Stuart Banyar Blakely, MD
Dr. Blakely on Obstetrics, 1933
Determining the Sex of The Human Fetus in Utero
Stuart B. Blakely, M.D.
Binghamton, N.Y.(Reprinted from
The American Journal of Obstetrics and Gynecology,St. Louis, Vol. 34, No. 2, Page 322, August, 1937)
The diagnosis of fetal sex had intrigued interest and baffled solution for centuries before the twentieth-century invention of ultrasound, which of course greatly simplified the matter. In fact, the new technology was so cheap and simple, it essentially eliminated the question without the fanfare usually associated with such a revolution. Among peoples of all ages and areas, efforts had been made in vain to bridge the tantalizingly narrow gap between the observer and the child in its mother's womb. Classifications of means and methods employed in fetal sex diagnosis and discussions of them in each group, immediately transformed from a catalog of "superstitions" into more mundane investigations--the original purpose of this paper-- only a few decades ago. A straightforward review, however sharply revised for more contemporary viewpoints, shows how calmly astounding insights may sometimes be accepted even though they had been universal mysteries for generations.
While the logic of primitive thought is often vulnerable, it is not inferior to much that is current today. Regarding the diagnosis of fetal sex, one might fancy that it proceeded somewhat as follows, although not, necessarily, as a line of conscious reasoning. Marked changes from normal are evident in pregnant women. These changes must be due to the action or influence of the growing products of her conception. These changes vary in different women and in the same women in different pregnancies. Some of these variations must be due to some difference in the fetus. The only confidently obvious difference between a fetus and newborn is sex which must also exist before birth. This difference, I.e. sex, is almost surely the cause of at least some of these variations. The male is profoundly different from the female and has been considered to be of greater value, strength, and importance. The effect of a male fetus on the mother must likely be different in kind as well as degree, although not necessarily in timing. Therefore, the signs and symptoms of a male pregnancy probably do differ in character and degree from those a female pregnancy, but probably less than once was conjectured.
All means that have ever been used to diagnose fetal sex may be placed in two great classes: supernatural and natural.
The means employed in THE FIRST CLASS were the prophetic interpretation of numerology (still existing as late as the sixteenth century in countries as far apart as China and Italy), astrology and dreams; of the examination of the entrails of sacrificed animals and of the flight of birds; of "ordeals"; of chance happenings and occasions; and of magic formulas and other procedures. Material on this phase of the subject can be found in the first volume of Ploss-Bartels. It is interesting that the use of strictly supernatural means to determine fetal sex was never persistent or extensive, compared with the second class. I have not met nor heard of a survivor. Legendre records a French folk belief in a curious mixture of lunar influence and numerology.
The SECOND CLASS, comprising the natural means to diagnose fetal sex, from time out of mind to very present, may be further divided into three broad groups. Group 1. The supposed origin of the male from the right side of the uterus, the female from the left; and the changes in the right side of the pregnant woman's body ascribed to or imagined to result from, such origin.
Group 2. The position, outlines, attitude and activities of the fetus during pregnancy and labor.
Group 3. The effect of a male fetus on the total maternal organism; i.e. the reactions of the female body to the introduction of a male element. This is the largest and most important group.
A notion of antiquity was that the human uterus consisted of right and left cavities, as is normal in many animals which were the chief source of the ancients' ideas of anatomy. Since the right side has always been considered the stronger, superior and "holier" side and the male the stronger, superior and more valuable sex even in its mother womb, it followed that the male must develop in the right side of the uterus, the female in the left. Hippocrates taught that "The Male fetus is usually seated in the right, the female in the left side of the uterus. " After it became known that the human uterus is not normally duplex, the idea became current that the male came from the right ovary, the female from the left. This must have been, however, a comparatively recent development, for knowledge of the part played by the ovary and him ova in reproduction is not old. Through historic time this idea is found scattered from China to Europe; right-handed signs and symptoms point to male pregnancy. There is more pain or heaviness or more or earlier movement in, or more prominence of, the women's right side, if pregnant with a male. The right breast is larger, "softer" and more sparkling with a wider pupil. All blood vessels on the right side of the body are fuller and beat more forcibly (the sublingual being especially mentioned), and the right pulse is stronger. The right shoulder is lower, and the right thigh thicker. The woman starts off first with her right foot and supports herself more with the right hand. Salt does not melt on the right nipple, and the right nostril tends to bleed. Many, if not all, of such ideas, may be found in the "e Secretis Mulierum", a book ascribed to Albertus Magnus (1193-1280), which was widely used in the scholastic time of medieval medicine.
While right-sided signs and symptoms are no longer valued in fetal sex diagnosis, a bit of the old belief still lingers in the theory of the ovarian or ovular determination of sex. The idea that sex is determined by the egg still lives and will not die, and among men of scientific training. As a matter of fact, the last word on the subject has not been spoken. Otto Schoener published his theory in 1909 and his results in 1924 and 1925. It has given rise to a large volume of German literature. Schoener held, and still holds, that the right and left ovaries alternate continuously in their activities (an idea suggested by Bischoff in 1844); that the human ovum possesses its sex "Anlage" before fertilization; and that the sex "Anlage " changes, --possibly better said, appears--, in each ovary in the following sequence: right ovary, male; left ovary, female; right ovary, female; left ovary, male. The cycle is repeated ad infinitum. E. Rumley Dawson proposed the hypothesis that male and female determining ova are discharged from the ovaries alternately, male from the right and female from left. Both these men claim that, after the first pregnancy, it is possible to quite accurately foretell the sex of future children by a careful history of the menses (actual and missed), assisted by the palpation of an enlarged tender ovary due to the presence of the corpus luteum of pregnancy. The difficulties of these theories are quite apparent; e.g., menstruation is not always associated with ovulation nor vice versa, and the sex of children after unilateral oophorectomy does not always conform to the rules. Through many years of observing pregnant women, I have never been able to determine any right-sided signs or symptoms peculiar to male pregnancy, nor evidence of either definitely alternating ovarian activity or of ovular determination of sex. It is probably safe to deny their existence, though dogmatic statements about the physiology of sex are dangerous.
The position, outlines, attitude and activities of the fetus during pregnancy and labor.
Hippocrates held that the boy moves in the womb at three months, the girl at four. This idea, with variations in the actual number of the months, was once widespread. It was also thought that labor was slower with a female child. These conceits are entirely consistent with a belief in male superiority. The girl was supposed to be born "face-up," looking at the rib whence she came, a bit of Genesis perhaps, or reminiscent of the usual position at coitus.
In this group belong two modern "natural" means that have been employed in an effort to solve the problem: the x-ray (two procedures) and the rate of the fetal heart. Roentgenologists agree that the ossification of the skeleton of the female is more advanced than that of the male throughout intrauterine life; it has been suggested that this fact might be utilized to foretell fetal sex. Visualization of the fetus in utero (including the outlines of the soft parts), by rendering the amniotic fluid opaque through the injection of strontium iodide into the amniotic sac, occasionally permits the diagnosis of fetal sex, if a true lateral view of the breach is obtained (menses).
In 1859, on the basis of a study of one hundred cases, Frankenhauser suggested that fetal sex might be determined by the rate of the fetal heart in the last three months of pregnancy, a persistently slow rate (averaging 124 or less a minute) indicating a boy, and a persistently more rapid rate averaging 144 or more a minute) -- a girl. A large number of observations have been made with corresponding literature. If the male fetal heart is slower, it must be due to some peculiar influence of male sex itself, maleness per se, for which I know of no evidence; or because the male is heavier or bulkier, but the average difference in the birth weights of the sexes would seem to be too slight to have much effect; or the result of some hormonal action, as yet unknown. It is generally conceded today that the method is of no, or at least of very little value, if for no other reason than that the usual fetal heart rate falls between the figures given and so into the uncertain class. Many of the laity express a wistful faith in it. Some physicians for unworthy or obscure reasons, encourage this faith by professing, at least not denying the same. Nevertheless, it may lay claim to having been a really intelligent effort to solve the problem.
The effects of the male fetus on the total maternal organism cells and organs, their functions and secretions.
In pregnancy, mother and child are a biologic unit. If the mother's own hormones produce well-recognized phenomena, why may not be added fetal hormones (which she surely receives) alter these phenomena in degree or character? If the male fetus introduces into her economy new or "foreign" hormones, why may these not alter her response; and, if harmful (as we know they may be), why may they not meet hormonal or humoral resistance (be protective?)? The maternal response to pregnancy may be physical, or biochemical (using the term in a broad sense), or both. Her reactions may be quantitative, qualitative or both. A discussion of these two possible types of reaction now follows.
Aristotle held that, since the female is on a lower developmental plane, a female pregnancy has less effect and makes less demand on the maternal organism than does a male pregnancy; that there is greater body warmth in a male pregnancy and therefore a better circulation; and that on these as a basis the diagnosis of fetal sex is possible. some observers today agree with Aristotle that a male pregnancy makes greater demands on the pregnant woman. There is claimed to be more iron in the male placenta; more adrenalin in male urine, and therefore (?) more in the urine of a woman pregnant with a male child. It is said that midwives in the Philippines used to prophesy the sex of the unborn child by the reaction of the pupil of a male dog's eye into which had been dropped some of the pregnant women's urine. Thinking along this line, I observed the pupillary reaction of twenty-five pregnant women on whom the Bercovitz test of pregnancy was done, to see if the contraction or dilatation of the pupil bore any relationship to the sex of the fetus. The results were negative.
The second idea, that the reaction of the pregnant woman to a male fetus is qualitatively different from that of a female fetus, is very old, runs as a common thread through most of the ancient methods of sex diagnosis, and is the basis of nearly all modern efforts to solve the problem. Hormones can and do pass the barrier of the placenta. Profound changes are produced in the pregnant woman's organ growth, circulation, skin, glands, etc.; she is often "rejuvenated". The origin must be in the fetus, a source of additional, possibly new and different, possibly even antagonistic hormones. If the fetus dies, these changes retrogress. There is no question but that a male hormone (using the singular for convenience) exists. There is some question when and in what quantity this hormone is first produced in the fetus. There is a still larger question if the male sex hormone, by circulating in the maternal bloodstream, induces or can induce recognizable specific changes in the mother's body, by acting as an antigen with the production of "antibodies" or by some hormonal effect. Every cell of the male fetus must differ from the female cells of the mother. The mother has no organ homologous with the fetal testis or the fetal tissues that produce male sex hormone. There is probably no antagonism between sex hormones as such, i.e., they do not neutralize each other when mixed together. But there does appear to be some sort of antagonism, direct or indirect, between the specific hormone of one sex and the specific hormone-producing organs or tissues of the opposite sex. Moore and Price reject Steinbach's and other's ideas of sex hormone antagonism; they admit that certain facts do point to such action but claim that the effect is indirect through the hypophysis. But compare the production of sterility by the parenteral injection of semen or even its vaginal absorption the production of agglutinins against spermatozoa, and the occurrence of freemartins and other phenomena to be discussed in the immediately following paragraphs. Does the introduction of maleness, e.g. a male fetus, into the female body produce quantitative or qualitative changes that can, possibly one might add, someday in the future, be recognized by the clinician or the laboratory worker? Is there any evidence that a male pregnancy has an effect on the mother, different in degree or character from that of a female pregnancy? In the attempt to answer these questions, let us examine further evidence which is closely bound up with the inescapable idea of some sort of sex antagonism.
Ancient relief. This must be neither, lightly regarded nor summarily ignored. The remarkable agreements of such beliefs among people widely separated in time, place and culture arrest attention. Somewhere in the welter, to be found someday by some seeing eye, maybe a little, or the little grain of golden truth. Not everything that we cannot prove scientifically is improbable.
The frequency of male abortions. The ratio of male to female abortions is at least 150 to 100. The cause must be in the "fruit". This may be the reason for nature's prodigality with male pregnancies because so many are destroyed by some unfavorable reactions to their presence in the maternal organism. Some women seem to abort all male conceptions, carrying only female to term; the reverse, at least in my personal experience, is rare. Male stillbirths are also more common, even after discounting the usual causes for this condition and the hazards of male birth itself. Cases of unexplained and of "habitual" death of fetus near or over term are 80 percent males. The excess of males among abortions and stillbirths is greatest during the first and last third of pregnancy; this may have something to do with the development of the interstitial cells in the fetal testis. While it is true that there are more male than female twins (1043:100; the ratio in single births, 1050-60: 100), due to the great preponderance of male pregnancies, the prenatal mortality of male twins is higher, and "as the number of individuals to a birth increases the relative proportion of males to females decreases. Nichols, who collected statistics of over 700,000 pairs of twins, has pointed out that the ratio of males to females decreases from 1059: 1000 in single births to 548:1000 in quadruplets. The Dionne's are girls, and so are most quadruplets of press renown. In sheep, there are over twice as many female as male triplets. For opposing view consult A.S. Parkes.
The occurrence of freemartins, in cattle and more rarely in other animals. A bovine freemartin, probably meaning "farrow heifer," is the female co-twin of a normal bull calf; the female of two-sexed twins. Cattle breeders from Roman times have known that such females are usually sterile, 87 percent or more (some observers claiming even 100 percent) instead of the normal incidence of less than 10 percent. Lillie has shown beyond all questions that a freemartin is a "blighted" female calf fetus with undeveloped or deformed sexual organs (usually internal only), and often with more or less male characteristics due to saturation with antagonistic male sex hormone from it co-twin which interferes with the normal female development. This is possible and occurs only when the chorionic or placental anastomosis between the binovular twins is early and extensive. Either the male shows an earlier sex differentiation and an earlier sex hormone is more "powerful". The former of these ideas suggest that sex is not absolutely determined by the spermatozoon but is profoundly influenced by the environment; the latter, again, the ancient thought of male superiority. Williams, in personal communication, reports "Quintuplets with two males and an asexual. Ten individuals with 4 males and six sexless. There were 8 abortions and two viable young (the twins)." Hartman believes that the process can be reversed in which a male co-twin is sterilized and made more or less asexual or intersexual (sexual intergrade) by the female. He calls these "reciprocal freemartins", and rather believes that both types do occur in man and may explain some cases of intersexuality (Novak). Contrary to a belief once held in rural England, no diminished fertility in the female of two-sexed human twins has been observed because a comparable placenta anastomosis does not occur in man. Sir J.Y. Simpson collected the married history of 123 women born co-twins with males and found that only 11 had no offspring.
Fetal malformations. As a whole, there are probably more male than female fetuses that are, malformed. Dr. D. P. Murphy of Philadelphia, in personal communication, says, "if you were able to secure figures on the sex ratio of 500 cases of any given type of defect you might well find... that the defects in most cases afflict the two sexes about equally." But the available figures show strange sex ratios of congenital deformities. Curiously enough, deformities of the brain and cord, and of congenital hip dislocation are much more common in the female. M.S. Michel of Minneapolis reported in 1928, 57 cases of craniorachischisis, of which 85 percent were female; Malpas, 44 cases of anencephaly with 70 percent females, and 80 of hydrocephalus and spina bifida with 57 percent of that sex. Of 5,494 cases of congenital hip dislocation, 84 percent were females. On the other hand of 3,309 club feet, 65 percent were males. Of 507 cases of harelip-cleft palate gathered from various sources, 55 percent were males. Ballantyne reports the sex ratio of his malformations as follows: iniencephalies, 1 male to 21 females (5 percent males); anencephalies, 10 to 30; genal fissure, 41 to 26; harelip, 180 to 118; diaphragmatic hernia, 47 to 20; preauricular appendages, 21 to 12. These percentages are approximate. He states that there are more female cyclopia and united twins; but more male urinary umbilical fistulas and polydactylies; of extroversion of bladder, male: female: "6 or 7:1"; of transposition of viscera, "2:1." I have not been able to secure much evidence for the suggestion that most pseudohermaphrodites are primarily males, the course of whose early sex differentiation has been altered by the antagonistic sex hormones of the mother. Such evidence would be very interesting. In 980 cases of placenta previa, the male-female sex ratio was 124: 100. While fetal malformations are not good witnesses to any distinctive effect of maleness on the maternal organism, still sex in some way would seem to play a part in their production.
The relation between male pregnancy and toxemia. An old belief, still alive, was that the pregnant woman vomits more if her baby is a boy. David suggests that the cause of the vomiting is something transmitted to the child from the father that is foreign to her blood; that the more the child resembles the father, the more the mother vomits; and that the pigmentation of the other parallels that of the child. In all this, no direct mention of sex diagnosis. Herrmann reports in 1,442 cases of eclampsia a ratio of male to female children of 122:100 (normal ratio, 105:100); in the last four months of pregnancy, this ratio rose to 156: 100; and in those eclamptic individuals with twins, to 173:100.
Serologic studies. These, while not conclusive, evidence a difference between male and female blood and serum greater than that afforded by chance.
The foregoing would seem to justify the conclusion that the introduction of the male element into the female body does produce effects. The mechanism by which the male fetus is protected against the antagonistic sex hormones of the mother is, at times, more or less broken down. Sufficient means and knowledge are not yet at hand to recognize such effects definitely and permit practical sex diagnosis.
The ancient ideas of the qualitative effects of a male pregnancy on the mother comprise a large number of "natural" means to diagnose fetal sex. Hippocrates said that "a woman with a child, if it is a male, has a good color; with a sense of well-being. The face is brighter, the color better, the skin clearer; she is cheerful (Arabian), happy (Indian), and untroubled (Jewish). Many of these may be explained by the belief that the increased heat production, held to be associated with male pregnancy, quickened the circulation and heightened metabolism; suggestion and wishful thinking may have played a role. Finally, however, with these as with many other ancient ideas about fetal sex diagnosis, we may be standing on the edge of an unexplored field of endocrinology.
Freckles, pigmentation, and vomiting were sometimes stated to indicate a boy, though Hippocrates held that freckles meant a girl. While "liver spots," a blotchy skin and a bad or pallid color were usually interpreted to mean a girl, pigmentation, in general, pointed to a boy. There was a widespread belief that the lack of pigmentation of the lineal alba below the naval meant a girl. The endocrinologists have here food for speculative thought. It was also an old idea that the desires of the pregnant women are an expression of the desires or will of the fetus often expressed in dreams. In India, if the pregnant woman dreamed of men's food, the baby would be a boy; in Russia, dreaming of a spring or well, meant a girl; of a knife or club, a boy (Freud?). There was no agreement in the interpretation of changes in sexual desire during pregnancy. Incidentally, the subjective sensations of the pregnant woman have never been considered of great value as evidence in fetal sex diagnosis; but this may be another entirely unexplored clinical field.
The most interesting "natural" means in Group 3, anciently used to foretell sex, have been the supposed effects of the fetus on the pregnant women's excretions: urine, milk, and sputum. A generation ago no one would have dreamed that the diagnosis of pregnancy was possible by an examination of the urine. But in ancient Egypt about 1350B.C. according to the Berlin Medical Papyrus, both pregnancy and sex could be determined by this means. "To see if the women are pregnant or not pregnant: barley and wheat are moistened daily with the women's urine, like dates or pastry in two bags. If they either generate, so will she give birth; if the wheat germinates, so will it be q boy; if the barley germinates, so will it be a girl; if they do not generate, so is she not pregnant." The idea had found its way to Europe by the seventeenth century. "Make two holes in the ground, in one place some wheat, in the other barley, wet with the women's urine and cover with earth. If the wheat sprouts first, the women have a male fetus; if the barley first, a female." The test is mentioned in the old English book, The Experienced Midwife. The manager repeated the experiment in 1933 and reported 8- percent correct prognostications, but his findings have not been corroborated. If any difference in the effect of male and female pregnant urine on the growth of these seeds does exist, it must depend on the presence of some substance produced, directly or indirectly, by the fetus.
There was a curiously widespread idea that the milk (sometimes specified as of the right breast) of a woman pregnant with a male was "tough" and thick. The test was to drop or squirt the milk onto a smooth surface, e.g. glass, a sword or a heated metal plate. If it remained conical or "stood like peas" or clotted, a male pregnancy was indicated; if it spread out or flowed off, a female. If some of the milk dropped into clear water or urine fell to the bottom, a boy was to be born; if it floated or dissolved, a girl. Another test was to knead the milk with meal into a small loaf to be baked over a slow fire; if it shriveled up or burned, a boy; if it "puffed up," a girl. It appears that these tests were occasionally, but much more rarely, applied to blood and urine. Much of the foregoing is not strange to primitive thought about sex.
With the two exceptions, marked vomiting which is still occasionally spoken of as sign of male pregnancy and sport with the pith ball, possibly the only other 'natural" means to diagnose fetal sex, existing in popular thought today, are the changes that "old women" think they discern in the shape and appearance of the pregnant woman's abdomen and back. There is by no means complete agreement; but in general, a hard, prominent, "high" and rounded and broad hip and back bespeak a male pregnancy. An abdomen sometimes described as "egg-shaped" is stated to indicate a female pregnancy. The origin and age of these ideas are not definitely known; some way has a phallic elusion from many wearied questionings and many observations, I am not willing to dismiss the matter as entirely without foundation. Possibly, an endocrine truth may be embodied in his popular persistent belief.
To digress a moment into veterinary medicine, cattle breeders have stated that the calf is more likely to be a male if the front quarters develop first in pregnancy and if the cow goes over term.
In modern times, excepting Frankenhaeuser's fetal heart study in 1859, there is no evidence that either science or scientific medicine concerned itself seriously, if at all, with the diagnosis of fetal sex in utero, until toward the end of the first decade of this century. Since then the problem has been attacked from many angles. Those in Groups 1 and 2 have already been the means employed; and the efforts, in the main, have followed the two ancient lines of thought about the effects of a male fetus on the maternal organism, the one, that they are quantitative; the other, that they are qualitative.
Excepting unsuccessful attempts to demonstrate a higher pH value in the blood of a woman pregnant with a male or a higher basal metabolic rate, the Manoiloff test is possibly the only modern example of the first idea, though not intentionally so in origin.
In ancient thought, all things had sex, which the study of language amply illustrates. The alchemists held that the elements were male and female. E. O Manoiloff, the Russian scientist, has revived that concept. He claims to be able to distinguish between male and female tissues and secretions (first in 1920), to determine the sex of the fetus by examination of the pregnant women's blood, to diagnose the sex of plants, and to separate male from female minerals. He claims sex differentiation from stone to man. As a matter of fact, female sex hormone has been recovered from minerals. Regarding fetal sex diagnosis, Manoiloff believes that a specific hormone from the fetal testis, or from the whole organism of the male fetus, passes into the maternal blood and changes its reaction. To the specially prepared blood is added an oxidizing agent, a reducing agent, an acid and an indicator. The results are determined by the absence or presence of color reaction. The idea of many investigators is that this test represents an oxidation-reduction process, of which the former predominates in the male, the latter in the female; that the substances involved parallelling the metabolic rate; and that the test is one of metabolic rate or level. It's quantitative, and not sex-specific. We are back again at the beginnings; one mark of sex is a difference in metabolic rate. Many modifications of the test have been made and its chemistry is complex; the necessary technic is delicate and subject to much possible error. Manoiloff's claim of 80 percent correct prognostications would seem overoptimistic.
A possible immunity reaction between the pregnant woman and her unborn male child has been the basis of most of the efforts of serology to solve the problem of fetal sex diagnosis during the past twenty-five years. It follows the second ancient idea that one of the effects of a male fetus on the maternal organism is a qualitative change, caused by the elaboration of specific substances, and is a predicated on the four following assumptions; (1) Even early in pregnancy there is sex differentiation in the fetus (morphologically, sex can be distinguished in a fetus 20 mm. Long and six weeks old), which becomes more marked as pregnancy advances. (2) The male secretions i.e. the "maleness," of the fetus passes into the mother's blood. (3) These secretions being "foreign" to her body cells and their products, act as antigens. (4) As a result, the mother produces "antibodies" against the invading "foreign" substances. The demonstration of these hypothetical "antibodies" has been attempted by precipitation reactions, agglutinations, complement fixation tests, the activity of ferments and allergic phenomena. The possibility must be constantly borne in mind that all such serologic tests may be invalidated by previous sensitization.
Petri experimented with precipitin reactions between a cow and steer serums and steer testis extract. Both serums gave precipitations when overlaid with the steer testis preparation, though stronger with the steer serum. The same results were obtained when antitesticular serum (from rabbits injected with this testis preparation) was tested against a cow and steer serums. Even after fractional precipitation of this antitesticular serum by cow serum until precipitation ceased, the addition of steer serum still gave a reaction. By these and other reactions he was able to determine the sex of serums in many cases, but the test was not dependable. Abraham from 1912 to 1914 conducted an extensive series of precipitin experiments. He injected rabbits with male and female pregnant serums and with male and female nonpregnant serums. Combinations and dilutions of serum from these sensitized rabbits were tested for precipitation against serums similar to those injected. His results were also not conclusive. His work stimulated investigation and his article contains an extensive bibliography.
The agglutination or immobilizations of animal and human spermatozoa by the serums of pregnant women has been briefly investigated by me. While the degree of the reactions varied from what might be called complete to none whatsoever, even the markedly positive cases did not seem to be of value in fetal sex diagnosis. Of course, it can be argued that spermatogenesis is not a function of fetal life; that it is not known to what degree "maleness" is dependent on the external secretion of the testis; and that the serums might have been from patients already sensitized. References to other work of this character have not been found.
Complement fixation tests for diagnosing fetal sex were employed by Petri using an extract of the fetal testis, inactivated navel blood, and fresh guinea pig complement. All gave hemoptysis. Others have tried to solve the problem by this method which would seem to merit further investigation. I had a personal interview with an individual who believed that he had succeeded in this method. The New York Academy of Medicine scheduled for the Section of Obstetrics and Gynecology on April 28, 1925, a paper by Isaac Fried, M.D., entitled "The Serodiagnosis of the Sex of the Fetus During Pregnancy," "by invitation." The paper was withdrawn before the day of the meeting arrived. The author's interesting, but not at all convincing, complement fixation test, featuring a very complicated, possibly even fantastic, antigen, was published in the Medical Review of Reviews, August 1924. He claimed 100 percent correct prognostications.
The principle of the Abderhalden test (the formation of proactive (?) ferments against living foreign protein) has been extensively used in trying to foretell fetal sex. Using testis instead of placenta. Waldstein and Erkler in 1913 reported positive results from the action of pregnant serum on the testis, but they considered it due to previous semen absorption and made no mention of is possible to use in fetal sex diagnosis. In 1914 Franz Lehman first suggested that fetal sex might be determined by a modification of Abderhalden test. Later, he attacked the problem himself. Koenigstein of Schauta's clinic in Vienna in 1913 found that there was more destruction of fetal, infant, and steer testis by male than female pregnant serum. In 1917 Kraus and Saudek of Bruenn published their stimulating work done in 1913 and 1914. They employed carefully prepared (kosher) steer testis and pregnant serum, claiming nearly 80 percent correct prognostications. Schaefer of Bumm's clinic tested fetal and adult human testis and calf testis with pregnant serum; the best results were obtained with a fetal testis, but the conclusion reached was that he tests were not reliable. The most determined effort to use a modified Adberhalden test in fetal sex diagnosis was made in 1924 by Luettge and v. Mertz at Sellheim's clinic, the scene of Abderhalden's original work. for a "substrate" they used carefully prepared bull testis (later, a commercial product free from amino acids), which was incubated with the serum to be tested. The high molecular proteins were precipitated from the filtrate by alcohol, using this instead of dialysis. After further filtration, the final fluid was tested for split proteins, presumably produced by the antitesticular ferments in the male pregnant serum, by a ninhydrin color reaction. In 1925 I spent a day in their laboratory, and later in the same year, tried to duplicate their results at the Kilmer Pathological Laboratory. Our first seventeen serums were diagnosed (?) correctly; the next eight were wrong. A large literature for and against the method and its accuracy exists. The originators claimed over 78 percent, even up to 98 percent, correct prognostications. Those interested may consult their book. The optical interferometric method of Loewe-Zeiss has been used by many investigators, especially P. Hirsch, to test the serum after incubation, quantitatively.
Allergic skin reactions have been the basis of a number of attacks on the problem of fetal sex diagnosis. Lehman tried skin inoculations with extract of the animal testis; Koenigstein cutaneous injection of testicular extract in pregnant animals and pregnant women. Their results were not definite. Human semen and extracts thereof, preparations of the testis (both animal and human) and male fetal blood serum have been employed in skin tests on pregnant women by scarification and intradermal injection. The reactions have been sometimes negative, sometimes slightly to markedly positive, frequently bizarre. While the results have been too conflicting to permit definite conclusions as to their ultimate value in prognosticating fetal sex, they have been without question better than those afforded by chance. The most recent report is by Davis who injects intradermally a stock \testicular extract, grades the test by the resulting wheal and reports between 80 and 90 percent correct findings. It is a hope that all these puzzling skin reactions may be better understood when the workers in allergy shall have been able to put their house in order.
