PIONEER MEDICINE IN VIRGINIA

By BLANTON P. SEWARD, A.B., M.D.

ROANOKE, VIRGINIA

(Concl usion *)

HE most distinguished anat- appointment as a prosector in anatomy omist and surgeon in Virginia in one of England’s leading medical during the eighteenth century, schools, and in being associated with a and one of the most distin- prominent surgeon in a nearby com- guished that Virginia has produced,munity. was Mr. Else, however, soon in- TWilliam Baynham. Baynham completed duced him, upon terms that were flatter- the course in medicine offered by St. ing, to return to London. Thomas’ Hospital, in London, in 1772, although he did not receive a degree, as He was to superintend the anatomical that institution did not confer degrees. theater and dissecting room, prepare the While he was a student a friendship bodies for his public demonstrations, developed between him and Mr. Joseph make preparations for the museum, and Else, the Professor of Anatomy, and it to instruct his pupils in the arts of dis- continued until the death of Mr. Else secting, injecting, making anatomical preparations, &c. at a salary of eighty and several years later. Baynham became so ninety pounds the first two years, and proficient in anatomy that he was en- one hundred pounds a year for live suc- gaged, upon the completion of his ceeding years—at the expiration of which course, by Charles Collignon, Professor (having qualified himself in the interim of Anatomy in the University of Cam- for the office) Mr. Else was to relinquish bridge, as his prosector. During the to him the professor’s chair, or to take summer months he worked in part- him as joint professor on equal terms as nership with Mr. Slater, a prominent he (Mr. Baynham) might choose.35 surgeon of Margate.35 How much Col- lignon thought of his young prosector Baynham worked assiduously in his may be gathered from his letter of new position at St. Thomas’ Hospital. April 12, 1772, to Mr. Else35: There he acquired the minute knowl- edge of anatomy for which he became Sir—I beg leave to return you thanks famous. In addition to teaching and for being instrumental in prevailing on preparing many valuable specimens for Mr. Baynham to assist me, as his services have been entirely satisfactory, and his the museum, he mastered the art of in- private behaviour very amiable and en- jecting small arteries. His skill in the gaging. I am, sir, your very humble serv- latter was often compared with the skill ant, of Frederick Ruysch. Charles Collignon, During this period he settled, by his Professor of Anatomy in the method of injection, a long disputed University of Cambridge. question between Else, Pott, Hunter, Thus Baynham was fortunate in his and other surgeons, whether in the op- * Part 1 appeared in the January, 1938, issue of Annal s of Medic al Hist ory , n.s. vol. x, p. i. eration for hydrocele, the injection of out its whole extent.”35 Through this caustic solutions into the tunica vagi- work he became known as the discov- nalis testis destroyed the tunica or ob- erer of the rete mucosum. Unfortunately for Baynham, Else died five years after their association began without having communicated his plans for his successor to the Board of Governors. A candidate for the Pro- fessorship of Anatomy, Baynham failed by one vote to be elected. Then he turned to surgery and for five years he practiced in London. His election to Fellowship in the Royal College of Sur- geons in 1781 gave him equal rank with the eminent surgeons, Abernethy, Coo- per, John Hunter, and Percival Pott.35 After residing in London for sixteen years, Baynham returned to Virginia. Even though he lived in a remote rural district, he soon acquired a large prac- tice, and patients came from great dis- tances to him for treatment. He also was frequently called in consultation long distances from home. While he per- formed with success all the operations that were known during his day, he be- came particularly famous for his lap- literated the sac between the two layers arotomies for extra-uterine pregnancy. of the tunica by the formation of adhe- Baynham was the second physician in sions. Else maintained that the tunica America to operate for this condition, was destroyed, while Hunter contended his first operation being performed in that irritants induced inflammation and 1791,3(5 twenty-nine years after that of the formation of adhesions. A patient John Bard of New York.37 After ex- whom Else was treating, and who was amining his patient Baynham made a thought to be improving, died suddenly diagnosis of extra-uterine pregnancy, from some other cause. Baynham skill- and advised an operation. When she re- fully injected the testis with a solution turned Baynham attempted the opera- colored with vermilion through the tion, but did not complete it as he had spermatic artery, and demonstrated that “neither books to consult nor medical the tunica was not destroyed but that friends to advise me what to do.” A few adhesions had formed. months later, when it became evident About the same time he “injected that something must be done to save the and demonstrated a fine vascular mem- patient’s life, he operated again, making brane on the surface of the cutis, imme- the incision longer and deeper. The diately under the rete mucosum, sepa- patient recovered satisfactorily and was rate and distinct from the cutis, and in good health nineteen years after- capable of separation from it through- wards. He performed the operation sue- cessfully in another case in 1799. When the gastric juice of herbivorous animals reporting these cases Baynham men- could not digest meat, and that the gas- tioned having seen two other cases of tric juice of carnivorous animals had no extra-uterine pregnancy, although he effect on vegetable substances, Ewell did not operate in either case on ac- proved by a two weeks’ experiment that count of the poor condition of the pa- a horse would “eat eighteen ounces of tient. In commenting upon ectopic meat mixed with meal, at once, without pregnancy he said: “’I am inclined to hesitation.” This and other experi- think cases of extra-uterine conception ments in which herbivorous animals ate are not as rare as is generally supposed, meat led him to conclude that the stom- although I find no account of any opera- ach is “capable of adjusting itself to tion for the extraction of the fetus in various kinds of food,” the stomach of all my reading; nor did I ever meet with man possessing “this accommodating a case 'where the fetus had grown to principle in the most eminent degree.” full size and maturity, until that of In attempting to explain how the stom- Mrs. Cocke presented itself.”36 Mrs. ach digests different kinds of food, he Cocke was the first patient upon whom supposed that the ingestion of animal he operated. While Baynham’s report and vegetable foods stimulated differ- reveals his skill in making a diagnosis ent