by Will Durant
X. He served as president of the Royal Society of London from 1778 to 1820, and bequeathed his library and collections to the British Museum.
CHAPTER XVII
Medicine
1715–89
I. ANATOMY AND PHYSIOLOGY
AND there was the impact of science upon medicine. The healing art was bound up with the improvement of the microscope and the thermometer, with the rise of chemistry and biology, and, above all, with the advancing knowledge of human and animal anatomy and physiology. Most of the researches in anatomy and physiology were the work of the doctors themselves.
Giovanni Battista Morgagni was typical of the many physicians who made medicine a science by keeping clinical records of the cases that came under their care. Seven hundred such cases were scrutinized by him in his devoted career as practitioner and professor of medicine at Padua. In his eightieth year (1761) he reported his observations in the form of seventy letters that founded pathological anatomy: De sedibus et causis morborum per anatomen indagatis (On the Seats and Causes of Diseases as Investigated by Anatomy). Here he gave classical descriptions of heart block, yellow atrophy of the liver, and tuberculosis of the kidney; he identified the clinical features of pneumonia with solidifications of the lungs; and he added significantly to cardiology. “The section on aneurysm [abnormal blood-filled dilation] of the aorta,” said Sir William Osler, “remains one of the best ever written”; and “what could be more correct than his account of angina pectoris?”1 Now, more clearly than ever before, the seat of each illness was localized in morbid alterations of specific organs. Impressed by Morgagni’s work, the hospitals—with no protest from Church or state—provided him and his assistants with cadavers from all classes of the community, even nobles and ecclesiastics; many individuals, in the wish to advance science, expressed a desire to have their bodies examined by Morgagni after their death.2 He made experiments on animals, again without protest from the Church. He continued to teach till his ninetieth year. In 1764, aged eighty-two, he was reported to be “as hale as a man of fifty, and still working without spectacles.”3 His students proudly proclaimed him “anatomicorum totius Europae princeps” In 1931 his native Forli raised a monument to him in the piazza that bears his name.
His pupil Antonio Scarpa became professor of anatomy at Modena at the age of twenty. When, aged thirty-six (1783), he was promoted to the chair of anatomy at Pavia, he joined Spallanzani and Volta in making that university one of the greatest in Europe. His anatomical studies of the ear, the nose, the feet, and the nerves won him international renown; his Osservazioni sulle principali malattie degli occhi (1801) continued for several decades to be the standard text of ophthalmology. Just a year younger than Scarpa, Félix Vicq-d’Azyr studied the comparative anatomy of birds, quadrupeds, and man; his results showed a remarkable and detailed similarity in the structure of the limbs in men and beasts, and shared in putting man in his biological place. He died at forty-six (1794), without having completed a work which had already brought the anatomy of the brain to its eighteenth-century peak.
In Great Britain two Hunters, born in Scotland, added brilliance to the Scottish Enlightenment by their work in anatomy and surgery. William’s lectures revolutionized the teaching of anatomy in London, where that subject had long been hampered by restriction on the availability of cadavers. He won fame by his epochal discovery (1758) of the absorbent function of the lymphatics, by his classic Anatomy of the Gravid Uterus (1774), and by his volcanic temper, which he explained on the ground that, being an anatomist, he was accustomed to “the passive submission of dead bodies.”4 He died in 1783, aged sixty-five, from exhaustion incurred in a lecture. He bequeathed his extensive anatomical collection to Glasgow, where it is still maintained as the Hunterian Museum.
