Medical Education

Rise of modern medicine

THE RISE AND DEVELOPMENT OF MODERN MEDICINE

THE middle of the seventeenth century saw the profession thus far on its way—certain objective features of disease were known, the art of careful observation had been cultivated, many empirical remedies had been discovered, the coarser structure of man’s body had been well worked out, and a good beginning had been made in the knowledge of how the machinery worked—nothing more. What disease really was, where it was, how it was caused, had not even begun to be discussed intelligently.

An empirical discovery of the first importance marks the middle of the century. The story of cinchona is of special interest, as it was the first great specific in disease to be discovered. In 1638, the wife of the Viceroy of Peru, the Countess of Chinchon, lay sick of an intermittent fever in the Palace of Lima. A friend of her husband’s, who had become acquainted with the virtues, in fever, of the bark of a certain tree, sent a parcel of it to the Viceroy, and the remedy administered by her physician, Don Juan del Vego, rapidly effected a cure. In 1640, the Countess returned to Spain, bringing with her a supply of quina bark, which thus became known in Europe as “the Countess’s Powder” (pulvis Comitissae). A little later, her doctor followed, bringing additional quantities. Later in the century, the Jesuit Fathers sent parcels of the bark to Rome, whence it was distributed to the priests of the community and used for the cure of ague; hence the name of “Jesuits’ bark.” Its value was early recognized by Sydenham and by Locke. At first there was a great deal of opposition, and the Protestants did not like it because of its introduction by the Jesuits. The famous quack, Robert Talbor, sold the secret of preparing quinquina to Louis XIV in 1679 for two thousand louis d’or, a pension and a title. That the profession was divided in opinion on the subject was probably due to sophistication, or to the importation of other and inert barks. It was well into the eighteenth century before its virtues were universally acknowledged. The tree itself was not described until 1738, and Linnaeus established the genus “Chinchona” in honor of the Countess.(1)

A step in advance followed the objective study of the changes wrought in the body by disease. To a few of these the anatomists had already called attention. Vesalius, always keen in his description of aberrations from the normal, was one of the first to describe internal aneurysm. The truth is, even the best of men had little or no appreciation of the importance of the study of these changes. Sydenham scoffs at the value of post-mortems.

Again we have to go back to Italy for the beginning of these studies, this time to Florence, in the glorious days of Lorenzo the Magnificent. The pioneer now is not a professor but a general practitioner, Antonio Benivieni, of whom we know very little save that he was a friend of Marsilio Ficino and of Angelo Poliziano, and that he practiced in Florence during the last third of the fifteenth century, dying in 1502. Through associations with the scholars of the day, he had become a student of Greek medicine and he was not only a shrewd and accurate observer of nature but a bold and successful practitioner. He had formed the good habit of making brief notes of his more important cases, and after his death these were found by his brother Jerome and published in 1507.(2) This book has a rare value as the record of the experience of an unusually intelligent practitioner of the period. There are in all 111 observations, most of them commendably brief. The only one of any length deals with the new “Morbus Gallicus,” of which, in the short period between its appearance and Benivieni’s death, he had seen enough to leave a very accurate description; and it is interesting to note that even in those early days mercury was employed for its cure. The surgical cases are of exceptional interest, and No. 38 refers to a case of angina for which he performed a successful operation. This is supposed to have been a tracheotomy, and if so, it is the first in the fourteen centuries that had elapsed since the days of Antyllus.(3) There are other important cases which show that he was a dexterous and fearless surgeon. But the special interest of the work for us is that, for the first time in modern literature, we have reports of post-mortem examinations made specifically with a view to finding out the exact cause of death. Among the 111 cases, there are post-mortem records of cases of gallstones, abscess of the mesentery, thrombosis of the mesenteric veins, several cases of heart disease, senile gangrene and one of cor villosum. From no other book do we get so good an idea of a practitioner’s experience at this period; the notes are plain and straightforward, and singularly free from all theoretical and therapeutic vagaries. He gives several remarkable instances of faith healing.

To know accurately the anatomical changes that take place in disease is of importance both for diagnosis and for treatment. The man who created the science, who taught us to think anatomically of disease, was Morgagni, whose “De sedibus et causis morborum per anatomen indagatis”(4) is one of the great books in our literature. During the seventeenth century, the practice of making post-mortem examinations had extended greatly, and in the “Sepulchretum anatomicum” of Bonetus (1679), these scattered fragments are collected.(5) But the work of Morgagni is of a different type, for in it are the clinical and anatomical observations of an able physician during a long and active life. The work had an interesting origin. A young friend interested in science and in medicine was fond of discoursing with Morgagni about his preceptors, particularly Valsalva and Albertini, and sometimes the young man inquired about Morgagni’s own observations and thoughts. Yielding to a strong wish, Morgagni consented to write his young friend familiar letters describing his experiences. I am sorry that Morgagni does not mention the name of the man to whom we are so much indebted, and who, he states, was so pleased with the letters that he continually solicited him to send more and more “till he drew me on so far as the seventieth; . . . when I begged them of him in order to revise their contents; he did not return them, till he had made me solemnly promise, that I would not abridge any part thereof” (Preface).

