1

V.

LIBRARY

UNIVE S!TY Oh
CA' 'FORM A
S vN .''EGO

A

3

OF THE

(Eambrt&g? Oittnn

There have been printed seven hundred and fifty sets
of which this is copy

INTERNATIONAL CONGRESS
OF ARTS AND SCIENCE

JOAN OF AEC LISTENING TO THE VOICE
Photogravure from the Painting by Francois Leon Benouville.

According to. a prophecy by Merlin, which was current in the native province
of Joan of Are, France was to be overwhelmed with calamities, but was to b«
delivered by a virgin out of the forest of Domremy. Joan, who was undoubtedly
familiar with the prophecy, imagined that she heard supernatural voices com-
manding her to liberate France. This ia the romantic theme of Benouville's
great painting.

INTERNATIONAL CONGRESS

OF

ARTS AND SCIENCE

EDITED BY

HOWARD J. ROGERS, A.M., LL.D.

DIRECTOR OP CONGRESSES

VOLUME XI

MEDICINE

COMPRISING

Lectures on Public Health, Preventive Medicine,

Pathology, Therapeutics and Pharmacology,

Neurology, Psychiatry, History of

Surgery, and Development of

Modern Medicine

UNIVERSITY ALLIANCE

LONDON NEW YORK

COPYRIGHT 1906 BY HOCGHTON, MIFFLIN & Co.

ALL RIGHTS RESERVED
COPYRIGHT 1908 BY UNIVERSITY ALLIANCE

ILLUSTRATIONS

VOLUME XI

FACING
PAGE

JOAN OF ARC Frontispiece

Photogravure from the painting by F. L. BENOUVILLE

PORTRAIT GROUP OF SCIENTIFIC LECTURERS .

Photogravure from a photograph

DR. PEAN OPERATING BEFORE His CLASS 20

Photogravure from the painting by H. GERVEX

MURAL PAINTING 304

Photogravure from the plafond painting by MICHAEL MUNKACZY

TABLE OF CONTENTS
VOLUME XI

INTRODUCTORY ADDRESS.

Utilitarian Science ......... 3

DAVID STARR JORDAN, PH.D., LL.D.

MEDICINE

The Modern Conceptions and Methods of Medical Science ... 23
BY PROP. WILLIAM THOMAS COUNCILMAN, M.D.

The Development of Modern Medicine ...... 41

BY PROF. FRANK BILLINGS, M.D.

PUBLIC HEALTH.

The Relations of Public Health Science to Other Sciences . 55

BY PROF. WILLIAM THOMPSON SEDGWICK, PH.D.

Public Health: Its Present Problems ...... 68

BY ERNST J. LEDERLE, PH.D., D.Sc.

PREVENTIVE MEDICINE.

The Logical Basis of the Sanitary Policy of Mosquito-Seduction . 89
BY PROF. EONALD Boss, M.D., D.Sc.

PATHOLOGY.

The Relations of Pathology 105

BY PROF. LUDVIG HEKTOEN, M.D.

The Relation of Pathology to Other Sciences ..... 123
BY PROF. JOHANNES ORTH, M.D.

The Behavior of Native Japanese Cattle in regard to Tuberculosis

(Perlsucht) 137

'BY PROF. SHIBASABURO KITASATO, M.D.

THERAPEUTICS AND PHARMACOLOGY.

The Relation of Therapeutics to Other Sciences in the Nineteenth Cen-
tury ........... 153

BY PROF. OSCAR LIEBREICH, M.D.

The Problems of Therapeutics 170

SIR LAUDER BRUNTON, M.D., Sc.D., LLD.

TABLE OF CONTENTS

INTEBNAL MEDICINE.

The Historical Relations of Medicine and Surgery .... 189
BY PROP. THOMAS CLIFFORD ALLBUTT, M.D., D.Sc., LL.D.

The Problems of Internal Medicine ...... 210

BY PROF. WILLIAM SYDNEY THAYER, M.D.

NEUROLOGY.

The Value of the Physiological Principle in the Study of Neurology . 225
BY PROF. JAMES JACKSON PUTNAM, M.D.

PSYCHIATRY.

Psychiatry in its Relation to Other Sciences . . . . . 243
BY PROF. CHARLES LOOMIS DANA, M.D., LL.D.

The Problem of Psychiatry in the Functional Psychoses . . . 262
BY PROF. EDWARD COWLES, M.D., LL.D.

SURGERY.

The History and Development of Surgery during the Past Century . 307
BY PROF. FREDERIC S. DENNIS, M.D., F.R.C.S.

The Morphology of Cancer . . . 382

BY PROF. JOHANNES ORTH, M.D.

CROUP OF SCIENTIFIC LECTURERS

The International Congress of Arts and Science presents men renowned in
almost every branch of Science, leading professors of the greatest institutions
of learning, astronomers, surgeons, technologists, economists, pathologists, an-
alogists, physicists — famous specialists and scientists from all quarters of the
globe.

The present group includes a number of these celebrities. In the front
row, from left to right, we have the full-length portraits of Prof. J. G. Hagen,
S.J., of the Georgetown University, which was founded by the Jesuits in 1788;
Dr. Carl Beck, Professor of Surgery in the New York Post-Graduate Medical
School ; Dr. Wil'helm Waldeyer, Professor of Anatomy, University of Ber-
lin ; Dr. Simon Newcomb, President of the Congress and Dean of American
Scientists ; Dr. Oscar Backlund, Astronomer of the Imperial Academy of
Science, St. Petersburg; Dr. Ormond Stone. Professor of Astronomy, Univer-
sity of Virginia ; and Dr. David Starr Jordan, President of Leland Stanford,
Jr., University, in California. In the second row on the extreme left, we have
the portrait of Dr. Benjamin Ide Wheeler, President of the University of Cali-
fornia, and on the extreme right stands Dr. Eugen von Philippovich, Pro-
fessor of Political Economy, University of Vienna.

DIVISION E — UTILITARIAN SCIENCES

DIVISION E — UTILITARIAN SCIENCES

(Hall 1, September 20, 10 a. m.)
SPEAKER: PRESIDENT DAVID STARR JORDAN, Leland Stanford, Jr., University.

UTILITARIAN SCIENCE

BY DAVID STARR JORDAN

[David Starr Jordan, President of Leland Stanford, Jr., University since 1891.
b. January 19, 1851, Gainesville, Wyoming County, New York. M.S. Cornell
1872; LL.D. ibid. 1886; Ph.D. Butler University, 1880; M.D. University of
Indiana, 1875; Post-Graduate, Harvard University, London, Paris. Professor
of Biology, Butler University, 1875-79; Professor of Zofilogy, University of
Indiana, 1879-85; President of Indiana University, 1885-91; Associate of the
U. S. Fish Commission since 1878; Head of Bering Sea Commission, 1896-98;
President of California Academy of Sciences; Fellow of A. O. U.; Member of
American Philosophical Society, etc. Author of many books, including Fishes of
Northern and Middle America ; Science Sketches ; Manual of the Vertebrates ;
Guide to Study of Fishes; The Innumerable Company, Care and Culture of Men;
The Voice of the Scholar, etc.]

IT falls to my lot to-day, to discuss very briefly, in accordance
with the Programme of this Congress, some of the common features
of utilitarian science, with a word as to present and future lines
of investigation or instruction in some of those branches of the
applications of knowledge which have been assigned to the present
division.

Applied science cannot be separated from pure science; for pure
science may develop at any quarter the greatest and most unexpected
economic values; while on the other hand, the application of know-
ledge must ' await the acquisition of knowledge before any high
achievement can be reached. For these reasons, the classification
adopted in the present Congress, or any other classification of sciences
into utilitarian science and other forms of science, must be incom-
plete and even misleading. Whatever is true is likely some time
to prove useful, and all error is likely to prove some time disastrous.
From the point of view of the development of the human mind, all
truth is alike useful, and all error is alike mischievous.

In point of development, pure science must precede utilitarian
science. Historically, this seems to be not true; for the beginnings
of science in general, as alchemy, astrology, and therapeutics, seem
to have their origin in the desire for the practical results of know-
ledge. Men wanted to acquire gold, to save life, to forecast the
future, not for knowledge's sake, but for the immediate results of

4 UTILITARIAN SCIENCES

success in these directions. But even here accurate knowledge must
precede any success in its application, and accuracy of knowledge
is all that we mean by pure science. Moreover, as through the ages
the representatives of the philosophies of the day, the a priori ex-
planations of the universe, were bitterly and personally hostile to
all inductive conclusions based on the study of base matter, men of
science were forced to disguise their work under a utilitarian cloak.
This is more or less true even to this day, and the greatest need of
utilitarian science is still, as a thousand years ago, that this cloak
should be thrown off, and that a larger and stronger body of workers
in pure science should be developed to give the advance in real
knowledge on which the thousands of ingenious and noble applica-
tions to utilitarian ends must constantly depend.

It is a fundamental law of psychology that thought tends to pass
over into action. Applied science is knowledge in action. It is the
flower of that highest philanthropy of the ages by which not even
thought exists for itself alone, but must find its end in the enlarge-
ment of human control over matter and force or the amelioration of
the conditions of human life.

The development of all science has been a constant struggle, a
struggle of fact against philosophy, of instant impressions against
traditional interpretations, of truth against " make-believe." For
men are prone to trust a theory rather than a fact; a fact is a single
point of contact; a theory is a circle made of an infinite number of
points, none of them, however, it may be, real points of contact.

The history of the progress of science is written in human psycho-
logy rather than in human records. It is the struggle of the few
realities or present sense-impressions against the multitude of past
impressions, suggestions, and explanations. I have elsewhere said
that the one great discovery of the nineteenth century — forestalled
many ages before — was that of the reality of external things. Men
have learned to trust a present fact or group of facts, however con-
tradictory its teachings, as opposed to tradition and philosophy.
From this trust in the reality of the environment of matter and force,
whatever these may be, the great fabric of modern science has been
built up. Science is human experience of contact with environment
tested, set in order, and expressed in terms of other human expe-
rience. Utilitarian science is that part of all this knowledge which
we can use in our lives, in our business. What is pure science to one
is applied science to another. The investigation of the laws of hered-
ity may be strictly academic to us of the university, but they are
utilitarian as related to the preservation of the nation or to the
breeding of pigs. In the warfare of science the real in act and motive
has been persistently substituted for the unreal. Men have slowly
learned that the true glory of life lies in its wise conduct, in the

UTILITARIAN SCIENCE 5

daily act of love and helpfulness, not in the vagaries fostered by the
priest or in the spasms of madness which are the culmination of
war. To live here and now as a man should live constitutes the
ethics of science, and this ideal has been in constant antithesis to
the ethics of ecclesiasticism, of asceticism, and of militarism.

The physical history of the progress of science has been a struggle
of thinkers, observers, and experimenters against the dominant
forces of society. It has been a continuous battle, in which the
weaker side, in the long run, is winner, having the strength of the
earth behind. It has been incidentally a conflict of earth-born
knowledge with opinions of men sanctioned by religion; of present
fact with preestablished system, visibly a warfare between inductive
thought and dogmatic theology.

The real struggle, as already indicated, lies deeper than this. It
is the effort of the human mind to relate itself to realities hi the
midst of traditions and superstitions, to realize that nature never
contradicts herself, is always complex, but never mysterious. As a
final result all past systems of philosophy, perhaps all possible sys-
tems, have been thrown back into the realm of literature, of poetry,
no longer controlling the life of action, which rests on fact.

This conflict of tendencies in the individual has become a con-
flict among individuals as each is governed by a dominant impulse.
The cause of tradition becomes that of theology; — for men have
always claimed a religious sanction for their own individual bit of
cosmic philosophy. Just as each man in his secret heart, the centre
of his own universe, feels himself in some degree the subject of the
favor of the mysterious unseen powers, so does society in all ages
find a mystic or divine warrant for its own attitude towards life and
action, whatever that may be.

The nervous system of .man, inherited from that of the lower
animals, may be regarded as primarily a means of making locomo-
tion safe. The reflex action of the nerve centre is the type of all
mental processes. The sensorium, or central ganglion, receives
impressions from the external world representing, in a way, various
phases of reality. The brain has no source of knowledge other than
sensation. All human knowledge comes through human experience.
The brain, sitting in darkness, has the primary function of con-
verting sensory impressions into impulses to action. To this end the
motor nerves carry impulses outward to the muscles. The higher
function of nerve-action, which we call the intellect, as distinguished
from simple reflex action and from instinct, is the choice among
different responses to the stimulus of external realities. As con-
ditions of life become more complex, the demands of external
realities become more exacting. It is the function of the intellect to
consider and of the mind to choose. The development of the mind

6 UTILITARIAN SCIENCES

causes and permits complexity in external relations. Safety in life
depends on choosing the right response to external stimulus. Wrong
choice leads to failure or to death.

From the demands of natural selection results the intense prac-
ticality of the mental processes. Our senses tell us the truth as to
external nature, in so far as such phases of reality have been essen-
tial to the life of our ancestors. To a degree, they must have seen
" things as they really are," else they should not have lived to con-
tinue the generation. Our own individual ancestors through all the
ages have been creatures of adequate accuracy of sensation and of
adequate power of thought. Were it not so they could not have
coped with their environment. The sensations which their brains
translated into action contained enough of absolute reality to make
action safe. That our own ordinary sensations and our own induc-
tions from them are truthful in their essentials, is proved by the
fact that we have thus far safely trusted them. Science differs
from common sense mainly in the perfection of its tools. That the
instruments of precision used in science give us further phases of
reality is shown by the fact that we can trust our lives to them. We
find it safer to do so than to trust our unaided senses.

While our senses tell us the truth as to familiar things, as rocks
and trees, foods and shelter, friends and enemies, they do not tell
us the whole truth : they go only so far as the demands of ancestral
environment have forced them to go. Chemical composition our
senses do not show. Objects too small to handle are too small to be
seen. Bodies too distant to be reached are never correctly appre-
hended. Accuracy of sense decreases as the square of the distance
increases. Sun and stars, clouds and sky, are in fact very different
from what they seem to the senses.

In matters not vital to action, exactness of knowledge loses its
importance. Any kind of belief may be safe, if it is not to be carried
over into action. It is perfectly safe, in the ordinary affairs of life,
for one who does not propose to act on his convictions to believe in
witches and lucky stones, imps and elves, astral bodies and odic
forces. It is quite as consistent with ordinary living to accept these
as objective realities as it is to have the vague faith in microbes and
molecules, mahatmas and protoplasm, protective tariffs and mani-
fest destiny, which forms part of the mental outfit of the average
American citizen to-day. Unless these conceptions are to be brought
into terms of personal experience, unless in some degree we are to
trust our lives to them, unless they are to be wrought into action,
they are irrelevant to the conduct of life. As they are tested by
action, the truth is separated from the falsehood, and the eiror
involved in vague or silly ideas becomes manifest. As one comes
to handle microbes, they become as real as bullets or oranges and as

UTILITARIAN SCIENCE 7

susceptible of being manipulated. But the astral body covers only
ignorance and ghosts vanish before the electric light.

Memory-pictures likewise arise to produce confusion in the mind.
The record of past realities blends readily with the present. Men are
gregarious creatures and their speech gives them the power to add to
their own individual experiences the concepts and experiences of
others. Suggestion and conventionality play a large part in the
mental equipment of the individual man.

About the sense-impressions formed in his own brain each man
builds up his own subjective universe. Each accretion of knowledge
must be cast more or less directly in terms of previous experience.
By processes of suggestion and conventionality the ideas of the
individual become assimilated to those of the multitude. Thus
myths arise to account for phenomena not clearly within the ordin-
ary experiences of life. And in all mythology the unknown is
ascribed not to natural forces, but to the action of the powers that
transcend nature, that lie outside the domain of the familiar and the
real.

It has been plain to man in all ages that he is surrounded by
forces stronger than himself, invisible and intangible, inscrutable in
their real nature, but terribly potent to produce results. He cannot
easily trace cause and effect in dealing with these forces; hence it is
natural that he should doubt the existence of relations of cause and
effect. As the human will seems capricious because the springs of
volition are hidden from observation, so to the unknown will that
limits our own we ascribe an infinite caprice. All races of men capable
of abstract thought have believed in the existence of something
outside themselves whose power is without human limitations.
Through the imagination of poets the forces of nature become per-
sonified. The existence of power demands corresponding will. The
power is infinitely greater than ours; the sources of its action in-
scrutable: hence man has conceived the unknown first cause as an
infinite and unconditioned man. Anthropomorphism in some degree
is inevitable, because each man must think in terms of his own
experience. Into his own personal universe, all that he knows must
come.

Recognition of the hidden but gigantic forces in nature leads men
to fear and to worship them. To think of them either in fear or in
worship is to give them human forms.

The social instincts of man tend to crystallize in institutions even
his common hopes and fears. An institution implies a division of
labor. Hence, in each age and in each race men have been set apart
as representatives of these hidden forces and devoted to their pro-
pitiation. These men are commissioned to speak in the name of each
god that the people worship or each demon the people dread.

8 UTILITARIAN SCIENCES

The existence of each cult of priests is bound up in the perpetua-
tions of the mysteries and traditions assigned to their care. These
traditions are linked with other traditions and with other mystic ex-
planations of uncomprehended phenomena. While human theories
of the sun, the stars, the clouds, of earthquakes, storms, comets, and
disease, have no direct relation to the feeling of worship, they can-
not be disentangled from it. The uncomprehended, the unfamiliar,
and the supernatural are one and the same in the untrained human
mind; and one set of prejudices cannot be dissociated from the
others.

To the ideas acquired in youth we attach a sort of sacredness. To
the course of action we follow we are prone to claim some kind of
mystic sanction; and this mystic sanction applies not only to acts
of virtue and devotion, but to the most unimportant rites and cere-
monies; and in these we resent changes with the full force of such
conservatism as we possess.

It is against limited and preconceived notions that the warfare of
science has been directed. It is the struggle for the realities on the
part of the individual man. Ignorance, prejudice, and intolerance,
in the long run, are one and the same thing. In some one line, at
least, every lofty mind throughout the ages has demanded objective
reality. This struggle has been one between science and theology
only because theological misconceptions were entangled with crude
notions of other sorts. In the experience of a single human life there
is little to correct even the crudest of theological conceptions. From
the supposed greater importance of religious opinions in determining
the fate of men and nations, theological ideas have dominated all
others throughout the ages; and in the nature of things, the great
religious bodies have formed the stronghold of conservatism against
which the separated bands of science have hurled themselves,
seemingly in vain.

But the real essence of conservatism lies not in theology. The
whole conflict, as I have already said, is a struggle in the mind of man.
From some phase of the warfare of science no individual is exempt.
It exists in human psychology before it is wrought in human history.
There is no better antidote to bigotry than the study of the growth
of knowledge. There is no chapter in history more encouraging than
that which treats of the growth of open-mindedness. The study of
this history leads religious men to avoid intolerance in the present,
through a knowledge of the evils intolerance has wrought in the
past. Men of science are spurred to more earnest work by the
record that through the ages objective truth has been the final test
of all theories and conceptions. All men will work more sanely and
more effectively as they realize that no good to religion or science
comes from " wishing to please God with a lie."

UTILITARIAN SCIENCE 9

It is the mission of science to disclose — so far as it goes — the
real nature of the universe. Its function is to eliminate, wherever it
be found, the human equation. By methods of precision of thought
and instruments of precision of observation and experiment, science
seeks to make our knowledge of the small, the distant, the invisible,
the mysterious, as accurate, as practical, as our knowledge of com-
mon things. Moreover, it seeks to make our knowledge of common
things accurate and precise, that this accuracy and precision may
be translated into action. For the ultimate end of science as well as
its initial impulse is the regulation of human conduct. Seeing true
means thinking right. Right thinking means right action. Greater
precision in action makes higher civilization possible. Lack of pre-
cision in action is the great cause of human misery ; for misery is the
inevitable result of wrong conduct. " Still men and nations reap as
they have strewn."

A classic thought in the history of applied science is expressed in
these words of Huxley : " There can be no alleviation of the sufferings
of man except in absolute veracity of thought and action and a re-
solute facing of the world as it is." " The world as it is " is the pro-
vince of science. " The God of the things as they are is the God of the
highest heaven." And as to the sane man, the world as it is is glori-
ous, beautiful, harmonious, and divine, so will science, our tested
and ordered knowledge of it, be the inspiration of art, poetry, and
religion.

Pure science and utilitarian science merge into each other at every
point. They are one and the same thing. Every new truth can be
used to enlarge human power or to alleviate human suffering. There
is no fact so remote as to have no possible bearing on human utility.
Every new conception falls into the grasp of that higher philan-
thropy which rests on the comprehension of the truths of science.
For science is the flower of human altruism. No worker in science
can stand alone. None counts for much who tries to do so. He must
enter into the work of others. He must fit his thought to theirs.
He must stand on the shoulders of the past, and must crave the help
of the future. The past has granted its assistance to the fullest
degree of the most perfect altruism. The future will not refuse; and,
in return, whatever knowledge it can take for human uses, it will
choose in untrammeled freedom. The sole line which sets off utili-
tarian science lies in the limitation of human strength and of human
life. The single life must be given to a narrow field, to a single strand
of truth, following it wherever it may lead. Some must teach, some
must investigate, some must adapt to human uses. It is not often
that these functions can be united in the same individual. It is not
necessary that they should be united; for art is long, though life is
short, and for the next thousand years science will be still in its

10 UTILITARIAN SCIENCES

infancy. We stand on the threshold of a new century; a century of
science; a century whose discoveries of reality shall far outweigh
those of all centuries which have preceded it; a century whose
glories even the most conservative of scientific men dare not try
to forecast. And this twentieth century is but one — the least,
most likely — of the many centuries crowding to take their place
in the line of human development. In each century we shall see a
great widening of the horizon of human thought, a great increase of
precision in each branch of human knowledge, a great improvement
in the conditions of human life, as enlightenment and precision
come to be controlling factors in human action.

In the remaining part of this address I shall discuss very briefly
some salient features of practice, investigation, and instruction in
those sciences which in the scheme of classification of this Congress
have been assigned to this division. In this discussion I have received
the invaluable aid of a large number of my colleagues in scientific
work, and from their letters of kindly interest I have felt free to
make some very interesting quotations. To all these gentlemen (a
list too long to be given here) from whom I have received aid of this
kind, I offer a most grateful acknowledgment.

Engineering

The development of the profession of engineering in America has
been the most remarkable feature of our recent industrial as well as
educational progress. In this branch of applied science our country
has come to the very front, and this in a relatively short time. To
this progress a number of distinct forces have contributed. One lies
in the temperament of our people, their native force, and their
tendency to apply knowledge to action. In practical life the Amer-
ican makes the most of all he knows. Favoring this is the absence
of caste feeling. There is no prejudice in favor of the idle man.
Only idlers take the members of the leisure class seriously. There
is, again, no social discrimination against the engineer as compared
with other learned professions. The best of our students become
working engineers without loss of social prestige of any sort. Another
reason is found in the great variety of industrial openings in America,
and still another in the sudden growth of American colleges into
universities, and universities in which both pure and applied sciences
find a generous welcome. For this the Morrill Act, under which each
state has developed a technical school, under federal aid, is largely
responsible. In the change from the small college of thirty years
ago, a weak copy of English models, to the American university
of to-day, many elements have contributed. Among these is the
current of enlightenment from Germany, and at the same time the

UTILITARIAN SCIENCE 11

influence of far-seeing leaders in education. Notable among these
have been Tappan, Eliot, Agassiz, and White. To widen the range
of university instruction so as to meet all the intellectual, esthetic,
and industrial needs of the ablest men is the work of the modern
university. To do this work is to give a great impetus to pure and
to applied science.

Two classes of men come to the front in the development of en-
gineering: the one, men of deep scientific knowledge, to whom
advance of knowledge is due, the other the great constructive engi-
neers; men who can work in the large and can manage great enter-
prises with scientific accuracy and practical success. Everywhere
the tendency in training is away from mere craftsmanship and
towards power of administration. The demands of the laboratory
leave less and less time for the shop. "Two classes of students,"
says a correspondent, " should be encouraged in our universities:
First, the man whose scientific attainments are such that he will be
able to develop new and important processes, the details of which
may be directly applied. This type of man is the scientific engineer.
The other is the so-called practical man, who will not only actually
carry on engineering work, but may be called on to manage large
enterprises. If his temperament and ability are such as to give him
a thorough command of business methods and details, while he is
in addition a good engineer, he will find a field of great usefulness
before him on leaving the university. The university should en-
courage young men to undertake the general executive work nec-
essary to handling men and in the many details of large enterprises.
The successful man of this character is necessarily a leader, and the
university should recognize that such a man can be of great influ-
ence in the world, if he is thoroughly and broadly educated."

"We need," says another correspondent, "men possessing a
better general training than most of those now entering and leaving
our engineering schools. We need more thoroughly trained teachers
of engineering, men who combine theoretical training with a wide
and constantly increasing experience, men who can handle the
factors of theory, practice, and economics."

"Technical education," says another correspondent, "should
look beyond the individual to the aggregate, and should aim to
shape its activities so as to develop at the maximum number of
points sympathetic and helpful relations with the industrial and
engineering interests of the state. This means careful and steady
effort towards the coordination of the activities of the technical
school with the general condition of industry and engineering as
regards its raw materials, its constructive and productive operations,
its needs and demands with regard to personnel, and its actual or
potential trend of progress."

12 UTILITARIAN SCIENCES

The coming era in engineering is less a period of discovery and
invention than of application on a large scale of principles already
known. Greater enterprises, higher potentialities, freer use of forces
of nature, all these are in the line of engineering progress.

"The realm of physical science," says a correspondent, "has
become to the practical man a highly improved agricultural land,
whereas in earlier days it was a virgin country possessing great-
possibilities and exacting but little in the way of economic treat-
ment."

In all forms of engineering, practice is changing from day to day;
the principles remain fixed. In electricity, for example, the field of
knowledge " extends far beyond the direct limits or needs of electrical
engineers."

"The best criticism as to engineering education came formerly
almost entirely from professors of science and engineering. To-day
the greatest and most wholesome source of such criticism comes from
those engaged in practical affairs. We have begun a regime wherein
coordinated theory and practice will enter into the engineering
training of young men to a far greater and more profitable extent
than ever before."

"The marvelous results in the industrial world of to-day," says a
correspondent, "are due largely to the spirit of 'usefulness, activity,
and cooperation' that exists in each community of interests and
which actuates men employing the means which applied science
has so bountifully accorded. I know of no greater need of engineer-
ing education in our country to-day than that its conduct in each
institution should be characterized by the same spirit of useful-
ness, activity, and cooperation."

In mining, as in other departments of engineering, we find in the
schools the same growing appreciation of the value of training at
once broad, thorough, and practical, and the same preference for the
university-trained engineer over the untrained craftsman.

The head of a great mining firm in London writes me that " for
our business, what we desire are young men of good natural quali-
fications, thoroughly trained theoretically without any so-called
practical knowledge unless this knowledge has been gained by
employment in actual works."

On the pay-roll of this English firm I find that five men receive
salaries of more than $20,000. All these are graduates of technical
departments of American universities. Seventeen receive from
$6000 to $20,000. Nine of these were trained in American univer-
sities, one in Australia, and two in England, while five have risen
from the ranks.

In the lower positions, most have been trained in Australia, a

UTILITARIAN SCIENCE 13

few in England, while in positions bearing a salary of less than
$2500 most have risen from the ranks.

"Given men of equal qualifications," says the director of this
firm, "the man of technical training is bound to rise to the higher
position because of his greater value to his employer. As a rule,
also, men who have been technically trained are, by virtue of their
education, men who are endowed with a professional feeling which
does not to the same extent exist among those men who have risen
from the rank and file. They are therefore more trustworthy, and
especially in mining work, where premium for dishonesty exists,
for this qualification alone they are bound to have precedence.
We do not by any means wish to disparage the qualifications of many
men who have risen from the ranks to eminent positions, but our
opinion may be concentrated in the statement that even these
men would be better men had they received a thorough technical
training."

The progress of chemical engineering is parallel with that in other
departments of technology. Yet the appreciation of the value of
theoretical training is somewhat less marked, and in this regard
our manufacturers seem distinctly behind those of Germany.

"The development of chemical industries in the past history of
the United States," says a correspondent, "was seriously delayed
by the usually superficial and narrow training of the chemist in
the colleges. Thus managers and proprietors came to undervalue
the importance of chemical knowledge. The greatest need at present
in the development of chemical industries is an adequate supply
of chemists of thorough training to teach manufacturers the impor-
tance in their business of adequate chemical knowledge. Epoch-
making advances in chemical industry will spring from the brain
of great chemists, and to insure the production of a few of these,
the country must expect to seed lavishly and to fertilize gener-
ously the soil from which they spring. Germany has learned the
lesson well: other nations cannot long delay."

Agriculture

In the vast range of the applications of science to agriculture, the
same general statements hold good. There is, however, no such
general appreciation of the value of training as appears in relation
to the various branches of training, and the men of scientific
education are mostly absorbed in the many ramifications of the
Department of Agriculture and in the state agricultural colleges
and experiment stations. There are few illustrations of the power of
national cooperation more striking than those shown in the achieve-
ments of the Department of Agriculture. I have no time to touch

14 UTILITARIAN SCIENCES

on the varied branches of agricultural research, the study of the
chemistry of foods and soils, the practice of irrigation, the fight
against adulterations, the fight against noxious insects, and all the
other channels of agricultural art and practice. I can only com-
mend the skill and the zeal with which all these lines of effort have
been followed.

The art of agriculture is the application of all the sciences. Yet
"agricultural education," writes a correspondent, "has not yet
reached the dignity of other forms of technical education."

"The endowment of the science of agricultural research in the
United States is greater than in any other country. The chief fault
to be found is in striving too rapidly for practical applications
and in not giving time enough for the fundamental research on which
these applications must rest. The proportion of applied agricul-
tural science in agriculture is too great in this country. While we
do not need fewer workers in applied agricultural science, we do
need more workers who would devote themselves to fundamental
research."

Two branches of applied science not specifically noticed in our
scheme of classification seem to me to demand a word of notice.
One is selective breeding of plants and animals; the other, the
artificial hatching of fishes. By the crossing of animals or plants
not closely related, a great range of variety appears in the progeny.
Some of these may have one or more of the desirable qualities
of either parent. By selection of those possessing such qualities
a new race may be formed in a few generations. The practical
value of the results of such experiments cannot be over-estimated.
Although by no means a modern process, the art of selective breed-
ing is still in its infancy. Its practice promises to take a leading
place among the economically valuable applications of science.
At the same time, the formation of species of organisms under
the hand of man throws constant floods of light on the great ques-
tions of heredity, variation, and selection in nature, the problem
of the origin of species.

In this connection I may refer to artificial hatching and accli-
matization of fishes, the work of the United States Bureau of Fish-
eries and of the fish commissions of the different states. There
are many species of fish, notably those of the salmon family, in which
the eggs can be taken and fertilized by artificial processes. These
eggs can be hatched in protected waters so that the young will
escape many of the vicissitudes of the brook and river, and a thou-
sand young fishes can be sent forth where only a dozen grew before.

UTILITARIAN SCIENCE 15

Medicine

In the vast field of medicine I can only indicate in a few words
certain salient features of medical research, of medical practice,
and of medical instruction in America.

In matters of research, the most fruitful line of investigation
has been along the line of the mechanism of immunity from con-
tagious diseases. To know the nature of microorganisms and their
effect on the tissues is to furnish the means of fighting them. " The
first place in experimental medicine to-day, "says Dr. W. H. Welch,
"is occupied by the problem of immunity." That medicine is be-
coming a scientific profession and not a trade is the basis of the
growing interest of our physicians in scientific problems, and this
again leads to increased success in dealing with matters of health
and disease. The discovery of the part played by mosquitoes in
the dissemination of malaria, yellow fever, dengue, elephantiasis,
and other diseases caused by microorganisms marks an epoch in
the study of these diseases. The conquest of diphtheria is another
of the features of advance in modern medicine, and another is
shown in the great development of surgical skill characteristic
of American medical science. But the discoveries of the last decades
have been rarely startling or epoch-making. They have rather
tended to fill the gaps in our knowledge, and there remain many
more gaps to fill, before medical practice can reach the highest
point of adequacy. The great need of the profession is still in the
direction of research, and research of the character which takes
the whole life and energy of the ablest men demands money for
its maintenance. We need no more medical colleges for the teach-
ing of the elements. We need schools or laboratories of research
for the training of the masters.

In the development of medicine there has been a steady move-
ment away from universal systems and a priori principles, on the
one hand, and, on the other hand, from blind empiricism, with
the giving of drugs with sole reference to their apparent results.
The applications of sciences — all sciences which deal with life,
with force, and with chemical composition — must enter into the
basis of medicine. Hence the insistent demand for better prelim-
inary training before entering on the study of medicine. "Only
the genius of the first order," says a correspondent, "can get on
without proper schooling in his youth. What our medical inves-
tigators in this country most need is a thorough grounding in the
sciences, especially physics and chemistry."

The instruction in medicine, a few years ago almost a farce in
America, has steadily grown more serious. Laboratory work and
clinical experience have taken the place of lectures, the courses

16 UTILITARIAN SCIENCES

have been lengthened, higher preparation for entrance has been
exacted, though in almost all our schools these requirements are
still far too low, and a more active and original type of teacher
has been in demand. Even yet, so far as medical instruction is
concerned, the hopeful signjs to be found in progress rather than
in achievement. A college course, having as its major subjects
the sciences fundamental to medicine, is not too much to exact of
a student who aspires to be a physician worthy of our times and of
the degree of our universities. First-hand knowledge of real things
should be the keynote of all scientific instruction. "Far more
effort is now made," writes a correspondent, "in both the prepara-
tory and the clinical branches to give the student a first-hand know-
ledge of his subject. This tendency has still a long way to travel
before it is in danger of being overdone. The practical result of this
tendency is that the cost of education per student is greatly in-
creased and the profits of purely commercial schools are thereby
threatened. This forms, doubtless, the main source of the objec-
tion made by the weaker and less worthy schools to better methods
of instruction. We need well-endowed schools of medicine that may
carry on their work unhampered by the necessities of a commercial
venture. Medical schools now exist in great numbers, — many
of them cannot keep up with modern requirements, and necessa-
rily their salvation lies in antagonizing everything in the nature
of more ample and more expensive training."

Another correspondent writes, emphasizing the value of biologic
studies: "The final comprehension of bodily activity in health and
disease depends on knowledge of living things from ovum to birth,
from birth to maturity, and from maturity to old age and death.
Anything less than such fundamental knowledge requires constant
guessing to fill up the gaps, and guesses are nearly always wrong."

In many regards, even our best schools of medicine seem to show
serious deficiencies. The teaching of anatomy is still one of the
most costly, as well as least satisfactory, of our lines of work. A
correspondent calls attention to the fact that in making anatomy
"practical" in our medical schools, " we expended last year $750,000
in the United States, twice the amount expended in Germany,
with as a result neither practical anatomy nor scientific achieve-
ment." "Anatomy," he continues, "should be made distinctly a
university department, on a basis similar to that of physics and
chemistry. Unfortunately, university presidents still stand much in
the way of the development of anatomy, for many of them seem to
think that almost any one who wears the gown is good enough
to become a professor of anatomy. Repeatedly have I witnessed
the appointment of a know-nothing when a recognized young man
might have been had for half the money." Our forces are dissipated,

UTILITARIAN SCIENCE 17

the fear of things scientific has destroyed even the practical in this
noble old mother science which is still giving birth to new sciences
and to brilliant discoveries.

Among other matters too much neglected are personal hygiene,
a matter to which the physician of the past has been notoriously
and joyously indifferent. Especially is this true as regards the
hygiene of exercise and the misuse of nerve-affecting drugs.

Public sanitation as well deserves more attention. "The demand
for adequately trained officers of public health is not what it should
be, and our public service as a whole is far below that of European
countries. Both public opinion and university authorities are
responsible for this condition."

The hygiene of childhood, in which line great advances are made,
is still not adequately represented in most of our medical colleges,
and the study of psychiatry and nervous disturbances in general
is not sufficiently lifted from the realm of quackery. "Not only,"
says a correspondent, "should psychiatry be taught in every med-
ical school, but it should be taught from a clinical standpoint.
Every city in which there are medical schools should have a psych-
opathic hospital for the reception of all cases of alleged insanity
and for their study, treatment, and cure. Such a hospital should
contain, also, a laboratory for the study of normal and of patho-
logical psychology. I am convinced that progress in normal psych-
ology will be made chiefly through the study of abnormal condi-
tions, just as physiology has profited so enormously through the
work of the pathologist."

A word should be said for veterinary medicine and its achieve-
ments of enormous economic value in the control of the contagious
diseases of animals. The recent achievements of vaccination against
the Southern cattle fever and against tuberculosis, the eradication
of the foot and mouth disease among other matters, have demanded
the highest scientific knowledge and the greatest skill in its practi-
cal application.

Unfortunately, veterinary science lacks in this country adequate
facilities for research and instruction. "Practically," says a cor-
respondent, "the veterinary sciences in the United States are lead-
ing a parasitic existence. We are dependent almost wholly upon
the results of investigation and teaching of European countries, not-
ably Germany and Denmark. The value of the live-stock industry
here is so tremendous that almost every state in the Union should
have a wrell-equipped veterinary school supported by public funds.
There is but one veterinary school in the United States that has
anything like adequate support." That this is true shows that our
farmers and stock-raisers are very far from having an adequate
idea of one of the most important of their economic needs.

18 UTILITARIAN SCIENCES

Economics

We may justify the inclusion of economics among the utilitarian
sciences on grounds which would equally include the sciences of
ethics and hygiene. It is extremely wise as well as financially profit-
able to take care of one's health, and still more so to take thought
of one's conduct. The science of economics in some degree touches
the ethics of nations and the "wealth of nations," a large factor in
the happiness of the individuals contained within them, depends
on the nation's attitude towards economic truths. Another justi-
fication of this inclusion is found in the growing tendency in our
country to call on professional economists to direct national opera-
tions. On the other hand, our economists themselves are becoming
more and more worthy of such trusts. The inductive study of their
science brings them into closer contact with men and with enter-
prises. By this means they become students of administration
as well as of economics. They realize the value of individual effort
as well as the limitations which bound all sorts of executive work,
in a republic. "Only a few years ago," writes a correspondent,
"the teachers of economics were far more generally unfavorable
critics of government work which interested them. They have
become more and more disposed to cooperate at the beginning
rather than to condemn at the end. Just as economics has taken
a more kindly and hospitable attitude towards politics, so similarly
has it towards business, as illustrated in the rapid rise of courses
in commerce." The demand for trained economists in public affairs
is " compelling the teachers of economics more and more to seek
contact with the men who are grappling face to face with economic
problems."

The relation of economic theory to administration is a subject
on which there is much diversity of opinion. It is claimed by able
authority that "economic science, by becoming ultra-theoretical, has
come into far closer touch with practical life than it ever attained
before. Laws, the statement of which seems like a refinement of
theory, determine the kind of legislation required on the most
practical of subjects." On another hand, it is claimed by high au-
thority that our country must have its own political economy.
"The generalizations arising solely from the uniformity of human
nature are so few that they cannot constitute a science. The classical
or orthodox political economy of England was conditioned from
start to finish by the political problems it had to face. We are only
beginning to acquire our national independence."

Still another view is that "all that has been achieved in the field
of economics that is of any value, has been the result of logical
analysis applied to the phenomena and experiences of every-day

UTILITARIAN SCIENCE 19

industrial life. The stages of past development can be determined
and interpreted only in the light of this analysis. The lesson which
the historical economist has never learned, is the importance of
that principle, which lies at the bottom of the whole modern theory
of evolution, and which was made use of by Lyell and Darwin,
namely, the principle that historical changes of the past are to be
accounted for by the long continued action of causes which are
at this present moment in operation and can be observed and
measured at the present day." "This," says my correspondent,
"needs saying and re-saying, until it is burned into the minds of
all students of economics."

The recent progress of economics in America has lain in part in
the development of economic theory by critical and by construct-
ive methods. An important reason for welcoming the exact and
critical study of economic theory is this: In the promulgation of
imaginary economic principles the social and political charlatan
finds his choice field of operation, just as the medical charlatan
deals with some universal law of disease and its universal cure.
The progress of science in every field discredits these universal
principles with their mystical panaceas. There is all the more reason
why in politics, as in medicine, those generalizations which deal
with necessary laws or actually observed sequence of events should
be critically and constructively studied.

In general, however, the progress of economics has followed the
same lines as progress in other sciences, through a " minute investi-
gation and the application of principles already discovered or out-
lined by painstaking inquiry as to facts." This method of work
has been especially fruitful in the study of monetary problems,
of finance, taxation, and insurance, in the study of labor problems
and conditions, in the study of commerce, and in the study of crime
and pauperism. In its development economics is, however, many
years behind the natural sciences, a condition due to reliance on
metaphysical methods and to the inherent difficulty in the use of
any other.

"Economics," says a correspondent, "has been less successful
than the material sciences in getting rid of the apparatus of meta-
physical presumptions. The economist is still too eager to formu-
late laws that shall disclose the ultimate spiritual meaning of things
instead of trying to explain how these things came to pass. He
has profited in small degree by those lessons which the progressive
evolutionary sciences have driven home in the past in the methods
of thinking of workers in other fields. Our science is still sadly behind
the times in its way of handling its subject-matter. The greatest
and most important work of economic investigations is to make
students see things as they are, to fit young men for the more highly

20 UTILITARIAN SCIENCES

organized business new conditions are ushering in, and give a
better appreciation of the problems of government and a better
training for participation in them."

Says another correspondent: "Training in research is in fact
essential to every technical man. The young technologist will be
confronted by new problems not covered by anything in literature
or in his past experience. Training in research is training in the art
of solving unsolved problems, and the practical man who has had
discipline of that kind has a great advantage over his more conven-
tional competitors. The Germans recognize this principle, and
behold their marvelous industrial growth. The student in every
department of science should be taught to think as well as to do."

The time must come when a man who has no training and no
experience in research will not be called educated, whatever may
be the range of his erudition. To unfold the secret of power is the
true purpose of education.

DR. DEAN OPERATING BEFORE HIS CLASS
Hand-painted Photogravure from the Painting by H. Oervex

The fascinating gruesomeness of a serious surgical operation incorporated,
so to .speak, with the scientific aspect, is the subject of Gervex's ambitious
effort, shown at the Paris Exposition, 1889. The operator is Dr. Jules
Dean, author of several works on Surgery, Officer of the Legion and Member of
the Institute, France. The painting represents a handsome young girl pre-
pared to undergo an operation for an affection of the throat. Dr. Dean is ex-
plaining the case to his class before using the knife, and the countenances of
his auditors indicate the gravity of his words, a treatment that evidences the
genius of the artist.

DEPARTMENT XVII — MEDICINE

DEPARTMENT XVII — MEDICINE

(Hall 1, September 20, 4.15 p. m.)

CHAIRMAN: DR. WILLIAM OSLER, Johns Hopkins University.
SPEAKERS: DR. WILLIAM T. COUNCILMAN, Harvard University.
DR. FRANK BILLINGS, University of Chicago.

THE MODERN CONCEPTIONS AND METHODS OF
MEDICAL SCIENCE

BY WILLIAM THOMAS COUNCILMAN

[William Thomas Councilman, Shattuck Professor of Pathological Anatomy, Har-
vard University Medical School, b. Maryland, 1854. M.D. Maryland Univer-
sity; A.M. (Hon.) Harvard and Johns Hopkins University. Graduate student
of Johns Hopkins University; special course, Vienna, Leipzig, Prague, Strass-
burg. Assistant in Physiology and Anatomy, Associate Professor, Johns
Hopkins University. Member of Association of American Physicians, National
Academy of Science. Author of medical works on Diphtheria; Small-Pox; and
Cerebro-Spinal Meningitis.]

AN acquaintance with present conditions in medicine and with
the literature of the past makes us aware of a great change both in
the conceptions of medicine and in the methods by which the con-
ceptions are reached. There has been a great increase of knowledge
brought about by investigation and experiment, a realization of
the value of knowledge and its acceptance and utilization. Medi-
cine has severed all connection with speculative philosophy and
taken its true place among the natural sciences. It has been brought
into closer accord with other sciences than ever before and has
accepted the methods of science. There are no systems, no schools,
no paramount authority; no hypothesis is so firmly held that it
is not instantly rejected when it fails to accord with new knowledge.
Progress in medicine has gone hand in hand with progress in all
departments of knowledge.

Medicine has for its problems the cause, the nature, the preven-
tion, the cure of disease. It is a branch of biology in that in all of
its relations it has to do with living things. The ontologic concep-
tion of disease as a thing differing from and entering into the organ-
ism is no longer held, but disease is regarded as a condition of living
things in which there is disharmony of function. The phenomena
of life depend upon actions exerted upon living tissue by its sur-
roundings. When the action exerted leads to forms of activity
which differ from and fail to come into accord with the usual activ-
ities, whatever produces such an action is a cause of disease. These

24 MEDICINE

causative agencies acting on the tissue, produce structural alter-
ations, in consequence of which even the action exerted by the or-
dinary surroundings may result in disharmony. The terms health
and disease both carry with them the conception of activity. Al-
though the abnormality of function is always associated with and
depends upon structural alteration, there may be extensive struc-
tural alteration which is so repaired or compensated for that it
does not result in disease.

In the history of the advance of knowledge in medicine we find
two methods by which knowledge has been sought. In one, the
endeavor has been made to form conceptions of the objects studied
by means of impressions conveyed by the senses. Great advances
have always followed the discovery of methods and instruments
by means of which the territory of investigation has been extended.
The inquiry does not stop with the mere description of the concep-
tions derived from the sense-impressions, but an effort is made to
correlate them, to ascertain preceding conditions, and the meaning
or idea involved. When the inquiry passes beyond the immediate
investigation, an ideal conception of the nature, the interrelation,
the cause or the result of the conditions studied, an hypothesis,
may be formed, based on experience and analogy. The hypothesis
must be tested by further observation under natural conditions and
by the experiment which involves observation under known and
controlled conditions. When the hypothesis has been so tested
and found to hold good in all cases under the same conditions, it
can be used as a basis from which new questions may arise.

The other method is by speculation. By a wide and illegitimate
use of analogy conceptions are formed and projected into the objects,
instead of being derived from the sense-impressions. A tendency
to speculation is inherent in the nature of man. Confronted al-
ways with the unknown, which has such enormous proportions
compared with the known, and so much of which seems to be re-
moved from the possibility of actual investigation, man is led to
attempt to answer the questions which the unknown thrust upon
him by means of the imagination. As knowledge becomes deeper
and more extended, speculation tends to become more confined.
True philosophy aims at a complete understanding of the causal
relation of all processes in nature and of man's relation to these
processes. Disease, as one of the most important conditions in
nature affecting man in all of his relations, has always had an im-
portant place in philosophy. All the systems of philosophy in the
past, from Plato down, have embraced speculations concerning
disease. The true ends of philosophy cannot be reached by specu-
lation, but by the use of all the material for observation given by
the natural sciences, and a philosophic system will contain just so

MODERN METHODS OF MEDICAL SCIENCE 25

much truth as there is natural science in it. Nature seems to de-
light in refuting all conceptions of her processes which are not
based on sense-impressions.

The progress of knowledge by these two methods has been the
same in all sciences as in medicine, but it is more easily followed in
medicine, because of the important place which its subject disease
has always held in the thoughts of man. It is possible to trace the
past in the conditions of the present. In the earliest period of medi-
cine, before there were any records of the study of the phenomena
of disease and any differentiation 'of disease, disease was regarded
as the visitation of the wrath of offended deities, and the surest
mode of its relief the propitiation of the deity by supplications and
offerings. Such beliefs are still held, or at least practices which
were based on such beliefs are continued. In almost all countries
at the present time it is the custom to offer supplications that the
disease of an important individual may be removed by divine inter-
position. It is true that such prayers may be a part of past tradi-
tion or a part of the discipline of a religious system, but undoubt-
edly their efficacy is believed in by many. Disease has played an
important role in systems of religions, and the teachers of the sys-
tem who had most fully embraced its tenets were supposed to be
the most efficacious in removing disease. Christian Science is only
one of a great number of religious systems held to-day in which
treatment of disease forms an important part of the cult. In the
past there have been systems of medicine which gave explanations
of all phenomena, and the system being perfect the phenomena
were removed from further investigation. Homeopathy is the most
important survivor of such speculative systems.

Speculation has undoubtedly been fostered by systems of religion
founded on what was accepted as supernatural revelation. Reve-
lation which sufficed for the explanation of phenomena at the time
when it was given becomes firmly and inseparably blended with
speculation when it must be expanded to meet a wider range of
phenomena. Knowledge cannot be diffused, accepted, or utilized
beyond the general development of culture. Any general influence
which can be exerted on the people, turning thought into new
directions, giving new subjects and proper methods, is of great
importance. Darwin, by substituting a rational and easily com-
prehended hypothesis, based on observation and experiment, with
a clear statement of the method by which the hypothesis was
formed, for a revelation which did not suffice and which could not
be twisted to conform to what was of general and accepted know-
ledge, exerted probably the greatest influence on general scientific
progress in the last century. Medicine, like all other sciences, has
felt its vivifying influence.

26 MEDICINE

One of the greatest changes which has taken place in the last
century is the general acceptance of the idea that medicine is a
natural science, in which knowledge must be sought by the methods
of science, namely, observation and experiment, and that disease is
the result of injurious conditions acting upon the tissues. A great
part of the mystery surrounding disease has been removed by know-
ledge of the conditions which give rise to it, with the further know-
ledge that it is possible to prevent disease by removing such con-
ditions. Even though some may still believe that an epidemic of
typhoid fever is an act of God, they must see that the action is
exerted by means of a defective water-supply, and the surest way
of removing the epidemic is not by supplication, but by purifying
the water. At no time in the world's history has the importance of
knowledge been so fully recognized as at present. People see the
application of knowledge in the arts, and that improvement in the
processes involved is directly dependent upon increased knowledge
of the processes. There is a closer union between science and art than
has ever been before. We see the influence of the appreciation of
knowledge in medicine in the general acceptance of the idea that
the hospital, in addition to taking care of the sick, shall furnish
facilities for the investigation of disease ; in the creation of institutes
devoted to the furtherance of medical knowledge, and in endow-
ments of universities to the same end.

A brief glance at some of the more important periods in medical
history will enable us to trace the influence and the results of the
two methods by which knowledge has been sought. The history
of medicine begins with Hippocrates. Before him there were only
superstition and tradition without systematic observation and
description. He described accurately the results of his study of the
phenomena of disease, classified the phenomena, and based his
methods of treatment on his observations. The influence of Greek
philosophy made him attempt to explain the phenomena, by the
assumption of a force residing in and presiding over the body. The
contemporaries and successors of Hippocrates who regarded him
as a god, and his conclusions as unfailing axioms, entirely neglected
the methods by which he arrived at them. It must ever remain a
source of wonder that the light which burst upon medicine with the
advent of Hippocrates should so soon have passed into darkness.
The Greeks chose rather to speculate on the meaning of phenomena
than to investigate them. Galen, next to Hippocrates, had the
greatest influence on medicine, an influence which was dominant
for more than 1300 years. Galen mastered all the knowledge and
traditions of medicine at his time and made important contributions
to anatomy and physiology. He was the first to introduce the
experimental method into medicine, and gave a firm foundation

MODERN METHODS OF MEDICAL SCIENCE 27

to nerve physiology by observing the paralysis of certain muscles
after section of the nerves. A voluminous writer as well as investi-
gator, Galen created a complete system of medicine which remained
as authority until men became bold enough to throw over authority
when it did not conform with what could be learned from investi-
gation. The stagnation and decline in medicine which followed
Galen and continued during the Middle Ages was due to the dom-
inance of a dogmatic religion in lands in which the general culture
of the people should have given the conditions for knowledge to
increase. The Church regarded its dogma as sufficient, and all
inquiry, all free activity of men's minds were prohibited. Dogma
based on supposed revelation sufficed. There was some attempt at
progress made by the Arabians, but their most important contri-
bution was the preservation of the old learning. Even the period
of the Renaissance passed with little or no influence on medicine,
for mental activity was turned exclusively into channels in which
dogma could not be disturbed.

Three circumstances served to bring about a new era in the pro-
gress of knowledge in which medicine shared. The discovery of the
art of printing by which knowledge became more diffused and more
exact by the substitution of record for tradition, the discovery of
America, with the stimulation which this gave to thought and
imagination, and the Reformation, which gave freedom to thought,
removed the weight of authority, and allowed investigation. The
reform in medicine was introduced in Europe by Paracelsus, whose
work was chiefly the overthrow of the Galen system, which had
sufficed and under which investigation was not possible. Progress
in the new reform was more active in England than in the land of
its birth. This was due to the freedom from war, the greater freedom
of the people in all ways, and to the work of Francis Bacon, who for
the first time showed clearly the methods by which knowledge
must be sought. With few exceptions, English medicine has remained
true to the precept of Bacon, that knowledge increases by the
observations of things with the proper utilization of past observa-
tions. There has been -an almost continuous line of great physicians
in England who have enriched medical knowledge by investigation
and who remained free from speculation. The contributions which
such men as Harvey, Sydenham, Hunter, and Bright have made,
remain and have served as bases from which knowledge has grown.
The theories which were founded upon their work have passed with-
out influence. That there came a time in England when medical
investigation was greatly surpassed in other countries, is to be attri-
buted to the introduction of methods of investigation which could
not be utilized in England. It was the introduction of the labora-
tory with the facilities for and the systematization of medical investi-

28 MEDICINE

gation which gave medicine in Europe its ascendency. Young men
at an age when authority has the least weight, and before there
was opportunity given them for the investigation of the clinical phe-
nomena of disease, found in the laboratory opportunity for inves-
tigation, and had small questions placed before them which could
be solved. The laboratory gave the workers scientific methods which
formed the basis, and gave the direction of further work in the
clinic. With the laboratory came also a division of labor, which
allowed certain men to devote their time to investigation and
teaching. Ambition was stimulated, for advance and the further
career was made dependent upon the ability for investigation.

It is interesting to follow a wave of speculation in medicine which
reached its acme in Germany in the early part of the nineteenth
century. In the period following the Reformation the most striking
figure in medicine was Albrecht v. Haller, a man who as investigator
and clear thinker has been equaled by few. Haller recognized the
important fact that life was a property inherent in the tissues and
manifested itself by sensation and movement. On the work of Haller
is founded the system of Brown, who though a Scotchman can be
regarded as the forerunner of the German Natur-philosophie in
medicine. The system of Brown is founded on the principle, which
he states clearly, that the living animal body is distinguished from
the dead and from all lifeless matter by the capacity for excitation by
external influences. The difference between health and disease lies
in the degree of irritability of the tissues. He divided disease into
the sthenic and asthenic types, according to the degree of irritability
developed by the excitant, and the treatment of disease was based
on this. In the hands of Brown's pupils and successors treatment
of disease was productive of great harm. The theory of Brown
found ready acceptance in Germany, not only by physicians but by
a group of men who sought to explain nature by the creation of laws.
The law once made was regarded as more correct than the observa-
tion. Schelling, who was the foremost figure in this philosophy,
sought to give a representation of all the phenomena in nature, to
develop the interrelation of the phenomena*, to show the action of
natural laws in all bodies, and believed that these laws originated in
a common point and were characterized as an advancing series of
higher phases of development of matter. Not only was it impossible
to construct a system of the world from the knowledge of nature
at that time, and it probably never will be possible, but Schelling
very imperfectly utilized what knowledge there was. This Natur-
philosophie dominated medicine in Germany during the first quarter
of the nineteenth century. It is expressed to a greater or less extent
in all medical writing. The most gifted men could not entirely
withdraw from its influence. Medicine was not a science following

MODERN METHODS OF MEDICAL SCIENCE 29

the methods of observation and experiment, investigation was
banished from the clinic and laboratory and found its place at the
writing-desk. Hartmann says that one reason why the Natur-philoso-
phie found such ready acceptance was the ease with which it was
possible by its aid to become famous as a writer. The young phy-
sician found it no longer necessary to become acquainted with the
material for study by toilsome investigation; he only needed the
philosophic forms of expression . and could apply these to what he
knew or did not know of medicine. Many systems of medicine were
founded which purported to give a complete explanation of all the
phenomena of disease. Of all these systems, the one which has
endured the longest was almost the most fantastic in its structure.
The success of the system of Hahnemann or homeopathy is, in the
first place, due to the fact that under it the treatment of disease
represented a great advance as compared with treatment under the
systems of Brown and Rasori. However zealous the exponents of a
system may be, it will find its condemnation from those who suffer
most from it. The system as presented by Hahnemann was com-
plete; it offered names and seeming explanations for all conditions.
The practice of the medical art under the system was easy and
involved no toilsome investigations. It was put forth at an early
period of the Natur-philosophie and was carried upward on the
tidal wave which swept through Germany. It at once found great
favor with the people and was taken up by great numbers of phy-
sicians. In the course of time the adherents of the system have
become divided into three camps. In one its principles have been
extended far beyond the conception of Hahnemann, in that the
products of disease have been used as remedial agents; a second
have remained true to the principles of the founder; and a third,
comprising a large number of intelligent physicians, hold only to the
name. Under the Natur-philosophie, combinations between religion
and medicine arose and a system, which represented a return to
medieval mysticism, was formed by Windischmann and Ringseis.
In this it was taught that the causes of disease are immaterial and
not to be sought for, since disease merely represents discord between
body and soul.

Such a remarkable phenomenon as the dominance of the specula-
tion which was a part of the Natur-philosophie must be regarded
as a part of the romantic movement which swept through Germany
and found its chief expression in poetry. All barriers to idealism
and speculation were cast aside. The movement was a part of the
awakening of Germany to a new national life. The great questions
of the time involving political liberty and even national existence
were absorbing. Under such circumstances only a few could turn
from the pressure of such large questions to the narrow field of

30 MEDICINE

scientific investigation. It is remarkable that the great awakening
in France which preceded it should have been characterized by the
opposite tendencies. During this period of speculation in Germany
valuable contributions to knowledge were continually being made
in anatomy and physiology. The chief exponents of the Natur-
philosophie were physicians who had to do with the clinical phe-
nomena of disease. Speculation was fostered because the methods
of gaining information from the study of disease were at the time
so meager that observation was restricted. So confirmed was the
habit of speculation that each new discovery in anatomy and physi-
ology, instead of serving as a basis for investigation, became food
for new speculation.

It is possible to see the influence of the Natur-philosophie on its
greatest opponent, Rudolf Virchow. No one more clearly laid down
the methods of scientific investigation than did Virchow in the
opening articles of his Archivs. He was a born investigator and
made valuable contributions to knowledge in every department
of medicine. The protocols of his autopsies are models of full and
accurate descriptions of observations. He made important additions
to the technic and methods of work by the use of which new know-
ledge was gained. He was a great teacher as well as investigator,
and men trained in his methods are among the most famous in
medicine.

It is difficult to find in the history of modern medicine any one
who can be compared with Virchow in the contributions made to
medical knowledge and the influence which he exerted. He sub-
stituted for the ontologic conception of disease, which was prevalent
in Germany at that time, the conception which we adopt to-day,
that it consists in life under altered conditions. This is not an
explanation, but a simple way of stating the summation of the
most obvious phenomena. He created the cell theory of disease,
which, though it represented an enormous advance over prevalent
theories and has been most stimulating to investigation, can no
more be held in its entirety as Virchow gave it than any of the
systems it supplanted. Unlike the other systems, it did not pretend
to be all-satisfying and all-explaining. The cell theory of disease
should be regarded as an hypothesis fully justified in being formed
from the knowledge at that time available. In Virchow's theory of
inflammation we see the great value of an hypothesis which, though
gradually proved incorrect by continued observations, has been
most stimulating to investigation. It is interesting to see the con-
tention which has been excited by theory. No one contends for the
acceptance of an observation, but is content to leave this for time,
but the contention is for the conception based on the observation
and the theory formed from the conceptions. Virchow properly

MODERN METHODS OF MEDICAL SCIENCE 31

Opposed the ontologic conception of disease, but this led him also
to oppose the proof given that certain diseases which he regarded
as due to the action of general causes, were due to parasites. Virchow
appeared in medicine at the time when Natur-philosophie, though
seemingly dominant in Germany, was really far advanced in decline,
and his mighty blows were delivered against a feeble body. It was
the knowledge of French and English medicine, where the advance
had been by investigation, the increase in knowledge in all the nat-
ural sciences giving too much to be covered by any system, which
gave the death-blow to this period of speculation in medicine.

It is possible now to see the effect of this period of unrestricted
imagination on medicine. It is true that it inhibited progress, by
restricting observation and experiment, that it substituted theory
for knowledge, and found satisfaction in empty phrases and jug-
gling with terms. But it gave birth to fruitful stimulation, and
opened wide and distant vistas which science has utilized. The
excitation of the imagination, provided the imagination be con-
trolled and theories be recognized as theories, is most useful in
science. Without the imagination, without the tendency to seek
for explanations of phenomena, there would be no progress. There
is only danger in the failure to recognize the true relation of the
hypothesis and in attempting to progress by adding hypotheses.
There was but little progress in the period, but progress resulted
from the stimulation which the period gave, and from the reaction
which followed it. Although as playing a great part and affecting
an entire people, such a movement has passed and will probably
not return, we constantly see the same tendencies. The medical
systems, often connected with religion, which are constantly arising
in all countries, and especially in this, the attempt to form theories
in explanation of the unknown, are due to the same mental states
which produced the Natur-philosophie. They arise, have a ready
following composed of birds of passage resting temporarily on any
bough provided, and disappear without making any real impression.
How completely the period of the Natur-philosophie has passed in
the country of the creation is seen in the history of medicine in
Germany for the last fifty years. By the adoption of scientific
methods, by the fostering influence of the government, which pro-
vided facilities for research, and by a system which gave reward for
investigation, Germany has become the leader of the world.

At no time in the world's history was there such rapid advance,
such a complete transformation in methods, such an array of great
men in all the departments of medicine as in France, following the
Revolution. The foremost of the men in this school in France was
Bichat. He undertook the gigantic task of creating for medicine
a solid foundation derived from the study of objects and from ex-

32 MEDICINE

periments. He carried the anatomic study of disease further than
ever before, endeavoring to ascertain not only the lesions in the
organs, but in the tissues which compose them. The relation be-
tween the anatomic lesions and disorders of function he says must
be studied by experiment. The work of Magendie in physiology
was hardly less important than that of Bichat in pathology. Phy-
siology had suffered from the theory of vital force which as a seeming
explanation weighed upon it as an incubus, opposing investigation.
He claimed for physiology the same methods as in physics and
chemistry, saying that the carefully conducted experiment is alone
decisive in testing the conclusions formed from observation of phe-
nomena. The work of Magendie had full recognition in France,
and he was followed by Claude Bernard and Brown-Sequard, who
further developed his methods. Corvisart, Andral, Louis, Rayer,
and Cruvilhier were among the most brilliant men in the new school
which was founded by Bichat and Magendie. Corvisart and Laennec
deserve especial mention in that the former brought to general
knowledge the method of percussion of Auenbrugger, which had
been forgotten, and the latter introduced and further developed the
method of auscultation.

In the advance of science new technical methods of investigation
play a most important role. The technical method enables the
observation to extend further and more deeply. Virchow has said
that the introduction of the microscope into medical research en-
abled us to approach several hundred times nearer disease than
before. The microscope introduced a new era in the study of disease ;
it came into general use when the study of gross pathology in the
absence of new questions had almost reached its limit. It gave more
correct ideas of disease by increasing the powers of observation; it
overthrew at once many theories and gave new points of view and
new questions, from which further observation could proceed.
Every improvement in the microscope by which its efficiency is
increased has the same influence. The knowledge of the influence
of bacteria in disease is due, in the first instance, to the improve-
ment of the microscope, and in the second, to the discovery by
Koch of methods of cultivation, by means of which the individual
species can be studied. Until this was possible our knowledge of
bacteria was inexact and their causative relation to disease only
an hypothesis. The development of knowledge of the minute struc-
ture of cells and tissues is principally due to the use of methods of
staining, which started with the simple carmin stain of Gerlach. In
clinical medicine the introduction of the microscope, the thermo-
meter, the methods of chemic investigation, the blood-counter, the
Rontgen ray, have all led to a closer insight into disease and the
substitution of knowledge for conjecture. There is a further indirect

MODERN METHODS OF MEDICAL SCIENCE 33

advantage which comes from the use of instruments of precision in
investigating phenomena, in that the continued use of the methods,
the constant seeking for exact knowledge of conditions removes the
tendency toward speciilation.

The brilliant results which have been reached in surgery, changing
this from the most despised to the leading branch of medicine, show
the advantage of methods which are founded on knowledge. Surgery
was despised in the period in medicine in which speculation was in
the ascendency, when the answers to its problems were sought in
the study rather than at the bedside and in the laboratory. The art
of surgery has been dependent upon direct observation of disease,
and its remedial measures were applied to the disease as revealed
by sense-impressions. Theories and systems in medicine have come
rather from internal medicine, in which field the diseased conditions
were not so susceptible to study as things. The broken leg, however,
is revealed by sight and touch, the tumor is an object. Moreover,
the training in the anatomic and other laboratories so essential for
a surgeon, gave the knowledge and the methods, and the manual
skill to make them effective. At an early period surgery had re-
course to animal experimentation, for the animal body offered the
readiest means for testing new devices. In surgery new knowledge
has been readily accepted and utilized. The demonstration of
anesthesia came first from the surgeon, and the surgeon was the
first to accept and apply the knowledge that infection is due to the
action of living organisms. By the use of anesthesia and of measures
of preventing infection, surgery has been extended into fields for-
merly supposed not to be open to the exercise of its art. Medicine
owes a debt to surgery for not only what it has accomplished, but
for holding to proper methods and demonstrating their importance.
The less advance in modes -of treating disease which internal medi-
cine has made, compared with that made in surgery, is to be attri-
buted to the difficulty of obtaining definite knowledge of the con-
ditions of disease in internal organs.

That the lack of power is due primarily to lack of knowledge
is shown by the fact that for diphtheria, formerly one of the most
dreaded, now probably the best-known of diseases, there is a remedy
which leaves little to be desired. The production of antitoxin is the
greatest triumph of scientific medicine and is due to knowledge
obtained by the application of scientific methods to the study of
a disease which gave unusual opportunities for investigation. It
points out what may be accomplished in the future by not seeking
for analogies between other diseases and diphtheria, but by pursuing
the same methods. Modern therapeutics is guided by two principles
in each of which efficiency is dependent upon knowledge of disease.
In the most important, the remedial agent has a specific action on

34 MEDICINE

the cause of disease, either destroying it or opposing its action. In
the second, the remedial agents are used not with the view of exert-
ing any specific action against the cause of disease, nor even in assist-
ing in the restoration of the tissue which has been injured, but
with the view of restoring function. Any agent acting as a cause of
disease produces injury of the tissue, and the effect of this is altera-
tion, or diminution, or destruction of function. There is a close in-
terrelation of function, that of one organ depending upon the others.
The effect of the alteration of function is seen in the supervention of
phenomena, which differ from the ordinary. The effect of impaired
function may be remedied by supplying the body with some sub-
stance which was formed by the impaired organ. Substances directly
derived from glands in the animal body, such as thyroid and pancre-
atic extract, may be supplied. Or the functional activity of an
organ may be increased by direct stimulation or increasing its blood
supply. Or the function of some other organ nearly related to the
organ affected may, by increased function, be caused to supply the
deficiency.

Therapeutics acts either as a guard against, or as a caretaker
of the body in disease. Its greatest triumphs are in prevention.
When the injury has once been produced, its effects are minimized
by the capacity of the body to adapt itself to new conditions. There
is a third use of therapeutics in the case in which the disease pro-
duces so much pain and discomfort that the remedial agent is used
for the purpose of diminishing the effect of sense-impression on the
central nervous system. It is clear how complicated the questions
are, and how much greater is the task presented to the physician
than to the surgeon. The surgeon acts directly, either adjusting
parts which are deranged or by removing tissue which is diseased.
The study of medical literature shows the mistakes and follies
which have been and are being perpetrated in therapeutics. The
more obscure the disease, the greater the number of remedies; the
more ignorant the practitioner the more confidence that certain
drugs will act as remedies in all diseases. Each year has served to
discard some remedy considered infallible and to substitute for
it another equally infallible. The discontent of the general public
with such therapeutics is shown in the success of charlatans who
advertise nostrums for the cure of all diseases. It is just as easy
for them to obtain certificates of cures by the nostrums as it is for
the practitioner to become convinced of cures effected by certain
favorite drugs.

The greater knowledge of the infectious diseases which has come
with their experimental study has especially served to place thera-
peutics upon a proper basis. It has become apparent that many
diseases are self-limited and tend to recover under any treatment,

MODERN METHODS OF MEDICAL SCIENCE 35

provided this be not too injurious, and that the medical art can be
more successfully exerted in preventing disease than in its cure.
The first effect of increased knowledge of disease was to produce
a feeling of powerlessness in the face of it, followed by a nihilism
in therapeutics which was as much to be deplored as overconfidence,
for it acted as a bar to progress. This nihilism was a prominent
feature of the Vienna school in the sixth decade of the past century.
The science of therapeutics as we find it to-day is founded on ex-
perimental pharmacology and pathology. In experimental pharma-
cology the action of drugs on the healthy animal is investigated.
It is sought to discover the mode of entry of the drug into the tissues,
the mode of excretion, the changes the drug undergoes while in
the body, and the changes in structure and function it produces.
The action of the drug may differ in different animal species. Know-
ledge of the pathology of disease shows in what part changes are
produced by the causative agent, the nature of the changes, and
the effect of these changes on function. The determination of what
is taking place in the body in disease is the most important ques-
tion in medicine to-day. For its answer all the resources of science
must be brought to bear. The subject is rendered more compli-
cated by the fact that we are not dealing with a fixed but with a
variable quantity. Age, heredity, temperament, and social en-
vironment must all be considered. We cannot say, except with
wide limitations, what changes and variation in function will be
produced by the action of certain conditions. With the knowedge
of the effect of the drug on the healthy body, and the knowledge
of what changes are being produced in disease, and the effect of
which we wish to minimize, an intelligent experiment may be made.
Previous experimentation on animals should deprive the experi-
ment of all danger.

Another change which has become apparent is the greater spe-
cialization not only in the exercise of the medical art, but in in-
vestigation. All increase of knowledge must bring with it special-
ization, for with the enlargement of the field comes the impossi-
bility of its control by one individual. Specialization has both
advantages and disadvantages. The advantages are, that inves-
tigations are more easily carried out by the simplification of the
questions and the familiarity with technical methods. Methods
of investigation have become so complicated that the necessary
skill can only be attained by the constant exercise of methods
only applicable in a very narrow field, and an investigator of ex-
ceptional ability in one line of work may be powerless in another.
A man may profitably devote his entire energies to the study of
the changes in nerve cells in disease, or may confine himself to the
study of a single species of bacteria. With the enormous increase

36 MEDICINE

in medical literature there has come specialization in this, and
certain journals are devoted to special subjects and are only read
by those working in the field covered. The first differentiation came
in the separation of anatomy, physiology, and pathology from prac-
tical medicine, that is, the medicine concerned with the exercise
of the art. The separation was a natural one, for not only could
progress be more rapid, but the subjects could be better taught
by one who had the knowledge which came from his own investi-
gations. It is no longer possible for a single individual to control
the knowledge in any of these primary subdivisions. The most
obvious disadvantage in specialization is the loss of the more gen-
eral aspects of questions. The large questions become broken up
into smaller, and the smaller questions become leading questions
to be again broken up. It is also felt that the knowledge gained
in such special investigations may not be of a character which can
be utilized in the treatment of disease. But few of the questions
which arise and form the basis for investigation come from the clinic,
and they apparently have only the most remote relation to the
problems of disease. The investigator very properly feels that his
investigations are justified, in that they form contributions to general
knowledge, and whether or not the results are directly applicable
to the treatment of disease does not disturb him.

There was an error perpetrated in not giving to those devoted to
the study of the clinical aspect of disease the same opportunity
to devote themselves to research, to answer the question which came
from the phenomena of disease, which was given to anatomy,
physiology, and pathology. Clinical medicine, the study of the
problems of disease coming from the bedside, must have the same
opportunity and must advance by the use of the same methods as
physiology and anatomy. Clinical medicine is behind the special
departments in the contributions it has made to knowledge, in the
methods by which it seeks to advance, and in the efficiency of
teaching. Provision must be made in the universities which will
enable men in the clinical departments to devote themselves to
research and teaching, and laboratories must be provided for such
research. Only one who is himself an investigator can direct in-
vestigation by recognizing and properly stating the questions. There
need be no fear that the knowledge which comes from investigation
will not be utilized. In what way may not be apparent at the time.
Often knowledge which seemed furthest removed from utility has
become the most important. That knowledge is poAver, and that it
is the only power is an accepted axiom.

Anatomy and physiology, originally arising from human medi-
cine for the furtherance of knowledge which could be applied to
the treatment of disease in man, have long outgrown such limita-

MODERN METHODS OF MEDICAL SCIENCE 37

tions. Both have become comparative. Physiology undertakes the
study of the processes taking place in living things, anatomy their
form and structure. The comparative view has more slowly entered
into pathology, for this has been more closely in contact with clinical
medicine, and mostof the questions for investigation have arisen in
connection with the diseases of man. Disease is found in every living
thing, in all animal and plant life. The phenomena of disease must
differ according to the conditions peculiar to the organism. Strictly
speaking there can be little similarity between the phenomena of
disease in a plant and in an animal. The functions that are destroyed
or altered by disease are too dissimilar. But this is not true when
we study the closer details of disease. In both, changes are pro-
duced and the changes affect function. We can study unicellular
organisms directly under the microscope, see the changes which
are being produced by injurious conditions and the effects of the
changes. Knowledge derived from such study may be said to be
the basis of our conception of inflammation. The studies of plant
diseases have been almost entirely directed from the economic
side. The economic results which have come from this study by
enabling the prevention of disease are almost incalculable. General
medicine has gained by this study a greater knowledge of para-
sites, their mode of action and the means by which the organism
is protected against them. That the knowledge has been so rapidly
gained is due to the facilities for investigation and experimenta-
tion. Plant experimentation has never given offense. It should
be regarded on the whole as very much better that the study of
plant disease has been directed from the economic side, for progress
has been more rapid, but there would be advantage in the closer
association of plant and animal pathology and the extension to
plant diseases of questions coming from disease in man.

Careful study of diseases in animals has been chiefly directed
to the infectious diseases and especially to those artificially pro-
duced. The questions have been chiefly those concerned with the
parasitic cause of disease and the mode of action of the parasites.
The more obscure diseases of animals have attracted but little
attention and only from the economic side. The phenomena of
disease in the higher animals have much similarity to the phenom-
ena of disease in man, and in certain aspects the diseases of animals
are more capable of investigation. Diseases are found in ani-
mals which are similar to the most obscure diseases in man. Our
ignorance of these diseases in man is due to their complexity and
the difficulties of investigation. To their understanding chemical
and physical methods are necessary, and some of these methods
cannot be carried out, for they may be harmful to the individual.
In animals we have the advantage that the disease can be inter-

38 MEDICINE

rupted at any stage and the conditions studied at this stage. We
know the infectious diseases of animals chiefly by their experi-
mental production. There has been but little study of these dis-
eases under natural conditions and much knowledge can be gained
by the mode of, and conditions predisposing to, infection. Ques-
tions of heredity have an important bearing on disease. The sus-
ceptibility of animals to disease varies. Common experience has
shown in man also that, under circumstances apparently the same,
certain individuals will acquire diseases, others remain exempt.
There is also foundation for the belief that susceptibility for cer-
tain infectious diseases is inherited and in other diseases inherited
susceptibility is beyond doubt. The most striking recent discovery
in medicine is that the blood-serum contains many complex sub-
stances. Some of them play an important role in the animal econ-
omy, for others we can as yet discern no purpose, and our know-
ledge of these substances is chiefly confined to their effects, but it
has recently been found possible to isolate one substance in pure
form with a known chemic composition. While these substances
may serve an important role in protecting the body against disease
they may act in the opposite way by providing a means by which
injurious substances are brought in contact with cells. Whether
chemic variation may not arise, be inherited, and play an important
part in disease susceptibility is an important question to be answered
by comparative medicine. For the purpose of such investigation
an animal clinic is necessary, which should be provided with thorough
facilities for the study of disease. The questions for solution should
come both from comparative medicine and from the clinic of human
disease.

Comparative medicine is intimately associated with experimental
medicine. There can be no contention as to the relative advan-
tages of observation and experiment. The experiment is only obser-
vation under simple and known conditions and supplements obser-
vation under the more complicated natural conditions. In the
experiment it is possible to divide questions into their simpler com-
ponents and make each the subject of experiment. In experimental
medicine just as in the animal clinic, the questions for solution should
come from both comparative medicine and the human clinic. The
most brilliant results in experimental medicine have come from the
study of the infectious diseases. Knowledge of these diseases stands
in direct relation to the possibility of their experimental production.
It is true that we have not been able to produce in animals many
of the diseases which are found in man. Experimental medicine
is comparatively new and the number of animal species experi-
mented upon has not been large. It has recently been found possible
to produce syphilis in the chimpanzee and there is every reason to

MODERN METHODS OF MEDICAL SCIENCE 39

hope that this will lead to knowledge of the nature of this most
obscure disease. Questions concerning the circulation and respira-
tion in disease which are closely related to physics will find their
answer in experimental medicine. The opponents of animal ex-
perimentation should remember that the greater our knowledge
of disease which comes in this way, the further will disease in man
be removed from experiment. Before our present knowledge of
diphtheria, tuberculosis, tetanus, and anthrax, all treatment of these
diseases was experimental. In certain cases experiments must be
carried out in human beings and even when the experiments may
have a fatal termination. Such experiments will only be resorted
to when this forms the only method of obtaining knowledge
of the highest importance, and the subjects of the experiment
must be adults who submit with full knowledge of the possible
consequences. Let us give all honor to the men who devised and
the brave men who submitted to an experiment, the knowledge
obtained from which has placed yellow fever in the list of pre-
ventable diseases.

There has been in the past too wide a separation between the
public and the medical profession. The public has derived its medical
information chiefly through the newspapers and the information so
given has been sensational and unreliable. Without correct infor-
mation of the problems which face the medical profession and of the
methods by which these problems are being solved, neither the sym-
pathy nor cooperation of the public may be secured. Active or passive
opposition may be encountered. There is evidence that this is being
slowly changed. The medicine of the romance is not so fantastic
as it was formerly. The general information in biology, human
anatomy, and physiology necessary for any appreciation of medi-
cine is being imparted by the schools. Many of the popular maga-
zines contain admirable articles on disease. The stories of such
diseases as malaria and yellow fever have actual fascination. The
medical education of the public is also furthered by the work of
boards of health in the control of infectious diseases. The public is
slowly but none the less surely learning that disease is not a mysteri-
ous entity, dwelling like a devil in the body, to be driven out by
the use of some equally mysterious agent, but a condition of life
which can be guarded against. The public is not slow in the ap-
preciation of the results of the work of boards of health, and is
willing to make provision for their work.

Medical education, the training of men to exercise the art of
medicine, has been revolutionized in the past twenty-five years.
The most marked change has been in the substitution of object-study
for the didactic lecture. The didactic lecture is still used, though
not with the idea of imparting knowledge, but of showing the in-

40 MEDICINE

terrelation of knowledge coming from objective teaching. The suc-
cessful practice of medicine depends more than ever before upon
the use of methods which give accurate knowledge of the con-
dition of the sick individual, and training in the exercise of these
methods is the most important part of medical education. It is
certainly of importance that the student should learn the structure
of the body, the functions of the different organs, and the changes
which organs and functions undergo in disease. The knowledge
acquired will be constantly used in solving the problems presented
in the practice of medicine. While this is true, a great part of the
value of these studies consists in the discipline which laboratory
study enforces.

In the laboratory the student learns to acquire conceptions of
objects and of the activities taking place in them, by means of sense
impressions, and to use and appreciate methods by means of which
the field of investigation is extended. He learns to approach pro-
blems from the scientific point of view. Progress and success in medi-
cine is directly dependent upon the habit of investigation. Medi-
cine is not and probably will not be an exact science with definite
laws, by the application of which the exact sequence of phenomena
can be foretold. Every case of disease is a problem, and on the
knowledge acquired from investigation successful treatment of the
individual depends. Science demands to know, and methods by
which knowledge can be obtained are of supreme importance.
Methods of obtaining knowledge have been widely extended in
clinical investigation. Every year sees the discovery of new methods.
There should be, and with the foremost men there is, no distinction
between the clinic and the laboratory. In both knowledge is sought
by the use of the senses, and methods of investigation have a su-
preme importance. The laboratory discipline can be given just
as well in the clinic as in the other laboratories, with the advan-
tage that the methods of the clinic are the methods which are used
in the practice of medicine, and facility in methods can only be
acquired by continual exercise. It is evident, however, that the
laboratories and clinics should only be conducted by men who
themselves know and fully appreciate the importance of methods.
It is probable that in the medical education of the future there will
be a restriction of the laboratory training in anatomy, physiology,
and pathology, and an extension of the training in the methods
of the clinical laboratory.

THE DEVELOPMENT OF MODERN MEDICINE

BY FRANK BILLINGS

[Frank Billings, Professor of Medicine, University of Chicago, and Professor of
Medicine and Dean of Faculty, Rush Medical College, b. April 2, 1854, High-
land, Wisconsin. M.D. Northwestern University Medical School, 1881; M.S.
ibid. 1890; Demonstrator of Anatomy, ibid. 1882-85; Lecturer on Physical Dia-
gnosis, ibid. 1883-87; Professor of Physical Diagnosis, ibid. 1887-91; Professor
of Medicine, ibid. 1891-98; Professor of Medicine, Rush Medical College, 1898;
Dean of Faculty, ibid. 1900. Member of Association of American Physicians;
Association of American Pathologists; American Medical Association; Illinois
State Medical Society; Chicago Medical Society; Chicago Pathological Society;
Chicago Academy of Science; Chicago Neurological Society; Chicago Literary
Club. Editor of Year-Book of Medicine.}

MODERN medicine is a composite of the knowledge of many sci-
ences. The last twenty-five years mark the period of the greatest
evolution of medicine in its history. The foundation of modern medi-
cine was laid by the labors of hundreds of earnest workers in the
field of science during the last three centuries. As a rule the value
to modern medicine of these pioneer investigators was in an in-
verse ratio to the length of the period which separated them from
modern times. Exceptions to this rule are found, however, even
in the seventeenth and eighteenth centuries. Indeed, at that period
when one considers the superstition, prejudice, mystic belief, magic,
astrology, dogma after dogma, and system after system which pre-
vailed, the inheritance of the dark ages, our admiration is excited
by the really great results of the work of some of the scientists.
Until the seventeenth century, Hippocrates, Galen, and Aristotle
were the authorities in medicine. There was practically no ad-
vancement in medicine in that period of time. Anatomy and patho-
logy were not understood; dissection was forbidden by the clergy
of the Middle Ages, because it was considered impious to muti-
late a form made in the image of God. Dissections of the human
body were practiced to a limited degree during the fourteenth and
fifteenth centuries, but the sixteenth century was marked by the
birth of Vesalius, a naturalist, whose investigations in human ana-
tomy marked the beginning of scientific medicine.

The seventeenth century marked the birth of realism. Galileo
was a reformer in physics, and other scientific men broke away
from the superstitions and dogmas .of the day and searched for
light along self-chosen paths. During the century, Harvey dis-
covered the circulation of the blood. Zoology and botany were
cultivated. Romer calculated the velocity of light. Lord Bacon's
brilliant mind shone resplendent. Sir Isaac Newton discovered
the law of gravity. Malpighi, Steno, Bartholin, De Graf, Wharton,

42 MEDICINE

Nuck, Bninner, Wirsung, Peyer, Havers, Cowper, Schneider, Hew-
son, Vieussens, and Merkel, and many others, dissected out ever-
lasting monuments of their genius and skill. Hooke introduced
the term "cell," and the cell-doctrine was founded by Malpighi
and Grew. Linnaeus, Kant, Richelieu, Mazarin, Moli6re, Bach,
Hayden, Beethoven, and Goethe were contemporaries of these
other great men. Peruvian bark was introduced into Spain during
this period.

The eighteenth century, called the golden age of medicine, wit-
nessed a continuation of the constructive and realistic work of the
previous century. Pathologic anatomy was born, and in the person
of Morgagni received an impetus which gave it everlasting life.
John Hunter, Baillie and Home in England, and Bichat in France
were worthy successors of Morgagni. In this century Leopold Aven-
brugger, the discoverer of percussion as a means of diagnosis of the
diseases of large organs of the body, introduced the method in clin-
ical investigation. Haller originated experimental physiology. An
ambulatory clinic was inaugurated at Prague in 1745, and the first
clinical institute was founded at Vienna in 1754 by Van Swieten.
Preventive inoculation against small-pox was performed, a method
of protection against variola which was practiced by the Chinese
a thousand years before Christ. The most notable event of that
period occurred at the close of the century with the discovery, by
Edward Jenner, of vaccination as a protection against small-pox.

The period marked by the first seventy-five years of the nineteenth
century was but a continuation of the tendencies of the preceding
period. The watchword of medicine was pathological anatomy
and diagnosis — the so-called scientific or exact medicine. This
tendency to realism was modified to some degree by the philosophic
teaching of Schelling, Hartman, Spencer, Haeckel, Hagel, and others.
Pathologic anatomy found brilliant exponents in Bretonneau,
Corvisart, Bright, Rokitansky, Louis Magendie, and many others.
The practical salutary effect of pathology upon practical medi-
cine was evinced by the epoch-making clinical observations of
Addison, Graves, Cheyne, William Stokes, Trousseau, Wunderlich,
Ziemmsen, Corrigan, and others. Notable was the advancement
made in physical exploration in diagnosis. Avenbrugger's inven-
tion of percussion was extended by the translation of his book and
the adoption and improvement of the method of percussion by
Corvisart.

In 1815, Laennec invented the stethoscope. Skoda developed
both percussion and auscultation and published his famous work
on these subjects in 1839. Thus in medicine we find that, even in
that early day, the pathologist and the clinician taught that by
the aid of its special senses and by the microscope and instruments

DEVELOPMENT OF MODERN MEDICINE 43

of precision the diagnosis could be made with a definiteness, im-
possible by the use of the symptoms alone.

The epoch-making work of Johannes Mueller in embryology and
physiology marked the beginning of modern physiology, and this,
with the unparalelled activity of Virchow in pathology, resulted
in an enormous development of scientific observation and product-
iveness.

Corresponding activity marked the work in the sciences of chem-
istry, zoology, comparative and human anatomy, physics, botany,
and general biology. The development of the microscope gave
impetus to the study of the lower forms of life. In 1838, Ehren-
berg regarded infusoria as animals. In 1852, Perty claimed that
most infusoria should be assigned to the vegetable world. Cohn
proved the correctness of this conclusion and perfected a classi-
fication. In 1837, Bassi discovered the parasitic nature of silk-worm
disease. The parasitic form of favus and thrush was proved by
Schoenlein and Nagel respectively. Dovaine recognized the anthrax
bacillus in 1850. In 1857, Pasteur demonstrated that fermenta-
tion and putrefaction were caused by lower organisms and at the
same time forever set at rest the superstition of spontaneous gener-
ation. Obermayer recognized the spirillum of relapsing fever in
1873. Bacteriology became an exact science with the discovery by
Robert Koch of cultural methods which made the differentiation
of germs possible.

The causative relations of bacteria and microorganisms to all
infective processes has been proved by the laws promulgated by
Koch. The discovery by Brieger, Panum and others of the poisons
produced by bacteria was another important step in the progress
of bacteriology as related to medicine.

From the discovery and development of bacteriology, and especially
through the brilliant researches of Pasteur and Koch and of their
students, has resulted a knowledge which has revolutionized and
marked the birth of modern medicine.

Parasites

The discovery of the hematozoon of malaria by Laveran; the
recognition of the ameba of dysentery by Loesch ; of the ray fungi
and especially the actinomyces as infective agents in the lower
animals and in man and the more exact knowledge of other ani-
mal parasites infecting man and animals, which the microscope
has made clear, have been as epoch-making in parasitology as
the discoveries of Pasteur and Koch in bacteriology.

The recognition of the relation of bacteria, protozoa, and ani-
mal parasites to infective disease has been the means of a more

44 MEDICINE

exact knowledge of the clinical phenomena of disease, of morbid
anatomy, of physiology, and of physiologic chemistry than would
have been possible without it.

Transmission of Infection

The knowledge of the cause of disease has led to a study of the
life-history of infective organisms outside of as well as in the animal
body. The mode of propagation, the means of transmission of in-
fective microorganism, by fomites and other agents, has become
known. The rdle of insects which infect animals play, as defin-
itive or intermediate hosts, has been studied and proved. The
discovery of Manson of the transmission of Filaria sanguinis hominis
by the mosquito was of vast importance as a suggestion of the
mosquito as a definitive host in malaria. The investigations of
Manson, Ross, Celli, Grassi, Dionise, Marchiafava, Bignami, Koch,
and others have made our knowledge of malaria exact. With the
microscope we may now not only recognize malaria and differentiate
it from the other infective fevers, but we may also at the same time
recognize by an examination of the blood the type of malarial in-
fection and foretell its course. Not only may we recognize the dis-
ease definitely and apply the drug treatment more rationally, but
the knowledge of the means of its transmission from man to man
enables us to apply preventive measures which are of the greatest
importance from a commercial as well as from a humanitarian
point of view. The recognition of the r61e of the mosquito in malaria
has been, furthermore, a stimulus to the study of the same insect
in relation to other infections.

The brilliant research work of Reed and Carroll in 1900 in Cuba,
by which they proved that the mosquito of the genus stegomya
is the sole means of the transmission of yellow fever from man to
man, is of great importance as a scientific fact. The influence of this
discovery upon mankind, as a prophylactic against a disease which
has killed multitudes, is wonderful.

Hardly less important is the fact that the Bacillus pestis may
infect fleas and these in turn infect rats, mice, and man. It is im-
portant, too, to know that pests like the house-fly may be carriers
of infective bacteria from refuse filth to kitchens and tables and con-
taminate food, and thus infect u swith typhoid fever, cholera, and
perhaps other diseases which are propagated by filth.

The study of bacteria in the laboratory and hi the blood tissues
of infected animals has led to the discovery of the means by which
bacteria disturb the animal economy and produce phenomena
expressive of disease. The fact that the blood and tissues of infected
animals contained a toxin which could also be isolated from pure

DEVELOPMENT OF MODERN MEDICINE 45

bacterial cultures in the laboratory and that this toxin when in-
troduced into an animal was capable of exciting the same phenom-
ena of disease as the bacteria themselves, was positive proof that
bacteria excite disease phenomena at least in some instances by
means of a toxin which they form. The elaboration of antitoxins
in the body of the infected animal was also promptly recognized,
and served to explain not only the self-limitation of many of the
infective diseases, but it also helped us to understand the immunity
which one attack affords in some of the bacterial diseases.

Protective Inoculation

Long before bacterial toxins were recognized as the cause of
disease phenomena, Pasteur established the principle of protect-
ive inoculation with bacteria of lessened virulence, which was
brought about by attenuation of the bacteria by a modification of
cultural methods and also by serial inoculation of certain lower
animals. This he successfully applied to charbon in sheep and cattle
and to chicken cholera. In both of these diseases the bacteria were
known and the problems of attenuation could be carried on in the
laboratory by direct study of the bacteria before inoculation and
afterward when they were recovered from the body of the animals
experimented upon.

His final life-work was no less important in firmly fixing the im-
munizing influence in rabies. Here the discovery was made that
the infecting bacterium escaped every known means of recognition
by microscopical and cultural examination of the tissues and blood
of the infected animals. Apparently there are pathogenic germs
which we do not know because we have not yet recognized the
proper culture material for the successful artificial cultivation
of them, nor have we discovered the tinctorial reaction which they
may possess; and, finally, it is not improbable that they may be
infinitely smaller than other germs and, therefore, more difficult
to recognize.

Pasteur recognized the fact that in hydrophobia the brain and
other nervous tissues of an infected animal are capable, when in-
oculated into another animal's brain, of producing the disease.
That the infected brain used for infecting animals contained the
germs which caused the disease was proved by the fact that a
stage of incubation occurred in the inoculated animal and that
a series of animals were successfully inoculated consecutively from
the first. Pasteur then successfully attenuated the unknown micro-
organism present in the nervous tissues of an inoculated animal
by dessication of the nervous tissue in a sterile apparatus by methods
too well known to repeat. Nor is it necessary to occupy time in re-

46 MEDICINE

peating the well-known methods pursued by Pasteur and his pupils
in the use of the graduated doses of attenuated toxin contained
in the nerve tissues in the prophylactic treatment of rabies. To
Pasteur, therefore, we owe the scientific recognition of the principle
of protective inoculation.

It is now a well-known fact, however, that inoculation against
disease was practiced by the Chinese a thousand years ago. They
inoculated the healthy with small-pox as a protection against the
disease. Variolization was also practiced in Europe in the seventeenth
and eighteenth centuries. We read that in 1718, Lady Montague
caused a son to be inoculated with variola in Italy, and that two
years later her daughter was inoculated in England. The practice
was followed in Ireland long after the successful establishment
of vaccine as a protection against variola. Inoculation against
syphilis, or syphilization, was practiced in Europe during the nine-
teenth century.

We owe to Jenner, however, the first example of the protective
inoculation by means of an attenuated virus. This attenuation we
now know was established by the accidental inoculation of milch
cows with small-pox, producing a modified disease, vaccinia. That
vaccinia, produced in man by inoculation, would protect against
small-pox was proved when, in 1798, Jenner successfully vaccinated
direct from the cow, the five-year-old lad William Summers.

The thousands of successful vaccinations which have since been
performed and the thousands of lives which haA^e been saved by
vaccination are proof of its validity and utility. The immunity
established by protective inoculation is apparently the same as
that induced by an unmodified attack of variola.

Serum Therapy

When chemistry had revealed the nature of bacterial poisons and
experiments established their relation to the phenomena of disease,
it was proved that substances were formed in artificial culture media
and in the blood and tissues of infected animals which had the power
to neutralize the effect of the bacterial poison in other animals
infected with the same organism. Further investigation showed
that an animal inoculated with the laboratory preparation of anti-
toxin was protected against the disease.

Furthermore, it was found that the blood serum of an animal
inoculated with bacteria in a non-fatal and repeated dose contained
an antitoxin. When the blood serum of an infected animal was
injected into a healthy animal, the latter was protected against the
original disease.

Antitoxin was, therefore, proved to be formed in artificial media

DEVELOPMENT OF MODERN MEDICINE 47

of bacterial cultures and in the bodies of infected animals. When
the antitoxin thus formed was injected into an animal, it had the
power to protect that animal against the particular bacterial infec-
tion, or, if given subsequent to the infection of the animal, to miti-
gate the severity of the disease or entirely to check it.

Thus Koch and his students established the principle of serum
therapy. Upon this principle there has been developed and given
to the world the anti-diphtheritic serum of Behring and of Roux,
and also an immunizing serum for Asiatic cholera, tetanus, ery-
sipelas, plague, epidemic dysentery, streptococcus infection, and
other diseases. While the serum treatment has not proved successful
in all of the diseases in which it has been used, it has been so success-
ful in some — diphtheria, for instance — as firmly to establish the
principle of serum therapy. The study of prophylactic sera by Paul
Erlich led to our present knowledge of immunity. His side chain
theory has established a working basis which affords superb fields
of research in physiologic chemistry which have already yielded
rich returns.

Bacteriology made possible the comprehension of perfect cleanli-
ness and enables the surgeon to invade every part of the body
without fear of infection and has saved thousands of lives which
twenty-five years ago would have perished miserably as the result
of disease at that time inoperable, or as the result of infection from
contact with the surgeon. By means of cleanliness and skill, in-
duced by a broader experience, the surgeon has been able to add to
our knowledge information of great value which could have been
obtained probably in no other way. He has been able to study dis-
ease in the living body and show the relation of a disease process
to infection. He has thus been able to clear away many of the
misconceptions of symptomatology and diagnosis, especially in dis-
ease of the abdominal organs.

Bacteriology has stimulated laboratory clinical diagnosis. Bac-
terial reaction to sera and blood cultural tests are of the greatest
aid to diagnosis. Clinical research work has command of an arma-
mentarium consisting of a knowledge of pathologic anatomy, of
physiology, of bacteriology, of chemic physiology, and of physics,
which allows of a precision in diagnosis never before at the command
of the physician.

The evolution of bacteriology has afforded a stimulus and aid in
the advancement of parasitology, physiology, physio-chemistry,
and of other fundamental sciences. This knowledge has been more
directly applied to practical medicine than ever before.

Indeed modern medicine is now so comprehensive that the student
must be thoroughly conversant with chemistry, inorganic, organic,
and physical, with physiology, with general biology, with human

48 MEDICINE

and comparative anatomy, with bacteriology, and parasitology, to
understand and appreciate it.

Slowly but surely the secrets of the cause of disease which baffled
the search of centuries have yielded to the brilliant light of modern
methods. The causative agents of most of the infective diseases
of man and of the lower animals are now known.

The unknown causative germs of the few remaining infectious
diseases will soon be discovered, and then the principles of immunity
and cure by inoculation or by the application of antitoxins will
find wider application.

Prevention of Infection

The recognition of the germ-cause of the infectious diseases enables
modern medicine not only to combat disease more rationally and
successfully, but it enables us to prevent them.

In most of the infective diseases due to germs, protozoa, parasites,
and fungi, the causative agents have been so fully investigated that
we know the life-history, and what conditions are best suited for
the propagation and multiplication of each, and also what will
remove and annihilate these dangerous enemies. So the diseases of
domestic animals which may also infest man, for example, actinomy-
cosis of cattle, trichina of swine, tuberculosis of animals, chicken
cholera, foot and mouth disease, charbon, etc., may be entirely
eradicated. The experience of one hundred years proves that small-
pox may be prevented by proper vaccination. If universally applied
and repeated at proper intervals the disease would probably disap-
pear.

Our knowledge of the living agents which provoke malaria,
typhoid fever, cholera, the plague, and the means by which they
propagate, develop, and the manner in which they infest man, enables
us, if we may command the situation irrespective of the financial
cost, not only to prevent but also in many localities to abolish them
altogether.

The discoveries of Reed, Carroll, and Agramonti of the relation
of the mosquito (Stegomyia fasciata) to yellow fever has been
practically applied with notable success in Cuba and elsewhere.

The study of bacteriology has developed general hygiene to a
high plane. The value of sunlight, pure air, and pure food are fully
recognized as preventives and also as rational curative measures
in many infective diseases.

Unfortunately there are a few of the scourges of mankind which
science has not yet conquered. Pneumonia, the bacterial cause of
which is known, is still a "captain of death." Cancer remains uncon-
quered. So, too, do many of the chronic diseases, namely, the primary

DEVELOPMENT OF MODERN MEDICINE 49

blood diseases, diabetes, the various degenerative processes, etc.,
which, though frequently easily recognized during life, are at best
only modified by our efforts to check or remove them.

Physio-chemistry, experimental medicine, physiology, and patho-
logic anatomy have given us much information of these processes,
and there can be no question that many of these problems will be
solved by the present methods of investigation.

The present knowledge of the cause of disease, of the evolution
of disease processes, of the natural expression of disease as recog-
nized by clinical investigation, has resulted in a rational mode of
treatment. Drug treatment is no longer looked upon as specific,
but as a helpful agent to modify and palliate disease processes,
in conjunction with proper dietary, hydratic, and hygienic measures.
Polypharmacy and indiscriminate drugging and drug nihilism are
recognized as equally irrational. It requires a nice judgment of when
to give, as much as when to withhold, drugs.

To enable a diseased or crippled organ more nearly to perform
its function; to fortify and prolong life, with the hope of a favorable
termination of a self -limited disease; to palliate suffering, are some
of the measures which drugs afford modern medicine. Pharmaco-
logy and pharmacy have developed equally with the other parts of
medicine and enable us to command drugs and active principles
with accuracy and comfort.

The discovery of the X-ray was a boon tosurgical diagnosis and
it has proved of wonderful therapeutic value in many of the disease
processes of the skin and superficial tissues. When the X-ray shall
be better understood its appreciation will be undoubtedly much more
extensive.

The rapid development of modern medicine has attracted wide
attention and excited the interest of students and investigators
over the whole world.

A larger percentage than ever before of the best-educated students
of the world have sought medicine as the most attractive field of
study and research. At this time there are hundreds of earnest,
thoughtful, patient, and energetic workers after truth who fre-
quently sacrifice home, friends, comfort, health, and even life for the
advancement of the science of medicine.

The advancement of modern medicine has also attracted the
attention of the philanthropic rich as never before. In recent years
institutes of research have been erected or are in the course of con-
struction and equipment which have rich endowment. Modern medi-
cine is therefore better prepared to develop now than ever before.

The development of medical literature has been in keeping with
the advancement of other sciences. Large and valuable libraries are
found in every land. Medical journalism is a science of itself and

50 MEDICINE

enables the physician at small cost to be in touch with all that is new
and progressive.

Modern medicine requires of its students an education which shall
fit them to take part as research workers or as practitioners to apply
the measures afforded them to prevent or more quickly to modify
disease. The modern medical student, therefore, requires the broad
education of the university and a training of his special senses in
the study of the natural and of the fundamental medical sciences,
preliminary to the study of applied medicine and surgery. Happily
both the old and the new world afford institutions which satisfy
all requirements of modern medical education. Many medical insti-
tutions exist which cannot furnish the necessary educational advan-
tages. These institutions are doomed. They are relics of the past.
It is to be hoped that they will be no exception to the rule of the
survival of the fittest.

