University of Virginia Library

IV

With the decline of Aristotelian science, the chal-
lenge to the Galenic doctrines by the revolutionary
Paracelsus, the reform of anatomy by Vesalius, and the
discovery of the circulation of the blood by William
Harvey, pathology had undergone decisive changes.
The humors did not disappear at once, but the new
physics and chemistry replaced the Galenic doctrine
of health and disease as a balance or imbalance, re-
spectively, of the qualities. Descartes thought of the
animal body as a soulless machine; even in man only
the conscious mental processes involved the soul. To
overcome the difficulty regarding acts which were
seemingly purposeful yet independent of, or even con-
trary to, man's will, Descartes introduced the idea of
reflex action. The Cartesian philosophy favored a
physiology and pathology on strictly mechanical prin-
ciples with the help of a corpuscular theory which
permitted the inclusion of chemical explanations.

If the body is a machine, health will be represented
by a well-functioning machine, disease by a defective
one. A machine can have some self-regulatory
mechanisms built in, but it does not create new ones
when the situation so demands. It was, therefore, logi-
cal for Robert Boyle to refuse to see all diseases as
healing processes. His theological bias was against the
pagan view of nature as a benevolent being. Natural
processes were blind and could be destructive. A
dropsical person might be plagued by thirst, yet drink-
ing would aggravate the disease (Boyle, 1725). The
radical Cartesian dichotomy of body and soul also
entailed a basic difficulty concerning mental diseases.
It was logically absurd to think of the soul, a res cogi-
tans, as being prone to sickness in the manner of the
body; this could only be done metaphorically in the
manner in which crime, sin, heresy had long been
called diseases of the soul.

Revolutionary as the new mechanical orientation
was, it did not sweep everything before it. Even those
physicians who were inclined towards mechanistic
theories admitted their ineffectiveness at the bedside.
They recommended a Hippocratic attitude and patient
observation of the disease. Many physicians were un-
willing to follow the new mechanistic trend, and to
some of them theories altogether meant little.

Generally speaking, in the seventeenth century
mechanization was less successful in biology than in
the world of physics. Harvey himself, van Helmont,

Glisson, Wepfer, Stahl are outstanding among those
who, in one form or another, did not believe that life,
health, and disease could be understood without as-
suming the participation of the soul or of vital princi-
ples immanent in the body. They spoke of anima, of
the Archeus, of a “president,” or they endowed all
fibres with irritability. It all meant that the human
organism was actively engaged in preserving or restor-
ing health.

Before the middle of the eighteenth century, discus-
sions about the respective roles of mechanism and
vitalism were mainly carried on by doctors of medicine,
who devoted their attention and practice to internal
diseases. Apothecaries were interested in chemical
medicine, and it fell to them to prepare the chemical
drugs that had come into vogue with Paracelsus. In
England they gradually assumed the role of general
practitioners. Here the apothecary, who sold the med-
icine, dispensed medical advice together with his med-
icines. For this kind of practice nosological orientation
was particularly valuable. Another class of medical
man, the surgeon, also looked upon disease differently
from the doctor of medicine. In the Middle Ages the
surgeons had become separated from the physicians
and were organized in guilds, usually together with
the barbers. They looked after wounds, ulcers, absces-
ses, fractures, dislocations, diseases of the skin and
venereal diseases, tumors, possibly also cataracts,
herniae, and stones of the bladder. Moreover, they bled
patients if the doctor so prescribed. Their domain was
external disorders in contrast to internal illness. In most
cases, these disorders were localized, and in judging
them and treating them the surgeon had to know
something of the anatomy of the human body. Anat-
omy became the surgeon's preferred science, as chem-
istry was that of the apothecary.

With the exception of relatively few well-trained
men, the guild surgeon was not educated enough and
his social status was too low to allow him a decisive
influence on medical thought. Nevertheless, it is not
by chance that, though a doctor of medicine, Vesalius,
the reformer of human anatomy, was professor of sur-
gery at the University of Padua. With the appearance
of his Fabrica, in 1543, normal human anatomy became
firmly based on dissections of human cadavers. Patho-
logical anatomy, which studied morbid changes, de-
veloped more slowly, in spite of the fact that post-
mortem dissections to establish the cause of death had
been performed prior to anatomies intended to teach
the structure of man's body. Postmortem dissections
concerned cases where the disease showed unusual
features or where legal questions arose. With G. B.
Morgagni's De sedibus et causis morborum (“On the
Seats and Causes of Diseases,” 1761) pathological
anatomy became a science in its own right. Its practical
aim was to correlate the course of the disease and its
symptoms with the changes noticed after death.

