Chapter XIV: Epilogue: 351 (8)

By injection of small and progressively increasing doses of Tetanus toxin into animals, a high and long-lasting degree of immunity to the disease is produced. The serum of such immunized animals has the capacity to protect animals susceptible to the disease against an injection of a fatal dose. It is now a routine treatment to inject serum derived from an immunized horse into those who have wounds likely to result in Tetanus. Owing to the rapid disappearance of the Tetanus toxin from the blood-stream, and owing to its tendency to unite with nervous tissue, it is important to inject the serum as soon as possible after the infliction of the wound. In some cases it is advisable to inject the serum into the sheath that surrounds the spinal cord in order to give it as rapid access to the nervous centers as possible. During the Great War prophylactic doses of Antitetanic Serum were given to every wounded man after 1914. Before the practice was adopted, the incidence of Tetanus among the wounded was 16 per 1,000. After the introduction of this line of treatment as a routine, the incidence fell to 2 per 1,000. Countless lives were thus saved. Antitetanic serum should be injected as early as possible in every case of a large ragged wound, especially if contaminated with soil.

_Typhoid Fever_ differs from Diphtheria, Plague, and Tetanus in that it can hardly be conveyed to animals. It has thus proved impracticable to produce anything in the way of passive immunity in man. On the other hand, there is no disease in which the production of active immunity by means of Vaccines of dead cultures has been attended with more favorable results. The researches which led up to the introduction of active immunization against Typhoid Fever are bound up with investigations concerning the diagnosis of the disease which are of wide importance in connection with several other diseases.

The discovery of Antibodies (p. 262) gave rise to great activity in their investigation. Among the most interesting and important of the antibodies is a group which will cause ‘agglutination’ or clumping of the disease organisms with which they are specially associated. This reaction is specific for the corresponding organisms, within certain limitations. Given, therefore, (1) a pure culture of an organism, and (2) the knowledge of the highest degree of dilution of the serum containing such an antibody that will cause agglutination of that particular organism, the physician has in his hands a means of detecting or excluding infection with that organism. The method was especially studied by the Parisian investigator Fernand Widal (1862-), who in 1896 succeeded in making it practicable for Typhoid Fever, and his name is attached to the test. It is now universally applied in that disease. Similar tests have been devised for Malta Fever and for other conditions.

There are other groups of antibodies that have been investigated. Some of these possess the power of dissolving the corresponding organism. They are, therefore, known as _Bacteriolysins_. Their existence gives a certain insight into the defensive mechanism of the animal body against bacterial invasion. They are sometimes of practical use in distinguishing types of disease-producing bacteria. The method is applicable, for example, in detecting certain types of dysentery organisms.

Another group of antibodies act not against bacteria but against certain specific substances. Antibodies of this type were first detected by the Belgian workers Jules Bordet (1870-) and Octave Gengou (1875-) in the year 1900. The physician avails himself of the existence of such an antibody in the test that is applied for Syphilis, which was introduced in 1904 by Ehrlich’s pupil, August von Wassermann (1866-), and is known by his name.

Of late years a special aspect of Immunity has come into view in connection with the so-called ‘Carrier Problem.’ With many diseases, acquisition of Immunity on the part of the patient implies the death within his body of the organism that has been causing the disease. There are conditions, however, in which the organisms may lurk in some individuals long after the symptoms have subsided. These persons may even contract the disease so lightly that they are unconscious of it, but nevertheless they become capable of conveying it. Such individuals are known as _carriers_. Evidently the existence of carriers introduces special difficulty into attempts to delimit an infective disease in any population.

Among the diseases of known bacterial origin that are sometimes conveyed by carriers are Typhoid Fever, Diphtheria, and Spotted Fever or Cerebrospinal Meningitis. A special case of the Carrier Problem is afforded by Infantile Paralysis, a disease due to ‘ultra-microscopic’ organism--since the virus is ‘filtrable’ (p. 274). This disease, like that of Cerebrospinal Meningitis, is probably transmitted by carriers who do not themselves suffer.

Typhoid Fever, Diphtheria, Influenza, Scarlet Fever, and many other conditions are often conveyed by ‘ambulant’ cases. This term is applied to those cases which, while definitely suffering from a disease, do not regard themselves as ill enough to take to their beds but continue their ordinary avocations. Such ambulant cases are not less but more dangerous to their neighbors than those more severely stricken.

The whole study of the Carrier Problem is in its infancy. It is beset with extraordinary difficulties. In the case of Diphtheria and Typhoid Fever, however, the demonstration that a suspected individual is or is not a ‘carrier’ is easy. The difficulty is to trace him in the first instance!

§ 14. _The Conquest of the Tropics._

Nowhere in Medicine has the rational spirit been more triumphantly vindicated than in connection with the diseases peculiar to hot countries. The increase in the habitability of the Tropics may be traced to two main causes. First is the application of the ordinary laws of Hygiene. Second is the increasingly exact knowledge of the microbic origin of tropical diseases, leading to a more complete apprehension and a stricter application of the laws of Hygiene.

We have glanced at the great changes wrought in the social organization of temperate countries by the rise of modern Hygiene (pp. 172-78), which commenced to be felt about the middle of the eighteenth century. The death-rate then began to fall, and has fallen steadily ever since. The mid-eighteenth century marks, for temperate countries, the end of the ‘Middle Ages’ of Hygiene. But with the advent of the modern period the fall in the death-rate in temperate countries has not been the only change in the public health. Even more significant is a change in the _causes_ of death.

