On the evening of the same day, September 30, 1846, Morton administered ether for the extraction of a tooth, the patient stating that he had felt no pain. On the following day he visited the office of a well-known patent lawyer for the purpose of securing letters patent upon his supposed discovery. This lawyer, learning of Jackson's connection with the subject, took time to consider the matter, consulted with Jackson, and came to the conclusion that the patent must be a joint affair, neither one having exclusive right to claim it. But Jackson, fearing the censure of the Massachusetts Medical Society should his name be connected with the patent, and Morton—as a dentist—having no such fine scruples, it was agreed that the patent should be made out in the names of both, but that Jackson was to at once assign his interest to Morton; in return for which he was to receive a ten per cent, commission. Meantime Morton called upon Warren, one of the surgeons in the Massachusetts General Hospital, who promised his co-operation and sent him an invitation to test his invention in the hospital on October 16. 1846. The clinic-room was filled when Morton placed the patient under the influence of his letheon, as he had named it; after which Warren removed a tumor from the neck of a young man, and as it appeared, without pain.
Upon the following day another operation was performed upon a young woman, with the same happy result, while on November 7th an amputation was made, entirely painlessly. At this time Morton endeavored to disguise the odor of the substance he was using by aromatic oils. It was not until the staff of the Massachusetts General Hospital declined to use an agent whose composition was kept secret that Morton revealed publicly the fact that this was nothing but sulphuric ether disguised by aromatics. From a report of the Commissioner of Patents, published a little later, the following paragraph is taken, the report being in the nature of a commentary upon the discovery:—
It has been known for many years that the vapor of sulphuric ether, when freely inhaled, would intoxicate to the same extent as alcohol when taken into the stomach.
The fact has stood, further, upon the pages of science for many years that the inhalation of sulphuric ether was productive of "temporary narcotic stimulant effects."
After the issuance of letters patent Morton began selling office-rights, such being the custom then, as now, among the dental profession, who are much more commercial in their proclivities than their brethren of the medical profession. The result was an almost endless litigation, with the development of the greatest personal animosity and rivalry between Jackson and Morton, as well as the friends and descendants of the other claimants. Morton wrecked his fortune and ruined his health in his efforts to get substantial recognition and remuneration from the United States Government; and the history of his repeated attempts to interest Congress and the various officials of the government, from the president down, is instructive, but far from pleasing, reading. In these attempts he practically failed, and died from an illness contracted through exposure, after maddening disappointment, although he had been the recipient of numerous honors and some small pecuniary recognition from societies and individuals. Morton died in 1868. In reviewing the history of his life and labors there is much to justify the inscription upon the monument erected to his memory at Mount Auburn Cemetery, Boston:—
"Inventor and revealer of anæsthetic inhalation, before-whom in all time surgery was agony, and by whom pain in surgery was averted and annulled; since whom science has controlled pain."
Charles T. Jackson graduated at Harvard Medical College in 1829. after having led an already eventful career as geologist and mineralogist. He spent several years abroad, meeting many of the most distinguished men upon the Continent and displaying, in many ways, a great deal of scientific talent and mechanical ingenuity. In 1835 he opened, in Boston, the first laboratory for teaching analytical chemistry in the United States. A year later he was made State Geologist of Maine, and spent three years in this capacity. He also did a great deal of work upon the State geological surveys of Rhode Island, New Hampshire, and New York, while he was the first to call attention to the mineral resources of the southern shore of Lake Superior, where, in 1845. he opened up copper and iron mines. In 1846 and 1847 he became deeply interested in the subject and discovery of anaesthesia, and after the successful introduction of ether by Morton, in the Massachusetts General Hospital, set up the claim that it was he who had suggested it to Morton. In a pamphlet, published a little later, he states: "In the year 1837 I discovered that ether-vapor was superior to alcohol as a remedy for the strangling and toxic effects of chlorine-gas after inhalations for that purpose in my laboratory." He then relates how he administered the vapor to himself for the relief of the irritation produced by inhaling chlorine, and describes his sensations upon going to sleep and awakening. This claim in its entirety was a great surprise to both Morton and Wells, and led to a most unseemly discussion, which degenerated into a downright professional fight. After the death of Wells, Jackson and Morton both claimed that nitrous-oxide gas was not an anaesthetic, and that insensibility to pain could not be produced by it, in consequence of which the use of the gas was quite discontinued. It became, then, simply a question of priority as to the administration of ether for relief of pain during surgical operations. Wells being dead, this brought Long into the conflict. Jackson visited Europe again, and presented his claim before numerous societies in such a way as to be recognized abroad as the discoverer of anaesthesia. The relative merits of the whole controversy appear to have been pretty well summed up in a memorial sent to the Senate and House of Representatives by several hundred members of the Massachusetts Medical Society, which contains the following paragraph:—"The undersigned hereby testify to your honorable bodies that, in their opinion, William T. G. Morton first proved to the world that ether would produce insensibility to the pain of surgical operations, and that it could be used with safety. In their opinion, his fellow-men owe a debt to him for this knowledge."
In the Public Garden in Boston there has been erected a monument to the memory of the discoverer of ether, the donor being, at the time, unable to mention the individual to whom it should be dedicated. Upon one face is this inscription:—
"To commemorate the discovery that the inhaling of ether causes insensibility to pain, first proven to the world at the Massachusetts General Hospital, in Boston, October, 1846."
Upon another face are these words:—
"In gratitude for the relief of human suffering by the inhaling of ether a citizen of Boston has erected this monument, A.D. 1867.
The gift of Thomas Lee."
Morton's untimely death, largely due to disappointment and, as he thought, to persecution, has been already mentioned. In 1873 Jackson's mind became deranged, and he died in an asylum in 1880.
