METHODS OF TREATMENT

In the early years of the nineteenth century, the principal therapies open to European and American physicians were general regimens of diet, exercise, rest, baths and massage, bloodletting, scarification, cupping, blistering, sweating, emetics, purges, enemas, and fumigations. There were multitudes of plant and mineral drugs available, but only a few rested on sound physiological or even empiric foundations: quinine for malaria, digitalis for heart failure, colchicine for gout, and opiates for pain. Many physicians continued to use compounds of arsenic for such diverse complaints as intermittent fever, paralysis, epilepsy, edema, rickets, heart disease, cancer, skin ulcerations, parasites, indigestion, and general debility. Antimony, which had its heyday in a previous century, was also still much in use, possibly sometimes aiding patients with parasitic infestations. For the most part, leading European practitioners, as well as some in America, permitted illnesses to run their course without interference, for careful observers noted little benefit from the therapies available. On the other hand, others believed that "desperate diseases require desperate measures" and favored the use of drastic drugs and procedures. In the United States, by the 1830s and 1840s, the influence of "heroic" medicine (such as bloodletting and strong drugs) was mitigated somewhat by the Louisiana Purchase in 1803, which introduced a large French-speaking population into the U.S. including French physicians who generally preferred assisting nature to battling the disease. Their close contacts with the Paris clinical school also taught them (and educated physicians in the northeast) the advantages of correlating clinical diagnoses with pathological changes in the organs.

Medical Systems

Claude Bernard wrote, "Systems do not exist in Nature but only in men's minds." Nevertheless, numerous systems of therapy and explanations for illness flourished in the nineteenth century, a few of which may be mentioned. Some now seem close to quackery, but generally these theories of disease and treatment were sincere attempts to reconcile the symptoms of an illness with current knowledge.

Perhaps the most influential system was homeopathy, a creation of Samuel Hahnemann (1755-1843) in Germany, which taught that drugs which produced symptoms in a person resembling those of a specific illness would cure the patient if used in smaller amounts. However, the homeopathic system used such infinitesimal doses that they could hardly have had any effect, and, furthermore, the homeopaths were uncritical in their evaluation of results. But while their methods may have denied patients the therapeutic benefits of the few available specifics like quinine and digitalis, the homeopaths did spare their patients the harm of bleeding and purging. The doctrine spread throughout the world and was especially popular in the United States, where schools of homeopathy were founded, notably in Philadelphia and New York. As newer knowledge in physiology, pharmacology, bacteriology, and pathology developed and as more useful therapeutic agents appeared, homeopathy lost much of its appeal.

Hydrotherapy, an all-purpose therapy, was based on the ancient concepts of the humors—the necessity for expelling excesses. Vincenz Priessnitz (1799-1851) the principal proponent, administered water in every conceivable way, but his regimen also included simple, nourishing food and exercise. This system, which achieved great popularity, led to the founding of hydropathic institutions in Europe and the United States. The opposite view—using only dry foods and substances—also had advocates, but they were few. The Thomsonians, who emphasized herbal medicines and steam baths, were one of a diverse group of practitioners—prominent especially in the U.S.—who stressed "Nature's remedies and folk medicine."

Another medical therapy, which arose in the eighteenth century but had a strong impact throughout the world in the following century, was cranioscopy. Also called phrenology, the doctrine was promulgated by Franz Joseph Gall (1758-1828), a clinician born in Germany and educated in France and Austria, who practiced and lectured in Paris for over twenty years. He taught that the shape and irregularities of the skull were projections of the underlying brain and consequently indications of a person's mental characteristics—a conclusion with no basis in fact. Gall's concept of localizing mental processes was a good idea, but his uncritical exaggerations carried it too far. However, the very notion that the brain is a composite of discrete but interrelated functions anatomically confined to specific areas, an old but incompletely realized concept, was a principle that was to become the basic tenet of brain physiology.

In the United States, Andrew Taylor Still (1828-1917), who had attended medical lectures in Kansas City, organized a doctrine of medicine in 1892 which he called osteopathy. Concluding that drugs were ineffective in producing cures, he set up a system with two basic tenets: the living human body contains within itself all the remedies necessary to protect against disease; the correct functioning of the body requires a proper alignment of the bones, muscles, and nerves. Considerable dispute developed between osteopaths and regular practitioners, but over the decades osteopathic physicians so modified the original principles that they became almost indistinguishable in their methods from traditional physicians. They took up drugs, accepted vaccines, and utilized surgery. Many schools of osteopathy in the United States now have virtually the same curricula, educational standards, and practices as the regular schools.

Another healing system which ascribes disease to derangements in structure and function of the vertebrae is chiropractic, founded in 1895 by Daniel D. Palmer (1845-1913), who had earlier practiced magnetic healing. Proper adjustments of the spinal column are supposed to cure the ailments of the internal organs—a doctrine physicians generally regard as without foundation. In 1968 the U.S. Secretary of Health, Education, and Welfare reported to Congress that the claims of chiropractic were invalid, were not subjected to research evaluation, and should not entitle its practitioners to be reimbursed under the Medicare law. Nevertheless, the U.S. National Center for Health Statistics estimated that in 1965-66 approximately two percent of the population consulted chiropractors for treatment of back problems and other ailments.

