fol-
lowing notes emphasize the chief dates in connection with the well-
known passage on the Circulation in the " Christianismi Restitutio."

1546. Earfiest known form of the passage on the circulation by

SERVETUS NOTES 777

S. Represented by the MS., not in handwriting of Servetus, now in
the Bibliotheque Nationale, Paris, MS. Lat. 182 12. Variants carefully
printed by Alex. Gordon in Theological Review, July, 1878, p. 4i7f.

1553. "Christianismi Restitutio," printed by Balthasar ArnoIIet
at Vienne, France. 1000 printed, but only three now known, Paris,
Vienna, and Edinburgh Univ. (this copy lacks first 16 pp., replaced
by transcript from the original draft). Reprinted 1723 (part only)
and 1790. Various MS. transcripts of the whole book were made in
the seventeenth and eighteenth centuries, apparently all 1665 or
later, and from the Vienna copy.

1694. Wm. Wotton's "Reflections upon Ancient and Modern
Learning," p. 230 quotes passage (C. R. Murr, pp. 170, I. 9 to I.
27 inclusive) — given to Wotton by Dr. Chas. Bernard, who knew
only that he had it from a learned friend who had himself copied it
from Servetus. Wotton's second ed. (cont. for first time Rich.
Bentley's famous exposure of the "Epistles of Phalaris") has a
P.S. to the Preface, explaining, p. XXVf., that Bernard received
the passage from Abr. Hill, who copied it from the complete tran-
script in the possession of Bishop John Moore, who has now shown
it to W., who prints further extracts. This transcript was made in
Cassel (Mosheim, p. 344), was listed in Edw. Bernard's Oxford Cat.
of MSS. in England and Ireland, 1697 (II, pt. I, 378, No. 9848, mis-
printed 6848), and is now in Cambridge University Library (Cat.
MSS. Ill, 320 ; 1858). I examined Hill's MS. commonplace books
in the British Museum without result.

1715. Jas. Douglas's Bibliogr. Anat. Spec, p. 189, and 1734,
p. 104 merely quotes Wotton.

1723. London unfinished reprint of the "Christianismi Res-
titutio" has Circ. passage on pp. 143-4.

1728. (Not 1727) Allwoerden, p. 2o6f., prints, from transcripts,
longer passage.

1763, De Bure's " BibHographie Instructive," I, No. 756, reprints
Circ. passage from Paris copy of book, making it well known.

1 790. Murr's reprint, printed by Rau, Nuremberg, pp. 1 69f. on Circ.

1892-95. "Christianismi Restitutio" translated into German by
Spiess (Wiesbaden, 3 vols.) the last section, Apol. to Melanchthon,
left in Latin. The 1S95 2d ed. of Vol. I is really the same sheets, with
new title, but omits a two-page "Vorwort."

A SIMPLE KEYWORD SYSTEM FOR INDEXING AND
CLASSIFYING CLINICAL CASE HISTORIES AND
CURRENT MEDICAL LITERATURE

By William H. Mercur, M.D., Pittsburgh, Pa.

^^LL the ideas advanced in this article that have any clinical
/ \ value revolve around two central factors: First, the differ-
jL. JLence existing between recollection and memory (see Diagram
i); second, the possibility of reviving, clinically, past recollections
as well as past memories by utilizing a very simple keyword system
(see Diagram 2).

The raison d'etre for this paper is the author's conviction,
founded upon personal, as well as practical, experience, that it is
possible for almost any busy practitioner to practice clinical medi-
cine much more intelhgently and efficiently, if he will make use of
the ideas here advanced. Furthermore, the author beheves that if
physicians who write clinical articles for the medical profession will
utilize, practically, the keyword idea and the simple nomenclature
and classification here advocated, they will succeed in convincing
a much larger circle of readers of the truth of their statements than
has hitherto been possible.

We will now discuss our first factor. Dr. Charles W. Burr, of
Philadelphia, in an article on "Aphasia," which he published in
The New York Medical Journal, May 9, 19 14, defines so beautifully
and simply the diff"erence between recollection and memory that his
definitions are here reproduced.

Recollections. "The bringing into consciousness of things stored
in the cerebral cortex. It is a mental process, an action. It should
never be confounded with memory."

Memory. "Memory is a physical thing, and passive, and it should
never be confounded with recollection. It is the permanent eff^ect
of stimuli on brain and indeed on many other cells. Thought uses
memories, but memories are not thoughts, until recollection brings
them into consciousness."

778

KEYWORD INDEX 779

The great value of our memory is founded upon the fact that our
intelhgence is altogether based upon our faculty of memory. Without
it, we can keep no record of experience; without experience to refer
to we can form no judgments. Based upon the faculty of memory,
intelligence is possible, and from it all intelligent acts proceed (Nels
Quevli). Hence, to be a successful and intelligent cHnical practi-
tioner, one must constantly try to learn from the study of clinical
cases, but as it is possible to recall at will only a certain percentage of
our former knowledge, one should also learn to appreciate the value
of being able to file away case records for future reference. This ob-
viates the necessity of learning the same thing over and over again.
The value of combining our own personal experience with that of
others as expressed in literature has been beautifully epitomized
by Sir Wm. Osler.^ "To study the phenomena of disease without
books is to sail an uncharted sea, while to study books without
patients is not to go to sea at all."

Our plan, in brief, offers to a busy physician a simple method of
instantly reviving by means of keywords or strings what his past
cases have taught him. That is, he has it in his power to put away
in the form of a few building stones for future thought the more or
less fugitive memories of the present.

Although the proposed plan is so simple in operation that almost
anyone can readily understand and use it, a few brief prehminary
remarks might be of interest. In the first place, it must be evident
to every busy man that he is able to recall at will only a very small
proportion of what he has really accomplished in the past, or of those
things which he daily sees, hears, or reads. The amount of informa-
tion, or knowledge, which any given individual can recall at will
must, and does, vary greatly. For the purpose of our present argu-
ment, it can be stated in a general way that the average man is most
fortunate if he is able to recall one-tenth of his former recollections,
and that fully 99 per cent of all his memories, which he would like
to recall, are not available to him in his daily work. Potentially,
therefore, as far as our recollections are concerned, we are rarely
more than one-tenth efficient. To most thinking people, the truth
of this statement will be almost axiomatic. Those who doubt, or who
desire further evidence, may be convinced if they will give a little

* "Books and Men," "vCquanimitas and Other Addresses," 1901.

78o

KEYWORD INDEX

study to Diagram i, in which the difference between recollection and
memory is graphically portrayed. Few of us realize, unless we
have given the matter some thought, how completely our mem-
ories are bound up and associated with our thoughts, and, fur-

Memoriei Coaclusion

Diagram i. Graphic Representation of the Cycle of a Normal Thought.

thermore, we do not realize that a thought on any subject, which
usually flashes into our minds and out again with such marvelous
rapidity, instead of being an undivided unit, can, from a mechanical
standpoint, easily be divided into three distinct parts. All our sensory
impressions, from which our thoughts are derived, can reach our
brains in only one of two ways — first, by means of our five senses,
singly or combined, and second, from memories of past sensations.

Diagnosis Treatment

1. Symptoms Road

2. Etiological Road

3. Anatomical or Sys-
Diagnosis- terns Road

4. Pathological or Lab-
oratory Road

5. Differential Diagno-
sis Road

Diagram 2. Graphic Representation Keyword System.

Diagram 2 represents the course of a normal complete thought
as consisting of three parts: First, a stream flowing into a lake;
second, the lake into which it flows, and third, another stream as an
outlet of this lake.

-Treatment.

KEYWORD INDEX 781

The stream flowing into the lake represents the sensory birth
of a thought; the lake its cortical, or gray matter life; and the stream
which emerges from this lake represents what occurs to a thought
after being acted upon by the gray matter of the individual, and is
referred to in our diagram as a motor discharge. That is, we must
first arrive at a conclusion before we can translate it into some form
of action. Hence, not only must all of our thoughts have a sensory
birth, but nature, in order to conserve our energies, is also kind
enough to index our thoughts, more or less mechanically, when they
reach our brain; i.e., similar sights, sounds, tastes, etc., index or
associate themselves with other previous and similar sensations.

The progress of a thought through this simple diagram can be
simply illustrated, if one will imagine that he has just experienced
the birth of a thought that he has never had before. Naturally this
thought does not associate itself with any previous thought, so it
would have to take a place by itself as thought one, illustrated in
diagram as Hne No. i. Later, as so frequently occurs, a similar
thought will be born, and now thought two associates itself with
thought one. To make our illustration a httle more clear, imagine
the birth of three more similar thoughts, or a total of five, which all
hne up together in our cortex. Now, without really wishing to think,
one is practically forced to do so, in order to explain what this suc-
cession of events really means. An individual now takes a certain
portion of his daily time, which can never exceed twenty-four hours,
and associates it with a certain amount of his gray matter, and sooner
or later reaches a conclusion indicated by a hne in our diagram.
The reason for arriving at a conclusion is that we may be able to
translate our thought into some form of action. Our final conclusion
is then discharged through the outlet of our lake. Thus the normal
cycle of a thought is completed.

To illustrate further — one hears, suddenly, a dangerous sound;
it at once associates itself with former dangerous sounds and one
jumps. Sensory birth, cortical hfe, and motor discharge follow each
other in logical but rapid succession. Our diagram will further
enable the reader to understand that, as it is quite evident that no
one can either eat or sleep for another, so also no one else can either
think through, or have a motor discharge for, another. The chief
difference between our memories and our recollections (Diagram i)

782 KEYWORD INDEX

is that our memories remain indexed in our cortical life, but our
recollections, which indicate something we have thought through
and translated into action, are represented by the dry bed of the
stream of the motor discharge. Furthermore, if one considers the
enormous number of sensory impressions which not only flow daily
into our cortex, but have been doing so daily since our birth, it is
self-evident that no one could possibly hope to arrive at any defmite
conclusion or have a motor discharge except for a small proportion
of such impressions.

Although, usually, it is a comparatively easy matter for one to
recall certain circumstances, it is always a most difficult matter to
reassemble our past memories, when one has the time and the clin-
ical case with which to utiHze them.

The keyword system, here advocated, was devised, or rather
grew out of, the necessity of the author's having to index and file
away in a simple manner, not only his own case histories, but also
to index a very large transportable reprint library, which he
utiHzes in his consultation practice. It was founded and evolved
upon ideas which he got principally from three sources. The author
wishes first of all to express his deep gratitude to, and his great
admiration for. Dr. J. L. Whitney, of San Francisco, for the aid
which he has given him in his little book, "List and Classifications
of Diagnosis," which was prepared for the use of the University of
California Hospital. Without the aid of Dr. Whitney's book this
paper could not have been written. Dr. Whitney suggests a very
simple plan for filing away all case histories with either an etiological
or an anatomical diagnosis. Nothing that the author has ever seen
could be better adapted for this purpose. As it was devised, primarily,
for diagnosis only, it did not lend itself, except partially, to the
filing away of recent medical literature. To overcome this difficulty,
the author obtained the classification used in the Index Medicus
from the editor of that periodical. In order to simplify matters, and
not to have any overlapping of the keywords used in the Whitney
classification, the author crossed out of the Index Medicus key-
word system everything which Dr. Whitney's book covered, both
etiologicallyand anatomically. No better illustration of the wonderful
simplicity and value of Dr. Whitney's classification could be given
than the fact that when this work was completed there was barely

KEYWORD INDEX 783

I per cent left of the Index Medicus classification. This now gave
the author a foundation to build on in simplifying his methods of
filing away case records and current medical hterature, but it by
no means solved the practical aspects of his problem, as the resulting
keywords, although scientifically correct, were still far too numer-
ous to be handled in a simple manner. At this time the author
heard of a new scientific classification which had been recently
installed in the Allegheny County Law Library, by their clever
librarian, Mr. J. Oscar Emrick. His predecessor, who did not con-
sider a catalogue necessary, and who was known far and near as the
"Human Catalogue," died, leaving to Mr. Emrick a unique oppor-
tunity of devising a scientific modern catalogue for an enormous
law library without being hampered by any traditions. As a basis for
his work of scientific classification, he finally adopted the American
Digest System. This starts out with the question. What does law
do clinically for the public? The simple conclusion reached is: All
that law can or does do for the public can be classified or grouped
under seven basal headings. By subdividing, scientifically, these seven
headings, 412 keywords work out; and under these 412 keywords
anything that an attorney might want in the way of text books,
references, legal decisions, or miscellaneous information may be
readily found. It is a wonderful experience to consult this hbrary
and to find that in barely fifteen minutes a vast amount of infor-
mation is available to the reader. The author then tried to apply
the same scientific principle to chnical medicine, with the following
results. He asked himself. What does clinical medicine do for the
public? The answer is: A physician first clinically diagnoses, then
treats, the public.