Sir James Paget has summed up the relative claims of our four contestants in an article entitled "Escape from Pain," published in the Nineteenth Century for December, 1879. He says: "While Long waited and Wells turned back and Jackson was thinking, and those to whom they had talked were neither acting nor thinking, Morton, the practical man, went to work and worked resolutely. He gave ether successfully in severe surgical operations, he loudly proclaimed his deeds, and he compelled mankind to hear him." As Dr. Morton's son, Dr. W. J. Morton, of New York, says, when writing of his father's claim: "Men used steam to propel boats before Fulton, electricity to convey messages before Morse, vaccine-virus to avert small-pox before Jenner, and ether to annul pain before Morton."
So much for ether. I have already stated that chloroform was discovered by Guthrie in 1831. But, though discovered in this country, it was first introduced as an anæsthetic agent in Scotland, by Simpson, who, in 1847, at the age of thirty-six, began to direct his attention to the discovery of some means of alleviating pain during childbirth, having a very large obstetric practice. Simpson was not satisfied with sulphuric ether, because of its strong and disagreeable odor, and inquired of his friend Waldie, Master of Apothecaries' Hall, of Liverpool, if he knew of nothing likely to be a satisfactory substitute. Waldie, acquainted with the chemical composition of chloric ether, suggested that chloroform be prepared from it and used. Simpson experimented with this in 1847, and established its anaesthetic properties, which he made known through a paper read on November 10th of the same year. It was arranged that upon the 13th of the month a public test should be made at the Royal Infirmary; but Simpson, who was to administer the chloroform, was unavoidably detained. Accordingly the operation was performed as of yore, without an anaesthetic, and during its performance the patient died upon the table. Had this death taken place during the employment of chloroform, it would have been the death-blow of that substance as an anaesthetic. The first public trial took place two days later, the test proving a great success. Simpson goes down in history, then, not as the discoverer of anaesthesia, but as the one who introduced chloroform for anaesthetic purposes. He died in 1870, and upon his bust in Westminster Abbey is this inscription:—
"To whose genius and benevolence the world owes the blessings
derived from the use of chloroform for the relief of suffering."
It is a bit of most interesting medical history that after Simpson's announcement of his discovery he was violently and vehemently opposed by the Scottish clergy, who reviled him for endeavoring to relieve the pains of childbirth, basing their opposition upon the primeval curse: "In sorrow shalt thou bring forth children." And the beautiful ease with which Simpson refuted this childish sophistry must ever be memorable; for with one short argument he silenced his opponents and turned upon them the ridicule of the entire profession. For he reminded them that the first operation recorded in history was performed under anaesthesia, since, when God created Eve from one of Adam's ribs, he "caused a deep sleep to fall upon Adam."
Cocaine is now such a universally recognized local anaesthetic that there is the best of reason for referring to it here—the more so because it affords another opportunity to do honor to a discoverer who has rendered a most important service not only to our profession, but to the world in general.
The principal active constituent of coca-leaves was discovered about 1860 by Niemann, and called by him cocaine. It is an alkaloid which combines with various acids in the formation of salts. It has the quality of benumbing raw and mucous surfaces, for which purpose it was applied first in 1862 by Schroff and in 1868 by Moreno. In 1880 Van Aurap hinted that this property might some day be utilized. Karl Koller logically concluded from what was known about it that this anaesthetic property could be taken advantage of for work about the eye, and made a series of experiments upon the lower animals, by which he established its efficiency and made a brilliant discovery. He reported his experiments to the Congress of German Oculists, at Heidelberg, in 1884. News of this was transmitted with great rapidity, and within a few weeks the substance was used all over the world. Its use spread rapidly to other branches of surgery, and cocaine local anaesthesia became quickly an accomplished fact. More time was required to point out its disagreeable possibilities, its toxic properties, and the like, but it now has an assured and most important place among anæsthetic agents, and has been of the greatest use to probably ten per cent, of the civilized world. To Koller is entirely due the credit of establishing its remarkable properties.
The writer makes no apology here for having introduced two distinct chapters,—one upon the history of antiseptic surgery, the other upon the history of anæsthesia. First of all, they are the two grandest medical discoveries of all time; and, secondly, they are of Anglo-Saxon origin,—the one British, the other American. To the introduction of anaesthetics and antiseptics is due a complete revolution of earlier methods, complete reversal of mortuary statistics, and the complete relief of pain during surgical operations; in other words, to these two discoveries the human race owes more of the prolongation of life and relief of suffering than can ever be estimated or formulated in words. What an everlasting disgrace it is that, while to the great murderers of mankind, men like Napoleon in modern times and his counterparts in all times, the world ever does honor, erects imposing monuments and writes volumes of encomiums and flattering histories, the men to whom the world is so vastly more indebted for all that pertains to life and comfort are scarcely ever mentioned save in medical history, while the world at large is even ignorant of their names. For this reason, if for none other, these chapters find an appropriate place in a work of this character.
Those interested in a somewhat more elaborate presentation of this subject may find it in an anniversary address delivered by the writer on October 16, 1896 (the semicentennial of Morton's public demonstration), in the Medical School of the University of Buffalo, and published in the Buffalo Medical Journal of November, 1896.
Sepsis, Asepsis, and Antisepsis. The Germ-theory of Disease. Gay-Lussac's Researches. Schwann. Tyndall. Pasteur. Davaine. Lord Lister and his Epoch-making Revolution in Surgical Methods. Modifications of his Earlier Technique without Change in Underlying Principles, which Still Remain Unshaken. Changes Effected in Consequence. Comparison of Old and Modern Statistics.
Modern surgery, and, in no small degree, modern treatment of all disease, have been so completely modified from previous methods by the introduction of the so-called antiseptic system that it seems to be only right to devote some time in such a work as this to a résumé of the history of the doctrines and experiments which have led to the perfection, as it would seem, of modern methods.
The adjective "septic" comes from the Greek word "sepsis," which is often transferred to the English, and which means "putrefaction," or that which is putrid, or undergoing decomposition. From this word are formed two others,—namely, "aseptic" and "antiseptic,"—the one implying the exclusion of all causes of putrefaction and complete freedom from it, the other referring to methods employed to antidote the effect or counteract the influence of the agencies which produce sepsis or destroy them while still within the living body. By general usage the term "antiseptic" has been construed as the more comprehensive; hence, the modern method is usually spoken of as "antiseptic surgery," and hence the title above: "The History of Antisepsis."