secretions in the stomach. of extra-uterine pregnancy in the days In another experiment he isolated, when such a diagnosis was seldom made, with ligatures, two feet of the jejunum and his boldness in carrying out the of a fasting dog, and injected into it well proper treatment, yet it also shows that boiled meat with an ounce of gastric he exercised judgment in selecting pa- juice obtained from a hog. The intes- tients for operation, and in directing tine was replaced in the abdomen, and the post-operative treatment. the wound closed. When the animal was A few years after Baynham died a killed three hours later an examination physician who knew him well wrote: showed about “one-third of the mixture “He was of those very few men whose was absorbed, and the mesenteric loss will be a public misfortune, for I glands coming from the tied intestine know not who is to succeed him in Vir- contained a small quantity of chyle; ginia as a surgeon. In his profession he there was also a small quantity in the was second to Dr. Physick only, . . . thoracic duct, which as well as the for- Dr. Physick and Mr. Baynham are the mer was more limpid than usual, being only two persons, whom I know in blended with the lymph with which the America, that have really improved the remaining glands were filled.” In exper- surgical profession.”35 imenting with other dogs, he injected Soon after the dawn of the eighteenth gastric juice, saliva, and bile separately century, Thomas Ewell made a notable into sections of the intestine isolated contribution to the physiology of di- in the same manner. When these dogs gestion. While a student at the Univer- were killed and examined three hours sity of Pennsylvania, from which he later, he found from one-half to three- graduated in 1805, Ewell made a num- fourths of the gastric juice had been ber of experiments and reported the re- absorbed, less than one-fourth of the sults in his graduating thesis: “Notes on saliva had been absorbed, while all of the Stomach and Secretion.”38 the bile still was in the intestine. He Doubting Spallanzani’s theory that concluded that gastric juice acts as a “peculiarly powerful stimulus to the formal treatise on physiology composed lacteals,” an idea he had suggested in a in America.40 It soon became a standard paper which he read at a meeting of the textbook, superseding the American Philadelphia Medical Society in 1803. editions of European authors as Riche- As far as we know Ewell was the first rand’s “Elements,” Hertius’ “Manual,” person in America to make vivisection the “Epitome of Bichat,” and a transla- experiments. tion of Broussais. Dunglison was not an In his essay Ewell suggested the ad- experimental physiologist; his sensitive ministration of gastric juice to patients nature would not allow him to engage with digestive disturbances, particu- in experiments causing pain or destruc- larly to those patients convalescing from tion of life.41 fever “when the atony of the intestine Although Dunglison was a prolific is great’’; to elderly people “who labour writer, his most popular contribution to under a distressing vomiting for weeks’’; medical literature was his medical dic- and to patients suffering with a “species tionary. The first edition of the diction- of diarrhea.” Since “gastric liquor” had ary was probably compiled in Virginia, proved to be so helpful in those condi- as the preface was written in the au- tions, he thought it should be given a tumn of 1832, eight or ten months be- place in “Materia Medica,” although he fore his farewell lecture at the Univer- recognized the difficulty of obtaining it, sity.42 and also its disagreeable taste. Ewell’s Long after the beginning of the nine- work was forward looking, and it teenth century empiricism dominated helped to increase our knowledge con- the medical treatment of diseases. It cerning the gastric juice. Soon after consisted of bleeding, blistering, purg- completing this work, he, unfortunately, ing and sweating, or to quote the lam- gave himself up to disputatious va- poon attributed to John Coakley Lett- garies. som,43 a prominent English physician: About the time William Beaumont began his notable experiments on When any sick to me apply, I physics, bleeds, and sweats ’em; Alexis St. Martin in the far North, a If, after that, they choose to die, young man, Robley Dunglison, who was Why, Verily! I Lettsom. destined to play a prominent part in the early history of physiology in Amer- In England and on the continent ica, joined the faculty of the University bleeding was the principal plan of treat- of Virginia. Dunglison came from Eng- ment. There was no god but the lancet. land in 1824, upon the request of In America Benjamin Rush was its high Thomas Jefferson, to be Professor of priest. While the free use of the lancet Anatomy, Physiology, Materia Medica, often carried patients to the verge of and Pharmacy. Nine years later he went eternity, yet the reparative powers of to the University of Maryland, where an outraged nature brought them back he taught one year, and from that school if they could come back. Be it said to he went to the Jefferson Medical Col- the credit of several physicians in Vir- lege. ginia and in the other colonies at the While in Virginia he wrote his book, end of the eighteenth century that they “Human Physiology,” the first edition realized that inordinate depletion by of which was published in 1832.39 We copious bleeding and purging was in- may reasonably assume this was the first adequate, often harmful, and they be- gan to advocate new and better methods Its incidence was also increased in un- of treatment. A notable example is usually rainy seasons. Furthermore he found in George Washington’s last ill- pointed out differences in the course of ness, when Elisha Cullen Dick, one of the two fevers. In what manner each the consultants, urged his confreres not was transmitted to individuals he did to bleed the General again, but they did not know, although he expressed the not heed his advice. Gustavus R. Brown, opinion that contagion played a larger the other consultant, acknowledged in part in the spread of typhoid than of a letter dated January 2, 1800, to James malaria. Craik, the personal physician and in- We cannot help being impressed with timate friend of Washington, that they his method of treating and preventing were Avrong in bleeding him so much.44 malaria. In the beginning of the attack During the eighteenth and nine- he prescribed a mild laxative, followed teenth centuries the fevers, malaria, by forty grains of Peruvian Bark every typhoid, and yellow, were a menace to two hours until six doses had been the health of the people. Much con- taken during the day for four or five fusion concerning the fevers existed, days. Following a course of the bark, he and little if any distinction was made prescribed chloride of iron for patients between them except in the