CHAPTER VI The Evolution of Modern Medicine | ||
SANITATION
WHEN the thoughtful historian gets far enough away from the nineteenth century to see it as a whole, no single feature will stand out with greater distinctness than the fulfilment of the prophecy of Descartes that we could be freed from an infinity of maladies both of body and mind if we had sufficient knowledge of their causes and of all the remedies with which nature has provided us. Sanitation takes its place among the great modern revolutions—political, social and intellectual. Great Britain deserves the credit for the first practical recognition of the maxim salus populi suprema lex. In the middle and latter part of the century a remarkable group of men, Southwood Smith, Chadwick, Budd, Murchison, Simon, Acland, Buchanan, J. W. Russell and Benjamin Ward Richardson, put practical sanitation on a scientific basis. Even before the full demonstration of the germ theory, they had grasped the conception that the battle had to be fought against a living contagion which found in poverty, filth and wretched homes the conditions for its existence. One terrible disease was practically wiped out in twenty-five years of hard work. It is difficult to realize that within the memory of men now living, typhus fever was one of the great scourges of our large cities, and broke out in terrible epidemics—the most fatal of all to the medical profession. In the severe epidemic in Ireland in the forties of the last century, one fifth of all the doctors in the island died of typhus. A better idea of the new crusade, made possible by new knowledge, is to be had from a consideration of certain diseases against which the fight is in active progress.
Nothing illustrates more clearly the interdependence of the sciences than the reciprocal impulse given to new researches in pathology and entomology by the discovery of the part played by insects in the transmission of disease. The flea, the louse, the bedbug, the house fly, the mosquito, the tick, have all within a few years taken their places as important transmitters of disease. The fly population may be taken as the sanitary index of a place. The discovery, too, that insects are porters of disease has led to a great extension of our knowledge of their life history. Early in the nineties, when Dr. Thayer and I were busy with the study of malaria in Baltimore, we began experiments on the possible transmission of the parasites, and a tramp, who
The other experiment, though of a different character, is quite as convincing. In certain regions about Rome, in the Campania, malaria is so prevalent that, in the autumn, almost everyone in the district is attacked, particularly if he is a newcomer. Dr. Sambon and a friend lived in this district from June 1 to September 1, 1900. The test was whether they could live in this exceedingly dangerous climate for the three months without catching malaria, if they used stringent precautions against the bites of mosquitoes. For this purpose the hut in which they lived was thoroughly wired, and they slept under netting. Both of these gentlemen, at the end of the period, had escaped the disease.
Then came the fifth and final triumph—the prevention of the disease. The anti-malarial crusade which has been preached by Sir Ronald Ross and has been carried out successfully on a wholesale scale in Italy and in parts of India and Africa, has reduced enormously the incidence of the disease. Professor Celli of Rome, in his lecture room, has an interesting chart which shows the reduction in the mortality from malaria in Italy since the preventive measures have been adopted—the deaths have fallen from above 28,000 in 1888 to below 2000 in 1910. There is needed a stirring campaign against the disease throughout the Southern States of this country.
The story of yellow fever illustrates one of the greatest practical triumphs of scientific medicine; indeed, in view of its far-reaching commercial consequences, it may range as one of the first achievements of the race. Ever since the discovery of America, the disease has been one of its great scourges, permanently endemic in the Spanish Main, often extending to the Southern States, occasionally into the North, and not infrequently it has crossed the Atlantic. The records of the British Army in the West Indies show an appalling death rate, chiefly from this disease. At Jamaica, for the twenty years ending in 1836, the average mortality was 101 per thousand, and in certain instances as high as 178. One of the most dreaded of all infections, the periods of epidemics in the Southern States have been the occasions of a widespread panic with complete paralysis of commerce. How appalling the mortality is may be judged from the outbreak in Philadelphia in 1793, when ten thousand people died in three months. [161] The epidemics in Spain in the early part of the nineteenth century were of
Many scientific discoveries have afforded brilliant illustrations of method in research, but in the work of these men one is at a loss to know which to admire more—the remarkable accuracy and precision of the experiments, or the heroism of the men—officers and rank and file of the United States Army; they knew all the time that they were playing with death, and some of them had to pay the penalty! The demonstration was successful—beyond peradventure—that yellow fever could be transmitted by mosquitoes, and equally the negative
Many with crossed hands sighed for her;
But these, our brothers, fought for her,
At life's dear peril wrought for her,
So loved her that they died for her.
