第26章

Justatthecloseofthecenturytherecameintoprominencetheschoolofhomoeopathy，whichwasdestinedtoinfluencethepracticeofmedicineverymateriallyandtooutlivealltheothereighteenth-centuryschools。ItwasfoundedbyChristianSamuelFriedrichHahnemann(1755-1843)，amostremarkableman，who，afterpropoundingatheoryinhisyoungerdayswhichwasatleastasreasonableasmostoftheexistingtheories，hadthemisfortunetooutlivehisusefulnessandlayhisdoctrineopentoridiculebytheunreasonableteachingsofhisdotage，Hahnemannrejectedalltheteachingsofmorbidanatomyandpathologyasuselessinpractice，andpropoundedhisfamous"similiasimilibuscurantur"——thatalldiseasesweretobecuredbymedicinewhichinhealthproducedsymptomsdynamicallysimilartothediseaseundertreatment。Ifacertainmedicineproducedaheadachewhengiventoahealthyperson，thenthismedicinewasindicatedincaseofheadaches，etc。Atthepresenttimesuchatheoryseemscrudeenough，butinthelatterpartoftheeighteenthcenturyalmostanytheorywasasgoodastheonespropoundedbyAnimists，Vitalists，andothersuchschools。Itcertainlyhadtheverycommendablefeatureofintroducingsimplicityintheuseofdrugsinplaceofthecomplicatedprescriptionstheninvogue。HadHahnemannstoppedatthispointhecouldnothavebeenhelduptotheindefensibleridiculethatwasbroughtuponhim，withconsiderablejustice，byhislatertheories。Buthelivedontopropoundhisextraordinarytheoryof"potentiality"——thatmedicinesgainedstrengthbybeingdiluted——andhisevenmoreextraordinarytheorythatallchronicdiseasesarecausedeitherbytheitch，syphilis，orfig-wartdisease，orarebroughtonbymedicines。

Atthetimethathistheoryofpotentialitieswaspromulgated，themedicalworldhadgonemadinitsadministrationofhugedosesofcompoundmixturesofdrugs，andanyreactionagainstthiswassurelyanimprovement。Inshort，nomedicineatallwasmuchbetterthantheheapingdosesusedincommonpractice；andhenceoneadvantage，atleast，ofHahnemann’smethods。Statedbriefly，histheorywasthatifatincturebereducedtoone-fiftiethinstrength，andthisagainreducedtoone-fiftieth，andthisprocessrepeateduptothirtysuchdilutions，thepotencyofsuchamedicinewillbeincreasedbyeachdilution，Hahnemannhimselfpreferringtheweakest，or，ashewouldcallit，thestrongestdilution。Theabsurdityofsuchatheoryisapparentwhenitisunderstoodthatlongbeforeanydrughasbeenraisedtoitsthirtiethdilutionithasbeensoreducedinquantitythatitcannotbeweighed，measured，orrecognizedasbeingpresentinthesolutionatallbyanymeansknowntochemists。Itisbutjusttomodernfollowersofhomoeopathytosaythatwhilemostofthemadvocatesmalldosage，theydonotnecessarilyfollowtheteachingsofHahnemanninthisrespect，believingthatthetheoryofthedose"hasnothingmoretodowiththeoriginallawofcurethanthepsora(itch)theoryhas；

andthatitwasoneofthelatercreationsofHahnemann’smind。"

Hahnemann’stheorythatallchronicdiseasesarederivedfromeitheritch，syphilis，orfig-wartdiseaseisnolongeradvocatedbyhisfollowers，becauseitissoeasilydisproved，particularlyinthecaseofitch。Hahnemanntaughtthatfullythree-quartersofalldiseaseswerecausedby"itchstruckin，"andyetithadbeendemonstratedlongbeforehisday，andcanbedemonstratedanytime，thatitchissimplyalocalskindiseasecausedbyasmallparasite。

