Although the early decades of the nineteenth century were a virtual continuation of medical developments in the previous century, two particular advances (anesthesia and the discovery of microorganisms as causes of disease) so altered the course of medical history that concepts of illness, methods of treatment, and hygienic practices at the end of the century bore only slight resemblance to what they were at the beginning. Of course there were other highly significant contributions which advanced the understanding of the structure and function of the living organism, such as the demonstration of the cell as the fundamental anatomical unit, the enunciation of the physiological principles relating to the internal environment of the body, and the introduction of new diagnostic tools into clinical methods. The effects of these other advances were more cumulative, producing their greatest impact in the following century.
On the other hand, the organization of physicians, hospitals, and public health activities arose out of the nineteenth century itself, owing much to the alterations wrought by the Industrial Revolution. The rapid changes that followed the building of factories and the expansion of cities led to extreme shifts and crowding of populations. The conditions of factory workers, the spread of slums, and the interdependence of communities and nations also affected medical practice.
Before the discovery of bacteria as the causes of disease, the principal focus of preventive medicine and public health had been on sanitation: the provision of potable water and the dispersal of foul odors from sewage and refuse, which were considered the important factors in causing epidemics. The invention of the water closet by John Harrington (1561-1612) facilitated flushing away human waste and helped to keep some dwellings clean, but the flow from these indoor privies ran into cesspools and ultimately into waterways and wells.
The health of workers in the factories was important to their efficient functioning, and since the spread of epidemic disease was a danger to all segments of the population, the need for remedial measures in public health was urgently appreciated. Johann Peter Frank’s System einer Vollstandigen medicinischen Polizey (1777-78), using statistics to establish the importance of public health, was a milestone even though its immediate influence was negligible. In 1848, the description by Edwin Chadwick of the sanitary conditions and health of English workers, however, did have a great impact on the upper classes and the governing bodies. His standards for the proper removal of sewage and the protection of water supplies was a stimulus to the government of Britain, as was Rudolf Virchow’s militant advocacy of public health measures in Germany.
Epidemics continued to devastate cities and countries. As late as 1854 in London there were 14,000 cases of cholera with 618 deaths. In the United States, cholera ravaged the entire country three times in the nineteenth century. Yellow fever, after striking the northeast from 1793 to 1805, began a series of attacks upon the southern and Gulf of Mexico ports which reached a peak in the 1850s. A sharp decline followed until 1905, when one last explosive outbreak killed over 450 residents in New Orleans. Planned attacks on cholera, typhoid fever, and other pestilences only became feasible after the causes were discovered in the bacteriological era.
The assembling of large numbers of raw troops for the American Civil War was accompanied by inevitable outbreaks of communicable diseases. On both sides little attention was paid to camp sanitation, housing and food were atrocious, and confusion was rampant. No one anticipated the enormous casualties in the first few battles, and seriously wounded men often lay where they had fallen for several days. Many wounded died for want of immediate care, but the North, which lost control of the battlefields in the early fighting, took the heaviest casualties.
Gradually both sides evolved effective ambulance systems and hospitals, procured adequate medical supplies, and developed well-trained surgeons. Yet it was not until the Battle of Gettysburg (July, 1863) that the Union forces were able to remove their wounded from the field at the end of each day’s fighting. It had taken two years of bloodshed and suffering to develop a good medical corps.
The man largely responsible for reforming the Union Medical Corps was Surgeon General William A. Hammond, a bright, energetic individual whose much-needed reforms irritated enough regular army officers and politicians to lead to his dismissal in November, 1863, and his subsequent court-martial. The South was more fortunate in that a capable and intelligent surgeon general, Dr. Samuel Preston Moore, took over at the beginning of the war and was able to develop a sound medical corps with a minimum of interference. The South, however, lacked an effective transportation system, did not have as many well-trained surgeons, and was hard put to provide adequate medical supplies. Despite these handicaps, Moore was able to tender southern troops medical care comparable to that given the Union forces. Not until the transportation system began to break down toward the end of the war did the South have any significant medical problems.
As the century began, France held the lead in medicine. Francois Magendie (1783-1855) was one of the early French leaders who painstakingly tried to keep his observations simple and free of speculation. He is especially remembered for his experimental proofs that the posterior roots of the spinal canal carry sensory nerve fibers (receiving impulses to the cord) and the anterior roots are motor nerves (transporting impulses away from the cord to the muscles). The priority of this accomplishment was challenged by Charles Bell, among others, and the principle is now called the “Bell-Magendie law.” Magendie’s analyses of the actions of drugs also made him a founder of the discipline of pharmacology. Never holding an academic position, he was nevertheless a typical investigator of the early nineteenth century in combining the careers of medical practitioner and laboratory experimentalist.
On the other hand, Claude Bernard (1813-78), the virtual founder of experimental physiology, was entirely a man of the laboratory. He further developed the precepts of his teacher Magendie, postulating questions that could be answered only through experimental vivisectional techniques, which he perfected into elegant experiments. One of his influential concepts was the principle of homeostasis, which stated that the “internal environment” is constant in warm-blooded organisms and that physiological mechanisms resist any external factors which tend to alter this internal state.
