Part 27

During the eighteenth century Small-pox was never absent from this country. From time to time the disease became epidemic, and there were grave and fatal outbreaks. Thus, in 1774 there was an outbreak of small-pox at Chester. Next year an investigation was made of the degree to which the population had suffered. It was then found that before the outbreak there were in Chester only 15 per cent. who had not already had the disease. The incidence on those unprotected by a previous attack was 53 per cent., with a death-rate of about 17 per cent. of those actually infected and of about 9 per cent. of the entire unprotected population.

With the certainty of contracting small-pox before their eyes, men sought a way of getting it in a mild form. Outbreaks of small-pox varied greatly in virulence, and infection with a mild form would lead to protection from a graver one. In the East a method of direct inoculation of the disease from a patient suffering from a slight attack was widely in vogue from an early date. The practice attracted little attention in Europe until Lady Mary Wortley Montagu (1689-1762) studied it at Constantinople. It was then soon taken up in England, and became recognized on the Continent.

The efforts of Lady Mary in England were reflected on the other side of the Atlantic. The famous Puritan leaders, Increase Mather (1639-1723) and Cotton Mather (1663-1728), turning from their exploits against the witches, ardently urged the operation. In England the learned Dr. Richard Mead (1673-1754), an eminent and far-seeing physician who exercised very great influence on the medical world in his day, published in 1747 a work in which he supported the practice of inoculation with all the weight of his authority. During the subsequent half-century the practice spread widely. The operation was largely in the hands of specialists who were not always medical men.

Such was the state of affairs when the country practitioner Edward Jenner (1749-1823) came upon the scene. In 1796 a dairymaid became infected with a disease of the udders of cows, distantly resembling small-pox. She developed pustules on her hand. Jenner inserted a little of the matter from one of these into the arm of a boy of eight, who developed typical cow-pox. Jenner next inoculated this boy with small-pox, which, however, failed to develop. The evidence, so far as it went, was complete. It is an entire justification of what might seem nowadays to be a reckless experiment, that at that time inoculation of small-pox was a normal and effective defensive procedure. The disease of cows has since become known as Vaccinia, and the process of inoculating it as Vaccination.

FIG. 94. HAND OF DAIRYMAID infected with cow-pox from a cow’s udder. From Edward Jenner, Inquiry into the Causes and Effects of the Variolae vaccinae, a Disease discovered in some of the Western Counties of England, particularly Gloucestershire, and known by the name of the Cow Pox, London, 1798.

The discovery of vaccination, important though it be, is a mere trifle compared to the train of new work and new thought that has been opened out by it. The whole study of Immunity, which has now become an independent science, arises from it. The work of Pasteur (p. 225), Lister (p. 239), and Koch (p. 234), and a large part of modern therapy, are among the achievements of this movement.

Besides Plague and Small-pox, many other epidemic diseases became more clearly understood during the period we are considering. Among these was Scarlet Fever, the history of which is particularly interesting for the variations which it has shown in virulence. It first became clearly recognizable as a mild disease without prominent symptoms about 1650. Good observers in the half-century that followed considered it a new disease. In England it continued to be of little importance till about 1748, when it began to be associated with grave throat symptoms and to be confused with Diphtheria. This phase continued for about ten years. The virulence then dropped and the disease continued of slight consequence till 1785. It then grew virulent again and remained so till about 1808. The malignancy then fell again and remained low for about thirty years. It rose about 1837 and from then till 1884 it was one of the great killing diseases, especially of childhood. Since then, the mortality from it has steadily decreased.

During most of its history Scarlet Fever has been liable to greater or less confusion with Diphtheria. The clinical distinction was first clearly made in 1826 by Pierre Bretonneau of Tours (1771-1862), who gave Diphtheria its present name. The same French physician performed the first successful tracheotomy in a case of Diphtheria. He is also known for pioneer work in the recognition of Typhoid Fever.

PERIOD OF SCIENTIFIC SUBDIVISION

(FROM ABOUT 1825 ONWARDS)

§ 1. Origins and Implications of Scientific Specialization.

We have seen how the philosophy of Newton, with its implication, the Reign of Law, which is the Uniformity of Nature, has come to pervade scientific thought (p. 137). Now, before Newton as after him, there were certain natural divisions of scientific activity corresponding, in some degree, to the types and faculties of men. Since Science first began there have been Mathematicians, Biologists, Physical Experimenters, because in fact the particular powers which enable a man to reach distinction in one of these departments are of less value in the others. Until the period of which we are now to treat, investigators were accustomed to explore at large within these great departments. Such specialist professions as Actuarial Calculators, Economic Entomologists, Physical Chemists, or, in the department of Medicine, Medical Statisticians, Aural Surgeons, or Vaccine Therapists--familiar to us now--were unknown and undreamt of then. This subdivision is a new thing, and is a characteristic product of the period of which we have now to treat. The subdivisions, unlike those of old, are largely artificial. Thus, the Aural Surgeon who deals with the organ of hearing cannot be separated clearly by his training, his powers and faculties, his operative skill, nor even perhaps by his field of work, from the Stomatologist who deals with the mouth, or the Rhinologist who deals with the nose. Nevertheless these minute subdivisions are convenient and beneficent in medical as in other departments. The question of scientific specialization is so important and characteristic that we must examine it a little farther.

