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Laa cartaa. planchaa. tableaux, ate. pauvant itra filmfo i daa taux da reduction diff«rants. Lorsqua la document ast trop grand pour ttra raproduit an un saul clich*. ii ast film* * partir da I'angia sup*riaur gaucha. da gauche i droita, at da haut an bas, an pranant la nombra d'imagaa n*cassaira. Las diagrammas suivants illustrant la m*thoda. 1 2 3 6 MICROCOPY RfSOlUTION TBT CHART (ANSI and ISO TEST CHART No. 2) tim 12^ , li;^ ■ so ■^ ^ l^ 1^ 1^ lU u nuu Mim 1^ ^ ^PPLIEiJ IN/HGE Ir r^'- '653 East Main Street S\£ /,5I'?""- '*" ^oi'l" '4609 USA •■^ (7'6) 482 - 0300 - Phone :^B: ("6) 288 - 5989 - Fox VIENN \ AFTER THIRTY- FOUR YEARS BY WILLIAM OSLER, M.D. Regitu Prqfettor of Medicine at the Umvertity of Oxford, Oxford, England VIENNA AFTER THIRTY-FOUR YEARS* I SPENT the first four months of 1874 here. I came from Berlin with Hutchinson, an Edinburgh man (Sir Charles F., who has re- cently died), and we 1'" d together near the All- gemeines Krankenhaus. \s illustrating the total blotting out of certain memories, particularly for places, I may mention that strolling to-day up the Alserstrasse I could not recall the street, much less the house, where we had lived for the four months. I found my way readily enough to the Riedhoff, where we were in the habit of din- ing, and where I first met my old friends, Fred Shattuck, E. H. Bradford, E. G. Cutler and G. K. Sabine of Boston. An extraordinary de- velopment has taken place in the city within thirty years, and I scarcely recognized the Ring- strasse. Then, only the foundations of the new university buildings and of the Rathaus had been begun. Now these, with the parliament house, the cour^^s of justice, the twin museums of art and natural history and the new Bourg * Reprinted from the Journal of the American Medical Association, 60: 1623. 1908. 8 VIENNA Theater, form a group of buildings unrivaled in any city. THE GERMAN CONGRESS FOR INTERNAL MEDICINE Tlie primary object of my visit was to attend the Congress fur Innere 3fedizin, and I had the pleasure of having with me my old student and friend. Dr. Joseph H. Pratt of Boston. We reached Vienna in time for the preliminary Sun- day evening social gathering in the Kursu. jf the City Park. Here we foc nd a greeting in tn-- German fashion and a hearty welcome from the president, Professor MuUer of Munich. The work of the congress began at sharp 9:30 on Monday morning with a discussion on the "Re- lation of the Diseases of the Female Generative Organs to Internal Maladies." Unfortunately, the large University Hall, in which the meeting was held, was most unsuitable. Though seated not very far away. Professor Rosthorn's remarks were almost inaudible. It is a miserable mistake in introducing a discussion on any subject to speak for more than half an hour, but to continue for an hour and a quarter is too much for human endurance, and a great many did not wait for Professor Lenhartz's discussion of the problem from the standpoint of internal medicine. Noth- AFTER THIRTY-FOUR YEARS ing new was brought out, and so far as I could gather, Professor Rosthorn took much the same ground as Clifford Allhutt in his well-known Goulstonian lectures dealing with the intimate relationship through the sympathetic nervous system of the generative functions with those of the other organs. Quite an animated discussion followed, in which Stintzing, Turban, Klemperer and others took part. Dr. Singer read a most interesting paper on "Intestinal Diseases in the riimac- teric," calling attention particularly to ' Vequent hemorrhages which he had known to arouse sus- picion of malignant disease. In the evening the city fathers gave a mt-gnif i - cent banquet to the congress in the superb hall of the Rathaus. At three long tables were seated some 600 guests. On Tuesday morning Professor Neisser of Breslau opened the discussion on the "Present Position of the Pathology and Therapy of Syph- ilis." This was a splendid address, delivered with- out notes, in a good clear voice, and the subject matter arranged in a most order' ^ manner. He dealt particularly with the three points brought out by recent investigations — Schaudinn's dis- covery of the spirochete, the discovery of Metch- 4 VIENNA nikoff that apes could be infected, and the dis- covery of Schaudinn that the fluids of infected persons reacted specifically. He dealt very fully with his own experimental work in Java, much of which has appeared, but it was particularly interesting to hear the relation of the