Although fetal sex hormones must be the primary cause of any differences that may exist in the effect of fetal sex on the pregnant women, endocrinology to date has disappointed high hopes for solving the problem of fetal sex diagnosis. The male and female sex hormones are closely related chemically, their differentiation in the blood is difficult, and "both male and female stimulating substances can be extracted from both male and female urines" (personal communication from Dr. Carl R. Moore. With the cooperation of Mr. Jesse Briggs of the Kilmer Pathological Laboratory, I have carried on some observations of the number and prominence of the developed follicles in the Friedmann test, to determine any relationship to the sex of the child. The number of observations has been too small to warrant the ay conclusion. Dorn and Sugarman injected intravenously into immature male rabbits, whose tests must be in the inguinal canals and not in the scrotum, the urine of women pregnant in the last trimester of pregnancy. If later examination of the testes of the animal showed increased vascularity and cellularity and beginning spermatogenesis, they believed that they could conclude from their series of cases that the women were pregnant with a female fetus. They thought that they had discovered, in the urine of women carrying a female child, a true and hitherto undiscovered sex hormone which can stimulate the cells in the testicular tubules of the pubescent male rabbit and cause a precocious development." They claimed 94 percent, 80 out of 85 cases, correct prognostications. Other workers have not been able to duplicate their results. Mathieu and Palmar cite numerous references record the results of their own investigations which did not succeed in accurately diagnosing fetal sex and indulge in some interesting speculations. It was inevitable that the hormone test for pregnancy would be employed in an attempt to solve the problem. It is encouraging to remember that endocrinology is the merest infant in the world of medicine.
All efforts ever made to diagnose the sex of the human fetus in utero may be placed into three groups.
Ancient beliefs about the diagnosis of fetal sex have almost entirely disappeared, but are still of interest, for ancient thought is the basis of nearly all modern attacks upon the problem.
More modern investigations of the problem have one or more representatives in each of the three groups. In the third group, serology and endocrinology have been the mean employed, with encouraging results.
Much thought has been expended and much work is done in this broad field, with its many converging paths of research, as evidenced by the appended bibliography, which is by no means complete.
In the first group are the beliefs that the male comes from the right side of the uterus or the right ovary, and that male pregnancies cause right-sided symptoms in the mother.
In the second group are the beliefs that the physical attributes of the fetus during pregnancy and labor differ in the sexes.
In the third group are the beliefs that the male fetus, through its secretions, affects the mother differently than does a female fetus. These differences in effect may be of degree or kind, and there is some evidence that they do exist. Sufficient knowledge and means are not now at hand to recognize these differences for practical use. This group is the largest.
Modern investigations of the problem have one or more representatives in each group. In the third group, serology and endocrinology have been the mean employed, with encouraging results.
Neither clinical observation, nor serology, nor endocrinology has solved the problem of the fetal sex diagnosis.
That much thought has been expended and much work is done in this broad field, with its many converging paths of research, as evidenced by the appended bibliography, which is by no means complete.
Neither clinical observation, nor serology, nor endocrinology has solved the problem of the fetal sex diagnosis.
The correct prognostication of fetal sex would satisfy a great curiosity and answer the pregnant woman's age-old question. It is true that it would not have great practical value. Research along other lines might well produce more solidly beneficent results. It may be true that such diagnosis, if possible early in pregnancy, might increase the incidence of induced abortions, though this does sound a bit timorous and farfetched. The parents made unhappy by knowing beforehand what they were going to have might easily be outweighed by those rejoicing in the knowledge that they would have a child of the sex they most desired. Its discovery might be exploited by the unscrupulous, as was salvarsan in its early history. All these and other objections have been raised. But the fact remains that no permanent harm has ever come by making the way of truth wider or smoother or straighter, or by pushing it a little farther. The diagnosis of fetal sex in utero is one of the unsolved problems of obstetrics. As such, it will remain a challenge. Someday, some eye will see clearly what men have as yet seen only through a glass darkly, or some laboratory worker will present the answer to us face to face. Clinical observation may come into its own someday, and what lies ahead in hormone study is not even dreamed of. The problem may still be solved.
The Prolongation of Life By: Stuart B. Blakely, M.D.
In the Garden of Eden grew a tree whose fruit conferred sternal life. The book of Genesis relates how the first man threw away his gift of perennial youth, and the sons of men through the ages have labored to undo Adam's deed. Man's struggles against oblivion, his efforts to prolong his earthly days make an absorbing story. All classes of writers and thinkers have at some time made an attack upon the problem. From Cicero's Essay on Old Age to Metchnikoff's Prolongation of Life the literature of this and allied subjects is very great. But we really know very little about longevity, either the greatest age ever attained by any human being or the normal span of human life. We have proof, however, that the average length of civilized life has been doubled in the last 350 years, and that it is steadily increasing. The solution to the problem seems to be educational and economic. Today we are to consider longevity in general, to pass in review celebrated instances of long life from ancient times to the present, to discuss the theory of old age and its diseases, and to examine some of the remedies and methods used at different times to defer the day of dying. And finally, we are to take unto ourselves any lesson or fact or truth that all the men and years past and modern science can offer in an effort to prolong life and to make life more livable.
It is the popular idea that primitive man had gigantic size, increased strength, and astonishing duration of life; that man and beast in peace and purity and happiness lived and roamed in perpetual spring the Elysian fields. We look backward and call it the golden age. As a matter of fact, it never existed; it is yet to come.
From Assyrian tablets we read the legend that 4000 centuries age men lived for 50,000 years. Tradition ascribed to Adam a height of 900 feet and a life of ten centuries. The ancient authors report many instances of men living to 1000, who were children at 100. India, whose magicians still perform miracles of rejuvenation, furnished several. Strabo relates that a Punjab people, by temperate life and limitation of feed, averaged three centuries. Pliny writes of man of 500, and of an island king of 800; Lucian, of a man of 600. Certain men and families of Ancient Greece were reputed to enjoy perpetual youth for centuries. Nester was said to have reached 300. The Ascribed ages at death of the ten men of the Bible who lived before the Flood, Enoch, excepted average 912 years. These astounding and incredible ages of Old Testament patriarchs have been explained in several ways. According to Jewish legend, their lives were prolonged to establish the length of astronomical periods. It has been asserted that to men of a strong peaceful race of sober simple habits such ages were possible in a dry healthy climate under good hygiene and sanitation. Another theory is that down to Abraham the year consisted of only three months and became twelve months only at Joseph's time. The most sensible explanation is that these ascribed ages represent the duration of the different patriarchal dynasties. By this method, the genealogy of the fifth chapter of Genesis is brought within the realm of reasonable possibility. For example, Adam lived 130 years and his "period" was 930; Jared lived 162 years and his dynasty lasted 962; Methuselah lived 187 years and the House of Methuselah was in power 969 years. Whatever may have been the ages of these Bible patriarchs, we shall see alter by passages from the Old Testament itself that such extremes were not known, and that ages of 100 to 150 were considered old even at that time. In Greek and Roman history some lived to be over 90 and a very few over 100. Pythagoras said that 60-80 was old man and that after 80 "he ceased to live". In the reign of Vespasian between the Apennines and the river Po among a population of three millions only 170 claimed to over 100, the oldest some ever 150.
The period from the time of Rome to the 19th century records many and astounding internees of long life, not to mention the claims of the charlatans and endorse of the elixirs of the middle ages. In 1799 James Easton compiled a list of over 1700 hussars reported dying over 100 years from A.D. 66 to 1799-17 centuries. Eight were reported between 150 and 180. Haller made a list of a thousand persons who had lived to be over 100, the oldest 169. These lists claimed to contain only reasonably authenticated cases, but few will bear careful scrutiny. They are very interesting and many of the author's comments are very quaint, but we can mention but a few. St. Anthony, the great, "model for Monks", died at 105, St. Patrick at 122, St. Munge at 185. The shield-bearer of Charlemagne lived to be 300. A "certain German", prisoner of the Saracens, was compelled by their king to drink a liquid presented him by a neighboring potentate which he mistrusted. Instead of poisoning, it prolonged the prisoner's life to 500 years. In 1566 a native of Bengal in India died at the reputed age of 370 years. a Portuguese writer relates that the native had had four sets of teeth, that his beard had repeatedly turned from black to gray and back again, that he had 700 wives, and that he had prolonged his life by eating of a certain fruit. In 1741 John Rovin died at the reputed age of 172 and his wife at 164, after 145 years of wedded life. Peter Czertan an Hungarian peasant, died in 1724 at 185, leaving sons of 97 and 155 years. A Norwegian named Drakenberg died at 146 and had been a sailor for 91 years. The Countess of Desmond died at 145. Several cases are cited of ages between 140 and 205.
The two most quoted instances of longevity are two English peasants, Henry Jenkins, and Thomas Parr. Henry Jenkins of Yorkshire died in 1670 at the age of 169 years. He once came to court with his two sons of 100 and 102 and testified concerning an event occurring 140 years before. Thomas Parr of Shropshire died in1635 at the age of 152 years. He married first at 88 and had two children; at 102 he impregnated a woman and married again at 120. Up to 130 years of age he was able to do the usual farm work. His feed was chiefly milk, bread, and cheese. His fame spread to London and he was presented at court. The Change in living killed him. The celebrated Dr. Harvey performed an autopsy on his body and found none of usual senile changes in his organs. He reported his death due to a "plethers from overeating". Old Tom Parr", as he was known, had two grandsons over 100, and a great-grandson of 102. He had lived under ten kings and queens of England and was buried in Westminster.
During the last century numerous cases of longevity have been reported from various parts of the world, particularly Russia, South America and the United States. In 1901 an English newspaper hunted out twenty persons who been born before 1800. In 1888 a Frenchman died at the attested age of 118 years. We all are, or until very recently were, familiar with the old man or women, especially negro, who claimed to have seen Washington or Lafayette. People lie or are ignorant about their ages; the impressions of interviewers and travelers and the statements of historians are all of little real value. It has been claimed, and the claim had never been absolutely refuted, that no person since the time of Christ has reached 100 years. Without question, however, men have lived beyond the century mark, but their numbers, however, men have lived beyond the century mark, but their numbers, comparatively speaking, are very few. Assuredly no man has survived two centuries.
The greatest age never attained by any human being has, however for us only an academic interest. We are much more desirous to know the length of the normal human lifetime. What is the normal span of human life? Omitting pure speculation, the methods used to determine the normal span of human life are of two classes, physiological and historical.
Aristotle was one of the first to suggest a possible relationship between the length of gestation and length of life. It is a purely comparative study. In birds, there is obviously no relationship. The period of gestation in man is about 280 day and let us say that he lives 100 years. Compare some other mammals. In the horse, the period of gestation is 330 days but the horse rarely lives over 40 years. In the cow it is 286 days, practically the same as man but the cow rarely lives over 20 years. In the monkey, it is about 150 days about half that of man but the monkey rarely survives beyond 10 years. The whole question has been exhaustively treated and discussed, but the method can give no valid answer. Another field of comparative physiology has been diligently searched, in the effort to determine the ratio of the period of growth to total length of life. To utilize such a method the investigator must possess two groups of facts. 1. We must have accurate records of the age of a large number of animals or groups of animals. Such we do not possess. Man has never seriously tried to prolong animal life, to determine or lengthen the span of brute existence. It is earlier, more economic, more satisfactory in every way to get rid of the old, to breed the new. Possibly nature feels the same about the human species. Propagation of the species seems to be the great destiny of all life. That accomplished the goal seems to have been reached and the organism speedily perished. 2. We must determine the point at which any given animal reaches maturity. It has been long observed in both plants and animals that slow growth and large size are usually associated with long life. But when is growth at the first maximum weight, I.e. exclusive of purely fatty increase. Others have claimed that certain bony changes mark maturity. The mouse reaches full development at about three weeks, the elephant at about 24 years, man between 20 and 30. Buffon on the last of the 18th century thought that seven times the period of growth would give the normal span of life. Man, by this reasoning should live about 150 years. Fleurens in 1856 believed that five would be a more accurate multiplier, and so determined on about 100 as the normal span. Whether the figures be correct or not, the method is obviously uncertain and wholly theoretical. The science of number cannot be here applied. The other line of investigation is hysterical. Haller and Hufeland on very questionable evidence determined on 150 and 200 years, respectively, as the normal length of a man's life. Let us examine some historical evidence. Abraham at 175 "died in a good old age, an old man and full of years". When told that a son would be born to him in his old age he said, "Shall a child be born to him that is a hundred, shall Sarah, who is ninety years old, bear"? If a life of serval centuries had been at all a common thing at that time on can scarcely explain such passages. Five centuries after Abraham Joshua at 110 was said to be very old. In Egypt, in Joseph's time the utmost limit of human life was but a little over a century. David was old at 80. In Gn. 6,35 the limit is set at 120, but "there were giants in these days". Is 65,20 seems to set it at 100. In a book of the Apochrypha, it states that the number of a man's days at the most is 100 years. No authentic history of any country records any extraordinary length of human life. In China in 1657 of 373,000 indigent old men, only one hundred claimed to have reached or passed the century mark. The Chinese call 70 "a rare bird of age", and 100, "age's extremity". It has been estimated that of a thousand born only one reaches 90, and only one or two in a century reach 150. According to the U.S. Census of claimed to be 100 or more. The Psalmist's figures of three score years and ten and fourscore years are not far wrong for the normal span of human life today.
Why do Men grow old? Two conceptions have been very easy for the human mind. One looks upon dried, shriveled, wrinkled age and says that the body juices of youth are dried up, have evaporated, have been dissipated. The other view likens the body to a timepiece set to run a given length of time. These views are purely speculative, but how often have the speculations of the dreamers' come near the truth. The modern, scientific view of ae is that we start life with certain potential longevity, that the tissues of our bodies are endowed with a certain amount of vital forces. This forces this ability to live may be lessened or drained by accident, misuses, disease, poisoning from without or from within. Chronic infections of all kinds, without doubt, take a heavy toll of years. But with all these eliminated and avoided we begin to age from birth, if not from before birth. Every phenomenon of that activity we call life hastens the break-up of the organism. The guiding, controlling force of the cells that compose our bodies, the nucleus, perishes. The cells lose their ability to repair, to replace themselves. We lose our capacity for growth. Death is the penalty that we pay for life. Death is, however, for man an acquired characteristic. The organism of a single cell, barring accident or disease, is immortal. We long ago left that stage. Our cells have become so highly differentiated into tissues that they have been compelled to relinquish the gift of immortality. One group, however, have retained the capacity for eternal life. These are the products of the glands of sex the ovaries. Through them, we may be immortal in our descendants. Many years age Charcot wrote a book on the Diseases of Old Age that has remained a classic, as have most of the writings of the famous French physician. It is but within the past few years, however, that the study of the diseases of the aged, geriatrics, has attracted the attention due the subject. Senile changes begin not locally, but generally, and consist of atrophy and degeneration of the tissues. The result is lessened function with diminished secretions and weakened metabolism. Shakespeare's description of the "learn and slipper's Pantaloon, sans teeth, sans eyes, sans taste, sans everything" is very striking. We are all familiar with the visage of age the dry and wrinkled skin, the thin grey hair, the toothless mouth, the shortened stooping form, the trembling hands, the shaking head, the tottering gait. The mental changes of intellect, memory, and emotion vary from none evident to those of senile dementia. Charcot mentioned fevers, rheumatism, pneumonia, asthma, and arterio-sclerosis as the most common diseases of the aged. It has been said that a man is as old as his arteries, and it is true that death comes to the most of us in the guise of some circulatory change. It is hard to admit that we are growing old. The thought that the world can jog along without us is displeasing. There comes a day when we suddenly awake to realize the distance that we have come along the road that passes from childhood through youth and middle life. Victor Huge has said that it is better to be fifty than forty, for forty is the old age of youth and fifty is the youth of old age. The ancients by the doctrine of crises divided life into periods of seven years. Infancy ended at seven, adolescence at fourteen, youth at twenty-eight; maturity was reached at forty-nine; the grand climacteric was seven times nine or sixty-three. Manhood ends and old age begins at sixty-five or seventy. The status of the aged has presented curios fluctuations and inconsistencies through the ages. Herodotus tells of a Scythian people that made their parents when they became old, hang from the branches of a tree. If they failed to maintain their hold when their offspring shook the trunk, they were devoured with avidity; if they clung successfully, they were allowed to ripen a little longer. Some races have made a practice of doing away with their aged folk, often from economic necessity. Among other peoples, more fortunately situated and of higher intelligence, the old men have been the Patres, the Patricians, the Fathers, the Senators, the Elders. Old men for counsel, young men for action; old men for decision, young men for strife. Even to this day among ourselves, it is interesting to note that there are two fairly distinct classes of the aged, the useless and the useful, but age is rarely despised, when not contemptible.
But a great change has taken place in the last half-century. Fifty years ago the average person was considered old at sixty. Grand-father was content to dream ever his pipe by the chimney fire with grand-mother opposite in lace cap and knitting. Today grand-father in duster and goggles owns and drives the car, and grandmother is a much interested in the fashion magazine and the various women movement as her grand-daughter. A famous philosopher and a famous physician have asserted that a man adds little to his stock of knowledge after forty, that a man cannot love new things after forty-five. This has a medium of truth, but it is unfortunate that Dr. Osler and chloroform have been inseparably linked together.
Some of the best work in this world has been done by men past sixty. Archimedes discovered the burning glass at seventy-five. Titian and Michael Angelo were still great artists at ninety. John Wesley preached up to eighty-eight. Longfellow and Tennyson wrote to beyond three score years and ten. Victor Huge was best at seventy-five; Voltaire was active at eighty-three. John Quincy Adams was in the Senate at like age. Savage Lander and Isaac Walton wrote till ninety. Gladstone at eighty-three said that he represented the youth and hope of England. Thomas A. Edison at sixty-eight and Luther Burbank at sixty-five are still magicians. James J. Hill at seventy-seven is still a force. The present European war has been called an old man's war. Kitchener is sixty-five, Jeffrey and French are sixty-three, Von Kluck and McKenson are nearing seventy. Many further examples might be brought of men and women too who were or are still active in some sphere at an age usually considered old. But some men are never old, and some are never young. It is not a question of years, or of figures on a dial.
We pass very few facts of the mortality of ages past. It is only within the last 400 years that any attempt has been made to keep vital statistics, and only within the past 50 years and in a few areas have any been at all reliable. We are today somewhat beyond the mental attitude of the Arab chief who, when asked how many of his tribe had died the year past, answered "Allah alone knows"; and to the question what the cause of their death was, replied, "It would be impious to ask". Still in the United States in 1914 only 66.9 p.c. of the estimated population were comprised in the registration area for deaths, and only eight states had adequate birth registration. The impetus for the better registration and keeping of vital statistics has come largely from commercial sources, and it almost makes one believe that only true power in this world is economics.
All the facts that we do possess show that human life is not warning. In ancient Rome, the expectation of life at birth was about 22 years. A man today at 25 lives on an average fifteen years longer than a citizen of like age under the Caesars. When Columbus discovered America the average length of life is thought to have been less than 20 years. In Genova, Switzerland, in the 16th century, the expectation of life at birth was 21,.2 years; one half died before 9 years, and only one third reached 20. Even in 1769, only one-half reached 10 and one in about 16 reached 60. Today two-thirds reach 20. In Massachusetts, at the time of the Revolution, the expectation of life at birth was about 35 years. One hundred years ago in the United States, it was about 28 years, in France 31.5. Today the New England and Middle Atlantic States have an expectation of life at birth of nearly 50 years. In New York City the figures are 44 years for males and 48 for females; for England and Wales they are 51 and 55. In India, by contrast, the expectation of life at birth is less than 25 years and has changed but little in the past two decades. In Europe in the 17th and 18th centuries life increased at the rate of 4 years a century, in the 19th at the rate of 9 years a century. Civilized life gas practically doubled in the past 350 years.
The death rate per 1000 inhabitants likewise exhibits striking improvement. In the 15th century, a death rate of 70-100 was not uncommon. In Geneva in the 16th century, it was 39.7; it's now about 17. Two hundred years ago the rate in England was over 100, in Italy over 40. Berlin two hundred years ago had a death rate of over 40; new about 15. The city of London had a death rate in 1600 of over 80; in 1665-the plague year 430; is 1800 about 29; it is now less than 15. The United States has a death rate of about 18, and New York City less than 14. The four cities of Boston, New York, Philadelphia and New Orleans had a combined death rate in 1815 of about 22, now about 15 per 1000. To illustrate the results of reduction of the death rate even by fractions New York state had a rate in 1913of 15, in 1914 of 14.6; this 0.4 represents 4000 lives saved to the state.
What has caused such striking changes? Let us look back on the picture of life 400 years ago. The floor of the average house was the earth, covered with straw that was often not changed for renewed for twenty years and containing bones, food and the excreta of men and animals. Flies and vermin must have abounded. Laundry, bath, and toilet facilities were practically nourishment. Walls were the source of water supply, even in the cities. The sewers were the open streets, into which literally every imaginable. There was little protection against summer rain, or winter snow and cold. There was no glass, few utensils, little furniture. The laborer ate meats, fruits and oats or barley. He rarely enjoyed the luxury of rye, and potatoes were unknown. There was destitution, often famine, little charity or human kindness. The death penalty was enforced for the most trivial offenses. In England in 1800 over 200 crimes wore punishable by death. Europe was almost constantly in a state of war. Labor was long, severe, and poorly paid. Reads and means of transportation and communication were most primitive. Read "Touring in 1600". Sensuality, ignorance, and superstition held away. Infant mortality was appalling in Geneva in the 16th century 44 p.c. of all deaths were under five years. The rudiments of personal hygiene, of public sanitation, of the causes and prevention of disease were unknown. Public disasters were ascribed to Heaven, the Devil and religious activity. In England in the 17th. Century seventeen percent of all deaths were due to pulmonary tuberculosis. Wide-spread epidemics were very frequent occurrences. In 1348-9 the Black Death killed twenty-five million in Europe, and in the 18th century small-pox killed fifty million. In London in 1602 out of a total of 42,00 deaths, 36,000 were caused by the plague. Between 1675 and 1757 ten percent of the population of that city died of small-pox. Not a finger was lifted against this appalling mortality. It was fate.
The dangers of former times have disappeared, have been lessened or disarmed. The causes of diseased are less in force and number. Disease itself has changed in character. Worldwide epidemics are no more. Civilization is organized for protection and prevention. The modern comforts of shelter food and clothing, of education and sanitation, machinery, lessoned labor and higher wages have lengthened life. But civilization has its drawbacks. Luxury, self-indulgence, drugs, and dissipation demand their toll. Alcohol, syphilis and overeating are over present foes. The mortality of ages after 45 has been increased by cancer and diseased of the kidneys and circulatory systems. Degenerative processes and minor ailments are still unchecked. Through our mortality figures compare most favorably with those of any period of time past, we still far from a death rate of 10 per 1000, which, with a stationary population, would represent an average age at death of 100 years. Unlimited existence on this earth would be a luxury. Immortal life here below is not desirable. This seems to be nature's plan. But life is sweet; death is rarely welcomed. Since man starts with the lamp of life filled and lighted, let us see how he has tried to conserve that flame, to retard old age, to prolong his days.
To the ancients' perennial youth and eternal life were gifts divine. The gods on Mount Olympus renewed their youth by nectar and ambrosia. Here was the bearer of the cup of immortally. Zeus, at the request of Aurora, conferred on Tithonian eternal life. The fickle goddess of the dawn failed to ask for her lover the boon of perennial youth, and when he because old and would not die she changed him into a grasshopper. Many and strange have been the methods used to live long, and many and strange are their survivals to this our day. Our ancient brother fasted, took emetics and cathartics, passed through states of trance, ate of certain fruits, drank infusions of certain herbs, dipped himself in certain waters, offered sacrifices to his god or gods. He wished to be born again, he wanted a new heart, he desired to enter upon a new life. To him it was reality. We maintain the same practices; to us it is symbolism, but their ancient use and meaning haunt us still. The idea that serpents renewed their youth, that human semen was the essence of life, and the belief in the efficacy of certain trees and fruits are clear as parts of early religious belief. The mistletoe, the "All Heal" called by Virgil The "branch of gold", has maintained a curious grip on the human mind from a very distant past. Such stories as The wandering Jew and Phra the Phoenician captivate our fancy. To the Babylonians and other early people blood was the "water of life". With the discovery of the circulation by Harvey in the 17th. Century blood as the chief fluid of the harmol pathology of that time came to the fore as a sovereign means of rejuvenation. Blood transfusion was taken up with enthusiasm, first from animal to animal, and then from animal to man. A blind old dog was reported to have become a playful young puppy: a decrepit old nag, a prancing horse. The blood of sheep and calves was used for man. The method failed utterly, as we now know it must have done. Several fatalities occurred and it was abandoned under ban of church and state. The modern revival of blood transfusion from man to man in many of its aspects reveals our ancient brother at his magic rites.
Three methods that have been used at all periods of the world's history against old age deserve separate mention gerokomy, fountains of the youth and elixirs of life.
Gerokomy is the belief that age and its infirmities may be mitigated by youth and its vigor. The idea is very old. The method was tried without success on King David. It is mentioned by Galen and was a popular Roman belief. The illustrious Boorhaave in the 18th century had the old burgomaster of Amsterdam sleep between two young persons and assures us that the old man increased visibly in vigor and activity. A Jewish physician advised Fredrick Barbarossa to sleep with two young men on his chest. The famous old German emperor, whom legend stories as not dead but sleeping, thought this too onerous a burden and substituted two young dogs. In the middle of the 18th.century Cohausen wrote a treatise on this subject, taking as his text the epitaph of L. Clodium Hermippus, a Roman schoolmaster, who had lived to the age of 115 years by the breath of young girls. It is still a popular idea that the emanations from a healthy young body are invigorating. It is commonly held belief today that a weak or ill person by sleeping with a strong well person partakes of the latter's health, often to the latter's detriment. The most modern of us believe that contact and association with youth and young ideas help keep old age at bay. It is the same old idea on a higher mental plan.
Primitive man must have observed the cleaning effect of water on the skin. It was, comparatively, but a step to the idea that somewhere there might be found a fountain, a plunge into whose magic waters would wash away the accumulated body change of the years. Sir John Mandeville tells of odoriferous fountains of youth near the river Indus. The Hawaiians had a life-giving fountain. A report was current in the Middle Ages that a Sicilian peasant found a golden vessel filled with water of which he drank and with which he bathed and lived 500 years. One of the romances of the New World is the quest of Ponce de Leon. Long before his time, the Indians of Central America and the Antilles had searched for a "fabled fountain of the North whose magic waters healed the sick, rejuvenated the aged and conferred immortal youth. It was said to be surrounded by magnificent trees, and the air laden with the perfume of flowers. The trees bore a golden fruit that was plucked by beautiful maidens and handed to strangers. It was the old story of the Garden of Hesperides. These marvelous tales were told the early Spanish explorers, and 400 years ago Ponce de Leon, worn and aged by his adventurous life, started on his quest for this fountain. He drank from and bathed in every fountain and spring of the Bahamas, and on Easter, Sunday came to the Florida coast. His quest was fruitless. They were fabled fountains.
The association of gold with fountains of youth, and as we shall immediately see also, with the elixirs of life, was very close. It is probably a garbled remnant of primitive religious belief. Gold represents the sun, the male element, the life giver; fountain, well or spring, or their waters, represent the female element, the life carrier.
Ovid relates how Medea's brew made Aeson young again. Into her brass cauldron, she put roots and seeds and grains and flowers and stones, dew, hart's liver, screech-owl's flesh, wolves and snakes intestines, and a thousand other things. When the withered olive bought with which she stirred the brew left and bore again and when the from scattered on the barren ground caused grass and flowers to grow, the drink was ready. She forthwith out the old man's throat, and into the wound and through his mouth she poured her witch's brew. His hair becomes black, his color comes, his wrinkles go, he gains in weight; he becomes strong and lusty, forty years younger in mind and body. He much admired the change as well he might. It was a grand elixir. This story from the age of fable reflects human nature that does not change. Before the Christian era, the Chinese believed in the existence of a draught of immortality. The time and energy that has been spent in the endeavor to discover the Elixir of Life has been untold. The intensity of the search reached its height in the fascinating and fanciful studies of the alchemists. Alchemy is usually understood as the art of turning base metals into gold and silver through the medium of some secret preparation of high value. This secret preparation, though given many names, was popularly known as the philosopher's stone, whose pursuit was a most popular pastime of Europe 14th., 15th. And 16th centuries, and from whose enchantment we have not yet entirely freed ourselves. The most bizarre and nauseating substances or combination of substances of most intricate formulas were hailed as this material prima. Each experimenter loudly urged the claims of his own special discovery which he was willing to dispose of for a price, and whose possession would give its purchase wealth and long life. It is a curious thing how near some truths these old philosophers came. A modern ferment acts as they hoped the philosopher's stone to act, a small portion on a large amount without loss of power. The discovery of radium and radioactive substances has again brought to the force the persistent idea of the possible existence of some all-powerful principle somewhere in the depths of nature. The reasons why alchemy turned so assiduously to the discovery of the elixir of life are intricate and complex. The worship of the sun is a perfectly understandable and logical belief and has maintained a most persistent hold and influence on the human mind. Gold was the prototype of the great life-giver, the sun. The yellow metal was therefore good for disease, and potable gold was earnestly sought as a panacea for all ills. Since the philosopher's stone could produce this precious metal gold, how much more powerful must it itself be against disease, old age, and death. A piece of philosopher's stone as big as a kernel of wheat soaked nine days in urine and wine and the preparation drunk every day was said to keep one well to the end of time. They believed that there was a specific hidden in nature that would arrest the changes of the years. Offset the effects of time, restore youth, prolong if not perpetuate life. Long after the claims of the ability to produce gold from other metals had become discredited generally the belief in the efficacy of such universal medicines persisted long after it had degenerated into pure charlatanism.
