by Henry Smith Williams, M.D., LL.D.
PHYSICAL DIAGNOSIS
Although Napoleon Bonaparte, First Consul, was not lacking in self-appreciation, he probably did not realize that in selecting a physician for his own needs he was markedly influencing the progress of medical science as a whole. Yet so strangely are cause and effect adjusted in human affairs that this simple act of the First Consul had that very unexpected effect. For the man chosen was the envoy of a new method in medical practice, and the fame which came to him through being physician to the First Consul, and subsequently to the Emperor, enabled him to promulgate the method in a way otherwise impracticable. Hence the indirect but telling value to medical science of Napoleon's selection.
The physician in question was Jean Nicolas de Corvisart. His novel method was nothing more startling than the now-familiar procedure of tapping the chest of a patient to elicit sounds indicative of diseased tissues within. Every one has seen this done commonly enough in our day, but at the beginning of the century Corvisart, and perhaps some of his pupils, were probably the only physicians in the world who resorted to this simple and useful procedure. Hence Napoleon's surprise when, on calling in Corvisart, after becoming somewhat dissatisfied with his other physicians Pinel and Portal, his physical condition was interrogated in this strange manner. With characteristic shrewdness Bonaparte saw the utility of the method, and the physician who thus attempted to substitute scientific method for guess-work in the diagnosis of disease at once found favor in his eyes and was installed as his regular medical adviser.
For fifteen years before this Corvisart had practised percussion, as the chest-tapping method is called, without succeeding in convincing the profession of its value. The method itself, it should be added, had not originated with Corvisart, nor did the French physician for a moment claim it as his own. The true originator of the practice was the German physician Avenbrugger, who published a book about it as early as 1761. This book had even been translated into French, then the language of international communication everywhere, by Roziere de la Chassagne, of Montpellier, in 1770; but no one other than Corvisart appears to have paid any attention to either original or translation. It was far otherwise, however, when Corvisart translated Avenbrugger's work anew, with important additions of his own, in 1808.
"I know very well how little reputation is allotted to translator and commentators," writes Corvisart, "and I might easily have elevated myself to the rank of an author if I had elaborated anew the doctrine of Avenbrugger and published an independent work on percussion. In this way, however, I should have sacrificed the name of Avenbrugger to my own vanity, a thing which I am unwilling to do. It is he, and the beautiful invention which of right belongs to him, that I desire to recall to life."[1]
By this time a reaction had set in against the metaphysical methods in medicine that had previously been so alluring; the scientific spirit of the time was making itself felt in medical practice; and this, combined with Corvisart's fame, brought the method of percussion into immediate and well-deserved popularity. Thus was laid the foundation for the method of so-called physical diagnosis, which is one of the corner-stones of modern medicine.
The method of physical diagnosis as practised in our day was by no means completed, however, with the work of Corvisart. Percussion alone tells much less than half the story that may be elicited from the organs of the chest by proper interrogation. The remainder of the story can only be learned by applying the ear itself to the chest, directly or indirectly. Simple as this seems, no one thought of practising it for some years after Corvisart had shown the value of percussion.
Then, in 1815, another Paris physician, Rene Theophile Hyacinthe Laennec, discovered, almost by accident, that the sound of the heart-beat could be heard surprisingly through a cylinder of paper held to the ear and against the patient's chest. Acting on the hint thus received, Laennec substituted a hollow cylinder of wood for the paper, and found himself provided with an instrument through which not merely heart sounds but murmurs of the lungs in respiration could be heard with almost startling distinctness.
The possibility of associating the varying chest sounds with diseased conditions of the organs within appealed to the fertile mind of Laennec as opening new vistas in therapeutics, which he determined to enter to the fullest extent practicable. His connection with the hospitals of Paris gave him full opportunity in this direction, and his labors of the next few years served not merely to establish the value of the new method as an aid to diagnosis, but laid the foundation also for the science of morbid anatomy. In 1819 Laennec published the results of his labors in a work called Traite d'Auscultation Mediate,[2] a work which forms one of the landmarks of scientific medicine. By mediate auscultation is meant, of course, the interrogation of the chest with the aid of the little instrument already referred to, an instrument which its originator thought hardly worth naming until various barbarous appellations were applied to it by others, after which Laennec decided to call it the stethoscope, a name which it has ever since retained.
