The Evolution of Modern Medicine
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THE EVOLUTION OF MODERN MEDICINE
A SERIES OF LECTURES DELIVERED AT YALE UNIVERSITY
ON THE SILLIMAN FOUNDATION
IN APRIL, 1913
by William Osler
THE SILLIMAN FOUNDATION
IN the year 1883 a legacy of eighty thousand dollars was left to the
President and Fellows of Yale College in the city of New Haven, to be
held in trust, as a gift from her children, in memory of their beloved
and honored mother, Mrs. Hepsa Ely Silliman.
On this foundation Yale College was requested and directed to establish
an annual course of lectures designed to illustrate the presence and
providence, the wisdom and goodness of God, as manifested in the natural
and moral world. These were to be designated as the Mrs. Hepsa Ely
Silliman Memorial Lectures. It was the belief of the testator that any
orderly presentation of the facts of nature or history contributed
to the end of this foundation more effectively than any attempt to
emphasize the elements of doctrine or of creed; and he therefore
provided that lectures on dogmatic or polemical theology should be
excluded from the scope of this foundation, and that the subjects should
be selected rather from the domains of natural science and history,
giving special prominence to astronomy, chemistry, geology and anatomy.
It was further directed that each annual course should be made the basis
of a volume to form part of a series constituting a memorial to Mrs.
Silliman. The memorial fund came into the possession of the Corporation
of Yale University in the year 1901; and the present volume constitutes
the tenth of the series of memorial lectures.
CONTENTS
Chapter I. Origin Of Medicine
Chapter II. Greek Medicine
Chapter III. Mediaeval Medicine
Chapter IV. The Renaissance and the Rise of Anatomy and Physiology
Chapter V. The Rise and Development of Modern Medicine
Chapter VI. The Rise of Preventive Medicine
PREFACE
THE manuscript of Sir William Osler's lectures on the "Evolution of
Modern Medicine," delivered at Yale University in April, 1913, on the
Silliman Foundation, was immediately turned in to the Yale University
Press for publication. Duly set in type, proofs in galley form had been
submitted to him and despite countless interruptions he had already
corrected and revised a number of the galleys when the great war came.
But with the war on, he threw himself with energy and devotion into
the military and public duties which devolved upon him and so never
completed his proof-reading and intended alterations. The careful
corrections which Sir William made in the earlier galleys show that the
lectures were dictated, in the first instance, as loose memoranda for
oral delivery rather than as finished compositions for the eye, while
maintaining throughout the logical continuity and the engaging con moto
which were so characteristic of his literary style. In revising the
lectures for publication, therefore, the editors have merely endeavored
to carry out, with care and befitting reverence, the indications
supplied in the earlier galleys by Sir William himself. In supplying
dates and references which were lacking, his preferences as to editions
and readings have been borne in mind. The slight alterations made, the
adaptation of the text to the eye, detract nothing from the original
freshness of the work.
In a letter to one of the editors, Osler described these lectures as "an
aeroplane flight over the progress of medicine through the ages." They
are, in effect, a sweeping panoramic survey of the whole vast field,
covering wide areas at a rapid pace, yet with an extraordinary variety
of detail. The slow, painful character of the evolution of medicine from
the fearsome, superstitious mental complex of primitive man, with his
amulets, healing gods and disease demons, to the ideal of a clear-eyed
rationalism is traced with faith and a serene sense of continuity. The
author saw clearly and felt deeply that the men who have made an idea or
discovery viable and valuable to humanity are the deserving men; he
has made the great names shine out, without any depreciation of the
important work of lesser men and without cluttering up his narrative
with the tedious prehistory of great discoveries or with shrill claims
to priority. Of his skill in differentiating the sundry "strains"
of medicine, there is specific witness in each section. Osler's wide
culture and control of the best available literature of his subject
permitted him to range the ampler aether of Greek medicine or the
earth-fettered schools of today with equal mastery; there is no quickset
of pedantry between the author and the reader. The illustrations (which
he had doubtless planned as fully for the last as for the earlier
chapters) are as he left them; save that, lacking legends, these have
been supplied and a few which could not be identified have with regret
been omitted. The original galley proofs have been revised and corrected
from different viewpoints by Fielding H. Garrison, Harvey Cushing,
Edward C. Streeter and latterly by Leonard L. Mackall (Savannah, Ga.),
whose zeal and persistence in the painstaking verification of citations
and references cannot be too highly commended.