Paracelsus is the best known of the alchemists. Born in 1493, son of a physician, his career was successively that of a reputable doctor, professor at the University of Basel, wanderer, outcast, charlatan. His aim and dream were to make alchemy serve medicine, and by its magic means to "restore to man the health and soundness that he had lost". He also had discovered a philosopher's stone and manufactured an elixir of life. To quote from one of his announcements "By it", I.E. this elixir, "all infirmities may be cured, human life prolonged to its utmost limit, and mankind preserved in health and strength of body and mind, power and vigor. All wounds are healed by it without difficulty, and it is the best and surest remedy against poisons; with it, too many other benefits to you and the community of your realm may be wrought, such as the transmutation of metals into actual gold and the purest silver". How familiar it all sounds, though written nearly 400 years ago! In 1541 at the age of 48 Paracelsus died with a bottle of his elixir in his pocket. He has been called a charlatan and a faker; an iconoclast he surely was, but with him began an era of trying to make chemistry serve medicine.
The unscrupulous of all periods of the world's history have preyed upon the fear of death, superstition, and credulity of their fellow. It was perfectly natural that alchemy should breed charlatans. The trade in all kinds of elixirs thrived, and the claims made for there were the most extravagant. One alchemist in the 12th.century claimed that he had lived over 1000 years by means of his elixirs. Old women were reported to have become young, and to have born children. In the 18th.century that arch charlatan Count Cagliostro appeared with his Aqua Benedetta, his Balm of Life, which drove away the wrinkles and made its users young again. You can hear the echoes of such claims in the advertisements of today. Cagliostro gravely maintained that he was immune to poisons, that he had lived before the flood and had been in the ark with Noah. There were cephalic waters and stomachic waters, waters of immortality, and cordial waters of Hercules. Our ancestors one hundred years ago bought steel lozenges for preserving life, imbibed vital wines and slept in celestial beds. There were all kinds of "drops" and "balms". even "old Tom Parr" had a medicine named after him. The formula for an elixir of long life has been but recently deleted from the German pharmacopeia. Go into any modern well-stocked drugstore, and you will find Elixirs and Balms of life that find ready sale. Omitting the innumerable and often unmentionable ingredients of the elixirs of other days it is interesting to observe that such elixirs, past and present, contain about the same basic elements a laxative, a bitter, an aromatic and alcohol. For each and all of these was and is a reason. The makers and the vendors of elixirs of life, ancient and modern, have never lacked for this world's goods, for the two most precious things in this world are health and long life and we are glad and eager to part with any of our possessions to retain or recover them.
The modern movement for longer life is taken seriously by many groups and classes. We have centenarian, longevity and live-a-little-longer clubs. The Life Extension Institute with its keep well Leaflets and its monthly Health Letter is making new paths toward longer life. We have days to buy cotton, days to clean up our cities, days to celebrate many things; we ought to have "a medical examination day". The modern intelligent well-read man knows that prevention and early recognition of disease mean longer life. Within certain limitation, an individual can himself determine his length of days, and a community its own death rate.
In olden times human life was purchasable and was cheap. It is still purchasable and is still cheap. One-third of all deaths can be prevented or postponed. Half a million people of the United States have pulmonary tuberculosis, and one half of these are totally incapacitated. Half a million workers are killed or crippled at their work each year, and half is needless waste. Every year in this country 10,000 children die of whooping cough, and there are 300,00 cases of typhoid fever from which 16,00 die. There are but a few of the preventable deaths that cut down the average of life. Two hundred years ago ten percent of all deaths were due to small-pox. To our grandparent's vaccination was almost religious duty, for they know well what small-pox meant. Now the autovaccinations want us to do away with vaccination that has increased the mean duration of life about 3 Â½ years. If disease is preventable, is it worth-while in dollars and cents? The mere indefinite prolongation of life is economically not desirable, however much so, it might be from the individual standpoint. The object is to eliminate the cost of unnecessary illness, death, and suffering; make life healthier and thereby longer; and through both to increased number of men of mature years and ripened judgment. In the United States, there are annually about million and a half deaths. Approximately three million are constantly ill, averaging about 13 days a year nearly four percent of the whole year for each inhabitant at a cost of at least $27.00 per year for every person this country. Each death represents more than two years of illness. Sickness and death cost us each year thee billions of dollars, a year in death claims. The annual deaths from tuberculosis in this country represent an economic loss of $727,000,000; one life insurance company pays out every year $800,000 for tuberculosis death claims alone. The extermination of syphilis would eliminate half of our institutions or defective and insane, that cost $85,000,000 a year. Headaches, tooth-aches, "colds" and minor cause each person an average of three days loss of time each year, and nine-tenths are preventable. The State of Pennsylvania during a period of seven years reduced its death rate 2 per 1000, and thereby saved 51,000 lives to the commonwealth. They are buying human life in The Keystone State. It has been estimated that the sickness and death rate could be reduced about one-third by an expenditure of about two cents per person per year.
If diseased can be prevented it is clear that the average of life would thereby be increased. Prof. Irving Fisher of Yale, President of the Committee of One Hundred on National Health, is authority for the statement that if we the people and the government put into practice all that is known about disease and its prevention fifteen years would be added to the average length of life in this country. To find a cure for cancer would add ten years to human life. Col. Gorgas is the authority for the statement that $2.00 added to the laborer's daily wage would increase the average of life by thirteen years. Within natural limitations, public health is purchased and so is length of life.
The prolongation of life and the making of it more livable resolves itself into a question of money and of brains, question of education and economics. The economic aspects of the problem have already been very briefly touched upon. A small portion of the money wasted by preventable disease and death would, if rightly used, give a thousand-fold return. It used to cost the city of Pittsburg three million dollars a year for its typhoid; a seven-million-dollar filter plant is considered a good investment. One small-pox epidemic cost Philadelphia twenty million dollars, that could have been prevented by the expenditure of one-third that sum. Health is wealth. a sick citizen is a liability. A healthy inhabitant is worth at least $2,900 to his country. The educational aspects of the endeavor to prolong life present great problems. Fairly efficient ruled for healthful living have been the property of some of mankind since history's dawn. Philosophy and medicine have both contributed to the science of longevity. The sanitary code of the ancient Hebrews was a classic of its kind. The ancient Egyptian hoped by two emetics a month and by sweating to avoid the baneful effects of the Nile basin. His customary greeting is said to have been, "How do you respire"? In the pure sir and under the sunny skies of Greece the Athenian hoped to live out his days by "rational enjoyment and continued use of his powers". It is interesting here to note that it was probably a preventable disease that destroyed the greatness of Greece. Hippocrates, Father of Medicine, who died at the age of 99, advised moderation, pure air, bathing, and exercise of body and mind. According to Pliny Rome two thousand years ago needed no physicians so generally were observed the laws of hygiene. This is probably a gross exaggeration, for the health of ancient Rome was notoriously bad. In the 15th.century Ludwig Cornaro, a Venetian nobleman, at the age of forty was told by his physicians that he had but two years more to live. He thereupon reformed his habits and lived for sixty years more on 12 ounces of food and 14 ounces of drink a day. He wrote a book entitled "A Sure and Certain Method of attaining a Long and Healthful Life". Roger Bacon in the 17th.century was the author of "The Cure of Old Age and the Prevention of Youth", that is wonderfully true and valuable through mixed with curious ideas and false beliefs of his time. The human race has never lacked for sound and sensible rules of health that it has steadfastly broken and paid the penalty. Many are current aphorisms. E.g., No day all day indoors; Drs. Diet, Quiet, and Merryman; Great temperance, open air, easy labor, little care; Live on six pence a day and earn it; Easy conscience, merry heart, contented mind; He who eats for health, eats little; Every wise man after fifty ought to lessen the quantity of his ailment, and at the last descend out of life as he entered it, even into the child's diet. Health cults, food faddists, schools of healing abound and prosper. Some men Fletcherite others walk barefoot through the dewy grass at morn. Others escrow meats and are vegetarians. Some sleep with their heads to the north to demagnetized the body. We have almost as many superstitions, are as much fatalists, are nearly as credulous as our benighted predecessors about our bodies and their care.
Two lines of modern thought that look toward the prolongation of life deserve more extended mention because they are so popular and so much in vogue. It has long been observed that vigor of body and mind are usually associated with sexual vigor, and that loss or removal of the sexual organs has a profound effect on the body and its development. We have already mentioned how human semen has been considered the essence of life. The idea that senility is caused or accelerated by the loss of the internal secretions is a subject full of interest and of promise, but at present chaos. Brown-Squad is really the father of this school of thought. This bold and original thinker and experimenter at age of seventy-two injected into himself extract and blood from the testicles f dogs and guinea-pigs. He claimed thereby to have become younger in body and spirit, and that others experienced the same beneficent effects. Spermin did a thriving trade. The present wide advertised animal and goat lymph compounds are such extracts. With the modern attack upon the problem of the internal secretions extracts of testicles, ovaries and other glands are on the market by reputable firms. The enjoy moderate popularity, can be used to advantage in certain conditions, but have no effect on old age. The loss of sexual power and the lessening of internal secretions are not the cause of old age, but a part of the process of senility.
Some years ago, Metchnikoff of the Pasteur Institute in Paris observed, or thought that h observed, a relatively great number of old persons in Bulgaria and the Near East. Since the use of soured milk in that part of the world is very ancient, Metchnikoff drew the conclusion assuredly false that their apparent longevity was due to what they drank. The theory of old age and its prevention that he evolved is briefly as follows. Old age is caused by toxins, or poisons, produced by bacteria or germs in our large intestine. These poisons are absorbed into our circulation. Sour milk is soured by and contains certain bacteria, known as lactic-acid bacteria, Bulgarian bacilli and the like. These bacilli, when taken into our intestinal tract, are antagonistic to the harmful germs growing there and forthwith processed to kill the foe or to inhibit their growth and action. As a result of the rapid and enthusiastic spread of Metchnikoff's ideas, we have heard much of intestinal stasis, auto-intoxication, intestinal poisoning and the like. Manifold preparations of lactic acid and Bulgarian bacilli, many absolutely insert and worthless, have been put upon the market. The drinking of buttermilk and other sour milk preparations has become a fad, one might almost say a cult. One enthusiast has written a book called "The Bacillus of Long Life". It is, without doubt, true and possible that the absorption of poisons from our intestinal tract may cause degenerative processes in our tissues, and that our large intestine may become a source of danger to us. Numerous operations have been aimed at it. Dr. Arbuthnot Lane of London removes it in its entirety, certainly a formidable proceeding. The solution of the problem lies in learning more about food and its fate in the body, move about the flora of the intestinal tract, not by sending an invisible army against a hypothetical foe.
Some years ago, the British Medical Journal investigated the characteristics of nine hundred old people, of whom seventy-four were over 100. I was found that the majority had regular habits, were moderate eaters with good digestion, sound sleepers, of medium height and weight, and most of them used no alcohol and tobacco. Let us now consider the main factors know to favor long life. The may be grouped under four heads- heredity, environment, public sanitation, and individual hygiene.
Certain families are noted for and are proud of the number of long lived members. A tendency to longevity can certainly be transmitted to the tissues of descendants, and eugenics, the much abused, can aid hereditary influences.
Preventative medicine has enabled man to be, to a large extent, master of or indifferent to his environment. Though climate and other factors of surroundings may be largely controlled or eliminated they still profoundly influence vitality.
Public Hygiene The lines of modern activity that can be brought to bear on the problem of the prolongation of life are vast in number, scope, and influence. Consider the machinery of federal, state and municipal hygiene; sanitary codes and their enforcement; the quarantine, reporting, and isolation of disease; and the keeping of vital statistics. Good drainage, efficient garage and sewage disposal clean streets, sufficient park area are all vital factors in a community's health. A progressive medical and dental science, god hospitals and sanitaria are assets and safeguards. Better babies, child welfare, milk depots, school inspection, old age compensation, relief and education of all kinds work toward a better and longer life. There is a 50-80 percent higher mortality among the poor. Infant mortality is in direct proportion to the environment and income of the family. In a city in Pennsylvania, it was found that in families with an income of $10 a week the infant mortality was 256 per 1000 births; in families with an income of $25 a week, the infant mortality rate was only 84 per 1000 births. The quarters of a city presenting neglected streets, unsanitary housing, crowded quarters compare most unfavorably with the better residential quarters. Man's food and drink, his housing his hours and conditions of labor, and his wages have all a direct bearing on the length of his life. Our neighbor's health is our business as well as his own.
Individual Hygiene- Nature is frugal and her wants are few. It is surprising how far a little health, well managed, may be made to go. The individual should have fresh pure air, a proper amount of suitable well-cooked food, clean surroundings, protection by clothing and shelter. It costs more than money alone to drink alcohol and use tobacco. Total abstainers have a 23 percent lower death rate. Two glasses of beer, or one of whiskey, a day will take at least a year off a man's life. The individual should cultivate regular habits of work, exercise, play, rest and sleep. It is not working but worry and the pace we set that kills. James J. Hill says that it is not so much the high cost of living, as it is the cost of high living. Men do not die, they kill themselves. The individual should know at least the rudiments of the anatomy and physiology of his body and its care, and the principles of the prevention and avoidance of disease. Moderation in all things, excess in none, is a difficult, though highly desirable mode of life. Let us not forget that there are no fountains of youth in this world save God's fields and hills and trees and streams, God's ocean and God's skies. There are no elixirs comparable to sunshine, fresh air, pure water, plain food, right living. A clean and healthy body and a calm contented mind are the best defenses against the attacking years.
And finally, we should not neglect a good philosophy of life. We should seek the right combination of work, play, love, and worship. Cicero's Essay on Old Age should be perused. We should recognize that there is a time to be old, to take in sail. Follow the spirit of Browning's verse- "Come, grow old along with me, the best is yet to be, the last of life for which the first was made". And it should be the richest, easiest, happiest time of life, giving us a chance to rest ere we are gone again on our adventure strange and now.
Binghamton, N.Y., November 15, 1915
Into any discussion of the problem of cancer there are immediately projected three human factors, the patient, the patient's physician and the specialist.
The great objective of the present campaign against cancer is the patient, actual or perspective. Never before has knowledge been more generally the property of the people. Nevertheless, ignorance and superstition still sway many minds. Avarice, fear, and credulity have not been eradicated from human nature. As long as "cancer cures" can be advertised from sea to sea or hawked from door to door, as long as cancerous and quacks abound, just so long will there be found persons to believe their cruel claims. The public must be educated. They must be shown the need and value of frequent physical examinations. They must know that any chronic ulceration or any abnormal tumor or swelling is pathological, will probably not disappear, and is a source of danger. They should be taught that any unnatural discharge from the nipple or from a body cavity, or any persistent or recurrent abdominal symptom must be investigated. Women must learn that a lump in the female breast eight times out of ten is, or will become, malignant; that any irregular uterine bleeding, especially intermenstrual or post-climacteric, however slight, is a signal to be heeded. It must be emphasized that cancer is not loss or weight. Bloodgood claims that benign tumors of the breast are more painful than malignant ones. As a matter of fact, pain and cachexia are late rather than early signs in cancer. Twenty p.c. of breast tumors occur under 40, and over five p.c. of all cancers under 35 years of age. The public must be instructed in at least the rudiments of scientifically correct anatomy and physiology, and in the early signs of cancer. All must realize that cancer in its incipiency is strictly a local disease, usually in an accessible area, that in a degree it can be prevented, and if taken early can be cured. About forty p.c. of all cancers have a recognizable precancerous stage or lesion. Cancer is a dangerous, insidious, rapidly increasing foe, and procrastination in beginning the end of cancer that should be feared.
How is this instruction and education of the public to be accomplished? It is, unfortunately, true that the medical profession is distrusted and discredited generally. The discussion of the causes thereof is beyond the scope and bounds of the present paper. We can only slowly retrieve our position as leaders. This we are accomplishing. Meanwhile, in the campaign for the control of cancer, all possible legitimate means should be employed to reach the public eye and ear. The education afforded by the relations of physician with patient or groups of patients may be very valuable but must necessarily be very limited in its scope. The fight against consumption has given us many lessons. Dr. Winters of Koenigsberg in Prussia was one of the pioneers in publicity about cancer, and his reports are favorable. Newspapers are the greatest hope and aid, and the attitude of the best on all medical subjects is most encouraging. Pamphlets', magazines, nursing journals, women's club, and societies should be used as a means to the end in view. Nurses, midwives, druggists, social workers, and spiritual advisers should be enlisted as missionaries of the gospel of prevention and early treatment.
What has the medical profession done to educate its own members about cancer and to disseminate this knowledge? As early as 1792 a cancer ward was opened at the Middlesex Hospital in London. In 1804 John Hunter started a medical society for the investigation of the cause of cancer. The present great movement began in England and Germany early in this century. The first International Association for Cancer Research has headquartered in Berlin. In Germany Ehrlich's and Wasserman's Laboratories and Czerny's Cancer Institute, and the Imperial Institute for Cancer Research under Dr. E. F. Bashford in England are known to you all. In Germany there are, or at least were, nine medical organizations and elven special societies entered in the fight. There is scarcely a so-called civilized nation of either hemisphere that is not now organized against the scourge. In the United States the American Medical Association, the Clinical Congress of Surgeons of North America and many other medical organizations have cancer committees. The American Society for the Control of Cancer was organized in 1913 to "disseminate knowledge concerning the symptoms, diagnosis, treatment and prevention of cancer, to investigate the conditions under which cancer is found, to compile statistics in regard thereto". Its ambition is to coordinate all existing forces into a single nation-wide effort to reduce the cancer death rate. It has interested the United States Census Bureau to publish a special cancer mortality report of the registration area for 1914. The best men of this country are associated with it and its influence will be felt. The Caroline Brewer Croft Fund for Cancer Research at Harvard, the Huntington Cancer Research Fund at Cornell and the George Crocker Laboratory in New York City are well known in the East. The Institute for the Study of Malignant Disease at Buffalo was started in 1899 and was formally placed under State control in 1901. No physician in New York State need lack pathological report on tissue. Twenty-six states are attacking cancer. Since 1909 the Pennsylvania Medical Society has been most active in this work. Through the influence of Dr. J. M. Wainwright of Scranton, Chairman of its Cancer Committee, sixty-six medical journals devoted the last July number, wholly or in part, to the subject. These workers in the field of purely scientific research are organized as the American Association for Cancer Research. The literature on cancer is vast. Of special journals, there are Cance in English, Krebsforschung in German, and Tumori in Italian.
What can the medical profession tell the public about cancer? The study of malignant growths has passed through various stages clinical, pathological, osteological and experimental. The experimental methods were made possible by the discovery of mouse tumors in 1902, and by the growth of cancer cells in vitro. What have men and methods and the years taught us?
1. How prevalent is cancer? Cancer causes about 5 B.C. of all deaths and about 8.6 p.c. of deaths above the age of forty-five. Not less than half a million dies of it every year throughout the civilized world. 75,000 succumb to the disease in the United States annually, of which about 40 p.c. are of the stomach and liver, 14 p.c. of the female generative organs, 12 p.c. of the intestines, 8 p.c. of the female breast, and 2-4 p.c. of the mouth and skin lesions are cancerous. It has been stated that one woman in eight and one man in eleven over the age of thirty-five years die of cancer. After forty years cancer is more of a menace than consumption. In the year 1913, there occurred in the United States in round numbers 45,000 deaths from cancer and 29,000 deaths from pulmonary tuberculosis over the age of forty.
2. Is cancer increasing? Sarcoma has probably changed but little, but carcinoma and epithelioma have practically doubled in the last thirty years. The annual death rate from cancer in Holland in 1875 was about 50 per 100,000 inhabitants; it is now over 100 per 100,000. In England and Wales in the decade 1851-60 there were 6000 deaths from cancer; in 1890-99, 30,000 deaths. The figures for the United States, New York States, the counties comprised by the Sixth Districts Branch and the city of Elmira are shown on the chart. Of course, it is only the figures of the more recent years that are of much value, but the absolute increase is very evident. In the United States, the death rate has increased to more than 25 p.c. in the past fifteen years. In the others, the rate has more doubled in the past quarter of a century. In the city of Elmira in 1913 more person were reported dying of cancer than of pulmonary tuberculosis. This increase has been general throughout the world, more marked in the cities than in the country, and more in the male than in the female. The gastrointestinal tract gas been the part of the body most affected by the increase. Such an increase cannot be entirely explained by better diagnoses, by more truthful reports, by more careful statistics nor by increased average human life.
3. Is cancer a disease of civilization? It would appear to be, though reliable figures are naturally lacking. In African negroes' cancer is said to form less than .33 p.c. of all tumors: among Europeans about 5.18 p.c. In this country, cancer is much less common in the colored race. In 1913 in the United States, the cancer death rate per 100,000 living was so for whites and 57.3 for colored. Japan is said to have a cancer death rate of 83-93 per 100,000.
4. Is cancer hereditary? Without question, the predisposition to cancer is to some degree transmissible. Clinicians record its possible influence in from 10 to 20 p.c. of their cases. Miss Maud Slye of the Sprague Memorial Institute of Chicago has shown that cancer can be bred in and out of mice at will and that resistance to cancer is a dominant Mendelian characteristic. Heredity influence cancer by determining the character of cell reaction to certain injury.
5. Is cancer infectious or contagious? All reliable evidence, clinical and experimental, speaks against it. Those most exposed are not more subject to it. It presents none of the picture of infection or immunity. The so-called houses have a better explanation on the basis of their usually poor and shifting inhabitants or heredity. The so-called cancer areas are not proof of infection. It is interesting to note, however, that while so called "cancer islands" occur in districts otherwise free from cancer, "cancer-free islands" do not occur in districts presenting a general diffusion of cancer. The fowl neoplasm of Rous is surely not a carcinoma if it is true malignant tumor at all.
6. What is the cause of cancer? An age-old question, to which still we can give no answer. Senile tissue changes are not an adequate cause. The theories of Cohnheim and Ribbert cannot explain all, cancer. We have no proof that it harbors a microorganism, though many have been called but none have been chosen. Even the earthworm has been maligned as the intermediate host. Green of Edinburgh believes that the smoke and combustion products of coal play an important role in cancer production and cities proof of his claims in comparative figures from the coal and wood burning districts of Great Britain and France. It is worthy here to note the possible part that soot may play in the chimney sweep's cancer and in the Kangri basket cancer. Barth claims that there is more cancer where the soil is chalky and less where silicates abound. This is reminisced of Zeller's treatment with silicates and arsenic. Lane of London believes that cancer is a late result of intestinal stasis. Some believe that civilized man has malignant growths because his food has been deprived of its natural mineral constituents. Laboratory workers have observed that an excessive carbohydrate diet seems to favor the development of experimental cancer, while Bulkery is firmly persuaded that forage protein is the crux of the matter. Dr. W.J. Mayo in an address before the American Surgical Association asks, "It is not possible, therefore, that there is something in the habits of civilized man, in the cooking or other preparation of his food, which acts to produce the precancerous condition".
Chronic irritation or oft-repeated trauma play some part in cancer production in many instances. Fibiger of Copenhagen beautifully demonstrated the action of parasites in tumor growth in the rat's stomach. We are all familiar with the occurrence of cancer in scar tissue, in leucoplakia, in ulcers, especially of the stomach. Five per cause cancer of the gallbladder. We all know the relative frequency of cancer at the narrowed angulated portion of the gastrointestinal tract. The public itself is acquainted with the smoker's cancer and the dangers of the X-Ray. The chimney sweep's cancer of the scrotum in England, the bladder cancer of the anillin worker and of the forearm of paraffin worker in Germany, the check cancer of the buoy chewer of the Far East, and Kangri basket cancer of the thighs and abdomen of Kashmir are notable example of chronic irritation causing cancer in unusual locations. We do not know how or where the chronic irritation acts, but the evidence of its influence in cancer production is overwhelming.
The real facts are few, the results of the year are meager. We can say that cancer arises from predispositions plus chronic irritation. The predisposition, as well as the reaction to cancer, seems to be local. It is, however, perfectly reasonable that some general body condition or condition, call it metabolic if we will, may render possible or facilitate the transformation of normal or of a congenitally deficient or abnormal cell into a cancer call, under the influence of some irritant. The balance between a living cell and its host is very delicate. Irritation, mechanical, thermal, chemical, infectious the deciding factor. We do not know the method or the agent that upsets the equilibrium between cell growth and cell restraint. As a matter of fact, we haven't yet answered the simple question why any cell grows. Dr. Wood says that the problem is to be attacked by clinical medicine, experimental pathology and general biology. 7. And, finally, can cancer be cured? Though a few spontaneous recoveries from cancer are on record, for all practical purpose the mortality of cancer, interfered with or treated "medically; is 100 p.c. Surgery is the only treatment worthy of the name that we possess. Its success depends entirely on prevention and early diagnosis. In superficial cancer, it should be 100 p.c. efficient. Postoperative results for five years vary greatly, but it is claimed that 80 p.c. of cancers of the lip, 20 p.c. of cancers of the tongue, 40 p.c. of cancers of the colon 30-50 p.c. of cancer of the uterus can be cured if the axilla is not involved, an only 25 p.c. if this has taken place. Probably less than 1 p.c. of cancer of the stomach remains well for five years after the operation, though the Mayo Clinic, Wertheim and a host of other operators report not satisfying but encouraging results. It is a far cry back to the statement of Dr. Agnew in 1890 who said that he had never cured a cancer of the breast. It is only the uninformed and the pessimist that says that a person with cancer has only one chance in ten, or in other words that cancer today has a mortality of ninety percent.
The second human factors in the cancer problem is the patient's physician. He must prevent cancer, he must recognize precancerous lesions, he must diagnose cancer, he must be honest about cancer. Any chronic inflammation, irritation or lesion of any kind anywhere in the body should be remedies. This is especially true of the skin, of the junction of skin with a mucous membrane or of mucous membrane with mucous membrane, and at the orifices a point of constriction of the gastrointestinal tract. 98 p.c. of women with cancer of the cervix have borne children. The physician must take cognize of an irritating pipe, a jagged tooth, an ulcer of the stomach. Moles, ulceration, tumors anywhere are a source of the danger. A digital rectal or vaginal examination may save a human life. No symptom is too slight not to merit recognition. Indigestion, flatulence, abdominal pain, hemorrhoids, diarrhea's, and constipation need investigation first and treatment afterward, such diagnoses, as well as dyspepsia, colic, metrorrhagia, change of life tumor and many others belong to the limbo of the past. They are symptoms of diseases, not disease itself. Tuberculosis, syphilis, and cancer should always be considered as cause of the symptoms in any given case.
It is the duty of the medical observe to observe and to record and to impart the results of his observations honestly to the patient or the patient's family or friends.
Two years ago, last November a woman of 52 came to me with a history of serval months of increasing constipation and localized paroxysms of cramp-like abdominal pain. Examination revealed localized visible peristalsis. An exploratory operation was advised and was refused. From that November till the following April another physician treated he constipation, by toniest for her anorexia and wasting, and gave her morphine for her pain. He then gave her up to die. She drifted back to me and was explored. She had a carcinoma at the hepatic flexure of the colon with extensive metastases. The tumor was inoperable.
None is infallible, every one of us errs in judgment, but we can at least make the efforts to be honest. If we do know and are sure, the course is clear. If we do not know, if we are not sure, an appeal for help and counsel is imperative, not to someone, however, who can bluff better than we or who gives lip-service only. The writer of this paper has not been in the practice of medicine as long as the most of those present here today, but he is fully persuaded that the policy of honesty in the long run pays. By honesty is not meant lack of tact or lack of gentleness. The patient comes to the physician in trouble and fear for advice. He or she naturally shrinks from disagreeable truth and prefers an agreeable falsehood. Your patients will honor and respect you for an honest opinion, and though you may be reviled and deserted your reward is sure.
The medical profession itself is largely responsible for much of the present attitude of the public toward operative procedures. The family doctor has been apathetic, skeptical, overconfident, grossly careless and incompetent. 18-25 p.c. of breast tumors are inoperable when they come to the surgeon, 26-39 p.c. of cancers of the stomach. Or the cancers of the uterus that Peterson saw through a period of ten years only 23.4 p.c. were operable. Kelly through a period of twelve years saw only about 54 p.c. that were operable. Dr. Howard Taylor reported that in New York City not one case in twenty of cancer of the uterus is operated on in time, and that of all dying of the disease only 25 p.c. had the benefit of a hysterectomy. The Cancer Committee of the Pennsylvania State Medical Society has published some illuminating and humiliating facts. of 382 cases of cancer investigated only 68 p.c. of superficial and 48 p.c. of deep cancer were operable when they reached the surgeon. In cancer of the cervix, the patient waited an average of four months before consulting a physician and then an average of eight months were allowed to elapse before any operative procedures were undertaken. In all cancers one year or more was allowed to pass between the discovery of the tumor a surgical aid. 3 p.c. of breast cancers were not examined, and 13 p.c. were given salves or told to wait. 9 p.c. of stomach cancer was not examined. 10 p.c. of cancer pf the cervix was not examined, and 20 p.c. was told to wait. Deaver found in 200 cases of breast cancer that an average of three years had elapsed between the discovery of the lump and the time of operation. I am not to be wondered at that both patient and physician have become skeptical about the surgical treatment of cancer. The best surgery is important in the face of such condition Such delay. On Part of patients and advisor, is criminal. The record of the general practitioner is pretty black. But there is another cause for the public's distrust. Too many prolapsed kidneys and uteri have been needlessly suspended. Too many appendices, innocent of wrongdoing, have been removed. There has been too much outing, too little conservatism. Hospital has been made synonymous with operation. The knife has been the magic wand invoked to heal all ills. Please do not misunderstand me or my intended meaning. Modern surgery has brought great benefits, but it has not been unmixed blessing. The public has keenly come to recognize the need of certain operative procedures, but they mistrust operations for conditions not obvious to themselves, and as they believe often not obvious to their medical advisor. They are therefore prone to refuse operation form a crack on the lip, a mole on the skin, a lump in the breast, or an exploratory laparotomy. Confidence in medical advisors must be restored. The laity must know that the only treatment of cancer worthy of the name is early wide excision.