Clinical medicine, therefore, begins with diagnosis and ends, or
should end, with treatment. Clinically speaking, and the suggested
classification is off"ered purely as a clinical one, there are only five
possible logical and scientific roads which a man can travel if he
wishes to make a diagnosis. (Diagram 2.) The first is the Road of
Symptoms. Clinical experience has demonstrated that patients
rarely come to a physician for diagnosis or treatment unless they
have symptoms, and if these are carefully collected and analyzed, a
primary diagnosis can usually be made in about 60 per cent of cases.
Frequently, however, the symptoms are too few in number, or they
are too vague in character, to make a diagnosis, and the observer

784 KEYWORD INDEX

now finds this road blocked. The second logical road presents itself
as the etiological road, a road which permits of very few, but
definite, subdivisions, such as Infectious Diseases, Diseases Due to
Poisons, Animal Parasites, etc. If this second road is blocked, the
third logical road is the Regional, or the Anatomical road, which
has been most beautifully outlined and classified by Dr. Whitney.
If, again, we find this road blocked, we can logically travel the fourth
road: the Pathological, or Laboratory Road; and if by this time the
above four roads do not lead us to a diagnosis, we find but one road
left to use: the fifth, or Diff"erential Diagnosis Road. By traveling
any one or all of these five roads, and the author knows no others,
we must logically arrive at our disease, or at No Disease, or at No
Diagnosis. In any event, we must now treat the case. If a disease,
we should treat it, if at all possible, etiologically; if this is not pos-
sible, it must be treated anatomically or symptomatically. If No
Disease, it must be treated psychically, and if No Diagnosis, it must
be treated symptomatically until a diagnosis can be made or the
patient leaves us for someone who can make a diagnosis.

Now for the most practical part of this paper. After a physician
has made a diagnosis of any given case, all he has to do is to index
it, together with the complications associated with it, either etio-
logically or anatomically, following the Whitney classification. If,
later, when one wishes to utilize it, it is not found alphabetically
under one heading, it must be under the other. One cannot go wrong.
The above covers the simple indexing of the first valuable source of
our clinical knowledge — our case histories. To index, now, the memo-
ries of our second valuable source of current knowledge; first index
and file them away under the name of the disease, as you will after-
wards want to use them. As an illustration, assume that you had just
read something new about Influenza. Under the heading Influenza,
Diagnosis of, you file away for future use, under our five keywords,
anything you have read, and wish later to recall, that is applicable
to the Symptoms, Etiology, Anatomy, Pathology or New Laboratory
Tests, or points in Difi"erential Diagnosis, concerning Influenza.
No difficulty will be found in filing away all your information under
these five simple keywords or their logical subdivisions. When, later,
you want to use this information, you simply pull one of these five
strings. The practical clinical advantage of this plan is that it brings
together, at the same place and time, all one wishes to recall about

KEYWORD INDEX 785

past similar cases, and assembles for you when you wish to use it,
in the form of building stones of thought, all the new ideas which
might help you. When one considers the rapidity with which new
ideas are constantly accumulating, it is a great advantage not to
assemble these in advance of the actual case, as the newer data
may, and often do, change all of our former conclusions. This is
one of the especial time-saving factors of the proposed plan. Why
build a house in advance of the time you are going to occupy it?
Save your gray matter and economize your time.

The author feels that the reason why this simple keyword system
has not been more extensively adopted is that no one thought that
such a compHcated and involved problem as the one we are deahng
with could be solved in such a simple manner. Most of our problems
are really very simple in their essence when we really understand
them, but are most puzzling and compHcated when we do not. It
is not at all surprising that if a man thought that, in order to recall
or remember certain things, he would have to classify and put them
away in about a thousand different places, he should at once be-
come discouraged and give up the problem as insoluble. But if he
could be shown a simple way of putting all these thousand things
away under only five simple headings, he would not hkely regard
his problem as being quite so hopeless.

The average man should not be too busy, if he is at all incHned
to be systematic, to do all the necessary work involved in carrying
the proposed plan for himself; but if he is too busy, or too unsyste-
matic to do so, he can easily employ someone to do it for him, as
the principles involved are so simple that they can easily be taught
to almost any inteUigent person.

The success of any scientific keyword system is founded, largely,
upon the well-known psychological fact that when once our per-
ceptions and ideas are welded together in our consciousness, they
tend to persist and are easily recalled. The author, in order to make
this simple plan practical, has combined the keywords of the Whit-
ney Classification with those of the Index Medicus, and has had all
these keywords mounted and arranged alphabetically on cards.
All minor subdivisions which these few keywords do not provide
may easily be added, when necessary, as the index and material
grow, by merely following the etiological and anatomical subdi-
visions of Dr. Whitney.

PROTHYMIA: NOTE ON THE MORALE-CONCEPT
IN XENOPHON'S "CYROPEDIA"^

By E. E. Southard, M.D., Sc.D.,

BuIIard Professor of Neuropathology, Harvard Medical School; Late Major, Chemical
Warfare Service, U. S. Army

Cyrus. To put enthusiasm (t6 irpodviiiav inffaXeTv) into troops, nothing seems
to work better than inspiring them with hopes.

Cambyses. Son, that would be like a hunter's calling his dogs all the time with
game calls. At first they obey eagerly (irpoOvfius). But, if he fools them too often, they
won't answer even if the game is there.

THIS passage is part of a long and well-balanced discussion
on the art of war, a talk between Cyrus and his father,
Cambyses, before Cyrus goes to war, in the "Cyropedia"
(I, VI, 19). Prothymia (jj irpodvu'ia) is a leading term in Xenophon
for some aspects of what we have come to call morale. Several
morale-making procedures of the constructive (or prothymic) group
are acutely discussed in the "Cyropedia," often occurring in
Socratic talks between the Persian paragon, Cyrus, and his gen-
erals. It cannot be denied that Xenophon himself, as the great
specialist in retreat, was a master of morale. Into his Admirable
Crichton, Cyrus, it is supposed that the great mihtary philosopher
contrived to insert virtually all the great quahties of generalship
of Xenophon's own associates, the real younger Cyrus and the
Spartan kings, Agesilaus and Clearchus, as well as of his teacher,
Socrates, and of Xenophon himself. It is said that the Romans,
such as Cato, Cicero, and the younger Scipio, highly valued the
"Cyropedia" as a sort of mihtary vade mecum. The Athenians
did not Hke it too well, because in the Persian picture they saw
all too clearly the Spartan outhnes. If a history of the morale-
concept were to be written (and this would be a rewarding task as
compared with much that goes as ethical discussion nowadays),

^ The Committee on Contributions to the Osier Anniversary Volume requests

additions to knowledge based on research in some branch of medical or biological

cience. The writer hopes that his excursion into antiquity may be so regarded. The

work was a by-product of study in connection with the Chemical Warfare Service,

the service which, of all military branches, had primarily to deal with morale.

786

MORALE-CONCEPT IN "CYROPEDIA" 787

the "Cyropedia" would take no small part in the history of morale
in antiquity.

Below I shall itemize the morale measures or prothymic proce-
dures proposed by Xenophon in the "Cyropedia." But I wish to
dwell a moment on the significance that underlies the terms
protbymia and prothymic as used of constructive morale. Terms
ending in -thymia have become rife in the hterature of some of the
mental sciences, especially in that of mental diseases, and, I beheve,
should come into more general use in the broader range of the
literature of the moral and even the political sciences. Morale takes
a prominent place in what might be called mihtary ethics, to say
nothing of the science or art of strategy. But we all now have
ringing in the backs of our heads the James phrase, "moral equivalent
of war" — we are all quite sure that in the coming struggle between
nationahsm and groupism the most gigantic hinges of fate are
going to turn on morale. But what is morale? A nomenclature and
algebra of discussion is lacking. Hence I suggest this ancient term
prothymia, for some aspects of morale, heedless of whether more
questions are raised than settled thereby.

As we examine below the morale suggestions of Xenophon,
let us bear in mind the trend of a leading term hke prothymia.
Such current terms (e.g., in psychiatric hterature) as hyperthymia,
bypothymia, cyclothymia, parathymia, all refer to some quantitative
or quahtative aspect of the emotional hfe. Any term ending in
-thymia turns toward the emotional or affective side of the mental
hfe, as the analogous terms ending in -phrenia (e.g., schizophrenia,
paraphrenia) turn toward the intellect; terms ending in -boulia
toward the will; and the long familiar terms ending in -esthesia
toward the senses. Prothymia, then, for ourselves as well as for the
Greeks, is a term which commits the users to a more or less definitely
emotional theory of morale. The ending -thymia refers to dvjxos,
originally the heart, but by transference used (as we ourselves
still use the term "heart") for the emotions of a man.

The term prothymia, then, draws us definitely away from the
intellect and the senses that supply the intellect, and draws us
definitely toward the emotions and the will, which we commonly
account to be controlled by the emotions. Although we admit that
morale might sharpen the senses (hyperesthesia), and increase the

788 MORALE-CONCEPT IN "CYROPEDIA"

rate, range, and accuracy of the intellect (a process, as one might
say, of hyperpbrenia), and still more readily increase the force
and celerity of the will (a sort of byperboulia), yet the use of the
term protbymia would tend to commit us to a certain primacy of
the emotions (some sort of bypertbymia) in all this. Do we mean
that the process of morale-making is predominantly through the
emotions, with the resultant morale something possibly in itself
not emotional at all? Or do we mean that morale is a state of the
soul in which emotion is the great ingredient? Does the emotion
bound up in morale come by way of cause or in the shape of effect?
Shall we use emotion to explain the origin of morale or to describe
its character once established?

Re Xenophon's above passage on morale or, as you might say,
on protbymics, Cambyses was talking with his son, Cyrus. They
agreed that generalship was not all tactics — that supplies and
health and physical training were indispensable too. Then the
youthful Cyrus advanced that too naive theory of morale which
was bowled over by Cambyses, who continued:

So with soldiers' hopes. If you raise false expectations too often,
you will not be believed even when the hopes are well grounded. Son,
you should refrain from saying what you are not perfectly sure of. You
^oy effect your purpose by making others your moutbpiece. Faith in your
own personal words of encouragement (irapaxeXevsLs), you must keep
absolutely sacred to serve you in the greatest crises.

Thus early was raised, as I indicate by italicizing a sentence
above, the question whether in the protbymic (morale-engendering)
process one ought not to connive at the inspiration of false hopes
through allowing subordinates to tell untruths. Cambyses and Cyrus
had apparently no doubt of this.

Having considered tactics, supplies, hygiene, physical training,
and morale, father and son speed on to questions of discipline and
of the manifold process of out-tricking the enemy, not forgetting
in the end the profit that attends obeying the gods. As for what I
have called out-tricking the enemy, there is some material for
morale discussion there also. Xenophon calls out-tricking the enemy
pleonexia {TrXeove^ia, form, to TrXeov exoiv, having more, i.e.,
getting advantage), and Xenophon makes Cyrus and Cambyses

MORALE-CONCEPT IN "CYROPEDIA" 789

have a little tilt on whether, in order to learn to out-trick the
enemy, one should not have practice in out-tricking one's friends.
The decision is against the use of pleonexic practice on one's friends,
though at the age of twenty-six or twenty-seven (which age Cyrus
had now reached) it seemed safe (to Cambyses) to teach men how
tricks hke those used in hunting and trapping animals might be
used towards men, one's enemies.

As for the more strictly prothymic methods of Cyrus (i.e., of
Xenophon, perhaps), let us proceed to our analysis. There is an in-
teresting passage in which mere exhortation is discounted, the
value of previous training extolled, and the results of war cries
and cheering told. So was the army of Cyrus filled with enthusi-
asm (irpodviJLia), emulation {(PlXotl/jlIo), strength {poifxr}), courage
(ddppos), good cheer (-jrapaKeXevcTiJiOs), self-control {aoj(j)poavvr]),
obedience (ireLdco). Courage in the form of fxevos and eagerness
to close with the enemy (to airevdecv (Tvtxixi^at) appeared later in
the contest with the Assyrians. More war-cries from Cyrus, and
the Assyrians fled (III, iii, 49-58).

Another practical prothymic procedure is hinted at in the sug-
gestion (VI, ii, 33) that we whet our minds when we whet our spears.

The most practical, or at all events the most beautiful, procedure
is naturally that of the Queen Panthea — witness that most pro-
thymic speech of VI, iv, 5-7, and the kiss of her hps on the chariot-
box of King Abradatas, going to his death.

Before undertaking an analysis of these various prothymic pro-
cedures of Xenophon, let us consider some modern conceptions of
morale, or at least such deposit of wisdom as can readily be scraped
from the maxim collections. Napoleon advised maneuvering about a
fixed point only: we have chosen the ancient contribution of Xeno-
phon as such a possible fixed point. How would the moderns agree
with Xenophon?

