Part 1

THE Cleveland Medical Gazette

_VOL. I._ _JANUARY, 1886._ _No. 3._

ORIGINAL ARTICLES.

A HISTORY OF MEDICINE.

BY JOHN BENNITT, M. D.,

Professor of Principles and Practice of Medicine in the Medical Department of the Western Reserve University, Cleveland, Ohio.

It may not be inappropriate to give in your journal a brief sketch of the history of medicine, by the consideration of which we may come to a better appreciation of our present standpoint as medical men. We may also the better understand how much we, as medical men, and the world at large, are indebted to the methodical, plodding workers of the past in the field of inquiry pertaining to the nature and cure of disease. Such review may have the effect of stimulating medical men to more careful observation and the recording the results of observations that they may be given to others for mutual benefit.

Science may be defined as “classified knowledge.” But all our knowledge is based on experience and observation. Medical science, like other sciences, taking the definition of Sir John Herschel, is “the knowledge of many, orderly and methodically digested and arranged so as to become attainable by one.”

In all cases art and observation precede and beget science, and give origin to its gradual construction. But soon science, so built up, begins to reflect new light upon its parents—observation and art—helps them onward, expands the range of vision, corrects their errors, improves their methods and suggests new ones. The stars were mapped out and counted by the shepherds watching their flocks by night, long before astronomy assumed any scientific form.

From the earliest ages the pains and disorders of the human body must have arrested men's anxious attention and claimed their succor. The facts observed, both as to hurts and diseases, and as to their attempted remedying, were handed down by tradition or by record from generation to generation in continually increasing abundance, and out of the repeated survey and comparison of these has grown the recognition of certain laws of events and rules of action, which together constitute “medical science.”

There is good reason for the belief that Egypt was the country in which the _art_ of medicine, as well as the other arts of civilized life, was first cultivated with any degree of success, the offices of the priest and the physician being probably combined in the same person. In the writings of Moses there are various allusions to the practice of medicine amongst the Jews, especially with reference to the diagnosis and treatment of leprosy. The priests were the physicians, and their treatment mainly aimed at promoting cleanliness and preventing contagion. The same practice is approved by the light of latest science.

Chiron, the Centaur, is said to have introduced the art of medicine amongst the Greeks, but the early history of the _art_ is entirely legendary. Æsculapius appears in Homer as an excellent physician of _human_ origin; in the later legends he becomes the god of the healing art. His genealogy is obscure and altogether fabulous. He, however, soon surpassed his teacher, Chiron, and succeeded so far as to restore the dead to life (as the story goes). This offended Hades, who began to fear that his realm would not be sufficiently peopled; complained to Zeus (Jove) of the innovation, and Jove slew Æsculapius by a flash of lightning. After this he was deified by the gratitude of mankind, and was especially worshiped at Epidaurus, where a temple and a grove were consecrated to him. His statue in this temple was formed of gold and ivory, and represents him as a god seated on a throne, and holding in one hand a staff with a snake coiled around it, the other hand resting on the head of a snake; a dog, as an emblem of watchfulness, at his feet (an intimation very appropriate for the medical profession). The Asclepiades, the followers of Æsculapius, inherited and kept the secrets of the healing art; or, assuming that Æsculapius was merely a divine symbol, the Asclepiades must be regarded as a medical, priestly caste, who preserved as mysteries the doctrine of medicine. The members of the caste were bound by an oath—the Hippocratis jusjurandum—not to divulge the secrets of their profession.

In Rome, in the year 292 B. C., a pestilence (probably malarial fever) prevailed. The Sibyline books directed that Æsculapius (statue!) must be brought from Epidaurus. Accordingly, an embassy was sent to this place, and when they had made their request, a snake crept out of the temple into the ship. Regarding this as the god Æsculapius, they sailed to Italy, and as they entered the Tiber the snake sprang out upon an island, where afterwards a temple was erected to Æsculapius and a company of priests appointed to take charge of the service and practice the art of medicine. The name Æsculapius, then, is only an impersonation of medicine in the remote ages, or early ages of Grecian history.

Hippocrates is the first writer of medicine whose works have come down to us with anything like authority other than fable. Indeed, he was the most celebrated physician of antiquity. He was the son of Heracleides, also a physician, and belonged to the family of the Asclepiades, said to be about eighteen generations from Æsculapius. His mother was said to be descended from Hercules.