The principle underlying the resort to antiseptic methods is summed up in the expression, now so generally received,—the "germ-theory" of disease. It refers, in general, to the so-called zymotic, or infectious, diseases, whose manifestations are protean, which are all communicable by one means or another, but which are not all necessarily contagious; some of which, being not at all amenable to surgical treatment, are regarded as "medical" diseases, while others, which occur mostly in connection with surgical cases, or which lead to conditions requiring surgical relief, are usually spoken of as "surgical" diseases. As excellent and only too common examples of these zymotic diseases may be mentioned tetanus, erysipelas, puerperal fever, typhoid fever, and those varied conditions which are generally grouped under the term "blood poisoning." Those which most concern the surgeon, and those in which most remarkable relief has been obtained are erysipelas and the various forms of blood poisoning. These, in their varied manifestations, have, until recently, been literally the terror of surgeons, and in military hospitals, for instance, have been the cause of more deaths than have ever resulted from wounds directly upon the battle-field. In civil hospitals, as well as in general and private practice, the mortality from these diseases was, until twenty-five years ago, simply frightful; while frequently, and over wide areas of territory, endemics and epidemics of puerperal fever would result in the death of almost every lying-in woman. In consequence of this terrible death-rate surgeons were afraid to operate, and certain classes of operations, especially those on the abdomen and joints, were never performed, except under most exacting circumstances. But few of the present generation can actually realize the completeness of the changes brought about by the adoption of the germ-theory, and the practical effect of its use as a working basis for combating disease.
While no intelligent student at present denies that the infectious diseases—of which the above named are but a very few—are the result of the introduction into the body, from without, of minute living organisms, for the most part vegetable,—thus constituting them in reality, as they are often called, parasitic diseases,—but few are so familiar with the history of modern discovery as to appreciate the basis upon which it has been demonstrated. The proof of the germ origin of disease is the legitimate outcome of the discovery of the actual causes of fermentation and putrefaction.
Aside from the crude and often wild notions which have appeared here and there in literature of previous centuries, about the first accurate investigations bearing upon this subject were with reference to the cause of alcoholic fermentation. About the beginning of this century Appert published a monograph upon the Art of Preserving Animal and Vegetable Substances, which consisted in placing them in closely corked or stoppered bottles, and exposing these to the temperature of boiling water. Gay-Lussac, the celebrated chemist, noticed that so soon as these vessels were opened, particularly if much exposed to air, their contents began to at once ferment or putrefy. This led to investigations into the production of alcohol, and the antiseptic effect of pure oxygen-gas; from which he concluded that oxvgen is necessary at the commencement of the process, but not throughout its continuance. Some thirty years later, Schwann, by the use of the microscope, then reasonably developed, discovered in fermenting substances numerous very minute globular bodies, which had the power of reproduction, and which were present in juices or fluids undergoing alcoholic fermentation, but not in others, and which he concluded to be the exciting cause. Schwann also discovered that if, in vessels sealed by Appert's method, lie allowed air which had been previously heated to come in contact with the fluids, no change resulted; from which it was evident that it was something other than the gaseous elements of the air which provoked fermentation. Schwann's investigations were corroborated, in 1843, by Helmholtz.
Schwann's results were contested by Liebig, one of the most eminent chemists of his time, who proposed a very different theory, ascribing putrefaction to the absence of oxygen and to the upsetting of molecular arrangements. He believed that non-nitrogenous substances did not spontaneously undergo putrefaction when pure, but they must be brought into contact with some substance already undergoing change, which latter was called a ferment, and which converted the oxygen of the air into carbonic acid. According to him, the ferment was some material undergoing decomposition.
The next researches on this subject were those of Schroeder and Dusch, in 1854 who studied the question whether filtration of air would prevent the fermentation of boiled fluids to which such filtered air might have access. The material used for filtration was cotton-wool; and they showed that air filtered through it was deprived of the agencies which produce fermentation. Then came Pasteur, who repeated the experiments of his predecessors and elaborated and confirmed them. He also found that it was not necessary to filter the air of its contained particles, but that if it were simply left undisturbed until these had settled by gravity, it might then be brought in contact with putrescible substances without causing any putrefaction.
In 1870, in a lecture upon haze and dust, Tyndall demonstrated beautifully and in public the presence of countless particles in the air, as well as that these were the agencies operating to produce undesirable changes in organic substances. Both Pasteur and Tyndall, as well as others, showed, as did also Lister, that heat as well as filtration was sufficient to render these particles innocuous. As the result of these and numerous other experiments, by various observers, which there is no time here to recount, it was gradually and irrefutably established that the gases of the air, per se, are powerless to cause fermentation or putrefaction in boiled fluids or tissues, or in material germ-free when exposed. It was sufficient, in order to so purify the air, to either previously heat it or filter it through cotton-wool or through fluids inimical to germ-life, while the boiling of organic material or its subjection to the boiling heat of water was sufficient to destroy all germ-activity in it at the time, or, as we say now, to sterilize it.
In this way, and even before any minute and systematic study of bacteria,—i.e., before the inauguration of bacteriology as a separate department of scientific study,—it was practically established that the agencies which produce putrefactive changes or fermentation were minute particles which were ever present in almost every substance, and that by heat or something corresponding to filtration it was possible to remove them or destroy their activity.
