The History of Medicine in Its Salient Features

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JOHN HUNTER
Painted by Sir Joshua Reynolds

THE HISTORY OF
MEDICINE

In its Salient Features

WALTER LIBBY, M.A., Ph.D.

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WITH HXUSTRATIONS

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1933

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PREFACE

In the doeing days of 1917 I was asked to give a
course of lectures on the history of medicine. This
book is the outcome of my attempt to comply with
the request made at that time. The course of lee-
turesy given in the first place in the early weeks of
1918, followed the lines of the present table of con*
tents. My auditors were third-year students in one
of the American Schools of Medicine, and the plan of
presentation was more or less consciously dictated^
at the start, by the recollection of what had chal*
lenged my curiosity and aroused my attention about
the time I had attained a like standing as a student
of medicine. Questions and class discussions evoked
by the lectures in 1918 and the three subsequent
years suggested, however, certain modifications of
the initial treatment of the subject and indicated
in what directions additions and elucidations were
most desirable.

Even at the outset I felt sure that the course
would be of greater interest to the men if I could
trace the development of medicine, however sue-
dnctly, from the earliest times till the present day.
I b^an, therefore, with an account of the dawn of
medical science in Egypt and Babylonia, in spite of

vi PREFACE

the imperfect state of the records and their need
of interpretation. Nor could I refrain — in April,
191 8 — from saying at least something concerning
''Medical Science and Modem Warfare," although
the time had obviously not arrived for setting forth
adequately the medical aspects of the World War.
Similarly, the distribution of space as regards an-
cient and modem medicine, the emphasis of what
seemed to me the most important stages in the evo-
lution of medicine, the avoidance of unnecessary de«
tails and of needlessly abstruse terminology, as well
as the general style of composition, have their ex-
planation in the nature of the audience before whom
and of the circumstances in which the course of lee*
tures was given. By the use of simple reading lists,
now represented by the References at the ends of
the chapters, I hoped so to interest the students
that they would soon become capable of construct^*
ing their own bibliographies, and that from the pe-
rusal of Allbutt, Garrison, Guerini, Hyrtl, Meunier,
Osier, Singer, SudhoflF, Withington, and other au«
thorities brought to their particular attention, they
might pass to an examination of Baas-Handerson,
Buck, Choulant, Daremberg, Diels, Friend, Haeser,
HoUtoder, Ideler, Ilberg, Le Clerc, Littr6, Meyer-
Steineg, Neuburger, Pagel, Puschmann, Schelenz,
Schwalbe, Sprengel, Wellmann, Wickersheimer, and
other more or less distinguished writers on the his-

PREFACE vfi

tory of mcklicine. GBrriBcm^s Introduction to the His^
tary of Medicine (third edition, 192 1) is a compre-
hensive and up-to-date work almost indispensable
to the serious student of the subject it treats. I am
especially conscious of my indebtedness to it, to the
Histoire de la Midecine of L6on Meunier, to the
Geschichte der Meditin of Max Neubuiigery and to
the Medical History of E. T. Withington, of whose
translations I have made use in the second chapter.
Through an almost inexplicable oversight I failed
to mention in the preface of iin Introduction to the
History of Science the "Science Room" at the Bodle-
ian Library, Oxford, where that book was written.
Some of the researches there carried on by Dr.
Charles Singer and those associated with him have
been embodied in two handsome volumes — Studies
in the History and Method of Science {1917 9 1921). I
take this opportunity of expressing my sense of obli-
gation to him, as well as to Dr. Geoiige Sarton, of
the Carnegie Institution, editor of Isis and exponent
on this continent of the claims of the history of
science. I wish also to thank Dr. Edna M. Guest,
of Toronto, for advice in reference to all the chap-
ters which she read in manucript, and for sub-
stantial help in the revision of the twentieth chap-
ter, — help which her military experience in the
E^t, as well as on the Western front, rendered
invaluable. All interested in the history of the

PREFACE

medical scienoes as well as of sctehoe in general
will welcome the annowicement of a work by Pro-
fessor Lynn Thomdike on The History of Magic, and
of a History of Biology from the pen of Professor
W. A. Locy.

Walter Libby

September t 1923

CONTENTS

I. The Priest-Physicians of Egypt and
Babylonia i

IL Hippocrates the Father op Medicine 23

III. Roman Anatomy AND Surgery 46

IV. The Transmission of Medical Science

BY THE Arabs 71

V. The Revivai. of Anatomy and Surgery in
THE Sixteenth Century 94

VI. William Harvey and the Revival of

Physiology 116

VII. Science and Practice:

Sydenham, Boerhaave 138

VIIL Comparative Anatomy:

John Hunter 160

IX. Morbid Anatomy, and Histology:

MORGAGNI, BiCHAT I8I

' X. Local Diagnosis:

AUENBRUGGER, LaeNNBC ' 200

XI. Advances in Physiology 218

XIL Embryology and Karl Ernst von Baer 238

XIIL The Cell-Theory and Cellular Path-
ology 257

XIV. The Introduction of Anaesthetics 276

XV. The Theory of Organic Evolution 296

XVI. The Founders of Bacteriology 316

XVIL Antiseptic Surgery: Lord Lister 335

X CONTENTS

XVIII. The History of Syphilis 354

XIX. Prevbntivb Mbdicinb in the Tropics 374

XX. Medical Science and Modern Warfare 396

' Index 415

ILLUSTRATIONS

John Hunter Frontispiece

From the photogravure in William Stirling*! Some Apostles
afPhysudoey (London. 190a) of the portrait by Sir Joshua
Reynolda in the Royal College of Surgeoni» London.

Facsimiles from the Ebbrs Papyrus in Egyptian
Hieratic Characters, containing Dental^Prb-
scriptions 6

From Guerini't Hisiory of DenHstry.

Hippocrates 32

From an engraving by W. Skelton, in Thomas Joseph Petti-
srew's Medical PortraU Gallery, of the bust found near
Albano among ruins supposea to have been the villa of
Marcus Varro. The bust is now in the British Museum.

Dissection showing the Female Viscera in Situ,
DRAWN BY Leonardo da Vinci, circa 1510 104

From Qwidemi d^Analomia.

Marie-Fran^ois-Xavter Bichat 190

From William Stirling's Some AposOes ef Physichiy.

Francois Magendib 190

From Some AposUes of Physioloiy,

Sir Charles Bell aaa

From an engraving by J. Thomson in Pettigrew's Medical
Portrail GaUery, after the portrait by Ballantyne.

Lord Lister 346

From a photogravure in Sir Rickman Godlee's Life of
LordLisier.

Plastic Surgery of the Face 413

From H. D. Gillles*s Plastic Surgery of ike Pau, Oxford,
1920.

i

i

THE HISTORY OF MEDICINE
In its Salient Features

CHAPTER I

THE PRIEST-PHYSICIANS OF EGYPT AND

BABYLONIA

Tbb medical lore of a very remote ps»t was handed
down from generation to generation by the Egyp-
tian priests, the overseers of the general welfare of
the people, to become ultimately known, at least in
part, to Hippocrates and other Greeks of the Peri-
clean age. The tendency to perpetuate traditional
teachings and practices, natural to the priestly
caste everywhere, was enhanced in Egypt through
the early development of the hieroglyphic and hi-
eratic systems of writing from the pictorial, and
encouraged by the preservative nature of the dry
Egyptian climate. The written records of the scribes
and clerics, their incantations, spells, exorcisms,
prescriptions, and clinical observations, were main-
tained intact from age to age, and finally embodied
in compilations, of which a few specimens survive in
the medical papyri of our libraries and museums.
At the same time the ease with which the dead

2 THE HISTORY OF MEDICINE

could be preserved irom putrefaction in the plateaus
above the Nile Valley led to improved methods of
tomb construction, which culminated in the erec-
tion of the pyramids between the thirtieth and
twenty-fifth centuries, as well as to the develop-
ment of the art of embalming, which reached its
highest perfection about the middle of the sixteenth
century, B.C. It is natural to find that in these
circumstances therapeutics and religious supersti-
tion were not mutually exclusive, and that the
efforts of the Egyptian priest-physicians to pro-
mote hygienic living and the attainment of longevity
were closely associated with a transcendental vision
(A a material life everlasting*

In Egypt more clearly than elsewhere can be
traced a rapid advance from barbarism to a high
degree of civilization. In the Nile Delta, not far
from the pyramids, are still to be seen the graves of
neolithic man containing such evidence of his primi-
tive industries as stone implements, pottery, frag-
ments of linen, grains of barley and split wheat.
These graves are not unlike those of primitive and
prehistoric men elsewhere, as, for example, the
graves of some of the aborigines of North America.
In fact, the early Egyptian, watering his fields by
a simple system of irrigation, living in huts of
mud-brick, employing an undeveloped method of
chronology, and unacquainted with copper or iron,

THE PRIEST-PHYSICIANS 3

18 in many respects comparable with the ancient
Pueblo Indian of New Mexico and Arizona. The
transition to a more advanced stage of development
came for the Egyptians when in the fifth millennium
B.C. they added to the use of gold and the rarer
silver that of copper, found native or obtained by
smelting from malachite. This acquisition led in
turn, about the middle of the thirty-first century,
to the empIo3rment of prepared stone as building
material, and, about the beginning of the thirtieth
century, to the erection of the first pyramid. This
step-pyramid was de ;igned by Imhotep, the first of
the priest-physicians whose name is known to us.
In later centuries his memory was held sacred in
hundreds of temples, and he became identified in
the minds of many Egyptians with Thoth, the god
of healing.

It is not strange that some resemblance should
exist between the surgery of Egypt, where, in the
desert sands, stone tools and flint arrowheads are
still to be found, and the surgery of primitive and
prehistoric peoples. Before the dawn of history
trephining, cupping, circumcision, castration, vene-
section, the use of the cautery and of splints were
known in many parts of the earth; though the
motives that led to the employment of these prac-
tices were not in each case identical with those of
modem surgery. Skulls recovered by the archse-

4 THE HISTORY OF MEDICINE

olpgist bear witness that trephining was practiced
among prehistoric peoples in the western as well as
in the eastern hemisphere. It was performed for a
variety and mixture of motives — to relieve head-
ache, to cure epilepsy, to let out the tormenting
spirit, to obtain amulets, or to propitiate the gods.
Even among primitive peoples to-day trephining is
sometimes effected by means of knives of flint or
obsidian. A slight link is estaUished between the
surgery of barbarian and that of civilized Egypt
by some representations of surgical operations of
2500 B.C. They were discovered on the doorpost of a
tomb in a necropolis near Memphis. Among the
pictures are two of circumcisions, in which the
surgeon is shown in the act of operating with a flint
knife. The Jews, who learned this adolescent rite
from the Egyptians, were still in their ceremonies
using the same sort of neolithic instrument cen-
turies later, as we know from the fifth chapter of
the Book of Joshua. \

On account of the conservatism of the priest-
physicians, Egyptian medicine never advanced far
beyond primitive medicine with its simple faith in
magic spells and the virtue of a rich pharmacopoeia,
and its belief that the cause of disease was the
malice of a demon, the justice of an avenging god,
the ill-will of an enemy, or the anger of the dead.
The medicine chest of an early Egyptian queen

THE PRIEST-PHYSICIANS 5

(about 2100 B.C.)* with its alabaster bottles coii«
taining medicinal roots, b typical of the Egjrptiaii
faith in the efficacy of drugs. In the London papyrus,
the lesser Berlin papyrus, and the Brugsch papyrus
the mystical element predominates, though in the
last-named we read of vermifuges, fumigations,
treatment of ulcers, of haematuria, of diseases of the
breast, heart, and ears. The Ebers papyrus, the
discovery of which was announced in 1873, though
by no means wanting in charms and incantations,
is less dominated by the m3rstical element than the
preceding or succeeding medical papyri. It is a
compilation of about the middle of the sixteenth
century B.C. Much of it reflects, however, the
practice of an earlier epoch, and it may be con-
sidered as representing the high-water mark of
Egyptian medicine.

It is in the main a collection of prescriptions, some
ci which had been tried frequently, as we learn from
mai^nal notes, and found good, or excellent. It
makes mention of some seven hundred remedies,
evidently accumulated in the course of the ages, and
put on record and preserved for posterity by the
priestly scribes. Among the remedies are found
poppy, castor-oil, gentian, colchicum, squills, aloes,
cedar, mint, myrrh, crocus, hyoscyamus, caraway,
elderberries, and many other medicinal herbs, that
call to mind the therapy of North American In-

6 THE HISTORY OF MEDICINE

dians and of all primitive tribes throughout the
worid. The Egyptian priest-physicians made use
also of certain inorganic remedies^ such as lead
oxide, earthy carbonate of lead, galena, meteoric
iron, blue vitriol, crude carbonate of soda, sodium
chloride, and sea-salt. Petroleum, bog-water, goose-
oil, turpentine, ink (made from charcoal and gum),
honey, probably antimony, possibly mercurials,
found a place in the Egyptian pharmacopoeia.
Honey was thought to be terrible to the dead,
though sweet to man. It may have been on the
complementary principle that what is abhorrent to
the patient is pleasant to the perverse demons of
disease that many disgusting substances were used
as remedies, such as the dung of the gazelle and the
crocodile, the fat of a serpent, mammalian entrails,
and other excreta, tissues, and organs. In some
cases the object seems to have been to wheedle, in
other cases to repel, the evil spirits that had taken
possession of the patient. The various medicines
were given as foods, potions, pills, plasters, in-
unctions, inhalations, etc.

Among the diseases spoken of in the Ebera
papyrus are ailments of the eyes and ears, stomach
troubles, worms, dysentery, and other affections
of the intestines, arthritis deformans, gout, lum-
bago, ascites, pemphigus, scurvy, leucorrhoea,
asthma, tumors, and a disease which some would

■■^^m

FACSIMILES FROM THE EBERS PAPYRUS IN EGYPTIAN

HIERATIC CHARACTERS, THE UPPER CONTAINING THREE,

THE LOWER ELEVEN, DENTAL PRESCRIPTIONS

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ar
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iQd

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othe
Sod

THE PRIEST-PHYSICIANS 7

identify as hookworm disease (Egyptian chlorosis),
others with bilharziasis. Both of these last-named
diseases are very prevalent in Egypt at the present
time; both are marked by anaemia and are asso-
ciated with arrest of mental development; both
are now known to be caused by parasitic worms,
the former by Ancylostoma duodenale (and Necator
americanus)^ the latter by Schistosoma kosmatohiutn.
Haematuria is one of the most constant symptoms
of bilharziasis, a fact which may have some bearing
on the identification of the disease mentioned in the
Ebers papyrus, for the symbol there used for the
disease is the phallus. As we shall see in the six-
teenth chapter, some of the other diseases treated
in the Egypt of the sixteenth century B.C. have in
recent times been studied by one of the leading
bacteriologists.

A few passages of the Ebers papyrus may bear
witness to a knowledge of anatomy, surgery, and
diagnosis somewhat beyond the range of primitive
and prehistoric peoples. One of these reads: "If
the physician place his finger on the head, neck,
hands, arms, feet, or trunk, everywhere he will find
the heart, for its vessels go to all parts.'' The
vessels of the body are said to run in pairs, and to
contain not merely blood, but air, water, milk, and
other fluids. Another passage says: "When you
find a man with a stoppage, his face pale and heart

8 THE HISTORY OF MEDICINE

palpitating, and you find upon examination that
his heart is hot and his belly swollen, that is an
affection caused by irritant food. Treat it with
something that is cooling and aperient, especially
with a draught of sweet 'beer, poured upon dry
nequat fruit. Four times shall he eat or drink/* A
third passage advises operation following diagnosis
of fatty tumor: ''If you find disease of fat in any
part whatsoever of the body of the person, and find
that it moves hither and thither under your fingers,
and that it trembles when your hand is at rest, then
you must say of it, 'It is a fatty tumor; it pains; I
will treat it.' Treat it with the knife; dress it as one
dresses open wounds.*'

The Ebers papyrus is not only the most important
source of information concerning ancient Egyptian
medicine, but the most complete book on any sub-
ject that has come down to us from those remote
times. The Kahun papyrus consists of two parts,
the first gynecological, the second veterinary. The
Hearst papyrus, recovered by the Hearst Egj^tian
Expedition of the University of California, is in
content identical with a part of the Ebers papyrus;
they belong to the same epoch.

A study of the art of embalming and an examina-
tion of mummies and other human remains throw*
light on the medical science of different periods of
Egyptian history, as well as on the various diseases

THE PRIEST-PHYSICIANS 9

to which the ancient Egyptians were subject. At
the same time we are afforded a glimpse of the in-
juries to which they were especially liable, and of
the methods of surgical treatment. Embalming is,
of course, of particular interest to us because of the
knowledge of anatomy it involved and because it
was essentially an antiseptic art. Any brief descrip-
tion of embalming is likely to prove an imperfect or
a composite picture, for the procedure was by no
means uniform. Evisceration of the dead was to
some extent customary before the sixteenth cen-
tury B.C., and the fact that the ceremonial flint
knife was always used to make the incision in the
abdomen indicates that the practice had a very

ft

early origin. After the embalmer's art had reached
its highest development, the brain was sometimes
removed by means of an iron or bronze hook, which
reached the interior of the skull from the nose by
perforating the cribriform plate of the ethmoid
bone or by tunneling the sphenoid. The cavity was
then cleansed with a solution of drugs. This diffi-
cult operation of removing the brain was as a rule
quite successful, though the less expert occasionally
broke through into the orbital cavities, or even
fractured the frontal bone from within. As already
implied, the intestines, stomach, liver, and spleen
were removed generally through an opening made
in the abdonGdnal wall* This was on the left side,

10 THE HISTORY OF MEDICINE

probably to allow free play to the right arm of the
operator. In some cases the lungs were also re-
moved by piercing the back part of the diaphragm
or by removing that muscle. The heart and kidneys
might be left in situ. After the organs had been
removed, the body was rinsed out with wine, myrrh,
cassia, etc. At times, instead of making an incision
in the abdomen, the embalmer injected a solution
of cedar-oil, which acted as a solvent on the viscera,
which then were removed through the anus. The
body was now kept for seventy days in a saline
solution, a solution, for example, of crude carbonate
of soda (natron) found native in different parts of
Egypt. Finally it was bandaged and wrapped in
linen smeared with gums or wax. Resin and pitch
were used extensively, as, indeed, the terms ''em^
balm'* and "mummy" imply.

During the last few years mummies and other
human remains have been examined with the pur-
pose of determining, as far as possible, the diseases
and injuries from which the ancient Egyptians
suffered. These belated autopsies, numerous as
they have been, a£Ford no evidence of sjrphilis,
little or no evidence of rickets (though there are on
record cases of distortion difficult to ascribe to any
other cause, as well as a case of achondroplasia), and
no evidence of tuberculosis except as involved in
Pott's disease, an extreme form of which is exhibited

THE PRIEST-PHYSICIANS ii

in the mummy of a priest of Ammon of about
looo B.C. Thousands of bodies exhumed in Nubia,
in the vicinity of the Assuan Dam, show on exami-
nation that the Egyptians suffered but little from
pyogenic infections, that the death-rate of children
was much lower in ancient than in modem Egypt,
and that in the earlier and less luxurious epochs few
of the inhabitants of the region suffered from pre-
mature decay of the teeth. At no period is there any
sign of filled or of artificial teeth, and even as late as
the sixteenth century B.C. a large proportion of
adults in some districts were able to show perfect
sets of teeth.

The examination of bodies belonging to all
periods of Egyptian history shows the prevalence of
the disease now known as arthritis deformans, of
which mention has already been made. It is de-
scribed as the bone disease par excellence of the
ancient Egyptians. It still afflicts the inhabitants
along the course of the Nile. Its etiology is uncer-
tain, but, though the view predominates that it is
a chronic infection, wet and damp may be among
the exciting causes. In the Egyptian cases that have
been examined the vertebrae are sometimes involved,
as also the shafts of the bones. Cases of vesical
calculus of the fourth millennium, renal calculus of
the third millennium, gall-stones of the third millen-
nium, variolous eruption and calcareous arteries

M ' THE HISTORY OF MEDICINE

and atheroma, have also been reported. Pleurisy
and appendicitis (Byzantine period) and a case of
true gout (sixth century a.d.) belong to a much
later time. Bouchard's nodes (indicative of dilata-
tion of the stomach), the enlarged spleen resulting
from malarial infection, mastoiditis, and infantile
paralysis, have also been proved to have occurred
among the ancient Egyptians.

Ribs of date-palm leaves were used as splints in
the early centuries of the third millennium, and
splints of the same material are still in use in the
Egypt of to-day. The ancient Nubian remains
exhibit many cases of fractures that had been per-
fectly set and had healed satisfactorily. Fractures
of the ulna near the wrist (as well as of the femur
and cranium) are quite common. These injuries
were probably sustained in attempting to ward off
the blow of the naboot. This weapon was a staff,
which was grasped, by the person wielding it, in
both hands. Its use was a favorite pastime of the
ancient Egyptians, and resembled the old English
quarterstaff play. Besides the injuries caused by
the naboot, fatal sword-cuts of the skull and cranial
ulcerations from carrying water-jars have been
noted.

For its skill in medicine Egypt became famous
among all the surroimding nations. The Odyssey
refers to it as a land producing an infinite number of

THE PRIEST-PHYSICIANS 13

drugs, where each phymdan possessed knowledge
above all other men. Similarly the Hebrew prophet
Jeremiah alludes to it as a land of many medicines.
The Greek historian Herodotus, the contemporary
of Hippocrates, speaking of the Egyptians of the
fifth century BX., says: "Medicine is practiced
among them on a plan of separation ; each physician
treats a single disorder, and no more; thus the
country swarms with medical practitioners, some
undertaking to cure diseases of the eye, others of
the head, others again of the teeth, others of the
intestines, and some those which are not local."
He also takes note of the habits, especially among
the priestly caste, of personal hygiene, light cloth«
ing, frequent baths, purgation, and careful diet, for
they have a persuasion that every disease to which
men are liable is occasioned by the substances
whereon they feed.

It was not till about 3 100 B.C. that the City of
Babylon, under the leadership of Hammurabi, a
Semitic (Amorite) king, gained ascendancy over the
Sumerian cities, which lay along the Tigris and
Euphrates toward the Gulf of Persia. In the ruins
of these cities has been discovered the record of a
civilization analogous in its development to Egyp-
tian civilization. Long before 3000 B.C. the Sume-
nans had learned how to control the freshets of the
Euphrates for purposes of irrigation ; they cultivated

14 THE HISTORY OF MEDICINE

barley and split wheat, reared cattle, sheep, and
goats, made use of the ox and ass in ploughing and
transportation; they constructed mud-brick dwell-
ings, as well as enormous stage-towers as places of
worship and sepulture; they had ornaments of gold
and silver, and knives of copper and bronze; they
were skilled in pottery and stone-cutting; they
developed a phonetic system of writing based on a
primitive pictorial system, for it was to these early
inhabitants of the land of Shinar that the East was
indebted for cuneiform writing. The intellectual
and professional life of the Sumerians, as of the
Egyptians, was dominated by the priestly caste.

The Amorites of 2100 B.C. were not the first nor
the last of the Semitic races to overrun the cities
and adopt the system of writing and the general
culture of the Sumerians. Many centuries after
Hammurabi, the Assyrians, who had from very
early times felt the cultural influence of the Sumeri-
ans, entered upon a career of conquest, and from
about the middle of the eighth till near the dose of
the seventh century controlled an e3ctensive empire
of which Babylonia formed a part. One of the great
Assyrian kings, Assurbanipal (668-626 B.C.), es-
tablished in his palace at Nineveh a cuneiform
library. The Code of Hammurabi, a collection of
laws inscribed on a large block of black diorite, and
the clay tablets of the library of Assurbanipal are

THE PRIEST-PHYSICIANS 15

the chief sources of information in reference to what
may be roughly called Babylonian medicine.

The following sections from thb earliest code of
laws known to history, the starting-point of medical
jurisprudence, throw light on the rights and duties
of the surgeon of 2080 B.C. ;

**!{ a physician operate on a man for a severe
wound (or make a severe wound upon a man), with
a bronze lancet, and save the man's life; or if he
open an abscess (in the eye) of a man, with a bronze
lancet, and save that man's eye^ he shall receive ten
shekels of silver (as his fee)/*

" If he be a freeman, he shall receive five shekels/'

"If it be a man's slave, the owner of the slave
shall give two shekels of silver to the physician."

"If a physician operate on a man for a severe
-wound, with a bronze lancet, and cause the man's
death; or open an abscess (in the eye) of a man,
with a bronze lancet, and destroy the man's eye,
they shall cut off his hands."

" If a physician operate on a slave of a freeman
for a severe wound, with a bronze lancet, and cause
his death, he shall restore a slave of equal value."

" If he open an abscess (in his eye), with a bronze
lancet, and destroy his eye, he shall pay silver to
the extent of one half of his price."

16 THE HISTORY OF MEDICINE

** If a physidan set a broken bone for a man, or
cure his diseased bowels, the patient shall give five
shekels of silver to tlie physician/*

** If he be a freeman, he shall give three shekels."

"If it be a man's slave, the owner of the slave
shall give two shekels of silver to the physician/'

"If a veterinary physician operate on an ox or
ass for a severe wound and save its life, the owner of
the ox or ass shall give to the physician, as his fee,
one sixth of a shekel of silver/'

"If he operate on an ox or an ass for a severe
wound, and cause its death, he shall give to the
owner of the ox or ass one fourth its value/'

It is evident that in this translation the term
"freeman" indicates a rank intermediate between
that of "man" (or gentleman) and that of "slave,"
and that the term "veterinary" is used in anticipa-
tion, since the horse was unknown in Babylonia till
some time after the formulation of the Code of
HanmiurabL

As already implied, the medical science of the
Babylonians was closely associated with their
religious beliefs and superstitions. Disease was
considered the seizure or attack of the patient by
some demon or other, such as the demon of con-
sumption, the demon of liver complaint, and the

THE PRIEST-PHYSICIANS 17

particularly hideous demon that haunted the bed-
side of women. Cures were to be effected by charms,
incantations, exorcisms, and other magic rites.
These led to the use of remedies, like mint, cassia,
chicory, sesame, honey, and liquorice, or a green
frog, the foot of a small insect, the daw of a black
dog, to fortify the patient and to drive or coax out
the demon of disease. As the Babylonian priests
sought to foretell the future by the study of the
heavens, of numbers, and of geometrical forms, so
they turned to the inspection of the viscera of
sacrificial animals as a means of divination. They
believed, like the Jews, that the blood was the vital
principle, in some sense identical with the soul;
that the blood was elaborated in the liver, and that
consequently that organ should be made an object
of particular attention. They held it possible, since
the deity passed into all animals offered up in
sacrifice, to read the disposition of the divine mind
by observing the markings and anomalies of a
sheep's liver. Clay models of this organ, dating
from about 2100 B.C., are as carefully marked off
into distinct areas as our modem phrenological
charts. The lobes, ducts, depressions, fissures, gall-
bladder, etc., on the under side of the liver were
minutely scrutinized and definitely named. Patho-
logical conditions were especially studied, because
all irregularities seemed to foretell unusual events.

i8 THE HISTORY OF MEDICINE

The practice of inspecting the liver for purposes
of divination — hepatoscopy — passed from Baby-
lonia as far west as Italy and was not without
significance in the development of anatomy and
physiology. In a like spirit and with greater results
for the progress of science, the Babylonian priests
turned their attention to the study of congenital
abnormalities in man and animal, and to the inter-
pretation of pathological symptoms. A monstros-
ity was an evil omen; hysteria and epilepsy and
leprosy were special marks of possession or of divine
condemnation. In the study of birth-omens and
sickness-omens, the Babylonians developed a knowl-
edge of the various parts of the body, and learned
to recognize the symptoms of various diseases.
Among the latter might be mentioned as finding
a place in cuneiform medical literature, colds, in-
digestion, rheumatism, neuralgia, headache, eye
troubles, heart disease, and jaundice.

Some of the early Babylonian prescriptions are
half exorcism and half directions for effecting a
cure. One cuneiform text, for example, dictates a
formula for calling down the wrath of the god Ea on
the worm that causes toothache, but advises that
while the curse is being uttered thrice, the aching
tooth should be treated with a mixture of henbane
and resin. Other prescriptions dispensed altogether
with the aid of magic: ** If a man is sick of a cold,

THE PRIEST-PHYSICIANS 19

which has turned into stomach pains, let him com-
pound . • • liquorice root . • • these seven drugs let
him drink as the star rises and in the morning
without food [that is, evening and morning, fasting],
and he will recover/' The tendency to rely less and
less on incantations and more and more on actual
remedies seems to have been more pronounced in
the later stages of Babylonian medicine. Of course,
primitive methods were resorted to in desperate
cases; as, for example, if ''a man's forehead b
affected and the demon in a man's body cries out
and does not depart," the traditional treatments
may be employed as a last resort. Further evidence
of the progress of medicine is afforded by letters
written in the seventh century B.C. to Assurbanipal
by a doctor called upon to treat the members of
the royal family for eye trouble, bleeding of the
nose, and other ailments. They read like the com-
munications of a rational, sympathetic, and capable
modem practitioner. One of these sends "Hearty
greetings to the little chap whose eye causes him
trouble" and gives reasons for expecting a speedy
recovery. A second letter with similar greetings to
the king's son contains excellent directions for
arresting persistent haemorrhage of the nose.

In the textbook literature of the library of Assur-
banipal are found long lists of remedies, which are
divided into two classes corresponding, it would

20 THE HISTORY OF MEDICINE

eeem from the particular Sumerian words used, to
the distinction of organic and inorganic substances.
Among the latter are found alkalies and salts, as
well as a number of stones which had probably been
thought efficacious as amulets before taking their
place in the pharmacopoeia. Only a limited number
of the drugs that enter into cuneiform prescriptions
have as yet been identified, but in addition to those
already set down the following might be mentioned ;
anise, cumin, caraway, colewort, colocynth, cori-
ander, cynoglossum, figs, dates, jasmine, juniper,
nard, oleander, willow, and sal ammoniac. Among
the therapeutic agents relied on by the Babylonian
priest-physicians are found purgatives, diaphoretics,
enemata, compresses, salves, poultices, liniments,
fumigations, diet, and rest. One might be tempted
to ascribe to them the knowledge of a form of
massage; but the impression must not be created
that the medical science of the Babylonians ever
attained to any considerable development. At its
best it was obscured by astrology and other super-
stitious beliefs, and at no time completely emerged
from the primitive stage. By the fifth century B.C.
it seems, indeed, to have deteriorated; for according
to Herodotus no physicians were to be found in the
Babylon of the Persian regime and patients were
brought into the streets to receive the suggestions
of the passers-by.

THE PRIEST-PHYSICIANS 21

In Babylonia as in Egypt the conservatism of the
priests preserved throughout the ages the medical
knowledge of an immemorial past, but the very
quality that enabled them to perpetuate traditions
prevented their making any marked advance to-
ward a real medical science. Their faith in the
virtues of drugs and in the influence of the stars
was detrimental to progress, and the dbtinction of
making the first great contributions to scientific
medicine was reserved for another people, among
whom the healing art was not dominated by the
priestly caste.

REFERENCES

Flnlaynn, James: "Ancient Egyptian Medidne," BHHsk Medicat

Journal, 1893, vd. i, pp. 748, 1014, 1061.
Harper, R. F.: The Code of Hammurabi. Chicago, 1904.
Holmes, B. T., and Kitterman, P. G.: Medicine in Ancient Egypi.

1914.
Jastrow, Morris, Jr.: (i) "The Medicine of the Babylonians and

As^oians," Proc. Roy. Soc. Med., 7*, History of Med. Sec*

tion, I9I3-I4» Pp. 109-76.
(2) " Babylonian-Assyrian Medidne,'' Amiab cf Medicat

History, vol. i (no. 3), 1917, pp. 231-57.
Joadiini, H.: Papyros Ebers, 1890. (German translation.)
Moodie, R. L.: "Studies in Paleopadiology," Surg. Oin^ vd. m,

pp. 481-96. Chicago, 1918.
Mflller, W. Max: Egyptological Besearckes. Carnegie Institution,

Washington, 1906.
Ruffer, Sir M. A.: Studies in the Paleopathology of Egypt. Chi-
cago, 1921.
Ruffer, Sir M. A., and Ferguson, A. R.: "Note on an Eruption

resembling that of Variola in the ^n of a Mummy of the

Twentieth Dynasty/* Joumat of Path, and BacLt 1910-11,

vd. I5» pp. 1-3.

22 THE HISTORY OF MEDICINE

Shattodr, S. G.: "A Report upon the Pathological G>ndition of
the Aorta of King Menephtah, traditionally regarded as the
Pharaoh of the Exodus," Froc. Roy. Soc. Med., vol. u,
Pathological Section, 1909, pp. 122-27.

Smith, G. Elliott, and Jones, F. Wood: TU Arckaohgical Sumy
cj Nubia, Report on Human RanaifUf vol. n. Guro, 1910.

CHAPTER II

HIPPOCRATES THE FATHER OF MEDICINE

Thbee great extraneous influences contributed to
the development of Greek medicine — theology,
philosophy, and athletics. And to the institutions
through which these influences made themselves
felt, namely, the temple, the school, and the gym-
nasium. Hippocrates sustained a well-defined rela*
tion.

Even in the early stage of Greek culture repre-
sented in the Iliad and the Odjrssey the priesthood
played a subordinate part in the healing art. These
Homeric poems, to be sure, speak of disease as due
to the anger of the gods, and tell of the efforts of
the priests to arrest epidemics, as well as of the
recital of appropriate incantations. But the physi-
cians, cunning in the use of medicines, are evidently
distinct from the priests, and form an adjunct of the
warrior caste rather than of the sacerdotal.

In the Iliad, iGsculapius, or Asclepios, is a Thes-
salian chief, who has received from the Centaur
Chiron instruction in the use of drugs; while his
two sons are warriors and army surgeons. By the
beginning of the eighth century B.C., tradition
had endowed him with supernatural powers. He

24 THE HISTORY OF MEDICINE

became an earth god — especially accessible to his
votaries in sleep — and was portrayed with the
snake and staff and other attributes of such a deity.
Not long after, iEsculapius was recognized as the
god of medicine, the son of Apollo, and the father,
not only of the surgeon Machaon and the phymdan
Pod^lirius, but of a younger son, Telesphorus, the
god of convalescence, as well as of Hygeia and
Panacea. Eventually himdreds of temples arose
throughout Hellas, on beautiful and salubrious
sites overlooking the sea and beside healing foun-
tains, dedicated to the worship of Asclepios. Among
the most famous of these were the Asclepieia of
Epidaurus, Cos, Cnidus, Crotona, and Pergamus.

In these healthful places, the strongholds ' of
miraculous medicine, the priests of the temples
were credited with cures comparable with the faith
cures duly attested to-day at Lourdes, Sainte Anne
de Beaupr6, and other Christian shrines. In the
history of the Greek temples there are some indica-
tions of the practice of fraud. The priests of iEscu-
lapius stirred the imaginations and played upon the
superstitions of the sufferers by sacrificial rites and
purifications, by the presence of tame snakes, con-
tact with which brought healing by the power of
the indwelling god, and, in the third place, by temple
sleep or incubation. The suppliant, lying down to
sleep, after due preparation, by the altar of the god,

THE FATHER OF MEDICINE 25

was at times granted a vision of iGsculapius himself,
and was forthwith healed. Sometimes the priest
condescended to impersonate the god, offering
equally efficacious treatment, or dictating remedies.
Again, the suppliant might be permitted to dream
by proxy. Those that were benefited by the sug«
gestions, by the remedies, or by the restorative
power of nature, left tablets telling of their cure, or
other tokens, such as models of the healed parts in
marble, or silver, or gold, the priests taking no
pains to conceal from their patients the therapeutic
virtue of a substantial fee.

Epidaurus, as befitted the reputed birthplace of
iEsculapius, was one of the loudest of the temples
in prodainfiing the benefits of divine healing, and
upon the founding of a new temple this mother
Asclepieion sent the gift of a snake, symbolic of the
god of medicine. Two pillars inscribed with the
record of faith cures have been recovered on the
site of the ancient shrine. The following translations
will indicate how the temple priests sought to over-
come the skepticbm of the Greek mind.

''A man with the fingers of his hand paralysed,
save one. He came a suppliant to the god, and
seeing the tablets in the temple he disbelieved the
cures, and ridiculed the inscriptions, and sleeping
he saw a vision. He seemed to be playing dice, and,
as he was about to throw, the god appeared, seized

26 THE HISTORY OF MEDICINE

his hand, and stretched out the fingers, then he
seemed to bend them up and stretch them out one
by one, and when all were straight the god asked if
he still disbelieved the inscriptions on the tablets,
and he said no. Then he said: 'Fear not for thy
former unbelief, but, that thou mayest believe in
future, thou shalt obtain what a believer obtains *(?)
[the sentence is much mutilated]. And when it was
day he went away whole."

"Ambrosia of Athens, blind of one eye. She came
a suppliant to the god, and going round the temple
ridiculed some of the inscriptions, saying it was
incredible and impossible that the lame and blind
should be cured by seeing a dream-vision only. But
having slept she saw a vision; the god seemed to
stand by her and say that he would heal her, but
would demand as payment a silver pig to be set up
in the temple as a memorial of her stupidity. Hav-
ing thus spoken he opened her diseased eye and
poured medicine on it, and when it was day she
departed cured."

The temple priests must not be confused with the
Asclepiads (Asclepiadae), often in attendance at the
temples, who formed a guild or brotherhood made up,
at first, of physicians claiming descent from iEscu-
lapius. At some of the temples the Asclepiads no
doubt long continued to connive at the theurgy and
charlatanry of the priests. In other places, however»

THE FATHER OF MEDICINE 27

and notably at Cnidus and CoSf they dissociated
themselves from the practice of mystic healing and
taught to their sons and disciples medidne as based
on rational principles.

Among the philosophers who brought the influ-
ence of the schools to bear on the development of
early Greek medicine Pjrthagoras, AlcmaK)ny Em-
pedodes, and Democritus are especially prominent*
Bom about 580 B.c. on the island of Samos, Py-*
thagoras traveled extensively, visiting Egypt and
probably Babylonia, , and settled at Crotona in
South Italy. There he founded a sect or society
which, to its interest in mathematics, ethics, and
other branches of philosophy, added the teaching
and practice of medicine aiid politics* He attended
his followers when they were sick, and advocated
adherence to a strict diet. In the Pythagorean
school there developed a mystical number lore, the
elements of which the master may have learned
from the Egyptian priests or the Chaldean astrol-
ogers. It is difficult to comprehend the peculiar
significance this philosophical school attached to
certain numbers and number relations. For ex-
ample, four was of interest to the Pythagorean
mind as the square of the first even number, and
still more so as symbolizing the perfection of eter-
nally flowing nature. Ten was considered a perfect
number. Something of the sentimental value asso-

/

/

28 THE HISTORY OF MEDICINE

dated with particular numbers by the Pythagoreans,
as well as by the Babylonians and other Extern
peoples, still lingers in the attitude of the imagina-
tive to the sacred number three and the mysterious
number seven. The number lore of the Pythago-
reans is important for us because it later conduced to
the Hippocratic doctrine of critical days.
y Other schools of philosophy had a more direct
interest in medical science. Alcmaeon of Crotona,
philosopher and physician, the first Greek anato-
mist, introduced abdominal section, by animal dis-
sections discovered the optic nerve, attempted to
explain the sense of hearing and the sense of taste,
and recognized the brain as the seat of mental
activity. Sleep and waking are due to the ebb and
flow of the blood, death to its cessation. Health
depends on the harmony of the material elements
of the body — cold, warm, moist, dry, bitter, sweet.
Empedocles of Agrigentum, Sicily, another phil-
osopher-physician, was the first Greek to think of
the universe as composed of four elements.

"Listen, first, while I sing the fourfold root of creation,
Fire, and water, and earth, and the boundless height of the aether,
For therefrom is begotten what is, what was, and what shall be."

Empedocles is said to have freed a town of pestilence

by diverting a stream and draining the marshes in

\ its vicinity, and to have improved the climate of his

native city by blocking up a cleft in the mountains.

THE FATHER OP MEDICINE 29

Democritus, a contemporary and friend of Hippo-
crates, studied the anatomy of animak and the
physiology of reproduction and of the senses. He
taught that all things are composed of an infinite
number of indivisible particles, or atoms, and that
the impressbns made upon our senses are the source
of all knowledge and of all thought.

The influence of athletics on the development of
Greek medicine was essentially different from that
of philosophy. The gymnasts were the devotees of^
practice, not of theory. Through experience they^
acquired skill in the treatment of sprains, disloca-
tions, fractures, and other injuries. They made use'^
of inunctions and fomentations. They controlled /
the weight and proportions of the athletes by
means of purgation, emesis, massage, steam baths,
exercise, and diet. These rude empirics were con-
sulted by the sick, and the gymnast Herodicus of
Selymbria, with whom Hippocrates came into con-
tact, even undertook to reduce fever by methods
borrowed from the gymnasium. Crotona, as fa-
mous for athletics as for theurgy and philosophy,
was the home of the greatest of wrestlers, Milo, six
times crowned victor at the Olympian, six times at
the Pjrthian, games. It is probable that Democedes
of Crotona, the first regular Greek physician of
whose life we have an account, owed some of his
surgical skill to the gynmasium of his native city.

30 THE HISTORY OF MEDICINE

Leaving home as a young man, Democedes became
public physician in rapid succession at iGgina,
Athens, and Samos, his salary as medical officer
mounting from $1200, to $2030, to $28oo» at a time
when the incomes of officials were generally very
low, and the purchasing power of money was very
high. Later he found himself a slave at the court
of Darius, whose favor he gained by healing a
sprained ankle, which had baffled the efforts of the
Egyptian physicians in attendance on the Persian
king, as well as by treating the queen successfully
for abscess of the breast. The one boon of freedom
was withheld. Finally, however, Darius permitted
Democedes to accompany a band of Persian ex-
plorers, the Greek undertaking to guide them in
their search for points on the coast of Italy most
favorable for the landing of a Persian army. Ar-
rived in Calabria, Democedes delivered his com-
panions into the hands of the king of that region.
He then hastened to his native Crotona, where,
shortly after, he married the beautiful daughter of
Milo the athlete.

The three influences that affected Greek medicine,
namely, the theurgic, the theoretic, and the em-
piric, though logically distinct, were not always
separated in fact. The Pythagoreans cultivated
gymnastics as well as dietetics. Milo belonged to
the political faction of the Pythagoreans without

THE FATHER OF MEDICINE 31

necessarily sharing their enthusiasm for pure mathe*
matics and an abstemious diet. The temple priests,
as we have seen, worked at times in conjunction
with the temple physicians, and there is evidence
that some of the Asclepieia were provided with
gymnasiums, in which tissue change was effected
by exercise, diet, and baths. To the combined in-
fluence of the priests, the philosophers, and the
gymnasts, it was natural that the genius of the
greatest physician, bent above all on the successful
treatment of the individual patient, should in some
way respond.

Hippocrates was bom in 460 B.C. at Cos on the
bland of Cos. His father and grandfather were emi-
nent physicians; and his descent has been traced
on the paternal side to iEsculapius, and on the
maternal side to Hercules. He received his first in-
struction in the medical art from his father, and
he may have come under the influence of the
Asclepiads of the neighboring city of Cnidus, as
well as of those of his native place. He traveled
extensively, practicing and teaching, and is known
to have visited the cities of Thrace, Thessaly, Asia
Minor, and the island of Thasus; and he may have
been acquainted with Athens, then at the height of
its glory, and with Scythia, Egypt, and Libya. He
gave instruction at the school of the Asclepiadae of
Cos and trained hb sons and son-in-law in the art.

32 THE HISTORY OF MEDICINE

He died at Lariasa, Thessaly, at a very advanced age*
• An early Hippocratic writing, "The Law,"

' descriptive of the education of an ideal ph]rsician«
throws light on the training of Hippocrates. " Who-
ever b to acquire a competent knowledge of medi-
cine/' it says, "ought to be possessed of the follow-
ing advantages: a natural disposition; instruction;
a favorable portion for the study; early tuition;
/ love cl labor; leisure. First of all, a natural talent
b required; for, when Nature opposes, everything
else is vain; but when Nature leads the way to what
is most excellent, instruction in the art takes place,
which the student must try to appropriate to him-
self by reflection, becoming an early pupil in a place
well adapted for instruction. He must also bring
to the task love of labor and perseverance, so that

., the instruction taking root may bring forth proper
and abundant fruits.

" Instruction in medicine is like the*culture of the
productions of the earth. For our natural disposi-
tion is, as it were, the soil ; the tenets of our teachers,
as it were, the seed ; instruction in youth is like the
planting of the seed in the ground at the proper
season ; the place where the instruction is communi-
cated is like the nourishment imparted to plants by
the atmosphere; diligent study is like the cultiva-
tion of the fields; and it is time which imparts
strength to all things and brings them to maturity."

HIPPOCRATES
The Bust in the British Museum

THE FATHER OF MEDICINE 33

The ancient Oath of the Asdepiads of Cos, also

known to have been written before the time of

Hippocrates, indicates the source of his professional

ethics:

THE OATH

^'I swear by Apollo the physician, and iGscu-
lapius, and Hygeia, and Panacea, and all the gods
and goddesses, that, according to my ability and
judgment, I will keep this Oath and this stipulation
— to reckon him who taught me this Art equally
dear to me as my parents, to share my substance
with him, and relieve his necessities if required; to
look upon his offspring in the same light as my own
brothers, and to teach them this Art, if they should
wish to learn it, without fee or stipulation; and that
by precept, discourse, and every other mode of in-
struction, I will impart a knowledge of the Art
to my own sons, and those of my teachers, and to
disciples bound by a stipulation and oath according
to the law of medicine, but to none others* I will
follow that system of regimen which, accordii^ to
my ability and judgment, I consider for the benefit
of my patients, and abstain from whatever is
deleterious and mischievous* I will give no deadly
medicine to any one if asked, nor suggest any such
counsel; and in like manner I will not give to a
woman a pessary to produce abortion. With purity
and with holiness I will pass my life and practice my

34 THE HISTORY OF MEDICINE

•

Art. I win not cut persons laboring under the stone,
but will leave this to be done by men who are
practitioners of this work« Into whatever houses I
enter, I will go into them for the benefit of the sick,
and will abstain from every voluntary act of mis-
chief and corruption; and further, from the seduc-
tion of females or males, of freemen and slaves.
Whatever, in connection with my professional prac-
tice, or not in ccmnection with it, I see or hear, in
the life of men, which ought not to be spoken of
abroad, I will not divulge, as reckoning that all such
should be kept secret. While I continue to keep this
Oath unviolated, may it be granted to me to enjoy
life and the practice of the Art, respected by all
men, in all times ! But should I trespass and violate
this Oath, may the reverse be my lot ! "

The tendency shown in the Oath to substitute
benevolence, social duty, and moral law for religious
superstition is no less marked in the writings €i
Hippocrates, the contemporary of Socrates. In his
treatise ''On Airs, Water, and Localities," which
deals with disease in relation to geographical and
meteorological conditions, or constitutionst Hippo-
crates states that the Scythians attribute the pre-
mature impotence of some of their men to a god, but
that it appears to him that such affections are just
as much divine as all others are, and that no one
disease is either more divine or more human than

THE FATHER OF MEDICINE 35

another, but that all are alike divine, for each has
its own nature, and that no one arises without a
natural cause. The Hippocratic writing "On the
Sacred Disease," written by some Huxley among
the disciples of the master, deals exclusively with
the claim of epilepsy to be considered divine in its
origin. If diseases are to be called divine because
they are wonderful and ill understood, then the
quotidian, tertian, and quartan fevers seem to the
author of the treatise no less sacred and divine in
their origin than epilepsy. Those who first referred
the latter disease to the gods were probably just
such people as the conjurors, purificators, mounte-
banks, and charlatans of his own time. These give
themselves out, the treatise proceeds, to be ex-
tremely religious, but it is no homage to the gods to
see their manifestation in the symptoms of epilepsy
—outcries, gnashing of the teeth, foaming at the
mouth, contortions, kicking, fever, delirium, fear,
and flight. Then, if the epileptics be divinely
possessed, why must they be submitted to purifica-
tion? They should rather be taken to the temple and
presented to the god, if a god be the cause of the
disease. However, in spite of this vehement con-
troversy, we must not think of Hippocrates and his
followers as atheists. While protesting against an
unworthy conception of divinity, they respected
the traditions, inculcated lofty ideals of profes-

36 THE HISTORY OF MEDICINE

slonal conduct, dignity of deportment, respect for
patients, devotion to universal charity and to
medicine. For, as they declared, where love of man*
kind is, there is also love of the Art.

The Hippocratic respect for tradition led, at the
same time, to a just appreciation of the teaching of
the gynmasium, much of it inherited, no doubt,
from the remote past. The writings of Hippocrates
'.^On Fractures" and '^On Dislocations," which have
been described (by Malgaigne) as the ablest works
ever written by a physician, as well as his treatise
'^On Injuries of the Head," and his other surgical
works, reflect the skill and wisdom resulting from
long experience. He was bold in the use of the
trephine and raspatory, employed ink and pitch
in the manner of the Egyptians, insisted on the
necessity of cleanliness and dryness in the handling
of fresh wounds, mentioned healing by first inten-
tion, referred to exfoliation ct the bone, and to the
dangers of erysipelas, tetanus, and gangrene, noted
the occurrence of fracture by cantre<oup and of
paralysis of the opposite side in cases of lesions
of the brain, described the treatment of compound
fractures, as well as various methods of bandaging
and of reduction with and without apparatus. In
his ''Aphorisms" Hippocrates remarks that it is
not well for athletes to develop tissue to the utmost
limit. Once arrived at the maximum, it is impossible

THE FATHER OF MEDICINE 37

to improve or to remain stationary. Instead of
slowly deteriorating, it b well to reduce rapidly in
order to begin again the process of repair. It is
dangerous, however, to carry methods of reduction
to extremes. In like manner, medicinal evacuations,
if carried to an extreme, aie dangerous; and, also,
a restorative course, if in the extreme, b dangerous.
A slender and restricted diet is always dangerous in
chronic diseases, and also in acute diseases, where
it is not requisite. Again, as diet brought to the
extreme point of attenuation is dangerous, repletion,
when in the extreme, is likewise dangerous.

The Hippocratic book "On Ancient Medicine,*'
which ingeniously traces the origin of the Art to the
practical study of diet carried on by man from the
remotest past, suggests to the physician that ad-
vances are still to be made by continuing the study
with full knowledge of what has already been
achieved. " Wherefore those who devote themselves
to gymnastics and training are always making some
new discovery by pursuing the same line of inquiry,
where, by eating and drinking certain things, they
improve and grow stronger than they were." What
must be said of those who prosecute their inquiries
in the Art by hypothesis rather than by the ancient
method of trial? The former procedure has its
difficulties. " For if hot, or cold, or moist, or dry, be
that which proves injurious to man, and if the per-

38 THE HISTORY OF MEDICINE

son who would treat him properly must apply oold
to the hot, hot to the cold, moist to the dry, and dry
to the moist — let me be presented with a man, not
indeed one of a strong constitution, but one of the
weaker, and let him eat wheat, such as it is supplied
from the thrashing*floor, raw and unprepared, with
raw meat, and let him drink water. By using such a
diet I know that he will suffer much and severely,
for he will experience pains, his body will become
weak, and his bowels deranged, and he will not
subsbt long. What remedy, then, is to be provided
for one so situated? Hot? or cold? or moist? or
dry?" Thus the treatise "On Ancient Medicine"
passes from a consideration of the empirics, con-
demned by Hippocrates only when they went be-
yond their proper sphere, to a criticism of the
theorists, or philosophers.

It has frequently been said that Hippocrates, !n
addition to repudiating the supernatural as a cause
of disease, was the first to separate medicine from
philosophy. That is indeed true if philosophy be
identified with vain speculation. For the fantastic
conjectiu'es of Pythagoras and Empedocles, Hip-
pocrates and his followers substituted a common-
sense philosophy, still potent in our own time.
They held that all general views of the nature of
disease must rest on practice and the use of reason.
All valid thinking is based on the data supplied by

THE FATHER OF MEDICINE 39

the senses, the understanding giving meaning to
these phenomena, noting the manner of their oc*
currence, their times, and the relation between
them of cause and effect. Conclusions must be
grounded in observation. The physician should,
therefore, hold to facts, so as to acquire mastery
in the medical Art. ''Theory b the flower, not the
root of experience/* The famous opening sentences
of the '' Aphorisms" attest the power of a philo*
sophic mind to rise to general conceptions, while
still mindful of the observations and practice from
which they were developed. '' Life is short, and the
Art long; the time is urgent; experiment is danger-
ous, and decision is difficult. The physician must
not only be prepared to do what is right himself,
but also to make the patient, the attendants, and
externals coSperate.*'

Dis^^osis furnished a solid basis for his generaliza-
tions. He observed the color and general state of
the skin and mucous surfaces, the eyes, the facial
expression, the movements of the body, the quantity
and nature of the dejecta and various secretions,
the temperature, and, to some extent, the pulse,
respiration, rash, spasm, sore throat, chills and
fever, localized pains, headache, tenesmus, thirst,
appetite, nausea, vertigo, lassitude, deafness, dis-
ordered vision, fear, loquacity, delirium, coma,
plucking at the bedclothes. He noted the distension

40 THE HI^ORY OF MEDICINE

of the abdomen, and by palpation determined the
enlargement of the liver or the spleen. He took
account of the form of the chest, the character of
the voice, and, employing succussion and ausculta-
tion, detected the signs of pneumohydrothorax or
of pleuritic friction. Not content with the mere
determination of symptoms, Hippocrates has left
us (''Epidemics,*' Books I and m) forty-two case
histories, which remained without parallel in the
history of medicine for about two thousand years.
The following is one of the briefest in the collection :

''Criton, in Thasus, while still on foot, and going
about, was seized with a violent pain in the great
toe; he took to bed the same day, had rigors and
nausea, recovered his heat slightly, at night was
delirious. On the second, swelling of the whole foot,
and about the ankle erythema, with distension, and
small bullae (phlyctaense) ; acute fever; he became
furiously deranged; alvine discharges bilious, un-
mixed, and rather frequent. He died on the second
day from the commencement.'*

Hippocrates did not rest satisfied with the record
of individual cases and their sjntnptoms. In his
treatise ''On Regimen in Acute Diseases'* he ad-
mits that the Asclepiads of Cnidus had described
accurately the symptoms of various diseases, and
even how certain of them terminate; but they had
unduly multiplied species. The physician should

THE FATHER OF MEDICINE 41

not make the number of species of disease as great
as that of their manifestations* In another treatise
{** Prognosdcs^') the Father of Medicine urges upon
the physician the need of so knowing the various
diseases in their specific tendencies and in their
relation to the constitution of the individual patient
as to be able to foretell their course and outcome.
"He should observe thus in acute diseases: first,
the countenance of the patient, if it be like the
countenances of persons in health, and more so, if
like itself, for this is the best of all; whereas the
most opposite to it is the worst, such as the following:
a sharp nose, hollow eyes, collapsed temples; the
ears cold, contracted, and their lobes turned out;
the skin about the forehead being rough, distended
and parched ; the color of the whole face being green,
black, livid, or lead-colored.*' This is the fades
Hippocratica, indicative of approaching dissolution.
We are, of course, indebted to Hippocrates for the
terms acute, chronic, endemic, epidemic, in their
application to disease, for the recognition of the
tuberculous nature of Pott's disease, for the de-
scription of the peculiar respiration ''like that of a
person recollecting himself," for clinical pictures of
various diseases, including puerperal, intermittent
and remittent fevers; the latter especially interesting
since the decline of Hellenic civilization may have
been owing to the ravages of malaria. But a few

42 THE HISTORY OF MEDICINE

quotations from the '^ Aphorisms" will show that,
true to his own teaching, he advanced to a knowl-
edge of diseases in their tendencies and outcome.
''Those cases of epilepsy which come on before
puberty may undergo a change; but those which
come on after twenty-five years of age, for the most
part terminate in death" (v, 7). ''Phthisis most
commonly occurs between the age of eighteen and
thirty-five years" (v, 9). "When sleep puts an end
to delirium, it is a good symptom" (11, 2). In the
same spirit of generalization he says: "An article
of food or drink which is slightly worse, but more
palatable, is to be preferred to such as are better,
but less palatable" (u, 38). "Acute diseases come
to a crisis in fourteen days" (n, 23). "A true
tertian comes to a crisb in seven periods at the
furthest" (iv, 59).

As already implied, a traceof Pythagorean doctrine
can be detected in the Hippocratic theory of critical
days. And a like concession to the four elements of
Empedocles is noticeable in the doctrine of the four
humors. According to this teaching, for the origin
and complete development of which Hippocrates
was not responsible, blood is hot and moist like air,
phlegm is cold and moist like water, yellow bile is
hot and dry like fire, and black bile is cold and dry
like earth. As one or other of these humors pre-
dominated in an individual, he was supposed to be

THE FATHER OF MEDICINE 43

of a sanguine^ phlegmatic, choleric, or melancholy
temperament. This view, which persists in scientific
and general literature even to the present time, may
be illustrated from Shakespeare's *' Julius Caesar,'*
in which play the sanguine Antony, the phlegmatic
Octavius, the choleric Cassius, and the melancholy
Brutus represent the four temperamental tjrpes,
while the ideal character is that in which the four
humors are naturally and harmoniously mingled.
Similarly in the Hippocratic physiologyt health
depended on the crasis, or blending, of the four
juices of the body. Unless they duly blend, there is a
state of dyscrasia, or crudity^ the humors, like raw
food, acting as irritants. Health must be restored
by a process of coction (or pepsis) wherein the in-
ternal heat of the body cooks the crude humors.
Upon this follows a crisis — a separation, or elimi-
nation — of the superfluous substance. The ele-
ments may be restored to a state of harmony and
equilibrium by the remedial power of Nature. It
was faith in this ms medicalrix naturm which led
Hippocrates to adopt an expectant attitude in the
treatment of many of his cases, to abstain at times
from surgical interference, and to prescribe drugs
and cooling drinks as auxiliaries of Nature in the
expulsion of the morbific matter after a fever
crisis.
However it may have been with his followers,

44 THE HISTORY OF MEDICINE

Hippocrates was carried away by no doctrine or
theory. Seeing the particular in the general and the
general in the particular, he bent his comprehensive
genius to the healing of the individual patient.
Plato justly compared him to the Athenian sculptor
Phidias, who beheld the ideal in the real and im-
pressed upon the rocks of Pentelicus the stamp of
an eternal beauty. To enjoy the practice of the Art,
to serve as a model for all true physicians, to be
respected and honored by all men in all times, was
and is the reward and destiny of the greatest of the
Asclepiads.

REFERENCES

Adams, Francb: The Genuine Works of Hippocrates. 2 voh^
London, 1849, 872 pp. (pagination continuous).

Allbutt, (Sir) T. C: *' Essay on the Medicine of the Greeks,*'
MeddctU^Ckkwrpcal Renew, vd. X3cxvin, pp. 483-98. Lon-
don, i866.

Caton, Richard: "Hippocrates and the newly-discovered Health
Temple of Cos," British Medical Journal, 1906, i, pp. 571-74.
(It is illustrated, and alludes to the supposed connection
between the worship of iEsculapius and the worship of
Imhotep.)

Clifton, Frauds: Hippocrates upon Air, Water, and Situation, etc.
London, 1734. 389 pp.

Fihlayson, James: "Hippocrates," Glasgow Medical Journal,
vol. xxxvu, pp. 253-71. 1892. (Excellent review of the
sources.)

Jones, W. H. S.: Malaria, a Neglected Factor in the History of
Greece and Rome. With Introduction by Major (Sir) R. Ross,
and a concluding chapter by G. G. EUett. Cambridge, 1907.
107 pp.

Jones, W. H. S. : Malaria and Greek History, to which is added the
History of Greek Therapeutics and the Malaria Theory, by

THE FATHER OF MEDICINE 45

E. T. WtChingtoiL Mancfaetter, The Unhmnty FktM» 1909.

175 PP-
Witfaington. E. T.: '' The Aaclepiache and the PHesti of Aade-

piii8»" Studies in ike History and Method of Science^ leooiid

series, edited by Charles Singeri pp. I9i-20S. Qaiendon

Fressi igax.

CHAPTER III

ROMAN ANATOMY AND SURGERY

That study of anatomy and practice of surgery
which within the bounds of the Roman Empire
reached their culmination in the first and second
centuries of the Christian era can be traced in their
development from the medical science of the age
of Hippocrates. Diodes of Carystus, who stood
next to the sage of Cos in age and distinction, was a
dissector of animals, and in a work on zootomy
described the heart, the large blood-vessels, and a
greater number of the smaller vessels than had been
recognized in earlier works. He agreed with his
contemporary Plato, as well as one of the less
authentic Hippocratic writings ("On the Heart"),
in looking upon the heart as the source that sent
its streams to all parts of the body. Diodes knew
the oesophagus, the biliary ducts, the caecum, the
ureters, and the Fallopian tubes. He was the in-
ventor of a bandage for the head, and of the graph-
iscus, a spoon-like instrument later used in the
Roman armies to extract arrows and spears from
wounds. He made use of opium as an anodyne, and
distinguished pleurisy from pneumonia. Praxag-
oras of Cos was the first to differentiate veins and

ROMAN ANATOMY AND SURGERY 47

arteries, the former filled with blood, the latter with
vital air, or pneuma. He recorded the local condi*
tions of pleurisy, was the first among the Greeks to
recognize the importance of the pulse in diagnosis,
and advised laparotomy, as a last resort, in in-
testinal obstruction, though there b no evidence
that this operation was actually put in practice in
his age. Diodes and Praxagoras are classed among
the Dogmatists, who were under the influence of
medical speculations concerning the pneuma (which
in the opinion of Diodes was renewed by respira*
tion) and concerning the four humors. For example,
both Diodes and Praxagoras attributed epilepsy to
a derangement of the humors, as did also the specu-
lative philosopher Plato and the author of ''On the
Sacred Disease,'' who was more successful in stating
what is not than what is the cause of that malady.
Aristotle of Stagira, the son of the Asdepiad
Nicomachus and the pupil of Plato, laid the founda-
tions of comparative anatomy by dissecting about
fifty spedes of animals, induding the deer, elephant,
horse, ox, pig, domestic fowl, chamsdeon (which had
been made a spedal study by Democritus), tortoise,
frog, sepia, crab, lobster, murex, and sea-urchin.
He carried into his investigations the experimental
spirit, which, contrary to the teachings of many
historians, was never wanting in the medical sdence
of antiquity. He vivisected some of the lower ani-

48 THE HISTORY OF MEDICINE

mals, discovered that the tails of saurians would
grow again after being cut off, that the chamaeleon
would continue to breathe for a considerable time
after being cut open along its entire length, and he
referred to the movements of the heart of the
tortoise after the organ had been excised. Aristotle
must be credited with a knowledge of the rudiments
of histology, as he recognized the various tissues —
bone, blood, fat, skin, cartilage, hair, connective
tissue, and so forth. He studied the embryos of
various animals, observed the early appearance of
the chick's heart, its brmn and eyes, the rapid
growth of the allantois from the fifth day of incuba*
tion, and the allantoic and vitelline blood-vessels
on the sixth. He was well acquainted in the adult
with the liver, spleen, jejunum, colon, sigmoid
flexure, rectum, the trachea, the brain membranes
and the network of blood-vessels covering the brain,
the structure of the lungs and the richness of their
blood supply. Perhaps his greatest single contribu-
tion was his study of the heart with its chordae
tendinese, and his attempt to describe the arrange-
ment of the blood-vessels, especially the branches
of the aortat as that vessel is called in the writings
of this father of science. A brief quotation from the
''Historia Animalium'* will serve as an example of
the many passages in which Aristotle anticipated
the investigations of modem scientists. "The ear,'*

ROMAN ANATOMY AND SURGERY 49

he says, ** is constructed internally like the trumpet*
shell, and the innermost bone is like the ear itself,
and into it at the end the sound makes its way, as
into the bottom of a jar. This receptacle does not
communicate by any passage with the brain, but
does so with the palate, and a vein extends from the
brain towards it.'' He failed to understand the
function of the nerves that lay before him, and em-
ployed the word neuron to indicate the material of
the tendons, ligaments, and of the fibrin of the
blood.

Luckily the structure and functions of the nerves
and brain were to a considerable extent elucidated
by the investigations of Herophilus and Erasistratus
at the beginning of the third century B.C. They
were enabled to carry on their investigations at
Alexandria through the patronage of the Greek
kings of Egypt, Ptolemy Soter and Ptolemy Phila-
delphus, who placed at their disposal the bodies of
condemned criminals for experiment and dissection.
Herophilus studied the membranes of the brain, the
sinuses of the dura mater, and noted the dilatation
of the superior longitudinal sinus now known as the
wine-press of Herophilus {tarcular HerophUi). He
examined carefully the ventricles of the brain with
their choroid plexuses, especially the fourth ventri-
cle, or ventricle of the cerebellum, which he con-
sidered as the seat of intelligence, and gave the

so THE HISTORY OF MEDICINE

furrow at the floor of the ventricle a name corre-
sponding to the Latin calamus scriptorius. Hero-
philus also traced a number of the nerves to their
connection with the brain and cord, and recognized
their function as transmitters of will and sensation.
Erasistratus, in turn, compared the convolutions
of the cerebrum to the folds of the jejunum, noted
their greater complexity in man than in the lower
animals, and ascribed the difference in complexity
to difference of mental development. He agreed
with Herophilus in regarding the cerebellum as the
special seat of intelligencei and remarked that the
structure of this part of the bnun differs from that
of the cerebrum. Erasistratus further agreed with
Herophilus m dividing nerves into nerves of move-
ment and nerves of sensation. He also taught that
the nerves arise from the brain substance and are
filled with marrow.

Herophilus contributed to other departments of
anatomy. He taught that the arteries arise from
the heart, have coats six times as thick as the veins,
and that they carry blood and pneuma. He called
the pulmonary artery the arterious vein, named the
duodenum according to its length, noted the termi-
nation of the lacteals in gland-like bodies. He de-
scribed the liver with some care, comparing the
liver of man with that of the lower animals. He
examined the salivary glands, the pancreas, the

ROMAN ANATOMY AND SURGERY 51

hyoid bdne^ and named the prostate. We also owe
to Herophilus an early account of the testicles,
epididymis, vas deferens, seminal vesicles, the
uterus, the structure of the ovaries, the spermatic
^ artery, the spermatic vein (even the relation of the
left spermatic to the renal), as well as the uterine
vessels. He wrote a treatise on the eye, describing
the three coats and the vitreous humor, and he im-
proved the operation for cataract. This pioneer in
human dissection practiced general surgery and
wrote a work on obstetrics. Through his teachers
he was in touch with the traditions of both Cos and
Cnidus. He developed the diagnostic methods of
his master Praxagoras, and was the first to describe
the dicrotic pulse. He held the teachings of Hippo-
crates in reverence, and did not abandon the doc-
trine of the four humors. In spite of conservatism
in this respect, Herophilus preferred observation
and experience to theory, and was the first to make
post-mortem examinations.