Certain diseases have gradually receded from the more civilized and settled temperate countries, and are now almost unknown there. Thus, Malaria, Plague, Typhus, Leprosy and Dysentery, once of world-wide distribution, have come to be regarded as more or less distinctively ‘tropical’ diseases. A time is approaching when we shall be able to place other diseases with which temperate countries are still afflicted, such as Typhoid Fever, in the same category. The ultimate exclusion of Typhoid as a disease of civilized communities is suggested by the death-rates of England and Wales.

_Average Annual Death-rate in England and Wales from Typhoid per million living._

1871-80 1881-90 1891-1900 1901-10 1911-20 1921-26
332 198 174 91 35 24

In the category of such removable diseases which, being excluded from temperate countries, are regarded as tropical are Malaria, Plague, Typhus, Leprosy, and certain forms of Dysentery. These diseases are ‘tropical’ only in the sense that it is in the Tropics that the general hygienic conditions most favorable to their development are still found. If the hygienic conditions of the Tropics could be raised to those of the civilized temperate countries--a task, it is true, of very great difficulty--these particular diseases might become as rare there as they are with us. Indeed, it is possible to foresee a world in which a number of these so-called tropical diseases will have disappeared altogether.

There are, however, other diseases that are tropical in another sense. Such diseases have seldom or never visited the shores of temperate countries, or at least have obtained no lasting foothold there, even when the conditions have been favorable to them. Among such diseases are Yellow Fever, Sleeping Sickness (which must not be confused with the so-called ‘Sleepy Sickness’), Beri-Beri, Dengue, Sprue, Kalar-azar, and a host of other less known conditions.

It must be said, to avoid misunderstanding, that ‘the Tropics’ in the medical sense is a region considerably wider and far less well-defined than the geographical Tropics. Moreover, despite the existence of diseases peculiar to the Tropics, ‘tropical diseases’ form no natural group based on any common organic causation. The organisms that give rise to the various ‘tropical diseases’ differ from one another just as much as the organisms that give rise to the diseases of temperate countries.

Since we cannot speak of tropical diseases on the basis of their common causation, we are forced to deal with them as separate entities and especially from the point of view of their prevention. We will therefore select two diseases, the history of which illustrates the process by which the Tropics have been rendered safer both for European and for native races. These will serve as types, and we will choose one from the truly tropical group which does not invade temperate climes, and the other from the group which is being gradually excluded from temperate climes. No better instances of these two groups can be adduced than Yellow Fever and Malaria.

FIG. 120. A common Malaria-carrying mosquito × 3.

FIG. 121. The Yellow Fever-carrying mosquito × 3.]

(a) _Yellow Fever._

In discussing the history of Yellow Fever, as of many other conditions, it is perhaps best to begin at the end, for modern knowledge of the organic cause of a disease often illumines and gives a meaning to historical records.

In 1918 the Japanese investigator Noguchi observed a very delicate and minute spiral organism in the blood of a case of Yellow Fever at Guayaquil, the principal port of Ecuador, on the West Coast of South America, one of the most important endemic centers of the disease. Noguchi showed that guinea-pigs inoculated with the blood of this infected case developed symptoms similar to those of Yellow Fever, and he was able to demonstrate the same organism in the sick guinea-pigs. He passed the disease by means of inoculation from one guinea-pig to another. He succeeded in obtaining pure cultures of the organism on artificial media. He passed such cultures through a series of guinea-pigs and finally recovered it in pure culture again. He showed that different strains vary greatly in virulence, a fact in accord with the great variability in the gravity of attacks of Yellow Fever.

One of the reasons why the discovery of this organism has been so long delayed is doubtless the very small numbers in the blood of patients suffering from Yellow Fever. Thus, the toxins must be extremely powerful. Indeed, it has been shown that 1/10,000 of a cubic centimeter of a virulent culture rapidly induces fatal symptoms in a guinea-pig.

There are other important points about the Yellow Fever organism. It passes through a stage in which it is so small as to be beyond the reach even of microscopic vision. This fact is known because the blood of a Yellow Fever patient is infective when passed through any but the finest filters. The organism in fact exists in what is called a ‘Filter-Passing’ stage. Of late years a number of infective diseases have been shown to be due to filter-passing organisms of this type. Among them is the organism of the disease known as Infantile Paralysis (p. 270). The study of ‘filter-passers’ bids fair to be in itself a special science.

Finally, Noguchi threw light on the nature of Yellow Fever epidemics. He was able to pass the parasite from one guinea-pig to another, not only by inoculation in the ordinary way, but also by means of the bite of a species of mosquito which has long been known to be the carrier of the disease for man. He showed that a period of some twelve days’ duration within the body of the insect is necessary for the parasite again to develop its dangerous phase. The period of incubation in man, that is, the time that passes between the infective insect bite and the appearance of the disease, is 3-5 days, but 12-14 days is the period that usually elapses after the introduction of a case of the disease before other cases occur. The discrepancy is now explained. The disease is not infectious except through the mosquito, so the developmental period of the parasite within the mosquito corresponds to the incubation period of the epidemic.

Outbreaks of Yellow Fever have struck the public imagination, have given rise to folk tales and have inspired poets. The story of the _Flying Dutchman_ is that of a ship stricken with Yellow Fever. The specter ship is supposed by sailors to haunt the seas around the Cape of Good Hope, and to bode ill for those who see it. A murder was committed on the ship, and following it ‘Yellow Jack’ broke out. All ports were closed to the wretched crew, who finally all died of the disease. The _Flying Dutchman_ was the subject of an opera by Wagner and a novel by Marryat. A picture of a ship smitten by Yellow Jack is to be found in Coleridge’s _Ancient Mariner_.