Among other exceptional accomplishments, Bernard clarified the multiple functions of the liver, studied the digestive activity of the pancreatic secretions and the association of the pancreas with diabetes, and pointed out the connection of the nervous system with the constriction and dilation of the smaller arteries. In his Introduction to the Study of Experimental Medicine in 1865, he set down the standards for future experimentalists. An imaginative thinker, he had a firm attachment to objectivity, as indicated by his admonition, “Put off your imagination as you take off your overcoat, when you enter the laboratory…”
Another French contributor to physiology who was a practitioner of medicine as well as an investigator, Charles Edouard Brown-Sequard (1817-94), the son of an American sea captain and a French mother, is sometimes considered the founder of endocrinology, although Bernard had actually opened the field. In the course of his many travels, he lectured in either French or English on a variety of topics which included some of his own discoveries. Brown-Sequard taught that the adrenals, thyroid, pancreas, liver, spleen, and kidneys had secretions (later to be called hormones) which entered the bloodstream and could be used in treatment. He also believed that injections of extracts of the testis would produce rejuvenation.
Germany’s role in medicine was in a large measure due to the influence of Johannes Peter Muller (1801-58), who started out as a romantic “nature-philosopher” but later developed a more objective view of biological functions. His work focused on morphology (structure) rather than experiment, but he inspired numerous students who were to contribute to knowledge in physiology.
Lacking laboratories and the communities of scholars essential for much of the work in the basic sciences, America contributed little to physiology and histology, but there was one notable exception. William Beaumont (1785-1853), an obscure army surgeon who had learned medicine through an apprenticeship, took advantage of a rare opportunity to pave the way for the present understanding of the gastric process. In 1822, while serving in Fort Michilimackinac in northern Michigan, he was called to treat a French Canadian who appeared to be dying from a shotgun blast at close range. The lower chest and abdomen were torn open and the left lung, diaphragm, and stomach were badly lacerated. The wound was filled with blood, bone splinters, lead shot, wadding, bits of clothing, and the contents of the stomach. Although it seemed obvious that the wound was fatal, Beaumont cleaned and dressed it, and tried to make his patient comfortable. Miraculously, after a lengthy convalescence, Alexis St. Martin, the patient, survived, but he was left with a permanent gastric fistula giving direct access to his stomach. Notwithstanding strong objections from St. Martin and other difficulties, Beaumont conducted a long series of experiments which he summarized in 1833 in his classic work, Experiments and Observations on the Gastric Juice and the Physiology of Digestion. While his achievement received only limited recognition in America, European scientists hailed it as a major accomplishment.
In England, many physiologists illuminated the functions of the nervous system in the nineteenth century. Marshall Hall (1790-1857) may be mentioned for his work on shock and his discovery that some reflexes could be elicited Without going through the higher centers. William Sharpey described the clearing action in mucous membranes by microscopic, mobile hairs, the cilia.
A far-reaching influence on physiology and on subsequent attitudes toward behavior came from the experiments on animals by Ivan Pavlov (1849-1936) in Moscow. After having studied in the laboratories of Ludwig and Heidenhain in Germany, he became professor of pharmacology and then of physiology at the Military Medical Academy in Russia. He made detailed investigations on the heart, liver, pancreas, and alimentary tract, but his most influential work was on the conditioned reflex. For instance, he showed that one could condition a dog to salivate and its stomach to secrete in response to an outside stimulus even in the absence of food, by repeatedly linking the stimulus to the providing of food.
Chemistry and Pharmacology
Just as correlations were made between bedside findings and changes in the organs, so too was the chemistry laboratory brought to bear on understanding the functional alterations caused by disease. By the middle of the nineteenth century, examinations of blood and urine were routine.
One of the most significant accomplishments was the synthesis by Friedrich Wohler (1800-82) of urea, a natural product of the body, from an inorganic compound, ammonium carbonate. After that, the separation between the organic and the inorganic was no longer distinct. Organic chemistry would become merely . the chemistry of carbon compounds. In applying the techniques of inorganic chemistry to the study of the chemical mechanisms of the body, Felix Hoppe-Seyler (1825-95) opened the field of physical chemistry. His discovery in 1862 of hemoglobin (the oxygen-carrying substance in the red cells of the blood) was a milestone in medicine.
As advances in physiology and chemistry proceeded, it became possible to isolate drugs in pure form and thus examine their actions in animals and humans. Thus the discipline of pharmacology was developed. On the basis of preliminary investigations in France by J. F. Derosne in 1803 and A. Seguin in 1804, F. W. A. Serturner in Germany isolated morphine in 1806. Pelletier and Caventou in 1818 did the same in France with strychnine, quinine, and other drugs. Pierre Robiquet was another of the many pharmacist-chemists in France and Germany who discovered and isolated the new plant alkaloids so important to medicine—among them atropine, colchicine, and cocaine.
Pharmacology became an independent subject for the first time through the efforts of Rudolph Buchheim (1820-79) in Dorpat and his pupil Oswald Schmiedeberg (1830-1920) in Strassburg. Schmiedeberg’s teachings on experimental pharmacology were brought to America by John J. Abel (1857-1938), who further enlarged upon the earlier activities of H. C. Wood and Silas Weir Mitchell of Philadelphia. Abel became head of materia medica and therapeutics at the University of Michigan in 1891, and later, at Johns Hopkins, he occupied the first chair in the United States in the new discipline of pharmacology. Other schools soon established departments of pharmacology, but the schools of pharmacy were relatively late in introducing this specialized discipline.
