Lecture held by Dr József Dohnál, County Chief Physician, on the occassion of Jósa-Celebration organized by the Medical Association of Szabolcs County, on the 21st December 1922
In 1919, the Szabolcs County branch of the National Medical Association decided that each year would organize a conference in the memory of Jósa András with a similar purpose to the conferences organized in Budapest to commemorate Markusovszky and Balassa. On this occassion I have the honorable task of opening the series of these lectures. This opportunity, however, came quite late. Four years have passed since Jósa’s death. It is also true, that this time lag was needed to some extent because, although, the lectures do not have to be related to the person of András Jósa, this time, I want to share something about his medical activity. Time was needed to achieve a certain perspective in which to set the subject of my lecture in order to see that outstanding man and doctor from a certain distance focusing on the whole impression rather than on details, like in case of an artistic painting. What I mean is that we have to divert our attention from the little details in order to enjoy the beauty of the overall impression.
The task I undertook is delicate because of the kinship that has bound me to the late Jósa. I can hardly believe that I can avoid the accusation of love-fuelled bias. The fact that I am still standing here to give a lecture on a subject so sensitive to me, can be justified by the fact that during the many years of our confidential contact, I saw and heard a lot from him that is important to appreciate his medical and human excellence and can be instructive for us, doctors.
András Jósa was not known in reality. In general, he was everyone's „Uncle Andris”, a genius optimist, a scientist who shared and evoked serenity around him, a doctor, and a bohemian. Yet he was not only Uncle Andris, but András Jósa, full of love for humanity, a patriot who was committed to the advancement of the society, a tiredless and enthusiastic worker, a devoted doctor, a far-sighted pioneer developing public health and culture. He despised pettiness. He underestimated formalities and appearance. For him real values and simplicity meant lot. He didn't look left or right, he was sraightforward and honest without rudeness. He was modest and selfless to the extreems. He worked without expecting rewards. Work, which was fuelled with the restless energy of his temperament provided his philosophy of life, which was symbolically embodied in carrying a market bag. In this bag, mocked by many people, do I see the symbolic image of his individuality, the culmination of his wisdom. It is the image of a truly humane and serene sage who despised vanity and never posed. A man, who himself carried home antiquities in a market bag to draw them, despite the fact that he was of high social rank, showed a man with great experience and wisdom that lifted him above conventions.
In addition to these excellences that form the value of his general human image, he also had, of course, flaws that resulted from his bohemian character and were almost associated with the peculiarities of his individuality. Merging into the values just mentioned, they contributed to the image of a harmonious, not at all average character. But I do not want to deal with the attractive personality of doctor András Jósa, in general. A picture of this simple, yet great man, would not fit into the frame of a lecture. I will return to my original task and share with you one or two ideas about András Jósa, the nationally renowned doctor.
I.
In 1852 he enrolled the University of Vienna to study law. However, he realized that he is not interested in institutions and laws. After 2 semesters, he continued and completed his studies in the academy in Magyaróvár. Then he was farming in Szántó, Bihar County, on his father's estate. From his paternal ancestors he inherited an interest for sciences. His grandfather, István Jósa was also a medical doctor, a judge of Békés and Szabolcs County, a nationally renowned physician. He was the chief physician of Békés County for 10 years and of Szabolcs County for 40 years. This inheritance defined András Jósa’s destiny. He also gave up farming and in 1860 he enrolled the medical faculty in Vienna. He followed his interest and turned to natural sciences, replacing the life of a rural gentleman with the life of a student in the capital, experiencing the poetry and the bohemia of student life, including fasting as part of it. He diligently studied the tremendous material that medical studies had involved even in those days.
The age in which he studied witnessed a real revolution in natural sciences and along with it in medical science.
Robert Schwan had already discovered the cells that make up all living organisms, and with this theory Virchov overturned the centuries-old hypocratic humoral pathology which was replaced by cellural pathology. In natural sciences the speculative research method was replaced by empiricism and induction.
Enormous work began and with it an almost dazzling progress in which Jósa’s professors in Vienna were all involved: Hyrtl, the anatomist, Brücke, the physiologist, Rokitanszky, the pathologist, Skoda and Oppolczer, the internists, Schuh, the surgeon, were all world-famous doctors. The Vienna school of medicine played a leading role then in medical science. In this spirit and environment was András Jósa developing and educating himself as a doctor, acquiring the scientific thinking of natural scientist, which later guided all his actions, and finally lead him to the field of archeological research. As an archaeologist he was looking for the traces of man where written history was no longer available in order to learn about past cultures and customs from finds. This research truly required the mentality of a natural scientist.