The third human factor in the cancer problem is the specialist. There are many of them. No, one today questions the value of radiograph in diagnosis or lesion of the gastrointestinal tract, and no one knows its limitations better than those skilled in its use. It is a valuable aid, but never quite so valuable as the cystoscope, the proctoscopy, and the gastroscopy. The pathologist, in the very broadest sense, is a very important factor. Microscopic examination to tissue is the foundation stone of malignant tumor diagnosis. The research worker has not evolved any thoroughly reliable diagnostic test for cancer, but the hope of the world will probably be realized in some laboratory. The relative position of internal medicine and surgery presents today a curious picture contrasted with former times. Surgery has abrogated to itself the chief place in the world of medicine. Anything that is interesting in the whole realm has been claimed as its own province. The surgeon wants to be everything but the drug therapist, and he is usually a drug nihilist. The best brains for a decade or two of physicians have entered this field because of the gain and glory attached thereto. Surgery has scorned medical opinion and has demanded as its right to remove anything that it pleases. But internal medicine is today asserting its independence, claiming its rightful place, coming back into its own again. The surgical treatment of cancer is a failure, a makeshift, the best we have today, but far from what we want and what the world demands.
One world in regard to the relations between the practitioner of internal medicine and the specialists named. No one can successfully cover the field of modern medical science. It is too broad. The practitioner should not, must not be content to be a routine, a grinding drudge, living poorly on skim-milk while someone else gets fat on the cream. The family physician is often a team of endearment, but just as often it conveys a veiled idea of incompetency. The fate of the practitioner of medicine rests in his own hands. he should be an internist, a diagnostician, make himself worthy to stand with the elect. The specialist should not be a being of a superior world, whose judgement and opinion is always the last word. All should be members of the same class on the same level, equals in the field and fight.
Finally, what is the attitude of the medical profession toward the cancer problem? What is our creed, what are our articles of faith?
We acknowledge our ignorance and our helplessness but are cheered by the advances accomplished under great leaders. We regret that there are millions for research, but scarcely a cent for clinical medicine, for through the one or the other shall eventually come the solution of the problem. We believe in public education, in prophylaxis, in early diagnosis. We strive to discover cancer producing habits, to avoid chronic irritation, and to remove precancerous lesions. We believe that good history and a careful examination are still the very best means of diagnosis. We realize that medical treatment is absolutely futile. Ferments, serums, and vaccines have disappointed. Chemotherapy offers yet but little. The glory of electricity, the X-Ray and radium have largely faded. Surgery is the best that we have to offer. And, finally, we anticipants the day when that last statement shall not go unchallenged, when someone shall stand up and say, "This is the cause and here is the cure".
October 3, 1915
The Psychology of Pregnancy
By: Stuart B. Blakely, M.D.
16 Stratford Place
"Read at the meeting of the American Association of Obstetricians, Gynecologists and Abdominal Surgeons, Excelsior Springs, Mo. September 28, 1940"
The writer of this paper is an obstetrician, not a psychologist nor a psychiatrist. This is not a venture into the neuroses and psychoses, but a discussion of some common mental states some attitudes of the pregnant women. A reasonably adequate search of medical literature has discovered but on article with the same title on this interesting and important subject.
The difference in the working of the male and female mind constitute a complex and controversial problem. Personally, I believe that the differences are profound and that they profoundly influence the women's attitude toward pregnancy and all that it signifies. Indeed, it has been suggested that these differences represent the effects of pregnancy itself on the female mind, acting through countless eons of time. There has been much speculation on how the male would react to pregnancy were he ever in that condition. Many obstetric patients express the wish that their husbands might share their experiences. Parenthetically, it must be emphasized that the pregnant state does not exhibit any new psychological elements, peculiar to itself.
Obstetrics offers the best opportunity to study the "animal" nature of the female, using "animal" in the broad biologic sense. Pregnancy and childbirth are so elemental; they reduce the women so completely to the level of her brute sister. Of this sensitive woman are not infrequently dimly aware and vaguely resentful. "Christian lady and plain animal sometimes wage a terrible subconscious battle".
The desire for a baby is basic in every women's soul. Her biologic destiny is childbearing and child-rearing, however much this may be, on occasion, resented and denied. The psychoanalyst knows the penalties exacted when this destiny is flouted, it matters not the reason nor how much freedom the women thinks she has achieved by "democracy", education and birth control. Childlessness' acts as a psychic trauma, though probably less today than when kitchen, children and church formed women' man-made sphere. Tennyson summed it up "women's wisdom is to bear and train a child".
A woman will often go to any length, even to impregnation by a man, not her husband, to achieve or to feign pregnancy. She may be motivated by inherent desire, or an irresistible urge, or by other reasons, often selfish or obscure e.g. as an escape vehicle (often unsuccessful); to bind a man to her; to meet the wishes or demands of husband or family; to retain support or inheritance. Among the more bizarre motives consider the advances made by women to fathers of talented children in the hope that they may have begotten on themselves offspring of like precocity. Formerly, simulation of pregnancy. Labor and the lying-in period, with the presentation of a borrowed or stolen infant, were not rare. Today, the sophistication of the present age militates strongly against its successful accomplishment.
On the other hand, is the astounding fact that a woman will also go to any length even to court death itself, to avoid or terminate pregnancy, proceeding against all pleading and advice, and for reasons entirely inadequate or at least past all understanding by the male. In these cases, she is usually motivated by fear.
The causes that produce the mental state of pregnant women are not well understood but may be grouped as follows. An inherited nervous instability (not going so far as to say a "psychopathic makeup) without doubt an important factor.
Toxins, infection, exhaustion, hormones and fetal products. Intoxications and infections are potent in the production of central and peripheral nerve lesion's; in less amount or degree theme easily might affect the psych's. Trendies endocrine changes occur in pregnancy, and hormones undoubtedly influence mental attitudes and behavior. Of fetal products and their effects, we know little, but we do know that they may have a most beneficent, as well as a most malignant, effect on the women's whole organism.
Physical discomforts and pain; fear, anger and mental strain; new responsibilities, and re and maladjustments all potential elements of psychic disturbance.
The impact of the fact of pregnancy itself, with all its implications and ramifications biologic, racial, social, religious, economic, etc. On the female mind with its varying background of heredity, environment and education. Whether the pregnancy is desired or undesired often materially influences the mental response.
Every part of the maternal organism reacts in some degree to pregnancy. I. The influence on the mind varies from slight to profound. The stolid bovine type shows little response; some women do not feel or know that they are pregnant. In others it is recognized by mental changes, not infrequently progressive for a time, of which three are prominent in the early months.
A changed or changeable disposition, sometimes excited and sometimes depressed.
Antipathies and aversions (possibly the expression of a rejection of the pregnancy); or, more often, curious inclinations and desires, especially in reference to foods. (5,9) This craving for strange articles of diet and the longing for unusual, possibly abnormal, things are called "pica", the Latin word for magpie. The greater the parity, the less the cravings. A common desire is for sour substances. One of the most bizarre was the case of the women who wanted a piece of her husband's arm and got it. While a completely satisfactory explanation of these curious anomalies of taste is not at hand, many are undoubtedly the expression of some unsatisfied body need. It is strange and interesting that these cravings of pregnancy are popularly believed to be the expression of a need on the part of the child; and that, if not satisfied, the child will be "marked", or will cry for the article till given it. Nausea, vomiting and rarer ptyalism of early pregnancy may have a toxic or endocrine basic but are most often largely psychic. Many patient's stats that they cannot be pregnant because they are not "sick". Coitus usually makes them worse. Numerous cases are recorded where the symptoms have been entirely relieved by an attempted but unsuccessful abortion, or where the patient was deliberately deceived therein. The lessened incidence of this symptom complex in recent years and the often speedy and spectacular relief by what is practically psychotherapy are strong arguments against a predominantly toxic or denial of the pregnancy an expression of fear, aversion or maladjustment. Occasionally it repression an effort to punish self or husband.
Most pregnant women are more impressionable and exhibit an increased sensibility to sensory stimuli and an increased suggestibility. They often complain in the early months of indolence or torpor, exhaustion and a tendency to sleepiness. What is sometimes regarded as dullness of intellect is probably the result of thought and feeling being concentrated on the pregnancy and approaching birth, with lessening of attention and indifference to environment. Pregnant women are also less solicitous for their souls, for they develop a strong egocentric attitude toward themselves and the child within them. This often changes their characters, occasionally for the worse. Such change, plus impulsive acts, is said to lead to increased criminality. It has been stated that shoplifters, for examples, usually do their stealing when menstruating or pregnant. Lombroso, however, says that pregnancy acts as a temporary moral antidote on the criminal women and that maternity is never the motive power of crime. Delee notes that in olden time pregnant women were considered mentally irresponsible, and the condition was advanced in extenuation of crime; they are not reliable as witnesses for their perception is less acute, their reasoning deficient and their interpretation false.
Changes in sexual personality during pregnancy vary. Libido, at least physical libido, is usually lessened. According to Kogerer, later in pregnancy the "psychosexual components" often appear in the active forms of Jealousy
2. Apparent lack of modesty, or exhibitionism due to their egocentric attitude and to the feeling that they have less sex appeal. They can see no reason to conceal what does no longer attract. This attitude is possibly more in evidence during the puerperium and the lactation period.
3. Tendency to employ substitutes, through the exhibition of simple neurotic or even hysterical reactions.
4. Erotic attitude toward the physician, often embarrassingly evident when coming out from the anesthetic.
Annoyance, resentment and anger are not uncommon mental states in pregnancy. One patient said that she was "mad" because she was pregnant and was just as "mad" when she miscarried. Women are frequently angered at the fact of their pregnancy because they are so impotent to avoid its consequences; and because they cannot transfer it to their condition. They resent being so forcibly reminded that they are animals, that their condition is their biologic destiny and that pregnancy and a child interfere with their "will to power". Many women never grow up, psychologically.
The pregnant women live in the midst of anxieties and fears. Many are dim and hazy, some of which have come down the "long road of women's memory" from the race's brute and pagan past. At the other extreme is actual terror. The degree of these fears may be altered or mitigated by heredity, environment and education. Let us name a few, remembering that we fear what we cannot control.
Fear of the expense involved, and of the financial strain of another mouth to feed with the attendant work and privation. So long as church and state, bolstered by medieval laws and medieval thinking, insist or imply that pregnancy shall not be prevented, at least so long should church and state aid and not penalize its members and its citizens for having children. Fear of the inadequacy or inability or unwillingness of the husband to bear the added burden of her pregnant self and the child to be, with the possibility of his desertion.
Fear of the loss of independence, and of social and economic freedom. Fear of the responsibility of bringing a new human being into a chaotic, sinful, warring world, and being unable to read it properly. Fear of the disgrace of having a baby, either because of the idea that pregnancy is dangerous in older women or because of the feeling that it is shameful to thus admit the continuation of sexual intercourse at that age. Fear of forfeiting the husband's love and affection by loss of figure or attractiveness, by the aging effect of childbearing and by enforced sexual abstinence. This fear may produce a feeling of animosity toward the unborn child, to be overcompensated for after its birth by an anxiety neurosis about it. The fear of loss of beauty and sex appeal may also be regarded as a Narcissist motive.
Fear of abortion and fetal death. Fear that the child will inherit evil or other undesirable family traits often really a protest against the pregnancy (also often true of other expressed fears.). Fear of telegony. Fear that the child may have been harmed by unsuccessful attempts at abortion. Fear of the possible harmful effects of the mother's activities and experiences on the unborn, a consideration of which would lead into the fascinating field of maternal impressions. One of the commonest questions asked the obstetrician today is "will alcohol and tobacco hurt the baby".
The greatest fear of the pregnant women is of the dangers of pregnancy and labor and the pain of childbirth exaggerated or accentuated by ignorance, the influence of "old wives tales", and the publicity in the lay press and magazines of the morbidity and mortality associated with having a baby. In no other field of human thought and activity is superstition rifer and ignorance more profound, with most harmful results. It is notorious that intimate and informal gatherings of women tend, as the afternoon or evening wears along, to become obstetric clinics, usually of the abnormal. Why older women often seem to delight in frightening young women pregnant for the first time with obstetric tales of horror, or by solemn but often silly fantastic admonitions, is hard to say. Jealousy and envy have been suggested. Possibly it is their desire to impress the younger women with their superior knowledge and experience. It may be the outcropping of the alleged antipathy of women toward one another. At all events, it is remindful of the refined cruelty of the cat. There is grave question whether the usual magazine article. Often lurid or sensational, concerning pregnancy and labor and their dangers is not psychologically harmful. Of course, there is no reason why a patient should not be furnished proper prenatal and other literature about pregnancy, compatible with her mentality. A supremely satisfactory book or booklet o prenatal care for the expectant mother has yet to be written.
However, in spite of baneful influences, physical discomforts, anxieties and fears, pregnant women, especially after the first few months, are usually happy, even exalted. They register a mixture of pride, selfishness, and self-sacrifice, and often seem to "walk in radiance like a bride". The impatient euphoria of late pregnancy is frequently striking. They cheerfully rise death for the life within them. No one has greater love; few so great a courage. But to state that these things are so because the pregnant women are fulling her destiny very inadequately explains a physical and psychic read just meant of whose mechanism we are almost entirely ignorant.
Menial attitude toward Illegitimacy
Illegitimacy is of course, purely a social idea. In an era not long gone, an illegitimate pregnancy was considered a grievous sin and branded the women with the scarlet letter, setting her apart for life and not uncommonly driving her to suicide. I can member in a small town a woman who reminded unmarried a grew old, shunned, barely tolerated and covertly obscenely derided because she had made a so-called misstep and had been found out. Everyone, at least the women of the village, thought that she should be so punishments are isolation. I have often wondered what the women's own thoughts were on the subject. Without question the value gets on virginity has diminished in recent years, whether for good or bad I do not know. Probably the average young women of today are not sure that as illegitimacy is a sin, but the only evidence of poor technic or poor judgment. If it is a sin, she is quite sure that it cannot be atoned for by a loveless marriage. She rarely resorts to self-destruction. Indeed, the modern girl seems to fear parental anger or disappointment, or the family disgrace, more than her own shame. Were it not for the social retribution still exacted, especially by the female of the species, I am persuaded that illegitimacy would be much more common, or at least more commonly found out, with fewer abortions. I am occasionally taken aback by the courage, possibly better bravado, shown by some young women toward the opinion of the world on this question. If they acknowledge the baby as their own and take it unto themselves they rarely marry, for their admission proves that they are "damaged goods". Possibly the time will come when a woman will have the right to maternity by the man of her choice. I am not an apologist for illegitimacy, nor am I defending it, but it does not necessarily destroy society, as shown by Scandinavia where often one-half of the births are out of wedlock, and by Russia where there is no such thing as illegitimacy. Even in New York State, the word is banned from the birth certificates. It is hard to understand why the omission of a marriage ceremony should doom an innocent child to infamy.
Attitude of the Women pregnant out of wedlock toward the father of the child. If she really loves him, she may not even tell him what has happened; often forgives him all and cheerfully bear her burden along a cruel road to the better end. On the other hand, if she does not love him, she will often to any length of rid herself of the pregnancy and punish him regardless of consequences. But not always. It has been truthfully but cynically said that women have the strange capacity to love the unlovable, to cherish the unlovely and to defend the indefinable.
Mental Attitude toward abortion, Abortifacients and Abortionists
I am sure that moral religious scruples against abortion are on the wane. Women are realists, less concerned with principles than with results. They are not much impressed with the illegality of something they may desire to do. Few hesitate to employ abortifacients, and the mechanical interruption of early pregnancy is very common. Abortion is today practically unpunished, even unpunishable, by the law. It is frequently made "big business". It has become almost an axiom, particularly relating to abortion, that it is not safe to believe the statements of any women about her sex life. This is something about which she is at times astonishingly unscrupulous and unreliable. Though in her heart the women despise the abortionist, I have yet to have a patient, dying as the result of a criminal abortion, volunteer the name of the person responsible for the crime. She often resists and successfully all attempts to persuade or compel her to divulge such information. The physician, who is led by motives of sympathy or gain to perform such abortions, sets his feet on the path that leads not only to professional ruin but also without exception to loss of the respect and confidence of his patients.
Even as in ancient Egypt the young women frequently go home and to her mother to have her first baby. The obstetrician who successfully conducts a women's first pregnancy and labor is often rewarded by loyalty and affection that is positively frightening. However, it is well to remember the story told by Dr. Frederick Loomis in his book "Consultation Room". He had planned to go to China. One of his patents, by her tearful pleadings, persuaded him to postpone his trip. After her delivery, he called her by name and said: "Now I suppose that I can go to China". She replied: "As far as I am concerned you can go to hell". Most obstetricians, sooner or later, become painfully familiar with this psychology also. Women often have curious reasons for choosing or changing accoucheur. I remember one who had just lost her only child of three years by meningitis. She announced that she was going to have another baby right away, but that she was going to have better luck next time with a different doctor, nurse and hospital for her delivery. One is tempted to ask, why not a different father also. Alexander Woolcott once asked the writer who was the obstetrician in attendance on Mrs. Oliver Wendell Holmes. He was interested in knowing the type of physician that the author of "The Contagiousness of Puerperal Fever" would choose to deliver his wife. The psychology of the attitude of the laity and the rest of the medical profession toward obstetrics and the obstetrician would make a chapter in itself.
Dream in Pregnancy
Pregnant women are supposed to dream predominantly of death, fire, and water. My own limited inquiry does not bear this out, though dreams about water do seem to occur rather frequently. The Aztecs called the sufferings of childbirth the tribute of death, and the death symbol is claimed to be the focal point of pregnancy psychology. Fire is a sex symbol, and in early creation myths, water was the feminine element from which live emanated. The interpretations of dream in pregnancy might well deserve the further attention of psychoanalysts'.
Esthetics and Pregnancy
While the women far advanced in pregnancy may be beautiful to the artist or the philosopher, the women herself is usually far from being in accord with that standard of esthetics for many reasons. When Shakespeare speaks of the "pride of pregnancy", he refers rather to the women's physical bearing than to her mental state.
Mental Hygiene of Pregnancy
From the obstetrician's standpoint, proper sex education and the psychological preparation for pregnancy are of vital importance in any discussion of mental hygiene. But there is time only for a brief consideration of mental problem of the actually pregnant, essentially normal women. Since the obstetric patient usually surrenders herself so completely to the physician of her choice, he bears a great responsibility. If the patient's mentality is not entirely hopeless, a great deal can be accomplished by thought and effort. As far as possible, physical discomforts are to be relieved; superstition and ignorance, combatted; emotional stress and strain, prevented; worry, anxiety and fear, eliminated. The tact, wisdom and cooperation of husband, family and friends must be enlisted. They, as well as the patient herself, usually sadly need education in physiology as well as psychology. The attitude of all should be that of envy, not sympathy; of cheerfulness, not gloom. The physician must take an active and intelligent interest, personal and professional, in the patient's pregnancy, listen patiently to her complaints and do all within his power toward the safety of her body, the serenity of her mind and the peace of her soul.
I hate the expression "only a confinement case", with all that it implies. Also, anathema to the writer is the doctor, who, for insufficient reasons or because he is a poor obstetrician, tells a woman that she should never have another baby or none within so many years, or that she must have a Caesarian in the future. Few realized how much mental harm can be done by such statement, or badly managed pregnancy and labor. Generally speaking, we are too much occupied with the mechanics of our profession, and too little interested in the minds of patients. In no other field of medicine is good psychology better rewarded and bad psychology more disastrous than in obstetrics.
There is no more remarkable phenomenon on this earth than the incarnation, development and birth of a human being. Pregnancy is the most important and momentous activity and experience of women's life. Often marvel why, how and that they go through with it, often under atrocious conditions, both physical and mental. The longer I practice obstetrics, while many of the processes of the female mind remain entirely incomprehensible to me, the more respect and admiration I have for pregnant womankind. Though their psychology is their own, they are the better half, these mothers of men. Men can never know the things that women keep and ponder in their hearts about the child to be.
History of Caesarian Section.
By: Stuart B. Blakely, M.D.
April 6, 1950
This paper will be limited to a discussion of the history of Abdominal Caesarian Section i.e. the removal of the products of conception from the pregnant women by an incision through the abdominal wall and the uterus. It usually implies that the fetus is viable, or nearly so, though, strictly speaking, the term may be applied to such removal at any stage of intrauterine life. Possibly such a procedure in early pregnancy is better called "abortion by abdominal hysterectomy".
The origin of the term "Caesarian Section" is actually not entirely clear. The Latin writer Pliny was undoubtedly confused and did not understand the origin of the term when he states that Julius Caesar was born in this manner, making it the origin of the term. Such a birth in the case of a man so famous as Caesar was would almost surely have been mentioned somewhere in his life story; Caesar's mother was living many years after his birth. Another explanation has been sought in an ancient Roman law (later noted in this paper) that required the removal of the child from the body of any woman dying undelivered. There is no good evidence that this law was ever known as "the law of Caesar", or that it was applied to living women. The most likely explanation of the origin of the word "Caesar" in the term is that it is derived from the Latin word "caedere" which means "to cut". Children born by cutting the dead woman's abdomen were called "Canciones". The term " Caesarian Section" must be considered a pleonasm (both words mean the same). Caesarian on the dead women undelivered of her child was a very ancient practice, even ascribed to Romulus. Its origin is lost in antiquity. Two of the most famous of such births in which the child is claimed to have survived are those of Dionysus (Bacchus) and Aesculapius, as told in Greek mythology. Hermes, at the command of Zeus, cut open the abdomen of Semele, as she lay on her funeral pyres after being struck by lightning, and extracted her seven months fetus, later known as Dionysus. Zeus had the infant sewn into his thigh or body, and so nourished him to term. Another story is that of Aesculapius who, at the command of Apollo, was removed from the uterus of his mother Coronis as she also lay on her funeral pyres. All children born thereafter in this manner are said to have been dedicated to Apollo and to have been endowed with bravery and sagacity.
In ancient India and Israel, the removal of the infant from its mother's dead body before burial was expressly commanded. The idea was embodied in Roman law, ascribed to Nuna Pompilius (713-673 B.C.), the second king of Rome i.e. no pregnant woman who died could be buried before the product of her conception was removed from her body. To become a law such a procedure must have been the custom for a long time. Roman law and Roman power kept the procedure alive for centuries. With the rise of Christianity, the law gained powerful support. Synods and councils commended and commanded the practice in the hope that few infants' souls might be saved by baptism. The Church later gradually abandoned its stand. Pope Gregory XIV, an abbot of St. Gall in the 10th century, and Bishop of Constance are said to have born by Caesarian on their dead mothers.
The origin of Caesarian on the dead is also quite obscure. Of course, it must have been observed at the sacrifice and on the hunt that the unborn might survive its mother's death. It has been suggested that they wanted to give the unborn "the hope of life". It must be remembered, however, that the ancients had very little respect for fetal lute. Caesarian on the dead, at least in the earlier years, was probably performed by slaves, for the physician had a pious fear of the dead and the touch of death was defiling. The performers of the operation knew speed was essential, and that the hope of success depended a great deal on the cause and suddenness of a woman's death. They realized the baby died because of lack of air; hence the custom of propping open the mouth and the vagina, and even injecting air into the uterus. The fact that the cases were so few, and the percentage of success so small (never over 10% and usually much less ) plus the withdrawal of the influence of the Church caused the gradual abandonment of the procedure. But even today a not inconsiderable number of people believe the full term or viable fetus should be buried in the coffin BESIDE the mother, and not left inside her body. At heart, we are still largely pagan in our thought.
Caesarian on the dying has been done many times without question, but our present mores do not sanction the procedure. The obstetrician today must wait till life is extinct in the mother, thereby markedly lessening the chances of the infant's survival. It might be well to call attention to the wisdom of never doing a Caesarian on a woman, living, dying or dead, without proper and complete aseptic preparation of all concerned. Caesarian on the living women has probably been done on occasion for centuries. The idea must have occurred to the observer of women in labor, unable to deliver her baby, that an incision in her abdomen would be an easy way to solve her difficulty. But don't forget that it was only 400 years ago that a pair of tongs or forceps was so constructed that a child could be delivered from below with reasonable safety and without the child's inevitable destruction. It has been tempting to believe that primitive peoples performed Caesarian on living women. There are stories of such among the American Indians and the Maoris of New Zealand. One of the most popular stories of such primitive practice is the description and drawing of a Caesarian section witnessed by a physician explorer named Belkin in Uganda in Central Africa in 1879. It was performed by a specialist of the Katanga tribe, a tribe advanced in many ways. The patient was a twenty-year-old gravida I. All the attendants were men. The operator washed his hands and the patient's abdomen with banana wine and gave some of it to the patient to drink. He incised the abdominal wall and the uterus, each with a single stroke of the knife; removed the child and placenta; held the uterus firmly in his hands till it contracted; turned the women on her side so that the blood and fluid would run out; closed the abdominal wall with seven acupressure nails and figure- of- eight sutures; dressed the wound with a paste of the chewed roots of two trees. During the operation, an assistant touched bleeding points in the uterus with a hot iron. The women's temperature and pulse postoperatively remained within the normal range, and the wound was healed in eleven days. The question has been asked how many years or centuries it took to develop such a technic.
There is no unimpeachable evidence that Caesarian section on living women was ever done by the Egyptians, Greeks, and Romans. It was pretty definitely performed in ancient India, was known to Israel before 140 B.C. and is spoken of in the Talmud. The description of a Caesarian done in 935 A.D. under wine anesthesia has come down to us rather vaguely, and one has been reported as having been performed in the 13th century. In the 16th century two ideas, both originating in France, had a far-reaching influence on the practice of obstetrics; 1. The rediscovery of version by Ambroise Pare; and 2. the awakening of interest in Caesarian Section as a means of terminating obstructed labor to obtain a living child. Incidentally, it is of interest to know what the great Pare thought of Caesarian Section. He said, "I would never advise doing such work where there are so great danger and not a single hope".
In that century (the 16th) without question, French Physicians performed Caesarians on living women. Scipio Mercurio (1568-1615), a former Dominican monk who practiced in Rome, witnessed Caesarians in France. Probably many of these operations consisted of removal of infected abdominal pregnancies that pointed through the abdominal wall. This is probably the case of the reports of two Caesarians, one by an Italian surgeon, Christopher Bain, in 1540; and the other by Paul Dirlewang of Vienna in 1549. In 1581 Francis Rousset, a French surgeon reported 15 cases of Caesarian on the living, none of which he had witnessed or done himself. His purpose was to overcome prejudice against the operation and to point out its value. His indications sound very modern, and he was the first treatise entirely on Caesarian Section. In 1586 Casper Bauhin, a physician of Bale or Basel in Switzerland translated Rousset's book from French into Latin for the wider use of Physicians generally. In an appendix to this Bauhin relates the story of Jacob Nufer, or Nueffer, a Swiss swine Gelder, as having delivered his own wife by Caesarian section in the year 1500.
Nufer lived in Siegershausen in Switzerland. It was his wife's first pregnancy, and she had been in labor several days. Thirteen midwives and several stonecutters were in attendance. The patient's condition was desperate. Nufer obtained the reluctant consent of the authorities for the operation. All but two of the midwives were of "faint heart" and left the room; the stone cutters remained, all being of "stout heart". Nufer shut the door, offered a prayer, laid his wife on the table and with one stroke of the knife delivered the baby without wounding it. When the midwives outside heard the baby cry, they all wanted to come in. Nufer would not allow this till the baby had been cleaned and the abdomen closed "like a veterinary way" by sutures. The child lived to the age of 77 years.
This has been generally accepted as the first actual recorded (?) Caesarian section. If the story is to be believed at all, and it was told 86 years after its alleged occurrence, it was also probably a case of extrauterine intra-abdominal pregnancy for the women later had a pair of twins and four other children. Anyway, it has captured the imagination and is the second of our popular stories about Caesarian section.
The first authentic, historically believable case of Caesarian Section on a living woman, described in detail by Prof. Dan Sennett, was performed by Jeremias Trautman at Wittenberg in Germany in 1610. The patient died twenty-five days postpartum. The child lived for nine years. The idea of a Caesarian section has always intrigued the medical profession, but its mortality, even up to very recent years, prevented its general acceptance. But many men kept working at the problem, approaching it from many angles. In 1751 Leveret tried to put the indications for a Caesarian section on a more scientific basis. He held that the single absolute indication was high-grade pelvic narrowing which had been named as an indication if the pelvic hand could not be withdrawn when grasping a foot. He thought that most Caesarian was unnecessary, and if frequently resorted to, indicated a poor obstetrician. To use slang, Leveret "had something there".