Hippocrates was born in the island of Cos (more anciently Meropis), an island of the Grecian archipelago of about one hundred square miles, probably about the year 460 B. C. Instructed in medicine by his father and other contemporary medical men, he traveled in various parts of Greece and Asia minor. He finally settled and practiced his profession at Cos, but died in Thessaly at the age of one hundred and four years (B. C. 357). Little is known of his personal history, other than that he was highly esteemed as a physician and an author, and that he raised the reputation of the medical school of Cos to a high degree. His works were studied and quoted by Plato. He was famous in his own time, and his works, some sixty in number, have in them many things that are not unworthy of consideration even after the lapse of twenty-two hundred years. Many of the works ascribed to Hippocrates are _not_ well authenticated.

He divided the causes of diseases into two principal classes—the first consisting of the influence of seasons, climates, water, situations, etc.; the second of more personal causes, such as the food and exercise of the individual patient. His belief in the influence which different climates exert on the human constitution is very strongly expressed. He ascribes to this influence both the conformation of the body and the disposition of the mind, and hence accounts for the difference between the hardy Greek and the Asiatic.

The four humors of the body (blood, phlegm, yellow bile and black bile) were regarded by him as the primary seats of disease; health was the result of the due combination (or crasis) of these humors, and illness was the consequence of a disturbance of this crasis. When a disease was progressing favorably these humors underwent a certain change (coction), which was the sign of returning health, as preparing the way for the expulsion of morbid matters, or crisis, these crises having a tendency to occur at definite periods, which were hence called critical days.

His treatment of disease was cautious and what we now term expectant, _i. e._, it consisted chiefly, often solely, in attention to diet and regimen; and he was sometimes reproached with letting his patients die by doing nothing to keep them alive.

His works written in Greek were at an early period translated into Arabic. They were first printed in Latin in 1525, at Rome. A complete edition in Greek bears a date a year later.

Several editions in Latin and other languages have appeared from time to time. An English translation of 'The Genuine Works of Hippocrates,' was published by the Sydenham society in 1848, in 2 vols., by Dr. Adams. The advance which Hippocrates made in the practice of medicine was so great that no attempts were made for some centuries to improve upon his views and precepts. His sons, Thessalus and Draco, and his son-in-law, Polybius, are regarded as the founders of the medical sect which was called the Hippocratean or Dogmatic school, because it professed to set out with certain theoretical principles, which were derived from the generalization of facts and observations, and to make these principles the basis of practice. The next epoch in the history of medicine is the establishment of the school at Alexandria, which was effected by the munificence of the Ptolemies, about B. C. 300. Indeed the whole race of Ptolemies (from Ptolemy I. to Ptolemy VII. B. C. 323 to 117) seem to have been patrons of learning and learned men. (Less so Ptolemy VIII. to XIII., B. C. 117 to 43. Ptolemy II., Philadelphius, was born in Cos about 150 years after Hippocrates.) It was by the patronage of these kings of Egypt that learning flourished in Alexandria during their reign.

In some of them this seems to have been the only redeeming feature of their character. Otherwise vicious, cruel, bloodthirsty in an extreme degree, they uniformly encouraged learning and learned men. (It seems to have been a hereditary trait.) Amongst the most famous of the medical professors of the School of Alexandria are Erasistratus and Herophilus.

The former of these was a pupil of Chrysippus, and probably imbibed from his master his prejudice against bleeding and against the use of active remedies, preferring to trust mainly to diet and to the _vis medicatrix naturae_.

Herophilus, born in Chalcedon, in Bythinia, flourished in the latter part of the fourth and the beginning of the third century B. C., and settled in Alexandria, especially was distinguished by his devotion to the study of anatomy. He is said to have pursued this to such an extent as to have dissected criminals alive. Several names which he gave to different parts of the body are still in use, as the torcular Herophili, calamus scriptorius, and duodenum. He located the seat of the soul in the ventricles of the brain. Only a few fragments remain of what he wrote.

About this time the Empirics formed themselves into a distinct sect and became the declared opponents of the Dogmatists. The controversy really consisted in the question, “How far we are to suffer theory to influence over practice.” While the Dogmatists, or as they were sometimes styled, the Rationalists, asserted that before attempting to treat any disease we ought to make ourselves fully acquainted with the structure and functions of the body generally, with the operation of medicinal agents upon it, and with the changes which it undergoes when under the operation of any morbid cause, the Empirics, on the contrary, contended that this knowledge is impossible to be obtained and if possible is not necessary; that our sole guide must be experience and that if we step beyond this, either as learned from our own observations or that of others on whose testimony we can rely, we are always liable to fall into dangerous and often fatal errors. According to Celsus, the founder of the Empirics was Serapion, who was said to be a pupil of Herophilus. At this period, and for some centuries later, all physicians were included in one or the other of these rival sects, and from the evidence of history the two sects or schools were about equal. From Phiny, who wrote about the middle and sixth, seventh and eighth decades of the first century, we learn that medicine was introduced into Rome at a later period than the other arts and sciences.