Born in 1682, Morgagni studied at Bologna under Valsalva and Albertini. In 1711, he was elected professor of medicine at Padua. He published numerous anatomical observations and several smaller works of less importance. The great work which has made his name immortal in the profession, appeared in his eightieth year, and represents the accumulated experience of a long life. Though written in the form of letters, the work is arranged systematically and has an index of exceptional value. From no section does one get a better idea of the character and scope of the work than from that relating to the heart and arteries—affections of the pericardium, diseases of the valves, ulceration, rupture, dilation and hypertrophy and affections of the aorta are very fully described. The section on aneurysm of the aorta remains one of the best ever written. It is not the anatomical observations alone that make the work of unusual value, but the combination of clinical with anatomical records. What could be more correct than this account of angina pectoris—probably the first in the literature? “A lady forty-two years of age, who for a long time, had been a valetudinarian, and within the same period, on using pretty quick exercise of body, she was subject to attacks of violent anguish in the upper part of the chest on the left side, accompanied with a difficulty of breathing, and numbness of the left arm; but these paroxysms soon subsided when she ceased from exertion. In these circumstances, but with cheerfulness of mind, she undertook a journey from Venice, purposing to travel along the continent, when she was seized with a paroxysm, and died on the spot. I examined the body on the following day…. The aorta was considerably dilated at its curvature; and, in places, through its whole tract, the inner surface was unequal and ossified. These appearances were propagated into the arteria innominata. The aortic valves were indurated….” He remarks, “The delay of blood in the aorta, in the heart, in the pulmonary vessels, and in the vena cave, would occasion the symptoms of which the woman complained during life; namely, the violent uneasiness, the difficulty of breathing, and the numbness of the arm.”(6)

Morgagni’s life had as much influence as his work. In close correspondence with the leading men of the day, with the young and rising teachers and workers, his methods must have been a great inspiration; and he came just at the right time. The profession was literally ravaged by theories, schools and systems—iatromechanics, iatrochemistry, humoralism, the animism of Stahl, the vitalistic doctrines of Van Helmont and his followers—and into this metaphysical confusion Morgagni came like an old Greek with his clear observation, sensible thinking and ripe scholarship. Sprengel well remarks that “it is hard to say whether one should admire most his rare dexterity and quickness in dissection, his unimpeachable love of truth and justice in his estimation of the work of others, his extensive scholarship and rich classical style or his downright common sense and manly speech.”

Upon this solid foundation the morbid anatomy of modern clinical medicine was built. Many of Morgagni’s contemporaries did not fully appreciate the change that was in progress, and the value of the new method of correlating the clinical symptoms and the morbid appearances. After all, it was only the extension of the Hippocratic method of careful observation—the study of facts from which reasonable conclusions could be drawn. In every generation there had been men of this type—I dare say many more than we realize—men of the Benivieni character, thoroughly practical, clear-headed physicians. A model of this sort arose in England in the middle of the seventeenth century, Thomas Sydenham (1624-1689), who took men back to Hippocrates, just as Harvey had led them back to Galen. Sydenham broke with authority and went to nature. It is extraordinary how he could have been so emancipated from dogmas and theories of all sorts. He laid down the fundamental proposition, and acted upon it, that “all disease could be described as natural history.” To do him justice we must remember, as Dr. John Brown says, “in the midst of what a mass of errors and prejudices, of theories actively mischievous, he was placed, at a time when the mania of hypothesis was at its height, and when the practical part of his art was overrun and stultified by vile and silly nostrums” (“Horae Subsecivae,” Vol. I, 4th ed., Edinburgh, 1882, p. 40).

Listen to what he says upon the method of the study of medicine: “In writing therefore, such a natural history of diseases, every merely philosophical hypothesis should be set aside, and the manifest and natural phenomena, however minute, should be noted with the utmost exactness. The usefulness of this procedure cannot be easily overrated, as compared with the subtle inquiries and trifling notions of modern writers, for can there be a shorter, or indeed any other way of coming at the morbific causes, or discovering the curative indications than by a certain perception of the peculiar symptoms? By these steps and helps it was that the father of physic, the great Hippocrates, came to excel, his theory being no more than an exact description or view of nature. He found that nature alone often terminates diseases, and works a cure with a few simple medicines, and often enough with no medicines at all.”