Erasistratus, bom about 330 B.C., through his
master Metrodorus came under the influence of the
teachings of Aristotle and of the school of Cnidus.
He was the exponent of a more exact method in
medical science than had prevailed before his time,
and as an anatomist and surgeon was not inferior to
his great contemporary Herophilus. He was more
exact than Aristotle or the Hippocratic writings in

52 THE HISTORY OF MEDICINE

the description of the heart, its chordae tendineas
and its valves, and named the tricuspid and sig*
moid. He also gave the trachea its name, and ex-
plained the {miction of the epiglottis. He observed
the lacteals in lower animals and in man. By post-
mortem examination he learned of the hardening
of the liver in cases of dropsy, as well as of the
anatomical conditions following pleurisy and a cer-
tain kind of snake-bite. We are indebted to Erasis-
tratus for a careful description of the normal liver.
Though recognizing design in the structure of the
body, he regarded some parts — the spleen, for
example — as serving no purpose. He failed also to
discover the function of the bile, and, rejecting the
doctrine of the four humors, greatly developed the
doctrine of the pneuma. like Diodes he taught
that the pneuma is renewed by respiration. When
the lungs are expanded, and a vacuum thus is
created, the air enters by the trachea, bronchi, and
bronchial tubes. When the heart dilates, the air
advances from the anastomoses of the bronchial
tubes to the arterioles, and thence by the pulmonary
vein (called by him the "venous artery") to the-
central organ. On the contraction of the heart the
pneuma is forced through the aorta into the general
arterial system, that part which feeds the intelli-
gence passing to the brain. Erasistratus denied, in
agreement with Praxagoras, the principle of inter-

ROMAN ANATOMY AND SURGERY 53

nal heat, and held that the pneuma and the blood
are the sources of the body's energy. The blood b
formed from food, and digestion is a trituration
process, not a coction. Following up his endeavor
to reduce physiology to mechanical principles, he
tried to prove by experiments with birds that there
may occur a loss of body weight other than that due
to visible excretions. Disease is generally caused by
plethora, an overfilling of the vessels. Inflamma-
tion and fever are the result of the plethora of the
veins; arthritis is the manifestation of plethora in
the joints. The presence of blood in the arteries is
pathological, due to the overfilling of the veins or to
a vacuum in the arteries following the escape of
pneuma. Naturally Erasistratus was unable to
anticipate the dbtinction drawn by modem science
between venous blood and arterial, but it is evident
that he turned to account the physical science of his
own times. In spite of his theory of plethora he
seldom resorted to venesection. He likewise ab-
stained from tapping the abdomen in dropsy, be-
cause the operation affected merely a symptom and
did not strike at the cause of the disease. Era-
dstratus invented an S-shaped catheter. He em-
ployed a hook-shaped knife to extract the dead
foetus, and is said to have opened the abdomen in
order to apply medicaments directly to ^the liver
and spleen.

54 THE HISTORY OF MEDICINE

According to the Latin writer, Aulus Cornelius
Celsus, Herophilus and Erasistratus "procured
criminals out of prison, by royal permission, and,
dissecting them alive, contemplated, while they
were still breathing, the parts which nature had
before concealed, considering their position, color,
figure, size, order, hardness, softness, smoothness,
and asperity." This hideous practice, already
alluded to, found advocates and apologists among
the Greeks, some holding "it is by no means cruel,
as most people represent it, by the tortures of a few
guilty, to search after remedies for the whole inno-
cent race of mankind in all ages." Celsus, however,
considered this sort of vivisection both cruel and
superfluous, though dissection is necessary for in-
struction. We learn from him that Ammonius, the
Alexandrian lithotomist, was accustomed to split in
pieces, by means of an instrument, calculi too large
to be removed from the bladder whole. Celsus also
makes mention of Heradides of Tarentum (230
BX.), to whom it first occurred to adapt to the re-
duction of dislocations the mechanical inventions
of Archimedes. Heradides was the greatest of the
Empirics, a medical sect who thought that success
in practice did not depend upon a knowledge of
philosophy or sdence, and that it is more important
to heal disease than to know its cause. According to
them, physidans, as was obviously the case with

ROMAN ANATOMY AND SURGERY 55

farmers and sailors, were in no need of theoretic in-
struction. To Heraclides, the best product of this
narrow school of medical thought, we are indebted
for the investigation of the effects of numerous
drugs, including opium.

Celsus, who flourished in the early part of the first
century A.D., was a Roman patrician and author,
who must be considered an enlightened amateur
and not a professional physician. Of his encyclo-
paedic writings dealing with the so-called Arts —
agriculture, medicine, war, rhetoric, philosophy,
and jurisprudence — only one complete work sur-
vives, namely, "De medicina, libri octo." It is
based on the writings of the Hippocratic and Alex-
andrian epochs and on the Greek medical works of
his contemporaries. It displays a good knowledge
of osteology, particularly of the skull with its su-
tures, foramina, maxillary bones, etc* It shows
that its author held a correct view of the part
played by cartilage in the articulations, and of the
diff^'ence in form between the male and female
pelvis. Among various other matters Celsus speaks
of the carotid arteries, and the cervical glands. In
the neck there begin two passages. Of these alterum
asperam arteriam naminant^ alterum stomachum.
Arteria exterior ad pulmonem, stomachus interior ad
ventriculum fertur: ilia spiritum^ hie cibum recipit.
The oesophagus (stomachus) was known to lead to

56 THE HISTORY OF MEDICINE

the stomach (ventriculus) ; while the trachea (or-
teria) carries air or spirit to the lungs.

The anatomy found in the "De medidna" is
largely incidental, but surgery is the exclusive topic
of two of the eight parts into which the work is
divided. Very little is known of the practice of
surgery at Rome before the time of Celsus, but he
makes mention of Asclepiades (about lOO B.c.)f
who by his tact and urbanity succeeded in gaining
for Greek medicine a foothold in the Roman metro-
polis. Asclepiades advised tracheotomy in certain
cases, employed venesection with discretion, and
noted two instances of spontaneous dislocation of
the femur. However, the distinction between
surgeons and physicians was definitely made among
the Romans, and Asclepiades was known as a
physician rather than as a surgeon. He taught that
the body consists of an infinite number of atoms,
which surround countless minute tubular spaces or
pores, a doctrine that became the fundamental
principle of the Methodic school of medical thought.

The pages of Celsus enable us to see the progress
made in surgery between the fifth century B.C. and
the first century A.D. For example, ligature was
unknown in the Hippocratic era, but Celsus, after
discussing various methods of arresting haemorrhage
— the application of dry lint, cold, compression,
vinegar, corrosives, and caustics — writes: ** Finally»

ROMAN ANATOMY AND SURGERY 57

if the bleeding continuesi the vessels which dis-
charge the blood are to be taken hold of and tied
on both sides of the wounded part, and cut through
in order that they may retract/* In case that such
procedure is impracticable, the red-hot cautery is to
be applied to the bleeding vessel. Sometimes the
application of a cupping instrument near the point
of hemorrhage may prove eflfective.

Contrary to the supposition of one of our writers
of general history the removal of limbs by amputa-
tion was practiced by surgeons before Harvey
demonstrated the circulation of the blood. In fact,
the Father of Medicine, in cases of gangrene, where
loss of limb became inevitable, ventured to assist
nature by amputating at the line of demarcation.
It is to Celsus, however, that we are indebted for the
first detailed description of amputation. Speaking
of him a great modem surgeon. Lord Lister, who
will be the subject of a subsequent chapter, writes:
" He directed that the soft parts should be divided
with a knife down to the bone, and then dissected
up from it for some distance, so as to allow the saw
to be applied at a higher level. The rough surface of
the sawn bone was then to be smoothed off, and the
soft parts, which, as he tells us, will be lax if this
plan be pursued, were to be brought down so as to
cover the end of the bone as far as possible. This
method seems calculated to afford good results;

58 THE HISTORY OF MEDICINE

particularly as it appears prot)able from his writings
that Celsus employed the ligature for arresting
haemorrhage after amputation, and dressed the
stump in a manner favorable to the occurrence of
primary union,"

From the lucid pen of Celsus we have also de-
scriptions of plastic surgery, of Uthotomy, the
couching of cataract, venesection, trephining, relief
of phimosis, urethrotomy, resection, the surgical
treatment of hernia, cancer of the lip, vomica of the
liver, and many other operative procedures. He
mentions suture of the abdominal wall (including
the peritoneum) and of the intestines, recognizes
the advantage to the surgeon of ambidexterity, and
gives the four classical symptoms of inflammation
{Noke vera inflammationes sunt guatuor^ rubor et
tumor f cum colore^ et dolore). There have been dis-
covered in the ruins of Pompeii surgical instruments
that throw further light on the practice of the first
century of the Christian era. These include iron
bistouries, bronze forceps and cupping instruments,
a lancet with silver blade and bronze handle, probes,
a double anal speculum, a three-bladed uterine, and
an S-shaped catheter. Pliny, who was a victim of
the same eruption of Vesuvius (79 a.d.) as destroyed
the city of Pompeii, mentions an artificial iron hand,
which was the product, however, of a much earlier
period than his own.

ROMAN ANATOMY AND SURGERY 59

■

The age following that of Celsus was one of the
most brilliant in the history of anatomy and surg-
ery, though only a small fraction of the medical
literature of the time is now in existence. Marinus»
who lived in the time of Nero (54-68 A.D.)> was the
author of numerous books on anatomy. He is
known for his careful study of the muscles, glands,
and nerves. He described seven pairs cl cranial
nerves, including the auditory, facial, and hypo-
glossal. His knowledge was gained by dissection,
as well as by animal vivisection and experimenta-
tion. About the time that the warlike Trajan, with
the most highly organized armies the Roman
Empire had seen, was extending his dominions to
their utmost limits and celebrating his triumphs by
the exhibition of ten thousand gladiators, there
lived among his subjects Leonides, Rufus, Archi-
genes, Aretseus, Heliodorus, and Soranus of Ephesus.
The last-named was the greatest gynecologist and
obstetrician of antiquity. He made use of the
obstetric chair, practiced version in order to induce
head presentation, and he discarded the old rough
methods of treating pregnant women (jolting on
ladders, etc.) which had been handed down by the
Asclepiads of Cnidus. Soranus had, before going to
Rome at the end of the first century B.C., been
trained in anatomy at Alexandria. He contributed
to the development of general surgery, especially

6o THE HISTORY OF MEDICINE

the treatment of fractures, and of injuries of tlie
head, as well as to various other departments of the
healing art. Unlike his great contemporaries, who
were adherents of the Pneumatic or Ex:lectic schools
of medical thought, Soranus was a Methodist,
following Asdepiades in medical doctrine and Epi-
curus, the disciple of Democritus, in philosophy.
He was naturally opposed to all forms of supersti-
tion, and tried to persuade the midwives to abjure
their reliance on dreams and the practice of mystic
rites and antiquated customs. The influence of
Soranus was greatly extended through the transla*
tion and interpretation of Caelius Aurelianus (fifth
century a.d), the only distinguished writer on medi-
cine, except Celsus, to employ the Latin language
during the period of the Roman Empire.

Rufus of Ephesus was educated at Alexandria,
dissected monkeys and other animals, and experi-
mented on live specimens. He knew that all bodily
function is under the control of the nervous system.
He was acquainted with the recurrent larjmgeal
nerve, and produced loss of voice and of sensibility
by compressing the pneumogastric in the region
of the carotid arteries. He discovered the optic
chiasma, described the capsule of the lens, and the
tortuous course of the uterine artery. As a surgeon
Rufus employed torsion of arteries and digital com-
pression, as well as other means, for the arrest of

ROMAN ANATOMY AND SURGERY 6i

haemorrhage. He associated Filaria
with impure drinking-water, and described leprosy,
which at about this time was carried to the West by
the returning Roman legions, as well as bubonic
plague, traumatic erysipelas, and other diseases.

Flap amputations were performed by Leonides
of Alexandria, and by the two greatest surgeons of
the time of Trajan — Archigenes and Heliodorus,
who, like Ruf us, both employed torsion of vessels to
arrest hsemorrhage. '^ Amputation above the elbow
or knee," writes Heliodorus, ''is very dangerous
owing to the size of the vessels divided. Some
operators in their foolish haste cut through all the
soft parts at one stroke, but it seems to me better
to first divide the flesh on the side away from the
vessels, and then to saw the bone, so as to be ready
at once to check the bleeding when the large vessels
are cut. And before operating I am wont to tie a
ligature above the point of amputation." Speaking
of operating for hernia he writes, ''We ligature the
larger vessels, but as for the smaller ones we catch
them with hooks, and twist them many times, thus
closing their mouths." Even more relevant is his
description of a minor amputation. "A circular
incision," he writes, "is made round the digit near
its base. From this two vertical incisions are made
opposite one another and the flaps so formed dis-
sected up. The base being thus laid bare, the digit is

fo THE HISTORY OP MEDICINE

to ht ranovtBd bjr c iittia^ fbraeps^ aod tke flaps are
UMi wm^iK finpeiiiti aDd witureiL
ttiidertix4c reaecticMM^ and the reoKnral of
and treatad stricture. b)r internal
Ardugenes perforned anqntatians not only for gan-
girene and revere nijiinu» bntt in care of nafignant
tonor or great delbniity« oanstricting the Knb
above the point of anpQtatioOy cutting dovn opon
tlie diief arteries and ligaturing tlienu He removed
mammary and uterine canoen^ e mp lo y ed tke vag-
inal ipeculunit treated injuries of the head, etc
Heliodofus is known only as a sufgeon« but Arcfai-
genes firrrilfd in many departments of w^^tnyf^ ,
Aretanis was pfobaUy indebted to Ardiigenes for
Us knowledge of the vascular system^ of the struc-
ture of the kidney and other ofgans, as well as for
mudi of his dinical wisdom. In the pages of Aretaeus
are found ctassical descriptions of phthisb, tetanus,
diphtheria, epilepsy with its aura, satyriasis, diar
betes, and elephantiasis. There are written in the
Hippocratic spirit. They are not care histories,
however, but generalized pictures that enable the
clinician to know each q^edes of diseare in its ante-
cedents, development, and probable outcome in in-
dividual cases. Aretaeus introduced the term ''syn*
cope^' into pathology, and established the distinc-
tion between paralysis of cerebral origin, involving
decussating fibers, and paralysis of spinal origin.

ROMAN ANATOMY AND SURGERY 63

Galen (130-201 AJ>.) was the greatest anatomist
of antiquity, and, after Hippocrates, the greatest
physician. His voluminous writings reflect the
spirit of the highly organized Empire of the An-
tonines, just as the Hippocratic writings reflect the
freer spirit of the Periclean age. Galen, bom at
Pergamus, directed in his early education by a wise
and cultured father, was early initiated in the
philosophy, medicine, and general learning of his
time. By nature and training an Eclectic, he chose
what seemed to him best in the teachings of all the
schools of philosophy and all the medical sects, and
ultimately harmonized all these in a system of his
own. He was a professed disciple of Hippocrates, a
votary of the Asclepieion of Pergamus, a follower of
Aristotle, a student of the works of Plato, and was
indebted for parts of his medical doctrine to the
dogmatic, empiric, pneumatic, and the methodic
schools of medical thought.

Galen received his training in anatomy at Alex-
andria and other places, and his works on that part
of medical science show that he had diligently
studied the writings of the great Alexandrian
anatomists, of Rufus of Ephesus, and, above all, of
Marinus, the expert dissector. Galen himself ex-
amined with great care the human skeleton, the
muscles of the Barbary ape, the brain of the ox, the
nervous system and the viscera of the pig, the

64 THE HISTORY OF MEDICINE

blood-vessels of the embryo, and dissected and
vivisected many animals — goat, fish, snake, etc.
He was particularly intent on the function of each
part of the body, and, seeking to demonstrate
design in nature and purpose in each structure, he
closely correlated anatomy and physiology. As a
youth of twenty, he had written three books on the
moveinent of the lungs, as well as a treatise for mid-
wives on the anatomy of the uterus; at the age
of twenty-eight, as physician to the gladiators of
Pergamus, he showed special skill in the treatment
of open wounds and of injuries to tendons; and,
leaving his native city for the world's metropolis, he
at the age of thirty-two demonstrated before the
61ite of Roman society by experiments on living
animals the mechanism of the nerves and muscles.
Galen's contributions, however, to the knowledge
of structure are found in almost every department
of the study of anatomy. His descriptions of bones
and ligaments approach the standard of the present
day. He classified the vertebrae as cervical, dorsal,
and lumbar, and employed the terms ** apophysis,"
** epiphysis," "symphysb." He knew in animal
dissection the seven muscles of the eye, named the
platysma, first described the popliteus and the
interossei muscles, and explained the nature of the
muscles involved in mastication, respiration, loco-
motion, etc. He described the branches of the

ROMAN ANATOMY AND SURGERY 65

aorta, the ductus arteriosus, the three coats of the
arteries, was aware of the anastomoses of the
minute veins and arteries, proved, by ligaturing the
femoral artery in two places and making an incision
between the two ligatures, that the arteries contain
blood. He gave directions for the dissection of the
brain, recognized the pituitary body and the in-
fundibulum; by dividing the hemisphere exposed
the corpus callosum and the fornix; by making
sections he studied the ventricles, the corpora
quadrigemina, and other parts of the cerebrum; he
mentioned the vermiform process of the cerebellum.
He carefully traced the course of the trigeminal,
auditory, facial, glossopharjmgeal, and other cranial,
as also the course of the spinal nerves, and the
connections of the vagus and sympathetic. Galen
described the pleura and the pericardium, lungs,
heart, and, very carefully, the abdominal organs,
following Herophilus in the description of the geni-
tals. More impressive than even his knowledge of
neurology or osteology b the method, sjrstematic
and comprehensive, displayed by Galen in his
treatises on anatomy.

As already implied, much of his knowledge of
anatomy is bound up with physiological discussions.
He was able to observe the motion of the exposed
heart in two patients, and noted that the heart con-
tinued to beat in vivisected animals after the large

68 THE HISTORY OF MEDICINE

plastic operations and of tracheotomy, is now re-
garded as a predecessor of Galen. Oribasius (325-
403) was the author of an encyclopaedia of medicine,
which extended the influence of Galen and pre-
served the memory of Archigenes, Heliodorus, and
Antyllus. To Aetius of Constantinople (sixth cen-
tury A.D.) we are likewise indebted for information
concerning the surgery of Rufus, of Leonides (re-
moval of glandular tumors from the neck, etc.)i and,
particularly, of Archigenes. His voluminous work
gives a definite account of the surgical treatment of
aneurism. Alexander of Tralles was the author of a
"Practica." With these Byzantine compilers is
usually mentioned Paul of iEgina (625-690), who
wrote an ''Epitome" of medicine in seven books.
Paul, however, was an expert surgeon and described
a great variety of operations. His treatment of
cataract by depression, his failure to perform
thoracentesis for empyema, an operation which had
been known in Hippocratic times, his neglect of the
methods of version followed by Soranus, and his
practice of removing the testicles in case of scrotal
hernia, indicate that surgery in his time had begun
to relapse from a classical to a medieval standard.
The pages of the ''Epitome" afford some insight
into the practice of military surgery in the armies of
the Roman Empire.
At the time of Trajan there had been twenty

ROMAN ANATOMY AND SURGERY 69

cohorts of garrison troops of one thousand to
fifteen hundred men each, with four surgeons to the
cohort. Nine cohorts of Pretorian guards were in
addition provided with physicians. In the rest of
the Empire there were thirty legions of ten cohorts
and about sixty*five hundred men each. These
troops were attended by surgeons of the legion
{medici legUmis)^ probably six or more to the legion.
They wore the uniform of the legionaries, but were
counted as of superior rank. In the fixed camps
there were special medical officers. About the same
time mention is made of military hospitals, also
provided with regular superintendents. In the
Roman armies of the sixth century every troop of
two hundred to four hundred men was accompanied
by eight or ten men on horseback to pick up the
wounded. These first-aid men carried each a water
flask, and received a gold piece for every man they
rescued. In the military hospitals were male
nurses. For each vessel in the navy, surgeons were
also provided.

REFERENCES

Adams, Francis: [The ExtatU Works of Aretaus (translation).

London, The Sydenham Societ>% 1846. 510 pp.; The Seven

Books of Pauius MgMata (translation in three volumes), vol.

n, pp. 247-511. London, The Sydenham Society, 1846.
Allbutt, Sir Clifford T.: Greek Medicine in Rome. London, 192 1.
Aristotte: Htstoria Ammalium (English translation by D'Airy

Wentworth Thompson). Oxford, Clarendon Phas, 1910.

70 THE HISTORY OF MEDICINE

Vol. IV of the Works of Aristotle, edited by J. A. Smith and

W. D. Ross.
Finlayson, James: "Celsus," Glasgow Medical Journal, vol

xxxvn, 1892, pp. 321-48; "Erasistratus," ibid., vol. xxxix,

pp. 340-52: "Galen," British Medical Journal, 1892, vol. i,

PP* 573f 730, 771; "Herophilus," Glasgow Medical Journal,

1893, vol. XXXIX, pp. 321-40.
Meunier, L£on: HisUnre de la MSdecine. Paris, iQix. 642 pp.
Marx, K. F. H. : Herapkilus, ein Beitrag tur Geschichte dor Medisin.

Carlsruhe and Baden, 1838. 103 pp.
Ttmer, Sir William: "Anatomy," Encyclopadia BritatmicOt

ninth edition.

CHAPTER IV

THE TRANSMISSION OF MEDICAL SCIENCE

BY THE ARABS

Before the death of Paul of JEpnsi the translatioii
of Greek and Syriac medical works into the language
ci the Mohammedan oonquerora of Asia Minor had
b^;un, and even before the end of the fifth century
the medical science of Constantinople had been
carried as far east as the Persian province of Khora-
san by the Nestorian heretics. The school and
hospital at Gondisapor» controlled for the subse-
quent centuries by this Christian sect, became the
focus from which Greek, Syrian, Persian, and In-
dian medical teachings were spread among the
followers of the Prophet* Here was educated the
Arab physician Harets ben Kaladah, who, though
a Christian, became the adviser of Mohanuned in
those hygienic and medical matters which Islam,
like Judaism, made a part of religion. When the
Arab conquerors overran Mesopotamia and Persia,
they left undisturbed their fellow monotheists, the
Nestorian physicians of Gondisapor. Among these
about the middle of the eighth century certain
Syrian families, the Bachtishuas, Messuas, and
Serapions, were especially prominent as translators.

72 THE HISTORY OF MEDICINE

In 765 George Bachtishua, whose influence had for
a time been supreme in the school and hospital of
Gondisapor, was called to the recently founded city
of Bagdad by the Abbaside Caliph al Mansur, who
induced him to undertake the translation of a
number of medical works into Arabic He returned
to Khorasan before his death in 771 » but his son was
later summoned to the court of Harun al Rashid,
and the gnmdson Gabriel and the great-grandson
were famous in the times of that Caliph and his
successors.

The Arabian Nights throws a curious light on the
medical knowledge and general culture of the East-
em Caliphate at the beginning of the ninth century.
Readers of the story of Abu al Husn and his Slave-
Girl will recall how the hero ''ate and drank, and
made merry and took his pleasure, and gave gifts
of gear and coin and was profuse with gold, and
addressed himself to eating fowls and breaking the
seal of wine-flasks and harkening to the giggle of
the daughter of the vine as she guf^led from the
flagon, and enjoying the jingle of the singing girls;
nor did he give over this way of life till his wealth
was wasted and the case worsened and all his goods
went from him, and he bit his hands in bitter
penitence." Then the slave-girl, the last of Abu
al Husn's possessions, said: "O my lord, carry me
to Harun al Rashid» fifth of the Abbasides, and

MEDICAL SCIENCE OF THE ARABS 73

seek of him to my price ten thousand dinars/*
When she is brought before the Caliph, her accom-
plishments and acquisitions are submitted to rigid
inquisition. Among the various branches of learning
open to students of the time she had not neglected
medicine. She proves to be versed in the four ele-
ments, the igm humor s, the thr ee kinds of spirits,
the five seng gt^ Jhe^ three ventricles of the tetin .
The number of veins is unknown, though some have
thought to fix it at three hundred and sixty. There
are two hundred and forty bones, and, contrary to
the teaching of Galen, the mandible, the sternum,
and the sacrum — intermediate between the verte*
brae and the coccyx — consist of one bone each.
The cause of all sickness is repletion and indigestion.
Scurvy may result from eating salt food fasting.
The endive is the most excellent of vegetables.
Fermented liquor banisheth care and gladdeneth
the heart of man, yet its sinfulness is greater than
its use. One should not bathe on a full stomach.
Yellowness of the whites of the eyes is indicative of
jaundice. Medicine is taken to greatest advantage
when Jupiter and Venus are in the ascendant.
Cupping, like venesection, should be practiced in
moderation, and it should be performed in the wane
of the moon, and if it fall on a Tuesday and in the
spring of the year, it will be the more efficacious, etc.
From these fragments it is evident that the Slave-

74 THE HISTORY OF MEDICINE

Girl's medical lore is borrowed from Greek, Hebrew,
Babylonian, and other sources. It is probable that
the corrections of Galen's osteology, a knowledge of
which is attributed in this fourteenth-century tale
to the time of Harun al Rashid, are to be credited
to Abdollatif (1162-1231), who, invited to visit
Egypt in the reign of Saladin, enjoyed greater op-
portunities of studying the human skeleton than
usually came to Mohanunedan phjrsidans.

The first of the Messuas to rise to distincti<M
spent the early part of his life as an apothecary at
Gondisapor, went to Bagdad as a physician, and,
gaining the favor of Harun al Rashid by successful
treatment and prognosis, entered into rivalry with
Gabriel Bachtishua. Messua's son, usually called
Messua the Elder, became the director of a college
of translators at the request of the enlightened
Caliph al Mamun (813-833), who wished to see
translated into the Arabic language the sciences of
all the lands under his sway. Messua the Elder and
Serapion the Elder dispute the honor of having
written the so-called Aphorisms of Damascenus.
Greater, however, as a translator than the Bach-
tishuas, Messuas, or Serapions was Honain ben
Isaac (809-^73), a Christian Arab who put into hb
native tongue the works of Hippocrates, Galen,
Oribasius, and Paul of iEgina, and who wrote a
treatise on ophthalmology and a commentary on

MEDICAL SCIENCE OF THE ARABS 75

Galen (Isagoge). During the ninth century the writ-
ings of Archigenes, Dioscorides, Ruf us, Aristotle and
other Greeks were likewise made accessible to read-
ers of Arabic. At the same time the Arabs revised
Syriac translations from the Greek, which had been
made by Sergius in the sixth century, and translated
a Syriac work C'Practica**) written by Serapion.

The greatest of all the physicians to write in Ara*
bic was the Persian Rhazes (860-^32), who studied
at Bagdad and was the author of a comprehensive
work on medicine, the ^* Continens,*' a briefer work,
the '' Almansor,'* and a treatise on the smallpox and
measles. He taught that inquietude, anxiety, and
nausea are more frequent in the measles than in the
smallpox; while, on the other hand, pain in the back
is more peculiar to the smallpox than to the measles.
He considered these diseases (the task of clearly
differentiating which was ultimately accomplished
by an English clinician) as an inevitable accompani-
ment of a natural change in the condition of the
blood. "Now the smallpox arises,*' he says, "wheQ
the blood putrefies and ferments, so that the super-
fluous vapors are thrown out of it, and it is changed
from the blood of infants, which is like must, into
the blood of young men, which is like wine perfectly
ripened: and the smallpox itself may be compared
to the fermentation and effervescence which takes
place in must." And this is the reason why children.

76 THE HISTORY OF MEDICINE

especially males, rarely escape being seized with
this disease, because it is impossible to prevent
must — the nature of which is to effervesce and
ferment — from changing into the state that super-
venes. In young men, the maturation of the blood
having been established, the disease seldom occurs,
except in those cases in which a mild form, which
has not brought to perfection the transition of the
blood from the first state to the second, has been
suffered in childhood. Old men are not susceptible
except in pestilential, putrid, and malignant consti-
tutions of the air, in which this disease is chiefly
prevalent. Rhazes sought by treatment to bring it
about that the unavoidable change in the blood
*' should not be effected all at once and in a short
time, with ebullition and fermentation, which are
accompanied by frightful and dangerous accidents,
but little by little, and in a long time, and gradually,
by way of ripening, not putrefaction, and without
fevers." He even sought to anticipate the occur-
rence of the disease.

There is no doubt that Rhazes was markedly
original as compared with other writers in Arabic
on medicine. He was called the "Experimenter/'
"I do not suppose," he says, "that any great harm
would happen to a man who should drink metallic
mercury except severe pains in the stomach and
intestines. I gave some to an ape which I had, nor

MEDICAL SCIENCE OF THE ARABS 77

did I see any evil befall him beyond that above
mentioned, which I conclude from the fact that he
twisted about, and kept biting at his stomach, and
pawing it with his hands/' He made use of mer-
curial ointments, and gave the first clear description
of spina ventosa. Asked to choose a site for a
hospital in Bagdad, Rhazes hung pieces of meat in
different parts of the city in order to ascertain the
place least favorable to putrefaction. Nevertheless,
in spite of the evident independence of his spirit, he
insbted on the value to the physician of supple-
menting personal experience by a knowledge of the
history of the medical profession. And when we
turn to his larger wcH-ks, which also treat of smallpox
and measles, we find to what an extent he relied on
his Greek and Arabic predecessors. In the "Con*
tinens*' (the ninth book of which was in the six*-
teenth century translated into Latin by Vesalius)
he refers to a dozen writers who had turned their
attention to the study of smallpox before his time.
These include Aaron, a Christian priest and physi-
cian, who had flourished at Alexandria in the first
half of the seventh century; Isaac, son of Honain,
more distinguished as a physician, no less expert as
a translator, than his father ; and Messua the Elder,
who had anticipated what seemed most original in
Rhazes, the view that smallpox is caused by an
innate contagion, or ferment, in the blood.

78 THE HISTORY OF MEDICINE

Two other Persian physicians^ Haly Abbas and
Avicennai preserved in encyclopaedic works written
in Arabic the medical science of the ancients. The
''liber Regis" of the former is largely based on
Galen, and epitomizes the knowledge of the Arabs
of the tenth century. It contains a good account of
the symptoms and treatment of diabetes, a disease
that had been described by Aretaeus and by one of
the great physicians of India; it refers to anthrax,
which was probably known to Rhazes as well as to
Hippocrates, whom Haly Abbas regarded as the
prince of the medical art* The book also gives
directions for the treatment of melancholy and other
forms of mental disorder. Haly Abbas advocated
the search for new drugs, the virtues of which should
be tested on animals. He held that the student of
medicine should not neglect the opportunities
offered for observation in hospital and private
practice. Avicenna (980-1036) in his ''Canon''
gave systematic and logical expression to Arabic
medical science. He based his doctrines on those of
Aristotle and Galen, and he is particularly compar-
able with the latter as a medical philosopher, whose
writings mark the culmination of a long period of
development. His book supplanted the "Conti-
nens" and the "Liber Regis,'' and for centuries
continued to be the authoritative textbook of medi-
cine in the Western world, as well as in the Eastern,

MEDICAL SCIENCE OF THE ARABS 79

wheret indeed, its influence is still dominant.
Avicenna described leprosy, already known to
Aretaeus; treated spinal deformities, as had Hippoc-
rates, by forcible reduction; observed filaria medi-
nensb, as had Leonides of Alexandria, not to men-
tion Agatharcides of Cnidus (second century B.c.)f
Soranus of Ephesus, and others. Avicenna empha-
sized the importance of diet and regimen, and paid
particular attention to sldn diseases and nervous
affections. Among other directions for determining
the value of drugs, he mentions experiment on
human beings. He was bolder than Paul of iEgina
in operating for empyema, advocated the use of
forceps in obstetrics, and, though addicted to the
cautery rather than the knife, employed the ligature
as one of the means of checking haemorrhage.

Isaac Judaeus (850-950) was a contemporary of
Rhazes rather than of Avicenna, but his mention
here will serve to mark the westward migration of
Arabian culture. He practiced in Egypt, and later
settled in Kairwan (Tunis), the sacred city of
Northern Africa. He was known for his treatment
of eye troubles, and left treatises on diet, urine,
fevers, etc. Besides these writings in Arabic, he is
also credited with producing in Hebrew ^'The
Physician's Guide,'' which reflects the wisdom of
an experienced practitioner, as the following quota-
tions bear witness. ** He whose business it is to bore

8o THE HISTORY OF MEDICINE

pearls must do his work carefully in order not to
mar its beauty by haste. Even so he who under-
takes the cure of human bodies, the noblest crea-
tions on earth, should take thought upon the
diseases with which he comes in contact and give
his directions after careful reflection, so that he fall
into no irremediable error. • . • The chief task of the
physician b to prevent disease. • . . The majority
of diseases are cured by nature. The more you
demand for your treatment and the more highly
you esteem your cure, so much the higher will you
stand in the eyes of the people. Your art will be
held of no account only by those whom you treat
gratuitously. . • • Visit not the patient too often,
nor remain too long with him, unless the treatment
demand it, for it is only the fresh encounter that
gives pleasure.'*

Albucasis (912-1013), Avenzoar ( -1162),
Averroes (ii 26^-98), and Moses Maimonides (1135-
1204) belong to the Western Caliphate. Avenzoar
was born in the neighborhood of Seville, Albucasis
near Cordova; while the other two were bom in that
capital, which as early as the tenth century boasted
one million inhabitants, hundreds of mosques, nu-
merous and splendid public libraries, and flourish*
ing institutions of higher learning which became the
models of the later European universities. Albucasis
was the greatest of the Arab surgeons, and fully

MEDICAL SCIENCE OF THE ARABS 8i

■

recognized the value to the surgeon of a knowledge
of anatomy. The last part of the "Tasrif," or col-
lected works, is devoted to surgery, and, published
separately and illustrated, is the earliest distinct
work on that subject. It is based on the sixth book
of Paul of iGgina* Albucasis, as was usual with the
Arab physicians, emphasized the importance of the
cautery, although the use of the ligature was also
known to him. He gave directions for the surgical
treatment ol defective, loose, and irr^:ular teeth.
He described a case of extra-uterine pregnancy,
anticipated the Walcher position in obstetric cases
with presentation of knees and hands, and his
illustrations picture forceps with crossed handles.
Albucasis employed a more developed form of
syringe than the bladder fitted with a reed used in
antiquity, and was aware of the occurrence of
haemophilia, and of salivation following the external
use of mercury. ''Avoid perilous practices," he
writes, ''as I have already warned you, so shall you
have the more praise and profit, if God will.''

Avenzoar was the greatest of the Arab physicians
after the time of Rhazes, and like him tempered his
reverence of the past with a self-respecting reliance
on his own clinical observations. The pages of his
chief work "al-Teisir" (Assistance) report a number
of interesting cases — an abscess of the pericardium
which, while Avenzoar was still a student, caused

82 THE HISTORY OF MEDICINE

the death of his father, an abscess of the mediasti*
num from which he himself recovered after cough-
ing up sanious matter, an inflammation of the
middle ear, cancer of the stomach, a hernia cured
by rest. In the case of a patient suffering from a
paralysis of the gullet he poured milk into the
stomach by means of a tube passed into the oesopha-
gus and made use of nutrient enemata. He per*
formed tracheotomy experimentally on a goat and
reconmiended resort to that operation in cases of
threatened suffocation. He recognized tuberculosis
of the intestines, and, like many physicians of
antiquity, prescribed milk for phthisis. '^ Some-
times there arise on the body,** he says, ^' under the
external skin, little swellings which are commonly
called Mtch,' and if the skin be removed there issues
from various parts a very small beast, so small that
he is hardly visible." Avenzoar was a surgeon as
well as a physician, and justly appreciated the
knowledge of osteology and of anatomy in general.
He dedicated his great medical work to his friend
and disciple Averroes, who was more eminent as a
philosopher and as the commentator of Aristotle
than as a physician, though he wrote a work — the
^'CoUiget" — on the general principles of medicine.
His enthusiasm for the teachings of Aristotle
tended to weaken the authority of Galen, who for
centuries had been regarded as almost infallible in

MEDICAL SCIENCE OF THE ARABS 83

spite of the independence of Avenzoar and other
Arab physicians. As a philosopher Averroes did not
believe in personal immortality, and, consequently,
he was regarded as a heretic both by the Christians
and by the Mohammedans. Toward the end of the
twelfth century Arabic culture in Spain was checked
by a recrudescence of orthodoxy, and after the
death of Averroes the medical science of the Arabs
suffered a rapid decline.

The great Jewish Rabbi Moees Maimonides,
driven from his native country by the persecution
of fanatics, eventually found protection and patron-
age at Cairo from the hands of the tolerant and
enlightened Sultan Saladin. It was in response to
Saladin's request for advice on matters of health
that Msumonides prepared his most interesting
medical treatise, the ''Book of Counsel'' C'Trac-
tatus de Regimine Sanitatis"). In the preface,
addressed to Saladin, the author describes the four
parts comprised in the treatise: ''The first is a brief
explanation of the general rules of health ; the second
is for those sick persons who cannot find a physi-
cian, or, at least, not one whom they can trust; the
third contains the regimen proper for my lord's case,
as it has been described to me; the fourth treats of
matters useful to sick and well in all times and
places." Maimonides wrote also a commentary on
the "Aphorisms" of Hippocrates, summarized the

84 THE HISTORY OF MEDICINE

writings of Galen, prepared a book of ^'Aphorisms'*
with quotations from Galen (whose errors and in-
consistencies, however, he does not hesitate to ex-
pose), as well as treatises on asthma, on poisons, on
dietetics, and a translation of a book of Avicenna.
Like that Persian physician Maimonides .was a
disciple of Aristotle and of Galen.

The chief wcMrk of Haly Abbas, a book of Galen's,
the '^Aphorisms" of Hippocrates with the conmients
of Galen, the treatises on fevers and on urine of
Isaac Judaeus were translated from Arabic to Latin
by Constantine the African in the eleventh century.
In the twelfth century Gerard of Cremona did a like
service for the '^ Aphorisms" of Damascenus, the
"Practica" of Serapion the Elder, the "Canon" of
Avicenna, a part of the writings of Rhazes, Albu-
casis, and other Arab physicians; while the greater
part of Galen and the ''Introduction" ("Isagoge")
of Honain were likewise translated. The'Xolliget"
of Averroes and the "Book of Counsel" of Mai«
monides were made accessible to Christian nations
about the middle of the thirteenth century. That
very much of the medical science of the Arabs was
available in western Europe at the beginning of the
fourteenth century is manifest in the pages of the
" Rosa Medicinae" of John of Gaddesden, who drew
his materials from translations of Greek, Arabian,
and Jewish physicians and from the works of Gil-

MEDICAL SCIENCE OF THE ARABS 85

bert the EngHshman^ who died in 1250, and the
French physician Bernard de Gordon, who taught
at Montpellier from 1285 till 1307. John of Gaddes-
den does not refer to the writings of Avenzoar»
which were later translated into Latin and printed
in Venice (1490). The English physician, however,
knows of Avenzoar, and maintains on his authority
that the brilliant smaragdus found in the head of
the green toad, if triturated with water or wine and
given in a nine-grain dose, is an effective emetic in
cases of poisoning.

The belief in astiology, which had early prevailed
in the Orient, spread throughout the civilized world,
and was cultivated at Alexandria and Rome long
before the time of the Arab conquests. Galen shared
the superstitious views of his contemporaries as
regards the influence of the heavenly bodies on
one's health and fate, and, though his disciple
Avicenna wrote a treatise on the uselessness of
astrology, this pseudo-science continued to form a
part of medical teaching for centuries. Purging and
blood-letting were regulated in accordance with the
positions of the planets and the signs of the zodiac.
Medicinal plants were gathered under the appro-
priate planetary influence. The moon was supposed
to rule the brain, Mars the bile, Saturn the spleen,
etc. Moreover, since among the Babylonians from
the very remotest times the sun, moon, and the five

88 THE HISTORY OF MEDICINE

that the metals are condensed vapors, in the ax-
teenth-century doctrine that three invisible sub-
stances, sulphur, mercury, and salt, by their
coagulation form physical bodies. Even at the
present time some trace of the two pseudo-sdences,
alchemy and astrology, remains in our use of the
terms spirits of wine, spirits of nitre, tincture,
martian preparations, saturnine compounds, lunar
caustic, jovial disposition, etc*

The pharmacy of the Arabs, interrelated with
their chemistry and botany, in the early centuries
of Mohammedan civilization had already made a
considerable advance. It is at this period that we
first hear of trade in drugs, developed from trade in
spices, as a distinct vocation. The father of Honain,
as well as the founder of the fortunes of the Messua
family, was an apothecary. As early as the eighth
century public pharmacies were established at
Gondisapor and at Bagdad. The Arabs derived a
knowledge of drugs from the Egyptians, the Hindus,
and even more remote peoples with whom they
came into commercial relations. They trandated
Dioscorides and knew of the Greek in addition to
the Indian means of producing anaesthesia. Before
the end of the ninth century the first pharmaco-
poeia had issued from the hospital at Gondisapor.
We have already noted an inclination among the
great Persian physicians to experiment on the

MEDICAL SCIENCE OF THE ARABS 89

effects of drugs. Isaac Judaeus advocated care and
restraint in the use of remedies. Moses Maimonides,
as already implied, showed the interest of his time
in the study of toxicology. Avenzoar excelled in a
knowledge of drugs, and was opposed to the use of
purgatives, but showed himself rather credulous in
reference to the virtues of the smaragdus, bezoars.
theriacsi and mithridates. Very important in the
history of materia medica are the Latin writings of
the tenth or eleventh century attributed to Messua
the Younger, which went through numerous edi*
tions and formed the basis of the European pharma-
copoeias. The work issued somewhat later under the
name of Serapion the Younger was also a very in«
fluential book of doubtful authenticity. The most
extensive work in Arabic on materia medica was
that written by Ibn Baitar in the thirteenth cen-
tury, who describes some four thousand drugs and
draws his material from Dioscorides, Galen, and
earlier Arab writers and supplements it with his
own observations. Senna, and other mild aperients,
orange, lemon, tragacanth, and other adjuvants,
syrups, juleps, robs, and other methods of admin-
btration, alcohol, and other products of distillation,
were known throughout Europe from the Arab
treatises on pharmacy. Besides the drugs already
mentioned, the following became widely used owing
to the influence of the Arabs: aconite, aloes, amber-

90 THE HISTORY OF MEDICINE

gris, camphor, cannabis indica, doves, cubebs, gold,
manna, mercury, musk, nutmeg, prunes, tamarind,
violet-root, rose-water, sandalwood, etc.

Arab institutions for the care of the sick were
modeled after the infirmaries and hospitals of other
nations. Besides the temples of health the Greeks
had had public iatreia, difficult to distinguish from
hospitals. Infirmaries for the indigait had existed
in India and Ceylon for centuries before the be-
ginning of the Christian era. The Romans provided
valetudinaria for slaves and for soldiers* At Edessa
in 372 a hospital of three hundred beds was estab-
lished under Christian auspices, and to this were
added in the following century a hospital for women
and a school of medicine. The Nestorians, who for
a time controlled these institutions, were compelled
in 489 to take refuge in Persia. Shortly after their
arrival in Persia the Nestorians, as we have already
seen, were engaged in the teaching of medicine in
the school and hospital at Gondisapor. The latter
became the model of institutions founded by the
Arabs in more than twenty of their cities. The first
of these was established at Damascus in 707. Spe-
cial provision was there made for the care of lepers
and the blind. Before the middle of th^ ninth cen-
tury, Bagdad had a hospital of which Messua the
Elder became director, and numerous other hospi-
tals arose in that city in the subsequent centuries,

MEDICAL SCIENCE OF THE ARABS 91

and with <me of these the great Rhazes was asso*
ciated, as we have seen. The most famous of the
Arab hospitals were the hospital founded at Damas-
cus about 1 160 by Nureddin, as a thank-ofiFering for
the deliverance of Islam from the menace of the
Second Crusade, and the Mansur Hospital of Cairo,
erected (1284) for rulers and subjects, freemen and
slaves, rich and poor, men and women. At Damas-
cus, Bagdad, and Cairo, provision was made for
medical education, libraries were established, and
courses of public lectures were given. The knoiN^-
edge of ophthalmology was particularly advanced,
and the insane were treated with much more con-
sideration by the Arabs than by the Christians of
the same period. In the Western Caliphate there
were numerous hospitals in Cordova and other
cities. In the twelfth century Avenzoar was superin-
tendent of a hospital at Seville.

It is true that the Arabs contributed little to the
advance of anatomy, for their beliefs made dis-
section a forbidden practice. They believed that in
the world to come the body must be subjected to the
examination of two angels, and that the absence of
any part might endanger the eternal happiness of
the person. Moreover, they held that death was a
gradual process only complete with putrefaction,
and that contact with a dead body was a contami-
nation. Nevertheless, though it was left for the age

92 THE HISTORY OF MEDICINE

following that of the dommance of the Arabs to
build upon the foundationa laid by the ancients in
the department of anatomy, in this field also there
is evidence of the transmission of medical science
through the channel of Arabic literature. When we
use the terms ligamentum nuchae, sagittal suture,
dura mater, pia mater, infundibulum, or speak of
the cochlea of the ear, or the auricles of the heart,
we adopt a nomenclature^ suggested by the writings
of Arab physicians, just as when we use the terms
Adam's apple, and cauda equina, we follow the
figurative mode of expression of the Jewish physt-
dans, associated at times, as we have seen, with the
Arabs.

REFERENCES

Arabian NiglUs, translated by Sir R. F. Burton In twelve volumea.
London, i8(H. Vol. iv, pp. 171-80.

Berthebt, M.: Introduction d Vkude de la ckimie des and^s H du
moym dge. Paris, 1899. 330 pp.; Les arigines de Vakkimie.
Paris, 1885, 446 PP-

Browne^ E. G.: Arabian Medicine. Cambridge> 1921. 139 pp.

Cholmeley, H. P.: John of Gaddesden and the JRosq Medicina.
Oxford, Clarendon Press, 1912. 184 pp.

Greenhill, W. A.: A Treatise an the Smallpox and Measles. By
Abu Beer Mohammed ibn Zacariya Ar-razi (commonly
called Rhazes). Translated from the Original Arabia Lon-
don, The Sydenham Sodety, 1848. 3ia pp.

Hopkins, A. J.: "Eadiest Alchemy," The Scientific Monthly, June,

19181 pp. 530-37.
Hyrtl, Joseph: Das Arabische und HArOische in der Anatomie.

Vienna, 1879. 311 pp.

Levy, Reuben: ''The 'Tractatus de Causts et Indiciis Morborum,'

Attributed to Maimonides," ix 225 in Studies in the History

MEDICAL SCIENCE OF THE ARABS 93

and Method ef Sciene^f edited by Charles Sii^;er. Oxford^

Qarendon PresB, 1917.
Spencer, Dr. Herbert: "Mercurio'sor Waldier's Positioii," Lancet,

1913, vol. I, pp. 1568-69.
Jewish Encyclopedia: "Moses ben Maimon,*' "Medidne," eta

CHAPTER V

THE REVIVAL OF ANATOMY AND SURGERY
IN THE SIXTEENTH CENTURY

Thb rise of modem anatomy and surgery is closely
associated with the development of the Italian and
French universities. Southern Italy was the natural
meeting-place of the influences that contributed to
the growth of medical science in the eleventh^
twelfth, and thirteenth centuries, and the tradition
that the University of Salerno owed its origin to the
combined efforts of an Arab, a Jew, a Greek, and a
Roman, may be accepted as indicating the sources
from which the Salemitan teachers of medicine de-
rived their doctrines. Much of the teaching in the
''civitas Hippocratica," as Salerno was called, re-
lated to diet and other matters of hygiene, but
anatomy and surgery were by no means overlooked.
One of the earlier teachers at Salerno, Copho the
Younger, a Jew, was the author of "De Anatome
Porci,*' the first modem work on anatomy (about
iioo). Toward the dose of the twelfth century,
another of the Salemitan doctors, Roger of Palermo, ]
wrote a treatise on surgery, " Practica," which was
revised by his pupil Roland of Parma in the thir-
teenth century. In the section dealing with wounds

THE SIXTEENTH CENTURY 95

of the intestines, the surgeon is directed to insert in
the intestinal canal a small tubular piece of elder
and then to stitch the raw edges of the bowel to-
gether over it. In the school of Salerno women were
admitted both as students and teachers, and one
of them, Mercuriada, wrote a treatise on surgery.
Nicholas of Salerno, in his '' Antidotarium," speaks
oi a soporific sponge, prepared by saturating a
natural sponge with a solution of mandragora,
opium, hyoscyamus, lettuce, camphor, and nenu-
phar. This anodyne was dried, kept till needed, and
then moistened with hot water or steam, and held
to the patient's nostrils till sleep was induced.

Bologna, the second of the European universities,
contributed to the advance of surgery and anatomy
through the work of Hugh of Lucca, his son Theo-
doric, Bishop of Cervia, William of Saliceto, Mon-
dino, and his pupil Bertuccio. Hugh of Lucca, who
is known to us through the writings of Theodoric,
was appointed city surgeon of Bologna in 12 14, a
few years later had experience of military surgery
with the Crusaders in Egypt and Syria, and died at
an advanced age about the middle of the thirteenth
century. He observed strict cleanliness in the treat-
ment of wounds, avoided the use of the probe, and
employed compresses soaked in wine. Theodoric is
quite definite concerning the advance made at
Bologna in surgery, "For," he states, "it is not

96 THE HISTORY OF MEDICINE

necessary, as Roger and Roland have written, as
many of their disciples teach, and as all modem
surgeons profess, that pus should be generated in
wounds. No error can be greater than this. Such a
practice is indeed to hinder nature, to prolong the
disease, and to prevent the conglutinaticm and
consolidation of the wound." Both Hugh and
Theodoric made use of anaesthetic sponges similar
to those described by Nicholas of Salerno. William
oi Salicejto (i 201-1977) was, however, the greatest
surgeon of the thirteenth century, and the author of
a systematic work on surgery C'Cyrurgia"). Like
Hugh of Lucca he had had experience on the field of
battle. He described wounds of various kinds, the
suturing of intestines and nerves, the treatment of
fractures and dislocations. His influence tended to
restore the use of the knife in surgery, though he
devoted considerable space to the discussion of
different methods of cauterization. Saliceto dis*
tinguished between haemorrhage from arteries and
veins, but his knowledge of anatomy was, like that
of all his contemporaries, very limited.

The practice of human dissection, which had been
held in abeyance by the force of traditional senti*
ment and religious prejudice from the third century
B.C. was indeed resumed to a certain extent in the
thirteenth century, but it was not till 13 16 that a
treatise on anatomy written by one who had dis«

THE SIXTEENTH CENTURY 97

fleeted the human cadaver made its appearance.
This was the work of Mondino (^'De cxnnibus
humani corporis interioribus membris Anathomia '')»
who had made numerous dissections, two of which
Qanuary and March, 13 15) are particularly men-
ticmed. In the work of dissection, Mondino was
aided by an able prosector, Otto Agenius Lustro-
lanus, and a devoted girl disciple, Alexandra Galiani.
It is further evidence of the enthusiasm for dissec-
tion in the University of Bologna at the beginning
of the fourteenth century that three years after the
appearance of the *' Anathomia'' four students were
brought to trial for having carried off by night the
body of a criminal, which they and others of their
kind were intent upon dissecting.

Peter of Abano, a friend of Mondino's and also a
dissector, but much better known as an exponent of
the philosophy of AverroSs than as an anatomist,
taught at the University of Padua; while Arnold of
Villanova, who wrote on surgery as well as on
alchemy and general medicine and, like Peter of
Abano, was accused of heresy, stood associated with
the famous school of Montpellier. More important
than either of these from our present point of view
was Lanfranchi, a third contemporary of Mondino's
and a pupil of Saliceto's, who, about the close of the
thirteenth century, carried to Lyons and to the Col-
lege of Saint Cdme at Paris the teaching and prac-

98 THE HISTORY OF MEDICINE

tice of Bolognese surgery. He was the author of two
works on surgery ("Chirurgia Parva" and "Chi-
rurgia Magna"), and, like his master, protested
against the tendency to fix a line between the func-
tion of the surgeon and the function of the physi-
cian, and between practice and theory. Lanfranchi
gave a good account of the symptoms of fracture of
the skull, and was the first to describe concussion
of the brain. He recommended ligature among
the means of arresting haemorrhage, held that ex-
posure to the air favors the formation of pus in
wounds, and advised neurotomy in cases of trau-
matic tetanus. Henri de Mondeville, the pupil of
Lanfranchi and Theodoric, who studied at Mont-
pellier as well as at Paris and Bologna, aided in the
introduction of Italian methods of surgery into the
French schools. He was the physician of Philip the
Fair and frequently attended that monarch and the
Count of Valois during their military campaigns.
Mondeville lectured on anatomy at the University
of Montpellier in 1304, and set forth views of the
structure and function of the body strongly remi-
niscent of the teachings of Galen and the nomen-
clature of the Arabs. His surgery, however, showed
the influence of his Italian masters and contem-
poraries. "Many more surgeons," he remarks with
characteristic incisiveness, "know how to cause
suppuration than to heal a wound."

THE SIXTEENTH CENTURY 99

Guy de Chauliac (1300-70) was the greatest
surgeon of the fourteenth century. The son of
humble country people of the French province of
Auveiigne, he studied at Toulouse, Montpellier,
Paris, and Bologna. He learned anatomy from
Bertruccio, who taught dissection in four sessions
devoted to the abdomen, thorax, head, and extremi-
ties, and made use of dried specimens and bones
prepared by boiling. De Chauliac was also in-
debted to certain anatomical illustrations (eighteen)
of Mondeville's. The 'Xhirurgia Magna" (1363),
one of the greatest contributions to the development
of surgery, shows that Guy de Chauliac was ac-
quainted with medical history from the time of
Hippocrates, and was under special obligation to
Galen, Avicenna, Albucasis, and other Arabic writ-
ers, as well as to his immediate predecessors in the
French and Italian universities. At the same time
his extensive knowledge of the practice and theory
of others did not deprive him of independence
and self-confidence. "For," he said, ''we are like
children astride the neck of a giant, who see all the
giant sees and something besides." In cases of
fracture of the femur, in addition to splints reaching
to the foot he employed a box or trusses of straw to
support the limb and attached to the foot a lead
weight by means of a cord passing over a little
pulley. He followed Theodoric and others in using

100 THE HISTORY OF MEDICINE

narcotic inhalations to produce insensibility to pain,
but adopted the theory of coction of irritant humors
and laudable pus in the treatment of wounds. Like
Saliceto he believed in restricting the use of the
actual cautery, and advocated a close alliance be-
tween surgery and medicine. He taught that cancer
should be treated at an early stage and preferably
with the knife; he gave directions for complete
ablation of the gland in case of adenitis, and for
suturing the intestines; he made use of the speculum
in certain obstetrical operations; he gave an account
of the Csesarean operation following the death of the
mother. True to his own principles he did not con-
fine his attention to surgery, but gained acquaint-
ance with all the medical science of his time. He
introduced the use of sugar in medicinal prepara-
tions, and gave a careful description of the sjrmp-
toms of leprosy to prevent the isolation of patients
unjustly suspected of being lepers and to protect
the general public against contagion. Much of Guy
de Chauliac^s life was passed at Avignon where he
was the physician of Pope Clement VI and his
successors. In the Black Death epidemics of 1348 *
and 1360 he took part in combating the pestilence,
of the different forms of which he has left descrip- ^
tions. Some of the manuscripts of the ''Chirurgia
Magna" contain illustrations of the opening of
inguinal and axillary abscesses, of venesection, of

THE SIXTEENTH CENTURY loi

the application of the (Gooch) splint, of instru-
ments for trepanning (borers, elevators, rugines,
etc.)» for fistula operation, and for cauterization
(olivary, dactiliary, punctuale, etc.)*

In spite of the foundations laid in anatomy by
Mondino and in surgery by Guy de Chauliac and
by the other anatomists and surgeons trained at the
French and Italian universities, the general Euro-
pean practitioner of the fourteenth century no
doubt deserved the satire leveled at him by the
English poet Chaucer a few years after the death of
Guy de Chauliac. Lines 5-8 in the following quota-
tion are rather obscure, but refer to the attempts of
the medical astrologers to bring magic influence to
bear by means of diagrams of constellations made at
the proper astrological moment. Such diagrams or
images were frequently engraved on gems and were
supposed to accumulate influence.

With us ther was a Doctour of Phisyk,

In al this world ne was tber noon him lyk

To speke of phisik and of surgerye;

For he was grounded in astronomye.

He kepte his padent a ful greet del

In houres by his magik naturel.

Wei coude he fortunen the ascendent

Of his images for his pacient.

He knew the cause of everich maladye,

Were it of hoot or cold, or moiste, or drye,

And where engendred, and of what humour;

102 THE HISTORY OF MEDICINE

He was a verrey parfit practiaour.

The cause y-knowe, and of his hann the rote,

Anon he yaf the seke man his bote [remedy].

Ful redy hadde he his apothecaries,

To send him drogges and his letuaries,

For ech of hem made other for to winne,

Hir frendschipe nas not newe to beginne.

Wei knew he the olde Esculapius,

And Deiscorides, and eek Rufus,

Old Ypocras, Haly, and Galien,

Serapion, Razis, and Avicen,

Averrois, Damasden, and Constantyn,

Bernard, and Gatesden, and Gilbertyn#

Of his diete mesurable was he,

For it was of no superfluitee.

But of great norissing and digestible.

His studie was but litel on the Bible.

In sangwin and in pers he dad was al,

Lyned with taffata and with sendal;

And yet he was but esy of dispenoe;

He kepte that he won in pestilence.

For gold in phisik is a cordial,

Ther fore he lovede gold in special.

In Germany the universities were particularly
late in providing instruction in medicine, and the
first celebrated German surgeons acquired their
skill on the field of battle. Pfolspeundt, a Bavarian
army surgeon of the fifteenth century, mentions
inddentally the treatment of gunshot wounds
(1460). Speaking of the more familiar arrow wounds,
he says, in the spirit of Chaucer's Doctour, that

THE SIXTEENTH CENTURY 103

recovery depends on the favorable conjunction of
the planet that is in the ascendant. His knowledge
of rhinoplasty and his use of a narcotic inhalation
show that he was somewhat influenced by Italian
surgeons. Hieronymus Brunschwig, an Alsatian
army surgeon, bom at Strassburg in the early part
of the fifteenth century, wrote as an old man "Das
Buch der Wund-Artzney " (1497). He held that
gunshot wounds are poisoned and that suppuration
should be induced as a means of purification. He
was acquainted with the work of the leading French
and Italian surgeons. Hans von Gersdorff, also a
native of Strassburg, gained experience of military
surgery in the campaigns of Charles the Bold and
was present at the battles of Granson (1476) and
Nancy (1477). He wrote a *' Feldtbuch der Wundt-
artzney " (151 7) illustrated, like Brunschwig's work,
with excellent woodcuts. He performed about two
hundred amputations, and developed a method of
his own. He did not believe that gunshot wounds
are necessarily poisoned, but in certain cases fol-
lowed the practice of pouring hot oil into the
^wounds. Giovanni da Vigo, in the " Practica Cop-
iosa" (1514), had taught, according to Par6, "that
wounds made by firearms partake of venenosity,
by reason of the powder ; and for their cure he bids
you cauterize them with oil of elder-flowers scalding
hot| mixed with a little treacle.'*

104 THE HISTORY OF MEDICINE

In the meantime anatomy had made a great ad-
vance in Italy under the influence of the Renais-
sance spirit. The practice of dissection, which had
gained a definite place in medical education through
the efforts of Mondino, was continued at Bologna,
Padua, and other Italian universities by 2^rbi,
Achillini, and Marc Antonio delta Torre in the
brilliant period of scientific and artistic activity at
the dose of the fifteenth and the beginning of the
sixteenth century. The greatest contribution, how-
ever, to the advancement of the study of anatomy
was made by the supreme genius of the time,
Leonardo da Vinci, 1452-15 19, who has been de-
scribed as a painter, sculptor, architect, engineer,
musician, poet, philosopher, chemist, botanist, and
geologist, and, in addition was referred to by
William Hunter as the very best anatomist and
physiologist of his time. We learn from an Italian
painter and writer of the sixteenth century (Vasari)
that Leonardo ''filled a book with drawings in red
crayon outlined with a pen, all the copies made
with the utmost care [from bodies] dissected by his
own hand. In this book he set forth the entire
structure, arrangement and disposition of the
bones, to which he afterwards added all the liga-
ments, in their due order, and next supplied the
muscles. Of each separate part he wrote an explana-
tion in rude characters written backwards and with

DISSECTION SHOWING THE FEMALE VISCERA IN SITU
Drawn by Leonardo da Vinci, circa 1510

THE SIXTEENTH CENTURY 105

the left hand, so that whoever is not practiced in
writing, cannot understand them, since they are
only to be read with a mirror/' These invaluable
anatomical drawings are still preserved, and within
the last twenty-five years have been made accessible
in a series of splendid reproductions.

Leonardo thus affords us one of the finest ex*
amples of the mutual influence of art and medical
science. The Greek sculptors, taught by the ob-
servation of naked youth in the palaestra and
gymnasium, had depicted the human form with
remarkable fidelity, even exhibiting in their statues
the contours of the pectineus muscle as developed
by gymnastic exercises. For the intuitions of Greek
artistic genius Leonardo did not disdain to sub-
stitute scientific observation based on the dissection
of more than thirty bodies of men and women. He
studied human development and deterioration,
measured the proportions of the skeleton, and com-
pared with the human foot the foot of the bear, the
ape, and the bird. He analyzed the play of the
muscles, the expression of the emotions, and move-
ment in general. He not only pictured the muscles
as they appear to the eye of the artist, but repre-
sented them schematically by straight lines and
explained their action as a system of levers. Ex-
plaining the mechanism of respiration, Leonardo
states: ''All these muscles serve to elevate the ribs.

io6 THE HISTORY OF MEDICINE

and the elevation of the ribs pnxluoes a dilation of
the chest, and the dilation of the chest involves an
expansion of the lungs and, consequently, an at-
traction of the air which through the mouth enters
the lungs now increased in capacity/' He did not
confine his attention to the bones, ligaments, and
muscles, but depicted in his seven hundred and
fifty or more sketches, the brain, nerves, blood-
vessels, lungs, gravid uterus, heart, stomach, etc.
It was Leonardo, who, with an artist's confidence
in his own powers of observation, struck from the
study of anatomy the fetters fastened upon it for
centuries by the authority of Galen. His influence,
however, was limited by his failure to bring to com*
pletion the projected work on anatomy for which he
had made such magnificent preparations. The
works of Berengario da Carpi (1470-1530), who
wrote extensive commentaries on Mondino, prove
that their author, though a dissector and touched
by the independent spirit of the Renaissance, did
not stand altogether free from the prepossessions of
traditional anatomy. It was reserved for the great
Vesalius in his systematic and well-illustrated work*
"De Humani Corporis Fabrica," to bring that
anatomy to the test of observation.

Andreas Vesalius, bom at Brussels December 31,
1 514, attended the University of Louvain, and in
1533 studied anatomy at Paris under the Galenist

THE SIXTEENTH CENTURY 107

Jacques Dubois (Jaoobus Sylvius). Interrupted in
his studies by the wars between Francis I and the
Emperor Charles V, Vesalius returned to Louvain
in 1536. In the following year he went to Venice,
and before the completion of his twenty-third year
received his doctor's degree at Padua, a city at that
time controlled by the enlightened government of
the Venetian Republic. In spite of his youth he was
inunediately appointed professor of surgery. As-
suming the responsibility of imparting a knowledge
of anatomy to the students of Padua, Vesalius al-
most at once departed from the established practice
of reading Galen in the lecture room, aiid directed
attention to what he afterwards referred to as '' that
true Bible, as we count it, of the human body and
of the nature of man.'' The lecturer became a
demonstrator, appealing from the authority of
Galen to the evidence of the senses. The chief
results of his observations as a dissector are em-
bodied in the ^'Fabrica," which, completed and
dedicated to the. Emperor in 1542, was printed in
1543, in which year also appeared the revolutionary
work of Copernicus. Discouraged by the opposition
offered to his expositions of the truth, Vesalius re-
linquished his professorship in the following year,
and accepted appointment as physician to Charles
V. On the abdication of that monarch, in 1556,
Vesalius became physician at the court of the son,

io8 THE HISTORY OF MEDICINE

Philip II, residing in Spain from 1559 till 1563.
From Spain he went as a pilgrim to Jerusalem,
probably cherishing the hope of eventually resum-
ing his activities as an anatomist at Padua. Broken
in health, however, before he had started on his
pilgrimage, further reduced by the privations of a
rough and protracted voyage as he was returning
from the East, Vesalius landed on the desolate
shore of the island of Zante, and there died in 1564.
Vesalius considered Galen as easily first among
the students and teachers of dissection and as the
greatest physician after Hippocrates. He followed
up Galen's physiological experiments on living
animals, and even accepted — provisionally at
least — the Galenic theories of the circulation and
other bodily functions. He did not fail, however, to
point out Galen's shortcomings, to many of which
he, as a dissector of lower animals, held the clue,
and he was particularly severe with those disciples
of Galen who contended that the Galenic anatomy
described man rather than the ape. He showed that
Galen in his description of the suture of the frontal
bone, of the division of the inferior maxilla, in his
account of the sacrum and coccyx, of the lumbar
and abdominal muscles, of the muscles of the leg,
foot, and hand, as well as in his account of the
vascular system, had been too much influenced by
observations made in dissecting apes. He showed

THE SIXTEENTH CENTURY 109

that the Galenic description of the occipital bone,
of the intestines in general, of the caecum (the ap-
pendix of which he knew to be particularly small in
man), was borrowed from the anatomy of the dog;
while the structure of both apes and dogs had vi-
tiated the traditional descriptions of the lumbar
vertebrae, the lungs, etc. Deluded by the dissection
of oxen, the great anatomist of antiquity had falsely
attributed to man a complex intracranial plexus of
blood-vessels {reU tmrabile) ; while his knowledge of
the uterus and of the form of the liver had also been
obtained by the dissection of brute animab.

Vesalius, moreover, corrected Galen's account of
the foramina of the skull, of the processes of the
cervical vertebrae, of the tubercles of the humerus,
of the shafts of humerus and femur, of the form and
consbtency of the sphenoid, of the internal struc-
ture of the phalanges. The Galenic account of the
muscles and movements was subjected to criticism
— the dorsal as well as the abdominal muscles, the
movements of the head, spine, and upper extremity,
Vesalius discovered the semilunar cartilages of the
knee-joint, and corrected Galen's mistakes in refer-
ence to the cartilage of the patella, the articulations
of the ribs, and the ligaments of the arm. Vesalius
gave a better description of the brain than had
been given before his time, discovered the inferior
longitudinal sinus, described the septum lucidum,

no THE HISTORY OF MEDICINE

pointed out Galen's inconsistencies in reference to
the ventricles, called in question his account of the
meninges, and of the structure and functions of the
nerves. He showed the defects in Galen's descrip-
tion of the veins of the upper arm and axilla,
mesentery and intestines, and claimed that Galen
had been unduly influenced by Aristotle in reference
to the vena cava, and the structure of the heart.
The attempt of Vesalius to accommodate his state-
ments to Galen's physiological doctrines did not
blind him to the fact that the interventricular
septum shows no visible perforations. He writes:
*'The septum of the ventrides, composed as I have
said of the thickest substance of the heart, abounds
on both sides with little pits impressed in it. Of
these pits, none, so far at least as can be perceived
by the senses, penetrate through from the right to
the left ventricle, so that we. are driven to wonder
at the handiwork of the Almighty, by means of
which the blood sweats from the right to the left
ventricle through passages which escape human
vision." In somewhat like spirit he treated the
questions of the presence in man of an indestructible
resurrection-bone, the absence of a creation-rib, and
the position of heart and umbilicus.

