this material is not original, it has been lifted, reduced and edited from a text that is no longer in print. I can't even give proper credit as I have lost the original! In any case, there is far more information presented here than needed for a decent overview. I request that you try to peruse the whole file, and limit yourself to an hour in doing so.
I will ask (later) that you try to identify 5 or 6 key observations as the result of your review. I do not recommend printing out the entire file, though "saving" the file for off-line viewing is practical.

GJP

Ps:  you'll have to ignore the little icons of speakers -- I convcerted this from Word file in which I narrated portions to cut down on the actual reading, but only the icons transferred, not the sound files.

An overview of the various advances, the retreats, and the theories and speculations regarding medicine from antiquity to the present.

[yang (light, male), and yin (dark, female).

five basic elements (wood, fire, earth, metal, water)

associated with five planets, five directions, five seasons, five colors, five sounds, and

five organs in the human body

Disease is regarded as a disharmony

Diagnosis is based primarily on observation  of the pulse (51 types)

and inspection of the tongue (37 different shades)

Their thinking reflected an Egyptian influence.

Four fundamental elements: air, fire, water, and earth

Four fundamental qualities: hot, dry, wet, and cold

Four constituent humors of the body: blood, phlegm, yellow bile, and black bile.

Link for page with illustration of the four elements

Diagram illustrating the Greek theory of the four qualities, the four elements, and the four humors. The elements were regarded as being related to qualities, and these in turn governed the respective humors. Imbalance in the qualities and humors could be compensated by using drugs associated with the opposite qualities.

These four humors originated in the heart, brain, liver, and spleen respectively. 

This theory provided the "reasons" for techniques of evacuation used long before, such as venesection, cupping, cathartics, emetics, sneezing, sweating, urination, and so on. Its popularity can probably be attributed to its simplicity. A disease of the black bile, for instance, which was "dry" and "cold," would logically be treated by "hot" and "wet" remedies.
 
 

The idea that man and the universe are composed of the same elements 

The idea that man and the universe are composed of the same elements justifies the concept of the human body as a microcosm, which mirrors the macrocosm. The microcosm/macrocosm theory fills the history of Occidental philosophy, from the predecessors of Socrates to Paracelsus, Leibniz, and the Romantics. It became the source of numerous, mostly dubious, analogies.

concerned with the patient as a whole

primarily interested, in prognosis and treatment (not prognosis).

the treatment of an individual, not of a disease,

and the treatment of the whole body, not of any part of it.

Treatment was based on the assumption that nature, physis,

had a strong healing force and tendency of its own,

and that the main role of the physician was to

assist nature in this healing process,

Health was a state of harmonic mixture of the humors (eucrask), and disease was a state of faulty mixture (dyscrasia).

the physician assisted nature via diet.

Against more violent means of elimination,

such as purging, vomiting, and bloodletting,

Only if diet failed were drugs used, and surgery was a last resort. In spite of the generally conservative character of Hippocratic surgery, some rather daring operations were performed, including the trepanation of the skull and the opening of empyemas.

High ethical ideals pervade all the Hippocratic writings.

Kindness ("Where is love of men there is also love of the art") and dignity are emphasized,

as well as the more technical virtues of cleanliness and dexterity.

(384-22 B.C.) the great philosopher, logician, biologist and ethicist

He had considerable influence on medicine,

especially during the late Middle Ages on Aquinas

and the Renaissance through certain basic principles:

Form and matter, the actual and the potential, the individual and the universal.

Assumed everything in creation has a goal (a telos).

This is a key to Natural Law ethical theory

Greek ethics of "moderation in all things."

(virtue is in choosing the mean between the extremes)
 
 

There is a three-hundred-year gap in the documentation of Greek medicine. When at last Greek medicine reappears in the pages of Celsus, it has lost much of its original simplicity and has produced many idle speculations; but it has also achieved much real progress. 

In the third century B.C. the center of Greek civilization and medicine shifted from the old Greek settlements toward the new Egyptian city of Alexandria. In the strange cultural melting pot of Alexandria, Greek science produced some of its greatest achievements, and, conversely, Oriental mysticism gained greater influence on Greek thinking. The early Alexandrian period is the only period in the history of Greek medicine where dissection was legalized. This produced the most gratifying results for anatomical and surgical knowledge.
 
 

made important contributions to all fields of anatomy

and gave good descriptions of the eye, the brain, the vessels of the body, the duodenum and the male and female genital organs.

observed that sensor and motor paralysis are not necessarily simultaneous in a body region.

tried to make pulse observations more objective.
 
 

Direct observation -- reacted against unwarranted speculation

enriched specific fields, particularly symptomatology, pharmacology, and surgery

the progress of physics, anatomy, and technology, surgery advanced greatly in Alexandria until Roman times.