SECTION A — PUBLIC HEALTH

SECTION A — PUBLIC HEALTH

(Hall 13, September 21, 10 a. TO.)

CHAIRMAN: DR. WALTER WYMAN, Surgeon-General of the U. S. Public Health

and Marine Hospital Service.
SPEAKERS: PROFESSOR WILLIAM T. SEDGWICK, Massachusetts Institute of

Technology.
DR. ERNST J. LEDERLE, Former Commissioner of Health, New

York City.
SECRETARY: DR. H. M. BRACKEN, St. Paul, Minn.

DR. WALTER WYMAN, Surgeon-General of the United States
Public Health and Marine Hospital Service, and Chairman of the
Section of Public Health, in calling the Section to order, expressed
his appreciation of the honor that had been conferred upon him in
being made the presiding officer of so important a section, and
congratulated the members of the Congress who were present on
taking part in a congress so unique in history, so distinguished in
membership, and whose proceedings would doubtless prove of such
great value to mankind.

Recent legislation (Act of July 1, 1902) had provided for the
United States a body practically fulfilling the requirements of a
national board of health under the name of Public Health and
Marine Hospital Service, an evolution from the century-old Marine
Hospital Service. The Service controlled a laboratory for the in-
vestigation of infectious diseases and matters relating to the public
health, its medical corps comprised between three hundred and
four hundred medical officers, distributed throughout the United
States and also representing the Service in foreign lands in sanitary
matters.

The difficulty had been hitherto to establish a national health
organization in which there might be a representation of the states
without weakening the administrative and executive force of the
national service and giving the states a voice in at least the
consideration of matters pertaining to the public health. This had
been brought about by the provision for annual conferences between
the state and national health authorities.

One difficulty which has always faced Congress in the establish-
ment of a national health organization was not to assume extra,
constitutional rights. The power of Congress in matters pertaining
to epidemic disease and matters relating to public health lie chiefly
in its power to regulate commerce, though doubtless many would
believe that under the public welfare clause of the Constitution

54 PUBLIC HEALTH

certain beneficent institutions could be organized and maintained
by the national government. As a matter of policy, the attitude of
Congress is also in accord with the spirit of the Constitution. It has
not been deemed desirable that the United States Government should
be too paternal, but should leave most of the details in public health
matters to the state and municipal governments. Occasionally
there is a tendency toward a weak leaning on the national govern-
ment, which should not be encouraged, but in the opinion of the
Chairman it is the wisest policy at present that the national govern-
ment should only give aid when it is necessary to do so in the interest
of several states or communities combined. The leaving of ordin-
ary public health matters to the management of the state health
boards would strengthen them in their organization and in their
appeals to the state legislatures for appropriations. Any national
system must necessarily include, for its efficacy, the health organiza-
tions of the several states and their development in power.

Time may develop a closer relation between the national and
state, or local, governments with regard to local sanitation, since
the latter is closely connected with epidemic diseases which become
the care of the national authorities.

Through the Hygienic Laboratory, with its advisory board, the
scientific work of the Public Health and Marine Hospital Service is
brought into contact with the scientific laboratories of the country.
Through the conferences with the state health officials the practical
administrative work of the Bureau and its various sanitary pro-
blems are now considered in conjunction with the official represent-
atives of the state governments; and a good scientific and execu-
tive framework of the national health structure exists in the corps
of specially trained medical officers, under military discipline, and
trained in government methods.

The national health organization, as thus outlined to-day, is much
stronger than was the old national board of health, but it should be
stated that while the organization seems to have sufficient scope,
much remains to be done to perfect the details.

THE RELATIONS OF PUBLIC HEALTH SCIENCE TO
OTHER SCIENCES

BY WILLIAM THOMPSON SEDGWICK

[William Thompson Sedgwick, Professor of Biology, Massachusetts Institute of
Technology, b. West Hartford, Connecticut, December 29, 1855. Ph.B.
Sheffield Scientific School, 1877; Ph.D. Johns Hopkins University, 1881;
Fellow, ibid. 1879-80. Instructor in Physiological Chemistry, Sheffield Scien-
tific School, 1878-79; Instructor and Associate in Biology, Johns Hopkins, 1880-
83; Assistant Professor, Associate Professor, and Professor hi Biology, Massa-
chusetts Institute of Technology, 1883; Biologist of Massachusetts State Board
of Health, 1888-96; Curator of Lowell Institute, Boston, 1879. Member of
American Association for the Advancement of Science, Society of American
Bacteriologists, American Public Health Associations, American Society of
Naturalists, American Academy of Arts and Sciences. Author of General
Biology (joint author); Life and Letters of William Barton Rogers (assistant
editor) ; Principles of Sanitary Science and Public Health; The Human Mech-
anism (joint author).]

"Physical science is one and indivisible. Although for practical purposes,
it is convenient to mark it out into the primary regions of physics, chemistry,
and biology, and to subdivide these into subordinate provinces, yet the method
of investigation and the ultimate object of the physical inquirer are everywhere
the same." — HUXLEY.

PHYSICAL SCIENCE is one and indivisible; that, as I understand
it, is the keynote of this great Congress, of which public health
science forms one section, and as I am invited to consider, in the
brief space of forty-five minutes, the relations of public health
science to other sciences, I shall take the liberty of selecting from
the whole number of " other sciences " only a few, the relations of
which to public health science seem to me for one reason or another
especially important at the present time. I accept the term public
health science without hesitation, for any division of human know-
ledge which has worked out its own laws with strict adherence to
the rules of inductive and deductive reasoning, as public health
science has done, and which has reached results enabling it to pre-
dict with accuracy, as public health science can now predict, is
entitled to a place and an honorable place among the physical sciences.

Public health science had its rise and a considerable development
in the eighteenth century. Before that time numerous procedures
tending to protect or promote the public health had, indeed, at one
time or another existed, but these were largely empirical and quite
as often directed to the convenience of mankind as to their sanitary
safety. In this class belong the Mosaic code; the water-supply
introduced into Jerusalem by Hezekiah; the sanitary engineering
of Empedocles; the Cloaca Maxima, the water-supplies of ancient
Mycenae and of Rome, and all the earlier, and too often futile,
forms of quarantine. Even the art of inoculation for small-pox
was only an ingenious knack introduced from the East, where it

56 PUBLIC HEALTH

had been long used empirically, and although it was a public health
measure now of the utmost interest and capable at the time of
great practical service, it had until recently no scientific basis, but
belonged in nearly the same class as the amulets and charms, the
prayers and incantations, of the superstitious.

It was not until the middle of the eighteenth century, namely,
in 1767, that Sir George Baker, by the use of the methods of pure
inductive reasoning, made the first scientific discovery in public
health science in the subdivision of epidemiology, namely, that
the epidemic cholic of Devonshire, England, was due to an obscure
poisoning by lead conveyed through the common cider used for
drinking in that district. In 1774, the foundations of state hygiene
and sanitation were laid in consequence of the patient investiga-
tions and startling revelations of John Howard, by an act of Par-
liament providing for the sanitation of jails and prisons. The
beginnings of marine hygiene and sanitation appear in 1776, when
Captain Cook, the navigator, was awarded the Copley Medal of the
Royal Society for his remarkable success in protecting the lives of
his sailors on his second voyage. In 1796, Edward Jenner, working
also in a strictly scientific manner, and employing the methods
of rigid inductive research, laid securely for all time the founda-
tions of personal hygiene and immunization, by showing how we
can produce at will such modifications of the physiological resist-
ance or susceptibility of the human body as to make it immune to
small-pox.

The importance of these fundamental and splendid discoveries,
not only to the public health of the time, but far more to the develop-
ment of public health science in all the centuries to come, is incal-
culable. Reduced to their lowest terms, we have in these eighteenth
century discoveries the germs of some of the most important
divisions of public health science as it is to-day, namely, (1) epidemi-
ology, (2) sanitation of the environment, and (3) immunization
of the human mechanism, this last the most marvelous phenomenon
hitherto discovered in personal hygiene.

Time fails me to do more than name some of the principal steps
in the advancement of public health science in the nineteenth
century. We have, for example, in 1802, the beginnings of factory
hygiene and sanitation; in 1829, the first municipal water-filter, one
acre in area, constructed for the Chelsea Company of London; in
1834, recognition of the important relation of poverty to public
health, in the famous report of the Poor Law Commissioners of
that year; in 1839, the beginnings of registration and accurate
vital statistics; in 1842, an important report on the sanitary con-
dition of the laboring population of England; and in 1843, a similar
report on the health of towns; in 1854, for the first time clearly

RELATIONS TO OTHER SCIENCES 57

taught, the lesson, even yet not properly taken to heart, that drink-
ing-water may be the ready vehicle of a terrible epidemic of cholera.
About 1860, striking epidemics of trichinosis first came into public
notice, and here, also, belongs the magnificent work of Pasteur,
while in 1868, Lister, following in the footsteps of Pasteur, revealed
to the world the basis of true cleanliness in asepsis, and in 1876,
bacteriology became firmly established as a science by Koch's
studies on anthrax. The decade from 1880 to 1890 may be called
the golden age of etiology, for in these years were discovered
the hitherto unknown parasitic microbes of typhoid fever, tuber-
culosis, malaria, Asiatic cholera, diphtheria, and tetanus. The last
decade of a century which has well been called " the wonderful,"
witnessed the discovery of antitoxins by Behring and the beginnings
of serum therapy. The list is long, and I have not mentioned
nearly all of the discoveries of capital importance, but because of
these and their fruits, I am in the habit of saying to my students
that with the single exception of the changes effected by the ac-
ceptance of the theory of organic evolution, there has been no modi-
fication of human opinion within the nineteenth century more
wonderful, or more profoundly affecting the general conduct of
human life, than that in our attitude toward the nature, the causa-
tion, and the prevention of disease — that is to say, toward public
health science.

No mere outline like this of the history of public health science
can possibly serve to show how, like other applied sciences, this
one has not grown as a branch grows from a tree, namely, from
a large stem or stock of knowledge, tapering out into thin air, and
with its latest growth its least and weakest. That common simile,
in which the various divisions of science are represented as branches
of the tree of knowledge, is a grotesque survival of a time when
neither trees nor science were understood. No simile is perfect
or even approximately correct, but one better than the tree and its
branches for the origin and relationships of any inductive science
is that of a river, rising from various and often obscure sources,
growing in size and importance as it proceeds both from the springs
within its own bed and by the entrance and contributions of tribu-
tary streams, and finally pouring its substance into the mighty
ocean of accumulated human knowledge.

Up to the time of the establishment of the registration of vital
statistics in England, in 1839, the stream of public health science,
although full of promise, was only a slender thread, but when the
results of registration were fully enlisted in its service it visibly
widened and deepened. Epidemiology, as has been said, had the
honor of giving birth to the science in 1767, and it added to its
offspring a rich endowment when, in 1854, Dr. John Snow proved

58 PUBLIC HEALTH

that the water of the Broad Street well in London had caused an
epidemic in which more than six hundred persons died of Asiatic
cholera. The stream of public health science was still further
enlarged and quickened by the revelation in and after the sixties
of the simple causes of numerous epidemics of trichinosis and of
typhoid fever, the latter sometimes through milk. There was an
extraordinary popular awakening in England to the importance
of sanitation and public health measures in the middle of the nine-
teenth century, but we look for some time in vain for any marked
inosculation between public health science and other sciences,
such as physics, chemistry, microscopy, bacteriology, climatology,
engineering, or education. We have, to be sure, minor contributions
from the microscopists, such, for example, as that from Dr. Has-
sall, who, in 1850, made a careful microscopical examination of the
water-supply of London and showed the presence in the public
drinking-water of muscle fibers, intestinal parasites, and other ma-
terials, plainly derived from sewage; but it was not until Petten-
kofer and his disciples, in Germany, and Angus Smith and others,
in England, began their splendid chemical investigation that the
tributary stream of sanitary chemistry enlarged materially that of
public health science. In saying this I do not forget that my late
friend and colleague, William Ripley Nichols, whose solid contribu-
tions to sanitary chemistry were among the first in America, and
will always remain among the best anywhere, long ago pointed
out that, as early as 1789, "Fourcroy studied the nature of 'lith-
arged ' wine, Berthollet (1801) the methods of preserving water for
long voyages, Chevreul (1846) various chemical reactions which ex-
plain the hygiene of populous cities, and (1856, 1862, 1870) methods
of preparing and preserving food; Graham and Hofmann reported
upon the use of acetate of lead in sugar-refining (1850), upon the
London water-supply (1851), and upon the adulteration of pale ales
with strychnine (1882); Dumas was interested in many sanitary
matters and made, among others, reports on the mineral waters of
France (1851), .on the water-supply of Paris (1859), on the treat-
ment of sewage (1867), and on the preservation of food (1870-72);
Wurtz was for a number of years president of the Comitt considtatif
d'hygiene and a year before his death was president of the Socie~t6 de
me'decine publique. His investigations and reports on sanitary sub-
jects are numerous — on the disposal of the waste from distilleries
and sugar-refineries, on the colors employed on German toys and in
articles of food, on the adulteration of wines, etc.

"Other names will occur to us — such as those of Sir Henry
Roscoe, Sir Frederick Abel, and Dr. Williamson, who served on the
Noxious Vapors Commission of 1876; of Frankland, who gave
years of service to the Rivers Pollution Commission of 1868 and in

RELATIONS TO OTHER SCIENCES 59

connection therewith devised an elaborate system of water analysis;
we think also of Schutzenberger devising a method for the deter-
mination of oxygen dissolved in water (not, to be sure, simply for
sanitary purposes), Mallet studying the various methods of water
analysis, Remsen studying the organic matter in the air, and Leeds
the practical effect of charging with oxygen (or rather with air)
water used for purposes of domestic supply." l

I dwell intentionally upon the service of sanitary chemistry to
public health science previous to the rise of bacteriology, because
I believe that, dazzled as we have been and still are by the blaz-
ing achievements of bacteriology, beginning, let us say, with the
discovery of the microbe of tuberculosis by Koch in 1882, students
of public health science have been too much inclined to underrate
the past services and present relative importance of sanitary chem-
istry. I know of few more important contributions to public health
science, even since 1882, than the chemical work of the State Board
of Health of Massachusetts under the able direction of my friend,
Professor, afterwards President, Drown (the successor of Nichols)
and his associates and successors; or that of another friend, the late
Professor Palmer, of the University of Illinois, whose chemical
studies of the rivers of Illinois will long remain a monument to a
life full of promise and too soon cut short; or that of still another
friend, Professor Kinnicutt, who fortunately is still engaged in fruit-
ful work.

I have perhaps said enough, though it would be difficult to say
too much, of the magnificent contributions to public health science
of Pettenkofer and his disciples in sanitary chemistry; but the
work of these investigators in sanitary physics and especially the
physics of the soil, of the atmosphere, of the walls of buildings, and
of heating and ventilation, in their relations to the public health
are quite as important, and perhaps to-day even more neglected.
In view of the increased facilities of transportation and the grow-
ing habit of traveling, together with the tendency to outdoor life,
which seem to be characteristic to-day of all civilized nations,
the next twenty-five years will probably see a return to the patient
and exact studies of the environment, such as the chemists and phys-
icists began, and have in some measure continued, since the middle
of the nineteenth century. These studies will be directed largely
to further knowledge and control of the environment, but they
will not end there, for personal hygiene, owing to recent advances
in physiology, is to-day one of the most inviting fields for work and
education, and I hardly need to point out to a company of experts

1 William Ripley Nichols, address before American Association for the Advance-
ment of Science, Proceedings, American Association for the Advancement of Sci-
ence, vol. xxxiv, 1885.

60 PUBLIC HEALTH

that the proper care and right use of the individual human mechan-
ism reacts favorably and fundamentally upon the public health
no less truly or effectively than an improved condition of the en-
vironment or of the public health tends to promote the welfare
and long life of the individual.

The sphere of hygiene may be divided, as it often is, into the
two hemispheres, public hygiene and personal hygiene, or it may
be cut into one portion dealing chiefly with the human mechanism
and its operation (personal hygiene), and another portion dealing
chiefly with the environment of that mechanism (sanitation). The
time has gone by when any one person can safely undertake to deal
with the whole sphere of hygiene. The physiologist and the phy-
sician must in the future leave to the architect and the sanitary
engineer such subjects as housing, heating and ventilation, water-
supply and sewerage, precisely as the sanitary engineer has never
presumed to deal with foods and feeding, vaccines and antitoxins,
exercise, sleep, and rest. The former subjects deal chiefly with the
control of the environment, the latter subjects chiefly with the con-
trol of the individual, and sanitation and hygiene must hencefor-
ward be regarded as separate hemispheres of the science of health.

The science of architecture, if under this head we include the
principles of building construction, and the heating and ventila-
tion of buildings, has done and is doing much of interest and im-
portance to the student of public health science. For my own part,
I am continually more and more impressed with the fact that the
air-supply, especially for the modern civilized and too often seden-
tary form of mankind, is in the long run quite as important as the
water-supply, the milk-supply, or any other supply. Surely, we can-
not be too careful of the purity of a substance which we take into
our bodies oftener, and in larger volume, than any other, and which
has come, rightly, no doubt, and as the result of long and painful
experience, to be known as the very breath of life. I am well aware
that human beings may survive and seemingly thrive, even for long
periods, in bad air, but I am certain that for the best work, the
highest efficiency, the greatest happiness, and the largest life, as well
as for perfect health, the very best atmosphere is none too good.
Hence I believe that the permeability of the walls of houses and
other buildings, and the heating and ventilation of dwellings,
school-houses, churches, halls, and other public places, require,
and in the near future will receive, a much larger share of our
attention than they have to-day.

In an age characterized by urban life and possessing sky-scrapers,
tenement-houses, and other huge beehives, in which human beings
aggregating vast numbers spend a large part of their lives, build-
ings require for their proper construction, lighting, heating, air-

RELATIONS TO OTHER SCIENCES 61

supply, water-supply, gas-supply, and drainage, the scientific serv-
ices not only of architects, but of engineers, and such public
buildings form one small section of the aid which modern engin-
eering science is now everywhere rendering to public health science.
The present has rightly been called an " age of engineering," and
to no other science, excepting only medicine itself, is public health
science to-day more indebted than to engineering science. I have
referred above to the construction of the first municipal filter at-
tached to a public water-supply as that of the Chelsea Company
of London, constructed in 1829. How different is it to-day! Not
only nearly the whole of London, but also Berlin and Hamburg,
and a thousand lesser cities all over the civilized world, are now
protected more or less perfectly from epidemics of typhoid fever,
Asiatic cholera, and other water-born diseases, by vast municipal
filters, ingenious and scientific in design and costly in construction,
the work of skillful and faithful engineers, and monuments more
precious if less enduring than brass to the contributions of engin-
eering science to public health science. Innumerable storage re-
servoirs and vast distribution systems for supplies of pure water
also bear witness to the enormous debt which public health science
owes to engineering science, as do proper street construction and,
still more, those splendid systems of sewerage with which so many
modern cities are equipped, and which not only serve to remove
quickly dangerous liquid waste of human and animal life, but
also keep low and wholesome the level of the ground- water, re-
ducing dampness and promoting dryness of the environment, and
thereby strengthening that physiological resistance by means of
which the human mechanism fights against the attacks of infec-
tious disease. Nor do the services of engineering science end here,
for the fluid content of the sewers must always be safely disposed
of, and sewage purification is to-day a problem of engineering
science no less important or difficult than that of water purifica-
tion. These same processes of the purification of water and sewage
are matters of so much moment in public health science that in
almost every country experiment stations are now maintained
at public and private expense for the purpose of working-out the
most practical and most scientific methods of purification.

In no respect have the services of engineering science to public
health science been more conspicuous than in the application and
the further study of the principles involved in the processes of water
purification. It has lately been shown, for example, that the in-
troduction of pure water-supplies has in many cases so conspicu-
ously lowered the general death-rate as to make it impossible to
escape the conclusions (1) that the germs of a greater number of
infectious diseases than was formerly supposed are capable of pro-

62 PUBLIC HEALTH

longed life in, and ready conveyance by, public water-supplies,
and (2) as a promising possibility, that as the result of the greater
purity of the water-supply the physiological resistance of the con-
sumers of pure water-supplies is enhanced, in some manner as yet
unknown; the net result being that the general death-rate is lowered
to such an extent as to lead to a rapid increase of population in
communities previously stationary or multiplying far less rapidly.
In the case of the city of Lawrence, Massachusetts, for example,
I have recently had the privilege of examining the results of studies
by the distinguished hydraulic and sanitary engineer, Mr. Hiram F.
Mills, which show that since the introduction of a municipal filter,
which purifies the water of the Merrimac River supplying water
to the citizens of Lawrence, while the population has increased
nearly seventy per cent, the total number of deaths remains about
the same as it was ten years ago. Mr. Mills concludes from the
results of his studies — and I see no escape from his conclusions
— that the introduction of the municipal filter has not only saved
the lives of thousands of citizens, but has also caused the popula-
tion to increase to a point much beyond any which it would have
reached had the city continued to use, unpurified, the sewage-
polluted water of the Merrimac River. A demonstration of this
sort shows how easily the diminishing increase of population under
a lower birth-rate may sometimes be counteracted without resort
to that fish-like spawning which seems to be the only remedy of
those who are terrified by "race suicide," so called. Moreover, it
is hardly necessary to point out that such a diminishing death-rate
means a far more rapidly diminishing morbidity rate — in other
words, it means a heightened working efficiency of the population
as a whole, and it must not be forgotten that for most of the re-
sults obtained in the scientific purification of water-supplies we are
indebted to the science of engineering.

On the other hand, we must observe that engineering science, so
far as water purification is concerned, is as yet only in its infancy
and by no means thus far altogether satisfactory. In the United
States, for example, in the last two or three years a number of epi-
demics of typhoid fever have resulted from the defective operation
or construction of municipal filters, and while much has been done,
it is clear that much still remains to do. In this connection it should
be said that public health science in the United States suffers con-
stantly and severely from an unsatisfactory condition of the science
and art of administration or government in many American cities.
Public health works are too often neglected, delayed, mismanaged,
or built at extravagant cost, to the sanitary and economic damage
of the people as a whole, and the tendency is far too common to
place the care and^operation of costly devices or systems in incom-

RELATIONS TO OTHER SCIENCES 63

petent hands. I cannot here dwell, as long as I should like to do,
upon the mutual relations of public health science and the sciences
of legislation and administration. Speaking of my own country
alone, I must confess that we are still very deficient in the applica-
tions of these sciences. We have not even a national board of health,
although we have, fortunately, in the Public Health and Marine
Hospital Service a strong substitute for one. The peculiarities of
our democratic and republican government have hitherto made it
impossible for the people of the United States to secure either from
federal authorities or from more local sources that measure of pater-
nal sanitary and hygienic protection which they ought to have, and
it is the duty of every American worker in this field to bend his
energies toward a better organization of the public health service
in every direction, municipal and state as well as national. The
appointment in 1886 of a distinguished hydraulic engineer to mem-
bership on the State Board of Health in Massachusetts marked an
epoch, so far as America is concerned, in both sanitary legislation
and administration. This appointment was a formal recognition
on the part of the public of the necessity of a larger proportion of
engineering science in matters relating to the public health, and the
results have justified the new procedure. It is now, fortunately,
becoming less rare in America to secure the services of engineers
upon such boards, and there can be no question that participation
of the expert laity with medical men is likely to be extended,
probably far beyond our present ideas.

In a notable discourse before the International Medical Congress
at the Centennial Exposition held at Philadelphia in 1876, Dr.
Henry P. Bowditch, of Boston, one of the pioneers of hygiene and
sanitation in America, divided the century then closing, as to its
relation to public health science, into three periods, the first, from
1776 to 1832, a period of reliance upon authority and upon drugs;
the second, from 1832 to 1869, a period of true scientific observa-
tion; the third, from 1869 onwards, an epoch in which the medical
profession is aided by the laity and state hygiene is inaugurated.
Dr. Bowditch has much to say of the desirability of a wider cooper-
ation of the laity in state hygiene and remarks: "In all that tends
to the promotion of state hygiene hereafter the laity will naturally
and cordially cooperate with the [medical] profession." The history
of public health science shows Dr. Bowditch's prediction to have
been well grounded. The names of John Howard and Captain Cook
in the eighteenth century, and of Edwin Chadwick, John Simon,
and Louis Pasteur (not to mention a host of lesser workers) in the
nineteenth century, show conclusively that public health science
has been, even from the start, by no means confined to medical
men. We may go further and say that even when forwarded by

64 PUBLIC HEALTH

medical men these have seldom been busy practitioners. Sir George
Baker and Jenner were, it is true, of this class, but not Petten-
kofer, or Koch, or Ross, or Billings, or Reed.1

Reflections of this sort naturally lead to a consideration of the
reciprocal relations of public health science and the science of edu-
cation. I do not need to dwell upon the beneficial effects of public
health science upon the hygiene and sanitation of school-children
or school-houses. These benefits have long been emphasized by
sanitarians and sanitary reformers and are sufficiently obvious.
The reverse of the picture, however, is by no means so well under-
stood. Unless one is familiar with the facts, it is difficult to conceive
how little impression the splendid progress which the last fifty years
have witnessed in public health science has as yet made upon the
curriculum of education. From top to bottom and from bottom to
top the schools, whether primary, grammar, high, normal, technical,
medical, or any other class, are recreant, inasmuch as they neglect
almost wholly any adequate training of their pupils in the principles
of public health science which are confessedly of such profound
importance to mankind. There is, to be sure, just now a popular
wave of enthusiasm touching the extermination of tuberculosis,
but in the United States, at any rate, both schools and universities
are singularly negligent of their most elementary duties in this
direction. Yet if what I have said before is true, if the laity are to
participate from this time forward with medical men in sanitary
and hygienic legislation and administration, if engineers and medical
men in particular are to serve upon boards of health or in other
executive positions connected with public works, then, surely, it is
the duty of the science of education to lend its powerful aid and
not to fail to save the lives and health of the people as these can be
saved to-day, but always to promote that public health and that
large measure of consequent happiness which can probably be more
easily and quickly accomplished in this way than in any other.

As to the function of medical education and engineering educa-
tion in respect to the dissemination of public health science, 'I shall
say only a word. In spite of the reiteration by medical men of their
belief in the importance of hygiene and preventive medicine as a
part of the equipment of the medical profession, it is a significant
fact that in America even the best medical schools devote very little
time to any adequate instruction in these subjects. It may be that
this is wise and that the pressing necessities of practical medicine
forbid any extended instruction in public health science. I am
willing to believe, if I must, that this may be the case; but if it is,

1 " During the course of an epidemic, physicians are too busy to make obser-
vations which require much time or care, or to make more than brief notes." —
J. S. BiUings.

RELATIONS TO OTHER SCIENCES 65

then the community must look for the most part elsewhere than to
medical men for adequate investigation, legislation, and adminis-
tration of public health science. Medical men, must, of course,
always participate in the work, in connection, particularly, with
the control of epidemics and in those forms of preventive medicine
which have to do with vaccines, serums, and other means of modify-
ing the vital resistance of the human body. But as regards the care
and control of the environment, medical knowledge is not indis-
pensable, and the entrance of the engineer and the sanitary expert
upon the field, as foretold by Dr. Bowditch nearly twenty years ago,
is to-day a conspicuous, and probably a wholesome, fact. As to the
attitude of engineering education toward public health science
there can be no question. If what I have said before is true, then
engineers are bound in the future to take constantly a larger and
more important part in public health work, and must be informed,
and if possible trained, accordingly. Moreover, as regards both
medicine and engineering, the problem is by no means insoluble,
for a very short course of instruction rightly given would easily
inculcate the necessary fundamental principles, while electives or
post-graduate work might enable those few whose tastes led them
in this direction to investigate and specialize and more thoroughly
prepare themselves for public service.

I cannot treat, nor do I need to treat, as thoroughly as I would
be glad to do, the mutual relations existing between medical science,
especially the science of medical bacteriology, and public health
science. These are already sufficiently obvious and well known.
From time immemorial medical men have served, often devotedly
and sometimes heroically, in the cause of public health science. I
take it, however, that since we have in this Congress and in our own
department a section of preventive medicine, I may pass over with-
out comment this part of my subject.

As regards sanitary bacteriology, however, the relations existing
between this and public health science are so fundamental, so ex-
tensive, and so important, not only on the medical, but also on the
engineering side, that although we have also in this Congress under
the department of biology, as is entirely proper, a section of bac-
teriology, I may linger at this point for one moment. The bacteria
and other microscopic forms of plant and animal life, all of which
are conveniently included under the term microbes, have so lately
begun to be understood and appreciated that we must still empha-
size their extreme importance. The discoveries of the botanists and
zoologists and revelations of the microscopists in this domain are
comparable, in their importance to public health science, with
nothing less than the revelations of the telescope to astronomy.
Astronomy had, indeed, existed long before the invention of the

66 PUBLIC HEALTH

telescope, and public health science, as we have shown above, had
its beginnings nearly a century before any considerable progress
had been made in micro-biology. But it is not too much to say that
the developments in micro-biology since Pasteur began his work have
not only revolutionized our ideas of the nature of the infectious
diseases, but have also placed in our hands the key of their complete
control.

Concerning the relations of physiology to public health science,
I must not fail to speak. Here is a field absolutely ripe for the harvest,
but one in which the harvesters are as yet very few. I have lately
had occasion to examine somewhat carefully the present condition
of our knowledge of personal hygiene — which is nothing more (and
should be nothing less) than the applications of physiological science
to the conduct of human life — with the result that I have been
greatly impressed with its vast possibilities and promise.. Man is
a gregarious animal, and mankind is to-day crowding into cities as
perhaps never before. Moreover, the industrial and commercial age
in which we live is characterized to an extraordinary degree by the
sedentary life. Yet the sedentary life is almost unavoidably an
abnormal life, or at least it is a life very different from that lived by
most of our ancestors. In the sedentary life the maintenance of a
high degree of physiological resistance apparently becomes difficult,
and if the vital resistance of the community in general is lowered,
then the public health is directly and unfavorably affected, so that
considerations of personal hygiene have a direct bearing upon the
science of public health.

There are, to be sure, interesting and suggestive symptoms of a
wholesome reaction, in America at any rate, against the evils of the
sedentary life. Parks and open spaces are being liberally provided;
public and private gymnasiums are rapidly coming into being;
public playgrounds are thrown open in many of our cities, free of
expense to the laboring, but, nevertheless, often sedentary, popula-
tion; vacations are more than ever the fashion; sports and games
are everywhere receiving increasing attention; while public baths
and other devices for the promotion of personal hygiene are more
and more coming into being. All this is as it should be, but all is as
yet only a beginning. Here, again, the science of education is sadly
at fault and in the direction of educational reform as regards per-
sonal hygiene lies immense opportunity for a contribution to public
health science.

The science of statistics, which has done great service in public
health science in the past, is likely to do much more in the future.
Without accurate statistics of population, mortality, and the causes
of sickness and death, the science of epidemiology is impotent, and
the efficiency or inefficiency of public health measures cannot be

RELATIONS TO OTHER SCIENCES 67

determined. And yet in ignorant hands statistics may be worse
than useless. It is a matter for congratulation to Americans that
we now have in Washington a census bureau permanently estab-
lished and under expert supervision, but until the various states
and cities of the United States follow this excellent example of their
Federal Government, one of the most important aids to public
health science will continue to be wanting, as is unfortunately too
often the case to-day not only in America, but in many other parts
of the civilized world.

PUBLIC HEALTH: ITS PRESENT PROBLEMS

BY ERNST J. LEDERLE

[Ernst J. Lederle, Consulting Sanitarian, New York City Department of Health,
b. Staten Island, New York, 1865. School of Mines, Columbia University,
1886. Ph.B. Ph.D. 1895; D.Sc. 1904. Chemist of New York City Depart-
ment of Health, 1888r1903; Commissioner of Health, New York City, 1902-
03. Member of American Chemical Society; Society of Chemical Industry;
Verein der Deutschen Chemiker; New York Academy of Sciences, etc.]

IN expressing my thanks for the honor which the organizers of this
Congress have done me in the assignment to speak upon the subject
of "Public Health: its Present Problems," I find two reasons for
so doing. The sense of personal gratification of course enters into
my acknowledgment, for it is a pleasure to feel that one's efforts for
sanitary reform, however slight in comparison with those of many
who will address you, are appreciated beyond the limits of the city
where those efforts were put forth.

It is an inspiration to the worker to find that whatever is of value
in his work is eagerly observed, taken up, and adapted to conditions
as they are found in other parts of our country. Perhaps the most
interesting and valuable recollection I have of my work in the
sanitary service of New York City is that, in the course of that
work, I was able to gain from my co-workers in other cities fully
as many ideas for sanitary betterment as we in New York could
give. The effect of . such cooperation is to make one realize that
sanitary reform \vork is not local, not even national, but world-wide;
and that every worker in its cause may draw at will upon the re-
sources of his fellows while he gives them of his own.

But the personal pleasure I feel in speaking on this topic is sub-
ordinated to another consideration. The fact that it should have
been assigned to any but a physician seems to me to be of much
significance.

Sanitary science has been, for so much of its brief existence, set
forth almost wholly by medical men, that it is still widely regarded
as their peculiar province. And properly so; the very nature of his
training and occupation makes the intelligent physician find in
unsanitary surroundings a predisposing cause of disease; and his
work has been and will continue to be so to improve sanitary con-
ditions as to minimize and finally to eradicate a great many diseases
which still make up a large part of the annual mortality.

Preventive medicine is the watchword of the new school. It is
a sign of the progressiveness of that school that, in all enlightened
communities, it has now realized the great scope of the preventive
work to be done, and has called into existence a new profession, that

PRESENT PROBLEMS 69

of the sanitarian, in order to have the aid of specialists in hygiene
in solving the problems of disease.

Modern public hygiene, in fact, has passed the point where the
overcrowding of population has made prompt solution of sanitary
problems imperative, there are many questions of administration
and policy to be solved, and for these the physician ordinarily has
little aptitude. His experience and training are rarely, if ever, of
the sort to make him a successful administrator. I do not by any
means seek to maintain that this function resides wholly in the
sanitarian, so called; far from it. But in the adaptation of means
to ends, in the countless circumstances of administrative duty
which public service entails, a layman, with skilled medical advice
upon purely medical questions, seems to me better fitted to accom-
plish results than the physician alone.

This leads me to a statement of what I believe to be the best
possible organization of a sanitary service, municipal, state, or
national, and one which I hope some day will be adopted not only
in cities and states, but by our Federal Government. At its head
should be a board of administration, consisting of a physician of
the first rank, skilled in the application of bacteriological and gen-
eral medical research to the problems of hygiene; a trained sani-
tary engineer; and third, if you like, as a balance-wheel to prevent
the eccentrics of the specialists from disturbing the workings of the
machine, a man of affairs in the broader sense of the word, who
should be versed in sanitary practice and, at the same time, chosen
mainly for administrative skill and for a certain practical common
sense which might guide such an organization wisely, and, per-
chance, prevent misuse of the great powers with which it ought to
be endowed. In the service of such a department of our government,
there should be a staff of specialists in every branch of medical and
sanitary science, laboratories equipped for research and diagnosis,
and all other adjuncts which make for efficiency in public hygiene.
One may question how such a body would be regarded by the
existing sanitary authorities of cities and states; but, to my mind,
it would be entirely feasible to coordinate all the minor divisions
of sanitary service into one comprehensive whole, in which the
central body, though maintaining its position of leadership, should
exercise police powers with extreme caution while developing its
advisory function to a degree of usefulness beyond any yet attained.

Those who see in such a plan an unwarranted extension of federal
power might profitably study the workings of such organizations
as the Kaiserliches Gesundheitsamt in Germany and the union of
British medical officers of health. Particularly in the former are the
beneficial effects of centralized authority evident. Our own gov-
ernment's centralized activity along such lines as that pursued by

70 PUBLIC HEALTH

the Department of Agriculture is proving its value as an educational
factor to our population beyond all question.

There seems to be no good reason why a similar organization for
sanitary work should not be instituted. Its beginnings are to be
found in the work of the Bureau of Animal Industry of the Depart-
ment of Agriculture, which has already demonstrated its efficiency
in enforcing interstate quarantine upon infected cattle, as well as in
other ways too numerous to mention. Another governmental effort,
conceived in the same scientific spirit, is to be seen in the founding
of various state agricultural experiment stations, which are practi-
cally chemical laboratories working upon problems which the
farmer, without scientific aid, might never be able to solve.

Federal establishments like these, for the study of hygienic pro-
blems and the betterment of health in sections of the country where
such betterment is sorely needed, would have an immense educa-
tional value, besides conducting great works of sanitation on broad
lines where now such work is either entirely neglected, or allowed,
for the most part, to fall between the two stools of municipal and
state sanitary authorities. Such a central body would also solve the
vexed questions of national quarantine, which are now left to the
varying judgment of local health officers in our seacoast cities, at
times undoubtedly to the menace of the public health of the United
States.

Another field of usefulness for a national board of health would
be the training of sanitary officers. Sanitary science is so new, and
the public appreciation of its benefits still so small, that the re-
wards for the pursuit of it as a life occupation are not sufficient to
induce enough good men to make it a study. The result has been,
thus far, that the men who do the actual work of sanitary inspection,
even in the service of well-organized bureaus of health in the large
cities, are as a class without other training than that which expe-
rience and, at best, a little reading on sanitation can give them.
They may have been plumbers or carpenters before entering public
service, but none of these bring any great amount of theoretical
knowledge to their work. A few, of course, have been educated as
physicians, but have turned to the sanitary field for one or another
reason; often, perhaps, it is to be feared, because the certain small
salary in the public service is more satisfactory than the doubtful
rewards of more or less unsuccessful medical practice.

Some time ago, seeing the need for attracting to the pursuit of
sanitation men of higher grade than the majority now engaged in
it, I suggested to the president of one of our largest universities the
plan of offering courses in hygiene and sanitation as part of the
curriculum. He replied that the experiment had been tried, but that
few or no pupils presented themselves; he thought that young men

PRESENT PROBLEMS 71

inclined to pursuits of this character chose rather the courses which
would fit them for engineering, civil or mechanical, and he therefore
advised that studies of this character might more profitably be
offered through the medium of night schools and the like.

This was evidence to me that young men of the class which can
afford a university education aimed at higher pecuniary rewards
than are now afforded to workers in hygiene; it was also evidence
that wider efforts should be made to demonstrate the great public
need of educated sanitary officers, and the great opportunity the
practice of hygiene affords for valuable public service. I believe
that, in time, we shall have in this country a class of educated
public sanitarians; but that time will not come until scientific work
of this character is adequately paid for, and it will come sooner if
the sanitary bodies in various states and cities, now working along
independent and often conflicting lines, are coordinated and made
a part of the greater activities of a national board of health, de-
riving its powers as do other main branches of the Federal Govern-
ment.

To define the present problems of a modern board of health is to
classify and describe its multifarious activities. Broadly speaking,
of course, its main objects are to prevent the spread of contagious
disease, and to enforce sanitary ordinances; but to these have been
added, some may say "arrogated," so many other powers and
duties that the sanitary officer of a generation ago would have great
difficulty in understanding the scope of the work to-day.

Public opinion, in the last analysis, is responsible for the exten-
sion of these powers. The expansion of sanitary police functions,
especially in the suppression of nuisances, has resulted from the
growth of public opinion as to what constitute nuisances; forty
years ago what we now define as "offensive trades" and relegate
to certain prescribed sections of New York City flourished on many
of the best streets. The force of public opinion has gradually branded
one nuisance after another as "detrimental to health," and driven
them to places where they are no longer an offence to the nostrils,
the eyes, or the ears. Power to affect these removals, and to keep
sources of nuisance under observation, has been given to boards of
health in continually increasing measure, because the public has
found that in the great majority of instances powers previously
delegated had not been abused. It is this support of public opinion
which has in recent years so increased the authority and multiplied
the duties of sanitary officers.

Thus supported and uplifted by the public which they serve, the
greatest of all the present problems confronting boards of health in
this country, I have no hesitation in saying, is the responsibility of
preserving the sanitary service from the evils of partisan politics.

72 PUBLIC HEALTH

The politician is nearly always the bitterest opponent of sanitary
reform, because nearly every order for sanitary betterment touches
the pocket of some of his constituents, who immediately run to the
politician for relief. How important, then, from the standpoint of
practical politics, it is that the party in power (I speak particularly
of our cities) should have control of the sanitary officers and use
their great authority to help friends and injure political foes. If the
politician controls the sanitary officers, he controls the appointment
of all subordinates, and soon demonstrates to them that he and not
the nominal head of the sanitary office is the man to come to for
instructions. When this occurs, the usefulness of a board of health
is ended, and its maintenance is money thrown away, if not worse.
Then, too, even if the office is not wholly in control of the politicians,
they sometimes are able to secure the alteration or even the nulli-
fication of important orders, and the inevitable result is injury to the
public that private interests may profit. The extension of the civil
service law has made the subordinate sanitary officers in many cities
independent of politicians' threats if they choose to be; but it does
not so favorably affect the more important activities of sanitary
bureau heads, who are still too much controlled by the appointing
power. There will never be a radical improvement in this condition
until our sanitary offices are taken entirely out of politics, and the
incumbents appointed for life or during good behavior.

How to prevent the spread of infection will always be one of the
chief problems for sanitary officers, and it continually presents new
phases, new difficulties, as the density of population in great cities
increases. This is particularly true of our seaboard cities, where
there is a constant influx of immigrants, latterly of a class which is
ignorant of the rudimentary principles of sanitary living, and of
grossly filthy personal habits. These people have been dumped
upon our coasts in swarms, several hundred thousand annually
coming to New York City alone. Students of the immigration
problem state that the more progressive elements of this new popu-
lation move westward to take up unoccupied farm-lands, or find
work in mines or mills, and that the most ignorant remain in the
cities. We of New York can well believe this. After all, the enforce-
ment of sanitary laws is bound up in the education of the ignorant
and filthy to the objects of such laws; and so it is necessary for the
sanitary authorities of New York and other maritime cities to carry
on a never-ending campaign of education, in populations constantly
renewed at the bottom of the ladder.

But new peoples are not merely ignorant and dirty; they often
bear seeds of disease. The Federal Government has up to this time
made no provision for the care of contagious sick immigrants in the

PRESENT PROBLEMS 73

largest American port, but has relied wholly on the local authorities
for their detention and treatment. Two years ago we found that
the sick immigrants were so crowding our contagious disease hos-
pitals (then notoriously insufficient to care for New York's own
contagious sick) that many citizens, who should have had first
claim to attention, were being excluded. We notified the federal
authorities that they must at once make preparations to isolate
and treat contagious sick immigrants without the use of the city
hospitals; and the result has been that the Government is building
an island in the bay for isolation hospitals.

Much mischief has resulted from former lax medical inspection
of immigrants, extending over many years. New York, and, I doubt
not, other seaboard cities, are to-day troubled with many cases of
contagious eye-disease, originally brought from Europe by immi-
grants and by them transmitted to their fellows in the East Side
tenements, who are some of them only a degree less filthy than the
new arrivals. To stamp out this disease will be the work of a gener-
ation, if not more, for its spread has been till lately entirely un-
checked by the sanitary authorities, and its victims probably
number many thousands.

It has seemed to us in New York that the best means of checking
the spread of contagious disease, of which trachoma is only one
comparative^ unimportant element, was through the public schools.
One of our leading sanitarians has well said that schools are the
foci of infection. This is amply proved by a study of the reports
of infectious disease cases in large cities; almost invariably the
number of cases begins to increase with the assembling of pupils in
the autumn, and continues large so long as the schools are in ses-
sion. Rigid medical inspection in the schools is therefore absolutely
necessary, and its advantages are manifest, for in New York City
(which I may safely say has now the most highly developed system
of medical school inspection in the country) the elaboration of the
present method two years ago resulted in a diminution of conta-
gious disease cases amounting to about 40 per cent. Incidentally,
also, the death-rates of 1902 and 1903 fell to a point never before
reached in the history of the city; with the lessened mortality
among children particularly marked.

This system entails extreme care and considerable expense, for it
demands the services of a competent medical inspector daily in
every public school in the city.

His work is to exclude from the class-rooms all children under
suspicion of infectious disease, and to notify the school authorities
of the exclusions, with the reason for each, in order that exclusion
may not be mistaken by them for truancy. At this point the dia-
gnostician's work ends, and that of the school nurse begins. The

74 PUBLIC HEALTH

nursing system was adopted with a view of providing minor medical
attention for excluded children and of carrying into the tenement
homes some elementary idea of the proper care of the sick, as well
as incidental instruction in household sanitation. The school nurse
is an adaptation of some of the principles of settlement work to the
problem of handling school exclusions for minor contagious ailments,
and, when she is a woman of experience and a graduate of some
recognized training-school, as we require in New York, the successful
results of her work are instantly manifest. One nurse can handle
the exclusions from four or five schools, averaging from 500 to 1500
pupils each.

It is not required that the nurse shall give any attention to cases
of contagious disease, such as scarlet fever, diphtheria, measles,
and the like. That is and should be left to the ordinary operation
of the bureau of contagious diseases, which has its established
corps of diagnosticians and district medical inspectors. The routine
handling of such cases involves, first, a rigid enforcement of rules
regarding notification by the family physician of all contagious
cases coming under his observation; second, the confirmation of
the diagnosis by an expert medical inspector and his decision whether
the case can be properly isolated in the home, or whether removal
to the isolation hospital is necessary; third, the enforcement by
the district medical inspector of the rules requiring a continuance
of isolation during the full period of the disease.

Proper handling of a contagious disease bureau requires not
only good judgment and strict obedience to department rules by
medical inspectors in their work, but a well-organized system of
keeping the records of all cases within the purview of the bureau.
Another important aid to successful operation is the transmission
daily to all school principals, teachers, librarians, and other per-
sons having charge of children in ordinary places of assemblage,
of complete and accurate lists of all contagious cases reported, and
of the termination of other such cases and the disinfection of pre-
mises. This puts such persons on their guard, and undoubtedly
checks the spread of contagion.

In spite of the enormous preponderance of evidence in favor of
vaccination, we cannot deny that the prevention of small-pox is
still a problem for local boards of health. I say local, for the hand-
ling of small-pox varies so greatly in different communities that
the efficiency of one is often largely nullified by the neglect of another.
Here again is a strong argument for centralization of disease-pre-
venting and sanitary work under the control of a federal bureau.
For example, in the first months of 1902, we in New York were con-
fronted with an outbreak of small-pox which amounted almost to
an epidemic. The disease was equally prevalent in other eastern

PRESENT PROBLEMS 75

cities. In that year, by vigorous effort, free public vaccination was
performed upon nearly 25 per cent of our population of 3,500,000
persons, and there is reason to believe that private vaccinations
reached an unusually large total, due to the alarm of the inhabit-
ants over their danger, which was purposely not allayed by the
sanitary authorities. In fact there was a genuine public awaken-
ing to the need of vaccination.

Cases of small-pox that year in New York numbered some 1900;
the next year they fell to less than 100, although the disease con-
tinued very prevalent in many neighboring cities where there had
been no determined effort to stamp it out. One result of this varia-
tion in practice was that New York was constantly visited by spo-
radic outbreaks of small-pox, brought from other cities. Fully half
the 100 cases in 1903 were either of immigrants newly arrived from
Europe or visitors from infected cities in the interior of the United
States.

I believe that compulsory vaccination, so-called, is not neces-
sary in most parts of our land. It may be demanded in countries
having a less intelligent population than ours; but we of New York
have founti that we needed only to arouse public opinion on the
necessity of vaccination to secure the results we wanted without
any compulsion. Vaccination is a requirement of entrance into
our New York public schools, and we have not, in my recollection,
had a single case of small-pox in the schools so protected; but
compulsion exercised upon adults often serves unnecessarily to arouse
public feeling against the sanitary authority, and gives a handle to
those ostrich-like scorners of facts, the anti-vaccinationists.

If we compare the variation in methods of contagious disease
prevention as between the large cities and the small towns and
rural districts, we find that in the latter few of the precautions
taken in the cities are exercised in the country. This results from
lack of proper facilities for isolation, and this lack is due to public
indifference on the subject; for if the public realized how much
the spread of disease could be checked by these means, provision
for isolation hospitals and competent medical inspectors would
be one of the first items of expenditure in their annual budgets.

As it is now, only the most intelligent of our secondary city gov-
ernments make adequate provision for their contagious sick. Many
others, of course, have buildings intended for that purpose, but
these buildings too often consist of miserable shanties in the outer-
most confines of the city or village, and the inhabitants complete
an ill-conceived work by calling these buildings "pest-houses"
and thus branding them as places of horror to be avoided by every
possible means. Such isolation hospitals destroy the value of pro-
perty in the neighborhood.

76 PUBLIC HEALTH

Contrast such places with well-ordered isolation hospitals like
those maintained in some of our smaller eastern cities, notably
in New England, and the observer must realize that patients there
treated not only have far better chances for recovery than if kept
in the ordinary home, but that they cease to be a source of danger
to the community.

Until such handling of contagion becomes general in our coun-
try, negligent communities will continue to nullify the efforts of
those which take proper care of their inhabitants. If the stimulus
to such action came as an order from a federal board, having juris-
diction and punitive powers throughout the country, the popular
knowledge on this subject would grow more rapidly, and the popular
conscience would be more quickly awakened.

Discovery and development of the serum treatment for certain
infectious diseases, notably diphtheria, has in the last ten years
brought new problems to sanitary officers, both in practice and
research. It may safely be said that the labors of the bacteriologist
have in this time done more than any other one thing in the pre-
vention of infectious disease. Speaking as a layman, of course, 1 am
led to believe that preventive medicine will in the next genera-
tion make its greatest progress along the lines of bacteriological
research. We are on the eve of still more important discoveries in
this direction, and it would not be rash to predict that serums for
the successful treatment of tuberculosis, pneumonia, and scarlet
fever will be the next great steps. The importance of such results
it is impossible to exaggerate.

Consider for a moment the beneficial effects already attained
by the anti-diphtheritic serum. I may cite the work of New York
City, where the work was first instituted in this country, and where
it has been most highly developed. In 1893, New York's case-fatal-
ity from diphtheria was 36.4 per cent, and in 1894 it was 29.7 per
cent. New York having in 1892 established the first bacteriolog-
ical laboratory under municipal control, the preparation of serum
for diphtheria treatment was begun in 1894, and in 1895 the distri-
bution of this serum was begun. It was given free to all public
institutions and to all persons who certified, through the attending
physicians, that they were too poor to pay the price charged for it,
which was fixed at a point only high enough to cover the cost of
manufacture and incidental expenses of the laboratory; a staff of
medical inspectors was also designated to administer the antitoxin
free upon request of an attending physician.

In that year, due almost entirely, I am convinced, to the use of
this new remedy, the case-mortality fell to 19.1 per cent, and it
has steadily decreased until in 1903 it had fallen to 11.1 per cent. It
is now the practice also to administer immunizing doses of anti-

PRESENT PROBLEMS 77

toxin to healthy members of a family having a case of diphtheria,
and in the last eight years upwards of 13,000 persons have been so
immunized by department inspectors and family physicians. Of
the persons so immunized, .3 of one per cent contracted the
disease, and one case terminated fatally. Could any stronger testi-
mony than these figures be offered as to the efficiency of diph-
theria antitoxin in the cure and prevention of the disease?

Naturally enough, such results have led to the establishment
of other laboratories for the preparation of this serum. Some are
maintained by state authorities, notably in Massachusetts, but
the larger ones are now under private auspices.

High prices are charged for serums by manufacturing chemists,
and there is no means of testing their efficiency comparable to the
records of public laboratories. It therefore would seem to be a
reasonable precaution, in the interest of the public health, that
these private laboratories should be placed under strict govern-
mental supervision and control, if, indeed, the manufacture of
serums should not be one of the functions of a national board of
health, organized according to plans which I have mentioned, and
which are by no means novel. Products of public laboratories might
be distributed free or at small cost, and thus be made far more
effective in the prevention of disease, while control of the labora-
tories by recognized sanitary authorities would be a more satis-
factory guarantee of the potency and uniformity of their serum
products. A highly organized governmental laboratory service
would also offer splendid opportunities for research work in a field
the enormous importance of which few people are yet in a position
to realize.

One of the most hopeful signs of progress in popular apprecia-
tion of sanitary endeavor is the general interest now awakening
in methods for the prevention of tuberculosis. Medical men are
everywhere agitating for better facilities to fight this disease, the
worst enemy of the human race, and lay associations are taking
steps to establish sanitariums for the reception of patients. This
work is a stupendous one, and we have thus far only touched its
edge. Efforts to. discover a serum for the cure of the disease, though
thus far disappointing, have already much increased medical
knowledge of the subject.

It is not enough that the world should wait on the researches
of the bacteriologist. Our cities are full of consumptives, spread-
ing infection among their fellows in spite of all efforts of the sani-
tary authorities to instruct them in personal precautions. We must
have sanitariums and hospitals of large capacity for the reception
of cases in all stages of the disease. The cost will be great; but
tuberculosis claims most of its victims at a time when their use-

78 PUBLIC HEALTH

fulness in industrial pursuits is greatest, and it can be amply proved
that the cost of their care and cure would be small indeed in com-
parison with the loss the community suffers by being deprived of
their services. Money spent in erecting and maintaining sanitariums
would be saved in almshouses and orphan asylums.

Even when such places of reception for consumptives are afforded
in anything like sufficient measure, there will still be a large class
of infected wage-earners who cannot leave their regular occupation
because their earnings are needed to support dependent members
of the family. For all such the sanitary authorities must exercise
greater care. This is one of the great objects in improving the
conditions of labor, the ventilation and sanitation of factories and
workshops, and the improvement of the tenements in which people
of this class are forced to live. Equally must the conditions sur-
rounding child labor be the subject of still further investigation
and regulation.

Development of the cognate science of vital statistics is highly
important in the study of methods for the prevention of disease.
It helps to measure progress and point out the next steps neces-
sary. But its aim is of course far wider than this; the record ob-
tained by this registration system are of basic importance not only
to the sanitarian, but to the student of sociology in all the rami-
fications of his work, in political economy, geographical race dis-
tribution, education, etc. Add to this their importance in private
affairs, where they are often the final arbiters in disputes over titles
and inheritance, and we have ample reason for using the pro-
ceeds of taxation liberally in developing the work of the vital statis-
tician.

In no respect have the powers and responsibilities of boards of
health developed more in the last generation than in the regula-
tion of public nuisances. I refer particularly, of course, to the regu-
lation of nuisances in cities, because the increase of population in
restricted areas in cities has in itself created new sources of nui-
sance and brought new problems for solution by the sanitarian.
The greater demand for comfort in city life, and the realization
that the public health is in large measure dependent upon a re-
striction of many things which in the past have made for discomfort,
have led to the institution and enforcement of a new body of sani-
tary ordinances of a scope not dreamed of even as recently as twenty
years ago. These have almost revolutionized sanitary practice
and have added enormously to the powers and duties of sanitary
officers.

It is noteworthy that the public demand for relief in this direction
has greatly expanded the list of nuisances which have been placed
under sanitary control. To the duty of protecting the public health

PRESENT PROBLEMS 79

has been added that of protecting the public comfort. For example,
I imagine it would be very difficult for sanitary officers to prove on
the trial of every case that a smoke nuisance is directly injurious to
the public health ; yet so strong is public opinion in favor of enforce-
ment of this ordinance that the sanitary authorities who proceed
vigorously under it have little difficulty hi suppressing such nui-
sances, even when the prosecution of offenders reaches the munici-
pal courts.

This is all a very new development in sanitary practice. The
growth of manufacturing by steam-power in large cities has greatly
increased the use of coal in boiler plants of large capacity. Of late,
because of the higher prices for anthracite, the use of bituminous
coal for manufacturing purposes has come into vogue. Imperfect
combustion, the result of careless firing, creates a nuisance. Sup-
pression of this nuisance should not be confined to arrest and pun-
ishment of the offenders; instruction in means to avoid nuisance
should accompany it.

Akin to the smoke nuisance is that from dust. Bacteriological
study has shown conclusively that dust is a carrier of disease-germs,
and therefore a menace to public health. Here is the greatest argu-
ment for clean streets and for improved methods of cleaning them.
In the New York tenement districts we have had great success from
the general use of asphalt pavement, which can be washed with a
hose, and so cleaned without raising dust. The great thing in getting
rid of dust is not to move it but to remove it. This applies to the dust
problem in houses, and in theaters, schools, churches, and all other
places of public assembly. Such places in New York were a year or
two ago, under our instructions, first brought under general sanitary
inspection, with excellent and rather remarkable results, consider-
ing how large a number of orders we had to issue to have them put
in proper sanitary condition. This work may be well adapted to a
countless number of public and semi-public buildings in cities, for
the places which every one year after year assumes to be in fairly
good condition are often the ones which really demand most careful
attention from the sanitary authorities.

As a vehicle for the transmission of the germs of tuberculosis, dust
in places of public occupancy, like railway and street-railway cars
and ferry-boats, should be rigorously fought. The matting and car-
pets upon the floors of public conveyances are sources of danger,
and should either be done away with entirely or cleaned and fumi-
gated at frequent intervals. Our American habit of spitting every-
where but in proper receptacles, undoubtedly conveys infectious
disease, and every city should pass and enforce an anti-spitting ordi-
nance. New York has had a course of public education in this respect,
and the nuisance is very greatly reduced, although hundreds of men,

80 PUBLIC HEALTH

some of them intelligent enough to know better, figure in the police
courts every year as prisoners on this account.

Noise, as an element of public nuisance, demands increased atten-
tion from the sanitary officer. Its injurious effect on the health of
individuals is beyond question. But the authorities must distin-
guish carefully as to whether a particular noise is a public or merely
a private nuisance, and whether it is a necessary concomitant of some-
thing of public utility.

Noise nuisances in connection with public utilities are in some
sense necessary. In cities the trolley-car is often a source of nuisance
to the inhabitants of the streets through which it passes, due to exces-
sive ringing of bells, and the operation of cars with unevenly worn
wheels. Both these nuisances can be minimized, either by calling the
attention of the railway operators to them, or, failing relief, by prose-
cution in the courts. The use of flat-wheeled cars is as much a waste
of power and equipment as is imperfect combustion of fuel, and, in
the interest of the public health, should be suppressed with equal
severity.

Offensive and dangerous trades also call for attention by the sani-
tary authorities. Most cities which have given proper care to this
subject have restricted their offensive trades, such as slaughter-
houses, gas-plants, and the like, to certain areas, and allowed their
operation only under permit from the board of health, revocable
for violation of the sanitary ordinance. This system appears to work
very satisfactorily for the public, so long as the sanitary officers are
neither negligent nor venal.

It is an interesting fact in connection with the handling of nui-
sances of this class that many improvements demanded by the sani-
tary authorities, such as the inclosing of rendering- vats to prevent
the escape of ill-smelling vapors or the collection and removal of
nuisance-making liquid refuse, have in themselves resulted in
cheapening manufacture; the discussions of methods for the innocu-
ous removal of such waste matter has opened the way for its profit-
able employment for the making of one or more of the numerous
by-products out of which large profits are gained.

These results might never have been achieved without the cor-
rectional action of the authorities.

The time has passed for the establishment of any of the so-called
offensive trades within the built-up portions of cities. Existing
plants should be gradually removed, with due regard to the vested
interests involved, and no more should be allowed to come in. Rail-
way transportation of dressed beef has become so general that there
is no longer any excuse for the building of slaughter-houses in east-
ern cities. Not only is this best on economic grounds, but the trans-
portation of live-stock for longer distances than absolutely necessary

PRESENT PROBLEMS 81

is to be opposed on medical and humanitarian grounds. Neither is
there any reason, but the inertia of their owners, for the maintenance
of manufacturing plants in the midst of cities, and their establish-
ment should be vigorously opposed by the sanitary authorities.

The so-called dangerous trades offer a field thus far little worked
by the sanitarian in this country, although the subject has had much
attention abroad. Here we have hardly any legislation under which
the sanitary authorities can take radical action to safeguard the life
and health of persons employed in those trades, and therefore they
may hardly be said to be under official control. There are many
trades, however, in which the ordinary processes of manufacture
induce disease, and others also which offer means for the spread of
infection. All will repay study by the sanitarian, with a view to
remedial legislation.

Jurisdiction of boards of health over public supplies, such as water
and milk, is already well developed in some states and cities, and
much valuable work has been done in respect to the sanitary purity
of these necessaries of life. Negligence by the public authorities,
however, is still resulting, year by year, in outbreaks of typhoid and
other enteric troubles communicated in impure water or milk. For
evidence of this we have recent typhoid epidemics in Ithaca and
Watertown, New York, and Butler, Pennsylvania.

The very rapid growth of our cities and towns and the improper
disposal of their sewage are causing general pollution of many water-
sources, and making it more difficult either to find pure water-sup-
plies or to keep existing supplies safe from infection. The only remedy
for this increasing menace is filtration, and that on a large scale and
under constant supervision by sanitarians and bacteriologists. This
work is very costly, but its maintenance after the installation is com-
plete will amply repay the expense, in the saving of life and the
preservation of health. Equally important are precautions for the
treatment of sewage. Bacterial purification of the liquid refuse of
cities and towns is now coming into use, with salutary effect; but
too often municipalities which have installed such systems imagine
that their work is done, when in fact such methods of sewage dis-
posal require constant expert attention in order to insure their maxi-
mum efficiency.

Thorough sanitary control of watersheds involves not only the
removal therefrom of all possible sources of infection and the prepara-
tion of reservoirs by the elimination of all decaying vegetable mat-
ter; there is also demanded an efficient, unremitting inspection of all
sources of water-supply, with frequent chemical and bacteriological
examination of the water itself. Statistics gathered in the course of
such investigations are all-important in tracing the nature and sources
of pollution. The extension of existing watersheds and the taking

82 PUBLIC HEALTH

of new ones, to meet the demand for more water due to the growth of
our cities, make such investigations imperative for the maintenance
of the public health. Cooperation between state and municipal au-
thorities to this end has already been productive of much benefit,
and for this reason it is highly important that these two divisions
of sanitary workers should operate in accord; even better results
might be achieved if they could be coordinated under the control
of a national sanitary body.

Bacteriological disclosures of the transmission of disease-germs in
milk, and of the dangers resulting from improper handling of this
product, have brought it more firmly under sanitary supervision.
The first step in the cities, of course, was to bring all milk-dealers
within the control of the board of health by prohibiting the sale of
milk without a permit. The next was to revoke permits when milk
found on sale fell below the standard adopted. It was frequently
found that the retailer was the innocent victim of an unscrupulous
wholesaler or shipper, consequently it became necessary for the
municipal sanitarian to reach out into the country districts and
investigate the conditions at dairy farms. With the investigation
went some instruction in methods of producing clean milk, by which
the honest farmer might profit. The establishment of model dairy
farms by men of wealth has also taught by example, and the high
prices obtainable in city markets for high-grade milk have stimu-
lated the farmer to continually greater effort. With this campaign
of education has come a demand on the railways for the proper icing
of milk-cans in transit.

Milk is a most favorable medium for the propagation of germ-life,
especially at temperature above 50° Fahrenheit. In this condition
it is often found to have a toxic effect, particularly when used for
infant feeding; consequently failure on the part of the sanitary au-
thorities to prevent the sale of such milk has the immediate and direct
result of advancing the rate of infant mortality.

Regulation of the sale of other foodstuffs has been less highly
developed. In some centres there has been established a fairly effi-
cient system for the inspection of beef cattle, but there is no doubt
that the meat of tuberculous animals is sold in considerable quantity
in all our large cities. Scientists have not yet definitely determined
whether or not tuberculosis can be thus transmitted to human beings,
but there is still adequate reason why the sale of infected beef should
be absolutely stopped and the sellers punished.

The danger of typhoid infection through the medium of shell-fish
is now so well established that we need have no question of it at this
late date. No more clean-cut instance of this can be found in all
medical history than in the epidemic of typhoid fever at Wesleyan
University ten years ago. Investigation by Professor Conn and others

PRESENT PROBLEMS 83

demonstrated conclusively that the disease had its origin in Fair
Haven, where the oysters eaten by these Wesley an students had been
fattened in an infected stream. It may be noted also that recent ex-
periments in the bacteriological laboratory of the New York Depart-
ment of Health have tended to show that the icing of infected shell-
fish does not destroy the virility of the germ-life therein.

With these facts accepted, what excuses the sanitarian from main-
taining a most careful supervision over the culture and sale of shell-
fish? Especial attention should be given to the so-called "fattening"
process, which is most often conducted in the brackish waters of
streams adjacent to tidewater. The liability to infection in such
waters is too obvious for argument, and the fattening process should
either be stopped, or restricted to locations where there is no danger
of pollution.

An important field is now opening to the sanitarian in the in-
vestigation of manufactured food-products. The extent to which
commercial adulteration and substitution is now practiced would
be absolutely incomprehensible to the layman. Competition in trade
has become so keen and the substitution of inferior constituents in
foods so general that the honest manufacturer has hardly a chance
to succeed. Even to name a small part of the many frauds of this
character would consume more than the time allotted to this paper.
The use of injurious preservatives has also been practiced to a
scandalous extent. The only remedy for this evil condition will be
the passage and enforcement of a federal pure food law; such a
measure has already been before Congress, but in the absence of an
aroused public opinion, the mysterious influences which bar the
way of much good legislation at Washington have been able to kill
it. Several of the states already have pure food laws, and a begin-
ning has been made under them, but this reform will only come after
one of the longest and hardest fights which the public sanitarian
has ever known.

Much the same opportunity is offered in a campaign against the
vender of patent medicines and secret nostrums. Few people under-
stand the extent to which these articles undermine the public health,
and there has been little or no attempt to assume official control
over their production and sale.

These nostrums are of several kinds. Some of them are prescrip-
tions which have been commercialized by some sharp business-man,
with all the help of advertising and guarantees of the remedy as
a "cure-all." Gullible people, who seem to be legion, are led into
the error of imagining that all diseases of the same general descrip-
tion will yield to the same remedy; they fail to recognize the
important factor of idiosyncrasy, arid the result is that nine out of

84 PUBLIC HEALTH

every ten persons using such a remedy are not helped and may be
injured in health, as they surely are in pocket.

In this class of nostrums must be ranked the various headache
powders, now for sale everywhere. Almost invariably these contain
drugs which should only be prescribed by physicians, and then
only with extreme caution.

In another kind of nostrums the active principle is some powerful
drug or stimulant, the use of which speedily becomes a vice. For
example, many so-called catarrh cures have cocaine as their active
agent; others, again, which are advertised to cure every ill, or to
break the user of the liquor habit, are loaded with alcohol, which
produces a passing stimulation, but leaves the patient in worse
state than before. All these are swindles of the most dangerous
character, and it is the plain duty of the public health officer to
secure their suppression.

The official chemist is called upon also to investigate and stop
the sale of impure and substituted drugs. It is not too much to say
that the drug trade is flooded with such deceptions on which the
public is being worse defrauded year by year, as the evil grows.

The remedy is official control. Makers of patent medicines,
nostrums, pills, etc., should be required to place upon each bottle
or packet the exact ingredients it contains, and should be prose-
cuted for any deviation which can be shown to be detrimental to
the health of persons using the remedy, or designed to perpetrate
upon them a commercial fraud. Further, the Federal Government,
or local boards of health, or both, should institute a division for the
inspection of these goods, and for a more careful general inspection
of pharmacies, to determine whether all compounders of prescriptions
are duly licensed, whether a record is kept of all poisons sold, and
whether the drugs there offered to the public are pure and not
substituted. To start a work of this kind will mean a fight all along
the line. The manufacturers of nostrums and adulterated drugs are
a very wealthy and powerful class in the community, and they will
oppose all remedial legislation to the uttermost. The only thing
they cannot stand against is aroused public opinion; and the sani-
tary officer must see that an intelligent public opinion on this
important question shall be created.

Any discussion of the present problems of the sanitarian, however
brief and superficial, would be incomplete without some mention of
the auxiliary forces at work. Chief of these is the wide and growing
public interest in sanitary problems and the evident desire of muni-
cipal and village communities everywhere to learn and apply the
most rational and effective methods to their particular circum-
stances and situation. When we recall that men still in the prime

PRESENT PROBLEMS 85

of life saw the beginnings of municipal sanitation in the United
States, we must realize the great progress that has been made.

It is not conceivable that we shall stop with this degree of attain-
ment. All the great sanitary questions, the prevention of disease
and nuisance, the promotion of municipal cleanliness, the disposal
of sewage, the utilization of wastes, and a score of other problems
which might be mentioned, are still in their infancy, and the handling
of them fifty years hence will make our present-day methods appear
almost prehistoric. In all this progress, the physician, the bacteri-
ologist, the chemist, and the sanitary engineer will combine their
efforts, and the public opinion will support and aid them.

Such a body of public opinion is now being educated in our schools,
where the physician, the nurse, and the sanitary inspector are object-
lessons in municipal hygiene; in the literature of the day, which is
giving especial attention to sanitation in its broadest sense; and,
not least, in the numberless voluntary associations in which public-
spirited citizens, prominently the women, are striving to correct
municipal abuses and aid the sanitary authorities in estabishing
a higher standard of public health. With such duties and such
aids, continued progress is imperative and sure.

SHORT PAPERS

DR. ARTHUR R. REYNOLDS, Commissioner of Health, City of Chicago, pre-
sented a paper containing a plea for twelve-hour milk, in which was discussed
the fact that in all state laws and city ordinances not a word is contained as to
the age of the milk which is sold.

DR. i. N. HURTY, Secretary of the State Board of Health of Indiana, pre-
sented a paper to this Section on "Dust," and its promotion of infectious dis-
eases.

SECTION B — PREVENTIVE MEDICINE

SECTION B — PREVENTIVE MEDICINE

(Hall 13, September 21,3 p. m.)

CHAIRMAN: DR. JOSEPH M. MATHEWS, President of the State Board of Health,

Louisville, Kentucky.
SPEAKER: PROFESSOR RONALD Ross, F. R. S., School of Tropical Medicine,

University College, Liverpool.
SECRETARY: DR. J. N. HURTY, Indianapolis.

THE LOGICAL BASIS OF THE SANITARY POLICY OF
MOSQUITO-REDUCTION

BY RONALD ROSS

[Ronald Ross, Professor of Tropical Medicine, University of Liverpool, b. May
13, 1857, Almora, India. D.Sc. Trinity College, Dublin, 1904. Post-graduate,
Bacteriology, under Klein, London, 1889; Diploma, Public Health, United
Colleges, London, 1888; Surgeon, afterwards Major, Indian Medical Service,
retired since 1899. Member of the Royal College of Surgeons, England;
Fellow of the Royal Society, London; Companion of the Order of the Bath;
Fellow of the Royal College of Surgeons; Nobel Medical Prize. Author of
works and papers on malarial and tropical diseases; and Algebra of Space
(Geometry).]

THE great science of preventive medicine is often called upon to
consider new policies of public sanitation, which, whether they
ultimately prove successful or not, are always of profound interest
and importance to mankind. Quite recently a new measure of this
kind has been proposed, which in the opinion of many promises to
rank with house-sanitation and preventive inoculation as a means
of saving human life on a large scale. Unfortunately, its value has not
yet been clearly demonstrated — with the result that it is not being
employed as largely as some of us hoped would be the case. I feel,
therefore, that I cannot better acknowledge the honor you have
done me in inviting me to address you to-day than by attempting
to discuss this important theme — in the hope that the discussion
may prove profitable to the cause of public health. The new sani-
tary policy to which I refer is that which aims at the reduction of
disease-bearing insects, especially those which are the disseminating
agents of malaria, yellow fever, and filariasis.

I presume that it is scarcely necessary to discuss the evidence
which has established the connection between various insects and
arthropods and many diseases of man and of animals. The fact that
the pathogenetic parasites which produce those great scourges of the
tropics just mentioned are carried by gnats is now too well known
to require reiteration. It is necessary only to remind you that the

90 PREVENTIVE MEDICINE

gnat acts as an intermediary, becoming infected when biting infected
persons and, some weeks later, infecting healthy persons in its turn
— the parasite passing alternately from insect to man. The hypo-
thesis that the infection in these diseases may be produced in any
other manner than by the bite of gnats has not been justified by
any recorded experiments or by any substantial arguments ; and we
may, therefore, assume for the present that if we could exterminate
the intermediary agents, the gnats, in a locality, we could also
exterminate there the diseases referred to. But here we enter upon
ground which in the opinion of many is much less secure. While
some believe in the possibility of reducing gnats in given localities
and consider that the point has been proved by experiment, others
are much more skeptical and hold that the experiments were not
sound. This state of uncertainty naturally causes much hesitation
in the adoption of measures against gnats, and, therefore, possibly
a continued loss of life by the diseases occasioned by them; and I,
therefore, propose to sift the matter as carefully as time will allow.

In the first place, we should note that experiments made in this
connection have not been very satisfactory, owing to the fact that
no accurate method has yet been found for estimating the number
of gnats in any locality. We can express our personal impressions
as to their numbers being small or large; but I am aware of no
criterion by which we can express those numbers in actual figures.
We cannot anywhere state the exact number of mosquitoes to the
square mile or yard, and we cannot, therefore, accurately gauge
any local decrease which may have resulted from operations against
them. A method of doing this may be invented in the future; but
for the present we must employ another means for resolving the
problem — one which has given such great results in physics —
namely, strict logical deduction from ascertained premises.

As another preliminary we should note that mosquito-reduction
is only part of a larger subject, namely, that of the local reduction
of any living organisms. Unlike particles of matter (so far as we
know them) the living unit cannot progress through space and time
for more than a limited distance. The diffusion of living units
must, therefore, be circumscribed — a number of them liberated
at a given point will never be able to pass beyond a certain distance
from that point ; and the laws governing this diffusion must be the
same for all organisms. The motile animal is capable of propelling
itself for a time in any direction; but even the immotile plant calls
in the agency of the winds and waters for the dissemination of its
seeds. The extent of this migration, whether of the motile or the
immotile organism, must to a large degree be capable of determina-
tion by proper analysis; and the logical position of the question of
local reduction depends upon this analysis.

LOGICAL BASIS OF MOSQUITO-REDUCTION 91

The life of gnats, like that of other animals, is governed by fixed
laws. Propagation can never exceed, nor mortality fall below, certain
rates. Local conditions may be favorable either to the birth-rate
or to the death-rate; and the local population must depend upon
the food-supply. Diseases, predatory animals, unfavorable condi-
tions, and accidents depress the density of population; and in fact
local reduction, that is, artificial depression of the density of popu-
lation, practically resolves itself into (a) direct destruction and
(6) artificial creation of unfavorable conditions.

Let us now endeavor to obtain a perfectly clear picture of the
problem before us by imagining an ideal case. Suppose that we have
to deal with a country of indefinite extent, every point of which is
equally favorable to the propagation of gnats (or of any other
animal) ; and suppose that every point of it is equally attractive to
them as regards food-supply ; and that there is nothing — such for
instance as steady winds or local enemies — which tends to drive
them into certain parts of the country. Then the density of the gnat
population will be uniform all over the country. Of course, such a
state of things does not actually exist in nature ; but we shall never-
theless find it useful to consider it as if it does exist, and shall after-
wards easily determine the variations from this ideal condition due
to definite causes. Let us next select a circumscribed area within this
country, and suppose that operations against the insects are under-
taken inside it, but not outside it. The question before us is the
following: How far will these operations affect the mosquito-density
within the area arid immediately around it?

Now the operations may belong to two categories — those aimed
at killing the insects within the area, and those aimed at checking
their propagation. The first can never be completely successful;
it is in fact impossible to kill every adult winged gnat within any
area. But it is generally possible to destroy at least a large pro-
portion of their larvae, which, it is scarcely necessary to remind you,
must live for at least a week in suitable waters, and which may
easily be killed by larvacides, or by emptying out the waters, or
by other means. This method of checking propagation consists,
in the case of these insects, of draining away, filling up, poisoning,
or emptying out the waters in which they breed. Obviously the
ultimate effect is the same if we drain away a breeding-pool or if
we persistently destroy the larvae found in it; though in the first
case the work is more or less permanent, and in the second demands
constant repetition. If we drain a breeding-area we tend to pro-
duce the same effect at the end of a year as if we had destroyed
as many gnats as otherwise that area would have produced dur-
ing that period. Thus, though we cannot kill all mosquitoes within
an area, even during a short period, we can always arrest their

92 PREVENTIVE MEDICINE

propagation there for as long as we please, provided that we can
obliterate all their breeding-waters or persistently destroy all their
larvae — which we may assume can generally be done for an ade-
quate expenditure. We must, therefore, ask what will be the exact
effect of completely arresting propagation within a given area
under the assumed conditions?

The first obvious point is that the operation must result in a
decrease of mosquitoes. If we kill a single gnat there must be one
gnat in the world less than before. If we kill a thousand every day
there must be so many thousands less at the end of a given period;
and the arrest of propagation over any area, however small, must
be equivalent to the destruction of a certain number of the insects.
But this does not help us much. It may be suggested that, after
the arrest of propagation over even a considerable area, the diminu-
tion of mosquitoes within the area remains inappreciable.. What
is the law governing the percentage of diminution in the mosquito
density due to arrest of propagation within an area?

The number of gnats (or any animal) within an area must always
be a function of four variables, the birth-rate and death-rate within
the area, and the immigration and emigration into and out of it.
If we could surround the area by an immense mosquito-bar, the
insects within it (after the death of old immigrants) would consist
entirely of native insects; on the other hand, if we arrest propa-
gation, the gnat population must hereafter consist entirely of immi-
grants. The question, therefore, resolves itself into this one: What
is — what must be — the ratio of immigrants to natives within
any area? What factors determine that ratio?

Ceteris paribus, one factor must be the size of the area. If the
area be a small one, say of ten yards radius, suppression of propa-
gation will do little good, because the proportion of mosquitoes
bred there will be very small (under our assumed conditions) com-
pared with those which are bred in the large surrounding tracts
of country, and which will have no difficulty in traversing so small
a distance as ten yards. But if we completely suppress propaga-
tion over an area of ten miles radius, the case must be very different
— every gnat reaching the centre must now traverse ten miles to
do so. And if we increase the radius of the no-propagation area still
further, we must finally arrive at a state of affairs when no mos-
quitoes at all can reach the centre, and when, therefore, that centre
must be absolutely free from them. In other words, we can re-
duce the mosquito-density at any point by arresting propagation
over a sufficient radius around that point.

But we now enter upon more difficult ground. How large must
that radius be in order to render the centre entirely mosquito-free?
Still further, what will be the proportion of mosquito-reduction

LOGICAL BASIS OF MOSQUITO-REDUCTION 93

depending upon a given radius of anti-propagation operations?
What will be that proportion, either at the centre of operations,
or at any point within or without the circumference of operations?
The answer depends upon the distance which a mosquito can tra-
verse, not during a single flight, but during its whole life; and also
upon certain laws of probability, which must govern its wander-
ings to and fro upon the face of the earth. Let me endeavor to
indicate how this problem, which is essentially a mathematical
one of considerable interest, can be solved.

Suppose that a mosquito is born at a given point, and that dur-
ing its life it wanders about, to and fro, to left or to right, where
it wills, in search of food, or of mating, over a country which is
uniformly attractive and favorable to it. After a time it will die.
What are the probabilities that its dead body will be found at a
given distance from its birthplace? That is really the problem
which governs the whole of this great subject of the prophylaxis
of malaria. It is a problem which applies to any living unit. We
may word it otherwise, thus — suppose a box containing a million
gnats were to be opened in the centre of a large plain, and that the
insects were allowed to wander freely in all directions — how many
of them would be found after death at a given distance from the
place where the box was opened? Or we may suppose without
modifying the nature of the problem that the insects emanate,
not from a box, but from a single breeding-pool.

Now what would happen is as follows: We may divide the ca-
reer of each insect into an arbitrary number of successive periods
or stages, say of one minute's duration each. During the first min-
ute most of the insects would fly towards every point of the com-
pass. At. the end of the minute a few might fly straight on and a
few straight back, while the rest would travel at various angles
to the right or left. At the end of the second minute the same thing
would occur — most would change their course and a very few
might wander straight on (provided that no special attraction ex-
ists for them). So also at the end of each stage — the same laws
of chance would govern their movements. At last, after their death,
it would be found that an extremely small proportion of the in-
sects have moved continuously in one direction, and that the vast
majority of them have wandered more or less backward and for-
ward and have died in the vicinity of the box or pool from which
they originally came.

The full mathematical analysis determining the question is of
some complexity; and I cannot here deal with it in its entirety.
But if we consider the lateral movements as tending to neutralize
themselves, the problem becomes a simple one, well known in the
calculus of probabilities and affording a rough approximation to

94 PREVENTIVE MEDICINE

the truth. If we suppose that the whole average life of the insect
contains n stages, and that each insect can traverse an average
distance I during one such stage or element of time, then the ex-
treme average distance to which any insect can wander during
the whole of its life must be nl. 1 call this the limit of migration
and denote it by L, as it becomes an important constant in the
investigation. It will then be found that the numbers of insects
which have succeeded in reaching the distances nl, (n — 1)1, (n — 2)1,
etc., from the centre will vary as twice the number of permuta-
tions of 2n things taken successively, none, one, two, three at a
time, and so on — that is to say, as the successive coefficients of
the expansion of 22n by the binomial theorem. Suppose, for con-
venience, that the whole number of gnats escaping from the box
is 22n — a number which can be made as large as we please by
taking n large enough and I small enough — then the probabil-
ities are that the number of them which succeed in reaching the
limit of migration is only 2; the number of those which succeed
in reaching a distance one short stage of this, namely, (n — 1)1, is
2.2n; of those which reach a stage one shorter still is

02n(2n— 1)

~^~

and so on. Hence the whole number of gnats will be found arranged
as follows :

Distance from centre nl (n — 1)1 (n — 2)1 (n — 3)1 etc. total.

Number of gnats 2+4n+2 ^(2n-l) +22n(2^-l) (2n-2)+etc =2 2»

2 3

It therefore, follows from the known values of the binomial
coefficients that if we divide the whole number of gnats into groups
according to the distance at which their bodies are found from the
box, the probabilities are that the largest group will be found at
the first stage, that is, close to the box, and that the successive
groups, as we proceed further and further from the box, will be-
come smaller and smaller, until only a very few occur at the ex-
treme distance, the possible limit of migration. And the same rea-
soning will apply to a breeding-pool or vessel of water. That is, the
insects coming from such a source will tend to remain in its imme-
diate vicinity, provided that the whole surrounding area is uni-
formly attractive to them.

The following diagram will, I hope, make the reasoning quite
clear.

We suppose that 1024 mosquitoes have escaped during a given
period from the central breeding-pool P, and we divide their sub-
sequent life into 5 stages — the numbers 1024 and 5 being selected
merely for illustration. Rings are drawn around the central pool
in order to mark the distance to which the insects may possibly

LOGICAL BASIS OF MOSQUITO-REDUCTION 95

wander up to the end of each stage; and the continuous line shows
the course followed by one which has wandered straight onward
all its life and has died at the extreme limit to which an insect of
its species can generally go, namely, the outermost circle, L. On
the other hand, the dotted line shows a course which is likely to
be followed by the largest number of the 1024 insects liberated
from the pool — that is to say, a quite irregular to-and-fro course,
generally terminating somewhere near the point of origin. The

DIAGRAM I. The chance-distribution of mosquitoes. P, central breeding-
pool. L, limit of migration. The numbers denote the proportions of 1024 mos-
quitoes starting from P which die at the distances 1, 2, 3, 4, 5, respectively.
The continuous line denotes a continuous migration always in one direction;
the dotted line, the usual erratic course.

numbers placed on each ring show the number of mosquitoes calcu-
lated from the binomial coefficients when n = 5, which are likely
to reach as far as that ring at the time of their death. Thus only
2 out of the 1024 mosquitoes are ever likely to reach the extreme
limit; while, on the other hand, no less than 912, or 89 per cent,
are likely to die somewhere within the second ring around the
centre.

The same reasoning will apply whatever may be the number
of mosquitoes liberated from the pool, or the number of stages
into which we arbitrarily divide their subsequent life. Suppose,
for example, that 1,048,576 mosquitoes escape from the pool and
that we divide their life into 10 stages. Then only 2 of all these
insects are ever likely to reach the extreme limit of the outermost
circle; only 40 will die at the next circle; only 190 at the next;
and so on — the large majority perishing within the circles com-
paratively close to the point of origin.

This fact should be clearly grasped. The law here enunciated may,
perhaps, be called the centripetal law of random wandering. It ordains
that when living units wander from a given point guided only by
chance, they will always tend to revert to that point. The principle

96 PREVENTIVE MEDICINE

which governs their to-and-fro movements is that which governs
the drawing of black and red cards from a shuffled pack. The chances
against our drawing all the twenty-six black cards from such a pack
without a single red card amongst them are enormous, as are the
chances against a mosquito, guided only by chance, always wander-
ing on in one direction. On the other hand, just as we shall generally
draw black and red cards alternately from the pack, or nearly so,
so will the random movements of the living unit tend to be alter-
nately backward and fonvard — tend, in fact, to keep it near the
spot whence it started. As there is no particular reason why it should
move in one direction more than another, it will generally end by
remaining near where it was.

But it will now be objected that the movements of mosquitoes
are not guided only by chance, but by the search for food. To study
this point, take the diagram just given, place a number of pencil-
dots upon it at random, and suppose that each pencil-dot denotes
a place where the insects can obtain food — suppose, for example,
that the breeding-pool lies in the centre of a large city and that the
pencil-dots are houses around it. Consideration will show that the
centripetal law must still hold good, because there is no reason why
the insects should attack one house more than another. There is
no reason why a mosquito which has flown straight from the pool
to the nearest house should next fly to another house in a straight
line away from the pool, rather than back again, or to the right or
left. The same law of chance will continue to exert the same influence,
and the insects will always tend to persecute most those houses which
lie in the immediate vicinity of their breeding-pool. Even when
there are many pools scattered about among the houses, there is
no reason why, after feeding, the mosquitoes will go to one rather
than to another; and the result must be that in general they will
tend to remain where they were.

Self-evident as this argument may now appear, it is not under-
stood by many who write on the subject and who seem to think that
mosquitoes radiate from a centre and shoot forever onward into all
parts of the country as rays of light do. Accepting this fallacy with-
out question, they argue that it is useless to drain local breeding-pools
because of the influx of mosquitoes from without. Such an influx
certainly always exists; but I shall now endeavor to show that it
cannot generally compensate for local destruction.

Let us consider a tract of country over which numbers of mos-
quito breeding-pools are scattered, with houses and other feeding-
places lying among them. Suppose we draw a straight line across
this country and drain away all the pools to the right of it, leaving
all those to the left of it intact. Then all the insects on the left of the
line must be natives of that part; and all those on the right of it

LOGICAL BASIS OF MOSQUITO-REDUCTION 97

must be immigrants which have crossed over the line from the left.
How many mosquitoes will there now be on the right side, compared
with those on the left side? The following diagram will enable us to
consider this question more conveniently.

First, examine the state of affairs before the drainage was effected.
We may suppose that mosquitoes were then breeding fairly uni-
formly over the whole country, and that their density was much
the same on both sides of the line. A certain amount of migration

BOUNDARY

UNDRAINED COUNTRY

NORMAL DENSITY MLL/(Vfi

HALF DENSITY

DRAINED COUNTRY

ZERO DENSITY

-x -L

DIAGRAM II. Curve of falling mosquito-density due to drainage on right
boundary. L and —L are the limit of migration on either side of the boundary.

across the line, both from right to left and from left to right, must
always have been going on ; and since the density was equal on both
sides, this migration must also have been equal and opposite — that
is, as many emigrants must have been constantly passing from right
to left as from left to right. Now, after the drainage has been effected
the following changes occur. The insects breed as before on the left
of the line, and some continue as before to cross over it into the
drained country; but, in the latter, on the right of the line, propa-
gation is entirely checked and, moreover, the migration from it to
the left of the line, which used to exist, now ceases. Hence not only
must there be a decrease of mosquito-density on the right of the line,
due to the local cessation of breeding, but also a decrease on the
left of the line, due to the cessation of the migration from the right
which formerly took place — that is to say, the drainage has affected
the mosquito-density not only up to the line of demarkation, but
beyond it. And moreover, since the migration was formerly equal
from both sides of the line, it follows that now, after the drainage,
the loss on the left side of the line due to the cessation of immigra-
tion from the right is exactly equal to the gain on the right due to
the continuance of the immigration from the left. That is to say, the
mosquitoes gained by immigration into the drained country must

98 PREVENTIVE MEDICINE

be exactly lost by the undrained country. This fact can be seen to
be obviously true if we imagine an immense mosquito-bar put up
along the line of demarkation so as to check all migration across it,
when, of course, the mosquito-density would remain as at first on
the left, and would become absolute zero on the right: then on re-
moving the mosquito-bar an overflow would commence from left
to right, which would increase the density on the right by exactly
as much as it would reduce the density on the left.

The dotted line on the diagram indicates the effect on the mos-
quito-density which must be produced by the drainage. If L is the
possible limit of migration of mosquitoes (it may be one mile or a
hundred, for all we know), the effect of the drainage will first begin
to be felt at that distance to the left of the boundary-line. From this
point the density will begin to fall gradually until the boundary is
reached, when it must be exactly one half the original density. This
follows because of the equivalence of the emigration and immigration
on the two sides. Next, as we proceed from the boundary into the
drained country, the density continues to fall, until at a distance
L on the right of the line, it becomes zero, the country now becom-
ing entirely free of mosquitoes because they can no longer penetrate
so far from the undrained country.

In the diagram the line giving the mosquito-density falls very
slowly at first, and then, near the boundary, very rapidly, subse-
quently sinking slowly to zero. The mathematical analysis on which
this curve is based is too complex to be given here ; but it is not diffi-
cult to see that the centripetal law of random migration must deter-
mine some such curvature. The mosquitoes which are bred in the
pools lying along the boundary-line must remain for the most part
in its proximity, only a few finding their way further into the drained
country, and only a very few reaching, or nearly reaching, the limit
of migration. Though an infinitesimal proportion of them may wan-
der as far as ten, twenty, or more miles into the drained country (and
we do not know exactly how far they may not occasionally wander)
the vast bulk of the immigrants must remain comparatively close
to the boundary. And as, for the reason just given, the mosquito-
density on the boundary itself must always be only one half the
original density, it follows that it must become very rapidly still
less, the further we proceed into the drained country. In fact, the
analysis shows that the total number of emigrants must be insig-
nificant when compared with the number of insects which remain
behind — that is, when they are not drawn particularly in one direc-
tion. We are, therefore, justified in concluding that, as a general
rule, the number of immigrants into any area of operations must, for
practical purposes, be very small or inappreciable a short distance
within the boundary-line. The following diagram probably repre-

LOGICAL BASIS OF MOSQUITO-REDUCTION 99

sents with accuracy the effects of thorough suppression of propaga-
tion within a circular area.

At the circle (a) and beyond it the mosquito-density will be the
normal density which existed before the operations were commenced.
At (6), the circle bounding the drainage operations, the density will
always be about half the normal density. At the circle (c) and within
it, the density will be small, inappreciable, or zero. The distance from
(a) to (6) may be taken as being the same as that from (6) to (c);

DIAGRAM III. Effect of drainage of a circular area. b = boundary of drained
area. Mosquito-density begins to diminish at the circle a; becomes one half
at the boundary 6; and is small, inappreciable, or zero at the circle c.

and, as the mosquitoes penetrating from (6) to (c) must be drawn
from the zone between (a) and (6), the average result will be the same
as if no immigration at all takes place. We do not possess sufficient
data to enable us to calculate the actual distance between (a), (&),
and (c) — this will depend in a certain measure on the activity of
the species of insect concerned and on the existence or absence of
special local attractions; but this fact does not discredit the general
principles involved.

One case has not yet been considered, namely, that in which
there exists only a single feeding-place in the whole tract of country
— such, for instance, as a single house or group of houses situated
in the midst of deserted swamps. In such a case the insects may be
compelled to come from considerable distances — from as far as
their senses are capable of guiding them — in search of food ; and
drainage operations carried on with a view to relieving such a house
may, for all we know, have to be extended over miles. But such
cases are not of great consequence, because drainage is seldom the
appropriate measure for isolated dwellings, which can generally
be protected at far less cost by means of gauze screens. Moreover,
it is very doubtful whether feeding-places for mosquitoes are ever
so solitary as the case assumes. Where there is one dwelling there

100 PREVENTIVE MEDICINE

are generally many, scattered at various distances over the country;
and the insects are known to feed on cattle, birds, and other ani-
mals. For towns, where anti-mosquito measures are most demanded,
our first assumed condition of uniform attractiveness must, as a
rule, be the one in force; and in such cases the centripetal law will
hold.

The effect of wind requires examination. Theoretically, if the
insects are supposed always to remain on the wing, wind blowing
on a generating-pool will merely have the effect of drifting the whole
brood to a certain extent in one direction without changing the
relative positions of the insects to each other. The result would be
the same as indicated in Diagram I, except that the generating-
pool would now be eccentric. If a proportion of the insects take
shelter, the circles of Diagram I would become ellipses with the
generating-pool as a focus. In such a case the wind, and especially
devious winds, would have a distributive tendency; but it must be
remembered that if the insects are scattered further apart their
numbers at a given point must be reduced. A wind which blows
mosquitoes into an area must blow others out of it. The net result
of devious winds on a circular drained area would be that the mos-
quito-density is not so much reduced at the centre, but is reduced
to a greater distance outside the boundary circle — so that the
average reduction remains the same. With a wind blowing continu-
ously from one direction, the indication would be to extend the
drainage further in that direction. Obviously, wind may scatter
mosquitoes ; but it cannot create them, nor prevent the total average
reduction due to anti-propagation measures, as some people seem
to think. It is, however, very doubtful whether wind does really
drive or scatter mosquitoes to any great degree. In my experience
they are extremely tenacious of locality. Thus Anopheles were
seldom seen on Tower Hill, a low open hill in the middle of Freetown,
Sierra Leone, although numerous generating-pools existed a few
hundred yards from the top, all around the foot of it, and the winds
were often very strong. If a continuous wind can drive mosquitoes
before it, then during the southwest monsoon in India they should
be driven away from the west coast and massed towards the east
coast; but I have never heard that they are at all less numerous
on the west coast. I have often seen very numerous mosquitoes on
bare coasts exposed to strong sea-breezes, as at Madras. As a rule,
they seem to take shelter in the presence of a strong breeze. Instances
of their being driven far by winds are frequently quoted, but in
my opinion they were more probably bred, in many such cases, in
unobserved pools close at hand. The wind-hypothesis is frequently
used by municipal officials as an excuse for doing nothing — it is
convenient to blame a marsh miles distant for propagating the mos-

LOGICAL BASIS OF MOSQUITO-REDUCTION 101

quitoes which are really produced by faulty sanitation in the town
itself.

Another and similar statement is often made with all gravity to
the effect that mosquitoes are brought into towns in trains, carts,
and cabs. So they are; but a moment's reflection will assure us that
the number introduced in this manner must always be infinitesi-
mal compared with those that fly in or which are bred in the town
itself. Moreover, if vehicles may bring them in they may also take
them out.

I will now endeavor to sum up the arguments which I have laid
before you — I fear very cursorily and inadequately. First, I sug-
gested that there must be for every living unit a certain distance
which that unit may possibly cover if it continues to move all its
life, with such capacity for movement as nature has given it, always
in the same direction. I called this distance the limit of migration.
It should perhaps be called the ideal limit of migration, because
scarcely one in many billions of living units is ever likely to reach
it — not because the units do not possess the capacity for covering
the distance, but because the laws of chance ordain that they shall
scarcely ever continue to move always in the same direction. Next
I endeavored to show that, owing to the constant changes of direc-
tion which must take place in all random migration, the large
majority of units must tend to remain in or near the neighborhood
where they were born. Thus, though they may really possess the
power to wander much further away, right up to the ideal limit,
yet actually they always find themselves confined by the impalpable
but no less impassable walls of chance within a much more circum-
scribed area, which we may call the practical limit of migration —
that is, a limit beyond which any given percentage of units which
we like to select do not generally pass. Lastly, I tried to apply this
reasoning to the important particular case of the immigration of
mosquitoes into an area in which their propagation has been arrested
by drainage and other suitable means. My conclusions are:

(1) The mosquito-density will always be reduced, not only within
the area of operations, but to a distance equal to the ideal limit of
migration beyond it.

(2) On the boundary of operations the mosquito-density should
always be reduced to about one half the normal density.

(3) The curve of density will rise rapidly outside the boundary
and will fall rapidly inside it.

(4) As immigration into an area of operations must always be at
the expense of the mosquito population immediately outside it, the
average density of the whole area affected by the operations must
be the same as if no immigration at all has taken place.

102 PREVENTIVE MEDICINE

(5) As a general rule for practical purposes, if the area of opera-
tions be of any considerable size, immigration will not very mate-
rially affect the result.

In conclusion, it must be repeated that the whole subject of
mosquito-reduction cannot be scientifically examined without
mathematical analysis. The subject is really a part of the mathe-
matical theory of migration — a theory which, so far as I know,
has not yet been discussed. It is not possible to make satisfactory
experiments on the influx, efflux, and varying density of mosquitoes
without such an analysis — and one, I may add, far more minute
than has been attempted here. The subject has suffered much at the
hands of those who have attempted ill-devised experiments without
adequate preliminary consideration, and whose opinions or results
have seriously impeded the obviously useful and practical sanitary
policy referred to. The statement, so frequently made, that local
anti-propagation measures must always be useless, owing to immi-
gration from outside, is equivalent to saying that the population of
the United States would remain the same, even if the birth rate
were to be reduced to zero. In a recent experiment at Mian Mir in
India the astounding result was obtained that the mosquito-density
was, if anything, increased by the anti-propagation measures —
which is equivalent to saying that the population of the United
States would be increased by the abolition of the birth-rate. In the
mean time, I for one must continue to believe the somewhat self-
evident theory that anti-propagation measures must always reduce
the mosquito-density — even if the results at Havana, Ismailia,
Klang, Port Swettenham, and other places are not accepted as
irrefragable experimental proof of it.

SECTION C— PATHOLOGY

SECTION C— PATHOLOGY

(Hall 13, September 22, 10 a. TO.)

CHAIRMAN: PROFESSOR SIMON FLEXNER, Director of the Rockefeller Institute.
SPEAKERS: PROFESSOR LXJDVIG HEKTOEN, University of Chicago.
PROFESSOR JOHANNES ORTH, University of Berlin.
PROFESSOR SHIBASABURO KITASTO, University of Tokio.
SECRETARY: DR. W. McN. MILLER, University of Missouri.

THE RELATIONS OF PATHOLOGY

BY LUDVIG HEKTOEN

[Ludvig Hektoen, Professor and Head of Department of Pathology and Bac-
teriology, University of Chicago, Director of Memorial Institute for Infec-
tious Diseases, b. July 2, 1863, Wisconsin. A.B. Luther College, 1883; A.M.
1902; M.D. College of Physicians and Surgeons, Chicago, 1887; Post-graduate,
Upsala, Berlin, and Prague. Pathologist, Cook County Hospital, Chicago,
1890-1904; Physician to Coroner's Office, Cook County, 1890-94. Co-editor,
Journal of Infectious Diseases, etc.]

OSTWALD, the inspiring interpreter of the great principles of
science, states that "We have just passed through a period in
which all sciences have been isolated, a period of specialization,
and we find ourselves in an epoch in which the synthetic factors
in science are gaining a constantly increasing significance. . . .
Everywhere the individual sciences seek points of contact with one
another; everywhere the investigator determines the value which
his special results may have in the solving of the general problems.
In short, all sciences are tending to be philosophical. No\vhere is
this tendency toward fundamental explanation so great as in
biology."

Pathology a Division of Biology

Disease is the common lot of all forms of life, high as well as low,
animal as well as vegetable, and it is the special province of patho-
logy, the science of disease, to study life in its abnormal forms and
activities. Hence pathology is a division of biology, and it is in
fact pathological biology, but its relationships as such have not
always been so clearly appreciated as they ought to be; in part
this may be explained on account of the very special stress placed
on its direct application to practical medicine in the service of the
art of healing. For this and other reasons pathology in many re-
spects has remained somewhat isolated among biological sciences.
The early pathologists took the almost exclusive standpoint of

106 PATHOLOGY

human medicine and for a long time the vast resources of general
biology remained practically unused in the study of disease. On
the other hand, owing to lack of appreciation of the fact that dis-
ease is a phenomenon of life, in other words, owing to the unnatural
separation of the biologic study of disease from general biology,
the subject of disease has rather repelled the average student of
biology, who therefore seems to have neglected to utilize fully the
approaches offered by pathology to a better knowledge of the
phenomena of life.

In view of the extent to which man has busied himself with the
study of all forms of animal life in all accessible parts of the world,
is it not rather strange and an evidence of lack of coordination
that the occurrence of cancer throughout the whole vertebrate
kingdom should have been made out definitely only during the
last year? Yet this demonstration by the Cancer Research Fund
in London, and the further demonstration that cancer has the same
fundamental characters as in man when it occurs in fish, reptile,
and bird, renders it extremely improbable that either climate or
diet of man has anything to do with the direct causation of cancer,
thus putting an end to much needless speculation and materially
narrowing the scope of a most important inquiry.