Another healing cult which is more religious than medical is Christian Science. In the eighteenth century, Phineas P. Quimby (1802-66), a mesmerist, attributed his cures to the faith of the patient. Mary Baker Eddy (1821-1910), one of his patients though not his direct disciple, in mid-nineteenth century founded the Christian Science church, which views health and recovery from disease as dependent entirely on following God's divine laws. Confrontations between Christian Science and physicians have occurred when an operation or other treatment deemed necessary has been refused by a church adherent.

There were also numerous quack cults whose objective was to amass money by hoodwinking the public, eager as it was to find more convincing cures than were offered by orthodox physicians. James Morison's "Hygeian" system in England held out the glowing prospect of a medical doctrine applicable to all types of illnesses—the cure of disease and the maintenance of health by freeing the blood of all impurities through the use of secret-formula pills (which later analysis showed to be a combination of strong laxatives). Although many reputable public figures within and outside the medical profession condemned Morison as a charlatan, and although newspapers lampooned the "Universal Pills," Morison's business thrived through widespread testimonial advertising and clever salesmanship in which the medical profession was castigated. Sales, which spread into France, the United States, Germany, and other countries, continued through the nineteenth century even after Morison's death in 1840. Even exposure of the fraud in notorious court cases failed to dampen the enthusiastic embrace of the public, which sent several petitions to Parliament containing ten to twenty thousand signatures condemning orthodox medicines and extolling the virtues of Morison.

Another cure-all of great popularity was "Dr. James's Fever Powder," which was developed in the eighteenth century and still used into the twentieth. Its principal ingredient was antimony. The good reputation of Dr. James and his apparently sincere belief in the efficacy of his nostrum, together with the extravagant promotional activities by James and the bookseller John Newbery, succeeded in spreading the powder's fame.

Since there was virtually no regulation of secret nostrums in most countries, the popularity of patent medicines depended entirely on the effectiveness of their advertising. Strong opposition to self-medication and proprietary drugs did not develop until the twentieth century. Indeed some nineteenth-century preparations were introduced by physicians themselves, and the government even allowed advertising on the very tax stamps levied on these products.

Anesthesia

Surgery made steps forward very slowly, limited as it was by lack of effective pain control during operations and by devastating postoperative infections. Both of these obstacles were substantially lifted by the discovery of anesthesia and the proof that germs caused infection.

Although effective anesthesia was first discovered and put to surgical use in the United States, soporific, narcotic, and analgesic agents such as opiates and plants containing hyoscyamus and mandragora had been put to such use for thousands of years. Alcohol also had been resorted to for centuries to make a patient oblivious enough to pain to permit surgical procedures on the surface of the body or on the bones. Abdominal operations, including Caesarean section, were indeed performed at various times and places, but the systematic invasion of body cavities and internal systems was not feasible until the patient could be put to sleep deeply and safely enough to permit unhurried operative maneuvers.

In 1772, Joseph Priestley discovered nitrous oxide gas. Later, whiffs of nitrous oxide (soon called "laughing gas") were indulged in at "revels" for social amusement and the euphoria produced. Noting a reduced sensitivity to pain in these "revelers," Humphry Davy (1778-1829) suggested that "laughing gas" might be useful to surgery, but no one followed up his suggestion.

Other means of preventing pain through the loss of consciousness were also put forth from time to time. Henry Hill Hickman in 1824 produced a state of "suspended animation" in animals through asphyxia achieved by inhalation of carbon dioxide, which permitted him to perform operations without causing pain. He recommended this technique for use on humans but could not convince scientists.

Mesmerism, or "animal magnetism" (although branded quackery it was an early form of hypnotism), also played a part in opening minds to the possibilities of making people insensitive to pain. Although James Esdaile in India, stimulated by the publications of John Eliotson, performed seventy-three painless operations of different types using mesmerism, the medical profession worldwide remained unconvinced. Indeed, upon John Eliotson (1791-1868), the principal advocate of mesmerism, the brunt of denunciation fell. The hostile reception that his demonstrations and writings received led to his virtual ostracism. A well-trained, energetic investigator and practitioner, he seems always to have been eager to embrace new ideas, though sometimes with insufficient critical evaluation. For instance, his vigorous espousal of phrenology was one of the reasons for opposition to his reports. On the other hand he had been among the first to take up Laennec's stethoscope, a step so unusual at the time that it also counted against him among his colleagues.

Unrecognized as a psychophysiological phenomenon (James Braid introduced the term "hypnotism" in 1843) and therefore misinterpreted by both proponents and opponents alike, mesmerism occupied the attention of doctors and the public for years. When the mesmerists learned of ether anesthesia they applauded its discovery, claiming that their own contributions had prepared the minds of the time to accept a sleep-induced state for operation. In England, Liston's remark on using ether for the first time, "This Yankee dodge beats mesmerism hollow," indicates that mesmerism's analgesic effects had been implicitly realized even by the antimesmerists.

As anatomical knowledge and surgical techniques improved, the search for safe methods to prevent pain became even more pressing. The advent of professional dentistry added a new urgency to this quest because of the sensitivity of mouth and gums. Although death as an alternative frequently drove patients to the surgeon, few people were known to die from toothache. The urge to see a dentist was easily resisted, so it may be more than coincidence that dentists seized the initiative in the quest for freedom from pain.