In the present revision, a number of important corrections, most of
them based upon the original MS., have been made by Dr. W.W. Francis
(Oxford), Dr. Charles Singer (London), Dr. E.C. Streeter, Mr. L.L.
Mackall and others.
This work, composed originally for a lay audience and for popular
consumption, will be to the aspiring medical student and the hardworking
practitioner a lift into the blue, an inspiring vista or "Pisgah-sight"
of the evolution of medicine, a realization of what devotion,
perseverance, valor and ability on the part of physicians have
contributed to this progress, and of the creditable part which our
profession has played in the general development of science.
The editors have no hesitation in presenting these lectures to the
profession and to the reading public as one of the most characteristic
productions of the best-balanced, best-equipped, most sagacious and most
lovable of all modern physicians.
F.H.G.
BUT on that account, I say, we ought not to reject the ancient Art, as
if it were not, and had not been properly founded, because it did
not attain accuracy in all things, but rather, since it is capable of
reaching to the greatest exactitude by reasoning, to receive it and
admire its discoveries, made from a state of great ignorance, and as
having been well and properly made, and not from chance. (Hippocrates,
On Ancient Medicine, Adams edition, Vol. 1, 1849, p. 168.)
THE true and lawful goal of the sciences is none other than this: that
human life be endowed with new discoveries and powers. (Francis Bacon,
Novum Organum, Aphorisms, LXXXI, Spedding's translation.)
A GOLDEN thread has run throughout the history of the world, consecutive
and continuous, the work of the best men in successive ages. From point
to point it still runs, and when near you feel it as the clear and
bright and searchingly irresistible light which Truth throws forth when
great minds conceive it. (Walter Moxon, Pilocereus Senilis and Other
Papers, 1887, p. 4.)
FOR the mind depends so much on the temperament and disposition of the
bodily organs that, if it is possible to find a means of rendering men
wiser and cleverer than they have hitherto been, I believe that it is in
medicine that it must be sought. It is true that the medicine which is
now in vogue contains little of which the utility is remarkable; but,
without having any intention of decrying it, I am sure that there is
no one, even among those who make its study a profession, who does not
confess that all that men know is almost nothing in comparison with
what remains to be known; and that we could be free of an infinitude
of maladies both of body and mind, and even also possibly of the
infirmities of age, if we had sufficient knowledge of their causes,
and of all the remedies with which nature has provided us. (Descartes:
Discourse on the Method, Philosophical Works. Translated by E. S.
Haldane and G. R. T. Ross. Vol. I, Cam. Univ. Press, 1911, p. 120.)
CHAPTER I -- ORIGIN OF MEDICINE
INTRODUCTION
SAIL to the Pacific with some Ancient Mariner, and traverse day by day
that silent sea until you reach a region never before furrowed by keel
where a tiny island, a mere speck on the vast ocean, has just risen from
the depths, a little coral reef capped with green, an atoll, a mimic
earth, fringed with life, built up through countless ages by life on the
remains of life that has passed away. And now, with wings of fancy,
join Ianthe in the magic car of Shelley, pass the eternal gates of the
flaming ramparts of the world and see his vision:
Below lay stretched the boundless Universe!
There, far as the remotest line
That limits swift imagination's flight,
Unending orbs mingled in mazy motion,
Immutably fulfilling
Eternal Nature's law.
Above, below, around,
The circling systems formed
A wilderness of harmony.
(Daemon of the World, Pt. I.)
