University of Virginia Library

7. EIGHTEENTH-CENTURY MEDICINE

THE SYSTEM OF BOERHAAVE

AT least two pupils of William Harvey distinguished themselves in medicine, Giorgio Baglivi (1669-1707), who has been called the "Italian Sydenham," and Hermann Boerhaave (1668-1738). The work of Baglivi was hardly begun before his early death removed one of the most promising of the early eighteenth-century physicians. Like Boerhaave, he represents a type of skilled, practical clinitian rather than the abstract scientist. One of his contributions to medical literature is the first accurate description of typhoid, or, as he calls it, mesenteric fever.

If for nothing else, Boerhaave must always be remembered as the teacher of Von Haller, but in his own day he was the widest known and the most popular teacher in the medical world. He was the idol of his pupils at Leyden, who flocked to his lectures in such numbers that it became necessary to "tear down the walls of Leyden to accommodate them." His fame extended not only all over Europe but to Asia, North America, and even into South America. A letter sent him from China was addressed to "Boerhaave in Europe." His teachings represent the best medical knowledge of his day, a high standard of morality, and

a keen appreciation of the value of observation; and it was through such teachings imparted to his pupils and advanced by them, rather than to any new discoveries, that his name is important in medical history. His arrangement and classification of the different branches of medicine are interesting as representing the attitude of the medical profession towards these various branches at that time.

"In the first place we consider Life; then Health, afterwards Diseases; and lastly their several Remedies.

"Health the first general branch of Physic in our Institutions is termed Physiology, or the Animal Oeconomy; demonstrating the several Parts of the human Body, with their Mechanism and Actions.

"The second branch of Physic is called Pathology, treating of Diseases, their Differences, Causes and Effects, or Symptoms; by which the human Body is known to vary from its healthy state.

"The third part of Physic is termed Semiotica, which shows the Signs distinguishing between sickness and Health, Diseases and their Causes in the human Body; it also imports the State and Degrees of Health and Diseases, and presages their future Events.

"The fourth general branch of Physic is termed Hygiene, or Prophylaxis.

"The fifth and last part of Physic is called Therapeutica; which instructs us in the Nature, Preparation and uses of the Materia Medica; and the methods of applying the same, in order to cure Diseases and restore lost Health."1

From this we may gather that his general view of medicine was not unlike that taken at the present time.

Boerhaave's doctrines were arranged into a "system" by Friedrich Hoffmann, of Halle (1660-1742), this system having the merit of being simple and more easily comprehended than many others. In this system forces were considered inherent in matter, being expressed as mechanical movements, and determined by mass, number, and weight. Similarly, forces express themselves in the body by movement, contraction, and relaxation, etc., and life itself is movement, "particularly movement of the heart." Life and death are, therefore, mechanical phenomena, health is determined by regularly recurring movements, and disease by irregularity of them. The body is simply a large hydraulic machine, controlled by "the æther" or "sensitive soul," and the chief centre of this soul lies in the medulla.

In the practical application of medicines to diseases Hoffman used simple remedies, frequently with happy results, for whatever the medical man's theory may be he seldom has the temerity to follow it out logically, and use the remedies indicated by his theory to the exclusion of long-established, although perhaps purely empirical, remedies. Consequently, many vague theorists have been excellent practitioners, and Hoffman was one of these. Some of the remedies he introduced are still in use, notably the spirits of ether, or "Hoffman's anodyne."

ANIMISTS, VITALISTS, AND ORGANICISTS

Besides Hoffman's system of medicine, there were numerous others during the eighteenth century, most

of which are of no importance whatever; but three, at least, that came into existence and disappeared during the century are worthy of fuller notice. One of these, the Animists, had for its chief exponent Georg Ernst Stahl of "phlogiston" fame; another, the Vitalists, was championed by Paul Joseph Barthez (1734-1806); and the third was the Organicists. This last, while agreeing with the other two that vital activity cannot be explained by the laws of physics and chemistry, differed in not believing that life "was due to some spiritual entity," but rather to the structure of the body itself.

