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THE PROGRESS OF SURGERY IN THE
NINETEENTH CENTURY *

HE end of the eighteenth century was made notable by

which has ever blessed the human race,-the discovery of the means of preventing small-pox. On May 14, 1796, Dr. Edward Jenner inoculated James Phipps. When we remember that 2,000,000 persons died in a single year in the Russian Empire from small-pox; that in 1707 in Iceland, out of a population of 30,000, sixty per cent., or 18,000, died; that in Jenner's time "an adult person who had not had small-pox was scarcely met with or heard of in the United Kingdom, and that owing to his discovery small-pox is now one of the rarest diseases," the strong words I have used seem fully justified. But the eighteenth century was not to witness the end of progress in medicine. The advances in the nineteenth century have been even more startling and more beneficent. What these advances have been in the department of medicine has been related by Professor Osler. It is my province to speak only of surgery.

I. METHOD OF TEACHING.

The first advance which should be mentioned is a fundamental one,—namely, methods of medical teaching. At the

*Early in 1901 the New York Sun published a series of articles on the advances made during the nineteenth century in various departments of knowledge. The papers were republished by Harper & Brothers in a volume entitled The Progress of the Century. I am permitted to reproduce my own contribution to this series by the kind permission of Paul Dana, Esq., the editor of the Sun, and of Messrs. Harper & Brothers.

beginning of this century there were only three medical schools in the United States: the medical department of the University of Pennsylvania, established in 1765; the medical department of Harvard, established in 1783; and the medical department of Dartmouth, established in 1797. The last report of the Commissioner of Education gives a list of 155 medical schools now in existence in this country, many of them still poorly equipped and struggling for existence, but a large number of them standing in the first rank, with excellent modern equipment, both in teachers, laboratories, hospitals, and other facilities. The medical curriculum then extended over only two years or less and consisted of courses of lectures at the most by seven professors, who, year after year, read the same course of lectures without illustrations and with no practical teaching.

The medical schools, even when connected with universities, were practically private corporations, the members of which took all the fees, spent what money they were compelled to spend in the maintenance of what we now should call the semblance of an education, and divided the profits. Until within about twenty years this method prevailed in all our medical schools. But the last two decades of the century have seen a remarkable awakening of the medical profession to the need of a broader and more liberal education, and that, as a pre-requisite, the medical schools should be on the same basis as the department of arts in every well-regulated college. To accomplish this the boards of trustees have taken possession of the fees of students, have placed the faculties upon salaries, and have used such portion of the incomes of the institutions as was needed for a constant and yet rapid development along the most liberal lines.

II. COLLEGE HOSPITALS.

The first step has been the establishment, in connection with most schools, of general hospitals in which the various teachers

in the college should be the clinical instructors and where the students would have the means not only of hearing theoretically what should be done to the sick, but of actually examining the patients under the supervision of their instructors, studying the cases so as to become skilled in reaching a diagnosis and indicating what in their opinion was necessary in the way either of hygiene, medicine, or surgical operation. More than that, in most of the advanced schools to-day the students assist the clinical faculties of the hospitals in the actual performance of operations, so that when they graduate they are skilled to a degree utterly unknown twenty years ago.

III. ESTABLISHMENT OF LABORATORIES.

Another step which was equally important, and in some respects even more so, has been the establishment of laboratories connected with each branch of instruction. A laboratory of anatomy (the dissecting-room) every medical school has always had, but all the other laboratories are recent additions. Among these may be named a laboratory of clinical medicine, a laboratory of therapeutics, in which the action of drugs is studied; a laboratory of chemistry; a laboratory of microscopy; a laboratory of pathology, for the study of diseased tissues; a laboratory of embryology, for the study of the development of the human body and of animals; a laboratory of hygiene; a laboratory of bacteriology; a laboratory of pharmacy; a surgical laboratory, in which all the operations of surgery are done on the cadaver by each student; a laboratory of physiology, and in many colleges private rooms in which advanced laboratory work may be done for the discovery of new truths.

In all these laboratories, instead of simply hearing about the experiments and observations, each student is required to handle the drugs, the chemicals, the apparatus, to do all the operations, to look through the microscope, etc.; in other

words, to do all that which is necessary for the proper understanding of the case in hand. In fact, it may be said that, in view of the opportunities and the requirements of modern hospitals, it is undoubtedly true that a hospital patient, the poorest of the poor, often has his case more thoroughly studied and more carefully treated than the wealthy patient who is attended at his home. On the other hand, however, so many laboratories with their expensive apparatus and a large staff of assistants mean an enormous increase in the expense of a medical education, for which the student does not pay anything like an equivalent. Hence the need in all of our best modern medical schools for endowments, in order that such work may be carried on properly and yet the student not be charged such fees as to be practically prohibitory, excepting for the rich or, at the least, the well-to-do. I do not hesitate to say that by reason of these facilities at the end of the second year many a diligent student of to-day is better fitted to practise than was the graduate of half a century ago.

IV. ANATOMICAL MATERIAL.

One of the most important means of the study of medicine, and especially of surgery, is a thorough acquaintance with the anatomy of the human body. No one would think of placing a complicated piece of machinery in charge of an engineer who had never become intimately acquainted with all the parts of such a machine and could take it to pieces and put it together again with ease and intelligence. Yet, until comparatively recently, this knowledge of anatomy was both required, and yet at the same time the means of obtaining it were forbidden, the medical student. If he performed an operation and was guilty of negligence or error, due to his want of anatomical knowledge, he was liable to a suit for malpractice. Yet his only means of becoming acquainted with the anatomy of the human body was by stealing the bodies of the dead. In

England, up to 1832, this was equally true. A regular traffic in human bodies existed there as well as here, and by reason of its perils the cost of bodies for dissection was very great; but it was only a question of money. In his testimony before the Parliamentary Committee, Sir Astley Cooper made a shiver run down the backs of the noble Lords who listened to him. when he said that in order to dissect the body of any of them it was only necessary for him to pay enough. The large pecuniary profits of such business, when the supply was very small, led to the horrible atrocities of Burke and Hare in Edinburgh in 1832. They deliberately murdered a considerable number of persons, and sold the bodies to the dissectingrooms in that city.

The discovery of their crimes finally led to the passage of the Anatomy act, which has been in force in Great Britain ever since. Similar violations of graveyards in this country have led to the passage in various States of somewhat similar laws, usually giving for dissection the bodies of those who were so poor in friendship that no one would spend the money necessary for their burial. But even to-day, in a large number of our States, the former anomalous condition of affairs still exists. The increase of anatomical material which has resulted from the enactment of wise and salutary laws for this purpose has given a great impetus to the study of anatomy, and has produced a far better educated class of physicians in most parts of the United States within the last few years. The enlightened sense of the community has perceived that to deny the medical schools the means of properly teaching anatomy was a fatal mistake and resulted in an ignorance of which the community were the victims. As a result it is possible now, by law, in most States to obtain a reasonable number of cadavers, not only for the study of anatomy, but for the performance of all the usual operations.*

*For the atrocities of Burke and Hare see pp. 20-22. For the Pennsylvania Act the best of all the Anatomy Acts see p. 14, footnote.

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