András Jósa moved to Nagykálló in 1864 as a medicinae doctor, where the great Frigyes Korányi had worked until then and who was just about to move to Budapest to occupy his university department. András Jósa became his worthy successor. In 1865 Jósa went to Vienna again for a few weeks to obtain his doctorate in surgery. His surgical success, which had a major impact on his first and later reputation, was grounded by the successful operation of Emánuel Kállay, an important personality of the Kállay family. In a patient who was most at risk of death due to excluded hernia and omentum, under conditions when antisepsis and assepsis were still unknown, he performed a neurotomy with the excision of the omentum. He hid into his pocket the two pieces of omentum, each the size of a fist, and took them out from the room unnoticed by the family members of the sick man. The patient recovered. He did not receive the big money that is due for such an operation today, but the news of the successul opertaion spread and founded his fame and his later practice.
For years, except for the days when he had his surgery hours, he roamed the countryside day and night by cart, by train, in rainy and windy weather, in snow and mud, along these duties, he operated in the hospital, and treated millions of patients, as he would say. In surgery days crowds camped around his house in carriages and wagons, as if there were a national fair in the town. Such was his life: a kind of life which only people with exceptional nerves could endure, and those who had a special enthusiasm for their work and consider healing „medical art”. It can indeed be said, that he pursued the medical art in the spirit of "l'ârt pour l'ârt." With almost incredible naivety and modesty, he could not profit from his hard, even superhuman work. He remained a poor man until his death. In his serious illness before his death, he still had to consult patients for his livelihood. Average people paid as much as they liked, and usually they preferred to pay "little". The nobility paid with a few good words, or if they were really very grateful for the medical help, the doctor was honored with a barrel of wine, often bad-quality wine. Sometimes half of the barrel was marc, which I can testify as I saw it with my own eyes.
The Jews, on the other hand, paid well. When Jósa turned up at places where the Jews lived in larger numbers, like in Máramarossziget, Munkács, Beregszász, etc. masses of patients literally sieged the doctor when they learnt that he was staying in their town for some professional duty. Occasionally, when he was dead-tired of work, he had to leave throught the window of the surgery in order to escape from the "millions" of patients. He once said to one of his gentlemen friends that "If I did not heal Jews, I could starve if it was up to you."
He really considered the medical fee just a tribute, he could never share the wealth of his ancient Roman predecessor, doctor Galenus. However he enjoyed all the more the moral good of the medical profession, not the "honores" to which the proverb "dat Gulenius opes atque honores" refers. Not much of the latter did he receive. But he did receive the grateful look of the wet-shining eyes of the patient who escaped from mortal trouble and the smile reflecting the awakening hope, the tears of joy of the parent, the child and spouse. He enjoyed the reward of the happy consciousness that only a doctor could feel when he saved a human life with his art of healing. This compensated him for all the meannes of his fellow men who could not provide him material security. Most artists who are faithful to their individual art remain poor. Dr. András Jósa was an artist, not only in this sense, but also in his medical practice.
Each of his diagnoses was a masterpiece of innate intuition, lightning-fast association of ideas, logical inference, and judgement with an amazing sense. With these, he also amazed the famous doctors of the capital. Back then, when there was little other exact method available to the doctor to recognize the medical diagnosis than the external examination, palpation, ascultation, percussion, and urine examination, it required talent, artistic intuition and great spiritual strength to recognize the disease. Much more talent was implied than it is today, when the advances in microscopy, blood testing, serology, bacteriology, the developing testing and laboratory techniques make it easier to determine the nature of the disease. The susceptibility and percussion of today’s medical generation, while still very important, on average, is not at the same level as that of the students of Skoda and his contemporaries. András Jósa was outstanding even among them. He was a real virtuoso in „knocking”. By the harder or softer touch of his fingers on the patient’s body, just like a pianist with the "Anschlag", he brought out a whole range of tones with the varying degrees of pressure of his finger. He also felt the resistance by only feeling the body with his fingers cutting off his hearing. Among other excellences of his, he owed much of his success and medical reputation to this virtuosity.
He was not a „miracle doctor” – as he was rumoured by ordinary, people. He was not without self criticism, but he was an inborn genius who had an artistic talent in setting up diagnoses. He achieved his excellent medical position without any freaking and posing. He solved the most difficult medical problems so simply, without any arrogance. The natural consequence of this was that the patient was never frightened because the doctor never magnified his trouble. His innate love for his fellow human beings would never allow this. Moreover, being optimistic, he often hid the seriousness of the disease and communicated more favorable news to the patient or his family than what was expected by the harsh theorems of the science. But he did so only where he did no harm. He adhered strictly to the "primum non nocere" („Firstly, do not harm”) rule.
