The Evolution of Modern Medicine

W >> William Osler >> The Evolution of Modern Medicine


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 Dr.
Welch and I had with President Roosevelt, he keenly felt this difficulty
and promised to do his best to have it rectified. It is an open secret
that at first, as was perhaps only natural, matters did not go very
smoothly, and it took a year or more to get properly organized. Yellow
fever recurred on the Isthmus in 1904 and in the early part of 1905. It
was really a colossal task in itself to undertake the cleaning of the
city of Panama, which had been for centuries a pest-house, the mortality
in which, even after the American occupation, reached during one
month the rate of 71 per thousand living. There have been a great many
brilliant illustrations of the practical application of science in
preserving the health of a community and in saving life, but it is safe
to say that, considering the circumstances, the past history, and the
extraordinary difficulties to be overcome, the work accomplished by
the Isthmian Canal Commission is unique. The year 1905 was devoted to
organization; yellow fever was got rid of, and at the end of the year
the total mortality among the whites had fallen to 8 per thousand,
but among the blacks it was still high, 44. For three years, with a
progressively increasing staff which had risen to above 40,000, of whom
more than 12,000 were white, the death rate progressively fell.

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 figures are taken that we see the
extraordinary reduction that has taken place. Out of every 1000 engaged
in 1908 only a third of the number died that died in 1906, and half the
number that died in 1907.

(*) Figures for recent years supplied by editors.

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 be effective by the mosquito
discoveries not only checked the progress of the pest, but banished
it forever from the Isthmus. In this way, and in this alone, was
the building of the canal made possible. The supreme credit for its
construction therefore belongs to the brave men, surgeons of the United
States Army, who by their high devotion to duty and to humanity risked
their lives in Havana in 1900-1901 to demonstrate the truth of the
mosquito theory."(7)

(7) Bishop: The French at Panama, Scribner's Magazine, January,
1913, p. 42.

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(7a) 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 could possibly be appointed as a public
health officer, not, as is now so often the case, the man with the
political pull.

(7a) Connecticut.

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.




TUBERCULOSIS

IN a population of about one million, seventeen hundred persons died of
tuberculosis in this state in the year 1911--a reduction in thirty years
of nearly 50 per cent. A generation has changed completely our outlook
on one of the most terrible scourges of the race. It is simply appalling
to think of the ravages of this disease in civilized communities. Before
the discovery by Robert Koch of the bacillus, we were helpless and
hopeless; in an Oriental fatalism we accepted with folded hands a state
of affairs which use and wont had made bearable. Today, look at the
contrast! We are both helpful and hopeful. Knowing the cause of the
disease, knowing how it is distributed, better able to recognize the
early symptoms, better able to cure a very considerable portion of all
early cases, we have gradually organized an enthusiastic campaign which
is certain to lead to victory. The figures I have quoted indicate
how progressively the mortality is falling. Only, do not let us be
disappointed if this comparatively rapid fall is not steadily maintained
in the country at large. It is a long fight against a strong enemy,
and at the lowest estimate it will take several generations before
tuberculosis is placed at last, with leprosy and typhus, among the
vanquished diseases. Education, organization, cooperation--these are the
weapons of our warfare. Into details I need not enter. The work done by
the National Association under the strong guidance of its secretary, Mr.
Farrand, the pioneer studies of Trudeau and the optimism which he has
brought into the campaign, the splendid demonstration by the New York
Board of Health of what organization can do, have helped immensely in
this world-wide conflict.


SOME years ago, in an address at Edinburgh, I spoke of the triple gospel
which man has published--of his soul, of his goods, of his body. This
third gospel, the gospel of his body, which brings man into relation
with nature, has been a true evangelion, the glad tidings of the final
conquest of nature by which man has redeemed thousands of his fellow men
from sickness and from death.

If, in the memorable phrase of the Greek philosopher, Prodicus, "That
which benefits human life is God," we may see in this new gospel a link
betwixt us and the crowning race of those who eye to eye shall look on
knowledge, and in whose hand nature shall be an open book--an approach
to the glorious day of which Shelley sings so gloriously:

Happiness
And Science dawn though late upon the earth;
Peace cheers the mind, health renovates the frame;
Disease and pleasure cease to mingle here,
Reason and passion cease to combat there,
Whilst mind unfettered o'er the earth extends
Its all-subduing energies, and wields
The sceptre of a vast dominion there.

(Daemon of the World, Pt. II.)