In subsequent years the form of the stethoscope, as usually employed, was modified and its value augmented by a binauricular attachment, and in very recent years a further improvement has been made through application of the principle of the telephone; but the essentials of auscultation with the stethoscope were established in much detail by Laennec, and the honor must always be his of thus taking one of the longest single steps by which practical medicine has in our century acquired the right to be considered a rational science. Laennec's efforts cost him his life, for he died in 1826 of a lung disease acquired in the course of his hospital practice; but even before this his fame was universal, and the value of his method had been recognized all over the world. Not long after, in 1828, yet another French physician, Piorry, perfected the method of percussion by introducing the custom of tapping, not the chest directly, but the finger or a small metal or hard-rubber plate held against the chest-mediate percussion, in short. This perfected the methods of physical diagnosis of diseases of the chest in all essentials; and from that day till this percussion and auscultation have held an unquestioned place in the regular armamentarium of the physician.
Coupled with the new method of physical diagnosis in the effort to substitute knowledge for guess-work came the studies of the experimental physiologists--in particular, Marshall Hall in England and Francois Magendie in France; and the joint efforts of these various workers led presently to the abandonment of those severe and often irrational depletive methods--blood-letting and the like--that had previously dominated medical practice. To this end also the "statistical method," introduced by Louis and his followers, largely contributed; and by the close of the first third of our century the idea was gaining ground that the province of therapeutics is to aid nature in combating disease, and that this may often be accomplished better by simple means than by the heroic measures hitherto thought necessary. In a word, scientific empiricism was beginning to gain a hearing in medicine as against the metaphysical preconceptions of the earlier generations.
PARASITIC DISEASES
I have just adverted to the fact that Napoleon Bonaparte, as First Consul and as Emperor, was the victim of a malady which caused him to seek the advice of the most distinguished physicians of Paris. It is a little shocking to modern sensibilities to read that these physicians, except Corvisart, diagnosed the distinguished patient's malady as "gale repercutee"--that is to say, in idiomatic English, the itch "struck in." It is hardly necessary to say that no physician of today would make so inconsiderate a diagnosis in the case of a royal patient. If by any chance a distinguished patient were afflicted with the itch, the sagacious physician would carefully hide the fact behind circumlocutions and proceed to eradicate the disease with all despatch. That the physicians of Napoleon did otherwise is evidence that at the beginning of the century the disease in question enjoyed a very different status. At that time itch, instead of being a most plebeian malady, was, so to say, a court disease. It enjoyed a circulation, in high circles and in low, that modern therapeutics has quite denied it; and the physicians of the time gave it a fictitious added importance by ascribing to its influence the existence of almost any obscure malady that came under their observation. Long after Napoleon's time gale continued to hold this proud distinction. For example, the imaginative Dr. Hahnemann did not hesitate to affirm, as a positive maxim, that three-fourths of all the ills that flesh is heir to were in reality nothing but various forms of "gale repercutee."
All of which goes to show how easy it may be for a masked pretender to impose on credulous humanity, for nothing is more clearly established in modern knowledge than the fact that "gale repercutee" was simply a name to hide a profound ignorance; no such disease exists or ever did exist. Gale itself is a sufficiently tangible reality, to be sure, but it is a purely local disease of the skin, due to a perfectly definite cause, and the dire internal conditions formerly ascribed to it have really no causal connection with it whatever. This definite cause, as every one nowadays knows, is nothing more or less than a microscopic insect which has found lodgment on the skin, and has burrowed and made itself at home there. Kill that insect and the disease is no more; hence it has come to be an axiom with the modern physician that the itch is one of the three or four diseases that he positively is able to cure, and that very speedily. But it was far otherwise with the physicians of the first third of our century, because to them the cause of the disease was an absolute mystery.
