V
To look upon disease as detrimental to the national
interest, as a natural process under changed but yet
natural conditions, as a process to be studied objec-
tively at the bedside, in the dissecting room, and in
the laboratory, was part of the “Enlightenment” of the
Western world after about 1700. But the Enlighten-
ment, notably in the teachings of Jean Jacques Rous-
seau, had its own sentimentality, which it also be-
queathed to the nineteenth century.
Rousseau and his followers looked upon health as
a gift of man's natural state, which luxury and civili-
zation had spoiled. Mothers should breast-feed their
babies, children should wear clothes that do not restrict
their bodies as fashionable dress does. It was bad to
expose the mind, especially the feminine mind, to the
incessant reading of novels. In the eyes of middle-class
society vices led to disease, and some diseases, notably
alcoholism and venereal disease, were shameful be-
cause rooted in an immoral life. The fight which Tissot
(1728-97) and generations of physicians after him led
against masturbation, warning against its alleged
baneful effects upon health, was a secular version of
a biblical taboo (onanism). On the other hand, Tissot
gave advice in matters of health to the people who
had no access to medical help, and Johann Peter
Frank's great work,
System einer vollständigen med-
icinischen Polizey (1779ff.), was to serve the absolute,
yet enlightened authorities in ruling their subjects for
the latter's own good.
That health was seen as such a good was in itself
significant. The more the promises of another world
receded, the more desirable health appeared, not only
as a state to which all people at all times had aspired,
but as an ideal toward which society might actively
work. The practice of variolation was a step in this
direction. Paradoxically enough, in the United States
it found an early advocate in Cotton Mather, who had
played so notorious a role in the Salem witchcraft trials
of 1692. Variolation, since it transferred real smallpox,
though by means of dried matter from a light case,
still was a risky procedure. The risk was eliminated
by Edward Jenner's introduction of vaccination with
cowpox in 1798. In this case at least it was now proven
that man need not be helpless but could remove the
very threat of epidemics.
Vaccination was introduced during the English in-
dustrial revolution, which created health problems of
its own and, like wars, illustrated the dependence of
health not only on nature but on social conditions as
well. Enlightenment and, to some extent, the industrial
revolution brought about a revaluation of the signifi-
cance of disease. Epidemics and the appearance of new
diseases had often been viewed as signs of the wrath
of God punishing sinful mankind. The 1495 mandate
of Emperor Maximilian, which mentioned syphilis as
the punishment for man's blasphemous life, was as
typical of this concept as were the sermons preached
in New York in 1832, when Asiatic cholera made its
appearance (Rosenberg, 1962). But medical disasters
could be averted. Edwin Chadwick, a pupil of Jeremy
Bentham and secretary of the Poor Law Commission,
was responsible for the report on The Sanitary Condi-
tion of the Labouring Population of Great Britain
(1842). The report urged the prevention of illness to
save expense and pointed out the sanitary factors re-
sponsible for widespread sickness and early death.
Moreover, industrialization had led to new hazards in
the occupational life of the workers, and these should
be prevented.
The attention of the student of public health was
forcibly drawn to the social conditions of the times.
It was against this background that Virchow, in 1848,
claimed for the history of epidemics a place in the
cultural history of mankind: “Epidemics resemble large
warning tables in which the statesman of great style
can read that a disturbance has appeared in the devel-
opment of his people which even indifferent politics
must no longer be allowed to overlook.” This meant
that social factors superimposed themselves upon bio-
logical ones to the extent that certain diseases really
were social phenomena (Ackerknecht, 1953). Such
ideas, evoked in the revolutionary period of 1848, were
largely dormant in the following decades, only to
reappear in the twentieth century.
Few movements might be expected to show less
affinity than industrial revolution and romanticism. Yet
while pulmonary tuberculosis was predominant among
industrial workers, it also numbered among its victims
John Keats, Novalis, Chopin, Schiller, and two of the
great medical explorers of tuberculosis, Gaspard Bayle
and Laennec. If periods have diseases fitting their style
(Sigerist, 1928), pulmonary consumption was a roman-
tic disease just as syphilis had belonged to the late
Renaissance, gout and melancholia or love-sickness to
the baroque. But apart from the high incidence of
tuberculosis during the time (1760-1850) covering both
the industrial revolution and the romantic movement,
disease, somatic as well as mental, received almost
loving care by romantically inclined authors and opera
librettists. This is not only true of tuberculosis, but also
of chlorosis, the anemia of the young girl, and of mor-
bid mentality ranging from madness in the gothic
novels to somnambulism and the bizarre characters of
E. T. A. Hoffmann and Edgar Allan Poe. The neurotic
character as hero made its debut with Goethe's
Werther (Feise, 1926). The romantic movement thus
reaccentuated the concept of disease as a contributor
to cultural life.
Equally romantic, however, was the frequent glorifi-
cation of healthy primitive life. “Beneath the rustic
garb of the plowman and not beneath the gildings of
the courtier will strength and vigor of the body be
found,” exclaimed Rousseau (Discours..., p. 104),
and “Healthy as a Shepherd-boy,” sang Wordsworth.
