PorterWk01 - 244 THE NEW SCIENCE In Le Me’decin malgre’...

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Unformatted text preview: 244 THE NEW SCIENCE In Le Me’decin malgre’ lui, Moliére presented the following exchange between a patient and a pretender: GERONTE: It was very clearly explained, but there was just one thing which surprised me — that was the posiu'ons of the liver and the heart. It seemed to me that you got them the wrong way about, that the heart should be on the left side, and the'liver on the right. SGANARELLE: Yes, it used to be so but we have changed all that. Everything’s quite different in medicine nowadays. Moliére got it right. There was still much that was laughable about seventeenth-century medicine; but it was changing fast. In The Advancement of Learning, Francis Bacon had proclaimed: Medicine is a science which hath been (as we have said) more professed than laboured, and yet more laboured than advanced; the labour having been, in my judgement, rather in circle than in progression. For I find much iteration, but small addition. By the century’s end, addition was more visible. CHAPTER X ENLIGHTENMENT IN SEARCH OF MEDICAL SCIENCE A MINOR EIGHTEENTH-CENTURY MEDICAL WRITER, Samuel Wood, looked back in his Stricmrer an the Gout (I 77 5) over the previous ‘two thousand years’ and deplored the ‘unenlightened state of the ancient Practitioners’, with whom ‘all was mere conjecture’. ‘There could be no Physiology at all,’ he insisted, ‘before our immortal Harvey’s Dis— covery of the Circulation of the Blood,’ since when, he concluded, ‘it is much more easy to account for life, for health, and for diseases.’ Early-modem times brought Harvey’s and other brilliant break— throughs in anatomy and physiology, but achievements proved more impressive on paper than in bedside practice; the war against death was stalled, and, to make matters worse, epidemics rained down on Europe in the decades around I 700 and mortality rates soared. Warfare, worldwide trading webs, giant cities and the thronging urban poor — the populations of cities like Naples, Paris and London were already topping half a million — all exacerbated health hazards. Better times were on the way, however, according to the new philo- sophy of progress proclaimed by enlightened intellectuals in the Nether- lands, Britain and France: original sin was a myth, and life’s journey was not the preachers’ vale of tears. Reason, proclaimed Enlightenment propagandists, would create a better future; science and technology, as Francis Bacon had taught, would enhance man’s control over nature, and social progress, prosperity and the conquest of disease would follow. In the 17905 the Marquis de Condorcet (1743—94) declared that future medical advances, supported by the civilizing process, would extend longevity, even perhaps to the point of immortality. ‘The improvement of medical practice,’ he declared, 245 246 ENLIGHTENMENT which will become more efficacious with the progress of reason and of the social order, will mean the end of infectious and heredi— tary diseases and illnesses brought on by climate, food, or working conditions. It is reasonable to hope that all other diseases may likewise disappear as their distant causes are discovered. The ogres of error and blind authority had already been challenged by heroes like Vesalius and William Harvey; further progress would‘make medicine yet more scientific. What precisely this scientific medicine should be like was hotly disputed. Iatromathematicians like Giorgio Baglivi (1668— I707) set great store by quantification. His De praxi medita (1699) [On Medical Practice] held that ‘the human body . . . operates by number, weight, and measure’. God, he asserted, ‘seems to have sketched the most ordered series of proportions in the human body by the pen of Mathe— matics alone’. And numbers counted. In 1707, Sir John Floyer (1649— 1734) published The Physician’s Pulse Watch, which acknowledged the Galenists’ skill in interpreting the pulse, but sought to establish objective numerical standards for determining abnormality, recommending checking the pulse against a watch with a special second hand. With the idolization of Isaac Newton (1642— I 727), whose Pfincz'pia had been published in 1687, experimental natural philosophy offered the most persuasive scientific model.'Leading the application of physics to medicine was the Dutch professor, Herman Boerhaave (1668— 1738), who construed health and sickness as expressions of such variables as forces, weights and hydrostatic pressures. Boerhaave was the pre— eminent early Enlightenment physician, holding a succession of chairs at Leiden University from I702. His influence spread through print: his textbook, Institutioner medicae (I708) [The Institutes of Medicine], ran through ten editions and was translated into five languages; protégés like Gerhard van Swieten (1700—72) exported his teachings to Vienna, Edinburgh and Gottingen. Boerhaave promoted mechanistic disease explanation within a cor— puscularian matter theory, seeing health in terms of hydrostatic equilib- rium, a balance of internal fluid pressures. He distinguished between disorders of the ‘solids’ and those of the ‘blood and humours’. Tubercu- losis was an example of weakness of the solid parts, blood clots an example of overly rigid fibres. Give milk and iron for weak fibres; let blood for rigid ones, he counselled. Such views encouraged experimentation. The mathematically ENLIGHTENMENT 247 inclined Anglican clergyman Stephen Hales (1677—1761) thus devised ‘haemodynamic’ experiments to measure blood circulation. Analysing the circulation in his Hammtirks (1733), he measured the force of the blood by inserting into the jugular vein and carotid artery of a living horse a goose’s trachea attached to a glass tube eleven feet long, to see how far up the tube the column of blood was carried. He recorded that the arterial pressure was far greater than the venous. A dauntless animal experimenter, Hales also explored Descartes’s notions of nerve action. His method involved decapitau'ng frogs and stimulating their reflexes by pricking the skin, noting that nervous responses continued. These experiments provoked anti-vivisection protests. The normally thick— skinned Samuel Johnson (1709—84) denounced doctors who ‘extend the arts of torture’. ‘1 know not’, he asserted, ‘that by living dissection any discovery has been made by which a single malady is more easily cured.’ Boerhaave’s hydraulic model of the body incurred criticism, how— ever, and attention shifted from the vascular to the nervous system. Vital qualities like irritability and sensibility were highlighted in the work of Albrecht von Haller (1708—77) in Gotdngen, William Cullen (1710—90) and his colleagues in Edinburgh, and Théophile de Bordeu (1722—76) and other Montpellier vitalists — all of whom developed a more dynamic life-force physiology than Boerhaave’s, in which health was the co-ordination of the separate life of each organ in the body. In other words, eighteenth-century scientific medicine was far from monolithic. Rival camps proliferated, and the traditional Italian and French centres of excellence were challenged by Halle, Leiden, London, Edinburgh, Vienna and Philadelphia, each with its own school. In Halle, Georg Ernst Stahl (1659— I734) denounced the materialism he detected in Boerhaavian mechanical philosophy, advocating instead an ‘animism’ which proposed a God-given, super—added soul (anima) as the prime mover of living beings. Highly influential in German-speaking lands, Stahl attacked reductionism: organisms were more than the sum of their parts, and purposive human actions could not be explained by mechanical chain—reactions alone; activity presupposed the guiding pur- posive power of a soul. This anima was the agent of consciousness and physiological regulation, and disease was the soul’s attempt to expel morbid matter and re-establish bodily order. Stahlian animism made medical sense, but it was also the product of evangelical Lutheran Pietism. Yet even in Halle Stahl did not reign unchallenged, for his colleague 248 ENLIGHTENMENT there, Friedrich Hoffmann (1660—1742), leant towards mechanism. ‘Medicine’, announced his Fundamenta medicime (1695) [Fundamentals of Medicine], ‘is the art of properly utilizing physico—mechanical prin- ciples, in order to conserve the health of man or to restore it if lost.’ Occupying the middle ground was Boissier de Sauvages (1706-67), professor of medicine at Montpellier. He accepted that the body was a machine, mathematically understandable, but disease was the effort by nature or the soul to expel morbific matter, and physiology was the science of that struggle. In their different ways, Boissier de Sauvages’s successors — Théo— phile dc Bordeu, Robert Whytt (I7I4—66) in Edinburgh, and John Hunter (1 728—9 3) in London - also denied the sufficiency of mechanics for explaining the body, postulating some vital force or organization. Very few physicians (the anti—clerical pbilosopbe Julien Offray de La Mettrie (1709—51) was one) went the whole hog and unashamedly reduced man to mechanism. Influenced by the spectacular working auto- mata constructed by craftsmen like Jacques Vaucanson (1709—82), La Mettrie held in his L ’bomme machine (I 748) [Man a Machine] that matter thinks; there was no need for a soul, for the body is ‘a machine that winds its own springs’. There were, in short, numerous ways in which medical authors sought to set their discipline on scientific rails; even so, that medicine failed to match the achievements of experimental physics or chemisz remained scandalous. Towards 1800, Thomas Beddoes (1760—1808), the Bristol practitioner who dreamed of curing lung disorders with respirable gases, rued that medicine was ‘remote . . . from such perfection’. Historians have sometimes explained this apparent paradox of Enlightenment medical science —— great expectations, disappointing results — as the consequence of over-ambitious theorizing. Yet that judgment seems misguided; for one thing, highly practical investigation continued unabated in fields like anatomy. As Italy’s star waned, the lights of science moved north, to France, the Netherlands, England, Scotland and certain German principalities. For long Leiden led the field, thanks to Boerhaave and his pupil, Bernhard Siegfried Albinus (1697—1770) — in a pious gesture, they re-published Vesalius’s works. Albinus’s own writings on the bones, muscles and the gravid uterus were exquisitely illustrated. Many other impressive anatomical atlases appeared, notably William Cheselden’s (1688—17 52) Orteogmpbia (I733) [The Bones Illustrated], Haller’s lame: anatomicae (I743- 56) ENLIGHTENMENT 249 [Anatomical Images], and William Hunter’s (1718—83) Anatomia uteri bumam' gravidi (I 774) [Anatomy of the Human Gravid Uterus], an aston— ishing depiction of the pregnant woman and her foetus in thirty—four copper-plates. Knowledge of gross anatomy was by then well-established, but in- novations were sn'll possible respecting the softer and more concealed fibres: the lacteal, lymphatic and particularly the nervous systems. Build- ing on Willis’s ‘neurologie’, it was studies by Jacob Winslow (1669— 1760) and the Prussian, Samuel Thomas von Sommerring (1755-— 1830) that established the classification of the cranial nerves. A Gottingen contemporary of the great Johann Friedrich Blumenbach (see below), Sommerring produced a major series of anatomical treatises on the sense organs, beginning with the eye (1801). Comparative anatomy received a boost from Pen-us Camper (I 72 z —89), who enrolled at Leiden at the tender age of twelve and went on to win fame for dissections of elephants, rhinoceroses and orang—utans. I-Iis attempt to measure ‘facial angle’ (the line of the brow and nose) was misused in later physical anthropology as an index of racial type. Comparative studies led Caspar Friedrich Wolff (1734—94) to con- clude that ‘all parts of the plant except the stem are modified leaves,’ a metaphysical tenet later endorsed by the poet and polymathJohann Wolf- gang von Goethe (I 749-— 183 2), who interpreted insect jaws as modified limbs, believed the skull was composed of modified vertebrae, and rejected mechanistic views of life in favour of a philosophy of holism. Exponents of Naturpbilosopbie, like Blumenbach’s student, Laurenz Oken (I 779- I 85 I), were soon suggesting that nature embodied a transcendental unity of plan, built upon elemental structural archetypes or anatomical building-blocks; this paved the way for philosophical morphology. It was not only Namrpbilosopbie which insisted there was more to bodies than pipes and pulleys, for experimentation itself revealed the limits of the mechanical model, forcing recognition of the astounding powers of living things — quite transcending clockwork. René Réaumur (1683—17 57) demonstrated the ability of lobster claws to regrow after being severed; Abraham Trembley (1710—84) chopped polyps into pieces and produced new individuals; in 1768 Lazzaro Spallanzani (1 729—99) succeeded in regenerating the tails of salamanders, snails and tadpoles. There was more to life than the mechanical philosophy had dreamt of. But how was it to be explained in an era no longer prepared to 250 ENLIGHTENMENT entertain miracles or Galenic innate virtues? Experimentation prompted new accounts of vitality and the reladons between body and soul, a movement whose towering figure was Albrecht von Haller. Haller learned much from his mentor, Boerhaave —- indeed, one of his first works was an edition of Boerhaave’s Institutes of Medicine (1739—44) — but he went beyond, unifying anatomy and physiology into a single science of ‘living anatomy’ (anatomia animata). An infant prodigy from Bern, Haller studied in Leiden and taught for seventeen years at the newly-founded University of Gottingen, before returning in 1753 to his native Switzerland. Linguist, poet, poly— math and devout Christian, his forte was physiological experimentation. His early Anatomical Image: depicted vascular anatomy, and continuing physiological researches led to a systematic physiology textbook, the Primae lineae physiologiae (1 747) [First Lines of Physiology], which went through several editions and translations and long served as a standard text. There followed his vast synthesis, the Elementa physiologiae empori: bumani (8 vols, I7 57—66) [Elements of the Physiology of the Human Body]. Its organizing assumption was Boerhaave’s principle that man possesses a physical body, analysable in terms of matter and forces, and an immaterial soul. Ironically, it was the pious Haller who conducted experiments which challenged his religiously reassuring dualism. In his De panibu: cor-port's bumani sensibilibw et initabilibu: (I 752) [On the Sensible and Irritable Parts of the Human Body], he made his key contribution to the study of animal economy by showing, rather in line with Glisson’s hypothesis, that irritability (contractility) was a property inherent in all muscular fibres, whereas sensibility was the exclusive attribute of nervous fibres. He thus established the fimdamental division of fibres according to their reactive properties: the irritable and the sensible. The sensibility of nervous fibres lay in their responsiveness to painful stimuli; the irrita- bility of muscle fibres was their property of contracting in reaction to stimuli. Haller therefore had an explanation of why the heart pulsated: it was the most ‘irritable’ organ in the body; composed of layers of muscular fibres, it was stimulated by the influx of blood, responding with systolic contractions. On the basis of animal experiments, Haller graded organs according to their fibres, ascribing to them inherent sensitivities independent of any super-added soul. As to the causes of such living forces, these were beyond knowing, or at least unknown: as with Newton on gravity, it was sufficient to study the effects. ENLIGHTENMENT 251 Haller’s model of fibre sensibility and irritability was open to varied interpretations. Robert Whytt, for instance, was troubled by its implied reductionism, fearing it would lead to materialism and atheism. Indeed, Haller’s findings were appropriated by radical philosophers like Denis Diderot (1713—84), eager for polemical reasons to develop a biological materialism which held that matter possessed vital properties. In On the Vital and Other Involuntary Motions of Animals (1751), Whytt reiterated the role of the soul, understood naturalistically not religiously. Unlike the Cartesian unextended soul, Whytt’s was ener- getic, sentient at a non-conscious level (and so, in a sense, automatic) and spatially extended in the body. The sentience of the soul was funda- mental to his notion of bodily co-ordination by means of sympathy, the irreducible perceptive power of the body. These views brought him into conflict with Haller, who found the notion of non-conscious perception unintelligible. . The problem of vitality also informed Haller’s work on embryological development, conducted in the context of the preformationist/epigenicist debate. Preformationists held that either the egg or the sperm contained a miniature representation (bmunculur) of the adult organism, foetal for- mation being a growth of parts already present at the moment of fertiliz- ation; epigenesists believed that