The first person who seems to have made it a distinct profession, separate from priestcraft, was Archagathus, a Peloponnesian, who settled at Rome about B. C. 200. His treatment of his patients was so severe and unsuccessful that he was finally banished, and no other mention is made of a physician at Rome for about a century, when Asclepiades of Bythinia, acquired a great reputation. His popularity depended upon his allowing his patients a liberal use of wine, and of their favorite dishes, and in all respects consulting their inclinations and flattering their prejudices; and hence it is easy to understand the eminence at which he arrived, for we see even in our own time men building up great reputations by similar practices.

This man with a long name—Archagathus—was succeeded by his pupil, Themison of Laodicea, the founder of a sect called Methodics, who adopted a middle course between the Dogmatists and Empirics. During the greater part of the first two centuries of our era the Methodics were the preponderating medical sect, and they included in their ranks C. Aurelianus, some of whose writings have come down to us.

They soon broke into various sects of which the chief were the Pneumatics, represented by Aretaeus of Cappadocia, whose works are still extant; and the Eclectics, who claimed as do the Eclectics of to-day, to select the best from all the other systems and to reject the hurtful. The most remarkable writer of this age is Celsus (about A. D.), whose work (De Medicina) gives a sketch of the history of medicine up to that time and the state in which it then was. He is remarkable in being the first _native_ Roman physician whose name has come down to us.

Dioscorides of Cilicia flourished about the end of the first century. He accompanied the Roman army in their campaign through many countries and gathered a great store of information and observations on plants. In his great work 'De Materia Medica,' he treats of all the then known medicinal substances and their properties, real or reputed, on the principles of the so-called humoral pathology. Two other works are ascribed to him but their genuineness is questionable. For fifteen centuries the authority of Dioscorides, in botany and materia medica, was undisputed, and still holds among the Turks and Moors.

[_To be Continued._]

REPORT OF A CASE OF EXTRA-UTERINE PREGNANCY.

BY H. J. LEE, M. D., CLEVELAND, OHIO.

The following case came under my care during my term of service in the wards of Charity Hospital in this city. Mrs. D., age thirty-five, married, one child two years of age, was admitted to the hospital July 14, 1885, with the following history: She had always enjoyed good health, and there was no history of uterine disease. She menstruated about the first of April, 1885, did not menstruate in May, and supposed herself pregnant, as she had always been regular before, and during the latter part of May she had considerable nausea and other symptoms of pregnancy. About the first of June, while in church, she was taken with a severe hemorrhage. She was taken home and a physician called, who examined her and decided from the symptoms and history that she had had a miscarriage. There was very little hemorrhage after she arrived home, in fact very little at any subsequent time, but she did not recover well, had some pains in the abdomen, and she said had some fever all the time. Not getting on well, as she and her friends thought, it was decided to change physicians, which was done. The second physician concurred in the diagnosis of the first, and treated her evidently on the expectant plan, as any one would be compelled to do, owing to the difficulty of making a correct diagnosis at such an early stage. After a time, there being no improvement, she decided to go to the hospital. On admission she was quite emaciated and had an anaemic appearance; her temperature was about 99° to 100° in the morning and 100° to 102° in the evening. There was considerable tenderness in the right iliac region, extending into the hypogastric region. Uterus was not felt to be at all enlarged, but the os was patulous. There was an enlargement to the right of the uterus. This could be felt both externally and through the vagina; was of an irregular outline, and quite tense and tender upon pressure. A sound was introduced into the uterus and passed in about three inches and was deflected to the left quite perceptibly. It did not appear quite certain that there was nothing in the uterus, and in view of the history of the case it seemed justifiable to explore the cavity. Accordingly a good sized sponge tent was introduced and allowed to remain twenty-four hours, when it was removed and the uterine cavity explored with purely negative results. The patient had now been under observation over a week, and attempts made to improve her general condition with tonics and nutritious diet, but without success. Her temperature continued about 101° most of the time. A positive diagnosis had not been made, though it seemed that about everything could be excluded except extra-uterine pregnancy. At this juncture Dr. W. J. Scott was asked to see the patient. He did so and made a very careful examination, and gave it as his opinion the case was one of extra-uterine pregnancy. The next day Dr. Dudley P. Allen was called in consultation with Dr. Scott and myself. Dr. Allen's examination was careful and exhaustive, and at its close he gave it as his opinion that while there were some obscure points, the most probable conclusion was that the case was one of extra-uterine fœtation.

