EIGHTEENTH CENTURY
EIGHTEENTH CENTURY
The air of the eighteenth century seemed to be surcharged with mental activity that permeated and stimulated many of the branches' of natural science beside medicine. Physics made enormous progress under the leadership of Newton, Franklin, Volta, Galvani and the Bernouilli family of mathematicians. Chemistry likewise, under such disciples as Stahl, Hoffmann, Priestly, Lavoissier, and Scheele made important scientific conquests. The great botanist Linnaeus, the zoologist Buffon, and the inecmpaiable biologist Albrect von Haller were all of them eighteenth century workers.
Limiting our interests exclusively to the development of medical science during the years from 1700 to 1800 we note in the first place that the fundamental subject of descriptive gross anatomy in spite of claiming numerous enthusiastic disciples, was advanced only along lines of minor importance. The great anatomists of the sixteenth and seventeenth centuries had left comparatively few worlds to conquer. The Italian Antonio Valsalva (1666-1723) after whom the arterial and pulmonary sinuses were named; the Dane Jacob Winslow (1669-1723) after whom the entrance to the lesser peritoneal sac is named; the Dutchman PieterCamper (1722-1789) who described the superficial abdominal fascia; the Englishman James Douglas (1676-1742), who discovered the peritoneal pouch behind the rectum and enjoys the questionable honor of having his name associated for all time with the most highly infective portion of the intestinal tract; the German Bernard Aibinus (1697-1770) famous for his atlas of anatomic illustrations-ail these men lived and worked in the eighteenth century; their work was not epochal, but it kept the spirit of anatomy quickened.A second important fact is that in marked contrast with the comparative barrenness of the field of anatomy, the departments of physiology, pathology and histology were developed intensively for the first time in medical history. As a result of the efforts of Albreehf voa Haller in physiology, of Giovanni Morgagni in pathology and Francois Bicht in histology these three branches of medicine may be truthfully said to have been Firmly established. Haller was to physiology, Morgagni was to pathology and Bichat was to histology what Vesalius had been to anatomy.
A third important fact was that despite the pace with which enlightenment was forging, full steam ahead, during this progressive eighteenth century, and despite the healthful realism of Voltaire and Rousseau and the sound philosophy of Locke, Berkly, and Kant, the inevitable philosophic distortions occured, and there crept into practical medicine the most subversive doctrines parading under the names of animism, vitalism, or more complicated terms, to explain the ultimate source of life and health.
And finally, the most important fact of all was that during the eighteenth century, practical medicine assumed a more dominating role than she had taken at any other time in history, except when some particularly outstanding practitiener furnished colour to his age, such, for example as Hippocrates, Galen, pracelsus, or Sydenham. In the eighteenth century the clinic came into its own.
In general then, the outstanding characteristic of the eighteenth century are the demonstrating of the fullness of gross anatomy, the quickened spirit of practical medicine, the practical foundation of histology, pathology and physiology and the outcroping of speculative philosophy that invaded medicine under the guises of animism and vitalism.
The remarkable feature connected with the sudden development of practical medicine is that it was not confined within any definite geographic limits. England, Scotland, Germany, Austria, Italy, France, Holland, Switzerland and even young America developed men of such acuity of clinical judgement and observation that many of the great names of that day still shine. The start was made, if one may apply the word start to an almost imperceptible beginning, by the so called three great systematizers, Hoffmann, Stahl, and Boerhaave. In general, the purpose of these men was to develop a theory of medicine that would embrace all known facts. Hoffmann's idea was to follow the inductive method, clinging closely to rationalistic processes. Stahl's ideal lay in the direction of stressing natural philosophy as the guiding principle underlying medicine. Boerhaave stressed eclectism, picking here and there the best of theories and ideas, and attempting always to correlate them on the basis of how they fitted in with bed side observations.
Friedrich Hoffmann (1660-1742) was born in Halle and studied medicine in Jena. In 1694, he accepted the chair of medicine in the newly established University of Halle. Through his personality as teacher and his industry as a medical worker, he did much to establish the fame of the new medical school. He made an astounding number of contributions to literature, but his main work was the Medicine rationalis systematica. In this work he attempted to develop an universal theory of medicine to serve all the needs of actual practice, and at the same time to correlate theory, experiment, reason and experience. On the face of it, this sounds well. Unfortunately, however, Hoffman lost himself in the mazes of his own thought, and before he could recover his mental equilibrium he had concocted a theory resting on the supposition that health represented tonus. Tonus expressed the interacting contraction and dilation of the solid parts of the body, and these forces were regulated by a hypothetical agent which he called nerve fluid. It is unnecessary to say that not a vestige of Hoffmann's work remains today. His name is embalmed in Hoffman's drops; and his fame is limited to his abortive attempts to frame medical practice within one theory.