Morale, according to Murray, is a moral condition, or conduct,
or behavior, especially with regard to confidence, hope, zeal, sub-
mission to discipline. The relations of morale to ethics and psy-
chology are plain, and the reference to the science of war is hardly
less constant in our usage — a usage in English less than a century
old and a frequent usage perhaps less than half a century old. Yet
on virtually every page of a book Hke Marshal Foch's "Principles

790 MORALE-CONCEPT IN "CYROPEDIA"

of War" is some consideration or other bearing directly on morale.
Hardly a commander but would now acknowledge the supremacy
of morale in warfare, and the more so in the modern nationalistic
warfare that followed Carnot and Napoleon. But is there a science
of morale? Or, if there is not now a morale-science in esse, is there
not one in posse, when the history of the Great War comes to be
written and all the motives show forth in rehef? Let us bear in mind
a useful point of Marshal Foch himself: That there is no science of
war, but only an art! Probably the same may prove true of the es-
sence of war, the behavior called morale. Even if we should obtain
a fixed point of discussion by a survey of ethics, psychology, and
polemics, we should still have to stick to an old saying of Lepelletier
de la Sarthe, Dans la culture du moral, Jaites toujours marcher
r education du coeur avant celle de V esprit. Morale then belongs more
to the heart than the head, and the task of a rational or scientific
or methodical morale must seem as ridiculous to the soldier as a
plan to use the stethoscope in a case of Sursum Corda.

The fixed point of maneuver in morale, let us say, then, is the
heart and not the head. And by heart we shall freely mean a good
deal more that lies in the thorax, and perhaps also the blood and
brawn and much that passes under the name of physique. Perhaps
we should not go so far as did Cabanis and say that morale is nothing
but physique from a special point of view. Nor should we take too
literally the grinning Voltaire with his "/e physique gouverne toujours
le moral,'* much as we should like to condemn this friend of Frederick
the Great for his own morale, doubtless based on his own scanty
physique. Morale will be a matter of the heart more than of the
head, more even of the belly and the members than of the head.
Morale will stand less opposed to physique than to the psychic part of
the man. These are some of the points that crowd into our minds
when someone proposes a morale-science, a rationalization and
formulation of the morale-problem, to the possible end of propa-
ganda. One stands in awe of dished-up formulae, of pumped-up
morale, like the poor appealing patient with her plaint to the doctor,
"Please don't try any of your psychotherapy on me!" And just as
the morale-pumpers can be too cerebral, so can they rely too much
on physique: it was an acute remark with some measure of truth
that Rousseau made, ''Si le physique va trop bien, le moral se cor-

MORALE-CONCEPT IN "CYROPEDIA" 791

rompt." The cultivation of morale by any extrinsic means strikes
us as nigh to a species of corruption, and propaganda seems closely
allied to fake.

Our difficulties with morale then are (a) of definition, partly
intrinsic, partly (6) due to the recent introduction of the term into
EngHsh, a term (c) which in French antedates nationaHstic warfare
in the Napoleonic sense, and which (d) has no corresponding Latin
or Greek term by which the mutable modern usages could be
controlled and at last fixed. It is unfikely that the intrinsic difficulties
of the morale-concept will be resolved until we can arrive at better
definitions of the concept itself. It was in a search for such definitions
that I came upon the "Cyropedia."

Now, the "Cyropedia" manifestly contains much that bears
on the modern morale-concept. Manifestly, also, however, the
"Cyropedia" could not foresee the French Revolution and the
developments of nationalistic warfare that followed. Accordingly,
the list of morale measures to be found in a work of Xenophon can-
not be exhaustive. I have preferred, therefore, to use Xenophon's
leading term prothymia as a general caption for a certain group of
constructive morale measures.

Following is a list of morale or protbymic factors occurring
more or less prominently in Xenophon's "Cyropedia." I present a
rough subdivision of these according to the predominance of
emotional or of vofitional ingredients:

PROTHYMIC FACTORS

Emotional Volitional

Hope Emulation i<t>i.\oTifila)

Enthusiasm (irpoOvftla) Strength (<rw;u7j)

Good cheer (irapavtX«i;s/irfs) Self-control {(nroi<i>poaivri)

Courage {O&ppoi, nivoz) Obedience (Trei^w)

Woman-in-mind (episode of War-cries and singing

Panthea and Abradatas) Desire to grapple {to <Txev5tiy trvufii^ai)

Spear-whetting

It may be asked whether the intellectual side of morale is not
unduly neglected by Xenophon — a large question. More narrowly
speaking, is there a degree of intellectuality in some of the morale-
factors which Xenophon does enumerate — a side deHberately ig-
nored in such a forced classification as that here made? Does not
emulation imply some more or less rational object of rivalry? Do
not self-control and obedience necessarily refer to the reason? If

792 MORALE-CONCEPT IN "CYROPEDIA"

one is a state of hope, or if, like King Abradatas, one goes to battle
with the Queen Panthea's kiss on (a) lips, (6) armor, and (c) chariot-
box, is not one by just so much a rationalist and above the brutes?
Perhaps; but the point of the analysis here is not to trace the genesis
of sundry mental states so much as to find those mental states
whose induction makes for morale. To that end, few will doubt the
value of suppressing intellect and stressing emotional and volitional
states of morale, regardless of the technique of their bringing-about.
The point comes out most plainly in an analysis of war-cries, which
surely work more or less regardless of the degree of intelligence used
in their construction.

But there is still greater and perhaps more important doubt
whether some of these prothymic factors are not wrongly placed in
the emotional or volitional columns. Of course behaviorists might
regard the distinction between emotions and will itself as forced
and unnecessary: that question can evidently not be answered with
such limited material as we now possess. On the other hand, some
believe that every act is so dependent on emotion that (for quite
an opposite reason) the distinction between emotions and will has
always been too sharply drawn. Without taking issue with either
the behaviorists, or the emotional monists, we may still profitably
preserve, on this practical level, a rough distinction between emo-
tions and will.

In fine, the "Cyropedia" of Xenophon has at the least a large
historical interest re morale, because Xenophon not only was a great
general and speciahst in the morale of retreat, but also could express
in the historical novel and tract called "Cyropedia" a number of
conceptions freed from the prejudice of politics. The picture was, to
be sure, more Spartan than Athenian, and not especially Persian;
nevertheless the Romans found the ideas of the "Cyropedia" per-
manently inspiring. Anything written before the French Revolu-
tion must either be very final or not at all final. The "Cyropedia"
shows a Httle of both qualities.

Many of the morale measures of the "Cyropedia" fall under the
general head of protbymia, a term derived from dvjjids, the Greek
word for strong feeling and passion, corresponding with the Latin,
animus. Homer placed the origin of dv^os in the chest or sometimes
in the midriff" (of course, dvfx6s, animus, is sharply distinguished

MORALE-CONCEPT IN "CYROPEDIA" 793

from dvixos, thymus, or sweetbread). As was above stated, the ending,
-thymia, is coming rapidly into psychiatric usage for quaHties or
degrees of emotional disorder. Plato even began the habit of -thymia
compounds, when he distinguished eTiOvfjila, appetite, from
duiJios, spirit or passion. The Trpo- of Trpodvuia probably signifies
readiness or willingness, and suggests pushing forward in space.
But 6viJ.6s is also a term implying much activity (dvo) — rushing,
excitement, or burning). If, then, dv/jids and its derivatives are to
relate to emotions, it must be conceded that the behaviorists can
claim much for their contention that emotion (like everything else
psychical) reduces to behavior. Probably the "rushing, excitement,
or burning" felt by the Greek, as his Ovjxds was in his chest, and
hence the Homeric placement of dvy.bs. Moreover, animus and spir-
itus suggest the same thoracic placement of emotion. Xenophon
and others use athymia, advfila, for want of heart, faint-heartedness,
despondency.

Prothymic procedures, then, are enheartening, inspiriting meas-
ures. Despite the Socratic and intellectualizing tendency of Xeno-
phon, his morale measures are within the domain of emotions
and will. Whether they belong more amongst emotion-producing
procedures or amongst voKtion-producing procedures is a special
question that can hardly be answered before the whole big question
of behaviorism gets an answer.

The tabulation of prothymic factors, above attempted, suggests
a prehminary answer to the question whether morale measures
are more emotional or more volitional. This preliminary answer is
that an itemized list of such measures places more of them on the
will side than on the feehng side.

Whether the morale or prothymia, duly produced according to
Xenophon, is more of an emotional or more of a vohtional state, it
seems clear that the technique of the production of this prothymic
status is a technique via the will. The roots of the terms that figure
most prominently in Xenophon's account have reference to move-
ment in some form (dvubs from dvo), rush: pw/x?;, poiofxat, to dart,
rohur; fxhos, root MA, yearning, excitement; cnrevdeiv, related to
speed; dappos, related to (/are). Other considerations deal with equally
behavioristic matters, such as war-cries, singing, and good cheer
{irapaKeXevafjLOs) .

794 MORALE-CONCEPT IN "CYROPEDIA"

I think it safe to conclude, therefore, that the indications from
Xenophon are that morale in his sense (or prothymia, if we may
generalize from a favorite term of Xenophon) is in the making
largely a volitional affair, an affair of behavior.

I call attention to the prominence of behavior related with the
chest {6v/x6s, war-cries, etc.) as connected with prothymia. Frederick
the Great in "Les Matinees Royales" (pp. 29-32) contributes a
morale-engendering or prothymic principle that brings out this
point re the chest: at least so I interpret a story Frederick the
Great told his nephew. After telling the "dear nephew" about
riveting the attention of Europe on his own skill in the art of war,
he goes on to say,

"I turned the head of all the Powers. Everyone considered himself
lost, if he could not move arms, Jeet, and bead in the Prussian style. All my
soldiers came to think that they were twice the men tbey bad been before
when they saw that they were everywhere aped."

The italics are not Frederick's. Note that the soldiers of Frederick
felt that they were twice the men they had been before: is not this
largely a matter of felt chest-expansion, a feehng of thoracic
lightness and power of expansion, a power of inspiration, aspiration,
spirit, afflatus? But, as for the rest of Europe, all they did (in the
words of the princely criminal) was to move arms, feet, and head
in the Prussian style. They arrived at rhythmic imitations of the
movements of the Hmbs and a perfect copy of the Prussian carriage
of the head. But the Prussian still felt himself twice the man.

Conclusions, i. The material in Xenophon's "Cyropedia" indi-
cates the probable great value of a historical study of the morale-
concept, a study that might enhven the ethics of the day.

2. The itemizing of morale-measures found in the "Cyropedia"
indicates the probable success of a behavioristic version of a large
part of morale as the Greeks saw it.

3. In particular, the roots of most of the words employed in
Xenophon's morale-description are roots having to do with move-
ment and speed (rather than with mere strength statistically
taken), and having little to do with mere feehngs.

4. In particular, also, many of the words indicate the thoracic
seat of the motions engaged (e.g., the early localization of dvfxos,

MORALE-CONCEPT IN "CYROPEDIA" 795

animus, strong feeling and passion, derived probably from 0uco,
rush) rather than a seat in the head or in the muscular system at
large: i.e., morale of Xenophon's description is more a matter of
heart than of brawn or of head, but "heart" gets a behavioristic
accounting rather than one in terms of felt emotion.

5. The morale of Xenophon's day, or at least the morale of his
account in the "Cyropedia," is plainly far from a complete story
of morale in the modern sense, especially the morale developments
in armies and nations subsequent to the French Revolution.

6. The term protbymia is indicated for the morale situation as
depicted by Xenophon. This term has several advantages:

(a) The term is a leading term in Xenophon's hst.

(6) The root word 6uijl6s has deep-lying hints of motion in it,
as well as general usage in compounds suggesting "heart" in a
figurative sense; and the prefix irpo- has suitable intimations of
pushing forward in space.

(c) Modern psychiatry has come to use the theme -tbymia in
many compounds describing variants of emotion (e.g., byperthymiaf
paratbymia) .

(d) The term protbymia is euphonious and readily suggests
variants, e.g., protbymic (adjective to be used of morale procedures)
and protbymics (substantive for the art of morale, or for our accumu-
lation of facts concerning morale).

THE MEDICAL HISTORY OF TWO CRUSADES
By James J. Walsh, M.D., New York

PERHAPS nothing would seem more improbable, not to say
quite impossible, to most of the men of our time than the idea
that there could be any even far-fetched comparison between
the medical history of the Great War through which the world has
just passed and that of the wars of old times. Above all, it would
seem as though there could be no possible medico-surgical com-
parison between our world war, "the crusade to make the world
safe for democracy," and those earher Crusades of the later Middle
Ages some eight centuries ago, when Europe poured out her men
so lavishly in order that the Holy Land might be made safe for all
those who wished to seek inspiration for life there where His foot-
steps had hallowed earth. Yet the surprising thing is that recent
developments in the history of medicine have made the medical,
and strangest of all, as it must seem, the surgical history of these two
periods take on much more of similarity than could possibly have
been credited, only that the actual documents with the details of
the story of that earlier period are now before us.

The most incredible feature of the old time Crusader history is
the wonderful chapter which gives the details of the surgical develop-
ment that took place at that time. Any surgery really worthy of the
name is commonly supposed to be an evolution of the last genera-
tion. Before that, surgery confined itself almost entirely to emer-
gency surgical intervention or to the saving or prolongation of life
when there was otherwise no hope for the patient. Lives were oc-
casionally saved by brilhant surgical interference, especially in the
tying of large arteries, but except for amputations, expectant treat-
ment was the rule, surgeons naturally dreading the occurrence of
infections and the almost inevitably prolonged convalescence, to
say nothing of the frequent fatalities which followed operations.