Pathological Processes in Evolution

In some quarters disease has been regarded merely as an expres-
sion of inferiority and weakness, and as part at least of the means
by which inexorable nature carries out the verdict of extermina-
tion. Parasitism for instance has been designated as a weapon to
eliminate those who fall below a certain standard. Consideration
of the nature of disease from this point of view gives to disease
merely a negative evolutional significance, as it would cause no
new and better qualities in the descendency. Closer examination
would tend to show, however, that processes of disease may have
a different significance of a more positive nature in evolution. There
are numerous simple as well as complex physiological processes
which, when set in motion by abnormal conditions, appear to be
of advantage not only to the individual but also to the species.
As examples of adaptive processes at first sight of more special
individual advantage may be mentioned regeneration, hypertro-
phy, the interesting adaptations to new and strange conditions
of which bones and vessels are capable, certain phases of throm-
bosis, and even atrophy, which has been described as the faculty
of an organ to adapt itself to conditions of diminished nutrition,
thus circumventing necrosis, a faculty of great advantage when
the period of dyninished food-supply is only temporary. No one

THE RELATIONS OF PATHOLOGY 107

can fail to see much that must be useful and advantageous in the
complex reactions to injuries observed in inflammations, the sig-
nificance of which has been greatly broadened through the well-
known comparative study of Metchnikoff. In the case of immunity,
natural and acquired, our wonder knows no bounds, so marvelous
are the precision and scope of the protective reactions, concerning
which so much has been brought to light in recent years and which
lend themselves well to comparative studies. In the case of de-
generations and tumors it is not possible to recognize any direct
or indirect advantage, and certainly no one has yet been able to
see malignant tumors in such favorable light. In these instances
first mentioned the pathologic reactions have physiologic proto-
types ; they are adaptations of physiologic processes. Regeneration
and growth are taking place constantly in health. Phagocytosis, on
which so much stress has been laid in inflammation, is merely an
exaggeration of normal nutritive processes in certain cells. At pre-
sent the production of antitoxins and other anti-bodies is best ex-
plained as the result of special adaptations of normal stereo-chem-
ical mechanisms whereby nutrition is carried on. A very noticeable
difference between the physiologic and pathologic manifestations of
these functions is seen in their imperfections and shortcomings
under many of the abnormal conditions. Incomplete regeneration
resulting in the formation of scars often has many disadvantages.
Inflammations frequently establish conditions in themselves fraught
with dangers. The reactions of immunity may not neutralize
quickly enough the toxins nor destroy promptly enough the in-
vading organisms. Hence there is abundant scope for the inter-
vention of the physician armed with all the various appliances of
his art, some of the most useful of which are the products of arti-
ficially produced biologic reactions. But after all the individual
organisms must enjo)^ the best chances for survival and reproduc-
tion that suffer least harm because best able to adapt themselves
and to protect the life and function of their cells under conditions
of disease.

Just as there are variations in the limits of physiologic regulatory
mechanisms, so also there are individual differences of degree in
the power of adaptive and protective reactions to establish them-
selves in disease and permit continuance of life. In progress-
ive evolution it naturally must be in the descendants of individuals
with the best adaptive and protective powers that an increasing
completeness and perfection of such powers will be found. Viewed
in this light many processes of disease assume a significance of
positive character in biologic evolution, a point of view that would
increase the interest in pathology among biologists in general,
and thus tend to further its development along broader lines and

108 PATHOLOGY

lead to coordination of knowledge and broad and still broader gen-
eralizations as to causes, nature, and processes of disease. At pre-
sent we may be said to be gathering materials for this broader com-
parative pathological biology of the future in the same way as the
older naturalists gathered materials for the biologist of the present
day.

Pathology and Research

At least in certain fields the student of the pure science of disease
is primarily interested in the knowledge of disease for its own sake
without much thought or immediate care as to any prompt practical
use to which such contributions as he may make to this knowledge may
be put. It is true here as it is in general that most things are done
only on account of the results expected from them in the future, but
immediate technical utility is not always the sole guiding principle
of the investigator in pathologic domains. The history of pathology
shows him that in this science as well as in its synthetic sciences all
actual increase in knowledge eventually helps to relieve suffering.
Everywhere the most intimate relations may be seen between the
progress of medical knowledge and the progress of medical art. Like
other sciences pathology furnishes many examples of the rather
unexpected importance and the even profound influence of the new
observation, the new methods of study, the new point of view that
at first seemed to have but limited significance. Indeed some of the
fundamental ideas of scientific medicine have arisen in this way.
It has been well said that no knowledge of substance or force or life
is so remote or minute, but that to-morrow it may become an indis-
pensable need (van Hise). We in America have therefore much
reason to rejoice because of the strong movement that is starting in
the interest of scholarship and of research in pathology, a movement
that of course does not limit its influence merely to the advancement
of knowledge, but exercises as well a powerful influence upon the
diffusion of knowledge. The man who is so full of enthusiasm for
pathology that he will "burn his lamp for its advancement" is
likely also to be an inspiring teacher illuminating the older know-
ledge with the discovery of to-day and placing the new facts in their
proper relations to what is already known and to what will be known.
Medicine in this country has been so preoccupied with building-up
medical education for the training of physicians that comparatively
little energy has been available for the upbuilding of medical science
itself. Thus pathology in the universities has not been taught until
very recently in such a way that graduate students might take it up
as a branch to be followed through long stretches of labor. This is
regrettable, but in some of our universities pathology is now placed
on equal footing with other natural sciences and fully recognized as

THE RELATIONS OF PATHOLOGY 109

a proper field for work leading to higher degrees, and this is a much
desired progress in a most important direction. The direct interest
now taken by many persons in medical research, the institutes and
funds their munificence has established, are also having a most pro-
found influence upon the development of pathology in this country.
Another mighty current in favor of this development has set in from
the scientific work carried on in our various governmental and state
institutions.

Pathology and Synthetic Sciences

Let us now attempt to trace briefly the present relations of patno-
logy to cognate sciences with the object of learning, if possible, in
which direction the hope lies for greatest progress and to mark out
the paths along which our investigators must journey in order to
gather the best materials for that wider and larger pathological
biology upon which we are still to work. The clearest conception of
the role that the more important synthetic factors have had and are
having upon the development of pathology will be obtained through
the historical perspective. In this way, too, it may prove feasible
to show how some of the special problems have been solved and to
bring into relief the great coordination of useful knowledge exempli-
fied by practical medicine and the influence upon it that various
sciences have had and are having through the medium of pathology.

The Anatomical Idea in Medicine

Anatomy was one of the earliest biological sciences to receive
cultivation. The first laboratory for the training of students was
the anatomical. One cause at least for this, if not the cause, was
the downright necessity for physicians to become closely acquainted
with the structure as well as the functions of the human body. It is
consequently not strange that pathology in the usual modern sense
should begin as pathological anatomy, that is with the study of the
grosser, evident alterations in structure that result from disease and
upon which in turn rest many of the disturbances of function observed
in disease. In its earlier stages pathological anatomy busied itself
with the accumulation of a store of facts and observations gained
almost wholly by the examination of human bodies after death.
Morgagni was the first to attempt any generalization from this store
of facts and by correlating the anatomical changes observed after
death with the disturbances of functions observed as clinical symp-
toms during life, he was able to draw conclusions of fundamental
importance in regard to the seats and causes, at least in certain
phases, of disease. This is the first instance of synthesis on a large

110 PATHOLOGY

scale of two biological sciences in the study of pathology, namely the
physiological or study of function and the anatomical or study of
structure. Morgagni's conception of disease as inseparably con-
nected with structural changes in the organs was designated happily
by Virchow as the anatomical idea in medicine, and this idea — the
greatest gift of anatomy to medicine — proved of incalculable
service in turning the minds of physicians away from speculation to
careful, objective study of disease during life as well as after death.
We catch an interesting glimpse of Morgagni's own point of view in
the following quotation from his writings: "The various steps in
progress ought not to be disregarded, for, in difficult research, we
derive encouragement from the recollection that although the exer-
tions of an individual may not advance philosophy in any perceptible
degree, yet, owing to the power of experiment and the successive
influence of opinion, the most obscure and apparently unsuccessful
inquirer may prove the first or the connecting link in a series of most
valuable discoveries."

The Cell Doctrine

The next advance was the result of Bichat's introduction of minute
anatomy and the demonstration that the organs consist of tissues to
which the seat of disease now was referred. Before long came the
epochal development in botany under the influence of Schleiden of
the cell doctrine, which was applied by Schwann to normal animal
histology, and by Virchow in 1858 to pathology, the direct outgrowth
being the justly celebrated cellular pathology beginning an era during
which medicine has made greater progress than in all preceding time.

Physiological and pathological processes were traced to the
elementary morphologic constituents of living organisms — the
cells. The famous phrase "omnis cettula e cellvla" completed the
liberation of medicine from abstract speculation already begun by
Morgagni. "The physician grew from a schoolman into a scientific
observer, and the surgeon, who appeared on the scene in livery and
without learning, grew from a handicraftsman to be a man of
science." Pathology became a natural science. What rich new
fields were now open for investigation! A vast amount of material
was accumulated from careful clinical and morphologic study of
individual cases and the basis thus laid for the construction of gen-
eral laws and fruitful theories of disease. During the earlier part
of this period attention was confined largely to man, but it also
was often turned in the direction of animals in the effort to pene-
trate deeper into morbid processes; the experimental method was
used to interpret correctly observations made in the clinic and in the
post-mortem room.

THE RELATIONS OF PATHOLOGY 111

Of fundamental importance for all branches of medicine was the
resulting organization of the teaching and investigation of patho-
logical anatomy. Following the leadership of Virchow in Berlin
pathologic o-anatomical institutes or laboratories were rapidly estab-
lished, and soon recognized as indispensably necessary for teaching,
for research, and for direct assistance to medical practice. In the
further course of development these laboratories have undergone
various modifications and enlargements of scope, principally as the
result of the advent of medical microbiology.

With surgery and the rapidly developing surgical specialties
pathological anatomy — gross and microscopic — soon assumed
permanent relations of fundamental character. The anatomical
study of the diseases in question was followed by great progress in
treatment, and the exponents of these branches of applied medicine
did not remain merely receptive of the work of others, but have
themselves prosecuted diligently pathological investigations of great
value. Indeed, in certain special branches, especially ophthalmo-
logy, otology, and dermatology, the clinicians have long been prac-
tically the sole occupants of the field of pathological anatomy of
their respective parts of the body. The close study of pathological
anatomy — being largely the study of the results of disease — stim-
ulated also to brilliantly accurate diagnosis of certain internal dis-
eases, which unfortunately in some cases was coupled with a dis-
heartening therapeutic pessimism. Said the therapeutic nihilist
Skoda: "We can diagnose disease, describe it, and get a grasp of it,
but we dare not by any means expect to cure it." That some of the
followers of cellular pathology in the narrower, dogmatic sense,
believed that the innermost secrets of disease could be reached by
morphologic methods, and that functional disturbances always could
be adequately explained by morphologic means may now be regarded
as an instance of the tendency man frequently shows to approach
his problems from the least accessible points. These unfavorable ten-
dencies in pathology led to the following protest by Clark in 1884:

"We are so much concerned with anatomical changes; we have
given so much time to their evolutions, differentiations, and rela-
tions; we are so much dominated by the idea that in dealing with
them we are dealing with disease itself that we have overlooked the
fundamental truth that these anatomical changes are but secondary
and sometimes the least important expressions or manifestations
of states which underlie them. It is to these dynamic states that our
thoughts and energies should be turned; they precede, underlie,
and originate structural changes; they determine their character,
course, and issues; in them is the secret of disease, and if our control
of it is ever to become greater and better, it is upon them that our
experiments must be made."

112 PATHOLOGY

Fortunately Clark's warning had been anticipated by development.
Virchow himself long before repeatedly emphasized that pathologi-
cal anatomy cannot deal forever with the product without searching
for the cause that led to its production. It seems to me that the
following highly remarkable statement in the Prospectus of the first
volume of Virchow's Archiv, published in 1847, shows that the
founder of cellular pathology had a wonderfully clear vision of the
role pathological anatomy was to play in the evolution of patholog-
ical physiology:

"The standpoint we aim to occupy is simply that of natural sci-
ence. Practical medicine, the applied theoretical, the theoretical-
pathological physiology is the ideal we shall strive to reach so far
as our powers permit. While we recognize fully the title and the
independence of pathological anatomy, and of the clinic, they serve
us preeminently as sources of new questions the answers to which
fall to the lot of pathological physiology. Inasmuch, however, as
these questions to a large extent may be formulated only through
painstaking and comprehensive detailed study of manifestations
(of disease) in the living, and of the conditions in the dead, we regard
the exact growth of anatomical and clinical experiences as the first
and most important demand of the present time. From an empir-
icism of this kind will result gradually the true theory of medicine,
pathological physiology!"

Microbiology, Etiology, Comparative Pathology

It was reserved for etiology, the offspring of microbiology, "to
lift pathology permanently out of the level of a purely descriptive
science, for with the entrance of a dynamic factor, a causal element,
under the guise of microorganisms, the experimental era began
definitely."

The coming of microbiology, long foreshadowed by ingenious
speculations concerning infectious diseases, at once made patho-
logy broader and definitely comparative in its scope, thus widening
its relations to general biology on the one hand, and to preventive
and curative medicine on the other. It. will be recalled that the
founders of bacteriology — Pasteur, chemist and biologist, and
Koch, physician — both made their appearance in medicine as inves-
tigators of animal infections. Infectious diseases constitute a promi-
nent part in the field of pathology, and deeper insight into their
nature required simple, easily controllable conditions accessible to
experiment and analysis. This became possible by the discovery
and study of microorganisms which could be used to set in motion
the complex phenomena of disease according to the pleasure of the
investigator. In animals the course of a disease may be cut short

THE RELATIONS OF PATHOLOGY 113

at any time for the purpose of investigation and better insight
obtained into the evolutions of morbid processes. The disease may
be studied in all its phases. Hence comparative pathology rapidly
became the refuge of the investigator finding his way blocked by
the necessary restrictions governing the study of human diseases.
The great influence of the comparative method of study of infectious
diseases is well shown in the relatively advanced state of our know-
ledge in regard to those human diseases of this class that are readily
communicable to animals as compared with our ignorance in regard
to the cause of certain other human diseases which so far as we know
are not transferable to animals.

As the secrets of the vast domain of parasitism were revealed,
and the teachings of specific etiology and pathogenesis became
appreciated, there sprang up in the place of the therapeutic hope-
lessness inspired by the study of pathological anatomy only, an in-
creasing interest of enormous consequences in preventive measures.
This was the natural outcome of the persistent efforts now made
to follow the chain of causation so far as it was possible to go; for
it early became established that the farther back of the immediate
causes of diseases we can come the more easily and economically are
they controlled and, reversely, the nearer we approach the period
in the evolution of disease characterized by open manifestations the
more difficult is disease to overcome. Hence the newer ideas of
cleanliness, of surgical asepsis, sanitary science, and preventive
medicine, — all are the offspring of the study of microbiology and
etiology in a wide sense. % Indeed, the great principle of prevention
may be applied with perfect success even when the actual cause of
the disease remains unknown. The discovery by Walter Reed, for
instance, that the cause of yellow fever is conveyed by a certain kind
of mosquito makes it possible to prevent this destructive disease
with absolute certainty by destroying the mosquito or preventing
its bite.

Interaction of Parasite and Host — Bio-chemistry and Immunity.

But the fundamental problems of etiology are not wholly solved
by the discovery of the causative agent, however important this
step may be; for it remains to explain how normal function and
structure are upset by the entrance of this new factor.

Now the study of bacteriology and comparative pathology has per-
mitted a deeper penetration into the nature and mechanism of cer-
tain infections. The discovery of bacterial and other toxins, complex,
soluble, and diffusible chemical substances, and of their wonderful
influence upon the metabolism of cells, opened new and rich fields
that under the hands of keen investigators have furnished precious

114 PATHOLOGY

materials for the advancement of medical science along new lines.
Henle had anticipated many of our ideas of the interaction of para-
site and host, but especially interesting are the teachings of Bre-
tonneau in regard to the specificness of infectious processes, and the
words of his pupil, the great Trousseau, have proved themselves of
prophetic significance: "There are [in infectious diseases] two fac-
tors; one is the morbific germ coming from without, and the other
is the economy about to receive it; there is required a special apti-
tude for the organism to respond to the action of the stimulus . . .
when there is no such predisposition the morbific germ perishes."
It was necessary to erect the great structure of cellular pathology,
and to make brilliant and epochal discoveries in morbific etiology
before the suggestions in Trousseau's statement as to the interaction
of host and parasite could be expressed in such definite terms, and
given such enlargement in scope as in the genial and heuristic side-
chain theory of Ehrlich. According to this theory a toxin is poison-
ous only when it unites chemically with some constituent in the cell
of corresponding stereochemical configuration. If the cell does not
contain this particular constituent the toxin is harmless; and when
these constituents course in the blood as the result of reproductive
processes in the cells they are protective — antitoxic — because
they unite with the toxin and thus prevent the disastrous union of
toxin with cells. In other words, the substance in the body which,
when situated in the cells, is a primary essential for the toxic process,
becomes a curative agent when it enters the blood-stream (Behring).

Fortunately for the therapy and prevention of diphtheria, tetanus,
and a few other essentially toxic infections, these antitoxins may
be caused to accumulate in large quantities in the blood of certain
animals when artificially immunized by the injection of increasing
doses of the corresponding toxin. It was a happy inspiration indeed
that led Behring to use the antitoxic serum of immunized animals
for curative and prophylactic purposes, thus turning to the common
good this innate faculty of the animal organism to develop in so
marvelous a manner its own resources.

Supported by numerous experiments among the most imagina-
tive and interesting of modern biologic investigation, Ehrlich's
theory has proven a veritable master-key to some of the innermost
secrets of toxic and antitoxic action and immunity in general. The
theory has been found adaptable to other closely related problems
in chemical biology, and its signal usefulness in promoting investi-
gation in this complex field upon broad comparative basis places
it among the great theories of science.

Ehrlich's side-chain theory has been applied with great success
to the explanation of the formation by cells, and also of the action
of the various lytic or solvent substances for animal cells, particu-

THE RELATIONS OF PATHOLOGY 115

larly red corpuscles, as well as for bacteria. The active hemolysins,
bacteriolysins, and cytolysins are formed by the union of two dis-
tinct bodies, amboceptor and complement, whose properties and
affinities are being studied most actively. These substances occur
to a considerable extent in the blood of normal animals, and may
be induced to develop freely under the stimulation of the injection
into animals of large quantities of the cells or bacteria to be acted
upon. The fact that hemolytic substances, though of a somewhat
different and apparently less complex nature are produced by cer-
tain pathogenic bacteria of common occurrence, especially strep-
tococci, has given us a new point of departure for the study of the
anemia that develops in streptococcal and other infections. By the
aid of Ehrlich's theory it has also proved possible to explain the
mode of action of the toxic substances in certain venoms, and in this
particular field highly valuable facts have been established by the
work of Flexner and Noguchi and of Kyes. In certain phases the
subject has been simplified by the work of Kyes, who succeeded in
showing that a definite chemical substance, namely, lecithin, may
act as a complement to amboceptors in venoms, with which it unites
as a crystallizable "lecithid."

The extraordinary complexity of the chemical bodies produced
by cellular activity is further illustrated by the group of sub-
stances known as agglutinins which have the interesting property
of drawing animal as well as bacterial cells together into clumps.
Agglutinins may be produced by bacteria as well as by animals. It
is more than likely that certain forms of thrombosis met with in
infections are caused by agglutination of corpuscles, a form of throm-
bosis which has been designated as agglutinative. Experimentally
such thrombi are produced with ease by the injection of various
agglutinating substances. In animals as well as in man certain infec-
tions, e. g., with typhoid bacillus, are associated with the develop-
ment of agglutinins having a specific effect upon the bacterium
causing the infection. Such agglutinins are being used everywhere
for two purposes, (a) to determine the nature of the infection for
purposes of clinical diagnosis (as in the agglutination test for typhoid
introduced as a clinical measure by Grunbaum) and (b) to identify
certain bacteria and establish their relations to the infection.

Another interesting group of substances of the same general class
is formed by the coagulins which have the power of causing certain
changes in colloidal albuminous solutions.

Furthermore it has been found that the serum of an animal treated
with a proteid forms precipitates with that one proteid, a property
that within certain limits appears to be specific. This has led to the
use of specially prepared precipitating serums for the diagnosis of
different proteids, e. g., the detection of human blood for medico-

116 PATHOLOGY

legal purposes, and for the study of the genetic relationships of cer-
tain animals, a study that in the hands of Nuttall has given results
of general chemico-biological interest from an evolutional point of
view.

Reviewing these remarkable developments one is profoundly
impressed with the fact that at the same time as they constitute
a most important widening-out of biochemical science they have
added greatly indeed to the permanent resources of practical medi-
cine, emphasizing again in the clearest way the everlasting identity
of the scientific and the practical. Let no one, at least in the medical
profession, ever doubt the practical value of the knowledge that
ripens on the tree of science! These developments also demonstrate
that there are other modes of progress toward knowledge of cellular
activity and biological mechanisms under pathological as well as
normal conditions than the purely morphologic highway which
hitherto had been followed with great persistence in pathology.

Here we are dealing with chemical substances and chemical and
physical processes which ultimately will be interpreted in terms of
chemistry and physics. Already Arrhenius and Madsen have at-
tempted to show that the laws of mass-action and chemical equi-
librium govern the reactions between toxin and antitoxin, an
attempt that has precipitated a sharp controversy with the Ehrlich
school which cannot but powerfully stimulate continued work in
this field. Recently we have learned too that many salts in ionizable
solutions and also more complex substances combine in such a way
with the complements in normal and immune serums as to hinder
the union of complement and amboceptor necessary for lytic action.
Perchance it is in this direction that we may look for some insight
into the changes in physiological mechanisms that permit various
organisms to enter and set up disease.

It seems that in the chemistry of immunity we soon may expect
most interesting developments. The fact that lecithin may act as
complement, that it forms a crystallizable "lecithid" by union with
the hemolytic amboceptor of snake-venom, and further, the evi-
dence now at hand that colloidal silicic acid may play the part of
amboceptor, warrant the hope that before long complete analysis,
and perhaps even synthesis, of lysins may become possible.

The Synthesis of Different Methods in Scientific and Practical Medicine

In the majority of cases we owe our first knowledge of the exist-
ence of distinct diseases to clinical observation. By keen study
physicians were able to distinguish even between more or less
similar pictures, but the clinical picture has not always proved
adequate for the determination of disease-entities. The clinical

THE RELATIONS OF PATHOLOGY 117

manifestations of certain diseases are so much alike that differen-
tiation finally was accomplished as the result largely of the study
of the more or less characteristic structural changes in the tissues of
the body. In some cases differentiation could be made only after
the discovery of the specific causative organism. This was the case
with diphtheria. The clinical manifestations and the local anatom-
ical changes in the throat caused by the bacillus of diphtheria may
be reproduced in streptococcal and other infections. Now it is self-
evident that real penetration into the nature of a disease demands
its complete separation from other, in certian respects more or less
similar, diseases. In the case of diphtheria, for instance, complete
etiologic differentiation was essential in order that the real value of
diphtheria antitoxin might be learned. It may be mentioned, too,
that it required the discovery by Koch of the same bacillus in
practically all forms of human tuberculosis before the doctrine of
the dual nature of this disease, at one time advocated by Virchow
on anatomic grounds, received its final overthrow.

In various local inflammatory diseases such as pleuritis, peri-
carditis, peritonitis, meningitis, and in many so-called septic con-
ditions, i. e., local infections with general intoxication but with or
without bacteremia, the same clinical manifestations and anatom-
ical changes may be produced by different organisms. The diseases
being different etiologically are consequently also in all likelihood
different chemically in spite of their clinical and anatomical sim-
ilarities, and for these reasons deeper penetration into their nature
as well as progress in direct treatment will depend largely on study
of the organisms concerned and of the products of their activities.
Clearly an essential step in this direction is the differentiation of the
diseases on etiologic grounds. Other examples of analogous nature
could easily be cited.

Now, practically every disease the nature of which we in some
degree understand may be cited in illustration of the close synthesis
of clinical observation (clinical pathological physiology), patho-
logical morphology, etiology, and microbiology, experimental and
comparative methods, and especially more recently of chemistry
in the development of our knowledge of disease. To the fullest ex-
tent this is true of certain infectious diseases. Starting with normal
physiology and anatomy, these have become the principal methods
by which material is accumulated for that pathological physiology
which Virchow put as the chief end of medical investigation. And
it is along this road too that the medical student passes to reach
membership in the medical profession; for here also "ontogeny
repeats phylogeny." Finally these are also the very methods of
procedure employed by the true physician in solving the problems
r>f diagnosis and so of treatment presented by the individual patient

118 PATHOLOGY

no matter to what specialty the case may be referred in conse-
quence of the great differentiation of medical art with which we are
familiar.

Practical medicine is availing itself more and more of the methods
of scientific medicine. The laboratory is entering into closer and
closer relations with the clinic. For the purpose of facilitating inves-
tigation as well as treatment it has been found advantageous to
include various laboratories in the clinic, and the use of laboratory
methods has extended to all departments of medical practice where
their field of usefulness is constantly enlarging. How these methods
may be made most easily available for the practitioner has now
become a problem of real urgency. Pathology is consequently a great
force in the interests of integration as opposed to differentiation in
medicine; for pathology gathers under her wings all the specialties
which differ not as to methods but only in the matter of the fields
investigated.

Whatever the role of pure morphology in the investigations of
fundamental biological problems — and it does not seem likely that
it will lose greatly in significance in this respect so long as biologists
regard the peculiar complexus of physical conditions called struc-
ture as absolutely essential to life — it always will maintain relations
of fundamental importance in medicine. Medical and surgical
diagnosis rests to a large extent upon the recognition of the nature
and cause of gross changes in structure and their consequences on
function. To the surgeon pathological anatomy is a guide whose
minutest direction he must obey. Exact clinical observation con-
trolled so much as ever possible by anatomical examination will
continue, as emphasized always by Chr. Fenger, the mainstay of
medical progress in every locality. The value of microscopic anatomy
in the study of diseases of the blood, in the differentiation of new
growths, and in inflammatory products needs only mention. Many
of the methods of microbiology are essentially morphologic. The
established classification of bacteria is based on morphology, and the
studies of the relations of microorganisms to the cells of the body —
often a matter of great importance — requires morphologic methods.

I believe there is no room for the opinion one occasionally hears
expressed to the effect that the value of the usual methods of mor-
phology and microbiology in scientific pathologic investigation has
been exhausted. Of course the field cannot be said to be so large as
at one time, but there are still problems enough demanding the use
of these very methods, refinements and improvements in which are
constantly increasing their usefulness. Unquestionably advances
in our knowledge of functional localization and in the tracing of
conduction paths in the central nervous system of man will con-
tinue to depend in the main on the careful study of anatomical

THE RELATIONS OF PATHOLOGY 119

lesions and their functional and structural consequences. Blasto-
mycosis and paratyphoid fever are brilliant examples of "new dis-
eases" recently established as the result of purely morphologic and
microbiologic methods of study in fields long diligently explored.
In trypanosomiasis and piroplasmosis of man and of animals we
have other examples of interesting diseases for the recent know-
ledge of the existence of which as etiologic entities we are indebted
chiefly to clinical observation and morphologic studies of the blood.
These facts indicate that microbic etiology may yet be forced to
yield up hitherto carefully guarded secrets to more or less familiar
methods of new modifications thereof.

Great interest has been awakened in the recent determined effort
by Councilman and his associates to solve by these methods the
etiology of variola, the final proof of the success or failure of which
must be left to more discriminating forms of microbiologic research.

In pathology purely morphologic methods have surely as great
an importance in establishing etiologic relationships and as a means
of orientation in various forms of investigation as they have in
unraveling the intricate connection between structure and function.
Progress in the domains of microscopic pathological morphology
and progress in normal morphology will always be mutually helpful
because pathological cellular changes — necrosis, necrobiosis, de-
generations, and proliferations — are probably largely identical with
normal cytomorphosis, being abnormal only as to time and place.
A recent morphological observation of great interest is that by
Bashford and Murray of a process of conjugation in cancer cells.
These observers found in cancer cells nuclear changes similar to
those by which sexual cells are prepared for fertilization and also
fusion of nuclei equivalent to the process of fertilization known as
conjugation. This discovery (if confirmed) will help to turn the
search for the causative factor in cancer directly to the very pro-
cesses in the cells themselves, a direction indicated already by the
singular fact that cancer always "breeds true," and that it is trans-
plantable only within the species in which it originates, and that it
behaves as an independent organism. Undoubtedly the newer
methods of study of micro-chemical reactions in normal cytology
will prove valuable also in pathological cytology. Perchance this
synthesis of morphological and chemical methods in time may give
us some insight into the normal relations and time-sequence of
chemical reactions in biological processes, normal as well as abnormal.

It proved to be an auspicious day both for chemistry and medi-
cine when Pasteur conceived his biological theory of alcoholic fer-
mentation. Ludwig's prophecy of forty years ago that chemical
physiology would largely prove a study of catalytic reactions has
come true, and the cell is now no longer considered as a simple struc-

120 PATHOLOGY

ture, but rather as a most complicated machine, the working of which
for the most part is dependent on enzymes. Into the finer details
of the manner in which these mechanisms may be disturbed under
abnormal conditions we as yet have hardly been permitted to pene-
trate, but the extensive recent researches dealing with the nature
and mode of action of ferments in diverse physiological activities
have awakened a lively interest in fermentations in pathological
processes which augurs well for the future.

Among the many intracellular ferments those causing self-digestion
or autolysis of cells are thought to play an active and essential
r61e in the removal of dead material, such as necrotic tissue in
infractions and inflammatory exudates. Some idea of the fermenta-
tive activities in autolysis may be obtained from its action in pneu-
monia. In a few days autolysis may so alter a mass of exudate
weighing several hundred grams that it is readily removed from the
lungs by absorption and expectoration.

The biochemical mechanisms of normal and pathological pigment
formation have now been shown to depend on the action of oxida-
tive ferments.

Cohnheim's demonstration that two enzymes, one coming from
the pancreas and the other from the muscles, are necessary for the
oxidation of sugar, appears to be a long step toward putting the
pathogenesis of diabetes in an entirely new light. While these and
other oxidizing ferments are the products of cellular activity, it at
once suggests itself that they need not be the products of the cells
of the same body which is later to use them. It has been suggested
that they may be introduced as needed much as antitoxins now are
introduced (Long).

The results of the work of Croft Hill and of Kastle and Loewen-
hardt on the reversibility of ferment action have been eagerly
grasped by pathologists and made to throw new light on the prob-
lems of fat absorption and translocation. Indeed, the newer chemi-
cal methods of study are changing completely our older ideas about
fatty changes in the cells, ideas that were based almost wholly upon
morphological appearances. Great progress has been made also in
other respects in recent years from the application of the methods
of physiological chemistry to pathological problems, but I must
refrain from going into further details. As a result the field of pure
chemistry as an aid to medical diagnosis is enlarging, not merely as
regards various analytical procedures for the testing of fluids and
other substances, but the newer methods of physical chemistry
such as testing the solution content by electrical conductivity and
eryoscopy have been found useful in order to obtain information
of help in reaching a correct diagnosis or a better understanding of
the nature of the functional disturbance.

121

As indicated in the foregoing we are now at the beginning of an
era of the application of newer physical and chemical methods to
many problems in medicine, problems that at one time were regarded
as approachable only by so-called biological methods, and the
number of problems that lend themselves promisingly to this form
of treatment seems to be constantly increasing. I have referred
already to their use in the study of chemical problems in immunity.
The many fundamental problems connected with the constancy
of osmotic pressure in the fluids of the body ; the great influence of
osmotic disturbances in the production of edema; the interesting
relations of ions to proteins; the physico-chemical properties of
ions of various salts in relation to pharmacological action — these
are some of the new questions that are being actively studied with
results in many cases of far-reaching importance.

In many of its phases this departure is the outcome of the appli-
cation by Loeb and others of general chemistry to biological study
the results of which we have followed with increasing wonder as they
have shown us the extent to which certain life phenomena can be
controlled unequivocally by chemical and physical means. Many
of the manifestations of life are physical in character, but biologists
are agreed that the source of energy in life phenomena is chemical,
and that general chemistry therefore must form the foundation of
biology. From this it follows directly that the deeper, fundamental
explanation of the mechanisms of pathological processes also re-
quires chemical and physical methods. Henceforth chemistry will
play an increasingly important role in the efforts to reduce the phe-
nomena of pathological biology to simpler laws. We thus find again
that sharp lines of demarkation cannot be drawn between normal
and pathological biology; for progress in one naturally exercises
determining influence on progress in the other, and in both develop-
ment is in the direction of synthesis with physics and chemistry.

Medicine has been called the mother of sciences, and not without
reason. She gave to physics Galileo, Mayer, Helrnholtz; to geology
Steno; to botany Linnaeus; to chemistry Black, Berzelius, Liebig;
to biology Aristoteler, Lamarck, and Huxley; but as pointed out
by Sir Michael Foster, her children are ever coming back to help
her. In medicine as a science and as an art many sciences converge
— physical, chemical, and biological methods join hands for the
advancement of knowledge and the relief of suffering.

WORKS OF REFERENCE

Of the various articles from which I have drawn freely in preparing this ad-
dress I would mention the following especially:

BARKER, L. F.,The Unveiling of the Cell, Jour. Am. Med. Assoc. xxxvii, 577-82,
1902.

CHIARI, H., Die Pathologische Anatomic in 19. Jahrhundert und ihre Einfluss
auf die Atissere Medicin. Verh. d. Naturforscher u. Aerzte, 1900, Allg. Theil.

COUNCILMAN, W. T., The Relations of Pathology to Medicine, cxxxvm, 557,
1898.

FLEXNER, S., An Aspect of Modern Pathology, Science, 1903.

HARBITZ, FR., Hovedtrak af den Patologiske Anatomis Udvikling. Norsk
Magazin for Lagevidenskaben, 1900.

LOEB, J., The Limitations of Biological Research, University of California Pub-
lications, Physiology, i, 33-37, 1903.

LONG, J. H., The Relations of Chemistry to Modern Medicine, Science, xx, 1-14,
1904.

OSTWALD, W., The Relations of Biology and the Neighboring Sciences, Uni-
versity of California Publications, Physiology, i, 11-31, 1903.

SALOMONSEN, C. J., General Pathology as a University Subject, Festskrift ved
Indvielsen af Statens Serum Institut, Copenhagen, 1902.

SMITH, TH., Comparative Pathology: Its Relation to Biology and Medicine,
Proc. Phil. Patholog. Soc. m, 165-181, 1900.

VESTBERO, A., Om de Sjukliga Foreteelsemas Biologiska Betydelse, Upsala
Lakaref6renigens Forhandlingar, 1903.

VIRCHOW, R., Morgagni und der Anatomische Gedanke, 1894.

WELCH, W. H., Biology and Medicine, The American Naturalist, xxxi, 756-
766, 1897.

BY JOHANNES ORTH

[Johannes Orth, Professor of Pathological Anatomy and General Pathology,
University of Berlin, since 1902. b. Wallmerod, Herzogthum Nassau, Janu-
ary 14, 1847. M.D. Bonn; Assistant am Pathologischen Institut, Bonn, 1870-73;
ibid. Berlin, 1873-78; Regular Professor, University of Gottingen, 187&-1902.
Privy Medical Councilor; member of the Royal Scientific Deputation for
Medical and Sanitary Science; Royal Association of Science of Gottingen;
Imperial Leopold and Caroline Academy of Natural History; and a number
of scientific and learned societies. Author of Cursus der Normalen Histologie;
Pathologisch-anatomische Diagnostik; Manual of Pathological Anatomy; and
numerous other memoirs and works on pathological anatomy.

WHOEVER has to speak of pathology in general, as is my task,
must first determine what he includes in pathology, for the ideas
which are evoked by this term are not always the same. The opinion
is common that pathology is synonymous with "science of disease,"
"nosology; " but this, as Rudolph Virchow 1 has attempted to prove
• repeatedly, is not true. Doubtless disease, or rather the diseased
individual, is the most important object of consideration of patho-
logy; it is, however, not the only one. The conception of pathology
is much more comprehensive. To pathology belongs, on the one hand,
every deviation from the normal structure and the normal composi-
tion of the body, and, on the other, every deviation from the normal
function of its parts. It therefore includes every variation from
what we consider the type of an organism. Variation from type is,
however, not disease. Disease is, as Boerhaave was the first to say,
" Vita praeter naturam," and life presupposes activity. When there
is no functional activity and thus no deviation from normal function,
there can be no disease. But not even every functional variation
from the normal indicates disease. The variation must be pernicious
in character, if it is to bear the name of disease. When there is no
detriment, there is no disease, although whenever a variation from
the normal exists, we have to do with a pathologic condition, no
matter whether the variation is morphologic or functional.

Purely morphologic variations without detrimental influence on
the rest of the body are found, especially among anomalies and
malformations, and who will deny that these belong to the realm
of pathology? An individual with a supernumerary nipple, a person
with polydactilism, a woman with uterus septus or bicornis, all are
pathologic, although none are sick. Thus, while the biologic phe-
nomena of the diseased state form the greater part of the realm of
pathology, they do not complete it. Its limits must be extended
much further, but how far is the point of contention.

1 Handb. d. spec. Pathol. u. Therapie, 1854, pp. 6 5.

124 PATHOLOGY

Many may consider the statement of Virchow * a witty paradox
when he says that the development of new species really belongs to
the realm of pathology, as a new species must find its origin in a
variation or deviation from the preceding type, and variation from
type is pathologic. Thus the whole teaching of evolution, the science
of phylogeny, is to be considered part of pathology. I share through-
out Virchow's opinion, and in my work on inherited and congenital
diseases, recently published,2 1 have again given this fact expression
that we must presuppose a variability of the embryonal protoplasm
(Keimplasma) and that variation or deviation from the previous type
either acquired or inherited or even arising from external influences
is the necessary preliminary to the formation of a new species, sub-
species, or variety. I would not, however, like to go so far as to call
everything arising in this way pathologic, no more than I can con-
sider it pathologic when, by immunization, a man is made better
than he was before. Such a man varies from the type of normal
man, but is not pathologic, because the variation is useful and appro-
priate. Only variation which is inappropriate or useless is pathologic.
I realize that it may often be difficult to determine the limits of the
inappropriate and useless and thereby pathologic, especially in the
development of varieties and races. Thus, I should not hesitate to
class the Crested Polish fowl with its exencephalocele as pathologic,
while I should exclude those breeds which the animal breeders have
made for useful purposes from pathology, no matter how near the
pathologic the products of skill might be.

Variations from type occur in inanimate as well as animate nature;
there are malformed crystals just as there are malformed plants,
animals, and persons, but we are not accustomed to speak of a patho-
logy of crystals or stones, but only of plant, animal, and human
pathology, for only with living beings can we rightly speak of useless,
inappropriate, or pernicious variations from the normal.

Human pathology, undoubtedly the most momentous and import-
ant for us, has made but little use of plant pathology as yet, although
there can be no doubt that many conclusions for general pathology
as for general anatomy are to be drawn from botany. The reaction of
plant cells to unusual conditions, and the morphologic and functional
disturbances which occur under such circumstances are easier to
observe, and may well serve as guides to the understanding of similar
processes in animal or human cells. Experimental pathology has
already made use of plants in its investigations,8 but only recently
have we begun to give more attention to the spontaneous diseases

1 R. Virchow, Ra&enbildung u. Erblichkeit, in Festschrift fur Batian, 1896.

1 Orth, Angeborene u. ererbte Krankheiten u. Krankheitsanlagen, in Krankheii
vnd Ehf, herausgegeben von Senator u. Kaminer. Munchen, 1904, p. 26.

1 O. Israel, Bwtog. Studien mit Rucksicht auf d. Pathol. Virchow' » Arch. 141,
p. 209, 1895.

RELATION TO OTHER SCIENCES 125

of plants, especially since we have learned how great a role parasitism
plays in vegetable as well as human pathology. At the head of the
parasitic problems of human pathology of the present day stands
that of the etiology of tumors; here cancer cells, here cancer para-
sites, so sound the battle-cries, and a parasitic new formation in the
vegetable kingdom, the club-root of turnip, did not only have to
furnish the paradigma of cancers in man and beast, but some inves-
tigators have even gone a step farther and see in Plasmodiaphora
brassicae, the parasite of club-root, the exciting cause of animal
tumors or at least a close relation of such cause.1

Very different is the relation of human to animal pathology,
not only on account of the closer relation between man and ani-
mal, by reason of which a comparison of observations between
animals, especially the higher vertebrates, and human pathology
is more permissible, but also because the questions to be decided
experimentally must be proved in the main on animals.

Even though a complete agreement between the phenomena of
human and animal pathology cannot exist, as the function and con-
struction of the animal body and its organs do not entirely agree with
those of man; even though many diseases which attack man do not
occur in animals, still analogies are not wanting and the similiarity
is greater the higher the group among the vertebrates to which the
animal in question belongs. An especial advantage of compara-
tive animal pathology is that the necessary material is not only
easier to obtain than the human, but that particularly by volun-
tary killing of pathologic animals accurate morphologic investi-
gations can be made at any desired stage and on perfectly fresh
tissues free from cadaveric changes. Especially valuable conclu-
sions can be drawn in those diseases, which are common to man
and animals, the zoonoses and the anomalies of formation, the
simpler ones as well as the monsters in the narrower sense.

A somewhat neglected realm of comparative pathology has re-
cently attracted the attention of pathologists in more and more
increasing degree; namely, tumor formation in the lower animals.2
From their construction we may expect to draw valuable conclu-
sions in regard to the pathology of human tumors, not only in the
morphologic but also in the genetic direction. One point espe-
cially comes into consideration, which also plays an important part
in the utilization of animal pathology in other directions, the pos-
sibility of purposeful inoculation experiments from animal to ani-
mal.*

Unfortunately the great value of experimental research for all

1 Gaylord, Zeitschr. f. Krebsforsckung, I, 1903.
1 Pick u. Poll, Berlin, Klin. Wochnsechr, 1903, p. 518.

* C. O. Fenger, Experim. Untenuch. Ober Krebs bei Munsen, Abh. f. Bakterio.
xxxiv, p. 28, 1903; Borrel, Eptihd. infectietuses Ann. de VInst. Pasteur, 1903, no. 2.

126 PATHOLOGY

branches of pathology * is not sufficiently known among the laity,
and attempts through governmental interference to lay difficulties
in the way of experimental investigation (vivisection as it is called
by the laity, scientific animal torture according to its opponents),
are constantly being made, not seeing that misuse of it, even
if it should occur, is considerably outweighed by its undeniable
value. Pathologic anatomy, bacteriology, pathologic chemistry,
and above all, pathologic physiology, cannot fulfill their scientific
value without animal experiment. A large part of the progress
in pathology is bound up with experimental research. Every ad-
vance in pathology has sooner or later been of use to man. Could
our progress in the pathology of the infectious diseases, and our
progress in the prevention and treatment of them, have been made
without experimental pathology? The explanation of the origin
of tumors must also finally arrive by experimental investigations,
and just there it will be of especial value to be able to carry on the
experiments on the same kind of animal in which the tumor natur-
ally occurs. If we should succeed in finding a specific, probably
parasitic cause, the possibility of demonstrating the pathogenicity
of this disease-producer on animals of the same sort is incalculable.
But such experiments presuppose exact knowledge of the pathology
of the animals experimented upon, that is, comparative pathology,
and many discussions of the present day have turned on the point
whether changes which were found after the experiment were
results of the experiment or chance pathologic findings to which
the experiment had no genetic relation. If one does not know
what kind of tumors occur in the organs of the animal which he is
using for experimental purposes, he will easily fall into the danger
of considering new formations as the result of the microorganisms
injected by him and will report having produced a tumor when
merely a spontaneous new growth existed.

So far I have considered animals only as passive objects of ex-
perimental pathology. I have spoken of animals and plants merely
as the most important subjects for comparative pathology. There
are, however, much closer relations between pathology and botany
and zoology. Both these sciences have had increasing importance
for pathology, as surer proof was brought that the most important
causes of disease belong to the plant and animal kingdoms.

Investigation of the causes of disease, of the different conditions
which form the basis of deviations from normal types, belongs as
much in the realm of pathology as the study of these deviations
and their development itself. The etiology and pathogenesis are
a part of pathology, and it is especially through them that patho-

1 R. Virchow, Ueber den Werth des pathologischen Experiments, Internat. Med.
Congress, London, 1887, Berlin, 1899.

RELATION TO OTHER SCIENCES 127

logy has its closest relationship with the other sciences. Mechanics,
general and cosmic physics, geology not less than geography, in-
organic as well as organic chemistry, social and military history,
sociology, and commercial science, etc., must all be considered for
the enlightenment of the etiology of disease and the explanation
of the appearance of disease, especially in regard to time and place
(historic geographic pathology). But above all stand zoology and
botany, for the most important and most common diseases are
produced by living beings, by parasites.

It is an old statement in pathology that a parasitic relation exists
in disease. For a long time the disease as such was thus per-
sonified; it was spoken of as an organism within the organism, a
parasite, which as Wunderlich * said, was anthroposed or phyto-
morphosed in every way. To it was ascribed an existence, a growth,
limbs and organs, a power of endeavor and of thought, even a sick-
ness, death, and finally a corpse. Pathology has done away with
this conception. It is true that we still speak of the disease, of
cholera, typhoid fever, pneumonia, etc., and that in practical medi-
cine we still speak of treating this or that disease. A treatment for
syphilis, for diphtheria, or some other disease is recommended as
if we spoke of something tangible, independent. But all this is only
for convenience of expression, and we know very well that what we
call a disease is not an entity but only a group of phenomena which
have for their basis a common cause. There are really no diseases,
but merely sick men, diseased organs, diseased tissues, diseased
cells, and it is the cause of these disturbances which brings about
the special phenomena which we observe in the diseased part.

This cause may be a parasite. Centuries ago the opinion was occa-
sionally expressed that diseases were caused by living beings, which
disturbed the life-processes in the human body. In the middle of
the last century the view that there must be contagium vivum
was victoriously upheld by Henle,2 but only in the last decades
of the nineteenth century was actual proof brought fonvard that
by far the commonest causes of disease are living organisms which
live parasitically on or in the human body. The disease is not the
parasite, but one parasite or many parasites cause those variations
from the normal structure and function of parts of the body which
in their entirety we call disease.

By parasitology a close union is made between pathology and
the described natural sciences and thus with general biology.

The great biologic question as to the origin of the lowest being
is related principally to the human parasites. In spite of the state-
ment of the great English physician Harvey, "Omne vivum ex ovo,"

1 Wunderlich, Hdb. d. Patholog. u. Therap. i, p. 12, 1852.

2 Henle, Hdb. d. Ration. Pathol. n, 2 p. 457, Braunschweig, 1853.

128 PATHOLOGY

the doctrine of spontaneous generation, which ruled for thousands
of years, had not vanished from science, and in the beginning of
the last century natural philosophy treated with preference on the
beginning of life, and some are not lacking in our day who believe
that they see in the doctrine, that the tissues of our bodies break
up in decomposing into small organisms,1 an expression of the
immortality of the life principle.

That the large intestinal worms do not arise from the dirt of the
intestinal canal, from saburra, but that for them Harvey's rule
holds, has been shown by both zoologists and pathologists. For
the smallest beings we may mention the chemist, L. Pasteur, with
the physician, Robert Koch, the former of whom conclusively dis-
proved the spontaneous generation of microorganisms; the latter
as the discoverer of the methods which permitted us to ascertain
simply and surely the constancy of form of a microorganism and
to give incontrovertible proof that in every single microorganism
the law of generation was true, not entirely in Harvey's sense, but
in the more general form: Omne vivum e vivo ejusdem generis.

But it is not only general biology which has been furthered by
the parasitology of the physician, but also special biology and the
systematic classification of parasitic animals and plants. Just here
is plainly shown that pathology cannot in any way be separated
from the other natural sciences, as it is not only the receiver which
makes practical use of scientific discoveries, but also the producer
which by its own effort, and through independent performances
furthers science. The modern development of bacteriology, the
determination and elaboration of exact methods of investigation, the
morphology and biology of bacteria, have not been entirely developed
by botanists, but it has been and still is physicians and pathologists
who may claim a large part of the results as due to their efforts.

The same relation in working together exists between pathology
and zoology in regard to the parasitic animals. Here the points of
contact of the two sciences are doubled, for on one hand the change
of generations of many human parasites, their occurrence in different
hosts, as well as the fact that animals may be the simple conveyers
of parasites, required the human parasitologist to bring the animal
world into the realm of their investigations; on the other hand, the
morphology and systematic study of the parasitic animals themselves
has been ascertained with considerable assistance from pathologists.
In the first class I will only recall the joint work of pathologists
and zoologists on trichinosis.2 In determining the relation of this

1 R. Arndt, Unters. uber d. Enischung von Kokken und Bakterien in organischen
Substanzen, Virchow, Arch., 82, p. 119, 1880; A. P. Tokker, Versuch. einer nauen
Bakterienlehre, 1903.

2 Zenker, Arch, i, p. 90; Leukart, Unters. tib. Trich. spiral. 1866, R. Virchow,
Lehre von den Trichinen.

RELATION TO OTHER SCIENCES 129

disease in pigs and other animals to that in man; malaria and the
role which anopheles play therein; the recent investigations on the
conveyance of plague and other infectious diseases by animals.
Names of physicians like Kiichenmeister,1 Davaine,2 and others
have given human parasites their final place in zoology. I wish also
to call attention to the very recent investigations concerning pro-
tozoa as disease-producers, one of the most burning questions of
modern pathology, a question of extreme importance, and also of
correspondingly great difficulty. Unfortunately, investigations on
the parasitic protozoa remain still in their infancy, but even on this
question the pathologists of Europe and North America may demand
recognition of their zealous work.

Closest and most numerous are, of course, the relations of patho-
logy to anatomy and physiology. Just as the study of the normal,
typic man is divided into anatomy and pathology with physiologic
chemistry, so also is pathology (apart from etiology and pathogenesis)
made up of pathologic anatomy and pathologic physiology with
pathologic chemistry. Just as health and disease pass imperceptibly
into one another, so there can be no sharp line drawn between patho-
logic and normal anatomy, normal and pathologic physiology. These
studies are not different sciences, but branches of the same scientific
tree with the same stem, the same roots. Their methods of investi-
gation are mainly the same. Discoveries in one generally mean
progress in the others.

The time is not long past when instruction in pathologic anatomy
in our universities was in the hands of the professor of normal
anatomy, and when men like Job. Fr. Meckel, Johannes Miiller,
and others enriched and fostered normal as well as pathologic ana-
tomy. Pathologic anatomy is only conceivable on a basis of normal
anatomy, and a glance at the history of medicine shows how every
progress in normal anatomy has produced an increase in the know-
ledge of pathologic anatomy. Only the flourishing of anatomy in the
sixteenth century made the development of pathology to a separate
science during the ensuing century possible. But here also pathology
was not only the receiving but frequently the producing science.
Pathologists not only enriched anatomic and histologic methods,
but contributed largely to the development of accurate anatomy,
the general as well as the special. Who does not think in connection
with "general anatomy" of Rudolph Virchow,3 the man who coined
the famous words "omnis cellula e cellula" corresponding to Harvey's
"omne vivum ex ovof" That saying while resting in great part on

1 Kuchenmeister, Die in und an d. Korper d. lebend. Menschen varkommen-
den Parasiten, 1878, 1879, 3. Aufl.

z Davaine, Traite des Entozoaires, Paris, 1877, 2. Aufl.

3 Die Cellular pathologie in Hirer Begriindung auf physiologische und patho-
logische Gewebekhre, 1. Aufl. 1858; 4. Aufl. 1871.

1 : . PATHOLOGY

observations, is equally true for pathologic and normal

with special anatomy it wfll suffice to refer to the
of the brain, especially to the course of its
order to show how much pathology has contributed to the
of normal structure, Tne great progress which the fine
brain anatomy made hi the last decades of the last century is due
in large part to pathologic oli 1 1 1 rtitmm, medical investigations,
conceived by physicians, and the result of investigations
brought forward in connected form, especially by medical

is true, but even to a higher duyw, of physiology , the
pathologic branch of which has unfortunately not received the

in every place as * separate
not been neglected by scientific

fieine

A large part of our knowledge of human physiology has been
bytheobserrationsof functions changed by disease as they
symptoms of disease in man or are produced artificially
by ^r>"TBP*t °» animals. Where would the physiology of the
brain be, if pathology had not made dear the position of the centres
;of the tracts from the constantly recurring sympt<
•thnlogic i ipiisMil had not proved the correctne

of the conduaons which were drawn from human observations 1
What would general cellular physiology be. if observation of the
of cefls under iswjiqg fife i imililiiaM had not given us
cneernmg the processes under normal conditions 71 la
cellular physiology rather a product of cellular patho-
logy? Was it not a iiiliniifcpi, IL Virchow. who introduced the
that the cefl is the final form element of all vital phenomena,
who arrived at this conclusion not least through pathologic

From the deviations one rarogniirs most readily the law. There is

as not received enlightenment
bom the experiences of pathology. The doctrine
to name only a few of these problems,, plays no small
pathology,, and many cases of pathologic heredity throw
on the subject and nature of heredity in general. The
tof pathology in the realm of hematology, the doc-
of amtauBi and pnsfpsliM^ !•* abMify led to most valuaMe
the ff^fffl biologic question of the blood
relationship off animals with one another. MM! of animals with man.
The blood of anthropoid apes and man shows similar behaviors,
from the blood of other animals. -

1 V«

RELATION TO OTHER SCIENCES 131

Especially numerous and close relations exist between pathology
and that branch of biology which treats of the development of the
human and animal body, and these relations are daily becoming
closer and more numerous, as more and more frequently it can be
proved or at least made probable, that pathologic phenomena of
all kinds form the basis of ontogenetic disturbances of the greatest
variation.

An important difference exists between normal and pathologic
anatomy, in so far as the genetic consideration plays a much greater
role in the latter than in the former. Finished conditions form the
basis of descriptive anatomy. Pathologic anatomy must always
consider phases of development and none of its observations can be
understood if their origin cannot be explained and if the original
condition and the further development of its changes cannot be
determined. The original condition, however, leads more and more
frequently back to the time of embryonal development. It is to the
eternal merit of Joh. Fr. Meckel,1 the anatomist and pathologist,
of Halle, that he showed for the first time in the case of a malforma-
tion of the intestinal diverticulum that the essential part of the varia-
tion from the normal consists in this, that a condition which is normal
for a certain period of embryonal life, but which should only have
a transient existence, is retained and is always recognizable in later
stages of development, even though changed by the progressive
growth of the part. This demonstration was the more important and
valuable, as it treated of a theme which had hitherto been the ground
of the most remarkable genetic theories. The apparently planless
variation from type was explained as the work of demons or devils
or as a freak of creative nature (lusus naturae). Now, it was shown
for the first time that also in the realm of malformations, order and
law governed the process and not arbitrariness and freakishness, and
that we must consider the embryonal development of these malfor-
mations if we would understand and explain these methodic processes.

Thus was founded the doctrine of imperfect development and
growth, and as the basis for the explanation of malformations
(Hemmungs-Missbildungeri) it has been especially fruitful, as the
fissures about the face, malformations of the female genitals, and
congenital malformations of the heart will show, but that they have
not yet closed the list is shown by the recent investigations of cystic
kidneys, which have proved these to be due to a checking of the
development of the embryonal organs. These examples show that
disturbances of embryonal development are not only of importance
in causing variations from the type, such as malformations, but also
for disease-processes in the narrower sense, which originate most
readily in malformed parts or organs. The idea that congenital heart

1 J. F. Meckel, Handb. d. p&thol. Anat. i, p. 553.

132 PATHOLOGY

disease was due to endocarditis in fetal life was largely due to the
knowledge of the susceptibility of the malformed part to secondary
so-called chronic inflammation. This is true not only of the macro-
scopic conditions like those mentioned, but it also favors the idea
that incompleteness in the formation and the later development of a
part cause a local disposition to disease. But this is only one side of
the relationship between disturbances of development and disease.
Another, perhaps even more important, is that which treats of the
development of tumors on a basis of disturbance of development.
The tumors of undescended testicles, the origin of new formations
from displaced adrenal fragments, are as familiar to pathology and
as surely established as the occurrence of dermoid cysts, which can
only be explained on the basis of the history of development. The
well-known theory, according to which all tumors depend on dis-
turbances in embryonal development, still lacks sufficient proof.
Both pathologists and embryologists have been successful in showing,
however, that one tumor at least, the dermoid of the ovary, only
finds a satisfactory explanation in the presence of derivatives of all
three embryonal layers, thus indicating a very early disturbance of
development.1 These tumors are closely related to malformations
and pass without sharp division into true monstrosities. The study
of all malformations, not only those due to impeded development
and which no one attempts to deprive pathology of, is not to be
separated from the study of normal development, for the origin of
malformations goes back to the earliest embryonal period, and not
only malformations of the whole body but anomalies of its single
parts can only be understood and their origin explained in the light
of normal developmental processes.

On the other side, experimental teratology, which is doubtless
a branch of pathology, has made most important advances in the
knowledge of the laws of normal development, the laws which govern
the details of the regular formation of the embryo. Here also no
sharp line can be drawn between pathology and embryology. Patho-
logy takes its place alongside of embryology, with equal right and
equal importance.

Thus we see pathology placed centrally among the biologic
sciences, bound inseparably to all of them, not subordinate to any
but their equal, receiving help from all sides but giving as much in
return. Lastly, it must be stated that it is the problem of life which
forms the subject of pathologic work. Even though it wanders in
its own ways, and possesses its especial questions, it is finally led to
the general question of every biologic investigation.

1 Marchand, Eulenburg's Real Encyclopaedic, xv, 432, 1897; Bonnet, Ergebn.
d. Anat. u. Entwicklungsgesch. ix, 820, 1899; Wilms, Die Mischgeschwiilste, 1899-
1902.

RELATION TO OTHER SCIENCES 133

Points of contact with philosophy are always presented by these
general biologic problems, and we need only name Lotze,1 the
physician and philosopher, and his work on General Pathology as a
Mechanical Science, to find the close relationship between philosophy
and pathology personified in modern times. Metaphysic consider-
ation of empiric assertions is necessary, as Kant has taught, to draw
general conclusions and formulate general rules and laws from the
observation of nature. Biology, and not least, pathology, lead
everywhere to the limits of our knowledge of nature, where fixed
knowledge finds its end, where we must, with Du Bois Reymond,2
acknowledge our ignorance of what lies beyond, but where philosophic
contemplations point a higher and more general way out of our
difficulty. These limits to our knowledge are not lasting, however,
for pathology. We will not remain in ignorance as long as the know-
ledge of healthy and diseased life progresses, and the boundaries of
natural science and philosophic contemplation of the problems are
being extended. Increasing knowledge of facts must be the basis of
philosophic contemplation, if this would have real value.

There was a time in pathology when philosophic conceptions
outweighed all other considerations, and when it was believed that
all the problems of general biology and those of general pathology
could be solved by pure reasoning. This period of natural philosophy
was as unfruitful for real progress in pathology as the period of
dogmatism in the Middle Ages, when Aristotle and Galen were looked
upon as the sum of all wisdom, and pathology was nothing more
than philology, as all scientific work consisted principally in criticis-
ing and commenting upon the Greek writings.

This changed only after we emancipated ourselves more and more
from the old dogmatic belief and through original investigations
laid a true scientific foundation for pathology. The maxim of the
great Morgagni,3 "Nulla autem est alia pro certo noscendi via, nisi
quam plurimas et morborum et dissectionum historias, turn aliorum
turn proprias collectas habere et inter se comparare," as well as his
other, " Non numerandae sed perpendendae sunt observations, " had
to receive general recognition before pathology was enabled to take
its place among the other natural sciences. This place it had lost,
for in the renaissance of science in the sixteenth century pathology
stood in close relation to the other natural sciences; and medicine
was for centuries the bearer of all natural science and included all
other sciences within itself, so that not only did the teachers of other
sciences belong in many cases to the medical faculty, but zoology

1 Lotze, Die aUgemeine Pathologic und Therapie ah mechanische Naturwissen,
schaft, Leipzig, 1842.

2 Du Bois Reymond, Ueber die Grenzen des Naturerkennens, Naturforscher-Ver-
Sammlung in Leipzig, 1872.

3 De sedibus et causis morborum, per anatomen indagatis, 1761.

134 PATHOLOGY

and botany, physics and chemistry, were taught by physicians. We
need only recall Haller and his great teacher Boerhaave, who suc-
cessively occupied the chairs of botany and chemistry, of practical
and theoretic medicine, and attained fame in all these branches.
All this has changed in the course of time; the children have sepa-
rated from their mother and have further developed themselves,
and their development to great sciences has proceeded more rapidly
than that of pathology. The time is not long past when the emanci-
pated looked down on pathology and would not recognize it as an
equal science. Did not Virchow find it necessary, before the congress
of German naturalists, in 1867,1 to insist on the scientific equality
of pathology, and to demand that the so-called exact natural sciences
should recognize pathology as an equal companion.

In fact, as pathology (excepting in purely etiologic studies) cannot
do without physics and chemistry, as she also strives to refer patho-
logic phenomena to physical and chemic laws, so she has given some-
thing to these sciences and even to the present time has furnished
workers which have assured themselves a lasting place in the history
of exact sciences. Is not the mention of the name of the physician,
Robert Mayer, the discoverer of the law of conservation of energy,
and of Helmholtz, who began his professorship in Konigsberg with
lectures on general pathology, sufficient proof? The literature of
Rontgen, radium, and other light-rays shows sufficiently how to this
day pathology takes part in the investigation of physical problems.

These investigations lead to another especially important field,
that of chemistry. Questions which were determined in the chemical
laboratory of my institute, the proof, namely, that by the effect of
radium rays on cancer tissue impediments which stood in the way
of the action of preexisting cytolysins are set aside, are nothing but
chemic questions. Thirteen years ago I stated in a rector's address,2
that only pathologic chemistry on a basis of cellular pathology
could take us further in the study of infectious diseases, that the
chemistry of bacteria, the normal and pathologic chemistry of the
cells, was the problem of the future. This statement can be enlarged
upon; in whatever branch of modern pathology we seek progress,
we finally always meet chemic questions, and it needs no prophet
to tell us that the greatest progress of pathology in the immediate
future will be along the lines of chemistry. In all directions patho-
logists have united with chemists to further the study of the chem-
istry of proteids. Physicians and pathologists have furthered the
knowledge of precipitins, agglutinins, and lysins of various sorts,
not only in their practical but also in their purely scientific relations,
and have begun to study these substances along different lines.

1 Ueber die neueren Fortschritte in der Pathologic, Vortrag in der 2. allgemeinen
Sitzung am 20. September, 1867.

1 U«ber d. Fortschritte der Aetiolofi*, Qottmgen, 4. June, 1891.

RELATION TO OTHER SCIENCES 135

Pathology stands in close relation not only with that group of
physical sciences which treat of life-processes and living organisms
but also with the exact physical sciences. To these also many
bridges lead, over which the connecting links flow in both directions,
pathology giving as well as receiving. A separation of pathology
from the other sciences could therefore only be made by force, for
pathology forms an integral part of the science of life, biology. I do
not consider it just, therefore, that in this Congress, bacteriology,
which draws its greatest importance from that part which belongs
to pathology, which is thus, principally, a part of pathology, has
been placed by itself in Division C, "Physical Sciences" (Natur-
wissenschaft), and pathology in Division E, "Useful or Utilitarian
Sciences." Is bacteriology not an eminently useful science? Has it
not found the most widespread use in medical practice? Have not
other branches of pathology, and especially pathologic anatomy,
been reproached because it has done little for the prevention and
treatment of disease, while bacteriology has done much in this
direction? Yet bacteriology is put under physical sciences and
pathologic anatomy with the rest of pathology among the utilitarian
sciences! On what grounds can we consider human pathology as
a different sort of science from the pathology of plants? If we class
plant pathology with plant morphology and physiology as a part
of biology (as is right), one must do the same for human pathology
and place the biologic sciences in the closest relation with human
anatomy and physiology. Human pathology is as much natural
science and a separate branch of biology as is phytopathology, and
pathology is no more a utilitarian science than normal anatomy and
physiology. Is medical activity conceivable without anatomy and
physiology? As little as without pathology! Has pathology only
importance through its relation to practical medicine? Not at all.
Pathologists also prosecute their scientific studies without regard
as to whether their work will be of immediate practical value or not.
They also follow the inner motive toward knowledge and truth.
They wish to satisfy that desire for increased knowledge which is
in every human breast, to share in disclosing the secrets of nature.
If the acquisitions of pathology have had a greater and more im-
mediate effect on medical treatment than those of anatomy and
physiology, that does not alter its scientific quality in the least;
that they were also useful has never injured other sciences or
lessened their scientific value. No one will value chemic and physical
sciences less because they have been the basis of the wonderful
advance in technic and industry, as displayed to the wondering
eyes in this exposition. Pathology rejoices in its relation to practical
medicine and would neither miss nor lessen it, for as physics and
chemistry constantly receive from practice stimulus to new en-

136 PATHOLOGY

deavorg and progress, so also pathology needs uninterrupted relation
to medical art. But it remains first of all an independent physical
science, which in its three branches, pathologic anatomy, physiology,
and chemistry, stands on an equal plane with normal anatomy and
physiology and physiologic chemistry, with them and etiology
forming the scientific basis for practical medicine.

But as for ages past a certain socialistic or rather humanitarian
spirit has ruled in medicine (and to medicine pathology must always
belong), which effected that with all pride over scientific demonstra-
tions the real and true joy over scientific progress was not reached,
if not only wisdom and knowledge were furthered, but also some-
thing of value has been accomplished for the general good, so it
may also remain in the future. Pathology will be recognized as a
natural science, but it will be its pride and joy also in the future
to be and to remain a utilitarian science.

THE BEHAVIOR OF NATIVE JAPANESE CATTLE IN
REGARD TO TUBERCULOSIS (PERLSUCHT)

BY SHIBASABURO KITASATO

[Shibasaburo Kitasato, Director of the Government Institute for the Study of In-
fectious Diseases, b. December, 1857, Kumamoto, Japan. Imperial Univer-
sity of Tokio, 1882 (Igakushi); Special Course in Koch's Institut fur Infec-
tion, Skrankherten, 1885-92; Igaku-Hokushi (Japan) in 1891; Professor
(Germany), 1892; Decoration of the Third Order of "Rising Sun," 1894; Di-
rector of the Government Institute for the Study of Infectious Diseases, 1899;
Adviser to the Government Sanitary Bureau, 1903. Member of the Japanese
Medical Society (President) ; Japanese Hygiene Society (Vice- President) ; Reale
Societa Italiana d'Igiene (Honorary); Sanitary Institute, London; American
Society of the Tropical Medical (Honorary); Medical Society of Manila; Har-
veian Society of London; New York Academy of Medicine (Honorary); Acad-
emy of Sciences, St. Louis.]

IN Japan it is a fact of common knowledge that the native Japan-
ese cattle are free from tuberculosis (perlsucht) under ordinary
conditions, while imported and mixed types of cattle (that is, such
as descend from foreign cattle on the father's side, from native
cattle on the mother's) contract the disease. This fact would be a
very noteworthy one if we could suppose that our native animals
are naturally insusceptible to tuberculosis, and are not so simply
because they have not had the opportunity to become infected.
As far as I know, no race of cattle is known to us which can prove
ownership to a real natural immunity against tuberculosis. The
claim has been made often enough, but each time the falsity of
the claim could be demonstrated through inoculation experiments.
To determine the position of the native Japanese cattle in regard
to tuberculolsis the following experiments were performed.

Before relating these experiments, however, I would like to
make a few general remarks concerning tuberculosis of the human
race in Japan.

TABLE I. — MORTALITY FROM TUBERCULOSIS IN JAPAN BETWEEN THE YEARS

1892 AND 1901.

Year.

Population.

Total number
of deaths.

Pulmonary
Tuberculosis.

Other
respiratory
diseases.

1892 . .

41,044,739

894 875

57292

109,705

1893

41,399874

930 009

57 798

133,162

1894

41,788335

845 293

52888

98963

1895

42,210,179

854 392

58992

96,531

1896

42 623 931

904 473

62790

105697

18971

43,064.658

875,103

65,597

101,360

18981

43,540,768

891,339

72,708

113,365

1899

43,960,008

920,340

75,226

108,262

1900

44,457,973

910,517

78,972

120,761

1901

44,968,769

932,365

81,669

123,929

138

PATHOLOGY

The relation of the total mortality and
mortality from tuberculosis to the total
population (compared with 1000 inhabit-
ants).

Percentage of tuberculosis
mortality to the total
mortality.

Year

Total
mortality.

Pulmonary
tuberculosis.

Other
respiratory
diseases.

Pulmonary
tuberculosis.

Other

respiratory
diseases.

1892

21.80

1.40

2.67

5.40

12.26

L893 . .

22.46

1.40

2.73

6.21

12.17

L894 . .

20.23

1.27

2.37

6.26

11.71

L895 . .

20.24

1.40

2.29

6.90

11.30

L896 . .

21.22

1.47

2.48

6.94

11.70

L897 . .

20.32

1.52

2.35

7.50

11.58

L898 . .

20.47

1.76

2.37

8.16

12.72

1899 . .

20.94

1.71

2.46

8.17

11.76

L900 ..

20.48

1.78

2.72

8.67

13.26

L901 . .

20.73

1.79

2.76

8.76

13.29

Vverage

20.88

1.55

2.54

7.41

12.19

Mortality from tuberculosis in the eight largest cities, all of them
having more than 100,000 inhabitants, and in the other towns of
Japan during the years 1899 and 1900:

TABLE II.

Place

**

^

b-zi

3=2

-a.23

S3 GQ

-- 23

03 9

1

b •

and
Year.

||

"S'l
l|

Jl

11 .

11

3? =

~ o

•H|

11

|]

- Q

flj -*-3 72

*

^.9

P-i _O

5

•*»

EH!

5

11899

1,468,953

29,274

4,238

343

499

37

5,117

2,812

Tokio . i 19QQ

1,497,675

27,869

4,254

336

458

56

5,104

3,767

«... / 1899

356,956

7,905

1,132

99

168

14

1,413

918

Kioto . 1 190Q

364,673

7,703

1,204

159

176

25

1,564

803

Oa, /1899

835,203

16,407

2,257

175

316

9

2,757

2,002

usafca . | 1900

865,021

15,991

2,431

221

337

17

3,006

2,036

Yoko- /1899

195,364

2,829

278

40

44

00

362

353

liama. \1900

201,036

2,487

401

32

34

3

470

305

Kobe / 1899

225,970

5,360

711

36

88

1

836

590

" ' \1900

240,917

4,808

719

27

74

5

825

642

Naga- /1899

114,144

1,489

196

12

15

1

224

192

saki .11900

125,231

1,804

234

22

34

4

295

189

-. ( 1899

243,767

4,622

543

29

84

3

659

591

rsagoya -^ JQQQ

252,068

4,675

597

19

65

1

682

627

Hiro- f 1899

126,039

1,937

207

3

24

4

238

305

shima . \ 1900

133,732

2,179

256

16

20

2

294

289

TOTAL OF THE EIGHT CITIES.

1899

3,566,394

69,823

9,562

737

1,238

69

11,606

7,66!

1900

3 680 351

67516

10,097

832

1,198

113

12,240

8,65!

JAPANESE CATTLE AND TUBERCULOSIS
ALL OTHER PLACES.

139

1899

40,393,614

862264

46376

2014

7 178

435

56003

105 792

1900

40,777,622

843 228

49 428

2344

7228

531

59531

116613

SUM TOTAL OF ENTIRE JAPAN.

1899

43 960 008

932 087

55 938

2 751

8 416

494

67 609

113 455

1900 . .

44 457 973

910 744

59*525

3 176

8 426

644

71 771

125 271

THE RELATION OP THE TOTAL MORTALITY AND MORTALITY FROM TUBERCULOSIS
TO THE NUMBER OF INHABITANTS (CALCULATED TO 1000 INHABITANTS).

Place

Total
mortality.

Pulmonary
tuberculo-
sis.

Total
tuberculo-
sis.

Other

respiratory
diseases.

Tokio

19 23

286

345

222

Kioto

21 63

3 24

4 13

238

Osaka

19 06

2 76

339

237

Yokohama

1341

1 71

2 10

1 41

Kobe

21.78

3 06

3.56

2.64

Nagasaki

13 76

1 80

2 17

1.59

Nagoya

1875

230

2 70

246

Hiroshima

1564

1 78

205

229

Average of 8 cities . . .
Other towns

18.95
21 01

2.71
1 18

3.29
1 42

2.25

2 74

Average figure

20.84

1.31

1.58

2.71

THE PERCENTAGE OF THE TUBERCULOSIS MORTALITY TO THE TOTAL MORTALITY

Place

Pulmonary
tuberculosis.

Total
tuberculosis.

Other
respiratory
diseases.

Tokio

14.86

17.89

11.51

Kioto

14.97

19.07

11.03

Osaka

14.47

17.79

12.46

Yokohama

12.77

15.65

10.50

Kobe

14.06

16.34

12.12

Nagasaki

13.09

15.76

11.57

Nagoya

12.26

14.42

13.10

Hiroshima

11.25

12.93

14.43

Average of 8 cities .
Other towns

14.31
5.62

17.36
6.77

11.88
13.04

Average figure

6.27

7.56

12.95

, A valuable paper on the statistics of tuberculosis has been written
by Tamaye Ogiya, under the directorship of Professor Sata, from
the pathologic institute at Osaka. This authoress states that dur-
ing a period of three and a half years she has found among 250

140

PATHOLOGY
TABLE III.

Place and
year.

Population.

Total
number of
deaths.

00

DO O

111
fl*J

*»

Total
number of
cattle.

Number
of diseased
cattle.

Perlsucht.

... f ^I

43,815

807

23 ( 2.85%)

5,188

36

1896 |Q

... f M .

44,029

768

18 ( 2.34%)

5,585

16

1897 \0 .

43,357

936

32 ( 3.41%)

5,389

21

1898 JQ

35,026

697

60 ( 8.60%)

1,964

37

, \r

43,370

805

31 ( 3.85%)

5,870

25

1899 \ X"

35,104

704

80 (11 30%)

1,952

115

, ,. _ _ f M

43,821

778

33 ( 4.24%)

5.491

20

1900 JQ

35,346

673

51 ( 7.55%)

2,257

75

te\r\t f M .

44,093

701

48 ( 6.85%)

5,473

32

1901 < Q

35,526

642

39 ( 6.07%)

2,214

67

45,043

762

58 ( 7.61%)

5,109

37

1902 1 Q

35,607

684

42 ( 6.14%)

2,245

31

i *\nn f M

766

62 ( 8.09%)

5,352

25

1903 < X

678

88 (13 00%)

46

M., Mikato; O., Osaka.

TABLE IV.

SIMILAR TABLE FROM THE DISTRICT ABU IN YAMA-GUCHI-KEN
FOR THE YEARS 1901 TO 1903.

Town-
ship.

ij

£

d

o

I

1
ft

Total mortality.

Mortality from
tuberculosis.

Total
number of
cattle.

Number
of diseased
cattle.

Perlsucht.

i

I

"8

X

§

"8
«

a

s

h- 1

0

1
fc

<u

1

T3

•
X

s

"8
•e

a

e

t—(

Sammi •
Udago •!
Fukuga \
Susa ... x
Akiraki -1
Nako

Ogawa •<

Tama- f
saki 1

1901
1902
1903
1901
1902
1903
1901
1902
1903
1901
1902
1903
1901
1902
1903
1901
1902
1903
1901
1902
1903
1901
1902
1903

3,246
3,333
3,262
2,022
2,058
2,015
2,839
2,892
2,901
5,223
5,225
5,292
2,924
2,547
2,603
3,957
3,932
4,058
4,180
4,205
4,247
3,952
3,994
3,851

51
48
73
33
29
43
79
47
71
98
91
106
49
40
39
78
79
54
106
87
86
89
83
95

1 ( 1.96%)
7 (14.58%)
3 ( 4.10%)
1 ( 3.00%)
1 ( 3.44%)

426
436
418
202
203
203
581
511
521
418
414
404
278
257
268
262
262
257
825
734
593
309
267
257

?!

^

}

3

2 ( 4.25%)
2 ( 2.81%)
5 ( 5.10%)
4 ( 4.40%)
4 ( 3.77%)
3 ( 6.10%)
1 ( 2.50%)
1 ( 2.56%)
4 ( 5.12%)
4 ( 5.06%)
1 ( 1-85%)
9 ( 8.49%)
2 ( 2.30%)
6 ( 6.97%)
5 ( 5.61%)
4 ( 4.81%)
4 ( 4.21 %)

3

3

?

3

3

1

12

1

3
2

•\

"9"
25

1

2
2

2

1

?

9

JAPANESE CATTLE AND TUBERCULOSIS

141

autopsies 116 cases of tuberculosis, amounting to 46.4% of the
total. Of the tuberculosis patients, 20 (17.3%) were under 18 years,
96 (82.2%) were more than 18 years; among these patients she
found 90 (77.6%) who presented lesions showing primary pulmonary
tuberculosis, 12 (10.34%) who had primary intestinal tuberculosis.
Among the latter 6 were more and 6 less than 18 years. Basing
the statement upon this paper, it may be said that the occurrence
of primary intestinal tuberculosis is not rare in Japan either among
adults or children, although cow's milk is employed but little by us
for the nourishment of children.

The table on the preceding page refers to districts in which man
suffered from tuberculosis, but his cattle were free from it (the years
considered are from 1896 and 1903); they are the districts Mikata
and Osaka at Tasima in Hiyogo-Ken; these districts possess only
native cattle.

The following table shows the number of cases of tuberculosis
(perlsucht) among the slaughtered cattle found during the years
1901 to 1903 in five large cities :

TABLE V.

Native cattle.

Mixed races.

Imported.

Place.

«w -rt

51

1

W •

|

«£T3

O m

1

a; ^'O

-9-3 a
1»J

0

1

V

ill

S Sf>c8
33O

§

1
B

"•5 ^

-Q^^3

ill

1

£. <S

fc-a

£

£ iS

^•i

M

*

Tokio

72,780

40

5,299

2,293 (43.27%)

4

2 ( 50% )

Tokio

4,416

7 ( 0.16%)

(calves)

Kioto

17,643

1,139

566 (49.69%)

9

9 ( 100% )

Osaka

50,173

2,808

641 (2289%)

41

13 ( 31.7% )

Yokohama . .

30,275

24

4,021

555 (13.85%)

Kobe

38,135

501

159 (31 73%)

Kobe

1,700

(calves)

It must be remembered that for a long time neither Tokio
nor Yokohama have possessed any purely native cattle; it is highly
probable that the tuberculosis animals mentioned in the foregoing
table as native animals belonged in reality to mixed races, inas-
much as we have mixed races which resemble the native animals
so closely that even an experienced veterinary physician cannot
distinguish between them.

The examination of bovines (inclusive of the mixed races and
the imported cattle) for tuberculosis (perlsucht) which has been
carried on in Japan since last September and up to March of this year
through tuberculin injections and other methods of examination,
has given the following results:

142

PATHOLOGY
TABLE VI.

Calculations are made on a basis of 1000 bovines; among them were found the
following number of tuberculous :

Tokio-Fu

377.54

Yamagata-Ken ...

47.45

Kioto-Fu

133.44

Akita-Ken

36.72

Osaka-Fu

57.66

Fukui-Ken

273.98

Kanagawa-Ken

147.89

Ishikawa-Ken

20.19

220.79

Toyama-Ken

91.93

45.72

Toritori-Ken . . .

14.49

Niigata-Ken

26.13

Shimane-Ken

2.94

Saitama-Ken

332.83

Okayama-Ken . .

11 43

Gumma-Ken

298.64

Hiroshima-Ken

36.27

Chiba-Ken

26.18

Yamaguchi-Ken

41.63

Ibaraki-Ken

162.72

Wakayama-Ken ... .

79.79

Tochigi-Ken

187.50

Tokushima-Ken .

39.89

Nara-Ken

209.37

Kagawa-Ken

1.47

Miye-Xen

114.30

Yehime-Ken

10.48

Aichi-Ken

333.47

Koochi-Ken ...

5.30

Shidzuoka-Ken

14.00

Fukuoka-Ken

188.05

Yamanashi-Ken

199.77

Oita-Ken

20.53

Shiga-Ken

169.83

Saga-Ken

75.74

Gifu-Ken

64.62

TCiima.fnntn-TCeT> ... , , ,

60.06

Nagano-Ken

93.08

Miyasaki-Ken

55.21

Miyagi-Ken

97.20

Kagoshima-Ken

24.96

Fukushima-Ken

40.89

Hokkaido-Ken

87.30

Iwate-Ken

6 78

7.15

Average of all

56.71

The following table shows how little cow's milk is partaken of
in Japan:

TABLE VII.

For every 10,000 inhabitants there are milk-cows in

Tokio-Fu

17.50

Akita-Ken

2.64

Kioto-Fu

15.78

Fukui-Ken

4.90

Osaka-Fu

8.21

Ishikawa-Ken

5.05

Kanagawa-Ken

11.81

Toyama-Ken

1.98

Hiyogo-Ken

5.60

Toritori-Ken

1.35

Nagasaki-Ken

5.88

Shimane-Ken

2.96

Niigata-Ken

3.91

Okayama-Ken

3.12

Saitama-Ken

2.82

Hiroshima-Ken

3.05

Gumma-Ken

7-68

Yamaguchi-Ken

5.63

Chiba-Ken

18.50

Wakayama-Ken

4.75

Ibaraki-Ken

1.75

Tokushima-Ken

1.70

Tochigi-Ken

2.70

Kagawa-Ken

2.52

Nara-Ken

2.86

Yehime-Ken

1.42

Miye-Ken

6.49

Koochi-Ken

2.00

Aichi-Ken

5.08

Fukuoka-Ken

3.31-

Shidzuoka-Ken

9.46

Oita-Ken

1.36

Yamanashi-Ken

2.86

Saga-Ken

3.33

Shiga-Ken

5.08

Kumamoto-Ken

2.37

Gifu-Ken

6.37

Miyasaki-Ken

1.84

Nagano-Ken

9.35

Kagoshima-Ken

2.28

Miyagi-Ken

3.78

Okinawa-Ken

1.84

Fukushima-Ken

1.33

Hokkaido-Ken

10.16

Iwate-Ken

1 61

Aomori-Ken . ...

2.05

Average of all

5.65

Yamagata-Ken

4.87

JAPANESE CATTLE AND TUBERCULOSIS 143

One milk-cow furnishes with us in the course of a year a daily
average of five liters of milk. From this follows that in Tokio-Fu
each individual consumes daily 8.85 cm., and in entire Japan 2.825
cm. of milk.

I. Experiments concerning the Susceptibility of Native Bovines to

Imported Perlsucht

Experiment A. On January 22, 1904, we treated altogether 15
native calves of pure race (from three to six months old and having
a body- weight of from 60 to 90 kilograms), which came from a region
where, until now, no foreign cattle had ever been imported, in the
following manner:

Each of seven animals was inoculated with 1 cm. of an emulsion
containing a pure culture of highly virulent perlsucht bacilli ; in two
of the animals the injections were made into the cervical vein, in two
into the abdominal cavity, in two into the trachea, and one was
injected subcutaneously. Each of three calves was permitted to
inhafe 0.5 gm. of living but dried-up bacilli. The remaining five were
each infected with 1 cm. of an emulsion from tuberculous organs, all
of which contained very large numbers of tubercle bacilli; in one
the intravenous route, in two the intraperitoneal, in one the intra-
tracheal, and in one the subcutaneous route was chosen.

As control animals were employed five animals of mixed races.
One of these received an injection of the emulsion of the tuberculous
organs into the cervical vein, three into the abdominal cavity, and
one was permitted to inhale a dried-up pure culture.

Before beginning the experiments, each of the calves was injected
with 0.3 cm. tuberculin, to determine the existence of previous tuber-
culosis, but all were found free of the disease.

Three animals died 24 to 72 days after the experiment; the re-
maining 12 were killed after periods varying from 225 to 363 days.

One calf, which had been given an intraperitoneal injection of an
emulsion of the pure culture of perlsucht bacilli, died as soon as the
twenty-fourth day. At the autopsy it was found that the intra-
peritoneal lymphatic glands were swollen, and that the outer lower
part of the left kidney contained yellowish nodules. The lungs were
markedly hyperemic and contained but little air, but tubercles
could not be demonstrated in any part of them. In the renal nodules
the microscope revealed a small number of tubercle bacilli, which,
when inoculated into the subcutaneous tissues of a guinea-pig, pro-
duced typical symptoms and signs of tuberculosis.

A second animal, which had been injected intravenously with the
emulsion from tuberculous organs, was found dead on the fortieth
day. The lungs contained very large numbers of tuberculous

144 PATHOLOGY

nodules and the glands of the thoracic cavity were swollen to an
enormous size.

The third animal, which had received an injection into the trachea
with the tuberculous emulsion, died after 72 days. The post-mortem
examination revealed both thyroid glands hyperemic and swollen;
at the point of injection the trachea was the seat of a mass the size of
a pigeon's egg; the surface of this mass was covered with cothitless
miliary tubercles. The lungs contained similar miliary nodules, and
the right lung was even adherent to the pleura. The mesenteric
glands were normal.

The remaining 12 calves were killed; three of them were more or
less tuberculous. The one which had inhaled 0.5 gm. pulverized
tubercle bacilli was killed after 259 days; the tuberculin reaction
before its death gave a doubtful result. The autopsy showed the
presence of a few very small nodules in the laryngeal mucous mem-
brane and of one nodule in the anterior wall of the left cardiac
chamber; this last one contained very many tubercle bacilli.

The second animal had been injected with 1 cm. of the emulsion
from the tuberculous organs; it was killed after 256 days. The tuber-
culin reaction was positive before its death. The post-mortem exam-
ination showed the inguinal glands in the neighborhood of the point
of injection very much swollen; the liver contained a few nodules;
all the intraperitoneal glands were swollen, and some of them were
already the seat of cheesy degeneration. The lungs were normal.

The third heifer had received an injection of 1 cm. of the emulsion
from a tuberculous lung into its abdominal cavity ; it was killed after
280 days. The tuberculin reaction before its death had also been
positive. The section revealed the peritoneum and liver to be the
seat of a small number of tubercles varying in size from a pea to
a small bean; some of them were cheesy. Both lungs were studded
with numerous grayish-white, hard miliary nodes.

The other nine animals were found to be entirely free from tuber-
culosis.

The five control animals were killed after from 217 to 364 days.
The autopsy showed four of them to be suffering from tuberculosis
and one to be free from it.

If the above-mentioned results are considered collectively it will
be seen that from among 15 experimental animals six became tuber-
culous, while nine were demonstrated to be insusceptible. It is
further worthy of note that the changes in the infected organs were
relatively very slight.

From a review of the entire experiment it can be seen that the
native Japanese bovines are to some extent susceptible to perlsucht
experimentally, but only if doses of tubercle bacilli are inoculated
so large as never to be received in the course of a natural infection.

JAPANESE CATTLE AND TUBERCULOSIS 145

We can conclude from this that our native cattle show so little sus-
ceptibility to perlsucht that natural infection appears almost im-
possible.

Experiment B. The same experiment was repeated on May 27
of this year; this time 33 native calves from 3 to 8 months old, and
weighing from 40 kilograms to 90 kilograms were employed. The
method of the experiment was exactly the same as in Experiment A.
To obviate too frequent repetitions these experiments will be
reported only briefly.

Fifteen of the animals were infected intravenously; in 10 pure
cultures of perlsucht bacilli were employed, and in 5 the emulsion
from tuberculous organs; 8 were infected intraperitoneally (5 with
pure cultures and 3 with emulsion from organs); 3 were treated
with inhalations of pure cultures, while the last seven were infected
subcutaneously (5 with pure cultures, 2 with organ emulsions).

Four mixed race animals were employed as control; in two of
them the injections were made intravenously (one with pure cultures
and one with organ emulsion); in the other two intraperitoneal
injections were given (one with pure culture and one with organ
emulsion).

Before the experiment all of the animals were injected with tu-
berculin ; in none of them was a positive reaction obtained.

Of the 33 animals, 7 perished in from five to 63 days after the
inoculation with the perlsucht bacilli, from a number of different
causes. Five of these animals showed some traces of the disease; the
other two were entirely free from it.

The remainder of the 33 calves are still alive (August 10, 1904),
and apparently in the best of health.

II. Experiments concerning the Susceptibility of Native Bovines and
of the Mixed Races to Human Tuberculosis

The experiments were performed on 14 calves, of which 6 were
Japanese, and 8 belonged to the mixed types. Eight of them were
treated with pure cultures; 2 of them were given intravenous, 3
intraperitoneal, and 1 intratracheal injections; 2 were given in-
halations; the other 6 were treated with an emulsion made of the
organs of a man, whose death was due to miliary tuberculosis; the
organs contained numerous fresh tubercle bacilli; 3 were infected
intravenously, and 3 intraperitoneally.

The tuberculin reaction before the experiment was negative in
all the instances.

Two of the native animals, having had pure cultures injected
into the cervical vein, died after 30 days and 56 days. One of them
developed high fever eight days after the injection, this persisting

146 PATHOLOGY

for some time; the animal died on the thirtieth day, with symp-
toms of general debility. The autopsy showed the apices of both
lungs dark red, and moderate swelling of some of the glands of the
thoracic cavity. The mucous membranes of the pharynx and larynx
were inflamed ; the neighborhood of the vocal cord was covered with
mucus in which a small number of tubercle bacilli could be de-
monstrated.

The second animal developed considerable fever about the tenth
day, which also lasted for a long time. After 40 days, conjunct-
ivitis appeared in both eyes, this gradually becoming so violent as
to destroy vision entirely; death resulted on the fifty-sixth day
after the injection, and as in the case of the first animal, seemed
to be due to weakness. The organs of the thorax and abdomen
were found normal, excepting that the left lung contained a very
small pea-sized tubercle, in which a few tubercle bacilli were de-
monstrable. None of the other organs contained anything abnormal.

In neither of these cases are we permitted to speak of infection,
as in the first place, the duration of illness was too short, and in
the second place, the tuberculous lesions so slight that they could
be found only with difficulty, and it goes without saying that in
the short time having elapsed between injection and death the
tubercle bacilli introduced into the organism could still have been
alive.

The rest of the calves, 12 in number, were killed after from 101
days to 327 days, but in no instance could a trace of tuberculosis
be found.

The number of calves and heifers used for these experiments was
altogether 71; of these 52 were purely native animals and 19 had
descended from mixed races.

The tubercle bacilli from the pure cultures as well as from the
tuberculous organs before being utilized for the experiments, had
been inoculated into guinea-pigs to note whether or not their viru-
lence was great enough. All of the guinea-pigs perished after the
usual lapse of time of typical tuberculosis.

From the results mentioned, the following conclusions can be
drawn :

(1) Human tuberculosis is as frequent in Japan as in the civil-
ized countries of Europe and America.

(2) Primary intestinal tuberculosis is relatively common in adults
and children, although cow's milk plays no r61e at all in the feeding
of children.

(3) There are large districts in Japan, where, in spite of the
existence of human tuberculosis, the cattle remain absolutely free
from the disease. In these regions it is not customary to consume
either meat or milk from bovines.

JAPANESE CATTLE AND TUBERCULOSIS 147

(4) This is very important proof for the fact that under ordinary
conditions human tuberculosis is not infectious for bovines, as the
opportunities for infection certainly cannot be lacking.

(5) Among Japanese in general very little cow's milk is used
and especially is it employed but little for the dietary of children.

(6) Under natural conditions the native animals show but very
little susceptibility for perlsucht. If large doses of perlsucht bacilli
are inoculated into them either intravenously or intraperitoneally,
they become tuberculous to a certain degree; they do not seem to be
at all susceptible to subcutaneous infection.

1 (7) The imported and mixed race animals are very susceptible
to perlsucht.

(8) Human tuberculosis is not infectious for native and mixed
race animals.

Before concluding I would like to say a few words concerning
the two opposing opinions of Koch and von Behring. As is well
known, Koch, at the congress in July, 1901, at London, made the
statement that human tuberculosis is absolutely different from
bovine tuberculosis, a conclusion which he had come to after two
years of experimentation on young heifers. Von Behring took
issue with this statement at the Congress of Natural Scientists,
at Kassel, in September of last year. Von Behring believes that
the milk taken by nurslings (cow's milk) is the chief source for the
development of tuberculosis. He also stated that human tuber-
culosis is identical with that of bovines.

The fact has already been mentioned that primary intestinal
tuberculosis is quite frequent in Japan, even though the natives
drink but very little cow's milk, and even though they employ it
but very little for the nourishing of their children; if the mother's
milk does not suffice, a wet nurse is instantly taken into the house.
This clearly proves that human tuberculosis in Japan can only be
transmitted from man to man. And from the fact that native
Japanese cattle are free from tuberculosis, and also are so little
susceptible to it as to make it almost impossible for natural in-
fection to take place, we can conclude that bovine tuberculosis
was imported into Japan only after the introduction 'of foreign
cattle. These importations, however, began only about 30 years
ago, while human tuberculosis has existed in Japan as long as we
have chronicles. Of especial deciding importance for the statement
that human tuberculosis is different from that of bovines is the
following: If this were not the case, it would be impossible to find
districts in which bovines are entirely free from tuberculosis, in
spite of their close connection with tuberculous human beings, and
who are constantly giving the domestic animals the opportunity
to infect themselves.

148 PATHOLOGY

On account of these reasons it is impossible to trace the tuber-
culous infection of man back to cow's milk respecting bovine tuber-
culosis, and therefore I must subscribe to the opinion of Koch and
say that the danger of the conveyance of tuberculosis from man
to man occupies first place. Concerning the views of von Behring
in relation to the mode of infection, I must confess that by us in
Japan the milk fed to nursing infants (cow's milk) cannot play a
role in the contraction of tuberculosis.

SHORT PAPERS

DR. CARLOS T. FINLAY, Sanitary Chief of the Cuban Government, presented
an interesting paper to this Section on "The Leucocytes," with suggestions as
to the role that may be assigned to them in connection with cell nutrition and
immunization.

DR. GEORGE COROMILAS, of Athens, Greece, presented a paper to this Section
upon the healing properties of sulfite of carbon, particularly in chronic maladies
of the lungs, and the treatment of tuberculosis.

PROFESSOR TESSIER, of the University of Lyons, France, presented a paper to
this Section on "Some New Studies of the Pathology, Diagnosis, and Special
Complications of the Abdominal Aorta."

SECTION D
THERAPEUTICS AND PHARMACOLOGY

SECTION D
THERAPEUTICS AND PHARMACOLOGY

(Hall 13, September 24, 3 p. m.)

CHAIRMAN: DR. HOBART A. HARE, Jefferson Medical College.
SPEAKERS: PROFESSOR OSCAR LIEBREICH, University of Berlin.

SIR LAUDER BRUNTON, F. R. S., London ; D.C.L. Oxon.
SECRETARY: DR. H. B. FAVILL, Chicago, 111.

THE RELATION OF THERAPEUTICS TO OTHER SCIENCES
IN THE NINETEENTH CENTURY

BY OSCAR LIEBREICH

[Oscar Liebreich, Director of Pharmacological Institute, University of Berlin,
since 1872. b. Konigsberg, Germany, 1839. Studied Chemistry under Fresi-
nius in Wiesbaden; studied' Medicine in Konigsberg, Tubingen, and Berlin;
Assistant in Medicine, University of Berlin, 1867-68; Professor of -Therapeu-
tics, ibid. 1868-72. Editor of Therapeutic Monthly; Encyclopedia of Thera-
peutics; Kompendium der Arzneiverordung.]

EVERY political historian will prefer to trace the development of a
period of history from one distinct event. A chronological introduc-
tion cannot be of such importance to him as an historical survey, in
which events of great moment form the basis of a new development.

What is true of political evolution applies also to the growth of
every branch of natural science and medicine. The first year of a
century, though filling men with joyful confidence and new hopes,
has not the same attraction for the investigator; and yet, in order
to obtain a general view of the growth of the different branches, it is
desirable not to lose sight of this idea, but to consider all the stages
of progress in common from a certain point of time, and thus the
study of the history of therapeutics must also be subordinated to
this aim.

Although the evolution of the nineteenth century has frequently
been threatened by heavy political clouds, we have seen them often
pierced by the sun of progressive science, which, especially in that
century, has called forth a fertility of culture such as has scarcely
been witnessed in an y previous period of one hundred years. The
past century more than any other has been distinguished by the
multitude of newly discovered facts in natural science, as well as by
the perfection and extension of the ideas of great discoverers of the
previous century.

154 THERAPEUTICS AND PHARMACOLOGY

It is the age in which the greatest progress in natural science has
been made. The vast numbers of new discoveries in medicine have
lessened, or even almost suppressed, on the part of many persons,
the feelings of admiration for each new acquisition.

The new phenomena and experiences which confront us on all
sides surpass the wildest dreams described in former centuries as the
eccentricities of fanciful minds. The abundance of material compels
our admiration and allows the astonished eye no time to gaze long
at one occurrence, for new impressions already crowd it out.

The nineteenth century has spoiled us; our demands for new
acquisitions increase, and we grow impatient to know more. In this
unsettled state the laborious work of the individual often seems
lost, but the true scholar is buoyed up by the gratifying knowledge
that mighty buildings can only be constructed of a mosaic made up
of single stones. Yet, truly, humanity often settles down in a new
building without admiring either the work of the architect or his
material.

Moreover, the capability of enjoying nature and whatever we have
added to our knowledge of the universe by laborious experiments
does not appear to be a natural gift of man. Only education and
culture can awaken the enjoyment of what is and of what is about
to be. Mighty natural phenomena, indeed, fill the casual onlooker
with admiration, but the observation of what is harmonious in
nature, and the capacity of assimilating it for our own culture, can
be gained only through education. This also holds good of art, and
it is even more difficult in science. Since the uneducated majority
is often inclined to pass by the greatest events with indifference, the
nineteenth century has spared no pains to inform humanity of all
the great innovations, to educate them, and thus to gain friends
for the progress of civilization. This, indeed, is the object of your
Congress.

There are various ways in which therapeutics (and it is here
chiefly a question of pharmacodynamic therapeutics, that is such
as concerns itself not with mechanical means but with chemical-
physical processes) may develop.

New knowledge of the conditions of life of the organism often lead
to remarkable discoveries in therapeutics. Thus physiology, es-
pecially the functions of the different organs, is of the highest
importance for the progress of therapeutics.

A striking example of this is furnished by digitalis. Originally
this plant was simply a popular remedy, which, like many substances
in use among the people, proved efficacious in the case of many
diseases, while, of course, of no avail in others.

When William Withering, in 1785, undertook a careful examin-
ation of digitalis, it was used for phthisis, dropsy, and scrofula, it is

THE RELATIONS OF THERAPEUTICS 155

true, and its power of slowing the pulse was known, but was not
utilized therapeutically. A proof of how little significance was
attached to these purely clinical experiments may be found in the
changes as to the admission of digitalis to the London Pharmacopeia.
In the year 1721 it was included; in 1746 rejected, and not reac-
cepted until 1778.

Now in the year 1846, Weber made the surprising discovery that
the vagus nerve has an inhibitory influence upon the heart, i. e.,
that exciting this nerve causes slower pulsation, and that cutting it
occasions extreme acceleration of the action of the heart. This
decisive experiment formed the basis of Traube's clinical investiga-
tions, and he was able to prove that the effect of digitalis on the
heart corresponded to the excitation or section of the vagus nerve.
This fact has been utilized clinically in diseases of the heart, arterio-
sclerosis, and dropsy, — and now upon a firm basis, — so that digi-
talis has emerged from its former position of uncertainty and taken
a place among the efficient and reliable remedies, and we can safely
say that it will not again disappear from the pharmacopeia, at any
rate not owing to any uncertainty as to its effect.

Such investigations have now been undertaken with a number of
other preparations, and on a large scale, such as, for instance, the
clinical researches of Sir Lauder Brunton on"casca" (erythrophleum)
and of Sir J. T. Fraser on Strophanthus hispidus, a plant similar to
digitalis, but differing in its effect on the vaso-motor system, and
which was also soon adopted in therapeutics. Much the same may
be said of atropine, which chiefly through the knowledge of its phys-
iological effect on the iris, on the non-striated muscular system and
the glandular secretions, affords us an exact indication of its scope
of utility in disease.

Thus we have here a source of fresh observations. Often the
functions of the organism are affected in an isolated manner that
we should scarcely have thought possible, for instance, by yohimbin.

This physiological method is applicable to all chemical bodies,
and the progress in our knowledge of curative powers depends
solely on the progress of experimental physiology.

The physiological action, however, does not always remain within
the limits of what is normal, for it may sometimes become patho-
logical. This was remarked by various scientists as early as the
middle of the eighteenth century, and shortly before the beginning
of the nineteenth century (1799) A. Fr. Hecker expressed this view
in his Physiologic, Pathologica, i. e., in " the theory of the composi-
tion and functions of the human body and its different parts in
an abnormal condition."