John Hunter was born ten years after his brother, and died ten years after his brother’s death. At twenty-one (1749) he had acquired sufficient knowledge to take charge of William’s class in practical anatomy. While with his brother, he solved the problem of the descent of the testes in the foetus, traced the placental circulation and the ramifications of nasal and olfactory nerves, discovered the tear ducts, and took a leading part in exposing the functions of the lymphatic ducts. At twenty-seven he entered Oxford; however, finding Latin and Greek deader than cadavers, he left college and joined the army as a surgeon. In active service abroad he learned much about gunshot wounds; at his death he left a classic treatise on that subject. Back in England, he practiced and taught surgery, and continued his investigations of anatomy and physiology. In 1767 he met with an accident that ruptured his “tendon of Achilles” (which binds the muscles of the calf of the leg to the heel); from observations then made on himself, and from experiments on dogs, he found successful surgery for club feet and other deformities involving tendons. Having inadvertently inoculated himself with syphilis, he delayed its treatment in order to study the disease at first hand;5 however, he made the mistake of identifying syphilis with gonorrhea. He proved by experiment that digestion does not take place in snakes and lizards during hibernation. In his house at Brompton he gathered for his researches a weird menagerie of pheasants, partridges, toads, fish, geese, hedgehogs, silkworms, bees, hornets, wasps, an eagle, two leopards, and a bull. He nearly lost his life wrestling with the bull and recapturing escaped leopards. He anatomized over five hundred species of animals. He studied the effects of various toxins, and admitted in 1780 that he had “poisoned some thousands of animals.”
In 1785 he sat for his portrait to Reynolds, but at first proved too restless; Sir Joshua was about to abandon the sitting, when Hunter fell into a deep and motionless reverie which enabled the artist to make the sketch for the portrait now in the Royal College of Surgeons. Like his brother, John was of an irritable and imperious temper. Finding himself subject to angina pectoris, he said, “My life is in the hands of any rascal who chooses to annoy and tease me.”6 Contradιcted by one of his colleagues, he fell into a rage, and died within a few minutes (1793). He was buried in Westminster Abbey, next to the remains of Ben Jonson. His collection of thirteen thousand specimens was acquired by the Corporation of Surgeons through a governmental grant, and became in 1836 the Hunterian Museum of London. The “Hunterian oration” delivered in his memory is an annual event in the English medical world.
In physiology the great name of this period was Albrecht von Haller. We have met him as a poet in his youth; in his later years he placed himself at the head of his kind by his Elementa physiologiae Corporis humani, which appeared in eight volumes between 1757 and 1766. They not only recorded all the current lore of human anatomy and physiology, but included his own discoveries on the role of the bile in the digestion of fats, and on the irritability or contractility of muscle fibers independently of nerves and even when separated from the body. Diderot concluded from these and similar experiments, “If life remains in organs severed from the body, where is the soul? What happens to its unity? … to its indivisibility?”7 He argued from such evidence that all physiological processes are mechanical. Haller disagreed; the irritability of organic tissue, he felt, indicated a vital principle absent in inorganic substances and incompatible with a mechanistic philosophy. Further studies by Haller showed that “the structure of the bones of quadrupeds is essentially the same as that of birds,” and that “the bones in man are not different in any part of their structure from those of quadrupeds.”8 In 1755 he made the first recorded observation of atherosclerosis, the accumulation of mushy fat in the walls of the blood vessels. “When we open the pages of Haller,” said Sir William Foster, “we feel that we have passed into modern times.”9
Other investigations lent support to a mechanistic view. Robert Whytt showed (1751) that reflex actions need involve only a small segment of the spinal cord. The work of Priestley, Lavoisier, Laplace, and Lagrange seemed to reduce respiration to chemical processes analogous to combustion. Réaumur’s experiments (1752) proved that digestion results from the chemical action of gastric juices;
Spallanzani showed (1782) that this action of the digestive juices upon food could go on even outside the stomach; and John Hunter discovered that after death these juices begin to digest the stomach wall itself.
Spallanzani was one of the major figures in eighteenth-century physiology. We have seen his experiments on “spontaneous” generation. His interest in digestion knew no bounds. He discovered the digestive function of saliva. He experimented on himself by stimulated vomiting, and by swallowing bags and tubes, which he patiently recovered from his stools. He was the first to show that the systolic contraction of the heart sends blood into the smallest capillaries. He showed that perspiration is not akin to respiration, but can, up to a certain point, take the place of breathing. Though an abbot, he became an authority on fertilization. He found that when the male organs of a frog were covered with waxed linen the female remained unfertilized after mating; but when he collected the male fluid from the linen, and placed it in contact with the female eggs, these became fertilized. He obtained artificial fertilization in mammals by injecting the sperm of a dog into the uterus of a bitch.10 The twentieth century finally appreciated the scope and significance of his indefatigable experiments, and recognized him as one of the elect in the priesthood of science.