So much had been established without reference to the etiology of disease. In order now to study the germ-theory of disease as applied to man we must go back a little, neglecting the vagaries or the pure conjectures of the ancients, to the era of pure philosophic speculation,—perhaps to the days of Needham and Buffon.—to the middle of the previous century, when scientists and naturalists began to discuss the so-called spontaneous generation of life; for it is well known that fluids, like milk and others, abound with life after a few days of exposure; and it was supposed that the living organisms it contained had a spontaneous origin. This question of the spontaneous beginning of minute living forms was agitated for a century, or practically until Tyndall and Pasteur gave it its death-blow by their accurate and convincing demonstrations. There was no lark of experimentation, but there was lack of exact knowledge and of accurate deduction from facts observed. The bacteria—which at that time were usually spoken of as "monads" and "vibriones," because of their spontaneous motion—were found under varying circumstances, which, not being scientifically inquired into, led thinking men into a most perplexing condition of mind. The two most ardent recent advocates of spontaneous generation were Bastian, of England, who wrote an elaborate treatise upon the subject, and Jeffries Wyman, of Cambridge, Mass., who gave it the benefit of all his influence. But, under the influence of blows dealt from the side of the physical laboratory by Tyndall, and from that of the biologists by Pasteur, the theory was weakened and effectually killed, so that to-day no one thinks of such a thing. On the contrary, life seems to be inevitably the gift of a preceding organism; and while the real origin of life is as unknown to-day as ever, there is not a single fact in the possession of scientists now justifying the view that life can have a spontaneous origin. Moreover the researches of Pasteur and others into alcoholic fermentation and the rôle played by the minute yeast-plant, and the early researches of Pasteur, Davaine, and Koch into the rôle of micro-organisms in producing disease in animals, and the scientific and elaborate study of bacteria and vegetable molds, inaugurated by Cohn and continued by many others, have as their legitimate outcome the creation of bacteriology as a science, and the establishment of the fact that the real condition in the so-called infectious diseases is one of fermentative or putrefactive alterations in the fluids and tissues of the living body, corresponding in minutiæ to the changes produced in saccharine fluids by the yeast-plant, or in decomposing animal or vegetable matter by the many known bacteria which are capable of producing such changes. To put it in another way, disease is simply an expression of the fact that these minute organisms, which are visible only under high powers of the microscope and which reproduce their kind with astonishing rapidity, gaining access to the surface or interior of the body, begin there to thrive and multiply, taking up from the living animal material for their own nourishment, thus robbing their host of that upon which his tissues must live, while at the same time, as the result of their activity, they produce various substances which, so far as they are concerned, are excretory in nature, and many of which are extremely poisonous to the animal organism which harbors them. Such a disease as puerperal fever, for instance, is simply an expression of the fact that within the living human body there is going on active putrefactive action by which the internal cells are being destroyed. this destruction being progressive and often far-reaching; and that, as the result of their presence in the still living body, the noxious or toxic excretory materials of which they get rid are absorbed, in consequence of which such varying symptoms as nausea, fever, purging, vomiting, delirium, and many other symptoms are produced, the objective evidence of their local activity being the actual destruction of tissues, as is seen in cases of abscess, phlegmonous erysipelas, etc. The condition known everywhere as gangrene, when moist and offensive, is nothing but the putrefaction of tissues en masse which are not yet detached or separated from the living body of which they but recently formed a living part.
Experiments with organic material outside the body have amply demonstrated that such putrefactive processes can be checked by certain precautions—such as filtration of air, heat, etc. It remained for the genius of Lister to show how similar processes of putrefaction and exclusion of germs could be made serviceable for the prevention of disease in the human race. To Lister, then, is due the credit of having originated the antiseptic system and brought about a condition long yearned for by surgeons throughout the world, but never previously attained. What a revolution he wrought by his masterly researches can be appreciated only when one compares the impunity with which surgeons now perform operations which, in the previous era were regarded as absolutley unjustifiable—a conclusion amply warranted by the statistics of that era.
Great as the credit due to Lister, it is equally desirable to state that his work was, for the most part, based upon Lister's, the researches of Tyndall, Pasteur, and Koch, which had established the germ nature of the terrible infectious diseases and the germicidal effect of filtration, of heat, and of certain other substances and methods which permitted of the development of his own system.
The antiseptic method, as it has since been known, was naturally at first crude, although its scientific basis has never been shaken; and that it has been since, in large measure, modified, and that surgeons now resort to little, if any, of the paraphernalia which first made it such a formal proceeding, in no regard shake the scientific nature of its foundation, but rather have tended ever to corroborate it and establish it more and more firmly. Lister began with the supposition that the air contains the germs which are most active and pernicious in producing disease. It has been since learned that air-contact is, perhaps, least of all to be dreaded. We, however, recognize the germs as always the efficient agents, though we have since learned that other sources of contamination are much more to be dreaded than air. It had been the custom, up to Lister's time, to observe usually the ordinary forms of cleanliness, but, not appreciating the multitude of germs which lurk in and about the skin, it had not been customary to scour and prepare it as we have learned to do since Lister's day. The ligatures and instruments which were used and the dressings which were applied, as well as the sponges used during the operation, usually went through the ordinary forms of cleansing; and yet Lister's investigations showed the utter inadequacy of such preparation. His most important object-lesson, however, was that everything that came in contact with fresh or bleeding tissues might carry infectious material (i.e., germs), unless it had itself been thoroughly freed from their presence. Accordingly, the system taught the accurate preparation of everything.—from the skin of the patient, which was to be carefully cleansed and shaven, to the hands of the operator, which were to be scrupulously scrubbed, as well as those of every assistant who might handle or touch any of the instruments or dressing materials. It included, also, the careful preparation of sponges, sutures, and ligature materials, all of which were kept protected from air-contact and in antiseptic solutions until the moment of their use. The dressing materials were impregnated with substances like carbolic acid, which had been proven to be germicidal; and impermeable material, like oiled silk, was used to cover the surgical dressing, in order that fluids which might leak through should not come in contact with the air, which might permit of their putrefaction, while, at the same time, air from without could have no access to the deeper parts thus protected.