Use of the ligature as a hemostatic, operations of goiter, hernia, cataract, and tonsils, and of plastic operations.

At Alexandria, surgery seems to have begun its separation from internal medicine.

Early indications of "immunization" (!) 
 
 

During the same period many of the numerous small tyrants of the Middle East turned to medical research. Their interest was more personal than scientific, and the object of their preoccupation was a special branch of the drug family -the poisons. Poisons have fallen out of fashion in modern times because science has made their detection easy. But they have been powerful allies of the ambitious throughout history. Knowledge of poisons and their antidotes was very important for a dictator. The best known of these royal amateur toxicologists was King Mithridates of Pontus (12063 B.C.), the last powerful enemy of the Romans in the Near East. A very common antidote of late antiquity and the Middle Ages was named after him. In his experiments with ducks he supposedly hit upon the idea that one could immunize against poisons through repeated application of small doses.

The stage for the last great drama of Greek medicine is set in Rome. Ever since the third century B.C. Greek physicians, freemen, and slaves had been drifting into Rome. At first the Romans energetically opposed the use of foreign physicians, partly out of a feeling of national pride and partly because the professional and ethical standards of the new arrivals were often rather low. But accomplishment by the Romans themselves in the field of medicine was conspicuously absent. In the long run Greek medicine was bound to triumph in Rome.

...a Greek physician from Asia Minor, born in year 12 B.C.

was opposed to empiricism and to humorism.

His pathology was solidistic and atomistic.

thought that the cause of disease was a mechanical disturbance of the movement of atoms through the pores of the body.

did not believe in the automatically beneficial effect of nature's actions and structures.

harsh words for the "passive attitude" of the Hippocratic physician,

studied mental disease and made decerebration experiments.

Slogan: cito, tuto, jucunde (safe, fast, agreeable), 

The therapeutic methods of Asclepiades, popularized by the slogan cito, tuto, jucunde (safe, fast, agreeable), were far less energetic than one might suppose from his theories. His fight against too active treatments made him

a great reformer of therapeutics:

He was opposed to blood-letting and purging, and

relied primarily on diet, baths and carefully developed gymnastics.

one of his preferred dietetic remedies was wine. (very popular!)

recommended tracheotomy in case of obstruction of the upper respiratory passages.

Pneumatism influenced by the Stoic philosophy

highly developed drug lore

praiseworthy attempts to differentiate between primary and secondary phenomena of disease.

extraordinary clinical descriptions of diabetes, tetanus, diphtheria, and leprosy show clearly that the clinical genius of the Greeks was still as alive and powerful in the second century A.D. as it had been in the sixth century B.C.

The description of diabetes is a good example:
 
 

Medicine remained in Greek hands throughout antiquity. The Romans, with their essentially utilitarian approach, did great things in the fields of law, government, warfare, and architecture, but they never developed any original talent in philosophy, art, or science. Latin medical works were essentially compilations (such as Celsus). 

The Greek physician Rufus of Ephesus (about A.D. 100) cannot be classed with any medical sect or school, but be is important for his anatomy, for his pulse lore, and for his clinical details on cancer and plague.
 
 

(A.D. 130-201), born in 130 in Pergamum in Asia Minor, the site of a famous temple of Asclepias.

probably the greatest of Greek physicians after Hippocrates.

developed into a good surgeon and physiotherapist while treating the gladiators.

In Rome he soon gained great fame as a practitioner, lecturer, and experimenter.

A plague "caused him to flee from Rome for a time, (behavior which was regarded as perfectly ethical up to the eighteenth century.)

He returned to become the physician of the Emperor-philosopher Marcus Aurelius.

An extremely fertile author, he wrote at least a hundred treatises. His surviving works fill no less than twenty-two volumes.

Galen's wordy, aggressive, and self-laudatory writings do not reveal a very attractive personality. There is also a widespread prejudice against Galen because of the very paralyzing role played by his writings in the medicine of the Middle Ages and early modern times. Yet for the latter phenomenon, at least, it was certainly not he who was responsible, but the conservatism and authoritarianism of the period. The easily aroused prejudices against Galen should not blind the reader to the fact that he was far more than a compiler.

Galen was a first-rate anatomist and physiologist, and with him medicine took a great step forward.

But also occasionally used the notion of pneuma, dear to the Stoic philosophers,

and the strictum and laxum of the Methodists

The "critical days" played a great role in Galen's pathology, and the prevailing acute diseases, pneumonia, typhoid fever, and malaria, supported such a belief.

Galen was interested in diagnosis as well as prognosis.

Galen's therapeutics were schematic, following a methodus.

