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DEVILS, DRUGS,
AND
DOCTORS
HOWARD W. HAG G ARD
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DEVILS, DRUGS, AND DOCTORS
DEVILS, DRUGS, AND DOCTORS
THE STORY
Of the Science of Healing from ^edicine-<:^an to Doctor
By Ho\vARD W. Haggard, M.D.
Associate Professor of Applied Physiology, Yale University Author of ''Tun Science of Health and Disease"
WITH many illustrations FROM
original sources
William Heinemann (Medical Books) Ltd. LONDON
PRINTED IN THE UNITED STATES OF AMERICA
THIS BOOK IS DEDICATED TO
. ' :'A
HI lid
JOSEPHINE F. HAGGARD ici-l
CONTENTS
Part One THE CONQUEST OF DEATH AT BIRTH
I. Childbirth and Civilization 3
The care given the child-bearing woman; an index of civilization — Medieval in- difference to the suffering of women — Baptism before birth — Filthy ages of faith — Conditions for the woman of today — Leaders in the conquest of death — The cultural lag — Low position of women in the United States — How primitive women bear their children — Why they have few difficulties — The detrimental influences of civilization — -Native confinements — Customs of purification — Labor believed a voluntary act on the child's part — Rough assistance in difficult labor — Saliva as a healing agent — ^The rise of the midwives— Early regulations to con- trol midwives — The obstetrical chair — Innovation of using a bed for childbirth — Indian obstetrical practices — The medicine of the ancient Greeks — Legends of y€!sculapius — Hygeia — A celestial professor — Restoring the population of Ha- des— Treatment in the Temple of ^Esculapius — Discrimination against child- bearing women — The oath of yEsculapius — Hippocrates the Great — Manifold duties of Greek midwives — Infant exposure — Abortion — Systematized supersti- tions of the Romans — The Greek physicians migrate to Rome — ^They collect their fees — Cato's prediction — Pliny — No laws against malpractice — The Greek physicians misbehave themselves — Royal intrigue — Greek medicine develops in Rome — Soranus — ^The peak of ancient midwifery — ^The opinion of Soranus on abortion.
II. Sairey Gamps and the Midmen x5
Medicine declines and fanaticism rises — The most unfortunate period in the history of womankind — Woman pays for the fall of man — A ban put upon abor- tion—C^csarean section advocated — Crude surgery — Sex concepts and theology — The supervision of midwives and prostitutes — Sairey Gamps and vagabond sur- geons— Shepherds and herdsmen excluded from obstetrical cases — A sign of advancing civilization — Sanitary conditions in medieval cities — Unpaved streets and pigpens — Before the time of handkerchiefs and nightgowns — The Garden of Roses for Pregnant Women — The Byrth of Mankynde — A physician burned for attend- ing childbirth — A gentler influence in civilization — Ambroise Pare — A place for God's hospitality — Conditions at the Hotel Dieu — Nordau's description of its horrors — Two hundred infants in eight beds — Managerial difficulties settled — Pare becomes an army surgeon — His experiences at the battle of Turin — Military compassion — "I dressed his wounds and God healed him" — Catherine de' Medici — Pare becomes chief surgeon to four kings of France — Massacre of St. Bartholomew's night — ^Treatment of gunshot wounds — Boiling oil — Pate's
vii
viii CONTENTS
gentler treatment — "A man very impudent and without any learning" — Par6 reintroduces podalic version — Conditions existing before its use — How the Cesarean operation got its name — The beginning of obstetrics — A school for midwives — Changing customs — A physician attends the mistress of Louis XIV — The midraen — Clement made royal accoucheur — The accoucheurs become fashionable.
III. "The Compassion of Peter Chamberlen" 44
The Chamberlen family flees to London — The invention of the obstetrical for- ceps— The invention kept a secret — The Chamberlens attempt to control mid- wifery— A Voice in Ra/nah — The compassion of Peter Chamberlen — Obstetricians opposed — Amazing prudery — Violent derision — William Smellie — Mrs. Nihell, the Hay Market midwife — "AndrianusSmelvgot" — "Dr. Slop"' — The "dangers and immorality" of employing "men in midwifery" — Survival of contemptuous attirude toward obstetricians — Hugh Chamberlen attempts to sell his secret in France — An unsuccessful demonstration— Medical ethics — Famous charlatans of the seventeenth and eighteenth centuries — Queen Anne's weak eyes — Sir William Reed and Dr. Grant — Chevalier Taylor — The most ignorant man Dr. Johnson ever met — Literary men inclined to quacks — "Spot" Ward— Satire of Moliere — Hugh Chamberlen sells his secret in Holland — A grim joke — "Dr. Slop's" for- ceps slip — Purpose of the obstetrical forceps — Pare's erroneous idea — His tale of an execution — A book for midwives "fitted to the meanest capacities" — Distor- tion of the pelvis — Rickets — Sunlight and cities — Measurement of the pelvis — Revival of abortion and premature labor to avoid difficult childbirth — The attitude of the French — Guy Patin's comments on the prevalence of abortion — Abuse of obstetrical instruments — Meddlesome midwifery — An extreme reac- tion— William Hunter's example — Princess Charlotte's death — Obstetrics cease to be a branch of surgery.
IV. "A Gentleman with Clean Hands May Carry the Disease" 66
The rise of a pestilence — Ravages of puerperal fever from the seventeenth to the nineteenth century — Hospitals where the disease flourished — "Laudable pus"— An extract from the record of a case of puerperal fever — A physician philoso- phizes— Midwifery in Colonial America — Disease and bigotry — The first regula- tion to control midwives in America — Mr. John Dupuy, M.D., man midwife, dies — New York champions "Granny" Brown — Dr. Shippen opens a school of midwifery in Philadelphia — He advertises for women who have virtue enough to admit their ignorance — The medical school of Philadelphia — King's College of New York — Yale University and the Colony of Rhode Island give irregular medical degrees — Dr. Turner — Dr. Shippen becomes surgeon-general of the army of the Revolution — Dr. Benjamin Rush — Oliver Wendell Holmes tells the cause of puerperal infection — His papers condemned — A quotation from his medical writings — "A gentleman with clean hands" — Ludwig Ignaz Philipp Semmelweis — Vienna in the eighteenth century — The old Vienna school of medicine — Baron van Swieten — Mesmer forced to leave Vienna — The AUgemeine Krankenhaus — The methods of Dr. Boer— Semmelweis becomes an assistant at the hospital — Horrible conditions in the lying-in-hospitals — The two divisions of the Vienna hospital — A difference in death rate — Semmelweis's problem — His discovery— Official injustice — The death of Semmelweis— Mortality at childbirth in the United States contrasted with that in other countries — An expression of indifference.
CONTENTS ix
Part Two
THE STORY OF ANESTHESIA
V. "In Sorrow Thou Shalt Bring Forth Children" 93
Anesthesia discovered in the nineteenth century — A new method of administer- ing drugs — Narcotics — Soporific potions — ^The mandrake and its legends — Pare ties his patients — Surgical operations verge on sleight-of-hand — A punishment for prudery — Soporific potions at childbirth — The prescription of Zerobabel Endecott of Salem — Biblical quotation on the pain of childbirth— Sir Humphry Davy uses nitrous oxide — Horace Wells repeats his experiments — William Morton — Dentistry before the days of anesthesia — "Ether jags" — Charles Jack- son— Morton experiments with ether — He administers it for a surgical opera- tion—Oliver Wendell Holmes applies the word anesthesia — Attempts to patent ether — The ether controversy — Dr. Long's operation — Hayden describes an operation before and after the discovery of anesthesia — James Y. Simpson dis- covers the anesthetic properties of chloroform — He administers it at childbirth — An extract from his paper describing his results — He enters a controversy — A reformer with a sense of humor — The clergy condemn anesthesia on religious grounds — Simpson's reply — Objections to all innovations — Anesthesia given Adam at the birth of Eve — Simpson's reply to the objections of the medical pro- fession— Simpson honored — Sir Walter Scott's suggestion — The loss of maternal instinct, an objection to the use of anesthesia — Those who objected — Queen Victoria accepts chloroform — The medical difficulties of Louis XIV — Painless childbirth not yet fully achieved — The cause of the pain — Childbirth without anesthesia — Twilight sleep — Difficulties of administering anesthesia — Recent advances in the search for means to make childbirth painless.
Part Three THE PROGRESS OF SURGERY
VI. Making an Anatomy izy
Surgical operations in ancient Egypt — Forty-three centuries of wound surgery — The great change that came in the nineteenth century — Essentials of surgery — Egyptians lacked knowledge of anatomy — Their method of embalming — Need for surgery shown by archeological surveys — Surgery of the Babylonians and He- brews— Bone of Luz and Adam's missing rib — Anatomical knowledge of the Greeks — Arabs subordinate surgery — Jewish surgeons during the Middle Ages — The crude surgery of that time — Treatment of wounded soldiers — Barbarities during the siege of Metz — Queen Elizabeth's physician — Sir John Pringle and the first Red Cross agreement — Thomas Gales tells of quacks in the army serv- ice— Surgeons in jeopardy of life — Dr. Radcliff and Queen Anne — The medical school of Salerno — The story of treatment given Robert, Duke of Normandy — A medical home health book in verse — A translation by Sir John Harington, the inventor of the water closet — A selection from the medical poems — Medical etiquette in the Middle Ages — Priests enter medicine and the Church issues edicts against this practice — Surgery not respectable — Three classes of men practicing surgery — "Making an Anatomy" — ^Andreas Vesalius dissects the human body —
X CONTENTS
He publishes his work — Violent opposition — Galenic anatomy overthro>»'n — Vesalius diplomatic toward theological concepts — Servetus burned — Vesalius destroys his manuscripts and retires — Scarcity of bodies for dissection — Grave robbers — Diary of Judge Samuel Sewell — The first announcement of a course of anatomy in America — Dr. Shippen's course at Philadelphia — He is attacked — The doctors" mob at New York — The first anatomy law of Massachusetts — Body- snatching — The notorious Burke and Hare of Scotland — The attitude towuid dissection today — Dowie's description of a dissecting-room — "Damnation and Hell hold high carnival."
VII. The Greatest Surgeon 159
Pare and Vesalius hold a consultation at the deathbed of Henry II — ^Red-hot iron and molten pitch to control hemorrhage— Pare reintroduces the ligature — His patient returns home gayly on a wooden leg — Former limitations of surgery — Pare's tale of the wounded King of Navarre — -A fatal wound in the shoulder — Pare treats the Marquise d'Arnet — Consultation with five surgeons — ^The course of treatment — The convalescence — Pare plays the part of a trained nurse — Femi- nine aid at the Siege of Metz — Servant nurses in the London hospitals — Women of drunken and dubious habits — Florence Nightingale dignifies the profession of nursing — Her part in the Crimean War — ^Training the "new-style nurses" — The beginning of hospital cleanliness — Lister and the antiseptic principle — "Laudable pus" — Wound infection and blood-poisoning in the hospitals — Fre- quent amputations — Lister applies Pasteur's discoveries — His experiments — Opposition to his work — The fourth essential of surgery supplied — Where the infection came from — Prevention of infection in modern surgery — ^The great change in surgery — A statement made in 1876.
Part Four THE PASSING OF PLAGUE AND PESTILENCE
VIII. The Black Death 179
Gibbon selects a period during which the human race was most happy and prosperous — A period of great pestilences — ^The bubonic plague — Malaria and other diseases — Gibbon justified — Conditions in his time and before — Diseases of the past — Influenza an uncontrolled pestilence — Stationary populations — The control of pestilence influences death at childbirth — Disease as an affliction from God — Example of this belief — Cosmic disturbances as a cause of disease — Medi- cine an accessory to theology — Cotton Mather's views of disease — The asafetida bag — Medicine comes into its rights — Contrast between medicine and surgery — Modern civilization founded on preventive medicine — A supreme benefit con- ferred on mankind — Medicine and the level of civilization — ^Typhoid fever during wars — Burning the lepers — The control of leprosy — Lazarettos of the Middle Ages — The "great killer" — The plague-ridden ages — The plague of Justinian — Omens of the plague — The plague at Constantinople — Gibbon's comments — ^The plague lies dormant for eight hundred years — The "black death" — Men's be- havior during the plague — Boccaccio's description of an epidemic — Comfort by absolution — Death of the holy pilgrims — A Pope in isolation — Waves of piety — Dice factories that made rosary beads — A quarter of the population swept off — Conditions in cities during epidemics — Persecution of the Jews — Plague spread-
CONTENTS xi
ers — Legal torture — The criminal code of Maria Theresa — Pictures of the plague — The plague in literature — Relation of rats to the plague — Quarantine applied by the Venetian Republic — Origin of the word quarantine — Rousseau detained — Napoleon infringes the regulations — Sieyes's motion to have him shot — Ravages of plague forgotten — An epidemic in the United States — Prevention controls the plague — ^Treatment futile — Medieval plague doctors — Origin of eau de Cologne — "Three adverbial pills" — ^The nobility desert the cities.
IX. Pestilence and Personal Liberty ziz
Asiatic cholera in New York City — ^The "white man's grave" — An epidemic of yellow fever in Philadelphia — Description of conditions there — Part played by the mosquito — Means of prevention — An achievement for civilization — St. Anthony's fire — Patron saints of disease — Shriveled limbs and maimed bodies — Recourse to the monasteries — The cause of St. Anthony's fire — A pesti- lence turned to the service of women — Personal liberty and the prevention of disease — Popular indifference — Smallpox — Famous victims of the disease — Ma- caulay writes of the smallpox of Queen Mary II — The diseases of William III — Smallpox in New England — ^The disease "clears the way for a better growth" — Inoculation as a means of prevention — Lady Mary Wortley Montagu's de- scription— Cotton Mather introduces inoculation into America — Oliver Wendell Holmes describes the introduction — ^The inadequacy of quarantine — Simpson draws some analogies and gives some examples — A beggar woman at Leith — Peddlers with smallpox — Jenner introduces vaccination — An unfavorable reception — ^The American Indians appreciate vaccination — Indifference and for- getfulness, obstacles to vaccination — -Jenner and Napoleon, a contrast.
X. Pestilence and Moralists 133
Moral concepts and fanaticism — ^Two plagues that could be eradicated — Igno- rance and bigotry the allies of syphilis — Plagues involved in the greatest problem of civilization — An imputation of divine origin — Sex is kept a problem — The corruption of the good word moral — False moralists — ^The panderers of the venereal diseases — All disease is immoral — Five centuries of syphilis — An his- torical problem — ^Theory that Columbus brought syphilis from America — A "disease which hath power over all Europe, especially among the Frenchmen" — " Fruit of All Saints againft the Disease of the Island of Espanola" — "A thorn joined to the Rose" — "Every Man His Own Doctor or the Foor Planter s Physician" — A doubt cast on the situation — Charles VIII in Naples — ^The spread of syphilis — Civilization and syphilization advance together — Cardinal Wolsey accused of giving syphilis to Henry VIII — ^The quarantine in Paris— "Four Paris sous to leave the city" — ^The Scottish regulation — Finding a name for the new plague — The fable of "Syphilos" — Syphilis among the American Colonists — John Win- throp records a case — "Blameless Manners" — ^The attitude toward syphilis — Ethics change but disease persists — Some famous victims and some who were not — Speculation as to the cause of syphilis — A patron saint — ^The origin of the name venereal — The leprous taint — Paracelsus advances a theory — Francis Bacon attributes syphilis to cannibalism — An absurd theory close to the truth — The discovery of the organism of syphilis — Animal inoculation — ^The character of the spirochete — Modes of infection — Syphilis a mild disease but persistent — The stages of syphilis — John Hunter's heroic experiment — The late effects of syphilis — Locomotor ataxia and paresis — Syphilis not hereditary — Contact in- fection— Gonorrhea a local disease — Consequences in women — Blind chil- dren— Humane laws for economic reasons.
xii CONTENTS
KI. The Medical Thread in the Moral Snarl 159
Moses on venereal disease — Prostitution held responsible for the spread of dis- ease— Bernard Mandeville's satiric defense of "Public Stews" — "The Exchange Wench" — Mandeville's plan — A home for superannuated courtesans — A house of prostitution under royal charter— It supports a university — The prostitutes revolt — A plan of treatment that failed — The old Statues of the Stews of Avig- non— Discrimination against the Jews — Antiquity of the distinguishing badge for prostitutes — The story of Judah and Tamar — Moses attacks the "strange women" — Solomon allows the regulations to relax — The Greek courtesans set the fashions — Prostitution a social institution — Socrates advises Aspasia — Pericles defends her — She marries a wealthy grain merchant — The moral stand- ard among the Romans — Prostitution grows — The crime of adultery tolerated — Promiscuity results — Glorified vice and the inmates of the fornices — The rise of the Christian religion — Its emotional appeal — Chastity becomes a religious virtue — The sexual instinct underrated — The sublimation of the instinct — Sup- pression and distortion — A strange manifestation of the suppressed instinct — The saints of the desert — St. Simeon Stylites — St. Mary of Egypt, a reformed prostitute — Theology seeks a way out — Sin preferable to demoralization — Pros- titution sanctioned — Continence as a cause of "corruption of the flesh" — A medieval fallacy — Benjamin Franklin's views — "Itinerant wives and maidens" — The brothel system reestablished — Prostitution under ecclesiastical control — A changing attitude and a persisting problem — Theodora's solution — Edicts of Louis IX — Futile attempts to suppress prostitution — Prevalence of syphilis among prostitutes — Man's responsibility and his hypocrisy — Early marriage, a possible solution — The medical thread in the moral snarl.
Parf Five THE HEALING ART
XII. The Halt, The Lame, and the Blind 2.81
Faith healing — Hygienic therapy — Drug cures — Civilization and the type of medical treatment — Primitive man's conception of disease — The medicine-man's method — Faith healing persists among civilized peoples — Inspired confidence — Excommunicated May bugs — Faith healing under many names — A useful form of treatment — The physiological basis for faith healing — ^Testby ordeal — Predic- tions of death — The martyr's anesthesia — Rage and pain— Male demons that attack women — Marks of their violence — Hysteria — Pseudo-pregnancy — Pseudo-hydrophobia — Shell shock — Loss of confidence — Railroad spine — Mind and body are one — Allegorical elevation of organs — Peculiar beliefs concerning blood transfusion — The correlation of bodily functions — Three classes of dis- ease— The body usually cures itself — Patients who die — Hoc ergo f rafter hoc — A royal touch for the king's evil — Edward the Confessor — Examination by the king's physicians — Dr. Samuel Johnson touched by Queen Anne — Touch pieces — The opinions of various kings — Louis XIV — Charles II the busiest toucher — Cramp rings of Henry VIII — Queen Elizabeth's blessed ring — The ages of faith — Christianity and the return of superstition — Demoniac cause of disease — Miraculous cures — The origin of hospitals — Conception of disease among early Christians — Possession by devils — King Charles II of Spain — Harmfulness of night air -Cure by exorcism — ^Testimonials — Brutal treatment of the sick — A
CONTENTS xiii
thriving business in relics— A fearher from the Holy Ghost — St. Peter's toe nails — Monastic rivalry — Relics of the three wise men from the East — Saint Ursula and her virgin martyrs — Loundres and St. Anne de Beaupre — Peace and security even though death results. "
XIII. White Magic and Black 303
Healing cults of today — Revival of medieval practices — Changing cults — Cagli- ostro — The "celestial beds" of James Graham — Lady Hamilton — Valentine Greatrakes the stroker — Robert Boyle's testimony — The Earl of Sandwich has the "gift of healing" — Andrew Jackson Davis, the seer of Poughkeepsie — His book of revelations — Attempts to make spiritualism a national institution — Davis's cult and his following — His principle opposite to that of Christian Science — George O. Barnes, the mountain evangelist — The Mormons set bones by faith — Francis Schlatter — A postal fraud — John Alexander Dowie — Doctors, Drugs and Devils — Phineas Quimby of Maine — Animal magnetism — Hypnotism — Quimby treats the ills of "misunderstood women" — New Thought — Mrs. Mary A. Morse Baker Glover Patterson Eddy — Her hysterical ailments — She appeals to Quimby — She becomes a faith healer — Science and Health — Disputes in the Christian Science organization — Delusions of persecution — Malicious animal magnetism — Queen Elizabeth makes witchcraft a capital offense — King James I writes a book on witchcraft — Persecution of witches — Trial of witches in Pennsylvania and New England — Mrs. Eddy attempts to revive witchcraft — White magic and black magic — Modern philosophies that are plagiarisms — The principle used by Mrs. Eddy — An ancient theory — Bishop Berkeley — Mrs. Eddy in a dilemma — Cleanliness not a cardinal virtue in her time — An index of moral frailty — Mrs. Eddy on bathing children — Disadvantages of white magic — The advantages of Christian Science — An impressive forn. of faith healing — Chiro- practic manipulation — Bone setters — Mrs. Mapp — Crazy Sal — Hogarth's cari- cature—Andrew Still gives bone-setting a new name — Osteopathy — Laying on of hands with impressive force — ^The English opinion — Disease from dislocated spines — Faith healing by diet — Cyril's liver — Fish and brains — Vitamins — Yeast — Appliance cures — Dr. Perkins of Yale — The famous Dr. DuBuke branded for stealing indigo — Perkins tractors — Cures with blue glass — Doctors avoid faith healing — An unsympathetic attitude.