It would be incomplete to characterize András Jósa as a doctor if I we did not mention in a few words his attitude towards his colleagues. Despite his high medical standards, he was never self-consciously proud or arrogant, this was ruled out by his individuality. He approached all his doctor colleagues with the greatest goodwill and nobility. He appreciated the hard work of all doctors that implied fatigue, self-denial, and suffering. He was not envious, jealous as he did not seek either rank or profit. As a consiliarius doctor, a doctor of great authority invited to consult with other doctors over a complicated case, he always behaved in a most correct manner. He examined the patient only in the presence of his own doctor. He did not compete with anyone because he was beyond competition.
From what I have said so far, I have striven to draw an image of this great doctor limited by a narrow framework. But, since this image would only be an approximate image of his medical individuality, I will continue to enlarge my presentation with a brief description of his activity in each field of the medical science.
Let us just see him as an internist.
With his excellent knowledge in pathology and pathological autopsy, he knew the course of the diseases and the changes caused by them in the human organism to the extent of the current state of medical science. Contributing to this was his already mentioned virtuosity in knocking and ascultation, as well as his all-encompassing and wide-ranging apperception, with the help of which he often identified the disease at a witchy speed. If the results of his observation and examination had to be summarized and applied to a specific case in order to make the correct diagnosis, his unusually acute but individual intuition, his astonishing speed, his exceptionally fast-paced association lead him to a diagnoses well ahead of his colleagues, who had hardly started to figure out the correlations when Jósa was already ready with his diagnosis, which, in most cases, was correct.
Talking about diagnosis, let me turn here to the remark made more than once by some of his fellow contemporaries who would often say that "Well, of course, for the good old Jósa everything is malaria and syphilis." In that regard, I have to note that this criticism came primarily from persons who were not entirely competent to criticize him, and had a way less experience in the diseases in question. Jósa had been successful in treating those diseases for which even the greatest authorities of the profession admired him. His critics were far from such kind of professional achievement.
On the other hand, the criticism is also unfair because dr András Jósa diagnosed heart problems, incipient tuberculosis, stomach cancer, etc. correctly even when these escaped the attention of his critics and others. So not "everything was malaria or siphilis for the old man." Moreover, he recognized these cases correctly even when renowned doctors in the capital failed to do so. This was one of the reasons for his large number and surprisingly successful cures. After all, doctors know best, that in the case of the two afore mentioned diseases - if, of course, they are detected in time and treated adequately - the doctor can achieve wonderful successes. Imagine the swamps of the Bodrog and Rétköz regions, the lakes of Nyírség, the reeds covering many thousands of acre, the water of the Ecsedi and Sárrét bogs which all explain the many occurences of malaria cases in the region. Thus András Jósa did not have to to be a magician, he only had the talent to recognize the disease where it was not recognized by others.
It was the war that brought malaria into the country, providing the opportunity to observe the then already rare disease. The results of these observations brightly confirmed dr András Jósa's statements with regard to this disease. Let us just listen to what a contemporary doctor declares regarding malaria. After having the opportunity to observe a large number of malaria patients who developed this disease during the war. Dr. Lajos Lévy writes in his work entitled “Malaria in War Time" the following remark: "We have to consider malaria at the bed of every patient with high fever”.
At the University Hospital in Boston, three cases were found in one week which were operated on because of the severe pain in the appendix accompanied with high fever, and all three cases were healed with chinin.
Lajos Lévy wrote about a similar case: "fortunately we did not operate the patient, the blood showed a tertiary infection."
Jancsó mentioned that pneumonia and malaria produced similar sympoms. Cabot also wrote that "Malaria can start with a sharp pain in the chest very similar to the pneumonia."
In his work mentioned above, Lajos Lévy wrote the following: "We are currently noticing cases where all the symptoms of meningitis are caused by malaria."
"One of my assistants presents a patient with symptoms of dementia parulytica, in whom the blood test revealed malaria tropicat; after the adequate treatment, the normal mental function was restored."
Chronic cases of disordered fevers are mentioned that have been hospitalized as pulmonary tuberculosis and apical pneumonia.
Jancsó mentiond diarrhea similar to dysentery, and Ödön Bíró described symptoms of cholera.
István Rusznyák wrote: "Symptoms of neuralgics in seizure-free period may produce symptoms that can be misleading in the form of typical trigeminal neuralgia, humbago, ischias, etc. which were all cured with chinin."