An historic case may be quoted. In 1837 a barque named _Huskisson_ was at Sierra Leone. She was lading when Yellow Fever appeared among the crew. All but two or three died. Yellow Fever broke out in the colony, but gradually died down. The _Huskisson_, in the meantime, remained in harbor without hands for three months. At last, hands were obtained, tempted by very high pay. Again the Yellow Fever broke out among them and again nearly all died. They were bitten by infected mosquitoes which remained in the ship during the three months. Many cases, no less dramatic, are on record. The disease is among those which are peculiarly common and fatal among medical men. Thus, Senegal has twice been denuded of medical men by Yellow Fever. In 1830 six died out of twelve, and in 1878 twenty-two out of twenty-seven.

An attack of Yellow Fever confers Immunity. In children it assumes a mild form, and therefore, in countries where the disease is endemic, the population consists largely of the survivors of attacks. On this account terrible outbreaks of the _Flying Dutchman_ or _Ancient Mariner_ type are always either on immigrant ships or in places which have remained long unvisited by the disease, in other words such outbreaks occur under conditions in which immune persons are few or absent.

The distribution of the Yellow Fever mosquito is wider than the distribution of Yellow Fever at the present day, but Yellow Fever is never found, save in sporadic outbreaks, where the mosquito cannot live permanently. The distribution of the mosquito corresponds, however, to the areas where the disease has in the past, from time to time, established itself, but is smaller than the area wherein sporadic outbreaks have been reported.

During the seventeenth and eighteenth and even the nineteenth century there were repeated outbreaks of Yellow Fever far beyond the region to which it is now confined. Along the eastern shores of North America it has at times extended as far north as New York, and there have been destructive outbreaks in Baltimore, Philadelphia, and even Boston. The disease has been found along most of the littoral of South America. In the Old World it has visited chiefly West Africa, where it was imported very early by the slave trade. It has visited at times Spain, Portugal, and Italy with devastating epidemics, and has even occasionally made a call in France and once in England. The last considerable outbreak in Europe was at Madrid in 1878.

England has always had important interests in the West Indies. During the eighteenth and first half of the nineteenth century she had, moreover, large military establishments there, which were regarded as very bad stations. In Thackeray’s _Vanity Fair_, which refers to the period just after the Napoleonic wars, the disreputable and unfortunate Rawdon Crawley is sent as governor to ‘Coventry Island’ in the West Indies, and is not expected to last long! There are many historic occasions on which the British forces in the West Indies lost almost incredible numbers from Yellow Jack, garrisons being practically wiped out. In Jamaica the mean annual mortality in the garrison was for many years 185 per 1,000! In the Bermudas the mortality was about 80 per 1,000. One should remember that soldiers are picked men in the prime of life, and that these mortality rates were in places now regarded as health resorts! A hundred years ago, Jamaica had the highest death-rate in the Empire, with the exception of West Africa, where the mean annual mortality of whites at Sierra Leone was 362 per 1,000!

Conditions in the West Indies began to improve definitely from about 1850 onwards. At that time there was no effective knowledge of the organic cause of Yellow Fever, nor, for that matter, of any other tropical disease. Only lately has the basic reason for this early improvement become obvious. From about 1850 onwards the water-supply in the more settled parts of the West Indies, and notably in the larger towns, came to be arranged by pipes. Now these towns were the special resorts of the Yellow Fever mosquito. The removal of open standing water, the enclosure of water-supplies, and the introduction of ordinary modern sanitation in the clearing away of rubbish, did good work without any knowledge of the organic cause of the disease.

We now know the life-course of the Yellow Fever mosquito. We know her breeding habits and how the water-living larvae congregate specially in the small collections of water in the neighborhood of houses. Precautions have been taken against them and under favorable circumstances the disease has completely disappeared in well-managed districts under British and American control. The romantic story of the destruction of Yellow Fever in the Panama zone, in Cuba, Puerto Rico, Jamaica, Barbadoes, Trinidad, New Orleans, has been too often recited to be detailed again. Every one has heard of the tragic event in connection with the American Mosquito Commission of 1900 and of the death of Lazear. He and his colleagues, led by Walter Reed (1851-1902), finally proved that the disease is never conveyed by bedding, or by clothes, or by other objects, but always and only, in nature, by the bite of an infected mosquito.

During the experiments of the American Commission, cases of Yellow Fever were produced in volunteers by bites of infected mosquitoes, by injection of blood of infected patients, and by injection of _filtered_ blood serum of infected patients (p. 74). With this knowledge in his hands, the American chief sanitary officer of Havana, William C. Gorgas (1854-1920), began to destroy mosquitoes systematically and to treat all Yellow Fever patients under mosquito nets. Within three months Havana was free from Yellow Fever for the first time for one hundred and fifty years. These wonderful results are brought out by a table:

_Deaths in Havana from Yellow Fever._

_Year._ _Deaths._ _Year._ _Deaths._
1885 165 1895 553
1886 161 1896 1,282
1887 532 1897 858
1888 468 1898 136
1889 303 1899 103
1890 308 1900 310
1891 356 1901 18
1892 357 1902 0
1893 496 1903 0
1894 382 1904 0

Except for the semi-civilized states of Central and South America, Yellow Fever is now generally under control. It is perhaps not always realized, however, that, while the local extinction of this disease may be among the future triumphs of modern science, its substantial control over large areas is part of the history of world hygiene (p. 278), and that it is part of the very same movement that has made our own cities healthier and more habitable than they were in the Middle Ages.