XIV. A Drug on the Market 3Z?
Drugs as a form of faith healing — The history of a drug told in the definition — Potatoes as a medicament — Potable gold — The treatment of Sir Unton — A bottle of medicine and a box of pills — The belief in their necessity for treatment — An example by Oliver Wendell Holmes — Carlyle and his wife's medicine — Drugs and superstition — Egyptian mummy — A protest by Pare — Unicorn's horn — A gift from Pope Clement VII^ — Unicorn used by kings of France — Its properties investigated by the Royal Society — Governor Endicott loans Governor Win- throp a horn — The bezoar stone of Charles IX — The king and Pare experiment on a condemned criminal — The bezoar fails as an antidote — The moss from the skull of a criminal — A piece of the hangman's rope — Cotton Mather prescribes sow bugs — Robert Boyle includes the sole of an old shoe — Urine recommended as a mouth wash — Madame de Sevigne — Richelieu's potion — ^The sympathetic powder of Sir Kenelm Digby — King James tries it — Proprietary medicines as faith cures — A fallacious test for drug — Drugs and spices — The drug trade — Sea supremacy and exploration — The Dutch control the drug trade — Bloodshed
xiv CONTENTS
for the clove — ^The death of King Charles II — ^The medical treatment he re- ceived— An endless array of drugs — King James I resists medical treatment — Poison lore — Cleopatra as a medical writer — Mithridates, King of Poncus, ex- periments— Egyptian medicine — The universal antidote — Theriac — Discordes compiles the medical drugs — Medieval Herbals — Galen's system of treatment — Vegetable simples — Galen's life — His medical theories — The qualities of the bodv — "Cool as a cucumber" — Herb doctors — The apothecaries' trade at Rome — Apothecaries of Europe — The grocers sell drugs — Conserves and other things for Sir Walter Raleigh and a physic for Mr. Edward Nichols — "Retired for physic" — An appalling amount of unnecessary purging — Bleeding as a form of treatment — Dr. Sangrado — Apothecaries that prescribed — The objections of the phvsicians — Situation in France and England — The comments of Pope and Dr. Johnson.
XV. The Turning-Point 345
Paracelsus introduces metallic poisons — Physicians that go off on a tangent of mysticism— Emmanuel Swedenborg — ^The life of Paracelsus — Medical practice, low company, and mysticism — His lectures at Basel— "From the obscene into the incomprehensible" — Charges against the character of Paracelsus — Medicine and nonsense — The fountain head of mysticism — Specific remedies — A remedy for svphilis — Physicians fail to cure syphilis — Vagabond quacks succeed — Over- dosing with poisons — How antimony got its name — The controversy over its use — King Louis XIV gets well — Napoleon takes one emetic and refuses a second — A type of reasoning in medical matters — The physician asks a question — Con- trol observations — An obvious method and its limited employment — Even an economist may be a medical faddist — Scientific methods — A complete revision of medicine — ^The rise of homeopathy — ^The signature of disease — Like cures like — Hahnemann — Oliver Wendell Holmes separates the valuable drugs and sinks the rest — The specifics he chooses — "Not discovered by our art" — Alexander the Great and Cromwell die of malaria — Louis XIV is cured with quinine — ^The introduction of coffee, tea, and tobacco — "Tobacco-drinkers" have their "noses slit" — Captain Cook finds a way to prevent scurvy — Fewer drugs but more attention to the needs of the body — Vitamins, iron, sunlight and salt — Goiter and cretinism — A suggestion of ancient beliefs — Fallacies of rejuvenation.
XVI. Toward a Better Civilization 358
Treatment gives way to prevention — Bacteria as a cause of infectious disease — The strongest weapon for the betterment of mankind — Louis Pasteur — From the diseases of wine to the diseases of man — A study of fermentation — Sponta- neous generation — A control experiment — Wines are cured — The diseases of silkworms — Pasteur discouraged — Lister's letter — Pasteur studies the diseases of animals — Vaccines — A challenge and a demonstration — Pasteur studies the dis- eases of man — Hydrophobia — Little Joseph Meister — Berger Gulippe — The chil- dren from New Jersey — Metchnikoff develops a prophylaxis against syphilis — He receives the Nobel Prize — Diphtheria conquered — The diagnosis of syphilis — Diagnosis as important as cure — A test for cancer needed — The demand for a better treatment for syphilis — Ehrlich exercises his chemical imagination — He develops a cure — Physicians and moralists, a contrast — ^The control of public opinion — The least developed field of medicine — Ancient customs in diagnosing insanity — An indication of uncertainty — ^The abuse of the insane — Bedlam — "A keeper the which the madde man do fear" — "Toms o' Bedlam" — Shake-
CONTENTS XV
speare anticipates physicians by a century — "A mind diseased" — The Lunatics tower — Treating symptoms — Philippe Fine! — The champion of the insane^ Dorothea Dix — Establishment of asylums — Paresis a form of syphilis — Noguchi's discovery — Salvarsan fails to cure paresis — Discrimination against syphilitics — Clinics— Ignorance and a moral attitude— The arrest of paresis— The civiliza- tion toward which the medical sciences lead.
Part Six MEDICINE THROUGH THE AGES
XVII. Civilization and Medicine 383
New York in darkness or New York deserted— Consequences of rising pesti- lences— Medical science ranks in importance with food supply — Indifference towards medical science — Active opposition and its consequences — Smallpox does not stay where legislation favors it— Modern people who cling to ancient philosophies — Savages riding in automobiles — Primitive medicine and rational medicine — Superstition and reason— The mystery of disease— Man is ancient but civilization is new— Modern men controlled by primitive instincts — Instincts overcome by education— Intelligent people who are controlled by- faith— Rational medicine a measure of civilization— The transition from primi- tive to rational medicine — Moses on sanitation — Divine healing among the Greeks — A reform in the temple cult — Hippocrates founds rational medicine — His precepts — His aphorisms — The first physician to differentiate diseases — The kind of treatment he gave — Decline of Greek civilization and medicine — Galen's theories — Medicine deteriorates — A theology hostile to science — ^Theology controls the western civilization — Subordination of body to perfection of spirit — A time of low civilization — Medicine reverts to its primitive state — Idealism leads to the founding of hospitals — Intellectual efforts in the Middle Ages — ^The Arabic civilization — Rational medicine revived — It returns to Europe — Revolt against bigotry and obscurantism — Paracelsus sets an example — Founding of human anatomy — Revival of the scientific spirit — Harvey demon- strates the circulation of the blood — The state of medicine at the beginning of the eighteenth century — Morgagni founds clinical medicine — Revival of the Hippocratic principles — Vaccination — The state of medicine at the beginning of the nineteenth century — ^The scientific spirit amplified — Great advances that resulted — Anesthesia— Control of puerperal infection — Trained nurses — Aseptic surgery — Preventive medicine — The healthiest period the world has ever known — The possibilities of scientific medicine — No assurance that these pos- sibilities will be realized — Medicine depends upon advancing civilization — Civilization prone to regress — ^The dangers to civilizatioa and to medicine— The persistence of bigotry and obscurantism.
Index 397
Part One THE CONQUEST OF DEATH AT BIRTH
"To overthrow superstition, to protecf motherhood from pain, to free childhood from sickness, to bring health to all man- kind:
"These are the ends for which, through the centuries, the sciiolars, heroes, prophets, saints and martyrs of medical science have worked and fought and died, as are here recounted."
— Yandell Henderson
"On either side of the river, was there the tree of life, which bare twelve manner of fruits, and yielded her fruit every month: and the leaves of the tree were for the healing of the nations."
— ^Revelation, xxii, 2,
C H A P T E R I
CHILDBIRTH AND CIVILIZATION
He position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged best by the care given her at the birth of her child. Accordingly, the advances and regressions of civilization are nowhere seen more clearly than in the story of '-J childbirth.
Child-bearing has always been accepted among primitive peoples as a natural process, and as such treated with indifference and
BIRTH OF CLEOPATRA'S CHILD
From a bas-relief on the Temple of Esneh. The amazingly large size in which the child is represented is indicative of its royal parentage. The position taken by Cleo- patra is still used during childbirth by many primitive peoples.
brutality. At the height of the Egyptian civilization and again at the height of the Greek and Roman civilizations the art of caring for the child-bearing woman was well developed. With the decline of the Greek and Roman civilizations the care of woman deterio- rated; for thirteen centuries the practices developed by the Greeks were lost or disregarded in Europe. The art of caring for the child-
4 DEVILS, DRUGS, AND DOCTORS
bearing \Noman was not brought back to its former development until the sixteenth or seventeenth century of our era.
The medieval Christians saw in childbirth the result of a carnal sin to be expiated in pain as defined in Genesis III: 16. Accord- ingly, the treatnient given the child-bearing woman was vastly worse than the mere neglect among the primitive peoples. Her sufferings were augmented by the fact that she was no longer a primitive woman, and child-bearing had become more difficult. Urbanization, cross-breeding, and the spread of disease made child- bearing often unnatural and hazardous. During medieval times the
BAPTISMAL SYRINGE For applying this rite to infants before birth in cases of difficult labor. The par- ticular syringe shown here was designed and described by Mauriceau in the seven- teenth century and Laurence Sterne, in Tristram Shandy, quotes the original descrip- tion in full. This syringe was the "squirt" of his "Dr. Slop." In some varieties of the instrument the opening of the nozzle was made in the form of a cross to add sanctity to its use.
mortality for both the child and the mother rose to a point never reached before. This rise of mortality was in part the consequence of indifference to the suffering of women. It was due also to the cultural backwardness of the civilization and the low value placed on life. It was aggravated by the increasing difficulty attending childbirth. These were the "ages of faith," a period characterized as much by the filth of the people as by the fervor and asceticism of their religion; consequently nothing was done to overcome the enormous mortality of the mother and of the child at birth. It was typical of the age that attempts were made to form intrauterine baptismal tubes, by which the child, locked by some ill chance in its mother's womb, could be baptized and its soul saved before the mother and the child were left to die together. But nothing was
CHILDBIRTH AND CIVILIZATION 5
done to save their lives. No greater crimes were ever committed in the name of civilization, religious faith, and smug ignorance than the sacrifice of the lives of countless mothers and children in the first fifteen centuries after Christ among civilized mankind.
With the Renaissance of European civilization there came a change in the care given the child-bearing woman. This change was slower in advancing than were many of the other changes which marked this period. Material advancement was made before humanitarian advancement.
The care of the child-bearing woman is an index of the civilization of the community as a whole and not alone of the leaders of the civilization. These leaders blaze the way, they show the path to a better civilization, but that civilization comes only when the path is followed. Throughout the story of childbirth these leaders of the conquest of death at birth stand out from other men like giants in their times. These men, whose praise is unsung and whose names are unknown to most people, rank higher in the advance of our civilization and are greater men by every standard than any of the kings and statesmen whose names are taught to school children and whose works are measured by the ephemeral boundaries which they won for the countries where they fought and intrigued. The great men who were the champions in the conquest of death at birth have not fought in vain. Their glory, to the measure which the advance of civilization will allow, is in every child who lives today and in every woman who bears a child.
The modern conquest of death at birth was started in the six- teenth century. As a result of its advance, the woman of today, if she will and if the civilization of her community gives her the privilege, may look upon pregnancy not as a curse, not as the inevitable result of a "sin," but as a privilege of her sex, to be indulged in only when she chooses to do so. Hers is a pregnancy no longer darkened with the shadow of the wing of death, but illuminated with the clear light of the precise medical knowledge of her condition. She is told in advance the safety of her state and delivered of her child with a minimum of suffering never dreamed of by her primitive sister of twenty-five centuries ago, nor even by her sister of three centuries ago, as she expiated her sin in the
6 DEVILS, DRUGS, AND DOCTORS
heritage of Nvomankind or was butchered to death by the midwife or the barber.
The conquest of death at birth has made its victories. In its means of advancement it has run ahead of the slowly moving civilization. It now waits for that lag of culture, the slow pulling of the feet out of the mire of medieval ignorance, which must end before woman can benefit to the fullest by the victories of the con- quest. The neglect of the parturient woman and her child, seen in the deaths at birth and in the hazard of bearing children, is no fault of the medical profession. That profession has led in the conquest, but it can give no more than the community will accept. It cannot of itself overcome the inertia of civilization, nor say what value shall be placed on the lives of women and children.
Young civilizations are like adolescent boys: they are strong and aggressive, they take a noisy pride in the toys of their material advancement, but the very uncertainty of their unproven strength makes them ashamed to stoop to acts of kindness for fear they will be accused of weakness. They have the Utopian ideals of adoles- cence, but they have, too, its self-consciousness and blindness and ignorance; they reach for the stars and tread the lilies underfoot; they ignore the real problems of life and civilization. There are twenty civilized countries in the world which record the proportion of mothers and children who die at childbirth. The order of those fatalities places the civilization of a country. The United States ranks nineteenth from the top. In only one of these twenty countries, and that one in South America, is there a greater hazard for the child- bearing woman.
Child-bearing among primitive peoples is today what child-bear- ing was to our ancestors twenty-five centuries ago, and little different from what it was three centuries ago, except that some of the hazards were greater at the later period than at the earlier. Intuition would lead the primitive woman, as it would the animal, to bear her young, and by laceration with her teeth to sever the cord which attaches the child to its mother. The primitive woman had little difficulty with childbirth; but she had not been exposed to the evils of civilization. Distortion of the bones of her pelvis by rickets, and the consequent difficulty or impossibility of natural birth, did not affect her, for she
CHILDBIRTH AND CIVILIZATION 7
had not yet been subjected to the diet evolved by civiUzation nor did she shut herself from the radiations of the sunlight by glass and clothing. Furthermore, she was not subject to that mongrelization characteristic of civilization, the cross-breeding which commerce makes possible. Her people were of one size; her baby was suited to the size of the pelvis through which it must emerge.
The native woman led a life of active work; in consequence, her child was small. By her exertions, carried on to the day of her delivery, the child was literally shaken into the normal head-down position for the easiest and safest birth. Even in urban communities today hard work and some privation have their effects in making childbirth easier. Among women who do no heavy manual work the babies are heavier at birth than among those women who do manual work; the easier births among the working class are not, as is often supposed, due to a nearer approach to natural conditions — often far from it — but, if they occur, are due to the smaller size of the children born. •
The woman of native or primitive peoples was not in horror of the devastation of childbed fever. The hand of no medical student or accoucheur of the pre-antiseptic age brought to her the con- tamination from the autopsy room or from her stricken sisters. Nor did she take her place in the filthy bed of a hospital of the seven- teenth, eighteenth and even early nineteenth centuries, to lie perhaps with four other patients in a bed five feet wide, as at the Hotel Dieu at Paris, and wait, if she survived the fetid air, the pestilence of the place, and the butchery of the midwife or student, for the fever, engendered by the "weather," which killed from two to twenty of every hundred of her sisters who were forced to accept the fatal charity of such places. The primitive woman met all of these refine- ments of civilization later — when she met the civilized peoples. She met also other things which influenced her child-bearing; she met syphilis and tuberculosis, plague and typhus fever, gonorrhea and alcohol, and worst of all she met the crowding into cities and the shame taught by the Christian religion.
The fact that labor is a more natural process among primitive women does not imply that most civilized women cannot bear their children with little help. But a vastly higher percentage are unable
8 DEVILS, DRUGS, AND DOCTORS
to do so than was the case with the primitive women. CiviUzation. and its blessings imposed an increasing number of penalties upon child-bearing, and for centuries, while our modern type of civiliza- tion was developing, no progress was made to counteract these penalties. Modern science has intervened at last and is able to compensate, and more than compensate, for the handicap of civiliza- tion. It can now save lives that would have been lost even under the most natural conditions. It can do more, for it can minimize for women the effects that child-bearing might have upon length of life, a consideration that did not affect the short-lived primitive peoples. The primitive woman had but one great fear in child- birth; that was that the child she carried would be in an abnormal position — as, for instance, transversely across the pelvis instead of in the normal head-down position — so that it could not be born. Such cases were fatal to both the child and the mother, but they are so no longer.
In childbirth among primitive peoples the woman usually retired from her tribe as the birth of the child became imminent. In some cases she would go alone, but more often she would be accom- panied by a friend or some old woman, the prototype of the midwife. She retired either into the woods beside a stream or lake, or into a shelter set apart for child-bearing; in some instances the women retired also to these shelters for the duration of their menstrual periods. While isolation was the usual custom, it was not so always; among the natives of the Sandwich Islands the "confine- ment" was public and the performance was witnessed by all who happened to be about. There, contrary to the common practice, an old man usually served in the capacity of midwife and the woman was delivered sitting on his lap, while her friends gathered about to render assistance and give advice. A surgeon of the American army attended, in the middle of the last century, the wife of an Umpqua chief. He states that he found the patient in a lodge rudely constructed of driftwood, packed to suffocation with women and men. The stifling odors that arose from their sweating bodies, combined with smoke, made it impossible for him to remain in the apartment longer than a few moments at a time. The assem.bly tt^as shouting and crying in the wildest manner and crowding about
CHILDBIRTH AND CIVILIZATION 9
the unfortunate sufferer, whose misery was greatly augmented by the kindness of her friends.
Among most primitive peoples the mother bathed in cold water when the child was born, and either returned immediately to her tasks or waited for some time until she had undergone a period ot isolation and sacramental purification. The purification among some peoples developed into a rite of a religious nature. Funda- mentally it served the purpose of giving the woman a much-needed
CEREMONIAL PURIFICATION AFTER CHILDBIRTH AMONG THE SIAMESE For thirty days after the first child, and for a shorter period after each subsequent child, the mother exposed her back and abdomen to a fire kept burning day and night and at a distance scarcely two feet from her.
rest, but often the ceremonial aspects which attached to it made it more of a torture than otherwise. For instance, among the Siamese it was required that the expulsion of the child should be followed by a month of penance for the mother. It was impressed upon the female mind in Siam that the most direful consequences to botl mother and child would ensue unless for thirty days after the birth of her first child — a period diminished to five days at subsequent births — she exposed her naked abdomen and back to the heat of a blazing fire, not two feet distant from her, kept up incessantly day
10 DEVILS, DRUGS, AND DOCTORS
and night. The woman, acting as her own turnspit, exposed front and back to the excessive heat, while the husband or nurse was at hand to stir up and replenish the fire. The practice had at least one virtue — it allowed the women of that land to escape the evils that result so often among other natives from resuming household duties too soon after the birth of their children. The Siamese mother was guaranteed by this custom one month of undisturbed rest by her own fireside.
Most primitive peoples have held the belief, which has persisted even among some civilized peoples almost to the present time, that labor was a voluntary act upon the part of the child, due to its desire to escape from its confined quarters. The woman who assisted at the birth did all she was able to coax out the child by promises of food, and resorted to threats if the child was obdurate. The expec- tant mother was even starved during the last week of her pregnancy in order that the child might be more willing to emerge and obtain the milk that awaited it. The character of the labor undergone by the woman was referred to the disposition of the child; all diffi- culties were blamed upon its evil disposition. This belief afforded good grounds for the destruction of the child by efforts at forcing its delivery and even by instruments designed for this purpose, since a child so perverse as to refuse flatly to appear merited death, as did the mother who carried such a child.
If the labor of the primitive mother was difficult, assistance of the straightforward type might be called into play. She was picked up by the feet and shaken, head down, or rolled and bounced on a blanket, or possibly laid on the open plain in order that a horseman might ride at her with the apparent intention of treading on her, only to veer aside at the last moment, and by the fear thus inspired aid in the expulsion of the child. Again, she might be laid on her back to have her abdomen trod upon, or else be hung to a tree by a strap passed under her arms, while those assisting her bore down on a strap over her abdomen. Such practices as these last were known in Europe four hundred years ago. Music, as in singing or the beating of drums, might form a part of the accompaniment of labor, and even a volley of gun-fire has been used. Among the ancient Greeks sacred son^s were sung during childbirth, and even
CHILDBIRTH AND CIVILIZATION
11
today the lower class of Jewish women wail their accompaniment to the shrill cries of the parturient woman. In diflficult labor the medicine-man of the tribe, or his successor at later periods, the priest, might be called in; the latter, perhaps, would hastily mumble a few verses of some book, for example the Koran, spit in the patient's face, and leave the rest to nature. If one doubts the efficacy
AN INDIAN BRAVE HASTENING LABOR
Formerly among some of the tribes of American Indians labor was hastened by placing the woman on the prairie and having a horseman ride at her with the apparent intention of trampling her. Although the rider turned aside at the last moment, the fear inspired in the woman was sometimes effective in shortening her labor.
of saliva, particularly fasting saliva, to aid the parturient woman, one h'as but to turn to Pliny's Natural History to see the multitude of diseases it cured in his time. Before we smile at Pliny's gulli- bility, or the natives' unsanitary practice, let us remember that Jesus cured the blind with spittle.
In even the most remote period, however crude or primitive the people, aid was given the child-bearing woman. The delivery of
12 DEVILS, DRUGS, AND DOCTORS
children and the healing of wounds are two arts that can be traced to earliest records and of necessity received attention from the most orimitive people. Women who had themselves borne children and were thus taught by experience assisted their neighbors, just as war- riors or hunters, exposed to injury, rendered aid to their injured fel- low men. As the organization of the community advanced, some of these women who assisted at childbirth did so regularly, and later for gain. Thus arose the midwife, at first a blessing and a comfort, but later the greatest impediment to the advance of the obstetrical art. With the coming of civilization the care of the wounded soldier or hunter fell into the hands of the physician, the priest, the barber or surgeon; advance was made, although slowly, because it was held back by blind prejudice. Not so with childbirth, for the mid- wife held her position. The art was in the hands of women of low caste. Assistance at childbirth was looked upon as a woman's work, and because of the type of women who plied this trade progress was impossible. The aid of the priest, or man possessed of mystical power, and later the physician, was called in difficult cases only when the efforts of the midwife were ineffective. It is only at the peak of ancient civilizations and quite late in our own, that the physician personally took charge of labor in occasional cases.