And somewhere, "as fast and far the chariot flew," amid the mighty
globes would be seen a tiny speck, "earth's distant orb," one of "the
smallest lights that twinkle in the heavens." Alighting, Ianthe
would find something she had probably not seen elsewhere in her magic
flight--life, everywhere encircling the sphere. And as the little coral
reef out of a vast depth had been built up by generations of polyzoa,
so she would see that on the earth, through illimitable ages, successive
generations of animals and plants had left in stone their imperishable
records: and at the top of the series she would meet the thinking,
breathing creature known as man. Infinitely little as is the architect
of the atoll in proportion to the earth on which it rests, the polyzoon,
I doubt not, is much larger relatively than is man in proportion to
the vast systems of the Universe, in which he represents an
ultra-microscopic atom less ten thousand times than the tiniest of the
"gay motes that people the sunbeams." Yet, with colossal audacity, this
thinking atom regards himself as the anthropocentric pivot around which
revolve the eternal purposes of the Universe. Knowing not whence he
came, why he is here, or whither he is going, man feels himself of
supreme importance, and certainly is of interest--to himself. Let us
hope that he has indeed a potency and importance out of all proportion
to his somatic insignificance. We know of toxins of such strength that
an amount too infinitesimal to be gauged may kill; and we know that
"the unit adopted in certain scientific work is the amount of emanation
produced by one million-millionth of a grain of radium, a quantity
which itself has a volume of less than a million-millionth of a cubic
millimetre and weighs a million million times less than an exceptionally
delicate chemical balance will turn to" (Soddy, 1912). May not man be
the radium of the Universe? At any rate let us not worry about his size.
For us he is a very potent creature, full of interest, whose mundane
story we are only beginning to unravel.
Civilization is but a filmy fringe on the history of man. Go back as far
as his records carry us and the story written on stone is of yesterday
in comparison with the vast epochs of time which modern studies demand
for his life on the earth. For two millions (some hold even three
millions) of years man lived and moved and had his being in a world very
different from that upon which we look out. There appear, indeed, to
have been various types of man, some as different from us as we are
from the anthropoid apes. What upstarts of yesterday are the Pharaohs in
comparison with the men who survived the tragedy of the glacial period!
The ancient history of man--only now beginning to be studied--dates
from the Pliocene or Miocene period; the modern history, as we know it,
embraces that brief space of time that has elapsed since the earliest
Egyptian and Babylonian records were made. This has to be borne in mind
in connection with the present mental status of man, particularly in his
outlook upon nature. In his thoughts and in his attributes, mankind at
large is controlled by inherited beliefs and impulses, which countless
thousands of years have ingrained like instinct. Over vast regions of
the earth today, magic, amulets, charms, incantations are the chief
weapons of defense against a malignant nature; and in disease, the
practice of Asa(*) is comparatively novel and unusual; in days of
illness many millions more still seek their gods rather than the
physicians. In an upward path man has had to work out for himself
a relationship with his fellows and with nature. He sought in the
supernatural an explanation of the pressing phenomena of life, peopling
the world with spiritual beings, deifying objects of nature, and
assigning to them benign or malign influences, which might be invoked or
propitiated. Primitive priest, physician and philosopher were one, and
struggled, on the one hand, for the recognition of certain practices
forced on him by experience, and on the other, for the recognition
of mystical agencies which control the dark, "uncharted region" about
him--to use Prof. Gilbert Murray's phrase--and were responsible for
everything he could not understand, and particularly for the mysteries
of disease. Pliny remarks that physic "was early fathered upon the
gods"; and to the ordinary non-medical mind, there is still something
mysterious about sickness, something outside the ordinary standard.
(*) II Chronicles xvi, 12.
Modern anthropologists claim that both religion and medicine took origin
in magic, "that spiritual protoplasm," as Miss Jane Harrison calls it.
To primitive man, magic was the setting in motion of a spiritual power
to help or to hurt the individual, and early forms may still be studied
in the native races. This power, or "mana," as it is called, while
possessed in a certain degree by all, may be increased by practice.
Certain individuals come to possess it very strongly: among native
Australians today it is still deliberately cultivated. Magic in healing
seeks to control the demons, or forces; causing disease; and in a way it
may be thus regarded as a "lineal ancestor of modern science" (Whetham),
which, too, seeks to control certain forces, no longer, however,
regarded as supernatural.
Primitive man recognized many of these superhuman agencies relating
to disease, such as the spirits of the dead, either human or animal,
independent disease demons, or individuals who might act by controlling
the spirits or agencies of disease. We see this today among the negroes
of the Southern States. A Hoodoo put upon a negro may, if he knows of
it, work upon him so powerfully through the imagination that he becomes
very ill indeed, and only through a more powerful magic exercised by
someone else can the Hoodoo be taken off.