George Erast Stahl (1660-1734) fared even less well than did Hoffmann. He was a contemporary of Hoffmann, born in 1660 in Germany, more or less mystic by nature, worshipfully devout (Garrison calls him a stiff necked, bigoted pietists, of excellent character) with seemingly an inner urge toward an idealistic interpretation of natural law. He "taught that the human body, in the last analysis, was a mechanical contrivance animated by a divine soul. Indeed, he coined the word "anima" to express the regulating soul force, and his doctrine goes by the name of "animism". We can ill affofd to wave this Stahlian doctrine aside with one gesture, for we are still actively engaged in our own day with a discussion of the "vital principle" of Driesch or the elan vital of Bergson. That Stahl considered the doctrine of animism to have been handed to him through divine revelation well that is another story. But even so he was not totally an impractical star gazer, for he wrote a treatise on Plethora, that is an admirable exposition of the role and importance of congestion in disease.
The greatest of the three systematizers was Hermann Boerhaave (1668-1738). He was born in Holland, studied at the Dutch University of Leyden, where later, he was at the head of the department of medicine. He attained such univeral fame as consultant and practitioner, so the story goes, that during his life time, a letter addressed "The Greatest Physician in Europe" would be delivered to him. An analysis of his life's work and methods reveals that he was a passionate disciple of Hippocrates, labouring most assiduously to observe carefully and interpret correctly the tangible evidences of disease. The bedside was his bailiwick, and he was the first man to popularize bedside teaching. Like Hoffmann and Stahl his aspiration was to develop a blanket theory that would embrace all the principles of disease, and like them he fell short. He appears, however, to have possessed one great virtue that his two contemporaries lacked, he never mixed his theories with his practice.
Another virtue to be credited to Boerhaave was his instrumentality in establishing what is known as the old Vienna school of medicine. The qualifying adjective "old" is used, to distinguish this group of men from the more brilliant group who constituted the new Vienna school, just a century later. This old Vienna school was made up of Gerhard van Swieten (1700-1772), Anton de Haen (1704-1776), Joseph Leopold Auenbrugger (1722-1809), Anton Stoerck (1731-1803), Max Stoll (1742-1787), Anton von Plenciz (1705-1786), and Joseph von Plack (1732-1807). These men represent a joint attempt, we might almost call it a premeditated attempt, to establish the supremacy of clinical observation as the prime essential in mastering disease. With the exception of Auenbrugger none of them did anything epochal, arid yet all of them together gave to practical medicine a force that did much toward elevating the study and treatment of disease into the realm of science. The use of electrotherapy, popularization of the clinical thermometer, detailed observation on the effects of drugs, the accurate classification of diseases, the attempt to ferret out the cause of epidemic infections all these activities were accomplishments of the old Vienna school.
Auenbrugger (1722-1809) alone among them, was the father of a brilliant thought and is generally esteemed as the leading member of the old Vienna School. As physician to the hospital of the Holy Trinity in Vienna, he interested himself in the problem of percussion, nothing over a period of years, the relations existing between diseases of the chest and the issultant alterations in sound on tapping it. He carefully checked his conclusions in the autopsy chamber and then, in 1761, published his celebrated \nventum novum exjT, cussione thoracis humani ut signo obstrusos internipecto, « norbos detegendi. His method consisted in lightly striking the chest with the tips of the four fingers and noting the variations of pitch and tone as evidences of underlying disease. Auenbrugger discovered percussion. No more need be said regarding his claim on fame. He was not a propagandist however,
but just a sweet-tempered, home-loving man of science, who could write a poem or an opera, who we are especially told, loved his wife, who did not battle disputatiously for his new discovery and who did not seem to be unduly nettled by the fact that his colleagues were inclined to ridicule percussion or that it was never adopted as a practical bedside procedure until it was revived by Corvisart just a year before its discoverer's death.Auenbrugger and the other members of the old Vienna School represent the direct effect of Boerhaave's personality on practical medicine, for these men were primarily inspired by him. Boerhaave exercised a much more important influence on fundamental, or what, for the want of a better phrase, we shall call academic medicine. 'This influence, it is true, was more or less fortuitous, resting as it did on the decision of a young Swiss student to study at Leyden, where Boerhaave was teaching; and yet had Boerhaave's intellectual horizen been less broad or his personality less pervassive, the young Swiss, in all probability would not have been stimulated to accomplish all that with which history credits him.