The midwife is found in the very beginning of those civilizations which have contributed to our ow^n. The progress of these civiliza- tions and the height to which they reached are marked by the development of regulations to control the practices of the midwives and by the care given to child-bearing women. Among the ancient Jews more attention was paid to the hygiene of pregnancy and child- birth than to any active assistance for the lying-in woman. Hygienic measures were, with the Jews, a part of religion, while in difficult births the women "were comforted until they died." With them delivery took place on a stool or in the lap of another w^oman. In the first chapter of Exodus, when Pharaoh commands the midwives to slay all Jewish infants of the male sex, mention is made of the obstetrical chair, "when you do the offi.ce of the midwife to the He- brew women, and see them upon the stools — ." It was not until the nineteenth century after Christ that the obstetrical chair ceased to be a necessary professional equipm.ent of the midwife, which she
CHILDBIRTH AND CIVILIZATION 13
trundled from patient to patient. Mauriceau of France in the seven- teenth century started the innovation of using a bed for childbirth. Among the Egyptians in 3000 B.C., and in India in the period of Brahmanism, 1500 B.C., the epoch of priestly aid was at its height. The priest no longer beseeched divine interference, but actually
AN OBSTETRICAL CHAIR The obstetrical chair upon which women sat during childbirth is mentioned in the Old Testament. The Greeks occasionally used a special bed or couch for this purpose, but the obstetrical chair continued in general use until the seventeenth century and was often used as late as the nineteenth century. Many different types of chairs were designed, but the one shown here was recommended by Eucharius Roslin in 1513.
rendered effective assistance when called in by the midwife; sur- gical procedures were practiced, manipulation was resorted to, and instruments for removing the dead child began to appear. The priesthood, with a certain knowledge of anatomy and medicine, by manipulation, by internal remedies, more especially cathartic and nauseating, and by mental impressions, overcame some of the diffi- culties of labor. Even podalic version, to be described and discussed later, at its reappearance in the sixteenth century, was known. Reli-
14
DEVILS, DRUGS, AND DOCTORS
gious laws dictated Ca^sarean section upon the dead, and a proper care of the pregnant and especially of the unclean or infected woman. The practices used in India for difficult labor involved calling in the physician, and he made it a bloody practice, a tendency to which the Oriental physician was given, but from which he was restrained to some extent by religious precepts. The Indian practice involves
OBSTETRICAL CHAIR IN USE A reproduction of a sixteenth-century woodcut appearing in The Garden of Roses for Pregnant Women, by Roslin.
the following directions: "When a child cannot be brought forth, the physician may employ the knife in such a way that he by no possibility cuts a living child with it; for if a child is injured, the physician may destroy both child and mother together." In the detailed description of the operation which followed this injunction of caution the only anesthesia mentioned was that embodied in the phrase, "Having cheered up the woman, ..." Nor was there any
CHILDBIRTH AND CIVILIZATION 15
anesthesia for such cases anywhere in the v/orld until the nineteenth century. The same operation of piecemeal removal of the dead child after the prolonged labor in impossible delivery appears in the bloody practices of medieval Europe. In fact, its performance then was the only excuse for calling in male help, but the caution against injuring the mother was not observed at this later period.
The Susruta, a book containing the ancient system of midwifery formerly handed down by word of mouth, states that a woman should be delivered by four aged and knowing women whose 7iails were well trimmed. The law regarding midwives, as it appeared in Athens, states that the midwives must be women themselves past the age of child-bearing, but who have had a child. It was in effect as if it had been said that the requirements for a surgeon were that he had passed the age of fighting and had been wounded. In the Christian era there were no regulations for midwives until 1555, and at that time only in the city of Ratisbon.
Modern medicine comes from Greek medicine. The Greeks were organizers of culture. They assimilated all that previous civiliza- tions had to offer and took the best from existing civilizations. They had the faculty of arranging these foreign elements and raising them to an extraordinary perfection. As the medicine of the early Greeks became organized it was in the hands of the priests of y^sculapius. whose temples of healing were located about the countryside /^sculapius was probably a real character, but in time he was deified and woven into the Greek system of mythology. According to legends, ^sculapius suffered many vicissitudes in his early life. By one tale he was said to be the son of Coronis and Apollo, and was saved at birth only by taking him from his mother's womb as she was brought to her funeral pyre. According to another tale his mother was Ascinoe and, while there were no difficulties in the matter of his birth, he was abandoned as an infant, but was saved from starvation by a goat, ^sculapius survived his stormy child- hood and lived to marry twice. By his first wife he had a daughter named Hygeia. His second wife was Lampetia, daughter of the sun-god. The name i^sculapius has passed from common usage in the language, but that of Hygeia is present in its various forms, such as hygiene, hygienic, and hygienist. The symbol of y^sculapius,
16 DEVILS, DRUGS, AND DOCTORS
the caduccus — the two snakes twined on a staff — has survived, and is still used today as a medical emblem. It is not to be wondered at that a god whose father, Apollo, was a physician and wno had been so intimately concerned with a Cassarean section, and one of the earliest examples of the artificial feeding of an infant, should turn quite naturally to the study of medicine. His instructor in the art was the centaur, Chiron, who, in spite of being half horse and half man, was the most versatile of the celestial professors. The death of ^sculapius came about as the result of an occurrence which has been attributed to no physician since his time. Pluto complained to Zeus that the prolongation of life on the earth, due to the minis- trations of .^sculapius, was keeping down the population of Hades. Zeus, to restore the balance of population, slew ^sculapius with a thunderbolt.
So great, as the Greeks believed, was the power of y^sculapius over disease, so wonderful were the cures which he accomplished, and so noble and pure his character, that they not only made him a god, but erected temples in his honor. These temples w^re not places of barren worship, but were sanatoria, termed .^sclepieia, which in the course of time became the prototypes of our hospitals, sanatoria, and schools of medicine. The means chiefly employed for the restoration of health were sunlight, fresh air, pure water, exercise, and diet. The priests did not, however, hesitate to use drugs and even perform operations if the patient's condition seemed to warrant them, but the whole of their medical procedure was strongly tinctured with superstition and religious practices. In spite of the excellent care given to the sick by the early Greeks, two classes of people were discriminated against — those who were mori- bund and women about to be confined were not allowed in the temple inclosure. The management of the latter class of cases was left entirely to the midwives. Later, as a mark of progressing civilization, the Emperor Antoninus Pius provided a special build- ing at Epidaurus in which confinement cases and those likely to endj fatally might be lodged.
Instruction in medicine was given in the Temple of ^sculapius This instruction was oral, since there were no written medical works among the Greeks before the fifth century before Christ. At the
CHILDBIRTH AND CIVILIZATION 17
conclusion of the medical course the pupils took an oath which embodied the tenets of the physician. This oath, often called the oath of Hippocrates, is in principle as applicable to the ethics of the physician today as it was 2,500 years ago. It is, in part: "I swear by Apollo, the physician, and ^sculapius and Hygeia and Panacea and all the gods and all the goddesses ... so far as power and discernment shall be mine, I will carry out regimen for the benefit of the sick and will keep them from harm and wrong. To none will I give a deadly drug even if solicited, nor offer counsel to such an end; likewise, to no woman will I give a substance to pro- duce abortion; but guiltless and hallowed will I keep my life and my art. I will cut no one whatever for the stone, but will give way to those who work at this practice. Into whatsoever house I shall enter I will go for the benefit of the sick, holding aloof from all voluntary wrong and corruption, including the seduction of females and males, of freemen and slaves. Whatsoever in my prac- tice or not in my practice I shall see or hear amid the lives of men I will not divulge, as reckoning that all such things should be kept secret. ..."
With the lapse of time the religious features of the temple fell away to give place to more and more rational medical treatment, and the priest and the physician separated. The greatest of these early Greek physicians was Hippocrates. His teachings are extant and in many respects form a basis of modern medical practices. Hippocrates the Great was born in the island of Kos in 460 B.C., thirty years after the battle of Marathon arid thirty-one years before the birth of Plato. For nobleness of professional character he has been the model of countless generations of physicians. Under the influence of Hippocrates medicine rose to a degree of development which was not to be attained again for centuries.
At the time of Hippocrates the midwives were a well-organized group with clearly defined duties. Their methods of handling the lying-in woman were at times rough and included the kneading and rubbing of the abdomen and even more forceful mechanical meas- ures such as picking up the woman and dropping her so that she struck forcibly against the bed. But their methods were regulated by the physician and in difl[icult deliveries he was called in to assist,
18
DEVILS, DRUGS, AND DOCTORS
although at this stage of the civilization some contempt was attached to this personal participation of the physician; he was called a "he- grandmother." The duties of the midwife included the execution and direction of the sacred songs sung during labor. When the child was born she did what nurses do today — she showed the child to the father — but her motives were different from that of the nurse;
ANCIENT METHODS OF HASTENING LABOR Among the Greeks at the time of Hippocrates the methods of assisting the par- turient woman were direct and often brutal. The woman was sometimes repeatedly lifted and dropped on a couch. Uncivilized peoples still use similar or even more brutal methods.
the father was to view the child before he acknowledged it as his own, which he did by lifting it. The midwife's duties extended beyond that of actual assistance at the birth. If the family decided not to keep the child, she "exposed" it on a hillside or temple steps, where it might die from starvation or be taken for adoption by some passer-by. At that period infant desertion was a legitimate practice and remained so until the Christian era. The midwife likewise gave
CHILDBIRTH AND CIVILIZATION
19
advice on the physical eligibility of those contemplating matrimony — she ran a sort of primitive matrimonial bureau — treated disease of women and produced abortion if desired. Abortion was then common and not illegal, but under the Hippocratic oath was not ethical for physicians. With their manifold social and medical duties the Greek midwives were an institution, but their field did not extend over into that of the physician.
ANCIENT METHODS OF HASTENING LABOR
A vaix. tion of the method shown in the previous illustration consisted in tying the woman to a couch, which was then turned on end and pounded against a bundle of faggots on the ground. The Greek physicians finally dispensed with these rough procedures, but they were revived by the midwives in the Middle Ages and persisted until the Renaissance and even afterward.
While the Greeks were developing their rational system of medicine their warlike neighbors, the Romans, were without any systematized medicine. The Romans had, instead, systematized superstitions. They looked for aid from their deities, of which there was one for every disease and indeed for every stage of every disease. Their medical practice is summed up in the statement that "even the itch was not without its goddess." About two hundred
20 DEVILS, DRUGS, AND DOCTORS
years before the birrh of Christ a few Greek physicians wandered over into the virgin Roman field. The Romans, like any other super- stitious people, were ready to embrace a new cult. They had never paid fees for having their sick helped. The votaries to the gods had been voluntary and that meant that they had probably con- sisted of promises of great awards while the illness lasted, but only slight compensation on the second thought after the illness was over, and, quite logically, no award if death resulted. The Greek physicians collected their fees. This fact impressed the Romans with the virtue of the treatment, on the principle of that which costs money must be worth having. As Cato phrases it, "a profession which they exercise for lucre, in order that they may win our confidence."
The early experiences of the Romans with Greek physicians were discouraging. Some of the physicians who came first to Rome were the dregs of the profession ; they took advantage of the gullible Romans and badly misbehaved themselves. .Cato, that irritable misanthrope of the second century B.C., as would be expected, had a condemning word to say of Greek physicians. Cato was a Roman Cotton Mather and had a good opinion only of Cato, for in his words he "owed less to the people of Rome than the people of Rome owed to him." Cato it w^as who concluded his speeches in the Senate by croaking out: "Carthage must be destroyed," to urge Rome on to the second Punic war. Of Greek physicians he says among other things: "They [the Greeks} are a most iniquirous and intractable race, and you may take my word as the word of a prophet when I tell you, that whenever that nation shall bestow its literature upon Rome it will mar everything; and that all the sooner if it sends its physicians among us. They have conspired among themselves to murder all barbarians with their medicine. . . . They are in the common habit, too, of calling us barbarians. ... I forbid you to have anything to do with physicians." The Romans had then "got on for six hundred years without physicians," and as subiequent events showed, Cato's warning was not without its merits. Some of his ire, however, may have arisen from jealousy, for he is said ro have had a famous book of recipes by aid of which he treated
CHILDBIRTH AND CIVILIZATION 2t
the maladies of his sons, his servants, and also, Pliny says, his friends, although, knowing Cato's character, that seems dubious.
The Romans at first had no laws to punish malpractice, poisoning, and the manipulation of wills by hired physicians. Pliny mentions
"HIPPOCRATES OF COOS, THE PRINCE OF PHYSICIANS"
From a woodcut in the Surgery of Ambroise Pare, sixteenth century. Hippocrates was the father of modern medicine ; he hved in the fifth century before Christ, but the principles he set forth for medicine were not developed fully until the nineteenth century.
some of the abuses which resulted from the inadequacy of legal pro- tection. He says: "It is at the expense of our perils that they learn, and they experimentalize by putting us to death, a physician being
22 DEVILS, DRUGS, AND DOCTORS
the only person that can kill another with sovereign impunity. Nay, even more than this, all the blame is thrown upon the sick man only; he is accused of disobedience forthwith, and it is the person who is dead and gone that is put upon trial." Pliny lived in the first century after Christ and was active in the practice of law at Rome and was a politician. By having a secretary to take down his dictation, at any hour of the day or night, he managed in his spare time to turn out 108 large books, covering biography, political history, and natural history, but containing very little that was original or even critically considered. His most famous work is his Natural History, in thirty-seven volumes, which covers almost every conceivable subject which might be classified under this title. He had great respect for the opinions of Cato, but was somewhat more just in regard to physicians, for he says: "These [malpractices and ignorance} are faults, however, which must be imputed to indi- viduals only; and it is not my intention to waste reproof upon the dregs of the medical profession, or call attention to the ignorance displayed by that crew."
As Pliny points out, the predictions of, Cato were realized, par- ticularly in the unprofessional philanderings of Drs. Eudemus and Vectius Valens, early medical arrivals in Rome. Eudemus had an intrigue with Livia and poisoned her husband, Drusus Caesar; and Valens had an affair with the notorious Messalina, who in turn had Livia executed and was herself murdered. Livia was the daughter of Agrippina, who, with the aid of the physician Xenophon of Kos, poisoned her husband, the Emperor Claudius. Pliny exclaimed over the misconduct of Eudemus and Valens: "What adulteries have been committed in the very houses of our princes, even!" If the Roman; were unfamiliar with malpractice, they at least had a familiarity with adultery. Eudemus was tortured and Valens was executed.
In spite of the unfriendly attitude of the Romans, Greek medicine migrated to Rome after the destruction of Corinth in 146 B.C. Eventually Greek medicine was accepted and city and court physi- cians were appointed. Nero employed the latter to treat the bruises he contracted during his nightly revels incognito in the streets of the city.
CHILDBIRTH AND CIVILIZATION 23
Greek medicine continued to develop at Rome and culminated in the ancient practice of midwifery as told in the writings of Soranus of Ephesus, second century after Christ. Soranus lived in Rome in the time of Trajan and Hadrian. His work on midwifery and the diseases of women set a standard beyond which there was no further advance for fourteen centuries and indeed much regression. His contempt for the Roman system of medical deities is complete in his blunt statement that "the midwife should be no believer in spirits." He had considerable knowledge of the anatomy of the female repro- ductive tract, but it was far from exact in its details, for the Greek religion would not tolerate human dissection, and for such anatomy as was not visible he was forced to base his knowledge on dissection of animals. His teachings brought the child-bearing woman a kind- ness of treatment she had never before received. He disapproved of the reckless employment of medicines for hastening labor or applying force to the woman for this purpose. He taught sensible, rational care and assistance based on knowledge and not on superstition. He reintroduced podalic version. This procedure of turning and extract- ing the child, instead of employing instruments to destroy it, marks the peaks of ancient midwifery. Its revival in the sixteenth century after Christ marks the point where medieval midwifery was finally raised to a par with that of the ancients. Soranus himself practiced midwifery, a custom that two centuries later passed from the West- ern civilization, to be not only ignored by the physician, but actually prohibited by custom and law until only a little over three centuries ago, when a king of France progressed far enough in his civilization to have a regard for his mistress, if not for his wife, such that he was moved to again call in the physician as a midwife.
The following extract from the book of Soranus shows something of the character of this great physician of antiquity, the greater because he devoted his services to the sufferings of motherhood: "There is a disagreement; for some reject destructive practices, call- ing to witness Hippocrates, who says: 'I will give nothing whatever destructive; and deeming it the special province of medicine to guard and preserve what nature generates.' Another party main- tains the same view but makes this distinction, namely, that the fruit
24 DEVILS, DRUGS, AND DOCTORS
of conception is not to be destroyed at will because of adultery or of care for beauty, but is to be destroyed to avert danger appending to birth, if the womb be small and cannot subserve perfection of the fruit, or have hard swellings and cracks at its mouth, or if some similar condition prevail,"
CENTAURESS NURSING HER CHILD
From an ancient cameo
CHAPTER II
SAIREY GAMPS AND THE MIDMEN
Ivilizations, like human beings, grow old, be- come decrepit, and die. But also like human beings their influence is sometimes felt long aftel they have died. The Roman Empire declined, and Greek medicine deteriorated. The Christian religion was in ascendancy, and under the influ- ence of its theology attention was turned from the physical aspects of life to the spiritual. Revelation replaced rea- son; the cause of disease became possessions by devils, and the cure of disease was attempted by exorcism or miracles. Rational medicine was replaced by superstition. The teachings of such Greek physi- cians as Hippocrates and Soranus were lost to the practices of the Western world. Yet these teachings were preserved in the manu- scripts collected in the monasteries of Christian Europe. They were buried there, to be resurrected, rediscovered, centuries later. While they waited, the struggle for medical knowledge was crushed by the power of the Church; the clergy zealously retained the gathered learning within the monasteries as a scepter to sway the masses, who were kept in ignorance. The teachings of able men were laid aside to be replaced by ridiculous theories and methods which originated in fanaticism and grew upon the ignorance of the people.
The Middle Ages were the most unfortunate period in the history of womankind. Complete ignorance prevailed, without the intuitive skill of the primitive period and without the knowledge of previous civilizations. Women were deprived of the aid, however poor, of the male physician, and at the same time the penalties of urban civilization were making childbirth more and more hazardous. The practices of the Middle Ages present the accumulated evils of pre- vious periods aggravated by ignorance and barbarism. Womankind
26 DEVILS, DRUGS, AND DOCTORS
had indeed fallen into evil days in that Christian era. She paid for the mythical fall of man, under her temptation of him, in the coin of pain and blood and death.
Primitive woman had resorted to abortion when she thought the birth of her child might be difficult or when she was nursing an- other child. From the quotations from Soranus given at the end of the last chapter it is evident that whatever the attitude of the mid- wives might have been, the Greek physicians themselves looked upon
FIFTEENTH-CENTURY KIDDY-CAR This woodcut, with variations, was used in the past in many books dealing with the care of children. It originally appeared in "Versehung des Leibs" a poem on the care of children written by a monk of the fifteenth century.
abortion in much the same light as do physicians today, to be performed not lightly, but only when the life or health of the mother was in danger. The Roman Church of medieval times put a bar to even this mode of escape for the tortured women of that period; the penalty of eternal damnation was threatened for the operation of abortion, and Caesarean section was advocated to replace the accursed procedure. The opening of the abdomen and uterus to remove the child was then an operation to be performed without anesthesia, with no knowledge of antiseptics, and with a crudity of procedure equal to that of the most barbaric people. The physician of the Middle Ages did not perform surgical operation?; such
SAIREY GAMPS AND THE MIDMEN 27
rhings were below his professional dignity and belonged to the executioner or to the barber, who was the forerunner of our sur- geons, or to whoever cared to undertake them, regardless of his qualification to do so. In the middle of the thirteenth century Bishop Paulus of Meirada, in Spain, is said to have performed a Caesarean operation on a living woman, though it is doubtful if he did ; the next to practice the art was a hog-gelder, who, two centuries later, performed the operation on his own wife.
Sex concepts have always been mingled with religion; thus we find today venereal disease defended by a quasi-religious attitude as a punishment of sin ; and the prevention of conception, ' which is an economic measure, similarly contested. In the medieval times religion took over the supervision of the prostitutes and the over- sight of the practices of the midwives. Thus the Dominican monk, Albertus Magnus (Albert von Bollstadt, 1193-1280), wrote a book for the guidance of midwives, and the Church councils passed edicts on their practices. These instructions and edicts were not, however, for the better care of the child-bearing woman, for the relief of her suffering or the prevention of her death. They were designed to save the child's life for a sufficient time to allow it to be baptized. Thus the Council of Cologne in 1280 decreed that on the sudden death of a woman in labor her mouth was to be kept open with a gag so that her child would not suffocate while it was being removed by operation. The intention involved was better than the physiology.
There is little actual knowledge of the practices of the midwives in medieval times, but their degradation can be judged by those at the beginning of the Renaissance. Even in a normal delivery the woman often died from infection or eclampsia. In difficult labor she was left to die or butchered to death if her midwire was of the type of Dickens's Sairey Gamp, or if a vagabond "surgeon" or hog-gelder could be found to assist at the slaughter. As a rule the matter was left entirely in the hands of the midwife, and in 1580 a law was passed in Germany to prevent shepherds and herdsmen from at- tending obstetrical cases — an indication both of the advance of civilization and what it had advanced from.