The original method of Lister was very elaborate, and included also the dissemination throughout the air of the operating-room of a vapor of carbolic acid, which was disagreeable, sometimes almost fatal, to operators and bystanders alike,—its use being based upon the notion that the air was the substance most to be dreaded. The instruments were placed in strong antiseptic solutions, usually carbolic, which were pungent and irritating to the hands of all that came in contact with them. So thoroughly and ubiquitously were antiseptic materials employed that it was soon learned that they were of themselves rather injurious to the best interests of the patients upon whom they were employed. Their use, of course, was contingent upon the notion, then everywhere prevalent, that powerful substances must be used in order to counteract the activity of the much-dreaded germs.
In the course of time, however, it was learned that the air was not so much to be dreaded as had been supposed, and that even if it came in contact with raw tissues infection did not certainly follow. It was found also that the antiseptic solutions which had been so freely used for irrigating or drenching the parts during an operation were by no means essential, and that tissues often healed better which had not been subjected to so much irritation. It was learned further that it was not necessary to impregnate dressings with these same solutions, providing, in the first place, they were carefully sterilized by the application of heat, which in time came to be used for the purpose of sterilizing everything not injuriously affected by it. In consequence, then, all dressing material, silk ligatures, instruments, nail-brushes, etc., were subjected to live steam or to boiling water for twenty minutes or more, which was demonstrated to be completely effective in the destruction of all organic or bacterial life. This, of itself, was a very great simplification of the antiseptic method. It was also demonstrated that the vital fluids of the animal body had of themselves great germicidal power, and that the strong antiseptic fluids previously used tended rather to impair this power than to enhance it. Accordingly, fluids for irrigation came to be used only when there was some noxious material to be washed away. It was found that fresh wounds healed most kindly when least irritated by applications of any kind, providing only that nothing came in contact with them which could infect them. And, in this way, as well as by resort to simpler rather than complicated procedures, there was gradually substituted for the so-called antiseptic method that which is now everywhere recognized, and always practiced, when possible,—i.e., the aseptic method. This simply means that it is very much better to exclude germs than to permit of their access and then try to kill them after they have lodged. The aseptic method is, therefore, now in vogue, and among the best operators always the so-called dry method of operating, which means that, so far as possible, nothing not absolutely needed at the moment should come in contact with the field of operation. This has been, in many respects, a great advance over the older antiseptic method, though based upon absolutely the same recognition of causes, being only an improvement in technique.
The benefits of Lister's studies, and of that which has grown out of them, are simply incalculable. The surgical infections which, thirty years ago, were the dread of all operating surgeons, have practically disappeared from civil and military hospitals. I esteem myself fortunate in this,—that I have been a living witness of the benefit of change from the old to the new, since when I began my work, in 1876 (over twenty years ago), as a hospital interne, in one of the largest hospitals in this country, it happened that during my first winter's experience,—with but one or two exceptions,—every patient operated upon in that hospital, and that by men who were esteemed the peers of any one in their day, died of blood poisoning, while I myself nearly perished from the same disease. This was in an absolutely new building, where expenditure had been lavish; one whose walls were not reeking with germs, as is the case yet in many of the old and well-established institutions. With the introduction of the antiseptic method, during the two years following, this frightful mortality was reduced to the average of the day, and in the same institution to-day is done as good work as that seen anywhere. The same was true without exception in the great hospitals of the Old World; and in Paris, where, thirty years ago, famous surgeons would go from one end of the building to the other, handling one patient after another without ever washing their hands, and where erysipelas and contagion of various kinds were thoroughly distributed, as it were, impartially, now the successors of these very same men, employing modern methods, get results which challenge comparison.
The world has seen few extensive wars since the introduction of the antiseptic system; but, in such as have occurred, its incalculable value in military hospitals has been amply demonstrated. The modern soldier is now taught how to make a prompt occlusive and antiseptic dressing of the wound which he may receive upon the battle-field, which, from the moment of its attention, continues to be treated according to the same enlightened method after he reaches the field-hospital, or when sent to the rear; so that men now receive extensive injuries to joints and to viscera, which previously were either promptly fatal, or fatal within a few days from erysipelas and hospital gangrene, from which they recover with useful—often with nearly perfect—limb or function of part restored.
The military hospital of to-day is, therefore, robbed of the terrors which used to make it almost a charnel-house; hospital gangrene, the special dread of active army-surgeons in time past, has almost disappeared from the category of known diseases, and one of the greatest dangers menacing the modern soldier has been removed from modern civilized life. The method has met with universal adoption among all civilized races and peoples, and all this through the energy and talent of the originator, now Sir Joseph Lister.
With the recognition of the germ nature of so many acute diseases has come also systematic study of the use of antiseptics internally; and, while no such exceeding satisfaction has resulted from labors in this direction, we have, nevertheless, learned that most of the infectious diseases of the alimentary canal—for example, cholera, typhoid, etc.—are well attacked by means of antiseptics administered internally; that many of the conditions that depress and annoy are due to the presence of germs in the alimentary canal and the urinary system, and are best combated by means which shall remove these agencies, if not destroy them. It has been learned, also, that many forms of skin disease are parasitic, and that these are only successfully treated by the employment of antiseptics externally.
And so the recognition of the germ nature of infectious diseases and the germicidal properties of certain substances, now spoken of as antiseptics, have kept pace, the one with the other; and in consequence the world has reached a period in its medical history never even dreamed of by our forefathers, when the infectious diseases have been shown to be practically preventable and, to a large extent, curable by the employment of drugs directed especially against their exciting cause. What the years to come may have in the way of further discovery in this direction, we may not foresee. So far as one can at present see ahead, the next advances must be in the direction either of means which shall fortify the human organism against the inroads of bacteria, or disease-germs, or else in the discovery of substances, such as we do not yet know, which shall be at the same time poisonous to the germs and innocuous to the patient, to whom they may be administered in doses sufficient for their purpose. Any material possessing these properties would be an ideal antiseptic for internal purposes. At present we only approach our ideal, but are very far from its active realization. In no way would mankind be more greatly benefited than by the prosecution of studies which may lead to satisfactory results in either of these directions.