Fortunately, the commander-in-chief at the time in Cuba was General Leonard Wood, who had been an army surgeon, and he was the first to appreciate the importance of the discovery. The sanitation of Havana was placed in the hands of Dr. Gorgas, and within nine months the city was cleared of yellow fever, and, with the exception of a slight outbreak after the withdrawal of the American troops, has since remained free from a disease which had been its scourge for centuries. As General Wood remarked, "Reed's discovery has resulted in the saving of more lives annually than were lost in the Cuban War, and saves the commercial interest of the world a greater financial loss each year than the cost of the Cuban War. He came to Cuba at a time when one third of the officers of my staff died of yellow fever, and we were discouraged at the failure of our efforts to control it." Following the example of Havana other centres were attacked, at Vera Cruz and in Brazil, with the same success, and it is safe to say that now, thanks to the researches of Reed and his colleagues, with proper measures, no country need fear a paralyzing outbreak of this once dreaded disease.
The scientific researches in the last two decades of the nineteenth century made possible the completion of the Panama Canal. The narrow isthmus separating the two great oceans and joining the two great continents, has borne for four centuries an evil repute as the White Man's Grave. Silent upon a peak of Darien, stout Cortez with eagle eye had gazed on the Pacific. As early as 1520, Saavedra proposed to cut a canal through the Isthmus. There the first city was founded by the conquerors of the new world, which still bears the name of Panama. Spaniards, English and French fought along its coasts; to it the founder of the Bank of England took his ill-fated colony; Raleigh, Drake, Morgan the buccaneer, and scores of adventurers seeking gold, found in fever an enemy stronger than the Spaniard. For years the plague-stricken Isthmus was abandoned to the negroes and the half-breeds, until in 1849, stimulated by the gold fever of California, a railway was begun by the American engineers, Totten and Trautwine, and completed in 1855, a railway every tie of which cost the life of a man. The dream of navigators and practical engineers was taken in hand by Ferdinand de Lesseps in January, 1881. The story of the French Canal Company is a tragedy unparalleled in the history of finance, and, one may add, in the ravages of tropical disease. Yellow fever, malaria, dysentery, typhus, carried off in nine years nearly twenty thousand employees. The mortality frequently rose above 100, sometimes to 130, 140 and in September, 1885, it reached the appalling figure of 176.97 per thousand work people. This was about the maximum death rate of the British Army in the West Indies in the nineteenth century.
When, in 1904, the United States undertook to complete the Canal, everyone felt that the success or failure was largely a matter of sanitary control. The necessary knowledge existed, but under the circumstances could it be made effective? Many were doubtful. Fortunately, there was at the time in the United States Army a man who had already served an apprenticeship in Cuba, and to whom more than to anyone else was due the disappearance of yellow fever from that island. To a man, the profession in the United States felt that could Dr. Gorgas be given full control of the sanitary affairs of the Panama Zone, the health problem, which meant the Canal problem, could be solved. There was at first a serious difficulty relating to the necessary administrative control by a sanitary officer. In an interview which
Of the six important tropical diseases, plague, which reached the Isthmus one year, was quickly held in check. Yellow fever, the most dreaded of them all, never recurred. Beri-beri, which in 1906 caused sixty-eight deaths, has gradually disappeared. The hookworm disease, ankylostomiasis, has steadily decreased. From the very outset, malaria has been taken as the measure of sanitary efficiency. Throughout the French occupation it was the chief enemy to be considered, not only because of its fatality, but on account of the prolonged incapacity following infection. In 1906, out of every 1000 employees there were admitted to the hospital from malaria 821; in 1907, 424; in 1908, 282; in 1912, 110; in 1915, 51; in 1917, 14. The fatalities from the disease have fallen from 233 in 1906 to 154 in 1907, to 73 in 1908 and to 7 in 1914. The death rate for malarial fever per 1000 population sank from 8.49 in 1906 to 0.11 in 1918. Dysentery, next to malaria the most serious of the tropical diseases in the Zone, caused 69 deaths in 1906; 48 in 1907; in 1908, with nearly 44,000, only 16 deaths, and in 1914, 4.[*] But it is when the general
In 1914, the death rate from disease among white males had fallen to 3.13 per thousand. The rate among the 2674 American women and children connected with the Commission was only 9.72 per thousand. But by far the most gratifying reduction is among the blacks, among whom the rate from disease had fallen to the surprisingly low figure in 1912 of 8.77 per thousand; in 1906 it was 47 per thousand. A remarkable result is that in 1908 the combined tropical diseases— malaria, dysentery and beri-beri—killed fewer than the two great killing diseases of the temperate zone, pneumonia and tuberculosis— 127 in one group and 137 in the other. The whole story is expressed in two words, effective organization, and the special value of this experiment in sanitation is that it has been made, and made successfully, in one of the great plague spots of the world.