In complete contradiction to this idea, however, we have the
surgical text book of Theodoric, who wrote down for us the details

796

THE MEDICAL HISTORY OF TWO CRUSADES 797

of the surgical practice of his father, Ugo or Hugh of Lucca, as he
was called, who was a surgeon on one of the Crusades and took
advantage of the experience thus attained to develop surgery to a
marvelous degree, along exactly the same lines that it has followed
in its recent evolution. The most surprising things Theodoric tells
us are with regard to the variety of the surgical operations per-
formed by his father, and the extent to which he went in surgical
intervention for the saving of Hfe and suffering. Ugo operated for
tumor and for abscess within the cranial cavity, opened the thorax
for pus as well as fluid, and operated within the abdomen on a great
many diff^erent conditions. He, or some of his contemporaries, per-
formed operations for the radical cure of hernia with the patient in
an exaggerated Trendelenburg position, head down on a board
leaning against a wall, in order that the loops of intestines might
fall away from the site of operation.

Ugo's operations within the abdomen, however, are the most
interesting for us, for he insisted that whenever the intestines were
wounded they must be sewed up, or else the patients would die.
He seems to have invented a series of special instruments and to
have elaborated a detailed technic in order to repair intestinal
wounds. Whenever the wound in the intestine was large, he sug-
gested separating the bowel into two parts and placing a hollow
metal cylinder within the lumen. Over this the severed intestinal
ends were brought together and sewed "with fine thread made from
the intestines of animals" or "with fine silk." The metal cyhnder
used for the purpose, he suggested, might be obtained from the
sackbut, a muscial instrument of the time, from which evidently
certain parts were readily removable.^

Theodoric tells us that the fives of a number of patients had been
saved in this way, and that the metal tube would pass out after a
while, but would usually not be displaced from its position until
after such agglutination of the intestinal ends had taken place as
would prevent leakage from the bowels. Some generations later,
dissatisfied with the use of the metal tube as an adjunct, the Brancas
in Italy, father and son, proposed the use of the trachea of an animal
as an adjuvant to maintain the patulousness of the intestines until
such healthy heafing took place as would prevent leakage. Mani-

* See Gurlt, "Geschichte der Chirurgie."

798 THE MEDICAL HISTORY OF TWO CRUSADES

festly, they had experienced delays and complications in the pas-
sage of the metal tube, and they suggested that this animal tissue,
the cartilage of the trachea, would be gradually absorbed, but not
until it had accomplished the purpose of keeping the intestinal
lumen open until safe heaHng had taken place. It is easy to under-
stand that men who were doing things of this kind were quite capable
of surgical intervention for other conditions within the abdomen,
and that they must have been rather successful, since the record of
their work remains some seven centuries later.

Of course it would have been quite impossible for surgeons to
have accomplished successfully such extensive operative measures
without the use of some form of antiseptic. At the beginning of the
late war, it is said that over 70 per cent of the wounds received in
the trenches were seriously infected. Army medical departments
had anticipated aseptic rather than antiseptic surgery, and were
utterly unprepared for this unlooked-for state of affairs, and so
their work for a time broke down rather seriously. Then there came
the development of antiseptic methods, and the situation was
saved, so that only a very small percentage of those who lived to
reach the base hospitals died from their wounds. The methods had
to be elaborated during the war, however; but, thanks to co-
operation, they were soon so perfected that a great deal of suffering
and mortality was saved. The immense call made on the sympa-
thy and intellectual resources of those who saw all the suffering
that there was, had almost inevitably to meet an adequate re-
sponse.

Similar conditions worked a like miracle of human resourceful-
ness in the Crusader times. They, too, learned the precious lesson,
probably not until after many lives had been lost, that certain
modes of dressing wounds saved complications and sequelae. They
found empirically that strong wine was particularly likely to be
followed by prompt healing. They soaked dressings of flax or linen
in this fluid, covered the wound with them, and, placing other
dressings above, bound up the parts. As the strong wine evaporated
after a time, they called this the "dry dressing," and Theodoric
was very proud of the fact that his father used it so successfully.
He boasted of his getting "union by first intention" with it, and
the very expression per primam intentionem, is a medieval Latin

THE MEDICAL HISTORY OF TWO CRUSADES 799

phrase which has no meaning in the modern languages when trans-
lated Hterally as "first intention," except what it borrows from the
old Latin.

Theodoric tells that his father not only cured wounds by this
means, but he made them "heal solidly as before," and succeeded
in obtaining "very beautiful {pulcherrimas) cicatrices without any
ointment." These last words are a reference to the fact that many
surgeons thought it necessary to make unguent applications of
various kinds in order to bring about heahng, yet they really only
hindered union.

It is no wonder that Theodoric understood perfectly clearly
the question of the formation of pus, and expressed himself very
decisively against the teaching which maintained that pus was
inevitable, and that the one hope of the surgeon must be to encour
age the formation of a kind of pus that would do as httle harm as
possible to the patient. There were evidently advocates of "laudable
pus," or something of that kind, at that time, and some of the older
teachers had laid down the doctrine which, unfortunately, in spite
of Theodoric's explanation of his father's practice, came to be
accepted as the standard teaching for centuries, even to our own
time. Neuberger, the German historian of medicine, quotes Theo-
doric as saying: "For it is not necessary — as Roger and Roland
have said, as most of their disciples teach, and as almost all modern
(itahcs ours to call attention to the use of the word 'modern' in
the thirteenth century) surgeons practice — to favor the generation
of pus in wounds. The doctrine is a very great error. To follow such
teachings is simply to put an obstacle in the way of nature's efforts,
to prolong the diseased action, and to prohibit the agglutination
and final consoHdation of the wound."

After reading this, it is much easier to understand some of the
details of this Crusader surgeon's technic, as given in his son's
text book. It is summarized in Gurlt's "Geschichte der Chirurgie"
(Berlin, 1898). He insisted on special care in bringing together the
edges of wounds, both deep and superficial sutures being employed
if necessary. He declared against the common teaching of the time
as to the use of a wick of absorbent material for draining. His reason
was that this prolonged heahng, encouraged uncleanhness, and
hampered repair and cicatrization. He warned against the use of

8oo THE MEDICAL HISTORY OF TWO CRUSADES

salves in wounds of the scalp particularly, and called attention to
the possibilities of serious complications here. The hair should be
shaved and a compress soaked in hot wine employed to bring the
edges together, sutures being dangerous. He had seen many patients
recover completely from injuries to the brain even after the loss of
some brain substance, though many surgeons had declared that
event surely fatal. He had seen one case where one of the cells of
the brain (probably a ventricle, as Gurit suggests) had been com-
pletely evacuated, and yet the patient recovered perfectly — an
anticipation of our famous tamping-iron case. He describes in detail
how tonsils should be removed, the uvula chpped, pharyngeal ab-
scesses opened, and nasal polyps removed. He dared even to suggest
radical operations for goiter, though he warned of the danger from
hemorrhage, and that, therefore, the operation must be undertaken
only with the greatest care and foresight.

Almost needless to say, it would have been quite impossible
to have done such extensive deliberate operating as is thus suggested
on head, neck, and abdomen without anesthetics. The greatest
surprise of all is to find that they were using anesthetics very
commonly at this time. When the Enghsh poet Middleton, early
in the seventeenth century, wrote of "the pities of old surgeons who
put their patients to sleep before they cut them," his readers of
the generations before ours scarcely knew what to make of Middle-
ton's suggestion of a former anticipation of what seems to us our
anesthesia. The old Crusader surgeons, and among them particu-
larly Ugo of Lucca, used a combination of mandragora, opium, wild
lettuce, and hyoscyamus for anesthetic purposes. Tinctures of these
pharmacals were employed and a sponge saturated with them. The
technic of anesthesia was to allow this to dry in the sun, and then,
having placed it in boihng water, to allow the patient who was to be
operated on to inhale the steam from it. The use of a sponge in this
way and the obtaining of narcosis by inhalation is particularly
interesting. There is no doubt at all that these old surgeons thus
secured thoroughly efficient anesthesia, though, almost needless to
say, their anesthetics were neither so safe nor so certain nor so
rehable as ours.

No wonder that surgeons who had solved the hardest surgical
problems so successfully as all this indicates could give explicit

THE MEDICAL HISTORY OF TWO CRUSADES 8oi

directions for the bandaging of a compound fracture as simply as
possible, with a compress over the wound moistened in warm wine,
the dressing not to be touched for ten days unless some compHcation
was manifestly developing. No albumin bandage was to be used in
compound fractures, and lard and honey salves must be avoided.
No wonder, either, that they warn of the possibility of capillary
fractures of the skull, or of fracture by contrecoup, that is, on the
opposite side, from the blow or injury. Manifestly, they were men
deeply intent on their work, making careful chnical observations
and not dependent at all on theory or tradition unless it was sup-
ported by their own experience.

Such good surgery could not have been accompHshed except in
well-conducted, thoroughly organized, and faithfully maintained
hospitals. We all know now that for good surgery, good nursing and
good hospitals are absolutely indispensable co-ordinate conditions,
and that before Lister's time the difficulty of doing good surgery
was greatly increased, not only by the lack of knowledge of the
principles of antisepsis, but also by the extremely unfortunate con-
ditions of the hospitals of that time. The nurses were often "ten-
day women," usually of no character, always looked upon as scarcely
more than menials, with only the most meager knowledge of how to
care for medical patients, and knowing next to nothing about the
care of surgical patients.

In this, then, was the second significant anticipation of our mod-
ern developments, for quite literally they must have had good
hospitals and good nurses. This is actually what is found in the
medical history of the time, for the hospitals very soon after the
beginning of the old Crusading period had become beautiful build-
ings, and the care of the patients in them was carried to a point of
refinement that has made them examples in history. We have the
story of the organization of a series of nursing orders, both men and
women, whose one purpose was the care of wounded and ailing
Crusaders. The famous nursing order of St. John of Jerusalem, whose
original purpose was solely to bring in the wounded and to serve
in the hospitals, and who came as a consequence to be called the
Hospitallers, is a typical example.

According to the letter of a pilgrim, about the middle of the
twelfth century, their hospital of St. John of Jerusalem was capable

8o2 THE MEDICAL HISTORY OF TWO CRUSADES

of taking care of 2000 patients.^ This would give one an idea of how
extensive were the hospital arrangements of the time. The Ladies
of St. Mary Magdalen represented the feminine branch of the Hos-
pitallers, and their hospital, according to tradition, was scarcely
less extensive. Besides, there was a nursing order of Lazaristsaswell
as that of the Templars, whose original hospital was on the site of
the Temple of Solomon, hence their name. Both the Knights of St.
John and the Templars afterwards found themselves compelled to
establish a fighting branch of their orders in order to defend their
wounded while they were bringing them in, and to care for the
pilgrims who were liable to attack. Our Red Cross met with the
same dangers in our time in spite of supposed progress in humanity
since. These military developments did not come, however, until
well on in the thirteenth century, and in the meantime, the origi-
nal purpose of a nursing order was the sole one and was fulfilled
admirably.

Two things they were famous for — first, the abundance of food
provided for patients, and secondly, the readiness to obtain any-
thing for those who were suffering that could possibly do them any
good. Theodoric has told us that his father considered nutrition
one of the most important adjuvants for the success of the surgeon's
work. He adds the weight of his own experience in this regard, and
as at the time he wrote he was a man of some sixty years of age,
who had had much practical experience, his opinion is of great
significance. He said:

"Since, therefore, nature herself cannot bring about the manufacture
of good blood without proper nutriment, nothing avails more in the healing
of small as well as great wounds as the care of the nutrition of the patient.
The physician must, above all, not be ignorant of the kind of food materials
that generate good chyme and good blood. Out of such materials the
wounded man must be fed, in order that a suitable diet shall bring about a
restoration of health and the renascence of the flesh and the restoration
of the continuity of the wound."

These hospitals were richly endowed, for the great heart of hu-
manity poured itself out for these early Crusaders quite as gener-
ously as for the Crusaders of our own time. The Hospitallers of St.
John of Jerusalem and the Sisters of St. Mary Magdalen came to

' See article, "Hospitals," Catholic Encyclopedia.

THE MEDICAL HISTORY OF TWO CRUSADES 803

own properties in many parts of Europe. Many of these donated
properties, especially along the seacoast of southern Italy, France,
and Spain, came to be used as what we would call sanatoria for the
care of convalescent soldiers from the wars in the East, under such
circumstances as would best enable them to recover their health
after the severe ills and wounds to which they had been subjected.
To a great extent these houses of recuperation were in charge of the
nursing sisters of St. Mary Magdalen, whose great hospital in
Jerusalem was, as we have said, almost as famous as that of the
Hospitallers themselves, and who took the occasion of these dona-
tions of properties to estabhsh branch houses in many parts of the
world.