The surgeons gradually came to realize that the greatest source of their Caesarian mortally before Lister was the drainage of the open uterus into the peritoneal cavity, especially the higher in the uterus the incision was made and the higher in the abdomen the drainage occurred. A sure and lasting separation of the uterine cavity and its secretions from the general peritoneal cavity was the goal to be striven for. The problem was approached in three ways.
Making the incision in the lower uterus, by various methods minimizing the opening of the general peritoneal cavity. This has been the basis of plenty of our technical advances, for the idea was sound. All pelvis tissues are more resistant to infection; the incision is in a part of the uterus that does not undergo contractions postpartum, and the uterine incision can be more completely covered by peritoneum. But it took a long time to arrive at our present status and knowledge of low section. F.B. Osiander in 1805 put his hand in the vagina, pushed the fetal head up against the lower abdominal wall and made his incision low in the uterus. A century later Hugo Sellheim cleared up the anatomy of the lower uterine segment. Frank of Cologne in 1907 operated through an extra-peritoneal pocket by incising the parietal peritoneum transversely and suturing it to a flap of visceral peritoneum turned up from over the lower uterine segment. This is a type of "exclusion" Caesarian which may be done in several ways. Kroening said that the good in Frank's technic was the fact that the uterine incision was covered with peritoneum -- a partial but not the whole truth. It was Kroening who introduced low section as we know it, using a vertical incision in the uterus. Kerr in 1926 suggested the transverse incision. There have been numerous variations introduced. Dr. Joseph B. De Lee, as well as Beck of Brooklyn, were great advocates of the procedure.
In about 1820 Ritgen did a real extra-peritoneal laparotomy. He had many bladder and bladder and ureter injuries, a mortality of 50% and the operation was gradually abandoned. Gaillard Thomas in 1870 rescued the procedure from oblivion, still with a mortality of 50%. The name of Latzko and Waters have been closely identified with the extra-peritoneal section in more recent years.
By removing the uterus. In 1808 Michaelis of Hamburg suggested that the uterus be removed at the time of a Caesarian. Eduardo Porro of Pavia and Milan opened up a new era with the popularization of this idea. He pulled the unopened uterus out onto the abdominal wall, sutured the parietal peritoneum about it amputated the uterus supracervical and sutured the stump into the lower angle of the abdominal wound. With one stroke he solved the question of uterine suture, as well as taking a long step forward in the prevention of hemorrhage and infection. His mortality was 25-50%. The removal of the uterus has some obviously undesirable features but the procedure still has a definite place in obstetrics. We continue to use the term "Porro" though the stump today is closed as in any supracervical hysterectomy and dropped back into the abdomen.
By closing the uterine incision. It is more than strange that for so long the incision in the uterus was not sutured but left open. Sutures in the uterus were considered dangerous, irritating and unnecessary. Naegele as late as 1867 and Zweifel as late as 1881 did not close the uterine wound. However, uterine suture had been employed by many men at various times. Lebas in 1770, Frank Polin in 1853 (silver wire), Simon Thomas in 1869; it had been used in the United States before 1800. It remained for Max Saenger of Prague in 1882 to make forever afterward the suture of the uterine incision a part of a proper Caesarian section. He used silver wire or silk and closed his incision, which was in the upper uterine segment, as follows. 1.) Excision of a strip of uterine muscle on each side of the wound and the undermining of the serosa on both sides; 2.) Muscular muscularized sutures avoiding the mucosa and suturing the undermined serosa inverting its edges. There was little or nontensioned in his sewing. He pointed out that it was not dangerous, but as a matter of fact, quite the contrary if properly and aseptically done. The objections raised against Saenger's suturing seem silly today: danger of peritonitis if an infection was present; postoperative intestinal complications; adhesions; rupture of the scar; higher mortality. Saenger's operation became known as the "Conservative Caesarian Section; Porro's, the "Radical Caesarian Section".
Five types of abdominal Caesarian section have emerged.
1. Classic, the incision is made in the upper uterine segment. 2. Lower Segment Transperitoneal, Extraperitoneal Exclusion; 3. Before the uterus is incised the area is closed off from the general peritoneal cavity by some type of peritoneal suture. 4. Porro in which the uterus is removed. 5. Portes operation: a French surgeon, who in the presence of an infected uterus temporarily exteriorized the uterus on the abdominal wall. Mortality of Abdominal Caesarian Section.
For nearly 400 years after 1500, the mortality averaged 60%. In the 18th and 19th centuries the mortality was 54%. In Europe, from 1750 to 1839 the general mortality was 62%; in the hospitals, 72%. In the 19th century, there is said to have been no successful Caesarian in Paris, and up to 1877 in the maternity hospital in Vienna, none survived. In Great Britain between 1739 and 1845, there were 38 Caesarians of which 4 survived. In 1871 Harris of Philadelphia reported 59 Caesarians of which maternity mortality of 48%. It is no wonder that symphysiotomy, induction of labor and craniotomy were preferred and resorted to. Caesarians were rarely performed; they were an event. Of course, asepsis and antisepsis are tremendous factors in reducing maternity mortality, but that was not enough. Possibly 25 years ago 25% of all maternal deaths in the State of Massachusetts followed the Caesarian section. The work and study of many men have reduced the dangers of a Caesarian section to such an extent that in many hospitals today the numbers of patients delivered by Caesarian section may be as much as 5%. It is not uncommon to see reports of 100 consecutive Caesarian without a maternal death. In spite of it all, it is still the most dangerous way to have a baby.
Before the final closing of this discussion of abdominal Caesarian Section, there are a few disconnected notes on the subject that may be of interest. A great deal of ingenuity and ink has been expended through the centuries on the question of the type and direction of the incision, not only in the abdominal wall but also in the uterus itself.
There have been numerous authentic cases of the patient doing a Caesarian on herself. In a few instances, the pregnant uterus has been opened when gored by the horns of cattle. It is barely possible that Shakespeare had this in mind when he speaks of Macduff as one "who was from his mother's womb untimely ripped".
The term "Caesarian Section" was first used in a book by Theophile Raynaud in 1637. The first illustration of a Caesarian as in 1506 in a non-medical book, "Lives of the Twelve Caesars", by Suetonius.
Jane Seymour, one of the wives of Henry VIII, is supposed to have been delivered of Edward I by a Caesarian from which she died of puerperal sepsis. The king is reported to have said: "Save the child by all means; for I shall be able to get women enough".
Garrison in his History of Medicine says that the first Caesarian in the United States was done in 1827. However, there is no question but that Dr. Jesse Bennett, In the backwoods of Virginia, did a Caesarian 0n his wife, January 14, 1794. She was out of bed on February 9th and walked February 15th. He was assisted by Dr. Alexander Humphreys who had been a preceptor of Dr. Ephraim Mc Dowell. Dr. Bennett took out her ovaries so that she would never have to go through it again. When asked why he did not report the case, Dr. Bennett is said to have answered: "No doctor of any feeling of delicacy would report any operation he had done on his wife". Also, that "No strange doctor would believe that such an operation could be done in the Virginia backwoods and the mother live, and he'd be damned if he would give them a chance to call him a liar".
In looking back over the history of the development of abdominal Caesarian section certain things stand forth with clearness and are worthy of a brief review. One of the most interesting is how the introduction of new studies, new ideas, new experiments, new technics advanced now one, now another phase or type of the operation. Methods and procedures exhibited longer or shorter cycles of disuse, dormancy or oblivion alternating with periods of prominence and popularity. Of the recent resurgence of extraperitoneal section.
The three great causes of death following Caesarian section have always been and still are shock, hemorrhage, and infection. How have these problems been attacked?
Shock it is only very recently that the nature of shock has been at all well understood, timely measures taken for its prevention and adequate and scientific methods employed in its treatment.
Hemorrhage as far as we know, nothing outside of uterine massage was employed until the introduction of hysterectomy and uterine suture. The use of blood in shock and hemorrhage is, comparatively, very modern.
Infection the procedures of Porro and Saenger, the placing of the incision in the lower uterine segment, the adequate covering of the uterine wound with peritoneum and the retroperitoneal approach all contributed to its prevention. Aseptic and antiseptic surgery brought nearer the conquest of infection, but not its entire elimination. The better conduct of early labor by today's obstetrician is a tremendously important factor in making Caesarians safer. We know that vaginal examinations and procedures, long and exhausting labor, long rupture of membranes add very greatly to the risk. The use of antibiotic is an additional safety factor.
The widening of the indications for a Caesarian section is a remarkable, comparatively recent development. It is hardly within the province of this paper to enter into a discussion of its wisdom.
One of the important factors that have made Caesarian safer is the rise of the obstetric surgeon which has almost completely eliminated from this field the general surgeon who is rarely familiar with any other type of Caesarian section except the classic operation. This study has impressed the writer with the old fact that very few things are entirely new. We stand on the shoulders of the many men who have thought and labored through the many years that have gone before. We, in turn, will be such men.
A history of the Caesarian section is largely a recital of the efforts made to make the operation safe. It has always intrigued the interest of the medical profession. The attitude of the obstetrician toward the problems of a Caesarian section has been like the attitude of the climber of Mt. Everest who, when asked why he persisted in face of defeat (to say nothing of danger) replied: "Because it's there". The final chapter on the development of the Caesarian section has not been written.
Read before an obstetric conference at the City Hospital, Binghamton, N.Y., April 6, 1950,
Abdominal Pain in Pregnancy
Stuart B. Blakely, M.D.
Abdominal pain in pregnancy is frequent and has not been thoroughly studied. Few women escape some abdominal discomfort or distress. Eighty-five percent definitely complain of such pain at some time during the nine months, but the literature on the subject is meager. Brief references are scattered through obstetric textbooks. Only two journal articles in English could be found; hence this clinical study of abdominal pain in 300 consecutive private obstetric cases.
Since it is entirely unpractical to attempt to name all the causes of abdominal pain, with or without pregnancy, this paper will deal only with abdominal pain directly caused by. or closely associated with the enlarging uterus or the pregnant state. Pregnancy is, of course, not immune to any of the numerous intra-abdominal and extra-abdominal condition that causes pain in the abdomen, a fact to be most strongly emphasized and ever borne in mind.
Nervous anatomy, detailed differential diagnosis, and therapy are not considered. There can be no discussion of the theory and definition of pain and only a brief reference to the mechanism of the production of abdominal pain. Much abdominal pain in pregnancy is somatic, i.e., arises in the parietes of the abdomen. Mackenzie's theory of the viscerosensory reflex may explain the localization of some true visceral or splanchnic pain. However, the conclusion that pain may be actually felt locally in both solid and hollow viscera seems inescapable. Examples of visceral pain felt locally in the organ involved are the pain of ablatio placentae, of a subserous fibroid under tension, or of a distended and inflamed ureter or kidney pelvis. John Morley has well summarized the differences in the character of visceral and somatic pain: Pure visceral pain is deep-seated, dull and heavy, often intermittent, widely radiating and imperfectly localized; in contrast, pure somatic pain is more superficial, sharp and stabbing, felt over a smaller area, more accurately localized, and at times associated with local tenderness and muscular rigidity. These differences should be remembered during the further development of this paper.
ETIOLOGY OF ABDOMINAL PAIN IN PREGNANCY
True inflammation is not an important etiologic factor. Most abdominal pain in pregnancy is the direct or indirect results of either uterine enlargement or uterine contraction. The uterine enlargement causes pain by its own distention (often with or followed by uterine contraction) or by pull (stretching) or pressure exerted on organs or tissues. The uterine contraction causes pain chiefly by smooth muscle tension, which Hurst believes to be the cause of all true visceral pain. However, it is difficult to explain why one uterine contraction is painful and another not, when the two are of the same apparent intensity and degree of hardness to the examining hand. The pain of both enlargement and muscular contraction of the uterus is augmented by the pain produced in the abdominal wall by these two processes. Disturbances of function (e.g. ureteral dilatation) and interference with the blood supply (e.g.. Degeneration in a subserous fibroid) are at times causative or contributory. Three other conditions must be mentioned in this brief consideration of the etiology of abdominal pain in pregnancy extrauterine gestation, certain types of placental hemorrhage, and "liver" toxemia.
Abdominal pain in pregnancy is frequently without physical signs, is with difficulty described by the patient, and often strangely comes and goes without apparent reason. Generally speaking, its severity is in direct proportion to the rapidity of the development of the cause. An atypical pain occasionally defies analysis; most of these can be traced to their source by study sometimes, it is true, only in retrospection. It is very important to remember that individuals differ markedly in their reaction to painful stimuli and also that many factors in all pain production are still underdetermined.
FACTORS INFLUENCING ABDOMINAL PAIN IN PREGNANCY
Age, Ranging in this series from 17 to 48 years, age alone apparently exerts no influence. Table 1. Complaints of pain by Month of Pregnancy.
Table 2. Complaints of Pain and Location in Abdomen
Lower part of abdomen... 341
Central part of abdomen..... 38
Upper part of abdomen......142
The complaints of pain were more than twice as frequent in the lower as compared with the upper part of the abdomen.
Parity, - Primiparas complain slightly more frequently of abdominal pain than multiparas. The latter are rarely able to recall any suffering in a previous pregnancy.
Habitus, - The tall slender asthenic women suffers more from stretching of the lower part of the abdominal wall, while the short stocky asthenic patient with short abdomen from the pubis to the ensiform cartilage tends to have more pain in the upper part of the abdomen. The difference is not marked.
Period of Pregnancy, - The incidence of pain increases with each month up to the ninth and then markedly lessens, there being only slightly more than one-half the number of complaints of pain in the last month as in the eighth. I have no explanation for this apparent contradiction. Practically all pain disappears post-partum, that of the biliary and urinary tracts occasionally excepted.
Time of Day, - Symptoms due to stretching of the lower part of the abdomen and round ligaments are worse at the end of the day. Pain that wakes the patient night is usually colic of a hollow viscus or an intra-abdominal accident.
Regions of the Abdomen, - Pain is more frequent in the lower than the upper part of the abdomen, and in both more on the right side. The lower part of the abdomen is the region of the greatest changes during pregnancy. The location of the appendix and gallbladder on the right, the displacement of the uterus toward that side and the greater activities of the right extremities may partially explain the preponderance of right-sided pain. Early in pregnancy, the pain is almost always low in the abdomen; if central, in the bladder or uterus; if lateral, in the ovary of occasionally in the tube or round ligaments. Later, the pain caused by stretching of the abdominal wall and round ligaments is common. In the last two months, the pain is still chiefly in the lower part of round ligaments is common. In the last two months, the pain is still chiefly in the lower part of the abdomen and is, without question, most frequently of uterine origin.
Table 3, 4 and 5, give the location of the complaints of pain in more detail, the number of complaints in the different areas and comments on the origins of the pain. There is a preponderance of pain on the right side in all.
Scars, - Among the 300 cases there were forty-seven operative scars of varying age, length, and location. In only seven instances was their pain in or near them a finding contrary to common impression.
Position, Exertion and the Like. - Walking or sudden body movement sometimes causes a painful local cramp in the distorted abdominal muscles or round ligaments. Lower abdominal pain caused by stretching these tissues or the pelvic joints is usually increased by the patient being on her feet and is relieved by rest and adequate support. A painful round ligament is not uncommonly stretched and made worse by the patient lying on the opposite side. Pain in the upper part of the abdomen is often made worse by sitting (pressure increased) and made better by standing (pressure lessened). A sudden increase of intra-abdominal pressure may start or aggravate abdominal pain; e.g., by coughing, sneezing, vomiting or the like. Jolting and jarring at times make worse the symptoms of an ectopic gestation or a "pyelitic." Weak feet, faulty shoes, relaxed Sarco-iliac joints, disturbances of equilibrium and changes of stress and strain in the back an abdomen are undoubtedly definite though often obscure factors in the production of abdominal pain in pregnancy.
Position and Presentation of Fetus, - In vertex presentations the side on which the buttocks are seems to be slightly more frequently the site of pain. Distress in the upper part of the abdomen is common with a breach.
Intra-Abdominal Conditions, - Previous pelvic or abdominal peritonitis does not particularly predispose to pain in a subsequent pregnancy if the inflammatory process has ceased. Adhesions in and of themselves are without symptoms unless by the action of the uterus they are made in some way to interfere with function. Some painful intra-abdominal conditions may be improved by or during pregnancy; e.g., abdominal hernia, visceroptosis, gastric ulcer. In general, however, the pregnant abdomen seems to be more prone to painful sensations than nonpregnant. Some preexisting intra-abdominal conditions are frequently worse; e.g., inflammatory processes, stasis or obstruction of the intestinal and upper urinary tract, disease of the liver and bile passages, and abdominal carcinoma.
CLASSIFICATIONS OF ABDOMINAL PAIN IN PREGNANCY
A satisfactory classification of abdominal pain in pregnancy is difficult. Possibly, excepting colic, muscle spasm, sudden rending of tissue and sudden peritoneal insult, the average patient's characterization of pain is not clear and is of questionable value. For this reason, little description of pain has been attempted.
The anatomic origin of abdominal pain in pregnancy may be grouped as follows:
Uterus, its contents and adnexa.
Extragenital locations intestine, liver with bile passages, and urinary tract.
It is probably simplest and best to consider in order pain originating in these locations, at the same time discussing the mechanism of its production, and the location of the pain as felt by the patient.
PAIN ARISING IN THE ABDOMINAL PARIETES
The term abdominal parietes include not only the anterior and lateral abdominal muscles with their facial coverings, extensions and insertions, the subperitoneal tissue and the parietal peritoneum, but also the pelvic girdle, the lower part of the thoracic cage, and the pelvic and costal diaphragms.
The posterior wall of the abdomen is not, strangely enough, a proved source of pain in pregnancy. It is entirely possible that some ill-defined abdominal pain may be a true referred pain from the posterior wall. A lower lateral abdominal pain, relieved by lying on the side with the thigh sharply flexed, has suggested psoas muscle origin.
Stretching of the skin and fat of the anterior and lateral abdominal wall does not cause actual pain, nor does the thickness of the wall seem to be an important factor. Short, Sharp, scattered, stabbing pains in the lower part of the abdomen suggest and only suggest stretching of the subperitoneal tissue. Indefinite, ill-defined, more or less general lower abdominal pain may be due to stretching of the wall or round ligaments (if early), but I believe it is more commonly of either large intestinal or uterine origin especially the latter. Generally speaking, pain caused by stretching of or pressure on the lower abdominal wall is felt most commonly along broadband curving from one anterosuperior spine down over Poupart's ligaments and the pubis to the opposite spine. The patient will often outline this pain by moving her hands up and down along this area or by putting her hands in a position as if to support the abdominal wall in this region. The painful sensations are sometimes complained of as being sharper over the centers of Poupart's ligaments (insertion of the round ligaments) and over the pubis and pubic spines (insertions of Poupart's ligaments and the rectus muscles). These pains are not in evidence in early pregnancy, are very variable in character and appearance irrespective of the tenseness of the wall and are influenced by factors already mentioned.
The region of the pubis may be painful by direct pressure of the fetal head or by stretching of the rectus insertions and the pelvic girdle. A low, central more or less vertical pain above the pubis, indicated at times by a typical up and down movement of the patient's hand and fingers, seems to be associated with relaxation of the symphysis pubis, often with demonstrable tenderness, even separation, of the joint as well as tenderness of sacroiliac joints. Rarely, sudden "lightning" may cause lower abdominal pain. Stretching of the pelvic diaphragm in the later months sometimes results in a sharp pain shooting from the pelvis or vagina up through the lower part of the abdomen.
An abdominal hernia may be painful by stretching of the ring or by a pull on adherent contents, hernias are "cleared" by the rising uterus and give no symptoms. The larger the hernia, the farther from the midline and the higher in the abdomen, the less likely is this "clearing" to take place. In a few instances, I believe that I have observed pain due to stretching of the tissues about the navel.
In the upper part of the abdomen, in the later months, is the discomfort, occasionally amounting to pain, caused by stretching of and pressure on the lower thoracic cage (including rib margins with rectus insertions) and on the diaphragm, which is at times felt in the back at the level of the insertion of the diaphragm, fairly common is the painful "slipping" of the (usually) seventh or eighth costal cartilage with definitely localized tenderness. As always, pain in the upper part of the abdomen may present many diagnostic difficulties.
PAIN ORIGINATING IN THE UTERUS AND ADNEXA
Two types of pain originate in the uterus; local and diffuse.
The local type, sharp, sudden, usually well localized, is caused by tension or tearing of uterine tissue or in a fibroid. It is often accompanied or followed by the diffuse type.
Diffuse uterine pain is caused by uterine distention and (or) contraction (the latter with an element of colic) and is felt in the lower part of the abdomen between the pubis and the navel, an area connected with the eleventh and twelfth segments of the dorsal cord. Occasionally, diffuse uterine pain is felt above the level of the navel or in the anterior thighs and has been explained on the basis of an anomalous nerve distribution or supply. However, I am not at all sure that diffuse uterine pain is a Mackenzie viscerosensory reflex. The patient usually indicates its site by drawing her hand more or less horizontally across, though not entirely across, the lower part of the abdomen, or by drawing both hands, in the same manner, a little lower nearer the pubis. The diffuse type of uterine pain is intermittent (though in early abortions apparently almost continuous), often begins at night, is accompanied by sacral pain and hardening of the uterus, is not relieved but usually made worse by enemas, and is often followed or associated with vaginal discharge.
Uterine contraction is by far the more frequent cause of the diffuse type of uterine pain, threatening or presaging abortion if early, labor if late. Here belong the "false" or "wild" pains. Rapid stretching of the uterine musculature produces the same type of pain without the element of colic (though this is often added or superimposed), as in acute hydramnios, accidental hemorrhage, and infected uterine contents. In this category is the incarcerated uterus with bladder distress. Any acute uterine distention may also exhibit pressure symptoms on the wall or contents of the abdomen. Abruptio placentae usually present a sudden sharp, more or less severe local pain due to tearing of the tissue, followed by diffuse pain. The same occurs with hemorrhage in a hydatidiform mole, though usually earlier in pregnancy. Rupture of the uterus gives the pain of muscle tearing, followed by that of peritoneal irritation due to escaped blood and uterine contents. If the rupture is rapid, extensive and in the upper part of the uterus, the peritoneal signs may be most marked in the upper part of the abdomen with shoulder pain. If the placenta lies under the point of rupture, all symptoms are frequently less severe. Abdominal pregnancy is usually quite painful because of more direct undamped fetal trauma. Fetal movements are occasionally painful, even in a normal pregnancy, especially in a tense uterus or when they impinge on a tender tissue or organ.
Fibromyomas in the pregnant uterus, even when large and multiple, are frequently without symptoms. They may cause pain by torsion of a pedicle, by tension in a fibroid (usually subserous) owing to circulatory, degenerative and even infective changes. This last cause (tension in a fibroid) is the most common cause of abdominal pain in pregnancy associated with uterine fibroids and is usually well localized by the patient. The prominence, tenderness, and pain of the tumor are increased by or with uterine contractions (cause or effect ?). Small fibroids of this type, or small intramuscular or subserous hemorrhages are, I believe, the most common cause of local pain and tenderness in the pregnant uterus. More or less continuous local uterine pain or painful uterine continuous over a considerable period of time without the onset of labor are produced in many cases by the efforts of the uterine musculature to expel small fibroids from its midst. A previous explanation has been "faulty uterine innervation."
The round ligaments might well be considered in many respects a part of the anterior abdominal wall. Pain by their stretching or contractions is common in the lower part of the abdomen from the tenth to the thirtieth week and is felt for a shorter or longer distance along their course from the middle of Poupart's ligaments to the angels of the uterus, though rarely if ever felt above the level of the navel. The ligaments or portions of them can often be felt as tender cords, and the patient usually indicates very accurately their location at least the painful segments. Here belongs the ligament pain associated at times with a previous suspension.
Salpingitis is rare in pregnancy, and I have not definitely observed pain from that source. Varicose veins of the broad ligaments are said to cause pain; their diagnosis must be difficult. Ectopic gestation exhibits abdominal pain that may vary greatly in location, degree, character, and order of appearance; e.g., the low unilateral pain of tubal distention and colic (the tube is stated to be connected with the twelfth dorsal spinal segment), often accompanied by the diffuse type of uterine pain; the local pain of slow rupture of the tubal wall and the effusion of blood into the pelvic tissue or the pelvic peritoneum; the sudden pain of tubal rupture or tubal abortion that "doubles the patient up" (visceromotor reflex?); the diffuse pain of peritoneal irritation. Much depends on the rapidity of the development of the cause.
Pain arising in the ovary during early pregnancy seems to be due to distention of the capsule by the formation of the corpus luteum with more or less hemorrhage, apparently intensified by the presence of "adhesions" and traction by the rising uterus. The pain of ovarian origin later in pregnancy is most commonly associated with the twisting of the pedicle an (or) inflammation of some type of ovarian tumor the word tumor being used here in the broadest sense. Then follows a more or less definite series of pathologic changes accompanied by various sorts of pain. Though the ovary is said to be connected with the tenth dorsal cord segment, the pain in the few cases of the twisted ovarian pedicle that I have seen appeared to be lower in the abdomen than the level to which the tenth dorsal segment is usually assigned.
PAIN ORIGINATING IN THE INTESTINAL TRACT
Occasionally, pain in the right or left upper quadrants, across the upper part of the abdomen or along the course of the descending and sigmoid colon is relieved by the passing of gas or by "unloading" the bowl. A laxative or an enema is sometimes a valuable diagnostic aid. However, real abdominal pain from flatulence or constipation is not so frequent as has been stated. This raises the question of the localization of pain of the large intestine. Hurst believes that pain arising in the more movable portions is felt as diffuse pain in the lower part of the abdomen. Transverse pain across the abdomen above the navel, frequently with or follow by painful uterine contractions, threatening the continuation of the pregnancy. In the three hundred cases studied there were only in which there was evidence of mechanical obstruction of the small intestine. The causes of their symptoms were definitely determined, for they did not come to operation. It is possible that some indefinite central abdominal pain in pregnancy originates in the small bowel. Pregnancy tends to increase intestinal stasis, or any intestinal obstruction, whether from intrinsic or extrinsic causes. The usual explanation is that the symptoms are produced by pressure on or angulation of the portion or portions of the intestine in question, influenced by increased vascularity and by the presence of adhesions and pelvic tumor. Definite symptoms of intestinal obstruction should never be ascribed to pregnancy alone.
PAIN ORIGINATING IN THE LIVER AND BILIARY TRACT
Any preexisting pathologic condition in the liver and biliary tract is almost always worse during pregnancy. Three conditions, induced by pregnancy and frequently associated may produce pain in this sensitive organ group: Trauma by the pressure of the uterus, or fetal part, or fetal movement in the upper portion of the abdomen and epigastrium. Changes in the liver, gallbladder and bile tracts due to increased absorption of toxic and infectious material from the intestinal tract. The conditions mentioned in 1 and 2 present no special diagnostic difficulties peculiar to pregnancy. "Liver" toxemia, so called, especially if acute and in late pregnancy. The pain, more or less continuous, is often very sharp and severe, usually centering in the epigastrium. The mechanism of the liver capsule by hemorrhage or necrosis in the liver parenchyma(?).
PAIN ORIGINATING IN THE URINARY TRACT
The bladder and pelvic ureters are rarely the sources of any pain during pregnancy. On the other hand, the abdominal ureters and the renal pelvis are quite commonly the sites of changes often on a preexisting base which gives rise to pain and other symptoms loosely and carelessly termed "pyelitic of pregnancy". Stasis and infection are the two prime causative factors. The stasis is due to two phenomena peculiar to pregnancy: (1) pressure of the uterus on the relaxed ureters lying on the bellies of the psoas muscles, whether they have been displaced by the uterus as early as the eighth months in 80 percent of pregnancies; (2) hypotonicity of the ureters and renal pelvis, probably caused by some specific substance elaborated during pregnancy. These hypotonic changes are 100 percent in evidence by the fifth months, increasing as pregnancy advances, 83 percent in both ureters, 15 percent in the right one alone, and 2 percent in the left alone. Bacteriuria is present in a considerable number of pregnant women. In most patients, the stasis exists with few or no symptoms, as does the infection. It is impossible to state with any degree of certainty just what extra factor or factors initiate pain in a given case. It seems fairly clear that it is produced by the tension of smooth muscle or an encapsulated organ (ureter, renal pelvis, kidney) by an obstruction, or infection, or both. The pain is rarely colicky but rather continuous with exacerbations. The patient indicates ureteral or radiating (?) renal pain by moving the hand from the region of the public spine outward and upward, parallel with Poupart's ligament, to near the anterosuperior spine of that side, and then curving back into the loin, more often on the right than on the left side. Occasionally, she passes the hand downward in the reverse direction. It may be at times difficult to distinguish this pain from that originating in the large bowel, round ligaments or abdominal wall; but the typical movements of the patient's hand and other symptoms usually make the situation clear.
Even marked pathologic changes in the renal pelvis and kidneys may cause no abdominal pain. When such pain does occur, it is usually indicated by the patient at some point in an area of moderate width extending from about the level of the navel (tenth dorsal segment) outward to just below the rib margin, and thence lateral and posterior into the loin. The diagnosis of a "pyelitic of pregnancy" should never rest on the evidence of abdominal or other pain alone.