In England Alexander Crum Brown (1838-1922) and Thomas Frazer advanced the discipline by correlating the actions of drugs with their chemical composition. As more and more drugs were isolated and their chemical nature understood, it became possible to create therapeutic compounds by building them from basic units. Alkaloids and antipyretics (fever-lowering compounds) were among the first drugs synthesized.
Matthias Schleiden (1804-81) and Theodor Schwann (1810-82), the latter a student of Johannes Muller’s, developed one of the most important conceptions of modern biology. Although it had been previously known that parts of plants were cellular, Schleiden was the first to state explicitly that each plant was a community of eels with each cell having a separate existence. Schwann generalized Schleiden’s conclusions to all life—animal and plant. Much of the information that led to the understanding and elaboration of the cell theory depended on technical advances in microscopes. It was not until the 1830s when Amici and Chevalier produced the achromatic lens that the finer structure of cells could be examined.
Even when the idea was accepted that all living creatures are composed of living cells, the question arose of how the cells originated. Schleiden proposed that the cell and its components formed as a result of a chemical precipitation out of an undifferentiated mass. It was another student of Muller’s, Rudolf Virchow, who overthrew the speculative explanations and firmly established the proposition (in which he was joined by many other investigators) that cells arise only from preexisting cells. At first the view proposed by Schleiden was embraced by many outstanding scientists, including Karl Rokitansky, a great pathologist of the time, but the concept of Virchow finally gained full acceptance.
Microscopic Anatomy and Embryology
Among the pupils of Johannes Muller who contributed to an understanding of the microscopic structure of organs was Jacob Henle (1809-85), who was also responsible for early ideas concerning microorganisms as causes of disease. Albert von Kolliker (1817-1905) wrote what may have been the first organized textbook on histology. He explained the development of the embryo on the basis of the new cell theory. The spermatozoan had been known for centuries, but Karl Ernst von Baer (1792-1876) gave the first description of the ovum (egg) of mammals. Robert Remak (1815-65) classified tissues according to their embryological origin into three primary systems (germ layers): ectoderm, mesoderm, and entoderm. The mechanism of cell division, the means by which the embryo enlarges, organs increase, and tissues regenerate was reported by Walter Fleming in 1882. Wilhelm Waldeyer (1836-1921) named the chromosome in the nucleus of the cell and put forth in 1891 the theory that the basic unit of the nervous system is the nerve cell, the neurone. He also pointed out that cancerous growths arise from epithelial cells in the ectodermal tissue layer.
In keeping with the spirit of correlating the clinical manifestations of illness with the pathological findings in organs, autopsies were the major focus in medicine. In the French and British schools the availability of corpses for pathological examination was quite limited, whereas in Austria and Germany medical institutions were often the centers in which autopsies were performed, usually by one prosector and his pupils. Moreover, in France and Britain the principal pathological studies were made by the clinicians.
Carl Rokitansky (1804-78), a Czech who worked in Vienna at the Institute of Pathology, was an example of the nonpracticing physician, a type that was. to become common in the nineteenth century. In his day he was the most outstanding morphological pathologist in the world, performing together with his assistants almost 60,000 autopsies in less than fifty years. His classifications of the changes in organs produced by disease set standards acclaimed by all. However, Rokitansky’s reliance on humoral theories (he tried to reconcile the ancient concepts with modern anatomical knowledge) led to devastating criticisms by the young Virchow which shook his standing, but he remained an honored pathologic anatomist throughout his life.
Rudolf Virchow (1821-1902), one of Muller’s students in Germany, was called the “Pope” of medicine in Europe because of the eminence of his scientific influence. He strove to integrate clinical medicine, morbid anatomy, and physiology. His dictum, “all cells come from other cells,” radically altered the direction of medical thinking toward the concept that disease was produced by disturbances in the structure and function of the body cells. Such ideas had occurred before, but Virchow was so thorough in proofs and so convincing in argument that the medical world readily accepted his pronouncements. Henceforth the target of treatment would be the cell. Among his other major contributions were the discovery of the disease entity leukemia and his studies on the nature of thrombosis, embolism, and phlebitis, which promulgated principles still valid today.
Virchow’s indefatigable energy and voracious mind took him into a variety of fields besides pathology: anthropology, archaeology, history, politics, public health, and sociology. His zeal for reform encompassed proposing that social conditions were a primary culprit in epidemics and advocating a reorganization of medical education and licensure.
However, with all his extraordinary gifts, Virchow was not above human frailties. His attacks on Rokitansky and on Karl August Wunderlich, the influential German clinician, while soundly based, contained elements of personal acrimony. Nor did he readily accept the bacterial theory of disease, pointing out that the presence of a bacterium in a diseased area did not of itself signify that it was the cause of the disease. His emphasis on the reaction of the body’s cells to an invading organism rather than the organism itself is consonant with present views that the host’s response to a noxious agent—bacterial, viral, or chemical—is as significant as the invader. Yet, Virchow did make too little of the role of microorganisms, and in the frustrating battle for asepsis by Semmelweis (described later) Virchow did not give his support.