case of yel- suffering from anemia and debility. In low fever. One of the first physicians order to prevent recurrences he pre- in America who differentiated clinically scribed thirty grains of the bark two or malaria and typhoid—intermittent and three times in the forenoon of every continuous fevers as they were called second day until frost came. At the same for a long time—was Alexander Som- time he emphasized the necessity for mervail, who came from Scotland to draining all low places where water Virginia in the eighteenth century. In was likely to stand, even in small areas his article, “On the Medical Topog- around springs, wells, and houses. He raphy and Diseases of a Section of stated that patients suffering with ty- Virginia,”45 published in 1823, he phoid should not be given strong laxa- called attention to certain characteris- atives, and also that Peruvian Bark had tics he had observed in the epidemiol- no effect on the course of the disease. ogy of malaria and of typhoid. Malaria, He did not employ venesection in the he said, occurred earlier in the warm treatment of either disease. months, and much more frequently Sommervail’s article is the most out- near the rivers, creeks,.and ponds; its standing one in American Medical lit- incidence was increased by unusually erature written prior to the discovery of rainy weather, by floatage in the ponds, the causes of the fevers. In commenting by strong winds blowing from bodies of upon it Nathaniel Chapman, the editor water across the land; it recurred fre- of the Philadelphia Journal of the Medi- quently in the same individual, and dis- cal and Physical Sciences, said: “We appeared soon after the first heavy recommend to the attention of our frost. He had observed that typhoid, on readers the ensuing article. It is the pro- the other hand, occurred more often at duction of a physician, no less venerable greater distances from rivers and ponds; for his learning than his age. The sub- it occurred much more frequently late ject is exceedingly interesting, the dis- in the summer and autumn, and it sel- cussion of it abounds with curious ob- dom recurred in the same individual. servations and ingenious reflections.” It is doubtful whether Chapman or any of third of the fundus. A gross examina- the readers realized the significance of tion revealed “all the characteristics Sommervail’s observations and reflec- of the hard, fibrous texture which usu- tions. ally precede cancerous affections. The During the first quarter of the last fungus growth exhibited a raw, uneven century John Peter Mettauer also dif- and rugged appearance at its anterior ferentiated typhoid from malaria. In extremity.” The patient was discharged one of his most notable articles, “Prac- from the hospital completely cured tical Observations on Continued Fever, one month later. as it Prevailed in Middle Southern Vir- R. M. Taliaferro, a rural practitioner, ginia during the Thirteen Years from appears to have been the first physician 1816 to 1829, Inclusive,”46 Mettauer in this country to perform the operation clearly showed that he was familiar with of episiotomy.49 He performed this op- the symptoms and the lesions of typhoid. eration on December 2, 1851, upon a While this article was not published woman who was not making any prog- until 1843, fourteen years after the dis- ress in labor although she continued to ease was given the name by Louis, of have strong pains regularly, and the France, Mettauer completed his obser- baby’s head had been on the perineum vations during the same year in which eight hours. Soon after Taliaferro made Louis’ researches on typhoid were pub- a medio-lateral incision, delivery was lished. The latter, however, wrote a easily accomplished. Although he made more complete account. In another no claim to originality for the opera- paper on “Continued Fever,”47 pub- tion, he did not know of another case lished in 1857, Mettauer advocated in which it had been performed. Afraid newer methods of treating typhoid. He of being condemned by other members had given up venesection, was allowing of the profession, he hesitated to talk the patient to take nourishment and about the operation until he learned fluids freely, and giving cool sponge several months later that a similar case baths. He prescribed drugs only when had been reported “in the last July No. necessary for meteorism, to aid in con- of the London Lancet.” He expressed trolling hemorrhages, and to stimulate the opinion that the perineum should the patient whose convalescence was be incised in similar cases to aid de- unduly slow. It is interesting to note livery as “a smooth incised wound be that he began employing these measures less injurious and heal more readily as early as 1816. than one by rough violence.” Rucker50 The first successful excision of the stated that the word, episiotomy, was cervix uteri in America was performed, first used five years after Taliaferro per- as far as we know, by a Virginian, John formed his operation. B. Strachan,48 on September 9, 1829. William A. Patteson51 made, in 1848, When Strachan saw the patient in con- what are called Duhrssen’s incisions in sultation with her physician, Theoph- order to overcome dystocia due to a ilus Field Gilliam, he advised the rigid cervix. This was done five years operation since she had not improved before Duhrssen was born and forty- on conservative treatment. As Gilliam two years before he recommended mul- did not perform major operations, he tiple incisions in cases in which a rapid referred the patient to Strachan. The delivery is urgently indicated, the cer- latter easily excised the cervix and one- vical canal is obliterated, but the exter- nal os is not fully dilated. Patteson’s delivered, the patient died. Puzzled patient, a primipara, twenty-nine years by the outcome of this case, he began of age, had been in labor more than looking up the literature for informa- fifty hours. After waiting several hours tion. He found the case reports of Jolly longer, Patteson proceeded with the and Hecker. After comparing the post- operation which he called vaginal hys- mortem findings reported by these men terotomy. Using his left index Huger as with the findings in his case of a rup- a guide, he made four incisions with a ture in the uterus extending into the blunt bistoury in the external os. In cervix, the placenta and membranes de- a short time the baby was safely deliv- tached and lying in blood in the pelvis ered. The mother recovered satisfac- 011 the side in which he found the torily, and she was in good health five tumor, he at once realized the signifi- years later. Two years after reporting cance of the appearance of the tumor. this case, Patteson reported two more, Early recognition of the sign, he pointed one in which no opening could be out, justifies an immediate laparotomy found in the cervix, and one of persis- in the hope of