It is often thought that, since no man can compass all knowledge, this scientific subdivision is merely an attempt to compass a part of that growing mass of knowledge which is becoming progressively less compassable in its entirety. The movement, however, both in origin and development, is less simple than this, for there never was a time when a man could know all that was known about his world. In this respect our own age is even as other ages. Were the view philosophically tenable--which it is not--that Science becomes yearly less comprehensible, our outlook would be gloomy indeed. For since there is no evidence of any increase in the mental capacity of the human race--at least in historic time--such a view would imply a progressive diminution in the number of those competent to treat any wide scientific area, and a corresponding progressive separation from each other of minds with scientific insight. Fortunately such conditions do not prevail; the view that they do is simply due to a gross, yet widespread, misconception of the nature of Science.

Equally fallacious is the idea, which has become diffused by the existence of scientific specialization itself, that the progress of any science is to be measured by the mass of observations that its votaries have succeeded in accumulating. This is far from being the case. The advance of a science is measured by the degree with which it succeeds in bringing a multiplicity of observations under general laws. Judged by this standard, we should probably rate very highly, for example, the present state of what is called Demography, the study of the life conditions of communities, while we should rank much less highly, for example, the present state of the study of Aural Surgery. Yet, for one publication on Demography there must be many on Aural Surgery. In the one case, however, the accumulation of knowledge follows a well-directed and rational scheme. In the other it is prompted and occasioned by the immediate needs of individual sufferers. This must not be considered as derogatory to those whose task it is to treat the sufferers. The point is that the one department, of its nature, exhibits the rational spirit better than does the other.

Since Rational Medicine is the subject that we treat here, we shall select for discussion those departments which best illustrate its spirit. This does not imply, and is not meant to imply, any belittlement of the less fortunate departments. On the contrary, the less any scientific department has succeeded in eliciting general laws, the more necessary it is that those most capable for the prosecution of such advance should devote their attention to that department. It may, indeed, reasonably be urged that a leading defect in our scientific organization is that men of scientific insight crowd to just those studies where their special powers have already been best exhibited.

In previous chapters, dealing with more remote times, we have been able to place our facts in historic perspective. Despite the enormous mass of scientific literature dating from the seventeenth, eighteenth, and early nineteenth centuries, there is no real obstacle to selecting what is most important in it. True, it is beyond the power of any one student to examine all this literature at first hand, but it has been arranged and indexed, posterity has passed its verdict, and the historian can find his way through the thicket. It is also true that important advances are sometimes forgotten, as happened to Mayow’s discovery of Oxygen in the seventeenth century (pp. 126, 151), which was repeated by Priestley a hundred years later (p. 154). But the fact that we know of such neglected discoveries shows that, however unjust the fates may have been to Mayow, yet his influence has not been underestimated by later historians. The History of Science, therefore, can up to a certain point be written along the same lines as political or economic history.

The face of affairs changes, however, when we pass into a period which differs for different topics, but may be roughly defined as beginning somewhere between about 1820 and about 1870. We then begin to encounter the very questions with which men of Science are occupied in our own time. Since many of these questions still remain unsettled, it is impossible for the historian to say with certainty which are the most fruitful lines of work. The most he can hope to do is to distinguish the most influential and stimulating thinkers and observers from those who have been less so, and to say something about the ideas with which the more important schools of thought were instinct.

When we look into the origin of the system of specialization, whether in Medicine or in any other department of Science, we shall find certain philosophical tendencies at work of which the modern man of Science is the heir, though often the unconscious and sometimes the ungrateful and even the misunderstanding heir. Neither men of Science nor medical men are always philosophers, or at least not always consciously so. Nevertheless, they are as surely influenced by the streams of thought of their time as they are by their heredity and their physical environment. The general tendencies of Medicine in this or in any other age cannot be interpreted without some reference to the intellectual atmosphere in which it has arisen and in which it has flourished.