the various organs were not all present but appeared gradually during the formation of the foetus. Early in his career Haller espoused epigenesis, but, in the 17505, once the unsettling implications of the new biological materialism were surfacing, he turned to preformationism. His main antagonist was Caspar Friedrich Wolff, who elaborated a rather Harveian epigenetic doctrine in his influential Tbeoria generationi: (I 7 59) {Theory of Generation]: tissues and organs differentiated and developed, maintained Wolff, rather than being preformed and merely ballooning in size in the fertilized egg. Experimental researches thus forced Haller to confront unpalatable alternatives: Boerhaavian dualistic mechanism (too crude for resolving the puzzles of life), Stahlian animism (concealed theology), or atheistic reductionism. His concepts of irritability and sensibility won support, however, and mainstream successors treated vitality as a property of the organized ensemble of living bodies. Modifying Haller, his Gottingen successor Johann Friedrich Blumenbach (1752—1840) delineated vital properties, including the nisw fbmativus or Bildungrtrieb, an inherent life-force shaping growth and regeneration. Appointed professor in 1776, Blumenbach was to dominate bio-medical thinking in Germany 252 ENLIGHTENMENT for over sixty years. In De generi: humani varietate nativa (I 776) [On the Natural Variety of the Human Race], he accepted Linnaeus’s belief that man (Homo sapiem) could not be exempted from the standard rules of primate taxonomy; nevertheless man should be housed in a separate zoological order (Bimna: two-handed). Committed to monogenesis (the single origin of the human race), be identified five racial varieties: the Caucasian, Mongolian, Ethiopian, Malay and American Indian. Scottish-born but London-based, John Hunter proposed a ‘life— principle’ in the blood to account for the properties which distinguished living organisms from inanimate matter; in France, it was the Mont- pellier pupils of Jean Astruc (1684—1766), who took up the vitality question. While accepting Boissier de Sauvages’s denial that mechanism could explain purposive action, they tended towards a more materialist stance, stressing the inherent vitality of living bodies. Bordeu in particu— lar maintained that each organ was naturally endowed with an inherent responsivity to stimuli: vital function was intrinsic to the fibres. It is no accident that Bordeu pops up as a character in one of Diderot’s philosophical d’esprit, arguing that the new physiology had proved that matter itself was the secret of life. In this speculative context the vogue for electrical experiments proved significant; Haller’s doctrines of sensitivity and irritability sug- gested parallels between physiological and electrical events. What fired the nerves? The force might be mechanical, as with a bell—pull; or chemical, akin to a gunpowder trail; but many thought it electrical. Electrophysiology was pioneered by Luigi Galvani (1 737—98). In his De viribu: eleaficitati: in motu musculari (1792) [On Electrical Powers in the Movement of Muscles], the Italian described experiments in which he sus- pended the legs of skinned dead frogs by copper wire from an iron balcony. As the feet touched the iron uprights, the legs twitched and the muscles contracted: muscular activity and electricity went together and electricity could apparently simulate life. These experimens were followed up by Alessandro Volta (1745- 1827), professor at Pavia, whose Memorie mll’ eletm'cita animale (1792) [Letters on Animal Electricity] showed that a muscle could be thrown into continuous contraction by successive electric stimulations. The electricity of life implied by such writings shaped later neurophysiology and inspired science—fiction fantasies like Mary Shelley’s (1797—1851) Frankenstein (1818), which depicted life being artificially created with the aid of an electrical spark. ENLIGHTENMENT 253 Post-Boerhaavian investigators thus probed the gap between the living and the inanimate, and many regarded the superior properties of living entities as deriving not from some super—added transcendental principle but from innate organization. Echoing the Great Chain of Being, a hierarchy of levels of organic complexity was suggested. All living things displayed powers of nutrition and reproduction; unlike mere vegetables, animals also had capacities for motility and sensi- tivity, associated with the sensory—motor system; ‘higher’ creatures (vertebrates, mammals), endowed with more sophisticated nervous organization, additionally had the potential for voluntary action. Blessed with consciousness, man was the apex of this pyramid of organized vital powers — albeit, Linnaeus insisted, only one primate among many. This gradation of faculties was expressed in the idiom of ‘develop- ment’: higher forms were more developed. But for most that term carried no implication of species transmutation over historical time - that is, ‘evolution’ in the modern sense — being rather a plan of Creation pre—ordained in the Divine Mind, unfolding by divine law. However, Erasmus Darwin (1731—1802) in Britain and Jean Baptiste Lamarck (1744—1829) in France turned the ‘stages’ model of the hierarchy of organized powers into full-blown biological transformationism, showing lower forms transmuting into higher, thanks to inherent dynamic drives and a capacity to respond to environmental challenge. Medicine’s interactions with what was by 1800 acquiring the label ‘biology’ thus posed key questions about the scientific understanding of life itself. If these proved intractable, other more modest investigations bore fruit. How did digestion work? By some internal vital force? By the chemical action of gastric acids? Or by mechanical churning, min- cing and pulverizing? Building on the work of Van Helmont and Sylvius, new inquiries were initiated by the French naturalist, René Réaumur. By training a pet kite to swallow and regurgitate small porous food-filled tubes, he demonstrated the powers of gastric juices: digestion was not a process of trituration and putrefaction of food, as then believed; gastric juice dissolved food. Testing whether digestion was essentially a chemical process, Spallanzani self—experimented by gulping down and regurgitating linen bags, establishing the solvent powers of saliva. Drawing upon the iatrochemical tradition, chemists meanwhile explored fermentation and the links between respiration and combus— don. Joseph Black (I 728~99), who taught chemistry at Glasgow and later Edinburgh, framed the notion of latent heat and identified fixed 254 ENLIGHTENMENT air or what came to be known, with Lavoisier’s chemical revolution, as carbon dioxide. Gas chemistry advanced rapidly, especially with the recognition that the atmosphere was not homogeneous but a cocktail of distinct gases. In 1766 Henry Cavendish (1731— 1810) identified hydrogen, and Daniel Rutherford (I 749— 1819) nitrogen in 1772. Soon after, Joseph Priestleyv(1733—— 1804) and Karl Wilhelm Scheele (I 742— 86) independently isolated the gas Antoine-Laurent Lavoisier (I743— 94) would name oxygen (1775). All this led to a new understanding of respiration. Black noted that the fixed air given off by quicklime was also present in expired air; though non—toxic, it could not be breathed. Priestley grasped that vegetating plants renewed vitiated air, which, as an advocate of the phlogiston theory developed by Stahl, he called ‘phlogistica'ted dephlo— gisticated air’. Lavoisier then elucidated the exchange of gases in the lungs: the air inhaled was converted into Black’s fixed air, whereas the nitrogen (‘azote’) remained unchanged. Rather like John Mayow before him, Lavoisier believed respiration was the analogue within living bodies of combustion in the outside world; both needed oxygen, and both produced carbon dioxide and water. Oxygen was evidently indispensable for the human body; while engaged in physical activities like digestion, it consumed greater quantities than when at rest. A little later, Spallanzani revealed that oxidation occurred in the blood and throughout the entire physical system, and by 1800 it was accepted that oxygen combined with the carbon contained in food to generate animal heat. These inquiries also led to attempts to measure the salubrity-of the atmosphere, with a view to purifying the noxious air of towns and fetid buildings. Pneumatic chemistry, it was hoped, held the key not just to environmental medicine but to therapeutics. The aim of Thomas Beddoes’s Pneumatic Institute, opened in 1799 in Clifton (Bristol), was to find by experimentation therapies for conditions such as tuberculosis. Beddoes