But throughout his long life Virchow’s scientific interests and influence never waned. By the time of his death, he had been acclaimed throughout the world. If medicine consists essentially of endeavors related to concepts of illness, methods of treatment, education and organization of the healing professions, and measures directed toward preventing disease and maintaining health, then Virchow was indeed the complete man of medicine.
CLINICAL SCHOOLS AND THE CLINICIANS
The outstanding characteristic of nineteenth-century medicine was the correlation of discoveries in the laboratory and autopsy room with observations at the bedside, and it was principally the hospital where such investigations and interconnections were pursued. In the first half of the century, leadership in clinical science resided in France, but it later passed to the British Isles, and then to the German-speaking countries.
An important factor in the emergence of Paris as the leading clinical school was the French Revolution. As the old regime was swept away, so were ancient ideas and inhibitions, opening the way to new approaches by experiment, an emphasis on pragmatism rather than theory, and bedside observation instead of reasoning by concept. The hospital became more important as the focus of medical activity, public health measures were seen as a duty of government, and medical practice was open to all classes. The wounds sustained in the savage turmoil of the Revolution and after had increased the need for surgery, and since physicians appeared to have little effect on illnesses and epidemics surgeons gained an equal status. Nevertheless, as surgery and medicine coalesced into one profession, specializations began to occur as the new discoveries accumulated.
Philippe Pinel (1745-1826) was representative of both the eighteenth and nineteenth centuries. His concern for the classification of disease was a holdover from the past, and his concentration on objective clinical study in a special field fitted the trend toward specialization. Pinel’s close observation of people with mental illness and his astute evaluation of the results of treatment led him to advocate a change in insane asylums from forcible restraint to gentleness, persuasion, and a cheerful environment which benefited from the influences of family and friends.
Rene-Theophile-Hyacinthe Laennec (1781-1826) was one of the greatest clinicians of all time. He made outstanding contributions to the pathological and clinical understanding of diseases of the chest—notably emphysema, bronchiectasis, and tuberculosis—but he is best remembered for his invention and use of the stethoscope.
Before Laennec, the sounds of the lungs and heart were studied by holding one’s ear against the chest, a technique with numerous disadvantages. After observing two children transmit scratching noises to each other’s ear via a wooden board, Laennec got the idea of rolling up a sheaf of papers to aid him in listening to a patient’s chest. His next step was to construct a wooden cylinder, and he was amazed to discern sounds he had never heard or hardly appreciated before. Using the new information, Laennec was able to illuminate the clinical picture of many diseases. His monaural stethoscope was further improved and eventually became the binaural device used today as a regular tool of every clinician.
As an adherent of the hated royalist cause, Laennec did not reach the popularity or influence that was achieved by his contemporary Francois-Joseph-Victor Broussais (1772-1838), whose physical vigor, brilliant personality, and devoted espousal of progressive social attitudes made him virtually the most influential physician in France. In agreeing with the Parisian school on the importance of matching the clinical picture with abnormalities (lesions) in the organs of the body, Broussais vigorously ridiculed attempts to classify diseases according to symptoms. In his view, proper treatment must focus on the pathologic changes in tissue, not on the outmoded doctrines of the humors. The remarkable numbers of intestinal lesions which he saw, especially of typhoid fever, led him to conclude that the gastrointestinal tract was the primary source of most illnesses, especially those with fever. Believing Brown’s doctrine that irritation was the basic property of living tissues, he considered changes in tissue heat the fundamental determinant of health and illness. From the congestion he saw in the intestines, he reasoned that disengorgement to reduce heat was necessary. He therefore used an accepted method of removing the plethora of blood: bloodletting. Instead of the cumbersome maneuver of venesection, he employed an easier means—applying leeches. So convincing were his teachings that the physicians of France imported in a single year over forty million leeches.
One of the most effective techniques of evaluating the efficacy of treatment is statistics, although circumspection and objectivity in collection and analysis are required. The very introduction of numerical analysis of bloodletting results by Pierre-Charles-Alexandre Louis (1787-1872) was not only a fatal blow to venesection but a major force leading to the scientific evaluation of all therapies.
Although Pierre Bretonneau (1778-1862) preceded Louis in establishing typhoid fever as a specific entity, Bretonneau’s complex term “dothienenteritis” was replaced by Louis’s simpler “typhoid.” On the other hand, Bretonneau’s “diphtheria” (diphtherie) had a more permanent place in history.
Among other outstanding names of the French school were Armand Trousseau (1801-67), who contributed masterful and perceptive treatises on illness; Jean-Baptiste Bouillaud (1796-1881) (evidently the model for Balzac’s Dr. Bianchon); Pierre-Adolphe Piorry, a pioneer in the use of an instrument for percussion of the chest (the pleximeter); Francois-Olive Rayer, a contributor to clinical and laboratory knowledge who inspired Bernard in physiology, and Davaine and Villemin in their work on infection. Guillaume B. A. Duchenne (1806-75) and Jean-Martin Charcot (1825-93) were the virtual founders of neurology in France. Duchenne, who started as a country practitioner, made use of the new electrical current reported by Michael Faraday (1791-1867) to treat patients with rheumatism and to study the actions of muscles. Charcot became world-famous through his clinical teachings at the Salpetriere Hospital of Paris where he made an extraordinary number of original contributions to different fields of medicine, most of them related to the nervous system. He was the eponym for several syndromes, including “Charcot’s joint” (the joint derangement of locomotor ataxia caused by syphilis). His reputation and his writings on hysteria and hypnotism attracted the young Freud in Vienna, who went to Paris specifically to observe the work of Charcot.