By another curious anticipation of the modern time, these houses
after the Crusades came to be looked upon as centers upon which
calls could be made in time of flood and famine and plague and war.
The development was indeed very like that of the Red Cross, and
came to be a great humanitarian resource at critical times in a
very wonderful way.^

In a word, here are rather striking anticipations in that older
time of most of the developments that would, at first thought, at
least, seem so surely novel in our time. There was a magnificent
evolution of surger}'^ in war time which proved of fine service for
civil surgery during and after the war. Anesthesia and antisepsis
were anticipated in the midst of the great needs of the time. With
these, surgery developed to an almost incredible ingenuity of detail
in technic and of power to save Hfe and suffering. Hospitals had to
be organized well to take care of these surgical patients, and nursing
was established on a new and finely efficient footing. Through the
channels of charity there flowed, quite as in our time, the off^erings
that made all this organization of welfare work for the Crusaders
possible, and that organization carried over into the time of peace
after the Crusades proved to be the best solution of the civil prob-
lems of suffering among mankind, which had before that nearly
always swamped the community in which they occurred, no matter
how much of good will there was.

A word in conclusion may serve to point out another similarity
between the Crusading times and our own, which we have every

• Nutting and Dock, "History of Nursing."

8o4 THE MEDICAL HISTORY OF TWO CRUSADES

right to hope will be fulfilled. A great many people have been inclined
to be pessimistic as to the immediate future of civilization after
the war, because so many men in the flower of their lives have been
cut off by war's destructiveness that surely the next two or three
generations will be seriously hampered in their efforts towards
progress. The answer of a French surgeon deserves to be recalled
in this regard. When it was remarked to him that France was
losing an immense number of men, he said, "Oh, yes, we are losing
enormously in numbers, but for every man we lose we are making
two men." His idea was that it is the spirit of man and not his
numerical quantity that counts for human achievement. Men who
in the words of a young Enghsh poet who died during the war, "have
had their souls touched by flame in the trenches," will surely have
a new power to do things after they come back from the war. As
one of our great captains of industry, "a dollar-a-year" man for
the Government during the war, said, "What we must have now is
not reconstruction, but renovation. We must not merely rebuild
the old world, but renew the very face of the earth."

What happened after the medieval crusades is very interesting
in this regard. Europe lost several millions of men during the twelfth
century when she could apparently ill afford them from her scanty
population. It might easily be expected that this would cripple the
power of achievement for several centuries. As a matter of fact,
it had just the opposite effect, and the crusading spirit touched the
souls of men so deeply that there are not a few of us who are inclined
to speak of "The Thirteenth as the Greatest of Centuries." Mere
material losses do not count if only the spirit of man is aroused from
over-attention to sordid, material affairs, and stimulated to do work
that is significant for the mind and the heart and the soul of hu-
manity. This deep touching of the human heart may very well
prove, after our modern crusade, as after those first Crusades, to
be the initiative of a magnificent period of accomplishment.

BIBLIOGRAPHY

"Cyrurgia Guidonis de Cauliaco; Cyrurgia Bruni, Teodorici Rolandi,
Lanfranci, Rogerii Bertapaliae, etc." 270 ff. folio Venetiis imp. Andreae
Torresani de Asula, 1499.

Gurit, "Geschichte d. Chirurgie," Berlin, 1898.

THE MEDICAL HISTORY OF TWO CRUSADES 805

Neuburger, "Geschichte d. Medizin," Stuttgart, 1908.

Buck, "The Growth of Medicine from the Earliest Times to about

1800," Yale University Press, New Haven, 1917.
Lallemand, "Histoire de la Charite," Paris, 1902-10.
Hoeser, "Geschichte christ. Krankenpflege," Berlin, 1857.
Nutting and Dock, "History of Nursing," New York, 1907.
Walsh, "The Thirteenth, Greatest of Centuries," New York, 1908.

A SOUVENIR OF THE MACARTNEY MUSEUM
By J. Collins Warren, M.D., Boston, Mass.

IN a recess of an old family cabinet there has reposed for over
three-quarters of a century a portion of tanned human skin.
Tradition had it that the former possessor was none other than
Madame du Barry, one of the celebrities of the court of Louis XV.,
and that it came from the breast of that famous beauty. In one
corner there is a perforation suggesting the site of the mammary
nipple, which lends color to this claim. The responsibihty for this
story is not quite clear, but the death of the former owner of
the specimen in 1867 has left this version somewhat shrouded in
mystery.

On the inner surface of the specimen is a faded inscription, which
with some difficulty may be deciphered as follows:

"A portion of the skin of Madame Barre, a heroine of the French
Revolution who left her body to be dissected (18 10) and to be
given the surgeon to defray expenses. Presented to J. M. Warren
by Dr. Macartney, Professor of Trinity College, Dublin."

The young man to whom Macartney had given this specimen
was one of a group of American medical students who, following
the fashion of that particular period, were devoting most of their
time to the Paris School. They were first and foremost pupils of
Louis, or, if surgically inclined, of Dupuytren, Roux, and Civiale,
but they loved to visit the great centers of medicine and surgery
in Great Britain which had been the resort of their fathers at the
beginning of the century. It was during one of these excursions that
Dr. Warren visited Dubhn, a seat of medical learning, which was
beginning to attract the attention of the faculties of London and
Edinburgh. No doubt it was largely due to the rising fame of James
Macartney as a teacher of anatomy and surgery that the travehng
student felt that he could not afford to allow such an opportunity
to be neglected.

806

A SOUVENIR OF THE MACARTNEY MUSEUM 807

Born in Ireland in 1770, Macartney's early education was
largely interfered with by the unrest of the times, but as a medical
student in London he was able to pursue his studies under the
many distinguished teachers who were following in the footsteps
of Hunter. From the lectures of Abernethy, Cooper, Davy, Haigh-
ton, and others he was able to give his natural tastes and abihties
full play. The history of his appointment as professor of anatomy
and chirurgery in the University of DubHn, his struggle with the
prejudices and conservatism of his colleagues, the development of
the DubHn School, and the formation of his famous anatomical
collection are too well told by another to permit me to dwell upon
them here.^

At the time of the young medical student's visit to Dublin,
Macartney had reached the height of his career, and in turning to
the letter of the son to the father for further information about our
specimen, we find incidentally much to interest us in the man
himself.

"Dublin, August 2, 1834
"My dear Father:

"... Part of another day I devoted to the museum of Dr. Macartney
at Trinity College. He made an appointment and occupied two hours in
showing me the whole of it. The preparations are many of them very
fine and made by himself, he giving the greater part of his time to the sole
object of preparing for his lectures on anatomy and physiology, of which
he is professor in Trinity College. Among the curiosities which he has here
is a paper signed by a great number of persons, himself at the head, for
giving their bodies after death to be dissected. He has already the skeleton
of one or two persons who have given their bodies, — one of Dr. O'Connor,
whose heart he has burned. He preserves the ashes in a little bronze vase
on a m.arble pedestal with an appropriate inscription. He also has the arm
exposed with the skin on in a dried state. Besides O'Connor's body, Dr.
Macartney has the skeleton of Madame Barre, a celebrated Amazon
under Robespierre in the French Revolution and a correspondent of Bona-
parte's. She left her body and ten pounds to have it dissected by the doctor,
writing this part of her will with her own hand. He has also a portion of
her skin tanned quite as good as shoe-leather, of which he gave me a piece
for your museum. He has also the skeleton of a man with many of the

' "James Macartney, M.D., St. Andrews and Dublin, Hon. LL.D., Cambridge,
F.R.S., Professor of Anatomy and Chirurgery in the University of Dublin." A
Memoir by Alexander Macalister, Professor of Anatomy, Cambridge, 1900.

8o8 A SOUVENIR OF THE MACARTNEY MUSEUM

muscles of the back completely ossified, also of the legs, and other parts of
the body. All the joints are in a state of anchylosis. The skeleton of an
Irish giant seven and a half feet high is also curious.

"Dr. Macartney is one of the most eccentric men I have yet come
across, and his conversation was very amusing. He seems to set but little
value on his wax preparations, which he keeps in a kind of outhouse in a
very good state of preservation. A small burying-ground for the remains
of the dissected is just behind the dissecting room, and over the entrance
a marble slab with something like the following inscription: 'Here lie the
bodies of those who after their death have honorably chosen to be of use
to their fellow creatures.*

"Dr. Macartney gave me some good hints as to making preparations —
one for the preservation of their color, which is to immerse them, previous
to putting them in spirit, in a solution of alum and nitrate of potash. Wet
preparations may be injected with this for preserving their forms, and
may also be sufficiently hardened to keep without the aid of spirit. . . .

"J. M. Warren."

It will be seen at once that the written testimony is quite at
variance with the version given at the beginning of this article. In
order to clear up its history before giving the fragment of skin a
final resting place in the museum of the Harvard Medical School,
information was sought from Sir William Osier, by whom my letter
was referred to Professor Alexander Macalister. In the preface to a
Memoir of James Macartney, Macalister says: "When in after years
it was my lot to succeed to the Professorship which he had held and
when, still later, I followed his Museum from Dublin to Cambridge
and taught from the specimens which his hands had made, the
Macartney teaching and the Macartney traditions became to me
realities of peculiar interest." I am therefore taking the liberty of
giving in full a letter from Macalister to Osier.

"TORRISDALE, CAMBRIDGE,

March 20, 19 16.

"As Madame du Barre (Marie Jeanne Becu) was guillotined in Paris
December 7, 1793, and was only in England for a short time in 1792
trying to sell her jewelry, it is obvious that the skeleton and story are
not hers.

"The Madame Barre whose skeleton I have here was at her death an
old woman over sixty, a well-known Danseuse of very bad character in

A SOUVENIR OF THE MACARTNEY MUSEUM 809

Dublin. I believe it is true that she left her body to Macartney, but I
have no documentary evidence. She called herself a French woman but I
believe she was Irish and really by name Barry.

"Dr. Warren is confusing two things. A certain doctor in DubHn (Dr.
O'Connor) did in his will bequeath his body to Macartney and left him
ten pounds to pay expenses of dissection. I have the will.

"As Barre died in poverty I think it much more likely that she died
destitute and was brought in by the Resurrectionists, but there is no
reference that I can remember among Macartney's papers to her. However
I shall look again over them.

"P. S. There is a life of the real Comtesse du Barre, by Douglas,
published in 1896, which gives particulars as to her execution and beheadal.
My skeleton was not beheaded."

From the above it is quite evident that the possessor of this
piece of skin was a person of the name of Barry and of Irish birth.
The terminal letter **y" in the name cannot, however, be admitted
as convincing evidence of nationality. In the Catalogue General
de la Bibliotheque Nationale the name is entered with various
spellings, of which two will suffice.

"Du Barry. Jeanne Becu. The authentic memoirs of the Comtesse
de Barre (Du Barry) by Sir Francis N., etc.

" Memoire Authentique de Madame la Comtesse du Barri, etc. "

Under an engraving in the possession of the writer, by Hum-
phrey, London, 1770, the title is given as Madame La Comtesse du
Barre (the "y" having been erased and replaced in ink by an "e"
with a grave accent) .

But we find in the catalogue referred to another person of the
same name.

"Dubarry (Anne-Marie-Therese-Rabaudy Montressin Vve.) La cityonne
condamne k mort par le tribunal revolutionaire de Toulouse au corps
Legislatif (pour revendiquer Th^ritage de son mari)."

In view of the evidence here submitted, the claim of the king's
favorite to the title of ownership may be definitely dismissed.

It is, however, quite clear that persons of the name figured in
the French Revolution, and it seems highly probable that Ma-
cartney's Mrs. Barry may have masqueraded as a "cityonne Du-

8io A SOUVENIR OF THE MACARTNEY MUSEUM

barry," either carried away by revolutionary fervor as a follower
of Robespierre, or serving in some capacity under Bonaparte, as a
traditional foe of England. If she were sixty years old at the time of
her death in 1810, she would have hardly passed her prime when
her namesake was beheaded in 1793, and who knows that the
possessor of this fragment of skin did not have some thriHing episode
of which history tells us not?

Be that as it may, the fact remains that the old keepsake has
been shorn of most of its historic prestige, and Hke Balzac's "La
Peau de Chagrin" has been shrinking rapidly in importance. But
we cannot say that this quaint old specimen has been preserved all
these years wholly in vain, for has it not been resurrected to revive
in memory and attract attention to the name of a surgeon and
scientist who possessed that transcendent quahty for a life's work
— enthusiasm; one who fought hard to build up a dormant institu-
tion, and who has left behind traditions which the Dubhn School
should prize as among its most precious possessions?

And is not this anniversary an occasion on which our thoughts
should turn to all that stands for that which is good and true, and
to one who has set us an example of what a member of our pro-
fession should try to be? In this spirit I venture to seek for this tale
of a bygone time a place among the contributions to the day we all
dehght to celebrate.

INFLUENCE OF ENGLISH MEDICINE UPON AMERI-
CAN MEDICINE IN ITS FORMATIVE PERIOD.^

By William H. Welch, M.D., LL.D.

IMPORTANT as have been the impulses derived from other
sources, kinship, community of language, and intercourse have
combined to render the influences coming from England and
Scotland the dominant ones in the development of American
medicine. This statement is particularly appHcable to the colonial
period and the first half century of the independence of the United
States.

After this formative period medicine in America assumed a more
independent character. In the thirties and forties of the last century
it received a great and beneficial impulse from France, as has been
set forth so admirably by Osier in his charming paper on the Ameri-
can pupils of Louis. Still later from the seventies onward the greatest
stimulus came from Germany, whither flocked a multitude of as-
piring American students. This influence was marked especially by
the development of pathology, bacteriology, and chemistry and by
the establishment of laboratories. These later foreign influences,
important as they were, were exerted upon a profession and a
medical art already established which was predominantly English
and Scottish in origin and character.