controlling the hemor- tent rigidity, in both of which he safely rhage and saving the lives of both the performed the operation.52 While ad- mother and the baby. mitting that cases in which the cervix Many physicians are familiar with should be incised are rare, he was of the Galt trephine, though few perhaps the opinion that when labor was pro- know it was invented by a Virginian, longed due to excessive rigidity, incis- Gabriel Alexander Dickie Galt. After ions carefully made would save the graduating in medicine at the Belle- mother much suffering and also save vue Hospital Medical College, Galt some babies. Later other physicians in served as an interne in the hospital. Virginia and elsewhere reported cases While serving in that capacity, he in- in which they performed the operation. vented the trephine, and presented it In 1874 Robert J. Preston53 reported to the profession through the surgical a case of rupture of the uterus occurring section of the Academy of Medicine of during labor, for the purpose of calling New York. In the report of Bellevue attention to the value of a sign in the Hospital for January 5, 1861, Lewis diagnosis of rupture—a subperitoneal Sayre, “the father of American ortho- tumor appearing in the hypogastric pedic surgery,” stated that he had used region, first mentioned by M. Jolly in “the beautiful and scientific trephine 1867. Almost simultaneously with invented by Dr. G. A. D. Galt, of Vir- Jolly’s statement of the value of the ginia.”54 He stated further that the sur- sign, Hecker confirmed it, at the same geons attending the meeting the night time stating that the location of the the instrument was shown examined tumor varies according to the site of and recommended it. The instrument, rupture. When Preston discovered the widely used until recent years, is now tumor at the utero-vaginal junction pos- used only when surgeons wish to save teriorly, which had not been present the “button of bone” to prevent cranial several hours earlier, he suspected a defects. Galt located in eastern Vir- pelvic hematocele, but as it seemed ginia where he carried on a large rural small, he did not think it would inter- practice and lived the life of a typical fere with the progress of labor. A few Southern gentleman.55 hours later and before the baby was William Cecil Dabney wrote, in 1888, a description of infectious pleurodynia of the disease, like that of today, was or devil’s grip,56 the first report of the palliative. disease emanating from America. In Fourteen years prior to the publica- describing the epidemic occurring in tion of this paper, Dabney, a microsco- and around Charlottesville, he wrote: pist as well as a clinician, wrote an arti- In every case which I saw the onset cle on “The Development of Connec- was sudden, and usually violent, some- tive Tissue.”57 The development of con- times with chills or a sensation of chilli- nective tissue had been studied by the ness. The pain, however, was, by far, the leading histologists of Europe. Stricker, most striking feature. ... In character Klein, and several others thought the it was usually sharp and lancinating, and fibers of connective tissue are produced was much more violent when the patient by the elongation and splitting of the attempted to move or draw a deep breath. formative cells, while Virchow thought (So agonizing was this pain that it was the fibers are produced from the inter- nick-named the “devil’s grip” by a suf- cellular substances, the formative cells ferer from the disease in Rappahannock taking no part in it although they are County, Virginia, and this name became converted into connective tissue cells. a common one thereafter, as I was told After studying the process of develop- by Dr. W. F. Cooper.) There was slight tenderness over the seat of the pain in ment of connective tissue in the embryo, every case. . . . The seat of the pain was in cicatrices, and in two types of tumors usually in the left side of the chest just arising from connective tissue, sarcoma below the nipple, but in some of the cases and fibroma, Dabney concluded: “The there was pain in the opposite side, or white fibrous element in cicatricial tis- in the shoulder of the opposite side; and sue, and in tumors belonging to the in a few of the cases, especially in chil- connective tissue class, is certainly pro- dren, there was pain in the abdomen, duced by the elongation and splitting usually in the epigastric region. . . . up of the formative cells, and in the de- Headaches occurred in nearly every case velopment of connective tissue in the and was usually severe. . . . The respira- embryo, this mode of development is tions were slightly increased in every by far the most probable.” Histo-pathol- case, and were rather shallow, but this in- crease seemed to be due entirely to the ogists regard this as the method by pain caused by drawing a deep breath. which fibrous tissue develops in the em- There was no cough, and no expectora- bryo in cicatrices, and in some tumors tion, nor were there any evidences of dis- belonging to the connective tissue ease to be found on physical examination. class.58 ... In every instance there was more or A rural practitioner in the mountains less fever usually ranging from 102° to of Virginia, Lewis G. Pedigo, was the 104°. first person to demonstrate the value of He observed the erythematous appear- amyl nitrite in cyanide poisoning. Be- ance of the skin resembling to some ex- coming interested in amyl nitrite as a tent the eruption of dengue and of possible antidote for drugs which in scarlet fever, although he did not con- large doses depress the cardiac and re- sider it an essential feature of the dis- spiratory centers, while a student, he ease. He observed further that the dis- had an opportunity to employ it a few ease occurred much more frequently in years after graduating when he was children and young people, and that called in consultation to see a patient it was short in duration. His treatment who through mistake had been given one half grain of atropine.59 Symptoms 1934.63 In it they gave Pedigo full credit of acute poisoning quickly developed. for his pioneer work. “After the appear- The attending physicians gave mor- ance of our paper,” they said, “it was phine, the drug generally regarded as our good fortune to learn by personal the best antidote for atropine. Several communication that an American physi- doses of morphine, amounting to one cian, Doctor Pedigo, in 1888 proved and one-fourth grains, were given in beyond doubt the value of amyl nitrite one and one-half hours. This increased against cyanide poisoning in dogs. . . . the patient’s state of depression. Pedigo The delay in appreciating his results suggested the inhalation of amyl has probably caused the tardy develop- nitrite. Several inhalations brought ment of the nitrite therapy.” about perceptible improvement, and Agrippa Nelson Bell, one