Surgery in Paris was comparatively well-developed, especially in the first half of the century, with much of the advance due to the bloody events of the Revolution and Napoleonic wars. Perhaps the most personally popular of all surgeons was Dominique-Jean Larrey (1766-1842), so highly respected and admired by friend and foe alike that Napoleon called him the most virtuous man he had ever known. Although Larrey was famous as a surgeon (he is said to have performed over two hundred amputations during a twenty-four-hour period in the Russian campaign) and also as a clinician (he wrote vivid descriptions of “trench foot,” scurvy, contagious eye infections, and a method of feeding through a stomach tube), perhaps his most influential contribution was the creation of “flying ambulances,” wagons for stretcher use during battle. Unheard of until then, Larrey’s vehicles and transport system went into operation as the action started, affording a tremendous boost to morale and a much greater opportunity for effective treatment. Moreover, his attention to the wounded of both sides in battle was, in a sense, the harbinger of the principles of the Red Cross, which was formed later in the century.
While Larrey was adored, his colleague Guillaume Dupuytren (1777-1835) was actively disliked, though still admired. A spellbinding lecturer, incisive bedside teacher, indefatigable worker, enormously successful practitioner, and brilliant contributor to surgical knowledge, he nevertheless alienated colleagues and acquaintances by his cold, abrasive manner and devious machinations against others. He was innovative in devising instruments and bold in performing daring operative feats with successful outcome. Pierre-Francois Percy (1754-1825), a surgical colleague, called him “the first of surgeons and the least of men.”
There were many other surgeons in Paris who were pioneer contributors: Recamier, who may have been the first to remove the uterus; Roux, the thyroid; Lisfranc, the rectum. Pravas introduced the syringe. Lembert contributed to intestinal surgery, Meniere to the medical and surgical aspects of ear diseases. Pierre-Paul Broca (1824-80) firmly established, on the basis of clinical and pathologic evidence, that the speech function is located in a distinct area of the brain, now called “Broca’s area.” He was also a pioneer in anthropology, a discipline opposed by the government and by churchmen who felt that the concept of the anatomical localization of the mind in the brain was too materialistic. Paris continued to be a great school for surgical teaching and learning throughout the century, although the principal centers of influence shifted in the later decades to Britain and the German-speaking countries.
Simultaneous with the great tradition that developed in Paris, a spirit of clinical investigation also arose in Dublin at Meath Hospital, both self-generated and influenced by Parisian principles. As in London, many of the clinicians in Dublin were Scottish in either origin or training. One may say that a strong Scottish thread ran through the fabric of medicine in England, Ireland, and the United States.
John Cheyne (1777-1836), although born and trained in Scotland where he published a book on diseases of children, made his greatest contributions in Dublin as an influential member of a group often referred to as the “Irish School.” His detailed accounts of a variety of diseases and his writings on education gained him a worldwide reputation as a great teacher and practitioner. The term “Cheyne-Stokes respiration,” a type of irregular breathing, has remained in medical parlance.
William Stokes (1804-78) was born in Dublin, but he too studied and wrote in Scotland (The Use of the Stethoscope) before returning to Dublin in his early twenties to become a highly popular lecturer and bedside teacher. Two of his books, Diseases of the Chest and Diseases of the Heart, were to become important standard texts for generations. In addition to the breathing abnormality which linked his name with Cheyne’s, there is a type of dysfunction of the heartbeat first described by Robert Adams in the same century called “Stokes-Adams” heart block. Although he mistakenly believed that typhoid and typhus fevers were the same disease, he understood and emphasized the importance of public health and preventive measures.
The most famous teacher of the Dublin group was Robert James Graves (1796-1853), whose bedside rounds were widely known as superb instructional exercises. He is the eponym (“Graves’ disease”) for that combination of thyroid enlargement, nervousness, sweating, and pronounced stare referred to as “toxic exophthalmic goiter.” It was Graves who overturned the past dietary restrictions for patients with fever by urging a full, nutritious diet for all ill patients. He suggested that his own epitaph could well read, “He fed fevers.”
Another influential clinician of the Dublin school was Dominic John Corrigan (1802-80). He is best remembered for his description of the pathologic cause and characteristic pulse, called “Corrigan’s pulse,” of a disease of the aortic valves of the heart. Abraham Colles (1773-1843) described so thoroughly the principles and methods of treating a fracture of the wrist that it has continued to be known as the “Colles fracture.”
London and Edinburgh
One of the most influential teaching institutions of the century, Guy’s Hospital and Medical School, built in 1724 through the sponsorship and financial support of Thomas Guy, a publisher and investor, became world-famous as a center for practice and study. The “great men of Guy’s”—Bright, Addison, Hodgkin, all physicians, and Cooper, a surgeon—were the leading lights of London and all were products of the Edinburgh Medical School.
One of the many innovations of Richard Bright (1789-1858) was the assignment of a special clinical ward with all the supporting facilities for the express purpose of studying one particular group of diseases, a forerunner of the subspecialty organization of the twentieth century. His masterful reports on the clinical and pathological nature of diseases of the kidneys led to the name “Bright’s disease.”