The meager body of medical knowledge brought from England
and Scotland by Thomas Wotton and Samuel Fuller and the little
band of their successors in the seventeenth century was considerably
increased by immigrant physiciansandreturningstudents, by impor-
tation of books, and by correspondence in the following century. It
was transmitted mainly by the apprenticeship system. That the

' As this paper has been written upon a steamship crossing to France, witiiout
access to books or notes, it has not been possible to insert references.

8ii

8i2 ENGLISH AND AMERICAN MEDICINE

spirit of inquiry was not absent is shown by the additions to the
indigenous materia medica, some of which have retained a per-
manent place, and by the introduction by Cotton Mather and
Labdiel Boylston in Boston of the practice of inoculation against
smallpox almost simultaneously with its introduction in England,
but quite independently, and with a skill and success equal to that
attained elsewhere. The eighteenth-century story of inoculation
has much the same interest and runs much the same course in
America as in England.

Before the end of the eighteenth century substantial contribu-
tions had been made to the knowledge, prevention, or treatment of
the three great epidemic diseases which in succession sorely afflicted
the colonies, namely smallpox by Labdiel Boylston, diphtheria by
Samuel Bard, and yellow fever by Matthew Carey, William Currie,
and Benjamin Rush. Samuel Bard's "Enquiry into the Nature,
Cause and Cure of the Angina Suffocativa or Sore Throat Dis-
temper," William Currie's "Historical Account of the Chmates and
Diseases of the United States," and Noah Webster's "Brief History
of Epidemic and Pestilential Diseases," are the works of greatest
permanent value to medicine pubhshed in this country before the
close of the eighteenth century, although we cherish John Morgan's
"Discourse upon the Institution of Medical Schools in America"
as a precious document of our medical literature.

While Philadelphia was the medical center of America in the
eighteenth century and later, and the names of its medical leaders —
Colden, Cadwalader, Bond, Morgan, Shippen, Jones, Redmond,
Rush, Wistar, Kuhn — sufficiently indicate their origin, there was
no more cultivated and attractive group of medical men in the third
quarter of the eighteenth century in America than that in Charles-
ton, S. C, which has been so well pictured by Mumford. Of these
Bull was a pupil of Boerhaave, and Chalmers, Moultrie, Lining, and
Garden were trained in Edinburgh. These men were abreast of the
knowledge of the day; some were naturahsts as well as physicians,
their names being perpetuated in those of plants, fellows of the
Royal Society, and correspondents of Linnaeus, Fothergill, and
other European savants.

After the Revolution American medicine assumed a character
of greater independence and reHance. Ehhu Hubbard Smith, the

ENGLISH AND AMERICAN MEDICINE 813

father of American medical journalism, established in 1797 The
Medical Repository, which survived until four years after the founda-
tion in 1820 of the journal now known as the American Journal oj
the Medical Sciences.

The most important channel of foreign influence is that of edu-
cation, and it is fortunate that so vigorous and healthy an influence
as that of the University of Edinburgh inspired the ideas of Morgan,
Shippen, Bard, Hosack, and other founders of medical education
in this country, who had been taught by CuIIen, the Munros, Black,
the Hamiltons, Gregory, the Bells, and other leaders of the Edin-
burgh School. These were the influences which presided over the
foundation of the Medical School of the College of Philadelphia —
later the University of Pennsylvania — in 1765, and that of Kings
College — later Columbia University — in 1768. We should always
recall with gratitude the deep interest and support and advice of
CuIIen and of John Fothergill and later Lettsom, the delightful
Quaker physicians in London, who were the friends, counselors, and
correspondents of so many American medical students and phy-
sicians in the latter part of the eighteenth century.

The rise in the nineteenth century of the many detached pro-
prietary medical schools scattered over the land, sometimes in small
country towns, is a phase in our medical history, peculiar to the
United States, which we cannot contemplate with satisfaction.
Acquaintance with the separate medical schools in London in the
later eighteenth and early nineteenth centuries, such as the famous
Great Windmill Street School, founded by William Hunter, Shel-
don's Great Queen Street School, Marshal's School at Thavies'
Inn, Brooks's School, the Webb Street School, the Little Dean
Street School, and others frequented by American students, may
have had some influence, but neither these nor the hospital schools
in London were empowered to grant the doctor's degree nor the
license to practice, and we must recognize the movement for separate
schools as in the beginning a response to the urgent needs of the
country for a rapid supply of physicians.

Objectionable as the system was in many respects, and inexcus-
ably long as it lasted, the results were better than might have been
anticipated, as defects were in a measure counterbalanced by the
devotion of excellent teachers and by the native intelligence and

8i4 ENGLISH AND AMERICAN MEDICINE

industry of the pupils. A unique product of these local conditions
was the peripatetic professor, strikingly exemplified in the person
of John Delamater.

The influence of English as distinguished from Scottish Medicine
upon America was most marked in the latter part of the eighteenth
and the first three decades of the nineteenth centuries. This came
largely from the great London surgeons, Percival Pott and John
Hunter and their successors, especially Abernethy and Sir Astley
Cooper.

John Jones, who begins the line of American surgeons with his
book for army surgeons entitled "Plain Remarks upon Wounds
and Fractures," published just before the Revolutionary War, had
been a pupil of Percival Pott. John Morgan, Richard Bayley, and
William Shippen, Jr., studied under William or John Hunter. The
list of American pupils of Sir Astley Cooper is a long one, and in-
cludes the names of John Collins Warren, James Jackson, Valentine
Seaman, Valentine Mott, Dorsey, William Gibson, Alexander H.
Stevens, John Kearny Rodgers, Edward Delafield, B. W. Dudley
(also a pupil of Larrey), John Wagner, and others. Physick was
almost as much a mouthpiece of the doctrines of John Hunter in
America as Abernethy was in London.

As the Munros prevented the establishment of a chair of surgery
in the University of Edinburgh until well into the nineteenth cen-
tury, although John Bell was an excellent extramural teacher,
early American surgery was derived mainly from the London group,
and to this we may attribute the interest in anatomy, normal and
pathological, which has characterized American surgery. We owe
to a surgeon, the elder Gross, the first American treatise on morbid
anatomy.

Matthew Baillie's classical work on morbid anatomy led in
England, as Bichat's did in France, in the early nineteenth century
to the first fruitful combination of clinical and pathological studies,
culminating in Richard Bright's "Reports of Medical Cases"
published in 1827. From both sources sprang the new era which
now arose in America, but it was from pupils of Louis, namely
Gerhard, aided by Stille, the younger Jackson, and Shattuck, that
there came America's great contribution, resting upon combined
clinical and pathological investigations, of the sharp and decisive

ENGLISH AND AMERICAN MEDICINE 815

distinction between typhus and typhoid fevers, following which
Elisha Bartlett published the first modern, systematic treatise on
fevers based upon the new doctrines.

Results of the remarkable development of ophthalmology in
England in the early nineteenth century by the work of Saunders,
Adams, Travers, Lawrence, and Mackenzie were brought to the
United States by Edward Delafield, who with Rodgers founded the
New York Eye and Ear Infirmary in 1820. As early as 1823 George
Frick published in Baltimore the first original American treatise
on the diseases of the eye.

The great reform in cHnical teaching by Graves and Stokes in
Dublin, transmitted to London by Robert Bentley Todd, had a
marked influence in America, where Graves' "Clinical Lectures,"
the most famous ever pubhshed in EngHsh, had an enormous vogue
at about the same period, when Sir Thomas Watson's "Practice"
and C. J. B. Williams' "Principles of Medicine" were the admirable
and favorite text books.

While America has not produced a Harvey, a Sydenham or a
John Hunter, one can recognize readily the lineage and the features
of famihar types of EngHsh physicians and surgeons in conspicuous
members of the medical profession of this country.

Benjamin Rush, the greatest historical figure in American medi-
cine, has been called with singular inappropriateness "the American
Sydenham." He belongs rather to a type not congenial to English
soil, the eighteenth century systematists, of whom CuIIen and
Brown, whose disciple he was, are the chief, as well as the last
British representatives. There was much more of that objective
naturalistic study of disease, unhampered by tradition and dogma,
which characterized Sydenham, to be found in the works of Nathan
Smith, Daniel Drake, and Jacob Bigelow. Physick, Mott, the War-
rens, bear favorable comparison with their contemporaries in English
surgery. Of the humanistic type and of the lineage of Mead, Garth,
and Arbuthnot were Hosack and his pupil Francis, interested in
letters and natural history, prominent in social Hfe, withal excellent
teachers and physicians, worthy to have inherited the gold-headed
cane had Matthew Baiiiie sent it across the Atlantic to New York.
Bartlett, the elder Jackson, Alonzo Clark, and the elder Flint
belonged to the Enghsh type of sane, judicious, objective clinicians^

8i6 ENGLISH AND AMERICAN MEDICINE

More picturesque and more distinctive of conditions then existing
in America was the group of physicians and surgeons, of whom
McDowell, Dudley, and Drake were the leaders, who lived in the
early part of the nineteenth century on the frontier on or near the
banks of the Ohio. While abreast in knowledge and skill with the
best in contemporary medicine, they had all the indomitable pluck,
the resourcefulness, and the native vigor of mind and body which
characterized the pioneers who won the West.

There has been no analogy in America to the London hospital
medical schools. These have their shortcomings as well as good
features, but efforts to unify and to prove them do not encounter
one of the main difficulties in improving medical education in
America, where hospitals and medical schools originated and were
developed apart from each other and the need of their affiliation or
union meets serious obstacles. The admirable system of dressers
and clinical clerks found in British hospitals was introduced first in
America by Osier at the Johns Hopkins Hospital.

Nothing has been more remarkable during the last generation
in American medicine than the estabhshment of independent
institutions for medical research and the rapid improvement in
medical education, so that our country in opportunities for the
training of students and the promotion of knowledge compares
favorably with those of Europe.

In these last remarks I have passed beyond the historical period
set for this paper. It would transgress both this and the hmits of
space allowed were I to attempt to speak of the important influence
upon American physiology of one of the glories of modern English
medicine, its school of physiology, or of the great developments in the
organization and administration of public health, in which England
leads the world, although in this field America too has made valuable
original contributions.

One of the results of the Great War has been to direct attention
forcibly to the state of science, medicine, and pubHc hygiene in the
leading countries of the civilized world with the view of profiting
by the lessons of the war and of readjustment to profoundly changed
internal and international conditions. The minds of both the pro-
fession and the public have been awakened to the need of improve-
ment in education and practice in science, medicine, and public

ENGLISH AND AMERICAN MEDICINE 817

health, of ampler provision for advancing and applying useful
knowledge, and of establishing between countries recently asso-
ciated in the war closer scientific relations and better reciprocal
opportunities for graduate study. Considerations such as these make
it well to recall the intimate association of British medicine and
American medicine in the past and to look forward to a future of
mutual helpfulness in which America may be able to repay a part
of her debt to British medicine.

THE EYES OF THE BURROWING OWL

WITH SPECIAL REFERENCE TO THE FUNDUS OCULI

By Casey A. Wood, M.D., Chicago, III.

OF all the Strigiformes there is none so interesting from the
standpoint of the visual apparatus as that widely distrib-
uted New World group — the Burrowing Owls. These birds
are found (as the typical species, Speotyto cunicularia) throughout
the pampas regions of Central South America and occasionally far-
ther south; and are well known, as a subspecies, in Florida {Speotyto
c. floridana), the West India Islands, and on the plains and in the
valleys of North America {Speotyto c. bypogxa) as far north as
British Columbia.

Of the numerous subspecies may be mentioned also the small,
pale-brown, insectivorous, Short-Winged Burrowing Owl {Speotyto
c. brachyptera) inhabiting the island of Santa Margarita, Venezuela;
and the Haitian form — Speotyto c. dominicensis. The Florida Owl
is also seen in the Bahamas. Although smaller than the typical
species, it has larger feet and bill; the plumage is, on the whole,
darker, with clear white spots.

All Burrowing Owls are comparatively small (less than 1 1 inches
in length), but this peculiarity is not so noticeable on account of
their unusually long, bare legs. Their habits are said to be mainly
diurnal, but observations of the North American species by the
writer incline him to the belief that they are essentially nocturnal
animals, like most owls. Burrowing habits seem to be common to
all the species.

Burrowing owls have a dull-brownish, spotted, and barred
plumage; the middle of the chest is white and is partly encircled by
a plainly marked buff-brown collar. The head is rather flat and small,
the facial disks are not well defined, the bill is short, and the wings
are relatively undeveloped, so the bird is able to fly only short
distances.

8i8

THE EYES OF THE BURROWING OWL 819

The food of these owls consists almost entirely of mice, gophers,
and similar mammals, as well as of small reptiles and insects. Of
these a family of owls, commonly ten in number, will consume
enormous quantities; each member disposing of his own weight
of pabulum in twenty-four hours!