( "cold" remedies were used against "hot" diseases and vice versa.)

Unlike the Hippocratics, his therapeutics were mainly active.

He was addicted to polypharmacy; sometimes as many as twenty-five drugs were used in one prescription, and such complicated prescriptions were henceforth called Galenics.

He used bleeding and evacuation frequently.

He prescribed climatic treatment for tuberculosis.

Galen was very much concerned with hygiene and stated in a rather modern fashion that prevention is preferable to treatment.

Indicative of the beginning of the cleavage between surgery and medicine was the fact that Galen no longer practiced surgery to any great extent after coming to Rome. In that slave-holding society, manual labor was considered beneath the dignity of a gentleman, and surgery was regarded as a form of manual labor. 

Galen subscribed to the theory of "laudable pus," which held that every wound produced pus normally in the process of healing. As a result, this theory became a tradition which up to the nineteenth century prevented aseptic treatment of wounds. Galen himself was far less dogmatic about the matter and obviously was able to heal tendons per primary intentionem (immediately, before pus formation). 

Galen himself was never a blind traditionalist but submitted tradition to experience and experiment. His ability to see problems was extraordinary. And Galen was, beyond any doubt, the greatest medical experimentalist, not only of his time, but of any time preceding the seventeenth century. 

While this short survey has had to concentrate on the clinical knowledge and theories of Greek medicine in Rome, some social aspects of medicine in Rome should at least be mentioned.

There were sickness insurance associations and medical societies in Rome;

there was an increasing tendency toward specialization and the state employment of physicians;

and, toward the end, mystical healing cults grew increasingly popular.

All these phenomena of the increasingly complex and decadent Roman society have a rather modern ring.
 
 

The greatest medical contribution of the Romans was an indirect one.

Inspired by their Etruscan predecessors, they built aqueducts, sewage systems, and bathing installations of unequaled magnificence, not only in Europe, but everywhere they went. It was in connection with building activities that three Roman authors, the agriculturists Varro (11627 B.C.) and Columelia (first century A.D.), and Vitruvius, the great architect of Emperor Augustus, advanced the bold hypothesis that malarial fever was produced by small animals or insects coming out of the swamps. Roman architects accepted this hypothesis and devised building techniques to prevent these invasions, thus considerably increasing general health and well-being.

In any discussion of the medieval scientific doctor, recognizable in pictures wearing his fur-lined smock and bolding a urine bottle, it should be remembered that these doctors formed only a very small percentage of the healing personnel. Paris, for instance, had only six such doctors in 1296, and only thirty-two in 1395. This was a proportion of one doctor for every 8,500 inhabitants. Economically these doctors were secure and did not depend on fees, being either clergymen or city-appointed. But they could not provide medical care for the mass of the population. That was left to low-class surgeons, barbers, bathkeepers, and lay healers of all descriptions. Zurich, for instance, as late as 1790, had only four academic doctors, but thirty-four barber-surgeons and eight midwives.

Perhaps the greatest medical accomplishment of the Middle Ages was the hospital. Christianity exerted in this respect the same stimulating influence that Buddhism had demonstrated earlier in India. This was not so much a reaction to certain material necessities as an expression of a new, different, more humane attitude toward the sick, which had begun in late antiquity. Although institutions rather like hospitals had existed for the benefit of slaves and soldiers under the Romans, they could not be compared in magnitude and importance to the Christian hospitals that originated under Constantine after 335. A second wave of hospital-founding had its inception-perhaps under Arab influence-in 1145 with the spread of the Holy Ghost hospitals from Montpellier. In the course of a few decades the whole of Europe was covered with a vast network of hospitals. It must of course be realized that these Christian hospitals were primarily not medical institutions but philanthropic institutions offering "hospitality" and refuge to the old, the disabled, and the homeless pilgrims. Hospitals first acquired a medical character in the institutions founded by Italian merchants under the administration of certain knightly orders in Palestine. The first provisions for regular medical care within hospitals are found in the statutes issued by the Order of St. John (founded in 1099) to its Jerusalem hospital in 1181. The transformation from charitable hospital into medical institution was greatly accelerated during the thirteenth century when administration of the hospitals was gradually taken out of the hands of the orders by city administrations.

Contemporary of Vesalius

In 1545 he published his book on gunshot wounds: colleagues turned against the treatment of gunshot wounds with boiling oil.

wrote twenty books which profoundly influenced the future of surgery.

In 1552, he became the first surgeon of Henry II.

One of his greatest accomplishments was the reintroduction of the ligature.

The ligature had been completely abandoned since antiquity and replaced, through Arab influence, by the cautery as a means of hemostasis.

Pare also reintroduced the podalic version in obstetrics.