How differently we may view physiologically active bodies can
best be seen in the blood. But here, too, we observe that a rational

156 THERAPEUTICS AND PHARMACOLOGY

system of therapeutics only became possible in the nineteenth
century after a knowledge of the physiological effects had been
gained. Berzelius was the first to recognize the presence of iron in
the blood. The discovery of a ferruginous coloring-matter of the
blood, hemoglobin, did not follow until much later. It is true that
in 1854 Wohler declared globulin and hernatin to be contained in
the blood corpuscles. But Funke (1852) and Lehmann (1853) had
already established the fact that the coloring-matter of the blood,
hemoglobin, is a distinct crystallizable substance which is capable
of absorbing and giving off oxygen. Hemoglobin, we may say, is,
to a certain extent, the quintessence of the respiratory activity.
This function may be destroyed by inhaling carbonic oxide which
enters into so close a combination with the coloring-matter of the
blood that its respiratory function ceases. Thus blood in such a state
is a menace to life which cannot be obviated by any drug, but we are
able since the respiratory function of the blood has been understood
to avert this danger in most cases by removing the poisoned blood
and transfusing fresh blood.

The greatest hopes for the further development of therapeutics
are raised by the fact that chemical substances are capable of
restoring pathologico-physiological processes to a normal state.
Here we may cite the antipyretics, which are able in the most striking
manner to reduce to the normal state a rise of temperature, that is,
a febrile phenomenon.

The drugs just mentioned are therefore of great importance in
therapeutics as symptomatic remedies. Of course, they are in no
way able to destroy the cause of disease, but merely alleviate or
avert injurious symptoms. For the physician, however, this very
quality is of paramount importance in the majority of cases. The
cause of disease may disappear through the spontaneous healing
process of the organism, while the symptoms are removed, which,
had they been left alone, would inevitably have led to the death of
the patient. Yes, we may say that it is one of the greatest aims of
therapeutics to treat disease symptomatically, for we must endeavor
to ease the sufferings of humanity, and the great advantage of this
method of healing becomes specially evident when the cause of
sickness cannot be destroyed by any remedy hitherto known. This
may best be demonstrated in the treatment of poisoning. If, for
instance, through a mistake, or for any other reason, a deadly dose
of strychnine enter the system, the sufferer will expire under the
symptoms of suffocation, caused by the convulsive contraction of the
respiratory muscles. As, however, we are enabled to arrest this
spasmodic contraction by means of chloroform, chloral hydrate,
and other drugs, we can thus give the system time to eliminate the
strychnine causing the illness. This being entirely thrown off, the

THE RELATIONS OF THERAPEUTICS 157

morbid phenomena also disappear, and complete recovery soon
ensues. It is possible, though as yet unknown, that purely symp-
tomatic remedies may also influence the cause of disease.

At the beginning of the nineteenth century, chemistry was still of
little service to the science of medicine. True, Lavoisier's greatest
discovery in regard to metabolism in the organism was known, that
is, that the oxygen of the air causes combustion, and when inhaled
accomplishes the same object in the system. This must have given
medical men an entirely new perception of the processes of life, but
the time had not yet arrived for experimental work on this subject.

Even at that time numerous elements were known, 30 in number,
whereas at the end of the century 76 elements had been found. A
number of these elements were made use of in therapeutics in a pure
state or in combination, without our being able to base their appli-
cation upon rational, theoretical hypotheses, as, for instance, in the
case of iron and its compounds, the use of which extends to the
remotest times. On the other hand, there were among them ele-
ments employed as drugs, such as antimony, which first came into
use in the Middle Ages, and which may be cited less as a proof of
the therapeutic value of this matalloid than of the antiquated preju-
dice of a French faculty which absolutely refused to acknowledge
any "drug," owing to its predilection for blood-letting. The rage
of dogmatic physicians may be recognized in the words of the
anathema against Torpet (cf. O. Liebreich, Die historische Entwick-
lung der Heilmittellehre, Lecture, Berlin, 1887).

On the other hand, the science of therapeutics placed great hopes
in the isolation of alkaloids, which marked the beginning of the
century. This era began with the recognition of the importance of
morphia by Sertiirner in the year 1804. Then followed the discovery
of nicotine by Vauquelin in 1809, quinine in 1811, cinchonine in
1820, and of strychnine in 1818. This, at any rate, suggested the
method of obtaining from extracts, frequently incumbered by
useless matters, the active principle, and making it available for
therapeutics, and hence a certain practical utility must even nowa-
days be accorded to pharmaceutical chemistry.

As regards a knowledge of the mode of action, however, the pro-
blem not only lies in the chemical composition and recognition of the
substance employed, but also in the chemism of the organism. Out-
side the organism it is a lifeless substance, but in the system it is not
only the substance itself but its metabolism and manner of action
which must be taken into consideration. The theory of metabolism
can only be of decisive value for therapeutics when not only the
properties of the drug applied but also the chemical action of the
organism are so far known as to enable us to judge of their mutual
effect. For this reason, of course, a knowledge of the chemistry of

158 THERAPEUTICS AND PHARMACOLOGY

the human system is of the greatest importance. Just a year previous
to the beginning of the nineteenth century the urea which appears
in well-formed crystals in the human organism was discovered by
Fourcroy and Vauquelin. This fact, certainly, did not appear so
strange, since crystalline matters had already been obtained from
plants, but even in the beginning of the century the idea was still
firmly rooted in the mind of the naturalist that these substances
could only appear as the products of vital energy. This presented
itself to the minds of men of that time as an entirely distinct force,
which, independent of physical and chemical laws, manifested itself
in a characteristic form in the organism. There is no discovery
which has so often been quoted in the interest of the medical and
other biological sciences as the observations of the chemist Wohler
who, in 1828, observed the formation of urea in a substance obtained
outside of the system, namely, ammonium cyanide, by the trans-
position of atoms. But if we rightly consider this grand discovery,
which completely refuted the followers of the theory of vital energy,
it would still, perhaps, be possible, in spite of this discovery, to
undertake the defense of the theory of vital energy as something
beyond the laws of natural science, for neither Wohler's synthesis
nor the manner of formation of urea from carbonyl chloride and
ammonia, or from ethyl carbonate and ammonia, or from cyanamide
by hydration, or from ammonium carbonate, as well as from leucine
and from other substances of the organism, gives any actual expl.ana-
tion of the formation of urea in the system. The synthetic product
is identical with the product of the organism, but the synthesis,
or rather the formation of urea in the body takes place in accord-
ance with laws, the exact nature of which we do not fully know even
at the present day. This is, indeed, the case with a large number of
other substances derived from animals or plants. Although the
chemical constitution of substances was constantly more and more
exactly defined in the course of the nineteenth century, the manner
of formation in the organism still remains hidden from us. We
frequently find it stated that we must not simply compare the pro-
cesses of the organism to the test-tube experiment of the chemist.
There is no doubt that processes of metabolism take place within the
body for which the synthesis performed outside of the organism
gives no explanation. From my somewhat dissentient attitude in
regard to the conclusions drawn from Wohler's experiment, I might
for a moment be thought to favor the view that the activity of the
organism in the form of vital energy is beyond the laws of natural
science, but that is not the case. Even if in synthetic experiments
other means are employed than are available within the organism,
the supposition is justified by the possibility of synthesis, that the
organic processes occur in accordance with purely physical and

THE RELATIONS OF THERAPEUTICS 159

chemical laws, but that other conditions not present in test-tube
experiments also play a part.

Here we must turn for a new mode of thought to Schwann's
magnificent discovery of the animal cell. Through it the anatomical
conception of the organism was placed upon an entirely different
basis. As human tissues consist of cells, and the entire development
of man results through cell activity, this must naturally lead us to
assume that the purely chemical part of human existence takes
place in as many cells as the individual possesses. That which in
chemistry we describe as a reaction must, if we leave out of the ques-
tion the chemical processes in the digestive tract, take place in small
separate spaces, such as the chemist never employs for his experi-
ments. The chemist does not usually assume that reactions occurring
in such exceedingly restricted spaces differ from those which take
place in the vessels used for his operations. It will be the task of the
biologist to investigate whether this chemical action in the cells
undergoes any modification through limitation of space.

I have been able to prove in the course of investigations on the
"dead space in chemical reactions outside the organism" that power-
ful phenomena of friction take place here. This could not be de-
finitely proven experimentally in the case of all reactions, but some-
times it could be shown that if the space inclosing the fluid be
diminished, the reactions in comparison with those which occur in
larger spaces are retarded if not completely arrested. The objection
might be raised that in these experiments the retardation or arrest
of reaction was generally due to the nearness of solid walls, but it
was observed that the same phenomenon is noticed when the bound-
ary of the fluid is only formed by surface tension, for the tense
surface behaves like a firm elastic membrane toward the fluid, as is
the case with many cells. The results showed that whenever the
friction of the liquid increased, the chemical reaction was retarded.
This hindrance of the reaction in small spaces, which differs in the
case of different reactions, naturally permits the conclusion that,
contrary to what happens in large spaces, in small ones entirely
different reactions will result. Of course, this observation can only
serve as the initial proof that the chemical action in the cells is unlike
that which occurs in test-tube experiments. We see that here also
the argument for the acceptance of the theory of vital energy which
I pointed out to you as possible, is refuted.

As regards drugs and their absorption these chemical processes
probably play an important part, for we observe that reactions
occurring outside of the organisms do not take place within it, and
on the other hand, combinations arise which are difficult to produce
externally. Here we may mention, by way of illustration, the facility
of decomposition of common salt into hydrochloric acid and alkali.

160 THERAPEUTICS AND PHARMACOLOGY

Moreover, I should like to remind you that, for example, in the
toxicological processes in poisoning with carbolic acid we were
entirely unable to foresee that the sulphuric acid of the organism
forms with the carbolic acid a complex sulphuric acid, which, being
non-poisonous, arrests the toxic effects of the carbolic acid.

Starting from this consideration, it does not appear strange that
a number of substances which, even when much diluted, have a
destructive effect on bacteria, manifest when taken up into the
system no trace of disinfecting power, such as, for instance, phenol
itself and corrosive sublimate in cases of anthrax.

The simplest example that the discovery of the cause of disease
is by no means decisive in therapeutics may be seen in the develop-
ment of the trichina. It is a humiliating fact that we are entirely
powerless against this enemy. Even the female trichinae developing
in the intestine after the consumption of meat infected with these
parasites cannot be made innocuous by any known anthelmintic,
and we are not even able to expel these intestinal trichinae by means
of purgatives. The embryos wander irrevocably into the muscular
tissues to destroy the organism, or by encapsulation remain per-
manently in the man or animal. Even in this process of calcification
of the trichinae we are quite powerless to intervene.

The nineteenth century has been distinguished by the discovery
of the causes of disease. But this does not give us means of "curing/'
As the history of therapeutics, however, shows that in the case of
serious maladies, such as syphilis and malaria, the remedies have
been found long before the recognition of their cause, we must con-
tinue to search for remedies independently of the causes of disease.
So far the knowledge of morbific agents has been more important
for prevention than for cure.

On the other hand, remedies like iodoform are entirely ineffective
on bacteria outside the system, whereas after the entrance of this
substance into the cells an energetic force is opposed to the invaders.
As in every observation we must be careful not to draw too far-
reaching conclusions, because the possibility of reactions taking
place outside of the organism may also hold good within it, as, for
instance, in the treatment of lead-poisoning. Therapeutics, thanks
to Melsens, celebrated a great triumph here, for the iodine of the
iodide of potassium administered in this disease combines with
the lead united to the albumen molecules, forming iodide of lead,
and can then leave the body dissolved in the alkaline juices of the
organism, and thus bring about a cure.

It may be said, in passing, that in the case of many active sub-
stances specific chemical processes take place as are, for instance,
seen, in phosphorus poisoning. Phosphorus, though usually so
easily oxidized, when absorbed, is not oxidized quickly enough by

THE RELATIONS OF THERAPEUTICS 161

the oxygen of the cells; in the presence of turpentine oil, however,
a transference of the oxygen occurs, and the phosphorus is more
rapidly oxidized, combines with the oil of turpentine, and, as we
must assume, forms turpentine-phosphoric acid, which is innocuous
to the system. By the ingestion of oil of turpentine the organism
can thus overcome the cause of illness.

Unfortunately we do not possess similar remedies for some other
toxic morbific agents which are taken up by the cell.

Since for the progress of therapeutics it is necessary to consider
the chemical and physical qualities of the body, therapeutics is
naturally dependent upon progress in chemistry. Although, as has
already been shown, pharmaceutical chemistry can be utilized for the
benefit of medicine, the results of theoretical chemistry have not as
yet become of much distinct importance for therapeutics. In the
first half of the nineteenth century distinguished chemists occupied
themselves with the laws of matter independent of biological pro-
cesses. Various chemical and physical theories followed each other,
and the theories propounded by Dumas, Gerhard, Williamson, and
Kekule" eventually developed into van 't Hoff's stereochemistry, and
in the physio-chemical researches. But these discoveries, though
made outside the limits of biology, came to be of great importance
to medicine when medical chemistry, fostered both by chemists and
physicians, began its growth.

In the beginning of the century theoretical views in regard to
drugs had to contend in part with the philosophical tendencies of
those times, in part with the ill success which formerly attended the
iatro-chemical and physio-chemical schools of physicians. Progress
in the application of therapeutical measures was left to pure empir-
icism, and the view was accepted that what applied to food would
also do for medicine; for we became acquainted with the use of
coffee, tea, chocolate, potatoes, etc., not through theory, but simply
through empiricism. This standpoint could be justified all the more
because. many important remedies, such as quinine, arsenic, and
Peruvian balsam (which last substance has almost led to the dis-
appearance of a contagious disease similar to leprosy in its terrible
forms) became available to humanity purely through empiricism
and not as the result of scientific investigations. Similarly, balneo-
therapy is of empiric origin; only recently, owing to the physio-
logical researches of Winternitz and others and the application of
physical chemistry, has it assumed the dignity of a separate branch
of science. In consequence of a false point of view and empiricism
the creative ideas of a Paracelsus were forgotten.

The progress in the chemistry of organic substances offered an
opportunity to combine chemical and medical research, especially
in the province of therapeutics.

162 THERAPEUTICS AND PHARMACOLOGY

I myself have had the pleasure of seeing that by this cooperation
of medicine with organic chemistry an impulse has been given to
therapeutics, which, in spite of a certain opposition, cannot again
disappear from the sphere of research, an opinion which was held
and expressed on the part of chemistry by the late A. W. von Hoff-
mann.

A good example is furnished by chloral, a drug formerly belonging
to the chemical rarities, because Liebig's method of production
provided no means of obtaining sufficient quantities for experi-
mental medical research. This body was known as a chemical sub-
stance as early as 1832; but its intrinsic, therapeutic value was not
discovered until the year 1868. It is in America more than anywhere
else that these investigations have received the fullest appreciation.
The use of chloral hydrate was based upon the idea that when taken
up into the blood a splitting-off of chloroform takes place, as is
the case outside the organism in the presence of all alkalies. This
point has been the subject of much controversy. There can be
absolutely no doubt that whenever chloral has had no soporific
effect, a considerable quantity of urochloralic acid can be found
in the urine, which must be traced back to the chloral. It is
equally certain, however, that small quantities of urochloralic acid
always are to be found in the urine after the administration of
chloral. But it is just as true that the main therapeutic effect de-
pends on the formation of chloroform. Only those who consider
these principles will, as is shown by clinical experience, be able
to observe chloral in the full unfolding of its effect. Shortly after
its effect had become known the Glasgow clinician, Russel, proved
that in conditions of excitement in typhoid fever, owing to the
marked increase of the alkalinity of the tissues, small doses of
chloral hydrate through their decomposition manifest the same
effect as that produced only by large doses in similar conditions in
other diseases. On the other hand, in gout the opposite happens.
Even large doses do not produce the desired effect, since .alkali is
lacking for the decomposition.

But we cannot judge of all organic bodies from the standpoint
of decomposition. Many take up substances from the organism, and
since the discovery that benzoic acid becomes hippuric acid, and
salicylic acid changes to salicyluric acid, it has been proved that the
opposite of decomposition takes place with a number of drugs.
Furthermore, it does not seem impossible that many substances
unite with the disease-products formed in the organism. This hypo-
thesis may be supported by the fact that the system itself produces
an acid, such as glycuronic acid, which carries off foreign substances
from the organism, such as camphor, phenol, etc., in the form of
a double combination.

THE RELATIONS OF THERAPEUTICS 163

Since the time that chloral came into use, organic bodies have been
particularly investigated. Owing to the tremendous amount of
material, there has been a tendency to place reliance upon the chem-
ical composition in making a choice, and it has been assumed that
the chemical constitution stands in a certain relation to the action
of a drug. Many experiments have been made in this direction. We
do not wish to deny that such an influence occasionally exists ; at any
rate, we see that when the action of a given substance is known,
changes in the molecule will produce a difference in action, and that
by the introduction of certain groups certain definite changes in the
effect may be expected. Among this group of bodies is antipyrin, in
which changes in the side-chains leave the nature of the effect
pretty much the same, even though new therapeutic advantages are
obtained, as is best seen in pyramidon. A similar example is offered
by veronal, lately suggested by E. Fischer as a soporific.

But it is as yet impossible to predict the effect of a chemical body
from its constitution, unless a decomposition product of known
action is formed, as in the case of chloral hydrate, or unless an active
and well-known nucleus forms the basis of the substance. There are,
of course, examples which point to the connection between consti-
tution and effect, such as the difference between the action of bi-
and trichlorinated aliphatic combinations. The trichlorinated bodies
have a lethal influence on the heart; the bichlorinated bodies, such
as chloride of ethyliden, only on the medulla oblongata. If tri-
chlorinated butylaldehyde (butylchloral) be administered to an
animal only an effect on the medulla oblongata is produced, in spite
of the triple chlorination. The reason of this is that allylchloroform
is formed in the organism, which, not being stable, splits up into
dichlorallylen, which is a bichlorinated body.

Owing to the progress in chemistry medical science has been
enabled to determine the relation which certain new drugs, by
reason of their composition, bear to other established remedies of
known constitution. This has been demonstrated by Gaetano Vinci
in eucain, whose composition is analogous to that of cocain. Eucain
is a drug which is truly fitted to replace cocain on account of its
slighter poisonous nature, especially in the form of its lactic acid
salt.

It has frequently been assumed that certain atomic groups in
the molecule are the bearers of a special action, and that accord-
ingly the bodies of a chemical series must exhibit a similar effect.
That is, however, by no means the case, for even formic acid and
acetic acid manifest markedly different biological properties. In
alcohols the theory is founded on the presence of a certain chemical
group, which is spoken of as the alcohol group. But we see this
group appearing threefold in glycerine, and yet no physiological

164 THERAPEUTICS AND PHARMACOLOGY

connection between the effect of common alcohol and of glycerine
can be established.

In general we must confess, however, that we cannot as yet
speak of a relation between constitution and effect, because what
we call effect must be regarded as an influence on the different
functions. Even if we consider the apparently simple mechan-
ism of sleep, we must remember that it may be induced by an in-
fluence on the brain, or equally well by an action on the peri-
phery. We cannot here enter into a physiological analysis of the
processes taking place in the organism, but, as the above example
shows, the most diverse parts of the system may be affected, so as
to produce a similar result. Moreover, the different hypnotics,
although fulfilling the same purpose, have an entirely different
composition. On the other hand, when investigating the action
of chemical substances we may always expect new results to be-
come manifest by chance, for when Baumann was studying the
effects of sulfonal it had never occurred to him that this body might
possess soporific powers. We can best see the prominent part played
here by chance in the introduction of salicylic acid into therapeu-
tics. After Kolbe had succeeded in synthetically producing this
acid, which is normally contained in the bark of the willow, he
thought that it would exhibit disinfecting properties within the
system by its decomposition. This decomposition does not, how-
ever, occur. Yet Kolbe's idea has led to the clinical application
of this substance, and the valuable results obtained by Strieker
from the use of salicylic acid in acute articular rheumatism, al-
though it is not by any means a specific, have stimulated to con-
tinuous researches, most fertile for therapeutics, upon the various
salicylic preparations.

It is not impossible that, starting from this small therapeutic
field, the indications for the use of salicylic preparations may be
greatly extended.

Even though the constitution of a chemical body gives us no
firm basis for pharmacodynamic investigations, we can yet de-
rive the most varied hypotheses from it. In pharmacodynamic
research we may uphold the same principle which Claude Berhard
expresses, namely, that by promulgating an hypothesis we are led
on to experimental research, the solution of which may be of the
greatest importance. G. Gore expresses his opinion in much the
same way :

"A discoverer is a tester of scientific ideas; he must not only
be able to imagine likely hypotheses, and to select suitable ones
for investigation, but, as hypotheses may be true or untrue, he
must also be competent to invent appropriate experiments for testing
them, and to devise the requisite apparatus and arrangements."

THE RELATIONS OF THERAPEUTICS 165

The science of therapeutics quite properly does not follow a one-
sided course, but seeks aid in all directions, and since the results
of the exact natural sciences are not yet ripe to guide us clearly,
we must take into consideration what has been gained by prac-
tical experience, for it would be a false principle to condemn popu-
lar medicines without examination. At the beginning of this lec-
ture the successful application of digitalis was already mentioned.

And here we must not entirely neglect the historical side of em-
piric observation. Frequently even the most absurd practices are
based upon theory. When we turn away in disgust from the unclean
excretory products of animals used in ancient times and by Asiatic
nations, which we now regard as the very outcome of folly, we cannot
ignore the fact that even this practice was founded on theory,
though a false one. This is proved by Pliny, who tells us that ani-
mals eat and digest plants, but the medicinal part is not absorbed
by the organism, but excreted, for which reason the feces contain
substances curing human ills. These prejudices remained for cen-
turies, as is proved by Paulini's book, published in 1697, but which
can now be read only with disgust.

Such excretions as musk and castoreum, which are undoubtedly
of value, should by no means be rejected. But particularly the
nineteenth century has directed attention to the question whether
the products of the organs themselves, or certain substances con-
tained therein, might not be employed as remedies.

It was no easy task for Brown-Sequard to prove that the prin-
ciples contained in the testicles of animals exercise a stimulating
and exciting influence on the system. The discovery of spermin
crystals, their occurrence in various organs, and the decidedly
stimulating effect produced by these substances, reminded physi-
cians that creatin, which had already been obtained from meat
extract, had an effect similar to that produced by the salts of potas-
sium on the animal body. This, as we may say, weak connecting
link yet led to the further development of a principle in therapeu-
tics. Medical chemistry has already succeeded in obtaining from
the organism substances which may be of the greatest importance
for therapeutics. You all know the effect of thyreoidin on the sys-
tem. Obviously the active principles here are albuminoid bodies,
the peculiarity of which has already been partly explained by
Baumann in that iodine is one of their component parts. Prob-
ably no one would have imagined that this element must be re-
garded as one of the constituents of the human organism.

The very much studied question of the constitution of albumen
will naturally lead to a more exact knowledge of the different kinds
of albumen which are of value therapeutically and open a new field
of observation to pharmacology.

166 THERAPEUTICS AND PHARMACOLOGY

The most surprising feature in the action of substances of the
organs is presented by the constituent of the supra-renal capsule,
adrenalin, not an albuminoid body, it is true. In order to better
illustrate the importance of the new domain, the following phar-
macodynamic experiment may be mentioned. Doses of cocain
which are absolutely fatal to animals are easily borne in the pre-
sence of adrenalin without any injurious effect whatsoever. These
substances, as they are found in the body of animals, are certainly
of importance for the life-processes themselves. Taken from the
animal body, they have the same effect as the human product,
and can thus be employed as curative agents in man.

But medical chemistry had already undertaken researches which
were not indeed utilized therapeutically at once, but came to exert
great influence on therapeutics. In 1869, Zuelzer and Sonnenschein
proved that alkaloidal bodies may be formed by the decomposi-
tion of the organic substances of the organism, and later on the
theory of toxins was derived from this observation. This again
has led to von Behring's remarkable and far-reaching theory of the
anti-bodies formed in the organism.

How to make the substances obtained from the bodies of ani-
mals useful for therapeutics, depends upon the state of our physi-
ological and chemical knowledge, and especially on the train of
ideas arising in connection with these subjects. This can be seen,
for example, in the case of the esters of cholesterin, the composi-
tion of which was already discovered by Berthelot, but not in con-
nection with biological investigations. On the other hand, choles-
terin esters had been observed in the form of wool-fat, and the
impure product was used medically and cosmetically even in an-
cient times for its curative powers. It was proved that a functional
significance as regards the animal organism must be attributed
to cholesterin esters, for they are present in mammals, birds, and
all creatures whose external surface is of keratinous character.
They give luster to the skin, but act chiefly, so to say, as a protective
varnish. The white substance of new-born children is therefore very
properly termed cheesy varnish (vernix caseosa). It was formerly
thought to consist of glycerine fat, but it is actually composed of
cholesterin esters. The higher members of these esters are charac-
terized by the physiological properties of wax. Gottstein has shown
that this substance offers no food for microbes, is very stable, dif-
ficult to saponify, and not decomposed by the oxygen of the air*
as are other fats. Thus it forms a protective matter, especially
effective by reason of its waxy nature, and this has led to the pro-
duction and application of therapeutic substances similar to choles-
terin ester, as, for example, fetron.

The influence of pathological anatomy on therapeutics belongs

THE RELATIONS OF THERAPEUTICS 167

entirely to the nineteenth century. To John Hunter in England
and Bichat in France belongs the credit of freeing pathological
anatomy from the brainless descriptive scientists, and of forming
it into the necessary basis for every form of progress in therapeu-
tics. From this time until Virchow's labors, the decisive import-
ance of which is recognized impartially by all nations, pathological
anatomy has exercised a great influence upon medical activity.
Cellular pathology especially, in spite of all former battles and
present attacks, will form the basis of every experimental and
therapeutic observation, though some of the views concerning it
may undergo modification through the progress of science, and
opinions which Virchow himself could not accept may be brought
forward again. The scientific question which appeared as a result
of cellular pathology is the question of the cause and symptomato-
logy of disease. Nothing can be more suitable in treating this ques-
tion than to quote Virchow's own words:

"An elementary pathological process in the sense of cellular
pathology appears thus: an external influence acts upon a living
cell and alters it in a mechanical or chemical way. The external
influence is the causa externa, or as we simply express it, the cause
of disease : the altered condition is called passio, disease. If now,
in consequence of the change undergone, an action (actio s. reactio}
takes place in the living cell, this change is called a state or irrita-
tion (irritamentum) , and the cause of disease irritants. If, on the
other hand, no action ensues, if the condition is limited to the
change "suffered" by the cell, we have to do with a mere disturb-
ance (laesio) or paralysis. Since, however, the same cause can
evoke irritation in one cell, merely a disturbance in another, and
even paralysis in a third, we assume a certain difference of the in-
ternal arrangement to be the cause of this varying behavior. Thus
we come to the internal cause or predisposition."

But these words, spoken in 1880, must be modified according to
present experience. According to Virchow the causa externa is
the cause of disease. The irritant acting upon the organism is under
all circumstances the morbific factor according to this assumption.
We do not wish to play with words. If, indeed, this foreign intrud-
ing agent produces a destruction of the cell-power or a morbid
modification of it, it obviously must be regarded as the actual cause
of disease. But when, for instance, we see that the invading body
produces only an entirely local irritation, or, although capable of
reproduction, as is the case with bacteria, no proliferation occurs,
it becomes difficult to consider the same factor as the cause of dis-
ease in all instances. Virchow terms this phenomenon of indolence
of the cell towards the intruder a want of p^disposition ; accord-
ing to the school of bacteriologists, however, T-the cell is not a cul-

168 THERAPEUTICS AND PHARMACOLOGY

ture medium in the given case. We see from this explanation that
Virchow himself assumes the cell-power to be variable, and we can
quite logically and correctly say that by the term disease, i. e.,
nosos, is designated that condition in which the external irritation
can accomplish the defeat of the cell.

Von Hansemann has shown from a pathological and anatom-
ical point of view that in cases of diabetes mellitus and other dis-
eases the tubercle bacillus involves secondarily the lung. Von
Hansemann calls this disposition, but we must certainly first of
all term it "nosos," since it is a question of proved deviation from
the normal.

This can also be illustrated by experiments. In a frog anthrax
bacteria do not proliferate. As soon, however, as we place the ani-
mal in an incubator, i. e., weaken the cell-power by heat, we are
able to make the animal susceptible to the inoculation of anthrax.
In this case the parasite is only a parasite of the diseased cell, and
this kind of infection I have termed nosoparasitism. Thus we must
describe as " nosos " the molecular change which we can no more
observe through the microscope than we can the course of a chem-
ical reaction, the outcome of which we judge only by the result.

The cell is subject to the same vital fluctuations as Brown has
assumed for the organism. Brownonian theory has had no special
value for practice, it is true, because at that time it was impossible
to base a system of therapeutics on these observations so as to be
of practical use. But it must be acknowledged that his theoretical
deductions can be applied to the vitality of the cell. This theoret-
ical explanation is under all circumstances of decisive importance
for therapeutics, and already physicians are beginning to direct
attention to this view in the study of therapeutics. Thus A. Menzer
says: "The solution I have attempted to give to the question of the
etiology of acute articular rheumatism is derived from the theory
of a correctly interpreted nosoparasitism."

This question has grown to be of special importance for pulmon-
ary phthisis. We cannot here enter into the subject of infection
by tubercle bacilli; only one thing is certain, namely, that the
bacillus is destroyed if the cells become healthy and only does
harm when the cells are diseased. Even before the discovery of
the tubercle bacillus this fact was proved by dietetic and open-air
cures, as described in the excellent work of the two Doctors Wil-
liams, father and son, and Freund again has shown lately that
the functions of the tissue of the lungs are impaired by abnormal
immobilization of the first rib, and that then the tubercle bacillus
can begin its work. ^

At the present J&y pharmacodynamics teaches that there are
indeed drugs which- do not merely act specifically upon a tissue,

THE RELATIONS OF THERAPEUTICS 169

as phosphorus acts upon the formation of bone, but that there are
also cell excitants, such as cantharidin, which, without themselves
having any effect on the bacteria, can bring about the cure of dis-
eased tissues, so that the nosoparasitic bacilli are destroyed.

But here begins a branch of science which, like the theory of
immunity and serum therapy, occupied the end of the nineteenth
century, and the waves of discussion still run so high that it is as
yet unsuitable for an historical survey. It is sufficient to say that
all the investigations of the present as well as of the past century
afford us a guarantee that we are following the right road of pro-
gress in therapeutics, and assure us that in regard to the healing
of disease there lie before us "infinite possibilities," to use the apt
phrase which has been already employed in regard to the devel-
opment of your country by Ludwig Max Goldberger, "Das Land
der un-begrenzten Moeglichkeiten."

THE PROBLEMS OF THERAPEUTICS

BY SIB LAUDEE BRUNTON

[Sir Lauder Brunton, Physician to St. Bartholomew's Hospital, London, b. 1844.
M.D., Sc.D., LL.D. (Edinburgh); LL.D. (Aberdeen); F. R. C. P.; F. R. S.
Author of The Bible and Science ; Text-Book of Pharmacology; Therapeutics and
Materia Medico; Disorders of Digestion; Lectures on Action of Medicines; Dis-
orders of Assimilation; Collected Papers on Circulation and Respiration; and
numerous papers in scientific and medical periodicals.]

THE subject of my lecture to-day is "The Problems of Therapeu-
tics." My audience is a select one of persons interested in science
and art. But science in these days has branched out so widely that
it is impossible for any single person to be acquainted with every
department of it, so that the terms used by a zoologist may be
unintelligible to a mathematician, or vice versa. There are some
here whose researches have led them far into abstruse departments
of science and if they were speaking I should gladly welcome a
few introductory words from them on the very rudiments of their
science in order to help me to understand a disquisition on the
more advanced parts of their subjects.

Judging others by myself, I think they may be glad if I do the
same, and I must beg the indulgence of those acquainted with
medical science and its branches if this lecture should seem to be
unnecessarily rudimentary. By therapeutics we mean the methods
of healing. In the great staircase of St. Bartholomew's Hospital
in London there is a large picture by William Hogarth represent-
ing the Good Samaritan. The poor traveler is seated on the ground,
the Good Samaritan is pouring oil and wine into his wounds, while
close at hand is a dog busily engaged in licking a cut which he has
received in the fray. Both dog and man are engaged in solving,
as far as they can, two of the primary problems of therapeutics,
viz.: (1) how to relieve pain, and (2) how to restore health. For
disease is want of ease, and health is only one form of the word
"whole," by which we mean that a thing is entire and neither cut,
broken, nor cracked. The closure of wounds is one form of restor-
ing "wholeness" or "health" to the body, but it is by no means
the only one, for the vital organs lie below the surface, and it is with
disturbances of their functions, even more than with external
wounds, that therapeutics, or the science and art of healing, is
chiefly occupied. As exemplified in the dog or in the Good Samari-
tan, therapeutics is simply an art. Certain things are done because
they have been found to do good before and so they are repeated
again and again, but neither the dog nor the Good Samaritan un-

THE PROBLEMS OF THERAPEUTICS 171

derstands the reason why their procedure is useful. It is only when
we learn the reason why that an art becomes converted into a sci-
ence. Therapeutics in its primitive form is one of the simplest of
all the arts and is practiced by animals as well as by man, but as
a science it is one of the most complex and most difficult of all be-
cause it requires a knowledge of the functions of the body in health,
or physiology; of their changes in disease, or pathology; of the
action of drugs upon the body, or pharmacology; and of chemistry,
physics, and other sciences on which physiology, pathology, and
pharmacology are based. Finally it requires the practical power
of recognizing from the symptoms (in any individual case) the
nature of the pathological changes present and the ability to apply
the right methods of treatment in order to counteract these changes
and heal the patient. It is evident that such complex knowledge
as this must be very difficult of attainment, yet nevertheless the
change of therapeutics from an art into a science is progressing
with considerable rapidity. In a text-book on the subject which
I published eleven years ago, I mentioned the use of quinine in ague
as the best example of the art of therapeutics whereby we could
cure a disease of which we did not know the nature by a remedy
whose curative action we did not understand. Since that time,
however, we have learned that ague depends upon the presence
of a foreign organism in the body and that the benefits obtained
from quinine are due to its poisonous action upon this intruder.
This malarial parasite is only one of the many minute organisms
which mar or destroy the health of the human body. Minute organ-
isms or microbes are most useful in their proper place and without
them the world would be uninhabitable because they are the nat-
ural scavengers which produce putrefaction in dead plants and
animals and thus bring about their return to dust, fitting them
for new life instead of allowing them to incumber the ground. But
not content with this function, some of them proceed to invade
living beings, attacking not only the weak but even the strong, and
by growing and multiplying within them weaken or destroy their
hosts.

One of the great problems of therapeutics, then, is to defend the
body from attacks of microbes. This may be done either (a) by
weakening or destroying the microbes themselves or (&) by in-
creasing the power of the organism to resist them.

It is convenient to speak of the body as a whole when we are dis-
cussing its invasion by microbes, but we must not forget that the
body, like a country, is composed of many parts. The interests of
the different parts are by no means identical, and while they generally
act together for the common good they may not always do so, and
either by their sluggishness and inaction or by their mischievous

172 THERAPEUTICS AND PHARMACOLOGY

activity may do harm instead of good to the body as a whole.
What is requisite for health is an harmonious action of all the dif-
ferent parts of the body, or as St. Paul very well puts it, "And thus
all the body framed and knit together through that which every
joint supplieth, according to the working in due measure of each
several part,maketh the increase of the body unto the building up of
itself" (Ephes. iv, 16, Revised Version), so "that there should be no
schism in the body and that the members should have the same care
one for another." No doubt in their long wanderings together Luke
the beloved physician discussed physiology largely to Paul, and his
expression is so good that I introduce it now.

Just as the people of a country is composed of individuals, so the
body is composed of numerous cells. The whole class of microbes
consists of isolated cells which are like a nomad population, each
individual complete in himself, and all ready to form a swarm for
attack and invasion. The cells which compose the body, on the con-
trary, are mostly fixed, and differ from each other in structure and
function, but ought all to act together for the common good, like
civilized people. Each cell lives in the fluid which surrounds it, blood
or tissue juice, from which it takes what it needs for its own nutriment
and pours back the products of its tissue activity which may be partly
waste and partly manufactured products of the utmost utility.

In order to have a complete comprehension of therapeutic prob-
lems it is necessary that we should know something about the life of
the cell, because the life of the whole body depends upon that of the
cells which compose it, and the cure of disease and the preservation
of life depend on our power to influence cell-life. The processes of life
are to a certain extent the same in the human body as a whole, in the
cells which compose it, and in the smallest living organisms or mi-
crobes as they are termed. They all digest and assimilate food, they
all breathe, and they all excrete waste products. A knowledge of the
processes of life in man helps us to understand them in low organisms
and vice versa. The use of pepsin and pancreatin in indigestion
is so common that almost everybody knows that these substances
have the power of dissolving meat and that pancreatin converts
starch into sugar. Everybody knows that these are got from the
stomach and pancreas of animals and that it is by similar substances
formed in our own digestive canal that we are able to dissolve the
food we eat and render it fit for absorption. It has recently been
found that pancreatic juice, as poured out by the gland which secretes
it, is very slightly active, but it is made active by another ferment
secreted from the intestine which is called enterokinase. The pan-
creatic juice contains several ferments; that which acts upon meat
is called trypsine and in its inactive state it is called trypsogen.
The action of the enterokinase on the trypsogen may be compared

THE PROBLEMS OF THERAPEUTICS 173

to that of a man who opens the blade of a knife and renders an
instrument previously inactive very active indeed. If trypsine were
absorbed into the blood unchanged it might digest the tissues them-
selves and it must be rendered again inactive. This seems to be
effected by certain substances present in the blood which have a
so-called "anti" action upon the ferments and render them again
inactive. But though the digestive ferments might do harm if pre-
sent in the blood in an active form and in large quantity, yet it is prob-
able that all the cells of the body digest the food which is brought
to them by the blood and tissue juices and break up this food for
their own use by ferments which they contain themselves. Thirty
years ago I advanced this view and supported it by the fact that I
was able to extract from muscle by glycerine a substance which
decomposed sugar. This observation received but very little atten-
tion at the time, but recently German literature is full of papers
which support my views and confirm my results, although their
writers apparently are ignorant of my work. Fifteen years ago,
along with Dr. Macfadyen, I showed that bacteria not only excrete
ferments by which the soil in which they are growing is digested,
but that they are able to modify these ferments in accordance with
the soil so as to digest either proteid matter or sugar. Curiously
enough, within the last few years the pancreas in animals has been
shown by Professor Pawlow to have similar powers.

No individual microbe has received so much attention as the yeast
plant and no poison which is formed by any of them has done so much
harm as the toxin or poisonous substance produced by yeast, for this
toxin is alcohol, whose poisonous action has given rise to the term
intoxication. The yeast-plant, when grown in sugar, excretes into it
a ferment, invertase, which splits up ordinary cane-sugar or sacch-
arose into two other sugars, dextrose and levulose. The yeast-plant
may be separated from the solution of sugar by filtration, but the
ferment which is already excreted will remain in the filtrate and may
still continue to act on the sugar, just as pepsin may dissolve a piece
of meat in a jar although the pig which produced it is dead and gone.
But no alcohol will be formed by this excreted ferment. Alcohol is
produced by something contained within the body of the yeast itself
and its production was formerly supposed to be due to so-called
vital action. It has now, I think, been proved that alcohol is pro-
duced by the action of a ferment which is contained within the body
of the yeast-cell and is not excreted from it, so long as the cell is
intact, but only passes out after the cells have been crushed into frag-
ments. Whilst the cell is alive and intact it absorbs the sugar into
its interior, breaks it up there, and forms the alcohol which is
afterward excreted.

To make this clearer I may perhaps be allowed to use a very crude

174 THERAPEUTICS AND PHARMACOLOGY

illustration and compare the ferment which is excreted by a bacil-
lus or by yeast to the saliva which is said to be poured out by a boa-
constrictor over its victim to facilitate its ingestion, while the fer-
ments within the microbe may be likened to those in the stomach
and intestine of the boa by which it effects the digestion of its prey.

Other microbes in like manner absorb nutriment and may form
and excrete toxins, though both the nutriment and the toxins of
bacilli in general differ from those of yeast.

To recapitulate what I have already said, we see therefore that

(1) Cells excrete ferments;

(2) They excrete poisons formed within their bodies; and

(3) When they are broken up they may liberate other ferments.

The ferments excreted by microbes apparently prepare the sub-
stance in or on which they are growing for assimilation, and the
ferments within the cell-body decompose it further in the process of
growth. It is probable that all cells, whether they be wandering
microbes or cells coordinated in an organism, prepare and assimilate
their nutriment by means of ferments, and Macfadyen and I found
that not only have bacilli the power of excreting ferments, but
apparently they are able to adapt the ferment which they excrete
to the soil in which they are growing in much the same way as Paw-
low has recently shown that the pancreas in animals modifies the
ferments it forms according to the food which it is required to digest.

Not only is digestion carried on in the stomach and intestines by
the ferments which are now so well known even to the general public,
pepsin, pancreatin, etc., which dissolve the ingested food so that it is
readily absorbed into the circulation and carried to every part of the
body, but the other cells which compose the various parts of the body,
muscles, nerves, and glands, probably carry on the functions of their
life by means of ferments also. By means of these they alter and
assimilate the various substances which are brought to them by the
blood and juices of the body, and after having supplied their own
wants they throw into the circulation the altered residue of their
pabulum as well as the substances which they have themselves formed
in their processes of growth. They probably repeat in fact what we
have already seen to occur with yeast, which not only alters the
sugar in which it grows by a ferment which it excretes, but also
produces carbonic acid and alcohol by means of a ferment which
remains within the yeast-cells so long as these are intact and only
becomes liberated when these cells are broken up.

An excessive quantity of their own products is usually injurious to
cells and too much alcohol will stop the growth of yeast. At the same
time these products are frequently very nutritious for cells of a differ-
ent sort and alcohol furnishes a most suitable pabulum for the organ-
isms which produce vinegar. Vinegar in its turn is toxic to the mi-

THE PROBLEMS OF THERAPEUTICS 175

crobe which produces it, but serves again as a soil for another which
gives rise to a viscous fermentation. By the successive action of these
ferments a solution of sugar may produce, first, alcohol, secondly,
vinegar, and thirdly, ropy mucus. In this particular series each
microbe produces a substance injurious to itself but useful to its
successor. This is, however, not always the case because a cell may
produce a substance not only injurious to itself but injurious to other
cell, and alcohol in large quantity not only kills the cells of yeast but
kills other cells as well. Similar conditions occur within living organ-
isms where the cells composing the different parts are connected
together and pass on the products of their life from one cell to another
by means of the circulation of the blood and tissue juices. The secre-
tions of one part may be, and indeed generally are, useful to other
parts of the organism and so long as no part sins either by deficiency
or excessive action the whole organism maintains a condition of
health. But this is not always the case and health may be destroyed
by (a) excessive, (&) defective, or (c) perverted action of one or more
of the parts composing the body.

But health is even more frequently destroyed by the invasions of
organisms from without. When these organisms fall upon an open
wound they tend to grow and multiply rapidly, they secrete ferments
and form poisons which enable them to destroy the tissues upon
which they have fallen, and then finding their way into the circula-
tion and being carried to all parts of the body they kill the animal
which they have attacked.

One of the great problems of therapeutics then is to discover how
best to defend ourselves against the attacks of microbes. In Hogarth's
picture we see two methods by which this is done. The dog licks the
wound it has received and thus removes from it any pathogenic
organisms which may have lighted upon it. By insuring their absence
it renders the wound aseptic, and asepsis, which is another word for
excessive cleanliness insuring the absence of organisms, is one of the
great measures by which the triumphs of modern surgery have been
achieved. The treatment applied by the Good Samaritan to the
wounds of the traveler is somewhat different, for he pours in wine
the alcohol of which may hinder the germination of any microbes on
the wound and thus prevent them from producing sepsis. This
method, which in the hands of Lister has revolutionized surgery,
is termed antiseptic as distinguished from the aseptic method used
by the dog. There is no doubt that the aseptic method has got dis-
tinct advantages over the antiseptic method as applied to wounds
because any substance which injures or destroys microbes will like-
wise injure the living cells of that part of the body to which it is
applied. For this reason the aseptic method can only be employed
to a very limited extent against microbes that have already entered

176 THERAPEUTICS AND PHARMACOLOGY

the interior of the body, although it may sometimes be used, as for
example in the treatment of dysentery, where repeated doses of
saline purgative are now given so as to wash out from the intestinal
canal the microbes which give rise to the disease, and even in ordinary
diarrhea, where a purgative is employed to get rid of both the
microbes and the poisons they have formed. More commonly, how-
ever, we have to depend on antiseptic methods either entirely or as
an adjunct to asepsis, and a study of the action of various chemical
substances on microbes has led to the introduction of a whole series
of antiseptics and indeed to their actual synthetic formation, the
problem to be solved being how to produce a body which will de-
stroy the microbes most efficiently and at the same time will have
the least injurious action upon the body of the animal invaded. Nor
is it only inside the body that the action of antiseptics is desired.
The search for preservatives for milk, meat, fish, vegetables, and fruit
which shall be at the same time efficient and innocuous is one con-
stantly going on at present. Asepsis is one of nature's methods of
defense. When irritating substances get into the eye a flow of tears
occurs to wash them away, from the nose and respiratory passages
they are ejected by sneezing or by cough, and from the stomach or
intestines they are removed by the vomiting and purging to which
they themselves give rise. Even in the addition of preservatives in
milk we seem to be following the example of nature because Andeer
has found resorcin in which is an antiseptic in the fresh milk of cows.
As Metchnikoff has shown, another method adopted by nature for
removing and destroying infective microbes is to bring down upon
them a host of white blood corpuscles, or leucocytes, which swallow
up and destroy them. The more leucocytes that the organism can
bring to bear upon the intruders the better chance it has of over-
coming them. One problem, therefore, in therapeutics is to increase
leucocytosis. At present we have comparatively few drugs that pos-
sess this power, cinnamate of sodium being perhaps the most active,
but one of the problems to be solved is to find other substances which
will do this to a greater extent than at present. The microbes on their
part are ready to attack the leucocytes and fixed cells by means of
toxic secretions or toxins and another of the defensive mechanisms
which the organism adopts is to form antitoxins, as the antitodes to
these toxins are generally termed. Some of these defensive bodies
or alexins actually destroy the invading microbes themselves, while
others simply neutralize the poisons or toxins they have formed.
The nature of such defensive substances has been examined by
Ehrlich to whom we owe much of our knowledge concerning them.
It is very complicated and we do not yet know the precise mode of
production of these antitoxins, but it is a curious fact that in many
plants we find two poisons which are antagonistic in their action and

THE PROBLEMS OF THERAPEUTICS 177

which are to a certain extent antidotal to one another. Thus in
jaborandi we have two alkaloids one of which, pilocarpine, stim-
ulates secretion enormously, whilst the other, jaborine, paralyzes
secretion, so that an extract of the jaborandi plant containing
them in proper proportion might possibly appear inactive although
it contained both alkaloids in considerable amount. The same is the
case with poisonous mushrooms which contain a poisonous alkaloid,
muscarin, which produces severe irritation of the intestine and an
atropine-like substance which antagonizes it. Opium likewise con-
tains alkaloids having very different actions, some being almost purely
narcotic and others purely convulsant. The animal body seems to
have a wonderful power of accommodating itself to the action of
many poisons and this is very marked indeed in the case of opium.
Many persons who begin with a small dose increase this gradually to
an enormous extent so that they are able to take with impunity
many times the ordinary lethal dose. The organism has a certain
power of storing up antidotal substances within itself and Dr. Cash
and I were able, by feeding animals with potash, to render them less
susceptible to the poisonous action of barium, but except in the case
of arsenic the organism seems to have but little power of becoming
accustomed to inorganic poisons. It is different, however, in the case
of organic poisons as shown by the resistance to the action of alcohol
acquired by habitual topers and to morphine by habitual opium-
eaters. A similar resistance may be acquired to snake-venom and to
the toxins produced by microbes; and here it does not seem to be
merely that the cells of the organism become accustomed to the
poison, but that the organism forms an antidote, not only in suffi-
cient quantity to neutralize the poison which is introduced, but
actually in such superabundance that serum separated from the
blood of an animal which has become immune to the action of snake-
venom or of toxins will neutralize the effect of the venom or
toxins in another animal. So great is this power that Sir T. R
Fraser has found by inoculating an animal with gradually increasing
doses that it may at length completely resist the action of fifty times
the ordinary lethal dose of snake-venom, and in an experiment of
M. Calmette I have seen an animal which had received the serum
from such an immunized animal remain healthy and well, although
another one which was inoculated at the same time and with the same
dose of snake- venom was dying from the effect of the poison.

When horses are inoculated with successively increasing doses
of the toxin of diphtheria, their blood acquires a high antitoxic
power, and the use of the serum of such blood injected into patients
suffering from diphtheria has robbed this disease to a great extent
of its awful power. Hydrophobia is another disease which has been
to a great extent deprived of its terrors by Pasteur's method of

178 THERAPEUTICS AND PHARMACOLOGY

treatment. This differs in its plan from that used in diphtheria.
In diphtheria the bacilli probably form a ferment which produces
a deadly poison by exercising its digestive powers on the material
it finds in the body. This poison is neutralized by the antidotal
serum which is formed in a horse and is injected into the patient.
In hydrophobia we have not been able to isolate the virus, but
from its mode of action we suppose it to be a minute organism. This
virus takes a long time to act in man, sometimes three weeks but
usually six weeks, but when cultivated successively in rabbits it
becomes very virulent indeed and acts much more quickly. It
apparently finds its chief nidus in the spinal cord. When the cord
is exposed to air the virus gradually becomes weakened and by
injecting with an extract of very weak cord on the first day and
with a stronger extract on each succeeding day the human body
becomes accustomed to the virus and forms its own antitoxins.
Thus by the time that the poison inoculated by the original bite
of the rabid animal has time to develop its action the person has
become immune.

One of the most important problems of therapeutics, therefore,
is to render the human body immune against pathogenic microbes,
against the ferments they form, and the toxins they produce. The
two examples I have already given show how the toxins and pos-
sibly the ferments may be rendered innocuous by injecting anti-
dotal sera and thus producing what is called "passive immunity,"
or by exciting the body to form antidotal substances itself and
thus produce what is called "active immunity." Both these meth-
ods have been used, and are being used, in regard to other diseases,
especially in those produced by micrococci of various sorts which
give rise to suppuration and inflammations. One great difficulty
in the way, however, is that the antidotal serum produced by one
coccus is not always efficient against the disease produced by
another, and so much is this the case that it would almost seem
as if an antidotal serum would require to be made for each par-
ticular patient. Nor are the sera altogether innocuous themselves
because their injection may be followed not only by annoying
rashes on the skin but by general swelling of the body like that
from advanced kidney disease, or by painful swelling of the joints
almost like rheumatic fever. Another of the problems of therapeu-
tics therefore is to obtain anticoccic sera which will not produce
any unpleasant or dangerous symptoms.

Yet another is to confer on the tissues of the body the power of
resisting or destroying microbes, their ferments, and their toxins,
and thus protecting themselves or in other words acquiring immunity
against the diseases which the microbes would produce. In consider-
ing this question it may help us if we remember that the products

THE PROBLEMS OF THERAPEUTICS 179

of our own digestion are poisonous and if the albumoses and pep-
tones formed by the digestion of a beef-steak in the stomach were
injected directly into a man's veins they would kill him, whereas,
when changed by the cells of the intestine and liver in the process
of absorption, they nourish and strengthen him.

The complexity of toxins and antitoxins is easily understood
when we consider that they are probably all formed by the split-
ting-up of albuminous molecules and thus vary enormously just as
the splinters of a broken glass vary in size, shape, and in power
to puncture or cut.

In my address at Moscow, in 1897, I ventured to formulate the
idea that immunity, natural or acquired, is nothing more than
an extension to the cells of the tissues generally of a power which
is constantly exercised during digestion by those of the intestine
and liver. When microbes were just beginning to be recognized
as the cause of infective disease, too much importance was attached
to the mechanical effects which they might produce in the blood-
vessels and tissues. As their mode of action became better known,
this view was to a great extent given up, but though the small
vegetable microbes, bacilli and cocci, have little injurious mechanical
action, this is not the case with some minute organisms belonging
to the animal kingdom, and such organisms of late years have be-
come more and more recognized as causes of diseases. In elephant-
iasis the lymph channels become blocked by the ova of a small
worm which inhabits the blood and thus the enormous swelling
characteristic of the disease is produced. Within the last few years
that dreadful scourge of tropical countries, malaria, has been dis-
covered to be due to an animal parasite, and Manson and Ross
have shown that the source of infection is the mosquito. By de-
stroying mosquitoes or preventing their multiplication the dis-
ease can be to a great extent prevented, but we are still dependent
upon bark, quinine, and arsenic as remedies to destroy the para-
site and cure the disease. These are not invariably successful and
we are still in want of medicines which shall infallibly destroy the
parasite. The same is the case with other maladies where the in-
fective microbe is of animal origin, as in sleeping-sickness, which is
now attributed to a minute worm in the blood, or of vegetable origin
as in ulcerative endocarditis, or of uncertain origin as in yellow fever.

But all these diseases excite much less attention than that
which is perhaps more dreaded than any other in temperate
climates, namely, cancer. We do not as yet know the pathology of
this disease. It has been shown that in it the cells of the affected
part multiply and grow in a different manner from that of ordin-
ary tissues. They assume a reproductive type and grow inde-
pendently of the tissues of the body in which they are situated.

180 THERAPEUTICS AND PHARMACOLOGY

We know that portions of carcinomatous growths may be carried
by the blood-stream from one part of the body to another where
they may act as new foci, but that they can only be transplanted with
difficulty if at all from one animal to another. Thus it is evident
that though their reproductive power is great their vitality is feeble.
Therefore what one may hope for is, that though all the drugs
hitherto tried have been powerless to prevent the life and growth
of such tumors, yet something may yet be found which will attack
and destroy them and nevertheless leave uninjured the healthy
jtissues by which they are surrounded. Lupus and rodent ulcer
situated on the surface of the body have been successfully treated
by the X-rays and ultra violet rays. These have little effect on
deep-seated cancer. My friend, Sir William Ramsay, thinks, how-
ever, that the emanations from radium, which are to a certain extent
soluble in water, might be administered with a view of destroying
internal cancer, more especially as he has already found that they
seem to have no injurious action when given to healthy animals.
In the case of cancer it is certain that groups of cells take on a life
of their own, and live independently of the wants of the organism
as a whole. In some other diseases we find that entire organs
become too active and thus injure the health of the whole body.
One of the best examples of this is the thyroid gland which, when
hypertrophied, produces, through the secretion which it pours into
the blood, a curious set of nervous symptoms, dilatation of the
vessels, palpitation of the heart, tremor, restlessness, excitement,
and rise of temperature. In the disease known as Graves's Disease
these symptoms exist and may possibly be aggravated by the condi-
tion of the nervous system which causes the characteristic protrusion
of the eyeballs and may even be the cause of the swelling of the
thyroid itself. But that most of the symptoms are really due to the
action of the thyroid secretion is shown by the fact that they may all
be observed after excessive administration of dried thyroid gland.

Here we have a toxin formed within the body by the over-action
of one of its parts and at present we have no satisfactory antitoxin
by which we can remove the symptoms, although supra-renal gland
has an action somewhat antagonistic to that of the thyroid, and this
gland or its extract when administered internally in cases of exoph-
thalmic goitre sometimes appears to be beneficial. The case is very
different, however, when, instead of being excessive, the action of the
thyroid is deficient. When this occurs in adults the circulation
becomes poor, the skin cold, the movements of the body and the
action of the mind slow, the aspect becomes dull and heavy, and the
features puffy and swollen. When thyroid gland or its extract is
given, all these symptoms disappear and the patient becomes healthy
for the time and usually remains so as long as the administration is

THE PROBLEMS OF THERAPEUTICS 181

continued. When deficiency of the thyroid occurs in childhood,
the effect of treatment is still more manifest, for the child thus
affected becomes stunted both in body and mind, is dwarfish, feeble,
and idiotic. Under the administration of thyroid it grows rapidly
and becomes strong and intelligent and indeed develops into a per-
fectly normal person. The cure effected by thyroid in such cretins
is one of the most marvelous achievements of therapeutics and many
attempts have been made with portions of other organs or extracts
of them to supply material which is supposed to be absent in vari-
ous diseases.

The first instance of this method of treatment, or opotherapy, as
it is called, was, I believe, my employment of raw meat thirty years
ago to supply the body with a ferment to use up sugar in diabetes.1
The method was reintroduced by Brown-Sequard with more suc-
cess, but it was not until the use of thyroid gland and its extract
that the potentialities of the method became acknowledged. It
is more than eighteen hundred years since the question was asked
"Who can add a cubit to his stature?" and all this time we have
remained ignorant of any plan by which we could add a single inch
to a child's stature. Yet it now seems possible that by the use of
thyroid gland and pituitary body, children, who would be other-
wise stunted, may grow not only to the normal size but even above it.

So long, however, as we do not know the chemical nature of the
substances which exercise such an extraordinary effect upon tissue
change we shall not be able to deal with them so satisfactorily as we
can now, in a way that was formerly impossible, regulate the tem-
perature in fever. The clinical thermometer not only shows us the
extent to which fever is present, but it enables us to stop the appli-
cation of our remedies in time so as not to reduce the temperature
to too great an extent. Cold water, ice, and diaphoretics were for-
merly the only antipyretic remedies, next salicin and quinine were
introduced, then salicylic acid was made synthetically, and be-
ing cheap was used extensively, and within the last thirty years
an increased knowledge of chemical methods and of the relation-
ship between chemical constitution and physiological action has
enabled numerous synthetic products to be formed, some of which
may be more useful in certain cases than the original salicylate
of soda.

A great many of these substances primarily intended to reduce
the temperature have turned out to have a still more important
action, namely, the relief of pain. There is no doubt that pain is
useful as a warning against conditions which tend to destroy the
organism and leads us to shun or remove these conditions to the
great advantage of our health, but it is not always possible to do

1 British Medical Journal, 1873.

182 THERAPEUTICS AND PHARMACOLOGY

this and pain per se is one of the greatest evils that poor humanity
has to bear. The introduction of antiseptics has completely re-
volutionized the art of surgery because it allows operations to be
done with almost certain success which would in former days have
almost inevitably proved fatal from unconscious contamination
of the wound by disease-germs. But the greatest triumphs of sur-
gery have only been rendered possible by the discovery of anes-
thetics. Previous to the work of Long, Jackson, Wells, Warren,
and Simpson rapidity of operation was everything, and careful
but long-continued manipulation was impossible because the long-
continued pain of the operation would inevitably have killed the
patient. Even the minor pains of neuralgia, neuritis, and head-
ache, though not dangerous to life, are most distressing to the suf-
ferer. Formerly there was almost no drug to relieve these except-
ing opium, while now we have phenacetin, antipyrin, phenalgiri,
and a host of others, and chemists are daily at work preparing new
and perhaps even better pain-killers.

Hardly, if at all, less distressing than pain is sleeplessness, and
here again our powers of helping the patient have been enormously
increased of late years. When I was a student almost the only
hypnotics used were opium, henbane, and Indian hemp. The latter
two were very unsatisfactory and practically one pinned one's faith
on opium which had to be combined with tartar emetic in cases of
fever. Then came the introduction by Liebreich of chloral, which
was not only a great boon in itself but marked an epoch as one of
the first instances of rational therapeutics, the application of a
certain drug in disease because of its pharmacological action. Now
we have any number of hypnotics, some of which are useful be-
cause they act on the nervous system itself and produce sleep with-
out depressing the heart and can thus be given where the circula-
tion is already weak, while others, like chloral, not only act on the
cerebrum but lessen the force of the circulation, and by thus di-
minishing the flow of blood through the brain assist it to rest and
aid the onset of sleep. Formerly when the circulation was too
active the chief depressants were mercurial and other powerful
purgative medicines, bleeding, tartar emetic, vegetarian diet, or
partial starvation. Although these means may still be employed with
advantage in proper cases, yet we have in addition a new set of
remedies, viz., vaso-dilators, including nitrites, nitrates, and pos-
sibly a good many substances which dilate the vessels and lower
the tension in the arteries, a tension which may be dangerous on
the one side to an enfeebled heart and on the other to an athero-
matous artery in the brain.

When the heart is failing we have a series of cardiac tonics and
stimulants. Foremost amongst these, perhaps, may be put strych-

THE PROBLEMS OF THERAPEUTICS 183

nine, the action of which on the heart was practically unknown when
I was a student, and perhaps now it is hardly sufficiently recog-
nized. At the time of which I speak, digitalis was looked upon as
a cardiac depressant, and almost the only cardiac stimulant that
was known was alcohol. Now digitalis, strophanthus, and a num-
ber of others are regularly used as cardiac tonics, and their power
of contracting the vessels is also sometimes useful in removing
dropsy. When this action is likely to be harmful to a weak heart,
it may be lessened by the simultaneous administration of vascular
dilators. We still, however, want drugs which will act only on the
heart, or only on the vessels. We require medicines which will
diminish the cardiac action and dilate the vessels for use in high
tension, such as so often occurs in gout, and we need drugs which will
make the heart beat more forcibly while they cause the vessels to
contract and raise the tension in cases of debility.

But prevention is better than cure, and if by modifying tissue-
change we can obviate the high tension and hypertrophy of the
heart which so frequently lead to apoplexy, or the atheromatous
condition of the vessels which leads to senile degeneration of the
brain or premature old age, we shall lessen the necessity for either
cardiac tonics or vascular dilators. Some authorities claim that
they can do this by vegetarian diet, limited in quantity as well as
in quality, while others would treat it by a diet almost entirely of
meat with liberal potations of hot water. The subject of diet is one
regarding which the most contradictory opinions prevail and there
is a sad want of precise knowledge upon which to base dietetic rules.
We may hope, however, that the investigation at present being con-
ducted by Professor At water under the United States Government,
combined with that which is being carried on under the auspices of
the Carnegie Trustees, will furnish the information we need.

Time will not allow me to do more than mention aerotherapeu-
tics, balneotherapeutics, and hydrotherapeutics ; the rest-cure which
is associated with the name of one of America's most brilliant and
versatile sons, Weir Mitchell; massage and movements which Ling
and his pupils, both in Sweden and elsewhere, have done so much
to elaborate and which when rightly used may be so beneficial
and wrongly used so harmful. For all these branches of therapeu-
tics we require a more exact knowledge of their action and the
rules for employing them, so that even those who have made no
special study of them may employ them rightly in all diseases in
which they may be of service.

Another method of cure consists in eliminating waste products from
the body by rendering them more soluble and while limiting the water
drunk would give lithia, piperazine, piperidine, and other substances
which increase the solubility of uric acid. Before therapeutics can

184 THERAPEUTICS AND PHARMACOLOGY

make much advance in this direction we must know more about the
pathology of gout and tissue-metabolism generally, and we may then
hope that not only will people be more free from the manifold symp-
toms that gout produces, but will live longer and the time of their
activity, bodily and mental, will continue nearly as long as life itself.
The power of increasing elimination of nitrogenous waste which urea
possesses in a marked degree is shared by other substances belong-
ing to the so-called purin group and day by day fresh bodies be-
longing to this chemical group are being made synthetically. Some
of the new ones seem to have a greater power of eliminating waste
than any we have hitherto had. The observations of Richardson,
that alcohols vary in their action according to their chemical com-
position, and of Crum, Brown, and Fraser, that alteration in chemical
constitution brings about a change in physiological action, are now
beginning to bear rich fruit, and the synthetic preparation of reme-
dies having different pharmacological properties along with our in-
creasing knowledge of pathology gives us much hope for the future
of therapeutics. More than two hundred years ago, Locke said :
"Did we know the [mechanical] affections of rhubarb, hemlock,
opium, and a man as a watchmaker does those of a watch, whereby it
performs its operations, and of a file which by rubbing on them will
alter the figure of any of the wheels, we should be able to tell before-
hand that rhubarb will purge, hemlock kill, and opium make a man
sleep." One of the great problems of therapeutics is not only to know
(a) what drugs to use in order to obtain certain effects, but to know
(6) how to make such drugs if we have not got them at hand. The
struggle for existence does not occur only between man and beast,
man and man, or nation and nation, nor even between individual
beasts or plants. It takes place also between cell and cell, not only
between those cells which we term microbes and the cells which
form the human body, but even between those which form the dif-
ferent parts of the body itself.

The great object of this Congress is to unify knowledge, to render
evident the similarity of the laws which govern phenomena of the
most diverse character, and it is therefore interesting to find that
the grand problem of therapeutics is for the cell what those of
religion and sociology are for the man, viz., to learn how to regulate
the environment of each cell or man in such a manner that the
individual shall not work for his or its own good alone, but for that of
others as well, and how to restrain or destroy those which are noxious.
When we are able to regulate cell-life by food, air, water, exercise,
inoculations, or medicines, we shall be able to relieve or remove
weakness, pain, or distress, not only from the bodies but also from
the minds of our patients, to maintain health, increase strength, and
prolong life to an extent of which at present we can hardly dream.

SHORT PAPER

DR. REID HUNT, Pharmacologist of the United States Public Health and
Marine Hospital Service, presented a paper to this Section on "The Relation
of Acute and Chronic Alcoholism to some other Forms of Poisoning."

SECTION E — INTERNAL MEDICINE

SECTION E — INTERNAL MEDICINE

(Hall 13, September 23, 3 p. m.)

CHAIRMAN: PROFESSOR FREDERICK C. SHATTUCK, Harvard University.
SPEAKERS: PROFESSOR T. CLIFFORD ALLBUTT, F. R. S., University of Cam-
bridge.

PROFESSOR WILLIAM S. THAYER, Johns Hopkins University.
SECRETARY: DR. R. C. CABOT, Boston, Mass.

THE HISTORICAL RELATIONS OF MEDICINE AND

SURGERY

BY THOMAS CLIFFORD ALLBUTT

[Thomas Clifford Allburt, Regius Professor of Physic, Cambridge, England, b.
Dewsbury, England, 1836. M.A., M.D., Cambridge; (Hon.) D.Sc. Oxford;
(Hon.) M.D. Dublin; (Hon.) D.Sc. Victoria; (Hon.) LL.D. Glasgow; F. R. C. P.
London; (Hon.) F. R. C. P. Ireland. Physician, Leeds, England, General
Infirmary, 1865-85; Consulting Physician, also, to the Belgrave Hospital for
Children, London; Commissioner in Lunacy, 1889—93; Physician to the
Addenbrooke's Hospital, Cambridge; Fellow of the Royal Society; Fellow
of the Linnean Society of London; Fellow of the Society of Antiquaries, Lon-
don; Honorary Member of the New York Academy of Medicines. Author of
many medical works; Science and Medieval Thought; Historical Relations of
Medicine and Surgery.]

IT was, I think, in the year 1864, when I was a novice on the
honorary staff of the Leeds General Infirmary, that the unsurgical
division of us was summoned in great solemnity to discuss a method
of administration of drugs by means of a needle. This method having
obtained some vogue, it behoved those who practiced "pure" medi-
cine to decide whether this operation were consistent wiith the
traditions of purity. For my part, I answered that the method had
come up early, if not originally in St. George's Hospital, and in the
hands of a house physician, Dr. C. Hunter; that I had accustomed
myself already to the practice, and proposed to continue it; more-
over, that I had recently come from the classes of Professor Trous-
seau, who, when his cases demanded such treatment, did not hesi-
tate himself to perform paracentesis of the pleura, or even incision
of this sac or of the pericardium. As for lack, not of will, but of skill
and nerve, I did not intend myself to perform even minor operations.,
my heresy, as one traitorous in thought only, was indulgently ignored;
and we were set free to manipulate the drug needle, if we felt dis-
posed to this humble service. About this time certain Fellows of the
London College of Physicians, concerned with the diseases of women,
had been making little operations about the uterus, and meeting

190 INTERNAL MEDICINE

with but slight rebuke, they rode on the tide of science and circum-
stance, encroaching farther and farther, until they were discovered
in the act of laparotomy; and rather in defiance than by conversion
of the prevailing sentiment within those walls, they went on doing it.

Meanwhile the surgeons, emboldened by great events in their
mystery, wrought much evil to the "pure" physicians; accusing
them with asperity of dawdling with cases of ileus and the like until
the opportunity of efficient treatment had passed away: nay, auda-
cious murmurs were heard that such "abdominal cases" should be
admitted into surgical wards from the first. Then, by dexterous
cures, growing bolder and bolder, the surgeons went so far as to make
a like demand for cases of tuberculous peritonitis, of empyema, and
even of cerebral tumor. As thus the surgeons laid hands on organ
after organ which hitherto had been sacred to "pure" medicine, and
as indeed the achievements of surgery became more and more glo-
rious, not only the man in the street but the man of the Hospital
Committee also began to tattle about the progress of surgery and the
diminution of medicine, until it was only by the natural sweetness of
our tempers that the surgeon and the inner mediciner kept friends.
At a dinner given on June 30 last to Mr. Chamberlain, in recognition
of his great services to tropical medicine, this vigorous statesman
said, "I have often heard that while surgery has made gigantic pro-
gress during the last generation, medical science has not advanced
in equal proportion;" then, while modestly disclaiming the know-
ledge to "distinguish between the respective claims of these two
great professions," he generously testified that "medical research
assisted by surgical science has thrown a flood of light on the origin
of disease, and that this at any rate is the first step to the cure of
disease." Now Mr. Chamberlain is the first of English statesmen to
ally himself actively with our profession; the first with imagination
enough to apprehend the great part which medical science is playing
in the world already, and to realize that only by medicine can vast sur-
faces of the earth be made habitable by white men, and those "great
assets of civilization," the officers of our colonies, be saved alive. It
seems to me, then, that the present is a critical moment in the rela-
tions of medicine and surgery, especially in England, where the two
branches of the art have been separated so radically as to appear to
be "two professions; " a moment when it is our duty to contemplate
the unity of medicine, to forecast its development as a connected
whole, and to conceive a rational ideal of its means and ends. But
this large and prophetic vision of medicine we cannot attain without
a thoughtful study of its past.

If, as from a height, we contemplate the story of the world, not its
pageants, for in their splendor our eyes are dim, but the gathering,
propagation, and ordination of its forces, whence they sprang, and

RELATIONS OF MEDICINE AND SURGERY 191

how they blend this way and that to build the ideas and institutions
of men, we may wonder at their creative activity, or weep over the
errors and the failures, the spoliation and the decay, which have
marred or thwarted them; and if we contemplate not the whole but
some part of men's sowing and men's harvest, such a part as medi-
cine, the keener is our sorrow and disappointment, or our joy and our
hope, as we admire the great ends we have gained or dwell upon the
loss and suffering which have darkened the way. "In the develop-
ment of medicine," said Helmholtz, "there lies a great lesson on the
true principles of scientific progress."

Pray do not fear, however, that to fulfill the meaning of the title
of this address, I shall describe to you the history of medicine and the
history of surgery, and on this double line compare and combine my
researches; in the time allotted to me no such survey is possible.
In the seventeenth century the handicrafts of anatomy, chemistry,
and physiology so penetrated medicine that the separate influence of
surgery is less easily discernible. My purpose, therefore, is to pass in
review certain eminent features of the history of these departments of
knowledge up to the end of the sixteenth century, and to compare
them with a view to edification ; your fear will be rather that I may
tell my story with the unrighteousness of a man with a moral.

In his address on "Morgagni," at Rome, in 1894, Virchow said that
medicine is remarkable in its unbroken development for twenty-five
centuries; as we may say, without irreverence, from Hippocrates to
Virchow himself. The great pathologist's opinion, however, seems
to need severe qualification; if it be so, the stream has more than once
flowed long underground. The discontinuity of medicine from Egypt
to Crotonaand Ionia is scarcely greater than from Galen to Avicenna;
during which period, in spite of a few eminent teachers in the
Byzantine Empire, it sank, in the West at any rate, into a sterile and
superstitious routine.

Classical medicine, the medicine of the fifth century, B. c., is
represented for us by the great monument of the Scriptures collected
under the name of the foremost teacher of the age, Hippocrates; in
genius perhaps the greatest physician of all past time. The treatises
of the Canon may be divided into medicine, surgery, and obstetrics.
The medical treatises, when read in an historical spirit, command
our reverent admiration. Written at a time when an inductive phy-
siology was out of reach, we are impressed nevertheless by their
broad, rational, and almost scientific spirit. Medicine, even when not
dominated by contemporary philosophy, has always taken its color
from it; and the working physiology of Hippocrates was that hu-
moral doctrine, originally derived from Egypt and the East, which,
as enlarged by Galen, ruled over medicine till recent times. Hippo-
crates, while distinguishing between the methods of outward and

192 INTERNAL MEDICINE

inward maladies (<f>avcpa. KOI a8rj\a voo^/nara), taught that even for the
inner, by careful sight and touch, laborious inspection of excretions,
and so forth, many facts are accessible to methodical investigations;
yet, as in inner diseases the field for inference is more spacious, the
data even of direct observation fell the more readily into the scheme
of the four humors, and by this doctrine were so colored that,
although observed with a rare clinical insight, they were set in the
frame of a fictitious pathology.

How was it then that the speculative side of the medicine of Hip-
pocrates embarrassed him so little? Because the clinical method of
the school was soundly based upon the outward maladies, where
direct induction was practicable. No sooner indeed does an inward
affection — an empyema for example — work outwards than the
mastery of Hippocrates becomes manifest. What we separate as
surgery, surgery which, from Guy to Pare", by clerks, faculties, and
humanists was despised as vile, and from Par6 to Hunter as illiberal,
was in the age of Hippocrates, as in all critical epochs of medicine
since that age, its savior.

If then our admiration of the inner medicine of Hippocrates, great
as it is, is a relative admiration, an admiration of the historical sense,
of his outer medicine our admiration is instant and unqualified.
Little as the fifth century knew of inward anatomy, as compared
with Alexandria about two centuries later, yet the marvelous eye and
touch of the Greek physician had made an anatomy of palpable
parts — a clinical anatomy — sufficient to establish a medicine of
these parts of the body of which our own generation would not be
ashamed.

In respect of fractures and luxations of the forearm, M. Pe"tre-
quin pronounces Hippocrates more complete than Boyer; in respect
of congenital luxations richer than Dupuytren. Malgaigne again
admires his comparison of the effects of unreduced luxations on the
bones, muscles, and functions of the limb in adults, in young children,
and before birth, as a wonderful piece of clinics. In Littre"'s judg-
ment, the work of Hippocrates on the joints is a work for all time.
On wounds Littre" pronounces that the Hippocratic books must be
pondered with deep attention; for they are founded on a wide ex-
perience, minute and profound observation, and an enlightened and
infinitely cautious judgment. Permit me to call your attention, how-
ever, to certain of his counsels: That a wound be let bleed, in order
to prevent inflammatory consequences; that if in fresh wounds
healing by first intention may take place, suppuration or coction is
the usual, and in less recent and in contused wounds the normal
course; also that wounds should be treated with linseed and other
poultices: counsels which, as we shall see presently, were to be as
hotly contested in the thirteenth and fourteenth centuries as in the

RELATIONS OF MEDICINE AND SURGERY 193

nineteenth. From amputation of the larger limbs he flinched, as did
most if not all responsible surgeons down to Pare"; for inner anatomy
was ill-known, and ligature, even in wounds, made slow way, indeed,
before Celsus, seems to have been unknown. Caries was not defin-
itely distinguished from necrosis, but a case of disease of the palate
with fallen nose irresistibly suggests syphilis. Of eye diseases we find
much of interest; of obstetrical practice I must be content to say
that it had reached a high standard; and to state once for all that
when surgery flourishes obstetrics flourish.

It is by comparison of one part of the Hippocratic Canon with
another that we learn how a strong grasp of inner medicine was
attained by way of intense devotion to its inductive or surgical side.
And this not by a mere empiricism; for it may have been from
Hippocrates that Aristotle learned how by empiricism (e/*7mpia) we
perceive a certain remedy to be good for this person or for that —
for Socrates, let us say, or for Callias — when he has a certain fever;
but that by reason we discern the characteristic common to all these
particular persons, wherein they react alike. In his Book of Pre-
cepts Hippocrates tells us that Tpiftrj /nera Xoyou is the basis of all
medical knowledge. Now rpi/3-^ is primarily a grinding or rubbing;
so the student must rub and grind at nature, using his reason at the
same time; but his reason must be a perceptive and interpretative
not a productive faculty, for he who lends himself to plausible ratio-
cination (\oyto-fjuS iriOavto Trpoo-txow) will find himself ere long in a
blind alley; and those who have pursued this course have done no
enduring service to medicine. How soundly, for the time, this lesson
was learned we see in the theoretical appreciation of these several
faculties in the first chapter of Aristotle's Metaphysics and in the
Sixth Book of the Ethics, where the senses, it is urged, cannot really
be separated from the mind, for the senses and the mind contribute
each an element to every knowledge. I am disposed to suggest that
this method of observation, experience, and judgment was estab-
lished first in medicine, because medicine is both practical and
imperative; and, as Aristotle points out, concerned with the indi-
vidual patient: to our art, then, may belong the honor of the appli-
cation of positive methods to other sciences.

The chief lesson of the Hippocratic period for us is that, in practice
as in honor, medicine and surgery were then one; the Greek phy-
sician had no more scruple in using his hands in the service of his
brains than had Pheidias or Archimedes ; and it was by this coopera-
tion in the fifth century that the advance was achieved which in our
eyes is marvelous. As we pursue the history of medicine in later
times we shall see the error, the blindness, and the vanity of physi-
cians who neglected and despised a noble handicraft. The clear eyes
of the ancient Greeks perceived that an art is not liberal or illiberal

194 INTERNAL MEDICINE

by its manipulations, but by its ends. As, because of its ends, the
cleansing and solace of the lepers by St. Francis and Father Damien
was a service of angels, so Hippocrates saw no baseness even in mani-
pulations, which obtained for his followers the name of coprophagi;
where there is no overcoming there is no victory.

Between Hippocrates and Galen, an interval of some five cen-
turies, flourished the great anatomical and medical schools of Alex-
andria. Our only important source, however, for the medicine of the
Alexandrian period is Celsus, who lived in the reign of Augustus. In
Celsus we find that the surgical and obstetrical sides of it had made
farther and substantial progress. Celsus, perhaps not himself a
practitioner, is sometimes vague in detail; still, beyond the Hippo-
cratic surgery, we read of treatment in piles, fistula, rodent ulcer,
eczema, fractures, and luxations; the nasal passages were cauterized
for ozena; dropsies were systematically tapped; hernias were sub-
mitted to radical cure; plastic operations were undertaken, and the
larger limbs were deliberately amputated, though only in extreme
need, and often with fatal results by secondary hemorrhage and
otherwise.

How active surgery was from Celsus to Galen, and how honorable
and progressive a part of medicine, we know from the scanty records
of Archigenes of Apamea, who also practiced in Rome, in the reign of
Trajan. Galen calls him an acute but too subtle a physician; such of
his subtleties, however, as are known to us — his distinction between
primary and consequential symptoms for instance — are to his
credit. He applied the ligature in amputations, and Antyllus applied
the method to the cure of aneurism, which indeed Rufus seems to
have done before him. Galen tells us where he got his "Celtic linen
thread" for the purpose, namely, "at a shop in the Via Sacra
between the Temple of Rome and the Forum." We learn also, from
Oribasius, that Antyllus practiced extensive resections of bone in the
limbs, and even in the upper and lower jaw.

Galen came to Rome under Marcus Aurelius. In the biological
sciences this great physician stands to Harvey, as in physics Archi-
medes stood to Galileo and to that other great physician, William
Gilbert; Galen was the first, as for many centuries he was the last, to
apply the experimental method to physiology. He embraced the
ancillary sciences, he opened out new routes, and he improved the
old. Unhappily, his soaring genius took delight also in speculation ;
and it was not the breadth of his science, rior the depth of his meth-
odical experiment, but the height of his visionary conceits which
imposed upon the Middle Ages. Galen did not himself forget the
precept of Hippocrates: To look, to touch, to hear (K<U JSetv, *eu
tfiyetv, KCU dKouo-ai) ; but he did not wholly subdue himself to the -n-elpa
r — this toilsome conversation with troublesome facts. Galen

RELATIONS OF MEDICINE AND SURGERY 195

did not make any great mark on surgery; his tracts on the eye are
lost; but, so far as we know, his surgery was adopted in the main
from the Alexandrians and from Soranus. However, Galen success-
fully resected the sternum for caries, exposing the heart; and he
excised a splintered shoulder-blade: moreover, with all his bent to
speculative reason, we have no hint that he fell into the medieval
abyss of regarding surgery as unfit for a scholar and gentleman.

After Soranus and Galen medicine came to the evening of its
second day, to the long night before the rise of the Arabian, Italian,
and French surgeons of the twelfth, thirteenth, and fourteenth
centuries.

In spite of the docile industry of Greek physicians of the Byzantine
period, medicine gradually sank not into sterility only, but into
degradation. The wholesome discipline of practical surgery had
fallen off. Eastern folk, who bear heaven-sent sores with fatal
stoicism, shrunk from the profane hand of man; and the tradition
of Galen made for a plague of drugs which were least mischievous
when merely superfluous. Rhazes, Albucasis, Avicenna the Arabian
Galen, had entered by the door of the East into a great scientific
inheritance, and, if they did little to develop surgery, it still was with
them a grave and an honorable calling; with them medicine had not
yet lost her right arm. The small benefits of the Church to medicine
issued in a far greater treachery. The Greek of Ireland, and of England
in the time of Bede, was banished by Augustine and the Benedictine
missionaries; and the medicine of Monte Cassino, itself a farrago of
receipts, in the monkish hostels of the West fell lower and lower.
We have reason, however, to believe that even in the cloister some
fair surgery was making way, when it was finally abandoned to the
"secular arm" by the Council of Tours, in A. D. 1163; and books on
surgery and midwifery began to disappear from the clerical libraries.
The University of Paris excluded all those who worked with their
hands; so that its students of medicine had to abjure manual occu-
pation, and to content themselves with syllogisms and inspections of
urine, often, indeed, without any inspection of the patient himself.
From the University the Faculty of Medicine took its tone, and the
Surgical Corporation of St. Come aped the Faculty. But by the
expulsion of surgery from the liberal arts, and the societies of learned
men, medicine herself was eviscerated; thus was made the pernicious
bisection of medicine which has not yet spent its evil ; the inductive
foundations of the art were removed, and the clergy and the faculties,
in France and England at any rate, devoted all their zeal to shoring-
up the superstructure. Surgery saw its revenge, its bitter revenge;
but in the ruin of its temple. In the thirteenth and fourteenth cen-
turies surgery, hated and avoided by medical faculties, scorned in
clerical and feudal circles, began in the hands of lowly and unlettered

196 INTERNAL MEDICINE

men to grow from a vigorous root; while inward medicine, with-
drawing itself more and more from the laboratory of nature, hardened
into the shell which till the seventeenth century was but a counter-
feit. The surgeons of the thirteenth, fourteenth, and fifteenth cen-
turies, reared in humble apprenticeships, not illiterate only, but for-
bidden the very means of learning, lay under heavy disadvantages;
yet, such is the virtue of practical experience, inductive method,
and technical resource, that by them the reform of medicine was
made. Towards the end of the fifteenth century, indeed, this pro-
gress had slackened, soon to be reinforced, however, by new and
urgent problems, not of the schools, but of direct rough and tumble
with nature. Of these new problems, of which Par6 became the
chief interpreter, new epidemics and the wounds of firearms were
the chief.

In medicine from the twelfth to the eighteenth centuries Italy
led the world; in the schools of Salerno, Naples, Bologna, Padua,
was contained a strong lay and imperial tradition which gave pause
to clerical ascendency. Bologna, until the predominance of her
law school, was indeed a large and plenteous mother to medicine
in its full orb; but already in Salerno far-seeing men had begun
to dread the divorce of surgery from inner medicine. The import-
ant Salernitan treatise of the end of the twelfth century, The
Glosses of the Four Masters on the Surgery of Roger and Roland,
edited by Daremberg and de Renzi, begins with a lament on the
decadence of surgery, which they attribute to two causes; namely,
the division of surgery from medicine, and the neglect of anatomy.
By the wisdom of Bologna and Naples, where chairs of surgery
were founded, this ill-starred divorce was postponed; in his Uni-
versity of Naples indeed Frederick the Second made it a condition
that surgery should be an essential part of medicine, should occupy
as long a course of study, and should be established on anatomy
"without which no operator can be successful."

Roger's Practica Chirurgiae was written in 1180, and though of
course it rests upon the traditional surgery of his day, there are
not a few points of interest in the book, such as certain descrip-
tions suggestive of syphilis. For hemorrhage Roger used styptics,
the suture, or the ligature; the ligature he learned no doubt from
Paul of Egina; but Roger, like most or all qualified physicians of
the period, was a "wound-surgeon" only, that is, he did not un-
dertake the graver operations. He was in favor, as a rule, of im-
mediate extraction of weapons from their wounds; but in these
wounds, even after extraction, he encouraged suppuration by
stimulating applications within and around them, and dressed
them with ointments on lint. To these points, especially to the
promotion of pus, and the unctuous dressings, permit me again to

RELATIONS OF MEDICINE AND SURGERY 197

draw your attention; for we enter now upon a surgical contro-
versy which, pale reflection as it may be of the great surgical day-
spring of the nineteenth century, is, historically speaking, of sin-
gular interest.

Hugh, of Lucca, says Malgaigne, is the first of the surgeons of
modern Europe whom we can cite with honor. This tribute is
a little strained; we may say, however, that of these honorable
ancestors Hugh seems to have been a chief. I say "seems to have
been;" for Hugh is even a dimmer giant than Roger or Roland.
We know that he was born of honorable family about the middle
of the twelfth century; that he served as surgeon in the campaigns,
and was present at the siege of Damietta; but of writing he left
not a line. Such vision as we have of him we owe to his loyal dis-
ciple, probably his son, the Dominican Theodoric, Bishop of Cervia,
and master of Henry of Mondeville. He completed his "surgery"
in 1266, but his life was almost coterminous with the thirteenth
century. What was Theodoric 's message? He wrote thus: "For
it is not necessary, as Roger and Roland have written, as many of
their disciples teach, and as all modern 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 conglutination and consolidation of the wound."
In principle what more did Lister say than this? Henry of Monde-
ville made a hard fight for the new principle, but the champions
of Galenism and suppuration won all along the line; and for five
following centuries poultices and grease were still to be applied
to fresh wounds, and tents, plastered with irritants to promote
suppuration, were still to be thrust into the recesses of them, even
when there was no foreign body to be discharged. If after all this,
erysipelas set in — well, says Henry, lay it at the door of St. Eli-
gius! Hugh and Theodoric for the fresh wound rejected oil as too
slippery for union, and poultices as too moist; they washed the
wound with wine, scrupulously removing every foreign particle;
then they brought the edges together, forbidding wine or anything
else to remain within. Dry and adhesive surfaces were their de-
sire. Nature, they said, produces the means of union in a viscous
exudation, or natural balm as it was afterwards called by Paracel-
sus, Pare", and Wiirtz. In older wounds they did their best to obtain
union by cleansing, desiccation, and refreshing of the edges. Upon
the outer surface they laid only lint steeped in wine. Powders
they regarded as too desiccating, for powder shuts in decompos-
ing matters; wine, after washing, purifying, and drying the raw
surfaces, evaporates. The quick, shrewd, and rational observa-
tion, and the independent spirit of Theodoric, I would gladly illus-
trate farther did time permit; in passing, I may say that he was

198 INTERNAL MEDICINE

the first to notice salivation as the result of administration of mer-
cury in "skin diseases."

Both for his own merits, and as the master of Lanfranc, William
Salicet was eminent among the great Italian physicians of the
latter half of the thirteenth century. Distinguished in surgery,
both as practitioner and author, he was also one of the protestants
of the period against the division of the craft from inner medicine;
a division which he justly regarded as a withdrawal of medicine
from intimacy with nature. Like Lanfranc and all the great sur-
geons of the Italian tradition, and unlike Franco and Pare*, he had
the advantage of the liberal university education of Italy; but,
like Par6 and Wiirtz, he had also large practical experience in camp,
hospital, and prison. His Surgery contains many case-histories.
He discovered that dropsy may be due to a "durities renum;"
he substituted the knife for the abuse of the cautery by the fol-
lowers of the Arabs; he pursued the investigation of the causes of
the failure of healing by first intention; he described the danger
of wounds of the neck; he forwarded the diagnosis of suppura-
tive disease of the hip, and he referred chancre and gangrene to
"coitus cum meretrice."

The Chirurgia Magna of Lanfranc of Milan and Paris, pub-
lished in 1295-96, was a great work, written by a reverent but in-
dependent follower of Salicet. He distinguished between venous
and arterial hemorrhage, and generally used styptics; white of
egg, aloes, and rabbit's fur was a popular styptic in elder surgery,
though in severe cases ligature was used. Learned man as he was,
Lanfranc saw the more clearly the danger of separating surgery
from medicine. "Good God!" he exclaims, "why this abandon-
ing of operations by physicians to lay persons, disdaining surgery,
as I perceive, because they do not know how to operate ... an
abuse which has reached such a point that the vulgar begin to
think the same man cannot know medicine and surgery. ... I
say, however, that no man can be a good physician who has no
knowledge of operative surgery; a knowledge of both branches
is essential" (Chirurgia Magna).

Henry of Mondeville, of whom we hear first in 1301, as surgeon
to Philip the Fair, was for the most part a loyal disciple of Lan-
franc, and, aided as it would seem by Jean Pitard, also surgeon
to the King, attempted for wounds to introduce the new methods
of Hugh and Theodoric; for his pains he exposed himself to bad
language, threats, and perils; and "had it not been for Truth and
Charles of Valois," to far worse things. So he warns the young
and poor surgeon not to plow the sand; but to prefer complais-
ance to truth, and ease to new ideas. I may summarize, briefly, the
teaching of Henry on the cardinal features of the new method:

RELATIONS OF MEDICINE AND SURGERY 199

Wash the wound scrupulously from all foreign matter; use no
probes, no tents — except under special circumstances ; no oily
nor irritant applications; avoid the formation of pus, which is not
a stage of healing, but a complication; do not, as Galen teaches,
allow the wound to bleed with the notion of preventing inflamma-
tion, for you will only weaken the patient's vitality (virtus), give
him two diseases instead of one, and foster secondary hemorrhage;
distinguish between oozing hemorrhage, hemorrhage by jets, and
that which pumps out of an inward wound, using for the first, styp-
tics, and for the last two the cautery, or, where practicable, digital
compression for not less than a full hour; when your dressings have
been carefully made, do not interfere with them for some days;
keep the air out, for a wound left in contact with the air suppurates;
however, should pain and heat arise, open and wash out again, or
even a poultice may be necessary, but do not pull your dressings
about — nature works better alone; if first intention fail, she may
succeed in the second, as a jeweler, if he can solder gold to gold
does so, if not, he has to take to borax; these resources, however,
we learn well, not by arguing but by operating. By the new method
you will have no stinks, shorter convalescence, and clean, thin scars.
In wounds of the neck he says that alterations of the voice suggest
implications of the larynx. When using the word " nature," he freely
admits that the word is an equivocal one, but he would speak of
her allegorically as a lute-player to whose melodies the physician
has to dance. Again he says: "Every simple wound will heal with-
out any notable quantity of pus, if treated on Theodoric's and my
instructions. Avoid every cause of formation of pus, such as irritat-
ing applications, exposure to air, high diet, edema, local plethora.
Many more surgeons know how to cause suppuration than how to
heal a wound." Now let me remind you that, until Hugh of Lucca,
the universal doctrine was that suppuration or coction is necessary;
and that if it does not set in, it must be provoked.

The greatest of the French surgeons before Pare" was Guy of
Chauliac, who flourished in the second half of the fourteenth cen-
tury. He studied in letters and medicine at Toulouse and Mont-
pellier; in anatomy at Bologna. The surgeon, ignorant of anatomy,
he says, "carves the human body as a blind man carves wood."
The Arabs and Paris said: Why dissect if you trust Galen? but
the Italian physicians insisted on verification. .Guy was called to
Avignon by Clement VI. During the plague of 1348 he stayed to
minister to the victims, and did not himself escape an attack, in
which he was ill for six weeks. His description of this epidemic
is terrible in its naked simplicity. He gave succor also in the visita-
tion of 1360.

His Chirurgia Magna I have studied carefully, and do not wonder

200 INTERNAL MEDICINE

that Fallopius compared the author to Hippocrates, and that John
Freind calls him the prince of surgeons. The work is rich, aphoris-
tic, orderly, and precise. Guy was a more adventurous surgeon
than Lanfranc, as was Franco, a later Provengal, than Pare". He did
not cut for stone, but he operated for radical cure of hernia and
for cataract; operations till his time left wholly to the wayfaring
specialists. In Guy the critical spirit was awake. He scorns the
physicians of his day, "who followed each other like cranes, whether
for fear or love he would not say." In respect of principles, how-
ever, Guy was not infallible. Too sedulous a disciple of Galen, he
was as a deaf adder to the new message of Hugh, Theodoric, and
Henry; and not only was he deaf himself, but, as the authorita-
tive master of the early renascence, he closed the ears of his brethren
and successors, even to the day of Lister.

This vigorous life which surgery gave to the medicine of the
thirteenth and fourteenth centuries was stifled in the West by the
pride and bigotry which, culminating in the Council of Tours, had
thrust surgery down into the ranks of illiterate barbers, reckless
specialists, and adventurous charlatans. In Italy, however, the
genius and bent of the people for art as well as for philosophy,
and the ascendency of the secular element in the universities, still
kept surgery in its place as "the scientific arm of medicine." l
Thus in Italy of the fifteenth century surgery did not droop as it
did in the West; if it slumbered for a spell, it soon awoke again,
refreshed in the new Hellenism. Pietro di Argelata (d. 1423), Doc-
tor of Arts and Medicine, and professor of Bologna, wrote an excel-
lent Surgery full of personal observation ; and perhaps for the first
time, was frank about his own mistakes. Bertipaglia, another great
Paduan professor, flourished a little after Argelata, but was a man
of less originality. Argelata followed the lead of Henry and Guy in
some bolder adventure in operative work as distinguished from mere
wound-surgery, and was himself a learned and skillful practitioner.

In the midst of the mainly Arabist professors of medicine of
the fifteenth century arose Benivieni, the forerunner of Morgagni,
and one of the greatest physicians of the late Middle Ages. This
distinguished man, who was born in 1448 and died in 1502, was not
a professor but a Doctor of Medicine, a man of culture and an emi-
nent practitioner in Florence. Although born in the new platonism ,
he was, like Mondeville, one of those fresh and independent ob-
servers who surrender to no authority, to Arab nor Greek. Yet
for us Benivieni 's fame is far more than all this; for he was the
founder of the craft of pathological anatomy. So far as I know, he
was the first to make the custom, and to declare the need of ne-

1 A phrase which Sir John Burden Sanderson once used in my hearing.

RELATIONS OF MEDICINE AND SURGERY 201

cropsy to reveal what he called not exactly "the secret causes,"
but the hidden causes of diseases. Before Vasalius, Eustachius,
or Fallopius were born, deliberately and clear-sightedly he opened
the bodies of the dead as keenly as any pathologist in the more
spacious times of Morgagni, Haller, or Senac, or of Hunter, Baillie,
and Bright. Among his pathological reports are morbus coxae (two
cases), biliary calculus (two cases), abscess of the mesentery, throm-
bosis of the mesenteric vessels, stenosis of the intestine, "polypus"
of the heart, scirrhus of the pylorus, ruptured bowel (two cases).
He gives a good description of senile gangrene. Thus necropsy
was first brought into practice to supplement the autopsy which
the surgeon had long practiced in the living subject.

It would be unjust to forget that in the latter half of the fifteenth
century Paris admitted some reforms; celibacy for physicians
was abolished, and with it diminished the allurements of prebends
and rectories, and the pernicious practice of the "me'decins reclus"
who did not visit patients nor even see them, but received visits
from ambassadors who brought gifts and vessels of urine, and
carried back answers far more presumptuous than the well-known
co.unsel of Falstaff's physician. Still not only was reform in Paris
very grudging, but it was capriciously favored and thwarted by
the French court. The faculty denied to St. Come "esoteric" teach-
ing, diagnosis, and the use of medical therapeutics; a jealousy
which ended in the physician being requested to do little more
than write the prescription. Aristotle was quoted as unfavorable
to the "vulgarizing of science." Joubert was attacked for editing
Guy in the vernacular. Fortunately the surgeons were carried into
the field of battle, a far better school than the Paris Faculty.

Thus it was that in the opening of that great century in the
history of the human mind, the sixteenth century, we find Italian
medicine still in the van, until the birth of the great French sur-
geons, Franco and Pare", and of Gersdorff and Wiirtz in Germany.

Franco, like Pare", was no clerk; he came of a class .lower even
than that of Pare* and the barbers, the wayfaring class of bone-
setters, oculists, plastic operators, and cutters for stone and
hernia; "runagates," as Gale calls them. Thus dangerous visceral
operations, and those on the eye, which but too often were swiftly
disastrous, fell into the hands of wandering and irresponsible crafts-
men, men of low origin, and too often ignorant, reckless, and rapa-
cious. As the truss was a very clumsy instrument, at any rate till
the end of the seventeenth century, the radical cure of hernia was
in great demand. It is not the least of the merits of Franco that
he brought these operations within the lines of responsible surgery,
and thrust them into the ken of Pare" and Fabricius. This illustrious
Provengal surgeon — "ce beau g&nie chirurgical," as Malgaigne

202 INTERNAL MEDICINE

calls him, in declining the task of entering upon so full a life — was
born about 1503. He began as an apprentice to an operating barber
and hernia specialist. He had no more "education" than Par6
or Wiirtz, and he was spared the misfortune of a speculative in-
tellect. He picked up some anatomy, educated himself by obser-
vation, experience, and manipulation, and as a simple operator
or "Master," won considerable renown. As upright and modest
as Pare1, though he never attained Park's high social position, he
submitted to call in the physician, and took his quiet revenge in
the remark that the physicians did not know enough to distinguish
good surgery from bad. Nicaise says roundly, "No surgeon made
such discoveries as Franco; for hernia, stone, and cataract he did
much more than Pare"." Whether from incapacity or the brutality
of habit, during the Middle Ages and down even to the middle of
the seventeenth century, it had been the custom in operating for
hernia to sacrifice one or even both testicles, an abuse against which
Franco took successful precautions, for he proved that the canal
could be closed and the ring sutured without castration. In irre-
ducible inguinal hernia he distinguishes between opening and not
opening the sac, and describes adhesions of sac and intestine.
From him, indeed, dates the rational operation for strangulated
hernia, and in strangulated scrotal hernia he founded the method.
Pare", and after him Petit, condemned the ablation of the testicle,
which procedure, however, many surgeons thought quite good
enough for priests; and Par6 gives credit to Franco for these
advances, though Fabricius does not even mention them. On the
interesting subject of plastic operations, which attained a remark-
able vogue in the Middle Ages, and were but restored by Taglia-
cozzi, I have not now time to speak.

The very eminence of Ambroise Par6 encourages if it does not
command me to be content with a few words of commemoration.
Himself of humble origin, he won for surgery in France a social
place and respect it had never attained before. Born in 1517, he
became a barber's apprentice in the H6tel Dieu, whence he fol-
lowed the campaign of Francis I against Charles V. As he could
not write a Latin treatise, his admission to St. Come was of course
opposed by the Faculty; but Pare* stoutly declared that the ver-
nacular tongue was essential to the progress of medicine. Riolan
the elder, who had taken part in the opposition, wrote a tract on
the other side, in 1577, with the following insolent title: Ad im-
pudentiam quorundam Chirurgorum qui medicis aequari et chirur-
giam publick profitere volunt pro dignitate veteri medicinae apologia
philosophica. Now at this time Par£ was 60 years of age and sur-
geon to the King. If in comparison with Pare", Haeser treats Franco
somewhat slightingly, and if in some respects Par6 may not be

RELATIONS OF MEDICINE AND SURGERY 203

lifted far above some of his great Italian contemporaries, such as
Maggi, Carpi, or Botallo, yet taken all around the founder of mod-
ern surgery surely surpasses all the physicians of his time as an
independent, original, and inventive genius, and as a gentle, mas-
terly, and true man. Yet I am often surprised to see, even to-day,
the invention of ligature of arteries attributed to Pare", whose sur-
prise, if our journals have an astral shape, must be greater still,
seeing that he himself refers the ligature to Galen. The attribu-
tion is of course a legend. Malgaigne discreetly claims no more for
Pare" than the application of the ligature from wound-surgery to
amputations; but in my opinion even this claim goes beyond the
truth of history. Celsus speaks of the ligature as an ordinary
method in wounds; from Oribasius we learn that Archigenes of
Apamea even tied vessels in amputation, after fixing a tight band
at the root of the limb. It seems probable that, unless performed
with modern nicety, secondary hemorrhage must have been fre-
quent; indeed in 1773, Petit deliberately discarded the ligature,
as Franco and Fabricius had done before him. Military surgeons
considered even Park's "ligature en masse" too delicate a method
for the battle-field. It is a more intelligent service to this great
man to point out that the ligature and other operative details were
no singular devices, but orderly steps in a large reform of method
in amputation, a reform made imperative by the ravages of fire-
arms, ravages which could not be covered up with Galenisms.