By 1831 all three basic anesthetic agents—ether, nitrous oxide gas, and chloroform—had been discovered, but no medical applications of their pain-relieving properties had been made. In all likelihood the first man to apply his social experiences with laughing gas to surgery was Dr. Crawford W. Long (1815-78) of Georgia. In 1842 he performed three minor surgical procedures using sulfuric ether. Apparently not realizing the significance of what he had done, Long made no effort to publicize his discovery until several years later when anesthesia had been hailed as a major breakthrough.

A Connecticut dentist, Dr. Horace Wells (1815-48), on learning of the peculiar properties of nitrous oxide in 1844, tested them by having one of his own teeth removed while under the influence of the gas. Delighted with the results, he administered it to several patients, and then demonstrated his procedure before Dr. John C. Warren's medical class at Harvard. For some inexplicable reason, the patient cried out, and Wells was booed and hissed. Following Wells's failure, his friend and fellow dentist William T. G. Morton (1819-68) began experimenting with sulfuric ether. Encouraged by its effectiveness in his dental practice, he, too, contacted Dr. Warren and in 1846 gave the first public demonstration of surgery without pain. News of this momentous event spread rapidly throughout the Western world, and a new era for surgery began. Until Oliver Wendell Holmes supplied the name "anesthesia," the Boston medical community had been at a loss for a term to describe the condition brought on by this new agent.

After ether was widely accepted, James Simpson in Edinburgh abandoned it for chloroform because of its disagreeable odor, irritating properties, and long induction period. For about a century, chloroform continued to be the choice agent in Britain until its unmanageable toxicity and delayed damage to the liver was appreciated. In Germany, even when in 1894 the superior safety of ether over chloroform had been clearly shown (a more than five times higher mortality for chloroform), chloroform remained the favored anesthetic for almost twenty-five years.

In Britain, Simpson's advocacy of anesthesia in childbirth was vehemently condemned by the Calvinist church fathers as contrary to the Biblical admonition that a woman must bring forth her child in pain. However, the employment of chloroform by John Snow (1813-58) for Queen Victoria during her delivery helped disarm the opponents. The development of anesthesiology as a specialty of medicine owes much to Snow, who devised techniques and analyzed the physiological effects of different agents.

Ether was taken up by many other countries shortly after its introduction: notably France, Sweden, Portugal, Spain, Cuba, and South America. Even in Germany, where chloroform held first position, some preferred ether. Johann Friedrich Dieffenbach (1795-1847), a pioneer in plastic surgery, wrote, "The wonderful dream that pain has been taken away from us has become reality. Pain, the highest consciousness of our earthly existence, the most distinct sensation of the imperfection of our body, must bow before the power of the human mind, before the power of ether vapor."

Other anesthetic agents were introduced near the end of the century. Ethyl chloride was sprayed locally to induce insensitivity. Cocaine by topical application to the eye was reported by Carl Koller in 1884. Sigmund Freud had earlier studied the anesthetic properties of cocaine but did not pursue the work. The injection of cocaine into nerve trunks to block sensation was investigated by William Halsted in the United States. Cocaine was also the first drug injected into the spinal canal in 1898 to produce anesthesia, but once its dangers were realized other less toxic and nonhabituating agents were developed. Numerous methods of administering anesthetics were tried, and the rectal route was introduced by Pirogov in Russia. Ore of France originated the intravenous method in 1874. After Fischer in 1902 had synthesized veronal, this barbiturate and other safer and more manageable agents for intravenous use were developed.

The "open" method of dripping the anesthetic on a gauze mask was replaced by "closed" systems in which an airtight mask could deliver a precisely measured amount of vapor and remove the exhaled carbon dioxide through absorption by a calcium compound. Advantages were also perceived in the insertion of tubing through the mouth and voice box into the trachea, thereby preventing the aspiration of secretions and controlling the patient's respiration. The twentieth century saw refinements in endotracheal anesthesia which permitted an anesthetist to control the flow of air, oxygen, and other gases into the lungs and thus have complete mastery over breathing during an operation. Muscle-relaxing drugs were also put to use in placing the anesthetist in control of respiratory movements and the surgeon in a position to perform manipulations through a totally relaxed abdominal wall.

At first, physicians and surgeons administered anesthesia in addition to their own specialties. As techniques became more complex and knowledge increased, special nurses and technicians were assigned the task. Even well into the 1940s many highly reputable hospitals continued to employ nurse-anesthetists rather than physicians specializing in anesthesia. In 1935 Frank Hoeffer McMechan, supported by his wife Laurette Van Varsevold McMechan, spoke for anesthesiology: "The safety of the patient demands that the anesthetist be able to treat every complication that may arise from the anesthetic itself by the use of methods of treatment that may be indicated. The medical anesthetist can do this, the technician cannot."

Surgery

When anesthesia had become commonplace and the limitations of pain had disappeared, surgical procedures multiplied in number and complexity. No longer did the operator have to place the first emphasis on speed and to limit his manipulations mainly to surface areas of the body and the skeletal system. Yet the potential benefits of surgery were overshadowed by the frequent, devastating infections which often resulted in death. Outstanding surgeons everywhere were continually plagued by the dread complications of postoperative purulent infection and gangrene. Only when the bacterial origin of disease had been discovered and the necessity for keeping germs away from the operative field had been proved, notably by Lister, could surgery enter with safety the interior regions of the body. Every country participated in the new age of surgical progress, but the German-speaking countries were early at the forefront.