developed a partnership with the engineer James Watt (1736— 1819), jointly publishing Considerations on the Medicinal Use ofFactitiou: Air: (1794), and with his apprentice, Humphry Davy (1778—1829), he discovered nitrous oxide (laughing gas), which he hoped would cure consumptives. In the event, aérotherapy or pneumotherapy achieved little, while the valuable anaesthetic properties of nitrous oxide lay oddly neglected. s ENLIGHTENMENT 255 MEDICINE IN PRACTICE Anatomy and physiology thus engaged in dialogue with experimental science, but biomedical findings did not often deliver clinical success, and divisions were opening up between research and clinical practice. Certainly, science was not what secured top clinicians their fame. Some achieved their busy practices through personal considerations: Richard Mead (1673—1754) was known for suavity (according to Dr Johnson, he ‘lived more in the broad sunshine of life than almost any other man’), whereas for John Radcliffe (1652—1714) what paid was bluntness (his infallible recipe for success was, ‘use mankind ill’). Others, like Mark Akenside (1721—70) and Samuel Garth (1661—1719) combined physic with wit. An affable courtly coffee-house physician, Garth’s literary star rose with Tbe Dispensa1y(1699), a mock—Iliad, likening a petty squabble between the College of Physicians and the Society of Apothecaries to the Trojan War. In a polite and enlightened age many physicians made their name as men of letters, philanthropists or improvers. Charles Darwin’s grand- father, Erasmus, studied medicine at Cambridge and Edinburgh, and also in London with William Hunter. Settling in Lichfield, in 1766 he helped form the Lunar Society of Birmingham, which aimed to develop knowledge useful to an industrializing society and included among its luminaries the potter Josiah Wedgwood (1730—95), the physician Wil— liam Withering (1741-99), the chemist Joseph Priestley, and James Watt. Darwin was an incurable inventor; claiming to travel 5000 miles a year on his medical rounds, it is small wonder he left plans for a steam-driven car. He expounded his medical ideas in Zoonomia (I 794— 96), advocating the use of elecn'icity and corresponding with Beddoes about pneumatic medicine. His fame, however, derived mainly from his breezy and colourful verse, especially Tbe Botanic Garden, part of which (The Love: oftbe Plants: r 789), was a droll popularization of the Linnaean classification. Darwin’s contemporary John Coakley Lettsom (1744—1815) built a massive London practice and a fortune to match; at times he was netting up to £1 2,000 a year — more than most noblemen. This he owed partly to sheer hard work; in r783 he reflected that ‘since I769 when I first settled in London I have not taken one half day’s relaxadon’. But 256 ENLIGHTENMENT he also won public regard thanks to his philanthropic activities and his improving essays on lying—in, charities, prostitution, the deaf and mute, religious persecution, Sunday schools, dispensaries, hydrophobia, sea-bathing infirmaries, cheap porridge for the poor, the evils of tea-drinking and quackery, the virtues of smallpox inoculation and vaccination, and many more. Though a Quaker, he was a social climber, being caricatured in' the press as ‘Dr Wriggle’. Every court and capital had its Dr Wriggle, in silver-buckled shoes, tricorn hat and sporting his gold-headed cane, skilled in ‘the Art of Rising in Physic’. The doyen in France was the Geneva-bom Theodore Tronchin (1709—81), an enlightened intellectual and Voltaire’s favourite doctor — though this was not saying much, since Voltaire believed that doctors poured drugs of which they knew little to cure diseases of which they knew less into human beings of whom they knew nothing. An advocate of inoculation, Tronchin was one of many physicians to point out that the stomach disorder called Poitou colic (in England Devon colic) was the product of lead poisoning. In polite circles public mien meant much, but physicians won their reputation primarily for their bedside care. William Heberden (17m— 1801), who advanced knowledge of angina pectoris, arthritis and night- blindness, left in his Medical Commentaries on the History and Cure of Disease: (I802) clinical descriptions which were models of acumen and limpid prose. He believed the essence of a good physician lay in bedside sagacity; his devoted patients agreed. ‘ Some new bedside skills were touted. In his Inventum novum (1761) [New Discovery], Leopold Auenbrugger (1722— 1809) of Vienna announced the technique of percussion of the chest. An innkeeper’s son, he had been familiar since childhood with the trick of thumping barrels to test their fullness. Moving from kegs to rib-cages, he noted that when struck with the finger, a healthy chest sounded like a cloth—covered drum; by contrast, a muffled sound or one of high pitch indicated pulmonary disease. Auenbrugger’s auscultation was ignored until the nineteenth cen- tury, however, and in conducting their diagnoses physicians generally rested content with the traditional uses of the ‘five senses’; they would feel the pulse, sniff for gangrene, taste urine, listen for breathing irregu- larities and observe skin and eye colour. This time-honoured approach remained essentially qualitative. Despite Floyer’s pulse watch, what counted in pulse lore was not the number of beats per minute but ENLIGHTENMENT 257 their ‘feel’. Skilled practitioners could judge patients by close personal attention. Diagnosis was an art of observation and inference. John Rutherford (1695— 1779), professor at Edinburgh, impressed upon his students the value of inspecting the patient’s facial appearance. Discussing a patient admitted to the Infirmary, he noted, If it had been daylight, I would have examined her gums and the internal canthus of her eyes . . . for by looking into the internal canthus and the gums and finding them in a florid state then the blood is in a good state, but if they are pale or livid it is a sign that blood is dissolved and watery; if they have a yellowish cast it is frequently attended with a degree of acrimony, but when the cast is of a greenish colour, the acrimony is much greater as we see in scorbutick people. His careful inspection of her face did not extend to other body parts. Though he concluded that her ‘disease seems to be owing to the mis- management she underwent in childbed. She says she was lacerated and probably it was her vagina’, he made no attempt to check that for himself, thereby revealing the limits of physical examination — in Britain at least. This hands-off approach owed something to social etiquette and sexual propriety, but traditional diagnostic thinking gave no reason to privilege physical examination. What counted most was interpretation of the patient’s own ‘history’ — the common practice of postal diagnosis was perfectly reputable. Armed with a fine memory, the clinician was thus, rather like a Freudian psychoanalyst, to be a good listener, doing his detective work by astute questioning. ‘Endeavor to get the history of the disease from the patient himself,’ advised the American physician, Benjamin Rush ( I 745 — I 8 I 3): Begin to interrogate your patient. How long he has been sick? When attacked and in what manner? What are the probable causes, former habits and dress; likewise the diet, etc., for a week before especially in acute diseases . . . In chronic diseases enquire their complaints far back and the habits of life. . . . Pay attention to the phraseology of your patients, for the same ideas are frequently conveyed in different words. A pain in the precordia is called by an Englishman a pain in his stomach, by a Scotchman in his breasts, an Irishman in his heart and by a Southern man mighty poorly. Patients often conceal the cause of their disease — therefore 258 ENLIGHTENMENT interrogate them particularly when you suspect intemperance as the cause of disease. If Galen had sat in, he might have viewed the American as his prize pupil. THE STUDY OF DISEASE The clinician had to know his diseases as well as his patients, and many trod in the Hippocratic footsteps of the revered Thomas Sydenham, charting epidemic disorders. John Fothergill (1712—80), a Yorkshire Quaker who attracted a lucrative London practice, gave a model clinical description of diphtheria, then growing more prevalent, in his An Account of the Sore Throat (1748). Understanding of scurvy was advanced by James Lind (1716—94), while in 1776 Matthew Dobson (d. 1784) reported experiments in which he evaporated urine and found a residue which smelled and tasted like sugar. Finding sugar in the blood sug- gested that diabetes (known since antiquity) was not principally a kidney problem. Other conditions attracted fresh attention. An age of luxury not surprisingly led to a plethora of works on gout and other fashionable disorders, while George Cheyne’s (I67I—I743) The English Malady (I 733) was only the most striking of many treatises addressing the ‘ner— vous diseases’ supposedly rife among the elite. Prosperous England was worst afflicted: ‘Since our Wealth has increas’d, and our Navigation has been extended, we have ransack’d all the Parts of the Globe to bring together its whole Stock of Materials for Riot, Luxury, and to provoke Excess.’ Sickness was the price of success. The remedy? A milk, seeds and greens diet, Cheyne advised, abstinence from alcohol in extreme cases, and plenty of exercise on horseback or on the eighteenth-century precursor of the exercise bike, the indoor wooden chamber horse. In French-speaking Europe a similar message was conveyed by the Swiss physician, Samuel Tissot (1728—97), whose moralizing echoes his compatriot Jean-Jacques Rousseau’s praise of healthy nature: ‘Beneath the rustic garb of the plowman and not beneath the gildings of the courtier will strength and vigour of the body be found,’ exclaimed the philosopher. Tissot’s Avis au peuple rur la :ante’ (I 761) [Advice to People with Respect to their Health] broached the problem of ‘depopulation’ and luxury, which he attributed to the seductions of cities. Another ENLIGHTENMENT 259 complaint he and many other physicians believed rampant was mas— turbation. In a book translated into English as Onanism or a Treatise Upon the Disorder: Produced by Masturbation (r 766), Tissot depicted it as yet another disease of civilization, brought on by idleness and meretricious novels. Piecemeal advances thus occurred, but the fundamentals remained contentious. What was disease? What was its true cause (vera mum)? In a clinical climate honouring Hippocrates, sickness was still largely attributed to personal factors such as diet and exercise. Such consti- tutional concepts made sense of the visibly uneven distribution of sick- ness (some people fell sick, others did not); they also underlined individual responsibility and strategies of containment through self—help. Theories of contagion were also in circulation, backed by the evi- dence of diseases such as syphilis. But contagion hypotheses had their difficulties: why were some people stricken and others spared? This problem partly explained the lasting popularity of miasmatic models, holding that sickness typically originated in the environment. With intermittent fevers like ‘ague’ (malaria), it was common knowledge that those living by estuaries and in wetlands were especially susceptible to what was often called ‘marsh fever’. Low, spotted and ‘putrid’ fevers, including our typhus, were recognized as infecting slum-dwellers and the occupants of barracks, ships and workhouses. Miasmatic disease was said to arise from poisonous exhalations exuded by putrefying animal remains, rotting vegetation and stagnant water: bad environments gen- erated bad air which then turned pestilential. After 1750, reformers directed attention to ‘septic’ diseases like gangrene and erysipelas decim- ating the populations of gaols and hospitals. Historians have tended to divide disease theorists into rival camps: miasmatists versus contagionists. But that is too crude; much theoretical finessing went on (for instance, emphasizing the distinction between predisposing and precipitating factors), and in any case investigators were less interested in theorizing a primary cause than in documenting the prevalence of sickness and controlling its spread. That is why the umbrella-term ‘fevers’ proved as useful to the eighteenth century as to the Hippocratics, forming the organizing principle of works like On Fevers (1750) by the Devon physician John Huxham 0692—1768). Fevers could be recognized as epidemic but also interpreted in classic humoral terms as a febrile ‘crisis’ in the individual, involving the patient’s ‘coction’ of morbific matter, to be resolved by the expulsion of peccant 260 ENLIGHTENMENT humours. The time—honoured view that fever was a process requiring ‘support’ rather than suppression still found favour, for the risk with heroic intervention was that fevers would ‘turn in’ and prove far more menacing. In reality, as experience showed, there was little that could be done with epidemic fevers, apart from supporting the patient and trusting to the healing power of nature. In the English-speaking world, the most influential attempt to set disease in a coherent framework lay in the teachings of William Cullen. After studying at Glasgow and Edinburgh, Cullen practised as a surgeon; in I 740 he took his MD at Glasgow and four years later began delivering lectures there on medicine, materia medica, botany and chemistry. He was formally admitted later as professor of medicine, and became friendly with Joseph Black, Adam Smith (1723—90) and David Hume (1711—76), leading lights of the Scotu'sh Enlightenment. In 1755 he was appointed professor of chemistry in Edinburgh, whose medical school was rising thanks mainly to the anatomy teaching of the Monros. In 1766 he gained the chair of the Institutes of Medicine, which com— prised physiology, general pathology and therapeutics; and from 1769 he alternated courses on the Practice of Physic with his colleague, John Gregory (1729-73), accepting that chair on Gregory’s death. Cullen broke with the Boerhaavians in viewing not the vascular but the nervous system as the key to the ‘animal economy’ (that is, physiological balance), and he attempted to describe the law-like behaviour of the organism while avoiding reduction of life to the mech- aniCal. The ftmdamental physiological fact was that life consisted in a state of nervous excitement produced by environmental stimuli. These produced sensations (some conscious, some not) which provoked irri— table tissues in the organism. According to Cullen, irritability was depen- dent upon the nervous system and not, as Haller maintained, on an autonomous muscular response. Though Cullen denied knowledge of the essence of the nervous power, he tended to identify it with an aetherial fluid which was also the basis of light, heat, magnetism and electricity. Rejecting humoralism, he held that all pathology originated in a disordered action (‘spasm’) of the nervous system — earning him the nickname ‘Old Spasm’. Partly for classroom reasons, Cullen tried to bring order to clinical medicine by drawing up his own nosology (disease classification) in which he treated diseases, like plants, as real entities, with characteristic pathognomonic signs or symptoms. Nosology was in vogue. Naturalists, ENLIGHTENMENT 261 such as the Swede Karl von Linné (Linnaeus: 1707—78) author of Syrtema naturae (I 73 5) and inventor of the binomial system, had developed new taxonomies for natural history, and symptom-based medical classifications inevitably followed. In his Nouvelle: classes des maladies ( I 731) [New Classes of Illnesses] and Nosologia methadica (I 768) [Methodical Nosology], Boissier de Sauvages classified diseases into 10 classes, 295 genera and a daunting 2400 species. Cullen’s nosology, set out in his influential First Line: oft/1e Practice qubysic (1 778—9), was far simpler. It reduced disease classes to 4, with the first 3 (pyrexias, neur— oses, cachexias) based on disturbances of the u‘aditional physiological functions: animal, vital, and natural. His fourth class (local disease) included local pathological changes. Cullen placed most infectious diseases in the category of Pyrexiae or febrile diseases, differentiated by local inflammations. Among such fevers, conditions like smallpox with well—defined symptoms and spread- ing by contact were attributed to specific contagious. Intermediate between these and the diseases of locality at the other end of the spec- trum (typified by ague or intermittent fever, associated with the rotting vegetation of marshes) lay the ‘doubtful’ diseases, which were ‘some- times contagious and sometimes not’ — an ad bat character quite alien to later bacteriological specificity, but compatible with ideas stressing filth and putrefaction as elements in disease. The least defined pyrexiae were the continued fevers, divided mainly into typhus, enteric (typhoid) and relapsing. Possessing some of the same characteristics were diseases related to common putrefaction — the ‘septic’ diseases: gangrene, septicaemia, scarlet fever, diphtheria, ' erysipelas and puerperal fever. In his clinical teaching Cullen devoted particular attention to slow and nervous fevers, diseases then rife in gaols and hospitals, stressing the role of filth