The intellectual atmosphere in which scientific specialism arose was that of the so-called ‘Utilitarian Philosophy’. Many of the dicta of that school, which came into prominence toward the end of the eighteenth century, are still used as part of the language of men of Science and others. ‘The greatest happiness of the greatest number’ is a formula launched upon our common speech by Joseph Priestley (1733-1804, p. 154). The pursuit of such happiness as the main object of human activity is taught by the ‘Utilitarian’ philosophy, a word coined by the English political and social thinker, Jeremy Bentham (1748-1832). To Bentham, the founder of that philosophy, we owe such useful additions to our language as ‘codification’ and ‘international’, and these, together with ‘utilitarian’, give us some clue to the character and mode of his thought. It is probable that no thinker had a larger share than Bentham in ushering in the era of the subdivision of the sciences.

Bentham made a sustained attempt to draw a parallel between the physical and the social sciences, and this gave him a special influence over medical thinkers and especially over those that dealt with the public health. His pupil, John Stuart Mill (1806-73), speaks of his master’s mode of working as ‘the chemical method’. It is thus not remarkable that Bentham should exert a profound influence on Medicine, both directly and indirectly. The peculiarly logical, uncompromising and perhaps un-English character of his mind, while it prevented him, fortunately for himself, from taking an active share in the task of government, did not prevent him from influencing those who did. Specifically, he is the direct begetter of our modern system of organization of the Science of Preventive Medicine.

FIG. 95. A CARTOON OF THE EARLY NINETEENTH CENTURY illustrating the condition of children in the factories of the time. A bale is directed to Sir Robert Peel. This is the first Baronet (1750-1830), father of the statesman. Peel the elder was a cotton-spinner who imported from the London workhouses deserted children whom he treated well, but used to work his factories in Lancashire. He was a Member of Parliament and in 1802 carried the Act which was the forerunner of all factory legislation, An Act for the Preservation of the Health and Morals of Apprentices and others, employed in Cotton and other Mills.

§ 2. The Revolution in Preventive Medicine.

Of all the many changes in Medicine and Medical thought that the Period of Scientific Subdivision has witnessed, none have been more revolutionary than those in the department which deals with Preventive Medicine. Great and important reforms were introduced during the course of the eighteenth century. These, however, even when the result of legislation, were the outcome of the effort of individuals, or were concerned with the Army and Navy (p. 169). In the period that follows, the Public Health becomes a general political, legislative, and administrative matter, and ‘Prevention’ becomes its watchword. The public consciousness--moralists will call it the public conscience--had been aroused, and has never again entirely slept. The chief agent in the awakening process, the intellectual force at its back, was and is Jeremy Bentham.

Rational Medicine has, in general, no national frontiers. To it men of all the national units have made important contributions. But the care of the Public Health in the period on which we now enter, being an affair of legislation and administration, has developed along national lines and it is difficult to discuss it save on a national basis. It is a source of justifiable national pride that Britain has, from the first and throughout, been the leader of the Public Health movement. But while we lose little and gain much by telling the story from the British point of view, it has still to be remembered that, just as Rational Medicine has, fortunately, no spiritual frontiers, so, unfortunately, sickness and suffering have no physical frontiers. Epidemics pass the most scientifically constructed boundaries upon the surface of the map, and without a passport. In our time this evident proposition has obtained, at least, formal recognition. International health legislation has at last appeared. A future historian of Rational Medicine will be able to write his chapter on the Public Health from the point of view of Humanity at large. The historian who has the misfortune to be born too early must still content himself with treating the subject along national lines.

(a) Preventive Medicine in Britain.

If Bentham be the spiritual father of Public Health legislation, the protagonists whose names must be associated with the development of the movement along practical lines in England are Thomas Southwood Smith (1788-1861) and Edwin Chadwick (1800-90).

Thomas Southwood Smith was a Unitarian minister, and long combined this office with that of physician. Settling in London in 1820 he came under the influence of Bentham. By his essay on The Use of the Dead to the Living he did something to remove the odium attached to dissection. The scandals of the time and the common sense of the ‘utilitarians’ (p. 190) led to the passing of the Anatomy Act of 1832. Thus by a proper legal process bodies became available for dissection by medical students. Bentham died just before this Act became law and by his will left his body to Southwood Smith to be the subject of dissection and of an anatomical lecture.

Southwood Smith’s services to the spread of interest in Public Health were very numerous. He circulated a simple and popular Philosophy of Health (1835). He served on a board of inquiry as to the condition of children in factories (1832, cp. Fig. 191), and he was especially useful to the Poor Law Commissioners by reason of his exceptional knowledge of fevers. He was the founder of a ‘Health of Towns Association’ (1840), and of another association for ‘improving the Dwellings of the Industrial Classes’ (1842). In 1848 he became a member of a new government department, the ‘General Board of Health’ (p. 195). His official reports on Quarantine (1845), Cholera (1850), Yellow Fever (1852), and on the results of sanitary improvement (1854), were of world-wide use.