(b) _Malaria._

The history of Malaria, which is also carried by a mosquito, is very different from that of Yellow Fever. Malaria was, till recent times, a disease of temperate as well as of tropical countries. The old name for the disease is _Ague_. The word _Malaria_ is of no great antiquity in the English language. It came into use only in the eighteenth century. Like the word _Influenza_, it is of Italian origin, and, like _Influenza_, it carries with it a forgotten pathological theory. _Malaria_ is simply _mal aria_, that is, ‘bad air’. So _Influenza_ is _the influence_, that is to say, the influence of unpropitious planets or comets that were held to rain down poison into the air. It was believed that these diseases were the result of local atmospheric conditions. In Rome and the Campagna the natives still believe that just as the sun goes down the air becomes specially poisonous.

While the _term_ Malaria is comparatively modern, nevertheless, recognizable accounts of the _condition_ are perhaps more ancient than those of any other disease. Of all diseases produced by micro-organisms, Malaria has perhaps changed its type least during the course of historic time. The disease is distinctly described in several places in the _Hippocratic Collection_.

The conception of diseases as separate entities is, of course, modern. In the case of most infectious diseases, therefore, we cannot hope to follow the history very far back. But the symptoms associated with a malarial attack are so definite that there is no difficulty in tracing the disease with certainty as far back as 1000 B.C. The real division into ancient and modern times comes, for this disease, with the use of Cinchona, which is the plant from which Quinine (p. 326) is now derived. Very soon after the introduction of Cinchona in the seventeenth century, fevers came to be habitually divided into those which respond to Cinchona and those which do not. Cinchona--and therefore its derivative, Quinine--is one of the drugs that we owe to the discovery of the New World (p. 95). The rind of the Cinchona tree was taken as a remedy by the aborigines. In Europe, where it was introduced by Jesuit missionaries, it became known as ‘Jesuits’ bark’. It was popularized by Sydenham (p. 100) and has ever since been widely used in medicine.

Sydenham gave a good description of Malaria. During the seventeenth and eighteenth centuries epidemic after epidemic of ‘Ague’ swept over England as over other European countries. These epidemics spread from their endemic centers, the low-lying ill-drained, swampy districts, where the Malaria mosquito could breed freely in the slowly flowing water. Of such places the principal in England were the Fens of Cambridgeshire, Lincolnshire, and the surrounding counties, the marshes on either side of the estuary of the Thames in Kent and Essex, the marshes of Romney and Pevensey on the South coast, and those around Bridgewater near the Bristol Channel (Fig. 122). There Malaria was never absent, though it differed greatly in prevalence and severity in different years. Ague remained prevalent in London as late as 1859. The proportion of ague cases to the total number of in-patients and out-patients at St. Thomas’s Hospital in London from 1850-60 varied from between 12 per 1,000 at lowest to over 60 per 1,000 at highest. Thus, over one-twentieth of the patients in a large London hospital suffered from what we now regard as a tropical disease, within the lifetime of men who are still with us!

In London the rise in the value of land led to the erection of the Thames Embankment, which effectually reclaimed the land around the river. Extensive works of drainage were at the same time being undertaken in other infested districts. These soon had their now well-known effect. In 1864 Malaria was found to be rapidly diminishing everywhere, and to have left many of its old haunts. The disease retreated rapidly. At the beginning of the twentieth century a systematic search was made for a native case in England. After much labor one single case was at last found. It may safely be prophesied that native Malaria will never again be anything but a rare disease in any temperate country with an efficient sanitary service.

The story of the discovery of the malarial parasite is worth recounting. These organisms inhabit the red blood corpuscles and were first seen by Alphonse Laveran (1845-) in 1880 in Algiers. His observations were extended by French and Italian observers, who showed that the sudden rise in temperature in Malaria coincides with a process of division of the parasite. Later the suggestion that the parasite might be conveyed to man by the mosquito was made by Patrick Manson (1844-1922). The matter was clinched in 1898 by Ronald Ross (1857-), who showed that the malarial parasite necessarily passes through a stage in the stomach of the mosquito. The process was first traced by Ross in a malarial parasite that is peculiar to certain birds, and was subsequently demonstrated for the allied species of parasite that produces human Malaria.

We have here an illustration of the value of comparative pathological studies. Since the demonstration of the life-cycles of the malarial parasites of man (Fig. 123), the chief attention of hygienists interested in

Malaria has been directed to the mosquito (Fig. 124). Controlling the breeding of the mosquito has proved the best method of reducing the incidence of the disease. Engineering and sanitary works in some places previously infested with Malaria have had the effect of almost entirely eliminating disease. The classical instance is the Panama zone, where, as is well known, the two mosquito-born diseases, Yellow Fever and Malaria, have disappeared. There are now many areas in the Tropics, previously infested, in which the disease is almost unknown. There are many devices for dealing with the mosquito larvae.

By advances such as have been made in the knowledge of Yellow Fever and Malaria, those areas of the Tropics which are under proper sanitary control have become far safer habitats. There is good hope of an early and rapid extension of the process, ultimately rendering new areas of the Tropics suitable for permanent habitation by the white races and healthier and happier places for the colored.