It was in Pare's time that the barber-surgeons began to take obstetrics out of the hands of midwives, where it had lain for millennia.

His popularity was such that in 1557 the elite surgeons of the College of St. Cosmo were obliged to accept in their ranks this barber who did not even know Latin. Pare', then a court surgeon, was spared in the notorious massacre of the night of St. Bartholomew in 1572, in which so many other Protestants were assassinated. He also escaped poisoning attempts that sprang from the same pious intentions. 

In 1582, in his treatise on the unicorn and the mummy, two very fashionable remedies of the period, Pare' destroyed the reputation of these two fake drugs forever.
 
 

"Je le pansais, Dieu le gugrit"

(I bandaged them, but God he healeth them). 

It is hard in the age of democracy to appreciate the tremendous implications of the rise of a lowly barber to such social and scientific heights in the highly stratified society of the Renaissance world. Only the highest intellectual endowment, coupled with relentless labor and study and the greatest strength of character, could achieve such a result. The humility of the man is all the more striking; at the end of such a career he could still say: "Je le pansais, Dieu le gugrit" (I bandaged them, but God he healeth them).

...saw the birth of a systematic and scientific legal medicine in the great treatises of the Vatican's physicians.

Medical statistics appeared on the scene, published in 1662.

An early attempt to organize preventive medicine was the collegium sanitatis in Prussia (1685).

Universities in general remained medieval and were not attuned to the scientific progress of the time. Practically all the great discoveries of the century were sponsored, not by universities, but by the so-called academies and learned societies. The works of Boyle, Malpighi, and Leeuwenhoek, for example, were published in the transactions of the Royal Society of London, which was chartered in 1662 and was an outgrowth of the "invisible college" founded in 1645. Similar free academies and scientific societies sprang up in all important European countries.

The brilliant accomplishments of the century, and the first signs of therapeutic skepticism (Daniel Ludwig, 1625-1680), should not obscure the fact that, in addition to official polypragmasy and polypharmacy, superstition was widespread and rampant, and quackery was extremely successful. This was the age of the "sympathetic powder" of Sir Kenelm Digby, which was supposed to heal a wound when put on the weapon which had caused it; of the "magnetic" cures of Valentine Greatrake; of the astrological medicine of Culpeper; and of the mass healing of scrofulosis (also called Kings Evil) by the touch of the French and English kings. The Rosicrucian and other mystic movements flourished.

The American Loyalist, Benjamin Thompson (1753-1814), who ended his career as Count Rumford and a great physicist in Munich, made remarkable studies of heating, ventilation, clothing, and food.

The most important factor in improving the health conditions of infants and children was probably the influence of the Geneva-born novelist and philosopher, Jean Jacques Rousseau. Thanks to him swaddling was discarded, and mothers returned to nursing their own babies. Rousseau's activities epitomize the effective participation of laymen in this and later public health movements. The first orthopedic institute for crippled children was opened in Switzerland in 1780. The increased interest in child welfare and child health found its statistical expression in a decrease in the appalling death rate of infants and children. The medical men who were guided by the philosophy of the Enlightenment were concerned not only about children, but also about mothers, old people, deaf-mutes, the blind, and so forth.

Preventive measures against Smallpox.

One of the great contributions to the new public health movement was the general introduction of an effective preventive measure against smallpox toward the end of the century. Smallpox was one of the main causes of childhood death in this period. It is significant that it was only during the eighteenth century, the century of the Enlightenment, that the West adopted a method of protection against smallpox that had been practiced in the East for many centuries. This method was variolation, an inoculation with true smallpox which produces a milder attack than spontaneous infection, thus giving protection against future attacks. But variolation was a dangerous method.

Once medicine had accepted the practice of prevention against smallpox, a far better and safer method was evolved by Edward Jenner (1749-1823). Jenner, a country practitioner, had heard of the immunity against smallpox enjoyed by milkmaids formerly infected by cowpox. With the encouragement of his teacher, John Hunter, he began to investigate this phenomenon. In his Inquiry into the Causes and Effects of Variolae Vaccinae, published in 1798, Jenner demonstrated that inoculation with cowpox would produce protection against smallpox in man without ill effects to the patient. The method, called vaccination, spread rapidly and has been of incalculable benefit to mankind. It has reduced the occurrence of smallpox to such an extent that the politically inclined World Health Organization found it possible to announce the "eradication" of smallpox. This announcement might be premature in view of the unreliability of statistics in underdeveloped countries.