The state of affairs that existed in the medieval period and early
28
DEVILS, DRUGS, AND DOCTORS
Renaissance is not to be wondered at, for this was a time when pubhc, domestic, and personal hygiene was at its lOwest ebb
FIFTEENTH-CENTURY NURSE AND CHILD From "Versehung des Leibs." Accompanying this picture were the following directions for selecting a nurse (translation is from Ruhrah, Pediatrics of the Past). "At times it happens that from various causes the Mother cannot suckle the child herself. In such a case one must choose a nurse for the child. Her qualifications should be as follows. The nurse must be of shapely stature, not too young and not too old. She must at all times be free from illness of eyes or body. Moreover, her nature must be such that there is no defect in her body. Mark also, that she must be neither too slim, nor too plump. If there should be any defect in her, the child would incline towards it. She must have a good character, modest, chaste and clean. Her food should be in conformity with the following directions, so that the milk may remain fully nourishing. I prescribe her to eat white bread and good meat, also rice and lettuce every day. Almonds as well as hazelnuts she should not do without. Her beverage must be a pure wine; and moderation must be used in bathing. Nor must she do much labor. In case her milk should give out, she must not forget to eat peas frequently and in quantity, also beans, and in addition gruel which should be boiled in milk beforehand. She must also rest and sleep a good deal so that the child may thrive on the milk. Moreover, she must carefully avoid onions and garlic; as well as any bitter or sour food and any dish containing pepper. She must eat no over-salted food, nor anything prepared with vinegar. Love's intercourse she must also avoid or go in for it very moderately. For in case she should become pregnant, fter milk would be harmful to the child. In order that the child may not be harmed in such a case, one must wean h from the milk."
The walled cities were for the 'lost part densely crowded and had no drainage. Filth accumulated in the unpaved Streets. The dwell- ing-houses were described by Erasmus as containing open cesspools,
SAIREY GAMPS AND THE MIDMEN 29
their floors were strewn with refuse, and in them was a pestilence of flies and vermin. They were indeed sinks of filth and infection. Ancient Rome had paved streets; Paris had none until the eleventh century. Handkerchiefs, nightgowns, and table forks did not come into use until centuries later. London had its first paved streets in the sixteenth century. In that same century Frankfort-on-the-Main started the innovation of requiring each house to have a privy and ordered that the pigpens of the city should be cleaned.
Fifteen centuries of the Christian era culminated in the production of one book, worthy of the name, for the direction of midwives, who throughout this time had been left literally to their own dis- cretion. Eucharius Roslin, of Worms, in response to the wishes of Catherine, the Duchess of Brunswick, wrote a manual from which the ignorant and careless old women who made up the midwives might learn to conduct their work in a safer and more efficient manner. This book was published in Worms in 1513 and contained nothing that was new, but did bring to light the work of the Greeks ; it was, however, marked with the superstition of medieval medicine, fumigation with dove's dung, and similar practices, and with the horrible doctrine of medieval surgical midwifery. The prejudices which at that time existed in the minds of the people, particularly in cities, against the slightest participation of males in the practice of midwifery, were so great that Roslin, who had probably never seen a child born, may have felt something of the humor of his position, for the title of his book was The Garden of Roses for Pregnant Women and for Midwives. The book, nevertheless, ac- complished much good; it was extensively plagiarized by later au- thors and was translated into Latin, French, Dutch, and English, in which last country the title became The Byrthe of Mankynde. The exclusion of men from the study of the child-bearing woman rose in some instances to fanatical heights. Dr. Wertt, of Hamburg, in 1522, put on the dress of a woman to attend and study a case of labor. As a punishment for his impiety he was burned to death.
In the sixteenth century can be detected the first stir that presaged the sweeping advances to be made in the care given the child-bearing woman and her child. The Rose Garden of Roslin was the first indication that this gentler influence was making itself felt in civili-
EUCHARIUS ROSLIN PRESENTING HIS BOOK TO THE DUCHESS OF BRUNSWICK An illustration from The Garden of Roses, 1513, showing the author presenting his book on obstetrics to his patroness. This was the first book on midwifery in Europe for nearly fourteen centuries. It was translated into many languages and was exten- sively plagiarized. The English edition appeared in 1555 under the title The Byrthe cf Mankynde.
SAIREY GAMPS AND THE MIDMEN 31
zation, and after that came attention, not to the woman, but to the child, and in this Ambroise Pare was the prominent figure.
Ambroise Pare, of France, typified the highest type of medical mind of his time and he was a character of which any generation might be proud. Pare was a man of gentleness, and as Soranus, from the greatness of his character, had given attention to the child-
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A PAGE FROM THE BYRTHE OF MANKYNDE William Raynalde's English translation of Roslin's book on midwifery.
bearing woman, so Pare gave attention to the child to be born. Pare came to Paris in 1529 during the reign of Francis I. He was then a rustic barber's apprentice, nineteen years of age. He received his early surgical training as a dresser at the Hotel Dieu. This institution, typical of the hospitals throughout the world at that time, deserves mention, that one, having in mind the modern hos- pital, may have also some conception of the conditions under which
oz
DEVILS, DRUGS, AND DOCTORS
Pare got his training and so appreciate his work the more. The Hotel Dieu is said to have been founded between the years 641 and 649 by Saint Landry, Bishop of Paris, but the first mention made of it in the records is in 829. Upon it Dr. J. S. BilUngs made this comment: "When the medieval priest estabhshed in each great city of France a Hotel Dieu, a place for God's hospitality, it was
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AMBROISE PAR£ AT THE AGE OF FORTY-FIVE This famous French surgeon of the sixteenth century was then the chief surgeon of King Henry II.
in the interest of charity, as he understood it, including both the helping of the sick poor and the affording to those who were neither sick nor poor an opportunity and a stimulus to help their fellow- men; and doubtless the cause of humanity and religion was advanced more by the effects on the givers than on the receivers." The truth of the last statement is amply proven by Tenon in his memoirs of the hospitals of Paris. In the Hotel Dieu there were 1,200 beds,
SAIREY GAMPS AND THE MIDMEN 33
of which 486 were for single patients; from three to six patients occupied each of the remaining beds, which were five feet wide. The large halls, unlighted and unventilated, held 800 or more patients crowded together and often lying about on heaps of straw which were in a vile condition.
Max Nordau has said of the hospital: "In one bed of moderate width lay four, five, or six sick persons beside each other, the feet of one to the head of another; children beside gray-haired old men; indeed, incredible but true, men and women intermingled together. In the same bed lay individuals affected with infectious diseases beside others only slightly unwell; on the same couch, body against body, a woman groaned in the pangs of labor, a nursing infant writhed in convulsions, a typhus patient burned in the delirium of fever, a consumptive coughed his hollow cough, and a victim of some disease of the skin tore with furious nails his infernally itching integument. . . . The patients often lacked the greatest necessi- ties. The most miserable food was doled out to them in insufficient quantities and at irregular intervals. The nuns were in the habit of feeding with confectionery those patients who seemed to them pious enough, or at least those who reeled off their rosaries with sufficient zeal, but the body exhausted by disease required not sweets, but cried for meat and wine. Such food, however, the sick never received in profusion, save when it was brought to them by the wealthy citizens from the city. For this purpose the doors of the hospital stood open day and night. Anyone could enter; anyone bring whatever he wished; and while the sick on one day might be starved, on another day they might very likely get immoderately drunk and kill themselves by overloading their stomachs. The whole building fairly swarmed with the most horrible vermin, and the air of a morning was so vile in the sick wards that the attendants did not venture to enter them without a sponge saturated with vinegar held before their faces. The bodies of the dead ordinarily lay twenty-four hours, and often longer, upon the deathbed before they were removed, and the sick during this time were compelled to share the bed with the rigid corpse, which in this infernal atmosphere soon began to stink, and over which the green carrion-flies swarmed. ..."
In this hospital there were beds for children; in fact, eight such
34 DEVILS, DRUGS, AND DOCTORS
beJs, which accommodated a total of 200 infants and young children, of whom the majority necessarily succumbed to the charity extended to them. About one-fifth of the patients in the Hotel Dieu died. Recovery from any surgical operation was in the nature of a rarity. The attention given to surgery in such hospitals ma} be judged from a description of one in Lyons in 1619. In that hospital, accom-
A ROOM IN THE HOTEL DIEU
From a woodcut of the sixteenth century. The beds shown were intended for two patients, but frequently five or six, regardless of sex or disease, were crowded into each one. Less fortunate patients found refuge on heaps of straw in the dark halU ways. This hospital was indescribably filthy, as were all others at this period.
modating 549 patients, there was only one medical man whose duty it was to look after the surgical cases; he resided outside of the building. When this surgeon required assistance in the dressing of wounds or in performing surgical operations, he was authorized to make use of the "apothecary boy." No doubt Pare gave the equiva- lent of assistance in the hospital of Paris. The stock of surgical instruments possessed by the hospital consisted of just five, which included a trephine for opening the skull and a mouth plug for keeping the jaws separated. In considering the barrenness of the
SAIREY GAMPS AND THE MIDMEN
35
provisions for surgery it must be borne in mind that tliis art had not yet been rendered "respectable" by the edict of Cliarles V, although Emperor Wenzel had made it so in Germany in 1404; but the German army surgeons' duty included the shaving of the officers as late as the eighteenth century. In the memoranda relating to the duties of the medical staff in the civil hospital of Padua (1569) there is the statement: "And a barber who is competent to do, for the women as well as the men, all the other things that
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HOSPITAL PATIENT IN BED WITH A CORPSE A common occurrence in charity hospitals of two or three centuries ago. etching by Daumier.
An
a good surgeon usually does." The "all other things" included every surgical procedure practiced except the applying of ointments to sores and wounds, that being the more "respectable" office of the surgeon himself.
In spite of the gross neglect of the sick and lack of organization, the Hotel Dieu of Paris was not free from the managerial diffi- culties which are sometimes encountered by hospitals even today. It was under ecclesiastical supervision, with the care of the sick in the hands of lay brothers and sisters; but in 1505 the parliament of Paris nominated a commission of eight citizens to manage the temporal affairs of the hospital. Whatever the shortcomings in
56 DEVILS, DRUGS, AND DOCTORS
medical practice may have been, there was at least a healthy direct- ness in handling administrative difficulties; the monks and nuns who objeaed to the changes that were made were dismissed, and the physicians who sided with them were committed to prison.
After three years of training in the Hotel Dieu, Pare became a lowly army surgeon under Anne de Montmorenci, lieutenant-general in the army of Francis I. France was at this time embroiled in the wars with Emperor Charles V which had resulted from the attempted conquest of Italy. Pare saw his first service at the battle of Turin in 1537, and of it he says:
"In the year 1536 the great King Frangois sent a great army to Turin to recover the cities and castles which had been taken by the Marquis de Guast, lieutenant-general of the emperor: where Mon- sieur the Constable [Anne de Montmorenci}, then grandmaster, was lieutenant-general of the army, and Monsieur de Montegan was colonel-general to the infantry of which I was the surgeon. A great part of the army having arrived at the Pass of Suze, we found the enemy holding the passage. . . . Captain Le Rat climbed with many soldiers from his company on a little hill, whence they fired directly on the enemy. He received a shot from an arquebus in the ankle of his right foot, wherewith he suddenly fell to the ground and then said, 'Now the Rat is taken.' I dressed his wounds and God healed him.
"We thronged into the city and passed over the dead bodies and some that were not yet dead, hearing them cry under the feet of our horses, which made a great pity in my heart, and truly I repented that I had gone forth from Paris to see so pitiful a spec- tacle. Being in the city, I entered a stable, thinking to lodge my horse and that of my man, where I found four dead soldiers and three who were propped against the wall, their faces v/hoUy dis- figured, and they neither saw, nor heard, nor spoke, and their clothes yet flaming from the gunpowder, which had burnt them. Beholding them with pity there came an old soldier who asked me if there was any means of curing them. I told him no. At once he ap- proached them and cut their throats gently and without anger. Seeing this great cruelty I said to him that he was an evil man. He answered me that he prayed God that when he should be in
SAIREY GAMPS AND THE MIDMEN 37
such a case, he might find some one who would do the same for him, to the end that he might not languish miserably."
Ten years after this battle, which gave Pare his first experience with military surgery, Francis I died, and his son, Henry II, came to the throne of France. He brought with him a woman to whom his affections were given, the former mistress of his father. Madam de Breze, better known as Diane de Poitiers. She was nineteen years his senior and a widow with two children. He also brought with him to the throne a wife who was embittered by the loss of her hus- band's affection and by the treatment she had received from the French because of her sterility during the first ten years of her mar- riage to the Dauphin. Although she subsequently had ten children in thirteen years, her rancor persisted. This wife later was to leave a mark of blood and ruin on the history of France. She was the Italian Catherine de' Medici. The excellency of Pare's work brought him to the attention of the king and he was made his chief surgeon. What was even more important, he became the friend of Catherine de' Medici. When, during a tournament in 1559 the lance of the ill-fated Montgomery accidentally pierced the helmet of the king and entered his brain, Pare attended him. His patient died, and with him passed the supremacy of Diane de Poitiers. Catherine de' Medici was free to vent her malignance on the French through her sons, Francis II, Charles IX, and Henry III. To each of these in turn Pare was chief surgeon, and with Henry III he received the additional title of "counselor to his majesty." After the brief reign of Francis II, husband of Mary Queen of Scotland, Catherine de' Medici ruled during the minority of her son Charles IX. She introduced then that intrigue, corruption, and financial disorganiza- tion which Rabelais, the doctor and priest, attacked with gross allegory. She was instrumental, too, in the persecution of the Protestants which through the activity of the family of Guises rose to its peak in the massacre of St. Bartholomew's night. Pare is said to have been the only Protestant for whom there was royal edict to spare his life on -that night, but it is also said that there was some question as to the fervor of his religious affiliations.
One of Pare's greatest claims to distinction was his breaking away from the pseudo-Hippocratic and pseudo-Galenic tenets thai
38 DEVILS, DRUGS, AND DOCTORS
bound the medical profession of his time; it took a man of courage CO depart from a course rigidly prescribed for centuries. His first advance in this direction was in the treatment of gunshot wounds, and although its bearing is greater on the work of surgery to be given in a later chapter, it is used here to illustrate Fare's character for a quotation cannot be given from his work on podalic version. He did not write extensively of that method, but taught it to his assistants, one of whom saved the life of Fare's daughter by its application.
Gunshot wounds were a new feature of the Renaissance surgery; and according to the precept that "disease not curable by iron was curable by fire," they were treated with boiling hot oil. The story of Fare's gentler innovation, so typical of the man, is best told from his own writings, which were sprinkled often with the phrase at once so modest and so true, "I dressed his wounds, and God healed him." In speaking of his experiences with the army in Turin in 1537, from which a quotation has already been given. Fare says:
"Now all the soldiers at the Chateau, seeing our men coming with a great fury, did all they could to defend themselves and killed and wounded a great number of our soldiers with pikes, arquebuses, and stones, where the surgeons had much work cut out for them. Now I was at that time an untried soldier ; I had not yet seen wounds made by gunshot at the first dressing. It is true that I had read in Jean di Vigo, first book. Of Wounds in General, chapter eight, that wounds made by firearms were poisoned wounds, because of the powder, and for their cure he commands to cauterize them with oil of elder, scalding hot, in which should be mixed a little theriac; and in order not to err before using the said oil, knowing that such a thing would bring great pain to the patient, I wished to know first, how the other surgeons did for the first dressing, which was to apply said oil as hot as possible, into the wounds, of whom I took courage to do as they did. At last my oil lacked and I was constrained to apply in its place a digestive made of the yolks of eggs, oil of roses, and turpentine. That night I could not sleep at my ease, fearing by lack of cauterization that I should find the wounded on whom I had failed to put the said oil dead or em- poisoned, which made me rise early to visit them, where beyond
SAIREY GAMPS AND THE MIDMEN 39
my hope I found those upon whom I had put the digestive medica- ment feehng little pain, and their wounds without inflammation or swelling, having rested fairly well throughout the night; the others to whom I had applied the said boiling oil, I found feverish, with great pain and swelling about their wounds. Then I resolved with myself never more to burn thus cruelly poor men wounded with gunshot."
Fare's medical writings were in the vernacular; he was not a scholar; the medical writings of all other prominent medical men of the time were in Latin. The organized physicians of Paris found therein an excuse for attacking the works of Pare and attempting to prevent their publication: they cited not only his ignorance, "a man very impudent and without any learning," but also that in his teachings he departed from the established practices of the ancients. In reply, among many other things. Pare states: "In outward dis- location of the vertebras Hippocrates commands to bind the man straight on a ladder, the arms and legs tied and bound, then after having raised the ladder to the top of a tower or ridge of a house, with a great cable in a pulley, let the patient fall like lead on the firm pavement, which Hippocrates said was done in his time. But I do not teach any such way of giving the strappado to men, but I show to the surgeon in my works, the method of reducing them safely and without great pain."
Sufficient of the life of Pare is given here to make clear the char- acter of this man who brought back to civilization and described fully a procedure, podalic version, which was for the child what the discovery of the infectious nature of childbed fever, three centuries later, was for the mother. Podalic version, as described by Pare, was to be used in those cases where the child was not in the normal position to be born. It consisted in inserting the hand into the uterus, grasping one or both feet (hence podalic) of the unborn child, and turning it {i.e., version) into such a position that it could be born. The child was usually extracted, pulled out, at the same time. In the few words which suffice to describe podalic version it seems like an obvious procedure, one that would have occurred even to the medieval midwives. But its application waited centuries for a man who had at heart the kindly interest of humanity
40 DEVILS, DRUGS, AND DOCTORS
and who had the humiUty to stoop, in that age, to such lowly things as the woman and her child. Pare had many attributes in his character which are seen in those of the founders of great religions, but not always seen in the zealous followers of such religions.
The importance of podalic version for the child-bearing woman can be understood best from a comparison with the conditions exist- ing before its development. As stated in the previous chapter, the
THE BIRTH OF C^SAR FROM THE 1506 EDITION OF SEUTONIUS
This illustrates the popular belief that Julius Caesar was born by the so-called Caesarean operation. In his time the operation was not performed on living women, but only after death as a religious measure. Caesar's mother lived for several years after he was born. The operation obtained its name from the fact that the Roman law required this procedure in case of the mother's death; the laws under the emperors became Caesarean laws, and the operation the Caesarean operation.
primitive woman had but one great fear at childbirth — that her, child might be in such a position, as, for instance, transversely across her pelvis instead of in the normal head-down position, that it could not be born. Such cases were fatal for both the child and the mother, but fortunately were rare because of the active life led by the primitive woman. With the coming of civilization a means was found for possibly saving the mother s life at the sacrifice of that of the child; the child, in an increasing number of cases, was killed and removed piecemeal with instruments that the pagan priest and later the physician devised for this purpose. Indeed, untU the time of Pare the performance of this act was the only
SAIREY GAMPS AND THE MIDMEN 41
reason for calling in the physician or barber to see the child-bearing woman.
There was one other procedure which gave an alternative to that above; a means was also found of possibly saving the life of the child at the expense of the mother, a procedure advocated by the Roman Church — Cassarean section. This operation, far different in its effects then than in its frequent performance today, consists in removing the child through a cut made in the front of the abdomen. The name Cassarean attached to it has given rise to the belief that Julius Cassar was brought into the world by this means, but at the time when Caesar lived the operation is not known to have been performed on the living woman, and his mother, Julia, lived many years after his birth, as is proven by his letters to her. The probable explanation for the name is as follows: In 715 B.C. the king, Numa Pompilius, codified the Roman law, and in the lex regia, as it was called, it was ordered that the child should be removed from every woman who died when far advanced in pregnancy, even in cases where there was no chance of survival for the child, so that the mother and child might be buried separately. The lex regia became the lex Cesare under the rule of the emperors, and the operation became known as the Csesarean operation, or section. Few such operations had been performed on living women at the time of Ambroise Pare, and, for even centuries after, the suffering it entailed and the high mortality that resulted from it made the operation one of last resort.
Pare opposed Cassarean section, and his opinion checked its further advance for more than a century; in its stead he suggested podalic version. This procedure cannot replace either Cassarean section or the destroying of the child in all cases, for it is not applicable to women who have abnormally small pelvises, but Pare did not have a sufiEicient knowledge of anatomy to know this; he believed, as had the Greeks, that the pelvis separated in the middle and opened out during the birth of the child and that the pains of childbirth were due to this separation of the bones. Podalic version was at the time a tremendous advance in the saving of the lives of infants and the suffering of women.
The development of podalic version constituted the first step in
42
DEVILS, DRUGS, AND DOCTORS
the emancipation of the child-bearing woman from the exclusive hands of the ignorant midwives where it had rested since the fall of the Roman Empire. It was something with which the physician could assist the woman in difficult labor without killing her or mutilating the child; it took the operative assistance of the child- bearing woman from the hands of the surgeon and laid the founda- tion for an independent art of medicine — obstetrics.
In Fare's time a school for midwives was opened at the Hotel Dieu at Paris. The position occupied by the child-bearing woman
A CESAREAN OPERATION IN THE SEVENTEENTH CENTURY
Very few such operations were performed at that time, for there was no anesthesia, asepsis, or adequate means of controlling hemorrhage. The woodcut shown here appeared in the works of Johann Schultes, a surgeon of the seventeenth century.
in civilization was rising; after centuries of neglect she received the consideration of the physician. The women graduated from the school of midwifery were of a type vastly superior to the bedraggled hags who had formerly trundled their obstetrical chairs from house to house. Louise Bourgeois, "sworn midwife" of the city of Paris, was among the first of the graduates; in 1601 she officiated at the birth of the Dauphin (later Louis XIII), and after- ward at the birth of the other children of Marie de' Medici.
