Medicine in Europe and the United States
From Clinical To Laboratory Medicine
Medicine was transformed institutionally, practically, and intellectually in the century after the 1750s. Medicine evolved from a cultural system to an occupation, as the practitioners of professional medicine grew in prestige and began to dominate their rivals, the charlatans or empirics of popular medicine.
One of the striking intellectual developments of this period was the emergence of physiology as an autonomous experimental science, probably first in France through the work of Bichat, François Magendie (1783–1855), and Claude Bernard (1813–1878). Physiology distinguished itself by the use of operative or experimental surgery, which might be seen as a mutation of an ancient tradition running from the Alexandrian school through Galen to the Italian schools and Harvey. Much knowledge was gained; many animals were sacrificed. With the advent of Bernard, the historian passes into a different conceptualization of the development of medicine: from pathological anatomy in the hospital to medicine in the laboratory. Medicine seemed in danger of becoming obsessed with the pathological, always a danger in the doctor's world of disease. Bernard's physiological medicine showed how essential it was to understand the normal as well as the pathological, indeed, that there is only a narrow divide between them. Understanding the functions of an organ became central to understanding a disease. For example, Bernard's experimental demonstration of the role of the liver in making glycogen and in regulating glucose levels in the blood provided the basis for understanding diabetes—an alteration or disorder in a normal function produced the lesion or disease. (The new world of internal secretions later gave rise to the science of endocrinology.) Such discoveries could only occur in a controlled laboratory experiment on an animal. Bernard's view was similar to that of Rudolf Virchow (1821–1902): "Disease is nothing but life under altered circumstances." Imitating Virchow, Canguilhem (p. 100) made a brilliant diagnosis: "Diseases are new ways of life."
Medical science in Germany.
In the middle of the nineteenth century the center of medical excitement and interest began to shift from Paris to German centers, where heavy investment in higher education had begun to pay large research dividends. The history of medicine at this point becomes of necessity rather Whiggish as discovery after discovery has to be cataloged, and the practice of medicine itself seems to have improved. Some of the progress was driven by instruments, especially the microscope, which had been of no interest to Bichat but was indispensable to Virchow, pathologist and Progressive politician. The great unifier of physiology and pathology, Virchow developed the medical implications of cell theory. To understand diseases, one had to understand the cell. From Morgagni's emphasis on the organ to Bichat's concentration on tissues to Virchow's consecration of the cell (Cellular Pathology, 1858), medicine, like the other sciences, turned increasingly microscopic. The whole patient would soon be hard to find, but the German model of medical science became universally admired and imitated, especially in a few select American institutions (Johns Hopkins, Harvard, and the Universities of Pennsylvania and of Michigan). Of course it would be a while before the chasm between laboratory and hospital (and physician) would be bridged and the hospital would begin "to resemble a factory" (Porter, p. 347).
The immediate influence that experimental physiology had on the practicing physician is not easy to assess; the impact of sciences such as chemistry (in anesthesiology), microscopy, and bacteriology was much clearer by the end of the nineteenth century. Over the long haul no doubt physicians came to place considerable reliance on various physiological instruments to record and analyze data. Most of these instruments, like the kymograph, were invented and developed in the German states. The stethoscope replaced the urinal as the symbol of the profession. A much-improved microscope became indispensable to medical and biological research in the second half of the nineteenth century and, with the white coat, the accessory of the successful doctor. Wilhelm Conrad Roentgen discovered X-rays in 1895, and by the 1920s diagnostic medicine embraced X-rays for large masses of people. Physics was becoming an essential part of medicine, which by the early 2000s was integrated into the world of engineering and physics through CAT and PET scans and magnetic resonance imaging in order to model the structure and functioning of the body.
The autonomous and monopolistic organization of the medical profession under governmental protection is a late development in the history of medicine, essentially post-Revolutionary (1789). Universities assumed the primary role in medical education, though private schools or institutes and, above all, hospitals played major roles in Britain and France. Medical history teems with women healers, but they were not admitted to medical schools until the late nineteenth century, with resistance holding out until the early twentieth century in Germany. Fortunately for Russian Jewish women, Switzerland's facilities were open, beginning with the University of Zurich in 1864. The mobilization and slaughter of male doctors in both world wars helped increase the number of women doctors, though Nazi Germany dealt a blow to the movement that had made one-fifth of the German medical profession female by 1933. After World War II, female enrollments in medical schools rose and continued to rise to near equality of the sexes (in numbers only) in the profession by the early twenty-first century. Not welcome in certain specialities such as surgery, women tended to go into general practice and areas of specialization such as bacteriology, anaesthesia, pediatrics, neuropsychiatry, dermatology, and nonsurgical gynecology.