Among his many other contributions to the de-
velopment of anatomy, Vesalius is to be credited
with the discovery of the ductus venosus, the de-

THE SIXTEENTH CENTURY in

scription of the vena azygos, the aeminiferous ducts,
the internal pterygoid and lingual muscles, the
mediastinum and the pleura, an account of the
structure of the pylons, liver, kidney, and spleen.
He made post-mortem examinations, was a success-
ful surgeon, and resisted the tendency to divorce
the study of one branch of medical science from an-
other. His great service was to make anatomy a pro-
gressive study through his comprehensive volume,
which recorded his own observations and contained
illustrations, probably reproduced from his own
drawings, and marked by a sense of truth and
beauty not unlike that of Leonardo.

" Mere knowledge without experience,'' said Am-
broise Par6 (1517-^)1 "does not give the surgeon
much self-confidence." The rapidly growing knowl-
edge of anatomy and experience in the wars of
Francis I and his successors combined in bringing
to perfection the powers of that most illustrious of
army surgeons. Bom near Laval in Maine, France,
Par6 received early training as a barber surgeon,
and even in his maturity he was treated super-
ciliously, if not by the surgeons of Saint Cdme, at
least by the doctors of the Facult6. Coming to
Paris as a youth, he continued his apprenticeship
and served three years as a dresser at the Hdtel
Dieu. He had his first experience of military
surgery in the Italian campaign of 1536, and soon

iia THE HISTORY OF MEDICINE

discarded Vigo's boiling-oil treatment, and further
distinguished himself by an exarticulation of the
elbow-joint, the first operation of the kind on
record. He returned to Paris in 1539, but his ser-
vices as an army surgeon were soon again in requisi-
tion. His pages tell of the successful treatment of
wounds inflicted by lance, sword, halberd, stone,
arquebus, pistol, culverin, and other firearms. His
treatise, ''La m^thode de traiter les plaies,*' ap-
peared in 1545. He studied, as opportunity offered,
the works of the great surgeons, pursued anatomy
under Sylvius, prepared an epitome of the ''Fa*
brica," and in 1549 produced an antomical treatise.
In 1552 Par6 amputated without cauterization the
leg of a gentleman hit by a cannon-ball. " I dressed
him, God healed him Qe le pansay, Dieu le guarist).
I sent him home merry with a wooden leg." His
example fully revived the use of the ligature, and
placed further restrictions on the use of the actual
cautery. At the close of the same year he smuggled
into the city of Metz, besieged by the Emperor,
medical supplies from Henry II, and was welcomed
by the nobles of the garrison, who said that since
he had arrived they would no longer feel in danger
of dying in case they should chance to be wounded.
Five years later, after the battle of Saint Quentin,
he was busy at La Fdre-en-Tardenois, and found the
wounded particularly difficult to cure. The earth

THE SIXTEENTH CENTURY 1 13

for more than half a league around him was all
oovered with the dead, and so many green and blue
flies arose from them as to hide the sun. ''It was
wonderful/' he continues, ''to hear them buzzing;
and where they settled, there they infected the air,
and brought pestilence with them/' In 1559 Pari
was consulted, along with Vesalius, in the case of
Henry II, accidentally wounded while tilting. The
patient in this case succumbed to concussion of the
brain. In 1564 Par6 courageously fought at Paris
an epidemic of the plague, and published an ex-
tensive work on surgery copiously illustrated. In
1569 we find him successfully treating a nobleman
near Mons, who had been suffering for months from
a gunshot wound with fracture of the femur. In
addition to local treatment, Par6, as usual, had
regard to the general condition of the injured man,
and advised the use of a forehead-doth of oil of
roses and water-lilies and poppies and a little opium
and rose-vinegar. At the same time the patient
must be allowed to smell flowers of henbane and
other narcotics.

Par6 described various forms of fracture, including
fracture of the neck of the femur, and fracture of
the parietal bone with extrusion of brain substance ;
he invented arterial forceps, many other kinds of
surgical instruments, as well as artificial limbs,
artificial eyes, and feeding-bottles; he encouraged

114 THE HISTORY OF MEDICINE

the use of the truss, insbted that regular surgeons
should not abstain from the treatment of hernia,
cataract, and stone, and followed the practice of the
old French lithotomists in employing a grooved
director; he suggested syphilis as a cause of aneur-
ism and hypertrophy of the prostate as a cause of
strangury; he revived version by the feet, advocated
prompt evacuation of the uterus in case of haemor-
rhage during labor, and knew of the possibility of
the Caesarean operation during the life of the mother ;
he performed bronchotomy, neurotomy, staphylo-
plasty, and made use of the figure 8 suture in cases
of hare-lip; he removed articular concretions, re-
frained from the too frequent dressing of ulcers,
improved the method of trepanning, and made
advances in eye surgery. Like Guy de Chauliac,
Par6 did not confine his attention to surgery, but
wrote on various branches of medical science and
insisted on isolation of those suffering from leprosy.
The work of the father of modem surgery was
supplemented by his favorite disciple Guillemeau,
by Rousset, by Pierre Franco, by Laurent Colot,
by the Italian Tagliacozzi, and by the naval and
military surgeon William Clowes (i 540-1 604). With
the father of modem anatomy must likewise be
mentioned his contemporaries Vidius, Charles
Etienne, the great Eustachius (1524-74), his pupils *
Fallopius and Columbus, his fellow-student Serve-

THE SIXTEENTH CENTURY 115

tuSy as well as Ingrassias, Aranzi, the brilliant
Varolius, Andrea Cesalpino, and Fabridus (iS37""
1619), the teacher of Harvey.

REFERENCES

' Ball, James Moores: Andreas Vesalius. St. Louis, 1910. 149 pp.
Hdzmann, Charles L.: "Military Sanitation in the Sixteenth,

Seventeenth, and Eighteenth Centuries," Annab cf Medical

Hishryf pp. 281-300. m •
Hopstock, H.: "Leonardo as Anatomist,'' Shtdies m Ike History

and Method of Science, pp. 151-91, Clarendon Press, 1921.
Leonardo da Vind: / ManoscriUi, edited by Sabacnikoff and

Piuroati, with French transladon, and an introduction by

Professor Duval. 2 vols. Paris, Turin, 1898, 1901.
Quademi ffAnatomiOj edited by Vangensten, Hopstock,

and Fonahn, with English and German translations.

Christiania. 6 vols. 191 1-16.
Locy, W. A.: "Anatomical Illustration before Vesalius," Journal

of Morphology, Chicago, 191 1, pp. 945-87.
McMurrich, J. P.: "Leonardo da Vind and Vesalius," Medical

Library and Historical Journal, 1906, pp. 338-50.
Plaget, Stephen: Ambroise Pari and his Times. London, 1897.

304 PP-
Pilcher, L. S.: "The Mondino Myth," Medical Library and

Historical Journal, 1906, pp. 311-31.
Roth, M.: Andreas BruxMensis (in German). Berlin, 1892.

500 pp.
Singer, Charles: ''The Figures of the Bristol Guy de Chauliac

MS" {circa 1430), Proc. Roy. Soc. Med., 1917, vol. x

(Section, History of Medicine), pp. 71-90.
"Thirteenth Century Miniatures illustrating Medieval

Practice," Proc^ Roy. Soc Med., 1915, vol. ix (S. H. M.),

pp. 29-42.
Welch, W. H.: The Times of Vesalius, Contributions cf Vesalius

Other than Anatomical. Johns Hopkins Hospital Bulletin,

I9i5t PP- 118-20.
Vesalius: De Humani Corporis Fabrica Libri Septem, cum indice,

etc. Venetiis, 1568. 510 pp.

CHAPTER VI

WILLIAM HARVEY AND THE REVIVAL OF

PHYSIOLCXIY

We have seen in an earlier chapter the views of
Erasistratus and Galen concerning the structure
and function of the heart, the arteries, and the veins.
The advance in anatomy led by Vesalius prepared
the way for a further advance in physiology. His
careful study of the structure of the minute ramifica-
tions of the veins and arteries must have brought
him to the very threshold of the discovery of the
circulation of the blood, and the second edition of
the "De Fabrica" (1555) shows that he became
very skeptical concerning the passage of blood from
the right to the left ventricle through the septum of
the heart. His incredulity on this score may have
been strengthened by the " Restitutio Christianismi "
of his fellow student Michael Servetus, published
in 1553. In this book Servetus taught that the blood
— or, at least, some of it — passes from the right
ventricle to the left, not through the cardiac septum,
but "is moved in a long passage through the lungs;
by them it is prepared ; it is made bright; it is trans-
fused from the arterious vein to the venous artery" ;
in fact, that what we call arterial blood is "a mix-

HARVEY AND PHYSIOLOGY 117

ture made in the lungs of the inhaled air with the
blood which the right ventricle communicates to
the left."

Before the death of Vesalius, Eustachius de-
scribed a large vessel extending downward from the
left subclavian vein, provided at its orifice with a
semicircular valve, and containing a scanty, watery,
fluid. The valves of the veins were known to
Charles Etienne, another contemporary of Vesalius,
to their master. Jacobus Sylvius, to Cannanus (in
1546), and other anatomists. Fabricius, the pupil of
Fallopius and the master of William Harvey, ob-
served the valves of the veins independently in
1574, and published an illustrated treatise on the
subject ("De Venarum Ostiolis'O the year after
Harvey's graduation at Padua. Two other pre-
decessors of Harvey took an honorable part in the
discovery of the circulation of the blood. Matheus
Realdus Columbus, who had been the assistant and
successor of Vesalius at Padua, became in 1545 the
first professor of anatomy at the University of Pisa,
and in 1548 was called to Rome. In the ^'De Re
Anatomica," which was published after his death in
1559, Columbus states that ''the blood is carried by
the artery-like vein to the lung and being there
made thin is brought back thence together with air
by the vein-like artery to the left ventricle of the
heart.'* Harvey indeed acknowledged his indebted-

ii8 THE HISTORY OF MEDICINE

ness to Columbus, *' that skilful and learned anato-
mist/' as well as to Galen, for guidance in reference to
the pulmonary circulation. Andreas Csesalpinus,
1519-1603, approached even more neariy the mod-
em explanation of the circulation of the blood. In
his "Quaestiones Peripateticae " (1571) he wrote as
follows: "Of the vessels ending in the heart, some
send into it the material which they carry, for in-
stance the vena cava into the right ventricle, and
the vein-like artery into the left; some on the other
hand carry material away from the heart, as for
instance the aorta from the left ventricle and the
artery-like vein, nourishing the lung, from the right.
To each orifice are attached little membranes the
function of which is to secure that the orifices lead-
ing in do not let out and that those leading out do
not let in.'' Caesalpinus also knew that the arteries
dilate as the heart contracts. Moreover, in his
"Quaestiones Medicse" (1593) he explains why, in
case of ligature for venesection, the veins swell on
the side of the ligature away froni the heart, and, in
general, that "there is a sort of perpetual movement
from the vena cava through the heart and lungs into
the aorta."

A year before the appearance of the "Medical
Questions," Caesalpinus left Pisa, where he had been
professor of medicine since 1567, for Rome. At the
same time Galileo, the father of dynamics, went

HARVEY AND PHYSIOLOGY 119

from Pisa, his native dty, to accept appointment in
the University of Padua. Though known mainly as
a physicist, Galileo exerted a very great influence
on the development of medical science. Bom in
1564, he had entered the University of Pisa as a
student of medicine in 158 1, and almost immediately
discovered that the time occupied by the oscillation
of a pendulum is constant as measured by the pulse.
This discovery soon led to the invention of a simple
instrument to determine the rate of the pulse
(pulsilogium). In 1589 Galileo was appointed pro-
fessor of mathematics at the University of Pisa, and
in the following year his treatise on dynamics, " De
Motu Gravium," was circulated as a manuscript.
Shortly after his removal to Padua Galileo invented
the thermoscope, the forerunner of the clinical
thermometer, and devised a small but powerful
machine for raising water. His lectures attracted to
Padua students from all parts of Europe, among
them the Archduke Ferdinand (afterwards Em-
peror Ferdinand II) and Cosimo de' Medici (after-
wards Cosimo II, Grand Duke of Tuscany). Before
the close of the century Galileo had under his roof
twenty resident pupils, including a number of
Englishmen. At the same time he was on familiar
term with Fabricius, the teacher and friend of
Harvey, and there is every reason to believe that
the immortal discoverer of the circulation of the

I20 THE HISTORY OF MEDICINE

blood in 1 598-1 602 came in contact with the il-
lustrious pupil of Andreas Caesalpinus.

William Harvey was bom at Folkestone, on the
south coast of England, in 1578. From his sixteenth
till his twentieth year he was in attendance at
Gonville and Caius College, Cambridge, which had
been refounded by John Kees (Caius), a former
pupil and colleague of Vesalius (153^43) at Padua.
During Harvey's undergraduate days Caius College
afforded instruction in Latin, Greek, logic, mathe-
matics, and anatomy, and there is evidence in his
mature preference for the works of Cicero, Aristotle,
and Avicenna, in his interest as an old man in the
"Clavis Mathematical of William Oughtred, and
in his lifelong devotion to dissection, that all of
these early studies took root in his docile and sus-
ceptible mind. He took his degree in Arts in 1597,
and a year later went to Padua to study under
Fabricius of Aquapendente, who seems to have
treated him with marked cordiality. Harvey took a
prominent part in the student organizations which
governed the University of Padua, gained the
friendship of several of Galileo's disciples (Wil-
loughby, Fludd, and others), and graduated with
distinction as Doctor of Medicine a few weeks after
the completion of his twenty-fourth year.

After his return to England, Harvey took up
residence in London, and was admitted to the

HARVEY AND PHYSIOLOGY 121

College of Physicians, founded by Thomas Linacre
— also a Doctor of Padua — in 1518. It was in a
lecture at this institution that Harvey gave the first
exposition (1616) that has come down to us of his
views concerning the movement of the heart and the
blood. In this lecture he expressed himself to the
following effect:

'4t is plain from the structure of the heart that
the blood is passed continuously through the lungs
to the aorta as by the two clacks of a water bellows
to raise water.

'^It is shown by the application of a ligature that
the passage of the blood is from the arteries into the
veins.

''Whence it follows that the movement of the
blood is constantly in a circle, and is brought about
by the beat of the heart/'

Further light is thrown on the genesis of Harvey's
views by the following passage from the works of
the distinguished chemist Robert Boyle:

''And I remember, that when I asked our famous
Harvey^ in the only discourse I had with him (which
was but a while before he died), what were the
things that induced him to think of a circulation of
the blood? He answered me, that when he took
notice, that the valves in the veins of so many parts
of the body were so placed, that they gave free
passage to the blood towards the heart, but op«

122 THE HISTORY OF MEDICINE

posed the passage of the venal blood the contrary
way; he was invited to imagine, that so provident a
cause as nature had not so placed so many valves
without design; and no design seemed more prob-
able, than that since the blood could not well, be-
cause of the interposing valves, be sent by the veins
to the limbs, it should be sent through the arteries,
and return through the veins, whose valves did not
oppose its course that way/'

It was not till 1628 that Harvey puUished his
** De Motu Cordis et Sanguinis in Animalibus,'' after
confirming his views of the motion and function of
the heart by the study of the structure of the
auricles, ventricles, cardiac valves, the larger and
smaller arteries and veins, by experiments in ligatur-
ing, by numerous vivisections, by draining off the
blood through a single small vessel, by calculating
the quantity of blood passing through the left
ventricle in the course of half an hour, by the ob-
servation of pathological conditions, by the exami-
nation of the vascular system in human embryos as
compared with that of fishes, toads, frogs, serpents,
and lizards. As a true Aristotelian Harvey held that
it was as vain to seek to base the science of anatomy
on an examination of the human body alone as to
attempt to establish political science on the study
of a single commonwealth.

As the title of Harvey's disquisition indicates, it

HARVEY AND PHYSIOLOGV 123

is on the motion of the heart that he laid the chief
emphasis. In the introductory letter to King
Charles, he speaks of the heart of animals as the
foundation of their life, and refers to what he has
written of the motions of the heart. Similarly, in
the dedication to the president and others of the
Royal College of Phjrsidans, he makes mention
of his new views of the motion and function of the
heart, and in the introduction proper Harvey
criticizes earlier doctrines as a preliminary to dis-
cussing the motion, action, and use of the heart and
arteries. These earlier doctrines appear untenable
after we have closely studied the structure and
mechanism of the heart. The opinion that blood
oozes from the right to the left ventricle through
pores in the septum is, according to Harvey, not to
be tolerated. "For," he proceeds, "the septum of
the heart is of a denser and more compact structure
than any portion of the body, except the bones and
sinews. But even supposing there were foramina or
pores in this situation, how could one of the ventri-
cles extract anything from the other — the left, e.g.,
obtain blood from the right — when we see that
both ventricles contract and dilate simultaneously?
Wherefore should we not rather believe that the
right took spirits from the left, than that the left
obtained blood from the right ventricle, through
these foramina?" Incidentally, if the septum were

124 THE HISTORY OF MEDICINE

permeable, what need would there be of the oxt)-
nary vessels? The opinion that the diastole of the
arteries is simultaneous with that of the heart is also
untenable; for how can two mutually connected
bodies, simultaneously distended, draw anything
from one another? Again, in the opening chapter of
the ^'De Motu Cordis et Sanguinb/' Harvey states
that he had discovered the motions and uses of the
heart after numerous vivisections, and had been led
to publish an exposition of his views. This he under-
took the more willingly seeing that Fabricius had
not written concerning the structure and functions
of the heart. In his second chapter, which deals
with the motion of the heart as seen in the dissection
of living animals, Harvey notes that the heart in its
systole — that is, in its essential motion — becomes
hard, diminished in size, of a paler color, and so
made apt to project or expel its charge of blood.
He was later able to supplement this knowledge of
the motion of the heart gained through vivisection
by direct observation of the human heart in a case
of extensive injury of the chest wall. He then
demonstrated to King Charles, who was interested
in his physiological and embryological investiga-
tions, that the heart in diastole is retracted and
withdrawn and in systole emerges and is protruded,
and also that the diastole of the arteries is simul-
taneous with the systole of the heart.

HARVEY AND PHYSIOLOGY 125

Proceeding to a closer scrutiny of the mechanism
of the heart, Harvey finds that the heart's motion
begins with the auricles and extends to the 'ventri-
cles, as in a piece of machinery one wheel gives
motion to another, yet all the wheels seem to move
simultaneously. The blood is thrown into the ven-
tricles by the action of the auricles. The motions
of the heart constitute a kind of deglutition, a trans-
fusion of the blood from the veins to the arteries.
The valves of the heart have the purpose of pre-
venting regurgitation. Blood continually flows into
the right ventricle and is continually passed out of
the left, and therefore moves from the vena cava to
the aorta. Proceeding on the other hand from the
right ventricle into the lungs by the pulmonary
artery, and incessantly drawn from the lungs into
the left ventricle, it cannot do otherwise than pass
continuously by the obscure porosities of the lungs
and the minute inosculations of vessels. What is
the quantity and source of the blood that reaches
the heart by way of the vena cava?

Influenced by the knowledge derived from vivi-
section, the structure of the ventricles and their
valves, the relative size of the conduits leading to
and from the heart, the quantity of the blood trans-
mitted, Harvey "began to think whether there
might not be a motion^ as it were^ in a circle. Now
this I afterwards found to be true ; and I finally saw

126 THE HISTORY OF MEDICINE

that the blood, forced by the action of the left
ventricle into the arteries, was distributed to the
body at large, and its several parts, in the same
manner as it is sent through the lungs, impelled by
the right ventricle into the pulmonary artery, and
that it then passed through the veins and along the
vena cava, and so around to the left ventricle in the
manner already indicated.*' That there is a circula-
tion of the blood is confirmed, according to Harvey,
by the fact that so large a quantity is transmitted
by the action of the heart. If only one eighth of an
ounce of blood were expelled from the left ventricle
of the human heart at each contraction, and if there
were two thousand or even one thousand pulsations
every hour, a larger quantity would seem to be
forced into the aorta in half an hour than is con-
tained in the whole body. " In the same way, in the
sheep or dog, say that but a single scruple of blood
passes with each stroke of the heart, in one half
hour we should have one thousand scruples, or about
three pounds and a half of blood injected into the
aorta; but the body of neither animal contains
above four pounds of blood, a fact which I have
myself ascertained in the case of the sheep.'*

Harvey recognized, as had Caesalpinus, that the
swelling of a limb ligatured as for venesection on
the side of the ligature away from the heart proves
that the veins carry the blood from the extremities

HARVEY AND PHYSIOLOGY 127

toward the heart. The valves which are found in
the cavities of the veins themselves make plain the
course of the circulation. Their function is simi-
lar to that of the valves of the aorta and the pul-
monary artery, namely, to prevent the reflux of the
blood. Moreover, the effect of such a ligature as is
used to bind a limb for amputation shows that the
blood is carried to the extremities by the arteries.
The arteries are conduits leading from the heart,
while the veins are conduits leading to the heart.
The blood passes from the arteries to the veins
either immediately by anastomoses, or mediately
by the pores of the flesh, or in both ways. It is
forced from the capillary veins into the smaller
branches, and from these into the larger trunks.
It is necessary to conclude, says Harvey, ''that
the blood in the animal body is impelled in a cir-
cle, and is in a state of ceaseless motion; that
this is the act or function which the heart performs
by means of its pulse; and that it is the sole and
only end of the motion and contraction of the
heart."

It has frequently been assumed that Harvey
failed to demonstrate the passage of the blood from
the arterioles to the venuoles, and that the circula-
tion of the blood was fully established only when
Malpighi gave ocular demonstration of the capillary
circulation. Of course it must be admitted by all

128 THE HISTORY OF MEDICINE

that Harvey, in proving that the blood is carried
from the heart to the extremities by the arteries and
is returned from the extremities to the heart by the
veins, gave logical proof of a connection between
the minute arteries and the minute veins. But the
fact that Harvey in 165 1 demonstrated by means of
experiment that all of the blood from the right
ventricle passes through the pulmonary artery to
the pulmonary vein has been disregarded by many.
In the presence of a number of his colleagues he in-
jected about a pound of hot water into the right
ventricle (of the heart of a man who had been
hanged) after having tied the pulmonary artery.
Not a drop of water or of blood made its way into
the left ventricle. Then, the ligature having been
undone, water was injected into the pulmonary
artery, upon which a torrent of the fluid, mixed with
a quantity of blood, immediately gushed forth from
a perforation which had previously been made in
the left ventricle. Before making this experiment
Harvey had reached the conclusion that spirit and
innate heat are to be thought of only as properties of
the blood. ''There is, in fact," he says, "no occa-
sion for searching after spirits foreign to or distinct
from the blood ; to evoke heat from another source ;
to bring gods upon the scene, and to encumber
philosophy with any fanciful conceits. What we are
wont to derive from the stars is in truth produced

HARVEY AND PHYSIOLOGY 129

at home. The blood is the only calidum innatum or
first engendered animal heat."

Almost immediately after the publication of the
"De Motu Cordis/' Harvey was drawn into the
royal service. In 1629 he was commanded by King
Charles to attend James Stuart, Duke of Lennox,
who was about to undertake an extensive tour of
the Continent. In the following year he received
appointment as Physician in Ordinary for His
Majesty's Household, and became the personal
friend and companion of Charles I. He accom-
panied the monarch on that journey to Scotland in
1633, which led to the ultimate breach between the
King and his Scottish subjects. Two years later, at
the command of Charles, Harvey examined the
body of Thomas Parr, who had died at the reputed
age of one hundred and fifty-two years and nine
months. Harvey came to the conclusion that Pan-
might have lived longer had he not, after being
brought to London by the Earl of Arundel, indulged
in rather rich fare, ''his ordinary diet consisting of
subrancid cheese, and milk in every form, coarse and
hard bread, and small drink, generally sour whey."
In 1636 Harvey accompanied the Earl's embassy to
Ferdinand II on behalf of Charles's sister Eliza-
beth of the Palatinate, mother of Prince Rupert;
and before the close of that year was sent to Italy
by the Earl about some pictures for His Majesty.

I30 THE HISTORY OF MEDICINE

Arundel was famous as an art collector, and inter-
ested in medical science, and, we may add, had been
seeking to secure a ''booke drawne by Leonardo da
Vinci." On his way to Venice Harvey was halted at
Treviso "to do his guarantina^^^ on account of the
pk^^ue (August 13), and displayed as much testiness
as did the choleric Vesalius when held up by ex-
tortionate customs officials at the Spanish frontier
in 1564. From Venice Harvey passed to Florence
(before September 17), where he was entertained by
the Grand Duke of Tuscany, Ferdinand II, patron
of the sciences and son of Galileo's pupil, Cosimo de'
Medici. By December he had returned to his prac-
tice in London.

During the struggle between Charles I and his
rebellious subjects Harvey was closely associated
with the Royalist cause. When in 1639 the King
joined the army under the Earl of Arundel in an
expedition against the Scottish forces, Harvey ac-
companied him. He was likewise present when,
three years later, Charles raised his standard at
Nottingham. It was probably about this time that
his lodgings at Whitehall were pillaged, and his
papers and specimens scattered or destroyed. At
the battle of Edgehill, Harvey had charge of the two
young princes and later aided in caring for the
wounded. Harvey was in attendance on the King
at Oxford, which the Royalist forces entered in

HARVEY AND PHYSIOLOGY 131

triumph October 29, 1642. About a year later he
treated successfully Prince Maurice, brother of
Rupert, suffering from a slow fever (typhus),
*'the raging disease of the army." In 1645 Harvey
was nominated by the King Warden of Merton
College. It was in the Warden's House at Merton
that Henrietta Maria, daughter of Maria de'
Medici, had her lodging during that stormy time.
On June 24, 1646, Oxford surrendered to the
Parliamentary forces; whereupon Harvey seems to
have retired to private life.

In whatever circumstances he might be placed,
his zeal for the advance of medical science was
always unabated. Traveling with the Duke of
Lennox through regions desolated by war, famine,
and plague, he complained of the absence of any-
thing to anatomize. Drawn to Scotland in 1633 in
the retinue of King Charles, he studied the flights of
gannets on the Bass Rock. While accompanying
Arundel in Germany he demonstrated the drcula*
tion of the blood at Nuremberg, and, in spite of the
unsettled state of the country, "would still be mak-
ing observations of strange trees and plants, earths,
etc., and sometimes like to be lost." The slaughter
of does in the royal hunt furnished material for his
studies in embryology, and shortly after arriving at
Oxford he used to visit George Bathurst of Trinity
G>llege, ''who had a hen to hatch eggs in his cham-

132 THE HISTORY OF MEDICINE

ber, which they opened dafly to see the progress and
way of generation." His example had a great in-
fluence on Highmore, on Scarborough, his favorite
pupil, who ** introduced geometrical and mechanical
speculations into anatomy," on Wharton, on Willis,
and other young men at Oxford interested in scien*
tific investigation, as well as on Glisson, on Ent, and
other original fellows of the Royal Society, organized
after the Restoration for the promotion of physico-
mathematical experimental learning.

In his treatise, "On Animal Generation,*' follow-
ing up the studies of Aristotle and Fabricius in no
subservient s^rit, Harvey declared that the genera-
tion of the chick is the result of epigenesis, and that
all its parts are not fashioned simultaneously, but
emerge in their due succession and order. Like his
two great masters he also wrote a treatise on loco-
motion ; he was a worthy successor of Aristotle in the
field of comparative anatomy, and had a clearer
knowledge than Fabricius of the physiology of
respiration. He made use of his discovery of the
circulation in surgery, and was not unacquainted
with the practice of obstetrics. In 1649 he spoke of
publishing a treatise on pathological anatomy based
on his numerous post-mortems, and four years later,
feeling still vigorous in mind in spite of his bodily
afflictions and advanced years, exchanged letters
with the Florentine Nardi concerning the problem

HARVEY AND PHYSIOLOGY 133

of contagion. About this time there was completed
at Harvey's expense a building for the G)llege of
Physicians^ to which honorable body he also pre-
sented his patrimonial estate in 1656. Toward the
close of his life attacks oi the gout, from which
disease he had long suffered* became more frequent.
He was stricken with cerebral haemorrhage June 3,
1657, and died the same day.

The scientists of Harvey's own time were pre-
pared to accept the mechanical theory of bodily
functions. As early as 1604, Kepler had explained
the phenomena of vision involved in the refraction
of light by the lens; in 1614 Sanctorius had recorded
his experiments to determine by weight the insensi-
ble perspiration of the human body, and in 1625 had
described a pulsilogium and a clinical thermoscope
of his own invention; and in 1622 Aselli had ob-
served the lacteals and had recognized the function
of the valves discovered in them. After the publica-
tion of Harvey's "De Motu Cordis et Sanguinis"
the French philosopher Descartes, accepting in the
main the doctrine of the circulation of the blood,
proceeded to sketch his views of the human ma-
chine (1634), man the automaton, which were later
developed in his treatise "De Homine." Jan de
Wale confirmed (1640), by making incisions in
ligatured vessels, Harvey's teaching concerning the
direction of the flow of the blood in veins and ar-

134 THE HISTORY OF MEDICINE

teiies; Georg Wirsung discovered (1642) the pan-
creatic duct; Pecquet made known (1651) his dis-
covery that the lacteals pour their contents into the
receptaculum chyli, and that the thoracic duct
(previously observed by Eustachius) leads thence
to the left subclavian vein; the l3ntnphatic vessels
were noted by the Cambridge student George Joy-
liffe in 1652, and, about the same time, Rudbeck
traced the connection of the l3ntnphatics of the liver
and intestines with the receptaculum chyli and
thoracic duct. Before the death of Harvey, Whar-
ton discovered the duct that bears his name, and
Glisson gave an accurate description of the capsule
of the liver.

Willis was aided in the preparation of his '' Cerebri
Anatome" (1664) by Sir Christopher Wren and by
Richard Lower, who in his "Tractatus De Corde'*
furthered the work of Harvey by definitely applying
the new science of physics to explain the mechanism
of the heart. Robert Hooke (the first microscopist
to observe the cellular structure of plants) by ex-
periments in artificial respiration (1667) proved that
life may be maintained without muscular movement
so long as the lungs are supplied with fresh air; and
John Mayow in the following year demonstrated
that in respiration only part of the air is taken up
by the lungs, and that the gas which supports life is
identical with that which supports combustion.

HARVEY AND PHYSIOLOGY 135

In the meantime the influence of Galileo and
Harvey had advanced the cause of physiological
research in Italy. Much of the progress centers
about the name of Ferdinand II of Tuscany, whose
brother Leopold de* Medici improved the thermo-
scope of Galileo and was the first president of the
Accademia del Cimento, founded at Florence in
1657. To the University of Pisa, Ferdinand called
Borelli, Malpighi, Bellini, and Stensen. For Borelli,
the disciple of Galileo, physiology was a part of
physics. He recognized that the action of a muscle
is a mere contraction of its length, due to the fibers,
or muscle substance proper, and not to the tendon.
He estimated in pounds the force of the muscles
of the jaw and heart. The motion of the heart
differs from that of the arm or leg in being non-
volitional ; it may be automatic, or caused by some
organic necessity. The heart is like a wine-press,
and, by propelling the blood into the arteries,
causes them to distend. The arteries, then con-
tracting, force the blood into their ramifications.
By means of the microscope Malpighi, distinguished
in embryology, pathology, and histology, observed
(1661) the capillaries in the lung, mesentery, etc.,
of the frog, as well as in the lung of the tortoise.
He thus found tJiat the blood is always contained
in vessels, and does not escape from the arterioles
to be taken up by the venuoles. These observations

136 THE HISTORY OF MEDICINE

were confirmed by Leeuwenhoek (1668), by the
Irish scientist William Molyneux (1683), and others.
In 1665 Malpighi observed the red blood corpuscles,
but in this discovery he had been anticipated by
Swammerdam. Bellini's study of the minute struc-
ture of the kidneys and Malpighi's histological
examination of the spleen, liver, brain cortex, lungs,
tongue, skin, etc., as well as of the kidneys, became
the basis of a more definite knowledge of the
physiological action of these parts. The correlation
of structure and function was the dominant idea of
these investigators. Stenson, the discoverer of the
duct of the parotid gland, furthered the investiga-
tions of Borelli in reference to the mechanism of the
muscles.

It seems almost like a travesty of the mechanical
theory of physiological action that in a later genera-
tion it was taught, not only that the heart and
vessels resemble waterworks and that the chest is
like bellows, but that the glands may be compared
to sieves, the teeth to scissors, and the stomach to a
iSask.

REFERENCES

Brooks, W. K.: William Harvey as an Entbryologisif Johns
Hopkins Hospital Bulletin, 1897, vm, pp. 167-74.

Curtis, John G.: Harvey's Views on the Use and CirailaHon of
the Blood. Columbia University Press, 191 5. 194 pp.

Foster, Sir Michael: Lectures on the History of Physiology,
Cambridge University Press, 1901. 310 pp.

HARVEY AND PHYSIOLOGY 137

Haldane, Elizabeth S.: Descartes, his lAfe and Times. London,

1905. 398 pp.
Mitchell, Weir S.: The Early History of Instrumental Precision

in Medicine, 2d Congress of Am. Physicians and Surgeons,

X891, pp. 159-81.

Some Recently Discovered Letters of William Harvey. Phila-
delphia, 1913. 59 pp.
Tiemey, M. A.: The History and AnHquUies of the Castle and

Toum of Arundd. London^ 1834, 2 vols. 772 pp. (pagina*

tion continuous).
Moore, Norman: "WiHiam Harvey," 7%e Dictionary of National

Biography.
Power, D'Arcy: William Harvey. London, 1897. 383 pp.

(Bibliographical appendix.)
Vi^lis, Robert: The Works of William Harvey. Translated from

the Latin with a Life of the Author. London, The Sydeo*

ham Sodety» 1847. 624 pp.

CHAPTER VII

SCIENCE AND PRACTICE; SYDENHAM.

BOERHAAVE

Is it possible to be a great physician without an in-
timate knowledge of up-to-date science? Should the
focus of a doctor's attention be something else than
anatomy, histology, physiology, embryology, bac-
teriology, chemistry, etc.? The lives of Thomas
Sydenham and Hermann Boerhaave give us occa-
sion to consider these questions.

Sydenham's early life served to develop his prac-
tical, rather than his theoretical, tendencies. Bom
of a family of Puritan gentry at Wynford Eagle,
Dorsetshire, September, 1624, he went in 1642 to
Oxford, where his eldest brother William — soon to
gain distinction as one of Cromwell's officers and
councillors — was already in residence. Thomas
was enrolled in May at Magdalen Hall, the recog-
nized center of Oxford Puritanism, but he was com-
pelled within a few months, or weeks, to quit the
University on account of the impending struggle
between the King and the Parliament. He returned
to his home in Dorset, where the Sydenham family
became, in the bitter local warfare that followed,
the leaders of the Parliamentary forces. The father

SCIENCE AND PRACTICE I39

fought with the rank of Captain ; William Sydenham
became Colonel and Governor of Weymouth; the
mother, daughter of Sir John Jeffrey, was killed by a
Royalist officer in 1644, and was avenged by one of
the elder sons; Francis, a gallant young Major, fell
a few months later in the defense of Weymouth;
and Thomas, shortly after, was wounded in a
cavalry skirmish.

The fortunes of war which caused the departure
of Sydenham from Oxford also brought about, as
we have seen in the last chapter, the arrival of the
Royalist Harvey; and, when peace was restored in
1646 and the University passed to the control of the
Parliamentarians, Harvey retired from his post at
Merton and the Puritan soldier retiuned to his
studies. Influenced by the advice of William's
physician, Thomas Coxe, a Doctor of Padua, and
later a Fellow of the Royal Society, Thomas Syden-
ham now devoted himself to the profession of medi-
cine. No doubt he availed himself of the opportuni-
ties afforded at Oxford for the study of anatomy
and botany and the reading of Hippocrates and
other medical classics, but, though he left Magdalen
Hall for Wadham College, soon to become, under
the Wardenship of John Wilkins, the center of
scientific research and the cradle of the Royal
Society, there is no evidence that he was at all at-
tracted to the pursuit of truth merely for the truth's

I40 THE HISTORY OF MEDICINE

sake. This is all the more striking in view of the line
of brilliant devotees of medical science who were at
Oxford during the years of Sydenham's prolonged
residence — Willis, Wharton, Highmore, Petty,
Goddard, Lower, Wren, Locke, Boyle, and others.
He was created Bachelor of Medicine in 1648, and
probably received also the degree of Master of Arts,
some allowance being made, no doubt, for the fact
that his studies had been interrupted by four years
of civil war.

In October, 1648, Sydenham was made a Fellow
of All Souls' College, an appointment he continued
to hold for about seven years. In the spring of
1651, however, he was commissioned Captain of
cavalry, and during the subsequent months he
served in the second Civil War, in which one of his
younger brothers, Major John Sydenham, was
killed in Scotland, and in which Thomas himself had
many stirring adventures, and seems on one occa-
sion to have been left on the field among the dead.
In September of the same year, all serious fighting
having ended with Cromwell's victory over Charles
II at Worcester, Sydenham was free to return to his
studies. Before the close of 1653 Christopher Wren
was appointed a Fellow of All Souls', but none of
the associations of college life could convince the
'' trooper turned physician" that the discovery of
some minute part in the human body, or the search

SCIENCE AND PRACTICE 141

for final causes and the essential nature of disease,
was the only way in which a doctor might promote
the glory of God and the welfare of the human race.
It was thus that he thought of his vocation. In
1655 he relinquished his fellowship, married, and
established himself in practice in London.

Although Sydenham was not ambitious of the
name of philosopher, and, as a follower of Francis
Bacon, sought to avoid premature hypotheses and
mere speculation, yet scattered through his writings
are passages which outline a sort of philosophy not
unknown in the American schools of to-day. In the
case of Sydenham it was the outcome of his strongly
marked individuality, his concentration of purpose,
his Puritan training, his career as a soldier and
successful practitioner. In his view practice is the
touchstone of theory; the proof of the pudding is in
the eating. He thought so little of opinions of any
sort that he distrusted his own when they came in
conflict with any one else's. And he would distrust
them even as regards his best established methods
of treatment, were it not that the phenomena of
practice support the judgment of reason. We are
forced to recognize the limitations of the human
mind. There may be beings in those brighter orbs,
which are scattered over the infinite expanse of the
universe, whose intelligences far exceed those of
finite man. ''Man, indeed/' he proceeds, ''may so

142 THE HISTORY OF MEDICINE

have his intellectual faculties shaped by Nature
[that is, the whole complication of natural causes]
as to be enabled to perceive not what is absolute
truth, but only that which is necessary for him to
know, and fitted to his nature. This applies to those
whose medicine consists in vain speculations rather
than in that solid experience which rests upon the
basis of the senses/'

Through his interest in religion, Sydenham was
even drawn into the field of metaphysics, as is to be
seen in the splendid fragment on "Rational The-
ology.*' In this, with the aim of encouraging right
conduct, the author develops arguments in favor of
the existence of God, the supremacy of the inmia*
terial over the material, and the immortality of the
soul, but breaks off when it dawns on his candid
mind that a belief in everlasting rapture and tor-
ment is not essential to the practice of virtue.

Sydenham's predominant interest in the imme-
diately practical inclined him to turn from problems
in medical science for which he saw no prospect of
an early solution. "Etiology," he writes, "is a
difficult, and, perhaps, an inexplicable affair; and
I choose to keep my hands clear of it." The in-
trinsic or essential nature of the plague and of
venereal disease is unknown; and as "to what may
be the essence of smallpox, I am, for my own part,
free to confess that I am wholly ignorant; this in-

SCIENCE AND PRACTICE 143

tellectual deficiency being the misfortune of human
nature, and common to myself and the world at
large/' It is in Sydenham's opinion impossible for
the physician to discover the ultimate causes of the
majority of diseases, which are inscrutable, and it b
quite sufficient to know whence the mischief imme-
diately arises. In fact, the "whole philosophy of
medicine consists in working out the histories of
diseases, and applying the remedies which may dis-
pel them; and Experience is the sole guide/'

During the first few years of his practice in Lon-
don, Sydenham had been fully occupied observing
the general S3ntnptoms of fever. At that time inter-
mittent fever and influenza were epidemic in Eng-
land. Not far from Sydenham's residence in King
Street, Whitehall, there lay a stretch of low and
swampy land, and it is interesting to note that
he early mentioned that abundant swarms of in-
sects in summer are the precursors of autumnal
diseases, and that before the end of his career he
believed that a causal relationship existed between
a marshy atmosphere and quartan ague. In Sep-
tember, 1658, Oliver Cromwell died at Whitehall of
an obscure fever, which his physicians called
"bastard tertian." In the following year it is prob-
able that Sydenham visited Montpellier, and his
absence from London at the critical period following
the Protector's death may have been suggested by

144 THE HISTORY OF MEDICINE

the dangers to which his political leanings exposed
him; for at the beginning of 1659 he had sought
election to Parliament as representative for Wey-
mouthy and having failed in his candidaturei re-
ceived a government appointment. We do not hear
of him again in London till the sunmier of 1660,
after the Restoration. Then he was suffering from
an attack of gout, to which disease, like Harvey, he
was a martyr.

After the summer of 1661 Sydenham was able to
pay attention to the more general aspects of the
diseases he met in his practice. To be appreciated
his writings should be studied in connection with
the mortality statistics of London, then a dty of
about 400,000 inhabitants, and the history of
epidemics. His first treatise, ''Thomas Sydenham's
Method of Treating Fevers, based on his own Ob-
servation" (1666), deals with the epidemics of
1661-1664. It was dedicated to Robert Boyle, who
in 1660 had published the results of his experiments
on air, who was interested in the effects of Peruvian
bark and the discovery of other specifics, who had
occasionally accompanied Sydenham in visiting the
sick, and who had suggested the composition of the
''Methodus Curandi Febres." Of the 16,665 deaths
occurring in London in the year 1661 the mortality
statistics assign fevers as the cause of 3490. Under
this class of disease were included, besides inter-

SCIENCE AND PRACTICE 145

mtttents, "spotted fever*' (typhus), and, probably,
infantile remittent fever and other ailments marked
by high temperatures. After some abatement of
fevers in 1662-64, there was an increase to 5257
deaths in 1665, but the prevailing epidemic of that
year was oi course the plague, which claimed no
fewer than 68,596 victims. This Great Plague of
London was associated by the Puritans with the
evils of monarchy. In the first year of the reign of
James I an epidemic of plague had caused 33,000
deaths in London, and in the first 3^ear of the reign
of Charles 1, 41,000. Sydenham speaks of it as ''the
scourge for the enormity of our sins," and considers
it as not amenable to ordinary treatment. He with*
drew from the city when the epidemic was approach-
ing its culmination, but returned later, and recorded
his observations in the second edition of the ** Meth-
odus.'* The appearance of this second book was the
occasion of a letter to Boyle, the father of modem
chemistry, 1668 (erroneously ascribed by the "En-
cyclopaedia Britannica," Latham, Payne, and other
biographers of Sydenham, to the year 1688), which
shows his pride in his practice, and contains a little
playful irony regarding his knowledge of science.
"I have the happiness of curing my patients," he
writes; "at least of having it said of me, that few
miscarry under me; but cannot brag of my corre-
epondency with some other of the faculty, who, not-

146 THE HISTORY OF MEDICINE

withstanding my profoundness in palmistry and
chemistry, impeach me with great insufficiency, as I
diall likewise do my taylor, when he makes my
doublet like a hopsack, and not before, let him ad-
here to what hypothesis he will/'

From this letter we learn also that the physician
and philosopher, John Locke, had been attending
with Sydenham very many of his variolous patients.
In the year 1666 the total number of deaths in Lon-
don had fallen to 12,738. These included 1998
deaths from plague, and only 741 from fevers, 38
from smallpox, and 3 from measles. In 1667 the
mortality from plague had dropped to 35, from
fevers had risen to 916, and from smallpox and
measles respectively to 11 96 and 82. In 1668 there
were 14 deaths from plague, 1247 from fevers, 1987
from smallpox, and 200 from measles. In 1669
dysentery and other intestinal diseases, which had
been on the increase since 1666, caused 4,385 deaths,
plague 3, fevers 1499, smallpox 951, and measles 15.
The dysenteric constitution, which Sydenham com-
pares with the epidemics of North Africa (Morocco),
was maintained during the next three or four years.
Before 1673 smallpox was again on the increase; it
continued to gain, and in 1674 became the predomi-
nant epidemic. Out of 17,244 deaths in London in
the year 1674 there were 2507 from smallpox, 795
from measles, 3 from plague, 2,164 from fevers, and

SCIENCE AND PRACTICE 147

1777 from dysentery and other intestinal ailments.
In 1675, as we learn from Sydenham, there pre-
vailed in London epidemic coughs with pleurisy and
pneumonia. ''Sometimes/' he states, ''there super-
vene upon the cough the following symptoms: a
succession of chills and flushes; pains in head, back,
and limbs; an occasional tendency to sweats (espe-
cially night sweats) ; sometimes the addition of pain
in the side; sometimes a constriction and tightness
at the chest; and, as the result of this last, difiiculty
of breathing, tightness in the cough, and violent
fever/' In a work with the significant title " Medical
Observations Concerning the History and Cure of
Acute Diseases" (1676), which may be considered a
third, much enlarged, edition of the "Methodus,"
Sydenham placed before the learned world an ac-
count of the history and treatment of the epidemics
of fifteen years.

The " Observationes Medicae'' is much more than
a contribution to epidemiology. It aims to give
graphic and natural descriptions of disease based on
well-considered clinical data, and to establish a
definite therapeutic procedure. He proposes as a
follower of Bacon to advance from the observation
of individual cases, and to reduce all diseases to
clearly defined ** species, and that, with the same
care which we see exhibited by botanists [like his
contemporaries Grew and Ray] in their phytolo-

148 THE HISTORY OF MEDICINE

gies/' To write the natural history of a disease the
physician should hold in abeyance every philo-
sophical hypothesis and prepossession, and imitate
" the exquisite industry of those painters who repre-
sent in their portraits the smallest moles and the
faintest spots/' At the same time it is necessary to
portray in the clinical picture what is typical and
characteristic of the species rather than the ad-
ventitious or merely individual phenomena. ''No
botanist/' says Sydenham, "takes the bites of a
caterpillar as a characteristic of a leaf of sage/'
Moreover, diseases must be studied in relation to
the time of year in which they occur, for though
many are good throughout the twelvemonth, others
follow the seasons as truly as plants and birds of
passage.

The main part of medicine is the discovery of the
indications of the various species of disease. These
indications or symptoms furnish a clue to the right
treatment, for disease is nothing but Nature's effort
to restore the health of the patient by the elimina-
tion of the morbific matter or to effect a renovation
of the blood. For example, gout seeks to purify the
blood of old men, plague to expel those infectious
particles which we have taken in along with the air
we breathe, just as an abscess may help to remove a
thorn. Our natures are the physicians of our dis-
eases, as indeed Hippocrates, that divine old man,

SCIENCE AND PRACTICE 149

taught. In the case of some diseases the practitioner
should maintain the expectant attitude, or remain
merely passive. He should, however, not hesitate to
reSnforce the efforts of Nature when she is enfeebled
and to coerce her when outrageous, always duly at-
tending to her method and time of working a cure.
To develop a system of natural therapeutics, a fixed
and consummate method of treating disease, veri-
fied by a sufficient number of experiments, must be
the result of codperation. "If, in each age of the
world," writes Sydenham, "a single person only had
properly treated upon one single disease, the pro-
vince of the physician, or the art of healing, would
long ago have reached its height ; and would have
been as complete and perfect as the lot of humanity
admits." Sydenham recognized that medicine was
to be advanced not merely by the preparation of
accurate descriptions of diseases and the establish-
ment of a definite method of treating them, but also
by the discovery of specific remedies, an interest in
which he shared with Robert Boyle.

In describing the symptoms of the fevers of 1661-
64, Sydenham states that all sgixes begin with shiv-
erings and rigors, succeeded by heat, and termi-
nated by sweats. In the hot and cold paroxysms the
patient has a strong desire to vomit. One may speak
of the stage of exhorrescence, the stage of ebullitiont
and the stage of despumation. The commotion of

ISO THE HISTORY OF MEDICINE

the blood is Nature's means of bringing about a
purification or renovation. For illustration it may
be compared with ebullition or fermentation. Vernal
intermittents are analogous to the workings of full
beer barrels, when, having lain long in cool cellars,
they are set near a fire. Depuration occurs by flow-
ers or by dregs. The physician should be guided by
Nature in the exhibition of emetics, diaphoretics, or
purgatives. Evacuation by means of clysters may
act as an oversized vent for beer whilst it is ferment-
ing. If the patient was advanced in years or had
been pulled down by evacuations, Sydenham pre-'
scribed cordials. " But," he writes, " if the fermenta-
tion be neither too active nor too languid, I leave it
to itself, and use no remedies." Sydenham, the Eng-
lish Hippocrates, had faith in the vis medicalrix
naturm^ and resembled the Father of Medicine in his
doctrine of atmospheric constitutions, in his avoid-
ance of extremes, in his distrust of speculation and
in the inclination to ground philosophy on observa-
tion and practice, in his lofty professional ideals,
respect for patients, and universal charity, in his
humoral physiology, in his diagnosis and prognosis,
in the use of cooling drinks, in his resort to hygienic
measures (diet, riding and carriage exercise) and in
his employment of simple remedies. At the same
time Sydenham's name is associated with advances
in the use of drugs, with the popularization of Peru-

SCIENCE AND PRACTICE 151

vian bark in the treatment of intermittent fever, with
its recognition as a tonic, with the introduction of
liquid laudanum and other preparations of opium,
and with the exhibition of steel and mercury. He
found antimonial emetics are not fit for children
under fourteen years of age. ''I wish, with all my
heart/' he writes, ''that instead of them something
more safe, and equally efficacious, could be dis-
covered." For kidney troubles he recommended the
waters of different mineral springs, among them the
waters of the suburb of London now known by his
name.

Among his contemporaries Sydenham was partic-
ularly noted for his so-called cooling method of
treating smallpox. He certainly held that the danger
from cold in this disease b far less than that from a
too heating regimen. He burlesqued the treatment
then in vogue, and asked whether the subject's life
might not be in danger if the stoutest porter in the
best of health were, for the sake of experiment, put
to bed with the curtains drawn and a large fire in the
room to keep him in a sweat for some weeks, there
being in attendance a nurse or two, who, if he should
shift his position or put a finger out of bed, should
correct his error by heaping on more clothes, and
who, during all this time, should deny him small
beer or other refreshing drinks and continue to ply
him with posset and cordials, /'From an overhot

152 THE HISTORY OF MEDICINE

regimen/' he writes, "never good came, any more
than from overhasty fruit any profit." The separa-
tion of the peccant matter from the humors must be
effected before it is eliminated by the sldn. We must,
however, "not be so intent upon ensuring 2^;ainst
an overheated state of the blood, as to expose our
patient to any injury from cold, and by so doing
arrest the eruption of the pustules/' Sydenham,
though he clearly distinguished the two diseases,
treated measles in much the same way as smallpox,
and taught that the former is a disease superinduced
upon the blood during an attempt at a new stasis,
and that one attack assures as a rule against
another. There is much, in fact, in Sydenham's
views of smallpox and measles that is reminiscent
of Rhazes, as there is also in his view that disease
may be explained as a fermentation of the humors.
It is probable, however, that the latter conception
at least was suggested to Sydenham by the writ-
ings of Willis or of some other physician of his own
time.

Indeed, although Sydenham focused his attention
on the symptoms and treatment, there is sufficient
evidence that he did not avoid adopting hypotheses
regarding the nature and causation of disease. In
harmony with Locke and Boyle he believed that
the human frame is adapted to impressions from
without, and that maladies are owing in part to

SCIENCE AND PRACTICE 153

mineral effluvia or other occult atmospheric influ-
ences — to particles of the atmosphere — and in
part to the different fermentations and putrefactions
of the humors. He even compares diseases with the
mosses, fungi, and mistletoe that grow on trees, the
nutritive juice of which may have suffered perver-
sion or depravation. At the same time he was aware
that not merely the delicate are subject to infection.
A man might be as strong as a wrestler, but if he
went to certain parts of the country where fever
was raging, he would sicken within a day or two.
When in cases of intermittent fever the despuma-
ticm has been incomplete, the fit may return when
the patient seems out of danger; the latent matter
presents itself anew, like ''broods of bees that
grow gradually at stated times." The conditions
that produce plague were for Sydenham a special
object of curiosity, and the study of them brought
him near to a juster view than Boyle's theories
afforded of the part played by the atmosphere in
the dissemination of disease. He had grave suspi-
cions that the mere atmospheric constituti<xi was
insufficient to originate plague. The disease must
be perpetuated in sporadic cases in the intervals be-
tween epidemics, or must continue to survive in
some fames f or arise from some infected person from
a pestilential locality. Otherwise Sydenham could
not account for the fact that through the sanitary

154 THE HISTORY OF MEDICINE

measures of the Grand Duke Ferdinand II there
had been stopped in 1650 at the borders of Tuscany
a plague that had devastated nearly all the rest
of Italy. When an epidemic rages, the exhalations
from the sick and from the corpses of the victims
of the disease spread the contagicm through the
whole atmosphere of the affected area, so that the
air, in itself and of itself, is sufficient to destroy
those whose humors are adapted to the receipt of
the influence. As regards the treatment of the
plague, Sydenham remarks that Nature's method
of eliminating the morbific matter by means of ab-
scesses cannot be furthered by means of diaphoresis,
and that it is here unsafe for the physician to at-
tempt to follow the path of Nature.

In 1680 appeared Sydenham's fourth book,
^'Epistolse responsoriae duae," addressed to two phy-
sicians connected with the University of Cambridge,
from which institution he had received the degree
of M.D. in 1676. The first of these letters deals with
the epidemics of 1676, of 1678, and the succeeding
years (intermittents again prevailing after 1678, and
influenza after 1679), with the administration of
Peruvian bark, and the treatment of rheumatism by
lenitives and by simple, cool, nutritious diet, such as
whey. The second letter deals with venereal disease.
Sydenham noted that venereal lues had declined in
strength since, in I493» it had first struck root in

SCIENCE AND PRACTICE 155

Europe, it being in his opinion characteristic of spe-
cies of disease that they are modified in the course
of time, that they become extinct and give rise to
new species. He recognized the primary lesion —
'^shanker''; called buboes the first stage of true
lues; and spoke of the disease as extending to differ-
ent parts of the body, attacking the bones, produc-
ing phagedaenic ulcers, etc The taint of either
parent may be transmitted to the offspring. A child
may communicate it to the nurse, or an infected
nurse may give it to a healthy child. Sydenham
knew that syphilis, which he differentiated to some
extent from gonorrhoea, had reached Europe after
the discovery of America, but he held that its origi-
nal home was not the West Indies, but the coast of
Guinea or some portion of the negro country there-
about. In fact, he thought it identical with the Afri-
can disease called the "yaws.'' Some argue, says
Sydenham, "that the cure of the venereal disease
should not be taught. With such I disagree. If we
reject all cases of affliction which the improvidence
of human beings has brought upon themselves, there
will be little room left for the exercise of mutual love
and charity. God alone punishes. We, as we best
can, must relieve. Neither must we be too curious
in respect to causes and motives, nor too vexatious
in oiu" censorship." According to his experience
there was no true instance of this disease having

156 THE HISTORY OF MEDICINE

been extirpated except by means of salivation ex*
cited by mercury.

Further daims on our admiration of the clinical
acumen and skill of the English Hippocrates are
made by his recognition oi the protean character of
hysteria and the relation of hysteria and hypochon-
driasis, by his account of scarlatina, by hb differen-
tiation of chorea from dancing mania, by his riding
treatment for phthisis, by his classical description
of gout and other chronic diseases. He described a
species of insanity following prolonged malaria.
Nor should we be misled by exaggerated statements
of his indifference to the science of his time ; for he
refers repeatedly to the circulation of the blood,
mentions the lacteals^ speaks appreciatively of his
English contemporaries who "have done good work
in each kind of science that advances medicine,'' and
held it essential for the physician, as for the surgeon,
to know thoroughly the structure of the human
body. He was not ignorant of contemporary studies
of the anatomy of the kidneys, and he was aware of
the encystment of renal calculi. He said that coma
arises from an obstruction in the cortex of the brain,
and that apoplexy may be caused by an extravasa-
tion of blood from the capillaries of the cerebral
arteries, and in his treatise on dropsy he made men-
tion of the results of post-mortem examination of
the abdomen. The special province of the physician.

SCIENCE AND PRACTICE 157

however, is not, in the judgment of Sydenhanii
scientific research. It is rather comparable with
that of a pilot whose only business it is to see that
the ship be not sunk, not to speculate on the ebb
and flow of the tide. The great English physician's
consecration to the welfare of his patients, as well
as to the Commonwealth, was a great factor in the
establishment of hb fame both in Britain and on the
Continent of Europe. Boerhaave is said never to
have referred to Sydenham without removing his
cap in salutation to " Angliae lumen, artis Phoebum,
veram Hippocratid viri speciem.'*

Hermann Boerhaave himself, bom near Leyden,
Holland, in 1668, is sometimes called the Batavian
Hippocrates. Like his Greek and English models he
was discriminating in the use of drugs and made
much of hygiene. He was a profound scholar, and
served for years as professor and rector in the Uni-
versity of Leyden. His numerous pupils, among
whom were Pringle, Haller, Camper, van Swieten,
and de HaSn, greatly extended the range of his in-
fluence. He is especially deserving of remembrance
as a clinical instructor. At his demonstrations he
concentrated attention on a few patients, made use
of a Fahrenheit thermometer, and he also sought to
verify his diagnoses by post-mortems, explaining
the pathological as a deviation from the physiologi-
cal. Like Sydenham he condemned philosophers

158 THE HISTORY OF MEDICINE

who seek to invent rather than to discover, but he
was in closer touch with the science of his own time
than the English physician had been with that of
the previous epoch. He taught botany and devel-
oped the botanical garden at Leyden. He was the
author of a work on chemistry (" ElementajChemiae/'
1732), in which he taught that unlike combines
with unlike, not like with like. He studied Boyle,
Malpighi, Leeuwenhoek, and edited under the title
''Biblia Naturae'' the writings of Swammerdam,
who had described red-blood corpuscles and had
opposed the ancient doctrine of spontaneous genera-
tion. Boerhaave maintained that epidemics of small-
pox are owing solely to contagion, and he showed a
greater faith than Sydenham in the power of the
human mind to arrive at the ultimate causes of
disease. "He who," writes Boerhaave, "with the
greatest possible exactness, weighs every particular
thing which shall happen or has happened to his
patient, and which may be learned from the obser-
vations of himself or of others, and who then com-
pares all these with one another, and places them in
opposition to such things as occur in a state of health,
and finally, from all this, with the nicest and strict-
est control of his speculative powers, rises to the
knowledge of the first cause of the disease, and of
the remedies fit to remove it, he, and only he, de-
serves the name of a true physidan/V

SCIENCE AND PRACTICE 159

One of his critics regrets that Boerhaave, pos-
sessed of remarkable powers of observation, should
at times have tied himself to groundless hypotheses,
in opposition to the very principles which he advo-
cated so strongly. His works are now little read, but
his pupils and the record of his enormous private
practice bear witness to his qualities as teacher and
physician. A monument raised in his honor by the
city of Leyden is inscribed : ** Sacred to the Genius of
the Health-giving Boerhaave (Salutifero Boerhaavii
Genio Sacrum)."

REFERENCES

Boyle, Robert: Works (edited by Thomas Birch). London,

1772. Vol. V, pp. 38 and 74-126.
Brown, J.: Spare Hours (Hora Subsedoai), third aeries, 1882,

pp. 39-110, and pp. 221-33.
Lusk, W. T.: ^The Illustrious Boerhaave,'* Popular Science

Monthly, vol. 47 (1895), pp. 110-20.
Osier, Sir William, and McCrae, Thomas: The Principles and

Practice of Medicine. Ninth edition, 1920, pp. 320-30.
Payne, J. F.: Thomas Sydenham, New York, 1900.
Picard, Fr£dMc: Sydenham, sa Vie, ses (Euores. Paris, 1889.
Sydenham, Thomas: Works (translated, with a life of the author

by R. G. Latham). 2 vols., 1848 and 1850. Published by The

Sydenham Society.
Creighton, Charles: A History of Epidemics in Britain. 2 vols.

Cambridge, 1891 and 1894.
Prinzing, Friedridi: Epidemics ResuUi»g from Wars. Oxford

(Clarendon Ptress), 1916.

.CHAPTER VIII

COMPARATIVE ANATOMY: JOHN HUNTER

John Hunter, born near Glasgow in 1728, was, like
Darwin, an indefatigable collector of natural history
specimen^. As a boy, instead of going to schoc4, he
wandered about the country, observing the ants,
the bees, the tadpoles, and the larvae of caddis-flies,
studying the habits of the birds, and making collec-
tions of birds' eggs, which he compared in size, color,
markings, and in the number characteristic of each
species. In his twenty-first year he began at London
those studies in anatomy and surgery which formed
the basis of his subsequent activities. After eleven
or twelve years of almost unremitting work in the
dissecting-room and the hospital, he went, as sur-
geon, with the military expedition to Belle-Ile,
where he collected specimens which formed the
nucleus of what is now known as the Hunterian Mu-
seum. Service in Portugal gave him the opportunity
of extending his observations. In 1764 he estab-
lished at Earl's Court, at that time well to the west
of the city of London, a country-seat stocked with
ducks, geese, pigeons, fish, frogs, eels, river-mussels,
sheep from Turkey, a shawl-goat from the East
Indies, buffaloes, leopards, a beautiful little bull

COMPARATIVE ANATOMY i6i

presented by the Queen, and specimens of various
other species, plant as well as animal. His town
house became crammed with natural history speci-
mens, so that, soon after his marriage in 1771, his
bride, the accomplished Anne Home, found herself
living either in a menagerie in the country or in a
museum in the city. In 1783 he set up his famous
establishment in Leicester Square. He held that
Francis Bacon had been the chief cause of the ad-
vance of science since the sixteenth century, and he
determined to base his own generalizations on com-
prehensive and careful observation of natural phe-
nomena. Animals dying at the Tower of London
and the city menageries were obtained by Hunter
for dissection, and no animal was brought to Eng-
land during the latter part of his career without his
having an opportunity to examine it.

Hunter lacked Darwin's opportunity of extended
travel, but the material brought to his door offered
an equivalent in some respects, and he lived in an
age when men's imaginations were kindled by voy-
ages of discovery as they had been in the Eliza-
bethan. In 1 77 1 Edward Jenner, Hunter's pupil
and familiar friend, was chosen at his suggestion to
examine and classify the collections brought to Eng-
land by Captain Cook from Australia, New Zealand,
and other islands of the South Pacific.

This incident serves to indicate the kind of influ-

162 THE HISTORY OF MEDICINE

ence exerted on Jenner by his master. It is indeed
true that Hunter was interested in the problem of
immunity and in the rivalry of diseases. He knew
that people constantly exposed to the cause of cer-
tain diseases become less affected, or less liable to be
affected. He recorded the case of two children, in
which smallpox, following inoculation, was held in
abeyance for a time by an attack of measles. He
said that cowpox and smallpox, if inserted at the
same time in different parts of the same person, pro-
duce each the same effect as if only one of them had
been inserted. Nevertheless, Jenner's indebtedness
to Hunter has sometimes been put in a false light,
and Hunter's famous exhortation to his pupil to rely
on experiment rather than on speculation or au-
thority referred to a problem in natural history and
not to vaccination. "I thank you," wrote Hunter,
''for your experiment on the hedgehog; but why do
you ask me a question by the way of solving it? I
think your solution is just; but why think — why
not try the experiment?" About three years later,
that is, in 1778, Hunter turns suddenly from a dis-
cussion of Jenner's disappointment in love to stimu-
late him to undertake fresh experiments on hiber-
nating animals. "I own," he writes, "I was glad
when I heard you was married to a woman of for-
tune; but 'let her go, never mind her.' I shall em-
ploy you with hedgehogs."^ Again he writes: "I

COMPARATIVE ANATOMY 163

have but one order to send you, which is, send every-
thing you can get, whether animal, vegetable, or
mineral, and the compound of the two; namely,
either animal or vegetable mineralized/*

His cupidity for Nature was never satiated. At
considerable expense he sent a surgeon to Greenland
to examine the anatomical structure of large marine
animals and to preserve the more interesting parts.
In 1793, the year of his death, his zeal in the study
of Nature was still undiminished. Writing to a
gentleman in Africa he asked for specimens of the
different species of swallows, in order that he might
obtain a clue to their migrations, everything re-
specting the bee tribe, such as wasps with their
nests, also hornets with theirs, cuckoos, ostrich-
eggs, and chameleons. "If a Foal camell was put
into a tub of spirits and sent, I should be glad. Is it
possible to get a young tame lion, or indeed any
other beast or Bird,"

Hunter's writings along with the specimens pre-
served in his museum show that he had dissected
twenty-one species of quadrumana (apes, monkeys,
lemurs), ten species of marsupials, fifty-one species
of camivora, twenty species of rodents, five species
of edentata, fifteen species of ruminants, ten species
of pachyderms, six species of cetacea, and twenty-
three other species of mammals scattered through
the sub-classes. As regards human anatomy Hunter

164 THE HISTORY OF MEDICINE

dissected thousands of cadavers. There is like evi-
dence that he dissected one hundred species of birds,
fifty-nine species of fish, thirty-nine species of
reptiles, forty-two species of molluscs, over ninety
species of '^ articulate" and "radiate'' animals, and,
in addition, twenty miscellaneous species of inverte-
brates. His museum contained 13,682 specimens,
including^ 2773 fossils.

Sir Richard Owen, the leading authority on com-
parative anatomy in the period following the death
of Cuvier, credits Hunter with the first great at-
tempt to arrange in concatenated system the di-
versified facts of that branch of science. The idea of
a graded series is a constant feature of Hunter's
studies of the various anatomical structures, as well
as of his attempts to lay the foundations of a phylo-
genetic classification of animals. He considered, for
example, whatever is uncommon in the organ of
hearing in fishes as only a link in the chain of varie-
ties displayed in the organ of like function in diflfer-
ent animals, descending from the most perfect to the
most imperfect, in a regular progression. Guided by
the same principle he traced the development of the
nervous system from the simple filaments of some
of the lower organisms to the highly organized
masses found in the monkey and in man, the most
complex of the animals. In like manner he followed
the development of the canine teeth, which he was

COMPARATIVE ANATOMY 165

the first to call cuspids, from the lion to man, noting
the similarity in shape, situation, and function.
Palmer, who edited Hunter's works in 1837, took
him to task for teaching that man was originally
constructed for the pursuit and capture of living
prey. Though the criticism may have been well
founded, it should be recognized that Hunter dis-
tinctly taught that man, a more perfect or compli-
cated animal than any other, is not made to come
at his food by his teeth, but by his hands, directed
by his superior ingenuity; also, that man is able to
live in a much greater variety of circumstances than
any other animal, has more opportunities of exer-
cising the faculties of his mind, and is possessed of
that high d^jee of sociability which implies superior
educability.