It is the privilege of the historian to make light of time and space ;
and it is not easy to leave Pare and his times without some reflec-
tion upon the great German surgeons, Brunschwig, Gersdorff, and
Wiirtz, who, like him, were concerned with the effects of firearms.
In Italy in the sixteenth century surgery was somewhat on the
wane, but in Germany Wiirtz, in the freshness and originality of
his mind and in his freedom from scholastic convention, reminds
us of Pare".

Paracelsus (born 1491) was a surgeon and no inconsiderable
one. Had this extraordinary man been endowed with a little pa-
tience he would have been a leader in wound-surgery, though, like
Wiirtz, he was not an operator. He pointed out not only the abuse
of the suture by the surgeons of the day, but also that suppura-
tion is bad healing, for, if left to herself, nature heals wounds by
a natural balm, a phrase which Pare" adopted. In his Grosse Wiin-
darznei he says he began at the surgical because it is the most cer-
tain part of medicine, and time after time he rebukes those who
withdraw medicine from surgery. Brunschwig was indeed the first
surgeon to write upon the surgery of gunshot wounds with any
fullness or precision. He held, however, as Vigo after him, that a
gunshot wound was a poisoned wound; and, to eliminate the poison

204 INTERNAL MEDICINE

by free suppuration, used the medicated tents, or in case of thorough
penetration, the setons which were to arouse the angry antagon-
ism of Wiirtz.

Felix Wiirtz, like Franco and Pare", had also the good fortune
to escape a scholastic education; he was lucky enough, however, to
enjoy the liberal education of Gesner's friendship, and to listen
to the fiery disputes of Paracelsus. Gifted with an independent
and penetrating mind, he is as fresh and racy as Henry of Monde-
ville had genius enough to be in spite of the schools. Like all his
compatriots, he wrote in the vernacular; and for its originality
and conciseness, Wiirtz's Practica, published in 1563, stands in
a very small company. Had he known as much anatomy as Pare",
his defect in which he bewails, he might have been as great a man,
for his clinical advances were both new and important. He pro-
tests against the kind of examinations for practice held in some
cities where candidates patter off cut and dried phrases like par-
rots, while apprentices "play upon the old fiddle the old tune con-
tinually." By setting his face against cataplasms and grease, he
made for progress, though neither he nor Pare" attacked suppura-
tion in principle as Theodoric and Henry had done. His chief title
to fame, a fame far less ripe of course than that of Sydenham, but,
as it seems to me, not unworthy to be remembered beside it, lies
in his clinical acumen, and especially in his conception of wound
infections and their results. His description of diphtheria is espe-
cially remarkable.

While surgeons from generation to generation were making the
solid progress I have indicated, what were the physicians about?
Now, of the fantastic conceits they were spinning, of the gross and
blundering receipts with which they stuffed their books, I have
not time to speak; fortunately, history has but too well prepared
you to dispense with this side of the story. One example I will
give you: In the sixteenth century the air was rent by the clamor
of physicians contending in two camps with such ardor and with
such acrimony that the Pope, and even Charles the Fifth, inter-
fered — and on what momentous principle? Whether, in such a
disease as pleuro-pneumonia, venesection was to be practiced on
the same side as the disease or on the opposite side? Brissot, who
questioned the Galenical tradition in this matter, was declared
by the Emperor to be a worse heretic than Luther. Unfortunately
for Imperial medicine, if indifferently for science and the public
weal, it came out, on the recovery of the text of Hippocrates, that
Brissot had happened to be on the side of the father of medicine.

England, if by England we mean no more than the Isles of Britain,
makes no great show in medieval or renascence surgery. Arderne
was probably a far better surgeon than Gilbert or John of Gaddes-

RELATIONS OF MEDICINE AND SURGERY 205

den; but he is little more than a name. Nor does it do to peruse
Thomas Gale (1507-1586?) after Mondeville, Guy, Pare", Wiirtz,
or Maggi. In the Wounds Made by Gonneshot, the third part of
his Surgery, lies Gale's merit, that he also withstood "the gross
error of Jerome Brunswicke and John of Vigo, that they make
the wound venomous."

With the sixtenth century my survey must end; from this time
medicine entered upon a new life, upon* a new surgery founded on
a new anatomy and on a new physiology of the circulation of the
blood and lymph. These sciences, thus renewed, not only served
surgery directly, but by the pervading influence of the new accuracy
of observation, and the enlargement of the field of induction, also
indirectly modified the traditional medicine of physicians unversed
in methods of research, as we observe in the objective clinical
medicine of Sydenham. Our physiologists tell us that destruction
is easy, construction difficult; but in the history of medical dogma
this truth finds little illustration. So impatient is the speculative
intellect of the yoke of inductive research, so tenacious is it of its
castles in the air, that no sooner did Harvey, by revealing the me-
chanics of the circulation, sap the doctrines of the schools, than
some physicians instantly set to work to run up the scheme of
iatro-physics ; others to build a system of iatro-chemics, but upon
Von Helmont rather than on Willis and Mayow; while Hoffman
and his school resuscitated the strictum and laxum syllogisms of the
Greek Methodists.

In this sketch of the past, a sketch necessarily indiscriminate,
but not, I trust, indiscreet, we have seen that up to the time of
Avicenna, medicine was one and undivided; that surgery was re-
garded truly, not as a department of disease, but as an alternative
treatment of any disease which the physician could reach with his
hands; that the cleavage of medicine, not by some natural and
essential divisions, xbut by arbitrary paltering to false pride and
conceit, let the blood run out of both its moieties; that certain
diseases thus cut adrift, being nourished only on the wind, dried
into mummy or wasted in an atrophy, and that such was medicine;
while the diseases which were on the side of the roots, if they lost
something of their upper sap, were fed from below, and that such
was surgery.

Thus the physicians who were cut off from the life-giving earth,
being filled with husks and dust, became themselves stark and fan-
tastic. Broadly speaking, until the seventeenth century pathology
was a factitious schedule, and medicine a farrago of receipts, most of
them nauseous, many of them filthy; most of them directly mis-
chievous, all of them indirectly mischievous as tokens of a false
conception of therapy. A few domestic simples, such as the laxa-

206 INTERNAL MEDICINE

tives, are indispensable; for the rest we are tempted to surmise
that mankind might have been happier and better if Dioscoride.s
had been strangled in his cradle.

This is the truth I have tried to get home to you, that in the
truncation of medicine the physician lost not only nor chiefly a
potent means of treatment; he lost thereby the inductive method:
he lost touch with things; he deprived his brains of the coopera-
tion of the subtlest machine in the world — the human hand, a
machine which does far more than manufacture, which returns
its benefits on the maker with usury, blessing both him that takes
and him that gives.

Pure thought, for its own sake, especially in early life, when the
temptation to it is strong and experience small, seems so disinter-
ested, so aloof from temptation of gain, that in the history of ideas,
speculation and the construction of speculative systems have played
but too great a part, and have occupied but too many minds of
eminent capacity. We must assume then that they have served
— and for aught we know may still serve — some good end. It
seems hardly likely that age after age men would busy themselves
to build up these vast constructions in idle exercise. That nature
is wasteful we know but too well; yet she is wasteful by the way,
not in the main direction of her work. If some of her seed falls on
stony ground, if her rain falls on the just and on the unjust, yet
the sowing and the rain are in the main fruitful and delightful.
Peradventure, in our modern conviction <Jf the efficiency of the
inductive method we may be too ready to denounce other methods
which, hard as it may be for us to conceive, may yet play some
lasting part in evolution. Even in our own day we may become
too analytical; on our good side we may be too exclusive. In the
pale hue even of inductive analysis may we not get sick, lose reso-
lution in too much deliberation, overlook the concrete, and forget
that if by any mode of generalization we lose hold of individuals
in types, and of things in the negations and eliminations of ab-
straction we may fall ourselves into the very error of the "school-
authors." If the search for entities was false, may there not be a
sort of imposition in "laws"? When in the last analysis we attain
to unresolved residua may we not err in giving even to a true resi-
duum too solid a name? Whether it be the summation of phe-
nomena or a vision of the imagination an abstraction is an abstrac-
tion, and abstractions carry us a long way from deeds and things.

In the minds of academical teachers the notion still survives
that the theoretical or university form and the practical or tech-
nical form of a profession or trade may not only be regarded sepa-
rately, and taught in some distinction, which may be true, but
in independence of each other; nay, that the intrusion of the tech-

RELATIONS OF MEDICINE AND SURGERY 207

nical quality by materializing, degrades the purity or liberality of
the theoretical; that indeed if he had not to get his daily bread
the high-minded student may do well to let the shop severely alone.
Thus the university is prone to make of education thought with-
out hands; the technical school, hands without thought; each
fighting shy of the other. But if in a liberal training the sciences
must be taught whereby the crafts are interpreted, economized,
and developed, no less do the crafts, by finding ever new problems
and tests for the sciences, inseminate and inform the sciences, as
in our day physics are fertilized by the fine craft of such men as
Helmholtz, Cornu, and Stokes; and biology by that of Virchow,
Pasteur, and Lister. At the commemoration of Stokes in West-,
minster Abbey, Lord Kelvin honored in him the "combination
of technical skill with intuition; " and Lord Rayleigh admired in
him "the reciprocity of accurate workmanship and instinctive
genius;" appreciations no less true of these two distinguished
speakers themselves. If it be true, as I have been told, that the
University of Birmingham has a coal-mine upon the premises, I am
ready to believe that the craft of coal-getting, by carrying practice
into thought, will fortify the web of theory.

There exists, no doubt, the contrary danger of reducing educa-
tion to the narrow ideas and stationary habits of the mere artisan.
By stereotyped methods the shop-master who does not see beyond
his nose, may cramp the 'prentice, and this 'prentice becomes shop-
master in his turn. If in the feudal times, and times like them in
this respect, manual craft was despised, and the whole reason of
man was driven into the attenuated spray of abstract ingenuity,
in other times or parts of society a heavy plod of manual habit so
thickened "the nimble spirits in the arteries" that man was little
better than a beaver: on the one side matter, gross and blockish;
on the other, speculation vacuous of all touch of nature. We need
the elevation, the breadth, the imagination which universities create
and foster; but in universities we need also bridges in every parish
between the provinces of craft and thought. Our purpose must be
to obtain the blend of craft and thought, which, on the one hand,
delivers us from a creeping empiricism, on the other, from exorbi-
tant ratiocinations. That for the progress and advantage of know-
ledge the polar activities of sense and thought should find a fair
balance, is set forth judicially enough in modern philosophy, and
is eminent in great examples of mankind. Moreover, it is appre-
hended in the reciprocal tensions of faith and works, of hypothesis
and experience, of science and craft. In our controversies on theory
and practice, on universities and technical schools, on grammar
and apprenticeship, we see their opposite stresses. The unison is
far from being, as too often we suppose, one merely of wind and

208 INTERNAL MEDICINE

helm, it is one rather of wind and wing; it consists not in a mere
obedience of hand to mind, but in some mutual implication, or gen-
erative conjugation of them. How these two forms of impulse
should live in each other, we see in the Fine Arts — in the swift con-
federacy of hand and mind in Diirer, Michael Angelo, Rembrandt,
Velasquez, Watteau, Reynolds. The infinite delicacy of educated
senses is almost more incredible than the compass of imagination.
When they unite in creation no shadow is too fleeting, no line too
exquisite for their common engagement and mutual reinforcement.
Michael Angelo and Leonardo da Vinci, the greatest craftsmen
perhaps the world has seen, were as skillful to invent a water-engine,
•to anatomize a plant, or to make a stonecutter's saw, as to build
the dome of St. Peter above the clouds of Christendom.

Solve the problem as hereafter we may, now we can take heed
at least that energy shall not accumulate about one pole or the
other. Our little children have a message to us if we would but
hearken to them. Every moment they are translating action into
thought and thought into action. Eye, ear, and hand are inces-
santly on the watch and in pursuit, gathering incessantly for the
mind and the forms of thought which as rapidly issue again in new
activities. If, as we mature, we gain the power of restraint, it is
not that we shall cease to act, that the mind shall depose the hand,
but that these variables shall issue in a richer and richer function.
If we forget the hands, that cunning loom which wove our minds,
if thrusting them into our pockets, we turn our eyes inwards, will
our minds still truly grow? That by virtue of the apposable thumb
monkey became man is no metaphor; in its measure it is sober
truth. For the last millennium too much thinking has been the
bane of our profession; we have actually made it a point of honor
to ignore the hands out of which we were fashioned, and in this
false honor to forget that the end of life is action, and that only
by action is action bred. While we profess to admire Bernard Palissy
or Jean Goujon, the medieval mason or the medieval goldsmith,
we act nevertheless as if fine arts only are honorable, and mechan-
ical arts servile; whereby we blind ourselves to the common laws
of growth, which, knowing not these distinctions, deal out barren-
ness to those who make them. We begin even with our children
to wean them from the life of imaginative eyes and of thoughtful
fingers; and instead of teaching them to rise from simple crafts
to practical crafts, to scientific crafts, or to lovely crafts, and thus
to pursue the mean of nature herself, we teach them the insolence
that, except in sports, the mind should drop the acquaintance of
the fingers.

Shall we wonder then that in this generation bold men call Eng-
lish people stupid; all stupid save those few men of genius or rich

RELATIONS OF MEDICINE AND SURGERY 209

talent who, like Gilbert, Harvey, or Darwin, were great enough to
be true to eye and hand, and to breed great conceptions by their
intimate coition with the mind? Shall we wonder then that medi-
cine fell into sterility when by most unnatural bonds surgery, her
scientific arm, was tied behind her, and her sight was turned inwards
from processes to formulas? Shall we wonder that even in the
eighteenth century, when medicine had begun tardily to occupy
itself in the crafts of pathology and chemistry, one visionary after
another, striding in long procession athwart the barren wilderness
of physic, wasted his generation in squeamish evasion of the things
that happen, and in vain pursuit of vacuous unities? Yet, if to the
high stomachs of our forefathers surgical dabblings were common
and unclean, still there remained some eyes curious enough and
some fingers dexterous enough to carry the art back to the skill
of Hippocrates, and forward to the skill of Lister; but it was by the
mouths of barbers and cutters, rather than of the pharisees of
the colleges, that medicine breathed her lowly message to her child-
ren.

THE PROBLEMS OF INTERNAL MEDICINE

BY WILLIAM SYDNEY THAYER

[William Sydney Thayer, Professor of Clinical Medicine, Johns Hopkins Uni-
versity, Baltimore, Maryland ; Associate Physician, Johns Hopkins Hos-
pital, 'ibid. b. Milton, Massachusetts, June 23, 1864. A.B. Harvard, 1885;
M.D. ibid. 1889; studied in Vienna, Berlin, and Paris ; House Physician,
Massachusetts General Hospital, 1888-89; Resident Physician, Johns Hop-
kins Hospital, 1891-98; Associate in Medicine, Johns Hopkins University;
1895-96; Associate Professor of Medicine, ibid. 1896-1905; Visiting Physician,
Union Protestant Infirmary. Member (Honorary) of Therapeutical Society of
Moscow; Association of American Physicians; Medical and Chirurgical Faculty
of Maryland; American Association of Pathologists and Bacteriologists; Wash-
ington Academy of Sciences; American Academy of Arts and Sciences. Author
of The Malarial Fevers of Baltimore (with John Hewetson); Lectures on the
Malarial Fevers.]

To recognize, to prevent, to protect, to heal — these are, in the
broadest sense, the tasks of internal medicine now as ever. But
how different are the problems which occupy our attention to-day
from those of the period commemorated by this Congress. Let us
for a moment glance back at the medicine of the close of the eight-
eenth and the beginning of the nineteenth centuries. For over two
hundred years the blind and binding faith of the Middle Ages, the
faith that had so long fettered the human mind, had been slowly
giving way before the forces of reason and truth. Now and again
with ever increasing frequency, great and courageous minds had
risen above the clouds of medical tradition and dogma which had
smothered the understanding and reason of mankind, as if, indeed,
medicine were a part of the religious doctrine which ruled the world.
For truly the medicine of the Middle Ages was largely a matter of
faith, and as a matter of faith one in which reason beyond a cer-
tain point was heresy and sacrilege. Vesalius with genius and cour-
age had begun to withdraw the veil from naked and iconoclastic
truth. Harvey had made his great discovery. Glisson had demon-
strated his theory of irritability. Mayow, with his "Spiritus nitro-
aereus," had anticipated the discovery of oxygen. Leeuwenhoek
and Malpighi and Hooke had opened to the human eye the realm
of the infinitely small. Bacon and Descartes and Newton and
Locke had introduced into the world a rational and natural philo-
sophy. Locke, himself indeed a wise physician, had pointed clearly
to the true path of medical progress. "Were it my business," says
he, "to understand physick, would not the safer way be to con-
sult nature herself, in the history of diseases and their cures, than
espouse the principles of the dogmatists, methodists, or chymists?"
But the clouds of medical tradition were slow to clear away.

PROBLEMS OF INTERNAL MEDICINE 211

Gradually, however, the first "lonely mountain peaks of- mind"
were followed by an ever increasing number of earnest and un-
trammeled students. In the seventeenth century the opportunity
to give one's life freely to the search for truth had become more
and more open to all. The mysticism and animism of Stahl, which,
in the early part of the eighteenth, hung over the medical world,
was already breaking away. The study of the natural sciences
was pursued more eagerly and generally than ever before. Re*au-
mur and Black and Haller and Spallanzani and Hunter and Priest-
ley and Lavoisier had lived. Morgagni, sweeping aside the dog-
matism of the old schools, had demonstrated the local changes in
many diseases and had opened the way for the objective patholog-
ical anatomy of Bichat. In the field of practical medicine such men
as Sydenham and Morton and Torti and Lancisi practiced and taught
much which holds good to-day. Boerhaave had introduced clinical
instruction. Cullen and Cheyne and Huxham and Pringle and
Heberden and Van Swieten and De Haen were all in many ways
true and faithful students; yet methods and doctrines that were
often strangely fantastic still held general sway — such, for in-
stance, as the Brunonian system. A perusal of the writings of Stoll,
one of the wisest practitioners of his day, cannot fail to impress one
with the meagerness of the basis of anatomy and physiology, normal
and pathological, on which medicine rested, the almost entire lack
of diagnostic methods, the absence of a rational therapy — how
much of the conjectural, how little of the scientifically exact there
was in medicine.

Diagnosis, based largely upon gross clinical conceptions, was
necessarily vague and uncertain.

Prophylaxis, in the absence of any certain knowledge of the
causes and manner of origin of disease, was devoid of any sound
basis.

Treatment was almost wholly empirical, and, where it was not
empirical, it was frequently based upon some theoretical system
so arbitrary and dogmatic that the unfortunate sufferer was too
often stimulated or purged, fed or bled, as he fell into the hands
of a Brown or a Broussais, rather than according to the nature of
his malady.

In the Dictionnaire de 1'Acade'mie franchise for 1789, a year
which marks the end of an era in the world at large, one finds the
following definition: "Me"decine. s. /. L'art qui enseigne les moyens
de conserver la sant6 & de gue"rir les maladies. (La me'decine est
un Art conjectural. * *)" Medicine a conjectural art! Such was
the estimate placed upon our profession by the French Academy
a little over one hundred years ago.

But the seeds of a new life had been sown and the germination

212 INTERNAL MEDICINE

had already begun. Even as these words were written Lavoisier,
too soon to fall a victim to the premature explosion of the forces
of pent-up freedom, was in the midst of his great work. In 1796
came the introduction of vaccination by Jenner, and but a few
years later, Bichat with his wonderful genius, took up the thread
dropped by Morgagni and placed anatomy and physiology, normal
and pathological, on a basis of accurate observation and experi-
ment. Hand in hand with the introduction of exact methods of
anatomical and physiological observation, Auenbrugger, in 1761,
had demonstrated in his Inventum Novum, a method of physical
investigation which, for the first time, enabled the physician to
determine changes in size, shape, and consistency of the thoracic
organs. At first unnoticed by the world, this important discovery
was destined to gain a sudden general recognition in the early days
of the nineteenth century. With the spread of knowledge of the
gross pathological changes in disease which followed the inspira-
tion of Bichat, the work of Auenbrugger, expounded by Corvisart,
became a common possession of the medical world, and, less than
ten years later, Laennec, by the introduction of mediate auscul-
tation, opened possibilities for accurate physical diagnosis such as
had not been dreamed of in the ages which had gone before.

With the great school of French observers which followed Laen-
nec, Andral, Chomel, Louis, Bouillaud, and Trousseau, with Skoda
and Schonlein in Germany and Addison and Bright and Stokes
in England, the exact association of clinical pictures with local
anatomical changes made great advances. Typhus and typhoid
fevers were distinguished; the relation between albuminuria and
renal disease was demonstrated; the association of endocarditis
with acute rheumatism was discovered; the corner-stone of our
knowledge of cerebral localization was laid. Clinical diagnosis was
becoming more than a conjectural art.

In the mean time physiology was making great strides. Majendie,
Bell, Johannes Miiller, Beaumont and finally Claude Bernard, and
a host of their followers, were shedding light upon many obscure
corners of our knowledge of the vital functions. In the hands of
Miiller the microscope began to open up new fields of study which
were destined in a few years through the cultivation of the genius
of a Virchow and a Max Schultze to bear a noble harvest. The "great
reform in medicine" which followed the introduction of the cellular
pathology laid solid foundations for much which is most vital in
our anatomical and physiological and pathological knowledge of
to-day, and the correlation of these observations with the results
of accurately recorded clinical studies, the application of the micro-
scope to the study of the urine, the sputa, the blood, to patho-
logical neoplasms, to exudates and transudates, soon brought new

PROBLEMS OF INTERNAL MEDICINE 213

material for the rising edifice of a rational, exact diagnosis. The
sphygmograph, the thermometer, the ophthalmoscope, the laryngo-
scope, the binaural stethoscope, the stomach tube, the various
means for studying the blood-pressure, all have brought their aid,
while but yesterday the discovery of Roentgen has given us new
and unhoped for diagnostic assistance.

At the same time physiological chemistry which, with the work
of Berzelius on the urine, had taken its place by the side of the
more purely physical methods of investigation, has year by year
given us greater diagnostic assistance in the analysis of the different
secretions and excretions of the body and in the explanation of
the various metabolic processes of the economy.

The development in the hands of Duchenne and Erb and Remak
of electrical diagnosis, together with the great advances in physio-
logy and pathology of the nervous system, has afforded explanation
for much that was previously incomprehensible and has given us
powers of diagnosis which a few generations ago would have seemed
almost magical.

Finally Pasteur and Koch, with the introduction of bacteriolog-
ical investigation, opened the way to the discovery of the causal
agents of a large group of infectious diseases. These discoveries,
followed rapidly by the evolution of methods allowing of the clin-
ical demonstration of many pathogenic microorganisms, afforded
an early, exact, and positive diagnosis, on the one hand in conditions
where previously the disease was recognizable only at a stage in
which it had made inroads into the system so great as to be often
beyond relief, as in tuberculosis, and on the other, in maladies,
the existence of which without these methods was to be definitely
determined only after the onset of an epidemic, as in cholera,
plague, and influenza. When one thinks of what the last quarter
of a century has taught us with regard to tuberculosis, anthrax,
tetanus, diphtheria, typhoid fever, cholera, plague, dysentery,
influenza, not to speak of the great group of wound-infections, we
may begin to realize what bacteriological methods have done for
diagnosis — how many diseases have been cleared up — how many
symptoms have been explained.

In like manner Laveran, with the discovery of the parasite of
malarial fever, did much to bring certainty and precision into a
field in which many had gone astray, while opening the way for
the important observations of Theobald Smith and all the know-
ledge which we have gained in recent years with regard to the
hematozoa of man and animals.

As a direct result of the introduction of bacteriological methods,
the study of the manner of action of infectious agents and their
toxic products upon the animal organism, as well as of the powers

214 INTERNAL MEDICINE

of resistance of the economy against infection, has given us, with
the discovery of specific agglutinines and precipitines, diagnostic
methods of the greatest value, not only for the recognition of vari-
ous infectious processes, but for the identification of specific sera,
affording in particular a test for human blood destined (probably)
to prove, when properly applied and interpreted, of great medico-
legal value.

This is indeed a gain over our knowledge of one hundred years
ago. In how many fields has the conjectural given way to the exact!
At the end of the eighteenth century the diagnostic effort of the
physician, unaided by instruments of precision or even by the
simplest physical methods of auscultation and percussion, was
directed toward the detection of gross anatomical changes. To-
day with our increased knowledge of anatomical, physiological,
and pathological processes, with our growing insight into the chem-
ical and physical features of vital activity, our duty no longer ends
in the recognition of physical changes in organs, in the determina-
tion of the presence of a specific lesion or infection; it is further
our task to search for the earliest evidence of disturbance of func-
tion, which may later lead to grosser, more evident change, to
separate the physiological from the pathological, to estimate, as
far as may be, the power of resistance of the different organs and
tissues and fluids of the body to insults of varying nature, to de-
termine the functional capacity of a given organ — its sufficiency
or insufficiency. In addition to increasing opportunities in the
field of pathological anatomy we find ourselves drawn further into
the study of pathological physiology — and knowledge in the field
of pathological physiology leads of necessity to power in functional
diagnosis.

It must be acknowledged that with regard to many organs the
determination of the limits of functional power and the estimation
of the degree of impairment in disease are matters most difficult
to appreciate, yet with improved methods and persistent research,
progress is being made.

We are, after all, but beginning to realize a few of the possibil-
ities before us, but even this is a step in advance which holds out
no little promise for the future and offers new and tempting oppor-
tunities for study and investigation.

At the end of the eighteenth century but three important, ra-
tionally conceived measures of prophylaxis had been practiced —
the dietetic measures of protection from scurvy, the older inocu-
lation and Jenner's great contribution of vaccination against small-
pox. It was not, indeed, until the development of bacteriology
that prophylaxis took its place as a scientifically exact branch of
medicine. The recognition of the specific cause of many infectious

215

diseases, the knowledge of the life-history of the pathogenic micro-
organisms, the discovery of the portals through which they gain
entrance to the animal economy, and the conditions under which
infection occurs, have brought to us material powers to prevent
and protect. The first great result of this new knowledge was the
development of antiseptic surgery and all that it represents. But
apart from this we have but to remember what has been gained
by a scientifically evolved prophylaxis against tuberculosis and
typhoid fever — to reflect upon how far cholera and plague have
lost their terrors — to contemplate the brilliant results of the dis-
covery by Ross and the Italian school of the life-history of the
malarial parasites as manifested in the anti-malarial campaigns
carried on in various regions by Koch, and in Italy by the Society
for the Study of Malaria, a noble institution, of which our Latin
brothers may well be proud, and lastly to look upon the bene-
ficent and far-reaching influence of the recent work of Reed and
Lazear and Carroll and Agramonte with regard to yellow fever,
to realize what bacteriological and parasitological studies are doing
for preventive medicine.

But beyond this external prophylaxis, the studies of the pro-
blems of immunity, beginning with Pasteur's inoculations against
anthrax in 1881, have given us, so to speak, an internal prophy-
laxis, a functional prophylaxis, if one will, in the possibility of
producing a greater or less degree of individual immunity, such, for
instance, as is now possible in diphtheria, cholera, plague, typhoid
fever, and dysentery.

The enforcement of scientifically planned and accurately de-
duced prophylactic measures has become to-day one of the main
duties of the practitioner of medicine. It is as much the task of
the physician nowadays to guard over the disposal of the sputa
of his tuberculous patient, of the excreta of the sufferer from ty-
phoid fever, or cholera, or dysentery, as it is to attend to the im-
mediate wants of the invalid. How rapidly has the exact replaced
the conjectural in this branch of medicine!

But while diagnosis and prophylaxis were being removed from
the domain of conjecture to the field of exact observation, and
reason, and research, while the possibilities of surgery were rapidly
widening through the discovery of anesthesia and the introduc-
tion of antiseptic methods, medical treatment, until the last two
decades, still remained largely empirical. The development of
exact clinical methods of observation and the statistical tabula-
tion of experience for which we are especially indebted to Laennec
and Louis, and their followers, gradually brought about, to be
sure, many advances, while a large number of useful therapeutic
agents introduced by the newly developed science of pharmaco-

I

216 INTERNAL MEDICINE

logy, and exactly tested by improved methods of physiological
study, added greatly to the armamentarium of the physician for
the relief of symptoms. The power to combat disease specifically,
however, remained much as it was at the beginning of the century.
Mercury in syphilis, quinine in malarial fever, were the only spe-
cifics known to the medical world — and the action of these was
unexplained.

The introduction by George Murray, less than fifteen years ago, of
the treatment of myxedema and allied conditions by extracts of the
thyroid gland, was a direct application of the results of physi-
ological observation to the treatment of disease. If this gave rise
to hopes of the possibility of obtaining like results from roughly
obtained extracts of other ductless glands, which have hardly been
fulfilled, yet the discovery was the first step toward the rational
scientific therapy to which we are beginning to look forward to-day.

But a moment ago I spoke of the importance of the influence of the
discovery of the causal agents of the infectious diseases upon the
development of exact diagnostic and prophylactic methods. Great
and impressive as these have been, yet the studies which have fol-
lowed as to the manner in which these agents act upon the human
organism, and of the powers of resistance which the body exerts
against them, the investigation of the problems of immunity have
opened out a far wider field. The early studies of Metchnikoff and
Buchner and Nuttall were followed with rapidity by the epoch-
making work of Behring and Kitasato and Roux with regard to
tetanus and diphtheria. The diphtheria and tetanus antitoxins were
not chance discoveries of empirically determined virtue, but true
specific, therapeutic agents, the results of experiment scientifically
planned and carefully prosecuted. Widespread investigations of the
various phases of immunity, bacterial and cytotoxic, have given us
in a few short years a mass of physiological knowledge, the full
import of which is scarcely yet to be comprehended. Few things in
modern medicine are more impressive than a survey of the work of
the last twelve years done under the inspiration of Ehrlich.

Beside the antitoxins of diphtheria and tetanus and the power of
producing a greater or less degree of immunity, as has already been
mentioned, by preventive inoculations against cholera, plague, and
typhoid fever, we have come to possess a bactericidal serum of a
certain value in combating the actual disease, plague, while the
favorable influence of Shiga's anti-dysenteric serum seems to be un-
doubted. There is much reason to hope that the recently promised
anti-crotalus serum of Noguchi as well as the anti-cobra serum of Cal-
mette may prove to be real boons to humanity. But it is not alone
in the production of specific anti-sera that the therapeutic value of
the modern studies of immunity lies. There are signs which justify

PROBLEMS OF INTERNAL MEDICINE 217

us in looking forward to the possible discovery of an explanation of
the mode of action of substances long empirically used, knowledge
the value of which may be readily appreciated.

When we consider these facts it is indeed easy to appreciate to
what an extent the exact has driven the conjectural from this last
field of medicine. A hundred years ago we were depleting and purg-
ing and sweating and bleeding according to theories often strangely
lacking in foundation, the prevalence of which depended rather upon
the individual force and vigor of the expounder than upon their
intrinsic merit. To-day from the study of the pathological physio-
logy of bacterial and cytotoxic intoxications, we are rapidly evolving
scientific preventive and curative measures, while searching out the
rationale and mode of action of our older therapeutic agents.

But a few days ago, I happened to open a copy of Littre" 1 bearing,
by a curious chance, the date of 1889, and read "Me"decine (me"-de-
si-n). 1°. Art qui a pour but la conservation de la sante* et la gue"rison
des maladies, et qui repose sur la science des maladies ou patho-
logic " — an essential modification of the definition of one hundred
years before and indicative of the changes of a century.

To meet the manifold problems of to-day, the training of the phy-
sician must of necessity be very different from what it was a hun-
dred years ago. The strong reaction which set in in the earlier part
of the nineteenth century against philosophical generalization in
medicine, the insistence upon a strict objectivity, all the more em-
phatic because of the prevalence of anatomical methods of research,
have held very general sway. Medicine, no longer resting upon a
basis of philosophical speculation, stands upon the firmer foundation
of the exact natural sciences. Almost from the beginning the student
of to-day is taught methods, where a hundred years ago he was
taught theories. The enormous expansion of the field which must be
covered has led naturally, not only to an ever increasing specialism,
but to the fact that the course of study which is regarded as properly
fitting the physician for practice is reaching backward farther and
farther into the earlier years of his school training. On the other
hand, in this country at all events, there is heard a common cry
that the academic medical training is extending over into years
which should be given to practice ; that the expense and dura-
tion of a medical education, so-called, will soon be such as to shut
out from the profession many a man who might be a useful physi-
cian and perhaps a valuable contributor to the world's knowledge.
To remedy this it is advised that the prospective student of medi-
cine should be led from the earliest stages of his training through the
paths of exact research into the domain of the natural sciences to the
greater or less exclusion of the classics — the old-time humanities,

Dictionnaire de la langue franfaise.

218 INTERNAL MEDICINE

the study of which, useful as it may be from a standpoint of general
mental training, is believed by many to be time wasted in the edu-
cation of the student destined for a scientific career.

But there are not wanting voices which question the wisdom of the
full extent of some modern tendencies. May the affectation of too
strict an objectivity bred though it may be of a wholesome skep-
ticism, the more general cultivation of the natural sciences to the
exclusion of the humanities, the search for facts and facts alone,
circumscribe the powers of synthetical reasoning without which the
true meaning of many an important problem might pass unnoticed?
May they perhaps tend to smother the development of minds capable
of grasping large general problems? Do the tendencies of the times
justify the epigrammatic observation of a recent French author:
"Autrefois on ge'ne'ralisait avec peu de faits et beaucoup d'ide*es;
maintenant on ge'ne'ralise avec beaucoup de faits et peu d'id6es " ? *

That the cultivation of a strict objectivity in research has ma-
terially impaired our powers of reason — that the exact methods,
which are largely responsible for the enormous advances of the last
fifty years in all branches of medicine, have bred a paucity of ideas,
I am not inclined to believe, despite the seductive formula of our
Gallic colleague. But that when in the period of so-called secondary
education it is proposed to substitute the study of the natural sciences
for a good training in the humanities, there is danger of drying-up
some of the sources from which this very scientific expansion has
sprung, seems to me by no means impossible. The study of the
classics, an acquaintance with the thoughts and the philosophies
of past ages, gives to the student a certain breadth of conception,
a stability of mind which is difficult to obtain in another way. A
familiarity with Greek and Latin literature is an accomplishment
which means much to the man who would devote himself to any
branch of art or science or history. One may search long among the
truly great names in medicine for one whose training has been de-
void of this vital link between the far-reaching radicles of the past
and what we are pleased to regard as the flowering branches of to-day.
Greek and Latin are far from dead languages to the Continental
student. They are dead to us because they are taught us as dead.
With methods of teaching in our secondary schools equal to those
prevailing in England and the Continent, it would be an easy matter
in a materially shorter period, to give our boys an infinitely broader
education than they now receive. There should be much less com-
plaint of time wasted, much less ground for suggesting the abandon-
ment of the study of branches which are invaluable to any scholarly-
minded man.

The assertion that the time spent in the study of the humanities
1 Eymin, Mtdecins et Philosophes, 8°, Lyon, 1903-4. no 4

PROBLEMS OF INTERNAL MEDICINE 219

results in the end in the encroachment of the academic training upon
a period which should properly be given to one's life-work is, it seems
to me, often based on an old idea — founded all too firmly, alas, on
methods that yet prevail in many of our medical schools — that with
his degree in medicine the student has finished a theoretical educa-
tion, that he must now spend five or ten years in acquiring expe-
rience — at the expense, incidentally, of the public — before he can
enter into his active life; that, therefore, unless some other branches
of early instruction be sacrificed to courses leading more directly to
medicine, so that he may enter upon his strictly professional educa-
tion at a period considerably earlier than is now the case, the phy-
sician of to-morrow will become self-supporting only at a period so
late in life as to render a medical career impossible to other than
those well supplied with the world's goods. With proper methods of
instruction this is a wholly false idea. Under fitting regulation of our
system of medical training, with due utilization of the advantages
offered by hospitals for clinical observation, the experience necessary
to render a man a safe and competent practitioner should not only be
offered, but required for a license to practice; and even if the length
of the strictly medical curriculum be extended one or two years
beyond that which is at present customary, it will not be time lost.
If one but look around him he will find, I fancy, that few men who
have had such a training wait long before finding opportunities for
the utilization of their accomplishments ; the public in most instances
soon recognizes the man of true experience.

But there is yet another side of the question which has hardly
been sufficiently emphasized, a side of the question which must come
strongly to one's mind when one considers the general education of
many of the men who are entering even our better schools of medi-
cine, a point of view which has been especially insisted upon by
a recent French observer. A large part of the success and usefulness
of the practitioner of medicine depends upon the influence which he
exerts upon his patients — upon the confidence which he infuses —
upon his power to explain, to persuade, to inspire. It can scarcely be
denied that these powers are more easily wielded by the man of
general culture and education than by one of uncouth manner and
untrained speech however brilliant may be his accomplishments in
the field of exact science. I can do no better than quote the words of
Professor Lemoine: "C'est qu'en effet 1'action morale qu'il peut
exercer sur le malade, et qu'il exerce d'autant plus qu'il est sup6-
rieur par son intellectuality, est un des principaux e'le'ments de guer-
ison. On gue"rit par des paroles au moins autant que par des rem^des,
mais encore faut-il savoir dire ces paroles et presenter une autorite"
morale suffisante pour qu'elles entrainent la conviction du malade
et remplissent le role suggestif qu'on attend d'elles. Ne fut-ce que

220 INTERNAL MEDICINE

pour cette raison, je me rangerai parmi ceux qui demandent le main-
tien d'e"tudes classiques tres fortes comme preparation a celles de la
me'decine, car le meilleur moyen de rehausser le prestige du me'decin
c'est encore de 1'e* lever le plus possible au dessus de ses contempo-
rains." l

These words express, it seems to me, a large measure of truth. May
it not be that in the tendency to the neglect of the humanities we are
taking a false step? May it not be that if, on the other hand, we
teach them earlier and better, we shall find in the end that no essen-
tial time is lost, while we shall gain for medicine-men not only with
minds abler to grasp the larger and broader problems, but with
materially fuller powers for carrying on the humbler but no less
important duties of the practitioner of medicine?

In that which I have just said I have touched upon the necessity
of the requirement of a considerable amount of clinical experience as
an essential for the license to practice medicine. To meet the enor-
mously increased demands of the present day, medical education
has become, of necessity, much more comprehensive, and must
therefore extend over a longer period of time. The methods of re-
search, anatomical, physical, chemical, which the student must
master, the instruments of precision with which he must familiarize
himself, are almost alarmingly multifarious; and experience in the
application of these methods and in the use of these instruments
demands increased time. Many of these proceedings, it is true, the
physician will rarely be called upon to use personally in practice, for
such measures must in great part be carried out by special students
or in laboratories provided by the Government. Nevertheless with
their significance and value he must be familiar — familiar from
personal observation and experience.

But after all there are few diagnostic signs in medicine, and not so
many of the improved methods of clinical investigation yield dia-
gnostic results, while to familiarize one's self with methods and in-
struments of precision is a very different matter from acquiring real
experience and skill as a diagnostician or a therapeutist. It is only
by gathering together and carefully weighing all possible informa-
tion that one is enabled to gain a proper appreciation of the situation
and to approach a comprehension of many conditions of grave im-

1 Indeed the moral influence which he (the physician) is capable of exercis-
ing upon the patient and which he exercises to an ever increasing degree with
his intellectual superiority, is one of the most important of therapeutic agents.
One heals by words at least as much as by drugs, but one must know how to
say these words and to exercise a sufficient moral authority, that they may
bring conviction to the patient and carry the full weight of suggestion which
is intended. Were it but for this reason I shall range myself among those who
demand the maintenance of extensive classical studies as preparation for those
of medicine, for the best means to uphold the prestige of the physician is still
to raise him as far as possible above his contemporaries. Congrte franfais de
medecine, vi Session, Paris, 1902, 8°, t. n, p. xli.

PROBLEMS OF INTERNAL MEDICINE 221

port to the patient. And in forming a sound judgment with regard
to these vital questions, that which comes from experience in the
close personal observation of the sick is far the most important
element. Bedside experience constitutes to-day, as it always has,
and always will, the main, essential feature in the training of the
physician. But this experience, if it is to bear its full fruit, must be
afforded to the student at a time when his mind is still open and
receptive and free from preconceived ideas — under conditions such
that he may be directed by older trained minds into proper paths of
observation and study, for few things may be more fallacious than
experience to the prejudiced and the unenlightened.

That such experience may be freely offered to the student there is
a grave necessity for a more general appreciation by institutions of
medical training as well as by the powers in control of public and
private hospitals and infirmaries, of the mutual advantages to be
gained by a cordial cooperation. It must be acknowledged that, in
this country at least, despite the cultivation of improved methods of
clinical investigation, there still prevails in the mind of the public the
perverted idea that this bedside observation, this application of new
methods of research and study are for the advantage of the student
or in the interest of general science rather than for the benefit of the
sufferer himself. It must further be recognized that a wholly mis-
taken conception of the true function of a hospital is widely prevalent.
It is all too common to see large and ornate institutions with every
arrangement for the comfort and even luxury of the patient, with
a medical staff utterly insufficient in number or training to study
properly the individual case, not to speak of carrying on scientific
investigations. The service, usually under the direction of a busy
driven practitioner with barely time to make a short daily visit —
large wards under the direct control of one or two young men whose
time is wholly occupied by routine work — every care taken for the
present comfort of the patient — little provision for enlightened
study or treatment of his malady — no opportunities for a contri-
bution on the part of the institution to the scientific progress of the
day. Better far for the sufferer were he in the dingy ward of an old
European hospital where he might be surrounded by active, inquiring
minds recording the slightest changes in his symptoms, ever ready to
detect, and as far as the power in them lies, to correct the earliest evi-
dences of perversion of function. What our hospitals need is men,
students, whether or no they have arrived at the stage in their career
— which, after all, is but a landmark, not a turning-point — that
entitles them to the right of independent practice, the enthusiastic,
devoted student who, in watching and studying the patient, is
contributing alike to the interests of the sufferer, the hospital, and
himself.

222 INTERNAL MEDICINE

The three main functions of a hospital — the care of the sick,
the education of the physician, the advancement of science — are
not to be met alone by building laboratories and operating-rooms
and lecture-halls, by furnishing the refinements of luxury to the
patient, useful adjuvants though these may be. What the hospital
mainly needs is men, men to study and think and work — students of
medicine.

It cannot be denied that in this respect we in America are behind
our cousins of the Old World. Despite our many honorable achieve-
ments, the part which we are taking in the modern study of the
physiology of disease is still not what it should be.

Ere long we must come to realize that our duty to the sick man
consists in something more than to afford him that which most sick
animals find for themselves — a comfortable corner in which he may
rest and hide from the world; that our duty to the public is to give
them as physicians, men of the widest possible general training,
ready to enter upon independent practice with an experience suffi-
cient to render them safe public advisers; that our duty to ourselves
is to miss no opportunity for the study of pathological physiology at
the bedside of the patient; that the accomplishment of these ends
depends in great part upon the appreciation by our universities and
hospitals of the mutual advantages of cooperation in affording every
opportunity for the scientific study of disease while offering to the
patient the privileges of enlightened observation and care.

But there are everywhere signs of a future rich in achievement.
An improving system of medical education, the increasing oppor-
tunities for scientific research offered as well by the generosity of
private citizens as by the wisdom of state and national governments,
the community of effort which results from closer fellowship among
students of all nations, are omens of great promise. The remarkable
developments of the last twenty years in all branches of the natural
sciences have brought a rich store of suggestion and resource for
application in our laboratory, which is at the bedside of the patient.
Let us look to it that our clinical methods keep pace with those
which are yielding so abundant a harvest in these neighboring
fields of scientific research.

SECTION F — NEUROLOGY

SECTION F — NEUROLOGY

(Hall 13, September 22, 3 p. m.)

CHAIRMAN: PROFESSOR LLEWELLYN F. BARKER, University of Chicago.
SPEAKER: PROFESSOR JAMES J. PUTNAM, Harvard University.

THE VALUE OF THE PHYSIOLOGICAL PRINCIPLE IN
THE STUDY OF NEUROLOGY

BY JAMES JACKSON PUTNAM

[James Jackson Putnam, Professor of Diseases of the Nervous System, Harvard
Medical College, since 1893. b. Boston, Massachusetts, October 3, 1846. A.B.
Harvard, 1866; M.D. Harvard Medical School, 1869. Physician, Massachu-
setts General Hospital, 1874; Instructor in Diseases of Nervous System,
Harvard Medical College, 1875-93. Member of the American Academy of Arts
and Sciences; American Medical Association ; American Neurological Associa-
tion; Association of American Physicians and Surgeons; American Association
for Advancement of Science; Massachusetts Medical Society; Boston Society
of Medical Sciences; Boston Society of Psychiatry and Neurology; Boston
Society for Medical Improvement. Author of numerous medical publications,
mainly on neurological subjects.]

THE subject of this address will be considered under three heads:
1. The limitation in usefulness of those methods of medical inves-
tigation which are based on the assumption that disease is always
a localized process. 2. The importance of the part played in
disease by readjustment and adaptation on the part of the organ-
ism, and the need of cultivating physiological conceptions as a
means toward a proper understanding of these processes. 3. The
impropriety of attempting to draw fundamental distinctions between
"functional" and "organic" disorders, and the significance of the
hypothesis of "energies" as applied to living organisms and to
disease.

When the late Professor Virchow was chosen to deliver the open-
ing address before the International Congress at Rome, in 1894,
he selected for his topic "The Anatomical Principle in the Study
of Disease" (Morgagni und der Anatomische Gedanke"),1 a doctrine
to the maintenance of which a great portion of his own long and
splendid labors had been devoted. The anatomical principle was
not conceived by Virchow in any narrow spirit. Its tenets were
that disease is always a localized process, and ought to be suscep-
tible of expression in some sort of anatomical terms, but he as-

1 Berl kl. Woch, 1894.

226 NEUROLOGY

serted that the search for this process might be made as properly
through the clinical examination of the patient by the trained phy-
sician, together with a careful study of his history, as through the
scalpel and microscope of the anatomist. He admitted that the
time was still far distant when we should be able to discover the
whole of the anatomical evidence, and urged that the inquiry should
be extended from the organs to the tissues, and from the tissues
to the cells, and even to the very "vital functions" themselves.
But he insisted, nevertheless, that in some sense — a sense not as
yet strictly denned or definable — every disease was to be thought
of as occupying circumscribed areas, in the midst of tissues for the
most part or in great part sound. " Ubi est morbus t" — "Where is
the diseased spot to be found?" — was proclaimed as the watch-
word of the investigator, while at the same time the students of
therapeutics were congratulated on having found means, as a result
of anatomic discoveries, to carry local treatment to portions of the
body hitherto regarded as out of reach.

It is needless to attempt a recital of the successes which have
been won under this banner of anatomical research. The princi-
ple which the great master Virchow proclaimed was one that had
appealed and still appeals alike to the faithful plodder and to the
man of genius; its history is the best part of the history of medi-
cine during the past half-century; it has been the best thread of
guidance since the history of medicine began.

The value of the anatomical principle has been quite as evident
for the department of neural pathology as for any other, and the
devotion to its maintenance quite as strongly marked. At the
meetings of neurological societies the pathologic anatomists have
always been more certain of an attentive hearing than investiga-
tors of any other sort; in the direction of their work has seemed
to lie the sure and trusted path of progress toward a better under-
standing and a better treatment of disease.

And yet, in spite of all that has been accomplished, there are
abundant reasons for the opinion that the very successes of the
anatomical principle have thrown unduly into the shade the claims
of another mode of approaching the problem of disease, without
the aid of which anatomical research must prove inadequate to
the task which has been imposed upon it. For this latter prin-
ciple, which emphasizes the importance of recognition, in disease,
the signs of more or less widespread modifications of function of
the organism as a whole, the designation of "physiological prin-
ciple" is appropriate.1

1 There has been a growing tendency to recognize the importance of this
standpoint, and very recently Professor Wolkow, of St. Petersburg, has devoted
an able and thoughtful essay to a series of considerations analogous to those
here offered. Die Physiologische Anschauung in der Klinischen Medicin, Berliner
kl. Woch, 1904, nos. 15 and 16.

THE STUDY OF NEUROLOGY 227

The argument is not that the anatomical principle is faulty be-
cause it has failed to accomplish all that had been hoped of it as
regards the discovery of the essential nature of disease, but that,
under it, certain local aspects of the disease-process are made the
exclusive subjects of research, and that the mind is thus turned
aside from a recognition of the fact that an equally important
object of study is the modification of functional activity, local or
general, which marks the efforts of readjustment on the part of
the organism to the effects of the primary disturbance. Such a
study as this cannot be adequately made without a thorough use
of physiological methods, or of clinical methods inspired and guided
by physiological conceptions, the term physiological being under-
stood as including all means of research which throw light upon
the mechanism of the processes of life. Psychological and chem-
ical investigations belong preeminently in this category. The faint-
heartedness which most of us have felt in searching for an ana-
tomical explanation of the great neuroses and psychoses has not
been simply a quailing at difficulties which were theoretically sur-
mountable, but has been due in part to a justifiable suspicion that
we were not altogether on the right track. We have striven to
ticket each one of the histories in our case-books with an anatom-
ical designation indicative of some localized pathological process,
but we have realized when we did so that our designations usually
fell far short of expressing the whole state of the sick man whom
we had before us when the history was made.

The widespread feeling that no investigation of symptoms, how-
ever thorough, could give us the sort of insight which we needed
has led us to underestimate the real value of such inquiries. If the
study of symptoms does not carry us to the heart of the disease,
neither does the anatomical study of the disease carry us to the
heart of the symptoms. In fact, a thorough inventory of symp-
toms, that is, an inventory of the signs of disordered functions of
the body as a whole, can often tell us more of what we wish to
know than an inventory of anatomical signs of altered structure.
No anatomical research can pierce to the secret of broken coordin-
ations, and yet it is in these that a great part of disease begins,
or comes eventually to consist. No anatomical research can help
us to estimate the margin of resistance against strain, and yet on
the estimation of this margin, for each individual patient, issues
depend which are of scientific and practical importance. One man's
health is very different in quality and quantity from another man's
health, though the two men, untested, may appear alike, and the
investigation into their respective powers of effectiveness and of
resistance is often a valuable part of the study of their diseases.1

1 Physiologists recognize that organs, such as the heart (cf. the address by

228 NEUROLOGY

We need, in short, to supplement our researches into the direct
and local effects of a given lesion by a study into the more or less
widespread modifications of energy which the organism exhibits
as a result of the lesion, and which it is customary to designate as
indicative of an attempt1 to repair the damages which the lesion
has induced. We need also to learn a great deal more about the
genesis of symptoms, even though we must remain ignorant about
the genesis of what one would call disease, in an anatomic sense.

The signs of readjustment constitute, in fact, all that we can
really learn in the study of disease, for the disease-process, con-
sidered independently of them, is an abstraction, without real ex-
istence.

And if this is so, then all the indications of this process of read-
justment are proper objects of our study, whether they be of the
nature of symptoms or of anatomic marks, whether they concern
special localities and organs which are the seat of primary "les-
ions," or other parts standing in functional relationship to them,
and even though they point to changes which are not to be classed
as morbid, but rather as modifications favorable to health. The
reactions after a so-called "healthy" fatigue, which often lead to
new and better powers of endurance, would be of this latter sort,
and the same is true of those reactions through which immunity
is secured after infectious disease. At such points as these, "dis-
ease" and "health" touch hands, and it becomes, indeed, evident
that neither disease nor health is a definite condition, but that both
of them are movements toward some relatively endurable equi-
librium,2 a goal which is never fully reached.

Of course, to a certain extent, investigations of this sort are daily
made by every student, but the question is: In what direction is
it now most important that the emphasis of research should be
thrown and scientific instincts developed? Imitation and fashion
play a large part, even in scientific investigation, and the almost
universal tendency to bend all energies to the search for the phys-
ical evidence of localized lesions has led too often to a disregard
of disturbances usually classified as functional. Not only is it es-
sential that "clinical medicine" should be studied in the light of
"physiology," but the field of morbid psychology, which now lies
untilled save by a few students, is one of the utmost practical
importance for each practitioner.

Welch, cited below) are able, under special stimulation, to work with more than
usual effectiveness. This extra force is called " physiologic reserve."

1 The word "attempt" and others of like meaning are here used not in a tele-
ologic, but only in a descriptive sense, for it seems plain that we must follow
the example of the biologists who have studied the problems of growth and of
repair (compare Thomas Hunt Morgan, " Regeneration ") and admit that there
is no justification for assuming a special vis medicatrix naturae.

* " Stationary Equilibrium. (Ostwald, Die Philosophic der Natur.)

THE STUDY OF NEUROLOGY 229

We can hardly treat a patient, no matter with what he may be
suffering, without having to reckon on the vast and complex part
which his mental attitude will play in controlling the result. In
many instances, indeed, the physician's success depends upon the
skill with which he makes this estimate. Yet how rarely is it sys-
tematically and consciously made, under the guidance of any de-
finite principle, and how gladly would most physicians crowd out
of sight the necessity for making it at all. A man meets with an
injury attended with great nervous shock, and the neurologist is
ready enough to spend infinite pains on the study of the necrotic
areas in his spinal cord, but is apt to overlook the fact that this
localized process does not explain why he has at the same time
lost flesh and strength and color, and has become the football of
his delusions and his fears. The data gathered by psychologists
and physiologists, and the principles based thereon, count for but
little in ' most assemblages of neurologists. The reason usually
given for this disregard of psychological and physiological data is
the insufficiency of our means for the verification and interpreta-
tion of them. But this fear should not hold us back from making
the attempt to utilize these facts, for the same uncertainties attend
anatomic research the moment we endeavor to use it for probing
the essential problems of disease and life. The confusion attend-
ing the recent discussions over the neuron theory and the real seat
of neural energy both justify and illustrate this statement.

This attitude toward the problem of disease, which claims path-
ology as a special department of physiology, is essentially the atti-
tude of Wolkow, to whose stimulating essay I have alluded already,
and it is also the attitude of Dr.»Hughlings Jackson, of London,
whose brilliant studies, stretching back for nearly half a century,
mark him as foremost among the advocates of the physiological
method in neurological research. Professor Welch,1 of Johns Hop-
kins University, has recently made substantially the same claim
in his address upon "Adaptation in Pathologic Processes," draw-
ing his illustrations from the department of general pathology.
Verworn2 takes the same position when he speaks of diseases as
stimuli (Reize), which alter the conditions under which life is car-
ried on, thereby adopting Virchow's designation: "Die Krank-
heit ist das Leben unter verdnderten Zustdnden."

The physical changes which the organism undergoes in this
process of adaptation may be few and slight, and mainly local, or
they may be so broad and numerous as wholly to overshadow the
lesions by which they were set in motion. In illustration of this
overshadowing of the direct effects of a lesion by the processes of

1 Transactions of the Congress of American Physicians and Surgeons, 1897.

2 Berl. kl. Woch, 1901, no. 5, and other papers.

230 NEUROLOGY

readjustment, I will mention three instances of widely different
sorts, yet similar, as I think, in principle. These are: First, myxe-
dema; next, the vast changes that sweep through the organism at
the great climacteric epochs of adolescence and the menopause; and
finally, those kindred processes of metamorphosis by which through
castration the bull is converted into the ox.

In all these cases we see two tendencies at work, the one suggest-
ing disease, or failure, the other pointing toward the establish-
ment of a new sort of equilibrium, containing well-marked elements
of stability and health. Is not the controlling principle in these
instances analogous to that under which the neuter bee is con-
verted into the queen bee through a change in nourishment, or that
through which some of the lower forms of marine animals are
altered in type by gradual removal from salt into fresh water, or
by some kindred modification of the chemical constituents of the
fluids by which they are surrounded?

The conservative physician is usually disinclined to admit bio-
logical principles as applicable to the problem of disease. Yet, in
fact, it is just in this direction that our search should tend, and
when we see complex disorders, such as Graves's disease, or even
certain types of neurasthenia, of unknown primary lesion but with
hosts of secondary physical and neural signs, we should remember
the processes I have cited, and should hesitate before stamping
summarily as "disease" modifications of structure and function
which doubtless represent, in part, movements toward a new and
relatively stable existence. Who can doubt that we ourselves,
regarded from another point of view than our own, are defective
and mutilated beings, who have sacrificed much to gain the faculties
which we justly regard as so important?

This would be a proper place to mention in detail, at least by
way of illustration, some of the more important contributions made
by physiologists, psychologists, and biologists, which have thrown
light upon the clinical problems of compensation and adaptation.

I have already referred to the principle of "physiological reserve"
force, as utilized by Welch in his important address, and speak
of it here again only as possibly helping to explain the numerous
instances where the organism shows the power of fostering certain
of the functions of the nervous system at the expense of other
manifestations of its life. The case of the runner from the field of
Marathon, who brought his message to Athens in spite of the gath-
ering dissolution which laid him dead in the market-place at the
moment of his arrival, is a striking illustration of a principle which
is of frequent application.

Thus, the disarrangements of the nervous system that are liable
to follow nervous shocks of some severity are sometimes very late

'

THE STUDY OF NEUROLOGY 231

in making their appearance, and in the interval the patient may
appear as if unaffected by the experience through which he has
just passed. The final "breaking-down," due to prolonged strain,
is often similarly postponed, only to come on eventually with great
suddenness.

The fact is often overlooked that there is an analogous "latent
period" in the early stages of toxic affections, when the symptoms
are masked by this strong tendency on the part of the organism
to continue offering an unchanged front in response to the calls
of the environment. Thus a patient who is exposed to lead or alcohol
may retain the power to use his weakened nerves and muscles for
a long period, until finally, under some slight additional strain,
complete disability suddenly makes its appearance.

It is apparently this same intense instinct to present a functionally
adequate front to the demands of the environment that enables the
hysterical patient whose vision is failing to retain the accuracy of
the central field, and guides the brain in the reassertion of its powers
after injury. The compensation in many cases is so complete as to
leave no trace of the primary loss, although some relatively slight
additional lesion may make it clearly evident. This is illustrated
by the interesting compensatory relationship between the sensory
motor functions of the cerebral cortex and those of the semicircular
canals discovered a number of years ago by Ewald.

It is as difficult to explain adequately why it is that the organism
thus seeks to reassert itself on the old lines, in a physiological sense,
as it is to tell why the lower animals are able to make good the loss
of important parts and organs, even those of the interior of the
body, with regard to which the "habit" of restoration cannot have
been acquired through evolution.

Many partial explanations, such as those indicated by Loeb
under the name of "tropisms," are indeed of value, but Morgan,1
after reviewing with great care the evidence at hand for the case of
the restoration of the lost parts, declares that a satisfactory explana-
tion is there impossible. One important reason for arriving at this
conclusion is that it is by no means invariably true that in the
process of restoration the interests of the organism as a whole are
consulted. In repair, as in development, the results are often (from
the standpoint of the ordinary observer) monstrous or grotesque.
And so, too, in human pathology, the processes of compensation
and readjustment seem sometimes to work distinctly toward dis-
ease instead of health. Nevertheless, these processes must remain
the main subject of our study, and the principles underlying them
must be re-stated more and more broadly in physiological and
philosophical terms, before a unifying conception can be reached.

1 Regeneration.

232 NEUROLOGY

It is to the clear insight of Hughlings Jackson1 that we owe some
of the most fruitful suggestions as to the mode in which symptoms
of disease arise when the normal balance between the various func-
tions of the nervous system has been broken. New light has been
thrown on many of the phenomena of which he speaks by the phy-
siologists who have worked on the vast subject of inhibition, and
the effects of a disturbance of the interplay between inhibition
and excitation. The names of Meltzer,2 Sherrington, Biedermann,
and Wedenski3 come to mind, especially, in this connection. Never-
theless, the fundamental principles which Hughlings Jackson so
long ago expressed retain for the most part their validity. He
made it clear that the signs and symptoms met in disease are of
dual origin, that portion of them which is due to a lesion such as
we might expect to demonstrate anatomically being often the less
conspicuous part, while the more conspicuous part is due to the
vital energy of the uninjured remainder of the nervous system,
acting without due control and yet with reference to such coordina-
tion as is still in force. Special and reciprocal coordination of this
sort exist between the cerebellum, and the cerebrum, so that the
special tensions and characteristics of either one is liable to come
singly or preeminently into play when the activity of the other
suffers a check. The disorders thus set up form "complementary
inverses" of each other. Similarly, when any portion of the nerv-
ous system is damaged, there are signs of defect, or "negative
symptoms," due to impairment of the more highly coordinated
functions of the part concerned and related parts, and signs of over-
action, or "positive symptoms," due to uncompensated activity
of the functions of "lower levels."

These "positive symptoms" might be classified simply as if due
to unchecked liberation of energy, or as attempts at compensa-
tion (in a duly qualified sense) on the part of the organism as a
whole. Sometimes the phenomena which seem at first glance to
bear the stamp of "disease" are really better classifiable as of con-
servative or compensatory nature, while under other circumstances
the reverse may also be the truer statement. Thus Strohmeyer *
has pointed out how "compulsive ideas" may sometimes have a
value for the mental health of the patient, and Hughlings Jackson
has suggested an explanation for the fact that motor convulsions,
in epilepsy, may, at least, be less injurious for the mental con-

1 The first lecture of "Hughlings Jackson Course," delivered in January, 1898,
contains a brief outline of the importance of his generalizations. (Lancet, January
8, 1898.)

2 Med. Rec., June 7, 1902. "The R61e of Inhibition in the Normal and Some
of the Pathological Phenomena of Life, and Other Papers."

s Pfluger's Arch. f. d. ges. Physiol, 1900.

4 "The Conception of Compulsive Ideas as a Safeguard Neurosis" ("Abwehr-
newosen"), Cbl. f. Nervenheilkunde u. Psych., vol. xrv, 1903.

THE STUDY OF NEUROLOGY 233

dition of the patient than the seemingly less serious psychic
seizures.

We owe also to Hughlings Jackson the generalization that lesions
which occur suddenly, and throw out of gear, as they are bound
to do, the more delicate of the functions represented in that part
of the nervous system which is concerned, are likely to be followed
by symptoms of a more violent sort than those which take place
slowly. Thus, the epileptic discharge accompanying a lesion so
slight as to leave no recognizable anatomic trace behind is liable,
by virtue of its suddenness, to give rise to a maniacal outbreak,
which represents the uncontrolled activity of relatively uninjured
portions of the brain, while, on the other hand, lesion which anatom-
ically may appear infinitely more serious are accompanied by no
such outburst. Different forms of epileptic discharge and their sec-
ondary results differ widely also among themselves in these respects.

These hypotheses are in need of further analysis and should be
tested anew by neurologists trained in physiological methods.

Reasoning on lines similar to those laid down by Hughlings Jack-
son, Edward Cowles has recently sought to unify the various mem-
bers of the large class of the psychoneuroses of exhaustion, or of
lowered mental tension. Thus the different phases of manic-de-
pressive insanity are not due, he thinks, to separate and specific
processes for which we might expect to find special chemic or ana-
tomic expressions, one process leading to excitement and another
to depression, but these phases, which in fact are often mixed, are
phenomena of secondary occurrence, and are explicable on prin-
ciples analogous to those outlined above as indicating the genesis
of epileptic mania.

Some of the principles brought out by Hughlings Jackson are
quite in harmony with those insisted upon of late years by a re-
latively small group of observers, abroad and at home, who have
brought psychologic investigations to the aid of clinical research.
I have especially in mind the fine work done by such men as Janet
and Treud in Europe, Morton Prince and Sidis in America, not to
speak of many others who have labored in the same field. To them
we owe such knowledge as we now possess of the contrast between
the dissociation of consciousness so characteristic of hysteria, and
of the contrast between this tendency and that which gives rise to
the complex and varied mental phenomena of asthenic states, or
to the temporary and quasi-normal disturbances of daily life.

It would be impossible even to name, in a few paragraphs, the
many clinical researches tending toward a better understanding
of mental symptoms, for the prosecution of which a knowledge of
psychological and physiological generalizations is essential. A few
illustrations must suffice.

234 NEUROLOGY

Thus, in every movement leading to exact thought and exact
expression, in every movement of the memory, vast numbers of
mental processes must cooperate, and if the outcome is to be effect-
ive, this cooperation must be governed from the outset by a lead-
ing idea as a ruling motive. The failure of this ruling idea leads to
the wayward flight of thoughts, so characteristic of various forms
of mental weakness, as has been pointed out by Liepmann.1 The
psychological bearing of this principle has repeatedly been insisted
on by the keen psychologist, Bergson, both in his work on memory
and matter,2 and in a more recent essay.8

The psychological researches into habit and set are likewise of
practical importance. The laws of habit describe the tendencies
under which the varied reactions of the nervous system recur under
forms which are really stereotyped and predetermined, although
simulating the purposive reaction of health, and often only with
difficulty to be distinguished from them. The term "set" describes
the process by which the reactions of every individual, beside their
purposive significance, receive a form and coloring, which, in a
measure, reflect the general characteristics of the personal life of
the actor, his temperament, his racial traditions, his education.
It indicates, as has been justly said, the "signature" in the mus-
ical sense, under which the movement of his life goes on. The
"set " of each patient must be understood before his illnesses can be
mastered. In the study of these important laws psychologists and
neurologists can lend each other mutual support.

If a further illustration was needed of the way in which a refined
study of physiology and psychology can be made of the highest
use to supplement anatomic data, in affording a basis for clinical
conclusions, it could be amply furnished by a consideration of the
problems of fatigue, that mysterious region, daily traversed, where
health and sickness are so strangely mingled.

Thanks to recent investigations, we know a good deal about the
anatomy, chemistry,4 and physiology,8 of the nervous system in
fatigue, as representing the primary lesions, but it needs only a
brief reflection to show how numerous and varied are the secondary
manifestations, neural and mental, involving eminently the func-
tions of the organism as a whole and in all its parts, that character-
ize the clinical outcome of acute or of prolonged exhaustion.* To

1 Ueber Ideenflucht, publ. by Carl Marhold, Halle, 1904.

2 Mati&re et mHnaire.

3 L'effort intellectuel, Rev. Philosophise, 1902, p. 53.

4 See especially various papers by Verworn and his pupils, which are published
or referred to in the recent volumes of the Zeitschrift f. Allgem. Physiologic, 1901
to 1904.

s See especially Richet, Dictionnaire de Physiologic, article "Fatigue."

• See "Neurasthenia," by Cowles, Shattuck Lecture, 1891, Boston Med. and

Surg. Jour. ; see, also, the various accounts of the Exhaustion Psychoses, and of

studies on the contests in the Olympian games.

THE STUDY OF NEUROLOGY 235

give to these manifestations an adequate expression would often
mean the passing in survey the functions of all the organs of the
body. This is a task which would be anatomically impossible,
since even the most extensive anatomical survey would fail to
take cognizance of the disarrangements of old coordinations and
the establishment of new ones.

Almost equally important with the generalization that the mani-
festations of disease are largely compensatory or adaptive, i. e.,
vital or physiological manifestations on the part of the organism,
is that which describes these changes as affecting not organs, but
functions. This view is justly made much of by Wolkow, who points
out that too close an adherence to the analytic methods of the
anatomist encourages a tendency to regard the body as a congeries
of organs, of tissues, and of cells, having an independence of each
other which, in reality, they do not possess. A mode of concep-
tion such as this robs the organism, regarded as a whole, of its in-
dividuality, and as a substitute for it we need to cultivate the habit
of regarding each individual as representing a vast system of in-
terlocking functions, partly known to us already, partly unknown.
It is during the disturbances and reorganizations of these func
tions, either in themselves or in their relations to each other, that
the symptoms of disease arise, and the problem of the physician
is to cast up the patient's account at each critical juncture, and
to reckon upon what assets, in a physiological sense, he has yet to
reckon, upon what powers of compensation and readjustment he
can still rely. In place of regarding the body so much by piece-
meal, we need to regard it more as a whole; as a supplement to
our study of structure we need a closer study of function. Some
diseases, as Wolkow suggests, could best be defined as disorders
of unknown functions. It is probable that, under the same prin-
ciple, those disorders which we now classify as due to premature
death of anatomical parts1 could be more properly described as
due to the premature falling-out of more or less specialized func-
tions.

In no department of pathology is it so difficult to arrive at satis-
factory conclusions by the aid of the anatomic method alone as in
the department of neural pathology. For it is the nervous system
upon which the organism preeminently depends for the very ex-
istence and efficiency of these interlocking functions which are
the basis of life. We can get on without admitting the existence
of matter, in the familiar sense of that word, but we cannot get on
without admitting the existence of energies,2 superposed one over

1 Termed by Cowers "abiotrophy."

2 Of course, in the final analysis, it must be admitted that any given conception
of "energies" can be taken only in a symbolic sense. It is, however, at present,
the term most conducive to clear thought and adeqviate generalization.

236 NEUROLOGY

another in ever increasing complexity of organization, and to admit
this conception of energies is at once to throw the emphasis of re-
search upon the study of functions, and to admit the significance
of the anatomical method only as a valued help toward the better
understanding of function.

One unfortunate result of a too close adherence to the anatomical
method is that it has introduced into medical literature, and, more
important still, into medical thought, a differentiation of disease
into two contrasted, although vaguely defined, categories designated
as "functional" and "organic," two terms which are objection-
able because they help to perpetuate false notions of physiologic,
pathologic, and clinical sorts.1

However useful these terms may have seemed as affording a
convenient, if rough, classification of diseases, and however in-
spiring it is to reflect that with the idea of "functional" goes that
of possible curability, it is nevertheless true that their employment
has had a mischievous because misleading effect, and that it turns
away the mind from the true recognition of a nature of the facts
at stake.

Contrast, for example, the cases of hysteria and epilepsy, with
regard to which these terms are often used, as if with an essential
meaning. If in calling hysteria "functional " and epilepsy "organic "
it is meant that the one is curable and the other incurable, neither
assumption is strictly accurate. If it is meant that in the case of
hysteria there is, presumably, no essential anatomic peculiarity of
the brain and nervous system, while in epilepsy such a peculiarity
is present, neither assumption is correct. For no one can doubt
that the brain of the hysteric is in some degree abnormal, and while
we must make the same assumption in the case of epilepsy, we
know nothing of the actual change which brings the epileptic fit
about or makes it possible, nor can we even say that the fit itself
is not a conservative process, in a certain sense. Again, the epilep-
tic paroxysm, as such, is a sign which distinctly deserves the name
of "functional," as much when occurring spontaneously as when
induced by experimental excitation of the cortex. Furthermore,
it would be only partially correct, and certainly not scientific, to
call hysteria a "functional" and epilepsy an "organic" disease
because epilepsy occurs oftener than hysteria in patients who ex-
hibit certain physical peculiarities which we classify as stigmas
of degeneration.

It would be equally erroneous to claim that having classified a
disorder as "hysterical," and therefore as "functional," we have the

1 Compare in this connection Obersteiner, Functionette und Organische Erkran-
kungen, 1900; and Krehl, Die Functionelle Erkrankungen, in Die Therapie der
Gegenwart, 1902.

THE STUDY OF NEUROLOGY 237

right to consider it as representing a condition which anatomy need
not take into account. Mental action is, in every sense, a real force,
standing on the same plane with the other forces which we regard
as more familiar, and as such it is capable of influencing the nutrition
of the body. It is only by evasions and subterfuges that we can deny
the reciprocal relationship between bodily processes and mental
states. Both of them are manifestations of energy, and there must be
some denominator common to them both. Between death from a
bullet that traverses the brain and death from an emotional shock,
the difference is one solely of detail. When any disorder such as we
should be inclined to call functional is hostile to the fundamental
interests of the organism, it leads at once to manifest disorders of the
nutrition. Not only is this true of depressive emotions, but even of
excessive intellectual preoccupations, as when Dante said, "My great
work has made me lean." This datum of common observation is
receiving, more and more, the solid indorsement of scientific thought.
Thus, Ostwald * dwells upon the fact that mental operations of a
pleasurable sort directly favor nutrition and the normal flow of chem-
ical energy, while those of a painful sort interfere with nutrition and
hinder the flow of chemical energy.

At both these latter points the barrier between the functional and
the organic is broken down. As a matter of fact, this barrier does not
by right exist, and we should not be tempted to use the terms "func-
tional" and "organic" as applied to disease at all were it not for two
reasons, the first being the convenience of the custom, the second
that there are many conditions which we recognize as being on the
whole hostile to most of the interest of the organism and which we
therefore feel justified in classifying as disease, yet where the dis-
order is not adapted for anatomical expression. If we adopted, as we
should, the conception defended by the clear-minded philosopher and
scientist (Ostwald), that the organism is a fabric built up, not of
atoms, but of energies, we should never draw these unscientific
distinctions between "function" and "structure," or "symptoma-
tology" and "anatomical expression," as standing for fundamentally
different and contradictory conceptions, or as affording the one a
truer and the other a less true method of approaching the study of
disease, but we should admit that the data gathered under these
different headings stand upon the same plane as regards their admis-
sibility as evidence. The data furnished by the study of symptoms,
which in the case of the so-called functional disorders constitute all
the evidence at our command, are data of a physiologic sort, and
throw light rather on the reactions of the organisms than on the
direct effects of the primary lesion. For this reason they are not sus-
ceptible to discovery by anatomic means.

1 Philosophic der Natur.

238 NEUROLOGY

In conclusion, then, I offer the following propositions:

Every organism, whether we call it diseased or well, presents
itself to our view as a web of interwoven "energies," which, in order
to study them by anatomic means, we must break artificially into
fragments that have, in reality, no correspondingly separate exist-
ence.

These energies, under tendencies which countless ages of evolution
have established, have woven themselves into a mechanism of inter-
locking functions, forming an endurable and relatively stable equi-
librium, which we denominate as health. This equilibrium, however,
must always remain but relative, and would become a real equi-
librium if that were possible only at the sacrifice of further evolution
and progress.

The processes of mutual modification and adjustment through
which such an organism seeks to gain and to maintain this equilibrium,
under the ordinary conditions which we classify as health, are the
only means which it possesses to meet the more serious needs created
by the unusual conditions that we call disease.

It rarely happens that these efforts 1 at readjustment (after any
considerable disturbance of this equilibrium) are thoroughly success-
ful, and in the abortive or exaggerated reactions on the part of the
organisms, energies are set free and habits are established which
are often hostile to the main interests of the organism as a whole,
and therefore are reckoned as evidences of disease.

In many cases the processes of readjustment are taken part in by
various functions of the organism which do not seem to be at first
sight related to the changes primarily at stake, to such an extent that
the earlier effects of the original lesion are overshadowed, and we
seem to be in the presence of what would be called a change of type
rather than a disease. In this way, for example, what are called by
biologists the "secondary sexual characters" arise. Clinical exam-
ples of this tendency toward such a generalization of the process of
readjustment have already been suggested.

Although these processes of readjustment do not seem to be guided
by teleologic influences, and although they often fail to benefit the
organism, and, instead, work it great mischief, yet in many instances
they do have all the outward appearance of being under the direction
of some general principle analogous to that which governs the pro-
cesses of growth, and is manifested in the repair of lost parts among
the simpler forms of life.

The tendency, according to which the processes of repair are
governed by a "general principle," presents interesting analogies
with the government of the flow of thought and memory by a "lead-

1 It is to be understood, as stated above, that the term " efforts " is here used in
a descriptive sense alone.

THE STUDY OF NEUROLOGY 239

ing idea." The same tendency probably finds application in fact, in
the case of all complex reflexes, no matter of what sort.

In order to give aid and guidance to the more favorable elements
of these processes of readjustment, we, as physicians, need to bend
all our powers to a better understanding of the resources which each
organism has at its command for compensation, for continued life on
the old lines, or for gaining a new and more stable life, no matter at
what sacrifice. The patient who thoroughly understands his resources
and is master of them, even if these are few and slight, is often in
a better position than one who has more to draw upon but who is
liable to be upset by surprises.

In the accomplishment of this task we need all the help that
anatomy can furnish, but as it is the organism in activity that we seek
eventually to understand, it is necessary that the splendid services
of anatomy should be supplemented by physiology, and the physi-
cian— above all the neurologist — needs, therefore, to be trained,
more thoroughly than at present, to work and reason in accordance
with physiological conceptions and methods as applied to the problem
of disease.

As regards our duty in the treatment of our patients, we should
not fail, first of all, to seek for the original cause, wherever it may lie
by which the old equilibrium of relative health has been, in one
direction or another, broken into, and we are, therefore, bound to
acquaint ourselves with all those functions and processes which are
related to nutrition in the broadest sense. Still, for the neurologist
in particular, the problem of nearest interest is often to gain a point
of temporary vantage for his patient by training him to make the
best of a present situation, and the methods by which this end is to
be accomplished are classifiable under the general name of education.

In these methods the future therapeutics of the nervous system is
largely to assist; to them we are more and more to look for guidance,
both in relieving our patients of their ills and in teaching them how
to bear them. The physician who knows best how to appreciate the
needs and resources of those coming under his care, to divine their
capabilities, to search out the hidden causes of their present troubles
— lying, perhaps, in the experiences of childhood — the physician
who has the trained keenness to recognize that, however poor the
material with which he has to work, there is almost invariably some
benefit to be gained, if not in the direction of relief, then in that of
compensation — such a physician as this can make himself of infinite
service to the community in which he lives and works.

As among the newer representatives of the successful laborers in
this field, we ought to recognize not the scientific investigators alone,
but also those practical workers, whether lay or medical, who have
shown what education can actually accomplish. I have in mind,

240 NEUROLOGY

especially, the physicians who have demonstrated that tabetic
ataxia can be relieved, the sufferers from obsessions and morbid
fears restored to their place in society, the vacant lives of imbeciles
and dements made more full, and new promise given to the efforts
for the reform of the waifs and wards of our great cities. In this out-
come is to be sought one of the best practical pieces of evidence for
the value of the physiological principle in the problem of disease.

SHORT PAPER

DR. C. L. HERRICK, of Granville, Ohio, contributed a paper, read by his bro-
ther, Dr. C. Judson Herrick, on " A Comparative Method in Psychology, par-
ticularly in its physiological and anatomical relations."

SECTION G— PSYCHIATRY

SECTION G — PSYCHIATRY

(Hall 7, September 22, 10 a. m.)

CHAIRMAN: DR. WILLIAM A. WHITE, Government Hospital for Insane, Wash-
ington, D. C.
SPEAKERS: DR. CHARLES L. DANA, Cornell Medical School, New York.

DR. EDWARD COWLES, Boston.
SECRETARY: DR. C. G. CHADDOCK, St. Louis, Mo.

PSYCHIATRY IN ITS RELATION TO OTHER SCIENCES

BY CHARLES LOOMIS DANA

[Charles Loomis Dana, Professor of Nervous and ad interim Mental Diseases,
Cornell University Medical College, New York; Visiting Physician, Belle vue
Hospital; Neurologist to the Montefiore Hospital, b. Woodstock, Vermont,
March 25, 1852. A.B. Dartmouth, 1872; A.M. ibid. 1875; M.D. CoUege of
Physicians and Surgeons, Columbia University, New York; LL.D. Dartmouth,
1905; Professor of Comparative Physiology, Columbia School of Compara-
tive Medicine, 1879-82 ; Professor of Physiology, Woman's Medical College
of New York Infirmary, 1882-90; Professor of Nervous Mental Diseases,
Post-graduate Medical School, 1886-96; Professor of Nervous Diseases,
Dartmouth College, 1892-95 ; ibid. Cornell University Medical College, 1896.
Member (ex-President) of the New York Neurological Society; American
Neurological Association : Charaka Club ; President, New York Academy
of Medicine; American Association for Advancement of Science. Author of
numerous articles and monographs on nervous and mental diseases.]

THE task of preparing an address upon the relations of psychiatry
to other sciences presents some embarrassments. Psychiatry itself,
in its narrower sense, is the science that deals with the phenomena
of disordered minds. But the psychiatrist has also an applied science
to utilize, or in reality a business to perform, which engages much of
his energy, and is a very dominant thing in his professional life.
This business is that of the administration and care of the insane,
and it is hard to ignore its immense importance in discussing psych-
iatry from any broad standpoint.1 Indeed, one may say that the
most real advance in the treatment of insanity lies in the improved
methods of hospital care that have been developed in the last thirty
years. Still, the science of psychiatry, as pursued by the clinician
and the pathologist, is that phase of it which must, for our present
purposes, be set apart and its "problems" and "relations" studied.

1 Among 5470 contributions to psychiatry made during the five years, 1894-
1899 (Jahresberichte fur Psychiatric u. Neurologic), the number devoted to differ-
ent groups of subjects was as follows : General symptoms, pathology and etiology,
1749; special psychopathology and therapy, 1581; administrative methods and
reports, 1286; forensic medicine, 854. Thus writings concerning administrative
care make up over 20 per cent of the total literature of psychiatry.

244 PSYCHIATRY

•I do not know how one can very well entirely separate these topics
from each other, and I must be excused if I sometimes slip from speak-
ing of a relation to dealing with a problem. After all, the thing
desired in such an address as this is, I assume, to find out how
psychiatry stands as a science now, what dependence it has on other
sciences, and what help it needs from them or can give to them.

Twenty years ago I was a member of an organization for securing
reforms in the care of the insane. It fell to me to present the situa-
tion then of psychiatry in America. It may be said that at that time
little science of this kind existed here. This was so much the case
that the superintendents of the insane asylums had withdrawn from
affiliation with the American Medical Association, and had for years
kept out of formal touch with general medicine and the activities
of medical science. Psychiatry had mainly one side : the business of
administration and custodial care. Only four medical schools pre-
tended to give any teaching in mental disease in the whole country.
There were then only 74 state asylums, with a population of 39,145
insane and considerably less than half of the insane of the country
were in institutions designed for their care. The cost of running
these institutions was about $200 per capita yearly, which is perhaps
a fifth greater than it is now. So that psychiatry represented a busi-
ness conducted in some places well, in some ill, as sentiment demanded
or as money was supplied.

This situation was a natural one considering the state of public
feeling and of medical science at that time; for the thing to do with
the alienated, when only one thing can be done, is to take good care
of them; after this we can study them and build up a science and an
art. And this is what has happened.

During the last twenty years there has been steadily developing
a science which deals with mental disease. Largely through the
influence of certain clear-sighted administrators of our hospitals, our
knowledge has developed until now we are justified in classifying
psychiatry among the medi'cal sciences, surpassing in exactness some,
and in importance, interest, and difficulty perhaps all, of the other
branches of medicine. For we are dealing in its study with the ulti-
mate and finest and most elaborately differentiated product of organic
life, and our task with it is not only to study and to classify, but to
prevent and to save that which is most essential to human progress
— the human mind.

During these past twenty years the administrative care of the
insane has also steadily improved, so that now in our best semi-pri-
vate and endowed institutions there is really little more that human-
ity could suggest or ingenuity devise for the comfort and care of the
patient. In many of our state institutions there has been also a
steady progress, which is hampered in some states by poverty and

RELATIONS TO OTHER SCIENCES 245

lack of intelligent interest, and in nearly all by the allied science of
politics. Indeed, while this last exists, state hospitals will always fall
a little short of the ideal. The psychiatrist stands on one hand
striving to bring things up to his highest views, the politician on
the other, urging something cheaper, and standing for an influence
that tends toward mere custodianship.

The science of psychiatry comes in touch with many branches of
human knowledge. In so far as psychiatry has a practical side, it
stands in close relation with what may be called, in general, economics;
to an extent, also, it is in relation with all those sciences which par-
ticularly tend to prevent and ward off insanity by improving social
conditions through sanitation, education, and better heredity.

The science of psychiatry utilizes, at all times, the work of the
psychologist, but, most of all perhaps, it stands in relation with
certain departments of internal medicine, such as pathology, and
chemistry. Psychiatry has also certain relations with the law, with
the criminal, and in general with abnormal man.

To take up all these relations in detail would make an address very
long and very desultory. Yet I do not see how, in the nature of the
case, my remarks will not have some of both these characters.
I shall, however, while touching on a number of topics, lay special
emphasis on a few that seem most important.

Psychiatry and Economics

The relation of psychiatry to economics is one of increasing interest
and importance. The loss to the state and the expense in money
from disease is a subject that has received increasing attention of
late years, until now in many directions public knowledge and state
action are almost adequate to the problems involved. The results
have been the extermination of some and the holding in check of
other diseases. Thus, in the more advanced communities, with the
exception of certain pulmonary troubles, and a few of the infectious
and eruptive fevers, the prevalence of microbic diseases has been
decidedly checked.

Nervous diseases, however, if we include also those due primarily
to vascular disease, are probably more numerous than ever. Statis-
tics are almost useless for determining this question, because there
is no common nomenclature, the diseases are not notifiable, and, at
best, we must go % death statistics. I believe it to be common
medical opinion, however, as it is certainly my own, that both
organic and functional neuroses are relatively more numerous than
they were fifty years ago.

As to the psychoses, there is little doubt that they are also increas-
ing, relatively, more than the population. This is shown in the reports

246 PSYCHIATRY

of those states in which statistics have been more carefully kept, as,
for example, in Massachusetts, New Hampshire, and New York, as
well as by the census statistics of this country and Great Britain.
We may say that in the last twenty-five years the ratio of sane to
insane has shown an apparent gradual increase from 1 to 450 to 1 to
300, and this latter seems to be about the ratio in those communities
of North America and Europe in which modern conditions of civiliza-
tion prevail.1 This average has varied but little in the last few years;
the slight yearly increase probably will not change rapidly and prob-
ably not continue. For when the increase in the insane reaches
a certain point of excess, society will have to take notice of it and
correct it.

For twenty-five years the explanation for this increase has been
that more cases were observed and more victims kept in institutions
than formerly; and this is still the explanation. It is my opinion,
however, that the increase is a real one, and it is one to be expected,
not only from the strenuousness of modern life and increase of city
population, but also because more feeble children are nursed to
maturity and more invalid adolescents are kept alive to propagate
weakly constitutions or to fall victims themselves to alienation; the
period of life susceptible to insanity is longer.2 A fourth of the cases
of insanity are due to so-called moral causes: emotional strain,
shocks, and vicious indulgences. But moral causes are not sufficient
to cause insanity if the individual has a sound constitution. Insanity
is increasing in part, then, because we are saving too many lives
by the careful regulations of our health boards. Hence, those who
are working so enthusiastically, and nobly, and successfully in pre-
venting disease achieve results which carry serious responsibilities
for the state.

1 The somewhat startling increase in suicide is corroborative of an increase in
psychopathic constitutions.

2 The expectation of life is now 43.59 (Newsholme). The death-rate of children
under 5 has dropped from 68.6 to 64.5 in the years from 1865 to 1895 in Massachu-
setts. The drop in the death-rate, from 5 to 40, has been much greater, while the
death-rate above 40 has increased. (S. W. Abbott, Vital Statistics, Wood's Ref.
Handbook, vol. vm.) The period of life during which insanity most frequently
occurs is 30 to 40, and next, that between 20 and 30. The average age at death in
England was:

Males. Females.

1840 27.15 29.38

1900 33.63 39.90

/— Excluding 0 to 4. — % /— Excluding 0 to 54 — >
Males. Females. Males. Females.

1840 46.46 46.77 ^2.09 73.05

1900 53.17 55.21 W0.41 71.92

— S. G. Warner.
Expectancy of life in Massachusetts :

1880 44.64

1900 46.05

— U. S. Census Bulletin, No. 15.

The average age at death has increased from about 28 in 1840 to 34.5 in 1900,
thus bringing more people into the third decade, which is the one most fruitful in
insanity.

RELATIONS TO OTHER SCIENCES 247

Let us see what the facts are regarding the economic loss of
insanity :

There are in the United States now about 145,000 insane; 120,000
feeble-minded; a ratio of about 1 to 300.

The annual increment of insane in Massachusetts, according to the
Massachusetts Board of Lunacy, is 400 in about 10,000, or 4 %.

At this ratio, the annual increment for the United States would be
approximately, 5600.

The cost of maintaining properly these 145,000 can be estimated
fairly on the basis of the cost of the institutions of the two large
states (Massachusetts and New York), where it is admitted the
work is at its highest efficiency.

The plant for caring for the 22,000 insane of New York is valued
at $22,000,000 (Mabon), and the plants for caring for our insane, if
we are desirous to care for them in the way creditable to a great
civilized and wealthy nation, should be not less than $150,000,000.
To run this national plant the cost is, at a moderate estimate, $3.50
weekly, per patient. This is about the average in New York and
Massachusetts and most properly organized state hospitals else-
where. This gives the insane no luxuries either; for the average cost
of properly caring for the insane in private institutions is $12 to $25
per week. This with the interest on the plant makes the actual
objective cost of caring for the insane of the United States every
year about $40,000,000.

This does not include the care of the feeble-minded. So far as the
state is concerned they are less of an expense because a large number
are cared for in families. Many do not need actual responsible super-
vision, and many can in a degree support themselves. Finally, the
feeble-minded are short-lived, while the insane live into and beyond
middle life. At the best, however, the idiot or feeble-minded are
persons whose lives are a burden and a sorrow beyond what is mea-
surable in money. An idiot cannot be supported for much less than
the insane, and it is safe to put down $20,000,000, yearly, as the sum
we pay for having the idiot with us. But $60,000,000 a year does not
represent all; 70,000 of the insane are men and presumably bread-
winners. The average worth to a community of a healthy worker is
about $400 a year. This sum is subtracted from industrial activity
by his sickness. Assuming that the 70,000 insane men could earn this
sum, we have a loss of $28,000,000 more per year. It seems to me
that it would not be far out of the way to say that the care and cost
of the diseased and defective brains of the country is over $85,000,000
annually, and is increasing absolutely at the rate of 4%. These
figures, perhaps, are not so very alarming to a nation with an income
of $600,000,000. It is a sum that would not quite run the city of
New York, or support an army or navy. But it is an item to be

248 PSYCHIATRY

reckoned with by economists; and the side which cannot be repre-
sented by figures is still more important, viz., the sorrow and suffer-
ing and indirect loss in health and happiness.

If there were a science of state medicine, the economic study of
insanity which brings out some such figures as those I have just
presented would be called into demand.

State medicine in some of its branches is supposed to give us means
of relief from social evils due to disease. In the case of insanity it
would have to call upon various minor divisions of science for help.
The study, for example, of the causes of insanity, teaches us that if
we could subtract alcoholism from our social life, and nothing took
its place, we should cut out about a tenth of the cases of insanity
brought on directly by this poison. We should probably subtract
a large number, brought on directly through alcoholic parents. If
we could subtract syphilis from our civilization, we could cut out a
tenth more of the insane. If we could do away with violent passions,
shocks, mental strains of various kinds, we could cut out perhaps
25 % more of the insane.

But after all, supposing even these practically impossible feats
could be accomplished, there would still be left a large percentage
of the alienated, and this percentage would include persons who
developed disordered minds because they were born with a tendency
to mental degeneration.

It follows that the most immeasurably important factor in attempt-
ing to limit and prevent insanity is to secure well-born children ; to
see that those people who have weakly constitutions, or poisoned
constitutions, do not propagate the kind. This is, of course, a thing
which can only be accomplished by long years of careful education
and training. The science of eugenics is hardly yet existent, and if it
were a full-fledged science, the people are not educated to receive its
teachings. There are, however, known to be certain fundamental
principles of "eugenics" which cannot be too strongly insisted upon.
One of these is that persons who have strongly alcoholic tendencies,
or who are dipsomaniacs or drug-takers, are almost sure of breeding
degenerate children. And the same is true of those who are plainly
syphilitic, or who are on both sides tuberculous, or on both sides
psychopathic or neuropathic. One further point only I wish to make
in connection with this subject, and that is the question of the results
of the amalgamation of races in this country. While the ratio of
insanity in the United States is fully up to that of other civilized
nations, it is not especially in excess, hence it cannot be said that the
fusing of different races here has yet caused deterioration. Never-
theless, it is a practical and serious question as to what will be the
eventual result. We know that when widely different races, like the
African and Aryan, mix, they do not breed good men and women.

RELATIONS TO OTHER SCIENCES 249

We know that, on the other hand, races such as the Jewish and the
Japanese, which have kept themselves pure for centuries, have
reached a very high stage of efficiency. So far as history shows, we
have no clear proof that the mixing of races breeds races of a higher
efficiency. But we do know very well that the mingling of very
widely different races leads to a degenerate quality of hybrid. What
will be the result of fusing together the typical Anglo-Saxon with the
dark-haired Latin, Slavic, and Semitic races of Southern Europe,
remains to be seen. Since they are all of Indo-Aryan stock, no harm
may result, but I have personally observed most disastrous results
among children of unions between the Scandinavian and the Spanish
races. 1

Psychiatry and Psychology

The science of psychology stands nearest to psychiatry of all the
non-medical sciences. It should, in fact, bear the same relation to
clinical psychiatry that physiology does to medicine. It furnishes us
the normal standard of mental activity, and should give name and
definite description of what takes place in the healthy mind. There-
fore, it is as important that the psychiatrist should have a sound
knowledge of the elements of psychology as that the neurologist
should know the anatomy of the nervous system.

For after all psychiatry is now and will long be essentially a clinical
science, a study of a grouping of symptoms. In neurology we make
three diagnoses when the art is perfectly exhibited. We have a
clinical diagnosis by which we recognize a symptom group, a local
diagnosis by which we recognize the seat of the disease, and a patho-
logic diagnosis by which we recognize the nature of the trouble. In
psychiatry only the clinical diagnosis is made as a rule, and this
clinical diagnosis is really dependent mainly on the study of the
psychology of the patient. Clinical psychiatry is, in fact, only
morbid psychology.

All this would lead us to think that the relation of psychiatry and
psychology should be an intimate one. As a matter of fact, psycho-
logists do not write with much reference to the morbid mind. This
at least is my experience in an effort to orient myself on this subject.

1 In a study of the subject of immigration and nervous and mental diseases,
made in 1882 (Annual Report of American Social Science Association), I reached
the conclusion that immigration tends slightly to increase the amount of insanity
out of proportion to the native population, partly through influence on social life
and partly through the introduction of poor stock.

Only a portion of the immigrants and certain special races have these tenden-
cies. Immigrants were found to develop an excess of organic disease, but to have
fewer functional nervous diseases than natives, due probably to their social con-
ditions and the exposure incident to poor methods of living.

Twenty years ago the foreign-born made up a fifth of our population, and con-
tributed to a third of the cases of insanity.

250 PSYCHIATRY

We as alienists do not need a large vocabulary or very recondite
knowledge of psychology. We do not require to hold opinions on
association theories, or on parallelism or monism, or epistemology.

We do very much need definite descriptions and harmonious
views of the elementary mental processes.

We deal in disorders of sensation and perception, in failures of
memory, perversion of judgment, states of feeling either too intense
or depressed, loss of the volitional function, and disorders of in-
stinctive reactions, of memory and of consciousness. Yet it is not
easy to find these states clearly defined among psychologic author-
ities. I have a list of the psychologic terms used to describe groups or
individual symptoms in psychiatry. This vocabulary of involved
symptoms has only about twenty-five terms, but they mean different
things according as the physician takes his psychology.

Psychiatry is having its great difficulty in classifying its cases.
Practically every writing alienist has a special classification of his
own. This is in part because cases cannot be observed completely
or recorded thoroughly without a proper language for recording
the facts. The older alienists never knew the science of psychology,
because there was none; the modern are only learning it. A thorough
and especially a uniform understanding of psychology is necessary
in order to give sharper definition to observed phenomena, to bring
out new facts and to clarify the symptomatology and make us
agree upon our groupings. For example melancholia used to be
considered as essentially a morbid depression of the mind. Now
we know there are other elements such as retardation and diffi-
culty of thought and action, of disturbance of attention and voli-
tion; we find, in fact, that there may even be a melancholia with-
out any melancholy. It is in the observation of the often obvious
psychic states and in the correct record of all deviations that we
may expect to make real progress. And we need a uniform psych-
ologic vocabulary for our purpose, as well as a pretty thorough
psychologic training.

I have collected from the writings of Stout, Morgan, James,
Baldwin, Ladd, Calkins, Titchener, Sully, the definitions or views
given by them of the elementary and other mental processes:

Sensation, impression, perception, percept, conception, concept,
image, idea, ideation, judgment, reason, reasoning, emotion, feeling,
sentiment, conation, will, volition, consciousness, memory, associa-
tion. There is substantial agreement about the significance of perhaps
the majority of them, and I quite understand that the mind is not
to be divided into sharply limited mental processes, but that mental
states are all complex and that one process overlaps another.

Nevertheless, there are decided differences and vaguenesses in
the views of sensation, perception, of concept, memory, image,

RELATIONS TO OTHER SCIENCES 251

idea, will, consciousness. The establishment of a better relation
between psychiatry and psychology is at any rate a thing much
needed, but belongs, perhaps, to the problems of psychiatry.

The following are examples of the differences in the definition of
elementary psychological terms among leading psychologists.

Impression is the simple result of a stimulus. (Morgan.)

Sensation is the discrimination and recognition of the impres-
sions as of such and such a quality. It is the reception and dis-
crimination of impressions which result from certain modes of
stimuli, like sight, hearing. (Morgan.)

Perception is the process by which sensations are given object-
ive significance, being supplemented by revived sensations. (Sully,
Morgan.)

Perception always involves sensation. (James.)

Percept is the aggregate of the revived and actual sensations,
integrated and solidified. (Morgan.)

Perception (Wahrnehmung, Anschauung) :

(1) Cognition, so far as it involves the presence of actual sensa-
tion as distinguished from mental imagery.

(2) Cognition of subjective process as such; the apprehensioc
of the actual presence of this process in distinction from the ideal
representation of it. (Stout, Baldwin.)

The old writers used perception as a synonym for cognition in
general. The later tend to fuse sensation and perception. Some
speak of inner sense, inspection or introspection as perception.

Perception (Wahrnehmung) is the process of the apprehension
of sense-objects.

Anschauung is rather sense-intuition. (Baldwin, Dictionary of
Psychology.)

Memories of percepts are simple, particular or concrete ideas.
(Romanes.)

Image (Bild). The mental scheme in which sensations or the
sensory elements of perception are revived. (Baldwin, Stout.)

Idea (Vorstellung). The reproduction with a more or less ade-
quate image of an object not actually present to the senses. (Stout,
Baldwin.)

A mental image is an idea, according to Ladd.

The German Vorstellung is sometimes used to cover both per-
ception and idea, and there is a tendency to give the same wide
application in English. (Titchener, Outlines of Psychology.)

In a perception the object perceived is usually supposed to be
present.

Ideas which are general and abstract are concepts. (Romanes.)

Ideas which are complex, compound, or mixed are recepts. (Ro-
manes.)

252 PSYCHIATRY

Ideation is the elementary mental process involved in all work
of the representative faculty. The products of this are mental
images or ideas. (Ladd.)

Conception is the function by which we identify a numerically
distinct and permanent subject- of discourse. (James.)

Concepts are the thoughts which are the vehicles of conception.
(James.)

A concept is a general notion or general idea. (Sully, Romanes.)

A concept is an image or general idea into which there have
entered elements which have been isolated by analysis. The term
soldier may stand for a percept or concept according as there are
associated with it qualities not identified with a particular soldier.
(Morgan.)

A concept (Begriffbildung) is cognition of a universal as distin-
guished from the particulars which it unifies. The universal ap-
prehended in this way is called a concept. It unifies a distinction
between the universal and the particular.

In philosophy it is common to apply the word more widely, so
as to cover the universal element in knowledge, e. g., the categories
of Kant were called concepts.

In psychology, John Roe is a particular concept; a triangle is
a general concept. (Stout, Baldwin.)

Reason, in English, means often reasoning or reflective thought,
less often intuitive and certain knowledge. (Diet, of Psychology.)

Reason is a form of knowledge which apprehends in one imme-
diate act the whole system, both premise and inference, and thus
has complete and unconditioned validity.

This distinguishes it from understanding (Ver stand), which is a
form of knowledge that is discursive, and hence based on premises
and hypotheses not themselves the basis of reflection. (J. D., Diet,
of Psychology.)

Reason (Verstand, Xoyos) is that faculty or process of mind which
consists in the drawing of inferences. (G. E. M., B. Diet, of Psych-
ology.)

There are other more restricted definitions given :

Reason is to pass from certain judgments to a new one. (Sully.)

Reason includes the formation of a judgment or concept, not
inference, then passing from it to a new one. (Morgan.)

Judgment (Urtheilskraft, Urtheil). The mental function and act
of assertion and predication. The term is also applied to the re-
sulting assertion as well as to the process or function. Judgment
as a mental process is similar to belief. (Baldwin.)

Modern psychologists find it difficult to define belief and judg-
ment without overlapping, and French psychologists class delusions
or false beliefs as disorders of judgment.

RELATIONS TO OTHER SCIENCES 253

Judgment is a conscious mental synthesis, a unifying act. (Ladd.)

Judgment is an inference in the form of a proposition. (Morgan.)

Conation (Streben). The theoretic active element of conscious-
ness, showing itself in tendencies, impulses, desires, and acts of
volition. "Conation" in general "is unrest." The term will (mile)
is often used in the same sense.

Streben is translated effort by Titchener.

Begehren is used for conation by others. (Diet, of Psychology.)

Volition is the faculty of the forked way, the possibility of action
or inhibition. Man has perceptual volition, in which he is conscious
of a choice, but does not reflect upon it. He has conceptual voli-
tion, in which he is conscious of choice, and can reflect upon his
choice. (Morgan.)

Volition is a definite conative activity consciously directed to-
ward the realization of some mentally represented end, preceded or
accompanied by a desire, and usually accompanied or followed by
the feeling of effort. (Baldwin, Stout.)

The settlement by the self of a psychic issue, the adoption of an
end. (Baldwin, Stout.)