Nature, the country, the wilderness were the antidotes
to the cities, the foci of human degeneracy. Disease
was caused by an infringement of the laws of nature,
and these laws, so the phrenologists claimed, included
mental life too, since the mind had its organs in areas
of the cerebral cortex. An infringement of Nature's
laws was an infringement of God's laws. Health was
not only desirable; in Anglo-Saxon countries its preser-
vation was propagated as something like a moral duty,
a glorification of God. This combination of enlightened
thought and romantic mood gave a religious overtone
to the sanitary movement in its broadest sense.
The medical profession was strongly represented
among the phrenologists and various kinds of sanitary
reformers. Skepticism of traditional curative methods
led many physicians to believe that the healing power
of nature was superior to any medication, especially
since the homeopaths with their unbelievably weak
solutions of drugs showed at least as good results as
did regular practitioners. Some expected progress from
prevention rather than from therapy. The so-called
therapeutic nihilists, e.g., Josef Dietl, thought that
medicine should exert all its efforts towards becoming
a science; until then, it would be best to abstain from
all healing and merely help nature by providing
hygienic conditions for the sick. There was, moreover,
no uniform understanding of disease and its causes. The
anatomico-clinical trend, which led to the recognition
of new disease entities, seemed to favor an ontological
concept of disease. But upon reflection, this appeared
doubtful. It could be argued that while an ulcer of
the stomach explained some of the concomitant symp-
toms, the presence of the ulcer itself remained unex-
plained. Anatomy did not provide an understanding
of the causes of disease, which could only be obtained
from physiology, an experimental science.
It was the stress on experiment that distinguished
the new physiological concept of health and disease
from the earlier one of John Brown and Broussais.
Claude Bernard's Introduction à l'étude de la médecine
expérimentale (1865; Introduction to the Study of Ex-
perimental Medicine, 1926) became the classical philo-
sophical exposition of the new concept. “The words,
life, death, health, disease, have no objective reality,”
wrote Claude Bernard. Life referred to a number of
functions which could proceed normally or abnormally.
The task of physiology was to find out how the body
worked, and this could only be done experimentally.
The supremacy of the physiological concept of disease
had been recognized by Claude Bernard's teacher
Magendie and by the German school of physiologists,
pathologists, and clinicians, who, in the 1840's, were
aligning German medicine with the progress made
abroad. It was also recognized by Virchow, though his
epoch-making contribution, DieCellularpathologie in
ihrer Begründung auf physiologische und pathologische
Gewebelehre (1858), was in some respects a culmina-
tion of older trends.
After Morgagni had looked to the organs as the seat
of diseases, after Bichat (1771-1802) had pointed to
the tissues, Virchow declared the cells responsible for
the body's health and disease. To Virchow, the body
was a social organism dependent on the functioning
of its elements, just as the state depended on the activi-
ties of its elements, the citizens. Virchow tried to
explain changes visible in the cells physiologically, by
recourse to the concepts of irritation (for active
processes) and degeneration (for passive ones). But
these physiological explanations were not the direct
outcome of experimental work, and cellular pathology
impressed the medical world as anatomical in charac-
ter. Nor was it free from vitalistic features displeasing
to a group of physiologists around Carl Ludwig, Du
Bois-Reymond, Brücke, Helmholtz. They, too, had
their own revolutionary program, which Du Bois-
Reymond proclaimed in 1848: eventually physiology
would be dissolved into biophysics and biochemistry,
with analytical mechanics as the ideal form of all
science. This was radical reductionism in its classical
form.
The physiological concept of disease, whether re-
ductionist or not, did not well agree with ontological
systems. There was no reason why nature should be
bound to rigid types. Since every individual differed
from another, and since life could be subjected to an
infinite variety of changed conditions, every sick person
really represented his own disease. Claude Bernard did
not overlook this. Ordinary causes, such as cold,
hunger, thirst, fatigue, and mental suffering, were
modified by idiosyncrasy, which was partly congenital
and partly accidental. The pathological predispositions
were nothing but special physiological conditions: a
starved and a satiated organism reacted differently.
In disease, nature played the role of the experi-
menter; the observable changes could be viewed as
experiments of nature and analyzed accordingly.
Nosology, it was argued, was no more than a practical
makeshift to be disregarded by the medical scientist.
The existence of a clear demarcation between health
and disease was altogether doubtful. Virchow, who had
followed Henle in defining disease as life under
changed circumstances, later came to realize the in-
adequacy of this definition. Circumstances might
change drastically; a man could find himself in jail and
yet remain healthy. Disease began at the moment when
the regulatory equipment of the body no longer suf-
ficed to remove the disturbances. “Not life under
abnormal conditions, not the disturbance as such, en-
genders a disease, rather disease begins with the insuf-
ficiency of the regulatory apparatuses” (Virchow [1869],
p. 93).
In this respect, Virchow and Claude Bernard were
not very far apart. The latter placed increasing em-
phasis upon the internal milieu, i.e., blood and tissue
fluids, which provided a steady environment for the
cells composing the body and made it independent of
the vagaries of the external environment. The con-
stancy of the internal milieu was largely maintained
through the regulatory functions of the nervous system.
Later (1928) Walter Cannon introduced the term
“homeostasis” to designate the condition of actively
sustained equilibrium prevailing in the organism. By
then, the significance of endocrine glands in the regu-
latory mechanisms of the body had been recognized.