The rise of psychiatry.
An enormous number of drugs were available to healers from Hippocrates to Magendie, whose Formulary of 1821 introduced the notion of chemical purity into the pharmacopoeia. In the materia medica in use before the 1950s there is a striking absence of psychotropic drugs; the first, lithium, used to treat manic depression, dates from 1949. (Phenobarbital had been found effective against epileptic seizures in 1912.) So how did doctors treat mental disease? The answer is that they did nothing for most of medical history. "Madness" was generally not the province of the doctor, but of the churches and the family. "Madhouses" were generally charitable or religious institutions with medical connections until the nineteenth century, when the treatment of the insane evolved into a specialized branch of medicine. The development of psychiatry was accompanied by the rise of the "new" asylum—new because of its practice of a humane treatment of the mentally ill. Politicians in the late-eighteenth-century French state, converted to the scientific gospel, became convinced that madness could be cured, with the hospital functioning as a healing machine. Ideologue doctors such as Pierre-Jean-Georges Cabanis (1757–1808) provided epistemological (that is, scientific) respectability for medicine by emphasizing its roots in classification and a content related to sensationalist psychology.
The moral treatment, made famous by Philippe Pinel (1745–1826) at Bicêtre, the Salpêtrière, and Charenton, indulged in sympathetic but firm handling and even theatrical performances by the actor-inmates. "A historic transformation … in Paris" (Weiner, p. 275): the mentally ill were recognized as human beings with natural rights, and mental illness was classified as a curable disease. Doctors soon invented new categories of disease out of the old simple divisions of insanity; perhaps the most notorious new disease was Jean-Etienne Esquirol's (1772–1840) concoction of monomania. Esquirol's work Mental Illnesses, a classic text, was published in 1838, the year the government voted to create a national asylum system. The treatment of the insane became a matter of a scientific management of the mind and emotions rather than the traditional bleeding and purging of the body. Psychiatry arrived in the faculty of medicine in Paris in 1882, when the neurologist Jean-Martin Charcot (1825–1893) was appointed professor of diseases of the nervous system. There is no evidence that all this science and institutional growth contributed to a higher cure rate for patients suffering from the old mental diseases or even the new ones such as neurasthenia and hysteria, which some doctors attributed to industrial civilization. A desperate Western psychiatry indulged in thousands of lobotomies between 1935 and 1950.
As with clinical medicine, psychiatry in Germany (and Austria) differed from psychiatry in France and Britain in being connected directly with research-related university medicine, particularly neurology. Wilhelm Griesinger (1817–1868), professor of psychiatry and neurology in Berlin, developed a department for the study of mental disorders and founded the Archiv für Psychiatrie und Nervenkrankheiten (1868). Sigmund Freud (1856–1939) specialized in clinical neurology, but he recognized the bankruptcy of the old organic psychiatry, which attributed mental disorders to structural disease in the brain. Pinel had similarly become disillusioned with the hope of finding lesions in the brains of the mentally diseased. Freud's new dynamic psychiatry with its radical views of the human personality is probably the most influential and most controversial medical paradigm in the history of Western civilization and its discontents. The success of the "talking cure," or psychoanalysis, in treating mental disorders provided the basis for modern psychotherapy, but much of psychiatry has since followed the biochemical path to Prozac and other psychotropic drugs. The ideology of most German (and French) psychiatrists was scientific materialism, with their medical science being basically neurological and neuropathological. Medicine loves classification: German psychiatry was obsessed by it. The twenty-first century's bible of the profession, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 4th edition, 1994) has its origin in the classification of mental disorders done by Emil Kraepelin (1856–1926), who drew on the work of several other men of method. To venture beyond the current DSM paradigm and DSM-IV framework, the powers in mental health issued A Research Agenda for DSM-V in 2002.
Did science matter?
Concluding his book on nineteenth-century scientific medicine, W. F. Bynum asked "Did science matter?" The answer is yes. Consider surgery. No branch of medicine changed more radically than surgery during the second half of the nineteenth century. Surgery itself had been socially and cognitively (through the study of anatomy) transformed by 1790. Surgery joined medicine as a liberal profession, that is, a group in possession of scientific or esoteric knowledge, transmitted through institutions; recognized by the state, the profession also controlled admission to its ranks and tried to control the practice of medicine within certain areas. The French doctorate in surgery, introduced in 1749, required a thesis in Latin, which nicely hid professional secrets from the polloi.