Will is that conative organization of which volition is the ter-
minus or end-state. Will is conation in the concrete, determined
in an actual terminus by volition. (Baldwin, Stout.)

Emotion (Affect). -A total state of consciousness considered as
involving a distinctive feeling-tone, and a characteristic trend of
activity aroused by a certain situation which is either perceived
or ideally represented. (Stout, Baldwin.)

Feeling or feeling-tone (Gefuhl) is absolute emotion.

The same conscious state may be regarded either simply as feel-
ing, emotion, passion, or sentiment. (Ladd.)

Consciousness (Bewusstein). The distinctive character of what-
ever may be called mental life. It is the point of division between
mind and not mind. (Baldwin.) Whatever we are when we are
not unconscious, that is consciousness. (Ladd.)

Earlier psychologists called it the mind's direct cognizance of its
own states and processes.

The word is not even indexed in Calkin's Elements of Psycho-
logy and is not defined by James.

Consciousness or awareness means, according to G. Spiller, that
a notion does not stand by itself, but is connected to another no-
tion; the word "connection" may better be used for it.

Psychiatry and Physics

The science of physics is in closer relation to the administrative
care of the insane than to psychiatry proper. Light and electricity

254 PSYCHIATRY

have as yet little to do with our pathology, and not much with
our therapeutics. We are watching, however, with interest, the
various newly-discovered light-rays and their influence on bodily
function, as well as the new conceptions of the elements, and their
possible bearing on the physiology of the mind.

So far the medical and surgical effects have been superficial and
have produced results only on gross and objective evidences of
disease, such as tumors, ulcerations, etc. Some claims have been
made that the Rontgen ray will relieve pain in neuralgia and tabes,
will lessen or check convulsive attacks in epilepsy, and have a real
physical effect upon the lymphatic and glandular tissues, as in
thyroidism. It is not impossible that some forms of radiant energy
passed through the nervous centres may modify the metabolism
and produce therapeutic results, but this is speculative, and it is
not likely that, at the best, much can be accomplished.

It seems to be well established that very rapidly alternating
electric currents of enormous voltage, when passed through the
body, increase metabolic changes, but here again nothing very
definite has yet been achieved therapeutically.

The problem of helping the alienated by physical means is a
serious one — it means that we must change a psychopathic con-
stitution so that a person who has a melancholia or is threatened
with it will be rid of the disorder and of the tendency to its re-
currence. Some readjustment of glandular activity of the liver
or stomach, or some increased activity of absorption and secretion
and elimination, must be secured, or by some subtle influence we
must teach the brain-cells to build up and break down in a normal
and well-balanced manner, or by specially directed training struc-
tural defects in the arrangement or insulation of the neuron must
be overcome.

Here is a field in which the finer physical forces may play a part,
and we already know that the influence of direct sunlight is help-
ful in delaying degeneration. Other physical agencies may be found
which will furnish more.

I can only suggest the possibility that in psychic activity there
may be radioactive changes, a breaking-up not only of molecules
which we know occurs, but of the atoms themselves. This hypo-
thesis is in the line of the alleged n-ray phenomena of Blondlot.

Psychiatry and Psychotherapy

It is a popular question whether the mind does not produce
more diseases than do organic changes of the body. In fact, the
supporters of the belief that the mind is more important than the
microbe make a large cult in this country.

RELATIONS TO OTHER SCIENCES 255

I do not know that the question really deserves very serious
consideration. A little acquaintance with dispensary and hospital
practice and the records of the health boards is sufficient to show
that mental states rank far below the infections, poisons, inflamma-
tions, or injuries as makers of symptoms among all classes. I think
it would be safe to say that the general practitioner meets a real
objective disease twenty times to one in which the symptoms are
due to the attitude of the mind. The mind disturbs functions and
creates symptoms, but it muddles rather than makes disease. To be
sure, it is indirectly a potent thing. Thus, in conditions of profound
depression there is a lessened vital and circulatory resistance, and
infection can creep in. It would never do for physicians to fight an
epidemic with cold hands. Conditions of the mind can favor or
delay digestion and peristalis, and there is, indeed, no function
more susceptible to physical control than the chylopoietic tract. One
can almost stop digestion by taking thought of it, and the influ-
ence of mental treatment and sugar pellets upon constipation can
be given objective proof in many instances. The mind has, in fact,
quite a lively though incomplete and temporary control over the
different functions of the body, and it can, after years, do some
damage to them. It can check and change secretions, indirectly
thicken arteries, cripple functional activity, and hurry on old age.
But after all, the mass of people are sick with tuberculosis, rheum-
atism, bronchial and heart diseases, and the infections and the injuries
of life.

As the mind can help on disease, so it can help on its cure; but
a healthy person cannot by an act of his mind make himself crazy;
and neither can he by any mental influence, if crazy, make himself
well. It has been proved beyond any question that persons who
have severe and profound degenerative traits cannot be cured by
psychic suggestions.

Hypnotism, for example, is powerless against the insanities after
they have developed, it is powerless even against the minor psycho-
ses that are long established and of severe type, such, for example,
as chronic hysteria, the long-established obsessions, vicious mental
habits, and severe degeneracy. What is true of hypnotism is true of
all forms of mental therapeutics, and all types of charlatanry that
appeal to the imagination. It may be noticed that the quack and the
exploiter of marvelous cures never starts a psychopathic hospital
or offers to work in an insane asylum. When the mind is a little
enfeebled, over-sensitive, or untrained, 'it is easily worked upon by
emotional influences and suggestions; when it is sound, and trained
by education and experience, and when it is seriously disordered, it
is not affected by these agencies. Psychic measures of treatment,
on the whole, find their legitimate field in internal medicine, among

256 PSYCHIATRY

those who have the minor symptoms and functional disorders in
which the mind is simply needing instruction to a new point of view,
or the stimulus of a strong hope which fixes attentions and steadies
the whole mental machine. Psychic therapeutics often cure by giving
faith and purpose to the weak, wavering, and discouraged. And
faith in something is always a sane and most helpful element in a
person's character.

So far as psychiatry is concerned, we can expect little help from
the science and art of psychic or hypnotic therapeutics. Its field is
narrow and does not take hold of our serious cases.

So far as internal medicine is concerned, mental influences pro-
duce many distressing disorders of function, which may simulate
various diseases. The mind is a factor always in modifying the pic-
ture of disease, and the physician can never diagnosticate or treat
his patient without taking the individual's mental attitude into
account. This fact, which psychiatrists learn, can be impressed with
advantage on the followers of internal medicine.

Psychiatry and Neurology and Internal Medicine

In the past the field of work of the psychiatrist has been perforce
much narrowed through the necessities of psychiatric administra-
tion. It was long confined to the study of types of mental disorders
which had reached their height and shown their hopelessness. It was
as though pulmonary tuberculosis had been mainly studied in its
third stage, or typhoid fever mainly in its second week, or heart
disease after dropsy had set in. For when a psychosis is fully devel-
oped and has bloomed into mania, or a dementia, the morbid con-
dition has arrived, the god is no longer behind the machine, but on
it. It can now be watched and its natural history studied, but in 75%
of cases this is all; it cannot be cured. In only a small percentage
will it be possible to learn why it came, and psychiatry can only
reach a certain stage of progress when its study is limited to the
middle and terminal parts of mental disorders.

The field of psychiatry needs thus to be broadened by securing the
help of those branches of internal medicine in which the earliest
phases of mental deterioration and disorder show themselves. It was
long ago noted that neurasthenia might be called an abortive par-
anoia. It is my experience that about a third of the cases of decided
melancholia are preceded by attacks of what is called nervous pros-
tration; and the same is in a measure true of the early demential
psychoses and of paresis.

In fine it seems to me that a most fruitful practical field just now
for clinical study is that of what I term the minor psychoses which
includes a vast number of indeterminate mental conditions, classed

RELATIONS TO OTHER SCIENCES 257

as neurasthenias, hysterias, phrenasthenias, obsessions, impulsive
manias, and mild melancholic and hypochondriac states. These
patients now fall into the hands of the general practitioner, who is
wearied and unimpressed by them, and who fails from lack of interest
to study them, or into the hands of specialists who treat their reflexes,
generally without avail, or into the hands of neurologists who deal
with them generally as having a temporary neurosis instead of a
psychosis or the thing out of which one may grow. It is to be hoped
and expected that the follower of internal medicine and the neuro-
logist will study the cases more seriously, and from the point of
view of the psychiatrist especially. In this way we shall be able to
learn the very earliest symptoms that suggest the oncoming of mania
and dementia praecox; we will learn better the type of infancy and
childhood out of which it grows; we shall learn how to check and
to prevent it.

An illustration of such help of neurology and syphilology to psych-
iatry is already shown in the development of our knowledge of
general paresis. This disease was recognized a hundred years ago. Its
etiology was not even distinctly suspected till fifty years ago. An
established connection of its relation to lues is hardly more than ten
years old, this being worked out by the cooperation of the syphilo-
grapher, the neurologist, and the psychiatrist. New features of its
course, particularly the physical symptoms and early symptoms, have
been derived within a few years largely through the help of psych-
iatrists, neurologists, and syphilographers working together, until
now the onset of disease is recognized almost before it is present. By
reason of this its course has been checked, and it is my belief that
cases have been permanently arrested in their progress, so that we
may now say that paresis may sometimes be aborted, if not cured.
All this has been done through the cooperation of alienists, neuro-
logists, and syphilographers.

So it seems to me a like cooperation will enable us some day to cope
with mania melancholia, chronic melancholia, and the precocious
dementias. In this work we must have the help of the practitioner
of children's diseases, of the general practitioner, and of the educator
who studies the growing child.

A great deal of work has already been done in measuring children,
studying their growth, their mental activity and reactions, but not
much has yet been formulated which is helpful to us as psychiatrists,
to foresee a coming psychosis.

'This field needs further study from the anthropologist and the
doctor of infancy and childhood. We do not want to know alone that
a child is nervous, excitable, easily febrile, a bad sleeper, and a noisy
dreamer. But what are the special symptoms which may lead us to

258 PSYCHIATRY

foresee a dementia praecox at eighteen, or an hysteria, or a mania
melancholia before adolescence, or a paranoia at maturity?

Psychiatry, Pathology, and Physiologic Chemistry

There is an increasing conviction among psychiatrists that some
inherited defect, often most subtle and difficult to recognize, is pre-
sent in all those who develop mental disorders without some
original weak spot in the psyche or soma, the man who is infected
will not get paresis or tabes; the man who has fevers, toxemias,
shocks, and emotional crises, will not get a delirium or insanity.

But the weak point in a degenerate constitution may not be espe-
cially in the nervous system. It may be in a glandular defect or
insufficiency. One can imagine a person having congenitally defect-
ive adrenal glands; as a result, the blood-vessels are not kept at
their proper tonicity, and widespread defects in function follow. In
the same way, there may be defective or overactive thyroids, and the
tonus of the nervous system is disturbed. There is no doubt that the
large colon has important functions in selective absorption, and to
an extent in secretion. It is an organ that seems especially attuned
to cerebral states. It goes wrong at times with every one, but if it is
congenitally wrong, if it is born wrong, it is then one of the stigmata
of degeneracy. Thus a person may have a psychosis, because he has
congenital defect in the colon or other organs than his nervous sys-
tem; the brain may be a very good one, but these adrenal organs —
the thyroids, the blood-making organs, the enteric membrane, the
liver — may be fundamentally defective or the circulatory organs
may be badly developed.

Now it will be the part of the clinical pathologist and. chemist as
well as of the anatomist to search out these factors, and in this way
help the psychiatrist to steer his way in the future.

I do not believe that the results of this work can be very fruitful
as regards the severe dementing forms of mental disease ; here there
is always fundamentally a fault with the brain in structure or func-
tion. But in the functional -and non-dementing psychoses, such as
mania and melancholia, and in the minor psychoses, such as hysteria,
many types of neurasthenic insanity, we may expect much help.

Insanity, on the whole, is not a very curable affection. It is prob-
able that less than a fourth get permanently well, and its rate of
cure is therefore less even than that of pulmonary tuberculosis,
pneumonia, or the infective fevers. Nor is it likely that the percent-
age of cures will ever be a very high one.

We may look to the sciences of pathology and chemistry, however,
for some help in this direction. It has been already shown that in
degenerative disease of the nervous tissue there is the perverted

RELATIONS TO OTHER SCIENCES 259

metabolism, which leads to the breaking-up of the lecithin, the
important fat constituent of the nervous substance, into poisonous
by-products, neurin and cholin. These circulate in the lymphatics
and blood-vessels and irritate and further poison the nerve-centres.
So that when the brain actively degenerates, it produces a poison.
This poison reacts on the nervous centres, causing new symptoms,
and thus a vicious cycle is set up. Some of the crises of paresis and
the dementias may have this origin.

The function of the lower bowel seems to have some close relation
with the functioning of the nervous centres, and an autotoxemia is
perhaps an important element in both depressive and maniacal
states. Indeed the appearance of mania especially suggests an auto-
intoxication. One cannot observe the apparently causeless recur-
rence of mania and melancholia without the conviction that behind
it all is a disorder of metabolism leading to a toxic state.

We may expect, therefore, much from the further studies of the
physiologic chemist. Such studies will include the activity of the
ductless glands, the adrenals and thyroid, and in particular of kidney.

We cannot, it is true, expect to find any objective explanation of
the tendency which the alienated possesses to pass repeatedly into
states of mania. But we may find the nature of the nutritional change
that excited it, and by proper methods we may be able to keep off
recurrence of insanity.

This it seems to me is a hopeful field of therapeutics which is now
presented to alienists.

The clinical pathology of the blood has as yet been of little help in
psychiatry. The examinations throw no light on the cause or type
of a psychosis. Nor do clinical pathologists promise us much here.
If we could find and cultivate the germ of syphilis, a field would be
opened. At present there are no biologic blood-tests that help us.
It seems as if the ingenuity of the investigator would some day in
some way show us objectively some blood-changes, for example in
acute mania or delirium — yet it has not been done.

Pathologic anatomy is a subject of more academic than practical
interest to the psychiatrist. The burden of our work should now be
away from morpholgy and more in physiologic lines.

Psychiatry and Criminology

The relation of psychiatry to criminal anthropology is a close and
important one. There is on the one hand the instinctive or hereditary
criminal, and on the other the moral imbecile and the insane who do
criminal acts perhaps casually or as an accidental product of violence
and delusion. It is for the psychiatrist to help in solving the difficult
problems of the border-line cases. As a rule we can say that the crim-

260 PSYCHIATRY

inal's act has a definite motive, and that his crimes are to his tem-
porary or apparent advantage. The moral imbecile, on the other
hand, is in most cases a person whose acts are done without rational
motive, or are to satisfy only some morbid feeling, perhaps remotely
sexual, perhaps something not easily defined, a kind of atavistic
lust-hunger.

But no definite laws can yet be laid down. 'Each case must be
studied by itself in the light of our best clinical knowledge of what
constitutes an insane mind. We must bear in mind in doing this that
society cannot on the one hand afford to be cruel, and on the other it
cannot afford to set aside easily individual responsibility.

For the purpose of securing the ends of justice in any of these cases,
such laws as have been enacted in Maine, New Hampshire, and
Vermont, and especially in Massachusetts, are best calculated to
help on the aims of justice. These laws authorize the prosecuting
attorney or judge to place the accused in a hospital where he can be
under constant surveillance of physicians, trained experts, and
attendants.

The Massachusetts law, for example, reads as follows:

" Chapter 21&, Section II. If a person under indictment for any
crime is at the time appointed for trial, or at any time prior thereto,
found by the court to be insane, or is found by two experts in in-
sanity designated by the court to be in such mental condition that
his committal to an insane hospital is necessary for the proper care
or for the proper observation of such person pending the deter-
mination of his insanity, the court may cause him to be committed
to a state insane hospital for such time and under such limitations
as the court may order."

Psychiatry and Forensic or Legal Medicine

Forensic or legal medicine as a separate branch of science seems in
a way to have died out. It used to be systematically taught in a
number of our medical schools, but the chairs have been abandoned.
This is not because the subjects which are dealt with have ceased to
be of importance (from 1894 to 1899 there were 854 contributions
to the forensic medicine), but because they have been assigned to
different specialties — the chemist, pathologist, psychiatrists, neu-
rologists, and lawyers. Forensic medicine has been broken up into
special branches and hardly exists any more as a particular depart-
ment of human knowledge.

Psychiatry has much to do with the law, however, and some
forensic medical knowledge may be considered almost a part of the
requirement of a psychiatrist. Happily, the harmonious cooperation
of law and medicine in the professional activity of the alienist is an

RELATIONS TO OTHER SCIENCES 261

object that has been fairly well attained, so far as regards the care
and guardianship of the insane is concerned. Thus, the matters of
commitment, detention, guardianship, discharge are problems fairly
well solved in many states, and their discussion is not in the sphere
of my address. I can but express the hope, however, that the tend-
ency of legislation will be to lessen the restrictions and simplify the
legal methods connected with the care of the insane. It should be
easy to get into a hospital and easy to get out. The insane should
more and more be considered as sick persons, which they are, and
treated as nearly as possible on such lines, both by the doctor and the
lawyer.

Psychiatry and Anthropology

The results of the work of anthropologists of the Lombroso school
have been fruitful to penology and the saner and more rational
dealing with criminals ; but they have so far not been of much help
to the psychiatrist. The elaborate measurements and observations
which have been made show a larger number of anomalies and marks
of deviation from the normal in the insane as a class than in the
healthy. But these stigmata are never sufficient of themselves to
justify one in saying that an individual is defective, or degenerate,
or insane.

In some very marked types of insanity they are practically
absent. This is especially true of insanities that develop late and
have slight dementing tendencies. Insanities with decided moral
defect, such as those known as original paranoia, or moral insanities,
those characterized by obsessions and compulsions, also show often
few stigmata of degeneration. Those with decided intellectual defects
and dullness have a large percentage of physical marks. Such, at
least, has been my observation.

The science is still young and it should receive the support of
psychiatrists. This is being given in some hospitals of this country.
An anthropologic laboratory, even if but a modest one, should form
part of the equipment of the psychopathic hospital. And observa-
tions should be made not perfunctorily and in accordance with some
limited conventional plan, but with great attention to detail and with
minds open and ready for advance and change. The simple accumu-
lation of fifteen or twenty measurements and notes has been done
until it has nearly fulfilled its usefulness.

The foregoing remarks do not lend themselves to recapitulation.
I have endeavored to show some of the relations of psychiatry to its
nearest allied sciences and to indicate the lines along which work can
be carried with mutual help to all, but to the special advancement of
a sounder knowledge of that capstone of all the medical sciences, the
pathology of the mind.

THE PROBLEM OF PSYCHIATRY IN THE FUNCTIONAL

PSYCHOSES

BY EDWARD COWLES

[Edward Cowles. Professor of Psychiatry, Dartmouth College, since 1886; Clin-
ical Instructor in Psychiatry, Harvard University, since 1888; Non-Resident
Lecturer in Psychiatry, Clark University, since 1904. b. Ryegate, Vermont,
1837. A.B. Dartmouth, 1859; A.M. ibid. 1863; M.D. Dartmouth Medical
College, 1863; College of Physicians and Surgeons, New York, 1863; Fellow
by Courtesy, Johns Hopkins University; LL.D. Dartmouth College, 1890;
Medical Corps, United States Army, 1863-72; Resident Physician and Super-
intendent, Boston City Hospital, 1872-79; Medical Superintendent, McLean
Hospital, 1879-1903; Consulting Physician, ibid. 1904. Member of the Ameri-
can Medico-Psychological Association; American Neurological Association;
American Psychological Association; American Association for Advancement
of Science; Associ6 Etranger, Socie"te* Me*dico-psychologique, Paris; American
Academy of Medicine; Massachusetts Medical Society.]

IN the study of mental diseases it is important to find their true
place in relation to other pathological conditions. Our conceptions
of the nature of mental symptoms should be framed in harmony
with the true principles of general pathology. These are essential
requisites for the progress of psychiatry. I shall try to present
some considerations to this end in discussing my subject: "The
Problem of Psychiatry in the Functional Psychoses."

It is essential here, as in all such inquiries, to have a clear un-
derstanding of the terms of the problem; words and phrases, and
the formulae of principles, should have correct and definite mean-
ings. Our ideas may be embodied at first in words which seem to
express exactly all that we know; but as our conceptions tend to
outgrow their verbal expressions, these may gain the larger import
and lose the narrowness of their derivations; or being used in an
earlier and more or less restricted sense they hamper thinking in
the shackles of authoritative phrases that obstruct reasoning, and
single words may perpetuate error and lead to confusion of inter-
pretation and discussion. The dicta of general principles accepted
as fundamental may sometimes harbor hidden fallacies and prove
to be untrue after having long retarded progress. It is a necessary
part of this discussion to examine first some definitions and the
formulae of certain accepted principles and the doctrines drawn
from them.

The terms in which the present subject is expressed contain no
ambiguity as to its meaning to lay down the proposition that the
problem of psychiatry is to be found in the functional psychoses,
meaning here mental diseases. But something needs to be said
defining the true province of psychiatry; and the words "functional
psychoses" lead at once into the maze of difficulty surrounding the

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 263

relations of functional and organic diseases. In the definition of
disease, as "any morbid deviation from- normal health," "the im-
portant distinction is drawn between organic or structural diseases
in which there is a lesion or pathological condition of some part
of the body, and functional diseases in which there is an irregular
action of a part but without organic abnormality." But keeping
to this distinction it is a remarkable fact that the word "psychosis"
is used in opposing senses in mental physiology and mental path-
ology. The psychologists, having regard to the normal processes,
use "psychosis" as "equivalent to the mental or psychical element
in a psycho-physical process, just as neurosis refers to that aspect
of the process which belongs to the nervous system." On the other
hand, in psychiatry the word "psychosis" is used pathologically
and "designates an abnormal mental condition;" it is described
as a typical form of insanity ("disease-form") which can be scien-
tifically differentiated and correlated with a specific "disease-pro-
cess," and the usage implies a structural change. In neurology
"neurosis" is also changed from its normal functional sense in
psychology and used to designate a "morbid or diseased condi-
tion." "Functional neurosis is a morbid affection of the nervous
system known only by its symptoms, and without anatomical
basis. It is doubtless true that an anatomical lesion of some kind
does in each case exist, and the classification of diseases as organic
and functional is but a concession to our ignorance."1 These in-
stances afford examples of looseness of usage in two most closely
interdependent lines of research showing the disharmony between
them that tends to confusion of understanding. It is allowable to
speak of the neuroses, and the meaning is plain as referring quite
exclusively to functional disorders; but to constitute a true psych-
osis, in the pathological sense, it must have a definitely differen-
tiated symptom-complex that can be designated as a "disease-form;"
this is commonly spoken of as a clinical "entity," and it implies
a correlated "disease-process." We may speak of acute and chronic
psychoses, or of organic psychoses, to distinguish the insanity due
to cerebral disease. But the psychoses proper being conceived as
real disease-entities, when in psychiatry we wish to speak of the
group of minor and often temporary variations of the mental func-
tions, parallel or corresponding to the neuroses in neurology, the
word functional must be added and the term functional psychoses
used as in the subject of this discussion.

1 Baldwin, Diet, of Philos. and Psychol.

264 PSYCHIATRY

The Position of Psychiatry as shown by Current Teachings

The point of view of this inquiry is that of general medicine for
one who, without predilection and .looking for light on all sides,
approaches the field of psychiatry and tries to understand its pro-
blems. In seeking the true place of mental diseases in relation to
other pathological conditions, and in order to harmonize his con-
ceptions with the true principles of general pathology, it is found
at the outset that the functional psychoses are to be regarded as
being in contrast with the psychoses proper associated with as-
sumed structural changes and "disease-processes," or with definite
organic diseases of the brain. Here as in general medicine this dis-
tinction of functional and organic disease appears to be an expres-
sion of the dominance of morphological conceptions in medical
knowledge. Diseases due to obvious structural changes can be
understood and subjected to treatment as in surgery; but the bodily
diseases called functional for which there is no pathological ana-
tomy constitute a very large group.

Although there is a greater reason for this being true also of func-
tional mental diseases, the inquirer finds in the psychiatry of the
time small interest in them. It is a very old idea that the different
forms of insanity may be explained by the study of the brain and
its degenerations. The history of modern psychiatry shows that
it has given great emphasis to these morphological conceptions
by its precise methods and achievements in histological investi-
gations of the brain. In recent years the German schools have
been the centres of interest. The environment of their origin had
preeminently the morphological stamp. Thus the effort to deter-
mine definite "disease-forms" and "disease-processes" has been
a distinctive characteristic of modern teachings in the search for
anatomical correlations and explanations. The application of the
scientific method in clinical study has been most fruitful of ad-
mirable results. The "disease-process" assumption has been stimu-
lating and helpful as a spur to morphological investigation, which
all agree should be carried to the utmost. But with the inherit-
ance of such conceptions the modern movement has been char-
acterized also by the continuance of the quest for mature forms
and types and for their systematic classification. The patholog-
ical principles being embodied in the designations "disease-form"
and "entity," and "disease-process," the consistent use of these
has implied that every such pathological process should have its
cause, course, and outcome. A psychosis thus constituted is held
to present the attributes of scientific truth, although some actual
morphological characters that furnish complete and proper proof
may yet be wanting.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 265

While these teachings have been taking form in the last twenty
years, the influence of modern psychology has been felt and is be-
coming apparent, especially in the last half decade. Although psych-
ological studies of mental functions are viewed with much of
the same distrust as before, the experimental method, in its clin-
ical use in psychiatry, excites interest by the objective character
of its results; they have the value of observed and measurable
facts of function which may contain the promise of being ultimately
traceable to facts of structure.

The present results of this movement are exceedingly interest-
ing and promising, although it is true that there is much diversity
in the products of these methods of study. With the increasing
number of observers the more variations there appear to be in the
interpretation of phenomena. This is shown in the differentiation
of named "disease-forms," and by a comparative study of some
new classifications.1 This, however, is a hopeful stage of progress.
In the extreme view it has been held to be unreasonable that any
conclusions can be drawn from the psychical activity of a diseased
brain; psychological explanation is of no value, it is said, without
an objective measure in definite "disease-processes" in the cortex.
According to other views, in which the conceptions of a "disease-
process" is still fundamental, conditions that do not lead to de-
terioration are conceived to be of a "special type," and a "bio-
logical entity" is conjectured as representing "a special kind of
disease-process or disease-principle." Again under broader con-
ceptions it is held that more than one point of view is needed to
do justice to psychiatry, and a special psycho-pathology is founded
upon normal psychology. But this meets with criticism as giving
undue prominence to psychological distinctions inconsistent with
a true medical conception of disease. ,

The influence of the new German schools has been strongly felt
in other countries. But the inquirer, extending his survey in these
directions, finds that the contemporary interest in the physiological
aspects of psychiatrical problems has not waned, though they are
somewhat overshadowed. In Italy, for example, Ferrari has studied
the pathology of the emotions, as has Fe>6 in France, where Ribot
has done the most to elucidate the relation of mental experience to
the personality, and Janet has made his remarkable contributions
to future psychiatry by the analysis of mental instability in the
borderland of insanity. The British alienists have conservatively
given attention to functional as well as to anatomical conceptions,
notably Mercier. Hughlings Jackson has magnified his distinc-
tion as a neurologist by his recognition of the importance of the

1 Meyer, A., A Few Trends in Modern Psychiatry, The Psychological Bulletin,
vol. i, 1904.

266 PSYCHIATRY

physiological factors in nervous and mental disease; his method
of reasoning from functional characteristics to interpret structure,
instead of inferring function through proofs in structure, is now
attracting renewed interest.

These English views have long held a like formative place in
America where they have not lost but have sustained their force
during the decade since the introduction of German teachings.
Attention was first attracted especially to Kraepelin and the methods
at the Heidelberg clinic with a consequent intensification of inter-
est in morphological conceptions qualified by clinical observation.
The painstaking studies of Meyer and Hoch approached the sub-
ject from the neurological side loyal to the scientific method;
through their work the conceptions of Kraepelin were submitted
to the tests of practical cooperative study and experience with
results anticipating his own later simplifications of "disease-forms."
There was also, not only the establishment of collections of ad-
mirable clinical records, valuable for further study and analysis
in future, at the McLean Hospital and the Worcester Insane Hos-
pital where this special work began, but the extension of this clin-
ical method to many other hospitals. Later in the movement came
the different interpretations of psychiatrical problems by Wer-
nicke and Ziehen, — the latter with an especially hopeful attitude
toward psychological explanations. There has appeared a tendency
to change in the views of these German teachers, of whom it is
said they "have emancipated psychiatry from the peculiar posi-
tion of an adjunct to neurology," — a position for which the claim
has long been made and is not yet yielded.

In the outcome of the decade in America the intensity of the
new teachings is being qualified by independent studies of the
problems involved, and the continuity of the current of earlier
views here has been maintained. This former trend has persisted
not only in psychiatry but it has appeared in neurology which was
formed in, and has held to, pronounced morphological concep-
tions. Dana, Putnam, and Prince, for example, have taken spe-
cial interest in the physiological and abnormal aspects of mental
phenomena. Herter has made the most noteworthy of contribu-
tions to the future understanding of mental as well as nervous
diseases, by studies of the chemistry of pathological physiology
and the disorders of nutrition and metabolism in seeking the
fundamental principles of practical therapy. Traceable here, as in
general medicine, is the influence of the immensely important work
of Chittenden; while this has little or no place in German teach-
ings of neurology and psychiatry, the chemical side of the com-
position and activity of nervous tissues is receiving attention in
England, in recent years, though the special studies of Mott and

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 267

Halliburton, which, however, relate distinctly to changes in struc-
tural disease. In America, the trend toward functional concep-
tions of mental pathology became embodied, with a special motive
inspiration from general medicine, in the work of the McLean
Hospital more than two decades ago. Early in this period, under
the added influence of the new teachings of physiological chemis-
try, the purpose was developed which has led, in the last half dec-
ade, to Folin's chemical investigations of disordered metabolism
in immediate connection with the clinical study of the physical
conditions and treatment of the insane; the parallel development,
on both physical and mental lines, of the original purpose there is
also finding its prime expression in the recent establishment of
another clinical laboratory in which Franz is applying the physio-
logical and experimental methods of the trained physiologist and
psychologist. This particular development of the tendency to
studies of the physiological aspects of psychiatry has been char-
acterized throughout by its essential purpose of seeking guides
for treatment of the physical conditions associated with functional
mental disorders.

It appears that the turning-away from the barrenness of his-
tological provings is becoming general; the improvements of the
clinical method and psychological experiment are inevitably draw-
ing attention to the closer observation of the individual patient, and
to the better study of the minor causes of his mental variations;
this means a trend toward physiology. It is a safe prediction that
pathological physiology is to be called to render such aid to psych-
iatry as it is giving in general medicine; and that the extraor-
dinary advances in pathological chemistry will become available
in mental diseases.

Such are some of the considerations suggested by a survey of
the present aspects of the field of psychiatry. The changing atti-
tude of psychiatry toward psychology is of great significance. These
circumstances guide the inquiry into the conditions and causes of
the present position of psychiatry.

The Relation of Psychiatry to General Medicine

Psychiatry belongs to general medicine.1 This view has been
presented in the annual reports of the McLean Hospital since
1882 ;2 my first statement of it, in the report of that year, was to

1 Cowles, E., Advanced Professional Work in Hospitals for the Insane, Am.
Jour, of Insanity, vol. LX, 1898; The Mechanism of Insanity, ibid., vols. XLVI,
XLVII, XLVIII, 1889-91 ; also The Shattuck Lecture, Neurasthenia and its Mental
Symptoms, 1891, Bost. Med. and Surg. Jour.; Mental Symptoms of Fatigue,
Transactions, N. Y. State Med. Assoc., 1893.

2 Cf. Annual Report, 1882, 1889, et seq.

268 PSYCHIATRY

the effect that the physiological basis of the treatment of the in-
sane lies in the fact that the normal functions of the cerebral organ
may be only temporarily disturbed or only partially impaired,
whether by transient disorder or pathological change; and the
consequent fact that, in most cases, some degree of normal func-
tion remains. This principle was stated to be in accordance with
the most important gain of modern pathology, the modern con-
ception that "Disease is, for the most part, normal function acting
under abnormal conditions."1

Mental diseases, in their study and treatment, include more than
is contained within one branch or department of general medicine
by having to deal with the mental effects of pathological condi-
tions of the whole body; psychiatry is not limited especially to
the nervous system with its central organ, which has functions of
a wholly different and higher nature than those of any other organ.
There are functions of the brain other than the common ones qf
receiving impressions and reacting uniformly upon them like a
reflex mechanism; by its mental function it receives impressions,
retains and recalls its conscious experiences, selects from and re-
arranges them, and in new and orderly forms initiates and con-
trols the processes of motor expression. The psychiatrist newly
attempting the precise study of mental symptoms is confronted
at the outset with the oldest of problems, the relation of mind
and body. If he turns to physiology and neurology for light upon
the physiological terms, mental and physical, of his problems he
meets everywhere such statements as that of Wundt: "In matters
psychological the naturalist can only affirm that psychological
phenomena run parallel with physiological facts, but that on ac-
count of their different natures he has no prospect of ever bridg-
ing the gulf between the two." Edinger 2 writes, "We have no
idea how it happens that a part of the work done by the nervous
system leads to consciousness." Lloyd Morgan8 offers the follow-
ing practical conclusion: "One of the difficulties is that of conceiv-
ing how mind can act on matter, or matter on mind. . . . Let
us at once confess our ignorance of the nature of the intimate rela-
tion of the one to the other. But certainly in many cases the
observed facts show that, our ignorance notwithstanding, they are
somehow related. . . . And since we cannot know the nature of
the relationship, let us be content to seek for some of its condi-
tions."

The psychiatrist is a physician who should take his point of
view in a field even broader than that of general medicine in its

1 Dr. Gairdner, Presidential Address, Brit. Med. Psych. Assoc., Jour. Ment.
Science, 1882.

2 Edinger, L., Brain Anatomy and Psychology, The Monist, vol. xi, 1901.
s Relation of Mind to Body, International Quarterly, vol. vi, 1902.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 269

largest sense, and not within the narrow limits of any specialism
which may seem to include the sphere of mental activities. He
has to deal with the physical effects upon the individual of all the
influences that act upon him in his environment, and that enter
into him from without, or are engendered within, which make for
the maintenance or impairment of his vital processes. Such phys-
ical influences contributing to conscious experience have their
mental effects; the psychiatrist must not only seek to understand
the physical changes and effects but he must deal with the patient's
consciousness of them; and the more subtle influences that affect
the subconscious mental life. The physician must study not alone
the influence upon the mind of the body in health and disease,
but also the external physical, social, and moral conditions of the
environment unfavorable to mental health and growth. It is in
association with this broader view of general medicine that, with
respect to mental disorder, he must seek explanation on the phys-
ical side of the organism, and turn to expert research for such aid
as can be given him by the contributing sciences.

The field of the medical sciences is as wide as that of biology,
which comprehends all the interdependent phenomena of mental
and physical life; the abnormal must be referred to the normal.
The first recourse of the psychiatrist is to physiology, whose do-
main is the study of the forces or functions of living matter. There
are no symptoms until there are deviations from normal func-
tion; without functional activity disease is impossible.1 On the
side of normal life, living substance necessarily presents the con-
ditions of structure, form, and function; these conditions are pri-
mary and disease is not necessary to the existence of living sub-
stance. Here the general physician finds himself involved in the
contention between the sciences of physiology and pathology; the
psychiatrist needs first a normal standard in his knowledge of
general physiology, and all that he can learn of mental physiology
and its relations to its mechanism, structure, and form. Psycho-
logy lays open to intimate study the facts of the mental life; on
the anatomical side we can know little, and that little explains
nothing of the relations between mind and body. It is at this point
that the physician must choose his point of view and form his con-
ceptions of fundamental principles. If these are true, they should
fit all discovered facts, whether of function or structure, and will
lead to advancement of his knowledge; if not true, they lead to
conflict and confusion, and obstruct progress. It is necessary to

1 Cf. Orth, J., Relation of Pathology to Other Sciences, Am. Medicine, vol. ix,
1905. "When there is no functional activity and thus no deviation from nor-
mal function there can be no disease." Published while this paper was in manu-
script.

270 PSYCHIATRY

examine the mutual relations of the biological sciences to know
their relative value to psychiatry.

The Position of Pathology and its Influence upon Modern Psychiatry

The science of pathology, with the justification of its brilliant
achievements, holds itself to be fundamental to the medical sciences.
Its elucidation of the phenomena of disease and its results puts it
into inseparable relation with life. It claims that its conceptions
comprehend all of biology, for on,all sides it bears essential relations
to the subsidiary biological sciences. Deviations from normal struc-
ture and composition of the body, and from the normal functions of
its parts, are held to belong to pathology; in this view the study
of structural variations in the evolutional and the developmental
processes from the normal in primordial and embryonal forms may
explain inherited and congenital disease, and, as a part of pathology,
throw light upon morphology. Physics and chemistry, as they under-
lie both function and structure, contribute to the explanation of
pathological change, and the disorders of function caused by disease;
and pathological physiology and chemistry, whose importance is
now receiving growing recognition, are to be regarded as subsidiary
to pathology and dependent upon it. In the sphere of general patho-
logy, dealing with function, it finds its duty to be "to correlate
symptoms with structural changes and trace the connection between
them,"

The science of pathology, presenting by its salient aspects such
claims to the physician who seeks for light upon the problems of
psychiatry, reveals a changing history. The leadership of the patho-
logical-anatomical school in France passing over to Germany cul-
minated in the "cellular pathology" of Virchow, this being founded
upon the principle that the cell is the unit of structure and function
and that all vital processes are to be referred to the activity of the
cells of which the body is composed; they are the "factors of exist-
ence." This includes the phenomena of disease and all alterations
of the organs and tissues, the principle being that whatever acts
upon the cell from without produces a change, either chemical or
physical, in the cell structure, and disease is constituted of such
changes. These principles became the foundation of the "exact
medicine" of the present day. Griesinger first established modern
psychiatry upon the exact basis of scientific research and patho-
logical principles, and through Meynert pathological-anatomical
teachings were greatly advanced; following them it was in such
an environment that the latest schools of psychiatry had their be-
ginnings with an immediate inheritance of its morphological con-
ceptions as the fundamental criteria of scientific truth. Such were

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 271

the conditions of the inception of the current teachings, based upon
a rigid morphology. The German schools of psychiatry became the
centres of interest and influence, and their characteristics have
already been noted. In the history of the time from Virchow, Grie-
singer, and Meynert to the present there have been momentous
advances in the other biological sciences as well as in pathology and
psychiatry. The two latter lines of research are being strongly
influenced by the concurrent changes. There are some very recent
and significant signs of changing views in psychiatry which possibly
betoken the freeing of itself from the too rigid dominance of struc-
tural pathology.

The Relation of Pathology to Other Biological Sciences, Especially to

Physiology

Physiology, when it declared itself an independent science by
breaking away from medicine and establishing its place in the great
realm of biology, entered upon a broader field of study of the func-
tional side of life with its complex phenomena in the functions of all
living matter. To morphology, as an equally independent science,
belongs the study of the structure and form of living matter; it
covers the whole field of anatomy in the special forms of zoology and
botany. But physiology and morphology, which are closely woven
together, are both built upon the foundation of the inorganic elements
of inanimate matter with its controlling laws of physics and chemistry
that govern the forces of inanimate phenomena. All these forces of
animate and inanimate nature are bound together; from a biological
point of view we do not know living matter without both form and
function.

On the part of the physician the inquiry at this point is as to the
true relations of pathology to the other biological sciences in medi-
cine. The scientific foundation of pathology, the development of its
work in the other sciences which it necessarily involves, support its
claim to an equal place in biology with the other natural sciences.

Prof. Orth, in an address at Kassel in 1903, described pathology as
consisting of two branches, anatomy and physiology. Although the
great Virchow remained a pure pathological anatomist, he contem-
plated the beginning of pathological physiology as the culmination
of his endeavors; "one of his favorite themes was the establishment
of pathological physiology, a subject which, to his mind, was the
foundation of scientific medicine, and therefore of medicine as a
whole." Practical medicine, according to Virchow, is coextensive
with pathological physiology; this is founded on pathological ana-
tomy, clinical observations, experimental researches; its problem is
the determination and investigation of bodily processes under abnor-

272 PSYCHIATRY

mal conditions, of illness and its symptoms. Virchow's experimental
investigations to clear up morphological characteristics of disease
go only to the beginning, and Prof. Orth urged that better attention
should be given to physiological methods for the determination and
interpretation of functional disorders in the unhealthy organ; yet
pathological morphology must remain the unchangeable ground-
work of all medical knowledge and thought ; its most important func-
tion is its purpose for the upbuilding of pathological physiology, for
the understanding of the living processes and their disturbances in
the sick body.

Bacteriology in its marvelous progress leads investigation directly
into the field of pathological physiology, and finds explanations in the
normal physical and chemical reactions that belong to the normal
cell physiology. Pathology, taking bacteriology into its special pro-
vince, is engaged in the study of problems relating to the nature of
disease. General physiology has shown that the physico-chemical
reactions in living substances are fundamental and essential factors
in the production of vital phenomena; it finds, in its investigation
of the component elements of cell-substance, that in physiological
chemistry is its chief aid in the explanation of vital activity and its
disorders. Herter 1 reviews our present knowledge of the chemical
defenses of the organism against disease ; it serves to emphasize the
varied chemical activities of the cells, and to render more intelligible
the phenomena of diseases that result from modifications or failure
of these cellular functions. He says: "Modern pathology has made
us familiar with the conception that disease is generally the expres-
sion of a reaction on the part of the cell to injurious influences. The
only rational conception of the ability of the human body to defend
itself against disease by means of chemical agencies is that these
defenses ultimately reside in the cells themselves. Many of the phe-
nomena of disease are caused by the modification of function that
occurs during the action of the cell in resisting injurious influences."
Ernst 2 has shown that, notwithstanding the great obscurity of the
subject and the somewhat conflicting theories, the point is main-
tained that in all reactions the cell activity intervenes at some stage
of the production of immunity; and that most probably the re-
actions that occur are closely related to these that go on under the
ordinary conditions of tissue metabolism. These considerations are
consistent with the fundamental doctrine of cell physiology and
pathology.

It appears from a brief survey of the history of pathology that
when at first it was part of anatomy, it was then preeminently mor-
phological, and that this characteristic motive still prevails to a

1 Herter, C. A., Chemical Pathology, 1902.

* Ernst, H. C., Modern Theories of Bacterial Immunity, 1903.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 273

large degree. After it became independent, pathology concerned
itself especially with deviations from the normal anatomical stand-
ard. It developed new relations with the other biological sciences as
they attained existence, and like morphological problems arose in
connection with them. There was mutual receiving and giving of aid,
but anatomy was the parent science and the study of the concrete
facts of structure being easier than ever-changing function, morpho-
logical conceptions have always kept in advance and pathology has
held them to be essential in giving finality to its explanations and
proofs. But with the slowing of progress, as normal and pathological
histology has approached the frontiers of present attainable know-
ledge, much of speculative theory has arisen in the endeavor to prove
apparent and conjectural realities of structure by reference to the
facts of physiological activity. The history of pathology reveals
evidence in support of the conclusion that, from the beginning, the
science of pathology has needed first the data of normal form and
function in order to study their deviations; also pathology has been
steadily tending to the finding of its ultimate dependence upon
physiology. Aside from the results called disease from actual trau-
matism of cell bodies caused by extrinsic agencies there must be many
transient conditions of intracellular rearrangements or molecular
disorder, beginning with functional and defensive reactions, long
before there can be any ascertainable structural findings. Such mole-
cular changes, beyond the ken of the microscopist, might be assumed
to be structural in fact; but the ultimate problem of the search for
explaining principles thus tends to become a physico-chemical one.
The facts of cell functions should hold an important place in the
study of the varying agencies and influences of cell stimulation in the
production of symptoms. The relation to physiology of the morpho-
logical side of pathology is especially instructive.

The Relation of Morphology, Normal and Pathological, to Physiology

Morphology presents considerations of the highest importance
which require special notice in this examination of the mutual re-
lations of the biological sciences. It is granted that pathology, on the
morphological side, is inconceivable without normal anatomy as its
basis. Pathological anatomy, being dependent on normal anatomy,
belongs to the science of morphology. This science, with its great
subdivision of embryology, has attained splendid achievements; in
the course of its advancement in many specialized lines of investiga-
tion in plant and animal life, it has enjoyed the advantage of being
able to study the problems of evolution and development in many
quickly succeeding generations of vital forms. The scope of its obser-
vations has extended farther than from the point of view of medicine,

274 PSYCHIATRY

and is reaching conclusions that may yet illuminate some of^the dark
places of psychiatry. The history of morphology has a special signi-
ficance in its development cotemporary with other biological sciences;
the changes in its course suggest a law of progress in scientific re-
search that has operated in other fields. After the emergence of mor-
phology, and of physiology, from the keeping 9f anatomy, the two
new sciences entered upon equal domains in the realm of biology.
Morphology asserted the independence of the science of form and
structure from that of function ; the doctrine was that form persists
and function varies. It was characterized by the conception of a
fixity of types, a rigid adherence to the study of mature forms which
it labored to arrange in a perfected and systematic classification.
With the breaking-away from these rigid conceptions, during the last
fifty years, the course of progress was in the study of the problems of
evolution; leading through the investigations concerning the origin
of species, it has come to the recognition of the supreme importance
of the problems involved in the development of the individual, and of
the biological laws that govern it ; and the wide range of variations
that may be produced in members of a given species. So in medi-
cine, instead of clinical types, the differentiations of disease are
becoming genetic and developmental in character.

In the morphology of plant and animal life it is agreed on both
sides that they are subject to the same laws; in both plants and
animals there are identical processes which are consistent with the
significance of the cell doctrine as being fundamental to morphology.
In the close relation of form and function the modern conception is
that the structural characters of which, an individual organism is
made up correspond to its functional characters; form characteris-
tics cannot be understood without considering the function charac-
teristics. Physiological characteristics are transmissible in the same
way as the morphological. The study of physiological cytology and
embryology is revealing the mechanism of the transmission of quali-
ties; with the aid of the experimental methods in the production of
variations in both form and function, there is great progress in the
understanding of the laws of descent and inheritance. The close
relation of physiological and morphological characteristics proves
that the problems of form and structure are also physiological prob-
lems. Physiological processes are influenced and often controlled by
the conditions of the environment both internal and external ; and it
is shown that mental as well as physiological characteristics are
inherited under the same laws. These brief references to the data of
morphology serve here to indicate the trend of progress in this science;
it points to the conclusion that influences which stimulate functional
activity play an essential part in determining the processes of
development and the resulting structural forms. The demonstrations

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 275

of the dominance of the sensory over the motor side of the nervous
mechanism is consistent with the fact that all movements are prima-
rily a response to sensory impressions and are performed under their
guidance. It follows from the teachings of Hughlings Jackson that
cell-groups are thus formed by a process of education. All motor
phenomena being responsive reactions to stimuli applied to the
neuro-muscular mechanisms, the laws of use and habit influence
functional activity and growth. The unity of all these sciences is also
shown. Physiology and morphology have to do with interdependent
manifestations of organic existence; there can be no disease until
there is first normal life with whose physical sequels pathology has to
deal. Inasmuch as the whole science of pathology must refer all its
material to normal standards, both on the functional and the mor-
phological side, a like freedom belongs to the minor province of mental
pathology; psychiatry is at least justified in seeking directly its
immediate explanations in the hopeful though neglected field of
function.

The Pathological Conceptions of Psychiatry stated in Terms implying
Morphological Ideas

In such a survey as this, of so complex a subject, certain difficult-
ies have appeared concerning special aspects of current effort, in the
field of the psychiatrist's labors. Allusion has been made to the
remarkable fact of the disharmony between mental physiology and
mental pathology. There are signs of the coming of better coopera-
tion, but so far the general fact is that the psychiatrist borrows from
psychology what seems fitting with his pathological conceptions, and
applies some of its psycho-physical methods; at the same time he
hesitates to use the data and even the terminology offered by expert
investigators in mental physiology. The importance of care in the
use of descriptive words has been mentioned; an inquiry like this
draws special attention to this subject and some extraordinary facts
are revealed that should receive further notice.

First among these may be mentioned the use of the word physio-
logical; its frequent infelicitous employment by both pathologists
and psychologists themselves emphasizes the width and depth of the
traditional gulf between mind and body. The distinction is com-
monly made between psychical phenomena and physiological phe-
nomena and the designations "mental side " and " physiological side "
are used to make the same contrast. Mental phenomena are them-
selves physiological, but the usage implies a distinct psychical ele-
ment as an extra-physiological epiphenomenon, when such a mean-
ing is not intended, and is therefore misleading. The mind event and
the brain event are both physiological.

276 PSYCHIATRY

More remarkable examples of doubtful usage, universal in medical
literature, and with far-reaching effects, are shown in the words
"disease-form," "disease-entity," "disease-process," and "patho-
logical process," which have already been mentioned. These words
still suggest old meanings now wholly obsolete; this is so obvious
that when thoughtful writers use such words "for convenience," the
explanation is not infrequently made that it is not intended to imply
that disease is a malign entity which invades the living body and
works its evil course. Yet, as usage sanctions it, writers continue to
employ the framework of words which would once have expressed the
ancient parasitic personification of disease. While, in the science of
pathology, this extreme conception is corrected by explanation, such
words in their modern usage still embody and positively convey the
sense of an underlying morphological counterpart of the symptom-
complex that runs its course of progressive degeneration as a disease
and reveals the terminal changes in post-mortem findings. To speak
of all disease in terms used in these senses is to emphasize structural
conceptions of pathology, and thus to impede the progress of the
reform which is clearly seeking to give adequate attention to func-
tional conceptions in place of the dominating demand for mature
types and forms and classifications.

It would be interesting to follow out the history of the usage of
these verbal embodiments of whole theories. Perhaps a reference to
main points will be enough to indicate the purport of these observa-
tions. First, as to the nature of disease, it cannot be correctly con-
ceived, as a state of disordered activity or disorder of a process in an
active sense ; there is a condition produced by a defensive contest
between the forces of the living cell and the harmful agencies; it is not
a state of perturbed activity but the result of it in diseased organs
or tissues. The causes of disease are extraneous and unnecessary to
cell-life, which can exist without disease. The only true process in
living organisms is the physiological, or life-process; the forces that
cause the reactions called vital phenomena are inherent and are
governed by the uniform laws of an invariable order of nature; like
effects result from like causes and conditions, and the life-process
presents the attributes of uniformity and continuity controlled by
the laws of descent. Reproduction is an original property of living
matter and life is continuous, and death is not due to such a prop-
erty; this is a proposition in which there would be a general agree-
ment with Weissmann. Roger l reduces the conception of death to
the formula: "Death is the result of an arrest of cellular nutrition;
whatever the multiple proceedings are that are called into play, the
final result is always the same."

A "disease-process" or "pathological process" cannot be con-
1 Roger, G. H., Introduction to the Study of Medicine, Trans., 1901.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 277

ceived as comparable with the physiological process; the causes of
disease being extraneous to normal cell-life are accidental, multiple,
discontinuous, without uniformity. It is consistent with this that
even in the problem of tumor growths there are some essential
explaining facts; whatever of the various theories may be employed
to account for them, they are not in dwelling entities, but depend for
their existence upon the inherent vitality of the parent organism
acting under abnormal conditions. When the organism dies the new
growth dies ; there can be no disease without prior normal life.

When applied to functional disorders, the assumption of a neces-
sary correlation between a "disease-form" and an underlying struc-
tural "disease-process" goes beyond the province of morphological
pathology; it involves the intracellular changes of physiological
chemistry. It is obstructive of a true conception of the wide varia-
tions of function that belong to molecular nutritive and metabolic
changes due to variations in condition, irritability, intensity of
stimulus, etc., though affecting the same physico-chemical opera-
tions by the same agencies. But an authoritative insistence upon
the "disease-form" and "disease-process" ideas, with respect to all
psychoses, has undoubtedly tended to distract attention from a free
consideration of functional conceptions of mental pathology. These
and kindred forms of words, with their distinctly morphological
stamp, show the character, in some degree, of changing conceptions
of pathology. They are kept in use by their convenience; and they
appear to be in harmony with certain accepted theories and doc-
trines concerning the nature of disease and death, and their relation
to life. The influence of these doctrines is so great as to require
examination here.

The difficulty of determining a sharp limit between life and death
has been stated by Verworn : * there is no definite time at which life
ceases and death begins in a complex organism, for one set of cell-
complexes may survive another for a long time; but "there is a
gradual passage from normal life to complete death which frequently
begins to be noticeable during the course of a disease. Death is
developed out of life." "Thus death does not come to the cell
immediately, but is the end-result of a long series of processes which
begin with an irreparable injury to the normal body, and lead by
degrees to a complete cessation of all vital phenomena." It is reasoned
that "life and death are only the two end-results of a long series of
changes which run their course successively in the organism;" also
that "death undergoes a development; normal life upon the one
hand and death upon the other are merely the remote end-stages in
this development, and are united to one another by an uninterrupted
series of intermediate degrees." This transition from life to death is
1 Verworn, M., General Physiology, Trans.,

278 PSYCHIATRY

termed necrobiosis, a word introduced into pathology by Virchow
and Schultz; it is understood to mean, according to Verworn,
"those processes that, beginning with an incurable lesion of the
normal life, lead slowly or rapidly to unavoidable death."

Thus the principle of necrobiosis is to be studied in the cell as well
as its vital phenomena; and it is held to apply also to the death of
compound organisms. By an extension of this conception it explains
the condition of natural death in old age, which thus appears to be
physiological. Senile atrophy, which leads finally to death from the
feebleness of old age, is to be regarded as simply the end-result of
a long developmental series; death in old age is the natural end of an
unbroken development and its causes exist in the living organism
itself. Life itself never becomes extinct, but there is a continuity in
its descent ; yet living substance itself, in the form of bodies, is con-
tinually dying.

Compare with the foregoing the views presented by Gowers l in
regard to "diseases from defect of life" to which he gives the desig-
nation "abiotrophy" to distinguish a newly differentiated clinical
group of conditions and symptoms; he acknowledges Mott's cotem-
porary recognition of these conditions. The conception is that of
"a degeneration or decay in consequence of a defect of vital endur-
ance; " it indicates a failure of life-processes due to defective vitality
which seems to be inherent. It is recognized that many degenerative
diseases of the nervous system are a result of such defect. The idea
is expressed by Mott:2 "The neurones of a particular system die
prematurely, owing to an inherited or acquired want of durability,
and the regressive process of decay may be looked upon as a nu-
tritional failure on the part of the same cells to maintain that meta-
bolic equilibrium essential and correlative to functional activity."
Every nerve-cell of the human body is conceived to be "endowed
with a specific durability whereby in the health-perfect organism
every neurone possesses an equally adjusted vital energy." This is
a statement of one of the two ways in which the regressive process
occurs, the other being "the metamorphosis incidental to old age
manifested by a gradual and general enfeeblement of the functions
of the whole nervous system." "In contradistinction to this nor-
mal senile decay are the premature pathological processes of decay
attacking groups, systems, or communities of neurones subserving
special functions." "The process maybe regarded as the inverse of
development; " in harmony with these views Hughlings Jackson is
quoted in regard to the helpfulness of considering diseases of the
nervous system "as reversals of evolution, that is, as dissolution."
Mott conceives that the process of primary degeneration is, morpho-

1 Gowers, W. R., Abiotrophy, Lancet, 1902.

7 Mott, F. W., The Degeneration of the Neurones, Croonian Lectures, 1900.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 279

logically, an evolutional reversal commencing in the structures
latest developed.

In the extensive literature concerning the life-processes and their
failure in disease and senility other diverging views may be cited,
but the purpose here is only to indicate certain ideas and reasonings
that bear upon the pathological conceptions with which psychiatry
has had to labor. With respect to physiological old age ending in
natural death the contending view is that the decline of life manifests
the summation of the effects of external injuries, the damage of wear
and waste, and is not something different and apart from disease. It
is to be noted in the doctrine of necrobiosis that the idea of a "disease-
entity," with its course and process parallel and antagonistic to the
life-process, is avoided by conceiving life or the life-principle as the
sole producer of two series of developmental processes, one of which
leads to its end-result in the existence of normal being; this life-
process is also conceived as turning against itself in another process
of producing a series of decrements that reaches to the end-result of
non-existence. One result must exclude the other, and we admit that
death is the common goal ; the life of every living thing ends in death
and there is only one end-result, — death is developed out of life.
But by shifting the position to the larger view the attempt is to set
up a dual conception of two processes, equal, parallel, antagonistic,
yet conjoined. The truth is that the whole of life comprehends all
living nature; the individual parts that bloom, fructify, and perish,
and the fragments chipped and sloughed off from the great embodi-
ment of life in matter, are always dying or dead, but the one chief
process of life goes on, and we say that life is developed out of death.
The minor casualties of injury and disease represent the chance
encounters of living substance in its struggle for existence with the
discontinuous opposing forces of the world of living and material
things. Living substance dies, but life is immortal. We may describe,
in such figures of speech, the dual developmental processes with their
contrasting end-results.

The paradox of the " processes" appears also in the application
of the doctrine of abiotrophy which, of itself, helps to make clearer
the terms of the problem by the conception of a failure of nutri-
tional energy with a consequent limitation of the durability of
the organism and of the length of life. In applying this doctrine
to certain pathological changes it is said that the overgrowth of
interstitial neuroglial tissue, when the nerve elements decay, is
in consequence of the fact that the two elements have "a com-
mon but inverse vitality;" when the nutritional energy fails to
maintain the growth of both, the more highly specialized tissue
ceases to live, while the less specialized tends to overgrow with
the tendency of the former to decay. It is explained that these

280 PSYCHIATRY

"tendencies are in the opposite direction, but they seem to be coin-
cident results of the same vital condition."

In the many well-known conditions of constitutional weakness
and instability it is easy to understand the nutritional failure to
develop normal growth and efficiency of function, or to maintain
them, and the consequent recession of the developmental pro-
cesses, even to the cessation of life. The doctrine of dissolution
as characterizing the many conditions of such recessions is clearly
consistent. When biological conceptions are invoked, it is also
easy to comprehend the general principles of development whereby,
through physiological reactions of the organism, there are adapt-
ations and modifications of characters due to changes of environ-
ment and favorable to life and health ; it is intelligible that through
use higher types of characters may be produced, or through dis-
use recessions to more primitive types, under the causative influ-
ences of the environment, and all this may be within the physio-
logical limits of the organism as expressions of the processes of
life. In the domain of biology it is, no doubt, helpful for descrip-
tive purposes to conceive of the developmental forces as acting
in an inverse direction, producing the effects of reversals and re-
gressions. But when this latter conception is applied to patho-
logical conditions, it is in harmony with our prevailing modes of
thought in medicine that there is conceived to be an attack, as
of some harmful agency, upon the living organism; a pathological
process of degeneration is supposed to ensue which is a regressive
process of decay, and this implies its active going backward against
the normal tendency of the nutritional energy to maintain life
and growth. As a further explaining principle the conditions of
acquired or inherited defect are conceived, and a process of de-
generation of which "heredity" is the motive force; thus the de-
velopmental forces turn against themselves, and, working in the
inverse direction, produce decay. It is the all-pervading disposi-
tion to seek an immediate cause for every effect, and it is easy to
describe agencies and processes. When the stamp of "degeneracy"
is fixed upon a fated organism we commonly think of its possessor
as a "degenerate" descending to inevitable doom.

Is it not evident that there is a misleading ambiguity in the pre-
vailing usage of the conception of "processes"? It is necessary
to the notion of a process that there is a passing over of one set
of phenomena into another, and this constitutes a change.1 A
"process" is constituted of a series of such changes when one stage
or aspect of the process necessarily succeeds upon another. The
action of a causative force or stimulus is essential to the change,
as in the biological processes. The requirements of the concep-
1 Baldwin, J. M., Development and Evolution, 1902.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 281

tion of two coincident processes appear in the principle of the psycho-
physical parallelism in the relation of mind and body. It being the
general fact that certain changes in those brain- and nerve-pro-
cesses with which consciousness is associated are always accom-
panied by changes in consciousness, and the converse being true
also, then certain other scientific principles are involved: (1) the
principle of equal continuity, with no breaks in either series of
changes, — if one series is continuous the other must be continu-
ous also; (2) the principle of uniformity, when certain phenomena
in each series in brain-process and conscious state are essentially
associated, then the concomitance of those terms may be looked
for on all other occasions; (3) the principle must be a universal
one, — whenever we find a series of phenomena in either of the
parallel trains of events the principle of parallelism has its appli-
cation. Structure and function must exist before there can be any
disease; the phenomena of life represent the supreme process in
animate nature; the phenomena of disease and degeneration ap-
pear as the results of discontinuous interferences with the life-
processes in which "normal function is acting under abnormal
conditions;" the assumption of a "disease-process," or of a "patho-
logical process" in the same sense, fails to meet the essential re-
quirements of a "process," — it is certainly not comparable with
the life-process. If we must speak, for convenience, of "patholog-
ical process" and "degenerative process," the terms should be
used only in a very narrow sense of comparatively transient in-
terferences, or in the sense of referring to normal function acting
pathologically.1

To the inquiring mind the contradictory presentations of these
matters is confusing and creates difficulty. The subjects are, in
their nature, complex, and our knowledge is limited, but much
ambiguity is undoubtedly due to the lack of precision in the state-
ment of the terms of the problems. One of the most common ob-
stacles to clear thinking appears to arise out of the fact that for
every predicate implying action we have to think of an actor, or
causative agency, and our minds habitually conceive of some form
of personification of such an agent as possessing motor and motive
attributes. Thus we think of life and death, and artists picture
them, in human forms; we are prone to dualistic conceptions and
the mind delights in such paradoxical phrases as, there can be
no death without life; no disease without health; no evil with-
out good. The use of the active predicate abbreviates expression

1 The writer's views of the inadequacy and misleading influence of the "dis-
ease-process" conception as a question in psychiatry was first presented to the
American Medico-Psychological Association at its meeting in Washington in
1902, in an unpublished paper on the principles of mental pathology and the
nature of mental symptoms.

282 PSYCHIATRY

and enlivens speech. Professor Sanford,1 discussing the influence
of physics on psychology, notes the fact that, as the result of man's
long primitive practice, his habits of thought are objective, and
the language he uses is saturated with physical connotations and
metaphors. It is not easy for even the best of us, he says, to keep
clear of this inveterate physical-mindedness and the subtle sug-
gestions of language; we help out our thinking by material figures
and feel a sort of dumb compulsion to make our psychological
theories accord with physical requirements. Ebbinghaus is quoted
as describing the older psychology as distinctly "mechanistic,"
many analogies from familiar material processes being used in the
exposition of mental phenomena. In regard to essentials, Professor
Sanford thinks it may be said that psychology has outgrown this
method. But turning to our own field of the medical sciences, the
ruling tendency of our thought and language leads to the concep-
tions of "disease" and "process," for example, in terms implying
immediate causative agents. The familiar conceptions of a pro-
cess of anabolism and a contending process of katabolism in the
cell are treated as the analogues of the life-process and death-pro-
cess. The analogy is extended to include in this conception the
fact that in the whole compound organism the anabolic processes
overbalance the katabolic till middle life, when the two processes
are more nearly in equilibrium, and that thereafter katabolism
predominates more and more in the normal decline of old age. It
is held that in the broadest sense the process of senescence begins
with the beginning of life in a progressive diminution of the power
of growth; and with the progressive waning of the vital powers
the leading somatic changes accompanying old age are atrophic
and degenerative. The same conception concerning the anabolic
and katabolic processes is equally legitimate concerning the idea
that an inherent tendency to degeneration is transmissible; the
inherited constitutional weakness and diminution of vitality may
be interpreted as belonging to the series of changes which imply
a process of dying continuing through several generations.

There appears through all these reasonings the prevailing method
of thinking in terms of "processes." The inquirer is moved to ask
whether the normal processes of anabolism and katabolism are
not both essential to the maintenance of a health-perfect cell and
both, therefore, parts of the normal life-process? We do not think
of the most healthily active cell as one most vigorously dying. If
we consider the physico-chemical changes in the cell inclusively
as a process of metabolism, it is consistent to think of the normal
building-up and breaking-down of complex compounds in growth,
vvork, and repair as harmonious, and not antagonistic, operations.
1 Sanford, E. C., Psychology and Physics, The Psych. Rev., vol. x, 1903.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 283

Hering separates assimilation as only a qualitative chemical change
from - growth as quantitative, and in like manner dissimilation
from atrophy. As to the transformations in the cells and the over-
whelming number of substances excreted from them, little is known
of the processes by which these are derived; but many products
are formed in both the ascending and descending portions of the
metabolic series. Disordered and imperfect adjustments of the
molecular arrangements of living substance may affect and arrest
both anabolism and katabolism; defect of the latter and not its
predominance can be conceived as a cause of the death of the cell.
In physiological theory the distinction is made between death
of the tissues and somatic death: in the former, it is reasoned that
constantly throughout life the molecules of living matter are be-
ing disintegrated and whole cells die and are cast away, — and
that life and death are concomitant; in the latter, death occurs
when one or more of the organic functions is so disturbed that
the harmonious exercise of all the functions becomes impossible.
This distinction has been referred to, and further inquiries are sug-
gested here. In respect to the death of the tissues, the "unit cell,"
being an organism of high complexity as to its structure and func-
tion, and its life-process, is not failure of this life-process of the
cooperative adjustments within the cell truly analogous to the
failure of life, or somatic death, in the whole compound organism?
In this connection the question again arises as to the concomitance
of the processes of life and death, — the latter being theoretically
analogous to the constant disintegration of living matter. Her-
ing's idea that assimilation and dissimilation are distinctly separate
from growth and atrophy permits the former to be regarded as one
intimately combined and normal metabolic process in a working cell,
having no theoretical significance except as wholly contributing to
the maintenance of the function of a health-perfect cell. The daily
shrinkage of the working and fatigued cell may be regularly made
up by rest and nutrition; this is not atrophy, either simple or de-
generative, for the continuity of cell-life may be unimpaired and
only the labile molecular inclusions be changed by normal use which
promotes the health of the cell. On the other hand, the^ function
of growth, being of a more primitive type, would appear to con-
tain the explaining principle of the life-process as contrasted with
the work-process. Consistent with this appears to be the sharp
differentiation by Adami between cells which have the habit of
growth and those which have the habit of work; these two func-
tions cannot be exercised by the same cell at the same time, and
a normal working cell may revert to the type of a vegetative cell.
This implies that cells of the primitive type having only the func-
tion of growth, their "work" (in the common usage of the word)

284 PSYCHIATRY

is without external manifestations of energy; but that the func-
tion of work, which is the power to store potential energy within
and to produce kinetic energy in external work, belongs to the
highly specialized cell as an acquired character which it may lose.
This being true we may understand that assimilation and dissim-
ilation, in the limited sense employed by Hering, constitute a
special kind of inclusive metabolic process different from the mole-
cular changes, perhaps less complex, productive only of growth.
It is not conclusive that katabolism typically represents destruc-
tion of life, though it means changes of substance in which life
exists. These considerations suggest questions that are not in
harmony with the generally accepted theory of life and death as
concomitant processes based upon an assumed analogy to the
physiological processes of the healthy living cell.

This inquiry is intended only to consider some examples of cur-
rent theories with the question whether they can be resolved into
more simple conceptions. The life-process being conceived as the
one supreme "process" in living organisms, this implies its main-
tenance by causative forces; assuming each individual to. be
endowed with a given vital durability, determined by antecedent
conditions and subject to modifications due to favoring or adverse
influences, the life-process reaches its possible attainments and
finally fails in the struggle for existence. Injury, interference with
normal function, overuse and disuse, disease, and the causes of
the changes of senility present alike adverse influences which the
organism fails to overcome. We must speak of disease and use
its meaning as referring to results in diseased parts, organs, or
tissues; and we may commonly think of the word as implying a
combination of disorders of functional activities which may or may
not be associated with ascertainable structural changes. But it
should be remembered that we are thinking of a patient and not
a "disease." There is no disease-process; no causative forces exist
in nature that induce and carry on processes of degeneration and
decay; gradual failure is the summation of the failures of com-
munity work due to the complexity of the organism, each organ
being subject to the harmful influences of the functional failure
of other members of the community. There may be deterioration
of function, and degeneration of structure in the sense of failure
to maintain it; there may be also regressions or rather recessions
of results, but no active pathological "process" of going backward
in the structural reductions called "degenerative." These consid-
erations do not support the idea of a "physiological old age," based
upon the conception of a normal process of degeneration or decay
as though the results of senile conditions in structural changes are
different from disease. This doctrine of natural decay and death

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 285

makes great trouble in dealing with senile conditions in medico-
legal cases; and in like cases concerning degeneracy in earlier life
the most contradictory and confusing notions prevail. They are
not in harmony with practical experience. This is largely due to
the adoption in psychiatry of generalizations in regard to heredity
not yet warranted by the science of biology. The morphological
ideas in the prevailing pathological conceptions, and the descrip-
tive terms employed, have undoubtedly obstructed the progress of
psychiatry. From all such preconceptions the psychiatrist should
be wholly emancipated.

A functional conception of pathology is not in conflict with a
pathological conception in the sense of the long-used distinction
between functional and organic diseases. The objection to this
is not lessened, but the fault is not with function. Life and the
science of physiology are first; function and all that pertains to
it are primary facts of the activities of normal life. Much dishar-
mony in the conceptions of pathology has been due to the setting-
up of ideas of "organic diseases" as the chief factors in pathology,
and the minimizing of function as worthy of serious scientific con-
sideration. Our conceptions of function are uncomplicated as re-
lating simply to the modes of action of the several parts of the
organism; but we must think of organic disease in two ways, of
changes of structure in results, and of changes of action in "pro-
cess." The functional factors are necessary to organic disease and
their distinction and true relation should be discovered in their
combination. The organic changes of disease are the sequels of
interferences with the prime process of normal life.

Physiology and its Relation.to Psychology

Physiology acknowledges its debt to Johannes Miiller, who mas-
tered the two great sciences, morphology and physiology, and
was a teacher of pathology. He took an active interest in psych-
ology, regarding physiology by empirical methods as essential
to advancement. After Miiller's death, nearly fifty years ago, the
fields of his scientific work were divided by the specializations
through which the present marvelous advancement has been gained.
Physiological chemistry became independent of physiology; and
physiological psychology developed on the lines of psycho-physical
experiment. It was then that mental physiology should have made
its union with mental pathology. It is easy to see that psychology
tried to accomplish this by its attempts to find a morphological
basis for its investigations through the experimental method, but
the field for this was limited. Psychiatry under like limitations,
by its morphological attitude, met the invitations of psychology

286 PSYCHIATRY

with inherited distrust of a functional pathology; psychology
was turned upon itself, and also, much of its own choice, sought
and found open ways back into the attractive regions of the inves-
tigation of psychical function and philosophy. The later phase of
psychiatrical interest in experimentation has been mentioned, and is
full of promise, but such movements require years of time. The
method of exhaustive study of the clinical expression of psychical
reactions through speech and behavior, and the use of experimental
tests which bring out individual characteristics and their variations,
are gaining a share, which must increase, of the attention and
interest heretofore centred in the pathological laboratory. This is
a new and definite revelation of a tendency toward the study of a
functional conception of pathology in psychiatry.

Psychology is still kept apart, however, from the practical study
of mental pathology; this is probably, in part, its own fault; al-
though some students of psychology have shown the requisite
interest, there is a lamentable want of opportunity. What would
really be the most promising interest in psychiatry should be found
in the establishment, in hospitals for the insane, of true experi-
mental psychology, with physiological methods applied clinically,
according to the principle of using instruments of precision in other
clinical work.1 The observer of these clinical manifestations trained
both as a psychologist and physiologist would find many new varia-
tions of phenomena not seen in the normal subject. A hospital
for the treatment of mental disorders is a laboratory of itself where
nature makes experiments in the excitation, suppression, and
combination of naturally correlated psychical and physical reac-
tions, giving many clearer displays of their nature, both by their
intensification and absence.

Mental diseases are peculiarly and essentially constituted of
mental symptoms; the study of their phenomena must refer them
to mental physiology, for the laws governing vital phenomena
under abnormal conditions are not different from those of normal
life. The study of mental physiology under pathological condi-
tions should be helpful for both psychology and psychiatry.

This inquiry being assumed to be free from all preconceptions
as to the true nature and place of mental pathology, and as to
forms and names of mental diseases, it may be turned to an ex-

1 For an account of the beginning of the present laboratory methods, both
psychological and chemical, at the McLean Hospital in 1889, see Les Laboratoires
de Psychologic en Amerique, by E. B. Delabarre, L'Annee Psychologiqite, 1895;
also Laboratory of the McLean Hospital, by G. Stanley Hall, Am. Jour. Insanity,
1895. The subsequent development of the pathological laboratory and the clinical
methods, — of the laboratory for pathological chemistry in 1900. — and of that
for pathological physiology and psychological experiment in 1904, constitute a
true psychiatrical clinic of a special character, designed from the outset for the
investigation of the functional conditions of mental disorder.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 287

animation of the relations of psychology, or mental physiology, to
all of the associated reactions of the physical organism. This is
the necessary basis of pathological physiology for psychiatry.
Approaching the subject newly from this point of view the physi-
cian should seek to inform himself concerning at least the imme-
diate facts of mental function and the accepted postulates of
psychology. But in preparation for such a study it should be
recognized that mental physiology is included in general physiology
as concerning a part of the vital activities of the living organism;
also that certain general modes of action in the body always have
a part in mental function. Some of the symptom-factors of mental
disorder have their genesis in conditions that affect primarily other
parts of the organism than the brain. General physiology there-
fore claims the attention of the psychiatrist to certain essential
principles whose importance can only be indicated here by mention-
ing some of those of immediate interest ; the purpose is to present
some of the physiological reasons for the proposition that the pro-
blem of psychiatry lies in the functional psychoses.

References to Physiological Principles

A distinctive feature of modern biology is the fundamental con-
ception of a living body as a physical mechanism (Huxley) ; under-
lying all the phenomena of the animal organism is the reflex action
of the nervous system, and physiologists generally agree to con-
sider every action as aroused by some cause or stimulus (Sedg-
wick); under the biological conception man is an organism for
reacting on impressions (James). The nervous and mental mech-
anisms being regarded as constituted of three minor ones, their
action appears in a sensory, — a central or transformation, —
and a motor process; in the central process part of the work done
by the nervous system leads to consciousness; the response to a
stimulus may be a muscular contraction, a secretion in a gland,
a vascular change, or even a trophic or metabolic influence, — all
pertaining to the centrifugal system. While reflex action is not
conscious action, one may be conscious of the act, and in many
cases conscious changes precede, accompany, or occasion the change.
The most important reflex of all is commonly ignored, viz., that
which provides for the constant readjustment of the parts of the
system to each other, by virtue of which the entire mechanism is
receptive even to minimal stimuli. This may be termed the neuro-
equilibrium reflex. The tone of the nervous system is this wonder-
fully complex adjustment of inhibition and stimulation. Every
metabolic process in all the nerve-cells exerts its influence on the
entire nervous system. One of the most remarkable reflex asso-

288 PSYCHIATRY

ciations is that between vaso-motor alterations and the seat of the
emotions, which are thus intimately involved with the viscera
and vessels in their minute connection with the sympathetic system.
This association has a most important influence in the mental
sphere, though beyond this fact little is yet known of the physio-
logical basis of these reactions.1

The intimate connection of mental states and the physical re-
actions of the whole body is well recognized by both physiologists
and psychologists; it is of fundamental importance in psychiatry.
Lombard2 describes the cells of the central nervous system, dur-
ing waking hours, as continually under the influence of a shower
of weak nervous impulses, coming from the sensory organs all over
the body; moreover, activity of brain-cells, especially emotional
forms of activity, leads to an overflow of nervous impulses to the
spinal cord and an increased irritability, or, if stronger, excitation
of motor nerve-cells. There is a constant inflow from the environ-
ment of a vast number of excitations ordinarily disregarded by
the mind but all the time influencing the nerve-cells; the effect
of this multitude of afferent stimuli, in spite of their feebleness,
is to cause the motor cells continually to send delicate motor stimuli
to the muscles and to keep them in the state of slight but continued
contraction or tension of muscle-tonus. In these mechanisms is
the seat of the kinesthetic sensations and the functional altera-
tions that play so essential a part in contributing to the well-known
symptom-factors of the "sense of effort" and "inadequacy," and
motor "retardation" and "excitation."

Some of the physiologists have given much study to the rela-
tion of mental and physical states. Sherrington's 8 discussion of
common and organic sensation and the contributing cutaneous
sensations has an extraordinary interest for psychiatry. Com-
mon sensation is understood to mean that sum of sensations re-
ferred, not to external agents but to the processes of the animal
body, and these sensations possess strong affective tone. Total
common sensation is the result of many component sensations,
and those that arise in internal organs and viscera contribute a
great deal to the total sum. Affective tone is the constant accom-
paniment of sensation; every form of common sensation is based
on perception of an altered condition of the body itself. In con-
nection with this comes the fact that all forms of common sensa-
tion present significantly preeminent attributes of physical pleas-
ure or physical pain; and all are linked closely to emotion.

1 Cf . Baldwin's Diet, of Philosophy and Psychology.

1 Lombard, W. P., The General Physiology of Muscle and Nerve, Am. Text-Book
of Phys., vol. n, p. 143.

3 Sherrington, C. S., Cutaneous Sensations, Schafer's Text-Book of Physiology,
vol. n, p. 969, et seq.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 289

The elaborate researches of many observers in recent years con-
cerning the nature of the muscular sense, the senses of touch, pain,
and temperature, and their special mechanisms, strengthen the
common fact that their sum contributes to the effects upon mental
feeling-tone. They are in their nature productive in part of the
organic sensations. Ribot 1 has studied, more than any one else,
the psychology of the emotions and the logic of their mental and
physical reactions; he describes the presentations in the conscious
mind of organic sense as constituting a vast aggregate of impres-
sions arising from within the organism and continually flowing
towards the superior nervous system; it is this region of sub-
ject consciousness that gives the consciousness of being, — the
sense of personality. The sensations from the special senses are
intermittent, of high intensity, and small in volume compared
with the voluminous though faint, continuous, and all-pervading
commotion produced by the organic sensations. These are intense
enough, however, to be susceptible in health of psychical interpret-
ation as a sense of well-being; from their disorders and intensi-
fication comes the sense of ill-being. These are the long recognized
changes of coenesthesia. Professor James has shown the intimate
relation of the emotional tone to bodily states; and Professor Ladd
makes clear the usefulness to psychiatry of a study of the affec-
tions and emotions in their relations to the train of ideas, and to
the different bodily organs; also the reflex effect of the changes in
these organs upon both the feelings and the ideas.

Underlying all these physiological phenomena of the living
organism is the primary attribute of irritability. All the functional
phenomena being influenced, within normal limits, by changes
of irritability in the central, peripheral, sensory, and motor mech-
anisms, and these changes being dependent upon the processes
of nutrition and metabolism, and upon conditions of use and dis-
use, rest and fatigue, etc., the alterations of functional efficiency
in the associated reactions of mind and body make the study of
cellular physiology imperative for psychiatry. Some of the most
commonly observed and characteristic symptoms in mental dis-
eases may be referred to such functional disorders in the physical
organism.

Physiology and its Relation to Psychology, continued

The healthy organism being fully constituted in structure and
function for its work, when put in use begins immediately to be sub-
ject to modes of action which are the effects of its own activities; in
other words the living organism acquires functional characteristics

1 Ribot, Th., Diseases of the Personality, and the Psychology of the Emotions.

290 PSYCHIATRY

as the immediate effects of use. Some of the common physiological
laws have a special importance here because they govern the work of
the physical mechanism and therefore of all correlated mental
reactions, not only in health but in disease, as long as any functional
activity continues.

(1) Association and Habit are fundamental in mental life; in
respect to the association of ideas it is not the ideas that associate
but the elementary processes of which the ideas are composed; on
the physical side the law reduces to the law of habit (Titchener).
Memory is an associative process; mental reactions (including per-
ceptions, ideas, emotions) are associated with their physical corre-
latives and motor consequences. Habit is closely related; it is the
functional disposition to repeat organic processes. This law of asso-
ciation and habit applies to "organic memory;" thus "associative
memory" is fundamental in, and unites, both psychical and physical
reactions.

(2) Inhibition. The animal organism has a motor character.
All sensations and mental states are motor; the entire neuro-muscu-
lar organism, mental and motor, acts primarily as a whole, governed
by the laws of association, and this is subject to control. "The phe-
nomena of nervous life are the outcome of a contest between what we
may call inhibitory, and exciting or augmenting forces" (Foster).
It is conceivable that all nerve-centres are normally at all times sub-
ject to continuous control or inhibition, and are maintained in a
condition of mobile equilibrium by the opposition of this inhibition
to their own inherent tendency to discharge (Mercier). "Inhibition
is an action which obstructs or impedes another action, and which
weakens or arrests it if it was already in action " (Oddi). "Voluntary
action is at all times the resultant of the compounding of our impul-
sions with our inhibitions" (James). "The inhibition of a mental
process is always the result of the setting-in of some other mental
process" (McDougall). It may be said as a physiological conception
that in living substance there are conditions of cohesion and inertia
by virtue of the anabolic tendency of its physical and chemical ele-
ments; this may be called physiological inhibition, and it is the pri-
mary factor in the mobile equilibrium conservatively holding the
balance against the tendency to discharge induced by constant
external stimulation. The psychological conception of the essential
physical fact is that one neural process inhibits another; it may be
said that as a will-impulse implies a neural process w.hich may
inhibit, or excite and augment, some other mental or neural process,
this may be called voluntary inhibition. The great importance of the
study of inhibition, which is only indicated here, lies in its holding
an equal and counterbalancing place in mental and physical pro-
cesse^.

(3) Energy of muscle and nerve. This refers to the principle of the
storage and discharge of energy, and the biological theory that
functional activity of a specialized tissue depends primarily upon
chemical changes in its individual cells. The fundamental idea is that
in the resting state the cell elaborates highly complex compounds
and that these break down to yield the energy by which the cell does
its work; discharge and restoration of energy is common to both
nervous and muscular elements. Hughlings Jackson characterizes
the animal organism as "an apparatus for the storage and expendi-
ture of nerve force." These principles are of essential importance in
the study of mental disorders. Inasmuch as functional efficiency
must be taken as a measure of the available energy, it should be
expected that exhausting influences would reduce functional power.
Such reductions characterize all forms of the functional psychoses,
and the variations of their symptoms are consistent with this
principle.

(4) Physiological use and fatigue, — waste and repair. The law of
use includes the wholesome effects of those just cited; normal use
develops functional activity and strengthens power, while disuse
weakens function. Overuse begets fatigue, and normal fatigue pre-
sents mental as well as physical effects. Physiological fatigue may be
continued beyond the point of regular recovery by rest and nutri-
tion ; it then becomes the pathological fatigue of nervous exhaustion
or neurasthenia with the characteristic symptom-groups. A func-
tional conception of the significance of these groups of mental and
physical symptoms should stimulate not only such a precise obser-
vation of them as is needed to constitute " disease-forms " and
mature types, but should lead to their being analyzed and traced to
their functional sources in the whole organism in accordance with the
principles of general pathology. This method reveals the genesis in
physical states of some of the most characteristic mental manifesta-
tions. Beginning with the fundamental attribute of irritability, for
example, wide variations occur within normal limits, but more
striking and significant changes appear in all forms of pathological
fatigue, and the functional psychoses; the irritable weakness and
languor of neurasthenia, and the psycho-motor excitations, retarda-
tions, and "confusions" of melancholia and mania are examples.
The study of these alterations of irritability involves the whole pro-
blem of reflex-action and the mechanism of responses to stimulation
of both mental and physical functions. It is to be recognized also
that all of these reactions contribute to the sensory returns from
the whole organism, — from the viscera, muscles, and even the spe-
cial senses including the special dermal sensations, to the central
nervous system, constituting the kinesthetic and organic sensations.
In mental physiology a functional conception of these reactions

292 PSYCHIATRY

reveals their importance for an understanding of the genesis or
emotional changes, and the alterations of the affective tone in
states of persistent mental depression. The sense of well-being and
ill-being depends upon these variations. Most important of all,
because so completely neglected in psychiatry, are the bluntings
and losses of organic sensations and the consequent effects upon
the feeling-tone and ideation; in this regard attention should be
called, especially, to a remarkable fact well established in physi-
ology and psychology. It is evident that the normal irritability
of nerve and muscle requires the maintenance of a certain chemical
constitution; slight variations from this, temporary or continuous,
alter or may destroy the irritability. Further, it is noticeable in most
cases that the first step toward deterioration is a rise of irritability ;
the cause being increased or continued, sooner or later exhaustion
supervenes, the irritability lessens, and is finally lost.1 These func-
tional reductions of sensibility, in a wide range of varied degrees and
combinations, are constant symptom-factors in psychiatry.

The relation of mental physiology having an essential importance
for psychiatry there should be a first reference of all mental symptoms
to their functional sources in the organism as far as possible with
respect to their correlation and association with alterations of bodily
functions. By the genetic method study should begin with the
minor changes from normal action; these alterations show intensi-
fications and losses of function, and symptom-groups are modified
by their varied combinations.

Mental Physiology and the Functional Psychoses

The true basis of a pathological physiology in psychiatry is mental
physiology and its physical correlations of function; variations of
nervous and mental' reactions in their initial stages may be wholly
functional. Approaching the subject newly from this point of view
the physician is assumed to know the modes of reaction of the
nervous and mental mechanisms and that part of the work done by
the nervous system leads to consciousness; he should know also the
primary postulates of psychology. Having to study the operations of
other minds, he needs to distinguish, in descriptive terms, his own
conscious experiences.

A helpful method in psychiatry is to separate the experiences that
relate to the outer world from those that belong to the inner life.
Professor Sanford presents this idea in discussing the relation of
psychology and physics, to which reference has been made. He
describes the conscious experiences that may be called physical phe-
nomena: percepts or series of percepts belonging chiefly to thesense-
1 Am. Text-Book of Physiology, vol. n, p. 61.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 293

fields of sight, hearing, and touch, including under the latter the
kinesthetic senses as well as pressure, heat, and cold; he speaks of
these as the senses that mediate the "life of relation" with the world
outside our own bodies, — the "physical group of senses." Taste,
smell, pain, the general and organic senses — all having little exter-
nal reference — are not mentioned at all in physics, except incident-
ally. The method of psychology on the other hand, while not essen-
tially different, has broader outlines; its phenomena are various
conscious experiences, including all those with wrhich physics sets
out, but also experiences involving pain, organic and general sen-
sations, feelings, emotions, memories, images, volitions, processes of
reasoning — and everything that belongs to such experience. Physics
dealing with outer experiences only practically works with terms
derived exclusively from the kinesthetic and a part of the dermal
and visual experience in its spatial function; these are the senses
capable of perceiving matter in motion, and the physicist in using
their terms excludes reference to the other senses of the physical
group, sight, hearing, and touch. Psychology deals with both inner
and outer experiences.

This general view of mental physiology has a special value for
psychiatry which it is possible here only to indicate. The conception
of a relation between conscious experiences and outer physical phe-
nomena implies an organism, with its special "physical group of
senses" in touch with the outer contacts, acting as a medium of trans-
mission between the two; this medium may be conceived as form-
ing also a somatic group of senses in the paths of communication.
But this mechanism of transmission does not afford, even normally,
open ways without friction or obstruction; to its reports of contacts
with the outer "life of relation" it adds the multitude of returns with
all their variations from its own physical workings, and for this
process the same mechanism of kinesthetic and other senses, in a
new grouping with others, including the organic and general sensa-
tions, is used. In abnormal as well as normal conditions these returns,
however imperfect, stand for the truth and the whole truth in con-
scious experience; in health we think as little as possible of the
medium of transmission, and in all conditions of well-being or ill-
being we can only describe our organic feelings in general terms. We
do not recognize for the most part the sources of these sensations,
yet they have a controlling influence upon our minds. These con-
siderations indicate three groupings of the functions of the sensor}7
mechanisms of conscious experiences: (1) the physical group of
senses of the outer "life of relation;" (2) the somatic group of senses
of the inner life — our conscious experiences of our own bodies;
(3) the central psychical life, which includes both of the other groups
of conscious experiences, besides those belonging distinctly to its

294 PSYCHIATRY

mental aspects. The interest of this to psychiatry is that compara-
tively little attention has been given to this inner sensory field of the
sources of conscious experiences; yet, it may be said, here are the
conditions and the very material of bodily and mental stimulations
and sensations with which the mental work is done. These explaining
principles have been almost wholly omitted from the accepted
formulae of the conceptions of modern advanced psychiatry which
has chiefly concerned itself with the motor aspects of mental life and
expression. These physiological references are needed to explain
many of the symptoms of the psychoses and should have their full
value in the formulation of the principles of mental physiology and
psychiatry.

A functional conception of mental pathology 1 directs observa-
tion to the first and smallest departures from normal action, upon
the principle that all variations of a pathological character are sub-
ject to the laws of normal function acting under abnormal condi-
tions. The study of the development of symptoms is equivalent to
noting the genesis and progress of the conflict between the func-
tional energies and the abnormal conditions. Symptoms as func-
tional modifications are the results in changes of action, — organic
effects are the results in changes of structure ; by the genetic method
the sequences of functional phenomena are noted; in the functional
psychoses there are variations of functional efficiency manifested
by its reductions and recoveries. The following characterization
in outline of the psychoses is an application of the functional prin-
ciples referred to in the foregoing pages. For the purpose of tracing
the several orders of symptom-factors from their genesis in func-
tional sources they can be considered most simply under the divi-
sions of the mental elements — intellect, feeling, and will, as these
terms are used in modern psychology for purposes of classification.

Characterization of the Psychoses according to Functional Principles

1. THE FUNCTIONAL PSYCHOSES. A study of the large group of
cases of non-deteriorating mental disorder yields certain general
conclusions as to what may result to the normal well-endowed
individual wrhen subjected to the effects of use, disuse, overuse, and
stress. Beginning with the least degrees of decline of functional
vigor, below normal fatigue, there is no point in the declension where
a line can be drawn definitely marking a change from one named

1 Cf. Barker, L. F., Methods in Medicine, Boston Med. & Surg. Jour., June,
1905. Referring to the value of a functional conception of pathology, it is also
said that "as medicine has become more scientific the mind has ceased to be
satisfied with such descriptive classifications as the clinical symptoms and syn-
dromes represent and with ' clinical types' set up, and is ever on the alert to replace
them by classifications of a developmental or genetic character." Quoted from an
address before the Mass. Med. Soc. published while this paper was in manuscript.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 295

"clinical type" to another, down to the lowest degrees of vital energy
and complete loss of voluntary function. Throughout all observa-
tions of these changes the essential principle of variations of irrita-
bility is never to be lost sight of nor the fact that the first step toward
deterioration of function is characterized by a rise of irritability.
Another pervading principle is that among the multiple functional
mechanisms failure of energy is unequal, and that changes and losses
of irritability must apply as much to sensory as to motor function.
The word "psychosis" can be used most profitably as correlative
with "neurosis," and as including both its proper psychological and
pathological meanings, leaving the differentiations of sanity and
insanity to be indicated by those words. A basis of inquiry, as above
described, prepares the way for the examination that comes first in
order of the initial departures from mental integrity, viz., the
affections called imperative and fixed ideas, and the primary asthenic
conditions of neurasthenia before the after-effects of chronic states
have supervened.

Insistent and fixed ideas refer to a wide range of kindred cases of
affections that can happen to sound minds in persons neither tem-
porarily nor constitutionally neurasthenic. The functional elements
are normal and the affections may attain characteristic forms in
normal minds; but this happens to them more readily when there is
neurasthenic reduction of inhibitory energy and greater degrees of
intensity and persistence occur in association with constitutional in-
stability. All observant sane persons estimate the purposes of others
by interpretations of their speech and behavior, and thereto fittingly
adapt their own conduct influenced by inferences and judgments in
a manner that would indicate "paranoid" suspicion under certain
circumstances. Inasmuch as this is a universal, functional, self-
protective principle, sane persons have normally the functional
disposition to produce ideas of suspicion and persecution, but well-
balanced minds control thought and speech. In any psychosis, how-
ever, associated with asthenic conditions there may be "paranoid
forms" not belonging to that psychosis as essential to the symptom-
complex; this reaction is liable to become casually intensified or
further developed and fixed by habit. In many cases not "psych-
asthenic," nor physically neurasthenic, the affection is purely a
functional accident; it may involve all forms of emotional reactions,
other than "phobias," and many cases recover.

Neurasthenia, in its early conditions, uncomplicated by the effects
of habit, presents the same elements, in mild degrees of functional
reduction, that characterize their greatly varied combinations in the
symptom-complexes of the graver conditions of melancholia, mania,
and exhaustion psychosis or confusional insanity. These neuras-
thenic conditions may occur in all persons, under sufficient stress,

296 PSYCHIATRY

but when there is constitutional weakness the power of resistance is
less. The functional elements of the organism, all working together,
constitute combinations of community- work of extreme complexity;
these elements being unequally reduced in efficiency the "clinical
types" are very much varied. A method of analysis of symptoms
with the endeavor to estimate their functional values and their
relations to their physiological sources will appear under the follow-
ing topics:

The functional psychoses constituting the main group of non-deteri-
orating affections pathologically regarded as insanities, all have
a basis of some kind or degree of asthenic reduction of functional
efficiency; as already indicated, these may include the whole range
of degrees from simple cases of nervous exhaustion downward
through the simple and pronounced cases of melancholia and mania,
including all varieties of phases and combinations of the symptom-
elements; also including the more actively induced exhaustion
psychoses and confusional deliria. Functionally considered, it is
proper to regard all these cases as "functional psychoses" until
proved to the contrary. Function comes first as the present criterion ;
organic change is a result. Cases carefully diagnosticated character-
istically tend to recovery. The designations, neurasthenia, melan-
cholia, mania, etc., are simply valuable descriptive terms; they are
Jthus not correct names of diseases as clinical types and we have yet
to study broadly the genesis and development of these conditions.
By the functional method we have merely advanced, as yet, little
beyond the general fact that two classifications may be made of the
psychoses — the non-deteriorating, and the deteriorating. By the
morphological, clinical-type method there is a singular lack of success
in adopting principles of valuation of symptoms by which men of
good minds can reach like conclusions. We are not yet ready to
determine species; this should be aided by the study of the genetic
character of the symptom-elements.

The significance of the unifying characters of the non-deteriorating
range of psychoses may be made much clearer by grouping them
according to the functional sources of the symptoms and their own
natures. The symptom-factors thus fall into natural groups, which
should be studied with complete freedom from preconceptions of
"disease-forms." No more is attempted here than to harmonize
these groups with the elementary postulates of psychology, and with
the general physiological facts heretofore cited.

(1) Feeling. (The feelings and emotions.) The emotional varia-
tions that are pathologically persistent are in close relation with the
changes of bodily states which are represented in the central nervous
system by the organic, kinesthetic, and general sensations; the sum
of these has, physiologically, a strong influence upon mental feeling,

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 297

and therefore in pathological conditions the emotional tone of the
psychical sphere corresponds with the sense of personality by "states
of mental depression" (melancholia) associated with malaise and
ill-being, and "states of mental exaltation" (mania) with sense of
well-being and false euphoria. The complex sources of the sense
of body have been described and the changes of irritability due to
fatigue and other causes; the consequent variations of the sense of
physical pleasure and pain are closely connected with the rise and
decline of irritability, its intensifications and losses, but not with
parallel changes.

In the emotional states of "neurasthenia" the depression is
variable; of "melancholia," persistent; in both the feeling-tone
may be combined in various ways with the first degree of functional
deterioration of irritability marked by agitation, restlessness,
"irritable weakness" (psycho-motor excitation), or by dullness,
slowness, languor (psycho-motor retardation). In nervous exhaus-
tion and melancholia the feeling-tone is constantly influenced by
bluntings and losses of organic sensation, strikingly shown in the
loss of the sense of fatigue — "fatigue-anesthesia," and the various
unequally distributed conditions described in the natural order of
decline as hyperesthesia, hypoesthesia, paresthesia, and anesthesia;
also ease and obstruction of motor expression have their reflex in-
fluence upon the affective states as in a feeling of facility, or the
"sense of inadequacy" and the "sense of effort." 1 Hopelessness,
introspection, retrospection, apprehension, self-reproach, are logical
consequences. All these variations are persistent intensifications
and differences of the normal connections of ideas and emotions,
with their correlated physical reactions; the persistence of morbid
emotional reactions indicates deteriorated body-states.

In the emotional states of "mania" there is the characteristic ex-
altation and exhilaration ; but in many cases there is depression of
feeling of the type shown by anger in its origin from painful states
of irritation, and by distressing delusions and aggressiveness. These
two prominent types of feeling-tone are associated with corre-
sponding variations of irritability marked by its rise from moderate
to high degrees of psycho-motor excitation, shown mentally in
"flight of ideas," corresponding to the agitation and irritable weak-
nesses in melancholia, — sometimes more extreme and sometimes
reduced and lost. -The clinical pictures in some cases may indicate
a simple absence of painful irritation, but they certainly show, char-
acteristically, the false euphoria of blunted sensations, as in alco-
holic intoxication.

(2) Intellect. (Sensations — perceptions and ideas.) The "think-
ing process," as it is rather vaguely called, may be definitely con-
• * Cf. Cowles, E., op. cit., Neurasthenia and its Mental Symptoms, 1891.

298 PSYCHIATRY

ceived to include the ideational reactions of the stream of conscious-
ness, constituted of the association-processes in combination with
the inhibitory or exciting control of the will working through atten-
tion and apperception; the emotional factor enters into the com-
bination and modifies the "thinking process" with intensifications
of interest and motive influences. It is impossible to describe
these function-factors separately because they all work together.
The character of the ideas — the sensations revived by memory
in the association-process, whether depressed in melancholia, or
exalted in mania, is in harmony with the emotional tone as it is
"lowered" or "exalted." The time-element in the processes of the
stream of consciousness varies with the rise in irritability and
especially with the coincident reduction of inhibition. This, in mania,
with the intensification due to irritability, produces "flight of ideas"
with quick reactions and superficial associations. The tendency is to
increasing weakness, reduction of clearness, incoherence, and final
arrest of mental functions in confusion or stupor. With disordered
perceptions there are illusions and hallucinations; delusions arise.
Maniacal states represent graver degrees of derangement than
melancholia, and a lower level of functional reduction, especially
of inhibition. The more profound conditions of acute exhaustion
(confusional insanity, exhaustion psychosis) occur sharply by
themselves from strongly exhausting influences and are varied mani-
festations of delirium; these may supervene in the severer types of
both melancholia and mania.

(3) Will. (Inhibition — attention and apperception.) In the
sense that acts of the will are such acts only as cannot be inatten-
tively performed it produces exciting or augmenting effects in the
"thinking process," or inhibiting effects; working through attention
and apperception its function of control appears in voluntary inhibi-
tion, and this has been described in part in connection with the other
elementary functions and in the reference to the physiological law of
inhibition. Normally inhibition, both physiological and voluntary,
stands in mobile equilibrium with the tendency of all conscious and
neural excitations to discharge into motor effects, open or concealed
within the organism. In the incessant change and succession in the
train of ideas in consciousness the attention holds the chosen or
attracting idea in the interplay of neural processes and thus inhibits
its tendency to pass away, other items being held with it in reason-
ing, and apperception being a special form of the same controlling
influence. This inhibitory function is a true index of the integrity of
vital energy; it is regularly reduced in efficiency with asthenic
reduction of the nervous forces. Voluntary inhibition is variably
reduced in neurasthenia, persistently in melancholia, and greatly so
in mania with loss in delirium.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 299

(4) Organic Sensations and States. (General and kinesthetic
sensations.) The importance has been shown of these function-factors
of the "somatic group of senses/' in respect to the representations
they bring into conscious experiences concerning the inner physical
life of the body. In health the sensory and motor reactions of our
bodies, and our conscious experiences, are adjusted to contacts with
the environment within normal limits; the organic and kinesthetic
senses normally contribute to the general welfare with only salutary
interferences, and these being mostly unnoticed we habitually ignore
their existence. It is in disordered physical conditions that the
abnormal influences arise and interfere with and derange the expe-
riences of the mental life; they are general and vague in character,
but are of essential significance, though only described as subjective
experiences. The phenomena of changes of excitability and loss of
function are well known and variously described; an interference
with the functions of any one system will disturb the normal func-
tional equilibrium that must of necessity exist in the action of the
whole.1 The principle of localized variations of irritability, as in the
neuroses, applies to all functioning groups of cellular mechanisms;
the threshold of excitation may be raised or lowered in any of the
sensory, motor, or central and psychical parts of the reflex mechan-
isms. Upon these changes may be predicated all the phenomena of
psycho-sensory and psycho-motor excitation and retardation, con-
ditions that appear in some kind or degree in the whole range of the
functional psychoses. These variations may be ascribed to reduc-
tions of the nutritional maintenance of the vital energies. Hyper-
esthesia and hyperkinesis are the complementary manifestations
that betoken fatigue, or equivalent weakness from some cause, of the
physiological inhibitory energy; this condition is often associated
with anesthesia of the fatigue-sense in the same case.