Towards the end of the century many great clinical teachers arose, of whom perhaps the most famous was Boerhaave, often spoken of as the Dutch Hippocrates, who inspired a group of distinguished students. I have already referred to the fact that Franciscus Sylvius at Leyden was the first among the moderns to organize systematic clinical teaching. Under Boerhaave, this was so developed that to this Dutch university students flocked from all parts of Europe. After teaching botany and chemistry, Boerhaave succeeded to the chair of physic in 1714. With an unusually wide general training, a profound knowledge of the chemistry of the day and an accurate acquaintance with all aspects of the history of the profession, he had a strongly objective attitude of mind towards disease, following closely the methods of Hippocrates and Sydenham. He adopted no special system, but studied disease as one of the phenomena of nature. His clinical lectures, held bi-weekly, became exceedingly popular and were made attractive not less by the accuracy and care with which the cases were studied than by the freedom from fanciful doctrines and the frank honesty of the man. He was much greater than his published work would indicate, and, as is the case with many teachers of the first rank, his greatest contributions were his pupils. No other teacher of modern times has had such a following. Among his favorite pupils may be mentioned Haller, the physiologist, and van Swieten and de Haen, the founders of the Vienna school.

In Italy, too, there were men who caught the new spirit, and appreciated the value of combining morbid anatomy with clinical medicine. Lancisi, one of the early students of disease of the heart, left an excellent monograph on the subject, and was the first to call special attention to the association of syphilis with cardio-vascular disease. A younger contemporary of his at Rome, Baglivi, was unceasing in his call to the profession to return to Hippocratic methods, to stop reading philosophical theories and to give up what he calls the “fatal itch” to make systems.

The Leyden methods of instruction were carried far and wide throughout Europe; into Edinburgh by John Rutherford, who began to teach at the Royal Infirmary in 1747, and was followed by Whytt and by Cullen; into England by William Saunders of Guy’s Hospital. Unfortunately the great majority of clinicians could not get away from the theoretical conceptions of disease, and Cullen’s theory of spasm and atony exercised a profound influence on practice, particularly in this country, where it had the warm advocacy of Benjamin Rush. Even more widespread became the theories of a pupil of Cullen’s, John Brown, who regarded excitability as the fundamental property of all living creatures: too much of this excitability produced what were known as sthenic maladies, too little, asthenic; on which principles practice was plain enough. Few systems of medicine have ever stirred such bitter controversy, particularly on the Continent, and in Charles Creighton’s account of Brown(7) we read that as late as 1802 the University of Gottingen was so convulsed by controversies as to the merits of the Brunonian system that contending factions of students in enormous numbers, not unaided by the professors, met in combat in the streets on two consecutive days and had to be dispersed by a troop of Hanoverian horse.

But the man who combined the qualities of Vesalius, Harvey and Morgagni in an extraordinary personality was John Hunter. He was, in the first place, a naturalist to whom pathological processes were only a small part of a stupendous whole, governed by law, which, however, could never be understood until the facts had been accumulated, tabulated and systematized. By his example, by his prodigious industry, and by his suggestive experiments he led men again into the old paths of Aristotle, Galen and Harvey. He made all thinking physicians naturalists, and he lent a dignity to the study of organic life, and re-established a close union between medicine and the natural sciences. Both in Britain and Greater Britain, he laid the foundation of the great collections and museums, particularly those connected with the medical schools. The Wistar-Horner and the Warren Museums in this country originated with men greatly influenced by Hunter. He was, moreover, the intellectual father of that interesting group of men on this side of the Atlantic who, while practising as physicians, devoted much time and labor to the study of natural history; such men as Benjamin Smith Barton, David Hossack, Jacob Bigelow, Richard Harlan, John D. Godman, Samuel George Morton, John Collins Warren, Samuel L. Mitchill and J. Ailken Meigs. He gave an immense impetus in Great Britain to the study of morbid anatomy, and his nephew, Matthew Baillie, published the first important book on the subject in the English language.