The young student was Abrecht von Haller born in Bern 1708. He was an infant prodigy, who wrote Latin verse and interested himself in the Chaldaic language at the age of ten. At the age of nineteen he received his degree of doctor of medicine from the University of Leyden, after having studied previously for a short time at the University of Tuebingen.At Leyden, he came 1 chiefly under the influence of Boerhaave and Albinus. After graduation, he travelled to London and to Paris, where he studied anatomy under winslow, then to Basel where he studied mathematics intensively under the great physicist and mathematician Bernouilli, and then back home to Bern where he engaged in private practice, established a private course in anatomy, and busied himself most actively with researches in botany and physiology. At the age of thirty-eight he accepted a call to the newly established university at Goettingen, where he shone so brilliantly as teacher and investigator, that tropps of students attended his courses. After seven years of university activity, his health failed became so unconquerably homesick that he returned to Switzerland devoting himself to literary work until 1777 when he died of cancer of the stomach at the age of sixtynine.
Such was Haller's life. His accomplishments have always stood as one of the marvels of medicine. The breadth of his learning is almost incredible and his tireless energy and indefatigable industry can be credited with no less difficulty. Before his time there had never existed a complete treatise on physiology. From 1759 to 1766 he published his great work, Elementa physiologiae corporis humani, in eight quarto volumes, thus establishing modern physiology and earning for himself the lasting title of father of physiology. In addition to possessing a phenomenally encyclopedic type of mind, stored with masses of facts, he was a brilliant experimenter. His great hand book on physiology was preceded by numerous dissertations on various physiological topics, among them his now celebrated experimental studies of irritability and sensibility. These studies substituted for the old Hippocratic principles of "pneuma" for the "Archaeus" of Pracelsus, for the "vital spiriis" of Sylvius for thj "anima" of Stahl, for all these vague meaningless things these studies of Haller substituted the simple principle of irritability, a force now recognized as present and experimentally demonstrable in all living tissue.Francois Xavier Bichat (1771-1802) a Frenchman, the son of a French physician, studied at Nantes, Lyon and Montpellier, later going to Paris where he became a favorite pupil and assistant of the famous surgeon Desault. As early as his twenty-sixth year, he delivered lectures on surgery and gave private courses in anatomy. In 1802 he died of tuberculosis at the early age of thirty-two. Like so many other famous consumptives in history, he was a man of intense and feverish activity. It is said that during the course of one winter he performed seven hundred autopsies; and even though he died at thirty-two, he left behind him nine volumes of contributions to medical literature.
Bichat is regarded as the founder of modern histology Malpighi had already established the idea of the histological architecture of organs, but it was preserved for Bichat to teach that the body was made up of a variety of different tissues, such as cellular tissue, nervous tissue, vascular tissue, osseous tissue, cartilaginous, fibrous, lymphatic tissues and so on to the number of twenty-one. He called his new science of tissues General Anatomy as distinguished from descriptive anatomy, and he made his studies without the aid of the microscope . After working out the basic fact of separate tissues, he established the truth that everytissue has everywhere a similar disposition and its diseases must everywhere be the same. Whether serous tissue belongs to the heart to the lungs to the jointsor the abdominal viscera, it takes on inflammation everywhere in the same way; everywhere dropsies occur in the same way. His theory of fundamental tissues, he worked out to his volume Traite des embranes (1799-1800).Pathological anatomy also was established in the eighteenth century by Giovanni Battista Morgagini (1682-1771). The founder of histology. Bichat, was a Frenchman, whose work was ended by death in his thirty-second year; the founder of pathology Morgagni, was an Italian who compiled his great work when he was within hailing distance of eighty. He was a pupil of Valsalua, whom he succeeded as Professor of Anatomy at Padua. He was the first man to direct special attention to the gross anatomical changes induced by disease. Before his time notice, was taken only of rare and unusual pathological findings, such as visceral stones, hydatid moles and cryptic ulcers. Morgagni, however, set about deliberately to gather from the literature everything bearing on pathology, to classify his own extensive experience in pathology and to collect pathological data verbally and by letter from a large number of other medical men, included among whom was his teacher Valsalva. In his book De sedibus et causis morborum per anatomen indigatis libri quinque, he classified and co-ordinated this material with the idea in mind of showing the differences between normal and diseased organs, and correlating postmortem findings with clinical diagnosis and interpretations. He arranged the book as letters, there being seventy letters in all, occupying five volumes. He permitted neither age nor blindness to dampen the ardor of his enthusiasm, which was rewarded finally in his seventy-ninth year, by the appearance of the book in this type. He was further rewarded by an additional ten years of life after the publications his epochal work.