In the late nineteenth century, perhaps the outstanding surgical innovator in Europe was Albert Christian Theodor Billroth (1829-94). Born a German and educated in Berlin, he made his principal contributions in Zurich and, especially, in Vienna, where he was the first to successfully perform extensive operations on the pharynx, larynx, and stomach. Billroth's honest, forthright nature was shown by his unprejudiced reports of results, good and bad, a practice he insisted on for all of his staff His teaching abilities, prominence as a writer on surgery, and personal influence were such that his students filled many of the prestigious chairs of surgery in Europe. His General Surgical Pathology and Therapeutics went through eleven editions, and his History of the German Universities, a book-length treatise on almost all aspects of medical education, set down the ideal tenets toward which schools in Europe and the United States aspired.

Throughout the world, the abdomen, neck, chest, cranial cavity, and spinal cord became common sites for surgical therapy. For instance, operations on the esophagus, stomach, and intestines—heretofore seldom dealt with effectively—were enlarged in scope and refined in technique, especially by the group surrounding Billroth. The nature of appendicitis, one of the most frequent surgical ailments, was elucidated only in 1886 when Reginald Heber Fitz (1843-1913) of Boston described the clinicopathologic entity formerly referred to as "typhlitis." In 1878 the gallbladder was opened by J. Marion Sims (1813-83), a founder of modern gynecology. The approaches to tumors of the brain and spinal cord by Victor Horsley (1857-1916) in England gave impetus to neurological surgery. Newer instruments and techniques were developed by Koeberle, Nan, and Lembert. Ruge introduced the frozen section method of quick pathological examination. The older, standard procedures, such as hernia repair, were modified by Bassini and others to obtain better results. Plastic surgery was improved by Dieffenbach and Thiersch. For every organ and every region, a roster of names could be assembled of surgeons in the nineteenth century who made outstanding contributions.

Especially notable were the advances in operative treatment of the reproductive organs of women. The pioneer work of Ephraim McDowell in 1799 and of J. Marion Sims in 1852 in the United States has already been described. In Europe, Thomas Spencer Wells in 1858, Robert Lawson Tait in 1871, and W. A. Freund in 1878 developed operative procedures on the ovaries, Fallopian tubes, and the uterus. Removal of the baby by Caesarean section became more efficient and safe through the techniques of Porro in 1876 and Saenger in 1882.

So many were the innovations and so far was the domain of surgery extended that by World War I most of the basic operative procedures performed today (with the principal exceptions of thoracic and cardiac surgery) had already been developed. For the most part, the remarkable achievements of surgery in recent decades have been due to increases in physiological understanding, the introduction of safe methods of blood transfusion, the production of antimicrobials, and the improved management of the patient before, during, and after operation.

THE PROFESSION

In the early half of the century, advances in physiology, pathology, and chemistry were not reflected in medical practice, for the physician's equipment was still limited. Doctors were even considered useless or harmful by large segments of the public conditioned by the failure of bleedings, purgings, and other manipulations to affect illness or stem epidemics and by the extravagant but convincing claims and cures promised by quacks. Attacks on nostrums and patent medicines were unpopular and generally ignored.

A dichotomy existed, especially in England, between those who favored mandatory licensing control over all healers, including physicians, and those who strongly advocated allowing anyone to practice medicine, giving patients a choice from among many practitioners and claimants. Political progressives believed that regulation would lead to domination and self-serving restriction of others by the medical profession; conservatives preached that only official bodies could or should determine who was fit to treat people.

Education and Licensure

The nineteenth century saw the establishment of more uniform educational and licensure requirements, but even in ancient times there had been some official supervision and rules for medical practice. The certification ordered by Roger II of Sicily in the twelfth century was expanded by Frederic II in the thirteenth century to comprise a nine-year curriculum, an organized system of state licensing examinations, a mechanism for regulating apothecaries, and a sanctioned schedule of fees. Spain and Germany followed with rules of licensure shortly afterward. In 1511, Parliament, during the reign of Henry VIII, created a certifying board which continued to function for about three hundred years.

By the eighteenth century in England, medical education was entirely in the hands of individual doctors, mostly but not exclusively surgeons, who had their own private schools which dealt principally with anatomy and surgery until other subjects were later added. Although the teachers, such as the Hunter brothers, often imparted a high order of instruction, the students received their clinical education by walking around the wards observing the leaders in the great institutions of London: St. Bartholomew's, St. Thomas's, St. George's, Guy's, London, and Middlesex hospitals. In contrast, Edinburgh had a regular medical school, operational since 1736, with formal courses of instruction which included regular lectures and bedside teaching.

Attempts to set up adequate certifying bodies met considerable difficulty. At one time there were three separate medical councils (for England, Scotland, and Wales), and the General Council of Medical Education of 1858 was created to try to produce order in the certifying process. A coordinating body was finally formed by the end of the nineteenth century.