of the first inhalations at intervals thereafter were physicians to enter the field of public all that was required until the patient health work, discovered the value of had completely recovered in a few steam as a disinfectant while serving as hours. In this case Pedigo was probably a naval surgeon on the ship Vixen in treating morphine poisoning as well as 1848. During the summer of that year atropine poisoning. He expressed this yellow fever appeared among members opinion recently in a conversation with of the ship’s crew. The immediate use the author. of steam over the entire ship prevented His success with amyl nitrite led him the occurrence of new cases. Soon after- soon afterwards to experiment with it wards Bell suppressed in the same man- in cyanide poisoning in dogs. Dilute ner an outbreak of yellow fever on the hydrocyanic acid was given and amyl ship Mahones. To Bell is due the credit nitrite was administered in different for introducing into practice steam as stages of poisoning. The dogs treated a disinfecting agent. His statement in survived the effects of the poison, while 1862 that a temperature of 145° F. was the controls promptly died. He re- an effective disinfectant seems to have ported the results at the meeting of the been disregarded until the Committee Medical Society of Virginia in 1888.60 on Disinfectants of the American Pub- Pedigo’s work fell still-born. Forty- lic Health Association reported in 1887 five years later Chen, Rose, and Clowes, that “a temperature of 62° C. (143.6° of the Research Department of Eli Lilly F.) is fatal to all of the pathogenic and and Company, reported favorable re- non-pathogenic organisms tested, in the sults with amyl nitrite used in experi- absence of spores (with the single excep- mental cyanide poisoning.61 As these tion of sarcina lutea, which in one ex- men did not know of Pedigo’s pioneer periment grew after the exposure to this work, they failed to mention his name temperature) .”64 in their article. When Pedigo sent Chen Bell also used sulphur as a disinfect- a reprint of his article, the latter graci- ant. He recommended it in the propor- ously acknowledged Pedigo’s priority tion of three pounds to 1000 cubic feet in demonstrating the antagonism be- in fumigating the ship Black Prince, tween amyl nitrite and hydrocyanic held in quarantine at New Orleans in acid.62 1879. The quantity he recommended The second article on antidotes in was practically the same as used in later cyanide poisoning by Chen and his col- years. laborators appeared in December, It is interesting to note that in 1887 Bell wrote an essay, “The Physiologi- made possible the control of yellow cal Condition and Sanitary Require- fever. Carter’s most notable work in ments of School-Life and School- connection with this disease was the discovery of its incubation period. While serving as quarantine officer on Ship Island in the Gulf of Mexico in 1888, he tentatively deduced, from the meager information at hand and from his own observations in several epi- demics, that the period of incubation of yellow fever in man was about five days. He made that the period of de- tention in quarantine of ships, counting the period from the last possible ex- posure of any member of the ship’s personnel after fumigation of the ship instead of from the date of its arrival in port.66 Since disinfection of the ship required about two days, the period of detention was in reality about seven days, which was later found to be suffi- ciently long. This basic principle of quarantine for yellow fever had not been applied at any of the sea-ports either in this country or in Great Britain. As early as i8go Carter advo- cated, and in 1893 he established, dis- Houses,”65 in which he related in detail infecting vessels at the port of depar- the hygienic requirements of an up-to- ture, so that time en route to port of date school building, as well as the entry could count against the period physiologic principles which should be of detention in quarantine. This meas- applied in the care and education of ure was characterized by Kitasato, the children. Although some investigations Japanese sanitarian, “as almost the only had been made of the health of school advance in maritime quarantine since children in certain places, it was not the days of the Venetians.”67 until a few years after Bell wrote this When Carter tentatively concluded essay, when epidemics threatened, that in 1888 that the period of incubation the larger cities began the inspection of yellow fever in man was about five of school children for the purpose of days, he had also observed that ships preventing the spread of communicable leaving port with fever cases did not diseases. In recent years all the require- become infective until the lapse of two ments pertaining to a healthier school to three weeks. This he called “the life advocated by Bell have been car- period of extrinsic incubation of yel- ried out. low fever,” and he based his control The names of two Virginians, Henry measures for epidemics upon it. It was Rose Carter and Walter Reed, stand not until ten years later, however, that out pre-eminently among those who he obtained sufficient data to convince other members of the profession. The on June 25 during an epidemic of yel- opportunity to make a sufficient num- low fever, the Commission immediately ber of observations, under circum- began its work. It spent the first three stances satisfying all his requirements, was finally offered in epidemics occur- ring in the isolated rural communities at Orwood and at Taylor, Mississippi, in the summer of 1898. The data ob- tained there completely tallied with those of his previous observations. He wrote an account of his observations in three papers, “A Note on the Interval between Infecting and Secondary Cases of Yellow Fever from the Records of the Yellow Fever at Orwood and Tay- lor, Mississippi, in 1898”;68 “The Pe- riod of Incubation of Yellow Fever’’;69 and “A Note on the Spread of Yellow Fever in Houses—Extrinsic Incuba- tion,”70 the trilogy forming a complete work. Carter's observations were ex- perimentally confirmed by the Yellow Fever Commission in Cuba in 1901. Carter’s studies on the incubation period of yellow fever are among the most notable that have been made in non-experimental epidemiology, rank- months investigating the widely accepted ing with those of Bretonneau and Wil- theory advanced three years previously liam Budd on the infectious nature of by Sanarelli, that the Bacillus icteroides typhoid fever, and of John Snow on was the specific cause of the disease. In cholera. While his work is not as well its investigations of Sanarelli’s theory known as that of Reed and Gorgas, yet the Commission made numerous bac- Gorgas himself said that “it places Car- teriological examinations of the blood ter in the class of the great original of patients sick with yellow