extraor- dinary influence of atoxyl on the infected ani- mals. It acts as a specific and prevents the devel- opment of the spirochetes, so that if given soon the disease could be completely stopped, and later the animal reinfected. Neisser was followed by Professor Wassermann, who described with great clearness his studies on the specific reac- tion. We have now apparently a diagnostic means by which the presence of the disease may be definitely determined at a very early stage. As the reaction may be present before secondary symptoms appear, it will have a very important influence in early treatment. The general expres- sion of opinion is very favorable to the method. Professor Finger spoke o^ it to me in the warm- est terms. It persists after all clinical symptoms have disappeared, and a positive response in locomotor ataxia and in gencidl paralysis clinches the question of the true syphilitic nature of these maladies. Both Neisser's and Wassermann's addresses were models. .FTER THIRTY-FO^'. "EARS 6 One of the most import*-; ; communications of the congress was from von Noorden's clinic. Two of his assistants have been carrying on re- searches on the "Mutual Relations of the Pan- creas and Thyroid." For many years von Noor- den has had the idea that there was some impor- tant mutual influence between these two organs. The remarkable fact comes out that in animals frc ^ which t} • thyroid gland has been rem vcd it is impossibl o produce diabetes by any of the known methods, not even by the Claude Ber- rird pii. fjrure of the medulla. Of the third day of the congress I saw but little. Professor Schmidt of Halle introduced a discussion on "New Clinical Methods of Investi- gating the Functions of the Intestine," in which he went over his recent work very fully, most of which has already been referred to in The Journal. DINNER TO THE CONGRESS At the dinner of the congress His threw out the interesting suggestion (apropos of the pres- ence of Grunbaum and Trevelyan from Leeds, Pratt from Boston, Barr from Portland, Ore., and myself), that the time had come to have an International Congress for Internal Medicine. 6 VIENNA The physiologists, the laryngologists, the alien- ists and others have such gatherings, and there now exist in France, Germany and Italy, Eng- land and the United States special societies de- voted to internal medicine. A congress once in four or five years would be most helpful. We should get to know each other and be able to ap- preciate better the work done in different coun- tries. Professor Schultze of Bonn gave his usual humorous sketch of the proceedings of the con- gress, which was greatly appreciated. A ripple of excitement spread around the tables when it was noticed that the places in the orchestra of the pianist and the first violin had been taken by von Neusser and His. The members gathered around the elevated gallery and the distinguished artists were greeted with loud applause and had a vigorous encore. THE VIENNA LIBRARIES Prof. Max Neuburger, whose name is so well known in association with Pagel as editor of the '' Handbuch der Geschichte der Medizin," very kindly arranged to show me the points of inter- est in the Vienna libraries. I may mention, by the way, that Professor Neuburger's new work on the "History of Medicine," of which one AFTER THIRTY-FOUR YEARS 7 volume has appeared, is being translated and will be published from the Oxford University Press. He expects to have Volume II completed this year, and we hope to issue the English edi- tion complete in one volume within the next fifteen months. I was greatly interested to see the new home of the Wiener medizinische Ge- sellschaft, built under the presidency of Billroth, which combines features of a library, a club and meeting place. The auditorium is exceptionally well arranged with seats for 300, and there is a large gallery. The library now numbers more than 40,000 volumes and is very rich in current periodicals. The university library is one of the largest in the city, and the arrangement in it for the accommodation of the medical students seems to be excellent. At the time of our visit the section of the reading room assigned to them was nearly full. A room has been set aside in con- nection with the medical faculty for the collec- tion of all the literature relating to the history of the school, for the collection of the works of all the famous old men connected with it, and a re- pository for pictures and instruments, etc., the wiiole to form a collection illustrating the