Before the eighteenth century closed practical medicine had made great advance. Smallpox, though not one of the great scourges like plague or cholera, was a prevalent and much dreaded disease, and in civilized countries few reached adult life without an attack. Edward Jenner, a practitioner in Gloucestershire, and the pupil to whom John Hunter gave the famous advice: “Don’t think, try!” had noticed that milkmaids who had been infected with cowpox from the udder of the cow were insusceptible to smallpox. I show you here the hand of Sarah Nelmes with cowpox, 1796. A vague notion had prevailed among the dairies from time immemorial that this disease was a preventive of the smallpox. Jenner put the matter to the test of experiment. Let me quote here his own words: “The first experiment was made upon a lad of the name of Phipps, in whose arm a little vaccine virus was inserted, taken from the hand of a young woman who had been accidentally infected by a cow. Notwithstanding the resemblance which the pustule, thus excited on the boy’s arm, bore to variolous inoculation, yet as the indisposition attending it was barely perceptible, I could scarcely persuade myself the patient was secure from the Small Pox. However, on his being inoculated some months afterwards, it proved that he was secure.”(8) The results of his experiments were published in a famous small quarto volume in 1798.(*) From this date, smallpox has been under control. Thanks to Jenner, not a single person in this audience is pockmarked! A hundred and twenty-five years ago, the faces of more than half of you would have been scarred. We now know the principle upon which protection is secured: an active acquired immunity follows upon an attack of a disease of a similar nature. Smallpox and cowpox are closely allied and the substances formed in the blood by the one are resistant to the virus of the other. I do not see how any reasonable person can oppose vaccination or decry its benefits. I show you the mortality figures(9) of the Prussian Army and of the German Empire. A comparison with the statistics of the armies of other European countries in which revaccination is not so thoroughly carried out is most convincing of its efficacy.

(*) Reprinted by Camac: Epoch-making Contributions to Medicine, etc., 1909.—Ed.

The early years of the century saw the rise of modern clinical medicine in Paris. In the art of observation men had come to a standstill. I doubt very much whether Corvisart in 1800 was any more skilful in recognizing a case of pneumonia than was Aretaeus in the second century A. D. But disease had come to be more systematically studied; special clinics were organized, and teaching became much more thorough. Anyone who wishes to have a picture of the medical schools in Europe in the first few years of the century, should read the account of the travels of Joseph Frank of Vienna.(10) The description of Corvisart is of a pioneer in clinical teaching whose method remains in vogue today in France—the ward visit, followed by a systematic lecture in the amphitheatre. There were still lectures on Hippocrates three times a week, and bleeding was the principal plan of treatment: one morning Frank saw thirty patients, out of one hundred and twelve, bled! Corvisart was the strong clinician of his generation, and his accurate studies on the heart were among the first that had concentrated attention upon a special organ. To him, too, is due the reintroduction of the art of percussion in internal disease discovered by Auenbrugger in 1761.

The man who gave the greatest impetus to the study of scientific medicine at this time was Bichat, who pointed out that the pathological changes in disease were not so much in organs as in tissues. His studies laid the foundation of modern histology. He separated the chief constituent elements of the body into various tissues possessing definite physical and vital qualities. “Sensibility and contractability are the fundamental qualities of living matter and of the life of our tissues. Thus Bichat substituted for vital forces ‘vital properties,’ that is to say, a series of vital forces inherent in the different tissues.”(11) His “Anatomic Generale,” published in 1802, gave an extraordinary stimulus to the study of the finer processes of disease, and his famous “Recherches sur la Vie et sur la Mort” (1800) dealt a death-blow to old iatromechanical and iatrochemical views. His celebrated definition may be quoted: “La vie est l’ensemble des proprietes vitales qui resistent aux proprietes physiques, ou bien la vie est l’ensemble des fonctions qui resistent a la mort.” (Life is the sum of the vital properties that withstand the physical properties, or, life is the sum of the functions that withstand death.) Bichat is another pathetic figure in medical history. His meteoric career ended in his thirty-first year: he died a victim of a post-mortem wound infection. At his death, Corvisart wrote Napoleon: “Bichat has just died at the age of thirty. That battlefield on which he fell is one which demands courage and claims many victims. He has advanced the science of medicine. No one at his age has done so much so well.”

It was a pupil of Corvisart, Rene Theophile Laennec, who laid the foundation of modern clinical medicine. The story of his life is well known. A Breton by birth, he had a hard, up-hill struggle as a young man—a struggle of which we have only recently been made aware by the publication of a charming book by Professor Rouxeau of Nantes—”Laennec avant 1806.” Influenced by Corvisart, he began to combine the accurate study of cases in the wards with anatomical investigations in the dead-house. Before Laennec, the examination of a patient had been largely by sense of sight, supplemented by that of touch, as in estimating the degree of fever, or the character of the pulse. Auenbrugger’s “Inventum novum” of percussion, recognized by Corvisart, extended the field; but the discovery of auscultation by Laennec, and the publication of his work—”De l’Auscultation Mediate,” 1819,—marked an era in the study of medicine. The clinical recognition of individual diseases had made really very little progress; with the stethoscope begins the day of physical diagnosis. The clinical pathology of the heart, lungs and abdomen was revolutionized. Laennec’s book is in the category of the eight or ten greatest contributions to the science of medicine.(*) His description of tuberculosis is perhaps the most masterly chapter in clinical medicine. This revolution was effected by a simple extension of the Hippocratic method from the bed to the dead-house, and by correlating the signs and symptoms of a disease with its anatomical appearances.