The life-histories of the parasites of the malarial diseases of man have been completely traced. The parasites run through a double cycle, one in man and the other in the mosquito. In our diagram the cycles of only one species are represented; there are however two other special malarial parasites in man.

On either side the head of the mosquito involved is diagrammatically shown, just below the ‘cycle in man’.

In man the parasites conveyed by the bite of the mosquito (32) or formed by a division of a parasite already in the blood (7) make their way into the red blood corpuscles (1 and 2), develop there (3 and 4). Some of them ultimately divide to go through the same cycle (5, 6, 7 and back to 1, 2). The process of division corresponds to the period of fever. Others develop into crescent-shaped bodies (8, 9 and 10), which can be differentiated into two slightly different forms corresponding to two sexes (9 male, 10 female). These, if sucked up by a biting mosquito of the right species, pass into the animal’s stomach where they develop further (11, 12, 13 male; 14, 15, 16 female) and end by dividing into forms which conjugate (17). The resultant of this conjugation or union of the two sexes (17) develops into a lanceolate form (18, 19, 20) which passes into the cells of the mosquito’s stomach (21, 22) and finally penetrates these cells (23). The parasite then secretes a cell-wall and forms a ‘cyst’ (24), which enlarges (25). The enlargement continues while the nucleus breaks up (26, 27, 28). In the cyst, which is still growing, a large number of needle-like forms develop, each of which contains a fragment of the nucleus (29). Finally the cyst bursts (30), the needle-like forms are cast forth into the body of the mosquito, and ultimately lodge in her salivary glands (31). When the mosquito bites another man, she injects some of her saliva into him through her proboscis. Thus she infects his blood with some of the needle-shaped parasites that lurk in her salivary gland (32). So the cycle is re-enacted again and again. We may note that to prevent this process of repeated reinfection it is only necessary to break either cycle at one point. Thus destruction of mosquitoes or of their breeding-places will suffice, or, again, protection of human hosts from bites of mosquitoes will be sufficient. Either process, if persisted in, will lead to the extinction of the parasite in the region under supervision. In England both methods have been in operation and the disease is almost extinct there so long as any of the malarial mosquitoes remain in one district. However, the disease can always be reintroduced by the introduction of subjects of malaria from without.

(From C. M. Wenyon’s _Protozoology_, Vol. II, by kind permission of Messrs. Baillière, Tindall and Cox. Slightly reduced in size.)]

FIG. 126. CHART OF CASES OF MALARIA reported in Italy in recent years, showing the seasonal variation of the disease. The date of the year is written, in each case, below a vertical line corresponding to midsummer. It will be seen that the maximum incidence is always in the months July to September, and the minimum incidence is always in the months January to March. This incidence corresponds to the known facts of the life-history of the mosquito and of the evolution of the malarial parasite within the body of the mosquito. ]

§ 15. _The Changed View of Insanity._

Insanity is as old as History. The Bible, Homer, and the _Hippocratic Collection_, for instance, recount numerous examples of the disease. Until the nineteenth century there was practically no scientific knowledge of the conditions classed as insanity. Nevertheless, hospitals for the insane were instituted at an early date. A well-known instance is Bethlem Hospital or _Bedlam_ in London, which was developed as an insane asylum in the fourteenth century.

The new era in the treatment of insanity begins with the abolition of the old system of restraint. This was primarily due to two noble-minded men, one a Frenchman and the other an Englishman. Philippe Pinel (1745-1826), physician at the Bicêtre and afterwards at the Salpêtrière at Paris, at great personal risk both to his life and liberty, insisted on freeing from their chains the unfortunate lunatics under his charge. His _Medico-philosophical Treatise on Mental Alienation_ (1791) was devoted to championing the humaner treatment of the insane. His contemporary, the Quaker philanthropist William Tuke (1732-1822), succeeded in 1792 in establishing at York a small retreat for the insane, where the antiquated, unnecessary and cruel restraints were abolished (Fig. 127).

While Pinel was beginning the humaner treatment of insanity in France, considerable interest was aroused in the subject in Germany. There, however, the medical profession was still under the influence of the mystical Stahl (pp. 132-3), who regarded all forms of insanity as perversions of the moral tendencies of the soul, produced by sin!

In France Pinel was succeeded in 1810 by Jean Étienne Dominique Esquirol (1772-1840). The influence of Esquirol was as radical for the scientific study of the subject as had been that of Pinel for the humane treatment of the sufferers. Esquirol threw himself into the task of founding properly conducted asylums, and he produced in 1838 his monumental work _On Mental Diseases considered in their Medical, Hygienic, and Legal relations_. It is the first important, rational, scientific treatise on the subject. Esquirol abandoned the barren type of speculation that had characterized previous works on the subject and devoted himself to the systematic collection of data. He was able to sketch out some of the main forms of insanity, including that now known as ‘General Paralysis of the Insane’. This disease was finally differentiated by one of his pupils. Another pupil of Esquirol was the first to succeed in the training of idiots. The main school of French alienists is descended from Esquirol. In the early forties his work resulted in the foundation of journals and societies devoted to the study of Insanity in France, England, the United States, and Germany.

England was behind France in her treatment of the Insane. Not until 1828 were there proper laws governing their certification. In 1844 the great and good Lord Shaftesbury (1801-85), the seventh Earl, brought in his Bill establishing the Board of Lunacy Commissioners with the duty of inspecting all lunatic asylums. It was a subject to which that great philanthropist gave much thought. The same period saw also an awakening in the United States, where Miss Dorothea Lynde Dix (1802-87) carried on a very successful campaign for the better treatment of the insane and the establishment of proper houses for their reception. Her labors resulted in the foundation of many asylums on a reformed model in the United States and Canada. In 1845 the provision of asylums out of the local rates was made compulsory on the local Justices in England.

