Part 25

The first efficient instrument of precision to merit clinical adoption was the ‘pulse watch’, by Sir John Floyer (1649-1734), an English provincial physician. It was introduced as early as 1707 as a ‘Physician’s Pulse Watch’ and was an instrument constructed to go for just one minute. At that time the making of a twenty-four hours watch with a seconds-hand presented great mechanical difficulties. Floyer’s invention was not widely adopted at the time. Attempts were also made to introduce a thermometer into practice, but again the construction of suitable instruments proved impossible.

Effective pulse watches and clinical thermometers did not penetrate into the general practice of Medicine till well into the nineteenth century. Two instrumental advances of first-class importance to Medicine were, however, introduced during the later eighteenth century. These were the methods of Percussion and Stethoscopy.

Percussion of the surface of the body yields notes of varying degrees of resonance. Its application has proved of great value to the physician in outlining the position of the organs and of lesions, especially those of the chest. It was invented by Leopold Auenbrugger (1722-1809), a Viennese physician who first introduced it in 1761. Like the thermometer, it was very slow in entering the general practice of Medicine.

Auenbrugger deserves great credit for his invention, but he did not work out its application with anything like the completeness that the Breton physician, René Théophile Hyacinthe Laënnec (1781-1826), applied to his ‘stethoscope’ (1819). Laënnec’s instrument was of the uni-tubular type that is now seldom seen. At first, indeed, he used a mere roll of paper. His idea was rapidly diffused into every country.

But Laënnec did far more than introduce a useful and convenient device into Medicine. He explored with extraordinary skill the physical signs in the chest which correspond to a large number of diseases. The major part of our chest-lore and much of the technique and nomenclature of chest examination come direct from him. Despite continual bad health and the shortness of his life, Laënnec’s brilliance and devotion to duty at a hospital in Paris enabled him to transmit his views and methods to many other physicians, both French and foreign. He is unquestionably among the greatest physicians of all time. Clinical medicine assumes with him a completely modern aspect. In reading his work one feels that, had he been called in consultation by a medical man of our own day, the two would have been able to understand each other perfectly, after only a little adjustment and explanation.

FIG. 79 is the complete instrument.

FIG. 80 is the instrument in section.

FIG. 81 is the ear-piece unscrewed.

FIG. 82 is the detachable chest-piece terminating in a thin metal tube.

§ 8. Surgery and Obstetrics.

During the eighteenth century the improved knowledge of Normal and Pathological Anatomy was a great aid to the surgeon. The technique of Surgery was certainly improved. Operations were now being performed with success that could not before have been attempted. Nevertheless few important new principles were introduced until long after the nineteenth century had dawned. It is indeed probable that as a means of life-saving Surgery had an almost inappreciable effect on vital statistics until the advent of Anaesthesia and Antiseptics. Even the greatest surgeon of the eighteenth century, John Hunter, introduced no fundamental new surgical principles. True, the names of many surgeons of the period have become associated with operations invented or introduced by them, but it was not till after the advent of antiseptic methods that these were practised with full success. There are but two surgical matters in which advances of great significance can be said to have been made. These were the treatment of Venereal Disease and the treatment of Labor.

Syphilis, which existed in Europe in the later Middle Ages, had usually been confused with Leprosy and other conditions (p. 98). Its treatment by Mercury had been practised at least as early as the fifteenth century, perhaps as an inheritance from the Arabic-speaking physicians. During the sixteenth and seventeenth centuries various other remedies were tried (Fig. 33); much quackery arose around them. In the eighteenth century the accumulated experience of generations returned again to Mercury. Satisfactory methods of administration were evolved and the treatment became standardized. It hardly changed until the twentieth century.

FIG. 83. LYING-IN SCENE in the sixteenth century from a contemporary work on midwifery. Drinking and feasting is going on in the room where, in addition to the patient, there are two men, five women, and two children. A dog chews a bone on the floor, cooking is in progress in the adjoining room. Food and drink is being forced on the unfortunate patient herself. The whole scene, which is intended to portray an upper-class household, suggests carousal, disorder, and dirt, as well as ignorance of the most elementary principles of hygiene.

The treatment and care of women in Labor made considerable progress during the period of which we are treating. We have seen how there were advances even during the sixteenth century (p. 93) by such a writer as Paré. Works on obstetrics intended for women were often printed in the sixteenth century in France, England and Germany. Scientific obstetric

works were produced especially in France in the second half of the seventeenth century. The obstetric forceps was known, but was still a family secret. At the time and for long after, there was a great objection on the part of pregnant women to treatment by men. The midwives were for the most part ignorant, dirty, unskilful and superstitious, and the loss of life and health that resulted from their mishandling was enormous. The objection to the ‘man midwife’ was only gradually overcome, though his advent was unquestionably attended by a fall in the mortality. About the middle of the eighteenth century, moreover, the obstetric forceps came into wider use. One of the ablest and most successful of the obstetric physicians was William Hunter (1718-83), the brother of John Hunter.

FIG. 84 is the very dangerous and brutal Speculum matricis used to force open the mouth of the womb in cases of difficult labor. A similar instrument has been used since antiquity to dilate wounds.

FIG. 85 is an even more terrible and powerful instrument, the Apertorium, provided with a sharp edge by means of which the mouth of the womb was violently cut or torn.