and poor ventilation rather than concentrating on traditional Galenic factors like diet. Since fevers of that kind were debilitating, blood—letting was contra—indicated. A simple inflammatory fever (as in a cold or pneumonia) with a strong hard pulse but no delirium was labelled by Cullen synocba. If accompanied by delirium or stupor, he called it typbus. In Scotland the prevailing form of continued fever seemed to be a combination of syno- cha and typhus which he termed synocbus. In short, fever was a general malady which might assume various forms, though its common under— lying phenomenon was a spasm of the arteries. Fevers developed in three stages: debility with relaxation (atony) of the arteries; a stage of 262 ENLIGHTENMENT irritation; and third, the hot stage resulting from the arterial spasm. A fever might be caused by atmospheric matter. If it arose from the bodies of the sick, it would be called contagion; if from marshes and standing water, miasma. Contagion or miasma exerted a sedative influ— ence on the body, inducing debility. Cullen recommended supportive treatment to overcome weakness; blood—letting might be used to relieve spasm, and there was always the healing power of nature. Though attempting a nosology, Cullen was not set upon the onto— logical view of disease. He believed most diseases to be caused by exter— nal influences — climate, foodstuffs, effluvia, humidity, and so on — and he taught that the same external factors could cause different diseases in different individuals, depending on the state of the nervous system. As the foremost teacher of his age, Cullen’s disease framework shaped the beliefs and practice of thousands of doctors throughout the English— speaking world for the next fifty years; broadly comparable systems were meanwhile being taught to students in Montpellier, Halle and Vienna. Some of the tendencies of Cullen’s theory were taken to their logical conclusions by his one—time pupil and later foe, John Brown (r735— 88), the Scottish Paracelsus, who insisted upon the unitary nature of sickness. There was only (me disease, though it assumed myriad forms and forces. Brown reduced questions of health to variations of irritability (his word was ‘excitability’). Life was thus to be understood not as a spontaneous state but as a ‘forced condition’, the product of the action of external stimuli. Sickness was disturbance of the proper functioning of eXcitement, and diseases were to be treated as ‘sthenic’ or ‘asthenic’ according as ‘excitement’ increased or diminished. Attempting to distil disease into medicine-by—numbers, Brown envisaged a thermometer calibrated upon a single scale, rising from zero (‘asthenic’ disorders, lethal under-stimulation of the body) to 80 degrees (fatal over—excitement); the mid—point formed a healthy equilibrium. The device of a single axis objectified illness into something quantifiable, and pointed to a therapeutics dependent upon dosage size. For Brown, treatment was essentially a matter of larger or smaller measures of sedatives and stimulants, principally opiates and alcohol. Though winning scant support in France and England, Brunonian medicine had the virtue of simplicity and was enthusiastically taken up in America by Benjamin Rush, and in Italy by Giovanni Rasori (1766— 1837); Christoph Girtanner (1760— 1800) and Johann Peter Frank (1745— I82 I) popularized it in German-speaking Europe. ENLIGHTENMENT 263 PATHOLOGY Cullen gathered, sifted and glossed available medical knowledge, his emphasis being on use rather than discovery. A new approach was, however, being developed which was to prove profoundly significant in transforming the very idea of disease aetiology. Since Vesalius, prac— titioners had pursued gross anatomy, and greater attention began to be paid to the connexions between the sick person and the disease signs afforded by the corpse. Anatomy thereby led to morbid anatomy in necropsy studies pursued by, among others, Johann Wepfer (I620— 95) and Théophile Boner (1620-89), both Swiss. The conviction that postmortem investigation was the key to the bodily changes brought about by disease (not least, cause of death) was largely due to Giovanni Battista Morgagni (1682—1771), professor of anatomy at Padua, who, aged almost eighty, published De sedibu: et cauris morborum (1761) [On the Sites and Causes of Disease]. Drawing on the findings of some 700 autopsies to show how bodily organs revealed the footprints of disease, this work achieved instant recognition; it was translated into English in 1769 and German in 1774. Born at Forli, Morgagni had studied under Anton Maria Valsalva (1660—1723), a remarkable experimentalist from whom he acquired extensive dissection experience. In I715, he moved to the chair of ana- tomy at Padua, becoming the leading Italian anatomist. De :edibw is divided into five sections, devoted respectively to diseases of the head, thechest, the abdomen and to surgical conditions, with addenda in the form of seventy letters to friends. Case histories, with their most striking symptoms and autopsy results, were followed by an elucidation of the relationships between the case history and morbid anatomy. Morgagni’s discoveries were numerous. He described the anatom— ical phenomena observable in angina pectoris and myocardial degen- eration, the fibrinous clots found in the heart after death, and the heart-block syndrome now termed Stokes-Adams. He associated cyan- osis (blueness of the skin) with pulmonary stenosis (narrowing of vessels) and made major observations on arteriosclerosis of the coronary and cerebral arteries and hypertrophy of the heart in mitral stenosis. He pointed out that apoplexy or stroke was not caused by a lesion of the brain but by alteration in the cerebral blood vessels. He accounted 264 ENLIGHTENMENT for aspects of gastric ulcers, the vermiform appendix, emphysema and numerous other conditions. De :edibus shifted emphasis from symptoms to site. Thinking anatomically, he demonstrated that diseases were located in specific organs, that symptoms tallied with anatomical lesions, and that such morbid organ changes were responsible for disease. The great significance of his work was recognized and developed by others. In Britain, Matthew Baillie (1761—1823) was prominent. A nephew of the Hunters, Baillie trained at his uncle William’s Great Windmill Street anatomy school and at St George’s Hospital, where his other uncle, John, was surgeon. William’s death in 1783 left the young Baillie the happy owner of the anatomy school, and by 1787 he was also physician at St George’s, later becoming physician extra— ordinary to George HI. Arranged by organs, Baillie’s Morbid Anatomy of Some of the Most Important Pam if the Human Body (1793) discussed the pathological changes caused by diseases. Working from autopsy evidence, Baillie confined himself to what he could see with his eyes without specu- lating on the ultimate causes of disease or bringing in symptom—based nosologies. Building on Morgagni while incorporating the newer pathological methods emerging in France, Morbid Anatomy contains several classic descriptions, including emphysema and cirrhosis of the liver, which he linked to alcohol. He offered numerous new descriptions, including ovarian cysts, gastric ulcer and the hepatization of the lungs in pneu- monia. Illustrated by William Clift (1775—1849) with superb copper— plates, depicting, among other things, Samuel Johnson’s emphysema, Baillie’s was more of a textbook than Morgagni’s, describing as it does the morbid appearances of each organ in succession. It went through eight English and three American editions and was translated into French, Italian, German and Russian. The second edition (I 797) developed the idea of ‘rheumatism of the heart’ (rheumatic fever), con— tributing to the early study of heart disease. J. B. Sénac (1693—1770) had published important findings in 1749, and in 1799 Caleb Parry (I 7 55— 1822) brought out his Inquiry into the Symptom and Causes of tbe Syncope Anginora, Commonly Called Angina Pet-tonic, discussing cases with their postmortem results, including ossification and obstruction of the coronary arteries, together with gross pathology of the aorta. Across the Channel, pathology’s possibilities were being extended through the publication in 1799 of the Traits” der membranes [Treatise ENLIGHTENMENT 265 on Membranes] by Marie F rancois Xavier Bichat (1771— 1802). A doc- tor’s son from the Jura, Bichat studied at Lyon and Paris at the height of the Terror. Army service provided him with ample surgical practice, and from June I 794 he settled in Paris, becoming assistant to the leading surgeon, Pierre-Joseph Desault (1 738-9 5). Bichat taught private courses and conducted some 600 anatomies, but never obtained a major hospital post and died tragically yormg. Designed to set medicine on a sound anatomical basis, his Traite’ and his Anatomic géne’rale (1801) focused attention on structures compar~ able in texture but found in different organs. Bichat’s key innovation was the doctrine of tissues: he described twenty—one such membranes, including connective, muscle, and nerve tissue, distinguished by appear- ance and vital qualities. The most widespread were cellular tissue, nerves, arteries, veins, absorbent and exhalant vessels; these were found intermeshed in most other tissue systems. More restricted ones included skeletal muscle, involuntary muscle, gland, cartilage, bone, mucous and serous membranes. These, he proposed, should be the analytical build- ing-blocks of anatomy, physiology and pathology, rather as elements were in Lavoisier’s new chemistry, and he set about delineating their structure, vital properties, abnormalities and responsiveness. Bichat dis— missed ‘souls’ or ‘vital spirits’ as metaphysical will-o’-the-wisps and avoided microscopes as machines of error. Tissues would provide a new map of the body, and henceforth diseases were to be lesions of specific tissues rather than simply of organs. The vital properties of tissues formed the focus of Bichatian physi— ology. He distinguished between those of animal life (voluntary muscle, sense organs and their nervous connections) and those of organic life (comprising lungs, circulatory system, alimentary canal and excretory organs). The former were said to form paired structures and to show a higher degree of sensibility and contractility, whereas the latter showed only the contractility characterizing all living tissues. Bichat saw pathology with fresh eyes. ‘The more one will observe diseases and open cadavers,’ he declared, ‘the more one will be convinced of the necessity of considering local diseases not from the aspect of the complex organs [as with Morgagni] but from that of the individual tissues.’ His work laid the foundations for nineteenth-century patho- anatomy, and helps to explain why, within a few decades, Cullen and his colleagues had gone the way of Galen. 266 ENLIGHTENMENT THERAPEUTICS Advances in pathology pinpointed a paradox: ‘I know better perhaps than another man, from my knowledge of anatomy, how to discover disease,’ Baillie remarked, ‘but when I have done so, I don’t know better how to cure it.’ Indeed. Pathology did not open the door to cures — hardly any eighteenth—century scientific advance helped heal the sick directly. Therapeutics made herculean efforts, but the net connibution of physicians to the relief and cure of the sick remained marginal. ‘Cur’d yesterday of my Disease, I died last night of my Physician,’ quipped Matthew Prior in 1714. Certain innovations were positively harmful. The new lying—in hos- pitals had horrendous mortality rates, for reasons little understood till the work of Ignaz Semmelweis in the following century (see Chapter 12). The fondness for heroic blood-letting, often coupled with heroic dosing, was deleterious. Phlebotomy won its most sanguine advocate in Rush, the ‘founding father’ of American medicine. Born in Philadelphia, Rush studied in Edinburgh and on his return to his native land was appointed professor first of chemisz and then of medicine at the Col- lege of Philadelphia. The American Revolution drew him into politics, and he was a signatory of the Declaration of Independence. Modifying Cullen, Rush concluded that a hyperactive state of the arteries (he called it ‘hypertension’) was the key to disease. This dictated an aggressively depletive therapeutics consisting of copious blood-letting.* Calling mercury ‘a safe and nearly a universal medicine’, Rush also recommended calomel purges — dubious methods destined to remain favoured by American regulars, partly because of Rush’s standing as the American Hippocrates. Calomel (mercurous chloride) appeared in every physician’s bag throughout the nineteenth century, and was an active ingredient in the ‘blue pills’ prominent in nineteenth—century English therapeutics. Many physicians felt driven to caution against the worth— ' Le Sage had already turned the abuse of blood-letting into fine satire in his Adventure: of Gil Blur (1715—3 5). He told of a cleric who consulted a Dr Sangrado for gout. The physician’s favourite remedy was copious bleeding. ‘It is a mere vulgar error, that the blood is of any use in the system’, prated Sangrado, who instructed a surgeon to withdraw ‘six porringers of blood’ and ‘as much more three hours hence’ and then to repeat the process the next day. ENLIGHTENMENT 267 lessness of the available drugs. ‘I do not deny’, wrote John Berkenhout in his Symptomatolagy (1784) that many lives might be saved by the skilful administration of proper medicine; but a thousand indisputable facts convince me, that the present established practice of physic in England is infin- itely destructive of the lives of his Majesty’s subjects. I prefer the practice of old women, because they do not sport with edged tools; being unacquainted with the powerful articles of the Materia Medica. But, then, could old crones be trusted? Didn’t they dabble in aborti- facients and the like? Genteel patients continued to be treated by top clinicians according to traditional learned medicine. Tailored to individual needs, thera— peutic strategies centred upon temperance and hygiene, good air, diet, evacuations, sleep, exercise and equanimity. These factors (the ancient ‘non-naturals’) were essential for avoiding what pedants sometimes called the ‘contra-naturals’; in common parlance, disease. The concept of health as natural balance pointed to various physical strategies, includ— ing dietetics, bathing and purging. Diet — still meaning a comprehensive ordering of life — was discussed down to the last lettuce leaf in works like the Erray Concerning the Nature ofAlimentr (I 7 3 I) byjohn Arbuthnot (1667—1735). The benefits of travel were also much touted, in accordance with the Hippocratic Airs, Waters, Place: tradition. With the spread of tuber- culosis, ‘phthisical’ or consumptive gentlefolk made winter pilgrimages to Lisbon or Livomo in search of balmy air, while travelling itself (colloquially ‘Dr Horse’) was said to recruit the constitution and strengthen the nerves. ‘1 must be on horseback for life, if I would be healthy,’ claimed John Wesley (1703—91) — and indeed the founder of Methodism was still galloping round the country delivering hellfire sermons in his eighties. For the fashionable, the benefits of travel were combined with taking the waters. Spas like Vichy, Bourbon and Baden Baden abounded across the Continent, but it was in England’s burgeoning consumer society that they first became big business, promising elegant healing rituals, social contacts and rich pickings for hoteliers and doctors. Pre-eminently Bath, but also Tunbridge Wells, Buxton, Scarborough and Cheltenham, provided balls, gambling, diversions and assignations, to accompany 268 ENLIGHTENMENT dipping, pumping and drinking the waters. By 1801, Bath, mixing medi- cine and merriment, had astonishingly become England’s seventh largest City. After 1750, with England leading the way, the therapeutic virtues of the seaside were also being praised. Dr Richard Russell (1687— 1 759), the booster of Brighton, contended that sea water should preferably be drunk (the salts were beneficial), but most people settled less heroically for bathing, with the additional boon of sea air, for consumptives in particular. The I Philadelphia polymath and inventor of bi-focals, Benjamin Franklin (1706—90), practised air-bathing, sitting naked each morning before an open window. Yet, despite the medley of physical methods long popular, there are signs that, even then, healing was growing increasingly medication- centred. Prescription of medicines was the expected outcome of medical consultations, as was admitted in Bernard Mandeville’s A Treatise of Hypochondriack and Hysteric/e Passion: (1 71 I), a witty exposé of unscrupu- lous practitioners. Routine prescribing of pills, rather than a comprehen— sive regimen, was still frowned upon in the best circles as the lazy practice of those who, so George Cheyne alleged, ‘are continually cram- ming their Patients with nauseous and loathsome Potions, Pills and Bolus’s, Electuaries, Powders and Juleps’. It was easier for practitioners to charge for their pills and boluses than for attendance or advice alone. In any case the new science was leading to pharmaceutical improve- ments, and large manufacturing druggists