As the title of his book indicates, Morgagni traced
the symptoms back to lesions in the organs, something
surgeons had usually done. But in surgical disorders,
the lesions were mostly visible or palpable, which in
internal diseases they were not. Pathological anatomy,
therefore, was of little use to the physician as long as
it was not possible to explore the condition of internal
organs during life. Two steps helped realize this goal.
Auenbrugger taught (1761) that changes in sound elic-
ited by percussion of the chest yielded information
about changes in the consistency of the organs of the
chest. Auenbrugger's work was popularized by Na-
poleon's physician, Corvisart, after the French Rev-
olution had led to a union of medicine and surgery.
The second step, made by Laennec, consisted in the
introduction of the stethoscope (1819). With its aid
Laennec was able to compare more effectively than
before the sounds heard over the heart and the lungs
under normal conditions with sounds heard when these
organs were ill. Percussion and auscultation helped the
physician to obtain an objective view of the patient's
illness; he was less dependent on subjective complaints.
The Paris school, leading in the new anatomical con-
cept of disease, found followers in London, Dublin,
Vienna, and elsewhere. The new insight into disease
through the combination of clinical and anatomical
pictures led to the elimination of old disease entities
and the solid establishment of others, like typhoid
fever, gastric ulcer, multiple sclerosis, and diphtheria.

The new objectivity found its place in the hospitals,
which housed a large number of patients, many of them
suffering from the same disease. Apart from wards,
hospitals also included dissection rooms and then
laboratories. Down to the later nineteenth century, the
hospital was predominantly a place for indigent pa-
tients, who were not under the personal care of a
particular physician but became “material” for obser-
vation and charitable treatment. Thereby the large
hospitals invited a statistical approach to sickness and
to therapy. In the eighteen-twenties Louis, in Paris,
investigated the influence of bleeding in the early
stages of pneumonia upon the course of the disease.
Some patients were bled early, as was the custom,
others were not. The results showed that early bleeding
did not improve the chances for recovery. A very
important insight into the unreliability of time-
hallowed therapeutics had been gained, and the nu-
merical method had been well illustrated.

The objective view of illness found in the large
hospitals had not originated there alone. The rise of
the modern state developed statistical methods which

covered the nation's health. In England, bills of mor-
tality stating the number of deaths from various causes
had come into use sometime in the sixteenth century.
Originally designed as intelligence about the spread
of epidemic disease, these bills, in the seventeenth
century, were used by John Graunt as a basis for vital
statistics. Mercantilism, with its advocacy of national
industries in the interest of a positive balance of trade,
calculated the economic advantages of health and the
loss incurred to the national economy through sickness
and untimely death. Bellers, in 1714, suggested that
Parliament make provisions for the improvement of
medicine so that the population

(p. 3).

The lack of sentimentality which permitted estimating
human life and suffering in terms of shillings and pence
presupposed the existence of a large anonymous popu-
lation in urban centers. It expressed the development
of a rationalized way of life.

With beginnings less clearly defined, the medical
application of scales, clocks, and thermometers also
promoted objective study of disease. These instruments
and a few simple chemical reactions were the forerun-
ners of the powerful array of the diagnostic laboratory.
Greek physicians had already used clocks to measure
the pulse rate and had proposed scales to determine
metabolic processes. Moreover, both these instruments,
and the thermometer for measuring the temperature
of the body, had been explored for medical use by
Santorio Santorio (1561-1636). But their widespread
acceptance was very slow. As late as 1860 Wunderlich
found it necessary to argue that the use of the clinical
thermometer was neither too expensive, neither too
time consuming for the practitioner, nor too bother-
some nor altogether superfluous (Ebstein, 1928). A
common principle underlying these instruments and
their much more complicated successors is the need
to establish numerical data. In the Galenic tradition,
normalcy had been viewed as an optimal natural state.
Vesalius described the human body in its theoretical
perfection. But the numerical limits of normal pulse
rate or body temperature must be based on measure-
ments in many individuals. The elaboration of tables
of numerical values gave health and disease a statistical
aspect, and the physiognomy of diseases could be ex-
pressed on graphs. The typical fever curves of many
infectious diseases, worked out by Wunderlich, enabled
the physician to make a tentative diagnosis from the
chart.

To be sure, all these aspects of modern “laboratory
medicine” (Ackerknecht, 1955) were far ahead of the
eighteenth century, when even scales, clocks, and
thermometers were used only by a few relatively
audacious minds. Yet it is not without significance that
De Haen (1704-76), whose hospital reports were a
major contribution to the practical medical literature
of the century, also urged the use of the thermometer
and tried to establish the normal temperatures for
various age groups (Ebstein, 1928). Essentially, the use
of numerical data in the diagnosis of disease presup-
poses that the latter is a physiological process. The
activities of the body can increase and diminish and
still remain within the range of the “normal.” There
is a transition from undoubted health to manifest dis-
ease.

This notion was elaborated in the system of John
Brown (1735-88). He assumed that the interaction
between the excitability with which the body was
endowed and the stimuli, external and internal, which
it encountered during life determined health and the
contrasting conditions of asthenia and sthenia. Health
was the territory between these two conditions. In a
few countries the direct impact of this system was
dramatic, in others it was slight. But its indirect influ-
ence on the development of physiological medicine in
the nineteenth century was very great. Both health and
disease represented life, and disease differed only in
representing life under changed circumstances.