It is true that here and there a physician had claimed to find an insect lodged in the skin of a sufferer from itch, and two or three times the claim had been made that this was the cause of the malady, but such views were quite ignored by the general profession, and in 1833 it was stated in an authoritative medical treatise that the "cause of gale is absolutely unknown." But even at this time, as it curiously happened, there were certain ignorant laymen who had attained to a bit of medical knowledge that was withheld from the inner circles of the profession. As the peasantry of England before Jenner had known of the curative value of cow-pox over small-pox, so the peasant women of Poland had learned that the annoying skin disease from which they suffered was caused by an almost invisible insect, and, furthermore, had acquired the trick of dislodging the pestiferous little creature with the point of a needle. From them a youth of the country, F. Renucci by name, learned the open secret. He conveyed it to Paris when he went there to study medicine, and in 1834 demonstrated it to his master Alibert. This physician, at first sceptical, soon was convinced, and gave out the discovery to the medical world with an authority that led to early acceptance.
Now the importance of all this, in the present connection, is not at all that it gave the clew to the method of cure of a single disease. What makes the discovery epochal is the fact that it dropped a brand-new idea into the medical ranks--an idea destined, in the long-run, to prove itself a veritable bomb--the idea, namely, that a minute and quite unsuspected animal parasite may be the cause of a well-known, widely prevalent, and important human disease. Of course the full force of this idea could only be appreciated in the light of later knowledge; but even at the time of its coming it sufficed to give a great impetus to that new medical knowledge, based on microscopical studies, which had but recently been made accessible by the inventions of the lens-makers. The new knowledge clarified one very turbid medical pool and pointed the way to the clarification of many others.
Almost at the same time that the Polish medical student was demonstrating the itch mite in Paris, it chanced, curiously enough, that another medical student, this time an Englishman, made an analogous discovery of perhaps even greater importance. Indeed, this English discovery in its initial stages slightly antedated the other, for it was in 1833 that the student in question, James Paget, interne in St. Bartholomew's Hospital, London, while dissecting the muscular tissues of a human subject, found little specks of extraneous matter, which, when taken to the professor of comparative anatomy, Richard Owen, were ascertained, with the aid of the microscope, to be the cocoon of a minute and hitherto unknown insect. Owen named the insect Trichina spiralis. After the discovery was published it transpired that similar specks had been observed by several earlier investigators, but no one had previously suspected or, at any rate, demonstrated their nature. Nor was the full story of the trichina made out for a long time after Owen's discovery. It was not till 1847 that the American anatomist Dr. Joseph Leidy found the cysts of trichina in the tissues of pork; and another decade or so elapsed after that before German workers, chief among whom were Leuckart, Virchow, and Zenker, proved that the parasite gets into the human system through ingestion of infected pork, and that it causes a definite set of symptoms of disease which hitherto had been mistaken for rheumatism, typhoid fever, and other maladies. Then the medical world was agog for a time over the subject of trichinosis; government inspection of pork was established in some parts of Germany; American pork was excluded altogether from France; and the whole subject thus came prominently to public attention. But important as the trichina parasite proved on its own account in the end, its greatest importance, after all, was in the share it played in directing attention at the time of its discovery in 1833 to the subject of microscopic parasites in general.
The decade that followed that discovery was a time of great activity in the study of microscopic organisms and microscopic tissues, and such men as Ehrenberg and Henle and Bory Saint-Vincent and Kolliker and Rokitansky and Remak and Dujardin were widening the bounds of knowledge of this new subject with details that cannot be more than referred to here. But the crowning achievement of the period in this direction was the discovery made by the German, J. L. Schoenlein, in 1839, that a very common and most distressing disease of the scalp, known as favus, is really due to the presence and growth on the scalp of a vegetable organism of microscopic size. Thus it was made clear that not merely animal but also vegetable organisms of obscure, microscopic species have causal relations to the diseases with which mankind is afflicted. This knowledge of the parasites was another long step in the direction of scientific medical knowledge; but the heights to which this knowledge led were not to be scaled, or even recognized, until another generation of workers had entered the field.