Yet another effect of the Enlightenment, and the resulting philanthropic trend, was the revival of interest in medical ethics. Thomas Percival's Code of Ethics, published in Manchester, one of the first modern industrial towns, in 1803, became the model for all later codes. Doctors in the eighteenth century enjoyed such high social standing and such high emoluments that later generations have looked upon this period as the Golden Age of the medical profession. The relatively small number of doctors were usually attached to the courts of princes or to the free spending families of the privileged aristocracy. In the speculation on how larger groups could be provided with medical care, insurance schemes and plans for university reforms appeared.

A child of the eighteenth century is the homeopathic system of Samuel Hahnemann (1755-1843). Hahnemann's system involved the use of infinitesimally small doses of such drugs as would produce the symptoms of the disease when given in large doses. The system is summed up in the phrase, Similia similibus curantur (Like is cured by like). This theory has not been confirmed by scientific experience, but it was probably no more erroneous than any of the other eighteenth century systems, and it became very popular in the early nineteenth century. At least Hahnemann's system offered a fairly innocuous alternative to the heroic and often fatal orthodox therapeutic methods of the age, which still consisted of extensive bloodletting, purging, large doses of toxic drugs, and induced vomiting. The dogmatism of his system has separated it from the main stream of scientific development, and it now lives on as a cult with a relatively small following. The other medical heresy of the late eighteenth century, Mesmer's "animal magnetism," will be dealt with later in relation to the growth of psychiatry. Both Hahnemann and Mesmer were freemasons.
 
 

THE CLINICAL SCHOOLS of the first half of the NINETEENTH CENTURY

The developments in medicine, in technology, and in science during this period were paralleled in economics by the growth of industry and capitalism, and in politics by the evolution of democracy and nationalism.

In later decades of the nineteenth century progress in medicine was largely gained through the adaptation of the results of natural science to medical uses. But the first great step forward in scientific medicine was not achieved in this way. Medicine began by rescuing itself from the morass of eighteenth-century theories and systems and made a sweeping return to clinical observation, checked and complemented by extensive and intensive studies on the autopsy table. This was more than a return to Hippocratic methods. The clinical "observation" of the early nineteenth century differed in three essential points from the classical Hippocratic observation.

The methods of the French Clinical School found their first application abroad in the great hospitals of Dublin, where medicine at this time went through a unique period of growth. Counting the pulse with a watch became a routine procedure mainly through the efforts of the Dublin School. The greatest surgeon of the Dublin School was Abraham Colles of "Colles' fracture" fame.

The two most famous leaders of the New Vienna School were Joseph Skoda (1805-1881) and Karl Rokitansky (1804-1878). Rokitansky was the greatest pathological anatomist of his time. Skoda developed auscultation and percussion along exact physical lines. Objective examination of therapeutics had made the French clinicians skeptics. The Viennese went even one step further; some of them became "therapeutic nihilists," holding that no treatment was better than any of the then existing treatments. And they were sometimes able to prove it. Such an attitude was in the long run untenable, but it had a sobering effect on what remained for a long time medicine's weakest field. The finest accomplishments of the New Vienna School lay in the realm of specialties. Vienna excelled in the application of the new approach to dermatology, syphilology, legal medicine, and the diseases of the eye, ear, nose, and throat. The specialist Semmelweis is probably the most typical representative of the New Vienna School both in his talents and in his limitations.

While British and French medicine made progress through sober observation, German physicians, under the leadership of the philosopher Schelling, indulged in extensive speculations on the essence of life and disease, on the polarities, and on Paracelsian analogies between macrocosm and microcosm.
 
 
 
 

The history of the clinical schools during the first half of the nineteenth century  in Paris, Dublin, London, and Vienna is one of the greatest chapters in medical history, and its lessons should never be forgotten. Yet the possibilities of its two basic contributions, physical diagnosis and gross pathological anatomy, were limited. Neither teaching nor research could forever be located exclusively in the wards of a hospital. Localism was a progressive movement, but it was far from providing an answer to all the problems of pathology. An inevitable dead end was reached. New ways had to be found; and they were found in the application of the basic sciences to the problems of clinical medicine.
 
 

...a new science, pharmacology, was born. It is no accident that Magendie, a leading physiologist, was one of the fathers of modern pharmacology. Modern pharmacology was possible only after the pharmacists had isolated sufficiently pure substances from the raw drugs. The first substances thus to be isolated were in the alkaloid family.

Sertuerner isolated morphine in 1806,

and Pelletier and Caventou did the same for strychnine in 1818 and quinine in 1820.

Magendie worked with strychnine, morphine, emetine, the bromides, and iodine.

His pupil Bernard analyzed opium, nicotine, ether, and curate.

In Germany, pharmacology became an independent discipline through Rudolf Buchheim (1820-1879).

His pupil Oswald Schmiedeberg (1838-1921) did important research, especially on digitalis and histamine. He became the founder of a school which spread all over the world.