(*) John Forbes’s translation of Auenbrugger and part of his translation of Lacnnec are reprinted in Camac’s Epoch-making
Contributions, etc., 1909.—Ed.

The pupils and successors of Corvisart—Bayle, Andral, Bouillaud, Chomel, Piorry, Bretonneau, Rayer, Cruveilhier and Trousseau—brought a new spirit into the profession. Everywhere the investigation of disease by clinical-pathological methods widened enormously the diagnostic powers of the physician. By this method Richard Bright, in 1836, opened a new chapter on the relation of disease of the kidney to dropsy, and to albuminous urine. It had already been shown by Blackwell and by Wells, the celebrated Charleston (S.C.) physician, in 1811, that the urine contained albumin in many cases of dropsy, but it was not until Bright began a careful investigation of the bodies of patients who had presented these symptoms, that he discovered the association of various forms of disease of the kidney with anasarca and albuminous urine. In no direction was the harvest of this combined study more abundant than in the complicated and confused subject of fever. The work of Louis and of his pupils, W.W. Gerhard and others, revealed the distinction between typhus and typhoid fever, and so cleared up one of the most obscure problems in pathology. By Morgagni’s method of “anatomical thinking,” Skoda in Vienna, Schonlein in Berlin, Graves and Stokes in Dublin, Marshall Hall, C. J. B. Williams and many others introduced the new and exact methods of the French and created a new clinical medicine. A very strong impetus was given by the researches of Virchow on cellular pathology, which removed the seats of disease from the tissues, as taught by Bichat, to the individual elements, the cells. The introduction of the use of the microscope in clinical work widened greatly our powers of diagnosis, and we obtained thereby a very much clearer conception of the actual processes of disease. In another way, too, medicine was greatly helped by the rise of experimental pathology, which had been introduced by John Hunter, was carried along by Magendie and others, and reached its culmination in the epoch-making researches of Claude Bernard. Not only were valuable studies made on the action of drugs, but also our knowledge of cardiac pathology was revolutionized by the work of Traube, Cohnheim and others. In no direction did the experimental method effect such a revolution as in our knowledge of the functions of the brain. Clinical neurology, which had received a great impetus by the studies of Todd, Romberg, Lockhart Clarke, Duchenne and Weir Mitchell, was completely revolutionized by the experimental work of Hitzig, Fritsch and Ferrier on the localization of functions in the brain. Under Charcot, the school of French neurologists gave great accuracy to the diagnosis of obscure affections of the brain and spinal cord, and the combined results of the new anatomical, physiological and experimental work have rendered clear and definite what was formerly the most obscure and complicated section of internal medicine. The end of the fifth decade of the century is marked by a discovery of supreme importance. Humphry Davy had noted the effects of nitrous oxide. The exhilarating influence of sulphuric ether had been casually studied, and Long of Georgia had made patients inhale the vapor until anaesthetic and had performed operations upon them when in this state; but it was not until October 16, 1846, in the Massachusetts General Hospital, that Morton, in a public operating room, rendered a patient insensible with ether and demonstrated the utility of surgical anaesthesia. The rival claims of priority no longer interest us, but the occasion is one of the most memorable in the history of the race. It is well that our colleagues celebrate Ether Day in Boston—no more precious boon has ever been granted to suffering humanity.(*)

(*) Cf. Osler: Proc. Roy. Soc. Med., XI, Sect. Hist. Med., pp. 65-69, 1918, or, Annals Med. Hist., N.Y., I, 329-332. Cf. also
Morton’s publications reprinted in Camac’s book cited above.—Ed.

In 1857, a young man, Louis Pasteur, sent to the Lille Scientific Society a paper on “Lactic Acid Fermentation” and in December of the same year presented to the Academy of Sciences in Paris a paper on “Alcoholic Fermentation” in which he concluded that “the deduplication of sugar into alcohol and carbonic acid is correlative to a phenomenon of life.” A new era in medicine dates from those two publications. The story of Pasteur’s life should be read by every student.(*) It is one of the glories of human literature, and, as a record of achievement and of nobility of character, is almost without an equal.

(*) Osler wrote a preface for the 1911 English edition of the Life by Vallery-Radot.—Ed.

At the middle of the last century we did not know much more of the actual causes of the great scourges of the race, the plagues, the fevers and the pestilences, than did the Greeks. Here comes Pasteur’s great work. Before him Egyptian darkness; with his advent a light that brightens more and more as the years give us ever fuller knowledge. The facts that fevers were catching, that epidemics spread, that infection could remain attached to articles of clothing, etc., all gave support to the view that the actual cause was something alive, a contagium vivum. It was really a very old view, the germs of which may be found in the Fathers, but which was first clearly expressed—so far as I know—by Fracastorius, the Veronese physician, in the sixteenth century, who spoke of the seeds of contagion passing from one person to another;(12) and he first drew a parallel between the processes of contagion and the fermentation of wine. This was more than one hundred years before Kircher, Leeuwenhoek and others began to use the microscope and to see animalcula, etc., in water, and so give a basis for the “infinitely little” view of the nature of disease germs. And it was a study of the processes of fermentation that led Pasteur to the sure ground on which we now stand.