Perhaps the most imposing of the leaders at Guy’s was Thomas Addison (1793-1860), whose severe, pompous manner, precisely chosen words, and physically impressive appearance struck fear into students. His thorough examinations and perceptive analyses earned him the awestruck respect of his colleagues. Pernicious anemia and adrenal insufficiency are both still referred to as “Addison’s anemia” and “Addison’s disease of the adrenals.”
The third member of the medical triumvirate, Thomas Hodgkin (1798-1866), was a man of exceptional generosity and modesty. A practicing Quaker, he dressed in the characteristic clothing of the sect and devoted much of his time to charity, eventually leaving clinical activities to engage in philanthropic work, travel, and study. “Hodgkin’s disease,” a term introduced by Samuel Wilks in 1865, is a clinicopathologic syndrome described by Hodgkin in 1832 which is characterized by enlargements of the spleen and lymphatic system.
Another famous member of the staff at Guy’s Hospital was William Withey Gull (1816-90). He especially condemned prescriptions containing multiple drugs and composed many widely quoted epigrams: “Savages explain; science investigates.” “Nursing, sometimes a trade, sometimes a profession, ought to be a religion.”
Many other physicians made contributions in the early half of the century. James Parkinson (1755-1824), for instance, gained recognition for his description of a neurological disorder now known as “Parkinson’s disease,” but he was also an important writer on paleontology. John Hughlings Jackson (1835-1911) and William Richard Gowers (1845-1915) advanced further the idea that functions of the brain and spinal cord are localized in specific areas, as had been established in the Paris school.
The fourth of the “great men of Guy’s” was Astley Cooper (1768-1841). Bettany wrote, “No surgeon, before or since, has filled so large a space in the public eye.” Although his financial position was secure because of his wife’s fortune, he slaved day and night—examining, operating, studying, demonstrating, lecturing, dissecting, and writing. In each of his many endeavors he was brilliant, thorough, and communicative. An elegant, careful operator (before the days of ether anesthesia!), he took pains to enable his students to witness clearly every step of the procedure. “Cooper’s fascia” and “Cooper’s hernia” are only two of the conditions which are named for his work.
Since he had a passion for dissection and lost no opportunity to pursue his anatomical studies, he had dealings, out of necessity, with people who obtained corpses surreptitiously—the so-called “resurrectionists.” He helped to defend them with argument and money. Those who were imprisoned he rewarded by supporting their families. Despite the clear antagonism of the populace to “body-snatching,” Cooper remained unassailable in position and esteem. His life from beginning to end seemed to be an unbroken upward path of success.
Mention may be made of an entirely different fate that befell Robert Knox (1791-1862) in Edinburgh, a contemporary of Cooper’s and one of the most famous teachers of anatomy at the time. When the nefarious activities of Burke and Hare, who murdered to obtain the bodies sold for dissection, were brought to light, Knox was falsely accused of complicity. Although later completely exonerated, he was vilified by the people, and his prestige was so irretrievably lowered that he never again achieved a position of influence.
The surname Bell, important in nineteenth-century surgery, was held by two unrelated families of Scotland. Benjamin Bell (1749-1806), a prominent, popular, practicing surgeon in Edinburgh trained in Paris and also in London, wrote a multivolume system of surgery that rivaled the influential text by Heister. His sons George and Joseph, grandson Benjamin, and great-grandson Joseph continued the highly respected surgical tradition into the twentieth century.
The second separate family of Bells contained even more famous members in the persons of the brothers John (1763-1820) and Charles (1774-1842), who were among the leading surgeons of Britain. Although Charles Bell was a highly competent surgeon, he became better known as an anatomist—especially of the nervous system. The priority of his experiments proving the motor function of the anterior nerve roots emerging from the spinal canal and the sensory characteristics of the posterior roots has been challenged by scholars who suggest that Magendie in Paris gave the first definitive proofs. Bell did discover that the fifth cranial nerve has both sensory and motor bundles and that the seventh cranial nerve could produce a paralysis now called “Bell’s palsy.”
John Bell, who also wrote and illustrated books on anatomy, is best remembered for his writings on history, vascular surgery, and wounds, and he may have been the model for Conan Doyle’s arch-detective Sherlock Holmes. The bitter, personal controversies which surrounded John Bell, at one time forcing him to leave Edinburgh for London, were typical of the acrimonious feuds which involved other surgeons of the English-Scottish schools.
Robert Liston (1794-1847) was probably the most dexterous operator in England, introducing innovative techniques and successfully removing tumors deemed by others to be unresectable. He was also the first in Britain to employ ether anesthesia. His colleague and antagonist James Syme (1799-1870) developed procedures which permitted the excision of joints, thus preserving the limb from amputation. A contemporary later wrote of Syme, “He never wasted a word, or a drop of ink, or a drop of blood.”
Benjamin Brodie (1783-1862), William Fergusson (1808-77), and James Paget (1814-99) were also outstanding surgeons of London. Brodie, a versatile and generous man, was a busy practitioner, physiologist, philosophic writer, and medical statesman, but the immensely popular Fergusson may have exceeded him in variety of interests. Not only did he write a highly reputed system of surgery and a book on the history of anatomy and surgery but he also invented instruments, did expert carpentry and metalwork, played the violin well, fished, danced, and enthusiastically supported budding writers and students.