In tracing the affinities of the different species of
animals Hunter supplemented his special studies of
anatomical structure — for example, of the whale
as a modified land animal, of the relationship of
birds and batrachians, of the weak wings and highly
developed legs of the ostrich — by common-sense
observation as well as by experiment. He did not
overlook the obvious resemblance of the horse, the
ass, and the zebra, nor that of the wolf, dog, jackal,
and dingo. Does not the natural gradation of ani-
mals from one to the other, he asks, lead to the
original species? The wolf has a closer resemblance

i66 THE HISTORY OF MEDICINE

to the fox than has either the dog or the jackal. The
shephaxl's dog, all over the world» as well as the
Esquimaux dog and the dingo, resembles the wolf
in shape and disposition. Hunter owned one of a
litter of puppies, the offspring of a wolf and a bitch.
He described it as easily startled and particularly
apprehensive of danger. It had the shape of the
wolf refined, and a long coat almost as fine as that of
the black fox. The mother was of the Pomeranian
breed. A bitch of this same litter had in all thirty-
five puppies, some of which were wild and so unruly
that they could not be controlled by the most skill-
ful dog-trainers. Hunter records another case of
four puppies, the offspring of a she-wolf and a grey-
hound. Two Were like the dog in color — large
black spots on white ground; one was black; the
fourth was dun, and would probably have been like
the mother. Hunter owned a puppy of a second
litter of this she-wolf. He also secured a female
puppy of a she-jackal and a spaniel. It was of a
wild disposition. When mature it gave birth to five
puppies. One of these was given to Jenner, who
subsequently reported that it was shy and appre*
hensive, and remarkably fleet.

Hunter's posthumous essays show with what care
he compared the anatomical structure of apes,
monkeys, and lemurs with that of man. In a species
of gibbon he observed the absence of the tail, the

COMPARATIVE ANATOMY 167

l^igth of the appendix, as well as the similarity of
the liver and other abdominal viscera to those of a
human being. The uterus in form and position is
like that of a child. In one species of Macacus he
found that the muscles of the eye are as in man, and
that the brain b very like the human. In another
species of monkey he noted that the prostate gland
is similar to the human prostate gland. ''The
monkey/' says Hunter, "in generstl may be said to
be half beast and half man; it may be said to be the
middle stage." Again he described the mongoose as
an exact degree from the monkey to the brute in its
external form.

Hunter supposed that the erect posture in man
rendered him more liable to rupture, and contrib-
uted to the descent of the testes. When the testes
remain in the abdomen in man, as they do normally
in the hedgehog and some other species of animab»
we have an example of what Hunter was the first to
call "arrested development.'' The erect posture
accounted likewise in his judgment for the disposi-
tion of the pelvic viscera in man, and affected the
curves of the spine and the form of the foot, as well
as the structure of the knee-joint. He noted the
difiPerentiation of the hand from the foot in man and
monkey. He believed that the thumb of the monkey
is not so strong as that of man, "and has not that
opposing motion." The walk of the monkey is very

i68 THE HISTORY OF MEDICINE

similar to that of a child who has hardly the power
of supporting the center of gravity, he says.

Hunter had observed at Belie-Ile that frogs live
upon wormsi beetles, grasshoppers, caterpillars, and
butterflies. Later he attained to the generalization
that the large animals are made as a rule to live
upon the less, and he anticipated the doctrines of
Malthus so far as to teach that it is necessary ** that
many animals should be made to prey upon others;
else we should be overstocked with the smaller."
He also held that modifications that occur in animal
structure tend to progression rather than to retro-
gression. Deviation from the original structure is
not necessarily deterioration. It appears, he remarks,
just the contrary; therefore we may suppose that
nature is improving its works, or, at least, has estab-
lished the principle of improvement in the body as
well as in the mind. Variation furnishes the mate-
rials of advance. In the individuals of each species,
writes Hunter, varieties are every day produced in
color, shape, size, and disposition. Some of these
changes are permanent with respect to the propaga-
tion of the animal, becoming so far a part of its
nature as to be continued in the offspring. In the
case of acquired properties, according to Hunter, it
is only the susceptibility to certain influences that is
inherited. Diseases like gout and scrofula are not
really hereditary.

COMPARATIVE ANATOMY 169

He remariced, in his comparative study of the
gizzard and stomach, the difficulty generally en-
countered by the anatomist of distinguishing the
proximate steps in the slow and imperceptible grada-
tions of nature. His recognition of the gradual
deviation from type as the rule did not blind him,
however, to the possibility of exceptions. ''How
far,'' he says, ''varieties in animals are gradual, or
in what degree they, at once, produce a very dis-
tinct variety, is perhaps not to be ascertained." He
mentions the case of a white negress who had three
children by a white man. One of the children was
black, while the two others were tawny. Hunter
was interested of course in atavism, and in the varia-
tions that occur in domesticated animals. He speaks
of latent hereditary dispositions, which pass over
one or two generations, and start up again in the
second or third. Again, animals living in a free and
natural state are subject to fewer deviations from
their specific characters than are animals influenced
by culture. " From the variations produced by cul-
ture, it would appear, that the animal is so suscepti-
ble of impression, as to vary nature's actions and
this is even carried into propagation."

In 1766, the year preceding that in which Hunter
became a fellow of the Royal Society, he wrote a
description of the anatomy of an Amphibious Bipes,
a species of Siren, which had defied the dassificatory

170 THE HISTORY OF MEDICINE

skill of linnseus. It was animals like this and the
Southern Chimera, which did not seem to fit into
the pigeon-holes of the System of Nature, that par-
ticularly fascinated Hunter. He was deeply inter-
ested not only in exceptional species of all sorts, but
in giants, dwarfs, henm^rodites, and other mon-
strosities. According to Owen he anticipated the
principles set forth by Isidore Geoffroy Saint-
Hilaire in his "Trait6 de T6ratologie '' (1832).
Hunter observed that the natural hermaphrodite
belongs to the inferior and more simple genera of
animals, of which there is a much greater number
than of the more perfect; and as animals become
more complicated, have more parts, and each part is
more confined to its particular use [by a physiologi-
cal division of labor], a separation of the two neces-
sary powers for generation seems also to take place.
He raised the question whether there ever occurs in
the genera of animals that are natural hermaphro-
dites, a separation of the two parts forming distinct
sexes, and he conjectured that the occurrence of
such a variation might account for the distinction
of sexes ever having happened.

Darwin begins Part II of "The Descent of Man*'
with the following statement: "With animals which
have their sexes separated, the males necessarily
differ from the females in their organs of reproduc-
tion; and these are the primary sexual characters.

COMPARATIVE ANATOMY 171

But the sexes often differ in what Hunter has called
secondary sexual characters, which are not directly
connected with the act of reproduction/' A glance
at the table of contents of this work of Darwin's will
convince the reader that Hunter's conception is the
dominant idea of the last two thirds of it. An in-
trcxluctory chapter on the principles of sexual selec-
tion is followed by chapters on secondary sexual
characters in the lower classes of the animal king-
dom — in insects, in lepidoptera, in fishes, amphib-
ians, reptiles, in birds, and in mammals. The third
and last part of ''The Descent of Man" consists of
two chapters on the secondary sexual characters of
man and a general summary and conclusion. "In
all animals we are acquainted with," writes Hunter,
"we see distinguishing marks between the male
and female, exclusive of the parts peculiar to each."
Hunter divides sexual characters into principal
and secondary, and among the secondary properties
which characterize the male and the female he
mentions the beard, mane, spurs, horns, voice, etc.
He carefully records cases in which the female
pheasant had assumed the plumage of the male. He
also refers to an interesting case in which the mam-
mary glands were fully functional in a man.

Owen says that Hunter was the first to enunciate
the principle of the resemblance of the phases of
embryonic life to the series of inferior forms of ani-

172 THE HISTORY OF MEDICINE

mal species. ** If,** wrote Hunter, ''we were capable
of following the progress of increase of the number
of the parts of the most perfect animal, as they first
formed in succession, from the very first to its state
of full perfection, we should probably be able to
compare it with some one of the incomplete animals
themselves, of every order of animals in the creation,
being at no stage different from some of the inferior
orders. Or, in other words, if we were to take a
series of animals, from the more imperfect to the
perfect, we should probably find an inferior animal,
corresponding with some sts^e of the most perfect.**
This idea, with which Hunter was struggling, has
been neatly expressed in our times by saying that
the human embryo in each of its stages of develop-
ment resembles the mature form of some species
lower than itself. Of course this generalization of
Himter*d rested on numerous observations. He re-
marked, as we have seen, that in the hedgehog the
testes continue throughout life to be lodged in the
abdomen, in the same position as in the human
foetus. The appendix of a species of lemur is like
that structure in the human fcetus, which, in turn.
Hunter compared with the foetal appendix of the
monkey. The resemblance of the disposition of the
abdominal viscera in the lower manunals in general
with that in the human foetus is another case in
point. G>ngenital hernia and certain other ab-

COMPARATIVE ANATOMY 173

normalities were explained by Hunter as pernsting
embryonic conditions.

Geology afforded him another due to the affini-
ties of the various species and genera of animals, as
well as to the interdependence of natural and phyd-
cal phenomena. He agreed with Hutton that geology
has nothing to do with the original formation of the
earth itself, but is concerned only with the changes
of the earth's crust. Hutton, as Lyell remarks, pos-
sessed little information regarding organic remains.
Hunter, on the other hand, before the appearance of
Hutton's ''Theory of the Earth,'" was attempting
to match up fossil animals with those living species
with which he was so eminently conversant. He
distinctly taught that we should be unable to con-
sider the operations affecting the surface of the
earth if we had not the preserved parts of animals
to guide us. They enable us to trace the history of
the earth's crust just as we should trace the political
events in any country by die monuments left. We
must judge of the past by the present, supposing
from the state of the earth as it now is what must
have taken place formerly.

Hunter further agreed with the uniformitarians
in believing in the antiquity of the earth. Speaking
of one collection of fossil bones he says that there
was probably a succession of them for a vast series
of yearsi many thousand years. In what was sup-

174 THE HISTORY OF MEDICINE

poeedly the last essay he wrote he used the exptes^
sion ** many thousand centuries/' This was criticized
and a representative of the Royal Society suggested
that he substitute ''years'' for ''centuries," but he
withdrew the paper rather than make the change.

Few fossils, says Hunter, correspond with recent
specimens. They may not be of different spedes,
but varieties of the same species. If they are really
diflFerent spedes, then we must suppose the old are
lost and that, therefore, a new creation nmst have
taken place. That many are actually lost seemed
plainly shown by the remains of land animals that
are not now known. How they became extinct is not
easily accounted for. His unexcelled kno^edge of
dentition enabled him to identify a fossil white bear
twice as large as the present white bear, and gave
him assurance that the fossil teeth found at Salt
Lick, near the Ohio, about 1767, bdonged to an ani*
mal larger than the elephant.

The teeth of the kangaroo are so singular that it
is impossible from them to say what tribe it is of. At
the same time Hunter was not unaware of the mar«
supial character of the Australian fossil mammalia.
Darwin, in that part of the "Origin of Spedes" that
treats of geological succession, pays tribute to the
work of Hunter by referring to his faithful followers
Clif t and Owen. " Mr. Clift," writes Daiwin, " many
years ago showed that the fossil mammab from the

COMPARATIVE ANATOMY 175

I

caves were closdy allied to the living
marsupials of that continent. In South America, a
similar relationship is manifest, even to an unedu-
cated eye, in the gigantic pieces of armor like those
of the armadillo, found in several parts of La Plata;
and Professor Owen has shown in the most striking
manner that most of the fossil mammals, buried
there in such numbers, are related to South Ameri-
can types/' Hunter had dissected of course arma-
dillos, sloths, and ant-eaters, and other specimens
of South American species that proved of interest
to Owen and Darwin.

William Clift, the last and most devoted of
Hunter's pupils, was received as an apprentice and
amanuensis on his seventeenth birthday, February
14, 1792. After Himter's death, in the autumn of
the following year, Clift was placed in charge of the
establishment in Leicester Square. Almost the sole
occupant of the large building diuing the subse-
quent six years, he spent his time studying the speci-
mens in the museum and making extensive excerpts
from his master's volumes of unpublished manu*
scripts. When, in 1800, the museum was taken over
by the G>llege of Suigeons and the collections were
removed to new quarters, Clift was continued in
charge with the title of Conservator. The greater
part of Hunter's manuscripts were destroyed by his
brother-in-law, Sir Everard Home, in 1823. In 1830

176 THE HISTORY OF MEDICINE

Richard Owen, who had studied under Hunter's
pupil Abemethy, was appointed Gift's assistant.
"From Clift/' says the "Dictionary of National
Biography," "Owen imbibed an enthusiastic rever-
ence for his great master, John Hunter, which was
continually augmented by closer study of his
works/' Owen married Clift's daughter in 1835, and
helped Palmer edit Hunter's works. The paper, al-
ready referred to as probably Hunter's last essay,
"On Extraneous Fossils and their Relations," was
not published till 1859, ^ ^^^ months after the ap-
pearance of the "Origin of Species." In 1861 Owen
published from Clif t's notes two volumes under the
title " Essays and Observations in Natural History,
Anatomy, Physiology, Psychology, and Geology, by
John Hunter, being his Posthumous Papers on these
Subjects." It was largely through Clift and Owen,
and visitors to the Hunterian Museum, such as the
younger Meckel (Johann Friedrich, 1 781-1833) and
Cuvier, that the influence of John Hunter in com-
parative anatomy and natural history was per*
petuated.

Hunter's attitude toward his profession was some-
what different from Sydenham's. He regarded
science as the essential basis of practice, and hoped
by his investigations to establish new methods of
treatment, or, as he said, to make discoveries in the
art itself* He is now recognized as the founder of

COMPARATIVE ANATOMY 177

scientific surgery. Many of the reforms he effected
in his profession were the direct result of his com-
prehensive study of natural phenomena. " It is con-
trary to the rules of surgery as founded on our
knowledge of the animal economy/' he writes, ''to
enlarge wounds simply as wounds/' which had been
the general practice before the time of Hunter. Hb
observation of tetanus in a deer as the result of a
compound fracture stimulated his interest in the
conditions of inflammation. He removed one ovary
from a young sow, found that it subsequently had
numerous offspring, and stated his conviction that
there was no reason why the female of the human
species should not bear spaying. His seemingly
whimsical experiments in the transplantation of
tissues have anticipated some of the most striking
achievements of modem surgery. In his experi-
ments on the temperature of animals he made use of
a thermometer of his own invention very similar to
the clinical thermometer of the present day. His
studies in comparative odontology enabled him to
observe the cause of the retardation and the difii-
culty in cutting of the wisdom teeth in man, which
arise, he says, from the want of room in the jaws for
these late teeth. In fact. Hunter's scientific study of
the teeth rescued dentistry from a state of crude
empiricism and placed it, as surgery in general,
on firm foundations. One of the most fruitful of his

178 THE HISTORY OF MEDICINE

investigations was his study of the circulation in the
antlers of the deer. He ligated the artery supplying
the circulation in the antlers of a buck in Richmond
Park. The antlers, which were in the velvet, de*
prived of their blood*8upprfy, grew cold. In two or
three days, however, Hunter observed that the
temperature had become normal again, and this he
attributed to the establi^ment of a compensatory
collateral circulaticm. Later investigation proved
that the ligated artery had become obliterated.

Soon after this experiment he applied his discov-
ery in the hospital in the treatment of a case of
popliteal aneurism, tying the femoral artery in the
upper part of the thigh. His example opened the
way to the triumphs of British and American vascu-
lar surgery. One must mention in this conneotion
Hunter's pupil Astley Cooper (the master of John
Collins Warren, who played so large a part in the
introduction of ether anaesthesia and in the founding
of the Massachusetts General Hospital, and of
Valentine Mott, who ultimately had one hundred
and thirty-eight ligations for aneurism to his credit),
Hunter's pupils Abemethy, Wright Post, and Phy-
sick, the Father of American Surgery, as well as
Physick's nephew, John S3mg Dorsey.

It is not altogether irrelevant to mention Hunter's
study of gunshot wounds, which gives him a place
among the founders of modem military surgery, his

COMPARATIVE ANATOMY 179

study of the repair of tendons and his relation to
subcutaneous and orthopeedic surgery, his influence
on the treatment of hernia, his observations on the
inflammation of veins, the clotting of blood, and the
communicalnlity of puerperal fever* Hunter dis«
covered the distribution of the olfactory nerves, ex-
plained the placental circulation, traced the course
of the tubuli uriniferi, advanced our knowledge of
the lymphatic system, distinguished Hunterian
chancre from chancroid ulcer, invented double bel*
lows for the resuscitation of the apparently drowned
and advocated the use of oxygen in the treatment of
such cases. He experimented in artificial feeding,
made a special study of intussusception, threw light
on the nature of alcoholic fermentation, recorded a
case of post-mortem digestion of the tissues of the
stomach, observed hydatids in the liver of the mon-
goose, and investigated the motion and the tempera-
ture of plants.

Hunter was interested in the mental processes
and their development as a part of an interrelated
system of natural phenomena. He studied color-
blindness ten years before John Dalton, was inter-
ested in the accommodation of the eyes, discovered
what was later called the specific energy of the
nerves, traced the growth of the perception of space,
noted the abundance of human instincts, antici-
pated modem psychology in reference to types of

i8o THE HISTORY OF MEDICINE

memory and imagination and the physiological
phases of the emotions, studied the expression of the
emotions in the lower animals, recognized the sur-
vival value of anger and fear, and wrote in an en-
lightened way concerning what is now called the
sublimation of the emotions.

REFERENCES

Baron, J.: lAfe of Jenner. 2 vols., London, 1827^38.

Groes, Samuel David: John Hunier and kis Pupils. Philadelphia,

1881.
Hunter, John: (i) Essays and Observations on NaHtral History,

Anatomy, Physiology, Psychology, and Geology, being his

Posthumous Papers, etc. Edited by Richard Owen. 2 vols.,

London, 1861.

(2) Observations on Certain Parts cf the Animal (Economy.
London, 1793.

(3) Worhs. Edited by J. F. Palmer. London, 1837.
Ottley, Drewry: The Life of John Hwtter. Philadelphia, 1839.
P^t, Stephen: John Hunter, Man of Science and Surgeon,

London, 1897.
Stirling, William: Some Apostles of Physiology. 1902.
Keith, Sir Arthur: Menders of the Maimed.
Guerini, Vincenzo: A History of Dentistry. Philadelphia and

New York, 1909, pp. 316, 318, 324.

CHAPTER IX

MORBID ANATOMY, ^ND HISTOLOGY:
MORGAGNI, BICHAT

WixraNGTON in his "Medical History" says that
local pathology, the study of the tissues, and local
diagnosis form the three legs of the tripod upon
which the genius of modem medicine took her seat.
The early history of these three — morbid anatomy,
histology (urro9, tissue), and one aspect of local
diagnosis — will occupy our attention in this and in
the following chapter.

Giovanni Battista Morgagni (1682-1771) has
been called the Father of Pathology. Hb book
"Concerning the Seats and Causes of Diseases in-
vestigated by Anatomy*' ("De sedibus et causis
morborum per anatomen indagatis," 1761) gave the
results of postmortems known to himself, to his
master Valsalva, and to others among their pre-
decessors, such as Bonetus. Morgagni's study of the
abnormal was based on a sound knowledge of the
normal. He considered the commonest diseases the
worthiest objects of investigation, and he was care-
ful to establish the relations between the records of
his autopsies and the symptoms of the precedent
diseases. His aim was to explain disease by refer*

1 84 THE HISTORY OF MEDICINE

nected is'syphilis. Of the various manifestations of
this disease a great many were known to him that
were unknown to Hunter and other younger con-
temporaries of the Italian pathologist. After telling
of a rather hurried autopsy in which he had found
aneurism of the aorta and a morbid condition of the
lungs Morgagni surmises that a further examina-
tion might have revealed a diseased state of the
kidneys. "For these four parts — the lungs, the
aorta, and the kidneys, with their appendages — we
have found to be injured in those who have labored
considerably, and for a long time, under this lues."
He observed, in other cases of venereal disease,
caries of the cranium, diseased epiglottis, as well as
condylomata and gummata. Morgagni had not
himself seen the liver affected, though very learned
men reported that this organ was particularly liable
to venereal infection. He believed indeed that the
lues venerea might vitiate any viscus whatever.

As early as 1743 Morgs^^ni observed the ossifica-
tion of the coronary arteries. "As I examined," he
writes, "the external surface of the heart, the left
coronary artery appeared to have been changed into
a bony canal, from its very origin to the extent of
many fingers' breadth, where it embraces the greater
part of the base. And part of that very long branch,
also, which it sends down upon the anterior surface
of the heart, was already become bony to so great a

PATHOLOGY AND HISTOLOGY 185

space as oould be covered by three fingers placed
transversely." The subject in this case — an old
man — had been carried into the hospital suffering
from strangulated hernia. Inflammation of the
bowels developed soon after his admission, and the
patient succumbed almost immediately. Moi^gni
was able to learn very little about his previous con-
dition. The pulse was reported to have been weak
and small, but not intermitting. Speaking of
another case recorded by others before 1761, he
wished we could know ^'what disorders, and what
kind of death, had preceded in the man, in whom the
coronary veins of the heart were found to be bony."
He wished we could know, likewise, what particular
disturbances had been felt by those in whom the
corresponding arteries were bony. One writer had
supposed that this condition might be extremely
fatal, but that it was so he had been unable defi-
nitely to affirm. After the death of Morgagni, Ed-
ward Jenner conjectured that the heart disease from
which John Hunter suffered for twenty years was
caused by the ossification of the coronary vessels.
In reference to his master's ailment he consulted
Heberden, who had been the first, in 1768, to use the
expression angina pectoris. Jenner's conjecture in
reference to the condition of the coronary vessels in
the case of Hunter was verified by the postmortem
made by Everard Home.

186 THE HI^ORY OF MEDICINE

Morgagni has been credited with the first descri{>-
tion of heart-block (later studied by Adams, 18271
and Stokes, 1836), and with the first recorded case
of disease of the mitral valve. He referred cyanosis
in congenital heart disease to the general congestion
of the venous system due to obstruction. He described
lobar pneumonia with hepatization. He treated very
fully biliary, renal, and cystic calculi and recorded
cases of yellow atrophy of the liver, infantile jaun-
dice, from which all of his fifteen children suffered,
and tuberculosis of the liver and kidneys.

According to Morg£^;ni, ^'In a woman who had
not experienced more than dullness of hearing, Val-
salva found the membrana tympani on both sides
either totally or nearly destroyed by ulceration.
On one side all the ossicles were thrown off, except
the base of the stapes; and on the opposite side the
incus was disjoined from the stapes.'' Morgagni
adds that he liad never heard of any one who pre-
served his hearing long after the stapes had been
removed. He differed from his predecessors in
reference to the causal relationship between intra-
cranial suppuration and discharge from the ear, and
supported his view by citing a case of abscess of the
brain which was the ''consequence of the suppres-
sion of ichor flowing out of the ear." No symptoms
of brain abscess had been observed before the occur-
rence of a diseased condition of the ear.

PATHOLOGY AND HISTOLOGY 187

Hydrophobia, in Morgagni*s opinion, is caused
by a virus insinuated into the body. "Whoever,
therefore, professes to have found out the nature of
this disorder, must demonstrate the nature of this
poison. But I do not even see that the seat of this
disorder is confirmed/' He mentions, however, one
case of hydrophobia in which the vessels in the
meninges were extremely dbtended with blood.
Tetanus was observed by Morgagni to result from
apparently trivial injuries, such as the bite of a tame
sparrow, or splinters driven into the hand. In one
of the cases of tetanus he records, "A cart-wheel
passed over the lower part of the left heel of a youth
seventeen years of age; but no other injury was
apparent except laceration of the common integu-
ments.'* The first seat of a virulent gonorrhcea, he
asserts, b in the larger canaliculi of the urethra.
The term "Morgagni's fossa" (fossa navicularis
urethrae) and many similar terms preserve his
memory as a careful anatomist. "Morgagnian
cataract" is a phase of hypermature cataract ob-
served by him. In reference to traumatic cataract
Morgagni, with his characteristic care in giving
credit to those who have furthered the growth of
medical science, quotes Hippocrates as saying that
the sight is injured by wounds that are inflicted on
the eye-brow or a little above it.

Morgagni was in his eightieth year when he com-

188 THE HISTORY OF MEDICINE

pleted the ** De Sedibus/' the greatest landmark in
the history of pathology. His birthplace was Forli,
Romagna. At the age of sixteen he had begun his
studies at the University of Bologna, where he im-
bibed the view, once voiced by Malpighi, that sys-
tems are ideal and mutable, observation and ex-
perience solid and unchangeable. Before he was
twenty he had graduated as doctor of medicine and
doctor of philosophy. He succeeded his master Wai''
Baiv3,33 demonstrator anatomicus. He became known
as a writer as early as 1706. Six years later he went
to Padua, where he was appointed professor of
anatomy in 171 5. He retained till the time of his

death the chair which had been occupied by Vesalius

•

and many other distinguished anatomists. He wrote
voluminously on a wide range of subjects, and was
celebrated for general erudition and the elegance of
his Latin. He had certain foibles, the parsimony
that might be expected of a father of three sons and
twelve daughters and the vanity that sometimes
marks the character of great scholars and writers.
The five books of the ''De Sedibus" contain the
record of over six hundred dissections made by the
author himself and the critical account of a great
number of autopsies with which his extended read-
ing had made him acquainted. In the words of
Virchow, these books contain all that was known up
to that time concerning changes produced by dis-

PATHOLOGY AND HISTOLOGY 189

ease in the structure of the human body. This
greatest pathologist of the nineteenth century
acknowledged the fundamental character of Mor-
gagni's contributions. They furnished a starting
point for the progress of modem medicine. '^The
search for the sedes morhi has advanced from the
organs to the tissues, and from the tissues to the
cells/'

It was Marie Frangois Xavier Bichat who made
pathology dependent on a study of the tissues. He
was bom in the village of Thoirette, France, Novem-
ber 1I9 1771, and died at Paris July 22, 1802. His
father was a doctor of medicine who had received
his professional training at Montpellier. The son,
Xavier Bichat, after a very thorough general educa-
tion at Nantua and Lyons, began the systematic
study of medicine in the latter dty in 1791. The
political conditions of the time stimulated among
the doctors a special interest in surgery, and Bichat
came under the influence of Antoine Petit, the chief
surgeon of the Hdtel Dieu of Lyons. The Bichats
were not Revolutionists, and, after the siege of
Lyons in 1793, Xavier left that city. Before the end
of the year he took refuge in Paris, and entered as a
student the school of the famous Desault, hoping
later to become an army-surgeon. He mingled
quietly with the other students of medicine at the
Hdtel Dieu of Paris. The fall of Robespierre in

190 THE HISTORY OF MEDICINE

July, 1794, brought to the young man a greater
sense of security and a fortunate incident gained for
him the friendship and consideration of his master
Desault. It was customary in the school for the
students to take turns in preparing r6sum6s of the
great surgeon's lectures. One day Desault spoke at
length on fractures of the clavide, giving a demon*
stration of the use of hb bandage. When the time
came for the r6sum6» the student who was to have
given it was not present and Bichat offered to take
his place. E>esault'8 assistant, in whose presence the
report was made, was deeply impressed by Bichat's
clearness of thought and of expressbn. He told
Desault of the incident, and the master, conscious
of Bichat's extraordinary endowments, took the
young man into hb home and treated him as a
familiar friend and disciple.

Henceforth Bichat seemed indefatigable. His only
relaxation was change of work. He assisted Desault
at the hospital, in hb operations, in his private
practice, his professional correspondence, hb re-
searches in surgery. When, toward the close of his
life, Desault gave an extended course of lectures on
the diseases of the bones, his tireless assistant pre-
pared a careful statement of the teachings of the
various authors from the time of Hippocrates con-
cerning each question taken under consideration.
At the same time Bichat continued to dissect. He

PATHOLOGY AND HISTOLOGY 191

along with Corvisart and others founded the Soci6t6
m^icale d'6muIation, before which he read a num-
ber of papers, including one on the synovial mem-
brane and another dealing with the tissues in a more
general way. After the sudden death of Desault, in
1795, Bichat edited the fourth volume of his master's
"Journal de Chirurgie/' compiled two volumes of
extracts from the "Journal," and brought out the
last volume of Desault's works.

In 1797 Bichat undertook to lecture on anatomy,
emphasizing the mutual relation of structure and
function, and verifying his views by the experi-
mental study of animals. He followed the course on
anatomy with one on surgery, but was forced to
desist for a time by a severe attack of haemoptysis.
On his recovery he gave a more extended course on
anatomy, establishing a dissecting room and direct-
ing the work of about eighty students. In 1800 ap-
peared two works setting forth Bichat's character-
istic views concerning structure and function —
"Traits des membranes," and "Recherches physi-
ologiques sur la vie et la mort." The former became
the basis of Bichat's "Anatomie g6n6rale" (1801),
which established his claim as the founder of his-
tology; the latter distinguished between the vie
animale and the vie organique. These correspond to
the functions which have to do with the external
adjustments of the organism on the one hand and to

192 THE HISTORY OF MEDICINE

the functions which preserve the automatic activi-
ties of the individual on the other hand* According
to Bichat the cerebro-spinal nervous system and the
ganglionic nervous system are the structures on
which the animal functions and the organic func-
tions respectively depend. At the same time he dis-
tinguished the muscles of the animal life from the
muscles of the organic life*

Before the appearance of Bichat's ''Anatomie
g£n6rale** the study of anatomy had been largely a
study of the organs. These, according to Bichat»
admit of histological analysis, disentanglement of
their component parts. The organs, as he says, are
made up of tissues which are of very different kinds
and which really constitute its elements. Chemistry,
he proceeds, has its simple bodies, which by various
combinations, of which they are capable, form com-
pound bodies; likewise anatomy has its simple tis-
sues, which, by their fourfold or sixfold combina-
tion, form the organs. Again, he compares the study
of general anatomy to that to which an architect
applies himself who, before constructing a house,
tries to learn in detail the nature of the various
materials he has to employ. The study of the gen-
eral anatomist, as already implied, is analogous to
that of the chemist who, before knowing the com-
pound bodies, examines in isolation the elements
which compose them, who before investigating, for

PATHOLOGY AND HISTOLOGY ;i93

example, the properties of the neutral salts, wishes
to know their radicals. The study of general anat-
omy, or histology, is in a sense, like chemistry, an
abstract study: for no tissue exists in isolation; all
tissues are combined in a more or less considerable
number.

What are the oi^ganic elements, which Bichat, in
his search for a morphological unit comparable with
the oxygen, nitrogen, carbon, and hydrogen known
to the chemists of his time, discovered to be the
components of the oi^gans of the body? He mentions
twenty-one : cellular, nervous of animal life, nervous
of organic life, arterial, venous, tissue of exhalants,
that of absorbents and their glands, osseous tissue,
medullary, cartilaginous, fibrous, fibro-cartilagi-
nous, muscular of animal life, muscular of organic
life, mucous, serous, synovial, glandular, dermal,
epidermal, and pilous. It is of interest to find that
the father of modem histology in the task of differ-
entiating tissue from tissue considered the micro-
scope of his time a hindrance rather than a help.
He chose, instead, to submit them to the action of
heat, air, water, the adds, the alkalies, and salts.
He observed them under putrefaction and various
other conditions, drying, boiling, and macerating
them. "The relation," says Bichat, "of properties
as causes with phenomena as effects is an axiom in
physics, chemistry, and astronomy, almost too

194 THE HISTORY OF MEDICINE

hackneyed to repeat to-day. If my work establishes
an analogous axiom in physiological science, it will
have fulfilled its aim." According to him one must
first discover the minute anatomy of the tissues, and
the vital fimctions of the physiological elements.
Pathological phenomena involve an alteration of
these elements; therapeutics is concerned with
restoration of the normal functions of the elements.
At the same time Bichat regarded general anat-
omy, or the study of the tissues, as an essential in->
troduction to descriptive anatomy as well as to
pathology and therapeutics. The twenty-one tissues
were- the subject of his "Anatomic g6n6rale"; their
various combinations were the subject of his "Anat-
omic descriptive." According to Bichat, descriptive
anatomy examines the organs just as nature pre-
sents them to us. It investigates first their external
form, position, size, direction, etc. Then, pene-
trating more deeply into their structure, it examines
the number of systems — nervous, muscular, serous,
mucous, etc. — which contribute to the formation of
each, and the particular modifications they may
undergo in each case; moreover, it must not be in-
different to the relations of the structure to the func-
tions. The stomach, for example, must be studied
as an assemblage of tissues — mucous inside, serous
outside, organic muscular in the middle. He who
attempts to study the organs by means of the scalpel

PATHOLOGY AND HISTOLOGY 195

is like the architect who examines each room of a
building, or like the chemist who investigates the
reactions of the compounds without regard to the
elements of which each is made up. Bichat pub-
lished two volumes of the " Anatomie descriptive" ;
at the time of his death he had almost completed a
third volume and had prepared material for a fourth.
Two of his friends brought the work to a conclusion
in a fifth volume. Bichat and those with whom he
was associated carried into the field of science the
ardor and enthusiasm of the Napoleonic age.

He pursued the study of morbid anatomy, espe-
cially after his appointment as physician at the
Hdtel Dieu in 1800, with an almost incredible vigor
and heroism. At the same time he had the oppor-
tunity of seeing all the remarkable cases of illness in
that metropolitan hospital, where his amiable and
magnanimous disposition almost disarmed envy it-
self. He was natural and spontaneous without being
inconsiderate. He was prepossessing, frank and
candid, incapable of anger or impatience, quick to
welcome the views or recognize the merit of others,
generous and tolerant, approachable even when
absorbed in work. He held, as we have seen, that
disease involves an alteration of the tissues of which
the organism is composed. '' Let us take for example
the lungs," he is reported to have said in his last
course of lectures. ''These organs are composed of

196 THE HISTORY OF MEDICINE

the pleura, of the parenchjrmatous structure of the
lungs, and of the internal membrane. In pleurisy,
the pleura only is inflamed, the pulmonary tissue
and the mucous membrane remain untouched. In
pneumonia, it is, on the contrary, the parenchjrmat-
ous structure of the lungs that is affected, while its
two membranes remain healthy. In the same man-
ner catarrhal cough is exclusively confined to the
mucous membrane, while the pulmonary tissue and
the serous membrane are sound and healthy. We
may reason in the same manner in relation to all the
other organs.*' Thus Bichat, consciously building
on the work of Motigagni, whom he considered the
founder of pathological science, sought to advance
from a pathology of the organs to a pathology of the
tissues composing the organs. "It is to him," says
Buisson, "that we are indebted for definite ideas
concerning diseases of the peritoneum, diseases
which had been usually confused with those of the
organs covered by that membrane. He proved that
each tissue has a special sort of malady, as well as a
special character of vitality, and that even in the
intestines, the morbid state of one tissue may be as-
sociated with the healthy state of the neighboring
tissues. Some authors had apprehended this truth ;
Walter had indeed indicated exactly the nature of
peritonitis; but, while all had observed particular
facts, none had attached these ideas to a particular
point of view."

PATHOLOGY AND HISTOLOGY 197

Bichat's study of therapeutics was, like his study
of pathology and descriptive anatomy, based on his
early study of the structure and functions of the
tissues. In the presence and with the coSperation of
more than forty students he examined the action of
drugs on the various systems into which he had
analyzed the organism. He was still engaged in this
investigation when death overtook him. He had
worn himself out with almost superhuman exertions.
Within a few months he had opened more than six
hundred bodies at the Hdtel Dieu and elsewhere.
The fatigue resulting from his ceaseless activities
had weakened his resistance to the inroads of dis-
ease. On July 8, 1802, he examined some macerated
tissues which were in such an advanced state of
putrefaction that the students were driven out of
the laboratory by the odor. When Bichat finally
withdrew from his task he fell on the staircase in the
hospital, and, hitting his head, was rendered for a
time unconscious. On the following day he tried to
resume his professional activities, but was seized
by a violent headache. He succumbed to typhoid
fever July 22.

Corvisart, Napoleon's favorite physician, wrote
to the First Consul: ''Bichat has just died on a
battle-field which has claimed more than one victim ;
no person, in so short a time, has done so much and
so well." Napoleon shortly after gave directions

198 THE HISTORY OF MEDICINE

that a tablet be placed in the Hdtel Dieu commemo-
rating the friendship and labors of Desault and
Bichat. "Bichat," wrote Bonaparte, "would have
greatly extended the domain of this science, so im-
portant and so dear to humanity, if pitiless death
had not struck him down at thirty years/'

Buckle says that, " If we compare the shortness of
his life with the reach and depth of his views," he
"must be pronounced the most profound thinker
and consununate observer by whom the animal
frame has yet been studied." He adds: "We may
except Aristotle, but between Aristotle and Bichat I
find no middle man." We shall be safer, however, in
accepting the soberer judgment of the physiologist
Carpenter, who says: "Altogether Bichat left an
impress on the science of life, the depth of which can
scarcely be overrated ; and this not so much by the
facts which he collected and generalized, as by the
method of inquiry which he developed, and by the
systematic form which he gave to the study of gen-
eral anatomy in relation both to physiology and
pathology,"

REFERENCES

Bichat, M. F. X.: (i) TraiU des Membranes. 1800.

(2) Eecherches pkysiologiques sur la vie ei la mart. i8oo.

(3) AfuUomie ghirale, 2 vols. 1801.

(4) Anatomie descriptive. 5 vols.

Eydeshymer, A. C: "Xavier Bichat," InterstaU Med. Journal,
St. Louis, 1908, vd. XV.

PATHOLCXIY AND HISTOLOGY 199

Morgagnif G. B.: (i) The Seals and Causes of Diseases (abridged

by William Cooke). Boston, 1824.
(2) The Seats and Causes of Diseases (translated by

Benjamin Alexander). 3 vols., London, 1769.
Virchow, Rudolf: "Morgagni and 'Anatomical Thought,'"

BriHsh Medical Journal, April 7, 1894. Eleventh Intern.

Med. Congress, Rome.
Walsh, J. J.: Makers of Modem Medicine. New York, 1907*

PP- 29-51.

CHAPTER X

LOCAL DIAGNOSIS: AUENBRUGGER. LAENNEC

In the same year as Morgagni's ''De Sedibus et
Causis Morborum/' appeared the ''New Invention
for Discovering Obscure Thoracic Diseases by Per-
cussion of the Chest." This "Inventum Novum"
was the work of Leopold Auenbrugger (i 722-1 809),
the son of an innkeeper of Graz, Austria. He was
educated at the University of Viennat and in 175 1
received an appointment in the Spanish Military
Hospital of the Austrian capital. It was the age of
Maria Theresa. In spite of the struggles of the Em-
pire with Frederick the Great of Prussia and other
enemies, Vienna continued to be one of the chief
centers of European culture. At the time of the ap-
pearance of the "Inventum Novum," the child
prodigy Mozart was about to make his d£but at the
Austrian court, Gluck was the Kapellmeister of the
Empress, while Haydn held a similar position under
the princely patronage of the Hungarian house of
Eszterhazy. Into the culture life of Vienna at this
time Auenbrugger was fitted by his talents and
temi^erament to enter. He was popular at the im-
perial court; extremely fond of music, he composed
the libretto of an opera, **The Chimney Sweep"

LOCAL DIAGNOSIS 201

("Der Rauchfangkehrer'Of to please the Empress;
and later received from her son, Emperor Joseph 11,
the title Edler von Auenbrug on account of his
geniality and other fine social qualitiest and not on
account of his contribution to the advance of medi-
cal science.

In fact, the '' Inventum Novum" brought only an
inadequate response from Auenbrugger's contempo*
raries of the Old Vienna School. His teacher, the
autocratic Gerard van Swieten, ignored it, as did
also Anton de HaBn. These two leaders and volu-
minous writers had studied at Leyden under their
fellow countryman Boerhaave, whose influence they
perpetuated. Maximilian Stoll (1742-86), however,
who succeeded de HaSn as clinical teacher at
Vienna, recognized the value of Auenbrugger'a
method both in the diagnosis and treatment of
pleurisy and empyema. And of course long after the
prophet's death he foimd honor in his own country;
for in 1839 Skoda, the leading clinician of the New
Vienna School, wrote a treatise on percussion and
auscultation, and '' diagnosis confirmed by post-
mortem'' became the watchword in the medical
circles of the Austrian capital.

In the preface to the " Inventum Novum" Auen-
brugger says: " I here present the reader with a new
sign which I have discovered for detecting diseases
of the chest. This consists in the percussion of the

202 THE HISTORY OF MEDICINE

human thorax, whereby, according to the character
of the particular sounds thence elicited, an opinion
is formed of the internal state of that cavity/' The
brief treatise was the outcome of seven years' ob-
servation, experiment, and reflection. ''What I have
written I have proved again and again, by the testi-
mony of my own senses, and amid laborious and
tedious exertions/' But in spite of his confidence in
the results he had achieved, he was far from believ-
ing that he had exhausted the possibilities of his
method, and he hoped that further observation and
experience would lead to the discovery of other
truths, in these or other diseases, of like value in the
diagnosis, prognosis, and cure of thoracic affections.
The sound obtained on the percussion of certain
parts of the healthy chest resembles the stifled sound
of a drum covered with a thick woollen cloth or
other envelope. The most sonorous region is from
the clavicle to the fourth rib anteriorly. ''The
thorax ought to be struck, slowly and gently, with
the points of the fingers, brought close together and
at the same time extended/' The patient is told at
first to breathe naturally; later he is directed to hold
his breath after a full inspiration. During the exami-
nation the patient must assume such an attitude as
will render tense that part of the chest wall which
at the moment is being subjected to percussion ; for
thus a clearer sound is obtained.

LOCAL DIAGNOSIS 203

Auenbrugger believed that thoracic diseases of
the worst description might exist without any symp-
toms save those revealed by his method of percus-
sion. If a naturally sonorous part of the chest is, on
percussion, devoid of the usual resonance — yielding
only the sound of a fleshy limb when struck — or if it
gives out a sound duller than usual, disease exists in
that part. He considered that the deviations from
the natural sound are owing to the diminution of the
amount of air normally contained in the lungs, a
diminution which might arise from the occurrence of
solids or liquids. An analogous sound may be ob-
tained by striking a cask partly filled with water.
The preternatural sound always accompanies a
copious effusion of fluid in the thoracic cavity.
Moreover, the '' effect of effused liquids in producing
the morbid sound is at once proved by the injection
of water into the thorax of a dead body; in which
case it will be found that the sound elicited by per-
cussion will be obscure over the portion of the cavity
occupied by the injected liquid." In addition to the
methods of investigation of which Auenbrugger
gives here an indication, there is abundant evidence
that he made it a practice, where it was feasible, to
confirm his di^^^nosis by post-mortem examination.

The appearances on dissection in cases where per-
cussion had revealed an abnormal condition fall into
two classes — those that involve primarily the

204 THE HISTORY OF MEDICINE

respiratory functions, and those found in the heart
and pericardium. Under the first class Auenbrug^er
noted the degeneration of the lung substance, the
post-mortem organ being so engorged with blood a3
to resemble liver in every respect, both as to color
and consistency. Among the symptoms exhibited
by patients suffering from such a d^eneration of
the lung substance he mentions the diminution or
entire absence of the natural sound over the affected
part, and the relative immobility, during inspiration,
of the chest on the affected side. Auenbrugger de-
scribed vomicae resulting from the degeneration of
the lung substance. They are encysted or contained
in a sort of capsule; some of them are purulent,
some are not; some are closed, others communicate
with the bronchi. If, in the case of a patient suffer-
ing from a purulent vomica which is discharging into
the trachea, while the patient is coughing and spitn
ting the physician places his hand over the site of
the vomica, the noise of fluid within the chest will be
distinctly manifest. When a vomica discharges its
contents into the cavity of the pleura and upon the
diaphragm, empyema is produced. ''If percussion
is now applied, it will be found that the natural
sound, which had been nearly lost on the site of the
vomica, has in some degree been restored in that
place; while it is more or less destroyed — according
to the quantity of pus effused — over the posterior,

LOCAL DIAGNOSIS 205

and inferior parts of the chest." By dissection Auen-
brugger also verified hisi diagnosis of unilateral and
bilateral hydrothorax. Among the symptoms re-
vealed by percussion he mentions a murmuring
sound about the hypochondriac region. Moreover,
in unilateral hydrothoraxt "the affected side, if com-
pletely filled with water, is enfeebled and appears
less movable during inspiration. In this case, also,
the affected side yields nowhere the natural sound
on percussion. If the chest is only half filled, a
louder sound will be obtained over the parts to which
the fluid does not extend, and the resonance will be
found to vary according to the position of the pa-
tient and the consequent level to which the liquid
attains.'' Auenbrugger mentions hemothorax with
and without an accompanying lesion of the lungs.
He had never seen chylothorax, though he believed
the disease existed in spite of the fact that the
thoracic duct runs outside the pleura.

As regards diseases of the heart and pericardium
Auenbrugger's researches contributed to our knowl-
edge of the symptoms and the morbid anatomy. In
health the whole sternum yields on percussion as
distinct a sound as the sides of the chest, except in
the cardiac region, where it is somewhat duller;
similarly on the left side of the chest, over the space
occupied by the heart the sound loses part of its
usual clearness. In hydropericardium the sound is

206 THE HISTORY OF MEDICINE

completely deadened as if the percussion were ap-
plied to a healthy limb. Post-mortem discloses — in
cases of dropsy of the pericardium — either a serous
effusion or a purulent effusion, which commonly re-
sembles turbid whey. The same signs are furnished
by percussion in either case. "In the first variety
the heart is rough, and, as it were, shaggy, with a
coating of the purulent matter/' In the case of
copious extravasation of blood into the pericardium
percussion elicits none of the natural sounds over the
space occupied by the extravasated blood. Similar
results are yielded by percussion in cases of dilata-
tion of the heart.

In spite of such recognition as the "Inventum
Novum'' early gained in Vienna and other centers
of German medicine and its translation into French
within a decade of its appearance, it remained for the
great French clinician Corvisart (i 755-1 821) and
his pupils to make Auenbrugger's influence at all
general. Corvisart was an enthusiastic admirer of
the teachings of the Vienna School, and was particu-
larly familiar with the works of StoU. In 1808, a
year before the death of Auenbrugger, he translated
the "Inventum Novum" into French and wrote
commentaries upon it. In 1806, under the direct
encouragement of the Emperor Napoleon, he had
published his own masterpiece, "Elssai sur les mala-
dies et les 16sions du coeur et des gros vaisseaux.'*

LOCAL DIAGNOSIS 207

In this work Corvisart directs attention in the first
place to diseases of the pericardium, notes the com-
parative dullness of the sound resulting from per-
cussion of the cardiac region in hydropericardium.
and, later, studies the symptoms of dilatation, as
well as of aneurism of the thoracic aorta. His diag-
noses seemed to his pupils at times the result of
intuition, but he was indeed a keen observer with a
delicate sense of touch, and an acute sense of hearing
that led him to anticipate the discovery of ausculta-
tion. He also urged physicians not to neglect post-
mortem examination, an injunction carefully heeded
by his pupils Bayle and LaSnnec.

"Our real knowledge," writes Osier of tuberculo-
sis, " is a nineteenth century contribution, beginning
with the work of Bayle on the structure of the tuber-
cle and on its identity in the widely distributed
lesions." In his early work, " Phthisie pulmonaire,"
Bayle spoke, like his predecessors, of types of
phthisis other than the tuberculous, but in his later
work, " Remarques sur les tubercles," he recognized
the specific character of the disease. He defined
tubercles as little cysts containing organized solid
matter, capable of softening and breaking down.
He had found them post-mortem in the lungs,
mesentery, liver, kidnejrs, prostate, and other or-
gans, but he had not observed them in the brain.
The fact that they might occur so widely distributed

208 THE HISTORY OF MEDICINE

in the one subject seemed to indicate that all tu-
bercles are identical in nature. He even used the
expression "tuberculous diathesis" to designate a
constitutional tendency to tuberculosis. In the
diagnosis of diseases of the chest Bayle resorted to
immediate auscultation. The employment of this
method by Bayle led to its adoption by his fellow
student LaSnnec and thus to the discovery of a
much better method.

Ren6 Thtephile Hyadnthe LaSnnec was bom at
Quimper, Finist^ (the French Land's End), Feb-
ruary 17, 1781. One of his relatives, under whose
direction he began his professional education, had
been a pupil of Jc^n Hunter's. Ren6 LaSnnec studied
medicine as early as 1795 at the Hdtel Dieu at
Nantes, accompanied a military expedition against
an insurrection in the west of France in 1800, had a
little experience in military hospitals, and before
the end of 1800 went to Paris for further training in
medicine. There he attended the popular clinics of
Corvisart at the Unit6 (Charit6), met Bayle, and
heard Bichat's last course. His medical education
was very thorough. During three years as student
at La Charit6 he wrote up four hundred cases that
came under his observation. He discovered the del-
toid bursa and the fibrous capsule of the liver; and
he became a recognized authority in morbid anatomy.
His culture was not confined to narrow professional

LOCAL DIAGNOSIS 209

lines; he was a linguist and something of a poet; he
was versed in the writings of Hippocrates and the
other great phjrsicians of the past, and he held that
discoveries in medical science are made only by those
who know its history.

Among the many influences that led to LaSnnec's
great invention was the work of Chladni in acoustics
which had been stimulated in the first place by an
intense interest in music. Chladni had given an ac-
count of his researches in the presence of some of the
leading scientists of Paris; and in 1809 had pub-
lished a French edition of his work under the title
"Trait6 d'acoustique." The Emperor had drawn
general attention to the subject by the terse remark:
''Chladni makes tones visible." One day about the
middle of October, 1816, LaSnnec saw some boys at
play in a court of the Louvre, who by listening at
the end of a beam were able to hear the sound of the
scratching of a pin transmitted from the other end.
On the following day there occurred an experience
which we shall relate in LaSnnec's own words.

"I was consulted in 1816/' he writes, "in the case
of a young person who showed symptoms of heart
disease and in whom palpation and percussion gave
poor results on account of her embonpoint. The age
and sex of the patient forbidding the sort of exami-
nation of which I have just spoken, immediate
auscultation, I happened to recall a familiar fact in

210 THE HISTORY OF MEDICINE

acoustics, namely, that if one places his ear at one
end of a piece of timber he can hear very distinctly
the scratch of a pin at the other end. It occurred to
me that I might take advantage, in the case with
which I had to deal, of this physical property. I
took a paper notebook, rolled it up tightly, applied
one end to the precardiac region and listened at the
other. I was as greatly surprised as I was pleased to
hear the. heart-beats much more dearly and dis-
tinctly than I had ever been able to hear them
through the immediate application of the ear. From
that time I took it for granted that this means might
become a method useful and applicable not only in
the study of heart-beats, but in the study of all
movements which may produce a sound in the
thorax, and, consequently, in the examination of the
respiration, of the voice, of the r^e, and perhaps
even of an effusicm in the pleura or pericardium.*'
Under this conviction LaSnnec began at once a
aeries of observations at the Necker Hospital (to
which he had just been appointed vbiting physician)
from which he was able to deduce a set of new signs
of diseases of the chest, which he considered certain,
simple, striking, and calculated, perhaps, to render
the diagnosis of diseases of the lungs, pleura, and
heart as definite as the indications furnished to the
surgeon in the case of a stone in the bladder or of a
fractured limb. The first instrument of which he

LOCAL DIAGNOSIS 211

made use was a cylinder of paper, tightly rolled, and
kept in shape by means of paste. Later he tried
various other materials. Following a series of ex-
periments, he employed in his examinations of the
chest sounds "a cylinder of wood, an inch and a
half in diameter, and a foot long, perforated longi-
tudinally by a bore three lines wide, and hollowed
out into a funnel-shape, to the depth of an inch and
a half, at one of the extremities/' To this instrument
he gave the name ''stethoscope'' (crr^tfos, chesty
and (TKoircti^, explore).

La£nnec reported some of his results to the Acad6-
mie des Science in 1818, and in 1819 published the
first edition of his work " De 1' Auscultation Mediate."
In 1820 he retired to Kerlouamec, where he spent
two years resting and recuperating. In 1822 he re-
turned to Paris, and received appointment as pro-
fessor of medicine at the Coll^ de France. In the
following year he was given the chair of clinical
medicine at La Charit6. In 1826 appeared the sec-
ond edition of his great work.

Like Auenbrugger, of whose method of percussion
he had made considerable use, LaSnnec sought first
of all to establish the sounds heard on the examina-
tion of a normal subject. "On applying the cylin-
der," he writes, "... to the breast of a healthy
person, we hear, during inspiration and expiration,
a slight but extremely distinct murmur, answering

212 THE HISTORY OF MEDICINE

to the entrance of air into, and its expulsion from,
the air cells of the lungs."

Shortly after beginning his observations by means
of the newly discovered method, LaSnnec, in the
case of a woman suffering with a slight bilious fever
and a recent cough, applied the cylinder below the
middle of the right clavicle while she was speaking.
Her voice seemed to come directly from the chest,
and to reach the ear through the central canal of the
instrument. This peculiar phenomenon was con-
fined, he proceeds, to a space about an inch square.
Ignorant of the cause of this singularity, he exam-
ined the greater number of the patients in the hos-
pital, and found the same phenomenon in about
twenty of them. He began to suspect that it might
be caused by tuberculous cavities in the lungs. The
subsequent death of the majority of the patients
who had exhibited this peculiarity gave him the op-
portunity to verify his conjecture. In all cases post-
mortem examination revealed lat^r or smaller cav-
ities, which communicated with the bronchial tubes
and which were the result of the breaking down of tu-
bercles. "I found the peculiar phenomenon (which
I have termed Pectoriloquy) to be perceptible accord-
ing to the density of the walls of the cavity and its
proximity to the surface of the lungs.''

LaSnnec, though inclined to admit, like Auen-
brugger, the possibility of a phthisis nervosa, taught

LOCAL DIAGNOSIS 213

that pulmonary consumption is caused by the de-
velopment in the lungs of tubercles which may ap-
pear as isolated bodies or as a tuberculous infiltra-
tion. Under the former come miliary tubercles,
crude tubercles, encysted tubercles, and tuberculous
granules. Under tuberculous infiltration he recog-
nized the gray and the yellow. LaSnnec observed
tubercles in the peritoneum, testicles, uterus, cervi-
cal and mesenteric glands, heart, spleen, brain,
bones of skull, ribs, vertebrae and their ligaments.
For him scrofula was tuberculosis of the glands; he
insisted on the frequency of tuberculous pleurisy ; in
fact, he supported the doctrine of Bayle in reference
to the specific character of tuberculosis. In pulmon-
ary tuberculosis tubercles should be especially sus-
pected at the apex of the lungs, and under the clavi-
cle. The cure of phthisis is possible, since autopsies
show us how nature has worked a transformation in
the so-called ulcers of the lungs, that is, tuberculous
cavities. Lafinnec had little faith in the therapeutic
value of medicines, etc., in cases of phthisb. He ad-
vocated, rather, hygienic treatment — nourishing
food, travel, and fresh air, particularly sea air.

In the judgment of LaSnnec segophony (a!^,
atyo^, wild goat^ ^mnj^ sound) was indicative of
pleurisy attended by a moderate effusion in the
pleura, or of hydrothorax or other extravasation in
the chest cavity. Simple aegophony is described by

214 THE HISTORY OF MEDICINE

him as a peculiar sound of the voice accompanying
or following the articulation of words. He speaks
of it as a kind of silvery voice, of a sharper and
shriller tone than that of the patient. It seems to
vibrate on the surface of the lungs, more like the
echo of the voice than the voice itself. ** It has, more-
over, another character, so constant as to lead me to
derive from it the appellation of the phenomenon —
I mean a trembling or bleating sound like the voice
of a goat, a character which is the more striking be-
cause the key or tone of it approaches that of this
animal's voice." In another passage Laennec says
that aegophony is characterized by the harsh, trem-
ulous, silvery tones of the voice, which is commonly
shriller than the natural voice of the patient, and
seems to be quite superficial, and to float, as it were,
on the surface of the lungs, instead of coming from
the interior, like pectoriloquy or bronchophony.
LaSnnec sought to produce experimentally the
tremulous echo of a voice that seemed to him to
occur in pleurisy with effusion, and other forms of
thoracic disease. Accordingly, before applying the
stethoscope he placed a bladder half filled with
water between the scapulae of a young man with a
well-marked natural bronchophony at this point.
The stethoscopic sound seemed sharper and also
slightly tremulous. A like experiment tried over the
larynx seemed to give the like result*

LOCAL DIAGNOSIS 215

We owe, of course, to the investigations of LaSn-
nee our knowledge of the various i41es and their
diagnostic significance. In his classic description of
lobar pneumonia we find the stages revealed by
post-mortem examination coupled with the physical
signs — the early crepitant rftle, and the mucous
i^le that accompanies resolution. He held that a
metallic tinkle could be heard in hydro-pneumo-
thorax or pyo-pneumothorax. Surpassing the work
of Bichat he gave a masterly description of bron-
chitis with its sonorous and sibilant r&les. He de-
scribed also the rdle humide and the souffle. We are
indebted to LaSnnec for descriptions of bronchiec-
tasis, oedema of the lungs, pulmonary "apoplexy,'.'
haemorrhagic pleurisy, gangrene of the lungs and
emphysema. It seemed to him that vesicular emphy-
sema is, next to hypertrophy, the simplest of all the
organic lesions of the lungs, since it consists merely
in the dilatation of the air cells. On this account it
remained long unknown, and had, he thought, not
been correctly described by any author before his
time. "I," he continues, "for a long time thougl^t
it very uncommon, because I had observed only a
few cases of it; but since I have made use of the
stethoscope, I have verified its existence as well on
the living as the dead subject, and am led to con-
sider it by no means infrequent." In some cases the
lung takes on a striking resemblance to the vesicular
lungs of Reptilia.

216 THE HISTORY OF MEDICINE

It did not occur to LaSnnec to make use of the
stethoscope in the diagnosis of pregnancy. This idea
came first to his friend Dr. Kergaradec while verify-
ing the facts contained in the first edition of " Medi-
ate Auscultation." Dr. Kergaradec's conclusions
are stated in the appendix of the second edition of
that work. In putting his idea to the test he ob-
served the foetal heart-beat, as well as the placental
bruit, in a woman very near her confinement. The
latter he described as an arterial pulsation accom-
panied by a bellows sound. The foetal pulse» which
is distinctly audible in the sixth month and some-
times a little earlier, is usually twice as rapid as that
of the mother. The placental sound, which is usually
perceptible about the fourth month, is, on the other
hand, isochronous with the pulse of the mother.

"LaSnnec," saj^ Osier, "laid the foundations not
only of our modem knowledge of tuberculosis, but
of modem clinical medicine." By the invention of
the stethoscope he brought into play one of the
higher senses and armed the profession with the
means of a more adequate diagnosis. He did not
underrate his own achievement, holding, as he did,
to the Hippocratic conviction that theory must rest
on observation, and adopting as the motto of his
work: An important part of the art is in my judg-
ment to be able to explore (fteya 8c /leXos rfytvfuaC
rrj^ rexyv^ cli/atro BvpacrOai cricoif eiv). Very much of

LOCAL DIAGNOSIS 217

LaSnnec's work was so well done that it needs tOKlay
little change in the way either of correction or addi-
tion. In the diagnosis of diseases of the heart his
endeavors were soon supplemented by the investi-
gations of his disciples of the Dublin School and
other great leaders in clinical medicine.

After completing the second edition, which was
almost a new work, of the *' Mediate Auscultation/*
LaSnnec once more retired to Finist&re in the hope
of again reestablishing his health. The sea breezes
and outdoor life failed, however, to revive his pow-
ers, exhausted by years of constant activity, and
August 13, 1836, he succumbed to one of those dis-
eases from which his genius has rescued so many
victims.

REFERENCES

Caxnac, C. N. B.: Epoch-making ContrHnUians to Medicine and

Surgery. 1909.
Meunier, L.: Histoire de la MSdecine, 191 1.
Thayer, W. S.: "LaCnnec — One Hundred Years After,"

Canadian Medical Association Journal^ vol. ix, no. 9,

Sept, 1919.
Walsh, J. J.: Makers of Modem Medicine. Third edition, xgi5«

CHAPTER XI

ADVANCES IN PHYSIOLOGY

Among the many advances in physiology in the
nineteenth century must be mentioned above all the
progress made in the study of the functions of the
nervous system through the investigations of the
experimental physiologists, Charles Bell, Ms^ndie,
Marshall Hall, Johannes Mttller, and Claude Ber-
nard. For this progress the way had been prepared
by Albrecht von Haller. Bom at Berne, Switzerland,
October i6, 1708, Haller was favored by striking
natural endowments, as well as by almost unlimited
opportunities for education. The accounts of his
linguistic, literary, and scientific attainments while
he was still little more than a child are not far from
incredible. His more advanced education began at
Tubingen, where he studied anatomy and, under the
direction of Camerarius, botany. From Tttbingen he
was drawn to Leyden by the reputation of Boer-
haave. After graduating at the age of nineteen, he
visited England, where he came in contact with some
of the leading British scientists. At Paris he came
under the influence of the anatomist Winslow, and,
at Basel, before returning to his native city, he
studied mathematics under Jean Bemouilli. In

ADVANCES IN PHYSIOLOGY 219

1736 Haller, after years of private practice, of a
limited sort, and much study, was induced by
George II of England to accept a professorship of
medicine, anatomy, botany, and surgery in the
newly established university of Gfittingen. Here as
elsewhere he was indefatigable. After seventeen
years' activity at this Hanoverian seat of learning
he returned to his native Berne, where he spent the
remaining twenty-four years of his life.

Of Haller's many claims to distinction his work as
a physiologist is the most convincing, though his
knowledge of human and animal structure, on which
his knowledge of physiological function was based,
was very thorough. Haller's influence increased the
range of experiments on living animals. He de-
clared that, in spite of its apparent cruelty, vivisec-
tion is of more value in the study of physiology than
all other methods and that a single experiment of
this kind has often cleared up misconceptions solu-
ble by no other means of investigation. The func-
tion and structure of mammals, birds, fishes, and
still lower forms of life, helped him to explain the
anatomy and physiology of man.

Haller laid the progress of phjrsiology under par^
ticular obligation by his experiments on muscles and
nerves and by the doctrine he based on these experi-
ments. In 1752 they were reported to the RoyaF
Society of Gfittingen, of which he was the founder

220 THE HISTORY OF MEDICINE

and president. He taught that irritability b the in*
herent property of musde, while sensibility is the
characteristic property of nerves. He used the term
"irritability" in the sense of "contractility"; that
is, in a much more restricted sense than Glisson, who
in 1677 had spoken of the irritability of all animal
tissues. Haller admitted that the usual stimulation
which brings about the contraction of a muscle is
conveyed by means of the nerves. Yet for this
means of stimulation there might be substituted
other forms which prove effective even when the
connection between the nerve and the musde is
severed. It is the function of the nerves, on the
other hand, to transmit to the consciousness the
changes called forth by peripheral stimuli; or, in
other words, the nerves are exclusively the organs
of sensibility. For example, the retina is a network
oi nerve fibers which serve to transmit sensations of
light. The rays of light coming from the object be*
fore us produce an impression on the retina which
constitutes a stimulus of the optic nerve. What we
feel isinot the object itself, but the impression which
the object makes on the particular nerve in question.
It would seem to follow from this that the nerve of
each sense has its own special mode of responding to
stimulation, and that sensations are subjective in
character, though they afford grounds for arriving
at a judgment in reference to the nature of the outer

ADVANCES IN PHYSIOLOGY 221

world. Irritability may be found in detached parts
of the body quite withdrawn from the empire of the
soul. It is therefore absurd to seek to identify the
soul with mere irritability. The nerves, the true
organs of sensibility, contain, Haller was inclined to
believe, a subtle, automatic fluid, being influenced
no doubt in this belief by the contemporary dis-
coveries in electricity. He also taught that memory
is developed through the persistence of impressions
on the brain substance.

In 181 1 Sir Charies Bell (1774-1842) circulated a
privately printed pamphlet, ^'An Idea of a New
Anatomy of the Brain.'* In this occurred this pas*
sage: "On laying bare the roots of the spinal nerves
I found that I could cut across the posterior f asdcu*
lus of nerves which took its origin from the posterior
portion of the spinal marrow without convulsing the
muscles of the back, but that on touching the an-
terior fasciculus with the point of the knife the
muscles of the back were immediately convulsed.''
In his work "The Anatomy of the Human Body"
(7th edition) he admitted that sensibility is indeed
seated in the nerves, but that is only one of their
functions. There are nerves which possess no sensi-
bility at all. He was led to surmise this difference of
function by observing beforehand differences of
structure, being early struck by the perfect regular-
ity of the spinal nerves as contrasted with the very

222 THE HISTORY OF MEDICINE

great irregularity of the cranial nerves. He argued
that if the endowment of a nerve depend on the rela-
tion of its roots to the columns of the spinal marrow
and the base of the brain, then the observation of
their roots must indicate to us their true distinction
and their different uses. It was necessary to know
in the first place whether the phenomena exhibited
on injuring the separate roots of the spinal nerves
correspond with what was suggested by their anat-
omy. He hesitated to put the question to the test of
experiment because of the cruelty that seemed
necessarily involved. It finally occurred to him,
however, that it was best to experiment on an ani-
mal in a state of insensibility, as otherwise it might
be difficult to distinguish between the expression of
pain and the effect produced through the motor
nerves.

^'I therefore,'* he continues, *' struck a rabbit
behind the ear, so as to deprive it of sensibility by
the concussion, and then exposed the spinal marrow.
On irritating the posterior roots of the nerve, I
could perceive no motion consequent, on any part
of the muscular frame; but on irritating the anterior
roots of the nerve, at each touch of the forceps there
was a corresponding motion of the muscles to which
the nerve was distributed. These experiments satis-
fied me that the different roots and the different
colunms from whence these roots arose, were devoted

SIR CHARLES BELL

ADVANCES IN PHYSIOLOGY ^23

to distinct officest and that the notions drawn from
the anatomy were correct/* In a paper communi-
cated to the Royal Society of London in 1821, we
find Sir Charles Bell pursuing a similar line of argu-
ment and reporting a similar method of investiga-
tion in ref er«ice to the function of one of the cranial
nerves. He drew attention to the complicated nerve
supply of the face, inexplicable on the assumption
that the nerves are confined to a single function.
He maintained that an oi^^an that has only one func-
tion has only one nerve, and assumed that the pres-
ence of a number of nerves supplying the same part
of the body gave ground for surmising a variety of
function. He submitted to special examination the
facial nerve (partio dura)^ the branches of which are
so largely concerned in the expression of the emo-
tions, and the paralysis of which gives rise to what
is now known as Bell's palsy. He produced artificial
paralysis in experimental animals by dividing the
nerve after its emergence from the stylo-mastoid
foramen. The cutting of the nerve called forth no
sign of pain. The muscles of the side of the face on
which the nerve was cut no longer acted in harmony
with the other muscles involved in the act of respira-
tion, and in the expression of emotion so closely as-
sociated with respiratory movements. If the facial
nerve of one side of the face is cut and that of the
other left intact and the animal is bled to deaths the

224 THE HISTORY OF MEDICINE

contrast in expression between the two sides of the
face of the dying animal is most striking.