SUMMARY OF ABDOMINAL PAIN IN PREGNANCY
Abdominal pain in pregnancy may be classified as to the anatomic origin, mechanism of production and location as felt by the patient. The anatomic organs may be grouped into (1) abdominal parietes, (2) uterus with contents and adnexa, and (3) extragenital organs and tissues.
The pain may be of somatic or visceral origins and is caused chiefly by distention enlargement or contraction of the uterus its source can usually be determined.
Eighty-five percent of pregnant women complain of definite abdominal pain at some period.
The incidence of pain increases with each month up to the last at which time there occurs a marked decrease.
There is more pain in the lower than in the upper part of the abdomen and in the both more on the right side. Abdominal pain pregnancy varies much in character a severity is not immune to any of the causes of abdominal pain.
CONCLUSION Sir James Mackenzie said that pain is the most important of complaints and the most instructive diagnostic sign. Knowledge of pain is scanty; exact information is largely lacking; an investigation is a difficult interpretation of observations is uncertain, and the subject is worthy of study. These words apply also to abdominal pain in pregnancy, a subject to which this clinical study is submitted as a modest contribution. 123 Murray Street
Radio Talk Prenatal Care
Binghamton, N.Y. March 16, 1930
Under auspices of the Kiwanis Club for the Binghamton Academy of Medicine
By Dr. S.B. Blakley
The medical supervision of the expectant mother during pregnancy is called prenatal or antenatal care. Broadly speaking it includes much more than just those few months. For example, as a child, the expectant mother may have had rickets which caused a bony deformity which in turn may seriously interfere with her labor. Again, she may have had scarlet fever which left a latent kidney trouble which in turn may be so lightened up by pregnancy as to threaten her health or life. Many other examples might be given showing how important all the years that go before, as well as the immediately preceding nine months, are to the patient under discussion tonight.
The expectant mother is the most important member of any social group whether of the city, state or nation. The number, health, and character of future citizens depend largely on her. Without her home with all that it means to us is rarely maintained. Anything that affects her health or usefulness or threatens her life is of deepest general concern. The mother of the family having a baby is infinitely more important to a community than the father of the family having his appendix out. All this would seem to be self-evident, but curiously enough is only within a comparatively recent time that its truth has been at all widely appreciated or recognized. In our present vaunted civilization which after all is but a thin veneer over an ancient and eternal paganism the following is a common picture with the following persons of the play an expectant mother, rarely even partially relieved of her household duties even up to the day of her trail; a preparation for this day most dread and important if her first experience often most completely inadequate for a situation that may demand more skill and assistance than any major surgical operation, a so-called experienced neighbor women, usually of the best intentions but entirely incompetent to act as nurse and housekeeper; any accident regarded as the inscrutable act of an all-wise Providence; and finally, the new mother again taking up her increased burdens after a totally insufficient period of rest. Soviet Russia is today the only country that gives and finances a period of rest before and after labor. It is to our shame that both state and church encourage, even demand, a high birth rate, while neither offer much aid in solving the problems involved which are largely educational and economic.
But there is evidence that the expectant mother and her child are being viewed in changing light. Much of the ignorance, superstitions, and taboos about sex are being swept away. Women are being emancipated in body and mind from the slavery of a dead past. Both the medical profession and the laity have come to realize that pregnancy is often, yes even usually, NOT a normal process whatever it may have been in ages gone and that the line between health and illness during that period is very narrow. The dictum that in obstetrics nature should be allowed to take her course is but the manifestation or colossal ignorance. Maternity hospitals and pavilions are being established, and both doctors and nurses are receiving better training in this branch or the healing art. The importance of the expectant mother is being recognized. She has become something more than just a "confinement case".
What should the expectant mother do? First, she should visit the physician of her choices as soon as the need for his future services is known. If she is not able to pay a private physician, the charity department of the city or county can make such service available to her. The physician then or later will, after taking her history, make a complete physical examination including the measurement of the bones of the pelvis and whatever special or laboratory tests are needed. the physician gives her advice and instruction, and instruction, and at stated intervals thereafter further examines and advises her. It is highly important that the patient follow the advice given to her, and carefully keep all appointments requested by the physician. It is not necessary here to enter into the details of prenatal care. The information was given by the physician may be and should be supplemented by reading. Every good library has books on the subject, many women's magazines have departments offering advice and pamphlets, and the Department of Labor at Washington and New York State Department of Health at Albany have excellent booklets on prenatal care, free for the asking. No women need to be ignorant on this subject that is of such vital interest to her and hers.
The average women should pass thru her pregnancy with a very small amount of discomfort and often with improved health and reach the end of the period with vigor or body and serenity of mind, ready to fulfill her biologic duty and realizes her dreams.
The universal exercise of proper antenatal care will enormously reduce the incidence of miscarriages and stillbirths, will almost entirely abolish the convulsions of pregnancy, and go a long way toward solving the problem of the type of infection formerly known as childbed fever. It can be possible only through an enlightened public opinion. It is no idle dreams, but a perfectly practicable achievement. In the whole realm of preventive medicine, there is no more promising field than prenatal care.
Management of the Early and the Mild Late Toxemias of Pregnancy
By Stuart B. Blakely, M.D.
Read at Syracuse, N.Y.
April 3, 1941
Profound anatomies and physiological changes in pregnancy. A dividing line between what is normal and abnormal is impossible to fix. When the pregnant women present evidence of perverted body function we usually say that she is "toxic" a highly indefinite term. In spite of a vast amount of research, "toxemia of pregnancy" still remains largely a hypothetical concept. While it may be justifiable to assume the presence in the women's body of some toxin or toxins (it is almost impossible to postulate only one), such pressure in the blood has never been demonstrated. The source and method of action are unknown. Any tissue may be involved, but especially the hepatic, renal, nervous and reticuloendothelial. There is a growing belief that endocrine disturbances and vitamin and mineral deficiencies play an important role. One writer says that vitamin deficiency may simulate toxemia. it may well be true that vitamin deficiency is the toxemia. But the ultimate cause eludes reaches. In general, we can only say that the symptoms of the toxicities of pregnancy are due to altered or abnormal maternal function, induced directly or indirectly by the products of conception.
As far as I know Dr. De Lee is the only textbook writer who has specifically considered what he calls the minor toxemias of pregnancy. He allows two pages to the subject. The symptoms are very varied and often obscure and may stem from any material tissues or organ. A few may be of great significance, but most of them are not serious, and many may be considered as, and are minor discomforts of pregnancy. Some may be really toxic, many are metabolic or endocrine in origin, a number simply mechanical. The possibilities and possible combinations are almost endless. I shall not try to define or unscramble or classify them but discuss some of the more common. I shall not stick too closely to my text. I hope that you will pardon the frequent use of the first person singular.
HEARTBURN- one of the most common, and to me, obscure and difficult to relieve. It has certainly never been demonstrated that it occurs exclusively or predominantly in those patients with increased gastric acidity. It is usually a rather late symptom if at all sever, and while possibly toxic is better considered as being in some way related to altered gastric motility. Reverse peristalsis has been offered. A better suggestion is that it is due to a relaxation of the cardio (all smooth muscle tubes relax and dilate in pregnancy) plus increased intraabdominal pressure which results in a regurgitation of acid gastric juice into the lower esophagus. Many remedies have been used, usually some combination of "antacids", such as sodium bicarbonate, magnesia, bismuth, other carbonates, often with the addition of aromatic. In my experience, milk of magnesia makes them worse. Many patients find relief in "tums". I have no experience with colloidal preparations, and little success with fresh cream, dilute HCL or finely chewed nuts. Occasionally the drinking of sparkling water benefits. Some are helped by the reduction of total food intake, especially if eating too much and of fats. Sleeping with the head elevated on a pillow or with the head of the bed raised often is of help. A few patients find relief in auto lavage. Most obstetricians have their own favorite prescription or method for the treatment of heartburn, thus proving the non-existence of any specific for the condition.
SORE TONGUE- glossitis in my own experience the exhibition of large doses of vitamin B complex with dilute HCl and iron has helped these cases quite definitely.
GINGIVITES- local treatment by a really good dentist is of great value, as the instruction of the patent in careful and persistent oral hygiene and the use of astringent mouthwashes. Attention should be directed toward the general health and the prescribing of iron and whatever "tonics" may be indicated. While vitamins A, B, and C have been suggested for this condition, I feel that I have had the best results with large doses of C a quart or more of orange juice a day.
PTYALISM- probably best considered and treated as one of the rarer complications of early nausea and vomiting of pregnancy. I have never thought that I have ever been able to do much for this annoying condition by any drug.
EARLY NAUSEA AND VOMITING- while this symptom group probably has a toxic basis and possibly an endocrine factor, I firmly believe that the psychic element is predominant. These patients suffer from a conflict of desires and/or fears that causes them to reject the pregnancy; occasionally their nausea and vomiting is a punishment of self or husband. why do I think so?
Its greatly lessened incidence in recent years due to a more sane and enlightened attitude toward pregnancy. An induced abortion for this condition is a rarity nowadays.
The weakening of the influence of old ideas how often do the young pregnant women say that she does not see how she can be pregnant when she is not "sick".
Cures by cervical treatments attempted or faked abortion and by all sorts of therapy, basically psychic.
The results of the modern treatment which is practically psychotherapy plus sedation and glucose. It is quite impossible to maintain the toxic theory in the face of the rapid and often dramatic and spectacular results so often obtained.
What do I do with early nausea and vomiting of pregnancy? I never mention the possibility to my patients. If they say that they are so troubled or I discover it by roundabout inquiry, the casual statement is made that it occurs in not over half of pregnant patients, it doesn't last very long and few women are much bothered with it anymore. If they do not want to eat, all right, but insist that they should have daily the equivalent of one good meal which is sufficient to maintain their health. Assure them that their baby is not in need of line or any particular food at this time. They can have ANYTHING they want I emphasize that often naming some crazy and impossible food combinations. If they have no particular choice, I suggest that they eat largely sugars and starches, mentioning several. It is better to eat a half dozen or more times a day if they wish they may "piece" all day long. I tell them to take their food dry, without soups and milk, etc., to drink little or nothing with their food. Often the taking of something before rising help, and one else's cooking. I have always felt that the insistence on diet lists for these patients, while possibly of merit, is largely psychotherapy. They are so busy keeping track of their diet, that they forget their troubles. These will usually get well anyway, for patients rarely come to the doctor earlier than six weeks and in another six weeks they are pretty well over their vomiting. Of the interne and his recommendations for afterpains. I often give them phenobarbital Â½-1 grain 3-4 times a day. I think it helps. I also believe that the reading of a good book or booklet on prenatal care, commensurate with their intelligence, is valuable. Finally, I have a talk with them. Sometimes I tell them that they don't want their baby, which they will indignantly deny. Then I explain. I tell them that they possess an inescapable instinct for a baby which cannot be denied, but that various conflicting factors enter into the pictures, and so arise fears and anxieties. Often these will come out if a little patience and ingenuity are exercised. Get them to face whatever the situation may be, and to adopt a good or at least as good as possible philosophy toward it. If these vomiting patients cannot be controlled and made reasonable comfortable by these measures, I insist on hospitalization, under the charge of a nurse who knows how to manage them. If nausea and vomiting are not then speedily controlled, I believe that abortion should be induced. I have had very little experience with the use of adrenal cortex or other endocrine substances or of vitamin B or other vitamins in the treatment of early nausea and vomiting of pregnancy. I cannot deny their worth nor would I disparage their use. Finally, and emphatically, in spite of whatever I have said this afternoon, believe me, I have the greatest respect for nausea and vomiting of pregnancy.
Late vomiting of pregnancy suggests an infection, not infrequently a pyelitic; or latent toxemia; or a reflex or mechanical cause, like a gallbladder disturbance. The older practitioners believed and often quite rightly in the intestinal origin of illness, and often prescribed for these patients a cathartic, usually a dose of calomel. It still often works well.
Of course, in all discussion of this type, it is not to be forgotten that pregnant women are not immune to diseases and conditions that may affect the non-pregnant women.
Extrasystoles occur frequently in pregnancy, are usually of no importance and the patient can be assured of their harmlessness. "Formes Frustes", or mild manifestations of hyperthyroidism, are common in pregnancy. I hope that, eventually, I can have a basal reading on every obstetric patient, for it might furnish a clue to many obscure symptoms. Besides, a lowered basal reading in early pregnancy is a factor in abortion, as well as the development of late toxemia.
Vertigo and fainting are evidence of vasomotor instability. It is said that if you see a young woman being helped out of church or the theatre, she is probably pregnant. For the fatigue, exhaustion, "no pep" symptom of early pregnancy, I suggest all the sleep and rest they can get or want, and the prescription of alcohol and strychnine, which the older doctors used to say should never be given together.
Varices are certainly not due to pressure. Some women can tell immediately when they are pregnant by their veins beginning to swell. Rest, elevation and support by adhesive, stocking or elastic bandage. Of the elastic bandages, the real rubber ones are best, though not always the most comfortable. With the injection treatment, which has staunch champions, I have had no experience. Possibly, like many of the older men, I am afraid of a radical quite so bad as often pictured. Hemorrhoids should generally be handled conservatively, except in the case of thrombosed external hemorrhoids where the complete removal of the clot under local anesthesia and strict asepsis gives great and welcome relief.
There has been a deal of discussion recently of anemia in pregnancy. The so-called physiological anemia of pregnancy is probably the result of hydremic, though may be toxic or result from the breakdown of the red cells to supply the fetus with iron. It seldom needs treatment unless the RBC drop below 3,500,000 and the hemoglobin below 70%. A pernicious type of anemia may occur, and the obstetric patient is not immune to a factor that produces secondary anemia. Hypochromic anemia is the most common form of severe anemia encountered in pregnancy, probably a manifestation of toxemia. Factors in its development seem to be the family tendency, gastric disturbance, and a diet deficient in meat and iron. It usually begins in the latter half of pregnancy with lowered HCL; RBC above 3,000,000; low Hgb, somewhat like chlorosis. The patient's complaints are usually sore tongue, brittle nails, and neuritis manifestations, as well as the symptoms referable to any anemia condition. Iron seems almost a specific but the dosage must be adequate. Dilute HCl, liver, and transfusions should be remembered. I wish that every obstetric patient could \have at least a red count and a Hgb, determination.
There are many toxic symptoms referable to the nervous system, such as psychic changes of pregnancy; headaches, which in all cases demand attention and are especially of importance if late, sudden, persistent and severe; pruritic; insomnia, usually late in pregnancy and which should not be dismissed lightly. Neuritis symptoms like numbness and neuralgias usually of the extremities are very common and most of them toxic. If in the sciatic region they are usually glibly ascribed to "pressure", while as a matter of fact they are rarely so caused, being either toxic or referred from the Sarco-iliac joints. Most toxic neuritis symptoms of pregnancy can be helped by iron, calcium and vitamin B complex in adequate doses. Heat often helps them, e.g. the therapeutic lamp and the wrapping of an arm in flannel at night. In this group can probably be classed the cramps in the calves, usually the right, that often waken the patients in the early morning hours. I believe that there is here often an associated circulatory element, else why in the legs? Besides the medicines mentioned above iron, calcium and vitamin B and D the following procedures often help elevation of the legs several times a day for periods of fifteen minutes or longer; elastic stockings or bandages; heat, especially at night, and cautious massage.
I would like to call your attention to a neuritis symptom complex that not infrequently occurs postpartum, apparently toxic. It is severe pain in the neck shoulder upper thorax area, or in that of the hip-thigh-pelvis. That is the upper extremity is usually ascribed to the draught from a window or door. Heat, counterirritation, aspirin and very large amounts of vitamin B seem to help them.
At this place it might not be amiss to briefly consider the daily amounts of vitamins and minerals required by the pregnant women since these have been so frequently mentioned up to now and are definitely of great importance to the pregnant women's metabolic processes, though probably in nowhere the degree usually claimed.
Vitamin requirements of the pregnant women daily probably twice as much as is required by the non-pregnant.
Vitamin A 10,000 international units
Vitamin B 800 international units
Vitamin C 100 mgs. Ascorbic acid
Vitamins D 800 international units
These figures are not to be considered final. If we can believe advertisements, three yeast tablets a day fills the bill. Mineral requirements in pregnancy.
Phosphorus usually adequate, if enough animal protein in the diet. Iron 15-20 mg. Daily
Calcium the most important; beat companied by Vitamin D. The usual daily adult calcium requirement is about o.6 mgs. The fetus deposits little calcium before the fifth month but in the latter part of pregnancy 20 30 grams, 60% of it in the last two months. In the latter part of pregnancy, pregnant women need about 1 gm. Of calcium daily.
One Quart of milk 1.5 mgs. Calcium The following medicaments contain calcium as follows;
Abbott- Bone Phosphates tablet 1.7 mgs. Calcium
Decal D. Wafer 3.5 " "
Decal D. Capsule 1.75 " "
Squibs Dicalphos. C Vicsterol wafer 3.5 " "
Calcium gluconate powder 8.9% calcium
Many writers believe that non-traumatic abruptic placentae are often one of the best examples of one type of pregnancy toxemia. Omitting all reference to its possible role in abortion and all use of progesterone, we shall confine the discussion to slight localized premature separation of the placenta in the latter part of pregnancy. Shute of Canada has studied and written much on this subject. He believes that the condition is characterized by the appearance of local areas of pain and tenderness (sometimes with rigidity) in the uterine wall, associated with sacral backache and often though not necessarily accompanied by uterine bleeding. He maintains that they are very common, and are always toxic in origins, that the toxemia is associated with (not the same as caused by) an increased estrogenic substance in the blood that causes the resistance of the serum to proteolytic ferment. He maintains that the condition can be controlled and cured by adequate doses of vitamin E which is antagonistic to the estrogenic substance. He used wheat germ oil for this purpose which must be kept under refrigeration where it retains its potency for about eight weeks. He gives 12 drams the first twenty-four hours and continues one dram a day, which had best be continued to term. Much larger doses have been given without harmful results, and the dose must be ADEQUATE. He claims that under the treatment one can observe the shrinking and disappearance of the areas described and the subsidence of the symptoms. I believe that he is, in the main, correct. Local pain and tenderness in the wall of the pregnant uterus (note that the round ligament is excluded) are due either to a fibroid or a hemorrhage.
It might be of interest to compare vitamin E products as to tocopherol (name of synthetic vitamin E) Content and approximate retail cost in Binghamton.
Wheat germ oil one dram 5mgs tocopherol 9 cents
Gerome E one cap. 4mgs " 6.5"
Roche Ephinal Acetate tablet 3mgs tocopherol 3.8 cents
Squibs Tocophorex cap. 24mgs. Tocopherol 7 "
Winthrop Tofaxin cap. 30mgs. " 9 "
Abbots Natopherol cap. 50 mgs. " 9 cents Plus
It is obvious that there is wheat germ oil and wheat germ oil, that vitamin E capsules are not all the same, and that tablets of tocopherol vary in strength.
A common obstetric experience is to be confronted by a patient in late (occasionally earlier) pregnancy with rising blood pressure, albuminuria, and evidence of water retention. These three are the cardinal symptoms late toxemia of pregnancy, though eye, cerebral, gastrointestinal and other disturbances may even then be present or may be added as the disease progresses. For our purposes, the first procedure is the determination of the type of toxemia, and the second, the management of the three symptoms named.
The nephropathies of late pregnancy are still unsolved. A disease of kidneys and blood vessels predisposes to toxemia. Pregnancy is a very delicate test of renal function and unmasks latent or aggravates already existing reno-vascular disease. It seems probable that pregnancy elaborates a toxin with a specific action on the kidneys and blood vessels.
Corwin and Herrick believe that there are two broad types of late toxemia of pregnancy.
Closely related to vascular renal disease, more commonly essential hypertension. It appears earlier with history or evidence of the pre-existence of these diseases. First, the blood pressure rises, and considerably later if at all, albuminuria and edema appear. HAs a good prognosis with rest, and rarely drifts into pre-eclampsia or eclampsia? Reacts to the cold pressor test, and not to intravenous Pitressin except as the normal women.
Has no apparent relation to vascular renal disease. Appears later with no history or evidence of such preexisting disease. Increased blood pressure is associated with, or preceded by, albuminuria and oedemic. Does not respond to rest, and drifts easily into preeclampsia and eclampsia. Does not react to the cold pressor test, but gives by .66 cc. pitressin response of 50mm. Or more for 15 minutes instead of the usual 45 or less. The idea is that this group the preeclampsia and eclampsia is the result of specific toxemia. However, the idea is growing that back of ALL pregnancies nephropathies stands renovascular disease. Preeclampsia and eclampsia are often followed by permanent essential hypertension rarely by chronic nephritis. The older the patient, the greater the parity, the higher the pressure and the longer the duration before delivery, the greater the probability of a permanent increase of the blood pressure.
The differentiation of these groups can usually be made, though some toxic cases must remain unclassified. The help of good internist in the treatment of these toxemias is very valuable.
Management of mild late toxemia of pregnancy. Very important is the appreciation of the danger inherent in the condition, not only present but potentially for the future, and of the need of thorough clinical and laboratory investigation of every case, and continuous observation. A very valuable but often neglected source of information is the eye grounds.
Management of the reno-vascular group except under most unusual circumstances I personally believe that a woman with proved chronic nephritis should not become pregnant, and if pregnant, her pregnancy should be terminated, preferably with sterilization. My own personal experience in trying to continue or prolong pregnancy in these cases has been unsatisfactory and sometimes disastrous. The mother's condition is usually worsened; the baby often dies and lengthening of its intrauterine life does not materially increase its chances for survival. I admit that there are exceptions. On the other hand, many cases of mild essential hypertension can be carried through pregnancy under a strict medical regime. Just when this should be done, is very difficult, at times, to decide. I feel that most of them are surely NOT improved by pregnancy, and I should hesitate to advise pregnancy for a woman with a blood pressure of 170 or over.
Management of preeclampsia and the three symptoms of increased blood pressure, albuminuria and edema.
Blood pressure in pregnancy. Low blood pressure in pregnancy, in my experience, is of a slight moment. With the patient reclining, it is not uncommon to have readings below 100 systolic, and many times I have not been able to definitely determine the diastolic. Normal blood pressure in pregnancy with the patient reclining is rarely over 120/80 often much lower. Surely any readings persistently over 140/90 are definitely abnormal, or any systolic rise of 40mm, or more. I have almost a rule though not quite that I induce labor in a preeclamptic patient whose systolic pressure passes 170, or diastolic 110, especially if the rise has been rapid and depending somewhat on her other symptoms. Rest and sedation are valuable in the treatment of hypertension.
Albuminuria or proteinuria. It is doubtful if albumin is ever present in the urine in normal pregnancy. The "albuminuria of pregnancy", "the kidney of pregnancy", the "low reserve kidney" probably represents a kidney with congenitally defective function, unable to stand the extra strain of pregnancy. It is characterized by an increase of blood pressure to say 150/90 in the last two months, small or very moderate amounts of albumin in the urine, normal blood chemistry, no other symptoms, disappears in the puerperium and though may recur, does not become worse in succeeding pregnancies. It is probably best to classify it as a manifestation of latent hypertension or mild preeclampsia and it represents about 35% of all late pregnancy toxemias. It has always been a puzzle to me what to do with the patient with a large amount of albumin in the urine, and nothing else demonstrably wrong. W. J. Dieckmann of the University of Chicago, who published a very good paper on the "Prevention and Treatment of Eclampsia" in the American Journal of Surgery of April 1940, says that the patient should be hospitalized and the pregnancy interrupted if the albumin is 3 plus or more than 5gms. In 24 hours. There is no specific treatment for the condition.
Weight increase and water retention in pregnancy. a woman gains, on the average, between 20-25 pounds over her usual weight during pregnancy. Rarely should she gain more? About 15 pounds of this is a fetus, placenta, amniotic fluid, and the increase in fat and water. The weight gain is roughly distributed as follows first three months, little or nothing; second trimester, one-half pound a week; In the last two weeks immediately before delivery, the normal patient often loses a pound or more, and this has been suggested as a possible indication of the imminence of labor. I insist that my patients keep their weight gain within reasonably normal limits; on many days, the topic of our conversation seems to be pounds and food and diet. I tell them that they will put less strain on their gastrointestinal and cardiovascular-renal system and that many of the minor discomforts will be less in evidence or even disappear. They feel better, look better, and do not have to struggle to lose fat afterward. Some are hard to convince that they do not have to eat for two. If a patient is definitely over weight at the beginning of pregnancy there is no reason why she should not lose some, or at least not gain, during her nine months.
Practically, an excessive gain of weight during pregnancy, not the result of hypothyroidism or too much food and drink, must be due to water retention. Some water retention is normal in pregnancy, especially late. Of, the women's smoothed face and her swollen face and hands so often complained of in the morning. It is associated with sodium retention, and the pituitary and adrenals are implicated, clinically water retention is determined by the gain of weight and edema, remembering that 8-10 pints or pounds of fluid may be stored up in the body tissues before any edema may be noted. An excessive or sudden gain of weight always suggests a disturbance of water balance, as a quarter pound in one day, two pounds in one week or over five pounds in one month. A moderate amount of edema below the knees is normal in pregnancy, but any edema higher in the body is definitely abnormal.
Abnormal water retention is an important sign of pregnancy toxicosis, and its secretion can be aided and the toxemia often relieved by the following. 1. Limitation of fluid intake. Dr. Arnold had his patients keep an intake output chart of them with the intake kept below output. 2. Limitation of sodium salts, by the avoidance of salty foods (name them) and the use of salt in cooking and at the table. The daily average salt intake is to be reduced from 10-20 mgs to three or less. In this connection is it well to remember that the use of large quantities of baking soda for heartburn may not be entirely innocuous. The rational of a skim milk diet in the treatment of preeclampsia is that it contains little sodium but is high in calcium and potassium. 3. Adequate consumption of animal protein. Though this has been disputed it does no harm even in the presence of albuminuria rather the reverse. 4. Iron for any anemia. 5. Certain saline laxatives. 6. Intravenous glucose. In eclamptic toxemia, abnormal water retention may occur before rising of blood pressure or albuminuria, and a pair of scales is an important instrument. Persistent or progressively increasing generalized edema, not greatly or permanently influenced by treatment, is an indication for the interruption of pregnancy.
This discussion of the minor toxemias of pregnancy has been sketchy, incomplete, not very scientific, and highly personal. I feel very humble in the presence of any pregnancy. Eventually, someone is going to tell us all about the toxemias of pregnancy. I fear that no one in this room will live to see it.
Superstitions about Health and Medicine
By: Stuart B. Blakely, M.D.
Superstition" is defined by the dictionary as "a notion maintained in spite of evidence to the contrary." This might be paraphrased as "an obstinate belief in something that is probably not so." It is quite impossible to define the words "health" and medicine" in any compact compass, but I think that we can reasonably well understand each other in their use. Please keep in mind though all my talk that definition of superstition "a notion maintained in spite of evidence to the contrary," I hope that you will not carry away with you the idea that I am a sadistic iconoclast, that I delight in destruction for the sake of destroying. I have great respect for ancient faiths and popular beliefs, for they often contain a golden kernel of precious truth. I could give you many examples.
I saw a most interesting one in a textbook on obstetrics published about one hundred years ago. In a footnote about the care of the navel in the newborn, the writer says-- "some midwives believe that if the sheers used to cut the cord is first heated before the fire, and if the cord is then covered with a piece of scorched linen, it (the cord) will heal kindlier. He then adds, "I can see no reason for such belief." We know now that the doctor was wrong, and the midwives right, for by these procedures the sheers and dressing were partially sterilized. They had properly observed cause an effect but had not thought the matter through. I once witnessed an amusing and potentially tragic survival of this ancient practice. I saw an old lady scorch a piece of linen and start to place it on an unhealed cord. When I called her attention to the fact that she had dropped the cloth on the floor and then picked it up again on the way from the kitchen to the nursery, she could not understand what difference that made for had she not followed the formula was it not linen and was it not scorched?
I am not going far afield today. I shall speak of superstitions remember the definition that is more or less current in any community and more or less familiar to you all. Some have their origin in the dim and pagan past. In general, however, they are examples of and result from three curious ways of false and sloppy thinking.
The "post hoe ergo proper home" type of reasoning. The Latin may be translated "after this, therefore because of this." Since B follows A, B is caused by A. For example, I am sick, I take a pill, I get well; therefore, the pill cured me. Not necessarily true at all. Closely linked with this is.
The drawing of conclusions from insufficiencies endorse a very common error. The same crude example of illness may be elaborated to illustrate this also. Ten persons with the same disease take a given pill and get well. Such a report is of little or no worth. If out of a hundred persons with the disease and given the same pill, ninety get well, we begin to have some evidence of the value of that pill in a given condition. I out of a thousand such cases so treated 900 recovers, the evidence is much stronger than the medicine had something to do with their cure provided that the recovery rate of a like number of controls was much lower. In all the cases we are assuming the presence of only one factor must be considered, the drawing of a correct conclusion may be a terribly complicated and difficult problem.
Blind acceptance of statements, hallowed by age or authority, without critical examination and analysis.
No one is immune to the contagion of these three methods of reasoning, for they are the easiest way. Herd, consecutive, antically, constructive thought is one of the hardest tasks that anyone can undertake. Dr. Vincent used to say that when most of us fondly imagine that we are thinking, we are only rearranging our prejudices.
Let us now examine a number of superstitions about health and medicine that are right among us believe by an astonishing number of people who should know better and whose ignorance can be laid directly at the door of our faulty educational system.