The late sixties and early seventies saw in every country a further change for the better in the treatment of the Insane. The causes of this improvement were two. On the one hand, Insanity came generally to be recognized as a group of diseases which, like other diseases, have usually a traceable physical basis. On the other hand, the great improvement of the system of nursing under the inspiration of Florence Nightingale (pp. 298-300) began to reach the asylums. In 1877 there was a Parliamentary investigation into the care of the Insane in England and Wales, and in 1890 the duties of asylum administration were transferred from the Justices to the County Councils. This has resulted in an immense improvement in the accommodation and treatment of the insane poor in England. At the same time the order of a magistrate became necessary for the consignment of a private patient to an asylum. In 1913 provision was made for the mentally defective, who do not come within the Lunacy Act. Lastly, with the establishment of a Ministry of Health in 1917, the general control of the Insane has passed to that body.

Many types of insanity have been traced to an organic cause in the Nervous System itself. The Morbid Anatomy, both coarse and microscopic, of some of these diseases has become recognized. Chief among them is the well-known condition known as ‘General Paralysis of the Insane’. During the intensive study of the factors in the causation of Insanity it has become clear that in some groups, as in General Paralysis, which is always preceded by Syphilis, a ‘toxic cause’ is at work. Other types of toxic insanity are due to the actual intake of a poisonous substance. This is sufficiently evident in cases which are associated with Alcoholism. There is also evidence that in a considerable number of cases toxic conditions result from perversion of metabolic processes, or, again, are associated with ‘deficiency’ states (pp. 302-8). This is a very hopeful finding, since by removing the toxic cause, or by remedying the deficiency, relief may be possible.

Much less hopeful is the outlook with those forms of insanity, especially common in the adolescent, which are of the nature of a perversion of development. Such is the large group known as ‘Dementia praecox’. These cases almost invariably originate from a mentally unsatisfactory stock. This is less so with the Epileptic insane, though a considerable proportion of epileptics may be classed with those who are born mentally defective and are liable to give rise to a bad stock. Whatever view may be taken of the question of the artificial limitation of human fertility, it is almost impossible to imagine that the free breeding of these classes of defectives, epileptics and their congeners, will continue unchecked in any civilized community.

The general care and treatment of the insane has improved out of all knowledge during the last quarter of a century. It is probable that there is now no class of sick person who is more skilfully and considerately cared for.

From time to time an alarm is raised at the rapid increase in Insanity, and it is a fact that the proportion of certified insane has been, for some time, steadily rising. A considerable part of this rise is certainly due to the greater willingness of the insane themselves to enter an asylum, and of their friends to allow them to do so. Part of the rise in numbers of the insane is due to their increased length of life under improved treatment. It must be remembered that more than 90 per cent. of the insane in England and a similar percentage in other countries are paupers, who are not readily discharged as they have no means of support. Mild mental cases and the senile insane go now to the improved asylums. Before they would have been kept at home or sent to a rate-supported or a State infirmary. The general conclusion of those best qualified to judge is that Insanity, if increasing at all, is doing so only very slowly.

being the first institution in England where the insane were accorded humane and scientific treatment.]

§ 16. _The New Movement in Psychology._

During the last half-century various new points of view have entered into our conception of Mind and its disorders. The evolutionary view of the origin of man, which was brought to wide notice by Charles Darwin, not only in his _Origin of Species_ of 1859 but also in his _Descent of Man_ of 1871 and his _Expression of the Emotions_ of 1872, has given rise to new ideas as to the nature of many instincts and emotions. These views have been co-ordinated with our knowledge of lower types of man, both in his existing state and in his extinct and fossil forms. Much that we call Insanity has been found to be related to what is normal in other and less developed environments. The Mind, breaking free from its habitual restraints, ‘reverts to a lower type’. There is a constant though unconscious ‘conflict’ in the mind, which is variously resolved.

Whole schools of Psychology have arisen in the discussion of the nature and resolution of these conflicts. Sigmund Freud of Vienna (1856-) takes the leading place among those who have dealt with this subject. He holds these conflicts to be rooted in sex and has introduced the method of _Psycho-analysis_, which lays great stress on the subconscious or unconscious element in mental life. Largely under the direction of C. G. Jung of Zürich (1875-), preventive and curative measures, based on this view, have been introduced into medicine. It has been established that painful experiences, lurking in the unconscious mind, disturb the equilibrium of health. Such disturbance is often of the nature of a struggle to repress into the unconscious unpleasant memories which are tending to surge up into the conscious. The psycho-analyst seeks to release the repressed experience into the conscious. The recognition and consideration that follow a success in this attempt is often far less painful than the repression. Persistent unreasonable fears on the part of adults, but especially of children, are frequently thus dispersed.

The importance of suitable environment to children has always been recognized. But a new significance has been given to the mental impressions received in infancy by cumulative evidence of harmful results in the adult life of events in the early years of life that are seemingly forgotten. This recognition of the enduring character of mental impressions has led to a movement for the better instruction of mothers, and has thus been a factor in the remarkable development, in recent years, of work for infant welfare.