In England Alexander Brown and Thomas Frazer (1841-1920) related chemical constitution to pharmacological effects.

Sir Thomas Lauder Brunton (1844.-1916) analyzed heart drugs and introduced the use of amyl nitrite for angina pectoris.

During the 1880's, the rapidly growing pharmaceutical industry introduced numerous synthetic drugs. Most of these were antipyretics, such as antipyrine, salipyrin, acetanilid, and sulfonal. From this beginning there developed in the twentieth century the science of specific drugs, or chemotherapy, which will be considered in a later chapter.

The basic sciences gave medicine an unprecedented knowledge of the intricate structures of the human body.

They provided a means of correlating pathological signs with changes in those structures;

they allowed the main functions of the body-respiration, circulation, digestion, metabolism, nervous action, internal secretion, and reproduction-to be understood as never before;

they made possible the objective measurement of these functions and their deviations from the normal;

and they made therapeutic action equally predictable and measurable.

It is obvious that this new background was to have a decisive influence on the future development of clinical medicine.

The idea that epidemic diseases were transmitted by contagion, and caused by micro-organisms, "seeds," or "animalculae," was not exactly new in the middle of the nineteenth century. The theory had been set forth by Fracastorius in the sixteenth century, and it had been defended by Kircher in the seventeenth century and by Lancisi and Linne in the eighteenth. As a matter of fact, it was at the lowest ebb in its history when Jacob Henle again proclaimed it in 1840; and he appeared to his contemporaries, not as the precursor of a new era, but as the gallant defender of an old-fashioned error. Epidemiological experience with yellow fever, typhus, and cholera, in which quarantines had proved to be supremely ineffective, supported the claims of the anticontagionists, who had in their ranks such respectable scientists as Magendie and Corrigan. To look for a living agent of contagion was even less fashionable in a period when belief in the prospects of chemistry was almost unlimited. Thus the chemist Liebig could successfully override even such clear evidence for the role of living forms in chemical processes as that presented in favor of the fermentation through yeast by Cagniard de Latour in 1836 and Schwann and Kuetzig in 1837.

Yet in the second half of the nineteenth century medical opinion was slowly to change. This was partially a pendulum-like return to a previous position, since anti-contagionism had proved to be just about as ineffective against cholera epidemics as the old-fashioned contagionism. A more positive factor was the rapidly accumulating evidence in favor of the causation of disease by microorganisms. One of the most important steps in this direction was the demonstration by the lawyer Agostino Bassi in 1835 that certain diseases of the silkworm were contagious, being produced by fungi. Bassi drew far-reaching conclusions from these discoveries as to the nature of contagious diseases in general. In 1837 Donne' demonstrated the presence of the organism Trichomonas vaginalis; in 1839 Schoenlein described the fungus causing favus (named after him by Remak); and David Gruby described other fungi causing skin disease in 1844.

Finally, in 1850, bacteria were added to the list of possible disease-causing micro-organisms. Bacteria had first been seen by Leeuwenhoek. They had been studied extensively by the Danish naturalist Mueller in the eighteenth century and by the naturalist Ehrenberg and the botanist Ferdinand Cohn in the nineteenth century. But so far they had not been suspected of pathogenic potentialities. Casimir Davaine (18121882) and Pierre Rayer (1793-1867) discovered the anthrax bacillus in 1850 in the blood of animals dying from anthrax and succeeded in transmitting it. In 1855 Pollender published the same discovery, based on observations he had made in 1849. It was no accident that the first pathogenic bacterium discovered was one of the largest. Davaine, a general practitioner, did not even have a laboratory; he kept his experimental animals in a friends garden. Other pathogenic microorganisms discovered during this period were the trichinas and the spirilla causing relapsing fever. In 1872 Coze, Feltz, and Davaine submitted extensive evidence for the bacterial causation of septicemia. The idea of contagion was supported by inoculation experiments on such diseases as glanders. The first of these was performed by Rayer in 1837. Villemin proved the contagiousness of tuberculosis by inoculation experiments in 1865. Similar experiments had been made by Klencke in 1843 without receiving recognition.

Louis Pasteur (1822-1895) --not a medical man but a chemist.

approached medical problems in a basic, scientific fashion, rather than reaching out immediately for practical answers.

his first great discovery established the existence of molecular dissymmetry.

he began his studies on fermentation in 1857.

Pasteur showed conclusively that fermentation was the work of various micro-organisms. These findings launched Pasteur into what was to become bacteriology.

Worked to abolish the theory of "spontaneous generation,"

he was now widely sought by governmental and private organizations to help save French industries, menaced by processes which seemed to be the work of micro-organisms.

His study of the diseases of wine led to his invention in 1863 of...