It is entirely true that one man's food is another man's poison, but a mass of superstition has grown up about articles of food and drink. This r that food is frequently said to be "especially good" or especially bad" for us; careful examination seldom addresses evidence to support such statements. Milk is certainly not perfect food at least for adults because it is over 90% water. Coffee is claimed to be bad children and cocoa good for then, but both have about the same content of similarly acting drugs. Of course, as usually prepared, cocoa contains more nourishment. In spite of advertising, cereals are not rich in body-building proteins and are not in general "all around" foods. There is no such thing as skin food, and it is not true that fish is brain food. There is no essential difference in food value, digestibility or other quality between light and dark meats. It is very easy to say that something is "hard to digest," but to prove that and to make clear just what is meant is quite difficult. Broths have practically no food value. I have never heard a completely satisfactory explanation of why oysters should be eaten only in those months that contain the letter "R".
Probably one of the most commonly held ideas, even by physicians, is that meat is "bead for", even if not a cause of, high blood pressure and kidney trouble. There is no good evidence that this is true. Vegetarians may suffer from high blood pressure as well as anybody else, and surely Eskimos, who eat meat exclusively, do not all die of kidney trouble. This story is told of Stephenson, the famous Arctic explorer. He was telling some skeptical friends of the harmlessness of a meat diet. His friends said that it might be all right in the frozen north but could not be done with impunity in this climate. Stephenson wagered that h and a companion could and would live exclusively on meat end its products in this country for two years. This they did remain well and in good health and medical examination of them at the end of that period revealed nothing abnormal. The greatest objections to a total meat diet are the bulk required and the cost.
The study of religious food taboos is of great interest, but there is no time. There is no reason why only those fruits should be eaten that grow in the climate of the consumer. An apple a day keeps the doctor away no better than many another wholesome fruit. Incidentally, there is no reason to believe that eating green apples causes colic. Fruit juices make the body less acid, NOT more acid. The advertisement that advises you to "get over on the alkaline side" is rarely scientific. Many advertisements play upon and up to the reader's superstitions. How often have you not known diabetic to reject a small amount of sugar while eating starchy foods in my quantities desired, and gorging on rye, gluten or bran bread which does not differ much from white bread in their carbohydrates content? Americans drink more water than any other people and European think us crazy in this respect. We claim that it is "good for us, but I never have seen it proved. A lot of nonsense has been written and believe about the effect of alcohol on health. Not for one moment do I belittle or underestimate the bad social and economic effects of drinking, but there exists no proof that alcohol in moderation causes any disease. Dr. Osler used to say that bad teeth and oral sepsis have caused more harm to the human race than alcohol. Many alcoholics develop curious ideas and defense mechanisms about their drinking habits. Many still believe that whiskey is an antidote for snake bits.
There are many fads in foods and diets. The strict vegetarian is in error, for the human intestinal tract is geared for a mixed diet. Many fears to eat lobster and milk at the same meal. A short time ago a popular fad was not to mix certain foods, for example, acids and starches. I know nothing to support such fancies. Reducing diets are frequently quite indefensible. The value of fresh against stale foods is large, if not entirely, esthetic. The advertisers of raisins used to ask, "Have you had your iron today?" At present, molasse is highly praised for its iron content. It is true that it is comparatively rich in that metal but not more so than oatmeal. If you need considerable iron and unless you are crazy about molasses, an iron pill is easier to take and cheaper. Vitamins are of real importance. Much is known about them, but a great deal yet remains to be discovered. They are of great interest in many ways one is that we can watch superstitions about them in the making.
It is fallacy that savage man is noteworthily healthy. I doubt that it can be proved that good health protects against diseases, or that exercise is conducive to health. It is not true that the Chinese pay their physicians only while they remain well. The early church was responsible for a hideous superstition when it taught that the human body was sinful and low, something to be scourged and mortified. That idea has permeated our whole life and thought; its eradication her just began, a slow and painful process. All sorts of things are introduced into school curricula, but rarely anything really valuable about a personal, community or general hygiene, using the word "hygiene" in the broadest sense. A man's body is his most precious material possession, the temple of his mind and soul, but he is practically never taught anything true and worth-while about its structure, functions, and care. In this respect, at least our educational system is appallingly stupid.
Germs come in for their share of superstitions. They are usually pictured in many bizarre shapes; actually, their forms are usually extremely simple. A citizen will object most strenuously to the establishment of a contagious hospital in his neighborhood, although the chance of contracting diseases from its presence is exceedingly small in comparison with the danger from common eating and drinking utensils, or from our sputum strewn streets. Fumigation was once held in high esteem but, as you know, has been practically abandoned, for as usually carried out, is without value. Bore acid and peroxide are very feeble antiseptics, and the efficiency of iodine far exceeds that of ordinary mercurochrome. A thing is sterile or not sterile there really is no middle ground, and the briefest and slightest touch of something else spoils its sterility. The possible value of external applications is rarely due to the absorbing power of the skin which is very slight. An iceberg over a threatened appendicitis is no better and no worse than a hot water bag, neither are of probably much value and may be the cause of fatal delay. A rusty nail is dangerous not because it is rusty, but its rust is evidence that it may have been whore tetanus germs abound. All say that frostbite should be rubbed with snow, but probably both friction and cold are bad advice in this condition. Normal blood pressure is NOT one hundred plus your age. A person cannot get warts by taking oil. Night air used to be "bad" when malaria-carrying mosquitos because active with nightfall. The word malaria comes from the Italian "malaria" which means bed air, and chat is its origin. The advice contained in the adage "Feeds a cold and starve a fever" should best be reversed. "Colds" are catching and are usually gotten from someone who has a cold like any other contagious disease.
Intestinal conditions rarely cause fever in adults, and laxatives do not reduce the temperature. Acute indigestion, if there is such an entity, is not associated with severe pain, and is never a cause of death. Grinding of teeth by children in their sleep is not a sign of worms. Worms do not come from candy or other food, but from a person or animal or meat that is infected with or harbors the parasite. Colic, teething, and worms are dangerous diagnoses to make in children, for they are rarely the cause of acute illness. Mothers feel obligated to take their babies out for the sun and air. They could save themselves much effort for their infants could get just as much air if wrapped up and placed in a room with opened windows; as ordinarily wheeled about, the amount, the amount of sun they get is legible with only their faces exposed and these often covered with a veil. While bad orders are objectionable, they do not cause disease. Grape seeds do not cause appendicitis, mad dogs do not cause it to grow thicker, and there are no such things as "growing pains".
Of all the fields of medicine, obstetrics offers the most outstanding example of superstition. The reason for this is a long story. You are probably familiar with some of them that it is dangerous to have the teeth pulled during pregnancy; that a seven months baby is more apt to live than one of eight months; that a raisin is good to put on the cord stump; that it is unwise to out the hair or fingernails of the newborn. Very possibly your attitude toward them is like that of a famous Englishman who said that he did not believe in ghosts but was scared to death of them. It is unnecessary to dwell on the darker of these beliefs. Probably no person here believes that a cat can kill an infant by sucking its breath. Today few believe in possibly some in this room have never even heard of the evil eye. But the old Irish lady who, after praising a baby, says "God bless him", unwittingly adds a saving formula to ward off the influences of evil that ever menace, especially the newborn. The ritual of the christening gives, among other advantages, the child the protection of a name. Probably one of the commonest superstitions is that a mother can, some experience or activity, affect her unborn child, in other words, "mark her baby". The origins of this belief, widespread through the world in all ages and cultures, is obscure but very interesting. Probably the best guess is that it contains the idea of the scapegoat. In savagery true today in our civilization through superfine sensitivity refuses to recognize it a deformed baby was a definite liability, and its mother was a natural scapegoat. In self. protection and as an alibi the idea of "marking" was evolved, by which the mother absolved herself from responsibility for such a birth. But someone will ask, "if that is not the case, how do you explain it?" This, of course, propounds a new question, and inability to answer it does not in the slightest prove the truth of the first. If I could answer all the question, and inability to answer it does not in the slightest prove the truth of the first. If I could answer all the questions that might be asked me about the human body and its working I should be God. If I could tell you exactly what happens in my brain and body when I thus crook my finger, my niche in the Hall of Fame would be assured. There exists no proof that any women have ever "marked" her baby. The cause of the deformities has never been explained.
A common superstition is that the suppression of menstruation will "throw" (just how, is quite obscure) women into tuberculosis. There are many erroneous ideas prevalent about the dangerous effects of cold and water on the menses. Some mothers will not allow their daughters. to even put their hands into cold water during their periods, and the number of women who fear to take a bath during that time is legion. False beliefs about the menopause or change of life are far too common and have led many women to their death. Really very few symptoms are directly attributable to a change of life itself, though almost everything is ascribed to it. It is unfortunate that bleeding is associated with a normal female function for about thirty years of every women's life. Abnormal bleeding from any other body cavity would drive her to seek the doctor early. Be it enough to say that in a normal change of life the bleeding is always less in amount, shorter in duration and farther apart. Anything else is ALWAYS abnormal, it matters not any statement by any person to the contrary, notwithstanding.
Superstitions about "Tumors"Incorrect medical terminology "tumors" means swelling whether caused by inflammation, blood clot, collection of fluid, new growth or what not. When your wife hits you on the head with the rolling pin and thereby produces a lump, that lump s, strictly speaking, a tumor. When the average women speak of a "tumor", she usually means either a fibroid of the womb or a cyst of the ovary. The proper word of all such as neoplasm or new growth. To new growths disappear spontaneously? Warts certainly do, and many persons have charms to get rid of them if they are not wart charmers themselves? Occasionally, smell cysts of the ovary do. At times, multiple small cystic tumors of the breast. PLEASE note carefully, I said MULTIPLE, not SINGLE tumors of the breast. To the best of my knowledge and for immensely practical and all safe purpose no other new growths ever do. There are two prevalent beliefs about cancer that are false. One, that cancer is always painful; the truth is that pain is never a sign of cancer except in the late and hopeless stage. The other, that cancer cannot be cured; the truth is that many cancers have been and can be cured by early discovery and proper treatment. We know little or nothing about the world the real cause of any tumor will have a place among the immortals of all time.
Superstitions about Healers and Schools of Healing.Dr. Locke of Canada is a good and recent example of such healers. He has had and still has, many sincere advocates, and he may believe wholeheartedly in himself, his mission and his ability, it has always been thus. But no doctor who has seen his action could by the greatest stretch of charitable imagination understand how the manipulations he performs can have the slightest permanent effort on crippled joints. With his enormous material, he has added nothing to our knowledge about orthopedics. Homeopathy has almost run its course. Some of you have probably been helped by spinal adjustments, and some may even be followers of Mrs. Mary Parker Eddy. It would be foolish to deny that some sufferers have been helped by such men and such methods. It would be strange it if were not so. Most of these schools of healing have taken one small, often neglected, item or branch of the great domain of medicines, and tried, sometimes in well-intentioned ignorance end sometimes in the spirit of pure charlatanism, to build it up into an independent science, though science is not the word. They exceedingly rarely contribute anything that is new or valuable. One of the best answers to all this lunatic fringe of medicine is that it will be a long dark day when trainloads of chiropractors will be rushed to a railroad wreck or the battlefield, or shiploads of Christian Scientists to stamp out a scholar's epidemic. The history of medicine abounds in such individuals and such movements'. They will continue to appear, to have their day, and pass into oblivion. Wishful thinking is no pleasant. It is much easier to say and believe that a thing is so than to prove its worth. Scientific medicine will still march on.
Superstitions about Regaining Lost Health.Energy, once expended, can never be restored. Once gone, it is gone forever; nothing can ever bring it back. Nature always exacts her penalty for folly. Man has always been willing to suffer agonies and torture, to do anything, to pay any price to recover lost health. We break or disregard the laws of health which are usually so plain that he who runs may read. Then we hopefully, frantically, often too late, strive to undo the evil by the magic of some cure: the waters of some reputedly healing spring; the restoring power of some system of mental therapy (remember the errant nonsense of Dr. Coue's "every day in every way I am getting better and better"); penance or prayerful petition to some anthropomorphic god; the exhibition of some holy relic, or a visit to some sacred shrine; the administration of some medicine of magic potency. Many patent medicines illustrate the last-named superstition and are still sold in large quantities. Someone has said that all patent medicines contain a bitter, an aromatic, a laxative and alcohol. Incidentally, many people are seen to judge the strength of medicine by its nauseating or near strangling power. The fountain of youth ever beckons us on. The elixir of life has yet to be found. We still believe in magic.
Superstitions about State MedicineHealth is not something that can be bought, bestowed, given away or insured. In all the drive and propaganda for socialized medicine formerly called "health insurance" and as seam but now dropped as an impossible concept, not a word is said about the MEANS of health, and nothing about individual instruction in and for health. Health is largely an educational and individual thing. The government fosters and attempts to foist upon the people of this country some miserable superstitions that illness is the greatest cause of poverty; that organized medicine has failed, and medical men are remiss and lack social consciousness; that socialized medicine can and will solve all the unsolved problems; that we shall, almost overnight and at relatively small cost, banish illness, disease, almost death itself. They are all cruel untruths.
In no please where socialized medicine has been put into effect has the incidence of illness been lessened, disease been prevented or the death rate lowered, the only honest criteria by which its efficiency can be judged. Mass production, assembly line tactics and political control do not work well in the domain of medicine. This country has the lowest disease and death rate in the whole world, and the finest hospital system in existence. The medical profession has made it so. No one knows better or is more genuinely interested in the medical needs and shortcomings of this country than the doctors. The medical profession takes strenuous exception to the false assumption that socialized medicine is the only method capable of solving the health and medical problems of the United States. The superstition of the benevolence, all-wisdom, and all-powerfulness of government is freighted with tragic disappointment for us all.
Superstitions about Doctors.
In some mysterious way the physician has been credited with possessing the powers of life and death. Such a mystery has always been feared; such power must be curbed. Accordingly, society has always wished to make the medical man either a slave or a god and still does. In many ways, it is unfortunate that the old family physician has been idealized into a see-all, know-all type of being because it is not a true picture. He is usually represented as follows he came, took the patient's temperature, counted the pulse, asked a few questions, mumbled a bit and doled out some medicine. If the patient recovered, the doctor got the credit, frequently deserved; if he died, it was God's will to be bowed to in resignation.
The attitude toward the physician has profoundly changed in recent time. There are several reasons for this. ONE the physician no longer lays claim to the omniscience which was freely ascribed to the stereotyped old practitioner,TWO the laity, I.e. the non-medical part of the population knows more about doctors and medicine, even though they know so many things that are (speaking ungrammatically) "just isn't so." THREE the present generation is impatient and wants things done in a hurry, a procedure that is rarely compatible with good modern practice. FOUR this generation is also unwilling to bow to God's or anybody's will. The reason that illness and death ought to be prevented, which all grant is desirable but by no means always possible. Since they are not prevented, they further reason that someone is to blame, which is some is to blame, which is sometimes true. However, they Seldom blame themselves, their own acts or their own ignorance, or the failure or shortcomings of the social order; nor are they over willing as the negro aid, to cooperate with the inevitable. They have been taught to shrink from the stark realities of life. They do not like to hear that we all must die. Instead, they frequently turn upon the doctor who is conveniently and helplessly near from birth through life to death. I have heard a person state to a group that Dr. So and so "killed Mrs. Jones, or Smith or Brown," a statement for which she had little evidence to any nothing about proof, and against which the doctor is powerless to defend himself.
Many harsh things have been said about my profession. I think it was Voltaire who said that doctors our medicine of which they know little into bodies of which they know less for diseases of which they know nothing at all. at the other end of the scale is Robert Louis Stevenson's Tribute to the Physicians. Doctors are sometimes foolish, sometimes ignorant, sometimes dishonest, occasionally knives. They make mistakes, which because of nature their work is sometimes tragic in their results. In other words, they are frail human beings like yourselves. There is no superior, all-wise being who chooses and decides who shall become your physicians. The modern doctor is better trained in his profession than in any period of the past. In general, he is the best-educated man in the community, as to being almost always has been. He is deeply religious, general impression to the contrary notwithstanding. he is humble for he deals with the intricate complexity of living things and is in content daily and intimately with the great mystery of life. The human body has been compared with an automobile. The comparison would be more valid if the automobile could repair itself with materials of its own production. While the physicians today possess a real specific cure for many diseased conditions, he still recognized the limitations of even modern medicine. He sincerely subscribes to the great truth in that sentence of Ambroise Pere, a famous harbor surgeon o the 16th century who said, "I treated him and God cured him." Individually and in groups he contributes a great deal to his community, and none deserves better at the hands of his fellow citizens. He exemplifies that "greater love hath no man this, that a man lay down his life for his friend."
I have reviewed (this afternoon) a few superstitions about health and medicine. I hope that I have interested you and have given you something to think about. If I have cleared away some of the notions that you have held about these things in spite of evidence to the contrary, I am satisfied. It has been a great pleasure for me.
I am her today under the auspices of the Broome County Medical Society. It is a part of the effort of the medical profession of the State of New York to prevent the passage of antivivisection bills introduced this year in the Legislature at Albany. As you know the antivivisectionists oppose all experiments on animals. As you know the wedge they usually specify dogs, for reasons to made clear later. As you also know doctors and all scientific workers are fully persuaded of the high value of animal experimentation. The outstanding champions of the antivivisectionists are the Hearst publications and Irene Castle MacLaughlin, the former dancer. Their rallying place is Chicago. A few years ago, I visited one of their exhibits in Chicago. The man in charge regaled me with the usual propaganda. In answer to my question, if he would refuse to experiment on or sacrifice a mouse to save his child, he emphatically answered, "Never". If he wasn't lying, it is hard for me to understand the workings of such a mind, to appreciate such an attitude, to grasp such a person's philosophy of life.
What are the claims of the antivivisectionists?
That all use of animals for experimentation or other scientific use is wrong. Just where shall the line be drawn in the use of animals for man? Is it right, or is it not, to sacrifice them for their meat, hides and another animal product especially glands? Is it right, or is it not, to kill them furs? We are often squeamish about the fact that all our food necessitates the death of some living thing. It would seem proper and justified that any reasonable use of animals should be made to prevent or cure disease not only in man but in the animals themselves; to educate and train students in medicine; to promote the advance of science. This brings us to the second of their arguments which is that.
Vivisection has never been of any value (or at least of very little value), has never produced or contributed anything to human welfare. There is not a reputable or recognized scientific worker of any standing in the world who will agree with that statement. The statement is entirely false. In surgery, not only the training of surgeons and the study of the production and results of disease but the solution of the basic problem of bleeding, such pain and infection would have been impossible without the use of animals. In the field of medicine, for example, animal experimentation has given to the world insulin for diabetes (at the cost of thirty dogs); the use of liver in anemia; the technic of plasma and blood transfusion; the working out of artificial respiration and resuscitation; the conquest of rickets and diphtheria; the dosage determination of drugs, such as the Sulphur group and penicillin. Nearly every advance in dealing with human suffering and preventable death has been made possible, wholly or in great part, through work on animals. If you are interested further red Howard W. Haggard most readable and informative book, "Devils, Drugs, and Doctors".
Reduction of deaths from childbed fever from 20% to less than one half of 1%. Their third argaman is that.
Vivisection is cruel; that the animals are, purposely or carelessly, subjected to great suffering. This statement is also entirely untrue. It is quite impossible, even fantastic, to imagine that all the workers in the field of animal experimentation are deliberate sadists, or even the birds have contributed much by far too human welfare than the dog. The use of the word in a disparaging sense is widespread. We say a dog's life, dirty as a dog, you dirty dog. One of the favorite pictures of the AVs, is one showing some boys asking a laboratory worker, "mister, have you seen our dog"? In theatrical parlance, pure corn. IN New York State every year 130,000 dog is destroyed in pounds or other places. Could they not be put to some use? The AVs has been called the Park Avenue Pekinese crowd. There are many things in America that are more worthy causes than the use of dogs for science in this country.
These bills have been killed in the Assembly committee and are probably out of the running for this year. They will be introduced again as they have been for fifty years. The doctors and scientists are beginning to be sick and tired of being called upon constantly to defend themselves and their work. The campaigns of the AVs and such ill are of vital interest to the public at large. There has been organized "The Friends of Medical Research". Support it, for the Avs, are well financed, well organized and very vocal and quite unscrupulous. This is your fight. Which is worth more a baby or a dog.
The Medicine of The Old Testament.
By: Stuart B. Blakely, M.D.
The Medical Record
June 5, 1915
In a study of the medicine of the Old Testament two points must be kept always clearly in mind: (1) It is a study of the non-medical literature of a primitive, nomad race. (2) References to disease and medical subjects are dark and incomplete. Careful study of the original Hebrew words themselves has been of little service. Most of the diseases described are either those of kings or personages of high estate or epidemics. If we realize that little is absolutely sure, that much must be inferred, and if we recognize the difficulties of the problems we shall not be led far astray in a medical survey of the Old Testament.
The scriptural references given in this article by no means exhaust the possibilities of the text.
The medicine of the ancient Hebrews was partly of Egyptian, partly of Assyrian and Babylonian origin with, in later times, a possible trace of Greek influence. The medicine of Egypt was famous in its time throughout the East. Cyrus and Darius both summoned physicians from that country. Many of the physicians at the courts of the kings of Israel were probably Egyptian. The learning and culture of Assyria Babylonia reached flood mark. The ancient Hebrews acquired tier medicine during the reign of Solomon, and during the captivities. the Hebrews were never scientists. They had no scientific institutions. Their science and their medicine were borrowed and empirical. To their minds, Jehovah was the Supreme Healer. (Ex. 15,26; Dt. 32,39; Ps. 6, 2; 30, 2; 103, 3; Is. 30,26.) Injury disease and death were usually regarded as expressions of his wrath, as direct results of his omnipotent will. As a consequence of this belief, we find little or nothing in the Old Testament concerning the cause, the course, or the curing of disease. Disease was often looked upon as a direct punishment for sin, a belief prevalent among primitive folk. Threats of disease for sin and disobedience and promises of protection against disease are very common. (Ex. 15, 26; Nu. 14, 12; Dt. 7, 15; 28. 59-62; 32, 39; II Sa. 24, 16; II K. 19, 35; II Ch. 21, 14; Job 2, 5-7; Is. 58,8.)
Among most early people's medicine has been at first the property of the priesthood alone. Among the Hebrews, however, the medical work of the priests seems to have been that of some sanitary police observing, isolating, and disinfecting. Their duties seem to have been always distinct from those of the physicians. (Gn. 50, 2; Ex. 21, 19; II K. 8, 29; II Ch. 16, 12; Job 13, 4; Jer. 8, 22.) The physicians gathered and prepared their materia medica, prescribed for symptoms of disease and treated wounds. The word â€œphysicianâ€ in Jer. 8,22, is literally â€œa bandage.â€ Many are said to have established themselves east of the Jordan. There are two references to definite consultations with physicians Asa to be cured of the disease of his feet and Joram to be healed of his wounds. (II Ch. 16, 12; II K. 8 and 9.) The profession was not so highly nor so strictly specialized as among the Egyptians the corps of physicians in the service of Joseph (Gn. 50,2.). It was usually held in high esteem, but Asa was reproached because â€œin his disease, he sought not to the Lord but to the physicians.â€ The author of the apocryphal book of Ecclesiasticus is thought to have been a physician. The prophets Abijah, Elijah, Elisha, and Isaiah, by virtue of what we call their miracles, may be classed among the healers of the Hebrews. Midwives followed their calling as they do today. (Ex. 1, 15-21.) Their duties were of the simplest. They received the baby, cut and tied the cord, washed the child, rubbed it with salt and wrapped it in swaddling clothes. (Ezk. 16, 4.) It has been suggested that the two mentioned by name in Ex. 1, 15, were the heads of corporations or societies of midwives. Such a thing as a hospital was unknown; the sick, except the lepers and probably the â€œunclean,â€ were cared for in their homes. (Lv. 13, 46; Nu. 5, 2; II Ch. 26, 21.) The dead were burned, buried or placed in sepulchers. The Hebrews did not Embalm. Their mind had no sympathy with the Egyptian idea that originated the custom. Jacob and Joseph were embalmed only to preserve their bodies until burial could take place. Among the Egyptians, the art of embalming formed a special branch of medicine. The process varied, not only according to the wealth and rank of the deceased but also at different times in Egyptian history.
It might be interesting to glance briefly at that ancient Hebrewsâ€™ ideas of anatomy. It is possible that dissection of the human body for scientific purposes had already been done at that early date, but in any knowledge thus obtained the Jewish slaves could have had no share. The Hebrews had no medical schools, no system of medical education. What little true anatomical knowledge they possessed of the internal organs was derived from injuries, war, and the slaughter of animals. All else was tradition or speculation. There are references to the heart, the liver, and the bile or gall, the diaphragm â€œthe caul above the liverâ€ (Ex. 29, 13), the kidneys, the intestines, and the internal fat, and the womb or matrix. The liver was evidently of value in divination. (Ezk. 21,21.) Certain verses of Proverbs and Ecclesiastes have been cited as proof of Solomonâ€™s knowledge of anatomy and healing art. Traces of a rude conception of embryology are found. (Job 10, 10; Ps. 139, 13-16; Eccl. 11,5.) Blood to them was life, therefore sacred, and together with the internal fat must be returned to God before the flesh was eaten. (Gn. 9, 4; Lv. 7, 23-27; 17, 10-14; 19,26; Dt. 12,23.) They knew that dreams originated from inside the head. (Dan. 4, 5, 13; 7, 1.) The liver was the source of happiness; in several places in the Psalms it is called the â€œglory.â€ (Ps. 16, 9; 30, 12; 57, 8; 108,1.) The navel was the seat of health, the heart the source of emotion and of mental and moral activity, the reins or kidneys the seat of desire and determination, the bowels the place of affection and sympathy. We still preserve many of these ideas as figures of speech, but many of these ideas as figures of speech, but the Hebrews believe them to be truths. The books of Job, Proverbs, and Ecclesiastes contain a curious store of medical lore.
Palestine was probably healthier than Egypt. In the latter country, the valley of the Nile was flooded every year, creating conditions favorable for the development of disease. The plagues of the Egyptians were closely associated with the rising of the Nile and with other well-known climatic conditions favorable for the development of disease. The plagues of the Egyptians were closely associated with the rising of the Nile and with other well-known climatic conditions of the country. Palestine, on the other hand, was isolated by land and sea. Communication with it as difficult. Disease was not apt to be carried to it. The land was dry and sanitation was good. There was no overcrowding and no poverty. Under the leadership of Moses, a priest from the temple of the Sun at Heliopolis, the Hebrews became the founders of public hygiene. In Leviticus and Deuteronomy are very definite rules and regulations regarding food, clean and unclean things, sexual hygiene personal predicting, and contagious disease. In Ex. 21, 22, and Lv. 24, are found traces of a medical jurisprudence.
The ancient Hebrews had many medicines. (Jer. 46,11. ) We hear of no specifics. The following were some of their therapeutic agents: leaves of trees (Ezk. 47, 12), olive oil, balm of Gilead, a famous resinous application for pain and wounds, and a valuable article of commerce, fig plasters, oil and wine for wounds. The mandrake root was used for barrenness, following the old doctrine of signatures. (Gn. 30, 14-17.) The word translated â€œgourdâ€ in the last chapter of Jonah is thought by some to mean the castor-oil plant. The personal and ceremonial use of ointments, perfumes, and incense was common, as among all Orientals. These were prepared by the apothecaries and confectioners. (ex. 30, 25; 37,29; Isa. 8, 13; II Ch.16, 4; Neh. 3, 8; Eccl. 10, 1.) The ingredients were both domestic and imported, and their list is long. Among them were frankincense, myrrh, aloes, calamus, camphire or henna, cassia, cinnamon, galbanum, rue, spicery, saffron, storax and others. The following were more strictly medical in their use, as condiments or carminatives cassia, cinnamon, coriander, cumin, salt, and probably also anise, mint and mustard. The prescription for the \holy anointing oil is given in Ex., 30. Salt was used to harden the skin, nitro and soap to cleanse it. (Jer. 2, 22.) The niter was natron, a mineral alkali; the soap was probably potassium carbonate mixed with oil. Elisha used salt to purify springs of water that were reputed to cause miscarriage and death. (II K. 2, 19,22.) Hyssop seems to have been a substance whose use approached that of an antiseptic. It was probably either the marjoram or caper plant. The Psalmist lauds its â€œpurgingâ€ powers; it was sprinkled on the doorposts of the Israelites in Egypt and was employed to purify leapers and leprous uses. (Ps. 51, 7; Ex. 12, 22; Lv. 14, 4-7, 49-52.) Mankind still clings tenaciously to the belief that the smoke or vapor from burning incense or other odoriferous substances possess detergent properties. It is possible that Hazael practiced hydrotherapy when he dipped a cloth in water and spread it on the face of Benhadad, King of Syria, though it sounds more like murder. (II K. 8, 15.) Mineral and oil baths were sometimes employed. The pool of Siloam possessed healing power. (Neh. 3, 15; Is. 8, 6.) Hot springs â€œmulesâ€ are mentioned in Gn. 36, 24. These were probably near the Dead Sea. The water of the Jordon contained Sulphur and was famous for its curative properties, Naamanâ€™s leprosy. The wearing of amulets, the use of charms and invocations and the laying on of hands in the presence of disease were common practices then as they are today. The influence of the state of mind on sickness was clearly recognized â€œa merry heart doeth good like a medicine.â€ Some kind of arrow poison was possibly in use, most probably aconite. The water of gall, or the â€œwater of poisonous plant,â€ may refer to the poppy. Food poisoning of vegetable origin possibly the plague that followed the eating of the quail. The Hebrews knew well the action of alcoholic drink. They made wine from honey, dates, grapes, and other fruits, and it was sometimes spiced. Certain localities were famed for their product of the vine. The drunkard has been inimitably portrayed in Pr. 23.