Finally, he comes to the conclusion, in which he is absolutely right, that “old doctors applied chinin more often, for seemingly non-malarial cases. We can also be in a situation to resort to this ex juvantibus diagnosis because it will often be difficult to rule out malaria. "
Because," according to Jancsó, "there are often cases of malaria in which both blood dye and plasmodium are missing from the blood." As if only I heared dr András Jósa when he mentioned the many forms of malaria to me listing cases of malaria showing symptoms of stroke (apoplexy), dementia, dermatitis, nephritis, etc.
The quotations above brightly confirmed him.
Seeing his own success, it is not a wonder that he always thought of the easily curable malaria.
Thus he cured what it seemed cachexia, kidney-disease, kidney inflammation and liver cancer, or tuberculosis, more over, he cured people with the symptoms of dementia or insanity that is, the most serious cases, not because he had supernatural qualities, but because he knew malaria can occur in unexpected instances when other doctors would not have thought of it.
I could talk about this topic for long, but being short of time, I turn to syphilis, the second disease that was already mocked at by Jósa’s colleagues, saying that the old chap was always thinking of either malaria or syphilis.
I heard from Jósa that in the Eastern part of the county, as well as in Szatmár and Bereg regions in the late 1860s and early 1870s, syphilis could be considered an epidemic. Thus, among other settlements, in the village of Panyola Nabrád, Szamosszeg, even infant generations became infected as a result of vaccination from arm to arm. In Szatmár, in Szinyérváralja, there was a separate hospital for patients infected by lues.
The health statistics of the army, even in the early 1990s, mention the towns of Szatmár County where the highest number of syphilis infections among soldiers occured among the garrison of the monarchy. This disease was therefore very widespread in this region. Even in the early nineties I myself had the opportunity to see severe lues cases in dr Jósa’s surgery, especially chronic tertiary cases, that I did not have the opportunity to see at the clinic or in the department of the sexual diseases of the military hospital. András Jósa had amazingly sharp eyes in recognizing this disease. The Schaudin's spirochet and Wassermann test had not yet been known, and despite the fact that these methods, which greatly help the diagnosis today, were not available, he identified the luest very many times when others had not even thought of it. Therefore, he had achieved amazing success in its treatment.
He cured bone and skin problems believed to be cancer, spinal cord syphilis, considered atrophy of muscles (atrophia musc progressia), and many other diseases, especially neurological problems that neurologists also considered incurable.
Mercury and Jodkali were efficient tools in his hands, and in case he used them, he used them in significant quantities. He also applied 20 lubrication cures, and most of all, he was able to judge amazingly whom to treat with this method.
I heard from him cases of syphilis in which the patient was half-blind or lame or had liver cirroshis and still recovered.
After that, no wonder that he constantly thought of malaria and syphilis. Yet he was not a disciple of professor Jendrassik, who would always say, "think of the syphillis in the morning, think of the syphillis at noon and in the evening, wake up with it and go to bed with it."
His successes did not make him arrogant, he was very inventive and never adhered to preformulated sets of ideas. He had very flexible thinking. He always interrogated the patient meticulously, examined him carefully, and only after he could rule out all other illnesses did he stated the diagnosis.
When listing his medical activity, his activity as a surgeon should also be presented.
As hospital director, he was the leader of the surgery department. This period (1864-1884) is the most prolific period of his medical ativity. His most often performed operation was the operation of displaced hernias, folwed by amputations, resections, lymphoma exterminations. But he also extirped tongues and even uterus. These are surgeries that can only be performed by a self-confident surgeon. He performed these operations successfully, although, then, due to the lack of antisepsis and assepsis, many operated patients died of accessory wound diseases.
He also excelled in ophthalmology. He was excellently familar with the eye disease caused by syphilis and malaria. He had successfully cured many optic ailments by skillfully handling the ophtalmoscope. Mercury, iodine and quinine then exerted their effects and thus the weakened or lost eyesight of many patients were restored. His ophthalmic operative work is also extensive and rich in success. He was a particularly distinguished operator of cataract. He perfprmed these, according to the methods of the time, without fixing the eyeball and without anesthesia, which required a great deal of dexterity, compared to which the present-day method of operation seems extremely easy.
He practiced these surgeries on a phantom in which the inserted pig’s eye which moved easily in all directions. Thus he gained such dexterity that there were days when he performed 5-7 cataract surgeries.
Before I continue to present dr Jósa’s activity as a county chief physician, I have to mention two of his features that are characteristic of his individuality as a doctor.