JENNERANDVACCINATION

Alladvancesinsciencehaveabearing，nearorremote，onthewelfareofourrace；butitremainstocredittotheclosingdecadeoftheeighteenthcenturyadiscoverywhich，initspowerofdirectandimmediatebenefittohumanity，surpassesanyotherdiscoveryofthisoranypreviousepoch。Needlesstosay，IrefertoJenner’sdiscoveryofthemethodofpreventingsmallpoxbyinoculationwiththevirusofcow-pox。ItdetractsnothingfromthemeritofthisdiscoverytosaythatthepreventivepowerofaccidentalinoculationhadlongbeenrumoredamongthepeasantryofEngland。Suchvague，unavailinghalf-knowledgeisoftentheforerunneroffruitfuldiscovery。

ToallintentsandpurposesJenner’sdiscoverywasoriginalandunique。Nor，consideredasaperfectmethod，wasitinanysenseanaccident。Itwasatriumphofexperimentalscience。Thediscovererwasnonoviceinscientificinvestigation，butatrainedobserver，whohadservedalongapprenticeshipinscientificobservationundernolessascientistthanthecelebratedJohnHunter。Attheageoftwenty-oneJennerhadgonetoLondontopursuehismedicalstudies，andsoonafterheprovedhimselfsoworthyapupilthatfortwoyearsheremainedamemberofHunter’shouseholdashisfavoritepupil。HistasteforscienceandnaturalhistorysoonattractedtheattentionofSirJosephBanks，whointrustedhimwiththepreparationofthezoologicalspecimensbroughtbackbyCaptainCook’sexpeditionin1771。Heperformedthistasksowellthathewasofferedthepositionofnaturalisttothesecondexpedition，butdeclinedit，preferringtotakeupthepracticeofhisprofessioninhisnativetownofBerkeley。

Hismanyaccomplishmentsandgenialpersonalitysoonmadehimafavoritebothasaphysicianandinsociety。Hewasagoodsinger，afairviolinistandflute-player，andaverysuccessfulwriterofproseandverse。Butwithallhisprofessionalandsocialdutieshestillkeptuphisscientificinvestigations，amongotherthingsmakingsomecarefulobservationsonthehibernationofhedgehogsattheinstigationofHunter，theresultsofwhichwerelaidbeforetheRoyalSociety。Healsomadequiteextensiveinvestigationsastothegeologicalformationsandfossilsfoundinhisneighborhood。

EvenduringhisstudentdayswithHunterhehadbeenmuchinterestedinthebelief，currentintheruraldistrictsofGloucestershire，oftheantagonismbetweencow-poxandsmall-pox，apersonhavingsufferedfromcow-poxbeingimmunedtosmall-pox。

AtvarioustimesJennerhadmentionedthesubjecttoHunter，andhewasconstantlymakinginquiriesofhisfellow-practitionersastotheirobservationsandopinionsonthesubject。Hunterwastoofullyengrossedinotherpursuitstogivethemattermuchseriousattention，however，andJenner’sbrothersoftheprofessiongavescantcredencetotherumors，althoughsuchrumorswerecommonenough。

Atthistimethepracticeofinoculationforpreventingsmall-pox，orratheravertingthesevererformsofthedisease，waswidelypractised。Itwascustomary，whentherewasamildcaseofthedisease，totakesomeofthevirusfromthepatientandinoculatepersonswhohadneverhadthedisease，producingasimilarattackinthem。Unfortunatelythereweremanyobjectionstothispractice。Theinoculatedpatientfrequentlydevelopedavirulentformofthediseaseanddied；orifherecovered，evenafteramildattack，hewaslikelytobe"pitted"anddisfigured。

But，perhapsworstofall，apatientsoinoculatedbecamethesourceofinfectiontoothers，anditsometimeshappenedthatdisastrousepidemicswerethusbroughtabout。Thecasewasamostperplexingone，fortheawfulscourgeofsmall-poxhungperpetuallyovertheheadofeverypersonwhohadnotalreadysufferedandrecoveredfromit。ThepracticeofinoculationwasintroducedintoEnglandbyLadyMaryWortleyMontague(1690-1762)，whohadseenitpractisedintheEast，andwhoannouncedherintentionof"introducingitintoEnglandinspiteofthedoctors。"