Reform of French medical education in 1794 integrated surgery into the regular training of doctors.
With the growing importance of the hospital and the increasing prestige of pathological anatomy, the professional status of surgeons soon equaled that of physicians. Whether chloroform did "a lot of mischief" by enabling "every fool to become a surgeon" (Sir Patrick Cullen, in Bernard Shaw's Doctor's Dilemma, 1906) is open to question. But it is certain that the cult of the surgeon could not have emerged at the end of the nineteenth century without anesthesiology. In 1846 the first amputation with a patient under ether was done in Boston; the next year James Y. Simpson (1811–1870), professor of obstetrics, first administered chloroform at the Infirmary in Edinburgh. The incorporation of bacteriology into surgical practice was equally important to the cult.
The medical acceptance of germ theory is a complex story. Since disease killed more soldiers than bullets, army doctors, desperate for an etiology and a therapy, were among the first to embrace the gospel of germs. The antiseptic, then aseptic practices of Joseph Lister (1827–1912)—Lister's system—was inspired by his reading a paper on fermentation by Louis Pasteur (1822–1895). Listerism was accepted most enthusiastically in German-speaking areas, where there was also a striking development of surgery of the abdominal, thoracic, and cranial cavities, and, more controversial, the female reproductive system. Pasteur, accepting the idea that fermentation, putrefaction, and infection are related, developed a germ theory of infection. What distinguished his theory was a set of brilliant if controversial experiments on wine diseases, chicken cholera, anthrax, and rabies. Without understanding the immune system—researchers are still investigating how it works—Pasteur and his colleagues developed vaccines to prevent disease. Development of immunization against rabies (such as Creutzfeldt-Jacob disease, a frightening but minor killer) made it possible for Pasteur to collect enough funds to establish the Institut Pasteur (1888).
Bacteriology was largely a German creation. Robert Koch (1843–1910) identified major killers such as the tuberculosis and cholera bacilli and codified a method for investigating the etiology of infections. His students went on to identify the microorganisms causing a large number of diseases (diphtheria, typhoid, gonorrhea, and syphilis, among others) Koch spent the period from 1896 to 1907 in Africa studying its diseases; partly as a result of European invasions that displaced populations, millions of Africans suffered from helminth (intestinal worm) infections, in addition to germ and viral diseases. Many other medical researchers of the imperial powers also spent time in areas where tropical diseases presented a challenge not to be found in Europe. The germ-theory model of disease with its simple etiology did not work for diseases such as yellow fever and malaria; the parasitological model required the concept of a vector such as the mosquito. If the prion, which has no nucleic acids (DNA and RNA), causes bovine spongiform encephalopathy (BSE, popularly known as "mad cow disease") and its human form, the "new" Creutzfeld-Jacob disease, then a new model of infection will appear in medicine.
With four institutes named after him, the imperious Koch went on to glory, though not so great as that of Pasteur, with whom he squabbled over the great germs of the day. Supported by well-developed chemical and pharmaceutical industries, German scientists were able to pioneer in serum therapy (antitoxins) and chemotherapy, whose most famous product might have been the arsenical compound salvarsan (not a magic bullet) for treating syphilis. More useful drugs to come out of Germany included chloral hydrate, aspirin, and phenobarbital. But no drug has ever been more useful or cheaper than quinine, the extract of the bark of the cinchona tree, used in fighting malaria, still one of the great killer diseases.
So what was the effect of all this progress in medical science on public health? Mortality did decline in the second half of the nineteenth century, particularly deaths from tuberculosis, scarlet fever, diphtheria, typhus, typhoid, cholera, and smallpox (mostly before 1850 in this case). The decline started before effective medical means could combat these diseases. Nonmedical factors seem to explain why people lived longer: first, improved nutrition, which made people more resistant to diseases such as tuberculosis; second, the attenuated virulence of some microbes, such as the diphtheria bacillus; third, effective public health measures such as supplying towns and cities with safe water, installing sewage systems, and clearing slums. The effect of the Malthusian check of infectious disease on population growth was severely reduced if not eliminated. The introduction of antibiotics lowered mortality even further. Sulfa drugs, the first effective step toward the control of bacterial diseases, became widely available only in the early1940s and penicillin shortly after.
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