fever, and of workers of our time.”71 the blood and organs of several patients The credit for the discovery of the dying of the disease, “having especially mode of transmission of yellow fever in view the isolation of B. icteroides.”72 belongs, as is well known, to Walter Repeated examinations failed to show Reed. Reed, a Major in the United the bacillus in a single instance. States Army Medical Corps, was ap- A short time before going to Cuba, pointed chairman of the Yellow Fever Reed’s attention had been attracted by Commission created by an order of the Henry Rose Carter’s article, “A Note War Department, to visit Cuba and in- on the Interval between Infecting and vestigate the cause of the disease. The Secondary Cases of Yellow Fever at other members of the Commission were Orwood and Taylor, Mississippi, in James Carroll, Aristides Agramonte, 1898.” Carter’s conclusion that the in- and Jesse W. Lazear. Landing in Cuba cubation period of the disease in man was about five days, and that an inter- a vestibule doubly screened to prevent val of two to three weeks elapsed before insects from gaining admission when a a house became infected after a patient person entered the building, and was sick with yellow fever was carried into divided into two compartments by a it, suggested the possibility of the in- fine mesh screen wire. Non-immune in- fecting agent passing through a period dividuals entered one compartment into of development in the body of a biting which mosquitoes that had bitten yel- insect, probably a mosquito. Later Reed low fever patients fifteen to twenty-four admitted that Carter’s observations de- days previously, had been liberated. termined the direction of his work by They remained inside long enough to making him realize the similarity be- be bitten. Non-immune individuals en- tween certain phenomena of yellow tered the other compartment where fever and malaria. The latter disease they stayed for more than two weeks had, a short time previously, been acting as “controls.” No mosquitoes proved by Ross and the Italians to be were allowed in this compartment. Not a mosquito-borne disease. Reed soon one of the “controls” subsequently went to the Military Governor, Gen- showed any signs of illness, while each eral Leonard Wood, to ask permission person who had been bitten by mos- to use volunteer immune and non-im- quitoes in the adjoining compartment mune persons, and also for a sum of developed yellow fever within five days. money with which to reward those who Then Reed allowed three persons in should offer themselves for experiment. whom he had tried to induce the dis- Wood, himself a physician, complied ease by contact with fomites, to go into with the request. The building of the this building to be bitten by infected experimental camp, named Camp mosquitoes. An attack of fever promptly Lazear in honor of Lazear who died of followed in each instance. That the in- the disease, was begun at once. fection in all of these cases was due Reed used the utmost precautions in to mosquito bites was plainly indicated constructing two buildings, in keeping by the fact that the “controls,” pro- records of the individuals used in the tected only by the wire screen partition, experiments, and in handling the mos- slept in the other compartment without quitoes. In one of the buildings which contracting the disease. was poorly ventilated, seven volunteers, The Commission found also that yel- all non-immune persons, or persons low fever could be induced in non- who had not had the disease, slept in immune individuals by the injection garments worn by patients with yellow of blood obtained from a patient during fever and on linens soiled by the pa- the first three days of an attack. Six tients. This attempt to infect these in- persons were infected in this manner. dividuals during a period of sixty-three Even a small quantity of bacteria-free days resulted in a failure. It proved, serum filtrate, obtained by passing the however, that yellow fever was not due diluted serum through a Berkefeld fil- to contact with fomites. ter and injected into two individuals, Before completing the experiments induced attacks. with fomites, the Commission began During the course of the experiments experimenting with mosquitoes in the with mosquitoes, which required about second building, which was provided five months, twenty-two cases of yellow with adequate means of ventilation, had fever were produced; fourteen by in- fected mosquitoes, six by the injection he advocated—a preliminary survey of of whole blood, and two by the injec- an old pond by a trained man; or be- tion of the serum filtrate. Not a single fore the building of a new pond, clean- instance of the disease occurred except ing the shores and banks of under-brush, at the will of the experimenters, and weeds and grass; raising and lowering fortunately each patient survived his the surface of the water in the ponds; attack. The precision with ■which the cleaning out floatage; and the introduc- experiments were conducted left noth- tion of larvae-eating fish, as the Gam- ing to be desired in order to fidfill the busia affinis, commonly called the min- requirements of a scientific experiment. now—are the same as those employed Reed no longer doubted that yellow today to prevent the Anopheles from fever is transmitted by the Stegomyia breeding around ponds.76 fasciata mosquito. A complete confir- Prior to the nineteenth century the mation of the results obtained by the barbarous methods employed in Eu- Commission by a series of experiments rope in caring for the insane were also carried out by Juan Guiteras, and also employed in America. The legal recog- the marked reduction both in the mor- nition of this unfortunate class of peo- bidity and mortality rates from yellow ple began at an early date in the colo- fever in Havana within a few months, nies with legislation giving overseers convinced the world of the truth of of the poor charge of the insane, or pro- Reed’s discovery. Reed briefly summed viding for the subsistence of slaves who up the results of his work in a paper might become “lunaticks” while be- which he read at the meeting of the longing to persons too poor to care for Pan-American Congress in Havana in them. I11 reality, however, the care of February, 1901.73 the insane was almost entirely a local Henry Rose Carter’s pioneer work enterprise, devolving upon the coun- on the epidemiology of malaria played ties or townships, and in some instances a great part in making possible the con- upon the vestries of the established trol of this disease. His study of yellow church.77 While Virginia was not the fever involved also a study of malaria, first colony to pass some kind of legis- and his vast experience acquired during lation providing for their care, yet it epidemics of the former was of great was the first to establish a hospital used value to him when in