The customs of the time were changing; trained and supervised midwives were a step toward the betterment of the child-bearing woman, and the next step was the participation of the physician
SAIREY GAMPS AND THE MIDMEN 43
himself in midwifery. Boucher was called in to attend La Valliere. mistress of Louis XIV, and the king is said to have evidenced his interest in this reinstatement of male midwifery by watching the procedure from the concealment offered by some curtains. In 1670 Julian Clement attended Madame de Montespan at the birth of the Due de Main, and in 1682 he delivered the Dauphin. Clement re- ceived the title of accoucheur, to replace the somewhat derisive ap- pelation of man midwife, or midman. Soon male midwifery became the fashion among the ladies of the court. The princesses of the period hastened to place themselves under the care of accoucheurs. Clement went three times to attend the wife of Philip V of Spain
ort"
THE AUTOGRAPH OF AMBROISE PARE
CHAPTER III
"THE COMPASSION OF PETER CHAMBERLEN"
N the sixteenth century civihzation had pro- gressed far enough so that Pare could reintro- duce podahc version, and thus bring midwifery back to the level it had reached among the ancients and open the way for the participa- tion of the physician in midwifery. Pare rein- troduced also the ligature in surgery, changed the method of treating wounds, founded orthopedics, and introduced massage and artificial eyes. In that same century Magellan circum- tiavigated the world, Charles V sacked Rome and declared surgery "respectable," and Cortez entered Mexico; Copernicus described the revolution of the nl^nets about the sun, Galileo demonstrated the law of falling bodies, Paracelsus founded chemicotherapy, Vesalius laid the foundation of human anatomy, and Fracastoro named the new plague syphilis. The Reformation took place, the black death, in- fluenza, and the sweating sickness swept Europe, and Catherine de' Medici, from behind the French throne which held her dissolute son, declared war on the Huguenots, and ordered the massacre of Saint Bartholomew's night in 1571. Pare survived the massacre; he was a friend of Catherine de' Medici's and so was spared, but to avoid it another Huguenot physician, Chambellan, fled from France to England.
This Chambellan came to England at a time when Henry VIII had concluded his matrimonial experiments; the year of the king's death was coincident with the founding of an insane asylum at St. Mary's of Bethlehem, London, which was to enrich the language with a corruption of its name, "bedlam." By the time the Cham- bellan family had settled and changed its name to Chamberlaine, Queen Elizabeth had been on the throne ten years, Shakespeare was
44
"THE COMPASSION OF PETER CHAMBERLEN" 45
six and Francis Bacon ten years old, and witchcraft had been made a capital offense. By the time the name Chambellan had gone through its final evolution of adoption to England and become Chamberlen, William Harvey was born, Timothy Bright had in- vented shorthand, and the Spanish Armada had been destroyed. These events bring us up to the year 1588, and the two sons of Chamberlen, Peter the younger and Peter the older, were devot-
A FIFTEENTH-CENTURY LYING-IN ROOM
ing their attention to midwifery and had invented the obstetrical forceps.
The Chamberlen brothers kept the secret of their invention and attempted to control the instruction of midwives. In justification of their pretensions they claimed that they could deliver patients when all others had failed. They passed along their jealously guarded secret to the next generation of Chamberlens, which was represented by another Peter, son of the younger of the two brothers. He was a man of considerable ability, but his character united at
46 DEVILS, DRUGS, AND DOCTORS
the same time some of the virtue of a reUgious enthusiast and many of the devious quaUties of a- quack. Like his father and uncle, he attempted to monopoUze the control of the midwives. When re- fused this privilege, he set forth his own vievv'S in a pamphlet en- titled A Voice in Kamah, or the Cry of Women and Children as Echoed Forth in the Compassion of Peter Chamberlen. Ambroise Pare had said of his patients, simply, "I dressed his wounds, and God healed him."
The secret which was Peter Chamberlen's was that of the obstetri- cal forceps which had been handed on to him by his father and uncle. This in turn he handed on to his sons, of whom Hugh, I63O-I7O6, was the most important. The secret was kept in the family, and in the words of Hugh Chamberlen, "My father, brother, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way of delivering women in this case without prejudice to them or their infants." He still kept the secret.
At the time Hugh Chamberlen, following the family custom, was attempting to control the instruction of midwives in England, physicians were making very slow advancement into the field of obstetrical practice. Pare had given impetus to the movement, and the title of accoucheur conferred on Clement had supplied a dig- nified name for the profession; but the attempts of the physicians to practice obstetrics were met with opposition. Except in the case of royalty the male physician encountered prudery which rose to amazing heights. Sometimes he was forced to tie one end of a sheet to his neck and the other end to his patient's neck; while the view of both parties was unobstructed above this guard, the physician could not see beneath it. He made his manipulations blindly, but he spared his patient's blushes. The title of accoucheur was not at first generally accepted and contemptuous names were often used to belittle physicians who practiced obstetrics. Thus when Dr. Wil- liam Smellie, in the eighteenth century, established a school in London for teaching midwifery, he was christened by his competitor, Mrs. Nihell, the Hay Market midwife, "a great-horse-godmother of a he-midwife." Smellie is remembered in medical history because he made and published the first exact measurements of the pelvis,
THE HEIGHT OF PRUDERY— A PHYSICIAN OPERATING UNDER
THE SHEET For thirteen centuries the physicians of Europe were not allowed to attend normal cases of delivery, but in the seventeenth century they began to participate to some extent. Except among royalty they met with amazing prudery and were often forced to carry out their manipulations blindly, as shown here, in order to spare the blushes of their modest patients. A woodcut from the works of a Dutch physician, Samuel Janson, 1681.
48 DEVILS, DRUGS, AND DOCTORS
but he has his phice, too, in literature. He is in Laurence Sterne's T list rum ShiUniy under the aUas of "Andrianus Smelvgot." He got into that delightful book by mistaking the words Lithopcedti Se}ionens}s Icon for the name of an author, whereas they were in reality the heading of a drawing of a petrified fetus. The error was pointed out by Dr. John Burton, of York, the original of the "Dr. Slop" who competed with a midwife to deliver Tristram.
The opposition to the participation of physicians in obstetrics did not cease altogether until nearly the present century. As late as the 'forties of the nineteenth century John Stevens, of London, denounced and exposed in his pamphlets "the dangers and im- morality" of employing "men in midwifery." He dedicated his efforts to the Society for the Suppression of Vice. The obstetrician of today is no longer exposed to condemnation and open derision. Nevertheless, in those countries which are backward in. their cul- tural development there still exists a remnant of the earlier atti- tude; it is shown in a certain evident, if unspoken, belittlemcnv of the physician who assists the child-bearing woman. He is felt by some people to be of lower caste than physicians in other branches of the medical profession — the surgeon, for instance. This at- titude is reflected in the inefficiency of the instruction in obstetrics given in medical schools, and sometimes in the inferior type of men who choose this branch of the profession. It is always reflected in the statistics of mortality at childbirth.
In the time of Hugh Chamberlen the opposition to male mid- wifery was at its height and he gained no popularity from the choice of his specialty; moreover, he dabbled in politics. The politics of England in the latter half of the seventeenth century were two- edged and Hugh Chamberlen found them so by his contact with them. In consequence he retired to Paris for the quieter atmosphere of Louis XIV's reign. While there he attempted to sell his precious family secret and was directed to Mauriceau, who was then the leading obstetrician of France.
Mauriceau had at that time just made the bold innovation of having his patients delivered in bed and had dispensed with the obstetrical chair, whose antiquity was greater than that of the Bible; in spite of the innovation, the obstetrical chair held its supremacy
"THE COMPASSION OF PETER CHAMBERLEN" 49
and the brides of Holland continued to provide them with their trousseaus until the nineteenth century. Chamberlen boasted to Mauriceau that by means of his secret he could deliver the most difficult case in a few moments. Mauriceau promptly placed at his disposal a woman deformed and dwarfed by rickets for whom every effort at assistance to deliver her child had failed. Hugh Chamberlen with a great display of confidence undertook the case, but after working for three hours admitted that he was having some difficulties — the woman died from the injuries she received from his manipulations. "To complete the story," says Mauriceau, "it should be remembered that six months before the occurrence of these events, this physician had come to Paris from England and boasted that he possessed a secret method by means of which he could, even in the most difficult case, promptly effect the delivery of the child, and had told the king's physician-in-ordinary that he would sell the knowledge of this secret for the sum of 10,000 Tha- lers" (about $7,500) .
From the standpoint of medical ethics alone, not to mention hu- manitarian aspects, the behavior of the members of the Chamberlen family in keeping secret a method by which suffering might be alleviated and lives saved was most reprehensible. A man may invent a mechanical device for the comfort, profit, or pleasure of mankind, manufacture and sell it to his financial betterment, with his process secret or protected by patents. He can do all this hon- orably, he may even become rich, and no one looks at him askance, indeed quite the opposite. Such is not the case in medicine, for the tenets handed down from the time of the priests of ^Elsculapius, and supported by that intangible thing called ethics, the respect and recognition of fellow-physicians, forbid such practices. A physician who seeks and finds a means of alleviating human suffering or pro- longing lives makes his discoveries public, that all of his profession may see and profit, with no financial recompense to him who has made the discovery. Such a procedure is followed in no other branch of human learning practiced for a livelihood. The obliga- tion to humanity, which the physician uncomplainingly accepts and himself enforces, is looked upon as a natural course by all those people who accept, as equally natural, quite the opposite course
50 DEVILS, DRUGS, AND DOCTORS
from all other members of society. Medicine arose from religion; fortunately, it has retained in its principles some of the religious virtue of sacrificing self to the suffering of others, a course that must seem most impracticable to many men of commerce. In all ages, in ancient times as well as today, there have been, and are, physicians who profit through secret methods which are of either real or imaginary virtue. The Chamberlens were men of this type, and there were others at that time also — many others.
England, at about the time in which Hugh Chamberlen exploited the obstetrical forceps, was particularly prolific in famous charlatans. The four most prominent, besides Chamberlen, were Sir William Reed, Dr. Grant, Chevalier Taylor, and "Spot" Ward. Reed and Grant depended for their fame upon the fact that Queen Anne suffered from weak eyes. There were no scientific ophthalmologists in her time and she fell a victim to quacks. Her favorite was William Reed, a tailor who, "having failed as a mender of gar- ments, set up as a mender of eyes." He was an illiterate impostor, but through the queen's favor was made a prominent practitioner and a knight. Dr. Grant, another oculist to Queen Anne, started life as a tinker, tried preaching, and drifted into his medical specialty after failing in these two ventures. His original occupation is alluded to in an epigram of the time:
Her majesty sure was in a surprise
Or else was very shortsighted, When a tinker was sworn to look after her eyes
And the Mountebank Reed was knighted.
Chevalier Taylor was an apothecary's assistant who became a self-made specialist of eye diseases. He is the prototype of all modern advertising medical fakers, and, as the result of his efforts became one of the most widely known men in the eighteenth cen- tury. He was even dignified by notice from Samuel Johnson, who said he "was the most ignorant man he had ever met." Taylor was appointed oculist to King George II and had among his patients Gibbon and Handle. He himself finally went blind and died in a convent hospital at Prague. He was admitted there, although in his "medical talks" he had often slyly hinted that, tautologically
"THE COMPASSION OF PETER CHAMBERLEN" 51
speaking, he had been in almost every "female nunnery in all Europe and could write volumes on the adventures of these religious beauties."
Joshua Ward, known as "Spot" because of a birthmark on his face, took up medicine when he failed in business as a dry-salter. He invented a "Pill" containing antimony, and by administering this remedy and at the same time practicing faith healing with the "laying on of hands," he developed a great reputation and became popular in the courts of King George II. Literary men in particular seem inclined to quacks, and Ward treated both Gibbon and Fielding. Gibbon, in his autobiography, mentions Ward among those "successively summoned to torture or relieve" him. Fielding had, like Moliere, a very low view of the regular medical practition- ers, but he was grateful to Ward for his treatments. Lord Chester' field also took Ward's medicine and gave a testimonial for it.
Reed, Grant, Taylor, and Ward were quacks made famous by the favors they received from the English royalty. The French court under Louis XIV likewise was a hotbed of quacks, whose foi- bles are set forth in the amusing satires of Moliere. The memory of these quacks merely shows the gullibility of prominent people and the fact that less prominent people employed the quacks be- cause the kings, queens, statesmen, and famous writers of the day did so. Even today the medical opinion of prominent but non- medical people is sometimes looked upon with respect by the public, even though the men offering the opinion are not qualified to do so.
None of the charlatans described above had anything of value for treating disease. The Chamberlens, on the other hand, held a valuable secret, and even in their time they were censured for their unethical procedure. There is no uncertainty in the words of de La Motte, obstetrician of Volgens, as he comments on the secrecy which has surrounded the discovery of the obstetrical forceps: "He who keeps secret so beneficial an instrument as the harmless obstetrical forceps deserves to have a worm devour his vitals for all eter- nity. ..."
Hugh Chamberlen was less successful than many of the contem- porary English charlatans. His political views got him into trouble and he was forced to flee to France. There, because of the inter-
52 DEVILS, DRUGS, AND DOCTORS
vention of Mauriceau, he failed to sell his secret. He returned to England, but in 1699 he was forced to flee again.
This time he went to Holland. There he sold his secret, but it continued to spread, perhaps from association, a blot on the fragile
SIXTEENTH-CENTURY LYING-IN ROOM, SWITZERLAND
After a woodcut appearing in the works of Jacob Rueff. a Swiss physician of that
period. In nearly all of the old pictures of the lying-in room the nurse is shown
washing the child. Frequently she has her feet immersi.d in the water to test its
temperature. The human foot is a much more sensitive "rhermometer" than the hand.
medical ethics of that time. The Medico-Pharmaceutical College of Amsterdam had the sole privilege of licensing physicians to practice in Holland, and it also had Hugh Chamberlen's secret. To eacii of its licensees it sold the secret for a large sum. This disreputable practice continued until a group of generous-spirited men purchased the secret and made it public. It was then found
*'THE COMPASSION OF PETER CHAMBERLEN" 53
that Chamberlen — possibly it was the college — had perpetrated a grim joke and had swindled the purchasers. The device they had purchased consisted of only a half, and a quite useless halt, of the forceps. The final chapter in the story of the Chamberlen family comes from the son of Hugh, Hugh Junior, an intimate friend of the Duke of Buckingham and a prominent physician in Eng- land. During the later years of his life he allowed his family secret to leak out, and the instrument soon came into general use.
The ideas of ethics are so strongly inculcated in the profession of medicine that the credit for the discovery of the obstetrical for- ceps is not always given to the Chamberlens, but instead to a Bel- gian, Jean Palfyne, who developed an instrument which he presented freely to the Paris Academy in 1721.
The forceps in their early form were crude, but rapid develop- ment in their design followed after their general adoption. Some- thing of the crudity of the early forceps, particularly in the lock that held the blades together, is suggested by Laurence Sterne in Tristram Shandy. He says: "Dr. Slop had lost his teeth — his fa vorite instrument [the obstetrical forceps} — by some misapplica^ tion of it, unfortunately slipping, he formerly, in a hard labour, knocked out three of the best of them with the handle of it. . . .
The purpose of the forceps is to assist in the extraction of the child when the propulsive forces of the mother are lacking, or when, by reason of her condition, or of that of the child, it is advisable to terminate labor rapidly. The forceps did not take the place of the podalic version of Ambroise Pare. Each of the three procedures of assisting at the birth of the child — podalic version, the use of forceps, and the operation of Caesarean section — has its particular province. Podalic version makes it possible to correct the position of the child and to extract it by its feet, but to apply podalic version the child must still be in the uterus and freely movable there. If labor has advanced with the child in the normal position, the head is forced into the inelastic ring formed by the pelvic bones. From this position it cannot be disengaged and pushed back into the uterus. It is then impossible to hasten its birth by pulling on its feet, as in podalic version, for its feet can no longer be reached. If the strength of the mother failed at this point an
54 DEVILS, DRUGS, AND DOCTORS
impasse was reached for the earUer practitioners of midwifery, tot they had no satisfactory w^ay of drawing the child from its position. Even in births which progressed normally several hours might elapse after the time the child's head became engaged in the pelvis but before it was delivered. If, during this time, the child's life be- came endangered, the earlier practitioners could not at once go to its assistance and extract it. They were forced to wait until it was born in the usual manner, and it was then often too late to save its life. The obstetrical forceps overcomes these difficulties. It was applicable when podalic version could no longer be used.
The forceps consists of two wide flat blades curved to fit gently over the child's head. The blades are inserted and brought into position separately, and are then locked together, firmly gripping the head. By turning and gently pulling the child is extracted. Any opening through which its head will pass will readily allow the passage of the remainder of its body, for the baby's head is of larger diameter than is its trunk or hips or shoulders.
The invention of the forceps brought another aid to the child- bearing woman which was to play its part in the saving of the lives of children and the suffering of women, but, like all things of which the limitations have not been defined, the use of the forceps w^as abused in the early stages of its development. Neither the application of forceps nor podalic version will aid birth when the ring made by the bones of the pelvis is too small to admit the head of the child. The efforts of Hugh Chamberlen with the deformed woman whom Mauriceau gave him as a patient were an instance of this kind. The only procedure which could have been applied to save her life and that of the child was Caesarean section, but Caesarean section was then far from the relatively safe and painless operation that it is today. Mauriceau refused to undertake it.
Although it was clearly recognized, by those who dealt with midwifery in the sixteenth century, that the child must pass through the ring formed by the pelvic bones, they did not know the exact structure or relation of these bones. Pare, in fact, believed, as did most other physicians, that the pelvis separated in the front and spread, as might a broken hoop, to make room for the child's
"THE COMPASSION OF PETER CHAMBERLEN" 55
head to pass. It was Andreas Vesalius (see Chapter VI) whc^ in his book of anatomy, in 1543, first showed, although crudely, the true relation of the bones of the pelvis. Three bones in all make the ring through which the child must pass. The flaring hip bones form the sides of the pelvis. In the rear they are joined by ligaments to opposite sides of the spinal column, at that part where the vertebrae are fused to form the sacrum, which is shaped like a blunt arrow head. In front, stout projections from the hip bones circle the bottom of the abdomen. They are united by ligaments at the mid-line, and act as braces to hold the shape of the pelvis against the thrust of the legs. The sacrum locks the pelvis in the rear like a keystone in an arch, but this keystone is an inverted one and when pushed outward by the forces at birth it locks tighter and no expansion is given to the pelvic ring.
Anatomical study, as begun by Vesalius, gradually showed the fallacy of the separation of the pelvic bones during childbirth. An extract from a book on midwifery published in 1682 indicates both the passing of this fallacy and also the means for the study of anatomy used by men as eminent as Pare. This book is entitled, The English Midivije, Enlarged, Containing Directions to Mid- wives; . . . the Whole Fitted for the Meanest Capacities. It was published in London, where it was "Printed for Rowland Reynolds, next door to the Golden Bottle in the Strand, at the middle Ex- change door." The book was a plagiarism of Wolveridge's Specu- lum Matricis Hihernicum, a standard text of its time, but now the rarest British book of its kind. The quotation in question, written a century after the time of Vesalius and Pare, is as fol- lows: "... Ambroise Pare, a most famous Chirurgion in his time at Paris (quoting many witnesses to the thing), gives us an History of a Woman in whom (having been hang'd 14 days after she was delivered in Child-birth,) he found (as he saith) the share bone separated in the middle the breadth of half a finger, and the flanck-bones themselves disjointed from the hoop-bone. But we will not in this matter accuse him of an imposture as having too much respect, and a better opinion of so worthy a person, and believing him to be too sincere as to commit such a crime; but do indeed believe the good man might be mistaken in this separa-
r H E ENLARGED,
Contnining
Direftions to Midwives;
Wherein is laid down whatever is rrvoft rcqui- fitefor thefafe Pradifiag her Art
A L JO
rn[\ruftion.9 for Women in their Con- ceiving, Bearing arid NurHngof Childhen.
VVidUwo nevv.Treatifes, one of the CQreoF Difcafes and Symptoms happtning to Wo- men before and after Child-birth.
And another of the Difeafes, &c. of little Children, and thexonditions neccfTarv to be confidcred in the choice of their Nniies and Milk.
The whole fitted for the mcaneft Capacities.
lllaftratetl with near 40 Copper-Cur?.
Lo})dor.^ Printed for Rowland Reynolds^ next
door to the Golder: Bottle in the Srr^rf, ac
the middle Bxchmn door., 1682.
TITLE PAGE OF THE ENGLISH MIDWIFE, ENLARGED Published in 1682. The text of this book is presented as a dialogue between the doctor and the midwife, and much sound practical advice is given. The book not only covers obstetrics, but also the diseases of children and the diseases peculiar to women; the limited knowledge on these subjects is shown by the fact that they are covered in 300 pages. The type of women undertaking midwifery and the care of women and children is indicated by the statement on the title page, "The whole fitted for the meanest capacities."
"THE COMPASSION OF PETER CHAMBERLEN" 57
tion; for we cannot probably conceive that being so at the time of her labor it would remain so a fortnight after, the breadth of half a finger; for then they would have been forc'd to carry this Woman to execution; (for they are executed at Paris within the City
L I B . 2 5 . Of Mongers and Trodigies,
Ihc fiCiuie of Dorothie, grctt jr/tlj cb(W* Kiia mamc chtljrcju
655
MAiun Cx'Merm the aucorofthe PoUrti hifto Th« oinb rie, writeth that one Margaret , a woman Book of the fprung from a noble and ancient familie ne«r PoUlhHiftor Cracovia , and wife to Count Virbofaus, "*" brouf;ht forth at one binh thirtie five live children, upon the twentieth dale of Jan. in the year ii^6.Francijcuf P'cm MiranduU writeth that one Doruibie an Italian had twentie children at two births; at thefirft nine, and at the fecond eleven, and that (he« was fo big, that Ihee was forad to bear up hcrbtUie, which laie upon her knees, with abroad and large fcarf tied about her neck,a» you may fee by this tigure.