An important characteristic of him was his healing method. He was a true proponent of that ancient medical rule according to which "principiis obsta sero medicina paratur,” that is, in his healing procedure he tried to eliminate the cause, considering the causal procedure to be superior to all therapies. With the large number of patients suffering from malaria and lues he had ample opportunities to practice this principle. And so he did. This method also simplified his theraphy. He did not practice polypragmasia. He usually prescribed only one type of drug. His treatment with high-dose quinine has been confirmed by the newest treatments in malaria cases.
I cannot fail to mention here that he successfully cured Tenia ecchinococcus - the bladderworm - without surgery by using fern extract. (Exti filicis maris). With small doses given for weeks, he managed to regenerate the enlarged bladder. Nowadays, the same practice is becoming popular. With regard to this method, however, the priority belongs to him. And his success proved the correctness of his treatment.
In his time, some symptomatic diagnoses were commonly accepted, such as anemia, gastritis, dysentery, etc. He was not satisfied with these, and, in accordance with modern pathological considerations, sought the cause of the disease. This sounds natural today, but back in those days such thinking was not common among physicians. He was well ahead of his time in his thinking and actions.
The proverb says that a good priest studies until his death. A good doctor should do the same. Because he who does not improve himself will fall back. Then, when András Jósa left the university and embarked his career, the medical science was in full progress. Pasteur, Semmelweis and Lister made important changes, antisepsis appeared in surgery, and linked to this this, the incessant work of Robert Koch founded bacterology and then serology. At this time he visited Koch and then visited Graefe to acquire his method in eye surgery, when he learnt the news about tuberculin, he went to Berlin again. It was amazing how quickly he integrated the new medical results into his knowledge and practice, as if these were his own findings. Until his very old age he was interested in everything new, and if he did not manage to read about the new discoveries, he asked others to report him about the progress in medicine.
Having summarized his activity as a doctor, I would like to continue with the brief presentation of his activity as the chief physician of the hospital.
In 1864, when András Jósa moved to Nagykálló, a hospital did not exist either in the then huge area of Szabolcs County, which included Egyek, Csege, Nádurvar, Püspökladány, or in the western parts of Szatmár, Hajdu and Bihar either. But the patients were numerous because of the malaria caused by the large inland waters, and also because of the syphilis which was equally widespread. The former appeared as endemic, the latter as epidemic. So in 1868 the public of the county asked the government to organize six medical practices because of the high number of cases of French disease. (Act No. 570 of 1868). It can be imagined, that, with such a large number of patients and without any hospital and very few physicians, how poor the treatment of the patients must have been. Most of the cases were treated by leeches and charlatans.
In the church register of the evangelical reformed church of Nagykálló there are inscriptions according to which that there was a "hospital" in Nagykálló at the end of the 18th century. It must have been a leprosorium, for leprosy, identical to the later lazarethum, which, however, in the 1860s was only mentioned as a county fund.
Between 1863 and 64 there was an emergency hospital in which dr Frigyes Korányi practised as a doctor and which was financed by the county.
In February 1863, Frigyes Korányi issued an enthusiastic appeal to the public of the county, pointing out the existing sad health conditions, calling on the public to form a "hospital association" with the aim of establishing a proper public hospital. This association, although its statute was ratified by the governors' council only in 1865, was established in 1864. From the contributions of its members, from the foundations collected from so called hospital bed contributions and collections, dr. Frigyes Korányi was able to furnish the eight-bed hospital of the Szabolcs County Hospital Association, which started its operation.
At the end of the year, instead of Frigyes Korányi, who moved to Budapest, András Jósa took over the management of the hospital, for the time being as a deputy director, and in 1865 as the director elected by the association. He did not draw his salary for eight years, he provided the hospital physician Ferenc Técsy with housing and food free of charge, only to strengthen the hospital financially and thus to promote its development.
The first county ball held in 1867 was organized in order to raise fund for the hospital. This, together with the later balls organized by András Jósa, resulted in raising enough money to keep up the hospital, albeit in a modest way.
In 1869, the county citizens asked the government to increase the number of beds of the association hospital to 22. This request was not met by the government due to lack of funds. Instead, it was recommended that the county’s public should seek ways to raise money through charity events, donation, and the imposition of an additional tax. The former ways of raising money, as presented before, had been practiced in the past as well, but the burden of extra tax was not accepted.
Finally, after 8 years of struggle, in 1873, the association hospital gained the character of a county hospital. It was then when dr. András Jósa, was invited to the position of chief physician of the hospital and dr. Gyula Lőrincz as a deputy doctor.