The different functions of the nerves afford a clue
to the functions of the brain and spinal cord. Some
of the nerve trunks are made up of filaments that
merely convey sensations; while other nerve trunks
are made up of filaments that merely convey motor
impressions to the muscles: a third class of nerve
trunks are made up of the two kinds of filaments,
as we have seen in the case of the spinal nerves.
The brain and cord in turn are divided into parts
concerned respectively with sensations and bodily
movements. By many authorities in physiology
Bell's contribution to neurology has been compared
in value with Harvey's discovery of the circulation
of the blood. As early as November 26, 1807, Bell
had written to his brother: "I have done a more
interesting nova anatomia cerebri humani than it is
possible to conceive. I lectured it yesterday. I
prosecuted it last night till one o'clock; and I am
sure it will be well received."

Francois Magendie, who founded the ''Journal de
physiologie exp6rimentale" in 1821, confirmed in
the following year, by experiments on a litter of
eight puppies six weeks old, the results obtained by
Sir Charles Bell in reference to the functions of the
roots of the spinal nerves. At that time Magendie
had not heard of Bell's experiments to determine

ADVANCES IN PHYSK)LOGY 225

these functions. First he cut, In one of the litter of
pups, the posterior roots of the lumbar and sacral
nerves of one side, leaving the posterior roots on the
other side uncut in order that he might have a basis
of comparison* The parts of the body to which the
cut nerves were distributed were still capable of
movement, though their sensibility was wholly ex-
tinct. A second experiment of the same description,
and a third, showed like results. Magendie then
succeeded in another pup in cutting the anterior
roots of the lumbar and sacral nerves of one side.
The results here also were not hard to interpret, the
part of the body concerned becoming completely
motionless and lax, while retaining its sensibility.
"Finally," writes Magendie, "to neglect nothing, I
cut the anterior and the posterior roots at the same
time; there was then an absolute loss of sensibility
and movement.'* He concluded from this investiga-
tion that the anterior and posterior roots have di£Fer-
ent functions, in fact, "that the posterior appear
more particularly destined for sensibility, while the
anterior seem more especially connected with move*
ment."

Just three months later Magendie published an
account of further experiments bearing on the func-
tions of the roots of the spinal nerves. Interested in
the action of drugs — morphine, strychnine, eme-
tine, veratrine, brucine, piperine, bromine, iodine,

226 THE HISTORY OF MEDICINE

and prussic add — as well as in the functions of the
nerves, he gave nux vomica to experimental animals
and noted the modification of the action of the poison
produced by cutting one or the other set of roots of
certain spinal nerves. If the posterior roots alone
were cut, tetanus was complete. When the anterior
roots of the nerves supplying the hind leg were cut,
this member remained supple and motionless, while
under the influence of the poison all the rest of the
body was thrown into convulsions.

In 1833 Marshall Hall read before the Royal So-
ciety a paper On the Reflex Function of the Medulla
Oblongata and Medulla Spinalis. Consciously bas-
ing his investigation on the work with decerebrated
animals of certain French physiologists, Hall was
particularly interested in phenomena brought about
by eccentric, or peripheral, stimulation. He wished
to distinguish these phenomena from sensation and
volition, the characteristic functions of the cere-
brum. Among these phenomena he mentions wink-
ing, sneezing, coughing, swallowing, vomiting, tenes-
mus and the maintenance of equilibrium. In the
reflex function the muscles are excited by a stimulus
acting along nerves proceeding to the medulla and
muscular nerves proceeding from the medulla. The
reflex function keeps the glottis open, through the
superior laryngeal nerve connected with the cord,
and keeps the sphincters closed. Infants bom with-

ADVANCES IN PHYSIOLOGY 227

out cerebrum or cerebellum are capable of sucking,
grasping, and crying. Strangury may be caused re*
flexly by the irritation of the rectum. Reflex action
tis increased by strychnine and opium, decreased by
ihydrocyanic add.

In reaching his illuminating conclusions Marshall
-Hall had experimented with snakes, turtles, frogs,
toads, newts, and guinea-pigs. He tells particularly
of dividing the spinal marrow of a very lively snake
(coluber natrix), between the second and third
vertebrae. ^'From the moment of the division of
the spinal marrow, it lay perfectly tranquil and
motionless, with the exception of occasional gasping
and slight movements of the head.'' Upon stimula*
tion, however, the body began to move with great
activity. When carefully protected "from all ex-
ternal impressions, it moved no more, but died with
the precise position and form which it had last as-
sumed." Hall argued that sensation can act, in in-
ducing muscular motion, only through the medium
of volition; that, in the experiments which were per-
formed by him, volition, that is, the will, and not
the power, to move, was annihilated; that in such
cases — volition being destroyed and the agency of
sensation excluded — the influence of external im-
pressions, which might be supposed to induce pain,
must have been exerted upon some property of the
nervous system different from sensibility. In fine.

228 THE HISTORY OF MEDICINE

in Hall's judgment the cerebrum is the source of
voluntary emotions, the medulla oblongata the
source of respiratory motions, the medulla spinalis
the middle arc of the reflex function, the sympathetic
nervous system the source of nutrition, secretion,
etc.

About ten years after Magendie had given clear
experimental proof of the difference in function of
the anterior and posterior roots of the spinal nerves,
a further confirmation of BelFs view was a£Forded by
the great German scientist Johannes Mailer (1801-
58), who has been called the founder of scientific
medicine in Germany. ''The happy thought at
length occurred to me," he writes, "of performing
the experiment on frogs. The result was most satis-
factory. The experiments are so easily performed, so
certain and conclusive, that every one can now read-
ily convince himself of one of the most important
truths of physiology. ... It is quite impossible to
excite muscular contractions in frogs by irritating
mechanically the posterior roots of the spinal
nerves; while, on the other hand, the slightest irrita-
tion of the anterior roots immediately gives rise to
strong action of the muscles. • . • The application of
galvanism to the anterior roots of the spinal nerves,
after their connection with the cord is divided, ex-'
cites violent muscular twitchings; the same stimu-
lus applied to the posterior roots is attended by no

ADVANCES IN PHYSIOLOGY 229

such effects. ... If in the same frog the three poste-
rior roots of the nerves going to the hinder extremi-
ties be divided on the left side, and the three an-
terior roots on the right side, the left extremity will
be deprived of sensation, the right of motion,*'

MttUer must also be held responsible for formu-
lating the so-called law of the specific eneiigy of the
nerves. We find it as an implicit assumption in the
works of Haller and other physiologists. John
Hunter had stated that the only kind of sensations
obtained by stimulating the optic nerve are sensa-
tions of light, irrespective of the nature of the
stimulus. According to Mailer the nature of the
sensation depends not on outside objects but on the
native substance of the sensory nerve involved in
the sensation. For example, the optic nerve cannot
be stimulated without giving rise, in accordance
with its inherent energy, to sensations of light and
color. Light and color do not exist as something
fixed and objective which, affecting the sense of
sight, calls forth a corresponding sensation ; but the
mechanism of sight produces always sensations of
the same mode whatever may be the nature of the
stimulus. Similarly, the auditory nerve cannot be
stimulated without giving rise to auditory sensa-
tions; the gustatory nerve causes only sensations of
taste. The character of the stimulus may be mani-
fold, as we all know in the sense of sight: pressure.

230 THE HISTORY OF MEDICINE

percussion, friction, heat, cold, electricity, chemical
reagents, the throbbing of an artery, an inflamma-
tion of the retina. Whatever stimulates the optic
nerve serves to dispel the sensation of darkness and
to substitute sensations of light and color, just as by
a stimulation of the motor nerves no effect may fol-
low except the contraction of the muscles to which
the nerves in question are distributed. It follows,
of course, from this doctrine of the specific energy
of the sensory nerves that our sensations do not re-
veal the essential qualities of the objective world.
Our knowledge of outside things is limited by our
knowledge of the sensations aroused in us by stimuli.
At the present time physiologists and psychologists
believe as a rule that the nerve fibers are mere con-
ductors, and that the specific differences of sensa-
tions depend on the nature of the receptors, the in-
born organization of the cortical areas to which the
afiferent impulses are conducted, or on both of these.
Johannes MflUer stands out as one of the greatest
leaders in the progress of physiology. The compre-
hensiveness of his interests as reflected in his two
volumes, "Handbuch der Physiologic des Men-
schen" (1833-40), the comparative character of his
physiology, his recognition of the dependence of
psych6logy on physiology (in which he followed the
lead of Cabanis, the real founder of physiological
psychology), and his striking personality, contrib-

ADVANCES IN PHYSIOLOGY 231

uted to make him a wonderfully inspiring influence.
Following the example of VirchoWi many speakers
and writers have said that there was something
superhuman about Johannes MQllen Adopting this
point of view, one should hasten to add that his was
a sort of inunanent divinity that wrought its most
notable achievements by purely human instru-
mentality. While no single first-class contribution
to physiology stands to his credit, the labors of his
pupils bear witness to the commanding character of
his genius. Let it suffice here to mention Helmholtz,
the inventor of the ophthalmoscope and the ophthal-
mometer, who measured the velocity of the nervous
impulse, and was no less distinguished in acoustics
than in optics; Du Bois-Reymond, who brought the
apparatus of the physicist to bear on the study of
the nerves and muscles; and Brttcke, who carried
MUller's influence to Vienna.

Claude Bernard (1813-77). advanced the study of
the functions of the nerves (to which Bell, Magendie,
Hall, and MUller so notably contributed) and
furthered remarkably the solution of problems in
other departments of physiology. He was bom near
Lyons, studied medicine at Paris, and, after taking his
degree, became an interne at the Hdtel Dieu under
the superintendence of Magendie, and in 1841 was
appointed assistant {prSparateur) in Magendie's
laboratory at the College de France. In 1839

232 THE HISTORY OF MEDICINE

Magendie, on the basis of experiments on the roots
of the spinal nerves, claimed that the anterior roots,
though motor, were not wholly devoid of sensibility.
This claim that there existed in the anterior txx>ts a
sensibUitS en retour^ or, as it was afterwards called,
sensibilitS rScurrente, was vigorously disputed, and
it was only after a long series of experiments on dogs
conducted by Magendie and Bernard that the claim
was upheld. According to Bernard by means of the
sensory fibers from the posterior txx>t which find
their way into the anterior root a functional har-
mony is established in the sensory-motor mechan-
ism. For him the reflex movements, studied as he
notes by Hall and Johannes Mailer, are the simplest
of all. "The excitation carried by the sensory nerve
arrives at the cord, it is propagated through the cord
to the anterior root, and through the latter to the
muscles.'*

By a series of experiments begun in 1852 he de-
cided the old question of the independent irritability
of muscular tissue. He was well aware that the
problem of the relation between nervous excitability
and muscular contractility had been under discus-
sion since the time of Haller. Curare, however, was
in Bernard's hands the means of reaching a clear
decision, for it kills completely the motor nervous
system without diminishing the range of contraction
of muscles. Bernard injected curare under the skin

ADVANCES IN PHYSIOLOGY 233

of a frog. He decapitated a second frog, laying bare
the lumbar nerves. When the first frog was dead,
he stimulated the hind legs of both by means of an
electric current applied to the nerves. The muscles
of the frog poisoned by curare did not contract
under these conditions. When, however, the cur-
rent was applied, not to the nerve, but directly to the
muscles, the contractions were as marked in the one
case as in the other.

In 1851 Bernard began to investigate the function
of the sympathetic nervous system, starting from
the hypothesis that the sympathetic nerves were
the producers of heat. On this assumption he cut
the cervical sympathetic of a rabbit. Contrary to
his expectation there was a decided rise instead of a
fall in temperature, and the increased temperature
was accompanied by a swelling of the arteries in the
external ear. Brown-S^uard, at that time in Amer-
ica, showed that the stimulation of the divided
cervical sympathetic had the effect of decreasing
the blood supply and the temperature in the ear of
the rabbit. Claude Bernard repeated this experi-
ment and verified the results obtained by Brown-
S6quard. In 1858 Bernard announced the discovery
that the submaxillary gland secretes under the
double influence of the chorda tympani and branches
of the cervical sympathetic. Both of these nerves
are vaso-motor, producing their effects through the

234 THE HISTORY OF MEDICINE

unstriated muscles; for example, the unstriated
muscular coat of the arteries discovered by Henle
in 1840. The function of the cervical sympathetic
is as a rule to cause a narrowing or constriction of
the vessels, while the function of the chorda tym-
pani is to cause a widening or dilation of the vessels.
Thus Claude Bernard completed his discovery of
the vaso*motor nerves, that is, the vaso-dilator and
the vaso-constrieton He also opened up the ques*
tion of the inhibitory functions of nerves by prov-
ing (1846) that the stimulation of the vagus arrests
the action of the heart, and that respiratory move-
ments are checked by stimulating the superior
laryngeal.

Claude Bernard's doctor's thesis (1843) had been
on the gastric juice in digestion. He found that cane
sugar injected into the veins of a dog is excreted in
the urine. If, however, it is first treated with gastric
juice, it does not so appear. Seeking, later, to find
out at what part of the body the sugar so treated
lost its identity, he came upon an unexpected result,
namely that sugar occurs in the hepatic vein in
greater quantity than in the portal vein. Moreover,
if the experimental animal be fed neither sugar nor
starch, the sugar in the blood nevertheless persists.
He obtained sugar from the liver itself, and, later
still, isolated glycogen. It appeared then that the
liver has two functions, and that one of its secre-

ADVANCES IN PHYSIOLOGY 235

tions is an ''internal secretion/* On the false as^
sumption that the vagus nerve might influence the
hepatic secretion, he punctured the floor of the
fourth ventricle, and produced what he called arti-
ficial diabetes (experimental glycosuria), in 1849.
He is considered, in consequence of this, the founder
of experimental medicine.

About 1848 he found one day on his laboratory
table some rabbits, which had been brought in from
the market. He noted that their urine was clear and
acid, like that of camivora. He then fed them herbs,
and, as he had anticipated, their urine became tur-
bid and alkaline. After they had gone without food
for a considerable time, he fed them cold boiled beef,
which, faute de tnieux^ they ate readily enough.
Again their urine became clear and acid. He con-
cluded that all animals fasting are in a sense car-
nivorous, since they are nourished on their own
tissues. In a later experiment the rabbits were
killed after a full meal. He found that the lacteals
were white in the lower part of the duodenum about
30 centimeters below the pyloris. This struck his
attention, as with dc^ in similar circumstances he
had noted the whiteness of the lacteals at the upper
part of the duodenum. He noted that this difference
coincided with the fact that in the dog the entrance
of the pancreatic duct is quite near the pyloris,
while in the rabbit its entrance b very low. The

236 THE HISTORY OF MEDICINE

idea then occurred to him that the pancreatic juice
might be the cause of the emulsion of the fatty
matter of the food, and thus facilitate its absorption
by the lacteals.

Like his master Magendie, Claude Bernard was
interested in the action of poisons (for example,
curare and carbon monoxide) and had constant re*
(Course to vivisection* Nevertheless, their methods
of investigation were in at least one respect con-
trasted. Magendie called himself a ckiffannier,
thus comparing himself, working haphazard in the
field of knowledge, with those who go about the
town picking up rs^, etc. Bernard, on the other
hand, always had a definite aim in view, holding an
hypothesb essential to successful research, though
too agile mentally to neglect the clues that chance
threw in his way, and too astute to be blinded by
prepossessions. " Put off your imagination,** he said,
"as you take off your overcoat, when you enter the
laboratory ; but put it on again, as you do your over-
coat, when you leave the laboratory.** He thought
that one had little chance of finding anything unless
he knew what he was looking for, yet in his own
investigations he was again and again rewarded by
the discovery of the unexpected.

REFERENCES

Bell, Sir Charles: "On the Nerves," Pkilosoffkical Transactians^
1821, pp. 397-424.

ADVANCES IN PHYSIOLOGY 237

The Anatomy qf Ae Humam Body. 3 vds., seventh

edition, 1824*
Bernard, Claude: Introduction d la Midecine ExpMmenUjie.

1865.
Lemons sur la Physiohgieei la Pathologie du SysAme

l^erveux. 1858.
FkMirena, M. J. P.: Memoir of Magendie (translation). Annwd

Xoporif Smithsonian Institution, 1866, pp. 91-125.
Foster, Sir Michael: Claude Bernard. (Masters of Medicine.)
Hadley, P. B.: "Johannes MaUer/' Popular Science Monthly,

vol. 72 (1908), pp. 513-33.
Hall, Marshall: "On the Reflex Function of the Medulla Ob-
longata and Medulla Spinalis," PkUosofkical Transactions^

1833. pp. 635-65.
Stirlingi Sir William: Some Aposfks oj Physiology. 1902.

^ «-

CHAPTER XII

EMBRYOLOGY AND KARL ERNST VON BAER

The eighteenth oentuty fell heir to two opposed
theories concerning the development of the embryo
— epigenesis, and preformation or predelineation.
They were supported by the authority of the two
greatest embryologists of the preceding century,
Harvey and Malpighi. Harvey had taught that the
organism is built up gradually by the addition of
part to part. Malpighi, on the other hand, had held
that the chick existed preformed before the begin-
ning of incubation. In the latter view two other
early microscopists had concurred, namely, Swam-
merdam and Leeuwenhoek. The first of these,
whose works did not become generally known till
1737, had studied the early stages of the develop-
ment of the frog, and, interested in the meta-
morphosis of the caterpillar, had observed the parts
of the butterfly in the chrysalis. Leeuwenhoek
( 1 632-1 723) was the first to describe the sperma-
tozoa. It would seem that the wonders revealed to
these early students of microscopy led them to be-
lieve that further revelations of minute structures
and minute organisms only awaited the develop-
ment of better instruments and finer technique.

EMBRYOLOGY AND VON BAER 239

Moreover 9 as Professor W. M. Wheeler in his ad-
mirable lecture on Wolff has indicated, there is a
class of mind predisposed to emphasize the static
rather than the dynamic, to view phenomena as
being rather than becoming, as stable rather than
transitional, and to fasten attention on the fixity of
forms and species rather than on their transforma-
tions.

The investigations of Charles Bonnet (1720-93),
and the authority of Haller, also favored, in the
eighteenth century, the inclination to believe in the
doctrine of preformation. While still a youth, Bon-
net reported his observations concerning partheno-
genesis in plant-lice, or Aphides. He had seen a
single virgin aphis give birth to ninety-four daugh-
ters, which without fertilization continued to pro-
duce after their kind. Haller declared that no part
of the animal frame was made after the other; that
all were made together; and that there was no such
thing as epigenesis. It follows logically from the
doctrine of preformation that the ovum contains a
complete animal that awaits the process of unfolding
or evolution, and that the mother of the race bore
within her all her posterity, preformed creatures
impacted in preformed creatures like a series of
boxes enclosed in boxes. This theory of emb(4te-
ment^ was, indeed, definitely taught by Bonnet,
Leibnitz and others*

240 THE HISTORY OF MEDICINE

Kaspar Friediich Wolff (1733-94) exposed the
preformation idea in his Theory of Generation,
which appeared first as a doctor's thesis in 1 759. It
maintained that development consists in a series of
new formations, and undertook to trace the stages
by which the organs are gradually formed. Accord-
ing to Wolff the theory of predelineation merely
affirms the fact of generation without offering an
explanation of the process. He dealt first with the
structure and development of plants in order to dis*
cover a clue to the more difficult problems presented
by animals. In all plants little globules are to be ob-
served before the appearance of fibers and vessels.
The nutrient sap at first follows the path of least
resistance; the vessels are formed by virtue of the
hardening of the liquid nutriment. This principle of
coagulation along with the vis essentialis corporis,
the force through which the liquids in the organism
are distributed and eliminated, is the cause of the
process of development in all organic beings, both
plant and animal. The primordial kidneys (now
frequently called Wolffian bodies in honor of theii
discoverer) are formed by the urine propelled by the
essential force of the body. The globular particles
which constitute all animal organs in their incep-
tion — heart, blood-vessels, limbs, alimentary canal,
kidneys, etc. — may always be distinguished under a
microscope of moderate magnification. How, then,

EMBRYOLOGY AND VON BAER 241

can the predelineationists claim that a body is in-
visible because it is so small, when the parts of which
it is composed are easily distinguishable? Wol£F*8
drawings illustrating the development of the chick
are, on the whole, inferior to those made by Mai-
pighi in 1672 and sent to the Royal Society of
London.

Wolff's opposition to the doctrine of preforma-
tion, in which he had no doubt been schooled by hb
Leibnitzian professor of philosophy Christian Wol£F,
created a very unfavorable impression. His Theory
of Generation implied that the act of creation was
an incomplete process, and he became the object of
the same sort of criticism as Darwin incurred just
one hundred years later. He was warned by Haller
of the danger of running counter to the teaching of
religion. He was helpless in face of the disapproba-
tion he encountered. During the Seven Years' War
he served in the military hospitab in Schleswig and
lectured on anatomy in a field hospital in Breslau.
But the support that this patriotic service gained
for him was not sufficient to overcome the hostility
his heresy had aroused. He was refused a profes-
sorship, and even forbidden to lecture on physiol-
ogy in Berlin. In 1766 he accepted an invitation
to the Academy of Sciences in St. Petersburg, and
he spent the remainder of his life in the Russia of
Catherine H.

242 THE HISTORY OF MEDICINE

Wolff's second great contribution to the advance
of embryology, "De Formatione Intestinorum/'
was published at St. Petersburg in 1 768 and 1769.
Here, speaking of the development of the anterior
body wall of the chick, he says: "This is one of the
most important proofs of epigenesis. We may con-
clude from it that the organs of the body have not
always existed, but have been formed successively;
no matter how this formation has been brought
about. I do not say it has been brought about by a
combination of particles, by a kind of fermentation,
through mechanical causes, through the activity of
the soul, but only that it has been brought about/'
As implied in a correspondence with Haller, Wolff
was not interested in proving that anything is true
that is not true, and he accepted it as axiomatic that
other investigators shared his simple devotion to the
truth. This study of the development of the intes-
tines was years after its production referred to by
von Baer as "die grdsste Meisterarbeit, die wir aus
dem Felde der beobachtenden Naturwissenschaf ten
kennen"; that is, the most masterful performance
known to us in the field of the observational sciences.
In this work Wolff anticipated the embryologists of
the nineteenth century by teaching that leaf-like
embryonic layers give rise to the intestinal canal,
the nervous system, the vascular system, etc. He
furthered the study of embryology by applying the

EMBRYOLOGY AND VON BAER 243

method of strict observation in this difficult field,
and by establishing a definite antithesis between the
doctrine of epigenesis and the theory of predelinea-
tion so tenaciously held by his contemporaries.

In 18 1 2 the "De Formatione Intestinorum'* was
translated into German, under the title "Ueber die
Bildung des Darmkanals im bebrflteten HUhnchen,"
by Johann Friedrich Meckel, sometimes called the
younger to distinguish him from his grandfather,
J. F« Meckel, whose name is associated with the
sphenopalatine ganglion. The younger Meckel is
famous as the discoverer of Meckel's diverticulum
of the intestines, which represents the remains of the
vitelline duct, and as the author of an extensive
work on comparative anatomy. He has already
been mentioned in these pages as having some ac-
quaintance with the work of Hunter. He is credited
with an early statement of the recapitulation theory,
namely, that the development of each higher animal
is ''an epitome of the ancestral stages which pre-
ceded it'* (Garrison). This theory, foreshadowed,
as we have seen, in the writings of Hunter, was not
accepted by von Baer without limitation, he, in-
deed going so far as to say that the embryos of
higher forms never resembled the adult stages of the
lower forms but merely the embryos of such forms
(Balfour). This theory, severely criticized by the
embryologists of to-day and all but annihilated, has

244 THE HISTORY OF MEDICINE

served to stimulate countless investigators, espe«
cially since Darwin's ''Origin of Species'' seemed to
lend it a new significance.

Karl Ernst von Baer was bom at the family
estate of Priep in the Russian province of Esthonia*
February 28, 1792. He passed a free and happy
childhood in the country. At the age of eight he had
not learned the alphabet, but this fact did not
hamper his later progress. He attended school at
Revalt and spent four years at the University of
Dorpat, where he received his degree as doctor of
medicine in 1814. Following his graduation he went
to ^^enna to complete his professional studies, but
his inclination for more general biological research
was stimulated by a chance meeting with the botan*
ist Martins in the spring of 1815. He decided to put
himself under the instruction of Professor Ignaz
DSllinger of WOrzburg, who in the previous year
had published works on the value and significance
of comparative anatomy and on the development
of the brain (" BeitrSge zur Entwickelung3geschichte
des Gehims"). DdUinger was a disciple of the
philosopher Schelling. At the same time he was a
keen observer, known to have improved the micro-
scope, and a skillful teacher. Under his direction
von Baer pursued the study of comparative anat-
omy for two years. Before the expiration of that
time, Ddllinger having expressed the wish to have

EMBRYOLOGY AND VON BAER 24S

somebody undertake a detailed study of the devel-
opment of the chick, Christian Heinrich Pander, a
friend of von Baer*s, was induced to come to Wflrz-
burg and devote himself to the investigation.

In 1817 Pander set forth the results of his research
in a Latin thesis, which before the end of the year
speared in a German translation, ''BeitrSge zur
Entwickelungogeschichte des Hflhnchens im Ei."
It was illustrated by sixteen excellent copperplate
engravings, the work of the anatomist and archaeolo-
gist E. J. D'Alton. Pander describes the formation,
within the first twenty-four hours of incubation, of
the three layers of what he was the first to name the
" blastoderm/' All subsequent development is noth-
ing else than ''a metamorphosis of this membrane,
endowed with an inexhaustible supply of creative
force, and of the three layers that compose it.'* The
outer layer he called the ''serous," the middle layer
he called the ''vascular," and the inner, the "mu-
cous." The metamorphosis by which these three
layers are transformed into the various organs and
systems of the body is more precisely described by
Pander, then a young man of twenty-four, than it
had been by Wolff, whose theory and observations
he in the main confirmed. In fact, it was not till the
appearance of Pander's dissertation that students of
embryonic development found the clue to the de-
scriptions and the generalizations of hb eighteenth
century predecessor.

246 THE HISTORY OF MEDICINE

Von Baer, in the meantime, after spending a few
months in Berlin, had gone to KSnigsberg as pro-
sector to Professor K. F. Burdach, under whom he
had studied at Dorpat. He was appointed professor
of zoStomy in 1819. In the same year, stimulated
by the results of Pander's investigation, he began
his special studies in embryology, which he pursued
with intense energy for the subsequent seven 3^ears.
In 1827 he began to publish statements of the re-
sults of his researches. He had discovered as present
in all vertebrate animals the notochord, the key, as
Sedgwick has called it, to the whole of vertebrate
morphology. He sprang into special prominence by
the announcement of the discovery of the mam-
malian ovum — '^Epistola de ovi mammalium et
hominis genesi.'* He had verified the conjecture of
Pr6vo8t and Dumas by finding the human ovum in
a Graafian follicle. This capital discovery gave a
new meaning to Harvey's dictum, omne vivum ex
cvOf confirmed man's place in relation to the lower
animals, and established human embryology as a
branch of general biology. Some of von Baer's more
general results appeared, also in 1827, in Burdach's
" Physiologie," which contained, in addition, con-
tributions on the development of invertebrates by
Professor Rathke, and on the Entozoa in particular
by the youthful K. T. E. von Siebold,

In 1828 appeared the first volume of the work

EMBRYOLOGY AND VON BAER 247

which established the fame of Karl Ernst von Baer
as the greatest embryologist of the nineteenth cen-
tury — "Ueber die Entwickelungsgeschichte der
Thiere — Beobachtung und Reflexion," The title is
doubly significant, in the first place as indicating
the beginning of comparative embryology, in the
second place as indicating von Baer's unique com-
bination of accurate observation and unerring pow-
ers of generalization. Following up the results of his
friend Pander, to whom the book was dedicated,
von Baer traced carefully the development of the
chick day by day, and at the same time took ac-
count of other embryos. He recognized two chief
layers in the blastoderm, the animal and the vege-
tative, Pander's vascular layer consisting, in von
Baer's judgment, of derivatives from the so-called
serous and mucous layers. These layers were in no
sense ordinary tissues, but true germinal layers, the
source of all the systems and organs of the body.
From the animal layer come the external skin, the
sense organs, and the nervous system in general;
from its derivative the muscular and osseous sys-
tems. From the vegetative layer come the internal
lining of the alimentary canal and all its dependen-
cies — salivary glands, lungs, liver, etc. ; while from
its derivative come the heart, blood-vessels, kid-
neys, spleen, sexual glands, etc. The germ-layers,
observed in the embryos of all species of animab

248 THE HISTORY OF MEDICINE

except the very lowest, produce the fundamental
systems by f ormmg tubular cavities, from which the
special parts and organs are in turn evolved. The
formation of the central nervous system by the fold-
ing of the outer germ-layer is an example familiar
to alL As far as the development of the alimentary
canal is concerned Wolff had anticipated the ob-
servations of von Baer. In a similar way the walls
ct the body and the bony skeleton arise from mus-
cular and osseous tubes.

By 1834 "^i^ B^^^ I^ added through continued
research to his data concerning the development of
animals. His publisher pressed him to complete the
material for a second volume, and finally, having
waited in vain, proceeded to publication in 1837
without receiving the consent of the author. Von
Baer in 1835 contributed a paper on the embryology
oi fishes — '' Untersuchungen fiber die Entwicke-
lungsgeschichte der Fische'' — and put on record
the observation of the segmentation of the yolk in
the ovum of the fish. The remainder of his long life
was, however, given up to other scientific interests.
As early as 1827 he had been invited to the Academy
of Sciences at St. Petersburg; he had gone to the
Russian capital to live in 1829, only to return to
KOnigsberg the following year. But in 1834 ^^ took
up permanent residence in his native country as
zoological member of the St. Fetersbuiig Academy.

EMBRYOLOGY AND VON BAER 249

Von Baer traveled extensively^ sometimes at the
instance of the Russian government, sometimes at
the dictate of his scientific curiosity. He visited
North Cape» Nova Zembla» the Volga^ the Caspian
Sea» the Sea of Azov. He was interested in the
phjrsical features of the country, in its resources,
especially in its fisheries, and in the distribution of
plants and animals. He had early written on the
subject of fossils. In 1845 he published a paper on
teratology. In i85ft-6i he visited the museums of
London and other European cities. He made a
spedal study of anthropology, particularly crani*
ology, and in 1861, in conjunction with another
embryologist, Rudolf Wagner, called together the
first Congress of Anthropologists. One is impelled
to ask whether after 1834 von Baer felt that fur*
ther progress in embryology must depend on a fun-
damental reconstruction of biological conceptions.
In 1S62 he resigned his position as an active mem-
ber of the Russian imperial Academy. A few years
later he wrote his Autobiography at the suggestion
of his admirers among the Baltic nobility, and on
November 28, 1876, he died at Dorpat in his eighty-
fifth year.

Von Baer's special training and his opportunities
for comprehensive observation would seem an al-
most ideal preparation for the appreciation, if not
indeed the discovery, of the doctrine of organic

250 THE HISTORY OF MEDICINE

evolution. On the basis oi his embryological studies
he sought to classify animals under certain types,
between which he recognized a distant kinship. In
fact, according to von Baer» for one brief moment in
the course of embryonic development there is a
degree oi conformity between vertebrate and in-
vertebrate animals. The further we go back in de-
velopment, he says, the more we find agreement in
animals of very different sorts. We are thus led to
ask, he continues, whether in the beginning of de-
velopment all animals are not essentially alike, and
whether there is not for all a common or^;inal form.
It need not, however, greatly surprise us to find
that von Baer raised his voice in opposition to the
teachings of Charles Darwin (''Reden und kleine
Aufsfttze,'" 1864-77). In this respect he may be
compared with Sir Richard Owen, from whom Dar-
win and his friends hoped to gain support for their
doctrines. The severest critics of a new theory are
not unlikely to be men who have long cherished
views only slightly dissimilar to those they feel
called upon to discuss, and who thus bring to the
discussion a special knowledge of the data and a
keen sense of the danger of the generalizations in-
volved.

Professor Locy, referring to the period in the
history of embryology between the work of von
Baer and that of Francis Balfour states that there

EMBRYOLOGY AND VON BAER 251

were great general advances in the knowledge of
organic structure that brought the whole process of
development into a new light. ''Among the most
important advancest" he continues^ ''are to be
enumerated the announcement of the cell-theory,
the discovery of protoplasm, the beginning of the
recognition of germinal continuity, and the estab-
lishment of the doctrine of organic evolution.*' In
a passage dealing with the last item in this enumera-
tion the same author says: "The general acceptance
of the doctrine, which followed after fierce opposi-
tion, had, of course, a profound influence on embry-
ology. The latter science is so intimately concerned
with the genealogy of animab and plants, that the
newly accepted doctrine, as affording an explana-
tion of this genealogy, was the thing most needed/'
These great advances in the knowledge of organic
structure were all made before the death <^ von
Baer. At the same time there was a marked im-
provement of the technique of investigation, and, of
course, a steady accumulation of results. The princi-
ples set forth by J. J. Lister in a paper read before
the Royal Society in the beginning of 1830 led to a
much-needed improvement of the microscope both
in England and on the continent of Europe. About
1855 von Gerlach made use of carmine as a nuclear
stain, and before 1876 Golgi had introduced the use
of silver nitrate in the study of the nervous system.

252 THE HISTORY OF MEDICINE

A further improvement in technique came through
the introduction of the microtome in the prepara-
tion of histological sections by Purkinje, by Lister,
and by Wilhelm His, famous for his study of the
devdopment of nervous tissue.

Among the contributions to embryology before
the discovery <^ the cell-theory mention should be
made of the work of von Baer's colleague at KSnigs-
berg, Martin Heinrich Rathke, who observed the
branchial clefts and the visceral arches in the em-
bryos of abranchiate animals, and by the applica-
tion of the germ-layer doctrine in the investigation
of lower species established his daim to be called the
founder of invertebrate embryology. Von Siebold
has already been associated with him. Herold's
eariy study of the embryonic development of spiders
should not be overlooked in this oxmection. Von
Baer's discovery of the mammalian ovum, as his
confirmaticm of the germ-layer doctrine, stimulated
' a series of special studies. As eariy as 1825 Puridnje
had described the germinal vesicle in the ovum of
the tnrd. In 1833 Coste reported the discovery of
the germinal vesicle in the mammalian ovum, and a
year or two later Wagner discovered the germinal
spot. Bischoff , early interested in human embryd-
ogy, ultimately traced the development of the ovum
in four species of mammals, namely, the rabbit, dog,
guinea-pig, and deer.

EMBRYOLOGY AND VON BAER 253

Johannes MfiUer contributed to the progress of
embryology personally and through the work of his
pupils. In 1829-30 he investigated the development
of the genito-urinary organs, and the name Mtil-
lerian duct is still applied to the duct of the pro-
nephros, which in the adult becomes converted into
the genital passages. Mailer's ''Handbook of
Physiology** by its statement of the results of in-^
vestigations in embryology helped (along with the
books of Wagner and Valentin) to make the teach*
ings of that branch of biological science widely
known. We must defer, till the next chapter the con-
sideration <^ the work of two of M(lller*s most dis-
tinguished pupils, Schwann and Virchow. A third
pupil, Reichert, by hb volume ''Histology and
Embryology,*' brought to bear on the study of em-
bryonic development the method and point of view
suggested by the formulation in the preceding year
(1839) of the cell-theory. In 1837 he had made a
special study of the transformation of the visceral
arches. The work of Reichert was followed by that^^
of a fcMorth pupil of- MiUWs, ;yon KOlUkevj who in
1841 explained the cellular origin of the sperma-
tozoa, their nature and function. In 1843 he pub- ,
lished a paper on the development of invertebrates,
and in 1861 he wrote the first book on comparative
embryology. Robert Remak, also a pupil of Jo-
hannes Mailer's, in a study of the chick and frog,

r

254 THE HISTORY OF MEDICINE

1851-55, reviewed and clarified the origin of the
germ-layers from the blastoderm, and indicated to
some extent their relation to the formation of the
body cavities. A few years before (1849), Huxley
had put forward the view that the ectoderm and the
endoderm of the Ccdenterata are analogous to the
serous and mucous germ-layers observed by Pander
in the development of the chick.

A few examples must suffice to show the nature of
some of the advances made in embryology between
the appearance of Darwin's/' Origin of Species*' and
the death of von Baer. In 1861 Gegenbaur showed
that the vertebrate ovum consists of a single cell,
i and in 1865 he turned his attention with like results
to the examination of the spermatozoon. That the
embryo is formed from these unicellular elements
and that development takes place through cell-
division became the natural presuppositions of sub-
sequent theories of heredity. The study of Amphi-
oxus by Kowalevsky in 1866 tended to break down
the sharp distinction that had been made between
the vertebrates and the invertebrateSi and his doc-
trine that all animals pass through a gastrula stage
— a doctrine elaborated by Haeckel — went further
toward establishing the unity of the development
of all organisms. At about the same time, Fritz
Mailer, one of the earliest German converts to the
teachings of Darwin, gave a new formulation to the

EMBRYOLOGY AND VON BAER 255

theory of recapitulation , to which reference has al-
ready been made, and which assumes that all animals
of complex structure are the descendants of simpler
forms. In 1874 another disciple of Darwin's, Francis
Maitland Balfour, who had pursued some of his in-
quiries at the newly established Zoological Station
at Ns^les, made report before the British Asso-
ciation at Belfast of some of those investigations
which culminated in his volumes on Comparative
Embryology (1879-81). And in 1875 Oscar Hertwig,
known to the twentieth century as the author of a I
monumental work on vertebrate .embryology (1901,
et seq.), published his discoveries concerning the pro-
cess of fertilization.

In his lecture on ''Embryology and Medical
Progress" Charles Sedgwick Minot says: "Embry-
ology supplies facts which are directly valuable to
the practitioner. It supplies explanations and in-
terpretations of many anatomical structures and
relations which would otherwise remain incompre-
hensible. It supplies the dues to many common and
rare anomalies, and it supplies to pathology a series
of fundamental conceptions, without which our
actual present pathological knowledge could not
have been upbuilt. These claims of embryology to
recognition are very great, but nevertheless they do
not include her greatest claim to a preeminent place
among the medical sdenoes. That greatest claim is

256 THE HISTORY OF MEDICINE

established in my opimon by the oontributioa of
embryology to the solution of the problem of or-
ganic structure."

REFERENCES

Haeckel, Ernst: EpoluHon of Man.

Locy, W. A.: ^'Malpig^ in Embryology/' Popular Science

Monthly^ 1905, v6i. 67, pp. 97-126.
Minot, C S.: "Elmbryology and Medical ProgreB a ," Popular

Science Monthly, 1906, vol. 69, pp. 5-30.
Wheder,W. M.: Caspar Friedrick Wolff and tkeTkeoHa Genera^

tionist Woods HoU Biological Lec^ires, 1898, pp. 265:-^
Whitman, C. O.: Bonnets Theory of EoohOion, and EeoUOien

and Epigenesis, Woods HoU Biological Lectures, 1894, pp.

225-40, pp. 205^24.

CHAPTER XIII

THE CELI^THEORY AND CELLULAR

PATHOLOGY

Thb oell-theory npsulted from the investigations of
the botanist Schleiden and the anatomist and
physiologist Schwann. It teaches that the tissues of
developing plants and animab are composed of cells,
and it may be compared with earlier attempts to
discover a morphological unit in the organism, such
as Haller*s theory of fibers, Milne Edward's theory
of globules, or Bichat's doctrine of elementary tis-
sues. Cells had been observed by microscopists as
early as the seventeenth century, notably by Robert
Hooke (1665), who examined sections of cork under
his compound microscope, and found them made up
of little boxes or cells. He described the sections as
''all cellular or porous in the manner of a honey-
comb, but not so regular.'' His drawings of these
cork cells were reproduced in his book ''Micro-
graphia," one of the very early publications of the
Royal Society. The observations made at this time
by means of the microscope seemed to confirm
speculations concerning atoms and pores which had
persisted among medical philosophers from the time
of Democritus. In the eighteenth century Wolff, as

258 THE HISTORY OF MEDICINE

already implied, recognized common elements in the
minute structure of developing plants and animals.
Huxley gives the following statement of Wolff's
views: "Every organ, he says, is composed at first
of a little mass of clear, viscous, nutritive fluid,
which possesses no organization of any kind, but is
at most composed of globules. In this semifluid
mass cavities (Blftschen, Zellen) are now developed ;
these, if they remain round or polygonal, become
the subsequent cells; if they elongate, the vessels;
and the process is identically the same, whether it is
examined in the vegetating point of a plant, or in
the young budding organs of an animal."

Mathias Jakob Schleiden (1804-81) was inter-
ested in the development of plants, their anatomy
and physiology, rather than in their classification
under barbarous Latin names. He studied the rela-
tion of the cell-nucleus, which had been discovered
by Robert Brown in 1831, to the development of the
cell. Moreover, he attained to the view that the cell
is the elementary organ of the plant. The develops
ment of plant tissues depends on the nucleated cell.
For Schleiden the development of the cells of plants
was a matter of supreme interest. His treatment of
this question appeared under the title " Ueber Phyto-
genesis" in Mtiller's " Archiv" (1838).

Theodor Schwann (1810-82) was a pupil of
Johannes MUller at Bonn, and later (1834-38) at

THE CELL-THEORY 259

Berlin. Besides the formulation of the cell-theory a
long list of triumphs stands to his credit, including
the discovery of the sheath of the axis-cylinder of
nerves, and the recognition of the organic nature of
yeast and its r61e in fermentation. In 1837 Schleiden
told Schwann of his observations of the nuclei of
plant cells. Schwann had himself noted (under
Mailer's direction) the nucleated cells of the noto-
chord. The two friends compared the results of
their investigations, and Schleiden recognized in
Schwann's sections of the notochord nucleated cells
similar to those he had himself observed in plants.
Subsequently Schwann included in his investiga-
tion the cellular origin and development of various
tissues, and arrived at the generalization that
"There is one universal principle of development
for the elementary parts of organisms, however
different, and that principle is the formation of
cells." In 1839 appeared his "Microscopical Re-
searches concerning the Harmony in Structure and
Growth of Animals and Plants." In this work he
says: "The development of the proposition that
there exists one general principle for the formation
of all organic productions, and that this principle is
the formation of cells, as well as the conclusions
which may be drawn from this proposition, may be
comprised under the term cell-theory.'*
The views of biologists concerning the nature and

26o THE HISTORY OF MEDICINE

origin of cells were soon modified by further dis-
coveries. In 1835 Dujardin had observed a semi-
fluid, jelly-like substance in protozoa, endowed with
all the qualities of life. The term "protoplasm'* was
first used by Purkinje in 1839, to designate the
germinal ground-substance of the embryo. In 1846
von Mohl observed a jelly-like substance in plants
to which he applied the name ''protoplasma." A
few years later Cohn noted the similarity, if not
identity, of animal and plant protoplasm. In 1852
Remak established the fact that it is by cell-divi-
sion that the tissues develop from the three embry-
onic layers. Two years later Virchow was making
the cell-theory the basis of his system of pathology.
Rudolf Virchow (i 821-1902) was bom in Pome-
rania, began the study of medicine at Berlin in the
year in which Schwann's Microscopical Researches
appeared, and received his degree during the dean-
ship of Johannes Mtiller, who was his model and
ideal. In the following year he was demonstrator of
anatomy at the Charit6 Hospital (Berlin). Here he
had special chai^ of chemical and histological inves-
tigations, and his work in microscopic pathological
anatomy suggested to his mind the need of studying
the relationship between pathology and physiology.
In 1847 he established the "Archiv" (fOr pathol-
ogische Anatomie und Physiologic und ftir klinische
Medizin") since known by his name. About the

THE CELL-THEORY 261

same time he was appointed by the Prussian govern-
ment to investigate an epidemic of typhus fever
in Upper Silesia. His report not only recommended
certain hygienic measures but took the government
to task for the deplorable social conditions in that
province, and advocated complete and unlimited
democracy, and *' education, with her two daughters,
freedom and prosperity/' He was already showing
the personal spirit and political tendencies that
later made him the vigorous opponent of Bismarck.
Some years later he wrote : " I uphold my own rights,
and therefore I also recognize the rights of others.
This is the principle I act upon in life, in politics and
in science. We owe it to ourselves to defend our
rights, for it is the only guarantee for our individual
develc^ment, and for our influence upon the com-
munity at large/' From the summer of 1848, the
year of the attempted revolution in Prussia, till the
summer of the year following he published a weekly
on Medical Reform, which ultimately had a great
effect on the sanitation of Berlin. But the govern-
ment could not tolerate his activity as an agitator.
Hb pay was suspended for a time in the spring of
1849, and Virchow took advantage of a call to Wurz-
burg to withdraw from Prussian territory. At the
University of Wtirzburg he was closely associated
with von K5lliker, who had treated the segmenta-
tion of the egg, and, as we have seen, other phases
of embryonic development.

262 THE HISTORY OF MEDICINE

In 1854 Virchow began to edit a six-volume
''Handbuch der spedellen Pathologic und Thera-
pie/' In the first volume he states that there is no
essential difference between physiological and path-
ological laws. The human body, like all organisms,
is composed of minute elements, each of which can
be ultimately traced to a single cell and its sphere of
influence. These organic cellular elements and ele-
mentary precincts are anatomically recognizable.
They are at the same time morphological and vital
units, differing from inorganic matter both in their
composition and in their power to reproduce them-
selves. It would be a mistake, however, to regard
the body as a mere aggregation of these vital units.
They are parts of a higher unity. Some would de-
scribe this higher unity as a vital principle or con-
structive vital spirit, which in consistency they are
bound to postulate in plants as well as in animals.
According to Virchow the expression '* constructive
vital spirit'' is purely figurative, like the expression
"Landesvater" as applied to a monarch. The unity
of the living body consists only in the interdepend-
ence of its living elements. The harmonious inter-
action of these elements, all derived or^^ally from
one simple element, is the condition of life. ''Life
does not proceed discontinuously, or by fits and
starts, but in the regular, legitimate succession of
generations.'' Pathological derangement must, to

THE CELL-THEORY 263

begin with, involve definite elements. Every dis-
ease has therefore a local, anatomical starting point
or seat.

In 1856 Virchow was recalled to Berlin as pro-
fessor of pathology and director of a new Pathologi-
cal Institute. In 1858 he gave a series of twenty
lectures to members of the medical profession.
These were published under the title "Cellular
Pathology as Based upon Physiological and Patho-
logical Histology." After pointing to the advances
in medicine which in the past had followed the work
of the Alexandrian anatomists, of Vesalius, and of
Bichat, who developed the principles of general
anatomy, Virchow says: "What Schwann, however,
has done for histology, has as yet been but in a very
slight degree built up and developed for pathology,
and it may be said that nothing has penetrated less
deeply into the minds of all than the cell-theory in
its intimate connection with pathology." In a rela-
tively short time Bichat came to exercise an extraor-
dinary influence on the state of medical opinion. The
hesitancy to build upon the discoveries of Schwann
was owing, according to Virchow, to the continued
incompleteness of knowledge in the medical pro-
fession of the intimate structiue of the tissues.
Particular difficulty had been found in deciding
which parts of the body are the source of action —
what parts are active, what passive. "The chief

264 THE HISTORY OF MEDICINE

point in this application of histology to pathology is
to obtain a recognition of the fact that the cell is the
ultimate morphological element in which there is
any manifestation of life, and that we must not
transfer the seat of real action to any point beyond
the cell/*

At the sautne time the idea of the cell was in need of
restatement* Hooke and other early observers were
inclined to magnify the importance of the cell-wall
and to minify the importance of the cell-contents.
Indeed, the very name ''cell" tended to fix upon the
enclosing membrane as the characteristic feature.
Virchow held that Schwann in his observations had
been unduly influenced by the botanist Schleiden.
Schleiden was particularly prone to exaggerate the
importance of the cell-wall because he thought that
the nucleus never lay free in the interior of the cell
but was always enclosed in the cell-wall. The typical
plant cell was thought to consist of an extraneous
membrane of cellulose, generally found to be desti*
tute of nitrogen, and nitrogenized contents di£Fering
from it. To this type of plant cell the cartilage cell
with its capsule seemed to be comparable, but the
capsule is not an essential part of the cartilage cell;
it is really the result of excretion, and in the young
cell may be observed to be very thin, Virchow came
to the general conclusion that when we separate
from the cell all that has been added to it by an

THE CELL-THEORY 265

after-development, ''we obtain a simple, homo-
geneous, extremely monotonous structure, recurring
with extraordinary constancy in living organisms.
But just this very constancy forms the best cri-
terion of our having before us in this structure one
of those really elementary bodies, to be built up of
which is eminently characteristic of every living
thing — without the pre-existence of which no liv-
ing forms arise, and to which the continuance and
maintenance of life is intimately attached."

In this opening lecture of the series Virchow also
restated his view of 1854 in reference to the relation
of cell to cell within the organism, making more ex-
plicit the analogy between the cells in the body and
the citizens in the State. The highly developed
organism, whether plant or animal, must be re-
garded as made up of a larger or smaller number of
similar or dissimilar cells. Every animal is a sum of
vital elements, each of which manifests all the char-
acteristics of life. Life cannot be especially attrib-
uted to one particular seat or organ, such as the
brain of man, but it must be recognized in each in-
dividual cell, the constantly recurring structure, or
morphological and vital unit. ''Hence it follows
that the structural composition of a body of con-
siderable size, a so-called individual, always repre-
sents a kind of social arrangement of parts, an ar-
rangement of a social kind, in which a number of

266 THE HISTORY OF MEDICINE

individual ezbtences are mutally dependent, but in
such a way, that every element has its own special
action, and, even though it derive its stimulus to
activity from other parts, yet alone efifects the
actual performance of its duties."

In his second lecture on "Cellular Pathology''
Virchow enunciated what Lord Lister has described
as the true and fertile doctrine that every morbid
structure consists of cells which have been derived
from pre-existing cells as a progeny. His earlier
study of parasitic organisms had not converted him
to a belief in spontaneous generation. In the first
volume of the " Handbook of Special Pathology and
Therapeutics," already referred to, he had written a
section on plant and animal parasites. We are in-
debted to him for the first good descriptions of some
of the nonbacterial fungus infections (mycoses) ; and
this volume of 1854 gives a list of thirty metazoan
parasites, classified as trematodes, cestodes, nema-
todes, etc. In this list are found the Tcenia solium^
Trichina spiralis (to which Virchow at a later date
directed his attention to the great benefit of the
public health), Ancylostoma duaderuUe, FHaria medp-
nensiSf as well as the parasitic causes of hepatic
distomiasis, and of bilharziasis. In 1858 he was pre-
pared to maintain that even in pathology no devel-
opment of any kind begins de novo, and that the
theory of spontaneous generation is to be rejected

THE CELL-THEORY 567

just as decisively in the history of individual parts
as in that of entire organisms. A taenia solium does
not owe its origin to the intestinal mucus nor a
fungus take its life from decomposing animal or
vegetable matter; ''equally little are we disposed
to concede either in physiological or pathological
histology, that a cell can build itself up out of non-
cellular substance. Where a cell arises, there a cell
must have previously existed {omnis ceUtda e ceU-
fda)t just as an animal can spring only from an
animal, a plant only from a plant. In this manner,
although there are still a few spots in the body where
absolute demonstration has not yet been afforded,
the principle is nevertheless established, that in the
whole series of living things, whether they be entire
plant or animal organisms, or essential constituents
of the same, an eternal law of continuous develops
ment prevails. There is no discontinuity of develop-
ment of such a kind that a new generation can of
itself give rise to a new series of developmental
forms. No developed tissues can be traced back
either to any large or small simple element, unless
it be to a cell." This clear statement of the law of
the genetic continuity of cells was based of course in
part on the studies of von K5llikeri Remak, and
other embryologists.

Karl Blind is the authority for an anecdote in-
tended to throw light on Virchow's view of his own

268 THE HISTORY OF MEDICINE

contribution to the development of the ceU-theory.
At a party given in honor of >^rchow on the eve of
his departure for Cambridge, where he was to give
an address at a Harvey celebration, Blind broached
the question of Harvey's claim to be the first dis-
coverer of the circulation of the blood. Professor
Hecker of Berlin had given proofs of the worthless-
ness of Harvey's claims in the early part of the nine-
teenth century, and Blind himself had found addi-
tional evidence in the writings of Leonardo da Vinci.
\^chow in a conversation lasting nearly half an
hour made eager attempts to convince Blind of his
mistake, and finally observed (according to Blind) :
'*It might as well be contended, and it has even
been contended, that the cellular theory was not my
own." This remark seemed, to the narrator of the
story, directed against those who had pointed out
the claims of Schleiden and Schwann. Blind's own
judgment was that Virchow had worked out a
cellular theory of his own, correcting the mistakes of
his predecessors, and giving a demonstration of his
aphorism, Omnis cdltda e cellula.

The pathology of Morgagni was a pathology of
the organs; that of Bichat a pathology of the tissues
composing the organs; cellular pathology in turn
fixed attention on the elements that go to the forma*
tion of the tissues. Naturally the cell-theory en-
abled Virchow to review the work of Bichat, and to

THE CELL-THEORY 969

make a more thorough analysis of the components
of the various organs and systems. As constituting
one class of normal tissues he recognized those com-
posed exclusively of cells. Of this class the epithelial
formations are typical — the epidermis, the rete
Malpighi, the nails, the crystalline lens, the mucous
and serous membranes, and the active elements of
the glands, which, Remak showed, owe their origin
to the proliferation of epithelial structures. A sec-
ond class of normal tissues includes those in which
the cellular elements are separated by a certain
amount of intercellular matter. To this class belong
those to which Johannes MttUer gave the name
"connective tissues.'' (In the earlier medical litera-
ture they had been called "cellular," that is,
"areolar"; which indicates very definitely how
the term "cell" had shifted its meaning.) To
Virchow's third class belong the highly specialized
tissues, under which class come the nervous and
muscular systems, the vessels and the blood. In
oonstdering the physiology and pathology of the
brain, we must take into account not only its
nervous tissue, but its membranes, vessels, and in-
terstitial substance. (We owe to Virchow the term
neuroglia," as well as "mycosis," "embolism,"
arthritis deformans," "heterotopia," etc.). Simi-
larly a long bone is to be r^arded as an organ con-
sisting of at least three tissues besides the osseous.

41
$€

270 THE HISTORY OF MEDICINE

Do the general types established for the phy^o-
logical tissues hold good for the pathological? Yes,
every pathological structure has its physiological
prototype. At times the new formation (neoplasm)
corresponds to the type of tissue in which it occurs
as a pathological phenomenon, as when a fatty
tumor develops in adipose tissue. The neoplasm is
then said to be homologous. In contrast with
homology heterology is the occurrence of a new
formation in a type of tissue from which it differs,
as, for example, in fatty defeneration of muscular
tissue, or amyloid degeneration of the kidneys.
Pathological conditions may arise not only from the
misplacing of tissues (heterotopia) but also from
their retarded or premature development (hetero-
chronia), as, for example, when bone is invaded by
a cartilaginous tumor, and, lastly, from the mere
variation of their quantity (heterometria). Under
heterometria is included hyperplasia, involving an
increase in the number of the cells. Hypertrophy
may result merely from the enlargement of the in-
dividual cells, as, for example, in the enlargement of
the hepatic cells in hypertrophy of the liver. Patho-
logical states may be caused also by intracellular
changes.

Virchow included in his "Cellular Pathology"
the consideration of the diseases of the blood and the
blood-vesseb. He describes the minute crystals of

THE CELL-THEORY 271

haematoidin, discovered by him, and mentions their
occurrence in the cicatrix following cerebral haemor-
rhage. Leukaemia, first observed and named in
1845, b here spoken of as **a permanent, progressive
leucocytosis.'* Virchow dbtinguishes it from pyae-
mia, notes the haemorrhagic tendency associated
with it, and connects it causally with the lymphatic
glands and the spleen. Chlorosis, which usually in-
volves imperfect development of the acxta, and
frequently of the heart and sexual organs, b not to
be confused with leukaemia. Perhaps, however,
Virchow^s greatest individual triumph in pathology
was hb doctrine of embolism, and the consequent
clearing-up of the nature of thrombosb and phlebi-
tb. Setting aside the speculations of the French
pathologbt Cruveilhier (1791-1873), with whom the
idea of phlebitis had become almost an obsession,
Virchow inquires in reference to the facts concerning
the composition and the origin of the thrombus.
Microscopic examination reveals that the coagu-
lated mass consbts of broken-down cells, of dis-
integrated fibrin, and of white and red blood-
corpusdes undergoing disorganization, and, in the
case of the last-named, in process of discoloration.
Though it may look like pus, it should never be
regarded as pus. The pathological condition begins
with the copulation, the formation of the thrombus
in the blood. Virchow readily admits that at times

272 THE HISTORY OF MEDICINE

phlebitis, as well as arteritis and endocarditis, may
give rise to thrombosis; but real phlebitfe is an in-
flammation of the walls, and not of the contents of
the vein* Moreover, he finds that not infrequently
the small branches of the peripheral veins become
quite filled with masses of coagulunx The greater
number of these thrombi become prolonged beyond
the mouths of the iM-anches, and greatly enlarged.
From these prolonged thrombi partides (emboli)
are carried along by the blood stream. Minute
fragments may hence be wedged tightly into the
nearest system of arteries or capillaries. *'Thus we
see that as a rule all the thrombi of the periphery of
the body produce secondary obstructions and meta-
static deposits in the lungs/' It is also noted that
embolism in certain cases occasions sudden occlu-
sions <^ the vessels of the eye or brain.

To Johannes Miiller, who had laid down the law
of the oorrespcxidence between embryonic and
pathological development, Virchow owed no doubt
S(mie of his interest in the pathology of the foetus,
in what he called "agenesia"* (aplasia cerebri), as
well as in allied subjects, such as the structure of the
umbilical cord, and tubal pregnancy. MQller's his-
tological study of tumors exerted a no less decisive
influence 6n Virchow's uncompleted work of three
volumes, "Die Krankhaften Geschwfllste" (1863-
67), one of his greatest contributions to pathology.

I

THE CELI^THEQRY 273

In this work is maintained the point of view of the
Cellular Pathology. It must be ever realized, said
Virchowy that tunx>rs, whether they are parasitic in
origin or not, are always portions of the body, and
do not develop from some morbid humor of the
organism, ncH* independently through some special
force of their own substance. He hdd that tumors
owe their origin as a rule to the less highly special-
ized tissues, to the connective tissue, and, more
particularly, the epithelial. At one time he was
inclined to trace the derivation of cancers to the
mesoblast, but, probably influenced by investi-
gators who thought these growths were also c^
epithelial origin, he left this part of his w(M*k unfin-
ished. He gave the first description of hematoma
of the dura mater, and of glioma.

Virchow was also the first to describe leontiasis
ossea; he discovered the lymphatic sheaths of the
cerebral arteries; in his doctor's thesis he treated the
topic of the inflammation of the cornea (keratitis),
and noted that wounds of the cornea repair without
the presence of plastic exudations; he maintained
that Peyer's patches are only lymphatic glands, and
that in disease they play a part comparable with
that of axillary and inguinal glands; he set forth in
detail the pathology of syphilis; he investigated
tuberculosis, and established the relation to it of
lupus; and he explained the forms of parenchymat-

274 THE HISTORY OF MEDICINE

ous inflammation. Virchow was not disdainful of
therapeutics, and his attitude in this regard may
have influenced his student Hoppe-Seyler, and
others closely associated with him. He is also men-
tioned in connection with the investigation of septi-
caemia, leprosy, cholera, smallpox, diphtheria, pella-
gra, the pearly disease of cattle, Addison's disease,
exophthalmic goitre, and cretinism. He was inter-
ested in the composition of adipodre. He was active
in municipal, as well as national politics, and in-
stituted in Berlin a system of sews^ disposal and
other sanitary reforms. In what was named, by
him, the ''Kulturkampf," he considered himself the
champion of liberal culture against the forces of
obscurantism. On the eve of the Franco-Prussian
War he stood as the advocate of European disarma-
ment, but during the conflict he took a very promi-
nent part in the organization of the ambulance and
hospital service. He also contributed to the im-
provement of civil hospitals and of nursing. Along
with his varied pursuits he made extensive collec-
tions, labeling over twenty-three thousand speci-
mens, which he presented to the Pathological Mu-
seum.

In the judgment of Virchow medicine as an ap-
plied science must rest on the firm basis of the
natural sciences. At the same time he looked upon
the classical literatures as the source of European

THE CELL-THEORY 275

culture. He encouraged the archaeological researches
of Schliemann, and in 1879 was with him in the
Troas» and, nine years later, in Egypt, Nubia, and
the Peloponnesus. Like von Baer he devoted a
great deal of energy to the study of anthropology,
particularly craniology. He followed the genetic
method of seeking the eq>lanation of things in their
origins. He applied that method to the study of
medicine. ''For me,'' he said, ''medicine does not
begin to-day, and I hold it impossible to be com-
pletely at home in it, if one does not interpret it
genetically/' He was the first to write on the rela-
tion of medicine to the fine arts. Perhaps it was his
sense of historical perspective that made him con-
temptuous of the trace of humoral pathology that
survived in the teachings of the great Viennese
pathologist Rokitansky, and made him at the same
time distrustful of the doctrines of Darwin, of Koch
and von Behring.

REFERENCES

Blind, Karl: "Personal Recollections of Virdiow/' North Ameri-
can ReneWf 1920, vol. 175, pp. 613-34.

Geddes, Patrick: "Protoplasm," EMcydopcedia Britannica.

Israel, Oscar: Rudolf Virchow, Annual Report, Smithsonian
Institution, 1901-02, pt. i, vol. 57, pp. 641-59.

Tyson, James. The CeU-Doctrine. 1878.

Virchow, Rudolf: Cellular Pathology as Based upon Physiological
and Pathological Histology (translated by Frank Chance).

Wilson, E. B.: The Cell in Deoehptnent and Inheritance. 1896.

CHAPTER XIV
THE nmODUCnON OFAK^SIHEnCS

The tide <d Friodeir's vorfc. -EMpahmemtM and
Obatufstioiit on DilJpiwit fGocb €t Air"* (i774* ^
90f[*)p gives flomc iiMJifiwioii <m iHiw flnie was umnu

^ T^P ^Pffff ffp y the CuClDIBtXV OK CSBCS flB uK BEtteT DttTC

<tf dbe righttTuUi uoiLBiy. Xhe <MMmmiitJUtt <tf tlie

fSH^ csfbofi dioKide, as well as oxygaif mtrageo, and
hydrogen^ wen kinds of air. The namrs by wUcli
wt know tfaem had Id wait upoo theo* dtffeicntia-
tacMit opoo their analysis, or upoo the analysis of the
oompotuids of which they formed parts, such as
water, nitric add and other adds. A great step for*
ward was made when, on August I, 1774, Priestley
in an apparatus from whidi air was exduded ignited
lithaiye by means of a buming-glasB. He tested die
facUiious air thus obtained by {rfadng in it a piece
of lighted dxarooal. In the belief that die supporter
of combustion is also the supporter of life he put two
mice into the neidy isolated gas. He then inhaled
some of the gas, and observed an exhilarating effect.
^'Who can tdl," he writes, "but in time this pure
air may became a fashionaMe artide in luxury?

ANiESTHETICS 277

Hitherto only two mice and myself have had the
privilege of breathing it/*

Before the end of the century the investigations
of Priestley, Scheele, and others inspired Dr.
Thomas Beddoes to found in one of the suburbs of
Bristol the Pneumatic Institution to carry on ex-
periments, and to treat patients by means of the
newly discovered factitious airs. This enterprise
has been described as a scientific aberration, but
Beddoes was fortunate in choosing as an assistant
to superintend the experiments Humphry Davy,
then (1798) nineteen years old. Davy experimented
for months with nitrous oxide, which had been dis-
covered some time previously and which in 1793
was produced by heating ammonium nitrate; that
is, the process still in use to-day. The fact that it
supports combustion like pure oxjrgen may have
directed special attention to it, but it had been
declared poisonous, and had even been described
as the "principle of contagion.'' Davy, however,
finally ventured on the crucial experiment of in-
haling large quantities of the gas. After being sub-
jected to nitrous oxide in an air-tight chamber for an
hour and a quarter he inhaled twenty quarts of the
pure gas.

"A thrilling," he says, in describing the experi-
ence, "extending from the chest to the extremities,
was almost immediately produced. I felt a sense (tf

278 THE HISTORY OF MEDICINE

tangible extension highly pleasurable in every limb;
my visible impressions were dazzling, and appar-
ently magnified; I heard every sound in the room,
and was perfectly aware of my situation. By de-
grees, as the pleasurable sensations increased, I lost
all connection with external things; trains of vivid
visible images rapidly passed through my mind, and
were connected with words in such a manner, as to
produce perceptions perfectly novel. I existed in a
world of newly connected and newly modified ideas:
I theorized, I imagined that I made discoveries.
When I was awakened from this semi-delirious
trance by Dr. Kinglake, who took the bag from my
mouth, indignation and pride were the first feelings
(xxxiuced by the sight of the persons about me. My
emotions were enthusiastic and sublime, and for a
minute I walked round the room perfectly regard-
less of what was said to me. As I recovered my
former state of mind, I felt an inclination to com-
municate the discoveries I had made during the ex-
periment. I endeavored to recall the ideas: they
were feeble and indistinct; one collection of terms,
however, presented itself; and with the most in-
tense belief and prophetic manner, I exclaimed to
Dr. Kinglake, ' Nothing exists but thoughts! The uni-
verse is composed of impressions ^ ideas ^ pleasures and
painsr'*
The discovery of the properties of ''laughing gas''

ANAESTHETICS 279

appealed to the popular imaginatioa, and inhaling
nitrous oxide became a regular form of entertain-
ment. Davy, made famous by this and other bril-
liant discoveries, was appointed assistant lecturer
in chemistry at the Royal Institution, London,
where his youth, scientific acumen, and wonderful
powers of expression soon drew upon him the atten-
tion of the fashionable world. In 1800, the year
preceding his appointment at London, there ap-
peared his '^Researches, Chemical and Philosophi-
cal, chiefly concerning Nitrous Oxide,** which sets
forth the following conclusion: ''As nitrous oxide in
its extensive operation appears capable of destroy-
ing physical pain, it may probably be used with
advantage during surgical operations in which no
great effusion of blood takes place.*' Davy's sugges-
tion led to no immediate effects in the practice of
surgery. Between the years 1820 and 1828 Hick-
man, a young surgeon of Shropshire, England, ex-
cruciated by the sufferings of those upon whom he
was called to operate, carried on a series of experi-
ments on animals in order to discover a method of
inducing insensibility to pain by means dt inhala-
tions. His early experiments were concerned with
the study of asphyxiation, animals being rendered
unconscious by enclosing them in glass and pre-
venting the access of air or by exposing them to
carbon dioxide prepared from calcium carbonate

28o THE HISTORY OF MEDICINE

and sulphuric add. Rebuffed by the profession In
his own country, he succeeded in 1828 in having his
methods of producing anaesthesia investigated by
the Academy of Medicine in Paris. He failed to
gain the approbation of that body, though there is
evidence that by that time he was u^ng nitrous
oxide and that his claims were supported to some
extent by the distinguished army-suiigeon Baron
Larrey. Ethyl ether was destined to be employed
before nitrous oxide in surgical operations.