the summer of exclusively for the insane. This was the 1913 he began a more intensive study “Publick Hospital for Persons of Insane of malaria. In his observations on the and Disordered Minds,” now the East- effect of impounded waters on the in- ern State Hospital in Williamsburg. It cidence of malaria as produced by the was opened for patients in October, great bodies of water of the hydro- 1773. As the building had cells and electric plants in the South, he found chains, it is doubtful whether anything Anopheles mosquitoes were breeding more was done for a quarter of a cen- along the shores sheltered by tall grass tury for the patients than to segregate and bushes, and also in the shallow them from society. Nevertheless, it was water artificially produced by floatage.74 a step in the right direction. In the summer of 1914 Carter suc- For many years the professional care cessfully conducted the first campaign of the patients was in the hands of visit- for the control of malaria in the United ing physicians, the first of whom was States.75 The methods of control which John de Sequeyra. Following his resig- nation in 1795, the three Gaits, John and mentioned many times in the suc- Minson, Alexander Dickie, and John ceeding years, although no definite steps Minson, II, successively cared for the were taken for the construction of one patients for a period of sixty-seven years. until 1780, when the legislature im- Soon after his appointment Alexander posed a tax on sailors and mariners who began employing the humane methods entered the ports of the state.81 Seven inaugurated by Philippe Pinel for treat- years later when the funds derived from ing the insane, although they had not the tax were thought to be sufficient, been approved by the profession at the legislature passed an act authoriz- large. John Minson, II, the first regu- ing the construction of a hospital near larly appointed superintendent of the Norfolk.82 After several unsuccessful at- institution, employed the same meth- tempts to complete the building, the ods, and, like his father, he kept ac- state, in 1800, offered to cede it to the curate notes on the results of the treat- Federal Government provided it would ment. He compiled his father’s notes pay the balance due the contractor. The and in 1843 had them published in a Government accepted the hospital on volume, Gait’s “Practical Medicine.”78 the conditions proposed by the state. Galt later wrote several articles on the Thus it became the first institution of treatment of the insane. its kind in this country, and it also Virginia was the first state to provide marked the beginning by the Federal also for insane negroes. Free negroes Government of a service that has been were admitted to the Eastern State Hos- recognized for its efficiency and organi- pital as early as 1773, and in 1846 the zation throughout the world. An ex- legislature granted a petition permit- cellent account of the Naval Hospital ting the institution to admit slaves. at Norfolk has been written by Hol- John Minson Galt, II, commented in comb.83 1846 on the privilege he and his asso- Medical legislation in Virginia is a ciates had in ministering to these un- subject of much interest. The first leg- fortunate patients irrespective of racial islation affecting physicians in this col- or social standing. One year previously ony, and incidentally in any of the Francis F. Stribling urged upon the colonies, was enacted in 1639. During legislature the necessity for providing a the remainder of the century seven simi- separate institution for negroes, al- lar bills were enacted. Judging from the though no step was made until 1870.79 language of these bills, the public as As a result the Central State Hospital, well as the law-makers had little confi- first located just outside of Richmond, dence in the physicians, for they were was established. Fifteen years later the spoken of as “avaritious and gripeing new buildings in Petersburg were practitioners of phisick and chirurgery” opened and colored patients were trans- who exacted “excessive and immod- ferred to them. erate prices” for their services. The It is interesting to know that the first word practitioners included charlatans, marine hospital in America was estab- who were numerous, as well as regular lished in Virginia. An outgrowth of a physicians. The Act of 1660-61, was, realization of the special health and so- however, more favorable to the physi- cial problems of sailors in port, it was cians since it provided for the collection suggested as early as 1705 by Lieuten- of fees out of deceased patients’ estates. ant-Governor Alexander Spotswood80 Another act thirty years later revoked the act making physicians liable to ar- sent his diploma to the General Assem- rest for overcharging. bly or to the Speaker, and receiving a During the eighteenth century a certificate that should be registered with larger number of bills of more re- the clerk of the county in which he de- strained language and of a more con- sired to practice.90 About the same time structive nature than those of the pre- the Virginia students in Edinburgh ceding century were enacted. We may petitioned the Council and the House infer from them that the public had of Burgesses to pass laws that would more confidence in the physicians, al- prevent a person who had not obtained though at different times the public a degree from practicing medicine.91 No complained of wide variations in the action, however, was taken by the As- quality and of the high cost of medical sembly. attention. An act of the House of Nearly one hundred years later- Burgesses in 1712 provided for “regis- 1851—the medical students of the Uni- tring Births, Christenings, and Bur- versity of Virginia petitioned the Legis- ials,”84 parents and masters being re- lature for an examining board to be quired to report births to the minister wholly independent of the medical col- or clerk of the parish, while the minister leges. There was much opposition to of each parish was required to keep a the plan, and it was not until 1885, register of births and deaths. Other acts after persistent efforts by the profession, provided for the care of the indigent that the examining board was estab- sick (1748),85 for the quarantine of lished in Virginia.02 ships coming from the countries in the The first physician’s license tax in Old World where the plague was epi- Virginia, a tax of five pounds, was im- demic (1722),86 for quarantine against posed in 1786 on every physician, sur- jail fever and small-pox (1767) ;87 sev- geon, and apothecary practicing in the eral acts between 1768 and 1777 regu- state. Four years later it was repealed.93 lated the inoculation of small-pox; and During the nineteenth century some a final act with slight modifications was of the more important acts of the Gen- passed in 1792 “to reduce into one the eral Assembly pertaining to