Fromthefactthatcertainpersons，usuallymilkmaids，whohadsufferedfromcow-poxseemedtobeimmunedtosmall-pox，itwouldseemaverysimpleprocessofdeductiontodiscoverthatcow-poxinoculationwasthesolutionoftheproblemofpreventingthedisease。Buttherewasanotherformofdiseasewhich，whilecloselyresemblingcow-poxandquitegenerallyconfoundedwithit，didnotproduceimmunity。Theconfusionofthesetwoformsofthediseasehadconstantlymisledinvestigationsastothepossibilityofeitherofthemimmunizingagainstsmallpox，andtheconfusionofthesetwodiseasesforatimeledJennertoquestionthepossibilityofdoingso。Aftercarefulinvestigations，however，hereachedtheconclusionthattherewasadifferenceintheeffectsofthetwodiseases，onlyoneofwhichproducedimmunityfromsmall-pox。

"Thereisadiseasetowhichthehorse，fromhisstateofdomestication，isfrequentlysubject，"wroteJenner，inhisfamouspaperonvaccination。"Thefarrierscallitthegrease。

Itisaninflammationandswellingintheheel，accompaniedatitscommencementwithsmallcracksorfissures，fromwhichissuesalimpidfluidpossessingpropertiesofaverypeculiarkind。

Thisfluidseemscapableofgeneratingadiseaseinthehumanbody(afterithasundergonethemodificationIshallpresentlyspeakof)whichbearssostrongaresemblancetosmall-poxthatI

thinkithighlyprobableitmaybethesourceofthatdisease。

"Inthisdairycountryagreatnumberofcowsarekept，andtheofficeofmilkingisperformedindiscriminatelybymenandmaidservants。OneoftheformerhavingbeenappointedtoapplydressingstotheheelsofahorseaffectedwiththemaladyIhavementioned，andnotpayingdueattentiontocleanliness，incautiouslybearshispartinmilkingthecowswithsomeparticlesoftheinfectiousmatteradheringtohisfingers。Whenthisisthecaseitfrequentlyhappensthatadiseaseiscommunicatedtothecows，andfromthecowstothedairy-maids，whichspreadsthroughthefarmuntilmostofthecattleanddomesticsfeelitsunpleasantconsequences。ThisdiseasehasobtainedthenameofCow-Pox。Itappearsonthenipplesofthecowsintheformofirregularpustules。Attheirfirstappearancetheyarecommonlyofapalishblue，orratherofacolorsomewhatapproachingtolivid，andaresurroundedbyaninflammation。

Thesepustules，unlessatimelyremedybeapplied，frequentlydegenerateintophagedeniculcers，whichproveextremelytroublesome。Theanimalsbecomeindisposed，andthesecretionofmilkismuchlessened。Inflamedspotsnowbegintoappearondifferentpartsofthehandsofthedomesticsemployedinmilking，andsometimesonthewrists，whichrunontosuppuration，firstassumingtheappearanceofthesmallvesicationsproducedbyaburn。Mostcommonlytheyappearaboutthejointsofthefingersandattheirextremities；butwhateverpartsareaffected，ifthesituationwilladmitthesuperficialsuppurationsputonacircularformwiththeiredgesmoreelevatedthantheircentreandofacolordistinctlyapproachingtoblue。Absorptiontakesplace，andtumorsappearineachaxilla。Thesystembecomesaffected，thepulseisquickened；