Ethyl ether had been described as a preparation
before the middle of the sixteenth century. As an
inhalation it was used in Birmingham, England, as
early as 1785, in the treatment of asthma and other
respiratory affections. Dr. John Collins Warren, of
Boston, Massachusetts, employed it in 1805 in the
treatment of the advanced stages of phthisis. In
18 1 8 there appeared a brief article in the ''Journal
of Science and the Arts," London, containing the
following statement: "When the vapour of ether
mixed with common air is inhaled, it produces effects
very similar to those occasioned by nitrous oxide."
It had already evidently been considered a source
of fun, for the writer, after describing the method
of inhalation and the effects, gives expression to a
warning, one gentleman after inhaling a large quan-
tity having been thrown into a ''lethargic state,
which continued with occasional periods of inter-

ANiESTHETICS a8i

mission for more than thirty hours/* This brief
article, or note, was pfx>bably written by the cele*
brated chemist Michael Faraday, then a young man
of twenty-seven acting as Davy's assistant at the
Royal Institution.

* In spite of the warning concerning its imprudent
use, ethyl ether, like nitrous oxide, continued to
furnish entertainment both in England and in the
United States (where the anaesthetic effects of ether
inhalation were soon recognized by Godman (1822)
and other physicians). In 1839 at an ''ether frolic"
at Anderson, South Carolina, a colored boy, who
had been forced to inhale a considerable amount of
ether, after remaining unconscious for an hour,
showed no subsequent ill effects. This may have
encouraged the others. At all events, one of the
j^ung men present on that occasion became in 1842
a pupil of Dr. C. W. Long, of Jefferson, Georgia,
and here the sport of inhaling ether was maintained*
Dr. Long observed that he and the others did not
experience pain from any blows and bruises they
received while under the influence of the intoxicant.
This led him to think it might be of value in surgery,
and on March 30, 1842, he administered ether to
James Venable and removed a small tumor from the
patient's neck. Venable, the first person to undergo
an operation under etherization, was somewhat
addicted to inhalation as a pastime, and his bill

282 THE HISTORY OF MEDICINE

from Long, whidi is still preserved^ shcyws that ether
with operation cost two dollars and ether without
operation twenty-five cents. Dn Long continued to
use the anaesthetic in his limited country practice;
but he did not publish an account of his experiences
with it, and there is no evidence that he exerted any
influence in bringing about the general use of ether
in Slurry.

Two or three years after this occurrence, an itiner-
ant lecturer, G. Q. Colton, entertained an audience
at New Haven, G)nnecticut, by a lecture on
'' Laughing Gas,*' demonstrating on a few of his
hearers the effects of inhaling nitrous oxide. A
j^ung dentist, Dr. Horace Wdls, who was among
those present, made an observation — similar to
Long's in the case of ethyl ether — that those ex-
hilarated by the inhalation of laughing gas seem to
experience no pain from even rather severe injuries.
Impressed by this fact, and hoping to turn it to ac«
count in his practice, he determined to submit him-
self to a decisive test. Accordingly, on the day
following the lecture. Wells had one of his own teeth
extracted while under the influence of the anaesthetic
administered by Colton. He felt no pain. Hence-
forth Wells made oxistant use of nitrous oxide in his
practice as a dentist. He foresaw not only the part
anaesthesia was to play in dentistry, but also its
value to surgery in general. In the autunm of 1845

ANiESTHETICS 283

he visited Boston in order to direct the attention of
the medical profession to the virtues of nitrous
oxide. He seized an opportunity to give a demon-
stration before the Harvard Medical Coll^;e; but
on this public occasion he failed. At this time he
was thrown in contact with Dr. Charles T, Jackson
and with William T. G. Morton (1819-1868). Wells
and Morton had been partners for a short time in
Boston in 1843. They were both interested in a new
method of making false teeth, and, therefore, had a
special motive for discovering a means of painless
extraction.

In 1844 Morton, without relinquishing his very
lucrative practice as a dentist in Boston, had entered
the office of Dr. Jackson as a student of medicine,
and had matriculated at the Harvard Medical Col-
lege. In that same year he had begun to experiment
with ether as an anaesthetic. He continued his ex-
periments, both on animals and human beings, in
the summer of 1846. From Jackson he learned the
different kinds and preparations of ether, the effects
of the inhalations (as observed by his preceptor in
the case of college students), and the necessity of
making use of ether free from impurities. Finally
Morton had the courage to try the effects of ethyl
ether inhalation on himself, in September, 1846.
He relates his experience in the following words:
** I shut myself up in my room; seated myself in the

a84 THE HISTORY OF MEDICINE

operating chair and commenced inhaling. • • • It
partially suffocated me but produced no decided
effect. I then saturated my handkerchief and in-
haled it from that. I looked at my watch and soon
lost consciousness. As I recovered I felt a numbness
in my limbs with a sensation like a nightmare and
would have given the world for some one to come
and arouse me. I thought for a moment I should
die. ... At length I felt a slight tingling of the
blood in the end of my third finger, and made
an effort to touch it with my thumb, but without
success. ... I pinched my thigh, but . . . sensation
was imperfect. ... I immediately looked at my
watch. ... I had been insensible between seven and
eight minutes.''

Before the end of the month, Morton, with char--
acteristic boldness, made successful use of ether in
extracting a tooth. The patient was given a hand-
kerchief saturated with the anaesthetic, and was
directed to inhale. He lapsed into unconsciousness
almost immediately. A firmly rooted bicuspid was
removed, and in about a minute the patient re-
covered consciousness. This was on September
30th. Within less than a week the enterprising^
Morton, then a young man of twenty-seven, called
on Dr. Warren, senior surgeon of the Massachu-
setts General Hospital, told of his success, and
asked for an opportunity to give a public demon-

ANiESTHETICS 285

stration of his method of rendering insensible to pain
patients about to undergo surgical operations. He
did not have to wait long for an invitation to be
present at an operation, and to put his method to
the test.

At the appointed time, ten o'clock on the morning
of October 16, 1846, Morton was not present. This
increased the skepticism of those assembled to wit-
ness the test, and raised a doubt in the minds of
some concerning the good faith of the young dentist.
Dr. Warren, the operating suiigeon, seemed to share
to some extent the general feeling of incredulity.
Indeed, after waiting for a time, he was about to
begin the operation without Morton's assistance
when the latter appeared on the scene. He had been
delayed in securing some apparatus he thought de-
sirable in administering the ether, namely, an in-
haler provided with a stop-cock and fitted into a
glass vessel containing the ether. He now adjusted
the apparatus, and in about three minutes the pa-
tient sank into a state of insensibility. The operator
made an incision about three inches long in the neck,
and proceeded to extirpate a tumor just below the
jaw on the left side. The patient, when he recovered
from the effects of the ether, said that he had suf-
fered no pain during the operation, though he had
had the feeling that a blunt instrument was passing
roughly across his neck. Warren, as well as the

286 THE HISTORY OF MEDICINE

others present, was convinced that Morton had
made good his claim, though the patient soon after
the first incision had begun to speak incoherently,
and had appeared to give indications of suffering,
his agitation continuing till the operation was over.
On the following day Dr. Hayward removed a
tumor from the arm oi a woman while she was under
the influence of the inhalation. In this case the
anaesthetic was adminfetered throughout the opera-
tion, and the patient remained unconscious except
for a disagreeable dream toward the dose. Morton's
triumph was complete.

The use of ethyl ether as an anaesthetic soon
gained the recognition it deserved. Every success-
ful operation under etherizaticm increased the con-
fidence of the profession and strengthened the public
faith in Morton's innovation. Three weeks after his
first success with the anaesthetic. Dr. Hayward am-
putated a lower extremity above the knee, the pa-
tient remaining unconscious throughout the opera-
tion. The prestige of the Massachusetts General
Hospital, and the support q( such leaders in the
medical world as Wanen, Hayward, and Bigelow,
account for the rapid headway of surgical anaesthesia
throughout all civilized countries. Henry J. Bige-
low, considered at that time one of the best surgeons
in America, who had been appointed to the staff of
the Massachusetts General Hospital and professor

ANiESTHETICS 287

of surgery In the Harvard Medical CcXleg^ in the
year of the great discovery, did his utmost to en-
courage Morton. As early as November 3d he read
a paper dealing with the new anaesthetic before the
Academy of Arts and Sciences. He published this
paper in the " Boston Medical and Surreal Journal "
November i8th. Three days later Dr. Oliver Wen-
dell Holmes suggested the terms "anaesthesia" and
"anaesthetic'' in the sense in which they are still
employed.

In the following weeks Bigelow carried a sample
of ether to London, arriving in that metropolis
December 17th. Two days later it was there used
by a dentist in extracting a tooth, and on December
2ist Robert Liston, the famous surgeon, employed
it in an amputation of the thigh. Syme, his cousin
and sometime partner, used it in his Edinburgh
practice the following year. On January 19, 1847,
Simpson, who had discussed with Liston in the pre-
ceding Christmas holidays the use of ethyl ether, led
a notable advance by introducing the anesthetic
into the practice of midwifery. After several
months, referring to his experience with ether, he
wrote: "I have employed it with few and rare ex-
ceptions, in every case of labor that I have attended ;
and with the most delightful results. • . • I have
never had the {Measure of watching over a series of
better or more rapid recoveries; nor once witnessed

a88 THE HISTORY OF MEDICINE

any disagreeable result follow to either mother or
child ; whilst I have now seen an immense amount of
maternal pain and agony saved by its employment.''
Among the European apostles of surgical ansesthesia
must also be mentioned Pirogoff, the illustrious
Russian^military surgeon. It seems almost incredi-
ble that in the year following the use of ethjd ether
for the first. time Jn an American hospital he could
have written his ''Practical and Physiological Re-
8earche^tx>nceming Etherization." Two years later
appeared a medical report of his expaiences in the
Caucasus containing interesting statistics of the
results of amputating under the new conditions.

On November 4, 1847, Professor (later, Sir)
James Young Simpson of Edinburgh ^ discovered
the anaesthetic effects of chloroform on human
beings. This compound had been discovered almost
simultaneously, in 1 831, by Guthrie in America,
Liebig in Germany, and Soubeiran in France. In
1834 ^^ great French chemist J. B. Dumas cor-
rectly described its composition and gave it the
designation ''chloroform." In the March preceding
Simpson's discovery, its anaesthetic effects <mi lower
animals had been recorded by the noted French

* "Chloric ether" — that it, an alcoholic solutkm of chloroform —
had been tried by Morton before his succeae with ethyl ether. Warren
had used "chloric ether" by preference after October 16, 1846. It
had also been employed at St. Bartholomew's Hospital, London, in
the summer of 1S47.

ANiESTHETICS 289

physiologist Flourens. In his search for an anaesthe*
tic inhalation less irritant than ethyl ether, Simpson
had been advised to try chloroform ('' perchloride
of formyle'') by Waldie, described as a chemist of
Liverpool, but bom, like Simpson himself, in the
county of Linlithgow, Simpson, after examining
with the assistance of his colleagues, Keith and Dun-
can, a great variety of chemicals in the hope of find-
ing a substitute for ethyl ether, decided to put
cUoroform to the test. The three friends inhaled it
one evening from tumblers in the dining-room of
Simpson's home in Edinburgh. They became exhila-
rated, and the members of the household enjoyed
the liveliness of the ensuing conversation. Then the
three became suddenly insensible. Nothing daunted ,
however, by this first experience, they inhaled the
chloroform repeatedly that same evening. Simp-
son's niece was inclined to try it also. Folding her
arms across her breast and inhaling the chloroform,
she fell asleep crying, 'Tm an angell Oh, I'm an
angel!"

Within the following week Simpson tried the new
anaesthetic on upwards of thirty people, using it in
extracting teeth, opening abscesses, to annul the
pain of dysmenorrhoea, neuralgia, etc. Moreover,
he employed it with conspicuous success in obstetric
practice. The lady to whom it was first adminis-
tered in child-birth had previously been delivered

290 THE HISTORY OF MEDICINE

in the country, after prolonged labor, only by sacri-
ficing the life of the child. In this, her second con-
finement, she was worn by anxiety and sleepless-
ness, and pains supervened a fortnight before full
time. Three hours and a half after the occurrence
of the first pains, at the beginning of the first stage
of parturition, she inhaled from a handkerchief on
which a teaspoonful of chloroform had been poured.
Ten or twelve minutes later a like amount was ad-
ministered, and the child was bom twenty-five min-
utes after the beginning of the first inhalations.
The patient was not aroused by the aying of the
child nor at the coming away of the placenta. When
she did regain consciousness she remarked to Simp-
son that she had had a very comfortable sleep, that
she had needed it having been so tired, but that she
would now be able for the work before her. Simpson
made no haste to set her right, and when the nurse
came back into the room with the child, the mother
could hardly believe it was her own living baby, as
she said.

Before ithe middle of November chlorofcMin was
used as an anaesthetic in three operations at the
Royal Infirmary of Edinburgh in the presence ol
Dumas, who chanced to be visiting Scotland at the
time. The notes of the operating surgeon. Professor
Miller, supply the following account of the first case,
'^ A boy, four or five years old, with necrosis of one

ANAESTHETICS 291

of the bones of the forearm. Could speak nothing
but Gaelic. No means, consequently, of explaining
to him what he was required to do. On holding a
handkerchief, on which some chloroform had been
sprinkled, to his face, he became frightened and
wrestled to be away. He was held gently, however,
by Dr. Simpson, and obliged to inhale. After a few
inspirations he ceased to cry or move, and fell into a
sound, snoring sleep. A deep incision was now made
down to the diseased bone; and, by the use of the
forceps, nearly the whole of the radius, in the state
of sequestrum, was extracted. During this opera-
tion, and the subsequent examination of the wound
by the finger, not the slightest evidence of the suffer-
ing of pain was given. He still slept on soundly, and
was carried back to his ward in that state. Half an
hour afterwards he was found in bed, like a child
newly awakened from a refreshing sleep, with a
dear, merry eye and placid expression of counte-
nance. ... On being questioned by a Gaelic inter-
preter who was found among the students, he stated
that he had never felt any pain, and that he felt
none now. On being shown his wounded arm, he
looked much siurprised, but neither cried nor other-
wise expressed the slightest alarm.''

In the other operations performed at the Royal
Infirmary at this time Simpson made use of a hollow
sponge in administering the ansesthetic. In one of

292 THE HISTORY OF MEDICINE

these cases — a soldier who*had an opening In the
cheek, the result of exfoliation of the jaw — Miller
recognized that it would have been impossible to
employ any complicated inhaling apparatus applied
to the mouth of the patient. In the other case Dr.
Duncan operated on a young man suffering from
necrosis of the first phalanx of the great toe and
ulceration of the integuments. On November 15th
Miller removed from a private patient an encysted
tumor beneath the angle of the jaw. At that date
Simpson had administered chloroform to fifty per-
sons.

As the acknowledged champion of surgical anaes-
thesia he was very successful in meeting the aigu-
ments and beating down the prejudices of his oppo-
nents. Many of his contemporaries in Scotland and
elsewhere considered pain as a punishment that
should be received in a spirit of meekness, and the
resort to anaesthetics seemed to them an impious
attempt to thwart the divine will. Simpson was
attacked from the pulpit and passages from the
Bible were quoted to prove the wickedness of his
undertakings. But he met arguments of this sort by
appealing to the same authority. ''My exponents
forget/' he said, ''the twenty-first verse of the
second chapter of Genesis; it is the record of the first
surgical operation ever performed, and that text
proves that the Maker of the universe, before he

ANiESTHETICS 293

took the rib from Adam's side for the creation of
Eve, caused a deep sleep to fall upon Adam/* En-
lightened clergymen gave him of course their sup-
port, and the opposition to the use of anaesthetics in
midwifery, which had been particularly bitter —
pointing to the wickedness of trying to remove a
part of the primal curse on woman — broke down
when Queen Victoria gave her countenance to the
use of chloroform on the occasion of the birth of
Prince Leopold in 1853.

Anaesthesia was not only, as it has been called, the
death of pain; it did away to a considerable extent
with shock, and, by obviating the necessity of great
speed in the performance of operations, made the
introduction of antiseptic methods possible. Before
ethyl ether and chloroform came into use haste was
one of the recognized criteria of good surgery. One
reads of Cheselden performing a lithotomy in less
than a minute; of Langenbeck, surgeon general of
the Hanoverian army in the Napoleonic era, ampu-
tating a shbulder while one might take a pinch of
snuff; of Sir William Fergusson, the founder of con-
servative surgery, who was at times so speedy that
the onlookers had to keep on the alert for fear of
missing the whole operation through one moment's
inattention; of Pirogoff, who was so rapid and dex-
terous in the use of the knife as to challenge com-
parison with a sleight-of-hand artist. When, on

294 THE HISTORY OF. MEDICINE

December 21, 1846, an anaesthetic was first used in
England in a major operationi the surgeon, Robert
Liston, proceeded as expeditiously as usual, remov-
ing the limb of the patient at the thigh in twenty-
five 'seconds, according to the statement of the
dresser. Among the onlookers on this occasion at
the University College Hospital, London, was a
young student of nineteen still working for his de-
gree in arts, Joseph Lister, whose contributions to
surgery about twenty years later were no less the
consequence of the introduction of anaesthesia than
of the development of bacteriology.

Within those twenty years the study of anaes-
thetics continued to advance. Ethyl chloride, the
anaesthetic effects of which on animals had been re-
ported by Flourens in 1847, was tried in surgery in
1848. Improved methods of administration arose
from the work of John Snow who invented an in-
haler in 1847 and published the results of his vari-
ous experiments in 1858. His successor, J. T. Clover,
invented his chloroform inhaler in 1862. This was
followed by the Junker inhaler in 1867. Nunneley
investigated in 1849, and the years following, the
anesthetic properties of carbon dioxide, ethyl bro-
mide, and other compounds. In 1853 Alexander
Wood invented the hypodermic syringe and thus
prepared the way for the triumphs of local anaes-
thesia; while in 1866 Sir Benjamin Richardson

ANAESTHETICS 295

added to his numerous oontributions^to anaesthesia
the use of the ether spray. In 1864 a committee of
the Royal Medical and Chirui^cal Society recom-
mended the mixture of alcohol, chloroform, and
ether first used by Harley. In the years following
1863 the use of nitrous oxide, which had been al-
lowed to lapse after the death of Horace Wells in
1848, was greatly stimulated through the advocacy
of Colton both in America and Europe; and in
1868 Edmund Andrews proved that the anaesthetic
effects of nitrous oxide do not depend on partial
asphyxiation. He thus cleared up a misconception
of long standing. His mixture of oxygen and
nitrous oxide gave very satisfactory results.

REFERENCES

Bigelow, Henry J.: Surgical Anasthesia. Addresses and Other
Papers. 1900.

Gofdon, Laing: Sir James Simpson (Masters of Medidne).
1898. 233 pp.

Gwathmey, J. T. (b collaboratioa with CSiarks Baskerville):
Anesthesia. 1914. 943 pp.

Kelly, H. A.: ''Hypnotism/' Maryland Medical Journal, vol.
Lm, 1910, pp. 81-97.

Paget, Sir James: "Escape from Fda; the History oC a Dis-
covery," The Nineteenth Century, vol. 6, 1879, pp. 11 19-32.

Rice, Nathan P.: Trials of a Public Benefactor. 1859. 460 pp.

Young, Hugh H.: Long, the Discoverer of Anesthesia, Johns
Hopkins Hospital Bulletin, vol. vxn, 1897, pp. i74-^«

CHAPTER XV

THE THEORY OF ORGANIC EVOLUTION

When Charles Darwin, in October, 1836, returned
to England from his voyage round the world, which
had occupied nearly five years, he had arrived at no
theory concerning the origin of species. In 1837,
however, he made the following note: "In July
opened first note-book on Transmutation of Species.
Had been greatly struck from about the month of
previous March on character of South American
fossils, and species on Galapagos Archipelago.
These facts (especially latter) origin of all my
views/' In the months intervening between Octo-
ber, 1836, and July, 1837, he had been thrown into
dose contact with the great geologist Sir Charles
Lyell, the champion of the uniformitarian doctrine.
This doctrine, that the changes that have taken
place in the earth's crust in the past were owing to
agencies still in operation, had been splendidly
stated by the Scotch geologist James Hutton in
1785. Hutton's views, howev^, had been ignored
by some scientists, and decried by others because of
their alleged anti-religious tendency. The hostility
to Hutton's teaching in 1822 was thus expressed by
one of the leading English geologists, who was will-

THEORY OF ORGANIC EVOLUTION ^^

ing to concede some recognition to the facts gath-
ered by the Scotch geologist in reference to granite
and other rocks: ''The wildness of his theoretical
views, however, went far to counterbalance the util-
ity of the additional facts which he collected from
observation. He who could perceive in geology noth-
ing but the ordinary operation of actual causes, car-
ried on in the same manner through infinite ages,
without the trace of a beginning or the prospect of
an end, must have surveyed them through the me-
dium of a preconceived hypothesis alone." Professor
Sedgwick, under whom Darwin had studied geology
at Cambridge, in a similar vein eloquentiy de-
nounced the unscriptural tenets of Hutton and
Hutton's disciples. Both Sedgwick and Henslow,
the botanist, Darwin's chief masters at Cambridge,
were dei^men, and Darwin, till the time of his
appointment as naturalist to the Beagle expedition,
planned to take orders ultimately in the Established
Church of England.

Sir Charles Lyell (i 797-1 875) had been an early
convert to the uniformitarian view, but fully con-
scious of the strength of the opposition, and natur-
ally kindly and sympathetic as regards the opinions
of his intellectual inferiors, his public utterances
were of the most tactful sort. A careful study of
Gibbon had convinced him that the frontal attack
is not the most effective method of combating re-

298 THE HISTORY OF MEDICINE

*

ligious prejudice, and had helped him to develop
further a pleasing style of composition, which an
early acquaintance with the classics and the con-
stant example of a father oi scholarly tastes had
already made second nature. At the age of twenty
he observed on the coast of East Anglia the action
of the sea in the f ornaation of new land as well as in
the wearing down of the cliffs; and in the following
years he found abundant evidence in his native
Forfarshire, in the action of rain and rivers and the
formaticHi of limestone, that all observable changes
in the earth's crust were not owing to the Noachian
deluge.

By 1825 Lydl was a convinced uniformitarian,
and was considering how he could express his con-
victions without rousing unnecessary opposition
and without giving offence to his older contempo-
raries. In 1827 he had completed the first sketch of
his Principles of Geology, and two years later, in
preparing the book for the press, he made a pre-
liminary statement, in a letter to a friend, of his
doctrine ''that no causes whatever have from the
earliest time to which we can look back to the pres-
ent, ever acted, but those that are now acting, and
that they never acted with different degrees of
energy from that which they now exert" The first
volume appeared in 1830 with the subtitle ''An
Attempt to Explain the Former Changes of the

r -

THEORY OF ORGANIC EVOLUTION ±99

Earth's Surface by Reference to Causes now in
Operation/* Lyell was not oblivious to the logical
outcome of applying the uniformitarian doctrine to
the study of the organic world, and when Sedgwick
and others charged him with holding that the crea-
tion of new species is going on at the present day he
readily admitted it. He thought it impossible that
any one should read his work without perceiving
that the notion of uniformity in the existing causes
of change implies that ^'they must for ever prcxluce
an endless variety of effects, both in the animate and
inanimate world.*'

When Darwin was leaving England in 1831 the
extremely orthodox Henslow advised him to take
Lyell's first volume with him, but to pay no atten-
tion to it, except in regard to facts, for it was alto-
gether wild as far as theory goes. Needless to say it
made a very deep impression on the mind of the
young naturalist. Lyell's second volume appeared
in 1832, and a copy of it was sent to Darwin at
Montevideo. This second volume was full of facts
concerning variations, hybridism, and the struggle
for existence; and it no doubt had a great effect on
Darwin's subsequent observations and on his
maturer generalizations. In fact, in dedicating the
second edition of ''A Naturalist's Voyage" to Lyell
the author with characteristic generosity writes:
''This edition is dedicated with grateful pleasure as

300 THE HISTORY OF MEDICINE

an acknowledgment that the chief part of what-
ever scientific merit this journal and the other works
of the author may possess, has been derived from
studying the well-known and admirable ' Principles
of Geology.* "

Darwin was very slow and systematic in arriving
at hb generalizations. Soon after he b^gan to col-
lect data relating to the transmutation of species,
he turned particular attention to the different spe-
cies and varieties of plants and animals under do-
mestication, and to the success of the horticulturist
and the breeder attained by a careful selection of
certain strains for purposes of propagation. Ad-
mitting that species might arise in nature by the
perpetuation of chance variations he was at a loss
to discover any causative influence corresponding
to what he saw at work in the improvement of
domestic plants and animals. In the autumn of
1838 he read Malthus's ''Essay on Population/'
which developed the teaching that it is a constant
tendency among all living things to increase more
rapidly than the means of subsistence; the resultant
disproportion between the two rates of increase was
the occasion of wars, vice, and misery. The idea
flashed into Darwin's mind of a natural selection^
comparable in its effects to the artificial selection he
had noted in his study of the improvement of culti-
vated plants and domesticated animab. Natural

THEORY OF ORGANIC EVOLUTION 301

selection might occur in such hard conditions as
would cause organisms to compete with one another
for their very existence. It occurred to Darwin that
under these circumstances '^favorable variations
would tend to be preserved, and unfavorable ones
to be destroyed. The result of this would be the
formation of new species. Here, then, I had a theory
by which to work."

He deliberately refrained from making a written
statement of his own views till 1842, when he wrote
out a sketch, which he expanded two years later to
a manuscript of 231 folio pages. He explained his
theory in a letter to the American botanist Asa
Gray in 1857. He stated that his belief that spe-
cies have really changed depended "on general facts
in the affinities, embryology, rudimentary organs,
geological history, and geographical distribution of
organic beings." He maintained that if such a
selective agency as has developed our breeds of
domestic animals, had, during the long ages revealed
by the study of geology, exerted an influence on the
organic world in general, it would have produced
the miracles of design and adjustment in plants and
animals that had hitherto baffled his powers of ex-
planation. Such an agency he now finds in natural
selection. He mentions also the slowness of the
changes in species, the struggle for life, and the
spontaneous occurrence of favorable variations.

302 THE HISTORY OF MEDICINE

Darwin had begun, in this year, at the urgent re-
quest of Lyell, who feared the new theory might be
forestalled by some other naturalist, the composition
of a treatise. When he had written about a half of
it, he received a manuscript from Alfred Russet
Wallace setting forth a theory almost identical with
his own.

Wallace's experience had corresponded in differ-
ent respects with Darwin's. He had spent many
years in scientific exploration in South America and
in the Malay Archipelago; he had come under the
influence of Lyell ; he had long considered the prob-
lem of the origin of species; and he had finally been
led to a solution by Malthus's ''E^ssay on Popula-
tion." He had learned from the "Principles of
Geology" that the inorganic world was and always
had been in a continual state of slow modification.
Consequently forms of life must have become modi-
fied and constantly adjusted to the new conditions in
order to survive. The slowness of the changes re-
vealed by the examination of fossils was such as to
afford opportunity for the continuous automatic
adjustment of organic beings to the inorganic en-
vironment. In 1855 he arrived at the conclusion
that each species has come into existence in the same
environment as a closely allied species and in suc-
cession to it. This indicated the fact of evolution,
but failed to explain the process, "In February^

THEORY OF ORGANIC EVOLUTION 303

1858,'* he writes, "I was suffering with a rather
severe attack of intermittent fever at Temate, in
the Moluccas; and one day, while lying on my bed
during the cold fit, wrapped in blankets, though the
thermometer was at 88 Fahr., the problem again
presented itself to me, and led me to think of the
' positive checks' described by Malthus in his ' Essay
on Population,* a work I had read several years
before, and which had made a deep and permanent
impression on my mind. These checks — war, dis-
ease, famine, and the like — must, it occurred to
me, act on animals as well as man. Then I thought
of the enormously rapid multiplication of animals,
causing these checks to be much more effective in
them than in the case of man ; and while pondering
vaguely on this fact, there suddenly flashed upon
me the idea of the survival of the fittest — that the
individuals removed by these checks must be on the
whole inferior to those that survived. In the two
hours that elapsed before my ague fit was over, I
had thought out almost the whole of the theory;
and the same evening I sketched the draught of my
paper, and in the two succeeding evenings wrote it
out in full, and sent it by the next post to Mn
Darwin/' .
^ In the "Origin of Species" (1859), which the
majority of scientists regard as exerting a greater
influence on the development of ideas than any

304 THE HISTORY OF MEDICINE

other book produced in the nineteenth century,
Darwin turns his attention first to the occurrence of
variation under domestication. He is not, as has
been supposed by some of his critics, unaware of the
occasional occurrence of sudden deviations from the
parental tjrpe, such as in the well-known case of
ancon sheep, to which he makes reference. He also
speaks of sporting plants, and recognizes that a
seedling may exhibit remarkable deviation from
type. But his main concern here is with those slight
variations of which the horticulturist takes ad*
vantage in the improvement of cultivated plants,
and whidi afford the material that enables the
breeder of horses, or cattle, or dogs to produce such
distinct types of domestic animals. He was re-
luctantly inclined to believe that all the different
breeds of horses were derived from one wild stock.
Domestic dogs on the other hand he thought had
probably descended from several wild species,
though one could not think that a parent type at all
resembling the Italian greyhound, the Blenheim
spaniel, the bull-dog, the bloodhound, etc., had
ever existed freely in a state of nature. Many of the
remarkable breeds and varieties are of course under-
going constant modification through a purposeful
process of artificial selection.

Darwin made a particularly dose study of the
breeds and sub-breeds of pigeons, keeping every

THEORY OF ORGANIC EVOLUTION 305

breed he could purchase or otherwise obtain, secur-
ing specimens of skins from India and Persia, con-
sulting eminent pigeon-fanders, and noting the
references to domestic pigeons in the ancient litera-
tures. He was convinced that the English carrier,
the tumbler, the runt, the barb, the pouter, the
turbit, the Jacobin, the trumpeter, the laugher, the
fantail, etc., all draw their descent from the rock-
pigeon (Columba livia). When two birds belonging
to two distinct domestic breeds are crossed the
mongrel offspring are liable to show the character-
istic color and markings of the ancestral rock-pigeon.
"I crossed," writes Darwin, "some uniformly white
fantails with some uniformly black barbs, and they
produced mottled brown and black birds; these I
again crossed together, and one grandchild of the
pure white fantail and pure black barb was of as
beautiful a blue colour, with the white rump, double
black wing-bar, and barred and white-edged tail-
feathers, as any wild rock-pigeon 1 " In spite of their
common ancestry the breeds are so different among
themselves that an ornithologist seeing them for the
first time would describe them as belonging to
well-defined species, the differentiation depending
not only on their general appearance, but on the
character of their voice and disposition, on the
shape and size of their eggs^ and on their anatomical
structure, for example, the shape of the skull, the

306 THE HISTORY OF MEDICINE

number of the ribe, and the number of the caudal
and sacral vertebrae. How have these differences
been established? By accumulative artificial selec-
tion, the pigeon-fander retaining for breeding pur-
poses the birds that showed certain desirable char-
acteristics. ''Some variations useful to him have
probably arisen suddenly, or by one step/' But in
general the variations put at the disposal of man's
choice have been limited in range, and the develop-
ment of new breeds has, consequently, been a slow
process. Of this fundamental part of his theory, so
directly an outcome of the personal observations of
an Englishman oi Darwin's class and associations,
he gave a fuller treatment in a later work — "The
Variation of Animals and Plants under Domestica-
tion" (1868).

''Why if man can by patience select variations
most useful to himself, should nature fail in selecting
variations useful, under changing conditions of life,
to her living products?" Even in the same species
no two individuals are cast in precisely the same
mould. This holds true of plants and animals in a
state of nature as in those under domestication.
Owing to the struggle for life, the fierceness of which
had in Darwin's judgment not been fully appre-
ciated by Lyell and others who had treated of it, any
variation, however slight, in any degree profitable
to the individual, "will tend to the preservation of

THEORY OF ORGANIC EVOLUTION 307

that individual, and will generally be inherited by
his offspring. The offspring, also, will thus have a
better chance of surviving, for, of the many indi-
viduals of any species which are periodically bom,
but a small number can survive. I have called this
principle, by which each slight variation, if useful,
is preserved, by the term of Natural Selection, in
order to mark its relation to man's power of selec-
tion." This process of natural selection Darwin
considered the main but not the exclusive means of
modification.

What are the proofs that the one million and more
living species now found on the earth owe their
origin to development from other species, that is, to
Evolution, rather than to acts of Special Creation?
Darwin helps us to answer this question by indi-
cating that in spite of the incompleteness of the
geological record it is evident that all extinct or-
ganic beings fall into the same system with living
beings, and that a continuity may be observed to
exist between classes of extinct and classes of living
plants and animals, as, for example, between the
fossil and the recent marsupials of Australia, and
between the fossil and the recent edentata of Amer-
ica. The facts of geographical distribution prove
that, besides this succession or continuity in time,
there is between like groups of living beings a degree
of contiguity in space. Just so far as they are not

308 THE HISTORY OF MEDICINE

liable to the invasion of plants and animals conti-
nents have their own characteristic faunas and
floras. The species of oceanic islands are related to
the species of that mainland from which they are
most accessible to the inmiigration of plants and
animals. In addition to the lines of proof suggested
by the facts of geological succession and geographical
distribution Darwin points out the interrelationship
of all organic beings. This is the argument from
classification.

On this subject he writes as follows: ''It is a truly
wonderful fact — the wonder of which we are apt
to overlook from familiarity — that all animals and
all plants throughout all time and space should be
related to each other in group subordinate to group,
in the manner which we everywhere behold —
namely, varieties of the same species most doaely
related together, species of the same genus less
closely and unequally related together, forming
sections and sub-genera, species of distinct genera
much less closely related, and genera related in dif-
ferent degrees, forming sub-families, families, or-
ders, sub-classes, and classes. . • . On the view that
each species has been independently created, I can
see no explanation of this great fact; but, to the best
of my judgment, it is explained through inheritance
and the complex action of natural selection, entail-
ing extinction and divergence of character." More-

THEORY OF ORGANIC EVOLUTION 309

over, the doctrine of common inheritance enables
us to explain the likenesses among organisms re-
vealed by the study of rudimentary organs, embry-
ology, and morphology in general.

It is with the consideration of these likenesses
that Darwin begins his volume on ''The Descent of
Man" (1871), which undertakes to make good the
prediction contained in the ''Origin oi Species" that
through the principles laid down in that work light
would be thrown on the origin of man and his his-
tory. The general anatomical structure of man is
analogous to that of other mammals. The human
skeleton may be compared bone for bone with the
skeleton of the monkey, bat, or seal. The "Origin
of Species" had mentioned the structural resem-
blance o( the hand o( man, the wing of the bat, the
fin of the porpoise, and the leg ot the horse, as well
as the likeness in the number of cervical vertebrae of
creatures so different as the elephant and the giraffe.
A similar correspondence is found in the muscles,
blood-vessels, viscera, and nerves of man and the
lower mammalia. The diief fissures and convolu-
tions of the human brain are comparable to those in
the brain of the orang-outang. Moreover, the fact
that man is liable to certain communicable and in-
communicable diseases that affect the lower animals
seemed to Darwin to indicate a dose similarity of
tissues and blood.

310 THE HISTORY OF MEDICINE

Embryonic development begins in man as in the
lower animals with the ovum. In the human em-
bryo the arteries run in arch-like branches as in
animals with functioning gills; the heart exists as a
simple pulsating vessel; the os coccyx projects like a
true tail. " In the embryos of all air-breathing verte-
brates» certain glands, called the corpora Wolffiana,
correspond with and act like the kidneys of mature
fishes/' The convolutions in the brain of the human
foetus at the end of the seventh month correspond
in their development to those of the adult baboon.
In the embryo the great toe is shorter than the other
toes, and projects at an angle from the side of the
foot, as in the adult simian. In 1859 Darwin had
explained the similarity of the embryonic forms of
mammals, birds, and reptiles on the principle oi
common ancestry.

The study of rudimentary organs, vestigial struc-
tures, arrested developments, and reversions, fur-
nished Darwin with further evidence of man's hum-
ble origin. In this connection he mentions the vermi-
form appendix, the os coccyx and filum terminale^
traces of a supra-condyloid and an inter-oxidyloid
foramen, the mammse of males (sometimes fully
developed and functioning), supernumerary mam-
mae, the nictitating membrane, cleft-palate, and the
imperfectly developed wisdom-teeth. As regards
the canine teeth he cites HaeckeFs observation that

THEORY OF ORGANIC EVOLUTION 311

in every large collection of human skulls some may
be found with the canine teeth projecting consider-
ably beyond the others as in the anthropomorphous
apes» but in a less degree. ''He," writes Darwin,
"who rejects with scorn the belief that the shape of
his own canines, and their occasional great develop-
ment in other men, are due to our early forefathers
having been provided with these formidable weap-
ons, will probably reveal by sneering, the line of his
descent. For though he no longer intends, nor has
the power, to use these teeth as weapons, he will
unconsciously retract his 'snarling muscles' (thus
named by Sir C. Bell), so as to expose them ready
for action, like a dog prepared to fight.'' (At the
time Darwin wrote this passage — rather excep-
tional in its tone — he was planning to publish his
work "The Expression of the Emotions in Man and
Animals," a subject sugs;ested to him by Bell's
work "Anatomy of Expression/')

The panniadus camosust and the structures as-
sociated in the same system with it, especially the
f unctionless muscles of the ear, are not overlooked
by Darwin. The frequency of deviations from the
so-called "normal" musculature is a commonplace
observation in every dissecting room. One anatomist
has recorded two hundred and ninety-five muscular
variations in thirty-six subjects. Many muscles
found occasionally in the human subject correspond

312 THE HISTORY OF MEDICINE

to musdes usually found in monke3rs and other
mammals. Darwin's tubercle, malformations of the
external ear, the arrested brain-development of
idiots, the persistence and distribution of hair, sup-
port the evidence afiForded by the muscles, teeth, etc.
Moreover, monstrosities are " so similar in man and
the lower animals, that the same classification and
the same terms can be used for both, as has been
shown by Isidore Geoffroy St. Hilaire."

A great deal of space in "The Descent of Man'' is
given to the development of the intellectual and
moral processes in man and the lower animals, and,
as we have seen in a previous chapter, to a consider-
ation of secondary sexual characters. Darwin thus
affords a biological basis for the psychology of the
cognitions, volitions, and emotions. Into the choice
of a mate, influenced by voice, brilliant plumage,
and other secondary sexual characters, a conscious
— aesthetic — element enters. Since sexual selec-
tion involves consciousness, it may be viewed in re-
lation to artificial selection; in fact, sexual selection
as between man and woman is a matter of artificial
selection. Therefore it is not surprising that Darwin
should reach the following conclusion: "Man scans
with scrupulous care the character and pedigree of
his horses, cattle, and dogs before he matches them;
but when he comes to his own marriage he rarely or
never takes any such care. He is impelled by nearly

THEORY OF ORGANIC EVOLUTION 313

the same motives as the lower animals, when they
are left to their own free choice, though he is in so
far superior to them that he highly values mental
charms and virtues. On the other hand he is strongly
attracted by mere wealth or rank. Yet he might by
selection do something not only for the bodily con-
stitution and frame of his offspring, but for their
intellectual and moral qualities. Both sexes ought
to refrain from marriage if they are in any marked
degree inferior in body or mind; but such hopes are
Utopian and will never be even partially realized
until the laws of inheritance are thoroughly known.'*
Darwin's doctrine of pang^iesis (1868), which he
put forward as a tentative hypothesis which could
be given up as soon as any better might be found,
has been described by Weismann (1834-1914), the
spokesman of the Neo-Darwinians, as the first
theory of heredity worthy of the name. Weis-
mann's own theory of the continuity of the germ-
plasm (1885) was anticipated to some extent by
Francis Galton in the year following the appearance
of "The Descent of Man." Haeckel, another early
German disciple of Darwin, speaks of the English
naturalist's influence in every branch of biology,
especially in comparative anatomy and ontogeny,
and in zoSlogical and botanical classification. It
was indeed revolutionary. "Darwin's extraordi-
nary marshalling of facts," says GarrisoUi, "in evi-

314 THE HISTORY OF MEDICINE

dence of the survival of the fittest by natural selec-
tion in the struggle for existence^ had the same far-
reaching influence upon biological speculation that
the discoveries of Copernicus had upon astronomy.
• . • It created the sciences of comparative physiol-
ogy and pathology, by pointing to the dose struc-
tural and functional relaticmship between human
tissues and those of animals and {Jants.*'

It is important that the student oi medidne
should recognize that many problems concerning
the relation of inheritance to pathology still await
solution. How shall we explain the facts of heredi-
tary immunity, such as Darwin noted in negroes as
regards malaria and yellow fever, or such as have
been observed in individuals in epidemics of cholera
and other deadly diseases? How shall we account
for the transmission of familial diseases like Fried-
reich's ataxia, or of such hereditary defects as hae-
mophilia, color-blindness, deaf-mutism, and poly-
dactylism? Has pathology solved the problems of
hereditary predispositions and diatheses? What
vestigial structures are pathogenic? What diseases
or malformations have resulted from the assump-
tion of the erect posture?

REFERENCES

Bland-Sutton, Sir John: EvoluHon and Disease, 1890.
Darwin, Charles: (i) The Origin of Species. 1859.

(2) The Descent of Man, 1871.
Osbom, H. P.: From the Greeks to Darwin. 1894.

THEORY OF ORGANIC EVOLUTION 315

Poulton, E. B.: Charles Ikumn, and the JTieary iif Natmal Sel^

tian. 1896.
Soott, W. B.: The neary €ff EpokUum. 1919.
Wdamann, August: The EnointHon Theory (tmnslated {rocn the

second German edition, 1904, by J. A. and Margaret R.

Thomson). 2 vob. 1904.
See also leferenoes on page aia of the author's IfUrodnutitM to
Ae History oi Scieme.

CHAPTER XVI

THE FOUNDERS OF BACTERIOLOGY

In 1820 Ozanam, a French historian of epidemic and
infectious diseases, wrote that many writers had
dealt with the animal nature of infectious materials.
Several had maintained not only that these develop
from animal substance but that they are themselves
organic and living beings. Varro, Columella, Lucre-
tius, Father Kircher, Landsi, Vall'sneri, Reaumur,
Christ, Long, Plendz, Menuret, Rasori, and others
had supported this view. Fremont had maintained
that infectious materials arise and develop in the
body through fermentation. ''I will not waste
time/' adds Ozanamt ''in refuting these absurd
hypotheses.''

Leeuwenhoek, by means of an excellent lens,
ground and mounted by himself, had observed
bacteria as early as 1683. In 1701 Nicolas Andry
expressed the conviction that air, water, vinegar,
fermenting wine, beer, cider, and sour milk are full
of germs; that germs exist also in blood, urine, and
the pustules of smallpox patients; and that mercury
cures venereal disease because it kills the invisible
pathogenic organisms. By the year 1726 the doc*
trine of the causal relationship between micro*

FOUNDERS OF BACTERIOLOGY 317

organisms and disease was so notorious as to be
made the subject of a French satire (''Sjrst&me d*un
m£dedn anglais sur la cause de toutes les esp^s de
maladies 'Of in which the fainter* the belly-nipper,
etc, were playfully described.

More serious attempts at classification appeared
before the dose of the eighteenth century. Linnaeus,
in the last edition of his ''Systema Naturae'' (1768),
classed bacteria along with other microscopic forms
in the cat^;ory " chaos/' In spite of his distrust oi
the observaticHis of the microscopbts, however, he
recognized that organic beings might be the cause
ci fevers, venereal lues, and exanthemata. In fact,
in an earlier work he had expressed the belief that
parasites cause measles, dysentery, plague, small-
pox, etc In 1786 was published the '^Animalcula
infusoria fluviatilia et marina" of Otto Friedrich
M jiller, of Copenhagen, who under the general name
of "infusoria" sought to classify, according to form,
movement, and habitat, the microscopic beings so
inadequately treated by Linnaeus. MuUer made
use of the terms "monas," "bacillus," "vibrio"
"spirillum"; though he laid the chief emphasis on
differences of form, he noted the serpentine and
other movements characteristic of some kinds, and
the inclination of others to form filaments, pellicles,
and clusters, and, above all, he furnished well-exe-
cuted illustrations of the organisms he had observed^

330 THE HISTORY OF MEDICINE

ments — that an insufficient quantity of air had
been allowed for the support of life in the infusoria,
and that the conditions of the experiments had
robbed the air of its life*8upporting quality. In 1836
Franz Schulze tried to meet these criticisms by
filtering the air in a flask (containing an infusion)
through concentrated sulphuric add. He renewed
the air in this way for over two months. The in-
fusion remained free from, micro-organisms. When
at the end of that time, however, unfiltered air was
admitted to the infusion, various living forms de-
vebped. In 1837 Schwann used molten metal or a
spirit flame for the same purpose as the concen-
trated sulphuric add served in Schulze's experi-
ment. Both Schulze and Schwann were open to the
criticism of having subjected the air to vitiating
influences. In 1854, however, Schroder and von
Dusch showed that a thick layer of cotton wadding
sufficed to exdude all germs, while permitting free
access of air. In 186 1 Pasteur found an even simpler
means of exduding germs while freely admitting
air. The infusion was placed in a flask the neck of
which terminated in a long stem, curved down and
then up somewhat like the letter ''S." This stem
was left open, and the outside air allowed to enter.
After the infusion in the flask had been boiled, the
germs from the outside air would at first be killed
by the steam, while, later, as the apparatus cooled,

FOUNDERS OF BACTERIOLOGY 321

such germs as found their way into the end of the
open stem would be arrested in its curves*

It was urged by Pasteur's opponents that if altera-
tions occurring in infusions, after they had been
duly boiled, were brought about solely through the
agency of germs in the air, then these germs must
everywhere be present in great abundance and
variety. Pasteur replied that they were much more
abundant in some localities than in others, and he
proceeded to secure experimental proof of his con-
tention. He filled a large number of flasks with in-
fusion, heated them to the boiling point, and then
hermetically sealed them. He opened twenty of
these flasks, sealing them again immediately, at the
foot of the Jural Alps; twenty others at an altitude
of eight hundred and fifty meters above sea-level;
and an additional twenty at an altitude of two
thousand meters. On examining the contents of
these sixty flasks after some days, it was found that
eight out of the first twenty, five out of the second
twenty, and only one out of the third twenty showed
the presence of microscopic beings. Other objections
to his doctrine of biogenesis he proved to be based
on careless experimentation. "No,'\he said at the
end of his communication to the Acad6mie des
Sciences in 1864, "there is no circumstance known
to-day that permits us to assert that microscopic
beings have come into the world without germs,
without parents similar to themselves/'

322 THE HISTORY OF MEDICINE

Several years before the final overthrow of the
theory of spontaneous generation, Pasteur had
demonstrated the part played by germs in various
kinds of fermentation. We have seen in previous
chapters that an analogy had been traced by the
predecessors of Rhazes between fermentation and
at least one form of disease, and that a like compari-
son was familiar in the time of Sydenham. Robert
Boyle had declared that ** He that thoroughly under-
stands the nature of ferments and fermentations
shall probably be much better able than he that
ignores them to give a fair account of divers phe-
nomena of certain diseases (as well fevers as others)
which will perhaps be never properly understood
without an insight into the doctrine of fermenta-
tions." In 1836 Cagniard de la Tour, the French
physicist, observed that yeast plays a part in al-
coholic fermentation, that it seems to be a living
plant, and that its growth keeps pace with the pro-
cess of fermentation. About the same time Schwann
arrived independently at like conclusions.

Pasteur was interested in 1856 in fermentation in
connection with the manufactiu^ of beetroot alco-
hol, and examined the globules of the ferment by
means of the microscope. In the years following he
succeeded in showing that lactic (1857), tartaric
(1858), butyric (1861), and acetic (1862) fermenta-
tions depend likewise on the presence of definite

FOUNDERS OF BACTERIOLOGY 323

living organisms. For example, if PeniciUium glau-
cum grows in a racemate solution, the solution
gradually becomes laevo-tartaric. (Pasteur's mas-
terly analysis of racemic acid into dextro-tartaric
and laevo-tartaric laid the foundation-stone of
stereo-chemistry in 1848.) In his study of the differ-
ent kinds of fermentation Pasteur first determined
in which constituent of the fermentable substance
the characteristic change occurred. In the second
place he studied under the microscope such organ-
isms as invariably accompanied the fermentation in
question. He then made a solution of the ferment-
able constituent, added such ingredients as he con-
ceived necessary for the growth of the organism,
boiled the solution so as to render it free of germs,
and placed in the solution thus prepared a trace of
the essential ferment. In this way he put to the test
his hypotheses concerning the organic causes of
fermentation. The cause of butyric fermentation
he found to be a micro-organism that could live only
in the absence of oxygen, in fact, an anaSrobic vi-
brio. Pasteur followed up these studies of fermenta-
tion by investigating the ammoniacal decomposi-
tion of urine and the part played in so-called putre-
faction by micro-organisms.

He now turned his attention to the diseases of
wine. He soon found that wine becomes sour
through the activity of Mycoderma acetic the pres-

324 THE HISTORY OF MEDICINE

ence of which is betrayed by the appearance of a
pellicle on the surface of the liquor, that the bitter-
ness of wine is owing to an organism that shows
under the microscope branching and twisted fila-
ments, while the turning and ropiness of wine result
from the development of other micro-organisms.
At the time of these investigations Pasteur had
become fully conscious of his purpose to arrive, as he
expressed it to the Emperor in 1863, at the knowl-
edge of the causes of putrid and contagious diseases.
After treating what he called the spontaneous alter-
ations or diseases of wines, he undertook, at the
urgent request of Dumas (now a Senator and par-
ticularly influential in the Ministry of Agriculture),
to investigate the diseases of silkworms. In 1836
Bassi had made the remarkable discovery that one
communicable disease of silkworms, muscardine, is
caused by a fungus, the minute spores of which are
transferred from the diseased to the healthy worms
through the atmosphere or by actual contact. In
1857 Naegeli had described the micro-organism of
the disease, pibrine^ that Pasteur was now especially
called upon to investigate. After five years of ardu-
ous labor Pasteur succeeded in tracing out the his-
tory of this infection, devised means of eradicating
it, and discovered the cause of a second disease of silk-
worms, flacherie^ which he ascribed to an oi^anism
that developed in the intestinal canal of the wwm.

FOUNDERS OF BACTERIOLOGY 3^5

In 1871 he resumed his study of alcoholic bever-
ages, and undertook to discover the causes of the
diseases c^ beer. Why does it become thick, sour,
slimy, or putrid? He came to the conclusion that
every *^ marked alteration in the quality of beer coin-
cides with the development of miax>-oi:f;anisms
foreign to the nature of true beer yeast/' Beer is
unalterable so long as it contains no living germs;
disease ferments will not develop in bottled beer
after being heated to a temperature of from 50^ to
55* C. When, says Pasteur, we see beer and wine
undergo marked alterations because they harbor
micro-organisms, which gain an entrance unnoticed
and then increase enormously in numbers, we must
be convinced that similar experiences must befall
in the case of the lower animals and of man.

A number of important advances in bacteriology
prepared the way for Pasteur's study of anthrax in
1877. The BaciUtis anthracis was observed as a
little rod-like structure in the blood of animals that
had died of anthrax, or splenic fever, by Delafond
in 1838. In 1850 a like observation was made by
Davaine (as well as by Rayer), who came to recog-
nize the importance of the discovery only after read-
ing Pasteur's paper on butyric fermentation. In
1863 he inoculated some rabbits with the blood of a
sheep that had died of anthrax, and upon the death
of the inoculated animab concluded that they also

326 . THE HISTORY OF MEDICINE

had succumbed to . anthrax. In that same year
Delafond studied the organisms under a watch
glass, saw the little rods grow into filaments, and
attempted to discover ''the mechanism of fructifi-
cation/' Even before the observations of Davaine
and Rayer, Pollender had observed the bacillus in
the blood o( cows that had died of anthrax (1849).
Important as are these observations of this patho-
genic micro-organism, the cause of widespread in-
fection, they are less deserving of emphasis in the
history of bacteriology than the achievements of
Ferdinand Cohn (1828-^8) and of Robert Koch.

Cohn's discovery, in 1857, of the sporulation of
microscopic organisms led to the clearing up of a
number of difficulties, such as the persistence of
living forms in infusions of hay, milk, and cheese,
which had baffled experimenters from the time of
Spallanzani. G>hn's researches concerning bacteria
furnished a system of classification, which, retaining
what was of value in earlier systems — such as the
Hallier's concept of the micrococcus and Ehren-
bei^g's concept of the spirillum and the spirochaeta
— still dominates to-day the grouping and the no-
menclature of schizomycetes. G>hn recognized that
all bacteria are plants. He classified the micrococci
as chromogenic, zymogenic, and pathogenic. Among
the bacilli he mentioned of course the bacillus
anthrads. He showed, moreover, by striking calcu-

FOUNDERS OF BACTERIOLOGY 327

lations the marvelously rapid increase of bacteria
under conditions favorable to their development,
and thus drew attention to the part they play in the
struggle for existence. In 1876 he observed the
germination of the spores of certain bacteria. In
April the same year Koch announced to Cohn the
results of his study of the anthrax bacillus. To this
brilliant investigation and to Koch's other achieve-
ments we shall return presently.

At the beginning of 1877 the French physiologist
Paul Bert maintained that by the use of compressed
oxygen he could destroy the bacillus anthracis in
the blood of animals that had died of anthrax, and,
then, by inoculating the blood so treated, cause
death in the inoculated animals without the appear-
ance of fresh bacilli. Therefore, he argued, the
bacillus anthracis is neither the cause nor the neces-
sary effect of anthrax. Pasteur, assisted by Joubert,
tackled the subject. He found it possible to obtain
a pure culture of the organism in urine rendered
neutral or slightly alkaline. The inoculation of a
trace of this culture produced a typical case of
anthrax. How then account for the results of Bert's
experimentation? In the first place Pasteur stated
that the spores of bacillus anthracis could resist for
three weeks the action of pure oxygen under a pres-
sure of ten atmospheres. In the' second place the
death of animals, following the inoculation of the

328 THE HISTORY OF MEDICINE

blood of anthrax victims^ without the appearance of
bacilli was really owing to septicaemia, which in
turn owed its development to pathogenic micro-
organisms. He was able to point out in the Uood of
animals that had died of anthrax, in addition to
bacillus anthrads, the vibrion septigue (bacillus of
malignant oedema), which he had himself discovered.
Nevertheless, he did not believe that septicaemia is
a specific infection, and he later discovered Staphy-
lococcus pyogenes and Streptococcus pyogenes.
Pasteur also discovered the pneumococcus.

Until Pasteur^s study of chicken cholera in 1880,
Edward Jenner's great success in the production of
artificial immunity remained an isolated phenome-
non. Some years before this the micro-organism of
chicken ch(^era had been described. Toussaint es-
tablished the causal relationship between the or-
ganism and llie disease. Pasteur found that the best
culture medium was a broth of chicken gristle
neutralized with potash, and that the smallest dxx>p
of a recent culture would kill a chicken. When, how-
ever, hens were given an old culture, which had been
put away and forgotten for a few weeks, though
they were affected by the disease they did not suc-
cumb to it. If these hens were then exposed to the
unattenuated virus, they were either unaffected, or
they experienced the disease in a mild form. "Was
not this fact," writes Vallery-Radot, "worthy of

FOUNDERS OF BACTERIOLOGY 329

being placed by the side of the great fact of vaccina-
tion, over which Pasteur had so long thought and
pondered?" Was it possible to develop an animal's
resistance to other infectious diseases? By the be-
ginning of 1 88 1 Pasteur was able to announce the
essentials of his preventive treatment for anthrax.
He had found that bacillus anthracis could be culti-
vated in neutralized chicken broth at 42** to 43® C.
without developing spores, and that by being kept
for ten or twelve days the culture became so at-
tenuated as to give rise merely to a benignant form
of the disease. Moreover, the weakened culture can
be cultivated at 30** to 35° C. and yet yield spores
of the same degree of virulence as the bacilli that
formed them. The bacilli may recover their original
virulence by being passed through a series of guinea-
pigs, the second being inoculated with the blood
of the first, and so forth. (Similarly, the micro-
organism of chicken cholera, after it has become
weakened through contact with oxygen, may be
strengthened by being passed through a series of
sparrows or canaries.)

It was the methods and principles established by
these studies that led to Pasteur's successful treat-
ment of hydxx>phobia in 1885, and to the subsequent
founding of the Pasteur Institute. "Here," says
Garrison, "Pasteur labored almost to the end of his
life, with such brilliant pupils as Metchnikoff , Roux,
Yersin, Calmette, Chamberland, and Pottevin."

330 THE HISTORY OF MEDICINE

Robert Koch (1843-1910) bom in the Kingdom
of Hanover, was a pupil at Gottingen of the dis-
tinguished histologist Henle, who in 1840 Iiad re-
vived the doctrine of a cotUagiunt anitnatum. Koch
took his degree in 1866, the year in which Hanover
was conquered and annexed by Prussia. In the
Franco-Prussian War he served as a volunteer army
surgeon. After the war was over, he was appointed
district physician of a small place (WoUstein) in
Posen. There he devoted himself to the study of
infectious diseases.

In 1876 Koch began to publish the results of his
investigations concerning the etiology of anthrax
("Die Aetiologie der Milzbrand-Krankheit, be-
grOndet auf die Entwickelungsgeschichte des Bacil-
lus anthracis"). He showed in the first place that
mice develop anthrax when inoculated with blood
containing the bacilli; that by successive inocula-
tions the disease may be passed from one to another
of a long series of mice. At the same time he noted
the rapid growth of the organisms in the blood,
lymph, etc., and the presence of countless numbers
of them in the spleens, of the inoculated animals.
He then proved that in a suitable culture medium,
such as fresh ox blood serum or the aqueous humor
of an ox's eye, at a temperature of from 18° to 40® C.
and with free access of air the anthrax bacilli grow
to great length and develop numerous spores. He

FOUNDERS OF BACTERIOLOGY 331

had been able to observe this process, by means of
the microscope, in a drop of aqueous humor to which
a small portion of fresh spleen containing bacilli was
added. In a fresh drop of aqueous humor he also
saw these spores develop into typical anthrax
bacilli. This beautiful piece of work, which of itself
entitles Robert Koch to a place beside Pasteur as
one of the great founders of bacteriology, placed in
his hands an absolutely pure culture of a patho-
genic micro-oi'ganism, and gave him the means of
proving that the bacillus anthrads is the sole cause
of splenic fever. The spores on account of their
resistance to the action of prolonged moisture or
dryness play of course an important part in the dis-
semination of the disease.

In 1878 Koch published his investigations con-
cerning the etiology of wound infections. He be-
lieved that the "parasitic" nature of these diseases
is probable, "but that an adequate proof therefor
had not been given and that such proof would not
be forthcoming till we succeed in discovering the
parasitic micro-organisms in all cases of the disease
under investigation, till we succeed in showing them,
moreover, in such numbers and distribution as to
explain all the morbid phenomena, and, finally till
we succeed in establishing for every kind of wound
infection a definite, morphologically distinct, micro-
organism as the parasite/' He sought to discover

332 THE HISTORY OF MEDICINE

the characteristic organisms in septicaemia, pysenua^
erysipelas, etc., by experiments on animals, inject-
ing into mice and rabbits such substances as putres-
cent meat infusion or blood. He was able to study
the effects of injecting, into mice, blood impreg-
nated with chain-forming micrococci, and to pro-
duce in rabbits a disease markedly resembling ery-
sipelas in man. The main result of this investigation
seems to have been to strengthen Koch's conviction
of the indubitable differences of pathogenic micro-
organisms and of their inalterable constancy of
behavior.

Koch always laid great stress on the value for the
progress of medicine of improved technique and new
methods of investigation. In 1877 he had advo-
cated the use of photography as practiced by him-
self in the identification of microscopic organisms.
He adopted Weigert's method of staining with ani-
line dyes, especially methyl violet and fuchsin, and
he sought means to overcome the constant move-
ment of the micro-organisms recognized by him as
one of the chief obstacles of the investigator. In
1881, a year after he was called to the Imperial
Health Bureau in Berlin, he devised his method of
obtaining pure cultures with fixed, coagulable,
culture media. After he had developed his method,
discoveries fell into the lap of the investigator like
ripe fruit, as Koch himself said.

FOUNDERS OF BACTERIOLOGY 333

In 1882 he announced the discovery (^ the JSociZ^Kf
tuberculosis^ thus confirming the views of others in
relation to the specific and communicable character
of tuberculosis. In the course of his experiments
carried on in the hope of discovering a cure for
tuberculosis Koch found that tuberculous guinea-
pigs differ from healthy guinea-pigs in their manner
of reacting to inoculations of tubercle bacilli, alive
or dead. From this fact he inferred that there was
in the bacilli a soluble substance which would prove
a means of diagnosis and of control. His tuberculin
— a glycerine extract of pure culture of bacilli —
was announced at the International Medical Con-
gress held at Berlin in 1890. Later he produced a
new tuberculin, which has become recognized as of
great value in diagnosis. He held that the bacilli of
bovine tuberculosis do not cause tuberculosis in man.

In 1883 Koch went to Egypt and India as leader
of the German Cholera Commission: recognized in
amoebae the cause of tropical dysentery; discovered
in the comma bacillus the cause of Asiatic cholera;
and in another bacillus the cause of infectious con-
junctivitis. In 1885 he received appointment at the
University of Berlin as professor in the faculty of
medicine and director of the newly established
Hygienic Institute. In 1891 his great powers as an
organizer were called into play in connection with
the new Institute for Infectious Diseases. In the

334 THE HISTORY OF MEDICINE

following year cholera broke out in the dty of Ham-
burg, but the menace to the fatherland was averted
by the medical science of Koch, always alive to the
dangers of water-borne infections. He further served
Germany by fighting t)T>hus in the southwestern
part of the country, as well as by suggesting sani-
tary legislation, and organizing conferences. In

1896 at the request of the British govemmtat he
investigated Rinderpest in South Africa, and de-
veloped a method of preventive inoculation. In

1897 he studied bubonic plague at Bombay. He had

•

recognized in 1883 that blood-suddng insects are
transmitters of disease, and a considerable part of
the last fifteen years of his life was spent in the study
of tropical medicine. In 1906 he was again in Africa
as head of the Sleeping Sickness Conunission.

REFERENCES

Dudaux, Exnile: Histoire d^un Esprit, 1896. 395 pp.

Knopf, S. A.: Robert Kock, Johns Hopldos Hospital Bulletin,

191 1, vol. xxn, pp. 425-28.
Kodi, Robert: (i) Bacteriologkal Dtagnosis cf Cholera (tran^-

tion by G. Duncan). 1894. 150 pp.
(2) InoestigoHans into the Etiology of Traumatic Infective

Diseases (translation by W. Watson Qieyne). 1880. 74 pp.
Roger, Henri: "Les Sciences MMicales," in the first volume of

La Science Fran^aise, 1915.
LOfHer, Friedrich: Vorlesungen uber die geschichtliche Banir

vickdung der Lehre von den Bacterien, 1887. 252 pp.
Tyndall, John: "Spontaneous Generation," Popular Science

Monthly, vd. 12, 1877, pp. 476-88 and 591-604.
See also references on page 230 of the author's Introduction to
the History of Science.

CHAPTER XVir

ANTISEPTIC SURGERY: LORD LISTER

Joseph Lister, the story of whose achievements in
surgery is so closely associated with that of the de*
velopment of bacteriology^ was bom in the London
district (Upton) April 5, 1827. He received his
early schooling at two Quaker institutions (his
family belonging to the Society of Friends), took his
bachelor's degree at University Coll^;e, London,
proceeded at the age of twenty-one to his profes-
sional education at the University College Hospital
and Medical School, and at the age of twenty-five
received the M.B. and F.R.C.S. He had already
come in contact with several men whose names are
known in the history of science: Joseph Jackson
Lister, his father, already referred to as contributing
to the production of the achromatic lens; Thomas
Graham, who formulated the law of the diffusicm of
gases; W. B. Carpenter, whose wc^k on ''Mental
Physiology*' has had a great effect on the progress
of psychology; William Jenner, who during Lister's
early years as a student of medicine was working
out the distinction between typhus fever and ty-
phoid; William Sharpey, the distinguished teacher
of physiology; and Wharton Jones, noted as an

336 THE HISTORY OF MEDICINE

ophthalmic surgeon and as one of the pkmeersy in
England, in the study of embryology. BefOTe tak-
ing his degrees in medicine lister had served six
months as house physician and nine months as
house surgeon (to Erichaen) at the University Col-
lege Hospital.

Among the results of his extended education were
a considerable command oi ancient and modem
languages, skill as a draughtsman and microsoopist,
love of scientific truth and a taste for researdi. In
i853t the year following his graduation in medicine,
he published two papers in the ''Quarterly Journal
of Microscopical Science." The first of these re-
corded the discovery oi the sphincter and the dilator
of the iris as distinct muscles, and confirmed the
views of K6lliker as regards the ncmstriated and the
cellular structure of the tissue in question. The
second paper, illustrated like the first by delicate
drawings, dealt with the arrectares ptii^ especially
those of the scalp. He prepared his sections by tying
the tissue to be examined between two thin slips of
pine and allowing it to dry for twenty-four houiB,
by which time the piece of scalp having adhered to
one of the slips could be cut, by means of a sharp
razor, in very fine shavings along with the wood in
any plane desired. This was an original form of
microtome.