II. THE INGENUITY OF DISEASE
Did the growth of knowledge defeat the resourcefulness of disease? Hardly. Voltaire estimated the average longevity of human life in his time at twenty-two years.11 The slums of the growing cities made for a high rate of infantile mortality, sometimes reaching fifty per cent.12 In London fifty-eight per cent of all children died before their fifth birthday.13 The abandonment of infants was widely practiced. In the eight years 1771–77 nearly 32,000 children were admitted to the Paris Foundling Hospital—eighty-nine per day; of these babies 25,476 (eighty per cent) died before completing their first year. A contribution to infant mortality was made in the eighteenth century by the spread of dry-nursing—the replacement of the breast of mother or wet nurse by the bottle. Sir Hans Sloane reckoned the death rate of bottle-fed infants as three times that of the breast-fed. The new method became especially popular in the upper classes of France, until Rousseau’s Émile (1762) made breast feeding fashionable.
Abortion and contraception continued. The linen sheath, recommended by Fallopio in 1564 to prevent venereal infection, was used in the eighteenth century to prevent conception.14 Dr. Jean Astruc, in De Morbis venereis (1736), mentioned debauchees who “have been employing for some time sacs made of fine, seamless membrane in the form of a sheath, … called in English ’condum.’”15 A Mrs. Phillips in 1776 issued handbills in London announcing that her shop had a full supply of such “implements of safety, which secure the health of her customers.”16 Despite these “machines,” as they were called, venereal disease took its toll in every class. Lord Chesterfield warned his son to be careful, for though “in love a man may lose his heart with dignity, … if he loses his nose he loses his character into the bargain.”17
We who live after Jenner can hardly imagine what a curse smallpox was before he converted the Western world to vaccination. Voltaire calculated that “in a hundred persons that come into the world, at least sixty contract smallpox; of these sixty, twenty die … and twenty more keep very disagreeable marks of this cruel disorder as long as they live.”18 Between 1712 and 1715 three heirs to the French throne died of smallpox. The Prince de Ligne thought that 200,000 inmates of nunneries and monasteries had sought refuge there from the humiliation of smallpox disfigurement.19 The disease reached epidemic proportions in Paris in 1719, in Sweden in 1749–65, in Vienna in 1763 and 1767, in Tuscany in 1764, in London in 1766 and 1770.
Epidemics in general were now less severe than in earlier centuries, but they remained among the hazards of life. They were more formidable in the countryside than in the cities, despite urban slums, for the peasants could seldom afford medical care. Epidemics of typhus, typhoid fever, and smallpox killed eighty thousand persons in Brittany in the one year 1741.20. In 1709 bubonic plague carried off 300,000 persons in Prussia; it reappeared with less intensity in the Ukraine in 1737, in Messina in 1743, in Moscow in 1789. Scarlet fever, malaria (mal aria, bad air), dysentery, were common, especially in the lower classes, where they were favored by poverty of public sanitation and personal hygiene. Epidemics of contagious puerperal fever occurred in Paris, Dublin, Aberdeen, Thurgau, and Bern. Influenza, which the French called la grippe (adhesion), reached the epidemic stage at various times in Italy, Sweden, and Germany. Occasionally it led to infantile poliomyelitis, as in the boy who became Sir Walter Scott. Pneumonia, diphtheria, and erysipelas now and then neared epidemic proportions. Whooping cough, which seems so minor now, was widespread and dangerous, especially in northern Europe; in Sweden forty thousand children died of it between 1749 and 1764. Yellow fever came in from America, and rose to epidemic form at Lisbon in 1723. To these and a hundred other ailments the ladies of the upper classes added “the vapors”—a confused mixture of nervous exhaustion, hypochondria, insomnia, and boredom, rising at times to hysteria.