shiverings，succeededbyheat，generallassitude，andpainsabouttheloinsandlimbs，withvomiting，comeon。Theheadispainful，andthepatientisnowandthenevenaffectedwithdelirium。Thesesymptoms，varyingintheirdegreesofviolence，generallycontinuefromonedaytothreeorfour，leavingulceratedsoresaboutthehandswhich，fromthesensibilityoftheparts，areverytroublesomeandcommonlyhealslowly，frequentlybecomingphagedenic，likethosefromwhichtheysprang。Duringtheprogressofthediseasethelips，nostrils，eyelids，andotherpartsofthebodyaresometimesaffectedwithsores；buttheseevidentlyarisefromtheirbeingheedlesslyrubbedorscratchedbythepatient’sinfectedfingers。Noeruptionsontheskinhavefollowedthedeclineofthefeverishsymptomsinanyinstancethathascomeundermyinspection，oneonlyexcepted，andinthiscaseaveryfewappearedonthearms:

theywereveryminute，ofavividredcolor，andsoondiedawaywithoutadvancingtomaturation，sothatIcannotdeterminewhethertheyhadanyconnectionwiththeprecedingsymptoms。

"Thusthediseasemakesitsprogressfromthehorse(asI

conceive)tothenippleofthecow，andfromthecowtothehumansubject。

"Morbidmatterofvariouskinds，whenabsorbedintothesystem，mayproduceeffectsinsomedegreesimilar；butwhatrendersthecow-poxvirussoextremelysingularisthatthepersonthathasbeenthusaffectedisforeveraftersecurefromtheinfectionofsmall-pox，neitherexposuretothevariolouseffluvianortheinsertionofthematterintotheskinproducingthisdistemper。"[2]

In1796Jennermadehisfirstinoculationwithcowpoxmatter，andtwomonthslaterthesamesubjectwasinoculatedwithsmall-poxmatter。But，asJennerhadpredicted，noattackofsmall-poxfollowed。Althoughfullyconvincedbythisexperimentthatthecasewasconclusivelyproven，hecontinuedhisinvestigations，waitingtwoyearsbeforepublishinghisdiscovery。Then，fortifiedbyindisputableproofs，hegaveittotheworld。Theimmediateeffectsofhisannouncementhaveprobablyneverbeenequalledinthehistoryofscientificdiscovery，unless，perhaps，inthesingleinstanceofthediscoveryofanaesthesia。InGenevaandHollandclergymenadvocatedthepracticeofvaccinationfromtheirpulpits；insomeoftheLatincountriesreligiousprocessionswereformedforreceivingvaccination；Jenner’sbirthdaywascelebratedasafeastinGermany；andthefirstchildvaccinatedinRussiawasnamed"Vaccinov"andeducatedatpublicexpense。Insixyearsthediscoveryhadpenetratedtothemostremotecornersofcivilization；ithadevenreachedsomesavagenations。Andinafewyearssmall-poxhadfallenfromthepositionofthemostdreadedofalldiseasestothatofbeingpracticallytheonlydiseaseforwhichasureandeasypreventivewasknown。

HonorswereshowereduponJennerfromtheOldandtheNewWorld，andevenNapoleon，thebitterhateroftheEnglish，wasamongtheotherswhohonoredhisname。OnoneoccasionJennerappliedtotheEmperorforthereleaseofcertainEnglishmendetainedinFrance。Thepetitionwasabouttoberejectedwhenthenameofthepetitionerwasmentioned。"Ah，"saidNapoleon，"wecanrefusenothingtothatname！"

Itisdifficultforusofto-dayclearlytoconceivethegreatnessofJenner’striumph，forwecanonlyvaguelyrealizewhataruthlessandever-presentscourgesmallpoxhadbeentoallpreviousgenerationsofmensincehistorybegan。Despitealleffortstocheckitbymedicationandbydirectinoculation，itsweptnowandthenovertheearthasanall-devastatingpestilence，andyearbyyearitclaimedone-tenthofallthebeingsinChristendombydeathasitsaveragequotaofvictims。