Rude Dentistry of Prehistoric Times. Early Instruments for Extraction Made of Lead. Dentistry on the Same Low Plane as Medicine during the First Half of the Christian Era. Dentistry Taught at the School of Salernum. Progress of the Art on the Continent. Prosthesis and Substitutes for Human Teeth. Introduction of Porcelain for Artificial Teeth; of Metal and of Vulcanized Rubber for Plates; of Plaster for Impressions. From being a Trade, Dentistry is now a Profession, in which Americans lead the World. Statistics.
The following is a synopsis of an address delivered at the opening of the session of the Dental Department of the University of Buffalo, in October, 1895. It is appended here because it is certainly apropos of the topics herein considered, the colloquial form being retained.
Called upon at short notice to welcome you here, and to offer remarks of general professional interest, it occurs to me to be retrospective for awhile and to consider the steps by which that which was once an exceedingly crude art has been developed until now it is an exact science. In other words, I would invite your attention, for a time, to the history of dentistry. At a time even before our combined art and science had a definite history we find that gold was used among the Egyptians for the purpose both of filling teeth and of supporting and directing them. In the bodies of many Egyptian mummies, especially of the higher class, there have been found teeth filled with gold or with wood which was covered with gold. It is known, also, that the Hindoos and Egyptians inserted artificial teeth and that some of these were made of wood, often covered with gold, and held in place by gold or silver bands and wires. Herodotus, who traveled so extensively in Egypt and wrote most entertainingly of his travels, has noted the division of medicine among the Egyptians into special branches and the existence of physicians, each of whom applied himself to one disease and not to more. "Some," said he, "are for the eyes, others for the head, others for the teeth, and others for internal disorders."
It is known, also, that about 300 B.C. Erasistratus deposited in the temple of the Delphian Apollo an odontogogue, or tooth-forceps, made of lead, intimating thereby that only those teeth should be drawn which were loose enough to be extracted with such an instrument.
Celsus, who was a contemporary of Christ and of Cæsar, was the first to recommend the use of a file within the mouth for the purpose of removing irritating edges and points of teeth. He also recommended bursting hollow teeth by putting into them pepper-corns, which should absorb moisture, swell, and thus break the teeth in pieces. He also recommended to take particular pains to try to shake or manipulate teeth loose before extracting them.
Galen, about 150 A.D., taught that teeth were true bones and that the canine teeth should be called "eye" teeth, because they were supplied by a branch of the optic nerve. Aëtius, 300 A.D., apparently discovered the foramina at the roots of the teeth through which the nerves enter.
In Rome false teeth and sets of teeth constructed of ivory and fastened with gold wire existed as early as the Laws of the XII Tables, and before the days of Roman civilization it is known that the Etruscans were skilled in manipulation of gold within the mouth, while your dean has described and has, I believe, in his possession beautiful examples of Etruscan work of this kind.
Among the Arabs, after the Arabian domination of the then civilized world, attention was paid to the teeth, although this was considered a very inferior part of the physician's work. Among these Arabians much later, and in spite of their study of Greek writers and their translations from the Greek, there may still be met such passages as this from Garriopontus, 1045 A.D.: "On the island of Delphi a painful molar tooth, which was extracted by an inexperienced physician, occasioned the death of a philosopher, for the marrow of the tooth, which originates from the brain, ran down into the lungs and killed that philosopher." For all that I know, this is the first record of a death after extraction of a tooth. Albucassis, 1100 A.D., gave directions for replacing lost teeth by natural or ivory substitutes. For centuries extraction of teeth had been and was considered a critical and dangerous operation, although itinerant quacks drew them without hesitation.
The Roman poets and satirists made many allusions, in their day, to the teeth and to operations performed upon them.
During the Middle Ages the most celebrated medical school that the world ever saw was founded at Saleraum, and was for several centuries the headquarters to which resorted men who desired to study medicine and patients from all parts of the world who desired to be cured of various diseases. It was a favorite stopping-place for crusaders on their way to and from the Orient, and history relates many interesting episodes pertaining to such visits. Under the influence of this school dentistry was more or less cultivated by those who practiced surgery. Bruno, of Langoburo (about 1250), mentions various operations upon the teeth and the antrum, although that was nearly four hundred years before Highmore carefully described this cavity. Johannes Arculanus (Giovanni d'Arcoli), in the fifteenth century, filled teeth with gold. I must digress for a moment to speak of another suggestion of Arculanus's. You know that quite recently the use of the magnet has once more come into vogue among oculists for the removal of foreign particles of iron or steel from the anterior chamber or the globe of the eye. It was Arculanus who, some five hundred years ago, suggested extraction of iron splinters from the eye by means of the attraction of amber electrified by friction. (For School of Salernum see page 72.)
During the sixteenth and seventeenth centuries the French surgeons, especially Dionis and Verduc, made many practical contributions to dentistry. In 1728 Fauchard wrote in Paris the first complete work on dentistry,—Le Chirurgien Dentiste, ou Traité des Dents. Auzebi, of Lyons, wrote another. Le Cluse first mentioned the English turnkey for extraction. Jourdain introduced a number of new and appropriate instruments and new forms of artificial teeth. Bourdet, dentist to the king, made artificial palates. Porcelain teeth were first introduced in France in 1774.
Among the Germans cosmetic dentistry, though still the favorite field of charlatans, was greatly cultivated. Serré wrote a treatise on Toothache in the Fair Sex During Pregnancy, but the first public dental clinic in Germany was not established until 1855, by Professor Albrecht, and in Vienna. It has been in Vienna, among the Germans, that dentistry has been in time past most honored, and was taught when it was scarcely recognized in the other German universities. Private dental institutions were also first established in Vienna.
Of all the tooth-extracting instruments, the dental forceps in crude form is the earliest, the first on record, perhaps, being that deposited by Erasistratus in the Delphian temple, as already mentioned. For hundreds of years these instruments scarcely changed in shape. It was Garengeot who invented the key, early during the last century. Before that, and for awhile, dentists who had abandoned the forceps used an instrument known as the pelican,—said to much resemble the skid used by lumbermen.