Having all arrived at this conclusion, independently of each other, it was agreed that as there was some obscurity in the case, and also that in the event of there being a fœtus outside of the uterus it had now advanced to about the fourth month of gestation; consequently the most favorable time for the employment of the electric current had passed. In view of these facts, and also of the fact that exploratory incisions are attended with comparatively little danger, it was decided to make an exploratory incision and determine what was the condition of things. If a fœtus was found remove it if possible. If the trouble was something that could not be removed, the incision could be closed and the patient probably in no wise injured. Dr. Allen was asked to operate, and on the sixth of August the operation was performed. There were present, Dr. Allen, Dr. Scott, Dr. Millikin and the house staff. The anæsthetic was administered, and before commencing the operation an aspirator needle of good size was introduced into the tumor through the vagina. Upon exhausting the air no fluid was obtained, but upon partially withdrawing the needle about a drachm of clear serum was obtained, which was thought to be peritoneal fluid. It was then decided to proceed with the operation. An incision was made about an inch above and parallel to Poupart's ligament, commencing at the anterior superior spinous process of the ilium, and terminating at the outer margin of the rectus muscle.

On opening the abdomen an adherent mass was found closely attached to the coecum. Strong bands also passed from the mass toward the symphysis pubis. In order to reach the mass more fully, and also the annexes of the uterus, the adhesions to the pubis were divided between ligatures. This having been done, it was still found to be impossible to detach the intestines which were closely adherent to the coecum, and nothing abnormal could be found in connection with the uterus. Failing to discover the cause of the adhesions about the coecum from the abdominal cavity, it was thought this might be accomplished by separating the peritoneum from the iliac fossa, and reaching the coecum from the outer and posterior side. This separation was continued until it could be carried no further without great danger of wounding the external iliac vessels, which were exposed for several inches. Although nothing further than a closely adherent mass of intestines had been found, an attempt to separate which had been carried to the limit of safety, and the cause of the malady had not been demonstrated with entire satisfaction, it was deemed best to close the abdominal incision, which was accordingly done.

The subsequent history of the cure was as favorable as could be desired. The wound united very readily. The temperature never rose above 103°, and was only at that point for a few hours; most of the time was 100° to 101.5°. Two weeks after the operation temperature was normal, a point it had not reached since her admission, and probably not for some time previous.

Patient was examined September 8; the tumor was found to be considerably diminished in size, and tenderness almost entirely disappeared. She had apparently gained in weight, and expressed herself as feeling well. She was discharged from the hospital September 9. On the tenth of October she again presented herself, according to agreement, and was examined by Dr. Scott, Dr. Allen and myself. The tumor had entirely disappeared, only a slight thickening of the tissues remaining, the uterus had resumed its normal position, and the patient, to all appearances, was as well as ever.

I have reported this case as one of extra-uterine pregnancy, and yet it will be seen by the report that the existence of that condition was not demonstrated at the operation, but it seems to me that the history of the case, both prior and subsequent to the operation, demonstrates pretty conclusively that it could be nothing else. Both the gentlemen who saw the case before operation were of the opinion that everything could be excluded except a collection of fluid, disease of the coecum and extra-uterine pregnancy, and to my mind (and the gentlemen who were called in consultation have expressed themselves in the same manner) the operation and the result of it excludes everything except the last mentioned condition. It may be said that in the treatment of the case less severe measures should first have been tried; that the electric current should have been employed before resorting to an operation. This subject was fully discussed, and the decision against the employment of electricity was unanimous, from the fact that the most favorable time for its employment had passed and the time had arrived when any further delay was dangerous. Then the danger from an exploratory incision is so small that it seemed to be more than counterbalanced by the knowledge that would be obtained by it. If an exploratory incision was made we would then be better able to tell what we had to deal with, and would also be in a position to deal with whatever was found in the most effectual manner, and it was thought that the most certain means of cure should be employed first and the patient not be subjected to the danger of delay in order that less certain methods might first be tried; also the high temperature seemed to render any delay more dangerous. The incision described was employed because it seemed that the tumor could be more easily reached and removed by means of it than by means of the central one. When, however, the mass was reached it was found to be so firmly attached to the cœcum by strong adhesions that it was absolutely immoveable. Under these circumstances it was decided that it would be unwise to attempt its removal, consequently the wound was closed and the operation desisted from. The subsequent history was all that could be desired, or could, under any circumstances, have been expected.

I think the most probable explanation of the disappearance of the tumor is this: The case was one of extra-uterine pregnancy of the abdominal variety, the ovum became attached to the peritoneum and a connective tissue proliferation was set up which surrounded it with a vascular sack, the walls of which kept pace with the growth of the ovum, and as they extended into the abdominal cavity formed adhesions to the cœcum, intestines, and other parts in the vicinity. During the operation these adhesions were ligated and divided, and in consequence the nutrition of the ovum was entirely cut off, and death and absorption was the result.