The practical foundation of three important branches of medicine physiology, histology and pathology in one century, in a phenomenon the like of which we have not encountered up to now in our survey of history.We were examining a sample of the practical medicine of Boerhaave and the old Vienna school, when we interrupted the story to look into the accomplishments of the great quartet of laboratory workers Haller, Bichat, Morgagni and Wolff. We are now ready to complete our inquiry into the state of practical medicine during the eighteenth century.England in particular was the country where clinical medicine seemed to thrive most actively during this period. The two Hunter brothers, William (1718-1883) and John (1728-1793) have become fixtures in medical history. William made admirable contributions to anatomy, obstetrics and surgery and became the leading consultant and obstetrician in London. John Hunter, more famous than his brother, was a born truth seeker, who although he has few literary productions to his credit, nevertheless is regarded as the practical founder of surgical pathology, and one of the earliest workers in comparative physiology. His interest in venereal diseases in manifest in the phrase "Hunterian chancre" descriptive of the initial lesion of lues. There is delivered annually, in his honor in London an oration on some surgical topic. Percival Pott (1714-1788) is immortalized by the fracture of the tibia and the tuberculous disease of the spine named after him. John Radcliffe, Richard Mead, Adam Askew, William Pitcairn, and Mathew Baillie were five famous eighteenth century English practitioners.
One Englishman we must single out for more special mention Edward Jenner (1749-1823) whose introduction of preventive inoculation for small-pox furnished medicine with one of her greatest victories. Jenner was born in Gloucestershire and was a student and protege of John Hunter. He made the important observation that the Gloucestershire dairy maids who contracted cowpox seemed to be immune to small pox. He wrote to his master Hunter, telling him he thought that on this fact, could be based an attempt to secure acquired immunity to small pox on a large scale. Hunter replied with the famous bit of advice. "Do not think, try; be patient, be accurate". Jenner did try, he was accurate and he was patient, making observations from 1788 until May 14, 1796 when he performed his first vaccination on a boy, using pus from the arm of a dairy maid, infected with cowpox. About two months later, the boy was inoculated with small pox virus and proved to be immune. In 1798 Jenner published his celebrated "An Inquiry into the Causes and Effects of Variolae Vaccinae."Jenner, who for the greater part of his life was a typical English country gentleman, spent his later years in London. Parliament made him a grant of 20,000 pounds, with which to carry on his experiments, and after his death, London erected a monument to his memory.
During the eighteenth century France was better represented surgically than medically. Jean Louis Petit (1674-1750) invented the screw tourniquet, was the first to open the mastoid cells and improved the operation for hernia and the technique of amputation. Those who remember anatomy will recognize his name in connection with the tringle of Petit. Dominique Anel (1628-1725) and Pierre Brasdor (1721-1797) are like wise familiar names in connection with the operation of ligation for aneurysm. Pierre Desault (1744-1795) a prominent surgeon, was the teacher of Bichat and the founder of one of the most important French jounals the journal de chirugie. Francois Chopart (1743-1805) devised the midtarsal amputation of the foot which still carries his name. Alexis Littre (1678-1725) is well known through his description of hernia of Meckel's diverticulam. These men and several others of less prominence mads Paris the eighteenth century center of surgery.The outstanding 1 alian clinician of this time was Antonio Scarpa (1747-1832) a Venetian who shone both as anatomist and surgeon, who was a skilled orthopaedist, a contributor to opthalmology, a classicist and also a first rate illustrator on copper. The name has a familiar ring by its association with the triangle of the things which Scarpa described.
During the eighteenth century, clinical medicine in Germany began to manifest signs of that intellectual activity which later placed that country in the first rank of medical leadership Heinrich Wrisberg (1739-1808), Johann Zinn (1727-1759), Johann Meckel (1724-1774), Johann Lieberkuehn (1711-1765), Samuel von Soemmring (1755-1830), Lorenz Heister (1683-1758) and August Richter (1742-1812) were men each of whom had made valuable contributions to medical science, The advance of Germany toward leadership is interesting as a manifestation of the shifts that occur in history.