"DOROTHIE, GREAT WITH CHILDE WITH MANIE CHILDREN"
One of the many marvels that Ambroise Pare figured in his Surgery. Pare was skeptical for his times, but he accepted on very shght evidence many occurrences of which he was not a witness. The story of Dorothie, however, was conservative in comparison with that of the Countess Hagenan, who was said to have been delivered of three hundred and sixty-five children at a single birth; one hundred and eighty-two of them were reputed to be female, a like number males, and the odd one bisexual. Pepys in his Diary mentions that he saw the basin in which these children were baptized.
or Suburbs,) because she would not have been able to have supported her self, or climbe the ladder of the Gibbet; and keep her self on her Legs according to the custome of other Malefactors; because the body is only supported by the stability of these bones; where- fore we must believe, as most probable, that such a disjunction and
58 DEVILS, DRUGS, AND DOCTORS
separation were caused either from the falhng of this Woman's body from the high Gibbet to the ground after execution or from some blow on that place from some hard thing."
As this book indicates, the pelvis cannot spread apart. The head of a child, when larger than the pelvic ring, therefore, can- not pass through it. This disproportion does not, as a rule, result from the abnormal size of the child's head, but rather from the small size or distorted shape of the pelvis. Such abnormality of the pelvis occurs particularly as a consequence of the disease rickets. Rickets is essentially a disease of civilization. It is due to lack of sun- light and is greatly influenced by im.proper diet. The actinic, or chemically active, light of the sun acting through the skin influ- ences the growth and development of bones. The disease rickets occurs in children; the growing bones do not harden normally and become distorted. The actinic light from the sun which pre- vents the disease is in excessive quantities harmful. It is the cause of sunburn. The natives of tropical or semitropical countries, where the actinic rays of the sun are particularly strong, are pro- tected from the injurious effects of the rays by pigment in their skin. A dark skin does not keep out heat any better than a white skin, but it affords a partial protection against the actinic rays of the sun. Even people of the blond races tan and freckle when exposed excessively to the sun's rays, and thus, so to speak, de- velop their own physiological sunshade. The dark-skinned peo- ple of the tropical and subtropical regions do not lose their pig- ment when they migrate to the cities of the temperate zone; consequently they remain too strongly protected against the feebler sunlight. To add to their trouble, the smoke pall which covers cities, of itself and from the fog that it causes, further cuts off the sunlight. The cold weather of winter drives children indoors, where the sunlight is filtered through glass, which stops the few remaining rays of chemically active light. For the children so placed a special diet rich in such substance as cod-liver oil is neces* sary to prevent rickets. In consequence of the ignorance or disregard of this requirement the disease is particularly prevalent among the dark-skinned people in the dingy slums of modern cities.
A well-developed case of rickets presents an unmistakable picture
*'THE COMPASSION OF PETER CHAMBERLEN' 59
The head is large and flat on top. The ribs are roughened and feel like beads to the touch — the so-called "rachitic rosary." The legs, and to a less extent the arms, are bowed. In older children pronounced bowleggedness is the most evident feature left by the disease, and with it goes distortion of the pelvis. A walk through
NURSES SWADDLING A CHILD
In die seventeenth century, the period of this woodcut, the baby, at birth, was first bathed and then salted all over (in accord with the teachings of Galen), and its head tightly bandaged to shape it. Next it was bound round and round in swaddling bandages until it was unable to make the slightest movement. These bandages were usually taken off only once a day, when the child was allowed a few minutes of exercise. The swaddling continued for several months. About half of the children so treated died during the first year of life. Even in the United States today a fifth of all deaths are in the first year of life — a very high mortality in comparison with other civilized countries.
the slums of any large city in the temperate zone, where there is a fair proportion of the dark Mediterranean peoples or negroes, will show, even to the casual observer, many cases in which rickets has left its mark. In one of our large cities a series of measure- ments was made of the pelves of women who were pregnant ; among the white women, 8.5 per cent were below the normal size; among the black women the percentage was 32.6. The difference is in
60 DEVILS, DRUGS, AND DOCTORS
part compensated by the smaller size of the children borne by the negro women.
Measurement of the pelvic opening can be made readily by the physician. He does so by determining the distance between cer- tain bony prominences about the pelvis or by X-ray examination. Such measurements are a regular part of the proper care of preg-
THIRTEENTH-CENTURY NURSES WITH SWADDLED CHILDREN This old woodcut shows the bandaging which babies had to endure for the first »ew months of life.
nam women of the present day and are made early in pregnancy, if any serious abnormality is found, provision can be made for it in time to avoid danger to the life of the child and mother.
Prior to the time of anesthesia and asepsis — that is, before the beginning of modern surgery in the last part of the nineteenth cen- tury— the woman with a deformed pelvis met serious difficulties at the time of her delivery. Caesarean section with its then high
"THE COMPASSION OF PETER CHAMBERLEN" 61
mortality for the mother might be attempted, or the pelvic bones might be cut apart at their joint at the front of the body, or the resort of earlier times might be used and the child destroyed, but in serious deformity even this last procedure was far from suc- cessful. The induction of abortion, or later of premature labor, offered a solution to this difficulty. Abortion had been practiced by primitive peoples when there was any reason for not wanting the child to be born. With the development of the Greek and Roman culture the practice of inducing abortion was continued, and in- deed used extensively by the midwives for any and all reasons. The more conservative position taken by the better class of physicians is clearly outlined in the quotation given from Soranus: "... The fruit of conception is not to be destroyed at will because of adultery or of care for beauty, but is to be destroyed to avert danger appending to birth. ..." With the supremacy of the Catholic Church in Europe the practice of abortion was forbidden under penalty of eternal damnation.
It was in England in the eighteenth century that the practice of the primitive peoples and of the ancients was revived as a means of avoiding, in part at least, the tragic consequences of birth with contracted pelvis. The means of measuring the size of the pelvis were sufficiently established then, so that the physician could rec- ognize the abnormality. In such cases the pregnancy was brought to an end late in the seventh month or during the early part of the eighth month, and thus before the child had reached its full development. The smaller size of the child made its birth possible through a pelvis much narrower than the normal. With good care the child thus prematurely born could be raised. It is of interest to note that the old Hippocratic belief that there was a better chance for raising the child born during the seventh than one born during the eighth month was passing with the medical profession at this early date. This fallacious idea persists today as a popular superstition. By inducing premature labor it was possible to secure a living child in cases in which the destruction of the child had been necessary in previous deliveries at full term.
The French physicians did not follow the example of the English physicians, and in failing to do so were probably acting under the
62
DEVILS, DRUGS, AND DOCTORS
influence of the Catholic Church in France. In spite of the attitude taken by the medical profession of that country and in spite of civil and ecclesiastical decrees and proclamations, abortion was exten- sively practiced and had been for many years, but its practice was not for medical reasons. The great ladies of the day made light of the earthly and spiritual terrors held up to them and resorted
SAGE-FEMME An etching by Daumier showing the midwife and her sign.
to the crime to hide the consequences of their sexual irregularities. Bayles, indeed, uses this fact to support the theory that fear of worldly shame is a stronger sentiment than that of religion. The conditions existing in Paris at this time, seventeenth and early eighteenth centuries, can be gathered from a letter of Guy Patin, at one time dean of the Faculte de Medecine. Patin was a man of satirical humor and of keen observation, as may be judged from
•THE COMPASSION OF PETER CHAMBERLEN" 63
the fact that as early as 1657 he made the statement: "As to our publishers — I can hope for nothing from them. They print noth- ing at their own expense but novela utrisque" (sex novels) . The complaint has persisted! At the time Patin wrote there was a large class of men and women who made a business of producing abor- tion; the women in this trade were chiefly from the midwives. Patin's letter, written in 1660, comments on the case of Made- moiselle de Guerchi, who had been seduced by the Due de Vitry and who had died from infection resulting from an induced abor- tion:
OVS efi^s friez. ^afijler au Convoy, Sav tee &, EnterrmentJedeffunt noble homme M ^ Gt4y Patin, ConfeiUer Mciecln, LeBcufy & Profefenr dft Roy au College Royd de France , & Do&ettr Regent en U Faculte deMedccinea Paris, dccede'enfamaifon ru'edu Chevalier du Guet* ^uife (era Vendredy 'premier tour dAvrlli<^7 -? a vnz.e heures vrecifes du matin , en I'Eglije Saint Germain Latixerrois fa far- roijfe.ouil fera inhumes L^es Dames sytrouveront sil leur flaill-
Vn De profundis.
INVITATION TO GUY PATIN'S FUNERAL
"They make a great clamor here about the death of Made- moiselle de Guerchi. They had imprisoned the midwife at the Chatelet, but she had been taken from there to the coficiergerie by order of the court. The cure of Saint Eustache has refused sepulture to the body of the lady. They say that k was carried to the hotel de Conde, and was there put in quicklime in order to consume it. soon, so that it could not be identified if anyone came to see it. The midwife had defended herself well up to now. . . . But I be- lieve the question [torture] will be put to her. The vicars-general and the plenipotentiaries went to complain to the Premier Presi- dent that in a year six hundred women, by actual count, have con- fessed to killing and destroying their fruit."
64 DEVILS, DRUGS, AND DOCTORS
The midwife was later found guilty and hanged at Croix du Tra- heir, as Pa tin says, "in good company."
At the time the English physicians revived the practice of in- ducing premature birth as a means of avoiding difficult labor, mid- wifery had not been separated from surgery. In earlier times tht only reason for calling in the physician at the time of childbirth was because of tlie necessity for performing some destructwe surgical procedure. The revival of podalic version and the inven- tion of the forceps reduced the number of cases in which it was necessary to destroy the child. The practice of obstetrics neverthe- less remained in the hands of the surgeons. They quite naturally had a tendency to make child-bearing a surgical operation and to use instruments whenever possible. The general use of the ob- stetrical forceps gave even a wider play to this habit of "meddlesome midwifery." It was said at that time of one prominent Germ.an obstetrician that he employed instruments twenty-nine times in sixty- one births, and of another that he "began to cut and slash" as soon as everything was not precisely normal, and in this way had a mortality of twenty per cent. The surgeons, moreover, could not resist carrying with them into the obstetrical field their practice of blood-letting, and the parturient woman was bled for prophylaxis if everything seemed normal, and for treatment if anything seemed abnormal.
The revival of the practice of inducing premature labor to avoid the necessity of surgery at childbirth was a reaction on the part of the English physicians against the participation of the surgeon in obstetrics. It was, in fact, a definite move in the direction of separating these two branches of medical practice. Like most re- actions, it was carried to an extreme. Even beneficial surgical and instrumental procedures at childbirth were discarded for a time. Thus in the middle of the eighteenth century William Hunter, to emphasize his views of interfering with childbirth, was in the habit of showing his obstetrical forceps covered with rust, as evidence of the fact that he never used it. William Hunter was trained in the University of Glasgow, an institution destined to be associated with the names of many men of medical fame, and he was the leading consultant in midwifery in London. His views had s. strong
"THE COMPASSION OF PETER CHAMBERLEN" 6t
influence on rhe physicians in England. The practice of avoiding the use of instruments and trusting in the powers of nature went so far that in 1819 Sir Richard Croft, obstetrician to Princess Charlotte, upon whose life depended the hope of the dynasty, per- mitted the princess to remain in labor for fifty-two hours. The child was born dead and the mother died six hours later. Crofi shot himself in remorse over what he realized was his mismanage- ment. The reaction against operative interference gradually ex tended to France and the rest of the Continent. There the reaction was less extreme and the only violent manifestation of the new order of midwifery was in the frenzied activities of a Parisian fa- natic, Sacomb, who, about the time of the French Revolution, opened an anti-Csesarean school in Paris and fought the Cassarean operation and in fact all other operative interference, with all of the weapons of the charlatan. While Sacomb's hysterical activities made no great impression at the time, it is of interest to note that there is no record of a Caesarean operation having been performed in Paris for a period of ninety years after his short-lived efforts. The mortality for the woman undergoing Caesarean section was at that time about 80 per cent.
The reaction against operative interference in childbirth served its purpose. The obstetrical art was no longer taught as a branch of surgery. In the nineteenth century obstetrics became a recog- nized part of medical education and practice. The rational use of forceps and other operative procedures returnea, but no longer a; primary instruments of delivery, merely as necessary aids in diffi cult cases.
EGYPTIAN WOMEN CARRYING THEIR CHILDREN
CHAPTER IV
"A GENTLEMAN WITH CLEAN HANDS MAY CARRY THE" DISEASE"
Y the nineteenth century obstetrics was well de- veloped from the mechanical side. Great prog- ress had been made in the art of assisting the child-bearing woman during the three hundred years which had passed since Pare had opened the way for the return of the physician to the lying-in room. But some of the advantages de- rived from the development of obstetrics and the extensive participa- tion of physicians in the art were offset by the increasing prevalence of a disease known as child-bed fever, or puerperal infection. This disease, which struck only at women who bore children, had been known from antiquity as an occasional occurrence. During the seven- teenth, eighteenth, and nineteenth centuries, however, it became a pestilence. Between the years 1652 and 1862 there were two hun- dred epidemics of this disease, which was then attributed largely to the state of the weather. In 1773 a great epidemic of puerperal fever more than decimated the lying-in hospitals of Europe, and after raging for three years culminated in Lombardy, where it is said that for a year not one woman lived after bearing a child.
The ravages of puerperal infection were greatest in the lying-in hospitals of Europe. This was particularly unfortunate, for there is no institution which in principle seems more humane than the iying-in hospital, where destitute women can receive aid during the birth of their children. But from the seventeenth to nearly the twentieth century these hospitals, which had been built for and dedicated to the care of child-bearing women, were humane in spirit only. In reality most of them were deadly for the women
66
* 'CLEAN HANDS MAY CARRY THE DISEASE" 67
who entered them. These hospitals were the centers in which puerperal infection flourished. At one time the deaths from the disease rose to such heights in the old Maternite of Paris and in the lying-in hospital of Vienna, that 10 to 20 per cent of all women who entered them died there. The attention of the public at large was finally attracted and the abolition of these institutions as men-
DEATH AND THE PHYSICIAN A woodcut by Hans Holbein.
aces to public health was considered. They would have been abol- ished if any other means could have been found of caring for the destitute women who had no other place to go to bear their children or who went to the hospitals in spite of the dangers because the state would then accept their children as orphans even if the mother survived. A means of controlling puerperal infection was developed in the nineteenth century; before that time childbirth ranked in mortality with some of the serious infectious diseases.
Puerperal fever starts within a few hours to a few days after the
68 DEVILS, DRUGS, AND DOCTORS
birth of the child. There is high fever and all the symptoms which are known today to accompany infection of the kind popularly called blood-poisoning. But such things as blood-poisoning or wound infection were unrecognized until half of the nineteenth century had passed and Lister had applied to surgery the work of Pasteur. Even as late as the nineteenth century the formation of pus in wounds was considered, as it had been since the beginning of the Christian era, as a normal part of the healing process; it vas called "laudable pus." The enormous mortality from surgical operation and the prevalence of wound infection in hospitals be- fore the time of Lister are dealt with at length in Chapter VL
Brief extracts from the record of a case of puerperal fever de^ scribed by a physician practicing during an epidemic at Aberdeen, 1789 to 1792, give some insight into the course of the disease and also into the medical practice of the time: "In the afternoon of the )9th of August, 1790, John Low, miller of Justice-mills, came to my house, requesting me to go in mediately to his wife, who, he said, "... was in great danger.' I accordingly went, and found her in a dangerous situation; she complained of an acute pain in the lower part of the abdomen, attended with a very great de- gree of fever, the velocity of the pulse being at the rate of 140 strokes in a minute.
"The disorder commenced with a violent rigor at six o'clock in rhe morning, being about thirty-six hours after delivery. ... I ac- cordingly ordered bleeding to the quantity of sixteen ounces."
The physician also ordered a physic and raised a blister on the patient's abdomen, gave her opiates to relieve the pain in that location, and concludes, "... the scene was soon closed." With his patient dead he philosophizes at length on the ingratitude of the patient's friends in particular and on the hardships of medical practice in general!
"... On this, as well as many other occasions, I found that scientific practice and popular opinion very seldom correspond.
"According to a vulgar custom, in this country, the women came from all quarters to see the patient, and to offer their advice. Several ladies likewise joined the crowd; and though they neither knew the nature, nor even the name of the disease, yet they gave
"CLEAN HANDS MAY CARRY THE DISEASE" 6S
their advice with great freedom! Some said it was wrong to bleed, others that it was improper to purge a patient in such a situation; some prescribed heating, and others astringent medicines ; and seem- ingly actuated by other motives than the good of the patient, they proposed different practitioners. ..."
The first definite statement, although unheeded, as to the cause of childbed fever, came from the United States. The narrative of the conquest of death at birth turns for the first time to this country.
In Colonial days obstetrics did not receive the attention in this country that it did abroad; and with the conditions of life here at that time there is no reason to expect that it should. Childbirth ir those early days of American civilization was considered a simple physiological function, to be carried out in secrecy with a friend or a midwife. The wife of Dr. Samuel Fuller, who landed from the Mayflou'er, was the first midwife of the Colony. The next was Mrs. Hutchinson of Boston, who was banished for her political heresy. She was succeeded by Ruth Barnaby, who lived to be one hundred and one. The first person to be executed in the Colony of Massachusetts Bay was Margaret Jones, female physician; she was accused of witchcraft. Incidentally, she is the only physician whose name was in any way associated — and her association was involuntary — with the scandalous persecutions which were guided by those zealots, Cotton Mather and Samuel Parris.
The efforts of the Chamberlens to control midwifery in England and Mauriceau's innovation of conducting childbirth in bed did not influence the activities of the Colonies, but other things from" Europe did. Syphilis entered Boston in 1646, ten years after Har- vard College was founded. The appearance of diphtheria in Rox- bury, Massachusetts, was timed closely with Louis XIV's ascension to the throne. While Hugh Chamberlen was trying to sell his obstetrical forceps in Paris, New York was busy with an epidemic of yellow fever, and Boston, soon after, with one of its numerous epidemics of smallpox. Forty-six years after Clement delivered the Dauphin of France and made male midwifery popular among the ladies of the court, New York City passed the first ordinance in America to control the activities of the midwives. In 1716 the professional ability of anyone and everyone in this country to of-
70 DEVILS, DRUGS, AND DOCTORS
ficiate at childbirth was still, nearly a hundred years after the land- ing of the Miiyjlower, taken for granted, but apparently the civil activities of those participating in this art needed some regulation, for the ordinance reads:
"It is ordained that no woman within this corporation shall exer- cise the employment of midwifery until she has taken oath before the mayor, recorder or an alderman ... to the following effect: That she will be diligent and ready to help any woman in labor, whether poor or rich; that in time of necessity she will not forsake the poor woman and go to the rich; that she will not cause or suffer any woman to name or put any other father to the child, but only him which is the very true father thereof; indeed, according to the utmost of her powers; that she will not suffer any woman to pretend to be delivered of a child who is not indeed, neither to claim any other woman's child for her own; that she will not suffer any woman's child to be murdered or hurt; and as often as she shall see any peril or jeopardy, either in the mother or child, she will call in other midwives for council; that she will not administer any medicine to produce miscarriage; that she will not enforce a woman to give more for her service than is right; that she will not collude to keep secret the birth of a child; will be of good behavior; will not conceal the birth of bastards. ..."
In 1739 a special department for instruction in obstetrics was created in the University of Glasgow, while in America it was si . years after that date that there was the first record of a "man midwife." The New York Weekly Post Boy of July 22, 1745, states: "Last night died in the Prime of Life, to the almost uni- versal Regret and Sorrow of this City, Mr. John Dupuy, M.D., Man Midwife; in which last Character, it may be truly said here, as David did of Goliath's Sword, there is none like him." Later there is mentioned Dr. Attwood of the same city, who "is remem- bered as the first doctor who had the hardihood to proclaim him- self a man midwife; it was deemed scandal to some delicate ears, and Mrs. Granny Brown, with her fees of two dollars or three dol- lars, was still deemed the choice of all who thought that women should be modest."
In 1762, the same year that New York was maintaining its mod-
"CLEAN HANDS MAY CARRY THE DISEASE" 71
esty and its preference for Granny Brown of the two dollar or three dollar fees. Dr. William Shippen, Jr., was opening a school for midwifery in the less modest but more progressive city of Phila- delphia. Dr. Shippen had returned from abroad, where, after study- ing with John Hunter and his brother William Hunter, he of the rusty forceps, he had completed his medical studies at the Uni- versity of Glasgow, Shippen brought back with him the advanced ideas of European obstetrics and at once opened a school to impart them to his less enlightened brothers and sisters in midwifery. His class started with an enrollment of twelve students. Dr. Shippen provided "convenient lodgings" for the accommodation of poor women during their confinement, and may thus be said to have established the first lying-in hospital in America. The following advertisement, inserted by Shippen, appears in the Pennsylvania Gazette of January 1, 1765:
"Dr. Shippen, Jr., having lately been called to the assistance of a number of women in the country in difficult labors, most of which was made so by the unskilled old women about them; the poor women having suffered extremely, and their innocent little ones being entirely destroyed, whose lives might have been easily saved by proper management; and being informed of several desperate cases in the different neighborhoods which have proved fatal to the mothers as well as to their infants, and were attended with the most painful circumstances, too dismal to be related. He thought it his duty immediately to begin his intended Course in Midwifery, and has prepared a proper apparatus for that purpose, in order to instruct those women who have virtue enough to own their ignorance and apply for instruction, as well as those young gentle- men now engaged in the study of that useful and necessary branch of surgery, who are taking pains to qualify themselves to practice in different parts of the country with safety and advantage to their fellow citizens."