Against such public enemies the governments provided some measures of sanitation. But offal was still for the most part emptied into the streets. Water closets appeared in Paris at the beginning of the century, but only in a few houses; they were almost entirely lacking elsewhere on the Continent. Bathrooms were a luxury of the rich. Public baths were probably less numerous than in the Renaissance. Hygiene made more progress in armies and navies than in cities. Sir John Pringle advanced military medicine (1774), and James Lind of Scotland revolutionized naval hygiene (1757). In Anson’s expedition of 1740 some seventy-five per cent of the crews were at times disabled by scurvy. In an epochal treatise on that disease (1754) Lind pointed out that orange or lemon juice had been used in treating it by the Dutch in 1565 and by Sir Richard Hawkins in 1593; through Lind’s influence this preventive was introduced in the British navy (1757). In Cook’s second voyage, lasting over three years (1772–75), only one case of scurvy proved fatal. In 1795 the use of citrus juices or fruits was made obligatory in the British navy (hence the name “limey” for a British sailor or soldier); thereafter naval scurvy disappeared.
It was a milestone in eighteenth-century humanitarianism when Victor Riqueti, Marquis de Mirabeau, laid down the principle (1756) that the health of the people is a responsibility of the state. Johann Peter Frank, who began life as a poor child abandoned at a street door, proposed a complete system of public medical service in his System einer vollständigen medizinischen Polizei (1777–78). These four volumes, the “noble monument of a lifelong devotion to humanity,”21 described the measures that should be taken by any civilized community to dispose of waste, to guard the purity of water and food, to maintain hygiene in schools and factories, and to protect the health of women in industry; for good measure the doctor prescribed the taxation of bachelors, gave advice on conjugal hygiene, and demanded the education of children in the principles of health. Napoleon was one of those who appreciated Frank’s ideas; he begged Frank to come and serve Paris; Frank remained in Vienna.
Hospitals lagged far behind the need for institutional care of disease. Their number grew, but their quality declined. England in particular multiplied its hospitals in the eighteenth century, but all of them were maintained by private contributions, none by state endowment.22 In Paris the leading hospital, the Hôtel-Dieu, received 251,178 patients in the eleven years from 1737 to 1748; of these, 61,091 died. The demands on this “Mansion of God” led to its putting three, four, five, even six persons in the same bed; “the dying and those on the road to recovery lay next to each other; … the air was tainted with the emanations from so many diseased bodies.”23 It was one of the many beneficent acts of Louis XVI that in 1781 he decreed that “henceforward 2,500 patients should have a separate bed, that five hundred should sleep in double beds divided with a partition,” and that there should be special rooms for the convalescent.24 Nevertheless, seven years later the hospital had single b
eds for only 486 patients; 1,220 beds held four or more patients, and eight hundred patients lay on straw.25 In Frankfurt-am-Main and other cities the air in the hospitals was so fetid that “physicians declined hospital service as equivalent to a sentence of death.”26
III. TREATMENT
A few doctors dared to undermine their income by spreading a knowledge of preventive medicine. Dr. John Arbuthnot of London, in an Essay concerning the Nature of Ailments (1731), argued that diet would do almost all that medicine could accomplish. He anticipated later complaints in a treatise, The Cost of Preserving Health (1744). The instruction of medical students improved slowly, with the Italian universities (Padua, Bologna, Pavia, Rome) still in the lead, and with Vienna, Paris, and Montpellier following; but even in these there were only four or five professors. Each teacher collected fees for his own course, and issued tickets of admission, sometimes on the back of playing cards.27 Certain hospitals now began to teach clinical medicine. Legal practice of medicine, or of midwifery, required a diploma from an accredited institution.
Just as Georg Stahl’s theory of fire as “phlogiston” dominated chemistry in the century before Lavoisier, so his concept of “animism” dominated medicine. Rejecting Descartes’ view of the body as a mechanism, Stahl pictured the soul as an immaterial principle of life molding the body as its instrument. Consequently (he held) nature, in the form of this life force, is the chief agent in curing disease; sickness is an effort of the anima to re-establish the normal tone, operation, and harmony of disordered organs; heightened temperature and quickened pulse are means that nature uses to overcome disease; a wise doctor will rely chiefly on such processes of auto-detoxication, and will be reluctant to administer drugs. Stahl left unanswered the question of the cause that produced the disorder. One answer was given by Marcus Antonius Plenciz, who in 1762 revived Athanasius Kircher’s conception of disease as due to infection by a microorganism; for each disease, said Plenciz, there is a particular invading organism, with a definite period of incubation. This remarkable prevision of the germ theory left no mark on eighteenth-century therapy, and had to be revived a second time in the nineteenth century.