"Fromsmall-poxandlovebutfewremainfree，"rantheoldsaw。A

pittedfacewasalmostasmuchamatterofcourseahundredyearsagoasasmoothoneisto-day。

Littlewonder，then，thattheworldgaveeageracceptancetoJenner’sdiscovery。Nourgingwasneededtoinducethemajoritytogiveittrial；passengersonaburningshipdonotholdalooffromthelife-boats。Richandpoor，highandlow，soughtsuccorinvaccinationandblessedthenameoftheirdeliverer。Ofallthegreatnamesthatwerebeforetheworldintheclosingdaysofthecentury，therewasperhapsnootheroneatoncesowidelyknownandsouniformlyreverencedasthatofthegreatEnglishphysicianEdwardJenner。Surelytherewasnootheronethatshouldberecalledwithgreatergratitudebyposterity。

VIII。NINETEENTH-CENTURYMEDICINE

PHYSICALDIAGNOSIS

AlthoughNapoleonBonaparte，FirstConsul，wasnotlackinginself-appreciation，heprobablydidnotrealizethatinselectingaphysicianforhisownneedshewasmarkedlyinfluencingtheprogressofmedicalscienceasawhole。YetsostrangelyarecauseandeffectadjustedinhumanaffairsthatthissimpleactoftheFirstConsulhadthatveryunexpectedeffect。Forthemanchosenwastheenvoyofanewmethodinmedicalpractice，andthefamewhichcametohimthroughbeingphysiciantotheFirstConsul，andsubsequentlytotheEmperor，enabledhimtopromulgatethemethodinawayotherwiseimpracticable。HencetheindirectbuttellingvaluetomedicalscienceofNapoleon’sselection。

ThephysicianinquestionwasJeanNicolasdeCorvisart。Hisnovelmethodwasnothingmorestartlingthanthenow-familiarprocedureoftappingthechestofapatienttoelicitsoundsindicativeofdiseasedtissueswithin。Everyonehasseenthisdonecommonlyenoughinourday，butatthebeginningofthecenturyCorvisart，andperhapssomeofhispupils，wereprobablytheonlyphysiciansintheworldwhoresortedtothissimpleandusefulprocedure。HenceNapoleon’ssurprisewhen，oncallinginCorvisart，afterbecomingsomewhatdissatisfiedwithhisotherphysiciansPinelandPortal，hisphysicalconditionwasinterrogatedinthisstrangemanner。WithcharacteristicshrewdnessBonapartesawtheutilityofthemethod，andthephysicianwhothusattemptedtosubstitutescientificmethodforguess-workinthediagnosisofdiseaseatoncefoundfavorinhiseyesandwasinstalledashisregularmedicaladviser。

ForfifteenyearsbeforethisCorvisarthadpractisedpercussion，asthechest-tappingmethodiscalled，withoutsucceedinginconvincingtheprofessionofitsvalue。Themethoditself，itshouldbeadded，hadnotoriginatedwithCorvisart，nordidtheFrenchphysicianforamomentclaimitashisown。ThetrueoriginatorofthepracticewastheGermanphysicianAvenbrugger，whopublishedabookaboutitasearlyas1761。ThisbookhadevenbeentranslatedintoFrench，thenthelanguageofinternationalcommunicationeverywhere，byRozieredelaChassagne，ofMontpellier，in1770；butnooneotherthanCorvisartappearstohavepaidanyattentiontoeitheroriginalortranslation。Itwasfarotherwise，however，whenCorvisarttranslatedAvenbrugger’sworkanew，withimportantadditionsofhisown，in1808。

"Iknowverywellhowlittlereputationisallottedtotranslatorandcommentators，"writesCorvisart，"andImighteasilyhaveelevatedmyselftotherankofanauthorifIhadelaboratedanewthedoctrineofAvenbruggerandpublishedanindependentworkonpercussion。Inthisway，however，IshouldhavesacrificedthenameofAvenbruggertomyownvanity，athingwhichIamunwillingtodo。Itishe，andthebeautifulinventionwhichofrightbelongstohim，thatIdesiretorecalltolife。"[1]

Bythistimeareactionhadsetinagainstthemetaphysicalmethodsinmedicinethathadpreviouslybeensoalluring；thescientificspiritofthetimewasmakingitselffeltinmedicalpractice；andthis，combinedwithCorvisart’sfame，broughtthemethodofpercussionintoimmediateandwell-deservedpopularity。