To primitive man life seemed "full of sacred presences" (Walter Pater)
connected with objects in nature, or with incidents and epochs in life,
which he began early to deify, so that, until a quite recent period, his
story is largely associated with a pantheon of greater and lesser
gods, which he has manufactured wholesale. Xenophanes was the earliest
philosopher to recognize man's practice of making gods in his own image
and endowing them with human faculties and attributes; the Thracians,
he said, made their gods blue-eyed and red-haired, the Ethiopians,
snub-nosed and black, while, if oxen and lions and horses had hands
and could draw, they would represent their gods as oxen and lions and
horses. In relation to nature and to disease, all through early history
we find a pantheon full to repletion, bearing testimony no less to the
fertility of man's imagination than to the hopes and fears which led
him, in his exodus from barbarism, to regard his gods as "pillars of
fire by night, and pillars of cloud by day."
Even so late a religion as that of Numa was full of little gods to be
invoked on special occasions--Vatican, who causes the infant to utter
his first cry, Fabulinus, who prompts his first word, Cuba, who keeps
him quiet in his cot, Domiduca, who watches over one's safe home-coming
(Walter Pater); and Numa believed that all diseases came from the gods
and were to be averted by prayer and sacrifice. Besides the major gods,
representatives of Apollo, AEsculapius and Minerva, there were scores of
lesser ones who could be invoked for special diseases. It is said that
the young Roman mother might appeal to no less than fourteen goddesses,
from Juno Lucina to Prosa and Portvorta (Withington). Temples were
erected to the Goddess of Fever, and she was much invoked. There is
extant a touching tablet erected by a mourning mother and inscribed:
Febri divae, Febri
Sancte, Febri magnae
Camillo amato pro
Filio meld effecto. Posuit.
It is marvellous what a long line of superhuman powers, major and minor,
man has invoked against sickness. In Swinburne's words:
God by God flits past in thunder till his glories turn to shades,
God by God bears wondering witness how his Gospel flames and
fades;
More was each of these, while yet they were, than man their
servant seemed;
Dead are all of these, and man survives who made them while he
dreamed.
Most of them have been benign and helpful gods. Into the dark
chapters relating to demonical possession and to witchcraft we
cannot here enter. They make one cry out with Lucretius (Bk. V):
O genus infelix humanum, talia divis
Cum tribuit facta atque iras adjunxit acerbas!
Quantos tum gemitus ipsi sibi, quantaque nobis
Vulnera, quas lacrimas peperere minoribu' nostris.
In every age, and in every religion there has been justification for
his bitter words, "tantum religio potuit suadere malorum"--"Such wrongs
Religion in her train doth bring"--yet, one outcome of "a belief in
spiritual beings"--as Tylor defines religion--has been that man has
built an altar of righteousness in his heart. The comparative method
applied to the study of his religious growth has shown how man's
thoughts have widened in the unceasing purpose which runs through his
spiritual no less than his physical evolution. Out of the spiritual
protoplasm of magic have evolved philosopher and physician, as well
as priest. Magic and religion control the uncharted sphere--the
supernatural, the superhuman: science seeks to know the world, and
through knowing, to control it. Ray Lankester remarks that Man is
Nature's rebel, and goes on to say: "The mental qualities which have
developed in Man, though traceable in a vague and rudimentary condition
in some of his animal associates, are of such an unprecedented power and
so far dominate everything else in his activities as a living organism,
that they have to a very large extent, if not entirely, cut him off from
the general operation of that process of Natural Selection and survival
of the fittest which up to their appearance had been the law of the
living world. They justify the view that Man forms a new departure in
the gradual unfolding of Nature's predestined scheme. Knowledge, reason,
self-consciousness, will, are the attributes of Man."(1) It has been
a slow and gradual growth, and not until within the past century has
science organized knowledge--so searched out the secrets of Nature, as
to control her powers, limit her scope and transform her energies. The
victory is so recent that the mental attitude of the race is not yet
adapted to the change. A large proportion of our fellow creatures still
regard nature as a playground for demons and spirits to be exorcised or
invoked.
(1) Sir E. Ray Lankester: Romanes Lecture, "Nature and Man,"
Oxford Univ. Press, 1905, p. 21.
Side by side, as substance and shadow--"in the dark backward and abysm
of time," in the dawn of the great civilizations of Egypt and Babylon,
in the bright morning of Greece, and in the full noontide of modern
life, together have grown up these two diametrically opposite views of
man's relation to nature, and more particularly of his personal relation
to the agencies of disease.