When the nineteenth century dawned, America had only four small medical schools to supply physicians for its burgeoning population, compelling most doctors to acquire their training by apprenticeship. In 1807 the University of Maryland Medical School was organized by a small group of Baltimore physicians as a private venture, and in succeeding years dozens of these proprietary medical schools came into existence. Three or four physicians would apply for a state charter, rent or buy a building, and begin advertising for students. The school year ordinarily lasted from eight to fourteen weeks, and the course work consisted exclusively of listening to lectures. Many proprietary schools granted degrees after one academic year, although they usually required the student to have served a one- or two-year apprenticeship prior to admission. Since these schools were dependent upon student fees for income, few applicants were ever turned down and even fewer failed to graduate. At the initial meeting of the American Medical Association a committee was appointed to examine medical education, and one of its proposals was to lengthen the school year to six months. When the University of Pennsylvania and the College of Physicians and Surgeons in New York followed the recommendation, their enrollments fell drastically, and the lesson was not lost on other schools.

Nearly all efforts to reform medical education foundered on this same rock. Those institutions which raised entrance requirements, lengthened the school year, or increased the amount of course work invariably found themselves losing students to schools with easier requirements. Despite pioneering efforts by Harvard, Michigan, and other schools, it was the end of the nineteenth century before the level of medical education was raised appreciably.

In an effort to bring a measure of unity into the profession, local and state medical societies had gradually come into existence, and these in turn led to the formation of the American Medical Association in 1847. While this organization did not become an effective force until the end of the nineteenth century, it was a strong advocate of improved medical education, fought to establish a code of medical ethics, promoted public health measures, and generally sought to improve the professional status of physicians. While the appearance of the A.M.A. boded well for the future, the public image of the American medical profession as of 1850 was at its nadir.

As the century drew on, a conjunction of circumstances moved American medicine toward professionalization. The most important of these were the fundamental developments in medicine itself. By 1900 the major outlines of human physiology were understood, the role of pathogenic organisms and their vectors was explained, and medicine could operate from a reasonably factual basis. A second factor was the rising American standard of living which brought with it a broadening of education at all levels, and medical schools could scarcely remain untouched.

The first medical school to lead the reform movement was associated with Lind University in Chicago (later Chicago Medical College and presently Northwestern University). In 1859 Lind raised its entrance requirements and lengthened its academic year to five months. The school received no support in its fight to raise educational standards until 1871, when Harvard overhauled its medical school and instituted a three-year graded course, a nine-month academic year, and written and oral examinations. Despite a better than forty percent drop in enrollment, Harvard persisted, and within a few years Pennsylvania, Syracuse, and Michigan swung into line.

The next major step came with the establishment in 1893 of The Johns Hopkins University School of Medicine, which assembled a remarkable faculty headed by William H. Welch and William Osler. Welch, a pathologist, was among the first to introduce microscopy and bacteriology into the United States, and Osler was a firm advocate of more bedside training for medical students. Under the guidance of these two, assisted by William S. Halsted and other outstanding professors, Hopkins drastically reshaped American medical education and set a pattern which persists today. From its inception, Hopkins required a college degree as a prerequisite for admission, provided a four-year graded curriculum, made extensive use of laboratories for teaching purposes, and integrated the hospital and college facilities to provide clinical training to advanced students.

Hopkins flourished, and within a few years its former students and professors were carrying the Hopkins system to all parts of the United States. Two other steps were still needed to place medical education upon a sound basis. In 1904 the A.M.A. created a permanent committee on education, which two years later became the A.M.A. Council on Medical Education. The council immediately began evaluating schools in terms of the ability of their graduates to pass licensing board examinations. However, the council was too closely identified with medicine, and its members recognized the need for a more objective evaluation. This was achieved by persuading the Carnegie Foundation for the Advancement of Teaching to undertake the task. The foundation employed Abraham Flexner, a man who had already studied American higher education, to survey the field, and the report which ensued was a damning indictment of medical education. More important, the Flexner Report (1910) brought foundation money to the better schools, and, by improving them, forced the weaker ones out of business. In the meantime the Council on Education had begun to classify schools on an A, B, C basis, evaluations which played a key role in standardizing medical education.

In France, the decrees of Napoleon in 1803 categorized those who could practice medicine into doctors of medicine, doctors of surgery, and health officer doctors, each division with its own educational prerequisites and licensing examinations. Schools for apothecaries were built and a system ordered for inspecting the shops of apothecaries, druggists, and spicers. Tuition at all of the four state medical schools was kept low to permit students of limited means to enter the medical profession.

In Germany, the regulations varied in the different principalities. In the Duchy of Nassau, for instance, before it was taken over by Prussia, the physicians and surgeons were in one body under the state, and although strict examinations had to be passed to practice medicine a university degree was not essential. In Prussia, in 1825, three classes of licensed doctors were recognized: graduate physicians (who had to spend four years at a university and pass rigorous state examinations—including an additional test for those who entered surgery); wound doctors, first class (with fewer years of schooling and less difficult examinations); and wound doctors, second class (with even less education and less rigorous examinations). Obstetricians, ophthalmologists, and public health doctors also had separate requirements.

State practice of medicine and social insurance were also seen in the German principalities, where the physicians were paid by the state but were also permitted some private practice. In Prussia, the proportion of doctors who depended on state stipends became less and less. Bismarck finally turned to medical and social insurance as a means of receiving the support of the general populace in his aim of unifying Germany.

In Russia, after 1864, local governmental organizations, the zemstvos, were responsible for medical service to the poor and mentally ill and acted as public health overseers. The feldsher, a combination of male trained nurse and pharmacist who went out into the countryside, was also a provider of health care. Regular physicians continued to be trained in the large city universities.