According to Knowlton and Ridgway (i) the Burrowing Owl is
more or less migratory, and after a return to its usual habitat mates
(probably for hfe) and then arranges its underground nest. The
contour of these nesting burrows varies; they are usually about 15
inches wide and from 5 to 10 feet in length. They enter the ground
in a diagonal direction for a few feet and then turn at an angle either
to the right or to the left. The nesting chamber (12 to 18 inches in
width), placed at the highest part of the burrow. Is mostly Hned
with dry dung, but sometimes with hair, feathers, or dried grass.
The eggs are six to twelve (generally eight) In number; their
color, when unsoiled. Is glossy white.

It must be remembered that while the great majority of these
owls dig their own burrows, many of them, especially the northern
varieties, make use of the abandoned holes of certain mammals,
notably of the prairie dog, fox, badger, skunk, and ground squirrel.
Doubtless in the latter Instances the Burrowing Owl may enlarge
or otherwise alter the size, length, and other dimensions of the newly
acquired hole.

The Burrowing Owl is not over-clean in his habits; the nesting
chamber and the remainder of the burrow are often fdthy and foul
smelling.

The writer has studied the habits of the North American and
Florida subspecies, with special attention to the eyes and eyesight
of the bird. From these observations he concludes that this owl,
hke all the others, Is a true night bird, adapting itself with but slight
success to daylight conditions. In spite of the fact that Bendire and
Hudson refer to the animal as a diurnal owl, their accounts of its
habits really bear out the writer's contention of a nocturnal animal
with fairly good day vision, yet distinctly embarrassed, uncertain,
and confused when the eyes are exposed to bright sunlight. Stress
is laid by a number of observers upon the fact that this owl Is seen
at all times of the day standing guard, often on a little mound of
earth in front of his burrow entrance, forgetting that, as a much

820 THE EYES OF THE BURROWING OWL

more interested householder, he also watches from the same post
all hours of the night !

Bendire gives the best account of their habits as observed by a
daylight student of their habits:

"When not unduly molested, they are not all shy, and usually allow
one to approach them near enough to note their curious antics. Their
long, slender legs give them a rather comical look — a sort of top-heavy
appearance. Should you circle around them they will keep you constantly
in view, and if this is kept up it sometimes seems as if they were in danger
of twisting their heads off in attempting to keep you in sight. Tbey bunt
their prey mostly in the early evening and throughout the night, more rarely
in the daytime. As soon as the sun goes down they become exceedingly
active and especially so during the breeding season."

As one result of a rather extensive study of the visual apparatus
of this interesting owl, the writer has never seen anything to convince
him that the bird ever performs an act requiring distinct diurnal
vision. Certainly the northern bird is decidedly nocturnal, occasion-
all}'^ using his eyes, but at a disadvantage, during dayhght hours.

This conclusion is confirmed in a noteworthy fashion by a com-
parison of the fundus ocuh of this owl with the same picture in
owls entirely nocturnal in their habits, and indeed with certain
other evidence (especially that they all show orange or reddish
fundi) constantly found in night animals.

These facts have been fully stated by G. Lindsay Johnson (2)
as regards the mammaha; and by the writer (3) for the avian eye.

As in all owls, the eyeballs are set well in front and surrounded
by more or less plainly marked, uniform and complete facial disks
(that probably act as reflectors into the eye of the diff'used and
faint rays of evening light).

Strigiform eyes more closely than those of any other order re-
semble human eyes; and they preserve, as in man, about the same
relation to other facial organs and are so placed as to obtain binocular
vision in front. Structurally, of course, birds' eyes are quite diff^erent,
especially in the morphology of the eyeball, in the possession by the
owl of a pecten instead of retinal vessels, in the covered optic nerve
and in many other particulars which it is not proper to specify here.

Slonaker (4) and the writer (5) have pointed out that all the
owls are exceptions to the rule that the retinal area of distinct vision

The Fundus Oculi of the Burrowing Owl— Speotyto cunicularia hijpogcea.

THE EYES OF THE BURROWING OWL

821

is in birds with a single fovea placed above and towards the nasal
aspect of the optic nerve entrance. The owls possess a single, deep
fovea encircled by a round, sharply defined area located above
and on the temporal side of the optic disk. This arrangement closely
approaches the binocular maculae of man.

The writer gives to the owls a class by itself in describing these
areae and affirms that the temporal monomacular fundus is found
almost exclusively in the owls.

In conjunction with Arthur W. Head, F. Z. S., the South Ameri-
can Burrowing Owls in the London Zoological Gardens were closely
studied and examined with the ophthalmoscope. In addition, the
interior of the eyeball
both of that type and
of several North Amer-
ican individuals were
examined by the writer
in prepared specimens.

The ophthalmo-
scope in particular
shows the fundus oculi
of Speotyto cunicularia
to be that of a typical
nocturnal animal. The
picture of this bird's
background is well shown in the accompanying colored plate,
painted by Head and faithfully reproduced here. The ocular
fundus of this species is irregularly round, as in all the owls, and
in prepared specimens these details show distinctly.

The single, temporal, oval macular region lies above and about
a disk length and a half from the upper end of the papilla. In the
center of the macula is the fovea — a dark pigmented spot with fine
granules arranged cap-hke above it. Outside this, again, is the ovoid
circumference of this region, incompletely edged with fine dots.
These are more numerously distributed below the macula than
above it. Connected with the macular region is a light-colored and
rather broad band that extends horizontally to the center of the
visible background. It is unevenly divided into two strips by a
parallel arrangement of minute pigment dots.

Lateral View of the Pecten of the Burrowing Owl —
Speotyto cunicularia bypogaea. x 9-

822 THE EYES OF THE BURROWING OWL

Seen from above, the relatively small pecten closely resembles a
disarticulated, acuminate leaf, the stem representing the spinous
projection immediately above the lowest terminal convolution. The
light double folds of the marsupium slope backwards and cover most
of the optic entrance; they meet above in a uniform, very narrow,
slightly undulating crest whose posterior end projects half the height
of the underlying coil well into the vitreous cavity. An extension
upwards of the long axis of the disk cuts the retinal band at the
junction of the inner and second fourth, making an infulapapillary
angle of, perhaps, 40°.

This interesting owl is especially subject, like other Strigiformes,
to pathological variations in the fundus picture after confinement
and domestication. Both Head and the writer examined a number
of individuals that undoubtedly exhibited choroidal disease and
other pathological changes. Rejecting these, the general color of
the fundus of this species is found to be dull-orange, mottled and
blotched in its upper half with deep orange-red. Choroidal vessels
are plaini}- visible, covering all the lower part of the eyeground, just
as in the Tawny Owl. The well-defined macular area is seen within
the outer half of the fundus, a Httle above the upper extremity of
the optic disk. It is distinguished from the surrounding choroid by
a collection of minute pigment granules or dots with a bright, white
spot in their center.

The optic disk is white and of oblong shape, sHghtly rounded at
the ends. From its edges run a few short nerve fibers that form a
complete fringe about the visible papilla.

The pecten is decidedly larger in proportion to bodily measure-
ments than one finds it in most of the larger owls, especially larger
than in the Tawny Owl. It extends well forward into the vitreous,
and its lower half appears very massive and of a dark brown color.
The pectinate convolutions are plainly seen and the anterior or
upper half is more delicate in structure, being perforated where it
joins the disk. Here it forms a dark network on the surface of the
nervehead, where, also, a few red granules mingle with the chocolate-
brown texture of the pecten.

THE EYES OF THE BURROWING OWL 823

BIBLIOGRAPHY

1. "Birds of the World," p. 537.

2. Phil. Tr., Lond., 1901.

3. "Fundus Oculi of Birds," Chicago, 19 17.

4. Jr. Morpb.y 1897, XIII, 445.

5. Am. Encyc. Opbtb., 19 14, IV, 2519.

THE REGULATION OF THE RED BLOOD-CELL

SUPPLY

By C. H. Bunting, M.D., Madison, Wis.

(From the Pathological Laboratory of the University of Wisconsin)

A MONG the many problems offered by the hematopoietic
A^ system, that of the regulation of the red blood-cell supply
jL. JLXo the circulation is not the least interesting. For weeks,
months, and even years of health, an individual man or animal has
a peripheral red-cell count which is for all practical purposes a
constant. This constant is maintained in spite of a wear and tear
which results in the daily destruction of a not inconsiderable pro-
portion of the total number of circulating red cells. Its maintenance
requires the production and the supply to the circulation of an equal
number of new cells daily. These new cells are produced in the ery-
throgenic centers within the bone-marrow and outside of the cir-
culation. Devoid of active ameboid motion, they must pass
through the endothelial hning of the vessels to enter the blood
stream by means of some force developed outside of themselves —
some VIS a tergo — and in the nature of that force hes the question of
the control of the red blood-cell supply. What is the impelling force
which pushes enough cells into the circulation per unit of time to
maintain the blood count at its level? Obviously one must seek for
a mechanical cause.

One may gain a hint as to the direction in which to push his
inquiry by a consideration of the rate of supply of red blood cells
to the circulation. While the absolute length of life of a circulating
red cell is not known, Zoja (i) and others have estimated that one-
tenth of all the hemoglobin in the body is destroyed each twenty-
four hours. This conclusion was reached by the determination of the
amount of hemoglobin which was represented in the daily excretion
of bile pigment; and it assumes that all the bile pigment is derived
from hemoglobin, an assumption upon which doubt has been cast
by Whipple and Hooper. (2) However, for the sake of argument, one
may disregard their criticism. If one-tenth of all the hemoglobin is
broken down each day, it can happen only with the destruction of

824

REGULATION OF RED BLOOD-CELL SUPPLY 825

one-tenth of all the red blood cells. In other words, the Hfe of a red
cell is approximately ten days. If an adult man possesses approx-
imately 5 liters of blood and 5,000,000 red cells per cu. mm., he
must have in his circulation in the neighborhood of 25,000,000,000
red cells, and with the destruction of one-tenth of these an equal
number, 2,500,000,000, must be produced each day in order to
maintain his constant count. A simple mathematical operation
demonstrates that if this rate of production be true the marrow must
furnish to the circulation approximately 28,935,000 red cells per
second of time. This rate of activity on the part of the bone marrow
is almost unbehevable, yet were the length of hfe of the red cell
fifty days, one would get the scarcely less preposterous rate of
5,787,000 cells per second as the number that must be produced to
maintain the constant.

That these figures he close to the realm of truth is indicated by
figures obtained in experiments upon animals. In a series of experi-
ments performed a number of years ago (3) in which rabbits were bled
a small amount daily, I found that if the bleeding was omitted for a
day the blood count would increase 500,000 cells per cu. mm. A
rabbit of two kilograms in weight has approximately 100 cm. of
blood, and so apparently is able (with hyperplastic marrow, it is
true) to produce 50,000,000,000 red cells in twenty-four hours in
addition to those lost in the daily wear and tear.

These figures suggest a continuity of action on the part of the
bone marrow, and this is further indicated by the rapid response by
the marrow with nucleated red cells after marrow injury. In a recent
experiment a rabbit was given an intravenous dose of 4 mg. of
saponin, after blood smears had been carefully searched for nu-
cleated red cells with negative result. The experimental data are
as follows:

Rabbit, albino, wt. 1545.

11:10 A.M. R.b.c. 6,476,000, W.b.c. 8000. No nucleated reds found

in smear. 4 mg. saponin given in ear vein.

1 1 :40 A.M. scattered normoblasts found.

1 1 158 A.M. W.b.c. 8000, 64^ nucleated reds per cu. mm.

12:18 P.M. W.b.c. 8000, 256 nucleated reds per cu. mm.

2 P.M. W.b.c. 7500, 1045 nucleated reds per cu. mm.

^ Number estimated from the number seen In counting 500 white cells in smear
preparation.

826 REGULATION OF RED BLOOD-CELL SUPPLY

Here we have indication of a very prompt reaction to the injury,
with the appearance of a few normoblasts within one-half hour, and
a large number (1045 per cu. mm.) within three hours.

In what way, it may be asked, do these figures aid in the solution
of the problem of the red blood-cell supply? First, they show defi-
nitely that to dehver the number of cells, indicated as that demanded
per unit of time, the marrow activity cannot be other than constant.
There must be a constant outpouring of cells and not the occasional
pushing of a cell into the blood stream.

In the second place, while they do not reveal absolutely the
effective delivery force, they indicate, when taken in connection
with marrow structure, what it must be. It is my intention to enter
into a description of marrow structure at this point only so far as
may be of value in elucidating the problem at hand. The marrow is
an extremely labile, plastic organ enclosed in a cavity with rigid
bony walls which give it fixed dimensions. This would seem to be an
adaptation not without purpose. The organ itself consists of a blood-
vascular system, fat cells, and the blood-forming elements supported
by a reticulum, and is without white fibrous elements except in the
adventitia of the arterioles. The circulation, as revealed by natural
injections of the rabbit's marrow, is unlike that of any other organ,
but resembles superficially that of the spleen pulp. There is no
capillary net- work. Slender arterioles or arterial capillaries run from
their origin near the center of the marrow, without capillary side
branches or anastomoses, to the extreme periphery, where they
open into wide thin-walled venous sinuses. These in turn run toward
the marrow center, uniting with their adjacent fellows in pyramidal
clusters, suggestive of the vascular tufts of granulation tissue, and
eventually forming large collecting veins which empty into the
central vein at regular intervals of about i mm., as shown by longi-
tudinal marrow sections. The arterial vessels are quite thick-walled.
The sinuses, on the other hand, have endothelial walls of extreme
tenuity, and it must be these vessels that the blood cells enter.
Between these venous sinuses are the fat-cells and the hemopoietic
groups.