In the seventeenth century less heroic measures began to be used, and the obstetric forceps was introduced.

FIG. 86 shows a pair of obstetric forceps as used in the seventeenth century. The instrument is the direct ancestor of that now in use, which, however, is a vast improvement upon it. The obstetric forceps was invented by a member of an hereditary family of man midwives, at the beginning of the seventeenth century. The nature of the instrument was long kept a secret. This particular instrument was found by accident in 1813, having been hidden under the floor by a member of the family of the inventor.

Despite the absence of any great new principle in the surgery of the period, there can be no doubt that a new spirit was introduced by John Hunter (1728-93). His complex and interesting character demands better treatment than it has yet received. As an investigator his powers were superb, but, like Leonardo, he was handicapped at every turn by literary incoherence. Nevertheless, with him Surgery begins to appear, at last, as a real Science and not as a mere applied Art. Hunter brought to bear on the subject a mind stored with ideas drawn from Comparative Anatomy and Pathology. Quick to detect analogy, shrewd in his scientific judgments, tireless and unsparing of himself in his pursuit of truth, a victim of disease self-inflicted in the service of science to which he was tragically a martyr in his death, he shows as a heroic figure, rendered no less heroic by some very human failings. Fully to appreciate so incoherent a writer, it is unfortunately necessary to wade through many works written in his own clumsy and ill-arranged manner. To gain any real idea of this great personality we must consult the writings of his contemporary colleagues.

So far as actual advances are concerned, two may be connected with Hunter’s name. Firstly, in the treatment of the deadly condition known as ‘Aneurysm’ he introduced a method of operation which is still in vogue. Secondly, he enormously improved the method of making and ordering a museum. His monument is the Hunterian Museum in London, based on his specimens of which many may still be seen there. The museums of Natural History, as now constituted in all civilized countries, have been influenced by, if they have not been derived from, that which he literally gave his life’s blood to found. He was right when he said musingly in his illness, ‘You will not easily find another John Hunter.’

FIG. 87. JOHN HUNTER’S COUNTRY HOUSE at Earl’s Court, Kensington, before its demolition in 1886. This house was in the country in Hunter’s day, though its site is now a busy part of London. For many years he used it as a laboratory and menagerie, and much of his best work was done there.

§ 9. The Beginnings of the Science of Vital Statistics.

Attempts to combat widespread disease and to improve the public health are to be found in the history of all civilizations, both ancient and modern. Nevertheless, the rational method cannot come into operation until it has exact data upon which to work. Such data may be numerically expressed, a fact first appreciated by the versatile English physician and inventor, Sir William Petty (1623-87), who is usually regarded as the father of the science of Political Economy. In 1662, and on many subsequent occasions, he joined a friend in issuing Natural and Political Observations upon the Bills of Mortality of London. In this work he endeavored to deduce population, death-rates, disease prevalence, and other matters of vital statistics from the crude figures of the day. He was fully aware of the imperfection of his materials, and on this account he urged the necessity of providing a system and a government department for the collection of trustworthy statistics. In his Political Arithmetick (1683), the basic work of modern Economics, he displays ideas of a very modern character. Among these is his view that the true wealth of a country is to be sought in its efficient man power.

A number of Petty’s fellow members of the Royal Society began to take interest in statistics. Chief among these was Edmund Halley, the astronomer (1656-1742). Toward the end of the century (1693) Halley produced a mass of statistics on the chances of life at various ages, designed for the estimation of the price of annuities. During the eighteenth century numerous writers devoted themselves to similar investigations. An important contributor to the mathematical basis of vital statistics was the French Huguenot and friend of Newton, Abraham de Moivre (1667-1754). His Doctrine of Chances (1715) and his Annuities upon Lives (1725) are important contributions to the subject. His celebrated hypothesis that among a body of persons over a certain age the successive annual decrease by death may be esteemed as nearly equal (that ‘the decrements of life are in arithmetical progression’) was under discussion for a century, but is now accepted.

In 1761 a Prussian clergyman, J. P. Süssmilch (1707-82), produced an extraordinary theological work, The Divine Ordinance manifested in the Human Race through Birth, Death, and Propagation. Its object was to exhibit God’s design in the constancy of the numerical relationships of vital statistics. Despite the motive--somewhat unpromising for a scientific treatise--the work is of great historic and scientific importance, for it was based upon a vast mass of statistics and showed a great advance in method. It stressed the importance of accurate data and the necessity for numerous observations, if reliable conclusions were to be drawn. From the time of the publication of the work of Süssmilch, the statistical study of population advanced rapidly. The basis of statistics was greatly improved by the introduction of the census system which was put into action in England in 1801.

The science of vital statistics was placed on a firm foundation by the Belgian astronomer Lambert Quetelet (1796-1874). His principal work, On Man and on the Development of his Faculties, An Essay on Social Physics, contains an account of his statistical researches on the development of the physical and intellectual qualities of man and on the ‘average man’ both physically and intellectually considered. He followed this in 1848 by his treatise, On the Social System and the Laws which govern it. In it he shows how the numbers representing the individual qualities of man may be grouped round the numbers referring to the average man in a way corresponding to the principles of the theory of probabilities. This conception, elaborated and further analyzed, has formed the basis of all subsequent researches in vital statistics.

§ 10. Military, Naval, and Prison Medicine.