the evolution of modern medicine-第30章
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tirred such bitter controversy； particularly on the Continent； and in Charles Creighton's account of Brown＇7＇ we read that as late as 1802 the University of Gottingen was so convulsed by controversies as to the merits of the Brunonian system that contending factions of students in enormous numbers； not unaided by the professors； met in combat in the streets on two consecutive days and had to be dispersed by a troop of Hanoverian horse。
＇7＇ Dictionary of National Biography； London； 1886； VII； 14…17。
But the man who combined the qualities of Vesalius； Harvey and Morgagni in an extraordinary personality was John Hunter。 He was； in the first place； a naturalist to whom pathological processes were only a small part of a stupendous whole； governed by law； which； however； could never be understood until the facts had been accumulated； tabulated and systematized。 By his example； by his prodigious industry； and by his suggestive experiments he led men again into the old paths of Aristotle； Galen and Harvey。 He made all thinking physicians naturalists； and he lent a dignity to the study of organic life； and re…established a close union between medicine and the natural sciences。 Both in Britain and Greater Britain； he laid the foundation of the great collections and museums； particularly those connected with the medical schools。 The Wistar…Horner and the Warren Museums in this country originated with men greatly influenced by Hunter。 He was； moreover； the intellectual father of that interesting group of men on this side of the Atlantic who； while practising as physicians； devoted much time and labor to the study of natural history； such men as Benjamin Smith Barton； David Hossack； Jacob Bigelow； Richard Harlan； John D。 Godman； Samuel George Morton； John Collins Warren； Samuel L。 Mitchill and J。 Ailken Meigs。 He gave an immense impetus in Great Britain to the study of morbid anatomy； and his nephew； Matthew Baillie； published the first important book on the subject in the English language。
Before the eighteenth century closed practical medicine had made great advance。 Smallpox； though not one of the great scourges like plague or cholera； was a prevalent and much dreaded disease； and in civilized countries few reached adult life without an attack。 Edward Jenner； a practitioner in Gloucestershire； and the pupil to whom John Hunter gave the famous advice： 〃Don't think； try！〃 had noticed that milkmaids who had been infected with cowpox from the udder of the cow were insusceptible to smallpox。 I show you here the hand of Sarah Nelmes with cowpox； 1796。 A vague notion had prevailed among the dairies from time immemorial that this disease was a preventive of the smallpox。 Jenner put the matter to the test of experiment。 Let me quote here his own words： 〃The first experiment was made upon a lad of the name of Phipps； in whose arm a little vaccine virus was inserted； taken from the hand of a young woman who had been accidentally infected by a cow。 Notwithstanding the resemblance which the pustule； thus excited on the boy's arm； bore to variolous inoculation； yet as the indisposition attending it was barely perceptible； I could scarcely persuade myself the patient was secure from the Small Pox。 However； on his being inoculated some months afterwards； it proved that he was secure。〃＇8＇ The results of his experiments were published in a famous small quarto volume in 1798。＇*＇ From this date； smallpox has been under control。 Thanks to Jenner； not a single person in this audience is pockmarked！ A hundred and twenty…five years ago； the faces of more than half of you would have been scarred。 We now know the principle upon which protection is secured： an active acquired immunity follows upon an attack of a disease of a similar nature。 Smallpox and cowpox are closely allied and the substances formed in the blood by the one are resistant to the virus of the other。 I do not see how any reasonable person can oppose vaccination or decry its benefits。 I show you the mortality figures＇9＇ of the Prussian Army and of the German Empire。 A comparison with the statistics of the armies of other European countries in which revaccination is not so thoroughly carried out is most convincing of its efficacy。
＇8＇ Edward Jenner： The Origin of the Vaccine Inoculation； London； 1801。
＇*＇ Reprinted by Camac： Epoch…making Contributions to Medicine； etc。； 1909。Ed。
＇9＇ Jockmann： Pocken und Vaccinationlehre； 1913。
The early years of the century saw the rise of modern clinical medicine in Paris。 In the art of observation men had come to a standstill。 I doubt very much whether Corvisart in 1800 was any more skilful in recognizing a case of pneumonia than was Aretaeus in the second century A。 D。 But disease had come to be more systematically studied； special clinics were organized； and teaching became much more thorough。 Anyone who wishes to have a picture of the medical schools in Europe in the first few years of the century； should read the account of the travels of Joseph Frank of Vienna。＇10＇ The description of Corvisart is of a pioneer in clinical teaching whose method remains in vogue today in Francethe ward visit； followed by a systematic lecture in the amphitheatre。 There were still lectures on Hippocrates three times a week； and bleeding was the principal plan of treatment： one morning Frank saw thirty patients； out of one hundred and twelve； bled！ Corvisart was the strong clinician of his generation； and his accurate studies on the heart were among the first that had concentrated attention upon a special organ。 To him； too； is due the reintroduction of the art of percussion in internal disease discovered by Auenbrugger in 1761。