Thuswaslaidthefoundationforthemethodofso-calledphysicaldiagnosis，whichisoneofthecorner-stonesofmodernmedicine。

Themethodofphysicaldiagnosisaspractisedinourdaywasbynomeanscompleted，however，withtheworkofCorvisart。

Percussionalonetellsmuchlessthanhalfthestorythatmaybeelicitedfromtheorgansofthechestbyproperinterrogation。

Theremainderofthestorycanonlybelearnedbyapplyingtheearitselftothechest，directlyorindirectly。Simpleasthisseems，noonethoughtofpractisingitforsomeyearsafterCorvisarthadshownthevalueofpercussion。

Then，in1815，anotherParisphysician，ReneTheophileHyacintheLaennec，discovered，almostbyaccident，thatthesoundoftheheart-beatcouldbeheardsurprisinglythroughacylinderofpaperheldtotheearandagainstthepatient’schest。Actingonthehintthusreceived，Laennecsubstitutedahollowcylinderofwoodforthepaper，andfoundhimselfprovidedwithaninstrumentthroughwhichnotmerelyheartsoundsbutmurmursofthelungsinrespirationcouldbeheardwithalmoststartlingdistinctness。

ThepossibilityofassociatingthevaryingchestsoundswithdiseasedconditionsoftheorganswithinappealedtothefertilemindofLaennecasopeningnewvistasintherapeutics，whichhedeterminedtoentertothefullestextentpracticable。HisconnectionwiththehospitalsofParisgavehimfullopportunityinthisdirection，andhislaborsofthenextfewyearsservednotmerelytoestablishthevalueofthenewmethodasanaidtodiagnosis，butlaidthefoundationalsoforthescienceofmorbidanatomy。In1819LaennecpublishedtheresultsofhislaborsinaworkcalledTraited’AuscultationMediate，[2]aworkwhichformsoneofthelandmarksofscientificmedicine。Bymediateauscultationismeant，ofcourse，theinterrogationofthechestwiththeaidofthelittleinstrumentalreadyreferredto，aninstrumentwhichitsoriginatorthoughthardlyworthnaminguntilvariousbarbarousappellationswereappliedtoitbyothers，afterwhichLaennecdecidedtocallitthestethoscope，anamewhichithaseversinceretained。

Insubsequentyearstheformofthestethoscope，asusuallyemployed，wasmodifiedanditsvalueaugmentedbyabinauricularattachment，andinveryrecentyearsafurtherimprovementhasbeenmadethroughapplicationoftheprincipleofthetelephone；

buttheessentialsofauscultationwiththestethoscopewereestablishedinmuchdetailbyLaennec，andthehonormustalwaysbehisofthustakingoneofthelongestsinglestepsbywhichpracticalmedicinehasinourcenturyacquiredtherighttobeconsideredarationalscience。Laennec’seffortscosthimhislife，forhediedin1826ofalungdiseaseacquiredinthecourseofhishospitalpractice；butevenbeforethishisfamewasuniversal，andthevalueofhismethodhadbeenrecognizedallovertheworld。Notlongafter，in1828，yetanotherFrenchphysician，Piorry，perfectedthemethodofpercussionbyintroducingthecustomoftapping，notthechestdirectly，butthefingerorasmallmetalorhard-rubberplateheldagainstthechest-mediatepercussion，inshort。Thisperfectedthemethodsofphysicaldiagnosisofdiseasesofthechestinallessentials；

andfromthatdaytillthispercussionandauscultationhaveheldanunquestionedplaceintheregulararmamentariumofthephysician。

Coupledwiththenewmethodofphysicaldiagnosisintheefforttosubstituteknowledgeforguess-workcamethestudiesoftheexperimentalphysiologists——inparticular，MarshallHallinEnglandandFrancoisMagendieinFrance；andthejointeffortsofthesevariousworkersledpresentlyt