emerged, selling wholesale and retail. The London chemist Thomas Corbyn (I71 I —9I), like many others in the trade a Quaker, stocked over 2500 different items of materia medica, employed a staff of ten, and by the 17805 was running a business with a capital of some £20,000. He traded extensively with North America, the West Indies and the Continent. Whether used simply or in compound mixtures, distilled, dried, ground or decocted, herbs still constituted the bulk of the materia medica employed by apothecaries and in kitchen physic. Herbal remedies were designed largely to act as emetics and laxatives, although elite medicine also made a fancy parade of alteratives, diluents, deobsu'uents and similar hifalutin categories, each with its own action and rationale. Alteratives were supposed to strengthen the system, bitters were said to brace the solids — e.g., to clear the head and settle the stomach after a binge, and stimulate the appetite. Medications, learned physicians stressed, must be regarded not as panaceas but as auxiliaries in bespoke therapeutic ENLIGHTENMENT 269 regimes. Dosage had to be modified perhaps every day, explaining the habit of prescribing only a few measures at a time but prescribing extremely frequently — a recipe for profiteering, accused the cynics. The palaver of prescribing may have masked the fact that few drugs did much good. Preparation of human cranium was still present in the Pharmacia Ant‘uerpiemi: of 1661 and oil of earthworms in the Leiden Pharmacopoeia Leodiemis of 1741. Still prescribed was the bezoar, a concretion found in the alimentary organs of ruminants, recommended as an antidote against poison. In 1696 a noted German physician, Christian Paullini (1643» I 7 I 2), published his Drecleapotheke [Filth Pharmacy]. Yet changes were coming about in the medical armamentarium. The fifth London Pharmacopoeia (I 746) eliminated human fat, spider webs, moss from human skulls, unicorn’s horn, Virgin’s milk (not the literal liquid but an alchemical remedy) and the like, but mithridate, woodlice, pearls, bezoar stones, vipers and coral remained. Most of the animal materia medica had disappeared from the sixth Pharmacopoeia (1788), while among the new drugs and compounds were aconite, castor oil, quassia, magnesia, ether, tartrate of iron, oxide of zinc, Dover’s powder, sarsaparilla decoc- tions and paregoric (liquid opium). Chemistry popularized mineral and metallic drugs: antimony-based medicines circulated as febrifuges, in England being patented as Dr James’s Powders; and calomel (the ‘blue pill’) became the purge of choice. The lumber—room of preparations inherited from antiquity was being sorted out at last. Significant also was the publication in 1745 of William Heberden’s Antitheriaka: an Essay on Mithridatium and Theriac, denying that these polypharmaceuticals had antidotal properties against poisons, venoms, or other harmful substances. The Pharmacopoeia Edinburng dropped theriac and mithridatium in 17 56, but pharmacopoeias in France, Spain, and Germany found a place for them well into the nineteenth century. Opium was freely available over the counter and widely used, often in liquid form as laudanum, as an analgesic, fever specific, sedative and diarrhoea corrective. ‘Providence has been kind and gracious to us beyond all Expression’, enthused Cheyne, ‘in furnishing us with a certain Relief; if not a Remedy, even to our most intense Pain: and extreme Miseries’ — tortured patients surely agreed. Some doctors, however, sus— pected that opium created dependency: Samuel Crumpe (1766—96) recorded that users deprived even for a single day ‘became languid, 270 ENLIGHTENMENT dejected, and uneasy’, a view confirmed by the experience of the poet- philosopher Samuel Taylor Coleridge (1772—1834) and others who began by dosing themselves for medical reasons but ended up suffering the horrors of addicdon. A few significant innovations were achieved. In 1763 the Revd Edmund Stone (d. 1768) drew attention to willow bark (Salix alha). Its bitterness reminded him of Peruvian bark; moreover, the willow grew in the damp places where agues and fevers abounded, and pious folk belief had it that God planted cures where diseases originated. Hence he suspected it would serve as an ague remedy, giving it to some fifty persons who had rheumatic fever symptoms and reporting satisfactory results. (Salicin, the active ingredient in willow bark, has an effect similar to aspirin.) Stone communicated his discovery to the Royal Society, but it was ignored. William Withering had better success. In 1785 he produced An Account of the Foxglove and Some of its Medical Uses etc; I'Vith Practical Remarks on Dropsy and Other Diseases, which demonstrated that digitalis had a powerful stimulant action on the heart, reducing the oedema commonly accompanying heart disease. A follower of Linnaeus and a medical botanist, Withering had heard from a Shropshire woman of a herbal tea (a secret ‘family receipt’) useful in treating swollen legs. Deducing that'the effective element in her twenty-ingredient dropsy medicine must be foxglove, whose leaves yielded digitalis, he monitored its use to ascertain the best dosage for treating both dropsy and heart disease. On 8 December 1775, he gave foxglove tea to a fifty-year-old builder with asthma and fluid in the abdomen, who ‘made a large quan- tity of water. His breath gradually drew easier, his belly subsided, and in about ten days he began to eat with a keen appetite.’ Foxglove proved effective against cardiac dropsy though not renal dropsy — a distinction later grasped by Richard Bright. In 1783 digitalis entered the Pharmaco— poeia Edinburgensis, and twenty-six years later the London Pharmacopoeia. Overall, however, pharmacy left much to be desired. Proprietary nostrums were often unsafe, and polypharmacy — complex druglcock- tails, some ingredients countering others — was a recipe for abuse. Viol- ent purgatives and lead— or mercury-based medicines caused spasm and colic, often relieved by belladonna or other concoctions that induced further poisoning. The Scottish naval doctor Thomas Trotter (1760— 1832) was not alone in warning that modern society was bingeing on harmful sedatives, tonics and narcotics, washed down with tea, brandy ENLIGHTENMENT 271 and other stimulants. Small wonder the German physician Samuel Hahnemann (1755—1843) reacted by developing his homoeopathic system, which valued purity of drugs and minimal dosage. INSANITY Particular forms of sickness also saw therapeutic developments. The theory and treatment of insanity had undergone a seachange; the notion of insanity as demonic possession was finally discredited among medical men and magistrates. Mania and melancholy, mad doctors argued, derived not from the heavens but from the body; insanity was organic. ‘Every change of the mind’, wrote the physician, Nicholas Robinson (1697—1775), ‘. . . indicates a Change in the Bodily Organs.’ They could build upon old humoral interpretations that emphasized the role of yellow bile (choler) in mania and black bile in melancholy. But humoral explanations also lost credit as the new science pictured the body as a machine and neuro—anatomy highlighted the role of the nerves. William Cullen thus defined insanity (vesania) as a type of dynamic neurological disorder (nemesis), but also regarded madness, following Locke, as a false association of ideas. The mad, according to Locke, ‘do not appear to me to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles’. One of the most exemplary encounters with madness was that of George III. The king experienced his first attack in autumn 1788, and as his condition worsened and the physicians-in-ordinary proved unable to cope or cure, the Revd Dr Francis Willis (I7I7—1807), a clergyman doctor who ran a madhouse in Lincolnshire, was called in. Partly because he insisted upon exclusive medical control, Willis encountered bitter opposition from the regular physicians. They regarded him as little better than a quack — he was, after all, a clergyman, and running a lunatic asylum was rather a disreputable specialty. From the first VVillis expressed confidence that the king would recover if he were allowed to follow his favourite methods of moral management, involving complete physical and psychological domination over his patient. Madness, he believed, was essentially a product of over—excitation; hence the chief priorities were calm and control. A man of vast faith in his own powers, Willis proved fearless in asserting his ...
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PorterWk01 - 244 THE NEW SCIENCE In Le Me’decin malgre’...

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