evolu- tion of the history of the medical department of the university. This example could very well be 8 VIENNA followed in all of our medical schools. It has been done to some extent at the University of Pennsylvania, as William Pepper III has already made large collections for this purpose. The Hofhibliothek is unusually rich in manu- scripts and early printed books. I was anxious to see the copy of "Christianismi Restitutio" of Michael Servetus, 1553, in which for the first time the lesser circulation is described. This is one of the only two known copies in existence. The entire edition was confiscated, and the author, at the time a practitioner in the little town of Vienne, near Lyons, fled for his life to Geneva. Here his heterodoxy was quite as ob- noxious to Calvin, into whose hands he fell, and he was burnt at the stake in the same year. The "Restitutio" is one of the rare books of the world. Only two of the 1,000 copies known to have been printed have survived. The one in the Bibliotheque Nationale originally belonged to Dr. Mead, and the history is fully given in an ap- pendix in Willis' work, "Servetus and Calvin." The Vienna copy is in excellent preservation, beautifully bound, and states on the title page that it came from the library of a Transylvanian gentleman living in London. It fell into the hands of Count de Izek, who presented it to the AFTER THIRTY-FOUR YEARS 9 emperor of Austria. It is a thick, small octavo of about 700 pages. The first one to give credit to Servetus for his discovery of the lesser circu- lation was Wotton, whose "Reflections Upon Learning, Ancient and Modern," 1694, is a most interesting book, for an introduction to which I have long been grateful to my friend, Dr. Norman Moore. The other work that I was most anxious to see was the famous manuscript of Dioscorides, prepared at the end of the fifth cen- tury for Julia, daughter of the Emperor Flavins. It is one of the great treasures of the library. Now to us in the West only a name, Dioscorides, an army surgeon of the time of Nero, fills a great place in the history of medicine, and is still an oracle in the Orient. He was not only a great botanist, but he was one of the first scientific students of pharmacology. Scores of fine edi- tions of his work, with commentaries, were issued in the fifteenth and sixteenth centuries. Two years ago this Vienna manuscript was re- produced infac simile at Leyden. Though very expensive, the two volumes costing $150, it is a work which all the larger libraries should get, and it is just the sort of present librarians should make our wealthy consultants feel it a privilege to give. 10 VIENNA THE HOSPITALS I was surprised to hear Professor MuUer say that he thought in hospital architecture Vienna led the world, and that there was here a group of architects who were adepts in all matters relat- ing to hospital construction. I have come to his conclusion, on what may appear to be very has- tily acquired data. It is not often that in the same day and in the same institution one passes from eighteenth to twentieth century condi- tions. Dr. Koessler took us to the old medical clinic, now in charge of von Neusser, where I found the old wards very much the same as I re- member them in 1874. Except in minor details, not only Oppolzer and Skoda, but probably also Peter Frank and de Haen could return to the Allgemeines Krankenhaus and not be surprised by any very unfamiliar sights. There is the same extraordinary wealth of clinical material. I must say it was a surprise to see the old type oi nurse; not, of course, that she is necessarily either unin- telligent or inattentive. Indeed, as we passed a bed in which there was a new patient whom the junior assistant had not seen, he tur icd to one of the nuises, who in reply to his question said, "Yes, Herr says she has mitral stenosis AFTER THIRTY-FOUR YEARS 11 i i and insufficiency!" I was interested to see in tiie ward a ease of Pick's disease, the pericardial pseudoc rhosis of the liver. The old question comes up here as to priority of descripti n. In the special number of the Wiener klinische Wochenschrift, issued for the congress, Professor von Neusser desciibes it as "Morbus Bam- berger." He states that in 1872 Bamberger de- scribed the condition as a special malady which he had already known for a long time and which up to that time had not been recognii.ed in the literature. Certainly Pick desei ves credit for hav- ing brought together all the known facts relating to a clinical condition to which very little