Out of these researches arose a famous battle which kept Pasteur hard at work for four or five years—the struggle over spontaneous generation. It was an old warfare, but the microscope had revealed a new world, and the experiments on fermentation had lent great weight to the omne vivum ex ovo doctrine. The famous Italians, Redi and Spallanzani, had led the way in their experiments, and the latter had reached the conclusion that there is no vegetable and no animal that has not its own germ. But heterogenesis became the burning question, and Pouchet in France, and Bastian in England, led the opposition to Pasteur. The many famous experiments carried conviction to the minds of scientific men, and destroyed forever the old belief in spontaneous generation. All along, the analogy between disease and fermentation must have been in Pasteur’s mind; and then came the suggestion, “What would be most desirable is to push those studies far enough to prepare the road for a serious research into the origin of various diseases.” If the changes in lactic, alcoholic and butyric fermentations are due to minute living organisms, why should not the same tiny creatures make the changes which occur in the body in the putrid and suppurative diseases? With an accurate training as a chemist, having been diverted in his studies upon fermentation into the realm of biology, and nourishing a strong conviction of the identity between putrefactive changes of the body and fermentation, Pasteur was well prepared to undertake investigations which had hitherto been confined to physicians alone.

So impressed was he with the analogy between fermentation and the infectious diseases that, in 1863, he assured the French Emperor of his ambition “to arrive at the knowledge of the causes of putrid and contagious diseases.” After a study upon the diseases of wines, which has had most important practical bearings, an opportunity arose which changed the whole course of his career, and profoundly influenced the development of medical science. A disease of the silkworm had, for some years, ruined one of the most important industries in France, and in 1865 the Government asked Pasteur to give up his laboratory work and teaching, and to devote his whole energies to the task of investigating it. The story of the brilliant success which followed years of application to the problem will be read with deep interest by every student of science. It was the first of his victories in the application of the experimental methods of a trained chemist to the problems of biology, and it placed his name high in the group of the most illustrious benefactors of practical industries.

In a series of studies on the diseases of beer, and on the mode of production of vinegar, he became more and more convinced that these studies on fermentation had given him the key to the nature of the infectious diseases. It is a remarkable fact that the distinguished English philosopher of the seventeenth century, the man who more than anyone else of his century appreciated the importance of the experimental method, Robert Boyle, had said that he who could discover the nature of ferments and fermentation, would be more capable than anyone else of explaining the nature of certain diseases.

In 1876 there appeared in Cohn’s “Beitrage zur Morphologie der Pflanzen” (II, 277-310), a paper on the “AEtiology of Anthrax” by a German district physician in Wollstein, Robert Koch, which is memorable in our literature as the starting point of a new method of research into the causation of infectious diseases. Koch demonstrated the constant presence of germs in the blood of animals dying from the disease. Years before, those organisms had been seen by Pollender and Davaine, but the epoch-making advance of Koch was to grow those organisms in a pure culture outside the body, and to produce the disease artificially by inoculating animals with the cultures Koch is really our medical Galileo, who, by means of a new technique,—pure cultures and isolated staining,—introduced us to a new world. In 1878, followed his study on the “AEtiology of Wound Infections,” in which he was able to demonstrate conclusively the association of micro-organisms with the disease. Upon those two memorable researches made by a country doctor rests the modern science of bacteriology.