"pasteurization."

He studied the diseases of the silkworm in 1865

and the diseases of beer in 1871.
 
 

Only in 1877, after twenty years of research into the biology of micro-organisms, did Pasteur extend his studies to the diseases of men and bigger animals.

He first identified, and then developed vaccines for anthrax and chicken cholera

1885 led to his most spectacular achievement,

preventive vaccination against rabies.

The principle of vaccination was extended in the nineties to diphtheria, to typhoid fever, and to cholera and plague.

A grateful nation built Pasteur a special research institute in 1889, and a grateful world honored him in every possible way. Pasteur is remembered for his restless, creative genius, and for his great human kindness. Yet he possessed another quality which was no less necessary in order to bring about the victory of his ideas-his tireless ability to fight. Great ideas and great inventions do not necessarily win acceptance because of their inherent value. Pasteur's victory was the more remarkable because he not only had to overcome the traditional conservatism of the medical profession but furthermore had to achieve this as an outsider, a non-medical man dictating in medical matters.

In an attempt to stem the wave of uncritical work that now started in bacteriology, Robert Koch issued his famous postulates, the genesis of which can be found in the treatise on contagion written by his teacher, Henle. These postulates were:
 
 

and in 1883, on a trip to Egypt and India, he found the cholera bacillus. 

These two discoveries made possible a successful offensive against two of the most pernicious enemies of mankind. When Koch submitted his tuberculin to the medical profession in 1890, the medical world felt that it had at last found an efficient method of treating tuberculosis. This hope was not to be confirmed by experience, but tuberculin proved to be a valuable diagnostic aid. Koch's last important research was his study of the cattle plague in South Africa in 1897 and the plague itself in India in 1898.
 
 

Koch was a far less spectacular figure than Pasteur. Arriving twenty years later on the scene, he found much better conditions for his work. Yet it should be remembered that his most characteristic qualities, great industry and technical ingenuity, are essential conditions for scientific progress.

After the first decisive steps were taken, the advances of the seventies and eighties were breath taking. At the same time, of course, there was a great deal of worthless work by incompetent enthusiasts who explained every disease and every biological function in terms of bacteria. A partial list of diseases whose causative agents were discovered during the next decades, together with the names of the discoverers, illustrates the rapid rate of progress:

1875 amebic dysentery (Loesch)

1879 gonorrhea (Neisser)

1880 typhoid fever (Eberth, Gaffity)

leprosy (Hansen)

malaria (Laveran)

1882 tuberculosis (Koch)

glanders (Loeffler)

1883 erysipelas (Feweisen)

cholera (Koch)

1884 diphtheria (Klebs, Loeffler)

tetanus (Nikolaier, Kitasato) pneumonia (A. Fraenkel)

1887 epidemic meningitis (Weichselbaum) malta fever (Bruce)

1889 soft chancre (Ducrey)

1892 gas gangrene (Welch)

1894 plague (Yersin, Kitasato)

botulism (van Ermengem)

1898 bacillary dysentery (Shiga)

1901 sleeping disease (Bruce, Dutton)

1905 syphilis (Schaudinn)

Eventually it became obvious that, though bacteria were a cause of many diseases, they were not the disease itself, as had often been thought in the first enthusiasm. Henle and Virchow had warned that there was a difference between disease cause and disease process, and their warning proved well founded. Bacteria were not the sole cause of disease. A great many more factors had to be considered beyond the mechanical encounter between a bacterium and a host. Constitutional, geographical, and social factors, which for decades bad been completely neglected because of a blind trust in bacteriology, had to be reconsidered. It was realized that even knowledge of the parasitical cause of a disease, and of effective methods for its treatment, might still not bring about eradication of the disease if certain social and economic factors were unfavorable to full application of such knowledge. This is obvious in the case of malaria, tuberculosis, and syphilis. Medical knowledge is probably now sufficient to eradicate these diseases, but social conditions insure their continued existence.

In spite of these qualifications, in spite of the fact that in the total framework of science the rise of bacteriology was only one among the many great biological discoveries of the times, there is no doubt that from the strictly medical viewpoint it was the most important development of the eventful nineteenth century and perhaps of all recorded time.

Ignaz P. Semmelweis (1818-1865).-- this Hungarian was probably the finest product of the New Vienna School.

discovered the clue to puerperal infection, which is identical with wound infection.

He laid his gift at the feet of the medical world and was laughed at, or at best ignored.
 
 
 
 
 
 

The history of modern asepsis begins on a tragic note and with a tragic figure. Almost a generation before the triumph of modern surgery, an obscure obstetrician discovered the clue to puerperal infection, which is identical with wound infection. He laid his gift at the feet of the medical world and was laughed at, or at best ignored. This man, probably the finest product of the New Vienna School, was the Hungarian Ignaz P. Semmelweis (1818-1865).

