the evolution of modern medicine-第29章
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r 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。
＇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。
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）。
＇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。）
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 arteriesaffections 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 pectorisprobably 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＇
＇6＇ Cooke's Morgagni； Vol。 1； pp。 417…418。 I cannot too warmly commend to young clinicians the reading of Morgagni。 English editions are availableAlexander's three…volume translation of 1769 and Cooke's Abridgement （London； 1822）； of which there was an American edition published in Boston in 1824。
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 systemsiatromechanics； 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 typeI dare say many more than we realizemen 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