The Animists taught that the soul performed functions of ordinary life in man, while the life of lower animals was controlled by ordinary mechanical principles. Stahl supported this theory ardently, sometimes violently, at times declaring that there were "no longer any doctors, only mechanics and chemists." He denied that chemistry had anything to do with medicine, and, in the main, discarded anatomy as useless to the medical man. The soul, he thought, was the source of all vital movement; and the immediate cause of death was not disease but the direct action of the soul. When through some lesion, or because the machinery of the body has become unworkable, as in old age, the soul leaves the body and death is produced. The soul ordinarily selects the channels of the circulation, and the contractile parts, as the route for influencing the body. Hence in fever the pulse is quickened, due to the increased activity of the soul, and convulsions and spasmodic movements in disease are due, to the, same cause. Stagnation of the, blood

was supposed to be a fertile cause of diseases, and such diseases were supposed to arise mostly from "plethora" —an all-important element in Stahl's therapeutics. By many this theory is regarded as an attempt on the part of the pious Stahl to reconcile medicine and theology in a way satisfactory to both physicians and theologians, but, like many conciliatory attempts, it was violently opposed by both doctors and ministers.

A belief in such a theory would lead naturally to simplicity in therapeutics, and in this respect at least Stahl was consistent. Since the soul knew more about the body than any physician could know, Stahl conceived that it would be a hinderance rather than a help for the physician to interfere with complicated doses of medicine. As he advanced in age this view of the administration of drugs grew upon him, until after rejecting quinine, and finally opium, he at last used only salt and water in treating his patients. From this last we may judge that his "system," if not doing much good, was at least doing little harm.

The theory of the Vitalists was closely allied to that of the Animists, and its most important representative, Paul Joseph Barthez, was a cultured and eager scientist. After an eventful and varied career as physician, soldier, editor, lawyer, and philosopher in turn, he finally returned to the field of medicine, was made consulting physician by Napoleon in 1802, and died in Paris four years later.

The theory that he championed was based on the assumption that there was a "vital principle," the nature of which was unknown, but which differed from the thinking mind, and was the cause of the phenomena

of life. This "vital principle" differed from the soul, and was not exhibited in human beings alone, but even in animals and plants. This force, or whatever it might be called, was supposed to be present everywhere in the body, and all diseases were the results of it.

The theory of the Organicists, like that of the Animists and Vitalists, agreed with the other two that vital activity could not be explained by the laws of physics and chemistry, but, unlike them, it held that it was a part of the structure of the body itself. Naturally the practical physicians were more attracted by this tangible doctrine than by vague theories "which converted diseases into unknown derangements of some equally unknown `principle.' "

It is perhaps straining a point to include this brief description of these three schools of medicine in the history of the progress of the science. But, on the whole, they were negatively at least prominent factors in directing true progress along its proper channel, showing what courses were not to be pursued. Some one has said that science usually stumbles into the right course only after stumbling into all the wrong ones; and if this be only partially true, the wrong ones still play a prominent if not a very creditable part. Thus the medical systems of William Cullen (1710-1790), and John Brown (1735-1788), while doing little towards the actual advancement of scientific medicine, played so conspicuous a part in so wide a field that the "Brunonian system" at least must be given some little attention.

According to Brown's theory, life, diseases, and

methods of cure are explained by the property of "excitability." All exciting powers were supposed to be stimulating, the apparent debilitating effects of some being due to a deficiency in the amount of stimulus. Thus "the whole phenomena of life, health, as well as disease, were supposed to consist of stimulus and nothing else." This theory created a great stir in the medical world, and partisans and opponents sprang up everywhere. In Italy it was enthusiastically supported; in England it was strongly opposed; while in Scotland riots took place between the opposing factions. Just why this system should have created any stir, either for or against it, is not now apparent.

Like so many of the other "theorists" of his century, Brown's practical conclusions deduced from his theory (or perhaps in spite of it) were generally beneficial to medicine, and some of them extremely valuable in the treatment of diseases. He first advocated the modern stimulant, or "feeding treatment" of fevers, and first recognized the usefulness of animal soups and beef-tea in certain diseases.