While working at the first obstetric clinic of the University of Vienna, Semmelweis was struck by the marked difference between his and the second obstetric clinic in the number of puerperal mortalities. The first clinic's mortality rate was three times as high as the other's. Only the first clinic was open to medical students, while the second served for the instruction of midwives. Through a judicious analysis of autopsy reports, Semmelweis concluded in 1847 that puerperal fever in the first clinic was produced primarily by contact with the contaminated hands of doctors and medical students coming from the autopsy room. He demonstrated the truth of his conclusion by introducing the routine of handwashing with a chlorine solution before manual examination. The result was a dramatic reduction in puerperal mortality. Semmelweis not only uncovered the cause of puerperal fever but also realized its identity with wound fever. Few of his colleagues were impressed with his puerperal theory, and all of them ignored his contention that wound fever stemmed from the same cause. As a reward for his discovery he was dismissed from his position at the Vienna clinic and had to return to Budapest.

The second great obstacle to large-scale surgery, in addition to wound infection and the resultant septicemia, was the inadequacy of the means available to surgeons for the control of pain. This restricted the scope of operations, intensified shock, and made speed essential. Future developments in surgery waited on the discovery of adequate pain-control methods.

Ether and nitrous oxide had served as sources of amusement at so-called "frolies" since the beginning of the century. European scientists, beginning with Sir Hurnphry Davy in 1800, had suggested the possibility of using such gases as anesthetics. But the decisive step in this direction was taken in the United States. In 1844 the Connecticut dentist Horace Wells (1815-1847) successfully started the practice of anesthetizing his patients with nitrous oxide.

In connection with the rise of specialties, the origins of the modern nursing profession cannot be neglected. Up to the middle of the nineteenth century nursing was in the hands either of nuns or of uneducated helpers of low quality. The first school for nurses was opened in 1836 by the German clergyman Theodor Fliedner in Kaiserswerth on the Rhine. The Fliedner institution served as inspiration to Florence Nightingale (1823-1910), an English lady from the upper strata of society, endowed with an indomitable energy and great ability. Her spectacular accomplishments in the abominable field hospitals of the Crimean War gave her the authority and the power to rejuvenate nursing in the English speaking countries. She opened a school for nurses at St. Thomas' Hospital in 1860. The first training school for nurses in the United States was opened in 1873 by Elizabeth Blackwell (1821-1910), who was also the first woman M.D. in this country (1849). In the twentieth century, nursing in turn has been subdivided into several branches, and other auxiliary medical specialists have arisen, such as the laboratory technician, the x-ray technician, and the medical social worker. All these innovations have greatly improved medical care, but they have also made it more and more expensive, primarily because treatment occurs increasingly in hospitals, with their ever-more costly technological equipment.

Preventive medicine did not rely entirely on legal methods of enforcement; educational methods received increasing attention. Through them, hygienic standards have changed completely. A hundred years ago one took a bath only when sick. The United States pioneered in one special field of preventive medicine, that of mental hygiene. Mental hygiene had long been promoted by doctors in individual cases, but mass application started only with the founding of the mental hygiene movement in New York in 1909.

The public health movement has produced a new type of doctor, the nontreating doctor. For the first time in history large numbers of medical men no longer treat individuals but deal exclusively with the health of larger groups of people. Another type of nontreating doctor is the nonpracticing scientist whose role has become more and more important since the middle of the last century. As professorships and Nobel prizes show, this role can even be played by nonmedical men and women.

The appearance of the nontreating doctor is only one of the many changes experienced by the medical profession during the nineteenth century under the influence of new scientific developments. Old problems, such as the separation of medicine and surgery, had disappeared. Through "academization" the barber-surgeons had become doctors, just as the toothpullers bad become dentists, the spicers pharmacists, and the blacksmiths veterinarians. Scientific progress had solved the problem of decline in social standing that the profession had felt so painfully in the 1840's. But scientific progress also created new problems. Medical care has now become incomparably more effective than it was a hundred or even fifty years ago, but it has also become incomparably more expensive. In 1870 an office call cost twenty-five cents, a house call fifty to seventy-five cents. The large investment in education, especially specialist education, and the high cost of apparatus force the modern doctor to charge much higher fees than his grandfather did. The cost of medical care may partially explain certain negative aspects of the health situation of the American people today. In the Second World War, for instance, 40 per cent of the twentv-two million young men examined for the draft were rejected. Medical care is financially out of reach of many families at a time when demand for it is continually increasing. It is this combination of circumstances that has led to the pressure for governmental action, and the general tendency toward the welfare state.