As among the Egyptians many remedies were dietary. The ancient Hebrews had an ample and excellent variety of food: meat, fish, fowl, game, locusts, eggs, butter, milk, cheese, sour milk, meal of various grains, bread, beans, cucumbers, onions, garlic, lentils, herbs, manna, honey, fruits, melons, figs, raisins, grapes, nuts, olive oil, vinegar or sour wine, salt, and condiments. The ancient Hebrews probably had no sugar; honey, manna, and fruit juice decoctions were substitutes. The â€œsweet caneâ€ of Is. 43, 24, and Jer. 6, 20, was probably the sweet flag or calamus. There is evidence of cannibalism taking place in Old Testament times under stress of circumstances. This is said to have occurred at the siege of Jerusalem by Nebuchadnezzar and at its destruction by the Romans.
The surgical lore of the Old Testament is very scanty. Knives of flint or metal were used for sacrifice and circumcision, and awls for boring holes in the ears. These procedures, castration and â€œUncircumcisionâ€ were probably the only operations. Inflammatory reactions following operative procedures are recorded in We hear of no tumors, benign or malignant. Burns must have occurred, but it is interesting and curious that nowhere in the Old Testaments is any method given for producing fire. In II Sam. 21, 20, is mention of giant born so with supernumerary digits, six fingers and six toes, twenty-four digits in all. In I Ch. 20, 6, his gigantism is described as hereditary. Moses is thought to have had some defect of speech. Legend says that when a boy he puts a live coal into his mouth and burns his tongue so that he was unable to pronounce the labials. It has been suggested, however, that Moses referred to his lack of practice in the Egyptian language. Lameness and blindness were common them as now. Just what happened to Jacobâ€™s hip when in his wrestling the angel â€œtouched the hollow of his thighâ€ we do not know, probably a severe sprain of the hip and thigh or a severe injury to the sciatic nerve. The â€œsinew that shrankâ€ was probably this nerve trunk or possibly an atrophied muscle. Saulâ€™s grandson was lame in both his feet, due to his nurse having let him fall when he was five years old, a common history of lameness to this day. Bone disease existed. A crooked back is often due to tuberculosis of the spine, and this was one of the physical blemished that barred a man from the priesthood. Dislocations were known. There are possible references to fracture of the skull. Eli fractured his neck by a fall backward from his seat on hearing the news of the death of his sons and the capture of the ark. Fractures of the long bones were put up in splints. There are three references to penetrating wounds of the chest, and three to penetrating wounds of the abdomen. There are battle wounds and infected wounds. NO methods are given for stopping hemorrhage. Wounds were washed, the edges drawn together and bound up in oil and wine. There is a possible reference to leeches. The pathology of Pr. 20, 30 is very obscure. There is a suicide by hanging, another by the burning down of a palace, and King Saul fell upon his sword. Abimelech would have committed suicide had he been able.
Without question the common diseases of today existed in Old Testament times. In Lv. 26, 16, and Dt. 28, 22, there are possible references to such diseases as tuberculosis, typhoid, malaria, Malta fever, and smallpox. â€œThe pestilence that walketh in darknessâ€ suggests malaria. Certain conditions were termed incurable. There are possible references to affections of the heart. Men were gray-haired and bald then as now. Diabetes is comparatively common among modern Jews, but no evidence is found of its existence among the ancient Hebrews. Scurvy almost surely prevailed during their desert wanderings. We do not know what was the â€œbotch of Egyptâ€ possibly smallpox. Liver disorders and bowel disturbances were known. The latter are said to have been most common among the priests because they went about so much in their bare feet on the cold floors of the temple. The Hebrews knew that some disease was contagious, and they recognized the results of a fever. Beyond that, the exact differentiation of most fevers has been made within the memory of men still living.
Of all diseases of Bible times and lands leprosy has always aroused the greatest interest. It was the most important and best known, was endemic in the land, and was considered infectious, contagious and even hereditary. Without question some, possibly much of leprosy so called of the Bible, as well as that of the Middle Ages, was not leprosy was confused with syphilis and tuberculosis, and was often not differentiated from such skin diseases as eczema, ringworm, and psoriasis. Leprosy, or at least scaly skin conditions, were common in Old Testament times. Lv. 13, shows the results of keen observation of the disease. The leprosy of garments and of houses was probably molds or fungi. As far as the writer can learn, the following are the only cases cited as leprosy in the Old Testament: (1) the hand of Moses becoming leprous (ex.4,6); (2) Miriam becoming a leaper (Nu. 12,10); (3) the four leprous men before the gates of Samaria (II K. 7); (4) Naamanâ€™s leprosy and its transference to Ghazi (II K. 5); (5) the leprosy of King Uzziah (Azariah) (II Ch. 26,19; II K.15,5); Five references in all. Some palpably could not have been true leprosy. The subject is too big to enter into any further detail.
The plague is one of the oldest diseases of mankind. It existed centuries before Christ. It was the Plague at Athens? During the Middle Ages, it destroyed one and a quarter millions of people in Germany alone. Seventy thousand died from it in London in 1664. It was the Black Death. It is to be seriously questioned whether the word plague as it occurs in the Old Testament means always the same disease; indeed, probably not. In the Old Testament, the term plague seems to have been applied to any epidemic disease, usually occurring in cities or camps, rapidly fatal to a great number. Let us analyze the five epidemics among the Israelites. (1) the plague caused by eating the quail. This sounds much like ptomaine, or meat poisoning, though it may have been the pulmonary form of the plague. (2) the disease among the spies sent by Moses to explore the region of the Red Sea. It is idle to speculate what this disease was, possibly cholera. (3) the plague that destroyed 14,000 after the rebellion of Korah. This resembles the real Black Death more than any of the other epidemics, especially since it followed an earthquake. (4) The plague of Baal-Peor from which 24,000 died. This was in all probability a venereal disease, most likely syphilis. Baal-Peor was a phallic god, and worship of this god seems to have been the ascribed cause of the disease. (5) a three days pestilence that destroyed 70,000. This may have been the plague, cholera, or influenza. It is manifestly impossible to identify each epidemic with a definite disease as known to science of today.
In passing it may be well to call attention to the fact that the ancient Hebrews were prone to exaggerate numbers. For example, 600,000 warriors are said to have left Egypt, implying a total population of a million or more an incredible number to have participated in the Exodus. In I Ch.21, 5, it is stated that Israel had a population of over a million, with 480,000 warriors in Judah. When Sennacherib overran the country, the Israelites numbered about 200,000 all told.
There are other plagues of the Old Testament that have caused much discussion. One is the sixth plague of the Egyptian. It was probably an eruptive disease accompanied by abscesses and ulcers boils and sores. The two most plausible guesses are anthrax, r smallpox, for the disease affected both man and beast. This was probably the so-called â€œbotch of Egyptâ€. The death of the firstborn was probably due to some epidemic disease. Another is the plague of the Philistines. This was probably syphilis and will be more fully discussed under the venereal disease. 185,000 of Sennacheribâ€™s army are said to have been smitten by an angel. We do not know what this visitation was. A great deal of energy has been expended in the effort to explain the â€œfiery serpentsâ€ that were visited upon the Israelites, and of which frequent mention is made. Actual serpents and their bites may be meant. The term may be a euphemism for venereal disease. An ingenious explanation is that these fiery serpents were guinea worms. These worms are several inches long, enter the skin, especially of the legs, produce ulcers and abscesses, and are the cause of the so-called guinea worm disease that occurs in the East.
Eye disease and blindness were, and still are, common in the Orient, due to neglect and to the blinding glare of the sun and sand. Leah was â€œtender-eyedâ€ because she had ophthalmia. Sudden blindness transient or permanent was not uncommon. The loss of sight due to advancing years was well known. Isaac; Jacob; Eli. Moses had probably the farsightedness of old age.
The venereal disease, gonorrhea, and syphilis were prevalent among the ancient Hebrews. Irregular sexual relations were widespread. There are many references to prostitutes and brothels. Possibly the best known are Rahab of Jericho, Delilah the Philistine, and the two harlots probably Greek who came before King Solomon. (Jos. 2, 1; Jdg. 16, 4-18; I K. 3,16) Read Gn. 38; Ezk. 16 and 23; Proverbs 7 is a classic. Sexual perversions were very common. The cities of Sodom, Gomorrah, and Gibeah were notorious for the number of sexual prevents among their inhabitants. Much of the â€œuncleanness by issuesâ€ of Lv. 15 undoubtedly refer to gonorrhea. Syphilis is the only disease that visits the sins of the father upon the children to the third and fourth generation. The word â€œemerods,â€ also translated â€œtumors,â€ which occurs in I Sa. 5, 6-9, and Dt. 28,27, meant the sexual organs. By making â€œgolden emerodsâ€ and worshiping copies of the diseased parts the people hoped that the disease itself would disappear, the idea that like cures like being a very old superstition. This was the plague of the Philistines and was undoubtedly a venereal disease, probably syphilis. The Plague of Baal-Peor, previously mentioned, was almost surely syphilis. Nu. 5, 22-27; II Ch.21, 13-15, may refer to syphilis. It has been claimed that Sarah, Abrahamâ€™s wife, and David both had venereal disease. The passages quoted in support of this contention are not conclusive. Certain verses of Psalms have been said to refer t gummata of the bones, the subcutaneous tissues, and even the liver. It is fairly certain that the Hebrews recognized the relationship of sexual intercourse and certain diseases, as attested by several passages, especially in Proverbs.
There are a few special individual cases that are of interest. Asa died f a disease of his feet. It was probably not gout, but either senile gangrene or dropsy, because it â€œmoved upwards in his body.â€ King Jehoram died of cancer of the lower bowel, or of a severe dysentery at the comparatively young age of forty years. King Hezekiahâ€™s disease is mentioned in three different places. It is described as inflammation, or boil, and was cured by a fig plaster, or literally â€œby rubbing a cake of figs upon the boil.â€ A very ingenious and not at all improbable theory is that this so-called boil was a neck abscess that later ruptured; for Is. 38,14, reads â€œlike a crane or a swallow so did I chatterâ€ the idea being that the abscess interfered with the action of the larynx and so with speech. We do not know what the diseases of Abijah, Benhadad, Elisha and Joash.
There has been a great deal of discussion about Jobâ€™s disease or diseases. The ancients believed that he had â€œblack leprosy.â€ The usual guesses for that are all that they can be are leprosy, syphilis, and Aleppo boil. It has been said that o fulfills all the symptoms presented, Job must have suffered from leprosy, elephantiasis, nightmare, gut, dysentery, ulcerated mouth, marasmus, and lice! It is probably better, at least for our purposes, to regard Job as an allegorical, rather than as a historical character.
Diseases and abnormal conditions of the nervous system were present among the Hebrews. The state of trace was recognized. Fainting attacks are told as occurring to Eli, Daniel, and Saul. Epilepsy was observed. Sun or heat stroke was not infrequent. We read that â€œthe sun shall not smite thee by day, nor the moon by nightâ€. To be moonstruck meant either epilepsy or lunacy. Jonah was stricken by the sun and heat. The incident told of the widowâ€™s three-year-old son in II k. 4, 18 refers in all probability to such a sun or heat stroke. The boy went into the harvest field to his father, he suddenly cried out, â€œMy head, my head,â€ and was taken home unconscious. Elisha was summoned and revived him. Another widowâ€™s son was revived by Elijah. This childâ€™s unconsciousness was probably due to infantile convulsions. Apoplexy and its results were recognized. Uzziah's death by the ark was probably caused by a stroke, possibly by an electric shock. Nabal died of a stroke of apoplexy due to arteriosclerosis, following a drunken feast, a common occurrence as all physicians know. The palsy of King Jeroboam was caused, probably, by the temporary arrest of an embolus or blood clot, in a vessel of the brain, or of the arm itself.
Of course, the ancient Hebrews had no classification of mental diseases. The belief in demons was widespread. Normal reason, normal mentality, and normal mental processes were to their minds, literally, the indwelling of the spirit of God. When a personâ€™s reason weakened or was lost, an evil spirit had entered into the individual. The person thus became insane. Insanity was not infrequent. David feigned madness, crudely but successfully, and so escaped from Achish, King of Gath. Lunatics are carefully respected in the Orient. The two most noteworthy cases of mental disease recorded in the Old Testament are those of King Saul and King Nebuchadnezzar.
The case of King Saul is very interesting. The King of Israel was handsome, shy, self-conscious, of weak judgment and violent passions, easily exalted or depressed. He had troubles at home and aboard. His enemies pressed him hard. He was threatened with loss of his kingdom. He became a prey of fear, had premonitions of his own death and showed homicidal tendencies. Samuel was dead and the priests had been driven away. He had no one to advise or counsel. In disguise and at night, harassed by haunting fears and loneliness, he consulted the witch of Endor. Little wonder that she could conjure up for his distorted mind, Samuelâ€™s spirit. Weak from lack of food and weak with fear he fainted. He had hallucinations of sight and hearing. Sometime later, sorely wounded, his sons slain, his kingdom lost to the Philistines in battle at Armageddon, King Saul fell upon his sword and committed suicide. The development and course of King Saulâ€™s mental malady may be traced in I Sa. 16; 19;22;28; 31. It was either melancholia or, more likely, manic-depressive insanity.
The other interesting mental case is that of King Nebuchadnezzar as related in the book of Daniel. This king of Babylon had visions of grandeur. A dream and its interpretations, preyed upon his mind. He had hallucinations, ideas of persecution, and periods of exaltation followed by depression. At the end of a year, he was driven away from men. He believed himself an ox, and for seven years lived as a beast, neglecting all care of his body, and eating grass. His was probably the metal disease called paranoia, though at the end of seven years he is said to have recovered his reason. The whole story of the companions of Ulysses becoming swine, and other old Greek tales of lycanthropy.
The mysteries of sex, pregnancy, and birth have always attracted and held the interest of all people of all times. The ancient Hebrews were no exception. No other medical subjects are so thoroughly covered in the Old Testament. The Hebrews discussed the primitive facts of life brutally, openly and unashamed. Without question, much that is really valuable has been lost to most of us by the translators toning down or eliminating passages that might shock our sensitive modern ear.
We cannot enter into any of the interesting detail of the obstetrics and gynecology of the Old Testament. We can glance at but a few passages.
A very old belief of ancient cattle breeders in the influence of prenatal or maternal impressions on the offspring is recorded in the last part of Gn. 30. The close relationship of menstruation, nursing, and the menopause to childbearing was well known (Gn. 18; Hos.1,8). It was observed that miscarriage might follow bodily injury or mental shock. Miscarriage is invoked in Hos. 9,14. Barrenness was looked upon as an affliction, as a calamity, often as a punishment. Pregnancy and children, especially after years of sterility, were regarded as a blessing, as a gift from God. Sarah is said to have given birth to Isaac at the age of over ninety years. Rebecca was barren for nineteen years. Manoah, Samsonâ€™s mother and Hannah were also elderly primipara. The nursing period often lasted two or three years. There are references to nurses and sick children.
Of the many births recorded in the Old Testament for are of special interest: (1) The death of Rachel in childbirth due to, or at least contributed to, by her age and the journey (Gn.35); (2) the premature labor of the wife of Phineas, induced by the shock of distressing news, and her speedy death, probably from hemorrhage (I Sa. 4, 19); (3) the twins of Rebecca (Gn.25).
The two pairs of twins are interesting because the diagnosis of twins seems to have been made before birth, and also because both were hand presentations. One of the wins is commonly larger and stronger than the other. This seems to have been the case with Esau and Jacob; besides, the former had an overgrowth of hair hypertrichosis. The rules for the lying-in period are given in Lv. 12. The days for the â€œpurifyingâ€ for a female child were longer than for a male child. This is traced to the very old superstition that it is more dangerous for a mother to give birth to a female child.
The Hebrews regarded old age as a reward for piety, as a token of Godâ€™s favor. A hoary head was a crown of glory? David is pictured as old and stricken in years in IK.1. One of the best descriptions of old age and death that has ever been written is found in Eccl. 12. The Preacher speaks in highly symbolic terms. It is the picture of an old man. The following seems to be the most reasonable explanation of the passage:
Verse 2. His mind, his physical well-being, often his prosperity fails. He is fretful and peevish, his pains recur, he often weeps and is depressed.
Verse 3. His arms and hands become weak; they shake and tremble. His legs are bent beneath their load. His teeth are few or gone; chewing is difficult. Hs sight fails often from cataract.
Verse 4. His lips and cheeks are sunken, referring to the peculiar appearance of a toothless, aged personâ€™s face, especially when chewing, the doors being the lips, and the street the mouth. The sound of the grinding is low because the mouth is shut and the teeth are few or gone. His early morning insomnia very characteristic. The bird, or cock, is easily aroused and is early astir. He becomes deaf and his voice is cracked and quavering, the daughter of music being voice and hearing.
Verse 5. He is feeble; he fears new undertakings. His hair is white, the blossoms of the almond tree being of that color. There have been other interpretations of this passage. He has an annoying rupture, the belly of a grasshopper resembling the sac of a large inguinal hernia. A dried and shriveled up old man is often a burden to his friends. His sexual desire fails to act.
Verse 6. His back is bent, his shoulders stooped, the silver cord being the white glistening ligaments that support the spinal column. The â€œgolden bowlâ€ is obscure. It may mean the watery eyes, or the chronic nasal discharged, so common in the old. It has been suggested that the loosing of the silver cord and the breaking of the golden bowl refer to the breakdown of his central nervous system, his spinal cord, and his brain respectively. His bladder is weak, he dribbles urine. The circulation at his heart fails. It has been here suggested that the breaking of the wheel at the cistern refer to the breakdown of his circulation, Venous and arterial respectively.
Then shall the dust return to the earth as it was, and the spirit shall return unto God who gave it.
Computers and the Regulation of Medicine.
George Ross Fisher, M.D.
I am going to take chance in this essay that I can hold the attention of the reader through a preamble of theory, before addressing the consequences for the practice of medicine. That seems necessary because I believe that the consequences are different from what most readers would intuitively expect and persuasion lies in first convincing the reader of the theory.
CLOSED AND OPEN SYSTEMS
There is a growing body of endeavor known as the Theory of System, which acknowledge that all events are consequences of pre-existing conditions (like the consequences of adding acid to bicarbonate in a beaker), and are thus â€œclosedâ€ systems. However, most events in biology and sociology are so complex that it is only possible to deal with them as â€œopenâ€ system, for which we substitute wisdom for scientific certainty. â€œWisdomâ€ is a set of traditions, maxims, opinions, and strategies which allow you to make predictions about the inevitable outcome of events within an open system. The teleological nature of human events was once referred to as Manifest Destiny, and realists like Talleyrand spoke of diplomacy as the art of manipulating the inevitable.
Wisdom has it that in your choice of a practice location, you should remember that â€œyou canâ€™t make money where it ainâ€™t.â€
And now a conclusion about the computer revolution: Since computers increase the capacity to store and manipulate detail, the computer revolution increases the number of closed systems, and shifts the scope of wisdom in decision-making from traditional areas to new subject which was formerly incomprehensible.
In dealing with open systems, managers and executives have evolved a basic strategy; they organize manageable subunits into hierarchies. Units are organized within departments, then organized within divisions, reporting to a policy-making body. Further, because the purpose of the organizational structure is to simplify management, each level of the hierarchy is oblivious to the techniques of the level below, and is only interested in the output of the level below.
The patient paying his bill is interested in the total amount that he has to write on the â€œbottom line,â€ which in his case is the dollar amount of the check he must write
The director of the x-ray department is concerned with a subtotal related to the x-ray department. The chief technician is concerned with individual studies. The dark-room attendant is only interested in pieces of film.
COMPUTER CONCLUSION: Primitive Computer Systems merely duplicate the pre-existing manual system. Their real power lies in the next step, which is to reorganize the reporting system. That is, they cause a reorganization of the hierarchy.
The prediction is made that management system will be forced in the direction of a hierarchy of three: Those who are able to make decisions, those who cannot make decisions but are necessary for some task, and the computer. One function often seen in non-computer systems is simply to pass the information unchanged up to the line. There is little doubt this activity will vanish.
Robert McNamara (from Princeton via Ford Motors) was a computer expert who became Secretary of Defense under John Kennedy. By installing computers, McNamara was able to jump the Army reporting system (Sergeant to Captain to Secretary of Defense) and confront the generals with discoveries before the generals had received the news. We are told that the generals didnâ€™t like it a bit. But can anyone doubt that Robert McNamara carefully filtered the data before h presented it to President Kennedy? The system of hierarchical reporting condenses the data to the next step up.
COMPUTER CONCLUSION: Many systems of management by delegation will soon be swept away by the computer revolution, and middle management will be the most threatened region. It will resist but it will lose.
Another function of delegated systems is to take raw information and reduce it to condensed form for the benefit of the next level upward. They do so by a process which is often a mystery to the next higher level, and hence a certain power is conferred on the lower subunit to modify the conclusion by modifying the system of manipulation. The method for controlling such activity is to produce a procedure manual which the next higher level must approve, but the inherent complexity which forced a delegated process to be created also obscures the power of the delegated subunit to modify the system.
COMPUTER CONCLUSION: Computer technology strictly defines and inflexibly follows defined procedures for steps in hierarchy. It thereby confers much stricter control power to the higher levels of hierarchy.
THE NEED TO KNOW
If for no better reason than to reduce programming costs, the computer process confers a new power to the lower levels of hierarchy. The higher level must now strictly define its reasons for asking for certain information. If it cannot demonstrate a need to know, it cannot justify the cost of knowing.
The PSRO, acting on behalf of the physician community, violently resists the inclusion of data elements in the reported tape sent to the Bureau of Quality Assurance. At the same time, it is anxious to acquire as much data as possible from units lower in the hierarchy, who in turn resist the process. It can be expected that this process will eventually settle out at roughly the best equilibrium for the community at large, although differing aggressiveness among the participants may cause temporary inequities. The weapons in the battle, which are at the disposal of the physicians are:
(1) Superior Claims on the decision-making process.
(2) The faith of the public in physicians as the most trustworthy custodians of their health privacy.
(3) A superior pool of talent, determination, and independent means committed to a vital issue.
COMPUTER CONCLUSION: If you have a good chance of being the winner in the reorganization of a hierarchy, it is better to participate to your utmost rather than hold back out of fear that someone else will be the winner, because only participants are winner.
We have spoken thus far of hierarchy as the only manageable approach to the complexity of open systems. A more general description would be â€œmodularityâ€ since modules can interact in a lateral direction as well as vertically. When they do, the result is a network of modules in three dimensions. Since computers increase the ability to cope with complexity, they increase the ability to work in three dimensions. Hierarchy is the last resort of manual management; just as three-dimensional chess is beyond the ability of people who are not even very expert at two-dimensional chess. In this sense, the computer revolution provides some hope for the American System, which presents hierarchy and naturally prefers networks when feasible. This is to some extent a philosophical preference and does not seem to be true of the Japanese social system, or the German mentality, or the Communist method. The natural American instinct for lateral equality is thus an ally in Medicineâ€™s conflict with Government, but a hindrance when it encourages Nurse independence or unrealistic consumerism.
Whether lateral or vertical, the interaction of modules in a complex open system is the same: delegation of a method, the output from one module as the sole input to other modules, and resistance to the need to know.
COMPUTER CONCLUSION: The organization of modules into vertical hierarchies or horizontal networks is largely a political process, with three-dimensional networks as the last resort of compromise, and with strict vertical hierarchies as the last resort of inadequacy.
Complexity is itself a major defense of confidentiality; since computers reduce complexity, they also destroy the smoke screen. Computer System which stumbles ahead or is manipulated into breaches of confidentiality is certain to raise a great uproar about the need to know and the right to conceal. In the PSRO system, the issues balance between the duty of accountability and the patientâ€™s right to privacy. When reduced to these terms the physician community has a clear advantage in the mind of the public, if the advantage can be effectively exploited. The latter can, however, be overturned by speedy pre-emption of the turf. it can be predicted that special pleaders will insist on accountability when all they really want is power and satisfaction of envy; it can fairly be predicted that some will weaken their claim to privacy by overextending its bounds.
Example: The system of peer review on Medicaid prescriptions in Pennsylvania has turned up a number of instances of patients who obtained multiple prescriptions for â€œcontrolledâ€ drugs from multiple doctors, filled at multiple drug stores, probably for resale on the streets. When the doctors and pharmacists were notified, they were universally grateful and took steps to curtail the problem. However, the computer vendor learned of the problem (regardless of the fact that all reports are shredded after review) and persuaded the state government to institute a system of restricting problem patients to a single physician. It may now be impossible to dislodge this meat-ax reaction, in spite of the fact that the computer peer-review system is probably able to cope with the problem without invoking hierarchical power.
A Second Example: The United States Navy recently developed a system of computer protection so elaborate that they boasted of it in the newspapers. Two computer scientists read of it, and in a monthâ€™s, the time had broken into the system via telephone. The Navy was then agitated to read of its disarmament in other newspaper articles.
COMPUTER CONCLUSION: There is no present foreseeable technical method of protecting the confidentiality of computerized data, except by physical ownership and physical protection of the machine itself and all of its activity.
The most significant event in the Twentieth Century is the Computer Revolution, just as the Industrial Revolution was the major event of the Nineteenth Century. By the greatest good luck for medicine, the computer revolution is capable of solving the four major problems which now threaten the American Medical System.
1. THE FAILURE OF THE PRE-PAYMENT INSURANCE MECHANISM. The removal of cost restraints on the patient (and thus the provider) has had a predictable upward effect on costs. The overwhelmed system has reacted in a typical hierarchical manner: try to convert insurance companies into regulatory bodies, and if that fails, into rationing systems. The computer revolution (if we are agile) has the potential of drastically reducing the information costs which are now 40% of hospital and insurance company costs. It also has the ability to control utilization abuses, and expose power abuse to public decision.
2. THE VAST INCREASE IN PARAMEDICAL PERSONNEL. Middle management is most vulnerable to computer replacement, and middle management now costs 20% of the hospital dollar. Physicians in complex medical centers are most alarmed about this problem, which they can easily identify by comparing the hospital parking problem with what it was, twenty years ago. Surgeons are typically least concerned since their role at the center of procedures is least threatened by aspirants. But surgeons are hearing of â€œunnecessaryâ€ surgery, and even the small-town solo practitioner has to hire girls to fill out forms. The complexity of our system must be reduced, and computers can do it. The best way to thwart the claims of aspirants to power is to eliminate jobs.
3. THE EXPLOSION OF SCIENTIFIC INFORMATION. No one would wish to reduce the output of the research community, but ways must be found to organize and transmit the information without resort to fragmentation by sub-sub specialists. The computer is ideally suited to the problem. THE MALPRACTICE CRISIS. Physicians are uncomfortable with the idea that peer review may soon become entangled in the malpractice system, as indeed it inevitably will. The matter comes down to biting the bullet, armed with a statistic. Surely consent for an arteriogram is more threatening if it is couched as â€œyou might lose your legâ€ than if you are told, â€œyou have one chance in five thousandâ€ of such an occurrence. Realistic insurance premiums can be set when the risks are defined. Juries can be provided with realistic statistics on normal risks and normal expectation of benefits.
Through all of these four problems runs a common theme: The cost of medical care. The PSRO seems to be the last best hope of curtailing the cost threat to medicine, and so the PSRO can be expected to be the vehicle for the computer revolutionâ€™s resolution of the issue. Senator Bennett probably had no idea of what he was doing, but he did it, and the problem is now our problem.
Determining the Sex of The Human Fetus in Utero
Originally written in 1933 by Stuart B. Blakely MD. and rewritten in 2018 by George Ross Fisher MD (his son-in-law) and Margaret Fisher. MD (his grand-daughter). That is, before and after technology had totally changed the medical premises of the beginnings of human life.
The Prolongation of Life
Stuart B. Blakely, M.D.
The Medical Aspect of Cancer
New blog 2018-05-02 18:24:55 description
Superstitions in Obstetrics.
New blog 2018-05-30 19:32:39 description
The Psychology of Pregnancy
New blog 2018-05-17 18:39:17 description
History of Caesarian Section.
New blog 2018-05-21 20:40:21 description
Abdominal Pain in Pregnancy
New blog 2018-06-07 21:16:05 description
CAUSATIVE FACTORS IN MATERNAL MORTALITY
New blog 2018-05-10 19:43:54 description
Radio Talk Prenatal Carre
New blog 2018-06-05 17:42:26 description
Management of the Early and the Mild Late Toxemias of Pregnancy
New blog 2018-05-31 15:38:52 description
Superstitions about Health and Medicine
Stuart B. Blakely, M.D.
New blog 2018-06-27 19:54:15 description
The Medicine of The Old Testament.
New blog 2018-07-11 15:24:23 description
New blog 2018-07-19 17:24:27
New blog 2018-07-19 17:24:27 description
Computers and the Regulation of Medicine.
New blog 2018-08-22 20:03:03 description