THE SYSTEM OF HAHNEMANN

Just at the close of the century there came into prominence the school of homœopathy, which was destined to influence the practice of medicine very materially and to outlive all the other eighteenth-century schools. It was founded by Christian Samuel Friedrich Hahnemann (1755-1843), a most remarkable man, who, after propounding a theory in his younger days which was at least as reasonable as most of the existing theories, had the misfortune to outlive his usefulness and lay

his doctrine open to ridicule by the unreasonable teachings of his dotage,

Hahnemann rejected all the teachings of morbid anatomy and pathology as useless in practice, and propounded his famous "similia similibus curantur"— that all diseases were to be cured by medicine which in health produced symptoms dynamically similar to the disease under treatment. If a certain medicine produced a headache when given to a healthy person, then this medicine was indicated in case of headaches, etc. At the present time such a theory seems crude enough, but in the latter part of the eighteenth century almost any theory was as good as the ones propounded by Animists, Vitalists, and other such schools. It certainly had the very commendable feature of introducing simplicity in the use of drugs in place of the complicated prescriptions then in vogue. Had Hahnemann stopped at this point he could not have been held up to the indefensible ridicule that was brought upon him, with considerable justice, by his later theories. But he lived onto propound his extraordinary theory of "potentiality" —that medicines gained strength by being diluted— and his even more extraordinary theory that all chronic diseases are caused either by the itch, syphilis, or fig-wart disease, or are brought on by medicines.

At the time that his theory of potentialities was promulgated, the medical world had gone mad in its administration of huge doses of compound mixtures of drugs, and any reaction against this was surely an improvement. In short, no medicine at all was much better than the heaping doses used in common practice; and hence one advantage, at least, of Hahnemann's

methods. Stated briefly, his theory was that if a tincture be reduced to one-fiftieth in strength, and this again reduced to one-fiftieth, and this process repeated up to thirty such dilutions, the potency of such a medicine will be increased by each dilution, Hahnemann himself preferring the weakest, or, as he would call it, the strongest dilution. The absurdity of such a theory is apparent when it is understood that long before any drug has been raised to its thirtieth dilution it has been so reduced in quantity that it cannot be weighed, measured, or recognized as being present in the solution at all by any means known to chemists. It is but just to modern followers of homœopathy to say that while most of them advocate small dosage, they do not necessarily follow the teachings of Hahnemann in this respect, believing that the theory of the dose "has nothing more to do with the original law of cure than the psora (itch) theory has; and that it was one of the later creations of Hahnemann's mind."

Hahnemann's theory that all chronic diseases are derived from either itch, syphilis, or fig-wart disease is no longer advocated by his followers, because it is so easily disproved, particularly in the case of itch. Hahnemann taught that fully three-quarters of all diseases were caused by "itch struck in," and yet it had been demonstrated long before his day, and can be demonstrated any time, that itch is simply a local skin disease caused by a small parasite.

JENNER AND VACCINATION

All advances in science have a bearing, near or remote, on the welfare of our race; but it remains to

credit to the closing decade of the eighteenth century a discovery which, in its power of direct and immediate benefit to humanity, surpasses any other discovery of this or any previous epoch. Needless to say, I refer to Jenner's discovery of the method of preventing smallpox by inoculation with the virus of cow-pox. It detracts nothing from the merit of this discovery to say that the preventive power of accidental inoculation had long been rumored among the peasantry of England. Such vague, unavailing half-knowledge is often the forerunner of fruitful discovery.

To all intents and purposes Jenner's discovery was original and unique. Nor, considered as a perfect method, was it in any sense an accident. It was a triumph of experimental science. The discoverer was no novice in scientific investigation, but a trained observer, who had served a long apprenticeship in scientific observation under no less a scientist than the celebrated John Hunter. At the age of twenty-one Jenner had gone to London to pursue his medical studies, and soon after he proved himself so worthy a pupil that for two years he remained a member of Hunter's household as his favorite pupil. His taste for science and natural history soon attracted the attention of Sir Joseph Banks, who intrusted him with the preparation of the zoological specimens brought back by Captain Cook's expedition in 1771. He performed this task so well that he was offered the position of naturalist to the second expedition, but declined it, preferring to take up the practice of his profession in his native town of Berkeley.