It is recognized, moreover, that certain instincts--such, for example, as the self-regarding instinct and the sex instinct--must have expression. Mere repression of such instincts is always harmful, but they are susceptible of a process of transformation, technically known as _sublimation_, to an almost indefinite extent. Thus the self-regarding impulse need by no means lead to the inconvenience and discomfort of others, but, rightly guided, may develop into a sense of personal responsibility for the welfare of others. So, too, sex instinct is but one aspect of that creative vital activity on which depends the continuance not merely of the human race but also of the culture that the race has built up. The sex instinct is thus habitually sublimed into other creative channels, and there are many altars, beside those of Venus, at which young men and women may kindle their essential fires.

§ 17. _The Revolution in Nursing._

During the Middle Ages, and in Catholic countries after the Reformation, attendance on the sick in Hospitals and elsewhere was the task of religious sisterhoods. In Protestant countries the absence of these sisterhoods necessitated the employment of women specially for the purpose. The task was not an attractive one, nor did any social distinction attach to it. The profession of nurse became despised and was followed, for the most part, by a low and illiterate type of woman, though midwives were sometimes better educated and of a higher class (p. 180). The great philanthropists of the eighteenth century (pp. 171-72) could do little to improve the nursing profession. The conditions of employment formed the root of the evil. The vast improvement that has resulted in health and happiness to our whole population from the improvement in the character and training of nurses is probably seldom realized, even by medical men. Yet it may reasonably be doubted whether all modern medical and surgical advances put together--apart from Preventive Medicine and Infant Hygiene--have saved as many lives as the Reform of Nursing.

The reader may gain some insight into the life of a nurse from the conditions that prevailed until beyond the middle of the nineteenth century at a very good and well-managed English provincial hospital, the Radcliffe Infirmary at Oxford. The salary of a nurse was £5 a year. There was no distinction between a nurse and a domestic servant. One nurse only was the allowance for a ward of seventeen patients. A nurse’s day began at 6 a.m. The wards were cleaned till 7, when a bell was rung and each nurse had to bring down her ashes and sift them under the direction of the porter, who then gave her coals for the day. She took breakfast with the patients, who helped her, so far as they were able, with the ward work. At 2 p.m. she went to the servants’ hall, where she had her dinner in company with the servants on daily hire. During the dinner the ward was left in charge of a patient. After dinner she took away a plate of meat and vegetables for her supper. For the night there was normally only one nurse for the whole hospital of about 100 beds. There were no regular holidays, and the nurse was never allowed to leave the hospital before 6 p.m. The practice of nurses receiving gratuities from patients continued till 1870 and even beyond. Those patients who wished to secure a nurse’s early attention for their dressings gave tips, those who did not frequently had to wait.

What sort of woman could such a system produce? That some nurses at least were kind and skilful, even under such conditions, is a fact, and is pleasing evidence of the natural goodness and wisdom that reside in the human heart. Many, however, can have been no better than Sairey Gamp and Betsy Prig.

The first important reform in Protestant countries began in Germany, through the influence of Elizabeth Fry (p. 171). In 1822 Theodor Fliedner (1800-64), the young pastor of the church at Kaiserswerth, a little town on the Rhine near Düsseldorf, visited England and was much impressed by Elizabeth’s teaching and example. Returning to his charge, he devoted himself to the spiritual and physical care of jail-birds. In 1833 he and his devoted wife Frederica (1800-42) opened a refuge for discharged female convicts. From them the couple turned their attention to the sick poor. The conception of an organized body of specially trained women crossed their minds. In 1836 they opened a small hospital.

At this hospital six young women of the most spotless character were induced to serve as ‘deaconesses’. It was their duty to perform all the tasks of the hospital in rotation. The physicians who attended the hospital gave them instruction. The Kaiserswerth idea rapidly spread and the ‘Kaiserswerth Deaconesses’ became and remain an important order, which is still occupied in good works in many parts of the world. The conception of the order is different from that of most religious orders in that the members make no attempt to withdraw from the world, and marriage is not forbidden to them. Moreover, the duties of the Kaiserswerth deaconesses are rather different from and more varied than those of a sick-nurse. They include teaching, both secular and religious, nursing, household duties, management of children and convalescents. In 1865 a preparatory school for probationers was opened.

In England Anglican orders of a somewhat similar character were formed in the forties and fifties. In 1850 and 1851 Florence Nightingale (1820-1910), who was a lady of good social rank, visited Kaiserswerth, and went through a regular training there. She was profoundly impressed by the extremely high character of the deaconesses, most of whom were only peasant women. The next three years she spent in writing and in examining hospitals in her own country.

Florence Nightingale’s opportunity came with the outbreak of the Crimean War in 1854, and the rapid breakdown of the medical services, which contained no women nurses. The French had a number of ‘religieuses’ to nurse their sick, and a feeling of shame arose in England at the neglect and mismanagement of the British sick and wounded. The Secretary of State for War asked Florence Nightingale to go to the Crimea to organize a nursing service. She left at once with thirty-eight nurses whom she selected personally. Ten of these were Roman Catholic sisters and all the others had had nursing experience. From that event dates the Revolution in Nursing. Florence Nightingale performed marvels under conditions of great difficulty (Fig. 128) and in the face of determined opposition. She returned home in 1856 a national heroine. She had no difficulty in establishing a school and home for nurses at St. Thomas’s Hospital in London in 1860. The example was followed by the other London hospitals.