In the autumn of 1853 Lister went to Edinburgh,

ANTISEPTIC SURGERY 337

on the advice of Shatpey^ in order to attend the
surgicai dinics of Syme, an excellent teacher and
the foremost sui^geon at that time in Great Britain.
The youi^ man was very cordially received. Hebe-
came a frequent visitor in Syme*8 home* where he
met a large number of agreeable and cultured people,
among them Dr. John Brown, the author of "Rab
and his Friends/' In the congenial society of Edin-
burgh, a city more beautiful then even than now,
Lister threw off much of his natural shyness and
restraint, though, in spite of the favor his accom-
plishments and admirable dispositicm gained for
him, he never lost his native modesty. He socm be-
came Syme's house surgeon at the Royal Infirmary,
where in this period following the introduction of
the use of anaesthetics, he had abundant oppor-
tunities to develop skill as an operator. About this
time he wrote home: *'If the love oi surgery is a
proof of a person's being adapted for it, then cer-
tainly I am fitted to be a surgeon; for thou canst
hardly conceive what a hig^ d^;ree of enjoyment I
am from day to day experiencing in this bloody and
butcherly department of the healing art." The
young house surgeon had twelve dressers, who
called him "The Chief," a title he retained for life
among his many loyal disciples. In the autumn of
1855 he gave an extra-mural course of lectures on
surgery. In the following spring he married Syme's

340 THE HISTORY OF MEDICINE

as if it had been drawn fresh from die veins of die
animal. Moreover, by ligating die vessek in die
amputated leg of a sheep or a cat he oould keep
blood uncoagulated for several days. After other
papers dealing with the cos^^ulation of the Uood
Lister delivered the Croonian lecture on that sub-
ject before the Royal Society of London in 1863.
Though he had been considerably influenced by the
work ol Hunter^ he refused to commit himself to the
vitalisdc hypothesis as regards coagulation, nor, as
he said, ''to any particular theory of the nature of
life, or even to the belief that the actions of living
bodies are not all conducted in obedience to physical
and chemical laws/' He was more and ukm^ inclined
to emphasize the influence on coaguladon of foreign
solids, and of diseased tissues which acted like
foreign solids.

At the beginning of i860 Lister had been ap-
pointed professor of surgery at the University of
Glasgow. At that institution he was the colleague
of Allen Thomson, the anatomist and embryologist,
to whom he was largely indebted for his appoint-
ment, of Sir William Thomscm (afterwards Lord
Kelvin), professor of physics, and of other men dis-
tinguished in letters and science. He sent his father
an interesting account of his induction as a member
of the Faculty. The ancient rite demanded that the
new professor should give a dissertation in Latin;

ANTISEPTIC SURGERY 341

but Lister was summoned to the oeremoay on very
short notice, did not set pen to paper till the morn-
ing of the day on which he was to appear before his
colleagues, and wrote the last third of his disquisi-
tion while on the train from Edinburgh to Glasgow.
He acquitted himself creditably, and was sochi busy
with his large classes and considerate private prac-
tice. He faced additional responsibilities when in
the following year he received appointment as
surgeon in the Glasgow Royal Infirmary.

In order to appreciate the benefits Lister con-
ferred upon surgery one must know something of
the condition of the hospitals before the introduction
of the antiseptic system. After the use of ether and
chloroform had become general, operations gradu-
ally increased both in number and range. Although
deaths from shock grew less frequent, the pres-
ence of septicaemia, pyaemia, erysipelas, and hospi-
tal gangrene, etc, caused an alarming mortality.
Worst of all, writes Sir Rickman Godlee, Lister's
nephew and biographer, ''was the appearance of the
moist grey slough surrounded by an angry blush,
which heralded the onset of hospital gangrene. The
limits of the original wound were then lost sight of.
What might be the shape or size or even the posi-
tion of the scar in the event of the patient's recovery
became a matter of the greatest uncertainty, be-
cause it was impossible to foresee the amount oi

34^ THE HISTORY OF MEDICINE

tissue which would perish from the destructive
effects of the disease and the heroic measures taken
to combat it." These diseases were particularly rife
in the large hospitals. Sir James Simpson led the at-
tack on "Hospitalism" (1869). A statistical inquiry
conducted by him showed that out of 2098 amputa-
tions in country practice 226 had proved fatal, and
that out of 2089 amputations in hospital practice
855 had proved fatal; and that the larger the hospi-
tal the greater the mortality. ''Most hospital sur-
geons/* he said» "ever remain content with losing
one-third to one hall of all their amputation cases,
and nine tenths of some." Institutions which had
been developed through centuries of philanthropic
endeavor were proving a curse, unable to meet the
needs of the cities ever increasing in size as a result
oi the industrial revolution.

Lister in his new appointment had to face the
practical problems of controlling these diseases, the
only solution of which had seemed to many able
surgeons the demolition of the hospitals. Glasgow,
with a population of 390,000, was then, as now, one
of the industrial centers of Great Britain, and in
1861 the Glasgow Royal Infirmary was no better
than other city hospitals. Sir Hector Cameron, at
one time Lister's house surgeon and assistant, says
that every wound discharged pus freely, and putre-
factive changes occurred in the discharges of all.

ANTISEPTIC SURGERY 343

''Secondary hsemorrlu^/tetanus, erysipelas, septi-
caemia, pyaemia, and hospital gangrene," he pro-
ceeds, "were never all absent from the hospital
wards, and at times pyaemia and hospital gangrene
became alarmingly epidemic." Lister, though he
had for some time past taught that suppuration is a
form of putrefaction, was still without the clue to a
real explanation of putrefactive changes. Even after
his successes had begun, a terrible state of affairs
was discovered at the Royal Infirmary. "A few
inches below the surface of the ground," he writes,
'' on a level with the floors of the two main accident
wards, with only the basement area, a few feet wide,
intervening, was found the uppermost tier of a
multitude of coffins, which had been placed there
at the time of the cholera epidemic of 1849, the
corpses having undergone so little change in the
interval that the clothes they had on at the time of
their hurried burial were plainly distinguishable."
He was horrified also by the custom of the "pit
burial " of paupers still practiced in the old cathedral
churchyard adjoining the Infirmary, more particu-
larly as he associated infectious disease with a con-
taminated state of the atmosphere. Such were the
circumstances in which Lister developed his method
of antiseptic surgery.

In 1864 he was especially interested in the study
of suppuration (in relation to decomposition), a

344 THE HISTORY OF MEDICINE

subject to which he had given considerable atten-
tion since his student days. He was therefore very
deeply interested in the fact that carbolic acid had
proved effective at Carlisle not only in deodorizing
the sewage, but even in destroying the entozoa that
had infested the cattle in the fields fertilized by the
sewage. It occurred to him that carbolic add might
prevent suppuration in cases of compound fracture.
He had long felt that to make an open wound behave
like a closed one would be a notable advance in
scientific surgery. The first attempt to use carbolic
acid in the treatment of compound fracture was not
successful. This was in the spring of 1865, the year
in which Lister's attention was first directed to
Pasteur's studies of fermentation and putrefaction.
In August of the same year, however, the new
method was employed with complete success in a
case of compound fracture of the tibia. The patient
was a boy of eleven, who had been run over by a
wagon. Lister felt that recovery was as rapid and
satisfactory as if the fracture had been merely a
simple one.

In announcing this and other successes Lister said :
** In the course of an extended investigation into
the nature of inflammation, and the healthy and
morbid conditions of the blood in relation to it, I
arrived, several years ago, at the conclusion that the
essential cause of suppuration in wounds is decom-

ANTISEPTIC SURGERY 345

portion, brought about by the influence of the atmo*
sphere upon blood or serum retained within them,
and, in the case of contused wounds, upon portions
of tissue destroyed by the violence of the injury.

"To prevent the occurrence of suppuration, with
all its attendant risks, was an object manifestly
desirable; but till lately apparently unattainable,
since it seemed hopeless to attempt to exclude the
oxygen, which was universally regarded as the ag^nt
by which putrefaction was effected. But when it had
been shown by the researches of Pasteur that the
septic property of the atmosphere depended, not
on the oxygen or any gaseous constituent, but on
minute organisms suspended in it, which owed their
energy to their vitality, it occurred to me that de-
composition in the injured part might be avoided
without excluding the air, by applying as a dressing
some material capable of destroying the life of the
floating particles/'

At the time of this statement — March, 1867 —
the list of successful cases of compound fractures,
abscesses, contused and lacerated wounds, amputa-
tions, strangulated inguinal hernias, etc., had grown
so great that Lister felt impelled to impart the
knowledge of his procedure to the profession. His
wards in the Glasgow Royal Infirmary had become
the healthiest in the world.

In 1869 Lister was called to Edinburgh as pro-

346 THE HISTORY OF MEDICINE

f essor of clinical surgery on the retirement of Syme,
and at first found himself in a very critical atmos-
phere. He gave in his first lecture a history of the
germ theory, referring to the work of Schwann,
Pasteur, and others. He had repeated Pasteur's
experiment in which putresdble fluids remained
pure in the presence of atmospheric air, and he
showed to his audience flasks in which the contents,
kept free from dust, were still sweet and clear after a
space of two years. As Lister said in later life, from
the beginning of his campaign in favor of the anti-
septic method he had the youth on his side. He was
idolized by the Edinburgh students, and his classes
were very large. The poet Henley, who was one of
Lister's patients at the Royal Infirmary, has ex-
pressed in a sonnet his sense of the surgeon's influ-
ence and personality.

THE CHIEF

Hit brow b large and pladd, and his eye

Is deep and bright with steady looks that stilL

Soft lines of tranquil thought his face fulfill —

His face at once benign ^nd proud and shy.

If envy scout, if ignorance deny

His faultless patience, his unyielding will,

Beautiful gentleness and splendid skill,

Innumerable gratitudes reply.

His wise, rare smile is sweet with certainties,

And seenu in all his patients to compel

Such love and faith as failures cannot quell.

We hold him for another Heracles,

Battling with custom, prejudice, disease,

As once the son of Zeus with Death and Hell.

LORD LISTER

ANTISEPTIC SURGERY 347

At Edinburgh, where Lister spent eight years in
teaching, practicing, demonstrating and developing
his method and technique (as previously at Glas*
gow, and later at London), surgeons from the conti-
nent appeared, eager to sit at the feet of the master
of modem scientific surgery, Dn Saxtorph, profes-
sor of surgery in the University of Copenhagen,
visited Edinburgh in the summer of 1869. In the
following year he wrote to Lister: '* Formerly there
used to be every year several cases of death caused
by hospital diseases, especially by pyaemia, some-
times arising from the most trivial injuries. Now, I
have had the satisfaction that not a single case of
pyaemia has occurred since I came home last year,
which result is certainly owing to the introduction
of your antiseptic treatment.''

In the same month in which these words of com-
mendation were written, the Franco-Prussian War
began. The Prussians felt convinced that the sani-
tary organization of their armies could compete with
the best in the world. A large medical division was
provided, which on occasion could be broken up into
smaller units. There were twelve light hospitals for
every thirty thousand combatants. Each soldier
carried a tin of dressings. One soldier in eight had
been especially trained for emergency duties. In-
structions had been given concerning the safety of
the open air and the dangers of infection in crowded

348 THE HISTORY OF MEDICINE

rooms. Many df the surgeons were aware of the
antiseptic value of carbolic add. Lister's treatment
was, however, not in use; though he published at
the beginning of September, 1870, a brief statement
of "A method of antiseptic treatment applicable to
wounded soldiers in the present war/' Stromeyer,
who has been called the father of modem military
surgery in Germany, in one series of thirty-six am-
putations through the knee-joint recorded one hun-
dred per cent failures; von Nussbaum amputated
in thirty-four successive cases without a single suc-
cess. In the lower limb scarcely an amputation re-
covered, death resulting from exhaustion, sloughing
of the flaps, and frequently from pysemia. Hospitals
became hotbeds of pyaemia in spite of what had
seemed perfect arrangements. Among the French
forces conditions were much worse. Their hospitab
surpassed in horror the records of the Crimean War.
Out of I3ii73 amputations of all kinds, including
those of fingers and toes, 10,006 proved fatal.

Before the end of the war, von Nussbaum was a
convert to the Lister method. In the years following
he was at the head of the Allgemeines Krankenhaus
in Munich. It was overcrowded, partly on account
of the industrial growth of the city, and a severe
epidemic of hospital gangrene occurred. In 1872,
1873, and 1874 the percentage of wounded or oper-
ated that were attacked by that disease — to-day

ANTISEPTIC SURGERY 349

almost unknown — mounted to twenty-six, to fifty,
to eighty. Von Nussbaum was in despair. He ap-
pealed to Lister for help, and dispatched one oi his
assistants to Edinburgh to learn the antiseptic
method. It was soon put into effect at Munich.
Henceforth hospital gangrene was banished from
the Allgemeines Krankenhaus. Von Nussbaum's
book, with an account of the antiseptic treatment
went through four German editions in six years, and
was translated into French, Italian, and Greek.
Thiersdi oi Erlangen (later oi Leipzig) was, how-
ever. Lister's first disciple among the surgeons of
Germany, and Richard von Volkmann his most re-
doubtable champion. Von Mikulicz-Radecki, who
was Billroth*s assistant at Vienna, was sent by his
master to visit Lister at London in 1879. Lucas-
Championni^re, the French pioneer of the antiseptic
method, had visited Glasgow as early as 1868; and
he published his "Chirurgie antiseptique " in 1876.
In the previous year Lister in response to urgent
invitations had visited a number of German uni-
versity centers — Munich, Leipzig, Berlin, Halle,
and Bonn. According to the "Lancet," his progress
through Germany took on the character of a
triumphal march.

While the antiseptic treatment was making rapid
headway throughout Europe, Lister felt that he still
had before him the task of converting his native

350 THE HISTORY OF MEDICINE

place to the truth of the new doctrine. The oppor-
tunity came in 1877 when he was invited to accept
the post of professor oi dinical surgery in King's
College, London. He reluctantly consented to do so.
He was received with a considerable show oi skepti-
cism. He and those who had accompanied him from
Edinburgh felt helpless for a time in facing a con-
servatism and inertia that seemed hostile to every
innovation. In about a month, however, a patient
appeared who had broken his knee-cap. Lister cut
down, and united the two pieces of the fractured
patella by means of a silver wire. He operated suc-
cessfully in cases refused by the leading London sur-
geons. Some who had been set up as his rivals and
competitors became his pupik and followers. It was
soon realized that through the introduction of the
antiseptic method the scope of surgery was greatly
extended. Both in London and elsewhere operaticHis
on the brain, as well as on the thoracic and abdomi-
nal viscera, were undertaken with ever-increasing
freedom. Orthopaedic sux^gery extended its range.
Albrecht von Graefe, the most famous of eye sur-
geons, recognized the added power that came from
the antiseptic method. Moreover, surgeons now
took courage to interfere in the early stages of an
affection, an advantage particularly notable in the
treatment of cancer.
One of Lister's old students at London writes

ANTISEPTIC SURGERY 351

(1918), in answer to a recent critic: **Fn>m the day
of Lister's entry we never saw the temperature rise
after an operation in any of his patients, and never
saw a blush on a wound. To us who had been
taught that inflammation was necessary for heal-
ing ... it was a miracle, the more so that Lbter
immediately did operations that hitherto we had
learned must always prove fatal/* It is true that
a formidable list of achievements, some preceding
the development of the antiseptic method, may be
placed to Lister's credit. For example, in 1861 he
described an original amputation in the neighbor-
hood of the knee. In 1862 he recorded the successful
use of a tourniquet of his own invention to control
the abdominal aorta. In 1864 Syme told with pride
that Professor Lister of Gla^;ow had succeeded in
the excision of the wrist for caries. In 1868 he tested
the value of catgut ligatures by tying the carotid
artery oi a young calf, and found a month later
Qanuary, 1869) that the ligatures had been replaced
by living tissue. He devoted much time to the study
of ferments, such as the lactic ferment, and the rela-
tion of micro-organisms to the blood; and came to
the conclusion about 1881 that the spray of car-
bolic acid solution, which he had long used in his
operating-room to destroy the pathogenic organ-
isms in the air, was not essential to the antiseptic
method. He also experimented with the double cya-

352 THE HISTORY OF MEDICINE

nide of mercury and zinc and other antiseptic pre-
parations. Nevertheless, it was not to these particu-
lar achievements, not to any of his later operations,
such as the excision of the knee-joint, that Lister
owed his fame, but to the steadfast vigilance with
which he applied a great principle.

Lister received a baronetcy in 1883. In the same
year he visited Austria and Hungary, but did not
hear for some time later of the work of Senmielweiss,
frequently regarded as his forerunner. In 1892 he
attended the Pasteur jubilee at Paris and with his
usual magnanimity ascribed all his own triumphs in
surgery to the work of the founder of bacteriology.
In 1895 he became President of the Royal Society.
In 1896 he was chosen President of the British As-
sociation for the Advancement of Science, and in the
following year he was raised to the peerage. In 1902
was celebrated the fiftieth anniversary of his en-
trance into the medical profession. At a banquet
given in honor of Lord Lister by the Royal Society,
Mr. Thomas Bayard, the American Ambassador,
addressing the great surgeon, said : ** My Lord, it is
not a profession, it is not a nation, it is humanity
itself which with uncovered head salutes you.''
Lord Lister died in 1912. A public funeral service
was held in Westminster Abbey, where a marble
medallion now commemorates him. But, in accord-
ance with special instructions he had given, he was

ANTISEPTIC SURGERY 353

buried beside his wife in a simple tomb in the West
Hampstead Cemetery.

REFERENCES

Allbutt, % Clifford T.: ''Lord Lister," Encyclopedia Britannica.

Bloch, Oscar: "Antiseptic Treatment oC Wounds," BrUish Medi-
cal Journal, 1902, pp. 1825-28.

Cameron,^ Hector: "The Evolutbn of Modem Surgery,"
British Medical Journal, 1902, pp. 1844-48.

fkxllee, Sir Rickman: Lard Listor, 1917. 676 pp.

Lister, Baron Joseph: CoUected Papers. 2 vols. -

Lucas-Championni^ Just: ''An Essay on Scientific Surgeryt"
BriHsh Medical Journal, 1902, pp. 1819-21.

Von Mikulicz-Radedd, Johann: "Treatment of Fractured Patel-
la," British Medical Journal^ 1902, pp. 1828-31.

CHAPTER XVIII

THE HISTORY OF SYPHILIS

T&B term '^syphilis" was first used, so far as we
know, by the distinguished Italian physician Fracas-
toro, who in 1530 wrote a poem "Ssrphilis sive
Morbus Gallicus/' But the synonymous expression
and its many equivalents — "French pox/* "Gal-
lische Krankheit/* '^mal francese/* etc. — were
extensively used before the dose oi the fifteenth
century, and were soon translated into some of the
languages of Africa and Asia. In France syphilis had
a great many names, but only one of these had any
geographical reference, namely, "mal de Naples,''
a term that found echoes in three or four other lan-
guages. In England the disease was called, among
other things, "Spanish pox''; and similar expres-
sions were used in Scotland, Holland, Germany,
and in the western part of North Africa. The Rus-
sians called it at times the "Polish disease"; and
the Persians knew it as the "Turkish disease." The
Portuguese, turning their eyes to the east rather
than to the west, spoke of the "Castilian disease."
The Spaniards, however, used occasionally the term
"Indian measles," and, also, "disease of the island
of Hispaniola" (that is, Santo Domingo).

i

THE HISTORY OF SYPHfLIS 355

There was a fierce epidemic of syphilis in Europe
near the end of the fifteenth century. Its diffusion is
associated with the military expedition in Italy,
under the leadership of Charles VIII of France, in
1494 and 1495. The army of the French kii^, made
up of adventurers from various countries, and ac-
companied by a dissolute train oi camp-followers,
met with little opposition. There was a slight en-
gagement with a force of Spaniards and Neapolitans
at Rapallo (near Genoa) in September, 1494.
Charles halted for a short time in FlcH^nce on his
triumphal progress south; lingered four weeks in
Rome, then governed by Alexander Borgia; and
entered Naples February 22, 1495. Here he stayed
for about three months. Some historians attribute
the epidemic to Spanish mercenaries in the army of
Charles; others put it down to the Spaniards in
Naples, which had for some time been a possession
of the House of Aragon, and particularly to the gar-
rison of a fcMtress in the harbor, who held out for
three weeks after the French troops had entered the
dty, and who then for the most part went over to
the service of Charles. Professor Robinson men-
tions as one of the momentous results of this cam-
paign that the intellectual leadership of Europe
passed from Italy to England, France, and Ger-
many. However that may be, the venereal plague
ran within a few months through the Italian cities.

356 THE HISTORY OF MEDICINE

and reached the borders of France, Switzerland, and
Germany.

There is evidence to show that syphilis had ap-
peared along the line of march in 1494, that is, before
Charles had reached Naples, namely, in the camp at
Rapallo, in the neighboring city of Genoa, and in
Rome. It developed into a virulent epidemic at
Naples before May, 1495, and, it seems reasonable
to suppose, hastened the retirement of the French
northwards. We hear of its breaking out in 1495 at
Florence, at Bologna (at which center of learning, as
elsewhere, it was regarded as a new and unheard-of
disease), at Cremona, Verona, and Novara, where a
part of the retreating army was besieged for several
months. The epidemic seems not to have reached
Modena, Ferrara, and Venice till the following year.
Syphilis at the time of this European epidemic was
extremely malignant, a fact explained by Bloch, who
maintains that this was the first appearance of die
disease in the Old World, on the ground that it here
found virgin soil, as he expresses it. The secondary
symptoms appeared very early — often in a few
days; the patients had high fever; they suffered
intense pains (especially in the joints) and severe
skin affections; they fell into general decline, and
very frequently died.

Charles reached Lyons in November, 1495, but
the greater part of his forces, after leaving Italy,

THE HISTORY OF SYPHILIS 357

had scattered in all directions. The disease was soon
prevalent in the south of France, and by the be-
ginning of 1497 had become so general that the
Parliament of Paris issued regulations in the hope of
controlling ''la grosse v^role," which for two years
had afflicted the kingdom, as well Paris as other
places. The Emperor Maximilian I, in an edict
dated August 7, 1495, recognized the danger for his
dominions of the new and unheard-of scourge. Some
of his troops had taken part with the enemies of
France at the protracted si^:e of Novara, where the
epidemic had prevailed; and German, Hungarian,
and Slav mercenaries had formed part of the army of
Charles. The fact that six thousand Swiss mercen-
aries also accompanied the French accounts for the
early appearance of syphilis in Switzerland. The
disease reached Great Britain in 1497 from French
and, probably, Spanish ports. It was carried to the
Netherlands in 1496 by the retainers of a Spanish
princess. It appeared in Russia in 1499 coming by
way of Poland. The latter country is said to have
got the infection from an individual woman, who
had made her way from Rome to Cracow as early
as 1495.

When we turn to Spain, we find new light is
thrown on the history of the syphilis epidemic by
the evidence of reliable witnesses. The most impor-
tant of these is the physician Ruy Diaz de Isla, who

358 THE HISTORY OF MEDICINE

at the age of thirty-one was practicing at Barcelona
at the time of the return of Columbus from the West
indies in 1493. Before 1521 this physician wrote a
book dedicated to the King of Portugal — "Against
the Reptilian Disease, Commonly Called in Spain
the Buboes/' The first chapter deals with the birth
and origin of the disease on the island of Hispaniola.
He states that it made its appearance in Spain in the
city of Barcelona in the year 1493. The city became
infected, and from it all Europe and all the known
and accessible parts of the earth. It had its birth
and origin in the island of Hispaniola. When the
island had been discovered by the Spaniards, they
had had intercourse with the natives, and the disease
being readily contagious it presently appeared on
the ships. At the time Columbus returned to Spain,
Ferdinand and Isabella were in the dty of Barce-
lona, and while they were receiving accounts of the
voyage and the discoveries the disease began to
infect the people and to spread through the city.
According to de Isla a great many Spaniards in-
fected with the disease joined the army of Charles in
the following year and thus infected the main body
of the French army. The Indians of Hispaniola
called the disease "Guajmaras,'' and applied other
names to it. As for the physician's own name for
it, he consider^ it appropriate; because a reptile
is a hideous, fearful, and dreadful animal, and the

THE HISTORY OF SYPHILIS 359

disease is likewise hideous^ fearful, and dreadful.
It is a severe disease, forming abscesses and cor-
rupting the flesh, breaking and rotting the bones,
and shortening and drawing up the sinews. And,
since de Isla knew that the disease from remote
times had existed in Hispaniola, whence it had
spread throughout the world, he called it the rep-
tilian disease of the island of Hispaniola. He also
insisted that the disease had never been seen and
never known before the voyage of Columbus, and
that nothing like it could be found described in
medical works.

De Isla's conviction that the reptilian disease had
existed from time immemorial on the island of His-
paniola rested on the fact that the natives had
developed a complete system of therapy in its treat-
ment — the use of guaiac, balata, and other vege-
table remedies, the regulation of diet, care regarding
water and air, and abstention for a certain time from
sexual intercourse. With an eye on the difhculties
experienced in his own time by civilized peoples in
dealing with an unknown disease, de Isla argued
that the very stupid natives of Hispaniola must
have known guaynaras for very many generations
before arriving at their clever and orderly treatment
of it. The Spanish physician maintained that mer-
cury was the only reliable remedy for the reptilian
disease as it existed in Europe ; he employed it as an

36o THE HISTORY OF MEDICINE

inunction. He advocated a well considered plan for
the state control of syphilis* Besides his experience
in treating at Barcelona some of the crew accom-
pan3dng Columbus (among them the pilot Vicente
Pinzon), as well as other people in the city infected
with the disease, de Isia saw practice at Seville
(where Columbus had passed four weeks or more
before reaching Barcelona), and, subsequently, had
served many years in All Saints' Hospital at Lisbon,
where he had abundant opportunities of studying
83^hilis.

The American origin of syphilis is likewise upheld
by Oviedo, the author of the "General and Natural
History of the Indies,'' who crossed the Atlantic
many times, spent over forty years in America, and
was particularly well acquainted with the island of
Hispaniola. As a boy of fifteen he had been present
at the landing of Columbus at Barcelona, where he
made friends with the sons of the discoverer and
with Vicente Pinzon. In 1501 Oviedo spent six
months in Sicily with Gonsalvo de Cordova, who in
1495 had been sent from Spain with an army to
oppose Charles VIII, and whose secretary Oviedo
became in 15 12. On a visit to Italy the young man
was much amused to hear that the Italians called
syphilis "mal francese" and that the French called
it "mal napolitain," for he was well aware it should
be called "mal de las Indias." According to him

THE HISTORY OF SYPHILIS 361

some of 4he companions of Columbus had become
infected at the time of the first voyage to America,
and> after their return to Spain, the infection passed
to Italy and other countries. It had not been known
in Spain until the return of Columbus in 1493.
Immediately it had spread among the lower classes^
and later had found its way among the gentry and
nobility. Oviedo knew that some of the soldiers
under the command of Gonsalvo de Cordova in
1495 were infected before quitting Spain.

Oviedo believed that syphilis was found not only
in Hispaniola, but throughout the West Indies and
on the American mainland. It was less dangerous,
he said I in those regions than in Spain and the other
countries of the Old World. The Indians knew how
to cure it by the use of guaiac (which was fresher and
consequently more efficacious in the Indies than in
Europe), and other vegetable remedies. Of the
Christians who had intercourse with the native
women few escaped with impunity.

The statements of Oviedo in reference to the
comparative mildness of the disease among the
American natives and the marked susceptibility of
Europeans to the infection are fully corroborated
by Las Casas, known as "the Apostle of the Indies/*
who also refers, like Oviedo and de Isla, to the suc-
cess of the native therapy. Moreover, he is able
to support by the testimony of the aborigines the

362 THE HISTORY OF MEDICINE

theory of de Isla regarding the antiquity of the
disease in the island of Hispaniola. He took great
pains, he says, to question the Indians as to whether
the disease had long existed on the bland. They
answered in the affirmative; it had been present so
long among them before the coming of the Chris*
tians that there was no memory of its beginning.
Of the truth of this, Las Casas felt there €X>uld be no
doubt« Indeed, we know from other sources that the
presence of guajmaras in Hispaniola was implied in
the earliest traditions of the natives.

Las Casas was bom in Seville in 1474* His father
accompanied Columbus in 1492, and the young man
was present when the discoverers in 1493 brought
ten Indians from Hispaniola to Seville, where they
remained for about a month before proceeding to
Barcelona. He went to the West Indies in 1498, and
was ordained as a priest in 1510 on the island of
Hispaniola, where he passed altogether twenty years
of his life. He was appointed Bishop of Chiapa,
Mexico, in 1543. He lived to the age of ninety-two,
and left a manuscript "History of the Indies." In
the judgment of this well-informed witness the
disease known to the Italians as "mal francese"
was carried to Europe by the Indians Columbus
took to Spain in 1493 or by the Spaniards who had
been infected in Hispaniola at the time of its dis-
covery.

THE HISTORY OF SYPHILIS 363

Ab regards the epidemic in Barcelona, following
the return of Columbus from his first voyage to the
West Indies, we have valuable corroborative evi-
dence in a letter written in June, 1495 (printed in
the following March), by the Sicilian phj^ician
Nicol6 Scillacdo. The letter is addressed to his
former teacher at Pavia, Ambrogio Rosato, physi-
cian to Ludovico Sforza (who a few months later
overcame the French resistance at Novara). Scil-
lacdo had left Italy for Spain in February, unaware
of the imminent epidemic. It is with some gusto he
announces to his master the advent of a new disease.
Among the symptoms he had observed in those
infected in Barcelona were purulent pustules, in-
tense fever, arthritis with severe pains, dermal
crusts, and swellings colored at first blue and later
blackish. The disease begins most frequently in the
genitals, but spreads to the whole body. According
to the statement of Scillacdo this new spedes of
malady had but recently invaded Spain. The
disease does not run longer than a year in an indi-
vidual case (annum morbus nan excedit). This state-
ment gives us reason to affirm that it had been
under observation in Barcelona for a year or two.

According to Osier, ''writers who contend for the
antiquity of the disease in Asia and Europe rely on
certain old Chinese records, on references in the
Bible and in old medical writers to diseases resem-

i

364 THE HISTORY OF MEDICINE

bling syphilis and on suggestive bone lesions in very
old skeletons. The balance of evidence, according
to the best syphilographers, is in favor of the Amer-
ican origin/' No European bones belonging to a
date earlier than 1493 show satisfactory indications
of the disease; though skeletons belonging to a later
period have been found with the characteristic signs
wherever the infection has been carried — even in
regions so remote from Europe as the Philippines,
New Caledonia, and Australia. In America, on the
other hand, this sort of negative evidence is not so
decisive. For example, two skulls have been found
in Tennessee, one of which shows signs of syphilitic
caries, the other the thickening of the nasal bones
indicative of syphilb. Their discoverer thought
them probably the most ancient syphilitic bones in
the world. It is not positively known, however,
that they belong to the pre-Columbian period.

The outbreak of syphilis in Europe at the end of
the fifteenth century was a challenge to the medical
science of the time. The problems it raised could
not be answered by consulting the volumes of Galen
and his commentators. Its extreme virulence seems
to have prevented its early observers from confusing
it with gonorrhoea. Berengario da Carpi treated it
with inunctions of mercury as early as 1500, and,
therefore, disputes with Diaz de Isla, the honor of
introducing this form of treatment. Before the

THE HISTORY^OF SYPHILIS 365

middle of the sixteenth century Mattioli employed
metxniry internally. Mercmial plasters came into
use» as well as fumigations, sulphur baths, and
guaiacum. Sarsaparilla, which had been used in
America in the treatment of syphilis, was used by
the Portuguese even on the coast of India as early
^ 1535* In addition to the symptoms already re-
ferred to, the phj^icians of the sixteenth century
took note of the primary lesion, the falling out of the
hair, affections of the internal organs, and disorders
of the nervous system. Paracelsus recorded the
observation of congenital syphilis. The venereal
nature of the disease and its special mode of trans-
mission were soon generally recognized, and in 1557
Femel stated definitely that the disease always gave
rise to a little sore and pustule at the point of the
primary inoculation. Par6 noted, as we have seen,
the connection between aneurism and syphilis, and
wrote in detail concerning hereditary syphilis.

After the beginning of the seventeenth century
there was a clearer recognition of the minor causes of
infection — the communication of the disease to
physicians and midwives by l)dng-in women, infec-
tion from drinking-vessels, inoculation by kissing,
and the transmission of the disease through the
operation of cupping, the infection of the child by
the nurse and of the nurse by the child. The list of
syphilitic affections was gradually increased —

366 THE HISTORY OF MEDICINE

chancre of the tonsil, nasal syphilis, lesions of larynx,
windpipe, and lungs, gummata of the brain, syphili-
tic neuralgias, and diseases of the spinal cord. As
we have seen in the seventh chapter, Sydenham
noted the lessened virulence of the disease in the
seventeenth century as gauged by the records of
the end of the fifteenth century, held that this
species of disease is not immutable, attempted to
trace the stages passed through in individual cases,
and considered syphilis identical with yaws.

In the eighteenth century Landsi described car-
diac syphilis, and supported the observations of
Par6 by giving syphilis as one of the causes of aneu-
rism. We have seen in the ninth chapter that Mor-
gagni held syphilis to be not only one of the causes
but the preponderating cause of aneurism, that he
had observed syphilitic lesions in nearly all of the
thoracic and abdominal viscera and believed that
venereal disease might vitiate any viscus whatever.
''At last, John Hunter came and laid the true foun-
dations of the science of venereal affections'*
(Ricord). It is true that Hunter, in spite of his
numerous post-mortems, failed to observe sjrphilis
of the viscera, and that he confused syphilis and
gonorrhoea; but he based his generalizations in this
field, as elsewhere, on observation and experimenta-
tion, and had the courage to inoculate himself with
venereal virus and to study the results over a long

THE HISTORY OF SYPHILIS 367

period before knocking the disease down with nier«
cury, as he expressed it. It is not improbable tliat
this was the cause of the angina pectoris from which
he suffered for many years and which resulted in his
death. As mentioned in the eighth chapter he suc-
ceeded in differentiating Hunterian chancre from
ch^mcroid ulcer. Before the end of the eighteenth
century Benjamin Bell taught that there is a differ-
ence between the virus of gonorrhoea and that oi
syphilis.

At the beginning of the nineteenth century Her-
nandez confirmed the views of Bell by inoculating
with the poison of gonorrhoea seventeen convicts at
Toulon. Hunter and Hernandez in their resort to
experiment in investigating venereal disease may be
regarded as forerunners of Philippe Ricord (1800-
89) who in the years 1831 to 1837 niade at Paris
twenty-five hundred inoculations, and proved that
gonorrhoeal secretion never produces chancre nor
constitutional syphilis. He established the three
stages of syphilis, held that the induration of the
chancre is subsequent to the passage of the poison
into the general system, and that in its third stage
the disease is non-communicable. Virchow, as
already stated in the thirteenth chapter, set forth
in detail the pathology of syphilis. In considering
the various phases of the subject he of course did not
overlook the histological. He noted, for example,

368 THE HISTORY OF MEDICINE

the resemblance of the indurated chancre to all
gummatous formations. He observed that a syphil-
itic cicatrice in the bones of the cranium gives eAd-
dence of a diminished growth in the center and an
increased growth in the periphery. This and other
indications of syphilis he maintained are not to be
found in skeletons of a date earlier than the closing
years of the fifteenth century. Further advances in
the knowledge of venereal disease followed the
development of the science of bacteriology. Neis-
ser's discovery of the micro-organism of gonorrhcea
in 1879, Ducrey's isolation of the bacillus of vene-
real ulcer in 1889, and the success of Metchnikoff
and Roux in inoculating monkeys with syphilis in
1903, cleared the way for the discovery by Fritz
Schaudinn in 1905 of the piotozoon Treponema palU-
dum as the cause of syphilis.

Schaudinn (1871-1906), bom at a small place in
East Prussia^ received his training as a zodlogist at
Berliui attaining the doctorate at the age of twenty-
three. Four years later he was an instructor in his
specialty, and in 1904 he was engaged at the Im-
perial Health Bureau as an expert in protozodlogy.
Under the auspices of this institution he pursued
investigations at Rovigno on the Istrian coast. In
the year of his death he accepted an appointment
in the Institut ftir Schiffs- und Tropen-hygiene at
Hambui^. He studied the hookworm recognized as

THE HISTORY OF SYPHILIS 369

the cause of anaemia among the miners of West-
phalia, and confirmed the discovery of Looss in refer-
ence to the life-history of that parasite. Schaudinn
made important contributions to the classification
of protozoa (such as Spirochata and Trypanosoma)
as well as their mode of reproduction, including the
mechanism of cell-division. Although he had not
studied medicine, the control of disease soon became
one of the main purposes of his work in science. He
insisted on the necessity of knowing the complete
history of microscopic parasites, and traced satis-
factorily the life cycles of a number of pathogenic
protozoa that infest man and the lower animals,
such as Plasmodium vivax (the relation of which to
the human blood-vessels he established) and 7>y-
panosoma nocHuB. He distinguished Entom^a his-
toliHca from Entomcsba coU. Moreover, he estab-
lished a method of studying protozoan infections
which helped to guide the investigations of odiers.
Five years after Schaudinn had determined the
causative i^nt of syphilis, Ehrlich announced the
discovery of a specific.

Paul Ehrlich (i 854-1 91 5) was bom at Strehlen,
Silesia; received his early education in his native
place and in the neighboring city of Breslau; after
spending a semester at the University of Breslau,
proceeded to Strassburg, where he began the study
of medicine; and later visited as a student at two

370 THE HISTORY OF MEDICINE

Other German universities. He took advantage of
the freedom of German university life and pursued
intensively those studies that laid daim on his
interest. Although at Strassburg he had the privi-
lege of the instruction of Julius Cohnheim, Ehriich
was more influenoed by Carl Weigert, his cousin,
with whom he was closely associated. He was soon
distinguished for his contributions to haematology,
based on improved methods of staining. In 1882
he employed f uchsin red in staining tuberde bacilli.
His investigations were early guided by the hy-
pothesis that the molecules of living tissue combine
with foods, poisons, dyes, and other chemicals by
virtue of selective affinities. In 1885 he reached the
conclusion that cell protoplasm takes up oxygen as
benzene takes up bromine. That is, the elements of
the protoplasm that enter into combination with the
extraneous molecules are analogous to the side-chain
of the benzene ring. In 1886 he injected methylene
blue in the blood of a rabbit and discovered that the
nervous tissue has a special affinity for that particu-
lar dye. In 1891 the phenomena of immunity of
mice to gradually increased quantities of vegetable
poison gave Ehriich ground for the extension of his
principles. By the exercise of what he called his
''chemical im^nation*' he pictured a poisonous
substance as made up of two kinds of parts, the
actual carriers of the poison, <x* toxophores, and the

THE HISTORY OF SYPHILIS 371

effecters of the connection with the protoplasm, or
haptophores. When the poison is administered in
small quantities, the side-chain elements — chemo-
receptors — of the protoplasm break away from the
ring and render the toxin harmless by combining
with the haptophore. At the same time the proto-
plasm is stimulated to produce a very great number
of chemo-receptors, which neutralize the poison
when adminbtered in larger quantities. Ehrlich on
the basis of further experiments eventually estab-
lished an international standard for the administra-
tion of diphtheria antitoxin.

The fact that pathogenic micro-organbms share
with the living tissues of the human body the prop-
erty of combining with certain chemical substances,
as their specific affinity for certain aniline dyes
bears witness, suggested means for their destriKrtion.
The pathogenic protozoa revealed by the micro-
biological studies of Schaudinn and others olff ered a
special field tor a therapy based on micro-chemistry.
Ehrlich had something of Sydenham's faith regard-
ing the discovery of specifics. Quinine is a specific
for a disease caused by a protosoOn. We must learn
to destroy all pathogenic protozoa without injuring
the tissues of the patient. The ideal was a tkerapia
steriUsans^ one injection of which would destroy all
the microbes, which, otherwise, might become im-
mime to the poisonous influence of the injected

Z72 THE HISTORY OF MEDICINE

chemical substance. In trypan red Ehrlich discov-
ered such a specific for sleeping sickness in mice.
This is, of course, a trypanosome disease. In 1894
Thomas and Breinl, of the Liverpod Sdxxd of Trop-
ical Medicine, had discovered that injections of
atoxyl destroy the parasite in human beii^ suffer-
ing from sleeping sickness. It was found, however,
that there are grave objections to its administration.
Atoxyl was found to be para-amino-phenylarsenic
add, and Ehrlich discovered (as he thought) in one
of its derivatives — arsenophenylglydn — a remedy
for all tr)rpanosomia9es. Would one of these com-
I^ex arsenic compounds prove effective against 7>e-
panema pallidum, the protozoSn of syphilis? After
a long series of experiments carried out by Ehrlich
and his Japanese asastant Hata a q^edfic was
found in "606" — Salvarsan, or dioxydiamido ar-
senobenzol. The discovery was announced in the
early part of 1911. It is interesting to note, in con-
nection with the conjecture of Sydenham regarding
the identity of syphilis and yaws, that "606'' acts
as an ideal remedy in the latter disease, which b
caused by a parasite — Treponema pertenue —
hardly distinguishable from Treponema pallidum.

The veteran Sir Jonathan Hutchinson (1828-
19 1 3), who had seen over a million cases of syphilis,
wrote shortly before his death: "For the student of
pharmacology syphilis has many important lessons.

THE HISTORY OF SYPHILIS 373

The marvel which we witness in the certain and
speedy disappearance under the influence of mer-
cury of a large sclerosis as hard as cartilage, is more
than equalled by the melting away of a big tumour-
gumma under that of iodide of potassium/' The
record of Hutchinson and others may serve to
remind us that the successful treatment of syphilis
had its beginnings before the advent of recent
chemotherapy.

REFERENCES

Blocfa, Iwan: Per Ursprung der SyfkiUs. 2 vob., iQOt.

Alao a brief history of syphilis in Power and Murphy's

System of Syphilis, vol. i, 1914, pp. 3-39.
Brown, H. M.: Must the History of Syphilis be Rewrittenf Bull.

Soc Med. Hist., Chicago, 1917, n, pp. 1-14.
Calkins, Gary N.: "Fritz Schaudinn," Science^ N.S., vol. xxiv

(1906), pp. 154-55-
Montgomery, T. H., Jr.: 'Tritz Sdiaudinn^'* Popular Science

Monthly, vol. 70 (1906), pp. 274-78.
SudhofT, Karl: The Origin of Syphilis, and The End rf the Fable

cf the Great Syphilis Epidemic in Europe foUcwing the Dis^

cavery of the AnHlles (tianslattons by A. Allemann), BulL

Soc. Med. Hbt., 1917, u, pp. 15-26.
See also obituary notice of Paul Ehrlich in the Proceedings of
the Rpyal Sodety, series B, vol. 92 (1921), pp. i-viL

CHAPTER XIX

PREVENTIVE MEDICINE IN THE TROPICS

More than a century before the appearance of
syphilis in Europe the eastern hemisphere was rav-
aged by another disease which had its origin in the
tropics. The Black Death, or Plague, which even
since the beginning of the twentieth century has
carried off millions of the inhabitants of India, in
the fourteenth swept to the northwest and claimed
about sixty million victims. This was not its first
nor its last visitation of Europe. We have already
seen its disastrous effects in London and elsewhere
in the time of Sydenham ; and within the last twenty-
five years this dreaded disease has threatened the
ports of Italy, France, Germany, and Great Britain,
as well as those of America both on the Atlantic and
the Pacific. The virulent outbreak at Hong-Kong in
1894 led to the study of the pestilence in the light
of modem bacteriology and parasitology. Within a
few months Kitasato and Yersin had discovered the
BadUiis pestis. Of the two forms of the disease —
the pneumonic and the bubonic — the former may
be conveyed from one person to another by means of
bacilli borne by the air. Bubonic plague is trans-
mitted to man from the rat by fleas. The chief

PREVENTIVE MEDICINE 375

preventive measure is the extermination of diseased
rats. Haffkine's prophylactic vaccine has a marked
effect both in decreasing the chances of infection and
in increasing the chances of recovery in cases in
which infection takes place.

It was Dr. (afterwards Sir Patrick) Manson who
prepared the way for the greatest triumphs of pre-
ventive medicine in the tropics by demonstrating
thoroughly, in 1879, that the mosquito is the inter-
mediate host of FUaria sanguinis hominis, the para-
site in certain particularly hideous forms of filariasis.
Manson traced the life-cycle of the nematode in the
mosquito and in the definitive host, man. He ob-
served the filarise in the stomach of the mosquito
after it had sucked the blood of a patient suffering
from filariasis, found that within a few hours they
broke down the blood corpuscles in the abdomen
of the insect, the escape of the haemoglobin bringing
about a thickening of the plasma. The viscosity of
the plasma seemed to stimulate the filariae to wriggle
out of their sheaths. Once rid of these they moved
about freely and found their way into the thoracic
muscles of the mosquito, where they underwent
metamorphosis, the young parasites showing a
remarkable increase in size. The mosquito, about a
week after sucking the blood of the filariasis patient,
lays her eggs on the surface of stagnant water, and
then dies. The filariae find their way into the water

376 THE HISTORY OF MEDICINE

from the dead body of the intermediate host, and
thence into the stomach of the definitive host, and
from the stomach reach the lymphatic tnmks.
There they attain sexual maturity, and give birth
to a new generation of filariae, which eventually pass
by way of the lymphatic vessels into the blood
stream.

In the year following Manson's discovery of the
life-history of FUaria sanguinis hominiSf Alphonse
Laveran, a French army surgeon on service in
Algeria, observed in the blood of patients suffering
from malaria parasites which he considered the
cause of the disease, a judgment that was soon con-
firmed by Dr. Richard and others. These protozoa
were accurately described by Marchiafava and Celli
in 1885. There are three varieties of this group
of hsemocytozoa, Pldsmodium vivaXf Plasmodium
maiaruB, and Plasmodium falciparum^ the parasites
respectively of tertian, quartan, and aestivo-autum-
nal fevers. Golgi, the histologist, who as early as
1885 had shown that the paroxysms of malarial
patients occur at the same time as the sporulation
of the parasites, took the first step (1889) toward
establishing the relationship between the varieties
of the parasite and the various forms of malarial
fever. Golgi 's discovery of the coincidence between
the malarial paroxysms of the patient and the sporu-
lation of Plasmodia was confirmed by Dr. (after-

PREVENTIVE MEDICINE 377

wards Sir William) Osier, while the task of determin-
ing the exact casual relationship between pemicious,
tertian, and quartan fever on the one hand, and P.
falciparum^ P. vivax^ and P. malaruB on the other
hand, was inmiediately completed by Marchiafava
and Celli*

In 1886 Dr. G. M. Sternberg directed the atten-
tion of the medical profession in the United States
to the views of Laveran concerning the etiology of
malaria, and these soon gained support from the
investigations of Councilman, Abbott, Thayer, and
others, including Osier. As early as 1883 Dr. A. F.
A. King had put forward as worthy of observation
and experiment the supposition that mosquitoes
(rather than marsh vapor) are the source of malarial
infection. In 1889 Theobald Smith demonstrated
that Texas fever is caused in cattle by a haematozoan
parasite, later (1893) shown to be carried by an
insect. It remained for Manson to formulate a
definite verifiable hypothesis concerning the relation
of the mosquito to the malaria parasite. With his
studies of filaria in mind he proceeded on the sup-
position that the protozoa, after undergoing sexual
reproduction, complete their life-cycle in the body
of an insect host. Laveran had observed in the blood
of malarial patients withdrawn from the circulation
that some of the gametocytes put forth motile fila-
ments. These processes, mistaken by Manson for

378 . THE HISTORY OF MEDICINE

spores (and later shown to be of the nature of
spermatozoa), he correctly supposed to play an
essential part m maintaining the life of the protozoa
in the body of some suctorial insect* In 1894 Man-
son communicated his hypothesis to Major (now
Sir) Ronald Ross, who undertook its verification in
the malarial districts of India, where he was on
service.

This was a very difficult task; for the spedes of
mosquito that might prove the intermediate host of
the protozo6n and the form the latter might bear in
the body of the insect were alike unknown at that
time. Ross, in the course of an investigation extend-
ing about two and a half years, fed hundreds of mos-
quitoes of different species on persons suffering with
malarial fever, and then examined the tissues of
each insect in the hope of discovering the parasite.
As he stated in 1900, '' nothing but the most con-
vincing theory, such as Manson's theory was,
would have supported or justified so difficult an
enterprise/' Finally eight mosquitoes of a species
with spotted wings were fed on a malarial patient.
On dissecting the seventh of these specimens the
investigator achieved his first success.

''The tissues of the stomach (which was now
empty owing to the meal of malarial blood taken by
the insect four days previously being digested) were
reserved to the last. On tumuig to this organ I was

PREVENTIVE MEDICINE 379

struck by observing, scattered on its outer surface,
certain oval or round cells of about two or three
times the diameter of a red blood corpuscle — cells
which I had never seen in the hundreds of mosqui-
toes eicamined by me. My surprise was complete
when I next detected within each of these cells a few
granules of the characteristic coal4>lacb melanin of
malarial feoer — a substance quite unlike anything
usually found in mosquitoes. Next day the last of
the remaining spotted-winged insects was dissected.
It contained precisely similar cells, each of which
possessed the same melanin; only the cells in the
second mosquito were somewhat larger than those in
the first. • • •

** These fortunate observations solved the nudarial
problem. As a matter of fact the cells were the
zygotes of the parasite of remittent fever growing in the
tissues of the gnat; and the gnat with spotted wings
and^boat-shaped eggs in which I found them be-
longed (as I subsequently ascertained) to the genus
Anopheles. Of course it was impossible absolutely
to prove at the time, on the strength of these two
observations alone, that the cells found by me in
the gnats were indeed derived from the hcBmanuB"
hid(B sucked up by the insects in the blood of the
patients on whom they had fed ; — this proof was
obtained by subsequent investigations of mine;
but . • . the clue was obtained : it was necessary only
to follow it up — an easy matter."

380 THE HISTORY OF MEDICINE

The zygote^ which is the ovum of the female game-
tocjrte fecundated by the motile filament of the male
gametocyte, gives rise to spores or blasts^ which are
found distributed in various parts of the insect.
** Beyond this it was difficult to go, but at last, after
examining the head and thorax of one insect, I
found a large gland consisting of a central duct sur-
rounded by large grape-like cells. My astonishment
was great when I found that many of these cells
were closely packed with the blastSf which are not
in the least like any normal structure found in the
mosquito. Now I did not, at this time, know what
this gland is. It was speedily found, however, to be a
large racemose gland consisting of six lobes, three
lying on each side of the insect's neck. The ducts of
the lobes finally unite in the common channel which
runs along the under surface of the head and enters
the middle stylet^ or lancet^ of the insect's proboscis.
It was impossible to avoid the obvious conclusion.
Observation after observation showed that the
blasts collect within the cells of this gland. It is the
salivary or poison gland of the insect, similar to the
salivary gland found in many insects, the function of
which in the gnat had already been discovered —
although I was not aware of the fact. That function
is to secrete the fluid which is injected by the insect when
it punctures the skin^ fluid which causes the well*
known irritation of the puncture, and which is

PREVENTIVE MEDICINE 381

probably meant either to prevent the contraction of
the torn capillaries or the coagulation of the ingested
blood. . • • The blasts must evidently pass down the
ducts of the salivary gland into the wound made by
the proboscis of the insect, and thus cause infection
in a fresh vertebrate host.*^

Ross's investigations were carried on from 1895 to
1899. In 1897 Dr. W. G. MacCallum discovered the
function of the motile filaments already referred to,
and in 1898-99 Bignami and others demonstrated
that all mosquitoes acting as hosts of malarial para-
sites belong to the genus Anopheles. In 1900 Dr.
Sambon, accompanied by friends and servants, suc-
ceeded in living in a malarial district near Rome
(Ostia) without contracting fever — and that from
the beginning of July till October 19th — exercis-
ing the sole precaution of remaining within a well-
screened hut from sunset to sunrise. It was also
shown that mosquitoes that had bitten malarial
patients in Italy could, when carried to England,
transmit the infection to people who had never been
in a so-called malarial district. Mr. Manson, the
son of Dr. Manson, submitted to the experiment
necessary to establish this fact.

Methods of sanitation, developed largely by Ross,
were soon extensively employed in the control of
malaria. These included the use of nets and wire
screens, the protection of tanks and other water

383 THE HISTORY OF MEDICINE

receptacles, the clearing away from the neighbor-

hood of human habitations of empty tins, broken
bottles, gourds, buckets, and bits of pottery in which
mosquitoes might lay their eggs, the drainage of
swamps, the filling-in of poob and puddles, the
extirpation of undergrowth, the oiling of stagnant
waters, the killing of mosquitoes by fumigations,
and the destruction of the larvae by means of fish
and other natural enemies. At the same time the
systematic use of quinine as a preventive was
greatly extended in the tropics through the influence
of Koch. Ross visited the west coast of Africa in
1899, and before the dose of 1901 encouraging re-
sults of sanitary measures suggested by the discov-
ery of the part played by Anopheles in malarial
infection were reported from Sierra Leone, Lagos,
Hong-Kong, certain points in the Malay Peninsula,
as well as from Italy, India, North Africa, and the
American Tropics. In 1902 Ross received the Nobel
Prize for his efforts to control malaria, the scourge of
the tropics, and of all diseases whatsoever probably
the most detrimental to the health and efficiency of
man. At Ismailia, on the Suez Canal, where Ross
was in charge of sanitation, the number of cases of
malaria was reduced from 1551 in 1902 to 37 (all
cases of relapse) in 1905.

It was by the ingenuity and resolution of Major
Walter Reed, an American army surgeon, that an-

PREVENTIVE MEDICINE 383

other great triumph over tropical disease was made
possible. Bom in Virginia in 185 1, he succeeded by
severe application to study in securing the doctor's
degree at the University of Virginia before he had
completed his nineteenth year. He continued his
medical studies in the Bellevue Hospital Medical
College, New York, had considerable hospital ex-
perience in that city and in Brooklyn, became dis-
trict physician in one of the poorest parts of the
metropolis, and was appointed one of five inspectors
on the Brooklyn Board of Health. He soon gave up
the idea of general practice, and, having passed the
examination of the Medical Corps of the United
States Army, he married, and at the age of twenty-
four entered upon his garrison duties in the West.
He had an extended experience of frontier life —
Arizona, 1876-80, Nebraska, 1882-87, and Dakota,
1891-93. For a short time in 1881 he was stationed
at Fort McHenry, Baltimore, and was able to pursue
at the Johns Hopkins University the study of phys-
iology, but a greater opportunity, which he seized
with avidity, came in 1890-^1, when he served as
examiner of recruits at Baltimore. He now devoted
himself to pathology and bacteriology, and was in
dose relation with Welch, Councilman, Abbott,
Thayer, Nuttall, and other leaders in medical sci-
ence, at the Johns Hopkins Hospital. He undertook
an investigation into the so-called lymph nodules of

384 THE HISTORY OF MEDICINE

the liver in typhoid fever, and gave further evi-
dence of an aptitude for research.

After his two years of service in Dakota, Reed
was appointed curator of the Army Medical Mu-
seum at Washington and professor of bacteriology
in the Army Medical School. He was deeply inter-
ested in the discovery of the Klebs-L5ffler badllus,
and was the champion of the antitoxin treatment
of diphtheria. He made numerous contributions to
professional periodicals, and prepared reports on
malarial fevers at Washington Barracks and Fort
Myer, and on serum diagnosis in typhoid fever. In
1897 Reed and Dr. James Carroll were appointed by
Surgeon-General Sternberg to investigate the claim
of Professor Sanarelli of Bologna that BaciUus ictef'-
oideSf found by the Italian scientist in the blood of
yellow-fever patients in Brazil, was the cause of
yellow fever. It was especially desirable that the
organism observed by Sanarelli should be compared
with Bacillus X, which had been observed ten years
previously, by Sternberg himself, in yellow-fever
patients. In a preliminary report in 1899 Carroll
and Reed stated that Bacillus icteroides (ultimately
shown to be identical with Bacillus X) is really a
variety of the hog-cholera bacillus, with which Reed
had become familiar while working with Welch and
Clement at the Johns Hopkins Hospital. After the
beginning of the Spanish- American War of 1898,

PREVENTIVE MEDICINE 385

Reed was made chairman of a committee to inves-
tigate the origin and spread of typhoid fever in the
United States military camps, but his great opening
came, when, in 1900, yellow fever having broken out
among the American troops in Cuba, he was made
chairman of an Army Board, composed of Carroll,
Lazear, Agramonte, and himself, appointed to inves-
tigate the cause of the disease.

How little was known, at the time of the Spanish-
American War, concerning the cause of yellow fever
and its mode of transmission is shown by a report of
the officers of the United States Marine Hospital
Service, which declared that it was spread by the
infection of places and articles of bedding, clothing,
and furniture. "More recently,*' this report of
1898 continues, ''the idea has been advanced that
probably the germ of yellow fever enters the general
circulation through the respiratory organs in some
obscure manner, and incubating in the blood di-
rectly poisons this life-giving stream. However this
may be, the present opinion is that one has not to
contend with an organism or germ which may be
taken into the body with food or drink, but with an
almost inexplicable poison so insidious in its ap-
proach and entrance that no trace is left behind/'
The American army in Cuba almost succumbed to
its unseen enemies. After two months' campaigning
it "was utterly used up and of no value whatever as

386 THE HISTORY OF MEDICINE

a fighting machine/* at least four fifths of the troops
being incapacitated by tropical diseases and ty-
phoid. When Gorgas took control of the sanitation
of Havana he was influenced by the rather vague
assumption that yellow fever was a filth disease.
Though he was thrown into daily contact with Dr.
Carlos Finlay, Gorgas took very lightly the mos-
quito hypothesis which the Havana doctor had been
maintaining stoutly since 1881. By the middle of
1900 Gorgas had made Havana, in his judgment,
the cleanest city in the world, but there were more
cases of yellow fever than for several years previ-
ously, and the inhabitants twitted him with the
fact that the disease was particularly prevalent in
the cleanest sections of the Cuban capital.

Reed, who arrived at this juncture — June, 1900
— soon found his way, with the able support of Car-
roll, Lazear, and Agramonte, through the welter of
misconceptions concerning the etiology and trans-
mission of yellow fever. Some time was spent by
the Board in giving the coup de grdce to Sanarelli's
hypothesis. Agramonte had previously — at San-
tiago — found Bacillus icteroides in thirty-three
per cent of the yellow-fever patients examined by
him. Now, however, eighteen cultures from as many
yellow-fever patients failed to show the presence of
the hog-cholera bacillus. At the end of July Reed
went to the Pinar del Rio Barracks, where a number

PREVENTIVE MEDICINE 387

of cases of yellow fever had occurredi and there he
made two very important observations* He noted
in the first place that several non-immunes had
come into intimate contact with clothing and bed-
ding contaminated by . yellow-fever patients with-
out any apparent deleterious effects. He noted in
the second place that a prisoner confined with eight
others in a cell of the guardhouse had contracted the
disease, while his companions had escaped infection,
and that it had been surmised at the time that the
victim had been bitten by an insect, perhaps by a
mosquito. Very soon after his arrival in Cuba Reed
had taken account of Finlay's hypothesis, as well as
of the attempts to put it to experimental proof, and
had obtained from Finlay eggs of the Stegomyia, the
supposed carrier of the pathogenic organism. More-
over, Reed had been impressed by the work of Ross,
Bignami, and others concerning the dissemination
of malaria. He declared it to be ''of the highest
importance that the agency of an intermediate host,
such as the mosquito, should either be proven or
disproven."

Ross's belief in an intermediate host had been
influenced by the report of Dr. H. R. Carter's ob-
servations in Mississippi (1898) concerning the time
that elapsed between the arrival of cases of yellow
fever in isolated farmhouses and the occurrence of
secondary infections. Finlay's attempts to produce

388 THE HISTORY OF MEDICINE

yellow fever by the Wte of Stegomyia had failed
because he did not know that the insect does not
become infectious till about twelve days or more
after feeding on a yellow-fever patient, and that
the blood of the patient does not infect the insect
except in the first three days of sickness. The first
experiments of Lazear with supposedly infected
mosquitoes failed for similar reasons, but on August
27th| Dr. Carroll allowed himself to be bitten by
mosquitoes that had fed on yellow-fever patients,
and one of the insects was able to produce the
desired result. After some slight premonitory symp-
toms he developed a severe case of yellow fever
August 3ist. On September 13th Lazear, while
working among yellow-fever patients at Las Animas
Hospital, Havana, observed a mosquito biting his
hand. He allowed it to take its fill. He was attacked
by yellow fever September i8th, and died of the
disease a week later. On the basis of these and other
cases Reed stated in the following month — ''The
Etiology of Yellow Fever: A Preliminary Note*' —
that the mosquito acts as the intermediate host for
the parasite of yellow fever. The task remained by
a series of well-controlled experiments to support
this statement and to test the claims of other pos-
sible means of infection besides the bite of the mos-
quito. Accordingly a quarantined camp, named in
honor of Dr. Lazear, was established about a mile
from Quemados, Cuba.

PREVENTIVE MEDICINE 389

" It was now proposed," writes Reed, "to attempt
the infection of non-immune individuals in three
different ways, namely, first, by the bites of mos-
quitoes which had previously bitten cases of yellow
fever; second, by the injection of blood taken during
the early stages from the general circulation of
those suffering from the disease; and, third, by
exposure to the most intimate contact with fomites.
For this purpose, in addition to the seven tents pro-
vided for the quartering of the detachment, two
frame buildings each 14 x 20 feet in size were con-
structed. These buildings, having a capacity of
2800 feet, were exactly similar, except that one of
them, known as the 'Infected Mosquito Buidling,'
was divided near the middle by a permanent wire
screen partition and had good ventilation ; while the
other, designated as the 'Infected Clothing Build-
ing,' was purposely so constructed as to exclude
anything like efficient ventilation. These houses
were placed on the opposite sides of a small valley,
about eighty yards apart, and each seventy-five
yards distant from the camp proper. Both houses
were provided with wire screen windows and double
wire screen doors, so that mosquitoes could be kept
within or without the buildings as the experiment-
ers might desire."

On December 5th Private Kissinger, who (with
Moran) had volunteered without pecuniary reward,

390 THE HISTORY OF MEDICINE

''solely in the interest of humanity and the cause of
science/' to submit to the experiment, was bitten by
infected mosquitoes, and in about tliree and a half
days suffered an unmistakable attack of yellow fever.
During the week following the onset of his illness
four other cases of the disease were produced by the
same means in the Infected Mosquito Building.
On December 21st and 22d Moran was bitten, and
on Christmas morning he had a sharp attack of the
fever; but two other volunteers, who slept for fifteen
nights on the other side of the wire screen partition,
by which the building was divided, remained in good
health because they were protected from the mos-
quitoes. A building is infected only in as much as it
harbors infected mosquitoes. In the Infected Cloth-
ing Building Dr. Cooke and Privates Folk and
Jemigan slept every night from November 30th till
December 19th in close contact with blankets,
sheets, pillow-slips and pyjamas polluted beyond
description by yellow-fever patients in Las Animas
Hospital and other institutions. The three remained
in perfect health in spite of passing twenty nights
in hot, ill-ventilated, and noisome quarters. In a
later experiment — January 4, 1901 — Jemigan was '
inoculated with blood drawn from a yellow-fever
patient in the early stage of the disease. He de-
veloped yellow fever in about four days. Blood
taken from him within the first three days of his

PREVENTIVE MEDICINE 391

31nes8 and injected into a non-immune proved cap-
able of transmitting the disease, a fact which was
taken to indicate that the casual agent is a living
organism and not merely a chemical toxin. It was
further proved by e3q)eriment that the blood of a
yellow-fever patient remains infectious after passing
through a fine filter, but that it loses its virulence
after being heated to 55^ C.

The general conclusions announced by the Army
Board were: That yellow fever is conveyed from the
sick to the well solely by the bite of the female
Stegamyia mosquito; that the insect can become in-
fected only after sucking the blood of a patient
within the first three days of the sickness ; that the
period of extrinsic incubfttion is from twelve to
twenty dajrs ; that the period of intrinsic incubation
is from three to six days; that yellow fever may be
produced artificially by injecting a non-immune
with the blood of a patient in the early sti^ of the
disease; and that the causal aig^t of yellow fever
is a sub-microscopic parasite. "These discoveries/*
writes Gorgas, "have been of enormous benefit to
mankind, and upon them has been based the sani-
tary work against yellow fever which has been so
successful."

To the splendid efforts of Major (later Surgeon-
General) Gorgas, who at the time of the Army
Board's report — February, 1901 — was chief sanir

392 THE HISTORY OF MEDICINE

tary officer of Havana, the practical success of con-
trolling yellow fever was due. All cases of the disease
occurring in the city were required to be reported
immediately to the Health Department. The pa-
tients were carefully screened from mosquitoes in
order that they might not become the source of
further infection. A war was carried on against the
insects by the use of fumigations of sulphur and of
pyrethrum powder, by the destruction of larvae,
and by the protection of barrelSi cisterns, etc., and
by the removal of tin cans and other breeding-places.
Any ship with yellow fever on board was fumigated
in order to kill infected mosquitoes, and the non-
immune passengers or members of the crew were
detained at a quarantine station for a period of six
days. There had been three hundred and ten deaths
from yellow fever in Havana in 1900; there were
only eighteen in 1901. Of these eighteen cases,
seven occurred in the month of January, five in
February, one in March, one in July, two*in August,
and two in September, For the first time since the
capture of Havana by the British during the Seven
Years' War, the city became free from yellow fever.
"For two hundred years before this time [1762],'*
writes Gorgas, "Havana had been subject to epi-
demics of yellow fever, but from 1762 up to the
year 1901, there was probably not a single day when
Havana did not have a case of this disease within its

PREVENTIVE MEDICINE 393

bounds/* Gorgas attacked the Anopheles mosquito,
as well as the Stegomyia^ and the number of deaths
from malaria in Havana was reduced from three
hundred and twenty-five in 1900, to one hundred
and fifty<Kine in 1901, to seventy-seven in 1902, and
to four in 1912,

Eariy in 1902 Gorgas called the attention of
Surgeon-General Sternberg to the value of appljdng
the principles established by the Reed Board to the
sanitation of the Isthmus of Panama in case the
United States should take over the construction of
the Canal. He was soon relieved of duty at Havana,
and ordered to the United States in order that he
might be in touch with preparations for work on
the Isthmus. In the spring of 1904 he, as sanitary
adviser accompanied the Commission (Isthmian
Canal) on a visit of inspection to Panama* His
oiganization b^an in June. Finding "that the
Fruich had lost yearly by death from yellow fever
about one third of their white force,'' he made an
onslaught on the mosquitoes, principally by the use
of fumigations in the city of Panama. Success was
not immediate. There was a great deal of yellow
fever within the ensuing twelve months, but in the
autumn of 1905 the number of cases rapidly de-
clined. After November the disease ceased to exist
in the dty of Panama. One case occurred at Colon
in the spring of 1906, but since then not one case of
yellow fever has originated on the Isthmus.

394 THE HISTORY OF MEDICINE

''Of the six important tropical diseases/' says
Osier, "plague, which reached the Isthmus one
year, was quickly held in check. Yellow fever, the
most dreaded of them all, never recurred. Beri-beri,
which in 1906 caused sixty«eight deaths, has gradu-
ally disappeared. The hookworm disease, ankylo-
stomiasis, has steadily decreased. From the very
outset, malaria has been taken as the measure of
sanitary efficiency. Throughout the French occa^
pation it was the chief enemy to be considered, not
only because of its fatality, but on account of the
prolonged incapacity following infection. In 1906,
out of every 1000 employees there were admitted to
the hospital from malaria 821 ; in 1907, 424; in 1908,
282; in 1912, no; in 1915, 51; in 1917, 14. The
mortality from the disease has fallen from 233 in
1906 to 154 in 1907, to 73 in 1908 and to 7 in 1914.
The death rate for malarial fever per 1000 popula-
tion sank from 8.49 in 1906 to o.ii in 1918. Dysen-
tery, next to malaria the most serious of the tropical
diseases in the Zone, caused 69 deaths in 1906; 48 in
1907 ; in 1908, with nearly 44,000 only 16 deaths, and
in 1914, 4."