During the successful activity of Dr. András Jósa, the people's reluctance from hospital treatment decreased. The number of beds had to be increased year by year. All beds were permanently occupied. Vacancies were scarce. The relatives of the patients did not allow to be refused, leaving their seriously ill family members in the courtyard of the hospital. The initial 8 beds increased to 30 by 1873 and then to 50 by 1884, and when dr András Jósa became the county chief physician and moved to Nyíregyháza, the number of beds was 84.
His successor became dr. Rudolf Kállay, and thanks to their joint efforts they managed to achieve the construction of today's Elizabeth Hospital in the memory of the millennium, which was then a high-quality, 250-bed medical institution. Unfortunately, this hospital proved too small again, its expansion was needed, especially with a department of pediatrics and a department of sexual diseases for both of which there was a great demand.
The foundation of the Public County Hospital of Kisvárda, serving the population living in the east and the north-east part of the county, was also possible due to the enthusiastic and blessed activity of dr András Jósa and the late dr György Küzmös, the district doctor of Kisvárda region. This hospital was initiated by the late dr György Küzmös, a district doctor from Kisvárda. At his encouragement, the Kisvárda public estate established the "Kisvárda public estate hospital" - which was initially private. In 1893, it was taken over by the County of Szabolcs and it was expanded to 30 beds at the same time receiving from the government the rank of public hospital.
As we are talking about medical institutions, I cannot leave unmentioned that to locate the state mental hospital in Nagykálló was also carried out by András Jósa.
With this, he achieved that the town of Nagykálló, which had been declining since the capital of the county was relocated to Nyíregyháza, gained a thriving institute which definitely boosted the town. The majestic, abandoned headquarters of the county council building was bought up by the state for the purpose of housing the hospital and thus giving the building a function and saving it from complete decay.
III.
Until the end of 1883 he worked as a hospital director in Nagykálló. From January 1, 1884, at the unanimous invitation of the Szabolcs County representatives, he took over the office of the county chief medical officer. As he declared about himself, he "degraded himself" to the county chief physician. He considered practical medicine, that is to alleviate the pain and to cure the sick his outmost important task to such an extent, that he considered the office work degrading, however, ultimately both served the same goal, and in his both positions he carried out an outstanding activity.
As he declared, he had to create the health care administration of Szabolcs-Szeged County practically from nothing. Yet he did not even know where to start because the statistics based on which measures had to be taken in health were not available. Statistics shows public health problems with the number of illnesses and deaths reported by place and time. It shows what measures to take and where. As a result, he severely demanded the reporting of diseases and, in order to obtain information about the causes of death, organized the coroner’s system. We are still following in his footsteps in this respect today, although now the national statistical office is processing health data, however we still use his documentation.
As a result, we get the information we need months before the national statistical office issues data. What an advantage this means for the public health, where rapid intervention is needed, I find it unnecessary to explain in details.
What I have said above is a statement of his result, without mentioning how much prejudice and indifference he had to overcome until he got to the point where the expediency of his proposed measures was realized.
One of his outstanding results was to enforce a ban on vaccination from arm to arm. I have already mentioned that syphilis was an epidemic at that same time in Szabolcs County.
Inherited syphilis was not uncommon among infants. Since there was no Wasserman blood test at that time, it could very easily happen, without the doctor's fault, that a child who had syphilis was used as strain vaccine, and thus syphilis had been vaccinated in other infants. This way, the youngest generation of an entire village could be infected with syphilis. He communicated these facts to his superiors, but found opposition, claiming that the new measures were hindered by lack of finance. Authorities suggested that he should eliminate those doctors who select a child with syphilis as a strain vaccine without realizing that the doctor’s eyes are not micorscopes, and the latent (latene) syphilis was impossible to detect without a blood test.
Nevertheless, he managed to implement the smallpox vaccination with the vaccine of the cow.
In his talk at the Millennium Medical and Health Congress in Budapest in 1896, which also appeared in print, he wrote the following about bladder pox: "There are three reasons for the fact that bladder pox has not yet been erased from the face of the earth.
I. that the duration of immunity is not the same for all individuals,
II. the possibility of transmitting diseases by arm-to-arm vaccination,
III. the fact that many individuals who are listed as successfully vaccinated, even though they have been vaccinated, this did not appear in their eyes and thus success could not be established, which led to errors in the reports. "
Based on his experiences, he urged the re-vaccination of the children aged 6 and 20, and the ban on vaccination from arm to arm, forcing vaccination of the general population in the event of smallpox.
Due to his efforts, from 1896 to 1915, no bladder pox occurred in Szabolcs County similarly to the cultivated western countries.
With the vaccination applied relentlessly and rigorously the the spread of bladder pox, a terrible disease during World War, was hindered from becoming a panemic.
In the past, in addition to malaria, syphilis, and tuberculosis, typhoid and Asian cholera took a huge human toll.