Specialization

Specialization in the nineteenth century was at first vehemently opposed by many in the profession who felt that it would be detrimental to the patient. Examples from the past of itinerant charlatans who specialized in pulling teeth, cutting for the stone, or treating only one kind of illness (for instance, venereal disease) caused ethical practitioners, and many lay people also, to regard with suspicion any physician who established himself to treat one group of diseases or one organ system. It smacked too much of the tradesman. Nevertheless, as the pressures of scientific, social, and economic factors became irresistible, specialization became an accepted fact. As medical information grew to be voluminous and new techniques became more complex, one practitioner could not encompass all. The patient was urged to seek a physician who devoted his time and skill to one type of illness or manipulation. Also, the opportunity for commanding higher fees, working less onerous hours, and receiving greater respect were all strong incentives to doctors to specialize. Moreover, the increasingly significant industrial principle of the division of labor also seemed to encourage the compartmentalization of medicine. In some instances the spur was principally the enormous increase in information (as in pathology), while in others it was the newly devised instruments which required special experience (as in urology and laryngology). Another factor was the abandonment of humoral ideas of general disease in favor of a focus on local organs in diagnosis and treatment.

Some examples may be cited. The invention of the head mirror by the country practitioner Adam Politzer in Vienna in 1841 aided specialization on the ear. In Britain, the first surgeon for ear diseases was James Yearsley, who founded a hospital in mid-century devoted entirely to the ear. William Wilde (1815-76), Oscar Wilde's father, helped to establish in Dublin the St. Mark's Hospital for the ear and eye. Operation on the mastoid for infection, which became a common procedure for many decades, was brought into otology by Hermann Schwartze in the 1870s. The first hospital in England specializing in the throat was a contribution of Morrell Mackenzie (1837-92). In the United States the organization of the Metropolitan Throat Hospital and The New York Laryngoscopic Society, both in 1873, were due to the efforts of Clinton Wagner.

Diseases of the eye, ear, nose, and throat were at first combined in one specialty. The first professor of ophthalmology was Joseph Baer in 1812 in Vienna, although a special dispensary for the eye was formed in 1805 in England. The ophthalmoscope invented by Helmholtz in 1851 was an incentive to specialization, as were the refractive principles of Donders and the surgical contribution of Von Graefe.

The itinerant, irregular bladder stone removers of ancient and medieval times were in a sense early urological specialists. The invention of instruments which could be passed into the bladder for observation gave impetus to the specialty. Nitze and Leiter in Germany, by improving earlier inadequate devices, constructed the first practical cystoscope. Since this was before the invention of the electric light bulb, the light source was an exposed platinum wire lit by electric current. After X-rays were introduced by Wilhelm Konrad Roentgen (1845-1923), it took until the 1920s before a feasible technique could be devised for adequately visualizing the urological tract. The intravenous method reported by Swick in 1929 was the forerunner of the later sophisticated angiography (injecting radiopaque dyes into the bloodstream to make the vascular system visible in X-rays). Much of urology was done by general practitioners and surgeons in the nineteenth century. Even in the 1930s, outstanding hospitals and teaching institutions still combined urology and general surgery in the same department.

The spirit of the Enlightenment of the eighteenth century and Rousseau's writings were among the incentives to concentrate on the problems of children. Nils von Rosenstein, George Armstrong, and William Cadogan were pioneers in this specialty. Charles Billard in France and Charles West in Britain were important contributors of the nineteenth century. In the United States Abraham Jacobi, fleeing from Germany because of his espousal of the political and social reforms of 1848, soon found himself giving most of his attention to children's diseases and influencing others to do the same.

Scientific dermatology had its beginnings in Hebra's work in the New Vienna school, but Lorry, Alibert, and Willan had taken the earlier steps. Syphilis was an important part of dermatologic practice until well into the twentieth century, when its protean manifestations brought it into internal medicine. Philippe Ricord and Jean-Alfred Fournier clarified the clinical nature of syphilis and separated it from other venereal diseases.

Neurology was relatively late in becoming a separate specialty, and then it was often combined with psychiatry. Neuropsychiatrist was a common title after Pinel. Psychiatrists such as Janet, Esquirol, Bayle, and Georget gave France the leadership until the reports of Griesinger and others drew attention to Germany. Emil Kraepelin's classification of mental disease into dementia praecox, manic-depressive psychosis, and paranoia was useful to the new specialty.

In the nineteenth and twentieth centuries, specialties and subspecialties became more and more numerous, so that now there is virtually no general branch of medicine or surgery without its subdivisions of specialization.

Pharmacy

Pharmacy has been a part of medical practice throughout the centuries. The physician frequently compounded and dispensed drugs in addition to practicing medicine, and the apothecary often engaged in medical practice as well as compounding and dispensing. Rivalry between the two groups, which was intense in the seventeenth century, continued into the nineteenth century. The respective roles of the physician and the apothecary or pharmacist gradually became clearer, but in some countries, notably the United States in the nineteenth century, the physician continued to prepare and sell medications out of economic necessity.

The social position of the pharmacist in most places was high, and educational requirements after the seventeenth century became more and more rigorous, especially in Italy. In France the new standards grew to include a university education, special training internships, and even specialized certifications for clinical laboratory analysis, community practice, or industrial pharmacy. In Germany, where the pharmacist seems virtually always to have occupied a high social and professional position, the apprenticeship system evolved into an elaborate progression of examinations leading to a stratification by educational accomplishment.