It should be noted that the changes of feeling-tone, of motility,
and of control do not run parallel to each other; hence the differ-
ences of the clinical pictures presented by typical melancholia
and mania, and the so-called "mixed cases ; " melancholia pre-
sents two principal types — emotional depression with excitation
and retardation; mania presents emotional exaltation with ex-
citation, and sometimes there are painful states of consciousness
and the acute reductions of function in exhaustion and stupor. There
are numerous phases in the unified melancholia and mania as con-
stituting one general group of variations of functional disorders
presenting clinical phenomena apparently widely divergent as
"clinical types," but falling into harmonious relations when ex-
plained consistently with their developmental and genetic char-
acter.

1 Cf. Mott, F. W., The Degeneration of the Neuroses.

300 PSYCHIATRY

2. THE DETERIORATING PSYCHOSES. These psychoses have
an important relation with the functional psychoses, which should
be mentioned here. They are characterized by persistent func-
tional deterioration and tend to dementia; this is consistent with
the opposing fact that the vital energies of the life-process some-
times appear to overcome in recovery the interferences with their
normal action. It has been said that the functional psychoses tend
to recovery; yet the failure to recover in some cases may be con-
sistently referred to constitutional weakness or the loss of vigor
in old age. This does not imply that heredity is an essential cause
of mental disease; "neuropathic" persons have less endurance
against all adverse influences. Among the deteriorating psychoses
the first place is given to a large group called "dementia precox ;"
its general form is not clearly differentiated, nor its special divis-
ions; no common basis is implied in the designations hebephrenia
(mental weakness), katatonia (motility disorders), paranoid forms
(insistent and imperative conceptions). A single case may change
from one "form" to another, and the recognition of some con-
stant characters is required to unify all the "forms;" the com-
mon fact of dementia is shown in the deterioration of capacity
that may occur in any of the functional mental elements, varied
in different cases; this implies structural changes. The character
of the failure is revealed in the quiescent states after the subsid-
ence of active symptoms. The most common fact is the deep-seated
deterioration of the emotional nature; hence the characteristic
indifference and apathy which favors the development of habit
automatisms, etc. Concerning this large group of deteriorating
psychoses, regarded as above stated, and including also the few
other "disease-forms" at present accepted as such, some general
conclusions now appear with respect to the functional psychoses.

Mental Physiology and the Functional Psychoses, continued

The unification of the functional psychoses can only be indi-
cated here with respect to the explanations and conclusions reached
during some years of teaching the principle that each of the groups
conveniently designated neurasthenia, melancholia, mania, etc.,
simply includes variations in combinations of different degrees of
functional disorder of the same physical and mental elements.
The essential unity of melancholia and mania was recognized by
Griesinger and others with differing explanations; modern physi-
ology and psychology broaden and simplify the whole subject
with better explanations of general principles.

In recent psychiatry there is an evident tendency to the unifica-
tion of the psychoses.

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 301

A significant contribution has been made by Dana; 1 in his large
neurological experience he has seen much to favor the idea that
most neurasthenias are mental cases, or non-insane psychoses;
the term phrenasthenia is used for a special group of neurasthenic
or degenerative psychoses including mainly those described by
Janet as psychasthenia; it is said that an innate constitutional
weakness underlies all the chief non-accidental functional insan-
ities. There is much reason for a simplifying psychiatrical con-
ception, complementary to Dana's view, that not only most but
all functional mental cases are subjects of asthenic reduction of
functional efficiency and are neurasthenic. The tendency is not-
able in the remarkable studies of Janet in which he reaches the
conclusion by psychological analysis that many of the apparently
diverse psycho-neuroses may be unified under the one principle of
psychasthenia; this implies a general and special insufficiency in all
the phenomena and is at the same time neurasthenia; these affec-
tions represent regular degrees of lowering of functional efficiency.

The genetic method leads to a comprehensive view of all the
psycho-neuroses. Considered biologically and physiologically neur-
asthenia, phrenasthenia, psychasthenia and all the functional psych-
oses are modifications of functional characters. Whether these
modifications were acquired newly by the individual himself, or
by his ancestor and thereafter transmitted as though they were
inherent variations, the problem is essentially the same. However
perverted, distorted, and anomalous the functional phenomena
of vital activity may be, they must be traced back to the first
interferences with the physiological elements to find their explana-
tions in their genesis. We may assume that all normal adult indi-
viduals are subject to certain acquirable functional modifications
— numerous and complex, thus forming the symptom-groups
called neurasthenia, melancholia, and mania, for example; all ab-
normal persons are subject not only to the same changes, but to
something more and something different, and these additions may
be simply special variations of intensity, or degrees of impairment,
or of differences pointing to other than functional explanations.
A general principle in mental pathology may be derived from these
considerations. Whatever the form of a deteriorating psychosis,
it has its own pathological characters; but superimposed upon
these symptom-factors, and relatively superficial, neurasthenic
manifestations commonly appear, and there may be episodes, more
or less transitory, of manifestations of the functional psychoses.
This occurs notably in the early stages of dementia precox and
manifests the practical concurrence of two diseases, viz., the per-

1 Dana, C. L., The Partial Passing of Neurasthenia, Boston Med. and Surg.
Jour., vol. CL, 1904.

302 PSYCHIATRY

manent deteriorating psychosis and the transitory phases (melan-
cholic, maniacal, and paranoid) of the functional psychosis. This
principle accounts also for the fact of there being maniacal as
well as melancholic types, and the "paranoid conditions," in the
"involution psychoses;" this principle is already well recognized
in respect to the neurasthenic, melancholic, and maniacal modes of
onset of paresis; and to the same types of functional disorder, and
tendency to obsessing suspicious and delusional ideas, in senile insan-
ity in which active symptoms may measurably or wholly disappear.
All the psychoses called functional for purposes of classification,
and being nearest to normal, constitute the main division of the
psychoses (considered as mental disorders); all the psychoses
called deteriorating, and being exceptions to the others, constitute
the minor division. In these the fact that in some particulars the
reductions of functional efficiency remain permanently deterior-
ating constitutes dementia, which implies some form of structural
change, though none strictly characteristic has yet been found.
The pathological principle here suggested leads to a practical method
of analysis of the symptom-factors of all possible forms of deteri-
orating psychoses. The first step is the distinction of the purely
functional modifications referable to physiological sources; these
relate to variations of the fundamental irritability as explanatory
of changes of motility and of the sensibilities and emotional tone,
all being comprehended broadly in relation with the "somatic
group of senses;" closely kindred with these are the reductions
of function of the processes of association, memory, attention,
inhibition, etc. Holding apart these phenomena of the main di-
vision of psychoses as being included in the functional conception
of their pathology, and as explainable through their genetic and
developmental character, there remain, of the symptom-factors
of a deteriorating psychosis, those that point to the causes of the
special deterioration. This helps to define the problem of research
for anatomical explanations. It should not escape observation
that when there is "innate constitutional weakness" in cases be-
longing to the main group of functional psychoses, special modi-
fications may be noted in the symptom-factors, especially of the
attention and inhibition element whose reduction is the most con-
stant and characteristic fact of constitutional insufficiency. It is
in these conditions that the law of habit has its most potent and
perpetuating influence. The functional psychoses, including those
answering to the definition of "a typical form of insanity," present
some points of special interest when analyzed in accordance with the
method and principles examined in the foregoing pages. Refer-
ence has been made to Griesinger's descriptive definitions of melan-
cholia as "states of mental depression" and mania as "states of

PSYCHIATRY IN THE FUNCTIONAL PSYCHOSES 303

mental exaltation." During more than half a century these de-
signations have held their places in psychiatry; the search for
more satisfactory statements has not been altogether successful.
The difference of the emotional tone is the criterion, but it is not
a wholly true one. The depression in melancholia is consistent be-
cause the " somatic senses" retain enough of normal function to
report truly to consciousness the fact of ill-being of the body; but
in mania the exaltation is not constant, the physical correlatives
of the feeling-tone are more disordered by reductions and losses
yielding more irritating excitations and in many cases a fictitious
sense of well-being. But the "somatic senses" produce other
equally important symptom-factors in the changes of motility;
in melancholia with impaired inhibition there are both psycho-
sensory and motor excitations and retardations, — in mania,
with graver changes and losses of inhibition, motility is more dis-
ordered. The word melancholia, by long usage and observation
of the facts, really stands correctly in the recognition of its mean-
ing all of its well-known symptom-factors other than emotional
depression; the word mania, meaning madness, stands equally
well for both its emotional variations and its motor excitement.
In mania there is graver derangement of the "thinking process"
and its "states" are at a lower level of reduction than melancholia.
These references though meager serve to show that the terms mel-
ancholia and mania are well understood as including a great variety
of states of varied combinations and proportions of their symp-
tom-factors; besides the many typical cases of each group there
are found to be very many "mixed cases." There are many phases,
and a two-phase conception to represent the original groups of
"states" does not hold good; for example, taking out the emo-
tional depression from one group, and the motor excitation from
the other, in order to designate the distinction of the phases and
to characterize the compound "disease-form," leads to the exclu-
sion from it of the very essential psycho-motor excitation often
associated with the depression in the former group, and to over-
looking the significance of the emotional changes in the latter. An
adequate study of the "somatic group of senses," as suggested here,
should help to clarify the whole matter. Compound designations
for the unified symptom-groups yet suggested do not satisfy the
requirements so well as their simple combination in "melancholia
— mania." The psychoses cannot be limited to the insanities;
we must speak of the "non-insane psychoses," and in psychology
the word refers to normal function. It might be said that the first
step in the classification of mental diseases discovers two great
divisions : functional insanity and deteriorating insanity.
This discussion of the thesis that the problem of psychiatry is

304 PSYCHIATRY

in the functional psychoses, required first an examination of the
terms and conditions of the problem. This necessitated an inquiry
concerning certain principles and conclusions of the biological and
medical sciences that have had a controlling influence in psychia-
try. Morphological conceptions being dominant in medicine, it
was found also that a number of terms and phrases are so com-
monly employed in medicine that their use has been compelled
in psychiatry, although they embody conceptions and theories
inconsistent with its dependence upon functional conceptions of
mental pathology. The inquiry having led to the conclusion that
the physiology of the life-process is the first recourse for psychiatry,
in the search for explaining principles it becomes necessary to be
emancipated from all preconceptions. The functional conceptions,
being framed, and applied consistently with the facts of physio-
logy and psychology, lead to a recognition of the developmental
and genetic character of the functional modifications, and indicate
their sources in physiological facts. A clearer idea is gained of the
relation of conscious experiences to body states, and of the influ-
ence of the "somatic group of senses" in the relations of the con-
ditions of the whole organism to the mental states. The depend-
ence of all functional phenomena upon the processes of nutrition
and metabolism for the maintenance of the nervous and mental
mechanisms points to the fundamental importance of pathological
physiology and chemistry. Physiological and psychological ex-
periment in the immediate clinical examination of functional modi-
fications shown in symptoms helps to determine the physiological
sources of the contributing disorders in the whole body as well as
the central nervous system.

The psychiatrist inclined to inquiry finds, in the pursuance of
his practical work, that as a physician he must treat the whole
body, and that a functional conception of mental diseases leads to
treatment. Psychiatry belongs to general medicine and mental
disease like bodily disease is not an entity nor an agency, but the
result of normal function acting under abnormal conditions; the
problem requires the investigation of the developmental and genetic
character of functional modifications.

MUBAL PAINTING
Photogravure from the original Plafond Painting by Michael Munkaczy.

In this fine composition the great painter, Munkaczy, has introduced the
portraits of various great painters and sculptors. The section reproduced her*
is part of the painted ceiling of the Museum of Historical Art at Vienna.

SECTION H — SURGERY

SECTION H — SURGERY

(Hall 13, September 23, 10 a. m.)

CHAIRMAN: PROFESSOR CARL BECK, Post-Graduate Medical School, New York.
SPEAKER: DR. FREDERIC S. DENNIS, F.R.C.S., Cornell Medical College, New

York City.
SECRETARY: DR. J. F. BINNIE, Kansas City, Mo.

THE HISTORY AND DEVELOPMENT OF SURGERY
DURING THE PAST CENTURY

BY FREDERIC S. DENNIS

[Frederic S. Dennis, M.D., F.R.C.S. England, Professor of Clinical Surgery, Cor-
nell University Medical College, b. Newark, New Jersey. A.B. Yale Univer-
sity, 1872; M.D. Bellevue Hospital Medical College, 1874; M.R.C.S. Royal
College of Surgeons, 1877; F.R.C.S. ibid. 1899; Post-graduate, Universities of
Heidelberg, Berlin, and Vienna, 1899. President of American Surgical Associa-
tion, 1894; Attending Surgeon, Bellevue and Saint Vincent Hospitals; Con-
sulting Surgeon, Montefiore Home and Saint Joseph Hospitals. Member of the
Clinical Society of London; German Congress of Surgeons; American Medical
Association; New York Surgical Society, and many others. Author of System
of Surgery; contributor to American text-book of surgery.]

THE first word of the speaker on this occasion must be a personal
one of respectful acknowledgment. To be invited by the adminis-
trative board to deliver an address upon any theme before this
august Congress, composed as it is of many of the world's most
distinguished men of science, is a distinction which any one might
justly prize. But to be chosen as the orator upon a topic so import-
ant, far-reaching, and comprehensive as the history and develop-
ment of surgery during the past century is an honor so exalted
that while it pleasantly gratifies, it also most seriously appalls.

Permit me at the outset to record my profound and grateful ap-
preciation of the high honor thus conferred, and at the same time
to express the hesitation which I feel in attempting to handle so
great a theme within the necessary limitations of the hour. It is
obvious that the task is as fascinating as it is difficult. It is under-
taken at the earnest solicitation of friends who have much stronger
confidence than the speaker in his ability to narrate in a fitting
way the triumphs of our great science.

To weigh the surgical events of a hundred years ago, and the
motives which gave rise to them, requires us to summon to our
thought, as far as possible all the circumstances of that period.
Only when this retrospect is made, and the meager results then

308 SURGERY

attained by surgery, are compared with its notable achievements
in the present day, can the idea be fully grasped of how great, how
wonderful, how grand, has been the progress during the past cen-
tury. The advances which have been made in every department
of human activity, the victories gained in every field, the innumer-
able inventions, the marvelous discoveries, the daring exploits car-
ried forward to successful completion, the magnificent results
secured along all scientific lines, are all discussed and celebrated
in the meeting of this International Congress. But while the other
sciences have indeed thrilling stories to relate, and can point with
just pride to excellent deeds performed, the science of surgery
stands out in bold relief and conspicuous grandeur, apart from
and above the others, in that it deals directly with human life,
that most precious of mortal possessions, often lending to it not
only a helping but a saving hand. At the same time its story is
so simple and yet so grand that the child and savant may alike
participate in the pleasure which the wonderful narrative is fitted
to convey.

Surgery as a science made no profound impression upon the
world until about a century ago. But from that time to the present
the almost miraculous works which it has wrought, increasingly mar-
velous with every passing year, have aroused astonishment and
admiration in every quarter of the globe.

In order to appreciate what surgery has accomplished, it is neces-
sary to refer briefly to its status prior to 1800. A little over a cen-
tury ago surgery as a science had no existence. It had no definite
or dignified position. It received no aid or support from reigning
monarchs or kings. It was in the hands of charlatans and quacks
and barbers, and it was practiced with some few exceptions by
uneducated and irresponsible men. It was only in 1800 that surgery
was divorced from the traditions of the past and was given a place
among the sciences. It was in 1800 that the Royal College of Sur-
geons obtained its charter from Parliament, which had refused
over and over again to grant it. So bitter was the opposition to
granting a charter to the "Company of Surgeons" that Lord Thur-
low is said to have proclaimed in the House of Lords that "there
is no more science in surgery than in butchering." It was only by
an appeal to King George the Third that this charter was finally
obtained. In marked contrast to this attitude of Parliament was
the scene enacted at the Centenary of the College of Surgeons, a
few years ago. Here were assembled the foremost statesmen of
England, and the leading scientists of the world, to do honor to
the occasion. The King himself joined in the banquet as an honor-
ary member of the Guild. During all these centuries prior to
1800, as has already been stated, surgery had no established place

DEVELOPMENT IN NINETEENTH CENTURY 309

among the sciences. Medicine, on the other hand, had a well-de-
fined and honorable status. It received abundant help and liberal
support from kings and rulers. Thus it becomes evident how bitter
the struggle has been for surgery to establish its claim to honorable
and dignified recognition. Thus it becomes apparent that the
difficulties to be overcome to establish that recognition were then
insurmountable. This is not to be wondered at when pain in
surgical operations, inability to control hemorrhage, and preven-
tion of blood-poisoning, were the obstacles to the successful practice
of the art. These evils retarded the growth of surgery. Their
removal since 1800, and chiefly during the past quarter of a century,
has cleared the way for the achievements of the present day. From
Hippocrates, who was born 460 B. c., to 1800 A. D., surgery made
little advance. It was practiced by illiterate men, with here and
there a masterful mind groping in the dark for light. There were
two great discoveries prior to 1800 that had an influence on the
progress of surgery after that time, and without which surgery
could never have become a recognized science. The first discovery
refers to the circulation of the blood, which was made by Harvey
in 1628, and the further discovery of the capillary system by Mal-
pighi in 1661. The fearful dread of hemorrhage from an unknown
source prevented any operations except those of dire necessity,
which were generally performed through dead and gangrenous
tissue. The second discovery refers to inflammation, the healing
of wounds by blood-clot, and the ligation of the vessels in their
continuity, by John Hunter, who was born in 1728. These two
great discoveries prior to 1800, like the two great discoveries after
1800, viz., anesthesia and antiseptics, have enabled surgery to
establish its just claim to recognition among the sciences. These
four great discoveries, the circulation of the blood, the repair of
wounds, anesthesia, and antiseptics, are the four corner-stones
upon which a superstructure has been erected that has become
a veritable temple of science, the dimensions of which eclipse in
grandeur all other temples.

The progress has been greater during the past century than in all
the preceding centuries since the beginning of the world. This pro-
gress which surgery has made is due, in great part, to the dissemina-
tion of medical literature, to the formation of medical libraries, to
the organization of modern hospitals, to the equipment of scientific
laboratories, to the foundation of medical schools, to the estab-
lishment of medical museums, to the organization of training-schools
for nurses, and, finally, to the two transcendent discoveries —
anesthesia and antiseptics. That medical literature has had much
to do with the advance of surgery during the past century is evi-
dent when it is shown that at the beginning of the Revolutionary

310 SURGERY

War there was only one medical book, three reprints, and about
20 pamphlets by American authors, while to-day there is on the
average one new book for each working day in the year, 300 jour-
nals, and 5000 original journal articles. American writers are pub-
lishing annually at least 500 medical volumes, to say nothing of
the issuance t)f nearly 10,000 journal articles each year. In the
department of surgery alone, during the two years of 1879-1880,
there were written in America no less than 45 surgical books of im-
portance and value, together with 1717 journal articles beside,
and from this record of nearly a quarter of a century ago some
idea can be gained of what surgical literature has accomplished
at the present time.

That the foundation of medical libraries has had much to do
with the progress of surgery becomes manifest when it is con-
sidered that a hundred years ago there were in this country only
about 250 medical volumes, all told, while to-day there are nearly
160,000 volumes in the libraries of medical colleges alone, to say
nothing of the large and general medical libraries throughout the
country, without mentioning the thousands and thousands of vol-
umes in the medical libraries in Europe.

That modern hospitals have had much to do with the advance
of surgery is apparent when it is remembered that there were
scarcely any hospitals a hundred years ago, while to-day they
crowd nearly every city and town. This statement is emphasized
by the fact that in New York and in Philadelphia there are four
free beds to every 1000 of their respective populations; and by
the further fact that any American city without adequate hospital
accommodations is looked upon as in disgrace and behind the age;
and, further, that the 433 hospitals in this country which main-
tain training-schools for nurses exceed in value $73,000,000, and
their endowments exceed $18,000,000. These figures represent
less than a fourth of hospital wealth, since many of the hospitals
maintain no training-schools.

That the establishment of scientific laboratories has been a potent
factor in surgical progress is proved by the fact that millions of
dollars have been recently devoted to this purpose, and the work
performed in these laboratories has had a tremendous influence
upon the world. To Andrew Carnegie is due the credit of build-
ing the first purely scientific laboratory for medical and surgical
research in this country; and from his example other like labora-
tories have been established in the land, until now America eclipses
the world in the wealth and magnificence of its scientific institu-
tions. The Laboratory of Hygiene in Philadelphia and the Caro-
line Brewer Croft Fund for the study of cancer at Harvard Uni-
versity are worthy of mention. Many well-equipped laboratories

DEVELOPMENT IN NINETEENTH CENTURY 311

have been built in connection with large universities; while the
magnificent gift of the Rockefeller Institute for Original Research
affords another example of the influence which these establish-
ments exercise in the development of medicine and surgery. In
the Carnegie Institute there is a fund yielding over $300,000 per
year to be expended on its work. In a conservative estimate the
property investment in all kinds of medical institutions, such as
hospitals, laboratories, medical colleges, health department bureaus,
training-schools for nurses, etc., is three or four hundred millions
of dollars, not to mention the endowment funds.

That the foundation of medical schools has had a great influ-
ence in the history and development of surgery becomes apparent
when it is considered that about a hundred years ago there were
only 200 medical men in practice in this country, while to-day
there are over 100,000 workers in the field. A century ago our own
country could boast of only two small medical schools, while now
there are 154 medical schools, affording instruction to 26,821
students annually, many of whom will work in the chosen field of
surgery; and nearly all of these medical schools are an integral
part of some great university; $418,000,000 scarcely represents the
value of the property belonging to medical schools, and $8,000,000
their endowment.

The recent munificent gift by Colonel Payne to Cornell Uni-
versity for the establishment of a medical department in New York
City marks a most important epoch in the education of the phy-
sician and surgeon in the country. It is a fact worthy of honorable
mention that the wealthy men of the present century have con-
tributed most liberally to the science of medicine, as is obvious
from a review of the recent different gifts and endowments amount-
ing to many millions, especially during the past few years.

That the establishment of training-schools for nurses has had
much to do with the progress of surgery is obvious when it is con-
sidered that about a quarter of a century ago there was not an
American trained nurse, if any, in the United States. To-day there
are about 11,000 pupils, and nearly 20,000 graduates. The inaugura-
tion of the first training-school for nurses in the United States
at Bellevue Hospital in 1873 marks an important epoch in the
history of modern surgery in this country. From the initial school
at Bellevue others have been established throughout the country,
and now every important hospital in the land has a competent corps
of trained nurses as an essential feature of the modern hospital.
The far-reaching and widespread influence of the Bellevue training-
school, which was the first in this country to grant a diploma, can-
not be over-estimated, as it relates to the improvement in the care
of the sick, to the establishment of other training-schools, and to

312 SURGERY

the opportunity offered to make possible the practice of surgery
of the present century. The valuable services of Mrs. W. H. Osborn
for nearly thirty consecutive years and the untiring labors of Mrs.
W. P. Griffin, who has been its faithful president for nearly twenty-
one years, entitles them to a high place of honor in the estimation
of the medical profession. The progress of surgery in this country
has been largely influenced by the help and aid which this depart-
ment of philanthropy has offered to suffering humanity.

It is indeed a truth that without the Bellevue Training-School
for Nurses, and the influences which have sprung from it, the sur-
gery of the present century and notably of the last quarter of a
century in America would not have been possible. The lady mana-
gers of the noble charity can feel a just pride in the silent and bene-
ficent work which they have accomplished on behalf of suffering
mankind, and can feel, moreover, that they have participated in
the great work that marks a milestone in the progress of surgical
science in the United States.

That medical museums have exerted an important influence is
apparent from the fact that a century ago there were none in the
land, while now there are many. Not a few of these are admirably
equipped and appointed. They contain over 200,000 gross speci-
mens. For their maintenance nearly $200,000 is expended annually,
or one dollar each for the preservation of each specimen.

The history of surgery during the past century furnishes one of
the most remarkable chapters in human affairs. It is obvious that
life is the most important factor and element in the history of the
race. Without life, of what avail is all else in the world? Surgery
has to do with the saving of human life, and as such is the grandest
and noblest of the sciences, and the most beneficent to mankind.
A study of its development brings us face to face with the most
startling and miraculous discoveries which have had an influence
upon the health, the happiness, and the mortality of the race.

It is only necessary to remember that a little over a hundred
years ago there were scenes enacted in the name of surgery which
eclipsed in horror the frightful cruelty of the Spanish Inquisition,
the untold miseries of the Bastile, the indescribable sufferings of
the Black Hole of Calcutta, the excruciating pains of the Turkish
bastinado, and the cruel massacre of the Huguenots. One shudders
at the horrible cruelties which were perpetrated on withering mor-
tals in the name of surgery. The records of suffering which have
come down to us through the years of the century have no coun-
terpart in the various experiences of modern life. Patients were
held down upon the operating-table by brute force and were operated
upon while in the full possession of their senses; they were heard
to shriek and to cry out in heartrending screams for a discontinua-

DEVELOPMENT IN NINETEENTH CENTURY 313

tion of their tortures; they were incised with red-hot knives, and
they were compelled to have their wounds dipped in a caldron of
seething tar to control hemorrhage.

Through God's infinite mercy in the progress of the century,
all this is now changed. The patient falls asleep without a struggle ;
and when he awakens to consciousness the operation is finished.
The convalescence is fever-free and painless; the mortality is
reduced almost to zero in many cases, and the operation itself
robbed of all its horrors. The evolution which surgery has made
to effect such a wonderful change is one of the most fascinating
studies in the world's history.

To dwell upon this in orderly manner is the purpose of the present
discourse. In order to simplify as much as possible the compre-
hensive subject, it is necessary to divide it into four different parts,
and to trace the rise, progress, and development of surgery in its
triumphal march as it pertains to these four great events in his-
tory, during the past century.

1. The discovery and employment of anesthetics.

2. The discovery and practice of antiseptics.

3. The discovery and application of modern therapeutics and of new
diagnostic aids.

4. The improvement of old and the discovery of new operations
with their mortality.

1. The Discovery and Employment of Anesthetics. Among the im-
portant events in the history of mankind which have been far-
reaching and beneficent in their influence, the discovery of anes-
thesia easily stands in the foremost ranks. What greater blessing
has science ever conferred upon the human race? Other discoveries
and inventions have indeed been revolutionary in their results for
social advancement and comfort; but anesthesia outranks them all,
in its combinations of kindness and power at a point of unutterable
need. This wonderful boon to suffering humanity, now gratefully in
use throughout the civilized world, comes from our own land —
America. No other nation has presumed to lay the slightest claim
to any priority in its discovery. Anesthesia with its world-wide
blessings is confessedly American.

In 1844, Horace Wells, a dentist of Hartford, Conn., heard a lecture
by Colton on nitrous oxid gas. In illustration of the lecture the gas
was administered to a person in the audience. The man fell to the
floor; but was insensible of his fall, confessing afterward that he was
absolutely unconscious. This episode caused Wells to think that per-
haps the gas could be utilized in dentistry for the painless extraction
of teeth. With a true courage of his convictions he tried the experi-
ment upon himself, inhaling the gas, and having one of his own teeth
extracted by his assistant. When a few moments afterward, he

314 SURGERY

returned to consciousness, he cried out in his enthusiasm, "a new era
has dawned upon the world, I did not feel it more than a pin-prick,"
and Horace Wells was a greater prophet than ever he dreamed him-
self to be in the moment of wild excitement.

In 1844, William Morton, a Boston dentist, heard that sulfuric
ether could be inhaled in small quantities, and that it produced a
certain degree of unconsciousness. Like Wells, Morton immediately
tried the experiment upon himself, a daring thing to do. After inhal-
ing the ether he became insensible for eight minutes. The moment
he came to himself, the thought flashed through his mind that in
ether was a vapor which would produce insensibility for a longer
period than gas, and that here was an anesthetic peculiarly suitable
for surgical work. Accordingly, he sought his opportunity. It came
on October 16, 1846, a red-letter day in the history of surgery, not
only in America, but throughout the world. That day Morton
administered ether to a patient in the Massachusetts General Hos-
pital, in Boston, who was to be operated upon by Warren for the
removal of a vascular tumor. Under the influence of ether the patient
remained unconscious during the operation, which was highly suc-
cessful. To be sure Crawford W. Long had administered ether prior
to this time, but Long did not quite trust the evidence of his own
experiment, and feared that his success might be due to an incidental
hypnotic influence. The work of Jackson should also be mentioned,
since as a chemist he made ether; but it was Morton who really
proclaimed the discovery of anesthesia in an emphatic way, so as
to arrest universal attention, and introduce a new epoch in surgical
science.

November, 1847, was another red-letter day in the progress of
surgery, for on that day Simpson, the famous Scotchman, made
announcement of chloroform as a valuable anesthetic.

One of the most memorable nights in the history of the world was
when Simpson resolved to try personally the inhalation of chloro-
form. Sitting with his friends, Duncan and Keith, around a supper-
table, he proposed a trial of the experiment. The three men, without
the slightest adequate knowledge of what the result would be,
inhaled the vapor. It was a brave, hazardous thing to do; but they
did it. Almost instantly their conversation sparkled with unwonted
scintillations of wit and humor; but it suddenly ceased, and a death-
like silence reigned in the room. In a few moments the sound of
falling bodies might have been heard; and then again all was silent.
Simpson was the first to recover consciousness. He says that when
he did so, he heard himself saying: "That is good." Then he saw
Duncan lying on the floor, sound asleep and snoring; while Keith
was struggling to regain the chair from which he had fallen when
the chloroform did its work.

DEVELOPMENT IN NINETEENTH CENTURY 315

That was an historic scene, fraught with inestimable value to
mankind. Here were three noble men, brave heroes, every one of
them, experimenting at the conscious risk of their own lives, with
a vapor respecting whose fatal qualities they knew not, in the hope
of discovering a way by which poor suffering humanity might be
spared from pain. They took the chance of sacrificing their own
lives if necessary, for the good of mankind. Such acts of patient
research, weary waiting, unselfishness, bravery, and heroism belong
only to a profession in which saving of human life at the risk of
losing one's own life is undertaken.

It appears that Simpson's mind had long worked on the great and
perplexing problem. His daughter tells us that "very early in his
student days he had so sickened at the suffering he witnessed in the
operating-theater that he had shrunk from the scene, decided to
abandon his medical studies and seek his way in the paths of law."
This, however, he did not do. On the contrary he resolved "to fight
a good fight" in the field upon which he had already entered, and he
did, getting to himself an undying fame thereby, and conferring
an immeasurable benefit upon mankind to the end of time.

Before leaving this part of our subject, it seems pertinent to call
the attention of the enemies of vivisection to the splendid heroism
and unselfishness which Wells, Morton, and Simpson displayed in
making these hazardous experiments upon themselves, and not upon
lower animals. This world would be far better off if these enemies
to the true progress of surgery would take this noble object-lesson
to heart, and cease their senseless tirade against vivisection, which
has been as absolutely accessory to science as its benefits have been
great. The only object and aim of vivisection is to save man from
suffering, misery, and death. Shakespeare's thought that "it is
sometimes necessary to be cruel in order to be kind" is true in this
connection.

The topic of anesthesia must not be dismissed without a reference
to Keller's discovery of local anesthesia by cocain, especially in
ophthalmic surgery. The use of the spinal canal for medication, of
which the injection of cocain for anesthesia is one of the adminis-
trations in vogue, was suggested by Corning in 1884. This particular
form and method of anesthesia has been a contribution to surgery
within the past quarter of a century, and has met the needs of a class
of cases to which general anesthesia could not be applied.

As to the mortality of anesthetics, Poncet concludes that chloro-
form is more dangerous than ether, since Juillard's and Gurlt's
statistics show one death in from 2000 to 3000 administrations of
chloroform, and one death in from 13,000 to 14,000 of ether, while
in nitrous oxid gas there are practically no deaths.

The influence of the introduction of anesthetics upon the progress

316 SURGERY

of surgery can be best illustrated by a reference to the statistics of
operations recorded in the Massachusetts General Hospital. Halsted
has given the figures for 10 years before and 10 years after the dis-
covery of anesthesia, which I quote. During the 10 years prior to the
employment of anesthetics, there were only 385 operations performed
in the Massachusetts General Hospital, or about 38 annually, or
about 3 each month, or less than 1 a week. In the 10 years after the
use of anesthetics began, and before the discovery of antiseptics,
there were 1893 operations, or say 189 annually, or about 15 every
month, or nearly 4 each week. If now the number of operations in
the same hospital during the past 10 years is considered, it is found
that they amount to 24,270, or about 2427 annually, 262 every
month, and about 50 each week, while of those performed in the
year of 1903, they number no less than 3109, or about 250 each
month, or about 65 each week. What a tremendous advance upon
the less than one operation each week of about half a century ago
to the 65 each week at the present time in one hospital alone. It
must be said, however, that this remarkable increase is largely due
to the introduction of antiseptics, as well as anesthetics, in surgical
practice. In other words, Hoffman has shown that the increase in
surgical operations during the past half-century has been more than
six times as great as the increase in hospital patients as determined
by the Massachusetts General Hospital. So we are led to the second
chief topic of this address.

2. The Discovery and Practice of Antiseptics equal in Importance
that of Anesthetics, and contribute almost as largely to the Progress
and Development of Surgery during the Past Century. This discovery,
unlike that of anesthesia, belongs exclusively to no one nation.
Pasteur, in France, discovered that putrefaction is due to the pre-
sence of bacteria in the air. Lister, in Scotland, applied the dis-
covery to surgery. In Germany and in the United States a yet
further application of the technic was made. Antiseptics, therefore,
have been an evolution in which all well-progressed countries,
notably Great Britain, have taken a part. Lord Lister's discovery
will always stand as one of the great milestones in the advance of
surgical science.

There are certain remarkable facts connected with the early
surgery of this country which clearly foreshadowed the introduction
of antiseptics. Absolute cleanliness was a characteristic feature of
Mott's surgery. His personal toilet and the cleansing of every
instrument before use indicated that he recognized perfect cleanli-
ness as a sine qua non to surgical success; also the employment of
animal ligatures in this country anticipated their general adoption
as an essential part of antiseptic technic. Dorsey, as early as 1844,
successfully ligatured large vessels with buckskin and catgut.

DEVELOPMENT IN NINETEENTH CENTURY 317

Hartshorne used parchment and Jameson proposed ligature from
deerskin. All these factors, which now are recognized as an essential
part of antiseptic surgery, were marked steps toward the perfect
aseptic technic of to-day.

The general subject of antiseptics cannot be passed over without
a just and generous recognition of Lord Lister's work. It is simply
right to say that to him belongs the exclusive honor of having
discovered antiseptic surgery. While at Glasgow, in his early pro-
fessional life, Lord Lister became impressed with "the evils of putre-
faction in surgery." What appalled him in his clinical observations
was the difference of healing between a simple and compound
fracture. In a compound fracture there was communication between
the seat of fracture and the external air. This condition gave rise to
suppuration, blood-poisoning, and death. In a simple fracture there
was no communication between the seat of fracture and the external
air, and the wound healed speedily without suppuration, blood-
poisoning, or death. This striking behavior in the action of wounds
led Lister to the discovery which has made his work imperishable,
and has given an earthly immortality to his name. Mr. Lister
believed that the blood in the wound underwent putrefaction in the
same way as Pasteur had demonstrated that meat decomposed
through exposure to the air. Lister's first endeavor was to overcome
the evil by scrupulous cleanliness, just as Mott had done. But he
quickly found that this method was inadequate to meet the need.
Studying the subject, he immediately realized that Pasteur's theory
was correct; that putrefaction was a fermentation produced by
bacteria in the air; that these microorganisms could not develop
de novo, in the putrefying substances; and that there was no such
thing as spontaneous generation of bacteria. He also saw that when
the bacteria in the air could be prevented from entering the wound,
the wound would not suppurate nor give rise to blood-poisoning.
He then asked himself the question, how can these bacteria be
destroyed, or how can their fatal entrance into a wound be pre-
vented? In other words, how could we kill the bacteria and yet not
harm the patient?

This was the problem and proposition. Its solution is antiseptic
surgery. Lister had heard of carbolic acid as a deodorizer. As such
he applied it, undiluted, to a compound fracture, with repeated
renewals. Watching with intense interest the application, he was
overjoyed to see that suppuration was almost entirely prevented
and so all fear of blood-poisoning and death removed.

This was, practically, the discovery of antiseptics. A method for
preventing putrefaction was found, and in consequence aseptic
healing by gradual evolution and by modern improvements followed.
No one can measure the vast influence which this wonderful dis-

318 SURGERY

covery has had upon the human race. It has eliminated local pain
in a wound, it has prevented general fever, it has made possible
many new life-saving operations, it has saved millions of lives.

The influence of antiseptics upon the increase of surgical opera-
tions, and the decrease of mortality attending them, is difficult to
estimate. Suffice it to say, by way of illustration, that in the Boston
City Hospital prior to the introduction of antiseptics there were, in
1878, according to Halsted's statement, only 132 operations per-
formed, while in the same hospital, in 1903, there were 2719. In the
New York Hospital, in 1878, there were 142 operations, in 1903,
there were 1680. How different and justly so the prevailing idea of
the day as regards the operative part of surgery. Prior to the past
century, operations were looked upon as a tacit confession of failure,
and such they commonly were. To-day, they are properly recognized
as the grand triumph of a new science. These facts tell the story of
the progress of surgery more forcibly and eloquently than could be
done by any spoken discourse, no matter how carefully prepared.

3. The Discovery and Practice of Modern and Surgical Therapeutics
and of New Diagnostic Aids. . This part of our subject embraces all
the non-operative methods of treatment of surgical affections which
have been devised during the past century. It is obvious that within
the limits of this address mere mention only can be made of the
various remedial agencies and the general results which have been
obtained by their application.

The Rontgen rays were discovered about 1896, and the civilized
world was startled by a discovery which ranks after anesthetics and
antiseptics as one of the greatest advances in the science of surgery.
Rontgen demonstrated that the Rontgen rays would pass through
the human body and throw a shadow picture on a photographic
plate. In other words, that the rays had the power to pass through
substances which were opaque to ordinary rays of light. Bullets can
be seen and located in the body, and bones can be distinctly outlined,
because they are denser than the soft tissues. Fractures and diseases
of the bones, dislocations and diseases of joints, as well as foreign
bodies in the economy, can be observed. Tuberculous processes in
the lungs can be distinguished, and the heart can be seen actually
pulsating. Gall-stones can be made out in the gall-bladder, and
calculi can be detected in the pelvis of the kidney and in the urinary
bladder. Sarcoma, myelitis, syphilitic osteitis, bone abscess, peri-
osteal and central origin of bone tumors can be diagnosticated.
Carcinoma, tuberculosis, osteoarthritis, osteoporosis can be made
out with distinctness. Brain tumors, notably gumma, Hodgkin's
disease, aneurism of the large vessels, and glandular enlargements
and growths in the mediastinum can be demonstrated.

The Rontgen rays have also been used with a view to the cure of

DEVELOPMENT IN NINETEENTH CENTURY 319

certain malignant diseases, notably cancer of the skin and sarcoma,
especially when the disease cannot be treated by ordinary means.
It does not appear to have been of any special value in other forms
of cancer located in the organs of the body. The Rontgen ray has
also been employed as a depilatory, also to bring about atrophy of
the glands of the skin and to relieve pain. The Rontgen ray also is
used to cure pseudoleukemia and splenomedullary leukemia, rodent
ulcer, lupus vulgaris, and chronic eczema.

Great credit belongs to our distinguished chairman for the mag-
nificent work which he has performed in the application of the
Rontgen ray to surgery, and his writings upon this subject are worthy
of close study.

The Finsen light is a discovery which was made about 1897, by
means of which certain forms of cutaneous disease of an infective
origin, notably lupus, have been cured. This result is accomplished
by means of a light which can be employed without accompanying
heat, and which causes an inflammation of moderate intensity upon
the skin. Sunlight fails to destroy bacteria, owing to the presence of
heat, while the Finsen light, deprived of heat, effects a cure.

In 1878, Blunt and Downes proved the efficacy of chemic rays of
light to kill bacteria. Finsen demonstrated that the action of light
was increased if it be applied through rock-crystal lenses, and the
heat absorbed by passing it through a violet-colored liquid and
water, while the part of the body to be treated is made anemic by
pressure. Finsen apparatus increased the efficacy of the violet or
chemic rays, and absorbed red or heat rays. The effect of light upon
bacteria is slow in its operation, but its rapidity is increased by con-
centration, by means of mirrors or by lenses. The heat-rays, such as
ultra-red, red, orange, or yellow, must be eliminated, as they burn the
tissues, while the blue or violet rays destroy the bacteria. The arc
electric light comes next, and is now often used because it can be
obtained at all times. The incandescent light is of no value, owing to
the fact that it possesses too few chemic rays. The electric light
requires a special apparatus for its use, since its rays are divergent
and not parallel, as is the case in the sun's rays. Professor Pupin
says that the time is not far distant when a new method of producing
light of short wave-length will be perfected, which will be far more
powerful than the Finsen light. The shortcomings of the present
method of producing light of great actinic power consist principally
in the absorption of this light by the glass of the vacuum tubes in
which it is produced. Within the last year a method has been dis-
covered of fusing quartz, and blowing it out by means of the oxy hy-
drogen flame into bulbs, which are used for electric vacuum tubes.
Quartz, as is well known, absorbs light of short wave-length to a very
slight extent, and it is the light of short wave-length which is em-

320 SURGERY

ployed at the present time for therapeutic purposes. When this dis-
covery is applied to surgery, the field of usefulness of light as a
remedial agent will be greatly enhanced, and without doubt many
new diseases will be relieved that the present Finsen light fails to
cure. The results of treatment of lupus by the Finsen light are
interesting. In 456 cases in which the treatment had been com-
pleted at the end of 1900, no fewer than 130 are known to be free
from recurrence for from one to five years. In the rest of the cases
the period of cure is too short to establish any reliable data. In 44
cases of lupus erythematosus, 14 were reported cured and 15 improved.
In 49 cases of alopecia areata, 30 were reported cured. In 24 cases
of rodent ulcer and cancroid, with 11 favorable results. In 25 cases
of acne vulgaris, 13 were cured. These statements give an approxi-
mate idea of what has been accomplished in a short time by Finsen
light, and, without doubt, improvement in the technic will result in
even a greater number of percentages of cure.

Radium is a new element which was discovered in 1899 by Madame
and M. Curie. The term "radium" is derived from the Latin word
radius, meaning a ray. At the present time there is great interest
in the question of the therapeutic use of this metal, but sufficient
time has not elapsed to determine its value.

Radium is a new therapeutic agent which has recently been used
in surgery, and furnishes a new illustration of the development of the
science. Radium as a therapeutic possibility is little understood,
but about which much has been written. The public press has been
flooded with sensational articles about radium, while the medical
press has been conspicuous for the meager accounts of its thera-
peutic uses.

The action of radium depends upon its "spontaneous source of
energy" upon living tissues. The action of radium upon the tissues
is very similar to the Rontgen rays, and its use is indicated in those
cases in which the Rontgen ray is applicable. Radium as a thera-
peutic agent depends upon its radiations, which are of three kinds,
and have been designated by the terms Alpha rays, Beta rays, and
Gamma rays. The Alpha rays consist of a current of electric charge
that contains an amount of energy far greater than the Beta rays or
the Gamma rays. The velocity of the Alpha rays is said to be 20,000
miles per second. Ninety-nine per cent of the energy of radium is
in the Alpha rays. The Beta rays consist of a negatively charged
stream of particles very similar to the cathode. The Gamma rays
travel with tremendous velocity and are similar to the Rontgen ray
from a hard tube. The Alpha rays have very slight actinic properties,
while the Beta and Rontgen rays are highly actinic, and are therefore
the rays used in therapeutics. Beta rays do not penetrate the tissues
deeper than half an inch, while the Rontgen rays from the pure

DEVELOPMENT IN NINETEENTH CENTURY 321

radium pass through the body. Radium gives off heat and a gas
called helium, but these properties have no influence in the thera-
peutic action of radium. Radium destroys bacteria and affects the
metabolism of cells and is used in the treatment of certain skin
affections, notably lupus, keloid, nevi, rodent ulcer, epithelioma,
carcinoma, and sarcoma. The action is similar to the Rontgen rays,
but the chief advantage of radium consists in a precise estimate of
the dosage, while the Rontgen ray, on the other hand, is a more
powerful energy, but it is difficult to estimate its exact strength.

Electricity has had great influence in the development of surgery
during the past century. It has been employed in many ways, both
as a diagnostic aid and as a means of cure. The electric light is used
as a means of diagnosis to explore the hidden parts of the body such
as the throat, larynx, esophagus, and stomach, also the bladder and
the intestinal canal. Perhaps one of the most useful purposes to
which electricity has been employed in a diagnostic way is illustated
by the cystoscope by means of which the interior of the bladder can
be explored with a view of determining the exact nature of the lesion,
the shape and anatomic relations of a growth, or the presence of a
foreign body in the hollow and heretofore impenetrable viscus. The
stomach also has been explored with a view to determine the nature
of the lesion. It is also used to test the contractility of muscles which
should respond quickly to the faradic current if the nerve is diseased.
In this way the surgeon can diagnosticate functional or organic
disease of the nerve by the behavior of the muscles when the electric
current is applied. The electric current is used in surgery as a cura-
tive means in the removal of small malignant growths and nevi, to
arrest primary hemorrhage in places when the ligature is inapplicable,
or secondary hemorrhage where compression is not admissible. In
the form of an ecraseur, electricity is used to remove pedunculated
tumors, to cauterize long sinuses, to arrest suppuration in the eye-
ball, to sterilize the pedicle after appendectomy, ovariotomy, or
hysterectomy, to cause coagulation of blood in the treatment of
aneurism, to overcome obstruction in the eustachian tube, to find
bullets imbedded in the human body, by a probe which was invented
by Girdner of New York, to stimulate muscles and nerves, to im-
prove the circulation of the blood, and even to relieve severe pain.

Serum therapy is a newly discovered method for the treatment of
certain surgical diseases, among which may be mentioned hydro-
phobia, tetanus, acute phlegmonous inflammations, anthrax, and
other infectious processes. The history and development of surgery
during the last quarter of a century would be incomplete without
a reference to the inoculation method to prevent certain surgical
diseases. The principle involved in this system is the one enunciated
by Pasteur, to whom the world owes an everlasting debt of gratitude.

322 SURGERY

In 1880, Pasteur announced to the French Academy of Science that
he had discovered a method of inoculation, by means of which he
could reduce the virulence of a disease caused by a special germ.
An attenuated virus of the germ-disease was inoculated into the
system of a susceptible animal, and this infection would give rise to
only a mild attack of the disease. The attenuation of the virus, as
Pasteur termed it, was accomplished by cultivation of the special
germ in certain mediums exposed to the air. His research up to this
time was limited to chicken-cholera; but he announced that in the
future he believed that the great principle of inoculation would
extend to other diseases. In 1881 he proved to the world the cor-
rectness of this view by announcing his cure of anthrax, that fatal
malady affecting sheep and cattle. The world was skeptical of his
discovery, and the president of the Agricultural Society of France
urged Pasteur to make a public test of his cure. To this proposition
Pasteur, in the true spirit of scientific faith, assented, because he
was fully convinced of the truth of his theory. Fifty sheep were
supplied by the president of the Agricultural Society for the test.
To this flock Pasteur requested that 10 cattle be added and 2 goats
be substituted for 2 sheep, with the understanding that failure in his
experiment with cattle and goats must not invalidate the test, since
he had never carried on experiments with cattle or goats. The accept-
ance of this challenge by Pasteur was a brave act; because he knew
if he failed in this public experiment the world would denounce and
deride him. The inoculations of the attenuated virus of anthrax were
then made on 24 sheep, one goat, and five cattle, at certain intervals
upon three successive occasions. After a proper time had elapsed
the 60 animals were inoculated with a culture of the anthrax microbe.
Forty-eight hours after this injection of the full-strength virus into
all the animals, the public gathered to witness the success or failure
of this most wonderful experiment in the scientific world. The sight
that the eyes of the vast crowd beheld beggars description. In the
paddock were seen dead or moribund every animal that had not
been previously inoculated with the attenuated virus. In this same
paddock were seen the remaining animals that were inoculated with
the attenuated virus walking about apparently in perfect health.
This paddock formed a veritable arena in which was witnessed the
greatest battle that science has ever fought. The victory was com-
plete, unequivocal, and overwhelming. This successful experiment
established a new epoch, and this new principle was soon applied to
certain human diseases.

In 1885 Pasteur proved the value of this method in the treat-
ment of hydrophobia. In this latter disease the virus of rabies
was inoculated into guinea-pigs or rabbits, and an attenuated virus
was made from the spinal cord of these inoculated animals. The

DEVELOPMENT IN NINETEENTH CENTURY 323

mortality of hydrophobia by Pasteur's treatment, by Celli, of Rome,
has been only 5 %, since 1899, at which time the institute was built
and organized, and during these four years 2000 patients have
been treated with the serum.

The value of serum therapy is shown by a reference to the work
of the lam.ented Walter Reed, of the United States Army, who
discovered a treatment for yellow fever, a disease which destroyed
over 80,000 persons in this country during the past century. To-
day this scourge has been wiped from the face of the earth. The
bubonic plague, the most frightful disease that could visit a coun-
try, created panics among the people in former years; but now,
owing to the efficacy of serum therapy, its entrance into this coun-
try creates only a passing comment. Even in New York the dis-
ease was observed at quarantine, and was stamped out imme-
diately. Thompson predicts before long that the bubonic plague,
which is now practically confined to the valley of the Euphrates,
will be annihilated from even that locality, as well as cholera from
the valley of the Ganges. Haffkine's serum for the treatment of
this bubonic plague reduced the susceptibility of those exposed
to the infection 75 %, and the mortality by 90%.

Oilman Thompson says that "thirty years of bacteriology in
all of its applications have done more for mankind than all the
medical research that has preceded. In an estimate made by Alfred
Russell Wallace of 25 discoveries of world-wide importance made
during the nineteenth century, a fifth were contributed by medi-
cal science, and all but one of these were made during the last half
of the century. Two more have been greatly influenced by med-
ical science, viz., the theory of the antiquity of man and the doc-
trine of organic evolution. Yet we have not wholly emerged from
the shadows of the Middle Ages, for have we not still among us
those who fain would abolish such experiments as have made
possible discoveries like those of vaccine, antitoxin, and antihy-
drophobic inoculations, even as there are those in Persia who
would mob physicians seeking to check the spread of cholera ? "

Tetanus is a surgical disease which baffled the skill of physicians
for centuries. Recently it has been treated with very encourag-
ing results by means of antitoxin. This method of serum therapy,
together with the application of antiseptic surgery, has yielded
results that offer a striking illustration of the onward march of
surgery. In olden times the mortality in tetanus, according to
Lambert was 80 % for acute cases, 40 % for chronic cases, and 60 %
as an average for all cases. The mortality in tetanus, treated by
antitoxin and by antiseptic surgery, was about 61 % for acute cases,
and 5 % for chronic cases, and 30 % for all cases.

From these statistics it is evident that antitoxin has reduced

324 SURGERY

the mortality half, and if the antitoxin were properly used, the mor-
tality would be much less than half. The reasons why antitoxin
has no better statistics at the present time are because the anti-
toxin has not been pure or long enough continued, or not in suffi-
cient doses, or too late in its administration. If properly used, the
reduction in mortality would be striking, and from now on the
results will be entirely different. Antitoxin has its widest field of
usefulness as an immunizing agent. All surgeons agree that it
would not be justifiable to immunize a patient on the vague sup-
position that tetanus might develop. The use of the antitoxin as
a prophylactic measure is consequently limited to those cases where
the wound has been inflicted in such a manner as to allow garden-
earth, plaster from walls, or manured soil to come in contact with
it, or where the traumatism has been caused by a rusty nail upon
which the bacilli are discovered, or in a given locality where tetanus
is prevalent, or where the wound is a lacerated one with entrance
of foreign bodies into it. In these cases Murphy states that the
injection of antitoxin has reduced the mortality 50 %.

Bazy, a French surgeon, had four fatal cases of tetanus in his
practice in one year, and subsequently began injecting 20 cc. of
serum into all patients who suffered from lacerated wounds, into
which extraneous matter had of necessity entered. Since he adopted
this practice, tetanus has not followed in those cases in which a
strong probability existed that this dreaded disease might develop.
Lambert mentions that Nocard, in veterinary surgery, immun-
ized 375 animals, and in no single case did tetanus develop, while
he had 55 cases of the disease in non-immunized animals in the
same environment. Antitoxin does not affect in any way the life
of the bacilli of tetanus, or the spores. Both the bacilli and their
spores, when they penetrate the tissues by a wound, live for days
and weeks. In these cases, when antitoxin is given for the purpose
of preventing the symptoms which would be caused by the toxins
during the first few days, it will destroy the action of the toxins.
If, however, some of the spores remain quiescent, they may only
develop into bacilli at a time when the antitoxin has been elimin-
ated, and if they then develop into bacilli the toxins produced
will be absorbed, and cause symptoms just as if they had received
no immunization dose of antitoxin. For this reason, the immun-
izing dose should be repeated after the first week, and even after
the third week.

Antitoxin as a remedy during the progress of the disease has
an important influence upon tetanus; but not to the same extent
as when employed for immunizing purposes. Welch believes that
the longer the period of incubation, the better will be the results
from the use of antitoxin, and that this remedy is of little value

DEVELOPMENT IN NINETEENTH CENTURY 325

with a short incubation period, that is, less than seven days. When
antitoxin is used under these circumstances, it should be continued
long after the symptoms of tetanus have subsided. Lambert has
also called attention to a most important point in the treatment
of tetanus, and that is, the great care the surgeon should exercise
after all symptoms have disappeared. For example, absolute quiet
should be insisted upon long after the patient has become con-
valescent, since he knows of five deaths recently in New York City
where the patients were awakened suddenly out of a sound sleep,
and a convulsion was brought on from which the patients died.

Antiseptic surgery plays an important r61e in the treatment
of tetanus, since it has been shown that in the majority of cases
of tetanus the infection proceeds from the development of the
spores rather than from the bacilli. It has also been demonstrated
that the spores develop better under special circumstances of a
mixed infection, and, therefore, all tetanus wounds should be made
aseptic in order to destroy the microbes of suppuration, notably
the streptococci and the staphylococci. It often happens that the
wound is situated on an extremity, notably on the finger or toe,
and the question arises as to the propriety of amputation of the
affected part. This operation is of no avail unless the sacrifice is
made immediately after the infliction of the injury, but it is indi-
cated if the .wound cannot be thoroughly disinfected. It is better
to live without a finger or toe, or even a leg, than to run the risk
of tetanus with its attendant suffering, which leads in the acute
cases so often to death. The small punctured wounds, which may
seem insignificant, should be incised deeply, thoroughly cleansed,
and then properly drained. The toxins of tetanus are chiefly elim-
inated by diuresis. To best utilize this channel of elimination the
imbibition of large quantities of fluid is indicated. The saliva has
also been said to be a channel of elimination. . The function of the
skin has not been proved to be of any avail in eliminating the poi-
son. The employment of anodynes forms also a prominent part
of the treatment. This step, therefore, should not be overlooked,
since it is clearly proved that much suffering can be relieved by
certain drugs. Among the drugs that are found to be most useful
are chloroform, morphine, chloral, bromides, physostigmin, anti-
mony, and nitrate of amyl. Chloroform is a most valuable remedy,
because it relieves the intense suffering and diminishes the inten-
sity of the spasm and also prevents suffocation. This agent must
be used with every precaution and with every stimulant present,
and ready for immediate use. Statistics show that when chloro-
form was employed in the treatment of tetanus, the mortality was
10 per cent less than in the cases when the drug was not employed.

326 SURGERY

Thus it is evident that the use of antitoxin, the employment of
antiseptic surgery, the administration of certain anodynes and the
enforcement of quiet to avoid reflex disturbances, comprise a plan
of treatment which will offer brilliant results in the cure of this
terrible malady. The success of this treatment in tetanus alone is
a monument of the progress which surgery has made during the
past quarter of a century.

The antitoxin treatment of diphtheria affords the most forcible
illustration of the value of serum therapy in the treatment of in-
fectious diseases. This disease does not, strictly speaking, belong
exclusively to surgery; but it affords an opportunity to show the
results of the use of antitoxin, and it often happens that the dis-
ease may require surgery for its relief. From the statistics of the
Health Board of New York City prior to January 1, 1895, the
mortality was as high as 64 %, and in 1902, as a result of the use
of antitoxin, mortality was reduced to 9.5%. From a period of
5 years, from 1888 to 1894, the mortality was from 64% to 44%,
and the following 4 years, from 1895 to 1898, the mortality dropped
to 12%. In 1902 the mortality was reduced to 10.9 %. In another
series the cases were also not selected. They were collected from
hospitals, asylums, private residences, and many of them were
moribund at the time of the use of the antitoxin, and the mortal-
ity was less than 8 %, as contrasted with 64 % to 44-% 20 years
ago, or before antitoxin was employed. In 1903 the improvement
was still greater, since in 1208 cases of diphtheria only 72 died,
thus giving a mortality of only 5.9 %. If the 26 moribund cases
were deducted, the mortality is only 3.8 %. There remains no longer
any doubt as to the value of serum therapy in this disease, and if
these results can be taken as prophetic of the result of serum therapy
in other infective diseases a new era has dawned upon the civil-
ized world. Billings has called attention to one fact, and that is
the necessity of the early administration of the antitoxin, since
in 1702 cases injected on the first day, only 85 patients died in-
cluding the moribund cases; the mortality was only 4.9 %. Finally,
in 1610 cases collected from 12 physicians in private practice,
and not including the moribund cases seen in consultation, there
were 24 deaths, or a mortality of only 1.5%. An antitoxin has
been made by Calmette, who worked in the Pasteur Institute, to
prevent death after the bites of venomous serpents. This anti-
toxin has already afforded immunity to thousands of persons who
had been poisoned by the bite of venomous reptiles in India and
Australia.

The antitoxin treatment of snake-bite was discovered by Vital,
of Brazil. He made some extensive experiments with antitoxin
at the institute over which he had charge. This serum was better

DEVELOPMENT IN NINETEENTH CENTURY 327

than the control tests with Calmette's anti-venom serum. Vital
called the serum anti-ophidic, and he reported 21 cases of bite of
venomous reptiles with recovery, without any appreciable clinical
symptoms. The strength of this anti-ophidic serum is shown by
the fact that even a fraction of a milligram of the snake-venom
causes severe symptoms to appear when injected into lower ani-
mals. In three of the 21 cases, the symptoms appeared almost
immediately after the bite of the snake, and were most pronounced
in type. In these three cases, however, 20 cc. to 60 cc. of the anti-
ophidic was injected and recovery took place, notwithstanding two
hours had elapsed in one case, and three hours in another case.
Vital has also prepared a special serum for the bite of rattlesnakes.

In India, 22,000 persons and 60,000 cattle die each year from
the bites of the poisonous ophidia. Many of these deaths can now
be prevented by inoculation of the anti-venene. In tuberculosis
the mortality has been reduced 50%. Koch's wonderful discovery
is an enduring monument to his greatness. In Germany alone
90,000 persons die annually from tuberculosis. This gives us an
idea of the far-reaching influence of Koch's marvelous discovery.

Blood analysis has had much to do with the development of
surgery, and affords a most valuable diagnostic aid. Without this
contribution from the science of hematology the development of
surgery would never have reached its present state. This is not the
place to enter upon any discussion of blood analysis except as it
pertains to surgical diagnosis, by means of which the broad field of
operative surgery has been enlarged. In speaking of blood analysis
a reference only will be made to the influence it has upon operat-
ive surgery. Blood analysis makes certain the diagnosis in some
surgical diseases, it aids in the diagnosis of other diseases, and it
helps to diagnosticate a condition, where from unconsciousness,
inability to speak, insanity, or malingering, a history is unattain-
able. The chief points to ascertain are the number of erythro-
cytes, the leukocytes, the ratio of one to the other, the number
of blood plaques, and the ratio to each other, the size, form, and
contents of the blood-cells, the amount of hemoglobin and of fibrin,
the specific gravity of the blood, and bacteria contained in it. The
erythrocytes or red blood globules normally exist in the blood in
the proportion of about 5,500,000 in a cubic millimeter. The term
oligocythemia indicates a deficiency in the number of red blood
globules, or a diminution of their relative proportion. The term
poikilocytosis indicates an irregularity in the shape and size of the
globules, and an increase in the red blood globules is called poly-
cythemia. Now oligocythemia is observed in hemorrhages, anemia,
etc. Polycythemia is observed in cases, where there is a loss of
fluid from the blood as in cholera, severe diarrhea, etc. The leuko-

328 SURGERY

cytes or white blood globules normally exist in the blood in the
proportion of about 7500 in a cubic millimeter. An increase of
1500 or more in the number of the white cells indicates a condi-
tion known as leukocytosis.

Now, a normal leukocytosis is observed in health after meals,
during pregnancy, following violent exercise, a cold bath, and
massage. An abnormal leukocytosis is observed in such diseases
as erysipelas, osteomyelitis, suppuration, malignant tumors, and
in pneumonia. The term leukemia indicates a permanent leuko-
cytosis. In the differential diagnosis of surgical affections, blood
analysis is of great assistance. For example, in shock from hemor-
rhage there is oligocythemia. In shock from concussion or com-
pression of the brain, there is no decrease in red blood cells. In
appendicitis and pus tubes, there is a leukocytosis, while in float-
ing kidney, ovarian neuralgia, gall-stones, renal and intestinal colic,
it is absent.

In meningitis, in cerebral abscess and cerebral hemorrhage,
there is leukocytosis, while in other intracranial lesions it is absent,
In all forms of sepsis, leukocytosis is present. Blood plaques nor-
mally exist in the blood in the proportion of 200,000 cm. to
500,000 cm. In disease, the plaques are increased.

Hemoglobin normally exists in the blood in about 90%, and be-
low 20 % is the minimum in life. The relation of hemoglobin to the
erythrocytes and the rapidity with which it regenerates after in-
juries, surgical operations collapse, and hemorrhages, enables the
surgeon to determine the prognosis. Syphilis and cancer retard
the regeneration of hemoglobin, while tuberculosis, curious to
state, increases the regeneration. In operation for removal of can-
cer, for example, the amount and rapidity of regeneration of the
hemoglobin enables the surgeon to determine whether complete
removal of the malignant tumor has been accomplished, and whether
the rapidity is sufficient to justify the conclusion that perfect health
can be reinstated.

4. The Improvement of Old and the Discovery of New Operations
with their Mortality. It is obvious that a consideration of this part
of the subject can only embrace a cursory review of the field of oper-
ative surgery. No attempt will be made to describe in detail an
operative procedure. A mere reference to the improvements in old
operations and the discovery of new operations will be made as
affording tangible evidence of what surgery has accomplished for
mankind. The operations that have been discovered and performed
within the past 100 years will be mentioned, and an endeavor will
be made to show to what extent the science of surgery has been a
benefaction to the human race. In order to demonstrate this pro-
position, it is necessary to record the date of the first performance

DEVELOPMENT IN NINETEENTH CENTURY 329

of each prominent operation, and then to show what result has been
accomplished since its introduction. In this way an idea can be
obtained of the value of each great operation, and the advance which
each has made toward saving life. A review of this kind naturally
is devoid of popular interest, but at the same time these important
factors are worthy of record and study. In this way only can the
true progress of surgery be measured, since the operations performed
prior to the past century are insignificant and unimportant. It is
only by a study of the operations of the past century that the mag-
nitude and usefulness of modern surgery become impressive and
apparent. If what has been accomplished during the nineteenth
century be taken from the sum total of knowledge of surgery,
nothing will be left to entitle surgery to a recognition among the
sciences. The work accomplished with the century, however, as a
study entitles surgery to a prominent place among the sciences.

The important operations will be considered in the following order:
Those belonging to the cranial, thoracic, and abdominal cavities,
and finally those of a miscellaneous nature.

External to the cranial cavity, the operation for the cure of race-
mose arterial angioma, aneurisms of the scalp, sinus pericranii,
dermoid cysts, sarcoma, and carcinoma, are among the recent opera-
tions that indicate the extension of surgery in this department. The
improvement in the technic of the operation for compound fractures
of the skull, fractures of the base, encephalocele, and within the
cranial cavity, the operations for the relief of hydrocephalus, com-
pression of the brain, ligation of the middle meningeal artery, are
worthy of mention, as denoting the progress which surgery has made
within recent years. Abscess of the brain has been recently treated
with success. Delvoie cites 21 cases of trephining for acute cortical
abscess, with 15 recoveries, and 33 operations for chronic deep-seated
abscess, with 19 recoveries. In cerebral abscesses secondary to
otitis media, Ropke reports 142 cases, 59 of which recovered, and
40% were permanently cured. Frontal abscesses of nasal origin
have been operated upon with brilliant success. This life-saving
operation which has resulted in cure, until recently hopeless, indi-
cates the progress of surgery. In thrombosis of the intracranial
sinuses with operation, results have been obtained. Thus Macewen
had only 8 fatal cases in 28 cases. For the cure of infective throm-
bosis, all of which die without surgical intervention, this is a remark-
able showing for this new operation.

Intracranial tension has very recently become a new indication
for operative interference. This operation affords relief in a class of
cases that heretofore were fatal. This operation is a contribution of
modern surgery, and is another milestone which marks the progress
of the science of surgery. The recent advances in clinical medicine

330 SURGERY

and clinical microscopy have opened up the heretofore unexplored
field for operative interference. Cases of coma with no external
injury of the skull have heretofore been treated by the expectant
plan, with almost uniformly fatal results. Surgery owes much to
these two departments of medicine for valuable knowledge upon
a subject which is comparatively new, and which offers an additional
field for operative work. Intracranial tension is a condition which a
study of modern pathology has shown calls for surgical interference.
Intracranial hemorrhage is one of the most frequent causes of intra-
cranial pressure. It may also be caused by bone, pus, and foreign
body. In order clearly to understand the theory of intracranial
pressure, it is necessary to bear in mind two facts: (1) that the brain
itself is incompressible; and (2) that the cranial cavity itself is
incapable of expansion, therefore, the pressure of a clot of blood or
a fragment of bone, or a collection of pus, or any foreign body, must
be accommodated in the limited space in which the brain is lodged.
If the foreign body is of sufficient size to fill the intracranial space
by a twelfth, death results.

The treatment of intracranial tension is a new subject, and one
which I have of late given special study. I am convinced that opera-
tive treatment is indicated in many of these cases. I have employed
this measure with most gratifying success. The indications for
operative interference are in some cases perfectly clear, while in
others the phenomena present would not justify resort to so severe
a measure. The greatest difficulty is to determine what the line of
demarkation is between the cases that demand trephining or lumbar
puncture, and those in which the plan of expectancy can be adopted.

These cases of intracranial tension can be divided into two classes
as regards operative interference. The first class includes those in
which intracranial tension is sufficient to produce profound coma.
Operation will save patients included in the first class that uni-
formly died under the expectant plan of treatment. Operation will
save the patients embraced in the second class when the symptoms
are gradually increased in severity. In regard to the indications for
operation to relieve intracranial tension in those cases included in the
second class in which coma is not present, the problem is difficult of
solution. I have been guided as to the operation by the condition
of the patient after a study of the symptoms from hour to hour and
from day to day. If the arterial pressure arises to a point and remains
stationary, and the vasomotor system does not fail, even with a well-
pronounced vagi disturbance, no operative procedure was practiced,
and recovery has taken place. In addition to the symptom of increase
of arterial pressure, the blood-count must be studied, the eye-grounds
examined, the urine tested, the reflexes studied, the disturbances
of cranial nerves noted, and all other phenomena investigated. If

DEVELOPMENT IN NINETEENTH CENTURY 331

the pressure is not daily increasing, and the leukocytosis not rising,
the red blood cells not increasing, and the urine not becoming glyco-
suric, the hebetude not emerging into coma, and the cephalalgia not
increasing, delay in operative interference is indicated. If all the
above-mentioned symptoms from a stationary point begin to
increase, operative interference is called for to save the patient's life.
If on the other hand, from this stationary point, all the symptoms
show an improvement, operation can be deferred at least for the
present, if not permanently.

The operation for relief of insanity is worthy of consideration. Sur-
gery has accomplished great victories in the restoration of reason in
the insane, when the lesion was due to traumatism. A little over
a hundred years ago the management of the insane was most revolt-
ing and brutal. In Europe the treatment of the poor outcasts was a
blot upon the civilization of the world. Imagine these poor wretched
creatures consigned to dungeons and manacled by chains for years.
In these dark prisons, the insane, considered as demons, were kept
in irons amid squalor and filth. It has been stated that the iron
tether was so short that these poor unfortunate victims could not
even stand upright and were held for years by chains riveted around
the neck or waist. The humane treatment of those poor unfortunate
people began about a century ago and great credit is due to neurolo-
gists who have rescued these sufferers by throwing aside their mana-
cles, by restoring to them their liberty, and by proffering them treat-
ment. Men like Tuke and Pinel and Rush took the initiative in this
great reformation. As soon as a rational, humane, kind treatment
was instituted, it became evident here and there that among these
insane, epileptic demons as they were called, there were some who
could be relieved and sometimes cured. Surgery has been employed
for this purpose, and some of the results are almost miraculous.

In the course of the development of surgery, operations have been
devised for the relief of insanity where the etiology was due to pelvic
disease. In DaCosta's monograph it is mentioned that Hobbs
operated on 116 cases of pelvic disease in the insane, with a mortality
of the operation less than 2 %, and recovery from the insanity in 51 %,
and great improvement in 7 %. "In the group of non-inflammatory
troubles, tearing of the perineum, uterine displacements, tumors, etc.,
25.5 % regained mental health, and 31 % improved."

In the surgery of the heart great progress has been made. Bimanual
massage of this organ has been successfully resorted to by Cohen in a
case of collapse following chloroform narcosis and during laparotomy.
In a case described by him: "Artificial respiration for two minutes
having no effect, he introduced his hand into the abdominal cavity,
pushed along the anterior abdominal wall until the diaphragm was
reached, and placing the hand, palm upward, in about the position

332 SURGERY

the heart would normally be, that organ was freely grasped through
intervening diaphragm. There was an entire absence of heart action.
Placing the right hand over the precordial region, externally, he now
plainly palpated the heart as it lay between his hands, and began
rhythmic compression, using both hands at a rate of about sixty a
minute. After about thirty seconds a slight beat was felt by the left
hand. The heart now began to beat slowly, gradually increasing in
strength and rapidity until at the end of a minute the beats regis-
tered about eighty, and respiration began to be partially reestab-
lished. About two minutes after this, respiration was normal, pulse
80, and shock being apparently recovered from, the anesthetic was
changed to ether, and the operation finished in about thirty minutes,
with recovery of patient."

For the relief of pericardial adhesions, a new operation has been
devised by Peterson and Simon. This operation is analogous to
Estlander's operation for pleuritic adhesions. The operation consisted
in a resection of a portion of several ribs, and in some cases a part of
the sternum. Murphy cites the fact that of 38 cases of stab-wound
of the heart, 90 % were penetrating, and only 19 % were immediately
fatal, thus leaving 81 % of the cases amenable to surgical treatment.
This new operation, the outgrowth of modern surgery, will afford a
new field for this science to save human life in a class of cases here-
tofore fatal.

In addition to the surgery of the heart, there are many other opera-
tions of the chest that deserve mention as indicating the pro-
gress which surgery has made within the past century. In surgery of
the chest the wounds of the pleura and lung have been successfully
treated since the introduction of antiseptic surgery. Abscesses of the
mediastinum, caries, and necrosis of the ribs and sternum, tumors
of the chest-wall, actinomycosis, and other infective processes, re-
moval of fluid from the pleural and pericardial cavities, are among
the recognized operations of the day.

Wounds of the heart during the past century, and especially during
the past 10 years, have been treated surgically with remarkable
success. Stewart reports that Roberts, in 1881, suggested the pro-
priety of suturing these wounds. Tillmann believed in the hopelessness
of this procedure, yet in 1897, Rehn published the first successful
case of cardiorrhaphy in man. Stewart likewise has operated with
success, and he has collected 60 cases with the brilliant result of
38.3 % of recoveries.

In the surgery of the Im^g advance has been made within the last
quarter of a century. The diseases of the lung which have become
amenable to surgical treatment are tumors, tuberculosis, abscess,
gangrene, hydatid cysts, actinomycosis, and bronchiectasis. Murphy
has collected 47 cases of tuberculosis; 26 patients were improved and

DEVELOPMENT IN NINETEENTH CENTURY 333

19 died; 8 cases of actinomycosis, in which the patients recovered;
96 . operations for pulmonary abscess, with 80% of recoveries; 122
cases of pulmonary gangrene, with 66% of recoveries; 57 operations
on bronchiectasis, with 60 % of recoveries, but only half permanently
cured; 79 cases of hydatid cysts of the lung, with about 90% of
recoveries. In some 400 cases of pneumotomy collected from various
sources by Murphy there have been about 300 recoveries, or about
75 %. This is a most remarkable result in a department of surgery
that has developed within a few years, and includes a class of cases
that were formerly practically hopeless. Much credit is due to
Murphy for his work as a pioneer in thoracic surgery. Perhaps one
of the most interesting operations in connection with pulmonary
surgery refers to tuberculosis of the lungs. In reference to excision
of tuberculous foci, Whitacre has shown that in nearly 98% the
operation is "impossible and irrational." In only 2% of the cases
can surgery afford relief, and in these cases the foci are located in the
apices of the lung. It is thus evident that there is little to be expected
in the future as regards pulmonary surgery as it refers to tubercu-
losis, since careful investigation has demonstrated the fact that, as
a rule, the tuberculous foci are not accessible to the surgeon. Before
dismissing this subject the nitrogen compression method intro-
duced by Murphy deserves recognition. The object of this method is
to compress the diseased lung by gas, thereby restraining its move-
ment to cause a mechanical obliteration of the cavity and the limita-
tion of the already existing focus, to favor fibrosis, thereby closing
in the avenues of dissemination to afford rest to the affected part in
the same manner as a splint to a fractured bone. In certain judi-
ciously selected cases this method is applicable.

In October, 1842, Sayre made a free incision in the chest in a case
of empyema, and the patient made a good recovery. Forty-eight
years ago Sayre raised the inquiry, "In the empyema of a tubercu-
lous patient from the rupture of an abscess into the pleura, should
we not be justified in tapping as soon as discovered?" In 1850, Dr.
Henry Bowditch suggested and practiced paracentesis thoracis.
Wyman, unaware of Bowditch 's operation, performed the same
operation. For a long time in this country, as well as in Europe,
paracentesis thoracis was condemned; but at last the operation has
advanced to the stage of full acceptance by all surgeons. It is almost
impossible to estimate the number of lives saved by this operation,
but the number is very great, and this operation forms an enduring
monument to the fame of American surgery.

Surgery of the stomach has claimed attention only for the past
quarter of a century, for previous to that time it was practically
unknown. The unsatisfactory state of the surgery of the stomach
previous to 1875 is best illustrated by a reference to statistics. It has

334 SURGERY

been shown that of 28 operations attempted upon the stomach,
there were 28 deaths, or a mortality of 100 %. From 1875 to 1884,
improvement took place in that 163 operations were performed with
133 deaths, or nearly 82 % mortality.

The reduction of the mortality of 100 % to 82 % was a gain in the
right direction; but it left much to be desired. The rapid strides
which scientific surgery has made in the operations upon the stomach
forcibly illustrate what can be expected in the future in this depart-
ment of surgery. There are at present about 12 recognized opera-
tions upon the stomach, and in 7 of these there is practically no
mortality, while in the remaining 5 it has been reduced to about 25 %.
Keen predicts as technic improves the mortality in the most diffi-
cult operations ought not to be higher than 10 %.

I should predict, from an examination of late statistics, that even
less than 10 % has already been accomplished, and in the future the
mortality will be still lower. Mayo has shown that in an investiga-
tion of over 900 operations upon the organs contained in the upper
abdominal zone there existed a relationship between gall-bladder
and ducts, the duodenum, the pancreas, and stomach. In other
words, that the continuity of tissue like the mucous membrane
makes the disease of one organ a menace to the others. Mayo also
believes that the duodenum, on account of its situation, acts as a
buffer, and is involved secondarily in about an equal proportion of
cases from gall-bladder disease and gastric ulcer, in the same way
Mayo pointed out that diseases of the pancreas were secondary to
gall-stone diseases.

Cardiospasm, in which there is difficulty in deglutition from a
spasm of the muscles of the cardiac end of the stomach, forms a new
indication for operation. It is comparable to pyloric obstruction,
and the operation for the relief of cardiospasm is similar to that of
pyloric stenosis. Mikulicz and others have performed this opera-
tion with brilliant results and effected a cure that could be obtained
only by surgery.

Pyloric stenosis is another and new indication for operative inter-
ference to relieve the distressing symptoms so often disguised under
the term of dyspepsia. In 1901 Roswell Park collected upward of 40
cases in which the patients were cured by surgery.

Gastroptosis is a prolapse of the stomach due to relaxation of the
ligaments which support the organ. This condition gives rise to
ordinary signs of dyspepsia accompained by acute pain and later
emaciation. Modern surgery in its evolution has devised an opera-
tion for the relief of this distressing and painful condition. The
stomach is elevated and held in its anatomic position by shortening
of the gastrohepatic and phrenic ligaments of the stomach. Thus the
normal ligaments are shortened and the stomach held in its proper

DEVELOPMENT IN NINETEENTH CENTURY 335

position without disturbing its mobility or function. In eight cases
reported, including four by Bier, seven patients were cured and one
improved. This is a new operation of modern surgery calculated to
relieve a distressing condition for which medical treatment was of
no avail.

Dilation of the stomach has been operated upon with a view of relief
of distressing symptoms to which it gives rise. The operation is
called gastroplication and consists in reducing the capacity of the
dilated stomach by tucking in folds of the stomach wall. It is a most
satisfactory operation, provided there is no pyloric obstruction
present. The operation is safe and effects a permanent cure.

Exploration of the stomach has been resorted to successfully by
Dennis to relieve hysteric vomiting. Hysteria, as is well known,
gives rise to persistent and uncontrollable vomiting, and in one case
in which no relief could be obtained by medical means, a laparo-
tomy was performed, the stomach drawn out and then returned into
the peritoneal cavity. The psychic effect or the mechanical stretch-
ing of the stomach itself resulted in cure.

Gastrotomy for the removal of foreign bodies in the stomach has
been resorted to successfully during the past 25 years. The foreign
bodies enter the stomach as a result of accident or are purposely
swallowed as a livelihood, or on account of insanity. In preantiseptic
days, Murphy reports 19 cases of gastrotomy, with 15 recoveries and
4 deaths, or a mortality of 21 %. In antiseptic days, 71 patients were
operated upon, with a mortality of 9 %. This includes early and late
cases and at the present time if the cases are seen early the mortality
is very low. Thus, modern surgery has developed to such a state of
perfection that the stomach can be opened and foreign bodies re-
moved with almost a certainty of success.

Gastrostomy is an operation employed for the relief of stricture of
the esophagus, either benign or malignant, or for certain lesions
connected with the stomach itself. It has for its prime object the
prevention of death by starvation.

In 1883 Le Fort compiled some statistics in 105 cases of gastro-
stomy, in which he showed that the mortality from 100 % was re-
duced to 74.2 %. In 1885 Zisas collected 162 cases of gastrostomy,
with 113, or 69.7 % of mortality. In 1886 Knis had 169 cases of gas-
trostomy, with a mortality of 66.6 %. In 1887 Heydenreich collected
33 new cases of gastrostomies, with 19 deaths, or 57 % mortality.
Since 1887 Guerin has collected 121 cases of gastrostomy, with 43
deaths, or 35.5 % mortality. Mayo has performed gastrostomy with a
much smaller death-rate than any mentioned. There can be no more
beautiful illustration of the development of surgery than is demon-
strated in this one operation, since formerly it was attended by a
mortality of 100 %, while to-day, after about a quarter of a century

336 SURGERY

the operation has by evolution achieved a record that is most re-
markable, since the latest figures show the mortality to be less than

30%.

Mikulicz recently performed 10 gastrostomies for the relief of
non-malignant strictures of the esophagus, with only 7 deaths, or a
mortality of about 20 %.

Dennis operated upon a case of impermeable stricture of the
esophagus, caused by ulceration and cicatricial contraction by ty-
phoid ulcers. This case is one of the two in which typhoid ulcers
have been found. The patient is now living, seven years after the
gastrostomy. His weight previous to the operation was less than
100 pounds, and to-day it is 184 pounds. He had not taken a mouth-
ful of food except through the fistulous opening for several years,
and is perfectly well nourished.

Gastric ulcer has become a recent indication for operation. It
has been performed 184 times as collected by Mayo Robson up to
1900. These 184 cases do not include those for perforation or hem-
orrhage; 157 patients recovered, and 31 died, thus giving a mor-
tality of 16.4 %. In 1901 statistics show that in 25 % of cases of
gastric ulcer the patients died under medical treatment, and only
5 % under surgical treatment, according to the latest statistics.
Gastric ulcer is a pathologic condition which formerly was con-
sidered exclusively from a medical point of view. To-day this dis-
ease in the stage of complication has been relegated to the domain
of surgery. It has been during the past quarter of a century that
progress has been made in the management of the serious compli-
cations, such as hemorrhage and perforation, of this intractable
disease. Under medical treatment, the mortality of gastric ulcer
in hemorrhage or perforation was nearly 100 %, while under sur-
gical treatment this frightful mortality has been reduced by the
Mayos to 5 % in the benign ulcers and 18 % in the malignant ulcers.
The advance that surgery has made in this disease has been in the
study of the mechanics of the stomach, rather than the chemis-
try. Medical treatment based on chemistry was of little avail.
Gastric ulcer of the stomach affords a striking illustration of the
progress of surgery within the past decade. In addition to the re-
duction of the mortality from nearly 100 % by medical treatment
to about 5 % by surgical treatment in the acute cases of hemor-
rhage and perforation, to 23 % in the chronic cases with malignancy,
there has been eliminated the danger of cancer engrafted upon an
ulcer which at the beginning was benign.

Gastric hemorrhage is a condition which has been relieved through
the mediation of modern surgery. These hemorrhages from the
stomach are peculiar in that the smallest ulcers, which can scarcely
be recognized by the naked eye on post-mortem appearances, have

DEVELOPMENT IN NINETEENTH CENTURY 337

given rise to fatal hemorrhage. Mayo reports five cases of acute
perforation and hemorrhage with three deaths.

Cancer of the stomach was a uniformly fatal disease. Under med-
ical treatment no patient ever recovered. Surgery has entered
this domain, and already the beneficent results are beginning to
be felt. It must be remembered that this invariably fatal disease
reaches, according to Haberlin, 40 % of all the cases of cancer that
invade the human body. Here is the most important and serious
problem with which surgery has been confronted. Mayo assigns
three reasons why surgery has never until recently interested it-
self in this fatal disease: (1) a belief that cure cannot be accom-
plished; (2) that the mortality of radical operations is almost pro-
hibitory; (3) that the diagnosis cannot be made until the case is
hopeless. In regard to the first reason, Mayo cites the fact that
McDonald found 43 cases of cancer of the stomach, in which a per-
manent cure was effected by operation. Murphy collected 189
cases, in which the operation was performed by several operators,
with 5 % permanent cures in cases of over three years' standing.
In some of these cures the patients were operated upon more than
two years, and hence would, by law of average, survive to bring
the percentage up to 8 %. Beside these recoveries, Kronlein has
proved by his statistics that human life is prolonged 14 months
over the unoperated cases. These facts are in striking contrast to
the uniformly 100 % mortality under medical treatment. The second
reason why surgery has never generally entered the operative field
for the relief of gastric cancer was due to the high mortality of
60 % which Billroth published. This mortality has been happily re-
duced to 10 % by improvement in technic and by early operation.
If the operation is performed before adhesions have formed, and
by men thoroughly trained in this field of operative work, the mor-
tality will soon be even less than 10 %. Mayo has had 41 cases of
excision of the stomach, with a mortality of 17 %. Out of the total
number, 13 were performed by an improved method, with only 1
death, or 6 %, while in the last 11 cases of excision of the stomach
there was not a death, or the mortality zero. The mortality has
been reduced in Mayo's last series of 11 cases to zero, from 60 %,
as reported by Billroth. No other statistics can be adduced to show
so emphatically what surgery has achieved within a period of time
that has elapsed since the erection of this magnificent building in
this wonderful exposition. This one fact alone is the grandest and
most striking proof of the miraculous work which surgery has
accomplished, and to Mayo is due the credit of leading the world
in this new department of surgery, which may be said to be the
highest, the final, the most triumphant monument of the contri-
bution of surgery to the human race. Here, again, is another strik-

338 SURGERY

ing illustration of what surgery has achieved. It has reduced the
mortality of an operation in cancer of the stomach from 60 % to
10 %, and in a limited number to zero, and with every prospect
in the near future of even a mortality of less than 10 % in a large
series of cases.

The third reason why surgery has not invaded this field lies in
the fact that the diagnosis cannot be made by medical means in
time to effect a cure. Exploratory incision to find out is recom-
mended by Mayo, and by this means an early operation can be
performed that will be attended by small mortality as regards the
operation itself, and a large percentage of cures as regards the dis-
ease itself. Cancer of the stomach, as a rule, is situated near the
pylorus, just below the lesser curvature. Moynihan states that from
this focus it spreads widely through the submucosa, and rapidly
toward the cardia, and slowly toward the pylorus. Until very
recently no surgery has been done upon the stomach for cancer,
for the reason that it was considered a hopeless disease. Murphy
collected 189 cases in which radical operation was done, with 26
deaths. Of these, 17 patients survived three years, or about 8 %
of cures. This is a gain in the right direction, since all patients die
without operation. This 8 % of cures was reduced to 5 % by a re-
turn of the disease after three years. Mikulicz in 100 cases had an
average duration of life of 15 months. The patients had relief from
suffering at least 15 months, and there did not follow that terrible
suffering so characteristic of the inoperable cases of cancer of the
stomach. The reason that the results are not better in cancer of
the stomach is owing to delay in operation, and when that obstacle
is overcome the results will be brilliant, compared with the gravity
of the disease. Time permits of adhesions, and when the opera-
tion is resorted to before adhesions form, the mortality is very
much lessened. Thus Haberkaut had a mortality of 72 % in cases
with adhesions, and only 27 % without adhesions. Gastrectomy
was done, as reported by Murphy, in Kappeler's clinic, with 26 %
mortality, Kronlein with 28 % mortality, Kocher 29 %, Roux 33 %,
and Mikulicz 37 % mortality. Murphy has called attention to the
prophylactic treatment of cancer. He believes in the removal of
conditions which seem to be essential in the majority of cases to
the development of the disease. Mikulicz has shown that 4 %
to 5 % of the human race suffer from gastric ulcer, and that a fifth
die as a result of the gastric ulcer. The other factor which largely
influences the growth of cancer is the pyloric stenosis when the
stomach cannot empty itself. The suggestion, therefore, is the
removal of gastric ulcers by excision, and the relief of the pyloric
obstruction by gastroenterostomy, and these prophylactic opera-
tions when performed early are attended with a comparatively

DEVELOPMENT IN NINETEENTH CENTURY 339

small mortality, eliminates the possibility of cancer of the stomach
arising from these two important and frequent causes.

Partial gastrectomy was twice performed by Langenbuch and
published by him in 1894. In both cases seven eighths of the stomach
was removed. In 1898 Kronlein records all his own cases of partial
excision of the stomach and Schlatter's case of complete excision.
There were in all 24 cases, with 5 deaths, or a mortality of about
20%. Maydl, in 1899, reports 25 cases of cancer of the stomach,
in which a partial gastrectomy was performed, with a mortality
of 16%. Of the patients who recovered from the operation, 7 had
recurrence very soon afterward, and the average duration of life
was 11.7 monthsi In 1898 Kocher has reported 57 cases of resec-
tion of the pylorus, with 5 deaths, or a mortality of 8%. In the
list there were 8 patients cured. Rydygier, in 1901, reported 25
partial gastrectomies, in which 8 patients recovered and 17 died,
or a mortality of 68%. Czerny, in 1899, reports 29 partial gas-
trectomies, with 11 deaths, or a mortality of about 40%, and the
average duration of life was 22 months. Morison reports 16 cases
of partial gastrectomy, with 7 deaths, or a mortality of about 43 %.
Two of Morison 7s patients are still living. In one 6 years have elapsed,
and in the other about 4 years. Mayo reports 48 cases of partial
gastrectomy for pyloric cancer, with a mortality of 12.5 %, and
in the last 19 cases there was only 1 death.

Complete gastrectomy was first performed by Conner, of Cincin-
nati, in 1883. The patient died upon the operating table. Com-
plete gastrectomy was performed by Schlatter in 1897. The patient
lived 13J months. Complete gastrectomy was next performed by
Brigham in 1898. The patient recovered from the operation. Com-
plete gastrectomy has been performed 12 times, as reported by
Robson and Moynihan. Four died as result of the operation, or
a mortality of 33 %. These cases are too recent for a pronounced
opinion as to the permanency of the cure.

Surgery of the liver forms a unique chapter in the development
of the science. Operations upon the gall-bladder and biliary ducts
afford the most striking illustration of what modern surgery has
achieved. Within the past 37 years this new operation has been
performed with most gratifying results. It is a source of great
national pride that this operation, destined to relieve so much in-
tense suffering and to save life itself, was discovered in this coun-
try. To Bobbs of Indianapolis is due the great honor of the dis-
covery of an operation which has accomplished these two bene-
ficent results. In 1867, 37 years ago, Bobbs performed successfully
the new operation of cholecystotomy and removed 50 gall-stones
by an incision into the gall-bladder. This event marks an epoch in
abdominal surgery that places this renowned Western surgeon

340 SURGERY

upon a pedestal that commands homage and respect from the civil-
ized world. Bobbs's first cholecystotomy was soon followed, in 1868,
by a second operation by another American surgeon, J. Marion
Sims, who removed 60 gall-stones from the gall-bladder. To Tait,
however, who was at the time of his death the greatest authority
on hepatic surgery, belongs the great credit of perfecting the technic
of this operation. Excision of biliary calculi by incision into the
umbilical vein was performed by Dr. John C. Warren of Boston
within the century. Such in brief is the history of the operation,
the development of which from its crude to its almost perfect technic,
forms a remarkable chapter in surgery.

Gall-stones with intestinal obstruction are attended under med-
ical treatment, with a mortality of nearly 100%, while surgery
has brought relief in a certain proportion of cases and with every
encouraging prospect of a very great improvement. Courvoisier
reports 125 cases, with a mortality of 44%; Schiiller had 82 cases,
with a mortality of 56%; Eve 28 cases, with a mortality of 40%;
and Bannard 8 cases, with a mortality of 57 %.

Cholecystotomy is an operation which consists in opening the
gall-bladder for the relief of various conditions. Cholecystitis or
inflammation of the gall-bladder is a disease that was formerly
treated by medical means, with little or no prospect of cure if septic
infection was present. In those cases in which gangrene or pus or
rupture has occurred, medical treatment is attended by death;
but surgical treatment may effect a cure in a large percentage of
cases. Cholecystotomy is one of the most gratifying operations
in surgery, because it relieves suffering, effects a permanent cure,
and is attended by the exceedingly low mortality of less than 3 %.
The statistics of the operation of cholecystotomy varies greatly,
owing to the special conditions for which the operation is performed.
Mayo Robson states that when the operation is performed for sim-
ple disease, as gall-stones, when malignant disease and jaundice
with infective cholangitis are absent, the mortality in 281 cases
was only 1.06 %. If now the complicated cases are included, such
as phlegmonous cholecystitis, gangrene of gall-bladder, infective
cholangitis with or without gall-stones, the mortaliy is only 2.7 %.
If further the malignant cases be collected, in which cholecysto-
tomy has been resorted to in the presence of cancer of the pan-
creas or bile-ducts, the mortality of the operation itself in 22 cases
was only 5.8%. As regards the recurrences, the statistics will be
mentioned latter. Mayo reports, in 1902, 227 cases of cholecysto-
tomy for various simple conditions, chiefly for gall-stones, with 6
deaths, or a mortality of 2.6%. The same operator reported, in
1903, 352 cholecystotomies for simple conditions, with 8 deaths,
or a mortality of 2.27 %. For malignant disease the same surgeon

DEVELOPMENT IN NINETEENTH CENTURY 341

reported, in 1902, 4 cholecystotomies, with 2 deaths, or 50% mor-
tality, and in 1903, 5 additional cases, with 3 deaths, or 60 %
mortality. It is thus evident that cholecystotomy is attended by
a high mortality when the operation is performed for cancer. It
must be remembered, however, that the mortality is 100 % under
medical treatment. The mortality of 100% under medical treat-
ment will never be improved, while the 50% or 60% mortality
under surgical treatment will be reduced as diagnosis and technic
improve, and early operation is performed. Kehr, in 1896, reported
209 cholecystotomies upon 174 patients. In the simple chole-
cystotomies, the mortality was only 1 %. In the complicated cases
the mortality was 58.8 %. In a later series Kehr reported 202 cho-
lecystotomies with 32 deaths, or a mortality of 16 %. The higher
mortality in this series is accounted for by the greater severity of
the cases which earlier did not submit to operation. In conserva-
tive cholocystotomies Kehr had 68 operations with three deaths,
or a mortality of 4.4%. In 1902 Kehr again reported his statis-
tics, which consisted of 720 operations for gall-stones, with a mor-
tality of 15 %. In the simple cases of cholecystotomy the mortal-
ity was 2.1%, and in the complicated cases, including cancer, the
mortality was 97%. Greig Smith reported 11 simple cholecysto-
tomies with no mortality, and one complicated case with death,
or 12 cases in total, with a mortality of 8.33 %. Lawson Tait re-
ported 55 cases of cholecystotomy with three deaths, or a mor-
tality of 5.4 %.

Thus in cholecystotomy alone is an operation that has shown a
steady improvement in its statistics. In no other operation is a greater
contrast between the medical and surgical treatment of a disease
at the present day.

Cholecystectomy is an operation which consists in excising the gall-
bladder in a manner somewhat similar to the removal of the appen-
dix. Ferrier reported, in 1901, 16 cases with 4 deaths, or a mortality
of 25 %. Courvoisier reported 47 cases with 12 deaths, or a mortality
of 25 %. Martig, in 1894, collected 87 cases of removal of the gall-
stones with 15 deaths, or a mortality of 17.2 %. Mayo Robson re-
ports 28 cases with 4 deaths, or a mortality of 14.2 %. Mayo, in 1902,
had 31 cases with 3 deaths, or a mortality of 9.6%, and in 1903 had
70 cases with 3 deaths, or a mortality of 4.3 %, and up to the present
time he states that he has had 204 cases with a mortality of 4 %.
Kehr reported 21 cases with 1 death, and a mortality of 5 %, and
later another list with the mortality of 3 %. Thus in cholecystectomy
is another operation that has shown steady improvement in its
statistics. This operation affords another illustration of the marked
contrast between the medical and the surgical treatment, for in the

342 SURGERY

former treatment no cure can be effected, while in the latter the
percentage is very large.

Choledochotomy is an operation which consists of opening one of the
biliary ducts and is a more formidable operation than opening the
gall-bladder. Ferrier, in 1893, reported 20 cases, with a mortality
of 25 %. Kehr, in 1896, reported 84 cases, with 31 deaths, or a mor-
tality of 37.8 %. In a later series his mortality was reduced to 12.5 %.
Mayo states that in 130 cases of benign series he had a mortality of
7.75%. Mayo Robson reported, in 1901, 37 cases, with 4 deaths, or
a mortality of 10%, and since 1901 51 cases, with 1 death, or 1.9%,
and later a consecutive series of 52 choledochotomies with no deaths.
Choledochotomy is one of the most difficult operations in surgery,
and the advance which surgery has made is shown by a reference to
the great mortality of these cases for which this operation is per-
formed, since under medical treatment suffering was not relieved
and death often supervened, whereas under surgical treatment the
mortality has been reduced even to 1.9%.

Cholecystenterotomy is a modern operation on the biliary passages,
and consists in establishing a new communication between the
gall-bladder and the intestine. Murphy reported 23 cases by use of
sutures, with 8 deaths, or a mortality of 34 %; 21 cases by Murphy's
button, with no mortality, and 2 cases for malignant disease, with
2 deaths, or a mortality of 100 %.

Cholecystduodenotomy has been performed by Murphy's button in
67 non-malignant cases with only 3 deaths, or a mortality of about
4%, and in 12 malignant cases by Murphy, 10 died, or a mortality
of 83.3 %. Mayo performed Cholecystduodenotomy on 5 patients
for chronic pancreatitis with no death, and 4 times for cancer with
1 death, or a mortality of 25 %.

Pancreatic disease affords a field for the display of what modern
surgery has achieved that astonishes the scientific world. Korte has
computed the mortality of the operation for the cure of pancreatic
cysts, and shows that Gussenbaur was the first to operate for the
relief of this fatal disease. Previous to Gussenbaur's operation,
the mortality under medical treatment was 100 %. In the 84 cases
collected by Korte, five patients died as the immediate result of the
operation, thus giving the low mortality of not quite 0.6 %. This
statement seems incredible and affords the most startlingly unpre-
cedented illustration which has no parallel in any other science.
This operation has attracted great attention in the scientific world
and its brilliant and unique record has been heralded throughout
Christendom. Still more striking is another report of 15 cases of
complete excision of the cyst of the pancreas with 13 recoveries, or
a mortality of about 13 %, and in 7 additional cases the extirpation
has been only partial, since some of the cyst-wall was so adherent

DEVELOPMENT IN NINETEENTH CENTURY 343

to important structures that its removal was impossible and 4 of the
patients died, thus giving a mortality of 57 %, which in contrast to
100% mortality under medical treatment is a great advance, though
it is admitted that it is not what is expected, since as technic im-
proves, the operation will be brought perhaps nearly as low as simple
ovariotomy in the future. In evacuation and drainage of the pan-
creatic cyst there have been collected by Takaysan 17 cases with 1
death, a mortality of not quite 6 %. Mayo had 5 consecutive cases
of chronic pancreatitis with recovery in each case, and 4 cases of
cancer of the pancreas with 1 death, or a mortality of 25 %. Opera-
tions upon the pancreas afford another brilliant example of the
achievements of surgery within the past few years. Mayo Robson
and Moynihan, in 1902, reported 24 operations for the relief of chronic
pancreatitis with 2 deaths and complete and perfect recovery in the
22 remaining cases. There is no more striking example of the pro-
gress which surgery has made than is afforded by this record. In
cancer of the pancreas, which is always fatal, the operation has been
attended by about 50 % mortality, and in the other 50 % the patients
have survived a comparatively short period. This is an operation
in which surgery in the future will have a better showing just as soon
as the methods of diagnosis are improved so as to operate in the early
stages of the disease. Mayo has had 37 cases of pancreatic disease
with 2 deaths, or a mortality of about 5 %.

Surgery of the spleen offers an illustration of the progress which
surgery has made during the past century. The cases of major opera-
tions upon the spleen are too few to make any extensive and reliable
statistics. The prognosis which is most marked, and which interests
us in connection with the subject of this address, shows improve-
ment each year. Thus Murphy shows that in 1890, in the operated
cases, the mortality was 70%. In 1897 the mortality was 37%. In
1899 the mortality was 26 %. These figures are unsatisfactory, except
to point out that in this new department of surgery great advance is
made each year. Fevrier grouped under four heads the surgical con-
ditions in the spleen that call for operative interference. They are
traumatism, abscess, tumors, and displacements. As these condi-
tions were nearly all fatal without surgical intervention, it is inter-
esting to inquire what surgery has accomplished in this new field.
Fevrier collected 56 cases of rupture of the spleen, in which splen-
ectomy was performed 46 times, with 23 recoveries, thus giving a
mortality of 50 %. There were 8 cases of stab and gunshot wounds,
with 3 deaths, or a mortality of 30 %. Abscesses and hydatid cysts
have called for operative interference, but there are no reliable
statistics on the results. Malarial splenomegaly was operated upon
117 times, with 31 deaths, or a mortality of 26%. Displacements
of the spleen have been operated upon by spenectomy and by splen-

344 SURGERY

opexy. Cases of extirpation of a movable spleen have been collected
by Stierlin, who shows that the mortality is now only 6.25 %. Splen-
ectomy in echinococcus of the spleen, according to Bessel-Hagen ,
previous to 1890, was attended with a mortality of 60 %, and from
1891 to 1900 the mortality was reduced to 10%.