The next great advance was the discovery by Pasteur of the possibility of so attenuating, or weakening, the poison that an animal inoculated had a slight attack, recovered and was then protected against the disease. More than eighty years had passed since on May 14, 1796, Jenner had vaccinated a child with cowpox and proved that a slight attack of one disease protected the body from a disease of an allied nature. An occasion equally famous in the history of medicine was a day in 1881, when Pasteur determined that a flock of sheep vaccinated with the attenuated virus of anthrax remained well, when every one of the unvaccinated infected from the same material had died. Meanwhile, from Pasteur’s researches on fermentation and spontaneous generation, a transformation had been initiated in the practice of surgery, which, it is not too much to say, has proved one of the greatest boons ever conferred upon humanity. It had long been recognized that, now and again, a wound healed without the formation of pus, that is, without suppuration, but both spontaneous and operative wounds were almost invariably associated with that process; and, moreover, they frequently became putrid, as it was then called,—infected, as we should say,—the general system became involved and the patient died of blood poisoning. So common was this, particularly in old, ill-equipped hospitals, that many surgeons feared to operate, and the general mortality in all surgical cases was very high. Believing that it was from outside that the germs came which caused the decomposition of wounds, just as from the atmosphere the sugar solution got the germs which caused the fermentation, a young surgeon in Glasgow, Joseph Lister, applied the principles of Pasteur’s experiments to their treatment. From Lister’s original paper(*) I quote the following: “Turning now to the question how the atmosphere produces decomposition of organic substances, we find that a flood of light has been thrown upon this most important subject by the philosophic researches of M. Pasteur, who has demonstrated by thoroughly convincing evidence that it is not to its oxygen or to any of its gaseous constituents that the air owes this property, but to minute particles suspended in it, which are the germs of various low forms of life, long since revealed by the microscope, and regarded as merely accidental concomitants of putrescence, but now shown by Pasteur to be its essential cause, resolving the complex organic compounds into substances of simpler chemical constitution, just as the yeast-plant converts sugar into alcohol and carbonic acid.” From these beginnings modern surgery took its rise, and the whole subject of wound infection, not only in relation to surgical diseases, but to child-bed fever, forms now one of the most brilliant chapters in the history of preventive medicine.

(*) Lancet, March 16, 1867. (Cf. Camac: Epoch-making Contributions, etc., 1909, p. 7.—Ed.)

With the new technique and experimental methods, the discovery of the specific germs of many of the more important acute infections followed each other with bewildering rapidity: typhoid fever, diphtheria, cholera, tetanus, plague, pneumonia, gonorrhoea and, most important of all, tuberculosis. It is not too much to say that the demonstration by Koch of the “bacillus tuberculosis” (1882) is, in its far-reaching results, one of the most momentous discoveries ever made.

Of almost equal value have been the researches upon the protozoan forms of animal life, as causes of disease. As early as 1873, spirilla were demonstrated in relapsing fever. Laveran proved the association of haematozoa with malaria in 1880. In the same year, Griffith Evans discovered trypanosomes in a disease of horses and cattle in India, and the same type of parasite was found in the sleeping sickness. Amoebae were demonstrated in one form of dysentery, and in other tropical diseases protozoa were discovered, so that we were really prepared for the announcement in 1905, by Schaudinn, of the discovery of a protozoan parasite in syphilis. Just fifty years had passed since Pasteur had sent in his paper on “Lactic Acid Fermentation” to the Lille Scientific Society—half a century in which more had been done to determine the true nature of disease than in all the time that had passed since Hippocrates. Celsus makes the oft-quoted remark that to determine the cause of a disease often leads to the remedy,(*) and it is the possibility of removing the cause that gives such importance to the new researches on disease.

(*) “Et causae quoque estimatio saepe morbum solvit,” Celsus, Lib. I, Prefatio.—Ed.

INTERNAL SECRETIONS

ONE of the greatest contributions of the nineteenth century to scientific medicine was the discovery of the internal secretions of organs. The basic work on the subject was done by Claude Bernard, a pupil of the great Magendie, whose saying it is well to remember—”When entering a laboratory one should leave theories in the cloakroom.” More than any other man of his generation, Claude Bernard appreciated the importance of experiment in practical medicine. For him the experimental physician was the physician of the future—a view well borne out by the influence his epoch-making work has had on the treatment of disease. His studies on the glycogenic functions of the liver opened the way for the modern fruitful researches on the internal secretions of the various glands. About the same time that Bernard was developing the laboratory side of the problem, Addison, a physician to Guy’s Hospital, in 1855, pointed out the relation of a remarkable group of symptoms to disease of the suprarenal glands, small bodies situated above the kidneys, the importance of which had not been previously recognized. With the loss of the function of these glands by disease, the body was deprived of something formed by them which was essential to its proper working. Then, in the last third of the century, came in rapid succession the demonstration of the relations of the pancreas to diabetes, of the vital importance of the thyroid gland and of the pituitary body. Perhaps no more striking illustration of the value of experimental medicine has ever been given than that afforded by the studies upon those glands.

The thyroid body, situated in the neck and the enlargement of which is called goitre, secretes substances which pass into the blood, and which are necessary for the growth of the body in childhood, for the development of the mind and for the nutrition of the tissues of the skin. If, following an infectious disease, a child has wasting of this gland, or if, living in a certain district, it has a large goitre, normal development does not take place, and the child does not grow in mind or body and becomes what is called a cretin. More than this—if in adult life the gland is completely removed, or if it wastes, a somewhat similar condition is produced, and the patient in time loses his mental powers and becomes fat and flabby—myxedematous. It has been shown experimentally in various ways that the necessary elements of the secretion can be furnished by feeding with the gland or its extracts, and that the cretinoid or myxedematous conditions could thus be cured or prevented.