Of the latter two diseases, the spread of typhoid has been observed to be usually associated with low groundwater levels resulting in the impurity of drinking water, which caused the increase in morbidity. In addition to this in 1863-66 and 1869-73 the Asian cholera epidemics, especially the one in 1893, spread in the villages along the river Tisza. The disease occurred in 36 villages, of which 33 were from along the river Tisza, and even in the three villages not belonging to the Tisza region, the infection was brought from the settlements on the bank of the river. It was also proved that the origin of the first occurences could be explained by the fact that people drank the water of the river Tisza. Further observations had also attested that the origin and spread of typhoid fever could, in many cases, be also explained by similar cause.
These observations and experiences lead dr Jósa to one of his most important measures in his capacity of the county's chief medical phisician, namely making the drilling of the deep wells compulsory. This step was very important in successfully improving public health in the region.
His lobby activity and the Asian cholera epidemic of 1893, persuaded the legislature body of Szabolcs County to issue a decree according to which every village is obliged to drill one well per one thousand inhabitants.
This rule, with the exception of a few villages, mainly along the river Tisza, was implemented by the settlements and its blessed results were felt right away.
In villages where a deep-drilled well was not established for some reason, there were still a higher number of cases of typhoid fever. A classic example in this respect was the village of Vaja, where epidemics broke out several times during the war because of the lack of a deep-bore well. The village wanted to save money, but the cost of combatting the epidemics would have been enough even for the construction of two drilled wells.
While before the spread of the deep wells, the number of deaths caused by typhoid fever was 150-200 per year, after the establishment of the wells it fluctuated between 60-80. If we calculate the number of patients based on 10% of this number, it turns out that nowadays, (the time when this speech was delivered) thanks to the existence of drilled wells 1000-1200 fewer people catch this disease which lastes for weeks causing severe suffering.
In addition, drilled wells also have an excellent positive impact on other epidemic diseases like cholera and disetry, against which the combat became more efficient.
I now turn to another great achievement of András Jósa, which had both social and health significance and aimed at reducing child mortality.
Szabolcs County was and still is in the first place among all counties in terms of the number of births. The number of births per year was 45% in the past and now (at the time when this talk was delivered) is 40%.
Where such a large number of children were born, child mortality ipse facto was very high.
He used to say that the county was "first eminent" among other counties in terms of birth rates, but lags far behind in terms of deaths.
In his annual report he always dealt with the mass mortality of the babies and pointed out the problem.
He was lookingfor for the causes of child mortality and soon realized that many of the serves of the tenants of the large estates do not have separate houses, but two families share one room: 10-16 people in an area of about 30 m². One child was being born in one corner and another was dying in the other. There is no need to describe here the consequences of such cohabitation from a moral and social point of view, it can easily be imagined. If a contagious disease occurred in such a place, children without proper immunity died.
And many other infants died as a result of bad air, uncleanness, and other adverse effects of mass housing.
He set a goal to eliminate this. And he managed to do so. At the cost of great struggles lasting for many years, later. Today there are no such houses in Szabolcs County. In his annual reports, starting from 1894 dr Jósa began the fight against such dwellings. In 1896, the legislature ordered by decree that each family should have a separate house. A rich landowner from the county influenced Kálmán Széll, the then Minister of the Interior Affairs, and in consequence this decree had not been approved. But, to the praise of the county administration, however, this humane measurement was implemented even in the absence of the minister’s approval. The multi-family one-room houses were abolished.
I wish I could say that the houses consisting of four dwelling sections with a shared entrance from a common patio have disappeared, but they still cause the death of many children.
Infant and child protection should have been started with the gradual elimination of these unhealthy houses.
In the late 80's and early nineties, a large number of children died of diphtheria in Szabolcs County. Child mortality was 1146 in 1892 and 1080 in 1903.
This high mortality rate meant a great problem for András Jósa. It was then that vaccination with Ronx and Behris antitoxic serum began to spread with encouraging results. To see clearly and to have adequate statistics with regard to this matter, he requested a report on all vaccinations against diphtheria.
From these dara, he made a report in 1895-96 showing that none of those vaccinated on the first day died, 8% of those vaccinated on the second day died, 19% of those vaccinated on the third day died, 23% vaccinated on the fourth day died, and 47% vaccinatedon the fifth day died. The average mortality rate for vaccinated infants was 13%, while the three-year average for those not vaccinated was of 48%. With establishing these facts and the consequences that can be drawn from them, his work can be considered groundbreaking in the country.