Tuberculous peritonitis has been taken out of the realm of internal
medicine and transferred to clinical surgery. It has now become an
established routine of practice that laparotomy is justifiable in
cases of ascites in which the etiology does not depend upon disease
of the liver, kidney, or heart. The method of invasion of the bacilli
in their attack upon the peritoneum varies in different cases. The
bacilli in rare instances may gain entrance through a perforation
from a tuberculous intestinal ulcer, or from a purulent tuberculous
vaginitis. Again, the peritoneum may become infected through a
perforating tuberculous appendicitis, or from a tuberculous ovary,
or fallopian tube. Williams, of the Johns Hopkins University, has
shown that from 40 % to 50 % of the cases of tuberculous peritonitis
can be traced to this origin. Abbe has demonstrated that about 66 %
of the cases of tuberculous peritonitis are due to infection of the
thoracic lymph-nodes, and in only 16% is entrance gained by the
mesenteric glands. It is thus evident that, while 16 % of the cases
of tuberculous peritonitis can be explained by infection through
the alimentary canal from milk or other kinds of infected food, the
great proportion is due to infection from the thoracic lymph-nodes.
There is little doubt but tuberculous peritonitis may arise as a sec-
ondary affection following tuberculosis of the intestinal canal. Here
again inhibition of infected milk and meats play an important role.
The entrance of tuberculous sputum into the stomach in those
affected with pulmonary tuberculosis explains intestinal and peri-
toneal infection. The latter method of invasion is considered a fre-
quent cause of peritoneal tuberculosis. The presence of tuberculous
ulcers in the stomach in phthisical patients who subsequently suffered
from intestinal tuberculosis has been thus explained by the investi-
gation of Klebs. Many experiments upon lower animals which were
fed by food containing tuberculous sputum and fragments of tuber-
culous lung have proved beyond doubt that intestinal and peri-
toneal tuberculosis can arise hi this way. It is a strange clinical fact
that laparotomy for the cure of this disease has become established
as a recognized procedure through errors of diagnosis. Sir Spencer
Wells cured a case of tuberculous peritonitis by a laparotomy per-
formed under the supposition that it was ovarian disease. Lapa-
rotomy, however, as a curative measure, was first introduced by
Dr. Van de Warker, of Syracuse, N. Y. He blundered upon a case
of tuberculosis of the peritoneum, under the supposition that he was
operating for the cure of a case of hydrops of the peritoneum. Dr.

DEVELOPMENT IN NINETEENTH CENTURY 345

Van de Warker presented this case at a meeting of the New York
State Medical Association in 1883. From this time on, the operation
of laparotomy for the cure of tuberculosis of the peritoneum has
been practiced. The operation has, however, been modified from year
to year; but most surgeons still adhere to the simple operation at
first devised by our American surgeon. As regards the result of
laparotomy for the cure of tuberculous peritonitis, surgeons differ
largely in their statistics. Parker Syms shows that some claim 80 %
of cures, while others 24 %. Marked improvement follows in 80 %
of the cases, and the mortality of the operation is only about 3 %.
Syms concludes that it is safe to estimate that 30 % of the cases of
tuberculous peritonitis are permanently cured by laparotomy.

In suppurative peritonitis surgery has opened up a new field
within the past few years. The operation of incision into the peri-
toneal cavity has effected cures in a class of cases that heretofore
were uniformly fatal. Murphy reports 7 recoveries out of 9 cases, or
77 % of recoveries in diffuse suppurative peritonitis following ap-
pendicitis, while Dennis has had 11 cases of diffuse suppurative
peritonitis without a death.

The radical cure of hernia presents one of the most forcible illustra-
tions of the onward march of surgery. Coley reports 1003 operations
with a mortality of less than a fifth of 1 %, and with relapses of less
than a tenth of 1 %. When it is considered that nearly one person
in every 20, and even by some statisticians one to every eight, persons
is born with a rupture, and these patients must wear trusses, the
bane of human existence, and which are as necessary to the comfort
and safety of the patient as a splint is to a fractured leg, the untold
blessings of this one contribution of surgery to the human race be-
come strikingly apparent. In other words, surgery offers to the
thousands affected in this way a sure, perfect, and safe cure, and with
the complete elimination of the uncomfortable, inconvenient, often
painful, and sometimes dangerous instrument of barbaric times, the
truss. What aseptic surgery has accomplished for the human family
in the relief of this one distressing and common condition, no one can
appreciate except he who has been the recipient of this blessing
offered to him by the science of surgery. Until recently great ex-
pense was incurred and time consumed in fitting trusses. Many of these
patients died as a result of strangulated hernia, which formerly had
a mortality of over 50 %. Now the possibility of strangulated hernia
is eliminated and a radical cure effected with less than 1 % mortality
and 1 % relapse. Perhaps one of the most forcible arguments to
show the effect of certain improvements in the technic of surgical
operations is demonstrated by the use of rubber gloves. In 116 cases
of hernia operated upon at the Johns Hopkins Hospital prior to
1896, there were 28 cases of suppuration in the wounds, or 24 %,

346 SURGERY

while in 226 cases of the same operation with rubber gloves upon
the surgeons' hands there were 4 cases of suppuration, or a fraction
over 1 %.

In umbilical hernia Mayo has devised an operation that offers
relief to those patients who heretofore followed a life of constant
suffering and danger. Mayo first performed his overlapping operation
in 1895, and in a series of 50 cases there was no mortality and no
relapses except in which the relapse was only a partial stretching.

The operation for the relief of acute appendicitis is clearly traced
to the work of American surgeons. In 1843, Willard Parker, and
later Gurdon Buck, did much to explain the nature of these iliac
inflammations, and Sands cleared the way for the perfected operation
of McBurney, which aims to prevent these dangerous peritoneal
inflammations, and to prepare the wound for aseptic healing. Sands
also first operated with success after perforation had taken place
and general peritonitis wras present. To McBurney is due great
credit for the perfection of this operation, which is now recognized
throughout the world as the best, safest, and most scientific way of
managing these varieties of suppuration hitherto so fatal. The
operation of removing the appendix vermiformis during the quiescent
period between relapsing attacks was suggested by Sir Frederick
Treves, of London, although the appendix was successfully removed
in this country by Dennis in 1887. In this case the appendix was
diseased, owing to adhesions to an ovarian tumor.

The surgery of the appendix is most interesting with a view to a
study of what surgery of the past century has accomplished. There
is probably no surgical disease about which so much has been written
as appendicitis. The subject is trite and threadbare in many respects.
There is little to be learned in regard to the etiology, symptomatology,
and diagnosis of the disease. The operative technic can be but little
improved upon in its present state of perfection. The mortality
under proper antiseptic and aseptic conditions is so low that in the
nature of the disease it will never in all probability be brought much
lower. The percentage in these days of aseptic surgery in this ab-
dominal operation is less than the percentage in the simple amputa-
tion of the ringer in the preantiseptic days. It would seem that
surgery had reached its climax in regard to mortality in operation
for the relief of appendicitis, yet the time will never come when
there will be no death-rate. Complications are certain to arise that are
beyond the control of the surgeon. Crural thrombosis, intestinal
obstruction, acetonemia, embolism, shock of operation, intercurrent
affections, all afford examples to show that some mortality must
always exist. If a fraction of a per cent can be gained in the reduction
of the mortality, it is an advance in the right direction. The ex-
perience of surgeons during the past few years has demonstrated new

DEVELOPMENT IN NINETEENTH CENTURY 347

methods, has pointed out new ways, and has discovered new facts, all
of which tend to reduce the mortality. It seems now the only thing
that is left is to combine the various views of experienced surgeons
into some uniform plan of treatment, in order to produce the best
results. The mortality in appendicitis in all cases under medical
treatment is about 16%, with 30% of relapses, while in diffuse
suppurative peritonitis it is almost uniformly fatal.

The mortality in appendicitis in all cases under surgical treatment
is about 4 %, and with no relapses, and in diffuse suppurative peri-
tonitis the mortality in published statistics is from 31 %, the lowest,
to 91 %, the highest, and in my 11 consecutive cases of diffuse sup-
purative peritonitis the mortality was zero.

Ochsner has recently contributed some statistics from his own op-
erations during one year, which reflect great credit upon his excellent
work. In the acute there was a mortality of 3 %, and in the chronic
cases there was a mortality of 1 %. In the entire number of cases,
both acute and chronic, there was a mortality following the opera-
tion of 2 %. Deaver has also recently contributed some statistics
from his own operations extending over a period of one year, which
likewise reflect great credit upon his surgical skill. In the cases of
general diffuse peritonitis there was a mortality of 31 %. In the
cases in which there was abscess there was a mortality of 12 %. In
the cases in which the disease was confined to the appendix, with
stricture, ulceration, and necrosis of the mucous membrane, there was
a mortality of 0.8 %, and finally, in all the cases operated upon, the
total mortality was 5 %. Richardson's published statistics are prac-
tically the same, and the result of these various operators gives an
idea of what surgery has accomplished. In a study of the last 119
cases of appendicitis occurring in my practice up to April 1, 1903,
the mortality of the disease, irrespective of operation or of any
special plan of treatment, was a little over 1.5 %. In the cases treated
without operation in which the attack was a mild, catarrhal one,
and in which the patients were not operated upon during the attack,
the mortality was zero. In this group of cases in which conservatism
was employed for special reasons, the appendix was in many cases
subsequently removed owing to repeated attacks, and the mortality
was zero. In the group of cases in which the appendix was gangrenous
and had ruptured into the peritoneal cavity with a general peritonitis,
of which there were 11 cases, the mortality was zero. In the cases in
which there was an acute perforative appendicitis, and in which the
appendix was gangrenous, and found in a circumscribed abscess
cavity, the mortality was 7 %. If now, in this group, all the operative
cases are collected, both acute and chronic, the death-rate was 2%.
If the two fatal cases in the entire list of 119 cases are eliminated,
which were hopeless from the start, but which were operated upon

348 SURGERY

because it was offering the only possible chance of life, forlorn as the
prospect was, the mortality of the disease was zero. The mortality of
the operation both for acute and chronic appendicitis was also zero.
Such cases as the two in which death occurred will always happen, and
will always prevent the absence of mortality in the disease. In other
words, if the two fatal cases are eliminated on the ground that
surgery is powerless to save when complications such as empyema
and abscess of the lung exist, the mortality in the medical and oper-
ative treatment of this disease in 117 consecutive cases was zero.
The two deaths which make the mortality of the operation in all cases
about 2%, which in itself is insignificant when the nature of the
disease is considered, deserve special consideration.

Richardson, of Boston, reports 574 appendectomies in the interval,
with no deaths. Mayo has had 1668 cases in the interval, with two
deaths, one from pneumonia secondary to an intercurrent attack
of grip, and the other to surgical kidney following the use of catheter
in an enlarged prostate.

Acute intestinal obstruction is a condition in former years almost
universally fatal, while to-day surgery has afforded relief in this dis-
ease. Thus Wiggins gives a mortality of 67.2 % for laparotomy. Ex-
cluding cases in which either the operation was abandoned, the bowel
incised, and an artificial opening made, resection attempted, or an
anastomosis effected, there are 45 cases, in which 24 resulted fatally,
or a mortality of 53.4 %. Counting only the operations that have been
performed since 1889, and throwing out those cases in which the
operation was not completed, we have a total of 18 cases, of which
14 were successful, and 4 unsuccessful, giving' a mortality of only
32.2 %. This Wiggin believes to be a fair estimate of the risk to-day
of laparotomy performed in a young infant for the relief of this con-
dition, if performed within the first 48 hours of the onset. This gives
a chance of success represented by 78%, which, according to this
author, would speedily rise to 90 %, as the patients come more fre-
quently to operation during the first 24 hours.

Cancer of the bowel is a uniformly fatal disease. The recent advances
in surgery have been the means of saving some of these patients.
Mikulicz and Korte have each reported 12 cases of operations in
which 9 of these cases had no return after four years, which is equal
to 37 % of permanent cures. Dennis operated upon a patient with
cancer of the cecum, resecting six or seven inches of the bowel, and
subsequently making an anastomosis with Murphy's button. The
patient is now perfectly well after a lapse of many years since the
operation.

Laparotomy was performed by Dr. Wilson, in 1831, for the relief
of intussusception. The patient was a negro slave, and had suffered
from intestinal obstruction for 17 days. The abdomen was opened,

DEVELOPMENT IN NINETEENTH CENTURY 349

the intussusception was found, and it was drawn out and released,
and the patient made a complete recovery.

In 1809 Physick was the first to ligate the e"peron, when an arti-
ficial opening had been made in the intestine on account of patho-
logic changes. In 1847 Gross urged the excision of a section of the
intestine, with suturing of the divided ends, with a view to establish
the continuity of the canal, but the patient refused, and in 1863
Kinloch, of South Carolina, accomplished this result. In 1834
Luzenberg laid open a strangulated hernia, found it gangrenous,
excised the mortified section of the intestine, stitched the serous
surfaces, and the patient fully recovered. This same surgeon sug-
gested, in 1832, exclusion of light to prevent pitting of small-pox.
The operation of laparotomy for the treatment of penetrating gun-
shot and stab wounds of the peritoneal cavity was the work of
American surgery. Gross, in 1843, and Sims, just before his death,
both suggested this method, but these surgeons never practiced this
method of treatment. It remained for Bull, of New York, to make
the practical application of the method, and to him is due the credit
of this great advance in surgery. It is a source of national pride that
laparotomy in penetrating wounds, and visceral injuries of the
abdomen, was conceived, developed, and perfected in America. The
widespreading influence of this operation is felt in abdominal surgery,
and much of the present advance is the result of Bull's surgery.

Cancer of the rectum is a disease which was formerly uniformly
fatal. Modern surgery has, hoVever, rescued many of these unfor-
tunate victims from a most distressing and painful death due to
inanition, hemorrhage, and exhaustion. Taking the three-year limit
as a point when it can be fairly stated that a return is rare after an
operation, Kronlein collected 640 cases with a cure of 14% of over
three years' lapse of time from the operation. Czerny, Bergmann,
Kraske, and other surgeons report from 20% to 30% of permanent
cures, and Kocher has had as high as 50 % of permanent cures. The
statistics of Kocher will be even improved upon as technic is per-
fected and early operation performed.

The first and only successful case of laparotomy for the relief of
perforation of the intestine during the progress of typhoid fever was
performed in this country, and to Dr. Weller Van Hook of Chicago
is due the credit of having first established an operation for the relief
of these cases, which hitherto were fatal.

Perforation in typhoid fever has given rise to an operation for the
relief of fatal suppurative peritonitis. This operation is one of the
most signal triumphs in modern surgery. In 1884 Ley den suggested
and Mikulicz performed the operation. Haggard collected 295 cases
in which operation was done up to May 1, 1903. Haggard states that
500,000 cases of typhoid fever occur in this country alone every

350 SURGERY

year with a mortality of about 10% to 15%. Thus 50,000 to 75,000
patients perish annually from this disease. Osier states that a third
of the deaths in typhoid occur as a result of perforation and "Taylor
thus estimates that 25,000 deaths occur yearly from this accident.
On a basis of a possible 30 % recovery by operative interference he
further concludes that 7500 persons perish in the United States
each year who might be saved." The mortality of perforation in
typhoid is estimated by Murchison at 90 % to 95 %, and Osier says
that "he could not recall a single patient in his experience that had
recovered after perforation had occurred." Harte has shown that the
mortality has steadily decreased as earlier operations were per-
formed and technic improved; thus in 277 cases in successive inter-
vals the mortality was as follows :

1884 to 1889, 10 cases; mortality 90.0 %

1890 to 1893, 16 " " 87.5 %

1894 to 1898, 110 " 74.5%

1899 to 1902, 141 " 66.6%

Duodenal idcer has been operated upon with great success and is
a signal illustration of what modern surgery has accomplished. Mayo
operated upon 56 patients, in which 6 of the operations were for the
relief of acute condition, with 3 deaths, or a mortality of 50 % ; and 50
operations for the relief of chronic condition, with 1 death, or a
mortality of 2 %. This operation marks an important epoch in the
history of surgery. When the nature of the lesion is considered, the
record is a most brilliant one. The difficulties of the diagnosis can
only be appreciated when it is considered how similar are the symp-
toms of duodenal ulcer with pyloric ulcer, gastric ulcer, gall-stones,
and other neighboring lesions. A few years ago there was no surgeon
who was bold enough to attempt this life-saving operation. The
uncertainty of the diagnosis and the frightful mortality that would
have ensued made this operation for the relief of duodenal ulcer
impossible.

Penetrating wounds of the abdomen are treated at the present time
by an exploratory laparotomy, the value of which operation is
evident by statistics reported by Postemski in 1891, in which he
demonstrated that 60 % to 70 % of 645 cases of penetrating wounds
of the abdomen terminated fatally, while the mortality was 100 %
when the abdominal viscera were injured. In a later series of pene-
trating abdominal wounds there were 36 uncomplicated cases, in
which the patients were treated by exploratory laparotomies; all
recovered, and 22 cases of penetrating wounds of the abdomen
associated with intra-abdominal injury, in which 12 patients re-
covered.

Rupture of the intestine affords another striking illustration of the
progress of surgery. Siegel has collected 532 cases in patients treated
without operation and the mortality was 55.2%. In 376 cases in

DEVELOPMENT IN NINETEENTH CENTURY 351

which operation was done, the mortality was 51 %. This does not
seem so great a triumph for surgery as might be expected, yet if
these statistics are carefully gone over it becomes evident that the
mortality is due to a cause which in the future can be obviated.
Aggressive surgery can do much in these serious cases if operation
is not postponed too late, as shown by Senn, and as for example:

Cases operated first 4 hours, mortality 15.2 %

" " 5 to 8 hours, mortality 44.4 %

9 to 12 " " 63.6%

later 70.7%

Rupture of the stomach has been cured by laparotomy; thus
Petry found 44.5 % of recoveries in 18 patients operated upon within
24 hours after the injury, and 25% of recoveries in 24 patients
operated upon more than 24 hours after rupture.

Gangrene of the intestine forms an indication for resection of a seg-
ment of the intestine and offers a prospect of recovery in a class of
cases otherwise fatal. Thus Roswell Park resected 8 ft. 9 in. of bowel
for the relief of a gangrenous condition and the patient recovered.
The same surgeon assembled from surgical literature 16 additional
cases in which over 200 cm. of bowel" were resected with 14 recoveries,
or 80 % of cures, or a mortality of 17 %. A singular fact recorded
by Park is that when from 100 cm. to 200 cm. was removed, the
mortality was 30 %.

Subphrenic abscess is another serious condition which terminates,
as a rule, fatally; but in which surgical intervention has been fol-
lowed in a certain percentage of cases, thus Maydl records 74 opera-
tions with 39 recoveries, and 35 deaths, or a mortality of 47.2 %.

Ovariotomy forms a new milestone in the march of surgery. In all
probability the most important surgical event that has ever hap-
pened in this country and the world, was the conception, birth, and
development of ovariotomy. To Dr. Ephraim McDowell of Dan-
ville, Ky., belongs this great honor. In 1809 he was the first one to
perform this unique and original operation which has made his name
immortal. The far-reaching influences that have proceeded from
this step are incalculable. Dr. McDowell is to-day recognized as the
originator of not only one of the greatest operations in surgery, but
also as the author of an operation, the influence of which has made it
possible to develop the present wide field of abdominal surgery.
McDowell's work will live in the memory of thousands in this land,
and will be honored the world over as long as time endures. In 1821
Dr. Nathan Smith performed ovariotomy in Connecticut, and with-
out the knowledge that it had been performed by McDowell; Smith
dropped the pedicle into the abdominal cavity and thus made a great
advance in McDowell's operation. In 1823 Allan G. Smith also
performed an ovariotomy in Kentucky, and David L. Rodgers in
New York in 1829. All these cases of ovariotomy were successful.

352 SURGERY

It was seven years after this last American operation before ovario-
tomy was first performed in England, and nearly 15 years before
ovariotomy was first performed in France. In 1870 T. Gaillard
Thomas first devised and performed successfully a vaginal ovario-
tomy. In 1872 Dr. Davis, of Pennsylvania, performed successfully
the same operation, followed in 1873 by Gilmore of Alabama, and
in 1874 by Battey of Georgia, and later by Sims. In 1872 Battey
performed his first oophorectomy, "with a view to establish at once
the change of life for the effectual remedy of certain otherwise incur-
able maladies." This is an operation also of purely American origin,
and has contributed much to the relief of human suffering. It has
been urged that while to an American surgeon the credit is honestly
due for the first performance of an ovariotomy, other nations
have perfected the operation, and more credit is due to-day to
other nations for the best results. Let us see how this statement
accords with facts. In 1857 the question of ovariotomy was brought
up for discussion at the French Academy of Medicine, and only
one surgeon considered the operation as sometimes justifiable. Up to
that time there had been in America 97 ovariotomies, with 34%
mortality; in Great Britain, 123 operations, with 43 % mortality; and
in Germany, 47 operations, with 77% mortality. American sur-
geons, therefore, not only obtained the best results up to that date,
but no American surgeon to-day will concede that our results are
inferior to those obtained by surgeons in any other country at the
present time. Few men can realize the influence of McDowell's first
ovariotomy upon the whole field of abdominal surgery. It is, indeed,
a sublime thought to consider that a man was found with the courage
of his convictions to do what no man had ever done, and to operate
with the noise of an infuriated mob beneath his windows. This
mob would have lynched him if the patient upon whom this first
ovariotomy was performed had died. Having escaped the angry
mob, he was pointed out as a murderer by his fellow colleagues, and
was condemned by the highest scientific authorities in Europe. In
America, therefore, under such circumstances and under such con-
ditions, the birth of the greatest operation in surgery occurred — an
operation which saves now the lives of millions of women. Keen
asserts that "it is estimated that one million years are added every
three years to the life of women in this country alone by a single
operation of ovariotomy."

The disapproval of this great operation of McDowell's by the press,
by the profession, and by the laity was pronounced. The Medico-
Chirurgical Review, speaking of McDowell's achievement, says:
"A back settlement of America, Kentucky, has beaten the Mother
Country, nay, Europe itself, with all the boasted surgeons thereof,
n the fearful and formidable operation of gastrotomy with extrac-

DEVELOPMENT IN NINETEENTH CENTURY 353

tion of diseased ovaries." All this vituperation was hurled at
McDowell; but time, as the great arbiter, has demonstrated that
what was said in sarcasm has become a transcendent and mighty
truth. The noble character and the true grandeur of McDowell's
nature, and his high and lofty ambitions, are illustrated by the fact
that he had performed three successful ovariotomies, operations
never before undertaken by man, without heralding the victories
as triumphs of his personal ambition. In the early days of ovario-
tomy, McDowell, and Nathan Smith, the Atlees, Dunlap, Peaslee,
Kimball, Sims, and Thomas established and brought to the front an
operation against which the most bitter and scathing invectives were
aimed. These great men, who have placed this operation upon a firm
basis, deserve the gratitude of a nation, and of the world, since they
have thrown a flood of light upon this dark region of surgery, which
is now illuminated by the work of recent operators whose successes
are simply miraculous.

Mayo Robson has contributed an article on the evolution of ab-
dominal surgery, a part of which has reference to the results ob-
tained in ovariotomy. He states that in Leeds Infirmary, hi 1870-
1871, no case was reported under abdominal surgery. In 1901, or
20 years later, there were performed in the Leeds Infirmary 569
abdominal sections. In reference to ovariotomy, he states that about
1870 ovarian tumors were considered a variety of dropsy, and tapping
was resorted to as a means of transient alleviation. Thus, in 1870, in
St. Bartholomew's Hospital, London, there were only 3 ovariotomies
performed, with 100% mortality. In Guy's Hospital, London, 5
ovariotomies, with 60 % mortality. In St. Thomas' Hospital, London,
1 ovariotomy, with 100 % mortality. In St. George's Hospital, Lon-
don, 2 ovariotomies, with 100% mortality. In 1875, ovariotomy
had such unfavorable statistics that tapping was done to defer
a radical operation. In 1875, in 12 cases of ovarian tumor, only
7 patients had an ovariotomy performed, and 5 died, thus giving a
mortality of 71 %.

Now mark the contrast. In 1901, ovariotomy was performed 64
times, with 4 deaths, or a mortality of about 6 %. When it is con-
sidered that in these cases some were malignant, gangrenous, and
suppurating cases, the story seems incredible. Mouillin reports, in
1901, 57 ovariotomies hi the hospital for women, with no death.
Richardson, of Boston, reports 93 consecutive ovariotomies without
a death. Ovariotomy in the aged shows most remarkable results;
thus Kelly has. reported in his book over 100 ovariotomies hi women
who were over 70, and operated upon by 59 surgeons, with only 12
deaths. This is a triumph of surgery that Ephraim McDowell fore-
shadowed in his courageous work. Sutton collected, in 1896, 11 cases
of ovariotomy in women over 80, with no deaths.

354 SURGERY

Ovariotomy during pregnancy has likewise a most astonishing
record, since Williams in his book reports 142 cases collected by
Orgler, with only a mortality of 2.77 %.

In 1902, in one London hospital there were 40 ovariotomies, with

1 death, or 2.5 % mortality, as contrasted with 100 % mortality
about 1870. Thus in a quarter of a century the mortality has been
reduced in one of the most formidable operations in surgery from
71 % to 6 %, and in exceptional series of cases even to 2.5 % mortality.
It may be of interest to show the progress which surgery has made
during the century in reference to the operation of ovariotomy,
from 1809 to 1904.

In America — McDowell 1809, and later, 12 cases; mortality, 66%

N. Smith 1821, 1 0%

A. G. Smith 1823, 1 0%

Several operators 1855, 21 70%

In America 1857, 97 34%

In England 1857, 123 43 %

In Germany ....1857, 47 77%

Hofmeier 1903, 200 4.5%

Hofmeier 1903, last, 115 1.74%

From the above table it appears that during the first quarter
of the nineteenth century, according to the combined reports of
McDowell and N. and A. G. Smith, the mortality in 14 cases of ova-
riotomy was 57 %. The combined English and American returns
for 1855 and 1857 give an average mortality of 48%. The most
recent figures are by Hofmeier, for 1903, who returns a mortality of
1.74%. If the earlier mortality prevailed at the present time,
Hofmeier would have had 180 deaths in a total of 315 cases, instead
of 11, which actually occurred.

Hysterectomy, or removal of the entire uterus, with or without the
ovaries and tubes, affords a most striking illustration of the recent
development of surgery. Hysterectomy shows brilliant results when
performed for malignant disease; but the result of the operation
when performed for malignant disease is the darkest chapter in the
present status of surgery. Bigelow collected, in 1884, 359 cases of
hysterectomy for fibroids of the uterus, with a mortality of 58%.
Kelly reports, in 1898, 100 cases of hysterectomy, including extirpa-
tion of the ovaries and tubes, with a mortality of only 4 %. Pryor
has investigated the subject of the mortality of abdominal hysterec-
tomy for myofibroma of the uterus, and states that it is not over

2 %, while in fibrocysts of the uterus, it is much higher, reaching at
least 10%, and states that this great increase in mortality is due
to "coexisting cardiac lesions, which so often accompany fibrocystic
disease." Pryor also states that his mortality of hysterectomy in
pus cases is about 3 %. Noble reports 58 cases of pyosalpinx and
abscess of the ovary, in which he performs hysterectomy with re-
moval of the appendages, and the immediate mortality was not

DEVELOPMENT IN NINETEENTH CENTURY 355

quite 2 %, and 36 cases of removal of the appendages without hys-
terectomy, with a mortality of 5%. Richardson, of Boston, had a
mortality of 3% in 111 cases during the past two years; and Polk,
of New York, has had a long series of cases with equally brilliant
results. Webster reports 65 hysterectomies for infective disease of
the uterus and appendages, with a mortality of 1.07%. With such
an array of statistics before us in hysterectomy, which may be con-
sidered the keystone of the arch, there is no more forcible illustration
of the steady advance of surgery than the improvement in this
operation. In regard to vaginal hysterectomy, statistics are likewise
brilliant ; thus Pryor has collected 228 cases of vaginal hysterectomy
for non-malignant disease, with one death. Webster reports 40
cases of vaginal hysterectomy for malignant disease of the uterus,
with no death from the operation itself. No mention is made of the
percentage of permanent cures in these cases.

Hysterectomy for the cure of cancer furnishes the most discouraging
and melancholy statistics of any modern operation. In this case it is
not so much the fault of the technic as it is the disease which calls
for the operation. Cancer is most fatal in the uterus; but the time
will soon come when early operations will effect a far greater per-
centage of recovery. Cancer of the cervix and body of the uterus is
most fatal, yet the faintest glimmer of dawn is upon the horizon,
and the results of hysterectomy for the permanent cure of cancer are
beginning to show signs of improvement. In the history of every
great operation the mortality is high at first; but as technic im-
proves and early and radical operations are resorted to, the result
will be different. Ovariotomy passed through just such a crisis, and
it is certain that hysterectomy for cancer will show better results in
the future and if so it will be the greatest triumph of surgery. The
statistics of hysterectomy for cancer are subject to the widest varia-
tion. Penrose states that his results have been most discouraging,
as he has only two or three patients who have permanently recovered.
Penrose also criticises the report of 20 % of cures for cancer of the
uterus at the Johns Hopkins Hospital, and claims that "after due
deduction and thorough sifting of their figures, 5 % of cures comes
nearer the actual truth." The mortality of the operation itself for the
cure of cancer has a favorable showing in contrast to the results of
permanent cure. Thus Pryor, in 1901, reports 98 cases of hysterec-
tomy for cancer of the uterus with a primary mortality of about 11 %.
In a very careful and thorough research of the literature of the sub-
ject, I find that abdominal hysterectomy for cancer has an immediate
mortality of nearly 20%, if the cases from all available operators
are taken, and that the immediate mortality for vaginal hysterectomy
for cancer has been as high as 16 %, and by some operators reduced
to almost zero.

356 SURGERY

The Surgery of the Bones and Joints. The management of frac-
tures has brought out the wonderful mechanical ingenuity which ie
a characteristic of the human mind. The application of the plaster-
of-paris bandage in the treatment of fractures is one of the greatest
improvements of the century. To the perfection of its technic,
Fluhrer's work deserves special commendation. The use of flexible
narrow strips of tin or zinc in the management of fractures was de-
vised by Fluhrer in 1872, with the object of securing immobility of
the fractured bones. The strips are not designed to act as rigid sup-
ports, although incidentally, by their width (a quarter of an inch)
they edgewise oppose resistance to angular motion when passing
through or near an axis of motion. Their principal effect is by virtue
of their inextensibility, not shortening or lengthening under strain
when bandaged to the limb in the principal planes of motion. They
are roughened on each side by perforations, so that fhey may be
securely held in position by the retaining bandage. They are not
designed to serve as an accessory strengthening of an immovable
splint; the strips themselves are the splint. The plaster-of-paris or
other material incorporated in the retaining bandages gives to the
provisional effect of the strips durability, which, of course, cannot
be obtained by a simple bandage. The work of Dr. James L. Little,
in the use of plaster-of-paris bandage, must not be overlooked, since
he utilized this dressing for various fractures, and perfected several
dressings for special fractures, notably the patella. Time will not
permit of a discussion of the manifold ways that this dressing can
be employed in the different fractures. It will suffice to mention the
present method of treatment of fractures of the thigh, in order to
afford the best illustration of the evolution of the general plan of the
treatment of fractures. If we start with Desault's splint, which was
crude and unsatisfactory, the first change that occurred was Physick's
modification, which consisted in making Desault's splint, which
reached only to the crest of the ilium, extend above to the axilla
and downward below the foot, with a perineal band for extension
and counter-extension. In 1819 Daniell of Georgia introduced the
weight and pulley. In 1851 Buck still further modified Physick's
splint, so as to do away with the perineal band, and accomplished
extension of the limb by the weight and pulley, after the manner of
its present use. This was a great improvement, in order to overcome
shortening of a fractured limb.

Van Ingen, in 1857, suggested the elevation of the foot of the bed
to permit the body to act as a counter-extending force. The coapta-
tion splints were used by Buck, in 1861, so that the present complete
and perfect method is one that is the result of evolution, the con-
summation of which has been accomplished by the work of American
surgeons. In 1827 Nathan R. Smith adopted the principle of suspen-

DEVELOPMENT IN NINETEENTH CENTURY 357

sion in the treatment of fractures, and the use of the sand-bag was
introduced by Hunt, of Philadelphia, in 1862. In fracture of the
clavicle, Sayre has originated a dressing which is not only unique,
but which is accepted as the simplest, most reliable, and most
satisfactory of all the different forms of apparatus. Physick suggested
the two angular splints for treating fracture of the lower end of the
humerus, and Gunning and Bean the interdental splint in the treat-
ment of the fracture of the lower jaw. Allis first called attention to
the pathologic condition found in fractures of the lower end of the
humerus, and suggested new principles in the treatment to prevent
deformities. In 1861 Mason devised a new method of treating
fractures of the nasal bones by passing a curved needle under the
fragments and elevating them. In the treatment of fracture of the
patella by the use of the metallic suture, American surgery can claim
the operation as far as priority is concerned, since Rhea Barton
wired a fractured patella in 1834, and McClellan, in 1838, and Cooper,
of San Francisco, in 1861, and after him Logan and Gunn.

While American surgery cannot justly claim the priority of this
operation as practiced by Lister with the modern aseptic technic, she
can at least claim to having brought the operation to its present
perfected technic, and can point to the fact that in New York the
operation has been performed more times than it has been in any
city, or in any country in the world. While the operation is not
one to be recommended universally, it is an operation yielding
brilliant results in suitable cases and in the hands of aseptic surgeons.
The first time that fractures of the lower jaw were treated by metallic
suture was by Kinloch of South Carolina. In the management of
ununited fractures, American surgery stands preeminent. In 1802
Physick passed a seton between the ends of an ununited fracture of
the humerus. In 1830, or twenty-eight years after the operation,
Physick obtained the specimen. The use of the metallic suture
was first successfully tried in 1827, by J. Kearney Rodgers, in a case
of ununited fracture of the humerus.

Perforation of the ends of the bones in an ununited fracture of
the tibia was accomplished in 1850 by Detmold. In 1825 Brainard
introduced the operation of drilling the fragments. In 1857 Pancoast
used the iron screw to accomplish the same object. In 1878 Pilcher
first pointed out the correct pathology and the treatment of fractures
of the lower end of the radius. Before dismissing the subject of
fractures, the work of Hamilton and Stimson must not be overlooked,
since they did more to systematize and to perfect the treatment of
fractures in general than any other surgeons. The saw devised by
Shrady for performing a subcutaneous section of the bone is an
instrument worthy of the highest commendation. Excision of the
superior maxillary bone, with the exception of the orbital plate, was

358 SURGERY

first performed by Jameson, in 1820. The complete excision of the
superior maxilla was first performed in New York, by David L.
Rodgers, in 1824. Excision of the inferior maxilla was first partially
and successfully made "without known precedent or professional
counsel or aid," by Deadrich, of Tennessee, in 1810. Jameson ex-
secfred nearly the entire inferior maxilla in 1820. Mott exsected half
of the jaw in 1821 ; Ackley in 1850; and Carnochan excised the entire
bone in 1851. Excision of the os hyoides was performed for the first
time by Warren, in 1803. Excision of the wedge-shaped piece of bone
from the tibia and fibula, with osteoclasis of the bones, to correct
a deformity by an osteotomy, was performed by Warren, in 1820.
In 1835 Barton devised an operation which is still practiced for the
relief of angular ankylosis of the knee. The entire clavicle was excised
successfully for necrosis for the first time in 1813, by McCreary of
Kentucky. The entire clavicle was again excised successfully for the
first time for malignant disease, by Mott, in 1828. The entire scapula,
three fourths of the clavicle, and the arm were excised for the first
time, and also successfully, by Dixi Crosby, in 1836. This same
operation was repeated by Twitchell, in 1838, by McClellan, in 1838,
and by Mussey, in 1845, and since then to the present time the opera-
tion has been performed many times throughout the world.

The entire scapula and the clavicle were removed successfully
six years after an amputation at the shoulder- joint by Mussey in
1837. Two thirds of the ulna was excised successfully by Butt, of
Virginia, in 1825, and the olecranon by Buck, in 1842, while the
entire ulna was excised by Carnochan, in 1853. The same operator
excised the entire radius in 1854. Both radius and ulna were ex-
cised by Compton, of New Orleans, in 1853. Excision of the coccyx
was first performed by Nott, in 1832, for the relief of severe and
persistent neuralgia. Excision of a portion of the rib by the tre-
phine, for affording drainage in empyema, was first performed by
Stone, in 1862, and excision of a part of one or more ribs for the same
purpose was first performed by Walter, of Pittsburg, in 1857. Be-
side these excisions for necrosis, suppuration, and malignant disease,
much credit is due to American surgery for the part it has played
in subperiosteal surgery. One of the most remarkable specimens is
the reproduction of the inferior maxilla by Wood, in 1856. Langen-
beck, the authority on subperiosteal surgery, said "that he did not
believe a corresponding preparation really existed anywhere,"
and remarked that "there was not another such specimen in the
whole of Europe." This was indeed a fitting tribute, from one of
Europe's greatest surgeons, to the genius of one of America's great-
est operators. Wood has also succeeded in reproducing many other
bones in the body by the application of the same principles of sub-
periosteal surgery. Thus it is evident, if the first successful excis-

DEVELOPMENT IN NINETEENTH CENTURY 359

ion of the superior and inferior maxillas, the hyoid bone, the entire
clavicle, the entire scapula, the ulna and radius, the coccyx and ribs;
also trephining for relief of osteomyelitis; the most perfect speci-
mens of reproduced bone, — be subtracted from the sum total of
operative surgery upon the bones, there is little left that is not the
offspring of American surgery.

In the surgery of the joints, American surgeons have accom-
plished brilliant work, since in the management of dislocations they
have contributed much to the sum total of our knowledge. Phy-
sick was the first to perform venesection to cause muscular relax-
ation, in order to reduce a dislocation. This was a most valuable
means, to which resort was made prior to the introduction of anes-
thetics. McKenzie and Smith, in 1805, reduced a dislocation of
the shoulder of six months' standing by the employment of vene-
section. This patient had been to England and all attempts at re-
duction failed, and upon his return to Baltimore, the reduction
was effected by relaxing the muscular system by blood-letting ad
delequium animi. The plan is now abandoned since the introduc-
tion of anesthetics. Warren excised the head of the humerus to
restore the usefulness of it after an unreduced dislocation of the
shoulder-joint. The invention of plaster-of-paris jacket by Sayre,
for the treatment of Pott's disease, in 1874, is one of the most im-
portant surgical discoveries of the century. The same apparatus he
devised for the treatment of lateral curvature. These cases of Pott's
disease, which hitherto were consigned to a distressing death, are
now permanently relieved of their sufferings, and are in many cases
entirely cured. Excision of the hip-joint was performed as a sys-
tematic operation, and successfully, for the first time in this country,
by Sayre, in 1854. To this same surgeon is due the credit of sug-
gesting and carrying into execution the principle of free drainage
in cases of empyema of joints. In hydrops articuli, Martin, of Bos-
ton, in 1853, suggested equable uniform compression by means of
an elastic bandage, and Sayre has applied the same principle by
using compressed sponges. Martin, in 1877, also employed the
elastic bandage for the cure of chronic ulcers of the leg. In 1826
Barton divided with a saw the great trochanter and the neck of
the thigh to relieve ankylosis of the hip-joint. In 1830 Rodgers
removed a disk of bone, and in 1862 Sayre perfected the operation
and introduced a new principle by removing a plano-convex wedge
of bone between the two trochanters, and made rotund the end of
the lower fragment in order to form a new and artificial joint. In
1835 Barton removed a cuneiform wedge just above the condyle
and fractured the bone, and made the limb straight to relieve angu-
lar ankylosis of the knee-joint. This operation is practically the
osteotomy of the present time. In 1840 Carnochan first operated

360 SURGERY

for the relief of ankylosis of the lower jaw by subcutaneously divid-
ing the masseter muscle. In forcing open the mouth after teno-
tomy of the muscle, he accidentally fractured the bone, thus pro-
ducing a false joint until the fracture united. Carnochan conceived
then the idea of excising a wedge-shaped piece from the jaw and
establishing a false joint. For the relief of this distressing condi-
tion, in 1873, Gross excised the condyle and a portion of the neck
of the bone, and in 1875 Hears excised the coronoid and condy-
loid process together with the upper half of the ramus. Wood, in
1876, cured a patient with fracture of the cervical vertebra associ-
ated with paraplegia and brachial paralysis, by the use of the
plaster-of-paris jacket. The patient,. though completely paralyzed,
made an excellent recovery and was able to resume his work as a
carpenter.

Compound fracture may be designated as the touchstone of sur-
gery, because a discussion of the treatment of compound fractures
includes all the great principles involved in every department of
the science. It embraces a consideration of cerebral, thoracic, and
abdominal surgery; it includes a discussion of the great principles
of antisepsis, it covers operative technic, it embraces the study of
surgical pathology, it touches upon the higher departments of the
science, and opens up the field where surgery must be considered,
as an arena for the exercise of sound judgment, for the display of
clear foresight, and for the exhibition of accurate knowledge and
ripe erudition. Finally, a full discussion of this subject inevitably
leads to a consideration of the progress of surgery during the pre-
sent century and its precise status at the present day. In consider-
ing the management of compound fractures, I shall confine my-
self to the results of my own personal work as embodied in an ex-
tensive clinical experience embracing a report of 1000 cases, which
I published some time ago, and since then hundreds more can be
added to my list, with substantially the same result. These cases
occurred within a period of a year in four metropolitan hospitals
devoted to the treatment of acute surgical cases, and also in pri-
vate practice. The accumulation of so vast an amount of clinical
material has been attained with considerable labor. The conscien-
tious treatment of these serious cases has been attended with a
sense of great responsibility, and the results have been attained
only by close attention to the minutest details in the management
of each individual case. There are some points in the treatment
of compound fractures that deserve special consideration, and it
is only by a study of these cases in groups that clinical facts of essen-
tial importance can be established. The same plan of treatment
has been carefully watched in many cases at the same time, and
it has been by a process of evolution that some of the opinions

DEVELOPMENT IN NINETEENTH CENTURY 361

which I shall enunciate have become fixed laws in routine prac-
tice. To see in one day nineteen compound fractures in the same
ward with a normal temperature is not a coincidence. The number
might possibly be, but the same condition in all is the result of the
application of fixed principles which have been established as the re-
sult of long study and observation. To see at another time twelve
cases in the same ward and all with a normal temperature is like-
wise no coincidence. These circumstances make it evident that
the application of fixed rules is necessary to arrive at certain and
uniform results.

The complete history of each one of the 1000 cases of compound
fracture is carefully preserved. Each case is given in full, with the
name of the patient, the date of his or her admittance to the hos-
pital, the age, a description of the injury, the treatment in full,
and the result, together with the name of the house surgeon on
duty at the time as a matter of reference. It is obvious that time
will not permit to discuss in detail these histories, and therefore I
can only give a summary.

The general summary in the 1000 cases is as follows:

Skull 178

Nasal, malar, maxillas, and patellas 89

Ann 40

Forearm 41

Fingers and toes 97

Ilium, clavicle 2

Thigh 87

Leg 295

Fractures involving shoulder, elbow, or wrist-joints, as a result of disease

or accident 39

Fractures involving hip, knee, or ankle-joints, as a result of disease or

accident 85

Fractures involving carpal or metacarpal, tarsal or metatarsal joints, as

a result of disease or accident 47

1000

Now, following the example of surgical writers who have care-
fully tabulated the results of treatment in compound fractures,
I shall eliminate all those cases in which primary amputations were
performed, because they do not concern the point at issue; and
I shall also, according to the practice of writers, reject all those
patients who died of hemorrhage, collapse, shock, etc., within a
few hours after injury. I shall also leave out cases of compound
fractures of the hand and foot, as too insignificant to be classed
with compound fractures of the long bones. After these deduc-
tions are made, there remain 681 cases of compound fractures, with
one death due to sepsis. This gives a death-rate of about ^ of 1 %.

In order to appreciate fully what aseptic surgery has accom-
plished in reference to the management of compound fractures,
it is necessary to compare the results obtained prior to the intro-

362 SURGERY

*

duction of antiseptic surgery. In the Pennsylvania Hospital, Norris
has made a statistical report of the compound fractures treated
between the years 1839 and 1851. During that time there were
116 cases of compound fractures of the leg and thigh (excluding
those cases requiring amputation) with 51 deaths, thus giving a
rate-mortality of 44 %. In the New York Hospital during the same
period there were treated 126 cases of compound fracture of the
leg and thigh (excluding those cases requiring amputation) with
61 deaths, thus giving a rate of mortality of 40 %. In the Obu-
chow Hospital reports of St. Petersburg there are 106 cases of
compound fracture with a mortality of 68 %. In Guy's Hospital,
from 1841 to 1861, there were reported 208 cases of compound
fractures with 56 deaths, giving a mortality of about 28%. Bill-
roth reports from surgical clinics of Vienna and Zurich 180 cases
of compound fractures (excluding cases of amputation), with a
mortality of 31 % from septopyemia. Now, after the introduction
of antiseptics, a study of Billroth's table of compound fractures
shows a reduction in the death-rate to about 3%. The influence,
therefore, of antiseptics has caused the death-rate to fall from 68 %
to about 3%. In my personal report of 1000 cases, the fractures
of the extremities only are compared, as has been done in all of
the above tables; there is no death from septopyemia, and thus
the rate of mortality from blood-poisoning is now reduced from 68 %
to zero. It may be said, therefore, that pyemia and septicemia,
which formerly destroyed as many as 68 % of compound fractures,
have been practically eliminated.

The science of surgery has at last demonstrated to the world
that it has fairly met these demons of destruction, and that it has
conquered them. Without doubt, the means of warfare have been
found in the establishment of bacteriologic laboratories, for with-
out these institutions the discoveries that affect the happiness and
mortality of the human race could not have been made. For my
own part, I remained a skeptic to the germ-theory of inflammation
until the Carnegie Laboratory afforded me an opportunity to work
out this great problem. The reduction of the death-rate from 68 %,
which half a century ago was considered a brilliant achievement,
and a result which was thought worthy of publication, to that of
a cipher, represents what surgery has done for the amelioration of
human suffering and the preservation of life. These statistics afford
us the most startling and impressive lesson of what surgery has
done. It has lessened suffering, it has annihilated pain, it has saved
limbs, it has conquered sepsis, it has saved life. Surely nothing
could be added to show more clearly the triumphant march of the
onward progress of the grandest profession hi the world.

Compound fractures of the skull require surgical interference

DEVELOPMENT IN NINETEENTH CENTURY 363

which formerly was not resorted to unless in extreme cases. The
intervention of operative measures has not only reduced the mor-
tality to a very small percentage by preventing an infective process,
but it also has eliminated the various nervous phenomena, such as
headache, ataxia, epilepsy, insanity, and other like conditions.
I have treated many hundred cases of compound fractures of the
skull, and at one time collected a series of 116 cases of my own, a
reference to which may give an idea of what modern surgery has
achieved in the past few years in the management of this class of
serious cases. Of these 116 cases of compound fractures of the
skull, excluding those deaths from shock within 48 hours, in accord-
ance with all statisticians, because these deaths were not the re-
sult of any special plan of treatment, there are two deaths which
may be ascribed to sepsis. Perfection has been almost reached in
the technic of the operation of trephining; but as yet there are
circumstances which are not controlled by the practical surgeon,
and in the study of these causes future scientific surgery must be
employed. In these 116 cases of compound fractures of the skull,
there were two deaths due to sepsis, which give a mortality of less
than 5%.

Traumatism of the vertebral column and the spinal cord have been
treated by Sayre's plaster-of-paris jacket. The utter helplessness,
the intense suffering, the absolute hopelessness, the wretched dis-
comfort, the living death make these patients objects of pity to
all under whose care they come. On the other hand, the recent
advances in the science of neurology, the precision of topographic
anatomy, the modern researches in physiology, the introduction of
anesthetics and antiseptics, the wonderful inventions in mechanical
art present a most vivid picture to the modern surgeon of what
surgery has accomplished by this new method of treatment. The
expectant plan terminates in death, the application of well-recog-
nized surgical principle to this peculiar class of hitherto neglected
cases, has demonstrated the possibility of salvation in at least a
limited number. The treatment of all these different varieties of
traumatism of the spine and cord by the plaster-of-paris jacket has
met with brilliant results. Before the employment of the jacket,
these patients were doomed to unalleviated suffering and death.
There is no reason why the same brilliant results should not follow
the application of the jacket when used in connection with spinal
meningitis or myelitis secondary to traumatism. Some time ago
I collected thirty-three cases of recovery after unmistakable fracture
of the spine, and to this list many others an be added of recent
date. Cases have been eliminated in which improvement only was
noted. This list is sufficiently large to attract the attention of sur-
geons and to induce them to employ this method of treatment in

364 SURGERY

all forms of traumatism of the spine and cord. Still again, the use-
fulness of the jacket is demonstrated in a large list of injuries,
among which may be mentioned sprains, concussion, hemorrhage,
lacerations, and inflammatory thickenings. Thus it is evident that
immediate extension and counter-extension with immobilization by
means of the jacket, in all forms of spinal injuries, offers the most
satisfactory plan of treatment that has been suggested, a plan of
treatment, too, in which the results show manifest evidence of im-
provement, and further a plan of treatment that has been attended
with a most gratifying success.

Orthopedic surgery is a department by itself, a part of which will
be discussed under pediatrics. Under orthopedic surgery there are,
however, a few operations that could be referred to briefly in order
not to overlook the importance of the subject. Orthopedic surgery
literally refers to the treatment of deformities; but the progress in
this department has already passed beyond the limits that originally
were set for it, and include now some of the operations in general
surgery. Among the advances mentioned by Taylor are the Lorenz
bloodless method of manual replacement of congenitally dislocated
hips, the correction of deformed limbs by forcible movement without
division of the tendons, the straightening of the kyphotic spine by
great force, as suggested by Calot, the use of Sayre's plaster-of-paris
jacket for correction of Pott's disease, the straightening of deform-
ities in the limbs by osteotomy, the correction of deformities affect-
ing the long bones by osteoclasis, the arrest of disease of the joints
by excision, the removal of osteomyelitic foci in bone by excision or
by the Rontgen rays, tendon grafting suggested by Dr. Vulpius, nerve
suture for transference of functional activity from a healthy nerve
to a paralyzed nerve, the tuberculin injection from diagnostic pur-
poses, the extirpation of articular disease, the cure of periarticular
bursitis and tenosynovitis, the healing of non-tuberculous joint
disease where the etiology is dependent upon microorganisms such
as are found in typhoid, pneumonia, gonorrhea, syphilis, and septic
infection; the management of atrophic and hypertrophic joint
disease by improvement in the physical condition and correction by
mechanical means, and finally the treatment of Paget's disease of the
joints, or osteitis deformans.

Surgery of the Vascular System. In the surgery of the vascular
system American operators have made most valuable contributions.
The innominate artery was ligated for the first time in the history
.of surgery by Valentine Mott, of this city, on May 11, 1818. The
operation was performed for the cure of aneurism, and the patient
died. The operation was essayed for the second time by Hall, of
Baltimore, in 1830, and again by Cooper, of San Francisco, in 1859.
Both of these cases terminated fatally. The artery was finally tied

DEVELOPMENT IN NINETEENTH CENTURY 365

successfully for the first time by Smyth, of New Orleans, on May 9,
1864. This last operator tied also the vertebral in the same patient
for the first time. Thus it is evident that the ligature of the innomi-
nate artery was first performed in this country, and it was first
ligated successfully in America. Mott tied 138 large arteries for the
relief of aneurism, and no surgeon hi the world ever has ligated so
many vessels. The primitive carotid artery was ligated for the first
time successfully, for primary hemorrhage, by Cogswell, of Hartford,
on November 4, 1803. Abernethy is accredited with tying the primi-
tive carotid first in 1798, but his patient died. The first successful
case, therefore, of ligature of the primitive carotid for primary hem-
orrhage was in America, and Cogswell had no knowledge of Aber-
nethy's unsuccessful attempt. Again the primitive carotid was first
tied successfully for secondary hemorrhage by Amos Twitchell, of
Keene, N. H., in 1807, eight months prior to Sir Astley Cooper's
famous case, which was supposed until lately to be the first on record.
The primitive carotid was first tied in its continuity successfully, for
the cure of aneurism, by J. Wright Post, on January 9, 1813. This
same surgeon repeated the operation successfully on November 28,
1816. The two primitive carotids were first tied in their continuity
successfully, within a month's interval, by Macgill, of Maryland, in
1823. Mott tied both carotids simultaneously in 1833, for malignant
disease of the parotid gland. In 1823 Davidge first tied the carotid
artery for fungus tumor of the antrum. The primitive and internal
carotids were first tied simultaneously by Gordon Buck, of New
York City, in 1857, and again by Briggs, of Nashville, in 1871. The
internal carotid was tied successfully above and below, for secondary
hemorrhage, by Sands, in 1874. Carnochan tied both carotids for the
first time for elephantiasis arabum of the neck and face, in 1867.
The subclavian artery in its third portion was first tied successfully,
for the cure of aneurism, by J. Wright Post, of New York City, in
September, 1817. The subclavian artery in its first portion was ligated
for the first time by J. Kearney Rodgers in 1845. The patient died
and the vessel has never been tied successfully until 1892, when it
was tied by Halsted, of Baltimore. The operation was for the cure
of aneurism, and the sac was dissected out by removal of the clavicle.
This is the only case in which ligation of the subclavian on its tra-
cheal side has ever been successful, although it has been attempted in
other countries; but the vessel has never been tied successfully, ex-
cept in this country. The primitive iliac artery was first tied in Amer-
ica by Gibson, of Baltimore, in 1812. The ligation was for the arrest
of hemorrhage following a gunshot wound. The patient died on
the thirteenth day. Valentine Mott tied the artery successfully for
the cure of aneurism, on March 15, 1827. In 1880 Sands first tied the
primitive iliac, by performing first a laparotomy and securing the

366 SURGERY

vessel by this procedure. The internal iliac was first successfully tied
for the cure of an aneurism by Stevens, in 1812, and again success-
fully by Mott, in 1827, and by White, in 1847. The two internal
iliacs were first tied simultaneously for the cure of double gluteal
aneurism by Dennis, in 1886, upon a patient belonging to Dr. Car-
penter, of Boonton. In this case a laparotomy was performed as a
preliminary step. The same operator has since tied successfully the
internal iliac for the cure of gluteal aneurism, for the first time, by
laparotomy, as a preliminary step to operation. The external iliac
was tied successfully in 1811, by Dorsey, and again successfully by
Post, in 1814. Onderdonk, in 1813, tied the femoral artery suc-
cessfully for acute phlegmonous inflammation of the knee-joint, and
Rodger did the same operation with success in 1824. Carnochan, in
the year of 1851, tied the femoral artery for the first time for the
cure of elephantiasis arabum, thereby inaugurating a new principle
of treatment. In addition to the various ligations already mentioned
for the cure of aneurism, the invention of a variety of compression,
known as digital pressure, was carried into practice by Jonathan
Knight, of New Haven, in 1848.

There are many modifications of digital pressure. Wood utilized
the bag of shot which was suspended above the patient, and by this
means the pressure was effected by it instead of by the finger. In
1874 Stone of New Orleans first cured a traumatic aneurism of the
second portion of the subclavian artery by digital pressure upon
the third portion of the vessel. Martin, in 1877, suggested the use of
the elastic bandage in the treatment of varicose veins, and recently
Phelps, the method of the multiple ligature of the veins from the
. ankle to the saphenous opening. He applies some 60 ligatures to the
limb, and the results of his operations have been most satisfactory.

There has been much diversity of opinion as to whom the credit
belongs for the introduction of the Esmarch bandage. In the public
clinics of the Jefferson Medical College, at the time of an amputation,
the limb was rendered bloodless by elevation of it, and by the appli-
cation of a roller bandage to it by the elder Pancoast and Gross. This
was done before a tourniquet was applied. The value of this pro-
cedure was not published, and to Esmarch is due the credit of having
adopted the principle with the modification of the elastic bandage,
and having published it abroad for the benefit of the profession.

In the surgery of the nerves the work performed by Americans is
most commendable. In 1856 Carnochan excised the second branch
of the fifth cranial nerve beyond Meckel's ganglion for the relief of
tic douloureux, and two years later Pancoast performed the same
operation in the pterygomaxillary fossa. The mortality of the Kraus-
Hartley operation for the relief of tic douloureux by removal of the
gasserian ganglion in 108 cases collected by Tiffany was 22.2 %. In

DEVELOPMENT IN NINETEENTH CENTURY 367

a later series collected by Murphy the mortality of the operation
was reduced to 16 %. The recurrence of pain after the operation is ob-
served in about 10 % of the cases. This operation is one of the most
beneficent ones in surgery, as it has afforded relief from the most
excruciating pain and suffering.

In 1863 Gross removed the inferior maxillary branch of the same
nerve. In 1871 Sands excised a piece of the brachial plexus for the
relief of persistent neuralgia of a traumatic origin. Gross for the first
time excised nearly two inches of the spinal accessory nerve. The
sutures of nerves, even three days after division, have been united
with restoration of the function of the nerve. Operation for the re-
lief of facial paralysis marks a new epoch in surgery of the nerves.
There have been 12 cases of facial paralysis reported by Faure. In
these cases the paralyzed facial nerve was exposed by dissection and
then united to the hypoglossal or the eleventh nerve, and through
this inosculation, motor stimulus was given to the facial, which had
lost its function. The results have been most satisfactory, even
though the face had been paralyzed from five months to three years.

Amputation shows a steady improvement in its results during the
past century. In this department of surgery American surgeons have
not only taken the initiative in the more important amputations,
but they have perfected methods devised' by eminent surgeons in
other countries throughout the entire world. The first successful
primary amputation at the hip-joint was performed by a Kentucky
surgeon named Brashear, in 1806. The amputation was repeated
with success by Mott, in 1824. Nathan Smith was among the first,
if not the first, to successfully and systematically amputate at the
knee-joint, in 1824, and the technic of this operation has been per-
fected by Markoe and Stephen Smith. The first successful ampu-
tation of the ankle-joint in any country was performed in 1842, by
Syme, in Scotland. Triple simultaneous amputations have been
performed successfully, also quadruple amputation. These are
among the curiosities of surgery, and illustrate the preservation of
human life in the face of the greatest danger.

In the invention of prothetic apparatus the ingenuity of the American
mind has discovered a most wonderful field of operation, since in no
country can be found the mechanism that is displayed in the manu-
facture of aluminium artificial limbs. I have at present patients who
can walk and even run with two artificial limbs, and one who has
artificial hands who is employed as a pharmacist.

Staphylorrhaphy was performed by Warren, in 1820, the same
year, it is just to state, that the operation was performed in France
by Roux, but Warren had no knowledge of Roux's method.

Excision of the tonsil was an operation placed upon a permanent
and safe basis by Dr. Cox, of New York. This surgeon invented, in

368 SURGERY

1820, an instrument which included the tonsil in a ring, and then
cut it by a ring-shaped knife. The guillotine principle applied to the
tonsillotome was an improvement upon this instrument.

The operation for the relief of goiter is a great advance in operative
work, since this was formerly one of the most serious operationsin
surgery. Wolfer reports 60 cases collected from Billroth, Socin, and
his own clinics with only two deaths. Reverdin's mortality was only
2.8 %, Kocher's results are most brilliant, 0.2 %. Mikulicz's, 2.6 %.
The treatment of cretinism and myxedema by thyroid extract is
another method of cure that has been followed by recent success in
a fair percentage of cases, though the use of the drug must be con-
tinued for at least two years.

The operation for rhinoplasty to restore a lost nose is one of the
triumphs of the century, and plastic operations for the restoration of
a partially destroyed nose is also a contribution of modern surgery.
Cheiloplasty, or the formation of a new lip, is another plastic opera-
tion, the product of aseptic surgery. Stomatoplasty, or the repair of
defects of the lips from contraction due to burns, and metoplasty,
or the repair of defects of the cheeks, and blepharoplasty, the repair
of defects of the eyelids, are illustrations of the beneficent work
that surgery has achieved.

Surgery of the Genito-urinary System. In the department of genito-
urinary surgery a great advance has been made by the invention of
instruments to facilitate and improve the technic.

The cystoscope is an American instrument, having been invented
by Fisher, of Boston, in 1824, Civiale and Heurteloup having in-
vented their instruments in 1827. The cystoscope of to-day is one
which has been evolved from the general principle of Fisher's endo-
scope. Otis has perfected the urethroscope by the addition of a new
lamp for the electro-urethroscope. Klotz has also devised a cysto-
scope which is in use at the present time. Brown has devised a most
useful urethral speculum for the purpose of making topical applica-
tion to the canal. The Gross urethrotome, also Powell's urethral
dilator, and the Otis dilating urethrotome, and the urethrotometer
are instruments deserving of worthy mention. The work of Bum-
stead and of Van Buren in this department of surgery have already
world-wide reputation. The operation of nephrectomy for the relief
of malignant disease of the kidney is of American origin, since it was
first performed by Wolcott, of Milwaukee, in 1860. British surgeons
give the credit of this operation to Simon of Heidelberg; but he did
not perform his operation until 1869, or nine years after Wolcott's
operation.

Nephrectomy was first performed in America for gunshot wound
of the kidney by Keen in 1887, and again two months later for the
same reason by Willard, and still again for the same cause by Price,

DEVELOPMENT IN NINETEENTH CENTURY 369

successfully, in 1888. The first successful operation for the relief of
extroversion of the bladder was performed in New York by Carroll
on April 13, 1858. Pancoast performed the same operation success-
fully the same year, and Ayres in 1859. All of these cases antedate
the British successes of Woods and Holmes, although there are two
operative failures reported by Crook and Lloyd in London in 1851.
In plastic surgery of the urethra another brilliant triumph has been
made by American surgeons. In 1892 Alexander succeeded for the
first time in the history of genito-urinary surgery in making a new
urethra, the retentive powers of which were perfect in a case of
complete epispadias in the female. There have been 12 cases in all of
complete epispadias, in none of which heretofore has the urine been
completely under the control of the patient. Physick did an internal
urethrotomy by a concealed lancet, and Stevens, in 1817, was the
first surgeon in this country to perform external perineal urethro-
tomy. He revived the operation, which had fallen into desuetude,
since at the close of the last century the mortality was so great that
the operation was practically abandoned. Prior to 1840 the opera-
tion was performed in this country by several surgeons; notably,
in 1820 by Jameson, in 1823 by Rodgers, in 1829 by Warren, and
later by several surgeons connected with the New York Hospital,
among whom may be mentioned Hoffman, Post, Watson, and also
by Alden March, of Albany, and Wood, of New York City. With-
out doubt the operation has reached its present state of perfection
through the labors of Gouley, who suggested the whalebone guide,
the tunneled catheter staff, and the beaked bistoury.

Hypertrophy of the prostate is a distressing and fatal condition
which modern surgery in the course of its development has to a
certain extent relieved, if not cured, in a large percentage of cases.
It is one of the triumphs of the art within the period of time of which
an inventory of the present surgical operations is taken. A review of
the operation for the relief of hypertrophy of the prostate would be
incomplete without an acknowledgment of the work of Reginald
Harrison, Alexander, and White. As regards the benefits which have
accrued to these sufferers from castration, it may be stated that White
has shown that 66 % or more have return of the power of micturition,
most of them a relief of the cystitis, and nearly all freedom from pain.
In a series of 98 cases with 7 deaths estimated by White, the mor-
tality of the operation was only about 7 %. This is after eliminating
a few deaths which had no relation to the operation itself. These
figures are striking, and as the time goes on and diagnosis is im-
proved and technic is perfected, and early operations are resorted to,
the percentage of alleviation of symptoms and of mortality will be
even better than those just mentioned. Castration will never take
the place of modern prostatectomy with its present low mortality, and

370 SURGERY

which is gradually improving each year from about 6 % as reported
by Mayo.

The operation for suprapubic prostatectomy was first performed
in this country by Belfield, in October, 1886. Prostatectomy is an
operation, the technic of which has been devised in recent years, and
it gives great comfort to the patient and saves life. Murphy has
reported 34 consecutive cases without a single death due to the
operation. This operation has been greatly improved upon by
the use of Gouley's prostatectome, which facilitates the removal
of the gland.

In lithotomy American surgeons have achieved brilliant results.
McDowell did 32 lithotomies in succession without a death. Dudley
performed over 100 consecutive operations without a fatal case. In
1846 Willard Parker removed a calculus from the bladder by pro-
ducting a rectovesical fistula; and subsequently performed this
operation for the cure of chronic cystitis, and in 1861 Bozeman did
this same operation to relieve a chronic cystitis in the female. In 1836
Physick removed over 1000 calculi. These brilliant results in lith-
otomy are most remarkable when it is considered that there was a
time in the medical history of this country when a patient actually
made the pilgrimage across the ocean in order to secure the services of
a surgeon to perform lithotomy.

Litholapaxy is an operation that was introduced by Bigelow in
1878, and has been the means of saving thousands of human lives
within the past quarter of a century. It forms one of the most promi-
nent advances in surgery that has distinguished the century. By
litholapaxy is meant the crushing of a stone in the bladder with an
instrument called a lithotrite and the immediate rapid evacuation of
the fragments from the bladder by a syringe especially made and
adapted for this purpose. It is a matter of surprise and interest
that Bigelow's entire apparatus for litholapaxy remains essentially
the same to-day as it did a quarter of a century ago, which demon-
strates how complete the mechanism is in all its minor details. Keyes
has made some great improvements in litholapaxy, thereby reducing
the mortality of the operation, among which may be mentioned in the
list of improved instruments the modern evacuating-tube, the altera-
tion in the mechanism, and other improvements in the technic of
the operation. Keegan performed Bigelow's operation 59 times in
children, with one death, and Freyer performed it 49 times without
a death. The record of Bigelow's, or the American operation of lith-
olapaxy, has certainly won for itself a fixed place in the annals
of surgery.

Rupture of the bladder was operated upon successfully by a lapa-
rotomy by Walters, of Pittsburg, in 1862, but to Sir William Mac-
Cormack is justly due the credit of establishing this operation.

DEVELOPMENT IN NINETEENTH CENTURY 371

Rupture of the bladder has been successfully treated by modern
surgery. Formerly these patients nearly all died; thus Ullman's
statistics show only 22 recoveries in 237 cases, and in 143 intraperi-
toneal ruptures only two patients recovered. If the patients are oper-
ated upon early and with aseptic precaution, the prognosis is as
brilliant as it was formerly forlorn.

Tumors of the bladder have been removed in recent years, and this
operation marks an important epoch in this department of surgery.
In benign tumors the mortality is about 10 %, while in malignant
tumors the mortality is 25 %. These statistics are certain to improve
in the future. Intravesical cauterization with the operating cysto-
scope for small tumors of the bladder has met brilliant results; thus
Nitze had 119 cases without a death.

In surgery of the kidney great progress has been made. The floating
kidney is successfully anchored, gunshot wounds of the kidney
cured, renal calculi removed, suppuration in the pelvis of the kid-
ney arrested, removal of the kidney itself undertaken for tuberculous
and other diseases, and tumors of the organ excised. These are
among the achievements of modern surgery, to relieve conditions
which were uniformly fatal in pre-anesthetic and pre-antiseptic days.

Nephrotomy for the extraction of calculi has been performed and in
aseptic cases has a mortality of only 2.9%. If infection is present
the mortality reaches 23 %. If nephrectomies for the past ten years
are taken, irrespective of the disease for which the operation is per-
formed, surgery has obtained a great victory, since in 365 cases of
lumbar nephrectomies there was a mortality of 17 %, and in 165 cases
of abdominal nephrectomies there was a mortality of 19%. These
figures indicate what surgery has accomplished in cases heretofore
fatal.

Nephrectomy for the relief of tuberculous kidney marks a great
advance in surgery of recent years. Statistics show that in 22
nephrectomies, 16 patients recovered, or about 70%. In another
group the recoveries were from 12 % to 33 %.

Aneurism of the renal artery has been operated upon by Albert,
Hahn, and Keen, and all of their patients recovered.

Wounds of the ureters have been successfully sutured, a triumph
of modern surgery, and the ureter itself catheterized for diagnostic
purposes.

Malignant tumors have been treated with brilliant success in recent
years. In fact, so much so in certain varieties that the term seems
almost a misnomer. In the management of malignant tumors,
American surgeons have displayed great ability. The early work of
Warren, of Boston, was among the first attempts systematically to
collect and study neoplasms from a clinical point of view. The writ-
ings of Gross upon tumors demand more than a passing notice,

372 SURGERY

while the contributions of Shrady and of Mudd to cancer of the tongue
are most exhaustive.

Malignant tumors are now often cured by radical operations. A
century ago these cases presented a frightful mortality. In the course
of the development of surgery, owing to anesthesia and antiseptics,
more radical operations are permissible, and cures are now effected
where formerly death was the inevitable result. The study of sar-
coma is fraught with great interest on account of the meager know-
ledge, and of its great importance owing to the fact of the terrible
mortality which attends the disease. Sarcoma of bone inevitably
terminates in death, and its early recognition and its complete
removal are subjects which are worthy the profound study of the
surgeon. Sarcoma, in the large majority of cases, is a disease more
deadly in its nature than any other variety of malignant tumor. Its
unprecedented rapidity of growth, its widespread metastases, its
insidious development, its uncertainty of early diagnosis, its absolute
certainty to kill, make this disease a subject of paramount importance.
In this address a study of the varieties, the etiology, and the dia-
gnosis has no place. The prognosis concerns us only.

The prognosis in sarcoma is as gloomy as can be imagined. It is
a disease which destroys life rapidly unless arrested by amputation.
The prognosis may be modified as regards time by the situation and
the particular cell variety of the sarcoma. In whatever way we look
at the prognosis it is serious. On the other hand a radical amputation
may rescue a patient's life, even in the cases of the most malignant
variety. I shall refer to some statistics already published by others,
and present the result of my own personal work, as evidence of the
progress which surgery has made within the past quarter of a century.
For purposes of illustration the malignant tumor known as sarcoma
will be first considered.

Sarcoma of glands is a malignant tumor concerning which reliable
statistics are very meager. The great English authority, Butlin,
states that he fails to discover a single case of permanent recovery
after operation. In my list there have been 12 cases of sarcoma of
the glands up to 1895, the subsequent histories of which are all
known. There have been some cases since that date; but sufficient
time has not elapsed since operation in some of the cases, and unre-
liable histories in some other cases, prevent the tabulation of these
cases subsequent to 1895. The principle of cure is the essential
feature, and the data up to 1895 have been most carefully investigated.
This may be said of all the cases of sarcoma. In these 12 cases, re-
covery occurred in every case but one, thus giving 83.3 % of per-
manent cures beyond the three-year limit of time. In these 11 suc-
cessful and permanently cured cases of sarcoma of the glands, there
were some which were very large. In two the tumors involved the

DEVELOPMENT IN NINETEENTH CENTURY 373

neck, one of which was larger than a child's head, necessitating a
deep and dangerous dissection, which exposed the large cervical
vessels. In another case the tumor was situated about the femoral
vessels. Some of the tumors were removed in the presence of alarm-
ing hemorrhage and involved a most formidable operation. Thus,
in sarcoma of glands with 100 % mortality, the permanent cure
amounted to 83.3 % in the 12 cases.

Sarcoma of bone in previous years has been attended with a fright-
ful mortality until surgery, with modern technic, has come to the
rescue of these unfortunate sufferers. Butlin records 78 cases of
subperiosteal sarcoma, of which the results in 28 cases were unknown,
and in 6 cases more the patients had not reached the three-year limit
of time, which leaves 44 cases in which the full subsequent histories
are known. Of these 44 cases, 14 died of the operation and 29 from
recurrences, which leaves but 1 permanent cure in the 44 cases. There
are thus 78 cases in which the operation was performed; 14 of the
patients died from the immediate effects of the operation, which
gives 18 % mortality for the operation itself, and of the 44 patients
whose full subsequent histories are known, there was but 1 per-
manent cure, or 2 %. In my list I reported 21 cases of subperiosteal
sarcoma of bone in which an operation was performed, 1 of which was
an amputation of the hip-joint, and the patient died from the im-
mediate effects of the operation. This gives only 5 % mortality for
the operation itself. The histories of 4 are unknown. In the remain-
ing 17 cases of the original 21 cases in which the results are known,
there are 3 deaths, 1 of which has just been referred to as a result
of shock, and 14 cures beyond the three-year limit of time, which
gives 82 % of permanent cures. This is in marked contrast to Butlin's
statistics, which records only 2 % of permanent cures.

Sarcoma of the breast is a disease that formerly was most fatal.
Modern surgery has accomplished much in reducing the terrible
death-rate. Butlin, in his book on malignant disease, gives no results
either as to mortality or as to permanent recoveries. Williams, in
his book, reports 10 cases of sarcoma of the breast, in which no deaths
occurred in consequence of the operation itself. The subsequent
histories of only 2 out of the 10 cases are known. Death occurred in
the 2 cases within 2 years from the date of the operation. The per-
centage of permanent cures, therefore, amounts to zero, since no
patient recovered so as to be free from the disease for a period of 3
years. It is to be regretted that nothing is known of the 8 cases since
among the list; there may be some cases of permanent cure. It is
unfortunate that these cases have been lost sight of, since no statistics
of permanent cure can be recovered unless the result is known.
Gross reports 91 cases operated upon, of which 12 were permanently
cured, giving 13 % of permanent cures.

374 SURGERY

I operated in 6 cases of sarcoma of the breast, in which no death
occurred in consequence of the operation itself. The subsequent
histories are all known. Four of the 6 patients were permanently
cured, and the remaining 2 died from a return of the disease. This
gives 62§ % of permanent cures in sarcoma of the breast.

Carcinoma of the breast affords a striking illustration of a disease
over which surgery has gained a decided victory. There is no more
brilliant example to show the progress of surgery during the past
century than is found in a study of cancer of the female breast. The
necessity of an investigation of carcinoma of the breast can be esti-
mated when it is considered that in England alone there are 7000
deaths annually from carcinoma, and that there are 30,000 patients
suffering at all times in that country from this affection, of which
number a large proportion involve the breast. When it is considered
that 50% of the cases of carcinoma of the breast die within three
years, and that a third die within two years, and that of all of the
tumors affecting the breast, 80 % consist of carcinoma, some idea
can be formed of the overwhelming interest and paramount im-
portance of this subject. The mere fact that carcinoma causes more
deaths in the United States in one year than the sum total of deaths
due to erysipelas, tetanus, hydrophobia, lighting, typhlitis, gunshot
wounds, joint disease, together with well-known surgical affections,
conveys at once an idea of the wide dimensions of this subject.
Carcinoma causes nearly half as many deaths in a year in the United
States as are caused by accidents and injuries of all kinds and de-
scriptions.

Dr. Billings has demonstrated by statistics that carcinoma is a
disease which is slowly increasing, and that it is a cause of a larger
proportion of deaths in nations which have reached the highest
state of civilization. For example, in the United States in a year
there were over 13,000 deaths from carcinoma, of which there were
twice as many deaths among females as among males. There were
1387 cases of death from carcinoma of the breast alone in this coun-
try during the year 1880, and since then statistics show the disease
is still increasing. The mortality of this disease, if left unoperated
upon, is nearly 100% at the present time, just as it has always been.
The mortality of the patients operated upon formerly was consider-
able, and the percentage of permanent cures very small, while now
the operative mortality is very small and the percentage of per-
manent cures is very high.

I shall refer to my own personal experience, the results of which
I have already published, adding, however, that the results in the
more recent cases are even better; but the data in full are not pos-
sible to collect for many reasons, and chief among these is the three-
year limit of time. I have collected within a given period a series of

DEVELOPMENT IN NINETEENTH CENTURY 375

116 cases of tumors of the breast, 19 of which were not operated
upon, leaving 97 cases in which the breast was amputated. In the
97 cases of amputation there 'was but one death, thus giving a mor-
tality of a little over 1%. The one fatal case was due to the presence
of hemophilia and is a death that might have occurred in connection
with any other operation, no matter how insignificant in character.
This death can therefore with propriety be excluded as far as bearing
upon the mortality of this special operation, and if so, there is an
unbroken series of 96 consecutive operations without a death. In
addition to the reduction of the mortality of the operation from as
high as 23 % recorded by Billroth to a zero, there was no case of pye-
mia, septicemia, or erysipelas of the 97 cases of amputation of the
breast. Twenty-three cases of sarcoma and other tumors than cancer
must be eliminated in order to compute the percentage of permanent
cures of pure carcinoma of the breast. These cases of sarcoma of the
breast are discussed in connection with the subject of sarcoma. Of
the 74 cases of pure carcinoma of the breast, the subsequent histories
of 41 are known. Three of these patients have not reached the three-
year limit of time, although they are still alive and free from the
disease; there remain 38 cases, therefore, of pure carcinoma of the
breast in which the full subsequent histories are known. In these
38 cases there are 17 cases in which a permanent recovery has taken
place. This gives 45 % of permanent cures. Among these 38 patients
whose histories are known there were but 2 local recurrences, which
gives but a little over 5 % of local recurrences. Since the publication
of this series I have had 15 consecutive cases of pure carcinoma of the
breast with no mortality from the operation itself. Of these 15
cases, 1 died several weeks following the operation from hemo-
philia, in which the major joints were filled with blood, and the
greater part of the body was affected with subcutaneous hemor-
rhages. Two of the 15 have not yet reached the three-year limit of
time. There are, therefore, 13 cases in which the full subsequent
histories are known; 2 of these patients died from a recurrence of
the disease and 1 from hemophilia, as stated before, and the remain-
ing 10 have passed the three-year limit time. This gives 77 % of
permanent cures in cancer of the breast in the last 15 consecutive
cases. I believe the last 15 consecutive cases will yield even better
results. At all events, the mortality was zero and the permanent
cures seem likely to be higher than 77 %. Modern surgery has much
of which to be proud in connection with amputation of the breast,
since the frightful mortality of a century ago has been replaced by
a steadily increasing percentage of permanent cures. In the future
even the present favorable percentage of permanent cures will be
increased as early and more radical operations are practiced.

In 1820 Sidney Smith, the great literary genius of his time,

376 SURGERY

made use of the following phrases in the Edinburgh Review, which
furnishes somewhat amusing reading in the light of to-day: "Amer-
icans have done absolutely nothing for the sciences. ... In the
four quarters of the globe, who reads an American book? What
does the world yet owe to American physicians and surgeons?
What new substances have their chemists discovered?" The con-
tradiction of the first phrase that "Americans have done absolutely
nothing for the sciences" is found in the brilliant and wonderful
achievements performed by them, as recorded in this address, by
which millions of human lives are saved. "In the four quarters of
the globe, who reads an American book?" To such a challenge
facts reply louder than words. Were you to take from the world's
medical literature, alone, all that has been contributed by Amer-
icans during the past century, the result would be astonishing and
the loss incalculable. "What does the world owe to American phy-
sicians and surgeons?" To this challenge the record of new opera-
tions, bold and undreamed of, the invention of new processes, the
introduction of new instruments and methods, all of which I have
endeavored to outline rapidly in this address, is the abundant re-
ply to this unique interrogative viewed in the light of to-day.
"What new substances have their chemists discovered?" The suffi-
cient answer is, "anesthesia," which one discovery apart from all
the other noteworthy ones which our chemists have made, places
the civilized world under unspeakable obligations to America.
Anesthesia is by far the greatest and most far-reaching discovery of
the century, a gift to the world which cannot be estimated, a direct
benediction from God upon mankind for the saving of life and the
escape of humanity from pain.

In a review of the statistics that have been presented, one pro-
minent fact stands out in clear and bold relief, and that is, that all
along the line constant and marvelous improvement has been made
in the science of surgery. To this statement there is not a single
exception in the entire surgical domain. Everywhere and in every
department there has been uninterrupted progress — a progress
which has not been hindered or hampered by the loss of any past
discovery.

In nearly all the other arts and sciences there is something which
has been lost. They have advanced, indeed, most gloriously, and
their present development is wonderful in the extreme; yet each
one has dropped some good thing by the way which can never be
recovered. Their votaries in bygone centuries possessed some se-
crets in methods and processes which not only died, but evidently
were buried with them. By these they secured certain remarkable
results which their modern followers, try as they may, are unable
to reproduce. Thus in the art of painting, sculpture, architecture,

DEVELOPMENT IN NINETEENTH CENTURY 377

mosaics, pottery, and physics, there are what we style "lost arts,"
as Wendell Phillips so eloquently has told us, contributions from
which have come down to us from the past, which cannot be dupli-
cated in the present. In painting, for instance, the superb color-
ing of the ancients in their Tyrian purple, and the brilliant scarlet
which fades not in centuries. In sculpture, the majestic chiseling
of Michael Angelo, that crumbles not in ages. In mosaics, the fus-
ing of gold and glass so that the yellow of the precious metal retains
its perfect color. In pottery, a variety of delicate tints and grace-
ful forms which baffle the skill of the potter in these modern times.
In physics, the pyramids of Egypt — how were the huge blocks
of stone ever carried to the summit, some of them nearly 500 feet
above the desert sands, to be laid there in courses which are abso-
lute in regularity and evenness? How were the gigantic monoliths
of Baalbec cut out of the mountains and set high in the walls of
the Temple of the Sun? How were the mighty obelisks, 16 cen-
turies B. c., transported from the distant quarries, and then set
on end with perfect exactitude? Or how was the massive capital,
weighing 2000 pounds, ever lifted to its place on the top of Pom-
pey's Pillar, 100 feet in the air? All these "are forcible illustrations
of arts which have been been lost.

But in the science of surgery it is wholly different, and there is
no such counterpart. No operation, no invention, no discovery in
this domain that was worth the keeping has ever been lost. The
truth is, surgery, as it is practiced nowadays, is so completely a
modern science that it does not rely upon anything in the distant
past for its present or future development. That distant past was
dark with horrible things which may well be tumbled into oblivion.
It is only a few decades ago that surgery emerged from the black
period of ignorance and cruelty and took to itself a new face and
another spirit and form. At once it began its onward march, which
speedily became a triumphant one, difficulties giving way before
it, obstacles being overcome, every step an advance, with here
and there a milestone set up to mark some distinguished feature
in the splendid progress. By this new science diseases, which were
formerly attended by 100 % of mortality, are now accompanied
by almost 100 % of recoveries. In fact there is no surgical disease
whose mortality has not been reduced. No other science can show
such brilliant achievements, and no other science can demon-
strate its ability to save so many human lives or to ameliorate their
condition. We live in an age that is marvelous for its discoveries
and achievements, but in no department of science have greater
changes been wrought or more brilliant results accomplished than
in surgery. It would now seem that we had almost reached the
goal. There are but few surgical diseases which our art in its pre-

378 SURGERY

sent condition of development does not cure. There are but few
operations in point of number that remain for succeeding genera-
tions to discover. There is still little to gain in the technic of asepsis
and anesthesia, and beyond the improvement of existing operat-
ive methods there is but little to expect. The science of surgery
has accomplished a great work — one of the greatest in the his-
tory of mankind. And when we consider the vast number of sur-
gical diseases which are now amenable to cure, and the very limited
number remaining for which the surgery of the future is to discover
ways and means of treatment better than those to which we have
already attained, we can realize that we stand on the heights of a
great profession — a profession which but a century ago was crude,
undeveloped, and uncertain. If there are higher heights to be reached
in the science of surgery, and doubtless there are, we may rest
assured that the vast and ever-increasing wealth of this great coun-
try will be utilized toward their attainment. Humanity demands
this, and this country will never be behind any nation of the world
in earnest efforts for the promotion and development of a science
whose special aim is the relief of physical suffering, and the pre-
servation of human life.

It is fitting on an occasion like this, when a national celebration
is in progress, that the attention of this Congress should be directed
to the part which our own country has played in the evolution of
this great science. This part is best set forth and realized by a
study of the facts recorded in this address. The question, however,
as to what has been the inspiring motive, and what has been the
controlling influence, must be sought in the life-history and habits
of the people.

The impartiality and promptitude of the American mind have
enabled it to seize with alacrity upon the best in every department
of science and art, wherever found, regardless of the source from
which it emanates. Accordingly, American surgeons all through
the past century have busied themselves in reaping a generous
harvest from every nation that had any good surgical idea, method,
or appliance to offer, and have gathered in abundant sheaves with
rejoicing, serenely indifferent as to the particular field which pro-
duced them. What mattered it to them whose hand sowed the
seed, or under what influences it was brought to maturity, so long
as the grain itself was desirable and could be secured for the Ameri-
can garner. A precisely opposite spirit has prevailed in some other
lands ; thus, during our colonial days, when Great Britain and
France were easily foremost in surgical attainment, so bitter was
their rivalry, so intense their national jealousy, that neither would
adopt anything, no matter how good or valuable, which had origin-
ated with the other. Of late years this same prejudice, this un-

DEVELOPMENT IN NINETEENTH CENTURY 379

willingness to indulge in a sensible reciprocity, has been manifest
between France and Germany, to the great detriment of surgery
in each of these rival countries. As an apt illustration, character-
istic of the difference between the English and American spirit in
this regard, may be cited the fact that in 1823 the writings of one
of the great French surgeons, Desault, the most noteworthy con-
tribution to the surgical literature of the world then published,
had never been translated for the use of British surgeons. No Eng-
lishman had the courage or willingness to demean himself by so
doing, since he would thereby acknowledge that some good thing
might come out of France. Yet at that very time, Smith, of South
Carolina, rejoicing as one who had found great spoil, was busily
engaged in putting Desault 's works into English for the benefit of
the surgeons of America.

So in this great triangle of nations formed by England, France,
and Germany, the surgical knowledge and suggestions of each re-
mained within its own walled domain, untouched by the others;
on the contrary, in a pleasantly independent spirit, and having
no unfortunate jealousies to cherish, America reached her eager
hand over the separating wall, and freely and gratefully laid hold
upon whatever she considered best in the surgery of those and
other nations, appropriating to her own use, for the good of hu-
manity at large, as many of their principles, theories, discoveries,
methods, and appliances as she considered it worth her while to
take. Availing herself of these factors, utilizing them as stepping-
stones, and combining them with the wonderful achievements . of
her own inventive genius and skill, she has rapidly risen to that
illustrious height in the surgical world which she so grandly occu-
pies to-day.

It goes without saying, gentlemen, that within the past decade,
America, without any effort of her own, without the least self-
seeking, but through the force of her national greatness — moral,
intellectual, physical — has come to the front as a world-power
among the nations of the earth. She now ranks second to none as
an important and controlling factor in the congress of nations,
and when she speaks, her voice commands the attention of a listen-
ing world. In this regard her science of surgery has kept even pace
with her political advancement upon the powers. At the present
time her surgeons are not outclassed by those of any other country,
while in her contributions to the general literature of surgery, she
stands unsurpassed. It is an actual fact, if you were to strike from
the notable surgical achievements and writings of the world what
has been contributed by America during the past few decades,
there would be left but little of new and original work for the older
nations to claim as their own.

380 SURGERY

There are many things which combine to explain the prominent
position which America has taken during the past century in the
consummation of this great work. Chief among them may be men-
tioned the innate courage which our Puritan ancestors possessed.
The undaunted bravery which enabled the people of the Mayflower,
and others of kindred heart and mind, to cross the great unknown
oceans and to settle in the primeval forest for the sake of liberty,
has infused itself into the American spirit and has qualified Amer-
icans to attempt and to perform daring deeds in surgery. There
is no science that calls for greater fearlessness, courage, and nerve
than that of surgery, none that demands more of self-reliance,
principle, independence, and determination in the man. These
were the characteristics which were chiefly conspicuous in the early
settlers of this country. And it is these old-time Puritan qualities,
which, descending to them in ordinary generation, have passed
into the surgeons of America, giving them boldness in their art,
and enabling them to win that success in surgery which now com-
mands the admiration of the civilized world.

Permit me to sum up in a few words the wonderful achievements
of surgery during the century which has gone. What has this
great science, so young comparatively and yet so strongly and
splendidly developed, accomplished in its onward march? Among
the blessings which it has brought to the human race may be men-
tioned these:

The annihilation of pain during surgical operation.

The elimination of sepsis after operations and injuries.

The eradication of physical suffering.

The restoration of sight to the blind.

The recovery of hearing to the deaf.

The return of lost functions to organs and glands.

The aseptic repair of injured parts.

The relief of the crippled and lame.

The restitution of speech and consciousness.

The return of activity to paralyzed members.

The removal of malignant disease.

The restoration of reason to the insane.

The correction of bodily deformities.

The alleviation of pain in disease.

The reaction from shock and collapse.

The cure of lockjaw and other infective processes.

The intervention of relief in intestinal perforation.

The extirpation of tumors from glands and cavities.

The cure of diseases and injuries of internal organs.

The resection of diseased viscera.

DEVELOPMENT IN NINETEENTH CENTURY 381

The excision of joints and necrosed bone.

The amputation of diseased members.

The cure of aneurism.

The removal of cerebral and spinal neoplasms.

The reduction of mortality in all surgical diseases.

The entire removal of mortality in some surgical diseases.

The restoration of health and reason.

The salvation of human life.

Surely, Mr. President, and fellow members of the International
Congress of the Arts and Science, the great science to which we
have devoted our talents and our lives, the science which kindles
our enthusiasm, and of whose achievement we are justly proud,
our science of surgery during the past century has come as a bene-
diction upon the human family, second to none which the century
has spoken. Its benefits cannot be measured by words, or realized
in thought. We are apt to speak of it as a human achievement.
In one sense, so it is; but it is come in the orderings of an all-wise
Providence; and with grateful hearts we acknowledge it as a gift
and blessing from the Almighty Father to His suffering children in
the world.

SHORT PAPERS

DR. CARL BECK, Professor of Surgery in the New York Post-graduate Medical
School, and Chairman of the Section of Surgery, presented an interesting technical
paper "On the Technic of Urethral Dislocation in Hypospadias and in Other
Defects and Injuries of the Urethra."

PROFESSOR JOHANNES ORTH, of the University of Berlin, presented the follow-
ing short paper on "The Morphology of Cancer and the Parasitic Etiology."

GENTLEMEN, — In answer to the request of your president, Dr. Carl Beck, I
address you to-day concerning Carcinomatous tumors. I can tell you nothing
new, but perhaps it will have a certain interest for you to hear the views of a
pathologist who agrees in general with the greater number of German patho-
logists in regard to two questions which read :

I. What are the morphologic characteristics of cancer?

II. What is the present position of the question of its parasitic etiology?

As regards the first question there can be no doubt that the characteristic and
determining elements are the cancer cells, and the cancer cells are nothing else
than epithelial cells. They are epithelial cells not only as regards their structure
but as regards the character of their protoplasm and their nuclei. Not only
epithelial as regards their biologic activities, they are also epithelial as" regards
their origin.

There is no metaplasia of connective tissue, or other cells into epithelial cells,
into cancer cells. Of course one sort of epithelium can change into another,
cylinder cells into squamous epithelium, squamous cells into cylinder cells, but
an epithelial cancer cell is never formed from a connective tissue cell.

In primary cancers the fact of the direct origin of cancer cells from preformed
epithelium is, however, difficult to prove, as the growth of a cancer is not the
same, nor is its primary origin. I, indeed, believe that there are cancers in which
the conversion of preformed epithelial cells into cancer cells proceeds continu-
ously in the surrounding tissues at the edge of the primary tumor, that there are
multicentric cancers, not only in the sense that at the same time cancerous trans-
formation occurs in numerous neighboring places, but also in the sense that one
place becomes carcinomatous later than another. I realize, however, that many
cancers are unicentric, that they originate from a single cell complex and possess
only interstitial, no appositional growth. Previously we assumed without proof
a cancerous transformation of preformed epithelium wherever epithelial and
cancer cells came into contact. That such a view is not permissible has been justly
pointed out by Ribbert; as it is possible that cancerous epithelium has grown
against preformed epithelium and secondarily displaced this; but we cannot go
so far as to explain the relation of cancer cells with normal epithelium which we
find at the edge or in the immediate neighborhood of a cancer in this way, although
we can often show positively in serial sections that an isolated growth of pre-
formed cells occurs in which the quality of the cells show a certain variation from
the appearance of the mother cells. That in such cases a special sort of karyo-
mitosis occurs, similar to the mitosis of a fertilized ovum, I have not been able

SHORT PAPERS 383

to convince myself, but without doubt changes in the behavior of the cells towards
stains occur, as may be shown most easily in the cancers of the gastro-intestinal
tract. Not every phenomenon of growth in preformed epithelium can, however,
be looked upon as the beginning of cancerous transformation, for there occurs at
the border and in the neighborhood of cancers and of other rapidly growing
tumors, cell division, as well as glycogen formation, which are only the expression
of purely hyperplastic processes, but when a distinct conical invasion of the under-
lying tissues, with transformation of the cell-body, can be demonstrated, we may
well think of primary cancerous transformation.

The origin of cancer cells from preformed epithelium can, of course, be re-
cognized most easily in very young cancers and Dr. Borrmann, Ribbert's assist-
ant, who collected such cases and investigated them carefully did a great service.
In his recently published work he brings proof of the epithelial origin of cancer
cells in young primary cancers.

Secondary cancers of all sorts give especial support to the view that all cancer
cells originate from epithelial cells in regular generation; because the numerous
mitoses which cancer cells show let us see how rapidly they are divided; so
rapidly that the entire growth of these secondary tumors may be completely
explained in this way. The occurrence of the first cancer cells in the lymphsinus
of the lymph glands, or the appearance of cancer cells in blood-vessels, shows us
that metastatic cancer cells are the basis and starting-point of new cancer nod-
ules. It can be shown most strikingly by study of serial sections of cancers of
embolic origin in the lungs or the liver that cancerous growth in the neighborhood
of the vessel always takes its origin from a cancerous penetration of the wall.
There is no auto-infection through the uninjured vessel wall of the connective
tissues surrounding the walls of the vessel, but a continuous connection between
the embolus and the peri- vascular cancer; the embolus by increase of its cells
has grown through the wall into the surrounding tissue.

The behavior of the parenchyma cells at the seat of the new tumor gives
especial support to the view that all cells of the secondary cancer have arisen
from displaced cells of a previously existing cancer. As we may show especially
in cancers of the liver, the local cells, the liver cells, have absolutely nothing to do
with the formation of cancer cells. They remain entirely passive, and are pushed
aside by the uninterruptedly dividing cancer cells, they become atrophic and
finally vanish completely.

All these facts show that the epithelial cells are the essential elements of cancer.
But they are not only the essential but the only essential element. The tissue
which in addition is present in cancers, stroma, has no bearing on the nature of
cancer.

There are carcinomatous tumors without any stroma. In the so-called lymph
vessel cancers, that is, the growth of cancer cells in the lumen of lymph vessels,
as known in cancers of the lungs, of the uterus, and of other parts, extremely
dilated lymph spaces can be filled, for long stretches, entirely by cancer cells
without a trace of stroma being present. In other cancers the local tissue of the
part may take the place of stroma. Thus there are cancerous growths in the lung
in which the alveolar lung framework fills immediately the place of cancer
stroma. Thus, in intro-vascular or infiltrating carcinoma of the liver, the liver
tissue itself, liver cells, and interstitial connective tissue form the stroma. In
other cases, however, the cancer stroma is a new formation, as is shown most
plainly in many cancers of the ductus thoracicus in which the lumen of the di-
lated duct contains not only cancer cells but also stroma, which consists, of course,
of completely new formed tissue, but of tissue which has originated from the
nearest local tissue, namely, the vessel-wall.

Professor Williams, of Buffalo, has in my institute at Gottingen studied such

384 SURGERY

a case in which elastic fibers were present in the stroma, the connection of which
with the elastic tissue of the duct wall could be demonstrated.

This shows that the stroma is throughout an accessory unimportant, unessen-
tial component of cancer; although in certain cases the stroma is of importance
in determining the character of the cancer; but that a scirrhus is not different in
its nature from a soft medullary cancer is shown most clearly by the fact that the
edges and the metastases of scirrhus may be entirely of a soft, medullary char-
acter.

If, as we have said, the essential character of cancer is the uninterrupted origin
from preformed epithelium, from the scientific standpoint all cancers must bear,
according to the customary nomenclature, the name of epithelioma. To distin-
guish it from other epithelial tumors it may be designated malignant, destructive,
or heterotopic epithelioma; for the distinguishing characteristic is, that in cancer,
epithelial cells occur in places where epithelium does not belong. Where there is
a sharp line between the epithelial and non-epithelial parts of an organ, as in the
gastro-intestinal tract (muscularis mucosae), the heterotopia of the cancer cells is
easily shown. In other places it is the occurrence of connective tissue inclusions,
especially of elastic and colloid fibers in masses of cancer cells, which proves that
cancer cells are present where they do not belong; that they have forced their
destructive way into other tissues.

Another result of the epithelial nature of cancer is, that the forms of cancer
must be determined by the behavior of epithelial cancer cells, and it is of especial
importance that however cancer cells may differ from normal epithelium (ana-
plasia of Hansemann) still, on the whole, the cells of the primary tumor, as well
as those of the metastases, retain a definite character in their arrangement as well
as in their morphologic and hi their biologic behavior.

Thus, we may distinguish two groups of heterotopic epitheliomata:

(1) Those with a typical arrangement of the cancer cells;

(2) Those with an atypical arrangement.

To the first group belong (a) cancers (usually formed of cylinder cells) arranged
after the gland type (Adenomata) which possess gland canals and complicated
glandular structure, and which, especially hi the gastro-intestinal tract, not
infrequently produce a mucoid secretion. (6) Cancers which resemble epidermis
in the form, character, and stratification of their cells, and which have borne for a
long tune the name of cancroids. It is specially important, for the doctrine that
all cancer cells of metastatic growths arise from cells of the primary cancer, that
in this first group of cancers, in adenoma as well as cancroids, the cells in the
metastases show the same form and the same arrangement or stratification as
those of the corresponding primary tumor.

The second group is composed of cancers whose cells are grouped irregularly
in heaps and cords which show no typical arrangement. The cells also show less
marked peculiarities, although we may say that they differ according to the
individual organs from which the original tumor may have developed. I might
designate these cancer forms with the word which forms the root of cancroid,
namely, Cancer.

There are, however, mixed forms and transition forms between these particular
types.

II

These facts give us important bases for the second principal question, that
regarding the parasitic nature of cancer; for, if the primary cancer with all its
metastases is nothing more, histologically and histogenetically, than a great
family of epithelial cells, which all have a common origin from preformed epithe-

• SHORT PAPERS 385

Hum; it is impossible that a parasitism can exist here in the same way as in the
well-known parasitic diseases, such as the pyemic diseases or the infectious
granulomata. Pus is a local formation, whether in a primary or a metastatic
abscess, tubercles, gummata, nodules of leprosy, and actinomycosis, etc., are
purely local formations wherever they grow, whether they are primary or sec-
ondary. No cellular connection exists between primary and secondary abscesses,
between primary and metastatic tuberculous masses.

That pus, tubercles, etc., may arise, it is sufficient that pus cocci, tubercle
bacilli, etc., arrive at a certain place. For the formation of secondary cancer it is
absolutely necessary that cancer cells from the primary tumor, or from a second-
ary tumor originating in the same way, arrive at the spot, and continue their
growth. In secondary cancers there is an effectual transplantation of cancer cells,
in suppuration, tuberculosis, etc., a transplantation of parasitic organisms, which
do not themselves constitute the new lesion but cause definite phenomena in
the local tissue without any cooperation of tissue from the primary lesion. Thus,
there exists between these two groups of processes an essential difference, and we
cannot conclude that because parasites play a role in abscesses, tuberculosis,
etc., that this must necessarily be the case in cancerous tumors. We can, however,
say that if parasites play a role in cancer, these parasites must be of an entirely
different sort from those, because they must bear the most intimate relationship
to the essential cancer cells. I feel that it is not impossible that an intracellular
parasite plays a part here, but it cannot possibly play an independent part; it
cannot possibly be the decisive element in the tumor; it cannot determine the
nature and character of the tumor, for the cells alone do this.

I consider the existence of such parasites not impossible ; — but what can be
done to show their presence?

Experiments to demonstrate the inoculability of tumors from one individual
to another show nothing in this regard. For this is nothing but the transplanta-
tion of tissue to another individual. Periosteum transplanted to another animal
is able to grow in its new host and to form cartilage and bone; or to take a more
familiar example, epidermis cells planted upon the surface of a wound of another
individual may assume an extreme activity. Successful inoculation of tumors is
in no way different. Here it is nothing else than the production of a secondary
tumor, or metastasis in a second individual. Parasites are not required.

If we had only succeeded in producing tuberculosis by means of tuberculous
tissue, the truth could never have been brought that tuberculosis was produced
by tubercle bacilli. The parasitic nature of tuberculosis was only permanently
and definitely established by the fact that by the inoculation of absolutely clean
tubercle bacilli, free from all remains of tissue, the same result could be obtained
as by tuberculous tissue, only by the fact that absolutely pure bacilli always
produce primary tuberculosis in proper animals. We cannot show the etiologic
nature of cancer or its power of transplantation by producing new secondary
cancers even in another individual but only by producing primary tumors. Until
that succeeds, and by pure, artificially grown organisms, the parasitic nature of
cancer has not been proven.

Another question remains to be considered, viz., whether the present condition
of our knowledge demands the assumption of a parasitic origin for cancer. Long
before the parasites of infectious diseases were discovered, there could be no
doubt that such must exist; and even to-day there are diseases, I need mention
only syphilis, in which we do not know the parasitic cause, but cannot doubt that
it must be present. Is the condition similar as regards cancer?

The fact which is to be explained in cancer is the limitless, the heterotopic
growth of epithelial cells. I will not enter further into the question of how this
may be explained than to state that there are many possible explanations and

386 SURGERY

tti at the facts are not such that a satisfactory explanation can only be obtained
by the assumption of a parasitic influence, but that we are quite able to explain
all the phenomena in the morphology and histology of cancer without parasites.
I come thus to the following conclusions in regard to the question of the para-
sitic origin of cancer:

(1) No one has at the present day brought proof that cancer has a parasitic
origin.

(2) There is no necessity of assuming a parasitic etiology for cancer.

DR. CARL PFISTER, of New York City, presented a paper containing a summary
of the treatment of three hundred cases for hernia.

ADDENDA PAGES

FOR LECTURE NOTES AND MEMORANDA OF
COLLATERAL READING

UC SOUTHERN REGIONAL LIBRARY FACILITY

CENTRAL UNIVERSITY LIBRARY
University of California, San Diego

JUN 3 Q

DUE

nil. 1 R RECP

C139

UCSD Libr.