PAINLESS SURGERY
Meantime, in quite another field of medicine, events were developing which led presently to a revelation of greater immediate importance to humanity than any other discovery that had come in the century, perhaps in any field of science whatever. This was the discovery of the pain-dispelling power of the vapor of sulphuric ether inhaled by a patient undergoing a surgical operation. This discovery came solely out of America, and it stands curiously isolated, since apparently no minds in any other country were trending towards it even vaguely. Davy, in England, had indeed originated the method of medication by inhalation, and earned out some most interesting experiments fifty years earlier, and it was doubtless his experiments with nitrous oxide gas that gave the clew to one of the American investigators; but this was the sole contribution of preceding generations to the subject, and since the beginning of the century, when Davy turned his attention to other matters, no one had made the slightest advance along the same line until an American dentist renewed the investigation.
In view of the sequel, Davy's experiments merit full attention. Here is his own account of them, as written in 1799:
"Immediately after a journey of one hundred and twenty-six miles, in which I had no sleep the preceding night, being much exhausted, I respired seven quarts of nitrous oxide gas for near three minutes. It produced the usual pleasurable effects and slight muscular motion. I continued exhilarated for some minutes afterwards, but in half an hour found myself neither more nor less exhausted than before the experiment. I had a great propensity to sleep.
"To ascertain with certainty whether the more extensive action of nitrous oxide compatible with life was capable of producing debility, I resolved to breathe the gas for such a time, and in such quantities, as to produce excitement equal in duration and superior in intensity to that occasioned by high intoxication from opium or alcohol.
"To habituate myself to the excitement, and to carry it on gradually, on December 26th I was enclosed in an air-tight breathing-box, of the capacity of about nine and one-half cubic feet, in the presence of Dr. Kinglake. After I had taken a situation in which I could by means of a curved thermometer inserted under the arm, and a stop-watch, ascertain the alterations in my pulse and animal heat, twenty quarts of nitrous oxide were thrown into the box.
"For three minutes I experienced no alteration in my sensations, though immediately after the introduction of the nitrous oxide the smell and taste of it were very evident. In four minutes I began to feel a slight glow in the cheeks and a generally diffused warmth over the chest, though the temperature of the box was not quite 50 degrees. . . . In twenty-five minutes the animal heat was 100 degrees, pulse 124. In thirty minutes twenty quarts more of gas were introduced.
"My sensations were now pleasant; I had a generally diffused warmth without the slightest moisture of the skin, a sense of exhilaration similar to that produced by a small dose of wine, and a disposition to muscular motion and to merriment.
"In three-quarters of an hour the pulse was 104 and the animal heat not 99.5 degrees, the temperature of the chamber 64 degrees. The pleasurable feelings continued to increase, the pulse became fuller and slower, till in about an hour it was 88, when the animal heat was 99 degrees. Twenty quarts more of air were admitted. I had now a great disposition to laugh, luminous points seemed frequently to pass before my eyes, my hearing was certainly more acute, and I felt a pleasant lightness and power of exertion in my muscles. In a short time the symptoms became stationary; breathing was rather oppressed, and on account of the great desire for action rest was painful.
"I now came out of the box, having been in precisely an hour and a quarter. The moment after I began to respire twenty quarts of unmingled nitrous oxide. A thrilling extending from the chest to the extremities was almost immediately produced. I felt a sense of tangible extension highly pleasurable in every limb; my visible impressions were dazzling and apparently magnified, I heard distinctly every sound in the room, and was perfectly aware of my situation. By degrees, as the pleasurable sensations increased, I lost all connection with external things; trains of vivid visible images rapidly passed through my mind and were connected with words in such a manner as to produce perceptions perfectly novel.