America also, during the eighteenth century, began to show signs of an advance that may be characterized as the first steps towards dominancy in the field of scientific medicine. During the seventeenth century, the young crown colonies enjoyed only the most primitive medical facilities and put forth no academic effects. This state of affairs changed markedly during the eighteenth century. Dr. Zabdiel Boylston of Boston very early in the century (1721) inoculated his own son and two of his servants against small pox using the natural virus, as it was at that time used in Turkey. The inoculations proved successful and were followed by many others, but Dr. Boylston called down upon himself a torrent of professional and public abuse that almost cost him his life. Young sixteen-year old Benjamin Franklin editorialized against the procedure and there was a general mental ferment that furnished us the most certain evidence of the medical awakening of America.
It was not until after the revolution, however, that American medicine began to take form. John Morgan (1735-1789) and William Shippen, Jr., (1736-1808) army surgeons with Washington, and Beniamin Rush (1745-1813) were the three men responsible for the lusty start of medicine in America. Morgan had been well trained abroad under William Hunter, the Monros and Cullen at Edinburgh. On his return home, he published a discourse on the necessity of medical schools in America and with Shippen he became the founder of the Medical Department of the University of Pennsylvania in 1765, and was the first occupant of the chair of practice of medicine. He was Director General and Physician in Chief to the American forces until he was ousted as a result of political intrigue and cabals against him.
William Shippen, Jr. like Morgan, also trained abroad at Edinburgh, held the chair of anatomy and surgery in the University of Pennsylvania medical department, which with Morgan, he founded, and was Morgan's successor as Surgeon General in 1777. Benjamin Rush (1745-1813) is the outstanding name in early American medicine. A graduate of Princeton in 1760 he secured his medical degree in Edinburgh in 1768. He succeeded Morgan as Professor of practice in the University of Pennsylvania. Rush was a man of striking personality, a vivacious impressive teacher, stubborn to the point of obstructiveness at times, as signer of the Declaration of Independence and no less militant as physician than he was a patriot. He constantly held in his hand a brief for practical medicine as opposed to medical science and theory; he has been called the American Sydenham, and yet despite this, he was an active theorist of not always the most rational type. He furnished a careful description of cholera infantum and of yellow fever, was among the very first to describe dengue, and wrote the first, and up to 1883, the only systematic treatise on insanity. He wrote actively against alcohol and for the extraction of decayed teeth as measure for the cure of certain disease. Ethnology and anthropology, hygiene and sanitation interested him and called forth essays from his pen. For fetched and aimost funny as the phrase sounds, it is pleasing to think of Rush as some of his contemporaries called him, the Hippocrates of Pennsylvania.
Besides Morgan, Shippen and Rush, there were no outstanding men in American medicine during the eighteenth century, but the spirit of medicine was very active and there were physicians a plenty with zeal, scientific aspiration and commendably wide clinical horizons. There were, before the close of the eighteenth century, five worthy medical schools in America University of Pennsylvania, Kings College in New Yourk, Harvard University, College r»f Philadelphia and Dartmouth College. Medical Societies were acti\ • in New York, Philadelphia, Boston and New Haven country, S.ate Societies were active in New Jersey, Massachusetts, South Carolina, Delaware, new Hampshire, Connecticut and Maryland. Medical journals were published in New York, Philadelphia, and Boston and medical libraries were established in the Pennsylvania Hospital, the New York Hospital and the College of Physicians of Philadelphia.
The eighteenth century is a century of clarification, in which art and science assumed more and more dominating positions; humanitarian idealism and general enlightenment manifested not only in medicine but also in the cognate sciences, in politics, and in philosophy; medically this is an era of theories and systems which inspired the succeeding centuries into correct action and marvellous accomplishments. The contemporary opinions, with which this chapter ends, will give a cross section picture of the then medical practitioners."A physician is one who pours drugs of which he knows little into a body of which he knows less" Voltaire."A doctor is a man who writes prescriptions till the patient either dies or is cured by nature" John Taylor."Whatever is good in medicine is to be found not in palaces but more often in the small unhealthy dwelling of the poor. To the praise of doctors be it said that no other citizens fulfill these splendid duties with so much zeal and courage. "American medicine has commenced its great mission.