medicine several Acts for regulating the Inocula- and public health provided for appro- tion of Small-pox within this Common- priations to medical schools; to institu- wealth.”88 tions for the insane; to the state colony As early as 1761 a suggestion for im- for epileptics; to the school for the deaf, proving medical practice through bet- dumb, and blind in Staunton; for regu- ter education came from the “Virginia lating medical practice; for physicians’ Club” in Edinburgh. This club, com- licenses; for the incorporation of medi- posed of young Virginians who wished cal societies; for the establishment of to obtain the degree in medicine, was the Board of Health; for quarantine; formed “solely for the improvement of for pure food and drugs; for the label- the members in anatomy, (which is ling of poisons; for the establishment of justly termed the basis of physic,). the bureau of vital statistics; and for . . .”89 Four years later Arthur Lee, a regulating the practice of dentistry and student at the University of Edinburgh, the practice of pharmacy. wrote his brother suggesting a medical An account of pioneer medicine in practice act requiring every physician Virginia would not be complete with- wishing to practice in Virginia to pre- out mentioning the work of Jesse Ben- nett, Hunter McGuire, and George Ben striven in darkness and little by little Johnston. Their work will, however, be added to our knowledge and prepared described in more detail in other ar- the minds of the scientific world, great ticles in this series. discoveries might have gone unrecog- One thought comes to mind in think- nized, medicine might never have be- ing over the lives of these physicians come a science. who made outstanding contributions to What shall we say of those men whose medicine. It may be expressed in the names have not been mentioned? Per- words of Mommsen, the great historian, haps the answer can better be given in in writing of a great man who made his- the words of Sir Thomas Browne: “The tory: “He never left undone the possi- greatest part must be content to be as ble good for the sake of the impossible though they had not been, to be found better.” Probably Baynham, Mettauer, in the register of God, not in the record Strachan and all of those far-seeing men of men.” They too were steadfast in who operated in kitchens of shanties purpose, loyal to their profession; un- with rough boards for tables were fear- tiring in industry and in their zeal to ful of the absolute lack of cleanliness alleviate human suffering; eager in their and realized that something vital was pursuit of knowledge; fearless in dan- wanting in their technic, but with un- ger, and patient under every condition. daunted courage they did all that the No doubt they had the same attitude as development of surgery at that time made it possible for them to do. Crawford W. Long, who spoke these Mitchell, Leigh, Sommervail, the Gaits, words: “My profession is to me a minis- Carter, Reed, and other physicians try from God. I am as much called upon showed an extraordinary degree of to practice medicine as a minister is to courage and boldness in expressing, on preach the Gospel.”94 If oblivion was their own initiative, seemingly revo- the seeming fate of a great many physi- lutionary ideas concerning drugs and cians, we know they went about doing the nature and treatment of diseases, good, and they had the reward that a but later investigations found them to clear conscience and a grateful clien- be correct. If all of these men had not tele confer. Ref ere nces 1. Cohn , A. E. Medicine, Art and Science. 6. Brow n , A. Op. cit.,1 23 451:479-480. Chicago, Univ. Chic. Press, 1931, p. 7. Brown , A. Op. cit.,3 1:353. 74- 8. Brow n , A. Op. cit.,3 1:493. 2. Smith , Capt . J. Works, 1608-1631. Edited 9. 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Letter to his brother, the Properties of Opium and its Ef- William & Mary Quart., s. 2, 3:134-136, fects on Living Subjects: With Ob- 1923. servations on its History, Preparations 19. Byrd , W., II. Letter to Sir Hans Sloane. and Uses. Printed for Charles Elliott, William ir Mary Quart., s. 2, 1:186- Edinburgh; and G. G. J. & J. Robin- 188, 1921. son, London, 1786. 20. Car rier , L. Dr. John Mitchell, Natural- 34. Mill er , J. L. John Leigh. Va. Med. ist, Cartographer and Historian. Ann. Monthly, 55:49, 1927-28. Rep. Am. Hist. Assn., 1918, Washing- 35. Biographical Sketch of William Bayn- ton, Gov’t. Printing Office, 1921, pp. ham, Esq., Surgeon. Phila. J. Med. 201-219. Phys. Sc., 4:186, 1822. 21. Braas ch , F. E. The Royal Society of 36. Bay nh am , W. An account of two cases Medicine and its influence upon sci- of extra-uterine conception; in each entific thought in the American colo- of which the foetus was extracted by nies. Scient. Monthly, 33:336; 469, an operation with success. 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Tr. raphy and diseases of a section of Vir- Med. Soc. Va., 19:124, 1888. ginia. Phila. J. Med. ir Phys. Sc., 6:276, 61. Che n , K. K., Ros e , Char le s L., and 1823. Clow es , G. H. A. Amyl nitrite and 46. Met ta ue r , J. P. Practical observations cyanide poisoning. J. A. M. A., 100: on continued fever, as it prevailed in 1920, 1933. middle southern Virginia during the 62. Correspondence of Chen and Pedigo thirteen years from 1816 to 1829, in- loaned by the latter to the author. clusive. Am. J. M. Sc., (n.s.) 6:33, 63. Chen , K. K., Ros e , Charl es L., and 1843. Clowe s , G. H. A. Comparative values 47. Mettauer , J. P. Continued fever. of several antidotes in cyanide poison- Monthly Steth. & Med. Rep., 2:1, ing. Am. J. Med. Sc., 188, 767, 1934. 1857. 64. Smith , S. The practical sanitarian, as 48. Str ac ha n , J. B. A case of successful ex- illustrated by a life sketch of A. N. cision of the cervix uteri in a scirrhous Bell. Sanitarian, 28:481, 1892. state. Reported by Theophilus Field 65. Bell , A. N. The Physiologic Condition Gilliam. Am. J. M. Sc., 5:307, 1829. and Sanitary Requirements of School- 49. Talia fe rr o , R. M. Rigidity of the soft Life and School-Houses. Tr. M. Soc. parts—delivery effected by incision in N. Y., 1887, p. 25. the perineum. Steth. & V. Med. Gaz., 66. Carte r , Miss Laur a A., daughter of 2:383, 1852. Henry Rose Carter, and his secretary 50. Ruck er , M. P. A Brief History of Obstet- for many years. Personal communica- rics and Gynecology in Virginia. Tr. tion to the author. Am. Assn. Obs., Gynec. tr Abd. Surg., 67. Carte r , H. R. Bull. Internat. Health 48:1, 1935. Board, 6:147, 1925. 51. Pat te son , W. A. On a case rigidity of 68. Carte r , H. R. A note on the interval be- the os uteri in which hysterotomy was tween infecting and secondary cases of practiced. Va. Med. tr Surg. J., 2:264, yellow fever from the records of yellow 1854. fever at Orwood and Taylor, Missis- 52. Pat te son , W. A. 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