atten- tion had been given before his paper. I had a most interesting talk with Pi :nd Brauer and Wenckebach on the whole question, which is not one simply of pericardial adhesion. Wencke- bach has helped to solve the problem in a recent number of Volkman's Vortrdge in an article on the "Relation Between Respiration and Circula- tion." Brauer of Marburg, who is coming over to the session of the American Medical Associa- tion, will discuss the subject in connection with his operation of cardiolysis. If anyone interested in hospitals — in every possible detail, construction, situation, general 12 VIENNA arrangements for the comfort of the patients, for the convenience of the students, for the advancj- meui, of science— if such an one wishes to have a Queen-of-Sheba sensation, let him visit the first group of the new buildings of the Allegemeines Krankenhaus. They have begun the rebuilding with the departments for women, and two of the three clinics, for midwifery and gynecology, are completed, one for Professor Schauta and the other for Professor Rosthorn, recently called from Heidelberg. About 10,000 deliveries a year take place in the three clinics, one of which is for midwives. The new clinics are exact duplicates of each other, and each has accommodation for about 200 patients. The buildings are of four stories, a central building with wings, built of brick and stucco, with spacious corridors, large windows, tiled floors and white oil-finished walls. Inside and out they form the most attractive hospital buildings that I have ever seen. But it is not so much this aspect that gives one that sink- ing of the heart of v^hich the Queen of Sheba complained when Solomon showed his treasures —it is the organization and the completeness of the arrangements for teaching and for the scien- tific study of disease. One large floor is assigned to students, who all live in the building while AFTER THIRTY-FOUR YEARS IS attending the midwifery eases. Each clinic has its own laboratory, a special museum for teach- ing purposes, a library and a fully equipped small laboratory adjoining the gynecologic operating room so that an opinion may be given immedi- ately as to the nature of a growth. Down to the smallest detail every care has been taken to make these two clinics the most perfect of their kind, and if the hospital is completed on this elabo- rate plan it will, indeed, be worthy of the fame of the Vienna school and there will be nothing like it in Europe or America. The government foots the bills, and the total cost of the two build- ings has been 9,000,000 kronen ($1,800,000). Professor Schlesinger very kindly took us to the Franz Josef Hospital, also a new building, on a less elaborate scale but vary complete iu all its appointments. It is particularly well arranged for the acute infectious diseases, and the most elabo- rate precautions are taken to isolate and disin- fect the patients. Professor Schlesinger is very popular with American students, and we found working in his wards Dr. George Cheyne Shat- tuck III of Boston, and young Dr. Fischel of St. Louis, both of whom have for some months been acting as voluntary assistants. It was interesting to see two wards devoted entirely to erysipelas; 14 VIENNA as far as possible all the cases in the city are sent here. Connected with this hospital is a beautiful new children's department, built by Professor Schlesin^^er's father-in-law. It looked to be an admirable model for the new Harriet Lane Johnston's children's department at the Johns Hopkins Hospital. In the arrangement for iso- lating cases, in the simple and easily worked character of the wards, in the laboratory arrange- ments and in the special incubators for feeble babies the hospital seemed much in advance of anything I had ever seen. The scientific laboratories of the medical school have been completely transformed. Dr. Frohlich took us through Professor Meyer's Pharmacologic Institute and through the new physiologic laboratory and the anatomic depart- ment—such a contrast to the old days! CRITICIS :l OF WORK Ol CONGRESS The general impression one gets of the work of the congress is very favorable. Too much, per- haps, is attempted. There are too many papers, but the keenness of the men and the scientific in- terest are most stimulating. As I remarked about the congress two years ago in Munich, there is a strong tendency in internal medicine to-day AFTER THIRTY-FOUR YEARS 16 toward physiologic and chemical problems. On the long list of papers, eighty-eight in number, there