Experimental work has also demonstrated the functions of the suprarenal glands and explained the symptoms of Addison’s disease, and chemists have even succeeded in making synthetically the active principle adrenalin.

There is perhaps no more fascinating story in the history of science than that of the discovery of these so-called ductless glands. Part of its special interest is due to the fact that clinicians, surgeons, experimental physiologists, pathologists and chemists have all combined in splendid teamwork to win the victory. No such miracles have ever before been wrought by physicians as those which we see in connection with the internal secretion of the thyroid gland. The myth of bringing the dead back to life has been associated with the names of many great healers since the incident of Empedocles and Pantheia, but nowadays the dead in mind and the deformed in body may be restored by the touch of the magic wand of science. The study of the interaction of these internal secretions, their influence upon development, upon mental process and upon disorders of metabolism is likely to prove in the future of a benefit scarcely less remarkable than that which we have traced in the infectious diseases.

CHEMISTRY

IT is not making too strong a statement to say that the chemistry and chemical physics of the nineteenth century have revolutionized the world. It is difficult to realize that Liebig’s famous Giessen laboratory, the first to be opened to students for practical study, was founded in the year 1825. Boyle, Cavendish, Priestley, Lavoisier, Black, Dalton and others had laid a broad foundation, and Young, Frauenhofer, Rumford, Davy, Joule, Faraday, Clerk-Maxwell, Helmholtz and others built upon that and gave us the new physics and made possible our age of electricity. New technique and new methods have given a powerful stimulus to the study of the chemical changes that take place in the body, which, only a few years ago, were matters largely of speculation. “Now,” in the words of Professor Lee, “we recognize that, with its living and its non-living substances inextricably intermingled, the body constitutes an intensive chemical laboratory in which there is ever occurring a vast congeries of chemical reactions; both constructive and destructive processes go on; new protoplasm takes the place of old. We can analyze the income of the body and we can analyze its output, and from these data we can learn much concerning the body’s chemistry. A great improvement in the method of such work has recently been secured by the device of inclosing the person who is the subject of the experiment in a respiration calorimeter. This is an air-tight chamber, artificially supplied with a constant stream of pure air, and from which the expired air, laden with the products of respiration, is withdrawn for purposes of analysis. The subject may remain in the chamber for days, the composition of all food and all excrete being determined, and all heat that is given off being measured. Favorable conditions are thus established for an exact study of many problems of nutrition. The difficulties increase when we attempt to trace the successive steps in the corporeal pathway of molecule and atom. Yet these secrets of the vital process are also gradually being revealed. When we remember that it is in this very field of nutrition that there exist great popular ignorance and a special proneness to fad and prejudice, we realize how practically helpful are such exact studies of metabolism.”(13)


(1) Clements R. Markham: Peruvian Bark, John Murray, London, 1880; Memoir of the Lady Anna di Osoria, Countess of Chinchona and Vice-Queen of Peru, 1874.

(2) De abditis nonnullis ac mirandis morborum et sanationum causis. 8th, Florence, Gandhi, 1507.

(3) Possibly it was only a case of angina Ludovici, or retro-pharyngeal abscess.

(4) Venice, 1761.

(5) Boerhaave remarked that if a man wished to deserve or get a medical degree from ONE medical author let it be this. (James Atkinson: Medical Bibliography, 1834, 268.)

(6) Cooke’s Morgagni, Vol. 1, pp. 417-418. I cannot too warmly commend to young clinicians the reading of Morgagni. English
editions are available—Alexander’s three-volume translation of 1769 and Cooke’s Abridgement (London, 1822), of which there was an American edition published in Boston in 1824.

(7) Dictionary of National Biography, London, 1886, VII, 14-17.

(8) Edward Jenner: The Origin of the Vaccine Inoculation, London, 1801.

(9) Jockmann: Pocken und Vaccinationlehre, 1913.

(10) Joseph Frank: Reise nach Paris (etc.), Wien, 1804-05.

(11) E. Boinet: Les doctrines medicules, leur evolution, Paris, 1907, pp. 85-86.

(12) Varro, in De Re Rustica, Bk. I, 12 (circa 40 B.C.), speaks of minute organisms which the eye cannot see and which enter the
body and cause disease.

(13) Frederick S. Lee, Ph.D.: Scientific Features of Modern Medicine, New York, 1911. I would like to call attention to this
work of Professor Lee’s as presenting all the scientific features of modern medicine in a way admirably adapted for anyone, lay or medical, who wishes to get a clear sketch of them.


SOURCE: THE EVOLUTION OF MODERN MEDICINE-A SERIES OF LECTURES DELIVERED AT YALE UNIVERSITY
ON THE SILLIMAN FOUNDATION-IN APRIL, 1913-by William Osler

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