The pharmacist in recent years, especially in the U.S., is becoming primarily a merchant and dispenser of medicines, owing to economics and the decreasing need for the compounding of prescriptions.

Pharmacopoeias

Lists of drugs to guide therapeutics have existed since ancient times, but the word pharmacopoeia (which means the making of medical substances) was first applied to such a listing in the sixteenth century. However, it was not until the nineteenth century that national pharmacopoeias were developed: Prussia in 1799, Austria in 1812, France in 1818, United States in 1820, Britain in 1864, and Germany in 1872. Many of these standard listings continued for a long time to include some of the bizarre, ancient substances combined in multi-ingredient formulas. For instance, theriac was still in the pharmacopoeia of London in the eighteenth century. Therapeutic agents in practice frequently did not keep pace with advances in general science, biology, physiology, and chemistry.

Dentistry

Dentistry really began its professionalization as an independent discipline with the work of Pierre Fauchard (1678-1761), who was the first clearly to devote full time to the teeth. He collated the considerable body of information that had accumulated through the centuries and described the use of tin and lead for filling cavities, but more importantly he established the ethical principle that secret methods should be openly reported in detail so that the results could be evaluated and used by others. Fauchard also emphasized the need for special training of doctors of the teeth and for the examination of candidates by those experienced in the discipline instead of by surgeons. His The Surgeon Dentist (1728), which became the authoritative text for generations, was the foundation of subsequent dentistry. Writings by others in France followed rapidly: Devaux (who also collaborated with Fauchard), Gerauldy, Bienn, Mouton (who constructed the first gold crowns and other new prostheses), Bourdet (who devised new instruments), and many others. Duchateau, an apothecary in the region of Sevres, molded the first porcelain dentures.

In Germany, incidental dissertations on the teeth by physicians and surgeons were replaced by reports from specialists such as the dentist to Frederick the Great, Philipp Pfaff, who in 1755 described how to make plaster models from impressions in wax. The craftsmen (usually woodworkers) who actually fashioned the prostheses designed by Adam Brunner were the forerunners of dental technicians.

Dentistry gradually became a separate specialty in other countries too, but it was in the United States especially that dentistry reached its fullest development in the nineteenth century and afterward, largely due to the efforts of Horace H. Hayden (1768-1844) and Chapin C. Harris (1809-60). The introduction of anesthesia by dentists was as important to dental procedures as it was to the surgery of other organs.

The first dental school in the world was established in 1839 as the Baltimore College of Dental Surgery. In 1870, although there were 10,000 dentists in the United States, only 1,000 were graduates of a school.

Advances in prostheses, such as the production of vulcanite in 1855 by Charles Goodyear, technical innovations in the management of cavities, improvements in the correction of occlusive derangements, and the elevation of educational standards gave American dentistry world leadership.

Eventually the specialization of dentistry, with its complex techniques, became so complete that it was separated from medical practice. However, in recent decades, the physiology and surgery of the head, neck, and mouth have brought a greater interdependency among physicians, surgeons, and dentists.

Nursing

Since nursing only became fully established as a profession in the nineteenth and twentieth centuries, we are accustomed to regard nursing care in earlier centuries as rudimentary and unstructured. Yet in India, hundreds of years before Christ, Charaka had summarized four qualifications for a nurse: "knowledge of the manner in which drugs should be prepared or compounded for administration, cleverness, devotion to the patient waited upon, and purity (both of mind and body)." We are also apt to think of nurses as exclusively women, but throughout history males also have attended to the sick in hospitals. During the Crusades, the Hospitalers of St. John, the Teutonic Knights, and the Knights of St. Lazarus performed nursing duties, and male members of the mendicant orders of St. Dominic (the black friars) and St. Francis (the gray friars) also acted as nurses in the Middle Ages.

Nevertheless, women have been the principal performers of nursing duties in every period and every country. The nuns of religious orders, such as the Poor Clares, and secular groups with religious purposes, such as the Tertiaries of St. Francis and the Beguines of Flanders, carried on most of the nursing in medieval and even later times. Perhaps the oldest religious group devoted entirely to nursing was the order of Augustinian Nuns in the Hotel-Dieu of Paris. Indeed, the idea of attending the sick is so closely associated with the Church that even in hospitals which are totally nonreligious the nurses are often called "sister."

During the Reformation, however, hospitals were generally removed from Church connection or control. The dedicated, free services of the nuns and charitable secular groups were frequently replaced by those of poorly paid workers. Hospitals tended to become filthy, germ-infested buildings where people often died of infection rather than the illness which brought them there. Sick people who could afford it were treated at home. A reactive move toward cleanliness and humanitarianism engendered by the Enlightenment of the eighteenth century was turned back again by the economic and social changes of the Industrial Revolution. The arduous, menial, and sometimes repulsive tasks involved in caring for the sick were certainly no inducement to anyone to go into nursing as a wage-earning activity, especially when industry opened up much more rewarding positions.

John Howard in the eighteenth century had shocked the upper classes with his book Hospitals and Lazarettos. Dorothea Lynde Dix (1802-87), in England and the United States, mounted a personal campaign which eventually achieved the transfer of the mentally ill from brutality and negligence in penal institutions to psychiatric hospitals with more appropriate nursing facilities. Elizabeth Gurney Fry (1780-1845), an English Quaker, organized the Society of Protestant Sisters of Charity in 1840, which attempted to send nurses into the homes of the sick whether poor or rich. Theodor Fliedner (1800-64), a Lutheran minister in Germany, and his wife Frederika were influenced by Fry's work. In 1835 they established a modest hospital in Kaiserswerth, staffed without pay by the deaconesses of his church, in which the character, health, and education of nurses achieved a high standard.