So far as is known, no women had "virtue enough to own their ignorance and apply for instruction." It is of interest that, although a disciple of the English school of moderation in midwifery. Ship- pen, nevertheless, called his art a "branch of surgery." Three years after he established his private school he joined w.irh Dr. John
72 DEVILS, DRUGS, AND DOCTORS
Morgan of Philadelphia in organizing the medical department of the College of Philadelphia, later the University of Pennsylvania, and there taught anatomy, surgery, and obstetrics.
The College of Philadelphia gave the first regular medical degree in America, conferring the Bachelor of Medicine on ten men in 1768. The following year King's College of New York, later Columbia University, graduated two men in medicine, having over- come in the meantime its regard for Granny Brown to the extent of giving instruction in obstetrics. The term "regular medical de- gree" is used here because prior to those given by the two American Medical schools there had been two irregular degrees conferred., One of these was in 1663, by order of the court of Rhode Island, to Captain John Cranston to "administer physlcke and practice chirurgerie . . . and by this court styled Doctor of Physicke and chirurgerie by the authority of this the general assembly of the colony." The other degree was given by Yale College. Although the Yale Medical School was not established until 1810, the Aca- demic College in 1720 conferred the honorary degree of M.D. on Daniel Turner in acknowledgment of books that he had presented to the institution. It was said facetiously that Yale's degree of M.D. in this case signified multum donavit. "Doctor" Turner's writings dealt largely with venereal disease; he effected improve- ments in the methods for contraception and was a staunch sup- porter of "prenatal influence." Some of the books which Turnei presented to Yale have been used as sources of material for this book.
The American Revolution interrupted the teaching of obstetrics at the newly founded medical school of Pennsylvania. In 1775 Congress appointed Dr. Morgan "director-general and physician in chief" of the American army. He was unjustly dismissed in 1777 and his place was taken by Shippen. Under Shippen the famous physician Benjamin Rush served for some time as a surgeon-general. He was one of the signers of the Declaration of Independence, but at Valley Forge he deserted Washington to join the Conway Cabal. Dr. Rush, although probably the ablest practitioner of his time, was somewhat of a theorist and a propagandist given to extrava- gant statements. It is of one such statement, "Medicine is my
"CLEAN HANDS MAY CARRY THE DISEASE" 73
wife and Science my mistress," that Oliver Wendell Holmes made die caustic comment, "I do not think that the breach of the Seventh Commandment can be shown to have been an advantage to the legitimate owner of his affections."
This same Oliver Wendell Holmes, just one hundred years after Mr, John Dupuy, M.D., man midwife of New York, "died to al- most universal regret," read before the Boston Society for Medical Improvement a paper entitled, "The Contagiousness of Puerperal
OLIVER WENDELL HOLMES AS DRAWN BY HIMSELF From a pencil sketch.
Fever," In this paper he showed clearly that the disease which ravaged the women in the lying-in hospitals of Europe, and which in America also took its toll of lives, was an infectious disease, and that the infection was carried by the physician or midwife from one patient to another through lack of cleanliness. This paper, setting forth the essentials of the greatest discovery ever made in the care of the child-bearing woman, was received with indifference in Boston, and with heated condemnation in Philadelphia by Dr. Meigs, who had succeeded Shippen in the chair of obstetrics at the
74 DEVILS, DRUGS, AND DOCTORS
university. Dr. Holmes replied to the attack with a paper, "Puer- peral Fever as a Private Pestilence," and in it stated that one "Senderein" had lessened the mortality from the disease by scrub- bing his hands with chloride of lime. The "Senderein" was Semmel- weis, of whom much more will be said presently. Holmes's papers were not even heard of in Europe until resurrected as historical curiosities over fifty years later. Holmes became professor of anatomy at the Harvard School of Medicine two years after the publication of his paper on puerperal infection, and, probably being engrossed in his new duties, he did not push further the discovery which he had tried to show to the obstetricians of America. The credit for one of the greatest boons that medicine has given to humanity goes instead to Semmelweis.
Oliver Wendell Holmes is not known to most people as a physi- cian. His fame comes from his literary work in quite another field than medicine, but his Medical Essays are as fascinating to the layman as to the physician, for his literary talents shone as brightly in these as in any of his other writings. They are perhaps more brilliant in places, for he was urged by the ardor of the reformer. A passage picked at random, somewhat broad in its satire, but suited to the fight he fought against the overdosing of the de- fenseless sick with medicine and pertinent here because of the treatment that was inflicted on the sufferer from puerperal fever, is given here:
"How could a people which has a revolution once in four years, which has contrived the Bowie knife and the revolver, which has chewed the juice out of all the superlatives in the language in Fourth of July orations, and so used up its epithets in the rhetoric of abuse that it takes two great quarto dictionaries to supply the demand; which insists in sending out yachts and horses and boys to outsail, outrun, outfight, and checkmate all the rest of creation; how could such a people be content with any but 'heroic' practice? What wonder that the Stars and Stripes wave over doses of ninety grains of quinine and that the American eagle screams with de- light to see three drachms (180 grains) of calomel given at a single mouthful?"
Nor did the rhetoric of Holmes fail him when he dealt with
"CLEAN HANDS MAY CARRY THE DISEASE" 75
puerperal infection. The most virulent opposition of Holmes's theory of the transmission of the disease through the agency of the physician's hands came from Dr. Meigs of Philadelphia, a most estimable physician but a chronic obstructionist. He was incensed by Holmes's imputation that the physician's hands were not clean; and he quoted a number of cases of infection which had occurred in the practice of the great Dr. Simpson of Edinburgh, an "emi- nent gentleman," according to Dr. Meigs. Holmes replied by first defining his position in the argument with Meigs as, "I take no offense, and attempt no retort. No man can quarrel with me over the counterpane that covers a mother with her newborn infant at her breast." He goes on to say in regard to Simpson: "Dr. Simpson attended the dissection of two of Dr. Sidney's cases (puer- peral fever), and freely handled the diseased parts. His next four childbed patients were affected with puerperal fever, and if was the first time he had seen it in his practice. As Dr. Simpson is a gentleman (Pr. Meigs as above), and as a gentleman's hands are clean (Dr. Meigs as above), it follows that a gentleman with clean hands may carry the disease."
Carlyle has said: "Consider how the beginning of all Thought worth the name is Love: and the wise head never yet was, without first the generous heart." How well this describes Soranus, Pare, and Holmes ; each championed the cause of the child-bearing woman. In the character of each there must have been much of the generous heart and humility which, though centuries apart, made them giants in the world. To these three must be added a fourth, the greatest of them all, Ludwig Ignaz Philipp Semmelweis.
Semmelweis, unsung in the history of the world, little known even though an international statue to him was unveiled in Budapest in 1906, has the mute testimony of his greatness in every child that is born and in every mother that bears a child in the civilized world. Holmes was not an obstetrician, but as a man of gentleness he was shocked by the deaths from puerperal fever and he pointed out to his fellow physicians what he reasoned out to be its cause. His passing words were unheeded. Semmelweis labored through a lifetime of oppression and persecution in the vile wards of the great charity lying-in hospitals of Europe. He found the cause
76 DEVILS, DRUGS, AND DOCTORS
of puerperal fever. He controlled it in the hospitals where he worked. He gave a practical method for its eradication. He died of its infection.
To obtain the setting for Semmehveis's work the narrative must return to Europe, to the Vienna of the eighteenth century. There Maria Theresa was ruling Austria first through her husband, Francis I, and after his death in 1765, through her son, Joseph II. There is a lull in the Austrian wars; the Turks have been driven from the walls of Vienna; Frederick the Great is on the throne of Prus- sia, and Maria Theresa's daughter, Marie Antoinette, is married to the Dauphin of France, later Louis XVI. In this time of general peace Maria Theresa turned her attention to the cultural develop- ment of her country. The fruits of her endeavors were the Vien- nese school of music with Haydn and Mozart at its head, and the founding of the old school of Viennese medicine, which is of im- portance because it laid the foundation for the brilliant new school of Vienna which came with the nineteenth century. For the re- establishment of medicine Maria Theresa turned quite naturally to Dr. Gerhard van Swieten. When the Archduchess Maria Anna had suffered an abortion, van Swieten had attended her with such satisfaction that she had recommended him to her sister, the em- press, who up to that time had been barren. Following the advice given by van Swieten, Maria Theresa had sixteen pregnancies and assured the succession of her family. Van Swieten was in Leyden, where his position was that of a physician and private teacher, for, being a Catholic, he could not hold a public professorship there at that time. Maria Theresa brought him to Vienna and made him president of the General Medical Department of Austria. She also made him a baron and appointed him censor; in the latter capacity he incurred the animosity of the Jesuits and of Voltaire and Haller, who accused him of applying his "damnature" to their works.
Van Swieten made an official systematization of medical practice and instruction in Austria, which had the weakness of allowing in- efficient men in high positions for no other reason than that of official favoritism. A more beneficial aspect of this organization is seen in the handling of the charlatan Mesmer. He established
"CLEAN HANDS MAY CARRY THE DISEASE" 77
iiis seances of mesmerism in Vienna, was immediately investigated, and ordered to leave within twenty-four hours. It so happened, however, that this hasty departure worked no hardship on the ex- ponent of animal magnetism, for he went to Paris, and there, under the protection of Marie Antoinette, acquired with his seances a fortune from broken-down roues and amorously inclined ladies.
In van Swieten's time the city hospital of Vienna consisted of twelve beds, six for women and six for men. As a result of the reorganization of medical affairs the "AUgemeines Krankenhaus," the great general hospital, was built in 1784. This institution in- cluded a lying-in hospital which was the largest in the world. Dr. Boer, who was to be the director of the new lying-in hospital, was sent by Emperor Joseph II to France and England to learn the practices of midwifery used there. On his return he introduced the conservative English methods; he practiced forbearance and trusted nature, interfering only when it was absolutely necessary to do so.
Two years after Boer undertook his work Joseph II died, and, during the political reaction that followed, Boer struggled on under serious discouragements. In spite of official persecution his work was extremely successful. In the last and thirty-fourth year of his service, 3,066 women were delivered in the wards of his hospital and of these only 26 died — that is 8.4 deaths in 1,000 births, a low rate in those days and one which does not compare unfavorably with that in the United States today.
Four years before Boer retired, in 1818, Semmelweis was born in Budapest, the capital of Hungary. He was the fourth son among eight children of a prosperous shopkeeper. The educational stand- ards in Hungary were at that time at a low level and Semmelweis received a deficient elementary training which shows in places in the style of his later writings. As he himself said, he developed in his youth "an innate aversion to everything that can be called writing." If Semmelweis had wielded the pen of Oliver Wendell Holmes his great discovery would have been adopted throughout Europe in the first twelve months after it was made; instead, he died too soon to see the general application of the principles which he set forth.
78 DEVILS, DRUGS, AND DOCTORS
When nineteen years old Semmelweis undertook the study of law at the University of Vienna, but, disappointed with that, turned to medicine. He completed his medical studies, and, after signing a declaration that he did not intend to remain in Vienna, received his doctor's degree in 1844, and later the same year the degree of master of midwifery. He at once applied for a position as as- sistant in the lying-in hospital and, at the hands of Klein, the suc- cessor of Boer, received the first of the official injustices which were to be his lot. His application, at first granted, was later rejected, and the term of the assistant then in office was extended for two years. As Semmelweis says, that was contrary to the custom pre- vailing in the Obstetrical Clinic, and "Dr. Breit was the first to whom this favor was granted." Dr. Klein, to whom Semmelweis, after two years ot waiting, became assistant, lacked the qualities of his predecessor, Boer; from first to last his career depended upon official favoritism. Boer had refused to teach midwifery to the students through the use of a dead body, and that had been given as one of the excuses for his dismissal. Klein consented to do so. His first year as director resulted in the loss of 237 lives from the 3,036 women delivered in the hospital, a mortality of 78 in 1,000 births.
While Semmelweis waited for his appointment as assistant he obtained the friendship of two of the medical leaders who were to make the Vienna school of the nineteenth century a great center of medical learning. These two were Skoda and Hebra. Skoda was the first physician at Vienna to adopt a "specialty." He de- voted his attention to diseases of the chest and developed the method of diagnosis by percussion — that is, tapping on the chest with the finger to obtain, from the sound elicited, a conception of the state of the structures of the interior — a procedure familiar to anyone who has undergone a physical examination. At Skoda' s time the practice "annoyed" the patients, and as it was considered a foolish procedure he was put in charge of the insane patients. He triumphed, however, over this act of official pettiness and was rewarded in time with a whole division of the hospital devoted to diseases of the chest. Hebra, without suffering the reverses of Skoda, de- veloped his specialty in diseases of the skin and laid the founda-
"CLEAN HANDS MAY CARRY THE DISEASE" 79
tion for the modern study of that subject. Both Skoda and Hebra remained firm friends of Semmelweis's. They defended him as best they could and even wrote papers setting forth his discovery when he found himself unable to do so.
An appreciation of the task to which Semmelweis set himself in trying to rid the lying-in hospital of childbed fever can be had from a brief description of the conditions existing in these hospitals throughout Europe. England and the Scandinavian countries had at this time, the middle of the nineteenth century, some ideas of cleanliness in hospitals, but the rest of Europe was untroubled with any scruples in this direction. In England childbed fever came as an occasional epidemic; in the hospitals on the Continent it was a perennial epidemic. Speaking of these epidemics, and still bound to the idea of "miasma" — that is, noxious air as a cause of con- tagion— Oliver Wendell Holmes said, "Now add to all this" [trans- mission of the disease by contact} "the undisputed fact that within the walls of lying-in hospitals there is often generated a miasma, palpable as the chlorine used to destroy it, tenacious so as in some cases almost to defy extirpation, deadly in some institutions as the plague; which has killed women in an Old World hospital so fast that they were buried two in a coffin to conceal its horrors." The miasma in these cases was filth.
Bearing in mind that childbed fever is wound infection caused by the contamination of the raw surface left in the uterus after the birth of the child, consider the state of cleanliness in the Maternite of Paris as described by La Forte after his visit there in 1864, only thirty-six years before the present century:
"The principal ward contained a large number of beds placed in alcoves like English horse-stalls along each side. Ventilation was almost impossible. Floors and partitions were washed once a month . . . the ceilings showed that they had not been whitewashed for many years. Lying-in women who became ill were transferred to an isolation room regardless of the nature of their illness — puer- peral fever cases and patients affected with diarrhea, bronchitis, measles, or any other eruptive fever. Midwife pupils attended nor- mal lying-in patients and fever cases alike, and performed all the necessary manipulations for every class of case."
80 DEVILS, DRUGS, AND DOCTORS
La Forte speaks of the apparent aversion to water at the hospital, of the clouds of dust raised by dry sweeping the unwashed floors, and concludes: "It is not astonishing that the Maternite of Paris has furnished a mortality without example in any European country. From 1861 to 1864 the patients numbered 9,886 of whom 1,226 died; equal to a mortality of 124 in 1,000 births." This is not a hospital of medieval times mentioned here, but a hospital in a center of cui- vure and in years from which many of the children born must be living today.
In 1858 Semmelweis, while advocating chemical treatment of the hands as a prevention of the spread of puerperal fever, received a letter from one of his students describing the conditions at Gratz: "Infection of all sorts occurs at the Gratz lying-in hospital. . . . The dissection-room is the only place where the students can meet and pass the time when waiting for their midwifery cases, and they often devote their attention to dissecting or studying and manipulating preparations." (Be it noted parenthetically that the cadavers of the dissecting-room at that time were not embalmed in antiseptics as they are today, and in Germany, where an autopsy occurred invariably after each death in the hospital, the body, afflicted with whatever disease, furnished material for the medical student.) "When they [the students] are summoned to the lying-in hospital, which is just across the street, they do not make any pretense at disinfection; some of them do not even wash their hands. . . . The patients might as well be delivered in the dissecting-room. As it is, the students cross the street with hands wet and bloody from dissecting; they dry their hands in the air, and stick them a few times into their pockets, and at once proceed to make examinations. ... It is no longer a riddle to me why, after a clinical meeting, the medical officer of Gratz exclaimed: 'The lying-in hospitals are really nothing but mur- der institutions!' "
Of the lying-in hospital of Budapest in 1850, it is said that the patients' view from the window was the burying-ground, varied on the other side by glimpses of the dissecting-room, with underneath the privies and an open sewer. In I860 the hospital was moved to a new building, and of this the following is written in a publication of that time:
"CLEAN HANDS MAY CARRY THE DISEASE" 81
"While it is not to be denied that the institutions have obtained the advantages of more room, it must be admitted also that the in- ternal littings (furniture, beds, etc.) are in the old wretched condi- tion; the broken tables and the ragged and worn-out bed clothes, all brought from the old hospitals. Especially the lying-in clinic is in an indescribably pitiable condition; there poor lying-in women are to be found, some of them partly on straw spread on the floor, some of them on wooden benches, others crouching in any corner of the room, weary and worn out; only to a few is it vouchsafed to find a regular bed on which to stretch their weary limbs. Everywhere you find dirty bed linen, with bedclothes old and worn and almost in fags."
With this quotation in mind, think of a modern charity hospital. There are two classes of patients in this country today who have superlative medical attention — the very rich and the very poor who go to the charity hospitals. Both classes are served by the same physicians.
The bed linen referred to in the quotation above as being almost in rags suffered also from other difficulties. In I860 graft was known in hospital administration and Semmelweis encountered and ended, for his wards, one of the most loathsome varieties. The mortality among his patients remained high in spite of his efforts, and he examined the instruments, the utensils, and the bedding. He made a shocking discovery. He found that patients in labor were laid upon filthy sheets which actually stank of decomposed blood and uterine discharge. These had been received and accepted as clean by the head nurse from the laundry contractor, who had accepted the contract at a specially low rate. All the circumstances pointed to dishonesty which extended all the way from the superintendent to the pupil-midwives. With his whole heart and soul filled to overflowing with desire to save from suffering and death the poor creatures consigned to his care, Semmelweis bundled together the evil-smelling "wash" and went straight to the chief official. His vehement gesture shook the linen in the face of that gentleman and demonstrated at close range to his eyes and nose the urgent call fof improvement. He obtained promptly all that he demanded for th<
82 DEVILS. DRUGS, AND DOCTORS
care and comfort of his patients, and obtained, besides, the dislike and hostiUty of the director.
It must not be thought that the conditions in the charity hospitals or the frightful loss of lives among the lying-in patients in these institutions applied likewise to the private practice of physicians among the well-to-do classes. Childbed fever occurred in occasional cases, and sometimes in epidemics, but, as Holmes particularly no- ticed, it was apt to run in a few consecutive cases of some one physic cian and then die out for a time. The lesser rate of puerperal infection outside of the hospitals, be it noted, was not due to any precaution of the physician, but rather to the ideal conditions for the spread of the disease which existed in the hospitals. Today, in the era of asepsis, the conditions are reversed ; it is vastly safer for a woman to be confined in a modern hospital than at her home. Such cases of puerperal infection as are seen in hospitals originate on the outside and are brought to the hospital for treatment. In- fection in the hospital has been reduced to almost the vanishing point as, for instance, one case in eight or ten thousand births.
With a picture in mind of the conditions existing in the maternity hospitals of the middle of the last century, we turn again to Semmel- weis and his problem. The maternity hospital of Vienna, where Semmelweis started his work, was in two divisions; in one the medical students were instructed and in the other the women who were to become midwives were trained. In the First Division, that of the medical students, there were from 68 to 158 deaths in each 1,000 births, with an average, over a period of six years, of 99. In the Second Division, that of the midwives, the average for the same period was 33 deaths in 1,000 births. The difference in these figures started the active mind of Semmelweis to puzzling over the reason; he passed in review all the possible causes which had been sug- gested.
Some physicians had confidently attributed the frightful devasta- tion wrought by childbirth fever in the First Division to epidemic influences, which in those days signified some not exactly defined state of the weather w4iich often spread over whole districts of the country and caused fever in women bearing children. But Semmel- weis dismissed this theory on the ground that the same atmospheric
"CLEAN HANDS MAY CARRY THE DISEASE" 83
conditions existed in both divisions of the hospital. He recognized that the cause of the disease lay within the hospital. He said: "A very common and successful method of diminishing the ravages of a puerperal-fever epidemic is to close the lying-in hospital. The hos- pitai is not closed in the expectation that the patients will die some- where else, but because of the belief that if they remain in the hospital they will die, owing to the epidemic influences at work within the hospital ; whereas if they are confined outside, away from the hospital, they will remain well."
Semmelweis makes point after point in tracing the course by which he established to his own satisfaction that the disease arose from some unknown cause within the hospital. It may be added that only a dreadful dilemma saved the lying-in hospitals from destruc- tion. The patients were charity cases and most of the children born were retained under the care of the state. Due to the hospitals, many women in the bloom of life were carried off by fever. With- out the hospitals a large number of women would remain well, but because of the anxiety over the maintenance of themselves and their infants they would resort to the crimes of abortion, child exposure, desertion, and murder. The hospitals were tolerated as the lesser of the two evils.