To suppress the diphtheria epidemics, he recommended that the serum be produced and made available to patients free of charge by the state, that preventive vaccinations be given to the patient's relatives, and that vaccination be given early, without delay, preferably on the first day. It is true that the state does not give serum for free even today, but despite this, vaccinations and preventive vaccinations have reduced mortality in diphtheria by 50 to 60 cases per year.
Although the state produces serum against diphtheria, but provides it for money, and the preventive measures are still not compulsory.
All measures involve money, but healthcare, which is meant to protect humanity’s most precious treasures: health and life, gets poor funding. Lack of finance usually hinders all health care reforms and progress, which is why the best proposals are laid in the desk drawer without any hope to be taken out again.
András Jósa felt the seriousness of the situation and was worried about it. In 1893, in an open session he told frankly to the then cholera government commissioner Miskolczy, who was looking for scapegoats in the county, that it was not possible to fight without means. To suppress an epidemic, you need money, money, money, just as for wars.
One of his very important proposals, which has not been implemented so far, and which was the outcome of his experience, was to make the fight against infectious diseases a task of the state which should bear the costs incurred. Today we have achieved that half of the cost is borne by the state and the other half by the local government.
Everyone who deals with public health, after many experiences and experiments gained, and often after struggling in vain, sooner or later comes to the conclusion that public health can only be improved along with raising cultural standards in general.
Unculturedness, ignorance and narrow-mindedness are the biggest obstacles in promoting healthcare and, of course, combatting epidemics.
It is almost shocking the devastation caused among humans and especially among children by ignorance, indolence and passive resistance. And this is also true for the higher social classes who consider themselves educated. I think superstitions and misconceptions related to human health that have existed for centuries are incomparably large and numerous, and their consequences are born by the patients and public health in general.
These caused that the precautionary measures against the spread of the disease were not implemented and strictly monitored in order to protect the individuals of the community.
András Jósa also had the opportunity to see and experience the consequences of this improvidence. This prompted him that from the sixth year in his position as a chief county physician in his annual reports he strongly demands that the people should receive the education in health and the rules of health protection should be taught with the utmost care in elementary schools. And in order to have trained staff able to teach health protection, the subject should be introduced in the curriculum of the teacher training colleges, theological institutes and secondary schools.
"We need to create the religion of health so that people should benefit from being familiar with the rules of hygiene” –he wrote in his lecture quoted above.
If the knowledge of the population, and the intelligentsia were such that they could self-consciously understand what is harmful to the health of both the individual and the public, then not only the protection against epidemics, but also child protection and the issue of alcoholism would be solved.
Unfortunately, we are still far from that. Although some health science is already taught, András Jósa imagined health education in a different way.
Public health conditions are at the same level as literacy. However, while the number of illiterates in the country is 30% of the population, we cannot hope for advanced public health. Radical measures can lead to success, as we saw during the war, but these were exceptional times.
Yet in the case of serious danger, we must resort to radical measures again.
I believe that from the activity of András Jósa, County Chief Physician, I mentioned all those aspects that show the excellence of his initiatives and his far-reaching and organizing abilities.
Until the age of 75 he worked as a medical civil servant for a period of 40 years, then, in 1906 he retired.
Neither during his active years, nor even in 1915 when he celebrated the 50th anniversary of his medical activity was he awarded any honour by the government. Probably not because he would not have deserved it, but certainly because he was a consistent rebel on whom authorities generally frown upon.
He was all the more appreciated on the 40th anniversary of his civil service by the public. The warm love, recognition, and respect of his county men was without precedence.
At the county assembly that discussed his retirement, so many of his admirers showed up, as if it were an election; at the banquet the hall was so crowded that it was barely possible to get a seat.
Doctor Jósa appreciated this spontaneous manifestation of love and honor more than anything else, because it was honest and came from the heart of the people. So he retired, but he never stopped working. His individuality could not exist without activity even at a very old age. He worked as long as he was able to. Until his death. If he got tired of medical work, he turned to turning, carpentry, planning how to improve or utilize this or that item. He worked even while he was having fun. To improve, to create, to bring prosperity was his element.
The fire of work burned in him, burned with flame, not flickering, all the way to the grave.
But alas, he also had to pass away. Many said then, that such a man should live forever. His immortality is ensured by his work. It is up to us to carry on what he has started, and to continue his legacy.
And this activity and energy was never needed more than it is today when our country is in ruins.
If our plundered country had many more citizens like Him, the ruins would soon be rebuilt, the broken tree, our country, would blossom again.
We hope that the time will come when András Jósa's dream of an independent, free, and great Hungary with a highly educated population will come true, an ideal to which he devoted all his life.