The purpose of this course of lectures is to sketch the main features of
the growth of these two dominant ideas, to show how they have influenced
man at the different periods of his evolution, how the lamp of reason,
so early lighted in his soul, burning now bright, now dim, has never,
even in his darkest period, been wholly extinguished, but retrimmed
and refurnished by his indomitable energies, now shines more and more
towards the perfect day. It is a glorious chapter in history, in which
those who have eyes to see may read the fulfilment of the promise of
Eden, that one day man should not only possess the earth, but that he
should have dominion over it! I propose to take an aeroplane flight
through the centuries, touching only on the tall peaks from which may be
had a panoramic view of the epochs through which we pass.
ORIGIN OF MEDICINE
MEDICINE arose out of the primal sympathy of man with man; out of the
desire to help those in sorrow, need and sickness.
In the primal sympathy
Which having been must ever be;
In the soothing thoughts that spring
Out of human suffering.
The instinct of self-preservation, the longing to relieve a loved one,
and above all, the maternal passion--for such it is--gradually softened
the hard race of man--tum genus humanum primum mollescere coepit. In
his marvellous sketch of the evolution of man, nothing illustrates more
forcibly the prescience of Lucretius than the picture of the growth of
sympathy: "When with cries and gestures they taught with broken words
that 'tis right for all men to have pity on the weak." I heard the
well-known medical historian, the late Dr. Payne, remark that "the basis
of medicine is sympathy and the desire to help others, and whatever is
done with this end must be called medicine."
The first lessons came to primitive man by injuries, accidents, bites
of beasts and serpents, perhaps for long ages not appreciated by his
childlike mind, but, little by little, such experiences crystallized
into useful knowledge. The experiments of nature made clear to him the
relation of cause and effect, but it is not likely, as Pliny suggests,
that he picked up his earliest knowledge from the observation of
certain practices in animals, as the natural phlebotomy of the plethoric
hippopotamus, or the use of emetics from the dog, or the use of enemata
from the ibis. On the other hand, Celsus is probably right in his
account of the origin of rational medicine. "Some of the sick on account
of their eagerness took food on the first day, some on account of
loathing abstained; and the disease in those who refrained was more
relieved. Some ate during a fever, some a little before it, others after
it had subsided, and those who had waited to the end did best. For the
same reason some at the beginning of an illness used a full diet, others
a spare, and the former were made worse. Occurring daily, such things
impressed careful men, who noted what had best helped the sick, then
began to prescribe them. In this way medicine had its rise from
the experience of the recovery of some, of the death of others,
distinguishing the hurtful from the salutary things" (Book I). The
association of ideas was suggestive--the plant eyebright was used for
centuries in diseases of the eye because a black speck in the flower
suggested the pupil of the eye. The old herbals are full of similar
illustrations upon which, indeed, the so-called doctrine of signatures
depends. Observation came, and with it an ever widening experience. No
society so primitive without some evidence of the existence of a healing
art, which grew with its growth, and became part of the fabric of its
organization.
With primitive medicine, as such, I cannot deal, but I must refer to
the oldest existing evidence of a very extraordinary practice, that of
trephining. Neolithic skulls with disks of bone removed have been found
in nearly all parts of the world. Many careful studies have been made
of this procedure, particularly by the great anatomist and surgeon,
Paul Broca, and M. Lucas-Championniere has covered the subject in a
monograph.(2) Broca suggests that the trephining was done by scratching
or scraping, but, as Lucas-Championniere holds, it was also done by a
series of perforations made in a circle with flint instruments, and a
round piece of skull in this way removed; traces of these drill-holes
have been found. The operation was done for epilepsy, infantile
convulsions, headache, and various cerebral diseases believed to be
caused by confined demons, to whom the hole gave a ready method of
escape.
(2) Lucas-Championniere: Trepanation neolithique, Paris,
1912.
The practice is still extant. Lucas-Championniere saw a Kabyle thoubib
who told him that it was quite common among his tribe; he was the son of
a family of trephiners, and had undergone the operation four times,
his father twelve times; he had three brothers also experts; he did not
consider it a dangerous operation. He did it most frequently for pain in
the head, and occasionally for fracture.