REFERENCES

Gorgas, W. C: SanilaUan in Panama. 1915, 998 pp.
Kelly, H. A.: Walter Reed and Yellow Fever. 1906. 293 pp.
Lankester, E. Ray: The Kingdom of Man (chapter m, "Sleeping
SickneflB"). ^907. 191 pp.

PREVENTIVE MEDICINE 395

Mastersi Walter E.: EsseiUiak (tf Trapkal MedMne. 1920.

703 pp.
Oder, Sir WiUiam: The EnMum rf Modem Medicine. 1921.

243 PP-
Rosenau, Milton J.: PreDenike Medicine and Hygiene. 1914.

1074 pp.

R068, Sir Ronald: Mosqmto Bri§ades and Hew lo Organm Them*

1901. 98 pp.

CHAPTER XX

MEDICAL SCIENCE AND MODERN WARFARE

The achievements of medical science in the emer-
gency created by the outbreak of war in 1914 were
owing in no inconsiderable degree to officers imbued
with the spirit of research and with the enterprise
that had checked the ravages of yellow fever and
malaria, discovered the cause and the mode of
transmission of Malta fever and trypanosomiasis,
developed a treatment for amoebic dysentery,
adopted measures for the cure of beri-beri, and
dealt successfully with hundreds of thousands of
cases of hookworm disease.

Preventive measures against typhoid, the appli-
cation of which to millions of men was one of the
important successes of the World War, were made
possible by the work of Sir Almroth Wright and
others. The Bacillus typhosus had been discovered
by Eberth in 1880. In 1896 PfeiflFer and KoUe suc-
ceeded in inoculating two volunteers with the
disease. In this same year Wright devised his pre-
ventive inoculation — an emulsion of dead typhoid
bacteria. With this he inoculated British troops in
India to about the number of four thousand in 1898-
1900. During the Boer War Wright, in co5peration

MEDICAL SCIENCE AND WARFARE 397
with Sir William Leiafaman, extended the prophylac-

tic treatmait to 100,000 troops in South Africa.
It was adopted by the medical officers of the Frendi
and German colonial troops. The prevention of
typhoid among the Japanese sddiers was one of the
outstanding features of the Rus8o-J^>anese War of
1904. Of 12,801 men of the United States army,
who during the Mexican border troubles of 1912 had
received preventive treatment under the direction
c^ Major Russell, only two devdoped typhoid. This
result is all the more striking when we recall that
at the time of the Spanish- American War there had
been among 107,973 men in the United States
encampments 20,738 cases of typhoid fever and
1580 deaths. During the World War preventive
measures, including the chlorination of waters and
the control of carriers, were made more and more
effective. The technique of prophylactic inocula-
tion was developed among the British by officers
working under the direction of Leishman. From the
beginning of 1916 the triple vaccine, for the pre-
vention of the paratyphoids — the bacteriology of
which had been set forth by Buxton in 1902 — as
well as of typhoid proper, came into use, and was
followed by other polyvaccines. Among the mil-
lions of United States troops, in the two years sub-
sequent to the declaration of war in April, I9I7>
there were only 227 deaths from typhoid fever.

39« THE HISTORY OF MEDICINE

The labors, toward the dooe of the nineteenth cen*
tury, of the Prussian army surgeon Emii von Behring
and others had prepared the way for the successful
emplojrment of serums in the World War. The Bacil-
lus tetani had been discovered by Nioolaier in 1884.
Five years later Kitasato had succeeded in growing
the organism in pure culture. In 1890 von Behring
in collaboration with Kitasato published an article
concerning the production of diphtheria immunity
and tetanus inununity in animals. His serum ther*
apy (as explained in Die Blutserumlherapie, 189a)
is founded on the principle that the serum of animals
rendered immune to a disease acts, if introduced
into a living organism, as an antidote to the virus
of the bacteria concerned. In the first part of the
World War there were a great many losses through
tetanus — so many, in fact, among the allied
troops in the weeks following the first battle of the
Mame as to give rise to the most serious apprehen-
sions. In the month of October, 1914, the ratio of
cases among the wounded was 32: 1000. This was
quickly reduced to 2 : 1000 by the use of anti-tetanus
serum. During the war the serum treatment was
used also to control cerebrospinal meningitis. The
pathogenic organism had been isolated by Weichsel-
baum in 1887. Dr. Simon Flexner had undertaken
the investigation of the disease in 1905 and after a
series of experiments bad produced a prophylactic

MEDICAL SCIENCE AND WARFARE 399

serum. In 1914-15 a severe epidemic broke out
among the Canadian troops and (according to
Osier) the infection was carried by them to England.
It was particularly rife in the camp on Salisbury
Plain. In 1915 it was discovered that a better serum
could be prepared by injecting into animals dif-
ferent strains of the menigoooocus, the differentia-
tion of which is still under investigation. It was
also found desirable to isolate soldiens suspected of
being carriers^ as the infection is readily conveyed
from person to person by coughing and sneezing.

Influenza, another disease disseminated through
discharges from the mouth and nose, baffled the
resources of medical sdaice, and became very
deadly in the armies, as well as in the civil pop-
ulations throughout the world. For example, it
b^an to attract special attention among the British
troops on the northern part of the western front
about April, 1918, that is, a few weeks after the
beginning of the final campaign. It was soon, known
to be pandemic and extremely infectious. The
earlier cases were quite mild, but the disease became,
as it spread, more and more virulent. June 23d a
committee which had been appointed to study
influenza reported to the Director General of the
Medical Services that the contagion of this disease
appears to be air-borne. "The main principle to be
followed, therefore, is to spread troops as widely

400 ^ THE HISTORY OF MEDICINE

as possible, avoiding the crowding of men in tents,
billets, messrooms, etc/* Whenever the military situ-
ation permitted, the troops were to sleep in the open
air in individual blanket-shelters. Influenza patients
were to be kept separate from other patients. Of
course it was frequently impossible to live up to
the sanitary suggestions contained in this British
report. This was notably the case in the traiisporta-
tion of troops. In September the American trans-
port Nestor left the United States for England with
2807 soldiers on board. Two or three days later she
was forced to land 660 patients and contacts at
Sydney, Cape Breton. But, in spite of this precau-
tion, 1000 more men were taken ill before the ship
reached Liverpool. The military camps in the
United States were severely smitten, and the deaths
from influenza and its complications outnumbered
the country's total losses in battle.

The stimulating influence of war on research in
the various sciences is obvious to every student of
history. The effect of the World War on the prog-
ress of medical science was early recognized and is
becoming every day more manifest. At the begin-
ning of 1917 Sir F. W. Andrewes expressed the
opinion ''that in pathology, no less than in the other
sciences, advances have been made, under the
stress of national necessity, during the two years
and a half of war which could hardly have been

MEDICAL SCIENCE AND WARFARE 401

expected in twenty years of ordinary woric; and
although it has been 'war work/ it represents a
solid contribution to science which will be valid for
the years of peace to come." The occurrence of
dysentery among the troops in Gallipoli, Egypt,
Mesopotamia* and other regions led to a renewed
investigation of the causative agents of both the
badllary and amoebic forms of the disease, and to a
modification of the use of emetine and emetine
bismuth iodide in the treatment of amoebic dys-
entery. Ailments like trench foot, trench nephritis,
and trench fever, incident to life at the front under
new and peculiar conditions, were a challenge to the
medical science of the twentieth century as syphilis
had been to the less highly developed medical science
of the sixteenth century. Trench fever, named toward
the end of 19 15, was proved by investigations to be
transmitted by the louse, and this discovery sug-
gested as a means of control such a crusade i^ainst
the insect carriers as had proved effective in combat-
ing tyjAus in Serbia and elsewhere. Trench fever
is probably not only a newly recognized disease but
an absolutely new disease, caused by a micro-
organism which has now for the first time invaded
the tissues of man. Trench nephritis, on the other
hand, had been described during the American
Civil War. Soldier's heart, closely studied by J. M.
Da Costa among the Federal troops, had been

402 THE HISTORY OF MEDICINE

observed in the Crimean War. After the outbreak
of the World War disordered action of the heart
(investigated by AUbutt and others) as well as
pyrexias of uncertain origin, became familiar to
every medical officer. Infective jaundice, which
was no doubt rife among the American soldiers in
1861-65, and is now known to be caused by a para«
site {Spirodiata icterofuBmorrhagia)^ was epidemic
at times during the recent war ; while toxic jaundice
was of frequent occurrence in munition factories.

Observations made during the World War give
considerable promise of advance in our knowledge
of psychiatry. Some of the methods of testing the
mental fitness of the men and of rating the officers
were rather crude and illogical, and the statistical
methods applied to the data led at times to results
which the scientific mind will receive with caution.
Nevertheless, great enterprise was shown — notably
in America — in the task of taking stock of the
mental equipment of millions of young men. It has
been claimed as the result of extensive investigation
that a very large percentage of twelve*yearK>ld
minds is found among American men of military
age. The records of the discharge of soldiers from
the British armies as permanently unfit on account
of nervous or mental diseases have, similarly, been
regarded as indicating that a considerable propor-
tk>n ol the male population of a highly civilized

MEDICAL SCIENCE AND WARFARE 403

country possesses a neurotic or neuropathic predis*
position.

The British War Office recognized three forms of
war neurosis — shell shock, hysteria, and neuras-
thenia. Needless to say, the symptoms described
under each of these cat^ories show that the classifi-
cation was not wholly satisfactory. Some cases
included under shell shock were definitely known to
be the result of the percussion of explosives, to the
direct effect of which organic changes, like the rup-
ture of the tympanic membrane and the alteration
of the spinal fluid, bore witness. Other cases of shell
shock seemed more purely psychic in their mani-
festations. Both types contributed to corroborate
the teachings of Darwin and James concerning the
intimate relations between the emotions — fear, for
eacample — and the physiological concomitants of
the emotions. Does the shattering effect, on the
body, of air-vibrations constitute the agitation we
call fear, or does ^he recognition of danger provoke
the physiological symptoms? The well-attested fact
that a cold wind playing upon a sleeper may give
rise to a dream of fear seems to support the view
that it is the bodily state that gives substance and
character to the emotion.

Colonel Mott holds that in any case there is a
vicious circle, the perceptual feeling of fear stimulat-
ing the physiological »vmptoms and these in turn

404 THE HISTORY OF MEDICINE

giving reinforcement to the psychic condition. In
his patients he found evidence of a persistence of the
bodily changes characteristic of a state of fear.
About ten per cent of the cases of severe neuras-
thenia showed some of the symptoms of Graves's
disease, among the exciting causes of which fright,
worry, and mental shock have long been recogniased.
Other cases gave evidence of an unusual amount of
adrenin in the blood, an increase of which secretion
occurs as a result of fright, as has been shown ex-
perimentally by Cannon. The view here taken con-
cerning the importance for the emotional life of the
internal secretions — of the thyroid as well as the
adrenals — might be supported by referring to
Addison's disease, in which the atrophy of the
adrenals may give rise to languor, anaemia, and
cardio-vascular asthenia. Fear, including the in-
creased heart rate, is a preparation for fight or
flight; but, as Mott remarks, in trench warfare,
which is particulaiiy prolific of war neuroses, the
emotions are deprived of their natural functions.
The soldier can neither fight nor take refuge in
flight; he can only adopt the crouching attitude of
immobility. The result may be a deep-seated
emotional derangement.

''In the dreams of soldiers, ideas of past war
experiences are revived with great vividness in the
great majority of cases, even in those who are unable

MEDICAL SCIENCE AND WARFARE 405

to recollect their dreams. For besides thoee patients
who wake up in a fright and cold sweat, there have
been numerous instances of soldiers who have
walked in their sleep, and many others have talked,
shouted out orders, and cried out in alarm as if
again engs^^ed in battle (not a few of these have been
mutes). But the strangest phenomena of foi^otten
dreams of soldiers suffering from shock are observed
in those who in their sleep act as though they were
engaged in battle, and go through the pantomime of
fighting with bombs, with bayonet, with machine
gun and with rifle, and yet remember none of these
things when they wake. Evidently during their
sleep vivid ims^inings of their previous experiences
are arousing defensive and offensive reactions in
face of the imaginary enemy." Neuropathic patients
who show symptoms, in the early morning, of
nervous exhaustion and irritability are not infre-
quently the victims of dreams of a highly emotional
sort which may be beyond the power of recall of the
waking consciousness.

In the treatment of war hysteria persuasion, sug-
gestion and psychoanalysis proved effective. It
was found advisable to explain the symptoms and
the natiue of the neurosis to a few of the more intel-
ligent patients and to employ their powers of per-
suasion to induce a new mental attitude in the
others. Grateful patients already on the highroad

406 THE HISTORY OF MEDICINE

to recovery thus became very helpful in bringing
about cures* Any form of treatment that in^ired
in the patient the confidence that something eflFee-
tive was being done in his bdialf had a therapeutic
value. Even where no bodily derangement was
Mspected a thorough physical examination was
necessary in Cfrder to establish the physician in the
confidence of the patient. The physician's p^^onal-
ity and the surroundings generally had a powerful
influence on the suggestible minds of the patients.
In addition to its suggestive value electricity enabled
the physician to prove to patients suflFering from
hysterical paralysis that their muscles had not tost
the power of contraction. It also restored sensibility
in cases of hysterical anaesthesia, and thus renewed
the patients' consciousness of the affected parts.
Passive movements of an apparently paralyzed
Kmb might afford the kinaesthetic cue for active,
voluntary movements. The metiiod of psychoanaly*
sis — t»eaking down dissociations and inducing an
integration of consciousness by the revival of re-
pressed emotional ^cperiences — found many cham*
pions among those who succeeded in the treatment
of war hysteria. The revival of the repressed e^q^^-
ence — such as remorse in connection with the
death of a comrade — must be emotional in diar-
acter in order to bring about a satisfactory catharsis ;
and the revived experience should be recalled ^ain

MEDICAL SCIENCE AND WARFARE 40^

and again till the memoty loses its dramatic vivid-
ness. The fact that an anxiety neurosis may super-
vene on the removal of the hysterical symptoms
should warn us that dissociation is after all a means
of defense against unbearable mental strain. ''My
dearest wish," wrote a young correspondent towards
the dose of the war, "is to forget the whole grew-
some business.*' What Culpin calls "the ever*
growing sense of horror" led at times to prolonged
amnesias, the treatment of which by the method of
psychoanalysis had to be undertaken with the ut^
most caution.

In reporting on the surgical developments of the
World War Dr. W. S. Bainbridge writes: "In the
many hospitals and casualty clearing stations
vi^ted, the method of treating war wounds varied
greatly. There were those who believed in the use
of the strongest antiseptics, as at the Grand Palais,
where phenolization was employed, while others
favored incising freely with drainage and practically
no antiseptics. More and more the two extremes are
being emphasized; on the one hand, the Carrel
treatment with its scientific laboratory control and
systematic use of strong antiseptic solutions, and on
the other, d&ridemefU and immediate closure/* The
faihire of the ordinary antiseptic methods to meet
the conditions of warfare on the western front, where
the heavily manured soil was charged with or«

408 .THE HISTORY OF MEDICINE

ganbms, soon led to modificatioiis, such as the vse
of drainage with antiseptics, and the use of hypo-
chlorites. The Carrel method, which attracted gen-
eral attention in 1916, soon found rivals in other es-
sentially antiseptic methods. In 191 7-1 8 the method
of primary wound suture, immediate or delayed,
came into special prominence. ''Under favorable
conditions," continues Bainbridge, "primary union
by immediate or delayed suture of war wounds
which have been operated on and properly purified,
is now the last word in this branch of sui^gery. Ex-
perience in the Worid War has taught entirely new
lessons to the surgeons who found themsdves con-
fronted with unprecedented conditions both in
regard to the masses and classes of war wounds
they were expected to handle. Perhaps the most
important lesson of all, with the closest bearii^ on
wound treatment in general, consists in the recogni-
tion of the fact that antiseptics are inefficient with-
out the most careful and thorough mechanical
purification of the wound, including the complete
removal of all dead or nonviable tissue/'

Sir Henry Gray eicpresses a similar conclusion.
''Much discussion," he writes, "took place during
the early periods of the war as to the best form of
dressing and the most effective lotions to be em-
ployed in the treatment of wounds. It was hoped
that by the early use of suitable disinfectants much

MEDICAL SCIENCE AND WARFARE 409

would be done to combat the d&set of sepds. It has
been found that antiseptics per se have but little
influence in this direction, and that the best hope of
averting the danger of severe sepsis lies in early and
efficient operation. The use of ordinary disinfectants
and impregnated dressings is of little or no value in
most cases until such operation has been carried
out/' He adds that eusol and similar solutions are
too evanescent in antiseptic action when in contact
with the tissues to make their use worth while, and
Carrel's method is out of the question in the eariy
treatment of war wounds. The experience of the
twentieth century has confirmed the judgment of
the sixteenth that all gunshot wounds are necessarily
infected, and for Gray sepsis, shock and haemorrhage
are interdependent phenomena. The wounded must
be carefully guarded against all emotional and sen«
sory stimuli liable to provoke shock, and the loss of
every additional ounce of blood is of the utmost
importance. "Nothing," as Gray says, "has been
more striking than the rapid spread of the use of
blood transfusion as a therapeutic measure for the
combating of shock-haemorrhage. During the first
two years of the war transfusion was performed only
by a few specially experienced surgeons, and was
regarded more as an interesting curiosity than as a
practical measure in the treatment of shock. It is
only during the last two years that its scope has

410 THE HISTORY OF MEDICINE

been realised, aod that it has beeo adopted as a
recognized part of the treatment of the severely
wounded man."

War sui^ery was greatly facilitated by improved
methods of anaesthesia, as wet! as by radiography
and other means of determining before operation
the nature of the injury and the exact location of
bullets, shrapnel, or other foreign bodies. Local or
regional anaesthesia was frequently employed even
in major operations. Nitrous oxide and oxygen came
into very general use. Sometimes these inhalations
were onnbined with small quantities of ether, or
administered after preliminary injections, nerve
blocking, etc. There occurred a revaluation of the
various anaesthetics and combinations of anaesthet-
ics, and an increased discrimination in their use.
Moreover, professional opinion was rendered so
unsettled in reference to the worth of the various
methods of inducing surgical anaesthesia that the
search for new drugs and anaesthetic preparations
has been greatly stimulated.

In the localization of foreign bodies, as well as of
fractures and other injuries, radiography was indis-
pensable. Unless the cases suffering from bullet or
shrapnel wounds were screened, it was as a rule
impossible to conjecture the location of a projectile.
A bullet entering the back above the scapula might
lodge in the anterior wall of the abdomen without

MEDICAL SCIENCE AND WARFARE 411

its passage through the lungs being revealed by any
remarkable symptoms. Small fluorescent screens
that could be closely applied to the skin of the
patients were used by some radiographers. Frac-
tures and other injuries that could not be detected
on the screen were often revealed by an examination
of the plates. In many cases stereoscopic radio-
graphs proved invaluable to the operator. Besides
radiography, other ingenious devices were used in
the localization of bullets and other projectiles.

The exigencies of the World War entailed a very
gre^t extension of orthopsedic surgery. Through the
activity of Sir Robert Jones — exponent of the
practice and principles of Hugh Owen Thomas and
John Hunter — the British Orthopaedic Centers
with only two hundred and fifty beds at the start
developed into the Special Military Surgical Hospi-
tals with thirty thousand beds. In these institutions
the general sui^eon, the orthopaedic surgeon, the
neurologist, as well as the experts in hydrotherapy,
massage, gymnastics, vocational training, etc.,
cooperated in the repair of injuries and the restora-
tion of the functions of nerves and muscles. To
obtain the best results it was essential to secure con-
tinuity of treatment. The importance of the work
of the advanced units in the prevention of deformi-
ties was very clearly recognized. At the earliest
possible moment after the occurrence of a fracture

412 THE HISTORY OF MEDICINE

It became the practice to adjust a suitable qiliiit.

such as a Thomas 1% sfrfint or a swiveled Thomas
arm splint. Fractures of the femur at the begimiing
of the war frequently resulted in serious deformities;
later* Jones was aUe to report a series of five hun*
dred cases of compound fracture of the femur with
an average shortening of less than half an inch.
Remarkable successes were gained by the patient
treatment of comminuted septic fractures. In the
judgment of Sir Robert Jones ''the weight oi the
body should not be allowed on the unsupported
femur for at least six months after the recumbent
treatment of the fracture.** A badly sprained ankle,
however, should make a complete recovery in four-
teen days: whereas immobilization for weeks in
plaster would indefinitely perpetuate weakness and
disability. The theory of the Belgian surgeon Wil-
lems that joint lesions should be treated on the
principle of immediate active mobilization led of
course to a procedure far more drastic than any
employed in the British Special Military Sui^cal
Hospitals, where an opposed principle in the main
prevailed.

One of the outstanding successes in restorative
work was the plastic surgery at Queen's Hospital,
Sidcup, at Val-de«Grftce (Paris), at Boulogne, at Le
Mans, and at the American Ambulance at Neuilly,
The general sui^geons and the dentists here entered

PLASTIC SURGERY OF THE FACE

414 THE HISTORY OF MEDICINE

eariy stages of the war* Moreoveri Tuffier ibund
that a considerable number of those whose limbs
had been amputated in 1914-15 had to undeiigo a
further operation before they could take advantage
of prosthetic devices of recent invention. However,
the severity of our criticism of the medical and the
surgital treatment of the soldiers in the opening
years of the World War may be considered in some
sense a measure of the progress that has been made
in the medical sciences in general, not only in the
special fields here emphasized but in the develop*
ment of the treatment of venereal disease, in brain
and heart surgery, and in various other depart*
roents of the healing art,

REFERENCES

Allbutt, Sir Clifford T.: "The Investigation of the Significance
of Disoidera and Diseases of the Heart in SoldierB," pp.
90-92, British Medicine in the War (collected from BriUsh
Medical Journal), 1917.

Bainbridge, W. S.: ''Report on Medical and Surgidd Devdop-
ments of the War.'* U. S. Namd Medical BuUeiin, 1919.

Culpin, Millais: Psychaneuroses of War and Peace. Cambridge.
1920.

Da Costa, J. M.: ''On Irritable Heart" American Journal cj
Medical Sciences, 1871, pp. 17-52.

Gillies, H. D.: Plastic Surgery of the Face. Oxford, 1920.

Gray, Sir H. M. W.: The Early Treatment of War Wounds. Lon-
don, 1919.

Jones, Sir Robert (editor and contributor): Orthopcedic Surgery
of Injuries, 2 vols. Oxford, 1921.

Lelean, Percy: Sanitation in War. Philadelphia, 1917.

Mott, F. W.: "War Neuroses," Handbook, Clinical and Sd-
entific Meeting. British Medical Assodationt 1919.

INDEX

INDEX

ec of Tnlla, M.
^JlbnU.SIr T. c'u. 69. 3S3.4T4-

AmbideiUrity. s*-

la ^BblIlM>c• M Nanllr. 41

Anatomy, It, lO. iT,i>,40MMq., ei.Oi.

•eq., lei at Kq., tot, 143 M Rq., ate.

Ancoo •beep. 3<u.

Andrem*. St F. W„ 400.

Andiy, Nicolu. SiC

Anniiiim.eT.dil, 114, 17), t(J,lS4, MT.

161,366.
AiMtlna pcctocli, 1B4, 1)1, 367.

». r*. W, 1*9 at M*

A^nriBU. d WppoaMM, sa. M. b.
^luta orebfl, >Ti.
Ap(X)livria,6f
ApopleiT, lot, its.

Appendb, vcfmUatm, io>. rtr,

AnUaoiM, »> All 4t, TI.
Antm*, St, 6a. T4.
Ari^Mtk. 47. 69. n. it, 14, I
Anny Bouil, 3>i ct ma,

afif"

AkIu*. 6.

A»;l«[daibl (ANltlllldKl. a. JI, 4

Ai-ijdvilulion. J J

I. 73.'«i%

Athlcclo. 13, 19, 31, 4ti,
Alomi. ae, SOl

Atropfa'r of tbe Urs, iSO.
Auenbruoter, aoo et mn.
' folMU, I7.

D, iRi, ii4> m. «(&

So. >i, Bj.

Bo, >a, B3, S4, 91.
7>. 79. ■?■ 99. [ao>

4i8

INDEX

Babykmb, x ec leq.

BaciBus otUhracis, 317, 397.

BaciUus icUroides, 384, 396*

BaciUMS, Krtk9-LAiUr, 384.

Ba e i ttiu pestit, 374<

BaciUus Utawi, 398.

Bacilhu tmbtrauosis, 333.

BaciUus typhosus, 396.

BaciUus X, 384.

Bacon, Fniiids, i6t.

Bttcteriolofy, 3x6 et '«q., 335. 3S*. IM,

383. 384. 4X<>
Bachtishwa, 73 et tea.
Bmt. Karl Braat v., tSi. t4t.
Bagdad, 7a, 88, 90*
Bainbridfe, W. S., 407. 4x4.
Balfour, P. M., aso, ass*
Ban, Jaawi lloorM, X15.
Bandacins, 36, 46, 67. x9Qb
Baroekma, 358.
Bark, Peniviaa, X44, 154*
Bann, J^ x8o.
Baakenrllie, dMrtetk sff.
Baad, 3a4.
Batte. X3, 31, 73*

Bayard, Tbomas, 35'*
Bayle, aoT, ao8.

Beddoet, Thomaa, a7T>

Belli Bic Bbdi ▼•, sTSt ^OS*

Bell, Bauamin. 367.

Bell. Sir Charlea, ai8, aai. 136, 3x1.

Bellevue Hospital Medfcal Cofl^, 3>3*

Bellini, 135. 136.

Betensario da Carpif >06k

Beri-beri, 394, 396.

Bernard, Claade, a 18, 131, 137,

Bernard of Gordon, 8s.

Bert. Paul, 3a7*

Berthelot, M., pa.

Bertucdo, 95. 99.

Bkfaat. t8x. 189. aoB, txs. tS7» ittS*

Bifldow, Henry J., a86, 095^

Bignami, 381, 387.

BUharxiaala, 7. a6dw

BUroth, 349.

Biotamia, 3ax.

Biology, 3x3.
BladiOR, 2$a.
Black Death, xoo, 374-
Bland-Sutton, air foim, 3i^
Blaitodenn, 145.
BlasU, 38a
Blind, Kail, 367, 21$,
Block, I wan, 373^
Block, Oacar, 353*
Blocking, nerve, 4x0.
Boerkaave, 138, 157. x8a, aoi, att.
; Bologna. 95, 99, x88, 356, 384.
Bone grafta. 4x3.
Booetut, z8x.
Bonnet. Ckarlea, I39» 3x8.
Boielli, X35. X36.
Borgia, Alexander, 355.
Boulogne. 4xa.

Boyle, Robert. 140, X44> X59. 3M,
Brain, a8, i09i ^ mugfry, 4x4.

Biandikd cfcft i, gS3^

Brelnl, 37a.

Bredau, 369^

Britidi Aandatkm for the A d t aimm et

of Sdenoe. 35a.
Braockiectada, ais,
BronckltJa. ax5.
Bronckopbony, SX4.
Bronckotomy, 1x4.
Brooks, W. K., X3tfi.
Brown, H. M.. 373-
B rown , J.^XS9. 337-
Brown, Robert, a58*
Browne, & G., 9*.
BrUcke, a3X.
Bmit. flacert al, ax6fc
Bronscuwig, Hieroayimii, Xttl>
Buboes, 353.
Buckle, 198.
Buisson, X96w
Buidack, K. F., 146k
Boms, treatment of with

4x3.
Burton, Sir R. P., fik

Cabanls,S3A.
CkUus Aureliafflis, 60.
Cvsalplnus, xxs. 1x8. xa6i.
Cesarean operation. ioo» X14.
CMamus scHptoHus^ 50w
Calculi, XX, X56, x86.
Calkins. Gary W., 373.
Calmette. 339.
Oamac. C. N. B., ai7«
Camkfidge, 154.
Quneniius, ai8.
Cameron, Sir Hector, 34a, 353*
Camp Laaear, 388.
Camper, X57.

Cancer, 58, 6a, 67, 8a, xoo, 35<^
Canine teetk. 3xa
Cmmtdbis indica, 90.
Cannanng, xx7.
** Canon, 78.
Cannon, W. B., 404.
CarboUc add. 344* 343^

Caries, asx.

Carmine. asi»

Carpenter, W. B., 198, 335.

Otftdyeaitmeat, 407 et aeq.

Carrieiv, 397.

Carroll. James, 384 et mn*

Carter, H. R., 387.

Case kistories, 40.

Casualty clearing stations, 407 cf ae

Cataract. 51, 58. 67, 68, X14, x87.

Catgut ligatures, 35X.

Catkerine II, a4X.

Caton, Richard, 44.

Cautery, 3, 57, 79, 8x, 96, tx«i

Cell nudeus, 358.

Cell-itheory, tsi, V3, 857 et se<u

CdU, 376, 377.

Cdsus. 54.

Cerebrospinal menkulCia, 398, 399.

INDEX

419

Cervical f « t ebm, 6»
Chamberland. 329,
Chancre, HmterlaA, 36?.
Cliarlea VIII, 355-
ChauUac, Guy de, 99.
Chemlatnr, 87, 15S, I9li
ChgiDo-reccpCoca, 37 !•
CheMlden, a93«
Chiclcea dnlcm, 3it*
Chladnl, 309.

Chlorinatkm of water, 397.
Chloroform, a88 et acq.
Chloroeia, 7.

^oleraja74.334,a48.

Qioliiieley, H. P., 93.

Chorea, xs6i

Chronic dueaae, 41.

Chylotborax, 305.

Circulatkm, 5ti 108, It6 et tea., 136,

173. it3* 339>
Cfaxnimcision, 3, 4.
Ctvitaa Hippooaticn, 94.
Classification. 35S, 308, 3I3« dl7» 3a6w
Clcttieiit, 384-
gift, i74f 175, 176.
Clifton, Francis. 44.
Clover, J. T., 394.
Clowes, William, XI4.
Cnidus, 34, 37. 3t. 40, Sif 99»
Coagulation, 339 et seq.
Coction. 43. 53f 67, 100.
CaUnUraUt, 3S4.
Cohn, Ferdinand, 360, 33A.
Cohnheim, Julius. 370.
College de France, 331.
CoUdge de Saint Cdme, til.
••Colliget," 83, 84.
Colon, 393*

Color-blindneai, X79> 314.
Colot, Laurent, 1x4.
Colton, G. Q., 383, 395*
Columbus, M. IL, 1x4, xif.
Columella, 316.
Coma, 39i 156.
Comma baciUus, 333.
Condylomata, 184.
Congress of Anthropolofllflta, t49k
Conjunctivitis, 333<
Constantine the African, 84.
Constitutions, 34i 76, 146, 190,
ConimgimH ^nimatmm, 330.
"Continens," 7S.

Continuity of the fermphMA, Zt^
Contractility, 330, 333.
Contraction, 133.
Cooke. 390.
Cooper. Astley, 178.
Copho the Younger, 94*
Cordova, 80.
Corviaart, 197. 306, ao8,
Cos. 34, 37, 3X. 51.
Coste, 353.

Councilman, 376, 383*
Craniology, 349, 379.
Crasis, 43.
Creightoo, Charles, iS9>

Crethiim, 974*

Crisis. 43.

Critical <li9«> 98, 4t.

Crotona, 34, 37* 38, 39, 30ii

Crudity, 43.

Cuba, 3Ss et seq.

Culpin, M., 407, 414-

CHHure, puis, 33X et Mi|b

Cupping, 3. 57. 74. 364.

Curare. 333.

Curtis, J. G., Z3A.

Cuvier, 176.

Csranosis, 186.

Cycles, life, 369. 377-

Da Coft». J. M., 401, 414^

D'Alton, 345.

Damascenus. 74, >4>

Damascus, 90.

Dancing numin, 156.

Darius, 30.

Darwin. Charles. 160, 170, X74i S4i* 330^

354/ 375. 396 et seq., 313, 314. 403-
Davaine, 335. 336.
Deal-mutism, 3x4.
Deafness, 39i x83>
DtMdememt, 407.
Delafond, 335. 390^
Delagtei^, 4x3.
Ddinum. 30.
Democedes, 39^
Democritus, 37, 39, 60. 357>
Dentistry, xx, X3. x8, 8x, 165, X77, xSo,

383 et seq., 4x3.
Desault. X89 et seq.
Descartes. X33i X37«
Development, arrested, 167, 3x0.
Diabetes, 63, 78; artificial, 335.
Diagnosis, 39« xoo, x8x, 300 et seq., 333*
Diaphoretics, 30.
Diathesis, 308.

Diet, 13, 30, 39, 3X, 37, 43, 79, 94. ISO.
Dietetics, 8^
Digestion, 53> 334-
Dilatatioa. 13, 306, 3071
Diodes, 40.
Dloscorides, 75* M.
Diphtheria, 63, 374. 37X. 384. 398.
Diseases, of beer, 33S; of wine, 334.
Dislocations, 30, 36, 54.
Disordered action of the henit. 409.
DissecUon, 49, 54, A». 60, 9l> 90, 104, to8L

I30, x6o et seq., 190^
Distomiasis, 366.
Dogmatists, 47, 63-
D6Uinger. 344*
Dorpat, 344.
Dorsal vertebne, 64.
Doraey, X78.
Dreams, 404-405.
Dropsy, 156. 306.
Drugs, 5. 6, 7, 33. 79, 87, 88, 89, 90. XS7.

197, 335.
Dublin School. 3x7.
Du Bois-Resrmond, 331.
Dudauz, Emile, 334.

i2o

INDEX

>M

^ E,, S46t sif» ipOi lfl4>

I. jot

IHpKllf ▼•, 390t

Dyaotcty, 6, 14^ 147.333. JM»JP(i4U-
Pipviw* set

BdodsB. JS4.
Kdcan* 90.

Bdinbaiih, 336 ct feq.
Edu ct io H , aw i dlc al , 7 V »♦ •> "^ 'ITt
_ 158, joi, 9iS, aai, jIs. im-
ta^* I ct aeo.,
nrenbof, 390b
nvlkh, 369 et ««.
I. IQ3-
^37.43*

Bliadr.86.
Bllett, G. G., 4^
yjnbatnitoi, 9, 3.

BmboUam, 969, 37>< 373*
Bnbryolofy, 4S. 131, i7t ct ceq., t33

et MQ., ass. 301, ao9» 310, 336. 34OW
Bmeaii. 29,
Emetics, isx*
Bmetlne, 401.'
Bmotion*. 180, 403 et m^t
Bmpedoclet, 37. 33.
Emphywaic, ais*
Empirics. S4> 63.
Empyema, 79, aoi, J04.
Epoemic aiseMes» 4Z«
Endocarditis, »7».
Eadodenn, aS4-
Bneoetat so.

Efliloaoa. 344-
Bpldaunis, 94, as.

Epidemic, 41. 144. I47, IS3, 134 138.
Epjsenesis, 13a, 14S. 933.
Bpilepssr, 4* iS, 3S» 49, te.
Epiphysis, 64.
Enslstimtos, 49.
Eridisen, 336.

Bnrslpelas, 36, 61, 339, 341*
Ether, aSo, 410 et «q.
Ether frolic. a8x.
Ether spray, a9S.

Ethyl chloride; ethyl bromide, 994.
Btienne. Charles, Z14, 1x7.
Etiology, 4, zi. x6. 18, 39, 149, IS9, 153,
156. 158, 330. 331, 377, 386, 388, 396.
Eugenics, 3za, 3X3*
Eusol, 409.

Eustachius, 1x4, 1x7, 134-
Exantheraata. 3x7*
Sxdaioo. 3SX, 3$a.
Exercise, 99. Stt Athletics and Gym-

eftke
69,

r,47.4PiSS.6«.«4Ci
7^ Tt. 79, 89. 88, ict, Z93, 198, 13s,
134, 149, iSi. ite, 191. i97» sea, 9X1.

9X4, 9X9, 999« 993. 997, 998,

977, 979, 98s. 3x8. 3l9w 338. 3SI.

9S.

Fandajr, a8x.

Fear. 39. x8o.

Peedag. attlftdal. 89, X7». .

FefdfaHad II, Giaad D^kt of

130. I3S. IS8.
Feisason, A. R., mu
FctgMSon, 393.

Fer ment a tfa o, 7S. 77. ISC» 939i 399. 344*
Fte t m e ats , 3aa et esq.

Ferad, 36s-
FcrdUsatioB, s^
Fibers, theory of, 9S7«
Ftfsrte, 6x. 79. 966^ 373*
Pfterlasis. 37S.
Flnlay, 386 et esq.
Ftejayson, James. 9X, 44, 98^
Flezner, SbnoB, 398*
FlouRoa, 337. 989. 994*
FhiORScent so^enSb 4ii«
Foments tfama, a9w
Fomes, XS3. 389.

FossHs. X73. X74. 309, 307-

Foster. Sir if ickad. X38, 937*

Fracaatortos, 354.

Fkactnics, xa. x6, 99, 38. 60, 98. 99. 113.

x8a, 190, 344. 34S. 3S0, 411 ct seq.
Franco, Piene, 1x4.
Fremont, 3x0.
Friedrdcfa^i ataiin, 314.
Pttchsla. 370b
Fwmlgstinns, $, to, a8iS» 389. 309 Ct ceq.

Gnddeaden, John of , 84, 90.

Galapagna Axchlpelaao, 996b

Galen, 63. 74. 7S. 84. 99. xo6. 107» 108.

Galileo, xt8, X3S*

Gall-stones, xx.

GouMtocyter. 377. 380.

Gangrene, 36, 57. 9XS. 330^

Garrison, 3x3.

Gas gangrene, 4x3.

Gaslndat 254,

Geber, 86.

Geddes. Patrick, 973.

Gegenbaur, 354.

Genoa, 356.

Geographical dlstilbation, 949. 30X, 307.

308.
Geological sorrecslon, 308.
Geology, 173.

INDEX

421

Geoi«i II. fig^
Ccmnlof

I. ▼., 951.

OermiiMil mnrinuJty, tsi. at6,SSi*
Germinal liQFcn, 245 ct mq., sS4>
Gcmlottl •pot. asa.
GcrmiBal vesicle. 3Ss>
Gcndorif, Ham ▼.. 109.
Gfflbert the RmHrfiman, $4,
GOliei. H. Di,4X^
GitotiMi, 243.

dobuiee, tlwoty 01, 999*
dycosen, S34-

«4X»3«»

Goddaid, I40w

Onflf^^ Sir Kiel

^^**^— **. ati.

Goitre. fipiirlMlwIt, S94» 404.

Golil. asi. 376.

GoDdlMpor. 71. S8.

GoBOVTlioea. Z55» ia7»J^3M«t

GofdoD. Laiag, 395.

GorvM, W. C. 388 et •§«.

Gfittinfea, 919.

Gout. 6, IS, 148. 156. tM.

Gnele. Albrecht ▼.. 338, 350^

Gnham, Thomas, 335*

Giaad Pahria. 409.

Gtapliiacui, 41*

Gnnrea's diseaee, 274, 404.

Gfay, Asa. 301.

Gny. Sir H. M. W.. 408 etna*

Greenliill, W. A.. 93.

Grom, & D.. 180.

Goerini, Vuioeiiao. i8a
GnUlemeaii, 114.
Gummata, 184. 366b
CiMshot wim i a J a , ia3»
Gtttlirie, a88.
Girathmey, J. T.. agf.
Gymnaatom, as. ap^ 3ii
Gsrmaaatica, 4xx*

Hadley. P. B.. 337.

Hadoei. as6. 310. 31J.

H tt mBm rnbid m, 379*

Hcmatoidia. 371*

Hematology, 3701

Hematuria, 5. 7*

Higmocyknoat 376w

Hgrnophilia, 81, 314-

HaBmorrhase. 19. 56, 60. 96, 183, 371,

409.
Hannothonuc, 305.
Hate, Aatoa de, iS7. aoi.
Haldaae, BUaabcth &, 137.
HaU. Marahall, 318, 336, 337.
Haller, 157. ax8, 339, 341. 3S7«
Hauler, 336.
Haly Abhaa. 78.
Hammniabi. Code of. 14.
Haptophorea, 37 x*
Harrta ben Kaladah. 71-

Iiariey.a9S.

Harper. IL F., 81.

Harua al Raahld, 71.

Hanraid Medical Cottage, 183. i9%

Harvey, iij, xi«, 188, a4»» 86IL

Hata, 37a.

Havana. 386 et Mq.

Hayward, a86.

HeaUnf by flrat hifriUloa, jd^

Hearat papyma, 8.

Heartji)^, i86( h. mnm. dM.

Hcberden, 185.

Hdamaan, iif.

HeUodoma, 59* 6i, dtb

Hehnholts. 331,

Hematoma, 373*

Heale, 334t 330.

H ealey, 346>

Henalow, 379, 3991

Hepatoaoopy, 18.

HeffacUdea. 84.

Heredity, 313.

Herma«*»Dditea, 198^

Hernaades, 367.

Hemfa^ 58,68, 80,. U4, 17a. z8gi

Herodlcua, 39.

Heiodotoa, X3.

Herald. 353.

HcropliUiia, 40. 6$.

Hertwig, Oacar, 355.

Heterochronla. 370.

Heterology, 370^

Heterometria, 37a

Heterotopia, 369, 370,

Higlimofe, 233, X40.

Hindua. 88.

Hippocxatea. x, 33^45. 46, 74* X3P. M^t

187 309w

Hto, WObelm, 3S3.

Hiapaniola, 354 at aeq.

Hiatology, 48, x8x et aeq.

Holmea, B. T., ax.

Holmea, OUver Wanddl, a88w

Home. Sir Bvetard. 175, 185.

Homology, 370, 309.

Hoaala, 74« 84.

Hong-Koog, 374, 383.

Hoolce, Robert, 34* ^57. a64.

Hookworm diaeaae, 7. 394. 30*.

Hopldna, A. J., 93.

Hoppe-Seyler, 374.

Hopatock, H.. xx5.

Hospital gangrene, 341.

Hospitalism, 343.

Hospitals, 7x. 78, 90, 374* 986, 34^

H6tel Dieu. 3o8, 331.

Humors, 42. 150. 373, 375.

Hunter. John, xoo et aeq., X85, 339, 343$

340.366.367,411.
Hunterian Muaeum, x6o, 176.
Hutchinaon, Sir Jonathan, 37a.

Hutton. Jamaa, 396^
Huxley, T. H., 358.
Hydatids^ X79.

Hydropericardium. 305. 307.
Hydrophobia, X87. 389.

423

INDEX

Hydro-pneiUBotlioraXc 9tS»
Hydrotbonuc, 205* ii3.
Hyveia, 24, 33.
HygleiM. 13. 04. 'SO, I57.
Hygienic IiifUtut«, 333*
Hyotcyamiu, 95*
Hyperplaala, a70>
Hypertrophy, no.
Hyitochlorltet. 408.
HypochondriMit, 156.
Hypodermic flyriiiae, jg4.
Hyrtl, 93.

Hyttoia, x8, 156, 403 et nq.
Hyiterlcal ■ngellieala, 406.
Hyiterlcal panlyiig, a$, 406^

Utielft. 90.
ba Baiur, 801
mhotep, 3>

iBiiieauite cI o hub of woundit 407*
aununity, 162, 3x4, 328, 370 «t Mq.,

396. .

mperlal Health BofCiii, 339f 3^
mpotenoe, 3^ t
Bcubatioa, 34; fitrhnir, 30i; latitadc,

39X.

adia, 90>

nflamaiatioii, 58, 338.
ailueaia, 147. 309-4oa
nftuoria, 3x7.
ngraMiat. lis*

nhalatioai, 6, lOo, X03f 276 et «q.
nheritaaoe, 3X3f 314.
nttitttte for Iitfectioos Dlwawe. 333-
BStruBieBta, 4. xs. 36, 46. $3. 58. 69, 8x,

xox, XX3, X34* X37. 338. 344, 355. 357.
Bteraal ■ecretioas, 335. 404.
ateraatiooal Medical Coagreii, 333.
ateroMd muaclet, 64.
Btrlasic hicubatioB, 39X.
auactiona, 6. 39f 360, 364. 39 x.
aveatam Novum of AueabruoBr, aoa
odide of potaadum, 373.
nltabllky, 330, 333.
.saaoHBa 84*

jia, Ruy Dias de, 357 et nq.
samiUa, 38 a.
•nel, OKar, 375*
Itaac ben Honain, 77*
saac JadKUif 79>
tch, 83.

^ ackna, Charles, T., 383*
^ ames, William, 403.

astrow, Morrii, jr., sx.
^ auadloe, x8, 73. x86, 403.

eaaer, Edward, X85, 328.

eaner, William, 335.

emina, 390.

oachim, H.. 3X.

ohas Hopkini UnlTenity, sSjt

1

\ ooea. Sir Robert, 4x1 et «q.
^ oaee, Whartoa, 335*
oaes, W. H. S., 44.

Junker Inlitler, 194.

Kahun papyrus, 8.

Keee, John, 130.

Keith, Sir Arthur, 180.

Keith, Dr.. 389.

KeUy. H. A., 395. 394*

Kepler, X33.

Keratitia. 373>

Kerpuadec aid

King's CoOese, Loodoa, aSOt»

Kircher. 3x6.

Kissincer. 389U

Kitasato, 374. 396.

Kittcrman, P. G^ 3X.

KUh^-LBMm lacflbM, 3S4*

Knopf, a A., 334.

Koch, 7. 375> 330 ct MQ., 38a.

KoUe, 396.

KOlllker, ▼., 353« i6x, 867* 33&

Kowalearsky, 354*

LadnneCf aoo at

Lancet, 349. ^
Landsi. 3x6. 366.
Lanfianchl, 97, 98.
Langenbecic, 393.
', & R.,

oubert, ^37*
byliffe.

134-

.394.

Laparotomy, 47.

Las Animas Hospital, 388, 3901,

Las Casas, 36X.

Laughing gas, 383.

Laversn, Alphonse, 376.

Law, The, 33.

Lasear. 385 et seq.

Leeuwcnhodx, X36, 338, 3x6.

Leibnitz, 239.

Leishnwn, 397*

Lelean, Percy, 4x4.

Le Mans, 4x3.

Leonardo da Vfaid, 104, iis» 130, a68i.

Leonidcs, 59. 6x, 79*

Ltomtiasii o«MS, 373.

L«prasy, 6x, 79> 90, XOO, It4« 874*

Leucocytosis, 371*

jL^ucorrhuea, 6b

LeukKmia, 37 x.

Levy, Reuben, gtt

Liber regis, 78.

Liebig, 387.

Ligature, 56, 6x, 67, 79» 8lf 9S, lit.

Linacre, xsx.

Liniments, sa

Linnaeus. 3x7.

Lister. Lord, 57. 153, 394. 335 et seq.

Lister, Joseph Jackson, asx, 335*

Liston. Robert, 287. 294.

Uverpool^i£o<^o/l^p!caPlledi^

372.
Locke, X40.

Locy, W. A.. XX5, 250, 257.
LOffler, Friedrich, 334. 384.
Long, C. W., 38x, a95t 3x6,
Lourdes, 24.
Louvaia, xo6w

INDEX

4»3

Lowo', Rldiard. iMi 14a.
I iiirM Chi in ptaanfem, Mp, stti
Lucca, Hugh ot, 95.
Lucmlui, jiO.

ij^'wJh.. ISO.

Lnll. sir Oaifaa, jgfi et
Lyoiu, it^

UcMniHch, J. P., iis.
Mumdlc. tiS. »4.
lUmonlda, Mom, So, Ij.
Uilaiti, II, il, 41. 141. 149> IS4. art
tt «., 3U « ieq.. 3*6.

St'Sf-K

Mutcn. W. B., M5.
Mano<dltl>, II.
Mutioll, 36;.
MudmUiu I, Bmpcr
Mayov. John, iJ4.

Medicine, experimental. IJS-

;:«..

UdU, T., «6o.

Udliraaix. WIDkM, 13d,

MoadevQle, Head ik, lA

Uoadlno, 9J, DT, 106.

Uonunmen. T. M., 373.

MontpeUla, Ij. 97. {«, DO. IM-

Moodie, R. L.. 11.

Moon, Normaa, I3T.

Moran. 3*5-

M^.K^tni. Oi, T8i, i»T, m,it*.i6i.

»«,>53.>to.lT*>

Neuron. 49.
NenrMomy. 9S. 114.
Nli:t»lu of Salenia. 9S.
Nlcolaler, 39S.
Nltroui odde. itt. et leq.,
Notocbord, lib, 15(1.
Novaia. ajfl, 3J?, 363.
Number Ion. >7 et mi.
Nunneley, 194.
Nuraddln. 01.
Nuidni, 174.
Nua^Mun, 1., 34*. 34>-

Oath, Tbe, 33.

Obatetiica, ji, gt, n, li, 1

OdontoCofy, m.
(Xdema, II J.

u ctUata ■ «U«1«, 367, J«I.

4*4

INDEX

Qph flwl Molotyt T4« •••

OpnthalmonwCcr, aai.

OphtbalmanoiK, ajs.

Opium, 46. S5.

Orpwk: eirohitkMi. 9$x« ag6 ct

OrpuM. mdi inM i t a r y, joi, 3O0>

CMbMius. 68. 74.

Ortbopaedlc Centen, 4x1 et leq.

OrthofMBdic •ursery, 4x1 et nq*

Onboni, H. P., 3x4.

Oder. Sir WlUJaa* XS0» J07f ax6i a63.

_377, J04. JM.

OKeolocy. 55. 65. 74-

OMeopoiotteal gnra* 41J.

Ottia, 3S1.

Oitiey, Oiewiy, i9m,

Oviedo, 360.

Ovum. 346, 35a, 354-

Owca. Riclwrd, 174. I7S. If6. ito, Sflw

Oxford. X30.

Oxyiea. 376 et leq., 995. 34St 4iOw

Oiamm, 316.

pMlna, X07f 18S*
PiBSei. Sir Jmincs. 99S.
PHwet. Stephen. 115. iMi
Pfeleontolo^. X73. I74«
PiiJner. J. P., ilo.
PalpsuJoo. 4a
Flaliy, Bett't. aas.

FuiaceA, 34. 33.
Plunma, 393 et leq.
Pauioeatic juioe, 33Ai
Piuder, C. H., 345.

PUgeiMile, 313*
Ponniculmt camosut, jll.
Panuxlnu. 365.
IHuBffiiwcgiii treatment, 413.
Plualyris. 3*. 63; artificial. 3331 hyater-

IcM. 35. 406; infantile, la.
Farultet. 366b
^raaitology, 374.
Pantypbold. 307.
Par6, Ambrolae, ixi et acq.
Parthenogeneaii, 339.
PaMeur, 320 et aeq.. 344. 34S» 34*. 3Sa.
I^Meur Inatitute, 339^
Pathology. tSi et aeq., 357 et aeq^. 314.

333.
Paul of iWaa> 6S, 74. 79. Sx.
Payne. J. P.. X59.
Pieariy diaeaae of cattla, a?^

P^brine. 324.
Pecquet. X34*
Pectoriloquy, aia, ax4.
PeUagia. 374.
Pemphigua, 6w
PtnidUium fllanoMi, saj.
Pepila,43.
Percuaakm, aoi.
Pergamua. 34. 63.
Peritonitia, 196.
Petit. Antolne, 189.
Petty. X40.
Peyer'e patcbei. 373.
Pfelffer, 396.

^4.«.if.Wtt,aii

. 5. 6. 7. 23, fpw •7. ••, 80, 9OW

157. 197. 335.

Phfloiiopher'a etoae. 86.

PhUoaopheta, 37.38.

PhikMophy. 33. 28, 29, A 14It iSOi

Pbimoaw. 58.
Phlebitis, 371. a7a.

Phthiaie, 43. 6a, 156, aia at aaq.

Phyiidc. X78.

Phyiiology. 38, 38. 43, 116 at aeq., iMk

X9x,et eec^^xS et ae«^ ajo, 314.
Pkard, PrtdMc, X59.
Pilcher. L. a, 1x5.
Pfnardel Rk> BamdeB, 386.
Pfnsan.360.
PifOffn. a88, 393.
Plague, 6x. too. ix3, UOi, I4S. IS4. 334.

374.394-
Plasmodia, 3A9. 376 at aaq.
Plaatcn, 6w

Plaatk aufgefy, 67. 68, m, 4S3. 414*
Platynna, 64.
Plends, 316.
Pletboia,SS-
Pleufinr. xa, 46, 47, X96,
Pleuritic filctlon. 40.
Pneuma, 47, 5a. 60. laS.
Pneumatic doctrine, 63.
Pneunmtic Inatitutioa, a77«
P ium mo c o e aUt 3a8.
Pneumohydrothoffux. 401.
Pneumonia, 46, x86» 196* axg-
Podalirlua. 34.
Pollender. 3a6.
Polydactylian, 3]
Popllteua muade.

Poppy. 5-

Poree, 56.

F^Mt. Wright, 178.

Poet-mortem, 5x. 5a, x8i et aeq., sot.

Poiture. ereet, x67-

Pottevin. 339.

Pott's diaeaae. xo, 41*

PoulUcea. ao.

Poulton. B. B.. 315-

Power. D'Arcy. X37*

PraicBflotaa. 46.

Predelioeation. 339-

Preformation, 239.

Pregnancy, 3x6; extn^nterina, 8x, a7g*

Preventive Inoculations, 396.

Preventive mrdiniw, 374 ci aeq.

Prfivost, 346.

Priestley. 376. 371-

Priest-physidana. x at aaq.

Primary anion, 58.

Primary wound suture. 408.

** Prinoplaa of Geology,*^ 398, 308.

Pringle. 157.

Prinsing. Priedrlch, X59.

Prognosia, 41, X50, aoa.

Propbyhuds, 397.

PKoatate, si. 167,

INDEX

42s

Protoplaaai, 251, jte.
I^otoBoa, 369, 375-
ProtojoOlogy, 366.
FqrcUatryr 7«. 9i. 40a.
Piychoanalyii*, 405 et aeq.
Piycbology, 179. xto. S30. aia. 40fl d

Ptolemy Philaddpbiw, 40^
Ptolemy, Soter, 40^
Puerperal fever, 41, 179.
Pulie. 7, 47, SI.
PultUofhim, Ii9t 13).
Purgation, 13, 29.
Purgativct, ao.
Purkinje, 35s.
Putrefaction, 77. 343. S44*
Pyemia, a?!, 33a. 34Z-
Pyofenic infectknifl, zi.
Pyo-pneumothorax, a 15.
Pyrethrum powder. 35a.
Pyrexia of uncertain origiii. 40tt
Pytbagofaa, 37. 3S*

Victoria, 393.
'■ Hospital, Sidcop. 4*9,
. 371. 3Sa.

Radlographf, ttereotOQplc. 411.

Radiogapky, 4i<^ii<

RAlet, aio. ais.

Ramandni, zSa, 183.

Rapallo. 355. aj&

Raaori. 316.

Rathke. ad6, 35s*

Rayer, 396. 3^7.

Rteumur, 316.

Recapltoiatioo tlMoiy, 343, 3SS.

Redi. 318.

Reduction, 3^

Reed. Walter, 38a et aeq.

Reflexes, aa6 et leq.

Reichert. as3.

Remak. 3S3. ate. 367. 369.

Resection, 58, 6a, 67. 4x3.

Reapiration, 41. 105; artificial, i^

Resuscitation, I79w

ReU mirabiU, 109.

Rbaxes. 75. 87. 9X, 9S*

Rheumatism, 18.

Rhinoplasty, Z03, 4X3. 4M*

Rice. Nathan P.. 395*

Richard. J75.

Richardson, Sir BaUnmin, 394^

RickeU, la

Ricord, 367.

Rinderpest. 334.

Robespierre, X89.

Robinson. J. H., 35S.

koger. Henri, 334-

Rofler of Palenno, 94*

Rokitansky, 338.

Roland of Parma, 94.

Rome, 350. 3S6b

Ro8ato,363.

Rosemui* m* J** 39S*

Ross. Sir Ronld. 44* 37S. 3T8 «t ieQ.»

387. 395-
Roth, M., IIS.
Rousset» 1x4.
Roux, 339. 36B.
Rovigno, 368.

Royal CoUeoe of Phyridans, 133.
Royal Infirmarv, of Edinburgh, 390*

337 et seq.; of Glasgow, 341 et seq.
Royal Society of London, 3S^
Rudbeck. X34.
Ruffer, Sir St. A., ti*
Rufus, 59. 63, 7S.
Rupture, 167.
Russell, M»iot, 397*

Sacred disease, 35.

Sainte Anne de Beaupi4, 34.

St. Hilaire. Isidore Geoffrey, 3x1.

Sal Ammoniac, 30.

Sa l e r no, 94.

Saliceto, Winiam of, 95» 96, 97. lOO.

Salivation, 8x, 136.

Salvaraan, 379.

Salves. 30.

Sambon, 381.

Saaarelli, 384 ct sag.

Sanctorius, 133.

Sanitation. 361 , 3T4* 334. 38i, 386 ct ae^

Santo Domingo, 354 ^ «^.

SarHiparlUa. 36s.

Satyriasis, 63.

Saxtorph. 347.

Scarborough, 133.

ScartaiUna, 156.

Schaudinn. 368, 369,

Scbeele, 377>

Schelliag. 344.

SckiUosoma kamaiobimm, 7,

SckitomyuUs, 336w

Schleidcn, 358.

Schroder, 3ao.

Schulae, Frans, 330.

Schwann, 353. 357 et

Science and pnctioe, x

ScOlacdo, 363.

Sck^rosis. 373.

Scott, W. B.. 315.^

Screens, fluoreaoent, 4'i*

Scrofula, x68, 3x3.

Scurvy, 6, 73.

.Secondary sexual chanctera, 171, 3x3.

., 3M, 393, 346w
et

Secretions, internal, 335.
Sedgwick, 346. 397. 390.
SegmenUtion of the yolk, 348.
Selection, artificial, 300, 304: mtrnil.

300 et seq.
Semmelweiss, 3S9.
Sensibility, 330, 333.
SeiMiS, 409.

Septkaemfai. 338, 333, 34X.
Septum, interventricular, no, xx6, 133.
Serapk>n the Elder. 74. 84.
Serapion the Younger, 89.
Setsiai. 73.

426

INDEX

ServetiM, ki4« 1x6.

Seville. 360. 36a.

Slom. Ludovioo, 363.

Sharpey. 335. 337*

Shell tbock, 403 et wq.

Shock, 34X*

Sidcup, plutic sursuy at, 4xa.

Siebold. v.. 346, asa.

Silver nitiHte, asi.

Simpton, Sir Junea Young, 987 et eeq.,

343.
Shiser, Charles. 45. 93» xiS-
Siuxia. aoi.

Sleeping lirlruMi (trypenoeomiaali), 334-
Smallpox, XX, 75* 146. iSi, X5a, i6a,

374-
Sniith, Theobald, 377*
Snow, John, a94.
Soldier^! heart, 401, 41^
Sonmua. S9. 79.
Soubeiran, aSS.
SouJU, a 15.
SpaUanxani, 3x9, 336.

Special creation. 307

Special Military SuigiGal Hoepitalf. 4x1

etteq.
Speciea of diaeaae. 41, 6t. 147. 14^1 XS5.

363.366.
Spedfica, X44, 140, 369 et mq.
Spencer, Dr. H., 93*
SptrmaUmaa, a3S* a53i tS4.
Spina PtntosAt 77.
SpiriUum, 326.
Spirita. S7.
Spirockmla, 326, 369.
Splenic fever, 335-
Splintt, 3. xa, 99, xox, 4x9.
Spontaneous generation, xsS, a66, 31S.

333,334-
Sporadic caaes, 153.
Sporea, 334. 337, 330, 33i» SSO.
SporuUtkm, 336, 376.
Sprains, 39. 4X3.
Staining. 333, 370.
Stapkyhcouut pyonmu, 33S.
Staphyloplaaty. XX4.
Steam baths, ap.
Steel, X51.

SUtamyic, 387. 3S8, 39Ii 393*
Stenaen, 135. 136.
Stereo-chemistry, 333.
Sternberg. G. M., 377. 3*4 et seq.
Stethoscope, aii.
SUrling. William. 180, a37.
StolcoB. x86.
StoU, 30X, ao6.
Stiaasburg, 369, 370.
SirtpkKocau pyoggnss, 338.
Stromeyer, 348.
Struggle for ttfe, 30X, 306, 3x4*
Succuaaion, 40*
Sudhoff, Kjurl, 373.
Suggestion. 405 et seq.
Sulphur baths. 365.
Surgery, 3 et seq., 36. 46 et asq.. 70. io.

8x, 8a, 94 at aeq., xte at aeq., a76 at

seq.. 335 et seq., 407 et seq.
Suture, of the intestines. 58, 95t 96, xoo{

of the nerves. 96, 4x3*
Survival of the fittest, 30X, 3x4.
Swammerdam, X36, X58, 338.
Swieten, Van, 157. aox.
Sydenham, X38-XS9. x83, 366, 373, 374-
Sylvius, Jacobus, X07. xxa.
Syme, 387. 337. 346, 351.
Symphysis. 64.
Syncope, 63.
Syphilis, xo, xt4, xsSt lt4« aT3. 354 et

seq.
Sysima Nakirm, 3i7*

Tmnia toUum, a66, 867*

Tagliacoxai, XX4.

"Tasrif."8x,

Technique. 333.

Tclesphorus, 34.

Temperature, 39>

Temi>le priesU. 31*'''

Temples of health, 13. 34, 90.

Tendon transplantation, 4x3-

Tenesmus. 39.

Teratology. X70, 349. 3Xt.

Tetanus. 36. 63, 98. X87. 336, 343* 898*

Thayer, W. a, 3x7. 377, 383.

Theodoric, 95. 98, 99.

Therapeutics. X94. X97. 374« 37t*

Tkerapia jUriUsaus, 371.

Thermometer. I57» X77*

Thermosoope. xxp. I33. X3S«

Theurgy. 36, 39.

Thieisch. 349.

Thomas. H. (X, 4x1; leg and arm splhitSa

4x3.
Thompson, D*A. Wcntvorth, 69.
Thomson, Allen, 340.
Thoracentesis, 61.
Thoth, 37.
Thrombosis. 371.
Tiemey, M. A., X37*
Tissues, transplantation of, X77«
Torculair HerophiU. 49.
Torre, M. A. deila, X04.
Toulouse, 99.

Tour, Cagniaid de k, 3St.
Tourniquet. 351.
Touasaint. 338.
Toxophores. 37O).
Trachea, 53.
Tracheotomy, $6, 89.
Trajan. 59.

Transmission. 386. 396. 40X. 409.
Transphmtation, 01 tendons, 413; at

tissues, X77.
Trench fever, 40X.
Trench foot, 40X.
Trench nephritis. 401.
Trephining, 3, 36, 58, 4x3.
Trtpontma poSUdum, 368; T. PtrUmtt,

371.
Trichina spiralis, 366.

Tropical medidne, 334* 374 et aeq.

INDEX

427

Trypao red, 37t.

Try^nosoma noeitim, 369.

TrypuuMomiMb, 373, 39^

Tuberclei, ao7, 9I3> 370>

Tuberculin. 333>

Tuberculods, 8a, 186, 973*

Tablnsen, a 18.

Tuffier, 414.

Tumon. 6. 8. 6a, aja, a73*

Turner, Sir wUlinm, 70>

Tyndall, 334.

Typhoid fever, 33S. 385. 386, 396 et leq.

Tyi>hut fever, X3i» MS. 161, 334. 335>

401.
Tytctti, Jamet, 978<

XJkxn, 5, 67. 114. 367.
Unifonnitarina doctrine, 196.
Univenltlet, early, 94.
University College (London), 335*
University of Glaiflow, 340.
University of Pisa. 119, X3S*
University of Virginia, 383>
Uretluotomy, 58, 6a«
Urine, 79. 84-

Vacdnation, 169.

Vaoclnes, 37S. 397-

Val>de-grftoe, 4xa«

Valentin, 353.

Valetudlnaria, 90>

Vallery-Radot, ReaS, 398.

Vallisneri. 316.

Valsalva, x8i, x8a, x88.

Valves, sa» XX7» xax, 12s, laj, t33, 186.

Variation. x68, 169, 300, 301, 304. 3o6.

VaroUttS, 11 j.

Varro, 3x6*

Veins. 46.

Venable. Jamca, 98t.

Venexeal disease, 10, 1x4, 154. 155. 156,

X79. X83. X84, X87. 973. 316, 354 ct aeq.,

414*
Venesection, 3. 56. 58, 74* 100.
Vermiform appadix, 109. 167* 17'. 3X0.
Vermifttget, $.
Vesalius. X06-XX5, a63«
Vestigial structures, 310, 314*
Veterinary surgeon, 16*
Vibrio, 3x7.
VIdius, XX4.

Vienna Sclwol, Old, New, MX.
VUlanova, Arnold, 97*

Vbcbow, x88, X99» 83t. 953* tte, 9751

267,
Vis medieatrix fMMra, a%, 43. 80. xso.
Vivisection, 47. 54. 59. 00, 64. xo8, 199,

ax9, aaa, aa?. a3a, azt.
Vocational training, 41 x.
Volkmann, v., 349>

Wagner, 953*

Walcher posltloo, 81, gj.

Waldie, 389.

Wallace, Alfred Ruasd, 309.

Walsh. J. J.. X99, 9x7.

Warfare, modem, 396 et m/i^

Walter. 196.

War neuroses, 403 et

Warren J. C, X78, a8o, 9I

Wdchselbaum, 398.

Wdgert. 33a, 370.

Weismann, 313, 3X5*

Welch, W. H., XX5. 383. 384.

Wells, HoTMe, a8a, a95*

Wharton, X3a, X34t 140.

Wheeler. W. M., 356.

Whitman, C. C, as6b

Wilson, B. B., 975*

Winslow, ax8.

Willems, 4xa.

WiUis. X3a, X34. X37> X40, ZSB.

WiUow. ao.

Wirsung, Georg. Z34.

Wisdom-teeth, 3x0*

Withhucton. B. T., 45. z8l.

WoUr. Christian, 94X.

Wolff. K. F.. 940, 345, a48, 957*

WolflSan bodies, 940, 3x0.

Wood. Alexander. a94*

World War, 396 et seq.

Wounds, gunshot, X78.

Wren, X34, X40.

Wright, sir Akafoth, 396 «t

Wdrsbozg, 944. a6z«

Yaws, X55. 366, 37t.
Yeast, 399, 395.
YeUow fever, 384 ct sag.

Yersln, 399.374.
Young, H. H., 995*

Zerbi, Z04»

ZoSlogiairstadon at Napki, 955.

ZytaU$t 379* 9l^

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