His many accomplishments and genial personality

soon made him a favorite both as a physician and in society. He was a good singer, a fair violinist and flute-player, and a very successful writer of prose and verse. But with all his professional and social duties he still kept up his scientific investigations, among other things making some careful observations on the hibernation of hedgehogs at the instigation of Hunter, the results of which were laid before the Royal Society. He also made quite extensive investigations as to the geological formations and fossils found in his neighborhood.

Even during his student days with Hunter he had been much interested in the belief, current in the rural districts of Gloucestershire, of the antagonism between cow-pox and small-pox, a person having suffered from cow-pox being immuned to small-pox. At various times Jenner had mentioned the subject to Hunter, and he was constantly making inquiries of his fellow-practitioners as to their observations and opinions on the subject. Hunter was too fully engrossed in other pursuits to give the matter much serious attention, however, and Jenner's brothers of the profession gave scant credence to the rumors, although such rumors were common enough.

At this time the practice of inoculation for preventing small-pox, or rather averting the severer forms of the disease, was widely practised. It was customary, when there was a mild case of the disease, to take some of the virus from the patient and inoculate persons who had never had the disease, producing a similar attack in them. Unfortunately there were many objections to this practice. The inoculated patient frequently

EDWARD JENNER

[Description: EDWARD JENNER, from a print engraved and colored by J.R. Smith.]

developed a virulent form of the disease and died; or if he recovered, even after a mild attack, he was likely to be "pitted" and disfigured. But, perhaps worst of all, a patient so inoculated became the source of infection to others, and it sometimes happened that disastrous epidemics were thus brought about. The case was a most perplexing one, for the awful scourge of small-pox hung perpetually over the head of every person who had not already suffered and recovered from it. The practice of inoculation was introduced into England by Lady Mary Wortley Montague (1690-1762), who had seen it practised in the East, and who announced her intention of "introducing it into England in spite of the doctors."

From the fact that certain persons, usually milk-maids, who had suffered from cow-pox seemed to be immuned to small-pox, it would seem a very simple process of deduction to discover that cow-pox inoculation was the solution of the problem of preventing the disease. But there was another form of disease which, while closely resembling cow-pox and quite generally confounded with it, did not produce immunity. The confusion of these two forms of the disease had constantly misled investigations as to the possibility of either of them immunizing against small-pox, and the confusion of these two diseases for a time led Jenner to question the possibility of doing so. After careful investigations, however, he reached the conclusion that there was a difference in the effects of the two diseases, only one of which produced immunity from small-pox.

"There is a disease to which the horse, from his state

of domestication, is frequently subject," wrote Jenner, in his famous paper on vaccination. "The farriers call it the grease. It is an inflammation and swelling in the heel, accompanied at its commencement with small cracks or fissures, from which issues a limpid fluid possessing properties of a very peculiar kind. This fluid seems capable of generating a disease in the human body (after it has undergone the modification I shall presently speak of) which bears so strong a resemblance to small-pox that I think it highly probable it may be the source of that disease.

"In this dairy country a great number of cows are kept, and the office of milking is performed indiscriminately by men and maid servants. One of the former having been appointed to apply dressings to the heels of a horse affected with the malady I have mentioned, and not paying due attention to cleanliness, incautiously bears his part in milking the cows with some particles of the infectious matter adhering to his fingers. When this is the case it frequently happens that a disease is communicated to the cows, and from the cows to the dairy-maids, which spreads through the farm until most of the cattle and domestics feel its unpleasant consequences. This disease has obtained the name of Cow-Pox. It appears on the nipples of the cows in the form of irregular pustules. At their first appearance they are commonly of a palish blue, or rather of a color somewhat approaching to livid, and are surrounded by an inflammation. These pustules, unless a timely remedy be applied, frequently degenerate into phagedenic ulcers, which prove extremely troublesome. The animals become indisposed, and