It is to changes in pressure relations in one of these three elements
that one must look for the force which pushes the red cells into the
venous sinuses. It would seem that there must be created an extra-

REGULATION OF RED BLOOD-CELL SUPPLY 827

venous pressure which must be of quite constant nature. While the
state of the fat-content of the marrow-fat cells changes, we cannot
conceive of a constant activity in this element which would produce
the result seen. In considering the possible role of the vascular
system in the production of the phenomenon under consideration,
one must recognize that changes in the cahber of the vessels do occur.
These are in the main, however, changes that take place over
a relatively long space of time and are concerned apparently with
various degrees of hyperplasia of the marrow and can have nothing
to do with the constant normal emigration of cells. The only vascular
change that might be of importance is the regular occurrence of the
pulse wave in the arterioles. They are so situated in the midst of
the hematopoietic tissue between the venous sinuses that their dilata-
tion under pulse pressure might give rise to sufficient increase in
intersinus pressure to force red cells into the sinuses. Yet the repe-
tition of that impulse would fall short of producing the same effect
without one further factor which seems to me most vital. That
factor lies in the hematopoietic cells themselves. The hematopoietic
tissue is far from inert. Signs of cell-division, in mitotic figures, are
numerous. The cells are constantly increasing in number. The birth
of each cell must increase the inter-vascular tension, and to make
room for it another cell must leave, and by the only available route,
the blood-stream. The erythrogenic groups of cells of the marrow,
as well as the leucogenic, are so arranged that the mature differen-
tiated cells lie on the periphery of the groups, so it is these cells
that would be pushed into the circulation.

It would seem, therefore, if our reasoning be true, that it is
the rate of division of the erythroblastic cells which regulates the
output of red cells from the marrow. Further, I think one must
assume, in view of the figures given as to the marrow output, that
this rate is constant and is in all probability the maximum rate
for a given amount of bone marrow. In other words, in health
there is a fixed tempo to erythrogenic tissue proHferation; and thus
the number of red cells furnished the blood stream in a given time
is a "function" of the amount of red marrow that a person has.
The vis a tergo which pushes the cells into the blood stream is the
increased extravascular pressure caused by division of the mother
cells of the group. Each individual, therefore, apparently acquires

828 REGULATION OF RED BLOOD-CELL SUPPLY

an amount of red marrow which at the given rate of proliferation
will supply to the circulation the number of cells necessary for
his daily wear and tear. That this tempo is the maximum rate of
production seems indicated not only by the almost impossible
number of cells produced, but by another finding. When an added
number of cells is required in the circulation, the marrow response
is not inunediate. 1 he new cells are furnished only after a delay,
and only, as shown by study of the tissues, after an extension of
red marrow has taken place. This extension is apparently the
result of dilFcrentiation of myeloblasts into erythroblasts with the
formalion of new erythrogenic centers. This increase in marrow
elements occurs at the expense of the adipose tissue cells which
give up their fat. This possibly accounts for the lipemia noted by
Boggs and Morris, (4) in experimental anemia in the rabbit. This
extension of marrow is noted in all anemias, experimental and
clinical, except where reaction of the marrow fails (aplastic anemia).

The stimulus to the extension of marrow seems to have been
conclusively demonstrated by Dr. Loevenhart (5) and his associates
to be a deficiency of oxygen. In atmospheres of diminished oxygen
content there is a marrow extension which results, after an interval,
in an increase in the peripheral red-cell count. This interval, when
taken with the sections of the marrow (which I have been privileged
to study), would indicate that the increase was not due to a change
in rate of proliferation of pre-existing red marrow, but to the normal
teinpo api)lied to an increased amount of marrow. This is confirmed
further by the fact that the count returns slowly to normal after
the animal is returned to an atmosphere of normal oxygen content.

The evidence at hand, then, would seem to indicate that the
constancy of the peripheral red-cell count is maintained by a
maximum activity of a fixed (for normal conditions) amount of red
bone-marrow, and that the active force producing emigration is the
force exerted by division and growth of red-cell progenitors.

BIBLIOGRAPHY

1. Zojn, Folia HxmatoL, iQio, X, 232.

2. Whipple and Hooper, J. Exper. A/., 1913, XVII, 593.

3. Bunting, J. lixper. Af., 1906, VIII, 625.

4. Boggs and Morris, Tr. Ass. Am. Pbysicians, 1909, XXIV, 467.

5. Dallwig, Rolls, Loevenhart, Am. J. Pbysioi, 1915, XXXIX.

THE ACTION OF ADRENALIN ON THE LEUCO-
CYTES AND ERYTHROCYTES

A CONSIDERATION OF THE MECHANISM BY WHICH THE ACTION

IS BROUGHT ABOUT

By David Murray Cowie, M.D., Ann Arbor, Mich.

(From the Department of Pediatrics and Contagious Diseases,
University of Michigan Hospital)

THE symptom of marked asthenia so prominent in the recent
epidemic of influenza and influenza pneumonia, together with
some autopsy findings recorded in another place, (i) sug-
gested to me the advisability of carrying out adrenahn treatment
in a series of such cases, not with the idea of supporting the circu-
lation, but of supplying a substance which we assumed was lost to
a greater or less degree by the effect of the infecting agent or its
toxin upon the chromaffin tissues.

While pursuing this investigation, my attention was called to
the work of Hatigan (2) on the changes in the white blood cells
caused by the subcutaneous injection of adrenahn. We were, at the
same time, investigating the treatment of influenza pneumonia by
the intravenous injection of non-specific protein (3) (typhoid pro-
tein), particularly because of the effect of the protein on the produc-
tion of leucocytes. Hatigan's report led me to investigate this point
with regard to adrenahn, and to trace, if possible, the relation of the
leucocyte changes induced by adrenahn to those induced by ty-
phoid protein.

Order oj Investigation. Control counts were made, usually, just before
and, in some instances, several times before the injection of adrenalin.
After the injection, counts were made every half hour for two hours and
every hour thereafter until the leucocytes returned to the numbers noted
in the control or until, for other reasons, the experiment had to be termi-
nated.^ In Case XVII counts were made every quarter of an hour after the
injection, for two hours, and every half hour thereafter. In those cases
in which food was taken during the experiment, it is so noted in the
records. Differential counts were made with 1/12 oil-immersion lens.

^ Acknowledgment is due to my interne, Dr. Campbell Harvey, for his painstaking
assistance in making total leucocyte counts. Each count was verified by a second count.

829

830 ADRENALIN, ERYTHROCYTES AND LEUCOCYTES

No.

TABLE I

Successive Leucocyte Counts Following the Injection of i Mg. of Adrenalin

Hours after Injection

< "

Control

Normal

8,700 1 12,500 1 10,700 1 13,000 1

H.700I

16,600 1

13.200

11,100

13.000 1

10,500 1 11,100

Normal

13,900 1 17,900 1 19,500 1 14,100 1

13.900 1

17,9001

16.300 1

14,100]

12,200 1

Normal

6,400 1 8,000 1 8,200 1 6,200 1

5,600 1

6,000 1

8,5001

Normal

6,800 1 12,8001 6,900 1 7.200 1

7.300 1

8,900 1

7,600 1

Normal

5,300 1 7,500 1 6,100 1 5,200 j

6,100 1

5,800 1

6,700 1

8,400 1

8,700 1

Normal

8,050 1 13,800 1 6,200 1 7,400 1

8,ioo|

9,900 1

Normal

8,400 1 9,800 1 16,1001 16,300

13,200

17,700 1

12,300 1

16,000 1

10,200 1

Mumps

8,000 1 15,200 1 9.600 1 9,200 1

8,100 1

8,200 1

7,800 1

Influenza

3.200 1 1 3.000 1 1

2,900 1

2,800 1

3.200 1

Influenza

1 1,700 1 23,200 1 12,900 1 17.800 1

17,200 1

1 1,900 1

ii.Sool

Pneumonia

14,500 1 15.400 1 17,800 1 13.800 1

15.600 1

1S.700I

1 2,600 1

14,600 1

13,600 1

Pneumonia

4.100 1 1 5,600 1 1

4,700 1

4,000 1

3.900 1

4,100 1

Pneumonia

5.600 1 11,200 1 4,800 1 4,600 1 1 1 1 1 1 1

Pneumonia

7,100 1 7,200 1 5,300 1 2,400 1

1,800 1

2,500 1

Pneumonia

3,000 1 3,200 1 3.400 1 3.200 1

3.200 1

3,300 1

3,000 1

2,800 1

1 2.700

The height of the initial rise in the leucocytes is indicated by heavy type.

CASE I. TABLE II

Time

Remarks

Leuco-
cytes

1/1
a:
<

is
0

1/1

H
H

U
0

14
H

S.
X

a
<
►J

z
<

a
<

en
III

0
Z

Atypical
Lymphocytes

Date

Q
Id
Pi

13-16-18

6:00 P.M.

Control

9,400 1 57 S

410

42s

1 OS

12-17-18

7:30 A.M.

Control

8,600 152-5

0-5

37Sl

OSl

46SI

i-o 1 40

3 5

12-18-18

7:30

Control

9.600 1 53 • S

37 0

46- Si

IS 1 IS

8:10

8.700 1

1 1

8:14

Adrenalin

1 1

8:50

1 12,500 142 5

40- 5

1 OS

55 S

2-Sl 4-Sl

9:20

10,700 168 0

21 0

29 5

l-3l 30I

i-o|

3-3

9:50

13,000 1 69 0

18 0

270

20| 70

i-6|

10:20

11,7001400

210

30 0

lol 40I

11:20

Dinner

1 1

11:30

16,600 1 64 0

22 0

340

iSl 30|

20|

12:20 P.M.

13,200 |68o

23 5

30 5

OSl 20|

2-5l

1:20

li,lool7iS

240

27S

i-ol 20I

o-sl

2:20

13,000 1 55 0

35 5

41S

30I io|

2-5l

3:20

10,500149 5

42s

0-5

48- 5

2-Sl 3Sl

1-5

4:20

ll,loo|46 0

440

510

30I 3Sl

i-sl

5:00

Supper

1 1

5:20

10,800 1 45 0

45 0

SO 0

sol 30I

6:20

9,600 1 18 -5

715

745

701 1

30|

2-5

7:20

9.600 1 43 5

445

54-0

20| 6sl

ADRENALIN, ERYTHROCYTES AND LEUCOCYTES 831

3«(

.lb b«e

'*^'

1718 1

1 a

ft^r !ln

«yt|»»^

4 e

16^000

16 oa'o

wiooo

Xz\oQO

OQO

11.

000

*•

lolocio

•

odo

■^

—

060

i •

•^

oo|o

»,

000

00(0

»x

,..

.)\

^4o

^^»-

-A

oojo

"-"'sW

00b

•

00^

\ ,

oo|o

•

1-7-191

\ndjixk 1 1 1 1

tentoj-

artei^ ibjaction |

1 ojrteB.

i 1* 2' 3 1 4

5I 517

ao.boci

; 1 1

1 1

ig.tod

i ;

is.ood

1 I

iT.ood

16,t)od

1,5,^00

i4,j)0C

ija.W

lE.ioC

U.Ooc

lo.dooj

kioo

Cn /\, \

^,<!>oo

•

\\ i-i N

i7,(!)00

• V

J6,<l00l

'\/

^.(ioo

\ ! 1

4,000

fe.ooo;

1 1

I 1 i

Case 1.

Case II.

CASE II. TABLE III

Time

Remarks

Leuco-
cytes

en
<
u
.J
u

§
E
a.
a,
0

,j
0

>
0

H
>■

cu
I

M
H
><
U
0

-J
ti)
u

<:
-5

z
0

1/1

u
0

X
a.
S

J2
0

Atypical
Lymphocytes

Date

<
►4

X-7-I9

10:3s A.M.

Control 1 13,900 1 63 | lo|32S

0.5

|35

10:3s

Adrenalin | III

11:03

1 l3,8oo|4SSl OSI43-5

o-slsi

2 0

6 S

11:23

1 I7,900|4isl i-5l46S

iSlS6-5

11:53

1 19.500 ISO 1 I36

40I46S

12:23 P.M.

1 I4,IOO|70 1 |2I

2 S|30

6 5

12:53

1 13.900I61 1 I28S

I 5137 5

1:53

1 I7,900|S5 1 0-5l32 5

2-5

0-sl42-S

3:10

1 16,300 |68sl |22-5

I ■ 0 1 29

3:53

1 I4,I00|66 1 0-5124S

0-5

0-5l3l

3 0

4:53

1 I2,200|6l 1 |29S

0Sl38

1-5

0-^

CASE rv. TABLE IV

I-3-I9

2:00 P.M.

Control 1 6,800 |S9S| I40S

I40S

2:00

Adrenalin | III