were only about five dealing with bacterio- logic questions. An extraordinary number dealt with questions in physiologic pathology and presented the results of experimental work. INFLUENCE OF VIENNA ON AMERICAN MEDICINE As a medical center Vienna has had a remark- able career and her influence, particularly on American medicine, has been very great. What was known as the first Vienna school in the eighteenth century was really a transference by van Swieten of the school of Boerhaave from Leyden. The new Vienna school, which we know, dates from Rokitansky and Skoda, who really made Vienna the successor of the great Paris school of the early days of the nineteenth century. But Vienna's influence on American medicine has not been so much through Skoda and Rokitansky as through the group of brilliant specialists — Hebra, Sigmund and Neumann in dermatology; Arlt and Jaeger in ophthalmology; Schnitzler and von Schrotter in laryngology; Gruber and Politzer in otology. These are the men who have been more than others responsible for the successful development of these special- 16 VIENNA ties in the United States. Austria may well be proud of what Vienna's school has done for the world, and she still maintains a great reputation, though it can not be denied, I think, that the Aesculapian center has moved from the Danube to the Spree. But this is what has happened in all ages. Minerva Medica has never had her chief temples in any one country for more than a gen- eration or two. For a long period at the Renais- sance she dwelt in northern Italy, and from all parts of the world men flocked to Padua and to Bologna. Then for some reason of her own she went to Holland, where she set up her chic." temple at Leyden with Boerhaave as her high priest. Uncertain for a time, she flitted here with Boerhaave 's pupils, van Swieten and de Haen, and could she have come to terms about a tem- ple, she doubtless would have stayed perma- nently in London, where she found in John Hunter a great high priest. In the first four dec- ades of the nineteenth century she lived in France, where she built a glorious temple to which all flocked. Why she left Paris, who can say? but suddenly she appeared here, and Roki- tansky and Skoda rebuilt for her the temple of the new Vienna school, but she did not stay long. She had never settled in northern Germany, for AFTER THIRTY-FOUR YEARS 17 though she loves art and science she hates with a deadly hatred philosophy and all philosophical systems applied to her favorite study. Her stately Grecian shrines, her beautiful Alexandrian home, her noble Roman temples, were destroyed by philosophy. Not until she saw in Johannes Miiller and in Rudolph Virchow true and loyal disciples did slie move to Germany, where she stays in spite of the tempting offers from France, from Italy, from England and from Austria. In an interview most graciously granted to me, as a votary of long standing, she expressed herself very well satisfied with her present home, where she has much honor and is everywhere appreciated. I boldly suggested that it was per- haps time to think of crossing the Atlantic and setting up her temple in the new world for a gen- eration or two. I spoke of the many advantages, of the absence of tradition — here she visibly v/eak'^'-'^d, as she has suffered so much from this poii 1 ihe greater freedom, the enthusiasm, and tnen I spoke of missionary work. At these words she turned on me sharply and said: "That is not for me. We gods have but one motto — those that honor us we honor. Give me the tem- ples, give me the priests, give me t^e true wor- ship, the old Hippocratic service of the art and 18 VIENNA of the science of ministering to man, and I will come. By the eternal law under which we gods live I would have to come. I did not wish to leave Paris, where I was so happy and where I was sei-ved so faithfully by Bichat, by Laennec and by Louis" — and tears fillea her eyes and her voice trembled with emotion — "but where the worshippers are the most devoted, not, mark you, where they are the most numerous; where the clouds of incense rise highest, there must my chief temple be, and to it from all quarters will the faithful flock. As it was in Greece, in Alexandria, in Rome, in northern Italy, in France, so it is now in Germany, and so it may be in the new world I long to see." Doubtless she will come, but not till the present crude organi- zation of our medical clinics is changed, not until there is a fuller realization of internal medicine as a science as well as an art.