the secretion of milk is much lessened. Inflamed spots now begin to appear on different parts of the hands of the domestics employed in milking, and sometimes on the wrists, which run on to suppuration, first assuming the appearance of the small vesications produced by a burn. Most commonly they appear about the joints of the fingers and at their extremities; but whatever parts are affected, if the situation will admit the superficial suppurations put on a circular form with their edges more elevated than their centre and of a color distinctly approaching to blue. Absorption takes place, and tumors appear in each axilla. The system becomes affected, the pulse is quickened; shiverings, succeeded by heat, general lassitude, and pains about the loins and limbs, with vomiting, come on. The head is painful, and the patient is now and then even affected with delirium. These symptoms, varying in their degrees of violence, generally continue from one day to three or four, leaving ulcerated sores about the hands which, from the sensibility of the parts, are very troublesome and commonly heal slowly, frequently becoming phagedenic, like those from which they sprang. During the progress of the disease the lips, nostrils, eyelids, and other parts of the body are sometimes affected with sores; but these evidently arise from their being heedlessly rubbed or scratched by the patient's infected fingers. No eruptions on the skin have followed the decline of the feverish symptoms in any instance that has come under my inspection, one only excepted, and in this case a very few appeared on the arms: they were very minute, of a vivid red color, and soon died away without advancing to maturation, so that I cannot determine whether they had any connection with the preceding symptoms.

"Thus the disease makes its progress from the horse (as I conceive) to the nipple of the cow, and from the cow to the human subject.

"Morbid matter of various kinds, when absorbed into the system, may produce effects in some degree similar; but what renders the cow-pox virus so extremely singular is that the person that has been thus affected is forever after secure from the infection of small-pox, neither exposure to the variolous effluvia nor the insertion of the matter into the skin producing this distemper."2

In 1796 Jenner made his first inoculation with cow-pox matter, and two months later the same subject was inoculated with small-pox matter. But, as Jenner had predicted, no attack of small-pox followed. Although fully convinced by this experiment that the case was conclusively proven, he continued his investigations, waiting two years before publishing his discovery. Then, fortified by indisputable proofs, he gave it to the world. The immediate effects of his announcement have probably never been equalled in the history of scientific discovery, unless, perhaps, in the single instance of the discovery of anæsthesia. In Geneva and Holland clergymen advocated the practice of vaccination from their pulpits; in some of the Latin countries religious processions were formed for receiving vaccination; Jenner's birthday was celebrated as a feast in Germany; and the first child vaccinated

in Russia was named "Vaccinov" and educated at public expense. In six years the discovery had penetrated to the most remote corners of civilization; it had even reached some savage nations. And in a few years small-pox had fallen from the position of the most dreaded of all diseases to that of being practically the only disease for which a sure and easy preventive was known.

Honors were showered upon Jenner from the Old and the New World, and even Napoleon, the bitter hater of the English, was among the others who honored his name. On one occasion Jenner applied to the Emperor for the release of certain Englishmen detained in France. The petition was about to be rejected when the name of the petitioner was mentioned. "Ah," said Napoleon, "we can refuse nothing to that name!"

It is difficult for us of to-day clearly to conceive the greatness of Jenner's triumph, for we can only vaguely realize what a ruthless and ever-present scourge small-pox had been to all previous generations of men since history began. Despite all efforts to check it by medication and by direct inoculation, it swept now and then over the earth as an all-devastating pestilence, and year by year it claimed one-tenth of all the beings in Christendom by death as its average quota of victims. "From small-pox and love but few remain free," ran the old saw. A pitted face was almost as much a matter of course a hundred years ago as a smooth one is to-day.

Little wonder, then, that the world gave eager acceptance to Jenner's discovery. No urging was needed

to induce the majority to give it trial; passengers on a burning ship do not hold aloof from the life-boats. Rich and poor, high and low, sought succor in vaccination and blessed the name of their deliverer. Of all the great names that were before the world in the closing days of the century, there was perhaps no other one at once so widely known and so uniformly reverenced as that of the great English physician Edward Jenner. Surely there was no other one that should be recalled with greater gratitude by posterity.