Semmelweis demonstrated that crowding could make little dif- ference in the distribution of deaths between the two divisions of this hospital, because each was crowded. Fear was declared by some physicians to be the cause of the fever, for the dread of going to the First Division was very great; so great, indeed, that it was thought the women sickened and died for that reason. In this con- nection Semmelweis says: "That they were afraid of the First Division there was abundant evidence. Many heartrending scenes occurred when patients found out that they had entered the First Division by mistake. They knelt down, wrung their hands, and begged that they might be discharged. Lying-in patients with un- countable pulse, meteoric abdomen, and dry tongue, only a few hours before their death would protest that they were quite well in order to avoid medical treatment, for they believed that the doctor's interference was always the precursor of death." Semmelweis dis- missed this theory that fear was the cause of the difference in mor-
84 DEVILS, DRUGS, AND DOCTORS
tality, because this difference in mortality would of necessity have to exist before the fear could develop.
Certain religious observances were also accused of increasing the mortality. The chapel of the lying-in hospital was so situated that the priests, bearing the last sacrament to the dying, could, in the Second Division, reach the ward where the patient lay without pasS'
DEATH AND THE PRIEST
A woodcut by Hans Holbein. The priest is carrying the sacrament to some dying man or woman; attendants follow with tapers and holy water, and death leads the way with a lantern and a bell to announce the coming of the priest. It was the sound of this bell which distressed Semmelweis.
ing through the other wards, but in the First Division they must pass through five wards before reaching the sick-room beyond. It was usual for the priests, arrayed in their robes, with an attendant marching before them ringing a bell according to Catholic ritual, to proceed to the sick woman to administer the sacrament. Accord- ing to ordinary arrangement this should be done only once in twenty- four hours, but in childbed fever twenty-four hours is a long time,
"CLEAN HANDS MAY CARRY THE DISEASE" 85
and the priests had to be sent for occasionally in a few hours after their regular visit. It is easy to imagine the impression which the fateful tolling of the bell would produce upon the lying-in women. "Even to me myself," says Semmelweis, "it had a strange effect upon my nerves when I heard the bell hurried past my door ; a sigh would escape my heart for the victim that once more was claimed by an unknown power. This bell was a painful exhortation to me to search for this unknown cause with all my might. During my first term of office I appealed to the sense of humanity of the servant of God, and without difficulty it was arranged that for the future the priests would take a roundabout route, without ringing the bell, so as to reach the sick-chamber in silence and unobserved. The two divisions were made similar in this respect, but the difference in their mortality still remained."
Other and even more absurd reasons were given for the difference in mortality. "It was alleged that the reason for the great mortality was because patients were unmarried women of the most hopeless class of the community, accustomed to earn their bread in want and misery and amid conditions which produced great and constant de- pression of spirits. If this had been the cause of the mortality it would have been as great in the Second Division, for to it exactly the same class of patients were admitted. The higher mortality of the First Division was ascribed to the wounded modesty of the poor women going through the process of parturition in the presence of men. Most of the patients in the First Division certainly suffered from fear, but not many were troubled with a sense of shame. Truly it shows with what want of thought the whole question of the eti- ology of puerperal fever has been discussed when the persons who at times are depicted as the most abandoned of the population, have attributed to them in the next sentence a tenderness of modesty such as the upper and highest classes of the community do not claim. Among the upper and even the highest ranks of society labor is conducted by physicians, and their patients do not die of puerperal fever in consequence of wounded modesty in the same proportion as is alleged of the inmates of the lying-in hosptials who, for the sake of argument, are qften depicted as the most loose and aban- doned of the coiTimunity."
86 DEVILS, DRUGS, AND DOCTORS
Semmelweis goes on step by step to eliminate ventilation, dirty laundry, and improper diet on the grounds that these things were the same in the two divisions. Yet as he eliminated these possible causes he knew that the real cause lay undiscovered before him in the hospital. This fact was proven by the observation that women who were overtaken with labor on the street while making their way to the hospital were not affected with childbed fever in the hos- pital, even though they might be taken into the First Division.
The restless energy of Semmelweis in his work in the hospital, his sympathy with suffering women, and his constant criticism of the old orthodox opinions on the causation of childbed fever, prob- ably reached the ears of the director, Kline, in exaggerated form. Semmelweis was demoted from his position of assistant in charge of the First Division, to that of provisional assistant; another physi- cian was put in his place. After some six months of depressing in- activity Semmelweis resumed his former position. At the same time the death of Dr. KoUetschka occurred at the hospital under circum- stances which greatly impressed Semmelweis. KoUetschka, while performing a post-mortem examination, received a puncture wound on the finger from the knife of one of his pupils. In consequence of this slight wound he sickened and died. The general symptoms of his malady were those of childbed fever. Of this occurrence Sem- melweis says: "In the excited condition in which I then was, it rushed into my mind with irresistible clearness that the disease from which KoUetschka had died was identical with that from which I had seen so many hundreds of lying-in women die.
"Day and night the vision of Kolletschka's malady haunted me, and with ever-increasing conviction I recognized the identity of the disease from which KoUetschka died with the malady which I had observed to carry off so many lying-in women."
Semmelweis was on the verge of his great discovery that childbed fever was wound infection, blood-poisoning, which was transmitted to women by the unclean hands of the physicians and medical stu- dents who examined them during their childbirth.
"In the case of KoUetschka the cause of the disease was cadaveric material carried into the vascular system; I must, therefore, put this question to myself: Did, then, the individuals whom I had seen die
"CLEAN HANDS MAY CARRY THE DISEASE" 87
from an identical disease also have cadaveric matter carried into the vascular system? To this question I must answer, Yes!"
All of the physicians and students attending the First Division of' the hospital had frequent occasion to come in contact with and work upon the bodies of those who had died at the hospital. Ac- cording to the usual method of washing the hands, merely with soap and water, particles adhering to the hands were never completely removed, a fact demonstrated by the odor which the hands retained. In the examination of the women in the wards, any of the students were entitled to make internal examination for their instruction; the raw surfaces left at delivery were infected; childbed fever followed. Moreover, when one woman was infected the hands of the examiner, unwashed between examinations, carried the infection to the next woman examined.
With his discovery made, Semmelweis at once required each student to wash his hands in a solution of chloride of lime before making examinations. At that time in his division there were 120 deaths in 1,000 births; in the next seven months the deaths fell to 12 m 1,000, and for the first time in the history of the hospital were below that of the Second Division. In that year also there were two months in which not one single death occurred among the patients of the First Division.
At this point in the career of Semmelweis the antipathies which his enthusiasm had aroused rose in turn to suppress him. Distracted by the petty acts of official injustice, he left Vienna abruptly and returned to Budapest. There he wrote his book setting forth his discoveries and rose to be head of the sm.all lying-in hospital of the city. There, too, he faced hostility and official injustice. He returned but once to Vienna. In 1865 his mental state aroused the anxiety of his wife and friends and he was taken to Vienna for the examina- tion of a specialist in mental diseases. This examination disclosed an injury to a finger which had probably occurred during one of his last operations. He was infected with the disease, blood-poisoning, whose identity with puerperal fever he was the first to recognize. He died August 13, 1865, a victim of the infection which he had devoted a lifetime to eradicate from the wards of the maternity hospitals. Thus ends a chapter in the conquest of death at birth,
88 DEVILS, DRUGS, AND DOCTORS
a chapter which gave, but not in Semmelweis's time, the modern lying-in hospital its supreme virtue — cleanliness. The work of Lister in the same decade completed what Semmelweis had started.
Today puerperal infection no longer ravages the lying-in hospitals. The infection is no longer carried there by the attendants, as Holmes says, "from bed to bed as rat-killers carry their poison from one household to another." Puerperal infection is a disease that is preventable. It will be prevented when civilization rises to that level where it will demand the prevention. It will be then, as Holmes declared it should be: "^. . . if there is any voluntary blind- ness, any interested oversight, any culpable neglect, even, in such a matter, and the fact shall reach the public ear, the pestilence-carrier of the lying-in chamber must look to God for pardon, for man will never forgive him." All women do not go to hospitals; they have only the kind of medical care which the civilization of their com- munity makes available for them. In the United States 6.8 women die in every 1,000 births, and of these, 40 per cent die of childbed fever. Every year in the United States more than 7,000 women die from this preventable disease and the public ear is still deaf to their deaths.
Nor are these 7,000 deaths the only consequences of the disease; for each woman who dies of it, three or more survive. Thus each year 20,000. or more women suffer from the disease and live, but many of them are left with some degree of invalidism.
The prevalence of puerperal infection is not alone the cause of the high mortality among women bearing children in the United States. Deaths from other causes account for a mortality of 4 in every 1,000 births. The death rate, even when thus modified by deducting the deaths from puerperal fever, remains higher than the general rate in some other countries. In Sweden, for instance, the death rate for mothers is 2.3 in every 1,000 births. In the care of the child-bearing woman in Sweden and the United States a striking difference lies in the fact that in Sweden 80 per cent of the deliveries are conducted by midwives, while in this country 80 per cent of the deliveries are conducted by physicians. There are physicians in this country who specialize in obstetrics and whose skill is as great as that of any obstetricians in the world. The service of these men
"CLEAN HANDS MAY CARRY THE DISEASE" 89
is given to all classes in the hospitals, but outside of hospitals it is available only to those women who can pay for the best service. The vast majority of cases of childbirth do not come into their hands, but go, instead, to men who practice obstetrics as a side line to their general medical practice, or else they go to untrained and ignorant midwives.
The attitude of indifference toward the child-bearing woman in this country — evident in our disgraceful mortality — is seen partic- ularly in the kind of training and supervision the midwives receive. In the United States there are at least 28,000 licensed and 18,000 un- licensed midwives. They have no standing. In some states they are tolerated by law; in other states they are ignored. Their work is supervised only in the most casual manner, and with one exception there is no place where they can be trained. Nevertheless they are annually intrusted with the lives of over 500,000 women bearing- children. In Sweden, on the other hand, the midwives are chosen from a class of women comparable to the better grade of trained nurses. They are thoroughly educated in the art of practical mid- wifery, are allowed to practice only under cldSe medical supervi- sion, and are required to call in a trained obstetrician in any difficult labor. The difference between the midwives in Sweden and the midwives in the United States is as great as the difference between the specialists in obstetrics and the common run of doctors into whose indifferent hands the lives of most of the child-bearing women of the United States are intrusted. These doctors are not so well trained in obstetrics as are the midwives of Sweden. More- over, the demands of their general practice and the necessity of earning a living leave them neither the necessary time nor the patience to deal properly with their poorly paid obstetrical cases. The persisting high mortality for mothers in the United States is not a matter fundamental to the economic condition of this country; it is merely an expression of indifference.
Part Two THE STORY OF ANESTHESIA
CHAPTER V
'IN SORROW THOU SHALT BRING FORTH CHILDREN"
He use of anesthetics to alleviate the pain of sur- gical operations and of childbirth was unknown before the middle of the nineteenth century. Prior to that time operations were performed only from the direst necessity ; the fully conscious victim of the operation was tied with ropes to prevent his escaping from beneath the surgeon's knife, and he bore his suffering with such fortitude as he could com- mand. This barbarous state of affairs, formerly accepted as inevi- table, shows by contrast with present conditions the humane aspect of the discovery of anesthesia. No greater boon has ever come to mankind than the power thus granted to induce a temporary but complete insensibility to pain. So far as surgery is now concerned, the means of inducing anesthesia are highly developed and extremely eft'ective. Such, however, is not the case in childbirth. Although anesthesia was early applied to relieve the pains of childbirth, and with much benefit, certain conditions, partly physiological and partly sociological, have prevented this use of anesthesia from being devel- oped and applied to the extent that has been attained for surgery. These difficulties are dealt with in this chapter; and as they are de- scribed it will be seen that behind them lies the old indifference to the suffering of women in this case, exacerbated by religious opposi- tion to the use of anesthesia for relieving the pains of childbirth. All of these difficulties are being slowly overcome. A time will un- questionably arrive when the general conditions now existing in regard to anesthesia at childbirth will be looked back upon and con- sidered as barbarous as were the conditions in surgery in the pre- anesthetic days.
93
94 DEVILS, DRUGS, AND DOCTORS
The discovery of anesthesia for surgical operations was first demonstrated with the use of ether in 1846. It depended not so much upon the employment of a new drug as upon a new method of administering drugs. The anesthetics are inhaled and therein lies their especial feature. The action of a drug which is swallowed cannot be controlled once the drug has passed into the body; its effects diminish only as the drug is slowly eliminated during hours or even days. On the other hand, the action of the vapors of gases which are used as anesthetics continues fully only as long as these substances are inhaled. When the inhalation ceases they are rapidly exhaled and their action can thus be accurately controlled. The narcotic action of such drugs as opium, hemp, and mandrake has been known from antiquity, as will be seen later, but these drugs cannot be used satisfactorily as anesthetics. They deaden pain, but they also exert a depressing influence upon the action of the heart and upon respiration, which, if the dose of the drug is large, may result fatally. Moreover, pain partially counteracts the action of the narcotic drugs. Thus when they are given in the large amounts necessary to relieve the pain of an operation, they may prove poison- ous when the operation is over and their effects are no longer neutralized by the pain. In the past such drugs were sometimes administered for surgical operations, but in the amounts that could be given safely they served merely to allay the sharpest agonies of the operation. The narcotic drugs did not furnish true anesthesia, and they were used in the past as they are used today — to relieve in part the suffering from wounds or painful diseases and thus to allow the sufferer to rest.
This deadening of pain by soporific potions was known even to some primitive peoples as well as those of the earliest civilizations. Helen cast "nepenthe" into the wine of Ulysses, and the Talmud of the Jews speaks of a narcotic called "samme de shinta"; there is the "bhang" of the Arabian Nights and the "drowsy syrups" of Shakespeare's time. Opium and Indian hemp, "hashish," were prob- ably known to the Egyptians and Greeks, and the mandrake to the Babylonians and Hebrews. This mandrake is the European plant, not the May apple, or mandrake, of America. Besides having narcotic properties, mandrake was said to have the power of arous-
"IN* SORROW BRING FORTH CHILDREN"
95
ing the sexual passions; Rachel sought mandrakes of Leah (Gen. XXX: 14-16), but it is uncertain for which purpose she used them. Mandrake wine was used in surgical operations by Dioscorides, an army surgeon in the service of Nero; the plant has played a part in early English and German folklore. There are tales of the human shape of its roots and the shriek of agony that it gave when it was uprooted. This shriek was supposed to cause madness in those who heard it. Shakespeare has Juliet say (Act IV, Scene 3) "And shrieks
GATHERING A MANDRAKE According to popular superstition the mandrake shrieked when pulled from the earth and anyone hearing the shriek went mad. The man shown here has tied his dog to the plant and the dog in seeking to escape is pulling out the root. As a further precaution the man is blowing on his horn to drown out the shriek. The supposedly human shape of the mandrake is evident from this old picture.
like mandrake torn out of the earth, — ^That living mortals hearing them run mad." In order to avoid the danger of hearing the shriek the plant was drawn from the ground by a dog. "Therefore they did tye some dogge or other living beast unto the roote thereof with a corde . . . and in the mean tyme stopped their own ears for fear of the terrible shriek and cry of the mandrake. In whych cry it doth not only dye itselfe but the feare thereof killeth the dogge. . . ."
Mandrake was the most popular substitute for an anesthetic due-
96 DEVILS, DRUGS, AND DOCTORS.
ing the Middle Ages. It held its vogue up to the sixteenth century and is referred to by Elizabethan poets. It was an inefficient anes- thetic and ceased to be employed. Its inefficiency is evident from the fact that Pare did not use it, and he was a compassionate surgeon who did not believe in torturing "poor wounded men." Pare used no anesthesia; he simply tied his patients so that their struggles would not interfere with his work.
The surgeons of the eighteenth and nineteenth centuries some- times intoxicated their patients with alcohol or occasionally drugged them with opium when the procedures of the operation necessitated freedom from struggling. But the surgeons of these pre-anesthetic days depended largely upon speed; an operation verged on being a sleight-of-hand affair designed to shorten to the minimum the suffer- ing of the surgeon's victim. Thus one reads of Langenbeck, surgeon- general of the Hanoverian army in the time of Napoleon, amputating a shoulder while one might take a pinch of snuff.
In all of this nothing is said of the child-bearing woman. Sopo- rific potions may have been used in ancient times, but no one then troubled about the pains of women. Indeed, the efforts to avoid the pangs of child-bearing sometimes called forth punishment. The Greek goddess Actemia, terrified by her mother's suffering at her own birth, besought from Zeus the favor of eternal virginity. Subse- quently she seduced Endymion and was punished for her early prudery by a truly god-like superf ecundation ; she became the mother of fifty daughters all at one time. One of the reasons that soporific potions were not used to relieve the pain of childbirth was because the nature of the substances available — opium, for instance — pre- cluded their employment in effective doses. They arrest the progress of the birth or are injurious to the child. There are, however, some recorded instances of painless childbirth during profound intoxica- tion which was not induced for this purpose. One such case occurred in a woman brought into the Hotel Dieu of Paris in 1818. There is also the celebrated case of the Countess de St.-Geran, who was rendered insensible by a draught given to her by the midwife; she was delivered and her child was abducted before she regained con- sciousness.
There is a prescription for relieving painful childbirth set forth
"IN SORROW BRING FORTH CHILDREN" 97
in a manuscript of Zerobabel Endecott of Salem. Zerobabel was a son of Governor Endecott by his second wife, but the records provide little information as to his career other than that he was a physician, that he served on an occasional jury, and was fined, in 1659, by the Quarterly Court for excessive drinking. Endecott's prescription is given here in full: "For Sharpe & Dificult Travel in Women with child Take a Lock of Vergins haire on any Part of ye head, of half the Age of ye Woman in travill. Cut it very smale to fine Powder then take 12 Ants Eggs dried in an oven after ye bread is drawne or other wise make them dry & make them to powder with the haire, give this with a quarter of a pint of Red Cows milk or for want of it give it in strong ale wort."
The alternative of ale for milk, as the vehicle for the ant eggs and human hair, was a wise provision; milk was exceedingly scarce in America in those days, but ale was both plentiful and cheap. While this concoction had no effect except on the imagination, it was at least less disgusting than were many of the medicaments used at that time.
The pain of child-bearing has always been woman's heritage. The pain and the fortitude with which she has met it are not new with modern civilization. It is said of the parturient in Biblical times (Jer. iv:3i), "For I have heard a voice as of a woman in travail, the anguish as of her that bringeth forth her first child, the voice of a daughter of Zion, that gaspeth for breath, that spreadeth her hands, saying, 'Woe is me now ! for my soul fainteth before the murderers !' " As for the fortitude of women there can be quoted (Jer. XLvni:4i, XLix:22), "and the heart of the mighty men of Moab at that day shalt be as the heart of a woman in her pangs."
Biblical quotations are not amiss in a chapter dealing with the use of anesthesia, for Biblical quotation and Biblical interpretation formed the basis for the opposition to the use of anesthesia. The introduction of anesthesia to alleviate the pains of child-bearing and for surgical operations aroused a violent controversy. It was science versus theology and progress versus stagnation, and would seem, amusing now if it were not for the human suffering involved. Similar controversies, no doubt equally amusing long after they are
98 DEVILS, DRUGS, AND DOCTORS
over, still arise and probably always will arise so long as human nature remains what it is.
The events leading up to the controversy over anesthesia started in 1800, when Sir Humphry Davy in England experimented upon himself with nitrous oxide. He states that, "As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage in surgical operations in which no great effusion of blood takes place." Forty-four years later Horace Wells of Hartford, Connecticut, began to use nitrous oxide in dentistry and thus was the first man to make a practical application of anesthesia. Wells was led to use the gas as the result of an observation made while attending a lecture given on nitrous oxide in New Haven, Connecticut. The lecturer allowed members of his audience to inhale the gas, and Wells noticed that those under its influence did not appear to be sensible to slight injuries caused by falling or by staggering against the furniture on the stage. Some years later a death resulted from an anesthesia which he gave, and this caused Wells to withdraw from practice. He eventually became depressed over what he regarded as his failure and put an end to his own life.
Wells reported the progress of his w^ork to William Morton of Charlton, Massachusetts, a friend and former partner. Both were keenly interested in any method which promised relief from the pain caused by the extraction of teeth. They had perfected a plate to hold false teeth, but its use necessitated the removal of all old roots left in the jaw from broken teeth. Many patients refused to submit to this prerequisite, and had their dental plate formed on the broken teeth still in their jaws, because of the pain involved in extraction without an anesthetic. Cocaine for local anesthesia was not in use until 1879. Wells and Morton realized that the intro- duction of their method necessitated an anesthetic of some kind and, after the failure of Wells with nitrous oxide, Morton was on the lookout for some substance which would be safe and reliable.
Morton practiced dentistry in Boston and undertook at the same time the study of medicine at the Harvard Medical School. His work there brought him into contact with Dr. Charles Jackson, and from him Morton learned of the anesthetic properties of ether.
"IN SORROW BRING FORTH CHILDREN" 99
Jackson had obtained this knowledge through an observation similar to that made by Wells at the lecture on nitrous oxide. Ether was sometimes inhaled by medical students at so-called "ether frolics," indulged in for amusement and for the mild intoxication or "ether jag" which the vapor produced. Jackson had noticed that when the students were thus under the influence of ether they appeared to be insensible to pain caused by falling over furniture. Jackson had never taken advantage of his knowledge to use ether for the purpose of obtaining relief from pain ; but Morton, searching for an anesthetic to be used in his dental practice, at once saw the possibilities pre- sented by ether. He accordingly experimented with ether at his home, first using the fajnily dog as a subject, and finally anesthetizing himself. His next step was to use it in his dental practice and an opportunity to do so was soon presented in the person of one Eben Frost. The following description of his first attempt (1846) to etherize a patient is taken from an article in McClure's Magazine for September, 1896: "At this moment the door bell rang and he [Morton] admitted a man named Eben Frost, whose face was band- aged and who was in that stage of mingled hope and consternation^ so familiar to all