Before artificial (porcelain) teeth came into use the following substitutes were employed, their estimated value being in accordance with the order in which I name them:
Human teeth, animal teeth, hippopotamus tusk and teeth, elephant-ivory, and bone.
Human Teeth.—Transplantation of teeth was at one time very common. After being inserted, they were held in place by pivots and ligatures, springs, and upon bases. The pivot method also included the use of screws. Ligatures for fastening teeth were made of silk-worm gut,—which, now so common in surgery, was used for this purpose, perhaps, two hundred years ago,—of gold wire, etc. The method by ligatures is the earliest of all. Human teeth have always been more or less expensive if fresh, few people being willing to part with sound teeth except for a money consideration. In 1784 a Philadelphia dentist offered, in an advertisement, two guineas each for sound front teeth.
Animal Teeth.—These were largely used, being held in place the same way as above, the principal objection being that it was difficult, often impossible, to match human with animal teeth. It was found, also, that the latter decayed very much more easily.
Hippopotamus-ivory.—This was at one time very extensively used. It was carved into the shape of the missing teeth, and was held upon a base; or it was carved into shape as a base upon which to rest human teeth. Most often it was used as a base for pivoting. Not infrequently a block was carved out which represented gum, teeth, and all, and partial dentures of this complex type were often so deftly fashioned as to be very realistic, the part representing the gum being colored. Unfortunately no dye nor color in the mouth could be made permanent.
Elephant-ivory.—This was used for the cheaper grades of work, being less durable.
Bone.—Bone was still more objectionable, and was used for only the cheapest work.
Artificial porcelain teeth were first introduced in France in 1774 and in America in 1817. Those which were first made were so large, awkward, rough, and ill-fashioned, without attempt to represent the gum, as to bear no comparison to the artistic products of to-day. They were intended for the most part for attachment to ivory bases. The artificial dentures made for George Washington were of this general character, and, although they called forth his encomiums in a letter to his dentist expressing his gratitude, they would pass for very shabby productions today. One of the greatest advances in dentistry was the introduction of gold bases as a substitute for the baseplates previously made of ivory or bone. This is distinctly an American invention, and is to be credited to Gardette, of Philadelphia, who produced the first bases of this kind in 1787. Since then other metals have been used only because cheaper, none having the valuable properties of gold.
Gutta-percha was introduced for this and various dental purposes in England, in 1851, by Trueman. In 1851, too, came Goodyear's process of vulcanizing, which the dental profession were at first slow to avail themselves of, but which led, as its value was recognized later, to expensive and almost endless litigation.
Another most valuable American invention was that of taking impressions by the use of plaster. This was introduced about 1844-'45. This method permitted the making of socket-plates, which, of itself, was a long step in advance.
So much for a very brief epitome of some of the most interesting facts in the history of dentistry. Did time permit, the matter would warrant treatment at much greater length. But what now is to be said of the condition of dentistry to-day? First of all, that it is no longer relegated to charlatans and itinerants, but is studied, practiced, and honored by men of the ablest minds and of the highest type. There is to-day scarcely any branch of applied science which calls for greater qualifications or for greater combination of mental endowment and manual dexterity than does dentistry. We, in New York, find ourselves now in position where the State has assumed not only to regulate the practice of dentistry, but even to pass upon the qualifications of those who propose to study it. In the assumption of this task by the State there is paid, perhaps, the greatest possible compliment to its dignity and to its importance.
The great field of medicine is now altogether too vast, and the various branches which pertain to it are too complex, to permit a mastery of all its details by any one mind. The man does not live who to-day can be considered facile princeps in more than a few departments of medicine. Life is too short to permit of it, and the study is altogether too extensive. There is also a growing public demand for specialization of work, and there is probably more excuse for the perpetuation of dentistry as a specialty than for almost any other branch. Nevertheless, it is necessary constantly to repress a tendency toward a failure to comprehend the general principles underlying all medical specialties, and it has been hard, at least until recently, to impress upon the men of the dental profession that they were really only practicing a branch of medicine, and that, in disregarding a general and comprehensive knowledge of the fundamental branches, they were but poorly preparing themselves for the practice of a dignified specialty. Certainly dentistry makes as many demands for mechanical training, digital dexterity, familiarity with the properties of materials, etc., as does. surgery, and in some respects even more. Of course, to a certain extent in these respects it is like a mechanical trade. The great trouble with the dental profession, until very recent times, is that they have regarded their work too much as a trade and not enough as a profession. By taking the latter view of it the work is ennobled and their interest for it cultivated. By taking the trade view of it they have lost those finer features which lift mechanical work out of the mere level of a trade. Moreover, men in time past have been guilty of altogether too much trades-union tactics, which are vehemently opposed to professional ethics, and this has been another feature to degrade rather than elevate dentistry.
This has been indeed a great misfortune, for men have been misled by the need for cultivation of their hands, or their manual powers, and have been persuaded away from a finer study of fundamental principles upon which the whole practice of dentistry should be based. And so it has happened that men have been so ambitious to become perfect operators that they have neglected anatomy, physiology, chemistry, and pathology, have even neglected odontology, sacrificing everything else to their work as mere artificers.