Florence Nightingale was a woman of the most powerful will and an admirable organizer and administrator. Her system of nursing contained many new features, not quite all of which have stood the test of time. That nursing rapidly and steadily improved from the moment she was in authority cannot at all be doubted. Looking back, it is apparent that the immediate success of her methods was due to two main factors. First was her capacity to secure women of high character and good social position to accept positions of responsibility. Second was her removal of the control of the nursing staff entirely from the hands of men into those of women. Her influence soon passed across the Atlantic, and she was associated with the United States Sanitary Commission and the women who took charge of army nursing during the American Civil War.

While Florence Nightingale was reforming Nursing, her contemporary, Mary Carpenter (1807-77), was applying herself to the kindred task of looking after neglected children, establishing Reformatory and Industrial Schools and improving the position of Indian women. She obtained a large measure of public support and exercised considerable influence in America, which she visited in 1873. Many other distinguished and devoted women worked on similar lines.

Among the indirect results of the activity of Florence Nightingale was the establishment at Geneva in 1864 of the International Red Cross Committee, the branches of which have done good service in many wars and have been no less useful in peace.

Florence Nightingale opposed anything in the way of State registration of nurses. Concentrating on a high ideal of competence and character for the nurse, she failed to grasp some of the secondary effects of her own scheme. A large nursing service is now a necessity in every civilized country, as a result of her efforts and example. Having regard to human imperfections, we can as little hope that every woman who nurses will be a born nurse, devoted to her task, as that every doctor or teacher will have a natural vocation for his work. In an imperfect world mankind must protect itself against the incompetent and the unfit. Registration is a way--doubtless an imperfect way--of doing this. A Nurses’ Registration Act became law in England in 1919.

There have been many improvements in the details of the training of nurses, incident on the changes in Medicine and Surgery during the last half-century. Apart from these, the main improvements in Nursing have been due firstly to an increased interest in the welfare and health of the nurse herself, and secondly to the recognition that Nursing is a profession for which, as for Medicine, some preliminary scientific knowledge should precede professional training. Thus, the very long hours of the nurse have of late been reduced, and in the best schools instruction is now given to nurses in Anatomy, Physiology, Hygiene, Bandaging, and Cookery, before the commencement of actual hospital work.

Further developments will probably be along the lines of State and Municipal Nursing Services. Since Health is a public as well as a private concern, the same must be true of the training and work of nurses.

_From a painting by Jerry Barrett_]

§ 18. _Some Modern Physiological Concepts of Clinical Import._

The vast activity in the sciences of Physiology and Pathology during the last fifty years, and their repeated divisions into independent sciences, each prosecuted by its own specialists, have yielded many ideas which have been imported into the clinical practice of Medicine. It is impossible to say which of these are of permanent value. All previous ages have had to discard part of the practice and a large proportion of the medical ideas that have been handed down to them, and there is no reason to suppose that the age that follows us will differ from those which have gone before us. Some ideas that have entered Medicine from the physiological laboratory, pushed by interested parties or seized on in despair by physicians at a loss for a line of treatment, are already seen by men of experience and judgment to be no permanent addition to our store. Other lines of physiological thought are still under discussion by them.

There are, however, certain physiological conceptions which, apart from their general implications in the economy of the body, have received such wide application that their future, as an organic part of medical practice, seems assured. Certain of these conceptions demand discussion in even the most cursory survey of medical development.

(a) _Ductless Glands and Internal Secretions._

The nature and action of the various glands of the body has been a classical physiological field. Malpighi (pp. 116-20) was the first to investigate the structure of these organs, and he was followed by many others. It became evident that many glands, such as the liver, the salivary glands, and the tear glands, are provided with ducts or tubes, which carry off the characteristic secretion of the glands. These secretions can be examined with comparative ease--as happened early with the secretion from the stomach, or ‘gastric juice’ (pp. 146-48), and later with the secretion of other glands. There remain, however, certain glands unprovided with ducts. The action of such ‘ductless glands’ long remained a mystery. Of these the type is the ‘Thyroid gland’. Much of our physiological knowledge of this organ, together with the conception of its function as indispensable to normal life, has come through Surgery.

It had long been known that certain symptoms were associated with enlarged Thyroid gland or ‘Goitre’. Attempts to remove the organ surgically were made after the introduction of antiseptic methods. Goitre is particularly common in Switzerland, and it is not remarkable that the technique of the very dangerous operation for the surgical removal of goitres was first perfected by Swiss surgeons, among whom Theodor Kocher (1841-1917) has taken the first place. The study of cases that had had their Thyroid glands removed gave a clue to the nature and action of the gland.

It was found that those surgically deprived of the Thyroid gland develop abnormal slowness in movement and response. The temperature is low, the pulse small, the muscles are torpid and sometimes rigid, and there is a failure in ordinary fine muscular movements. The patient shows a thickening and swelling of the skin and presents a dull and very characteristic appearance. When the operation was performed on one whose growth was not yet complete, development was checked. Such a patient remains infantile or childish both in body and mind.

The conditions were recognized by Swiss surgeons in the seventies as resembling those of a spontaneous disease to which the name _Myxoedema_ was attached. Further the close relationship both of the surgical and of the spontaneous condition to the state of idiocy known as _Cretinism_ came gradually into view. In Switzerland, as in other parts of Europe, stunted beings known as _Cretins_ had long been known. These defectives are sometimes goitrous, sometimes without a Thyroid gland, but their general appearance and condition is an exaggerated version of what has been described for those with Thyroid glands removed (Fig. 129).

_From the Collection of the Royal College of Surgeons._]