Others, too, attempted to better the lot of the sick by upgrading hospitals and nurses, but it was Florence Nightingale (1820-1910), with a virtually single-minded sense of mission to make over nursing, who was the motivating force that led toward a truly professional status for nurses. Her interest was not to establish a feminist movement but, rather, to provide more highly skilled and humane treatment of the ill. She nursed her grandmother through a terminal illness, as well as the tenants on her father's estate, but her first formal exposure to medicine was a three-month course of training at Kaiserswerth, with the deaconesses.

Her experiences in various charitable institutions, during which she wrote critical reports of the needs of hospitals, were finally crowned with the assignment by Sidney Herbert, the secretary of war, to take a contingent of Catholic, Anglican, and secular nurses to Scutari to care for the British wounded in the Crimean War. Miss Nightingale found conditions in the overcrowded military hospitals appalling: miles of dirty beds, no facilities or equipment with which to care for or properly feed the soldiers, and a mortality rate which at times reached over forty percent.

Although most of Miss Nightingale's hours were spent in organizing, directing, and writing, the soldiers quickly responded to her obvious concern for their welfare. "We lay there by the hundreds; but we could kiss her shadow as it fell and lay our heads on the pillow again content." Intense opposition to her by local military officials evaporated gradually in the face of ever-increasing casualties and deaths. Her presence and administrative genius during the years 1854 and 1855 saved the hospital from total demoralization. After the war, in renewing her fight to reform the military system, she was responsible for the establishment of the first military medical school and also for many other innovations which made military barracks safer and more sanitary. She also had many rebuffs and disappointments along with her successes. When Secretary of War Sidney Herbert was about to die in 1861, he said to his wife, "Poor Florence, poor Florence, our joint work unfinished."

In civilian life, hers was also the moving spirit and architectural mind behind the reconstruction of St. Thomas's Hospital and its founding as an educational institution for nurses, whose first class was graduated in 1861. Miss Nightingale's energies and writings were in large measure responsible for the transformation of nursing from a low, unpopular, almost casual endeavor into a highly respected, essential part of the healing arts. However, her crusade was not without its personal cost. Worn down by resentment, bickering, and exhausting activity, she had a number of illnesses that probably were largely nervous breakdowns. Her health had remained fragile ever since she contracted a serious febrile illness (probably typhus or typhoid) in the Crimea; nevertheless, she continued to write intensively and to exert considerable influence.

Not all of the opposition to Miss Nightingale was merely personal. Even in the twentieth century, some leaders of nursing believe that the Nightingale focus on bedside care to the virtual exclusion of more scientific methods of teaching and practicing is too narrow. Curiously, she was not convinced that bacteria caused disease and continued to hold the ancient belief in "miasmas" as responsible. But she preached the necessity for cleanliness and saw clearly that the separation of maternity patients from sick people in a hospital was essential to their safe care. Her basic tenets are still cogent: "The art is that of nursing the sick. Please mark, not nursing sickness... This is the reason why nursing proper can only be taught at the patient's bedside and in the sick room or ward. Lectures and books are but valuable accessories."

The Red Cross

Since the sixteenth century, many agreements had been mutually arrived at by opposing forces regarding the treatment of prisoners and the wounded, but in practice these rules were rarely followed. During the military action of the combined forces of France and Italy against Austrian troops in 1859, Jean Henri Dunant (1828-1910), a Swiss banker, happened to visit the scene of battle at Solferino in northern Italy after the fighting had ceased. The pitiable condition of the tens of thousands of wounded soldiers still lying unattended on the ground so aroused him that he immediately set about persuading the victorious French commanders to free the captured Austrian military surgeons to help care for the injured of all three nations. Dunant himself pitched in to try to save as many lives as possible. "Tutti fratelli" (all brothers) he kept repeating when local civilians resisted helping the enemy wounded. His book, Un Souvenir de Solverino, published three years later, shocked European leaders into action. Writers such as Victor Hugo, the Goncourt brothers, and Joseph Ernest Renan took up the cry for international humanitarianism. In the second of two international conferences, the Geneva Convention of 1864, sixteen nations signed a treaty establishing the International Red Cross and specifying the regulations that should apply to the treatment of wounded soldiers, which included the recognition that all hospitals, military and civilian, were to be neutral territory; that medical personnel of any country, and their equipment, were to be free from seizure or molestation. The protective insignia was to be a red cross on a white field (the reverse of the Swiss flag). The new spirit passed its first test in 1866 when a group of volunteer civilian students entered the battlefield to care for the Austrian wounded after the battle of Koniggratz. Austria, which had withheld its signature from the original convention, immediately joined.

Dunant lost his fortune—some say because of lavish expenditures in founding the Red Cross—and in 1867 he was bankrupt. After dropping out of sight for about fifteen years, he was discovered in a small home for the aged in Switzerland, poor in resources and unstable of mind. In 1901 when he received the first Nobel Peace Prize (together with Frederic Passy), he donated the entire sum to charity.

Albert S. Lyons

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