Month by month a little, gray-covered pamphlet was published by Colonel Gorgas, a "Report of the Department of Sanitation of the Isthmian Canal Commission." I have been one of the favored to whom it has been sent year by year, and, keenly interested as I have always been in infectious diseases, and particularly in malaria and dysentery, I doubt if anyone has read it more faithfully. In evidence of the extraordinary advance made in sanitation by Gorgas, I give a random example from one of his monthly reports (1912): In a population of more than 52,000, the death rate from disease had fallen to 7.31 per thousand; among the whites it was 2.80 and among the colored people 8.77. Not only is the profession indebted to Colonel Gorgas and his staff for this remarkable demonstration, but they have offered an example of thoroughness and efficiency which has won the admiration of the whole world. As J. B. Bishop, secretary of the Isthmian Canal Commission, has recently said: "The Americans arrived on the Isthmus in the full light of these two invaluable discoveries [the insect transmission of yellow fever and malaria]. Scarcely had they begun active work when an outbreak of yellow fever occurred which caused such a panic throughout their force that nothing except the lack of steamship accommodation prevented the flight of the entire body from the Isthmus. Prompt, intelligent and vigorous application of the remedies shown to he effective by the
One disease has still a special claim upon the public in this country. Some fourteen or fifteen years ago, in an address on the problem of typhoid fever in the United States, I contended that the question was no longer in the hands of the profession. In season and out of season we had preached salvation from it in volumes which fill state reports, public health journals and the medical periodicals. Though much has been done, typhoid fever remains a question of grave national concern. You lost in this state[164] in 1911 from typhoid fever 154 lives, every one sacrificed needlessly, every one a victim of neglect and incapacity. Between 1200 and 1500 persons had a slow, lingering illness. A nation of contradictions and paradoxes—a clean people, by whom personal hygiene is carefully cultivated, but it has displayed in matters of public sanitation a carelessness simply criminal: a sensible people, among whom education is more widely diffused than in any other country, supinely acquiesces in conditions often shameful beyond expression. The solution of the problem is not very difficult. What has been done elsewhere can be done here. It is not so much in the cities, though here too the death rate is still high, but in the smaller towns and rural districts, in many of which the sanitary conditions are still those of the Middle Ages. How Galen would have turned up his nose with contempt at the water supply of the capital of the Dominion of Canada, scourged so disgracefully by typhoid fever of late! There is no question that the public is awakening, but many State Boards of Health need more efficient organization, and larger appropriations. Others are models, and it is not for lack of example that many lag behind. The health officers should have special training in sanitary science and special courses leading to diplomas in public health should be given in the medical schools. Were the health of the people made a question of public and not of party policy, only a skilled expert
It is a long and tragic story in the annals of this country. That distinguished man, the first professor of physic in this University in the early years of last century, Dr. Nathan Smith, in that notable monograph on "Typhus Fever" (1824), tells how the disease had followed him in his various migrations, from 1787, when he began to practice, all through his career, and could he return this year, in some hundred and forty or one hundred and fifty families of the state he would find the same miserable tragedy which he had witnessed so often in the same heedless sacrifice of the young on the altar of ignorance and incapacity.
CHAPTER VI The Evolution of Modern Medicine | ||