Of the three, however, Paget’s name is best known to succeeding generations, partly because of the eponymic “Paget’s disease” of the nipple (an eczema which heralds the presence of carcinoma) and “Paget’s disease” of the bones (a deformity produced by an error in calcium metabolism). He discovered the trichina infestation in human muscles, wrote brilliant essays, gave painstakingly prepared, eloquent lectures, and at St. Bartholomew’s Hospital gained the reputation of being the best surgical diagnostician in Britain, with fabulous prescience in deciding what operation to do. “Go to Paget to find out what is the matter, and then to Fergusson to have it cut out” was a popular saying.
James Young Simpson (1811-70), perhaps the most famous obstetrician and gynecologist in Britain, born, trained, and nurtured in Scotland, introduced chloroform as an anesthetic. In his quest for a more pleasant and more controllable agent than ether, he had tried a drug suggested to him by a Liverpool chemist which had just been named “chloroform” by J. B. Dumas in Paris, but it had been discovered earlier, in the 1830s, by each of three independent investigators: S. Guthrie in the United States, Soubeiran in France, and Liebig in Germany. One evening Simpson and friends inhaled the substance at home and found they all had been rendered unconscious. Impressed by its effectiveness and pleasant smell, he tried it for operations and deliveries. For the next half-century, chloroform was the most frequently used anesthetic in Great Britain. Simpson also made many other contributions to obstetrics and gynecology. Although he was a highly principled man, supporting women’s entrance into medicine, his personal animosity toward James Syme spilled over to include the teachings of Joseph Lister, Syme’s son-in-law.
In the German-speaking countries Naturphilosophie was still prominent at the same time as the scientific-minded were advancing the cause of observational medicine. If the British and French schools were skeptics in therapy, the Vienna school was virtually nihilistic, placing little if any reliance on drugs. The leading man in medicine in Vienna was Karl Rokitansky, but he was entirely a pathologist. The outstanding clinician and perhaps the most nihilistic of all was Joseph Skoda (1805-81), a pupil of Rokitansky’s. Skoda refined Laennec’s ausculatory and percussive techniques to explain the physical bases for the various sounds produced by pathological lesions in the chest, showing that it was not the disease itself but the alterations in the physical conditions in the organ which produced the properties of pitch and timbre. An objective evaluator of treatment, he saw little use for medications or active interference in sickness, even giving placebos to patients with pneumonia to demonstrate that the illness ran its course unaffected by any therapy. At the time, this nihilism was probably more beneficial than the bleedings, emetics, and purgings that were still part of medical treatment.
Ferdinand Hebra (1816-80), one of the first to specialize entirely in skin diseases, began his career on Skoda’s service for chest diseases but, with his teacher’s support, founded a division of dermatology. He based his classification on the gross and microscopic changes in the tissues instead of on symptomatology or on general disease categories. His treatment was therefore directed toward the local problem rather than abnormalities in the humors which were still considered the primary causes. He discovered that the destruction of the itch-mite parasite cured scabies, a condition he recognized as transmissible from person to person.
There were other exceptional leaders in Vienna, one of whom, Joseph Hyrtl (1810-94), originally from Germany, became a famous teacher and historian of anatomy. Perhaps the most noteworthy historical figure in Vienna was Ignaz Semmelweis, whose important contributions and tragic career are described in the chapter on infection.
The theorizing, mystical Naturphilosophie which enveloped scientific and medical thinking in Germany in the early part of the century gradually gave way to direct observation and experiment, with the establishment of laboratory studies on body functions led by Johannes Muller and his followers.
Meanwhile a clinical school was emerging all over Germany, not in just one or two cities; possibly this was because Germany at the beginning of the century was a conglomeration of divided, independent political units, with no one central city representing the focus of feeling or governmental organization. Johann Lukas Schonlein (1793-1864), erected a classification of diseases, as a Natural History school, which turned out to be so arbitrary and artificial that it did not outlast him. But his intensive use of percussion and auscultation, incisive lectures and clinical demonstrations, and emphasis on the newest methods, including examination of the blood and urine, made him a leader in clinical medicine. His name was given to a bleeding disease, “Schonlein’s purpura,” and to a parasitic fungus, Achorion (or Trichophyton) schonleini.
Hermann von Helmholtz (1821-94) was one of the great geniuses of medicine, who entered the profession only because a career in physics appeared to offer little chance of a livelihood. Eventually he did become a physicist and professor of physics in Berlin in 1871, but the thirty years spent in medical practice and investigation were never forgotten. “Medicine was once the intellectual home in which I grew up; and even the immigrant best understands and is best understood by his native land.”
Even while a young army surgeon he had maintained his interest in physics and mathematics, and in 1847 he published a treatise of far-reaching importance to physics and physiology, Uber die Erhaltung der Kraft (The Conservation of Energy), which formulated the law (also independently developed by J. R. Mayer in 1842) that although energy could be transformed into different forms its total amount was constant—whether in the universe or in a living organism. In his later years as a physicist Helmholtz also added to the knowledge of electrodynamics, and his assistant Heinrich Hertz (1857-94) discovered the waves on which the electromagnetic transmission of the twentieth century is based.