"I existed in a world of newly connected and newly modified ideas. I theorized; I imagined that I made discoveries. When I was awakened from this semi-delirious trance by Dr. Kinglake, who took the bag from my mouth, indignation and pride were the first feelings produced by the sight of persons about me. My emotions were enthusiastic and sublime; and for a minute I walked about the room perfectly regardless of what was said to me. As I recovered my former state of mind, I felt an inclination to communicate the discoveries I had made during the experiment. I endeavored to recall the ideas--they were feeble and indistinct; one collection of terms, however, presented itself, and, with most intense belief and prophetic manner, I exclaimed to Dr. Kinglake, 'Nothing exists but thoughts!--the universe is composed of impressions, ideas, pleasures, and pains.' "[3]
From this account we see that Davy has anaesthetized himself to a point where consciousness of surroundings was lost, but not past the stage of exhilaration. Had Dr. Kinglake allowed the inhaling-bag to remain in Davy's mouth for a few moments longer complete insensibility would have followed. As it was, Davy appears to have realized that sensibility was dulled, for he adds this illuminative suggestion: "As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place."[4]
Unfortunately no one took advantage of this suggestion at the time, and Davy himself became interested in other fields of science and never returned to his physiological studies, thus barely missing one of the greatest discoveries in the entire field of science. In the generation that followed no one seems to have thought of putting Davy's suggestion to the test, and the surgeons of Europe had acknowledged with one accord that all hope of finding a means to render operations painless must be utterly abandoned--that the surgeon's knife must ever remain a synonym for slow and indescribable torture. By an odd coincidence it chanced that Sir Benjamin Brodie, the acknowledged leader of English surgeons, had publicly expressed this as his deliberate though regretted opinion at a time when the quest which he considered futile had already led to the most brilliant success in America, and while the announcement of the discovery, which then had no transatlantic cable to convey it, was actually on its way to the Old World.
The American dentist just referred to, who was, with one exception to be noted presently, the first man in the world to conceive that the administration of a definite drug might render a surgical operation painless and to give the belief application was Dr. Horace Wells, of Hartford, Connecticut. The drug with which he experimented was nitrous oxide--the same that Davy had used; the operation that he rendered painless was no more important than the extraction of a tooth--yet it sufficed to mark a principle; the year of the experiment was 1844.
The experiments of Dr. Wells, however, though important, were not sufficiently demonstrative to bring the matter prominently to the attention of the medical world. The drug with which he experimented proved not always reliable, and he himself seems ultimately to have given the matter up, or at least to have relaxed his efforts. But meantime a friend, to whom he had communicated his belief and expectations, took the matter up, and with unremitting zeal carried forward experiments that were destined to lead to more tangible results. This friend was another dentist, Dr. W. T. G. Morton, of Boston, then a young man full of youthful energy and enthusiasm. He seems to have felt that the drug with which Wells had experimented was not the most practicable one for the purpose, and so for several months he experimented with other allied drugs, until finally he hit upon sulphuric ether, and with this was able to make experiments upon animals, and then upon patients in the dental chair, that seemed to him absolutely demonstrative.
Full of eager enthusiasm, and absolutely confident of his results, he at once went to Dr. J. C. Warren, one of the foremost surgeons of Boston, and asked permission to test his discovery decisively on one of the patients at the Boston Hospital during a severe operation. The request was granted; the test was made on October 16, 1846, in the presence of several of the foremost surgeons of the city and of a body of medical students. The patient slept quietly while the surgeon's knife was plied, and awoke to astonished comprehension that the ordeal was over. The impossible, the miraculous, had been accomplished.[5]
Swiftly as steam could carry it--slowly enough we should think it to-day--the news was heralded to all the world. It was received in Europe with incredulity, which vanished before repeated experiments. Surgeons were loath to believe that ether, a drug that had long held a place in the subordinate armamentarium of the physician, could accomplish such a miracle. But scepticism vanished before the tests which any surgeon might make, and which surgeons all over the world did make within the next few weeks. Then there came a lingering outcry from a few surgeons, notably some of the Parisians, that the shock of pain was beneficial to the patient, hence that anaesthesia--as Dr. Oliver Wendell Holmes had christened the new method--was a procedure not to be advised. Then, too, there came a hue-and-cry from many a pulpit that pain was God-given, and hence, on moral grounds, to be clung to rather than renounced. But the outcry of the antediluvians of both hospital and pulpit quickly received its quietus; for soon it was clear that the patient who did not suffer the shock of pain during an operation rallied better than the one who did so suffer, while all humanity outside the pulpit cried shame to the spirit that would doom mankind to suffer needless agony. And so within a few months after that initial operation at the Boston Hospital in 1846, ether had made good its conquest of pain throughout the civilized world. Only by the most active use of the imagination can we of this present day realize the full meaning of that victory.