＇10＇ Joseph Frank： Reise nach Paris ＇etc。＇； Wien； 1804…05。
The man who gave the greatest impetus to the study of scientific medicine at this time was Bichat； who pointed out that the pathological changes in disease were not so much in organs as in tissues。 His studies laid the foundation of modern histology。 He separated the chief constituent elements of the body into various tissues possessing definite physical and vital qualities。 〃Sensibility and contractability are the fundamental qualities of living matter and of the life of our tissues。 Thus Bichat substituted for vital forces 'vital properties；' that is to say； a series of vital forces inherent in the different tissues。〃＇11＇ His 〃Anatomic Generale；〃 published in 1802； gave an extraordinary stimulus to the study of the finer processes of disease； and his famous 〃Recherches sur la Vie et sur la Mort〃 （1800） dealt a death…blow to old iatromechanical and iatrochemical views。 His celebrated definition may be quoted： 〃La vie est l'ensemble des proprietes vitales qui resistent aux proprietes physiques； ou bien la vie est l'ensemble des fonctions qui resistent a la mort。〃 （Life is the sum of the vital properties that withstand the physical properties； or； life is the sum of the functions that withstand death。） Bichat is another pathetic figure in medical history。 His meteoric career ended in his thirty…first year： he died a victim of a post…mortem wound infection。 At his death； Corvisart wrote Napoleon： 〃Bichat has just died at the age of thirty。 That battlefield on which he fell is one which demands courage and claims many victims。 He has advanced the science of medicine。 No one at his age has done so much so well。〃
＇11＇ E。 Boinet： Les doctrines medicules； leur evolution； Paris； 1907； pp。 85…86。
It was a pupil of Corvisart； Rene Theophile Laennec； who laid the foundation of modern clinical medicine。 The story of his life is well known。 A Breton by birth； he had a hard； up…hill struggle as a young mana struggle of which we have only recently been made aware by the publication of a charming book by Professor Rouxeau of Nantes〃Laennec avant 1806。〃 Influenced by Corvisart； he began to combine the accurate study of cases in the wards with anatomical investigations in the dead…house。 Before Laennec； the examination of a patient had been largely by sense of sight； supplemented by that of touch； as in estimating the degree of fever； or the character of the pulse。 Auenbrugger's 〃Inventum novum〃 of percussion； recognized by Corvisart； extended the field； but the discovery of auscultation by Laennec； and the publication of his work〃De l'Auscultation Mediate；〃 1819；marked an era in the study of medicine。 The clinical recognition of individual diseases had made really very little progress； with the stethoscope begins the day of physical diagnosis。 The clinical pathology of the heart； lungs and abdomen was revolutionized。 Laennec's book is in the category of the eight or ten greatest contributions to the science of medicine。＇*＇ His description of tuberculosis is perhaps the most masterly chapter in clinical medicine。 This revolution was effected by a simple extension of the Hippocratic method from the bed to the dead…house； and by correlating the signs and symptoms of a disease with its anatomical appearances。
＇*＇ John Forbes's translation of Auenbrugger and part of his translation of Lacnnec are reprinted in Camac's Epoch…making Contributions； etc。； 1909。Ed。
The pupils and successors of CorvisartBayle； Andral； Bouillaud； Chomel； Piorry； Bretonneau； Rayer； Cruveilhier and Trousseau brought a new spirit into the profession。 Everywhere the investigation of disease by clinical…pathological methods widened enormously the diagnostic powers of the physician。 By this method Richard Bright； in 1836； opened a new chapter on the relation of disease of the kidney to dropsy； and to albuminous urine。 It had already been shown by Blackwell and by Wells； the celebrated Charleston （S。C。） physician； in 1811； that the urine contained albumin in many cases of dropsy； but it was not until Bright began a careful investigation of the bodies of patients who had presented these symptoms； that he discovered the association of various forms of disease of the kidney with anasarca and albuminous urine。 In no direction was the harvest of this combined study more abundant than in the complicated and confused subject of fever。 The work of Louis and of his pupils； W。W。 Gerhard and others； revealed the distinction between typhus and typhoid fever； and so cleared up one of the most obscure problems in pathology。 By Morgagni's method of 〃anatomical thinking；〃 Skoda in Vienna； Schonlein in Berlin； Graves and Stokes in Dublin； Marshall Hall； C。 J。 B。 Williams and many others introduced the new and exact methods of the French and created a new clinical medicine。 A very strong impetus was given by the researches of Virchow on cellular pathology； which removed the seats of disease from the tissues； as taught by Bichat； to the individual elements； the cells。 The introduction of the use of the microscope in clinical work widened greatly our powers of diagnosis； and we obtained thereby a very much clearer conception of the actual processes of disease。 In another way； too； medicine was greatly helped by the rise of experimental pathology； which had been introduced by John Hunter； was carried along by Magendie and others； and reached its culmination in the epoch…making researches of Claude Bernard。 Not only were valuable studies made on the action of drugs； but also our knowledge of cardiac pathology