Helmholtz made his greatest impact on medicine through quantitative determinations in the physiology of sight, sound, and nerve impulses. Taking the original work of 1801 by Thomas Young, an English ophthalmologist, he confirmed and broadened the studies to develop an explanation of color vision, the Young-Helmholtz theory. Intent on trying to look inside the eye of a living person, he devised an instrument consisting essentially of a concave mirror with a hole in the center which shone light into the pupil and enabled the viewer to see the reflected image of the retina. Helmholtz reported “the great joy of being the first to see a living human retina.” From then on, abnormalities in the eye were open to the diagnostic gaze of the physician.
Another influential member of the German clinical school, Karl August Wunderlich (1815-77), was in large measure responsible for popularizing the thermometer in clinical practice. Although Wunderlich went too far in believing that each disease entity had its own characteristic fever graph, his studies on fever made practitioners realize how important the temperature curve was. Wunderlich also wrote extensively on his reactions to what he saw at various clinics abroad. It was he possibly more than anyone else who brought back to Germany many of the principles and methods of the Paris school. He emphasized the need for more intensive study of therapy, which had been virtually left out in the French and Austrian institutions.
The United States
Although American medicine throughout the nineteenth century continued to depend upon Western Europe for innovations, individual American physicians demonstrated both intelligence and initiative. Ephraim McDowell (1771-1830), a physician practicing on the Kentucky frontier, was confronted in 1809 by a patient suffering from a large ovarian cyst. Fortunately for the patient, McDowell was a well-trained practitioner who had studied at the University of Edinburgh. He informed his patient that an operation to remove the cyst was considered almost certain death, but if she were willing to travel the sixty miles to his office in Danville he would attempt the operation. The patient, in the midst of winter, made the long trek on horseback and placed herself in his hands. McDowell recorded that while she recited psalms, he opened her abdomen and removed a diseased ovary weighing almost twenty pounds. Twenty-five days after the operation the patient returned home to live for another thirty-one years. McDowell successfully removed several more ovarian cysts before publicizing his work and gaining international recognition.
Obstetrical and gynecological problems are common to all peoples, and this may explain why still another American physician, equally far removed from the centers of medical learning, also pioneered in this area. J. Marion Sims (1813-83), a Southerner, acquired his medical education at the Charleston Medical School and Jefferson Medical College in Philadelphia—an education, he later wrote, which taught him nothing about the practice of medicine. He subsequently began practicing in Alabama, where he discovered a penchant for surgery. In this capacity he was called in to help with a young slave girl who had been in labor for seventy-two hours. Using forceps he delivered the child, but the mother had suffered so much injury that she was left with an opening between the vagina and urinary bladder—a condition considered hopeless. Encountering other cases of this type, he determined to help them. He assembled several slave women suffering from this condition, vesicovaginal fistulas, and at his own expense began four years of experimentation.
He despaired of success until one day he made a startling discovery. While treating a middle-aged woman for a retroversion of the uterus, he remembered the advice of a professor to place the patient in a knee-elbow position and to push the uterus back into position by using one finger in the rectum and another in the vagina. Reluctant to add to his patient’s discomfort by introducing a finger into the rectum, he sought to correct the situation by means of two fingers inserted in the vagina. In the process of turning his hand, the womb seemed to disappear and the patient was suddenly relieved. As she rolled over on her side, she was embarrassed by an explosive sound of air. Sims realized that in turning his hand he had permitted the external air pressure to push the vagina back into normal position, and he could scarcely wait to get back to the hospital to apply his findings. He placed one of his fistula cases in the same position, opened the vagina, and heard the air rush in. He wrote later: “Introducing the bent handle of a spoon I saw everything, as no man had ever seen before. The fistula was as plain as the nose on a man’s face.” After the discovery of the knee-elbow (Sims’) position (later modified to a side position), he devised a special (Sims’) speculum and catheter, learned the value of silver sutures, and developed new surgical techniques which finally enabled him to restore his patients to health. In the process he laid the basis for the specialty of gynecology.
Many other American physicians and surgeons deserve mention: Dr. Philip Syng Physick (1768-1837), generally credited with establishing surgery as a specialty in America; Drs. Joseph and John Warren of Revolutionary War fame and their descendants who provided leadership in New England medicine for several generations; Daniel Drake (1785-1852), stormy petrel of American medical education; and Oliver Wendell Holmes (1809-94), poet, essayist, teacher, and medical practitioner. Holmes, best known as a literary figure, was the first to recognize the contagious nature of childbed or puerperal fever. Holmes’s observations antedate by four years those of Ignatz Semmelweis, the man generally credited with this discovery.
In the second half of the century, one of the most famous physicians was William Osler (1849-1920), who was born and educated in Canada and held professorships not only there but in England and the United States, notably at the Johns Hopkins Hospital and Medical School in Baltimore. Although he was a pragmatic practicing physician who made outstanding contributions to clinical medicine, his main influences were as a beloved teacher of a long line of pupils destined to make lasting contributions to medicine; as a writer of an encyclopedic medical text which was a standard for generations; and as the model of a cultured, articulate, insatiably curious, highly principled physician. He also gave a significant impetus to the study of the history of medicine in the United States.