It remains to be added that in the subsequent bickerings over the discovery--such bickerings as follow every great advance--two other names came into prominent notice as sharers in the glory of the new method. Both these were Americans--the one, Dr. Charles T. Jackson, of Boston; the other, Dr. Crawford W. Long, of Alabama. As to Dr. Jackson, it is sufficient to say that he seems to have had some vague inkling of the peculiar properties of ether before Morton's discovery. He even suggested the use of this drug to Morton, not knowing that Morton had already tried it; but this is the full measure of his association with the discovery. Hence it is clear that Jackson's claim to equal share with Morton in the discovery was unwarranted, not to say absurd.
Dr. Long's association with the matter was far different and altogether honorable. By one of those coincidences so common in the history of discovery, he was experimenting with ether as a pain-destroyer simultaneously with Morton, though neither so much as knew of the existence of the other. While a medical student he had once inhaled ether for the intoxicant effects, as other medical students were wont to do, and when partially under influence of the drug he had noticed that a chance blow to his shins was painless. This gave him the idea that ether might be used in surgical operations; and in subsequent years, in the course of his practice in a small Georgia town, he put the idea into successful execution. There appears to be no doubt whatever that he performed successful minor operations under ether some two or three years before Morton's final demonstration; hence that the merit of first using the drug, or indeed any drug, in this way belongs to him. But, unfortunately, Dr. Long did not quite trust the evidence of his own experiments. Just at that time the medical journals were full of accounts of experiments in which painless operations were said to be performed through practice of hypnotism, and Dr. Long feared that his own success might be due to an incidental hypnotic influence rather than to the drug. Hence he delayed announcing his apparent discovery until he should have opportunity for further tests--and opportunities did not come every day to the country practitioner. And while he waited, Morton anticipated him, and the discovery was made known to the world without his aid. It was a true scientific caution that actuated Dr. Long to this delay, but the caution cost him the credit, which might otherwise have been his, of giving to the world one of the greatest blessings--dare we not, perhaps, say the very greatest?--that science has ever conferred upon humanity.
A few months after the use of ether became general, the Scotch surgeon Sir J. Y. Simpson[6] discovered that another drug, chloroform, could be administered with similar effects; that it would, indeed, in many cases produce anaesthesia more advantageously even than ether. From that day till this surgeons have been more or less divided in opinion as to the relative merits of the two drugs; but this fact, of course, has no bearing whatever upon the merit of the first discovery of the method of anaesthesia. Even had some other drug subsequently quite banished ether, the honor of the discovery of the beneficent method of anaesthesia would have been in no wise invalidated. And despite all cavillings, it is unequivocally established that the man who gave that method to the world was William T. G. Morton.
Introduction- A History of Science
I have included extracts from the 4 volume set of A HISTORY OF SCIENCE by Henry Smith Williams, M.D., LL.D. assisted by Edward H. Williams, M.D. A set of texts published early in the 20th century. I recommend reading the 4 volumes as they are an interesting read and written with a different "feel" in language to those texts written today where brevity is carried to such lengths as to make most writings either bland or uninteresting.
This section of notes provides an historic context for the notes covering recent developments in Embryology Research.
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