If one scrutinizes the subject properly, there is no reason why there should not grow up a class of men fitted to attend to any lesion of the mouth or of the parts adjoining. In other words, there is no reason why there is not more excuse for true oral surgeons than there is for any other class of specialists, save possibly those who treat the eye. Aural surgery, nasal surgery, pelvic surgery, rectal surgery, etc., are simply voluntary limitations and applications of general surgery to special parts; but he who attends to the teeth has to do so much work of a character which the surgeon is not called upon to perform in any other area, that I have always claimed the oral surgeon deserved a place, as he had a field, by himself. Nevertheless, the knowledge which shall fit a man for such work is not to be obtained in the ordinary dental course, nor in three years of study, even under the best of auspices. The man who would be an ideal oral surgeon must be not only generally familiar with anatomy and physiology, but must thoroughly know the embryology of the face and teeth, the physiology not alone of the organs of the mouth, but of all the secreting glands and the chemistry of all their secretions; not only the anatomy of the cranium, but general anatomy as well, and even comparative anatomy. He must be well informed in the explanations of all the congenital defects met about the face and mouth; he must be familiar not only with the ordinary principles of pathology and bacteriology, but he will find in the fluids about the mouth such a fertile opportunity for bacteriological study that, be he ever so expert or erudite, he has still much left to investigate in this direction. There is no disease-germ with which he can afford to be unfamiliar, and, as any form of tumor may be found in or about the mouth, he should be familiar with the entire subject of tumors and their surgical treatment.
Then, again, he must be familiar not only with the physical properties of metals and the various materials used in plastic dentistry, nor expert alone in the operations about the teeth, but, inasmuch as he has to cope with various wounds, injuries, and operations about the soft parts, he must be thoroughly familiar with the principles of wound-healing; with the causes of sepsis and the agents which produce it, and the means of avoiding it; in other words, he must have a general training in operative surgery, and, according to my ideal, which may be high, he should be a man able to do almost any operation in surgery before he limits himself to surgery of the mouth. Unless he have this ability, he will not do such operation as well as a general surgeon can, because the underlying principles are the same, and the latter will have the greater command over them.
When, then, this perhaps ideal man has become thoroughly familiar with the principles of surgical anatomy, operative surgery, surgical pathology, and bacteriology, in addition to the things already mentioned, then, and not until then, may he and should he assume to operate for harelip, cleft palate, cancer of the tongue, and various other lesions in the parts about the mouth.
I wish I could say and demonstrate more to impress upon you the important bearing of modern surgical pathology to dentistry. Perhaps I can give you no better illustrations than you can see in the studies and writings of Prof. W. D. Miller, of Berlin, of whom I am proud to say that he is an American, and that he is the only American occupying a professorship in a German university. In his studies on the causes of dental caries and upon the bacteria of the mouth he has identified and named nearly a hundred species of the bacteria, many of which he has shown to be the active causes of dental decay. He has done, then, for dental pathology in this direction what other eminent observers have done for the processes of suppuration and ulceration in other textures and tissues, and has helped to show that they are all evidences of pernicious germ activity. By his researches, also, upon inflammation in elephant-tusks, and the results of injury, mainly by bullet wounds, he has shown us that the phenomena attending these changes in dental tissues are practically identical with those in bone. His researches have done very much to explain the pathology of that common disease, pyorrhoea alveolaris, which is known to be but one expression of local infection, while the possibility of migration of infectious organisms and of metastatic lesions in other parts of the body, having their origin in infectious disease in or near the teeth, has been brilliantly demonstrated by his interpretation of well-known clinical facts.
That American dentists are most highly regarded abroad is more than a matter of every-day knowledge. It has got to be so now that a foreigner will purchase instruments of American make, and then advertise himself as an American dentist for the purpose of getting business,—a purpose in which, as a rule, he is quite successful. But let me stop here to do honor to another American dentist who is more highly honored abroad than one ever can be at home, and of whom it might be said, perhaps, that he has had more friends among the royalty and nobility of Europe than any other man of his time. This is Dr. Evans, who has lived for years in Paris, who was the personal friend of Napoleon III and the trusted guide and companion of the Empress Eugenie when she fled from Paris. While it may be said of him that the qualities that made him so universally popular were personal qualities, rather than professional knowledge, it must be said in reply that it was his eminent professional attainment which first brought him such influential friends.
But time presses, and I want, before closing, to say a little about dentistry in America. It was about 1835 that Dr. Harris, then residing in Baltimore, though born near Syracuse, conceived the modern idea of the scope and practice of dentistry. He was ambitious to put the dentists of his time upon a higher professional level, and to make of dentistry a specialty in medicine. He applied to various medical schools to found dental chairs, and to teach oral pathology along with dental mechanics, as one of the branches of medicine, the graduating degree to be M.D., as with other medical specialties. But the men of his time were so short-sighted and of such constricted mental calibre, and the dentists were so uneducated, that the Baltimore schools declined. He therefore established a separate school, being forced to take this step. This school was the Baltimore College of Dental Surgery, established in 1839,—the first in any country. The dentistry of that day was crude, and its teaching was comparatively inefficient. It was not until six years later that the next, the Cincinnati College of Dental Surgery was organized,—in 1845. Then, in time, followed Philadelphia. But all these colleges were separate institutions, teaching only those branches which it was held necessary that a dentist should know and having very little of medicine in their curriculum. They conferred the degree of D.D.S.
In 1868 Harvard University did what she ought to have done at the outset. She opened a dental department and began the teaching of dentistry as a branch of medicine, establishing therefor a separate degree,—D.M.D.,—Den-tarioe Meclicince Doctor. In 1874 the University of Michigan established a dental department, and a little later the University of Pennsylvania did the same. These university schools gave an immensely widened scope to the study, which was made broader with each succeeding year.
There are now forty-five dental colleges in the United States. Forty of these are members of the National Association of Dental Faculties, organized for the purpose of securing uniformity in teaching and in graduating men. Membership in this association is a certificate of high standing and of comprehensive advantages.
Last year (1894) the number of students in dental colleges was 4979, while the number of graduates was 1208. At present nearly all the States have legislation governing the practice of dentistry, and often more strict than that regulating the practice of medicine. In New York the law places dentistry on precisely the same plane as medicine,—prescribes the same qualifications for matriculation, the same length of study, exactions for graduation, examination, etc. In other words, the law is quite as strict regarding admission to dental colleges as to medical. After 1897 at least a full high-school course will be demanded for matriculation, and from now on we may look forward to having a really educated dental profession.