LECTURE 9 Directions and achievements in the 19th century medicine

1. LECTURE 9Directions and achievements in the 19th century medicine

2. The nineteenth century • The development of morphology • Representative medical personalities in the field of anatomy, histology and cytology • The development of physiology and physiopathology. Representative figures. • The development of microbiology and immunology • Louis Pasteur – the pioneer of microbiology • The development of the internal medicine • The development of surgery and anaesthesia • The development of neurology, neuropathology and psychiatry • Romanian medical personalities of the decade

3. The nineteenth century • The early decades of the nineteenth century were a continuation of medical developments in the previous century. However, in the later decades two particular advances: anaesthesia and the discovery of microorganisms dramatically changed the course of medical history. • The rapid changes that followed the building of factories and theexpansion of cities led to crowding of populations. • The health of workers was important to their efficient functioning. Since the spread of epidemics was a danger to all segments of the population, public health measures were appreciated. • In 1848, the description by Edwin Chadwick of the sanitary conditions and health of workers had a great impact on the upper classes and the government authorities. Chadwick established standards for the proper removal of sewage and the protection of water supplies. • Epidemics continued to devastate cities and countries. As late as • In 1854 in London there were 1 4,000 cases of cholera with 618 deaths. • As the century began, France held the lead in medicine.

4. The nineteenth century • Francois Magendie (1783-1855) rejected the academic speculation that still clouded scientific thought, insisting that the human body obeyed the same natural laws as everything else in nature. • He was the first to describe the separation of nerves joining the spinal cord into sensory and motor roots. Magendie demonstrated the pathway of reflex action from a sensory organ along a nerve, to the spinal cord by the sensory root, then from the spinal cord by the anterior root and lastly to the responding organ. • His experiments with diet established the main ingredients needed, in particular the different food value of different proteins. Magendie was also a founder of modern pharmacology. He isolated the active principles of many plant drugs and described their actions. • Never holding an academic position, Magendie was a typical investigator of the early nineteenth century in combining the careers of medical practitioner and laboratory experimentalist.

5. The nineteenth century • On the contrary, Claude Bernard (1813-1878), the founder of experimental physiology, was entirely a man of the laboratory. Professor of physiology at the Sorbonne he was the greatest of all physiologists. • Claude Bernard introduced the concepts of homeostasis, which "fed that the "internal environment" is constant in warm-blooded organisms and that physiological mechanism resist any external factors which tend to alter this internal state. • He later discovered several functions of the liver, the digestive ton of pancreas, the control of blood vessels by nerves, the carriage oxygen by red blood cells. In his "Introduction to the Study of Experimental Medicine" in 1865, he set down the standards for future experiments. • Germany's role in medicine was in a large measure due to the influence of Johannes Peter Muller (1 801 -1 858). He is best known for is theory of "specific nerve energies": a given sensory nerve conveys in a single kind of sensation, regardless of how it is stimulated.

6. The nineteenth century • A great influence on physiology and on attitudes toward behaviour had the experiments on animals made by Ivan Pavlov 1849-1936) in Moscow. After having studied in Germany, he became professor of pharmacology and then of physiology ad the Military Medical Academy in Russia. He made detailed investigations on the heart, liver, pancreas and alimentary tract, but his most influential work was on the conditioned reflex. During his experiments, mainly with dogs, he found that salivation was induced not only by stimuli directly concerned with eating, but by any stimulus (for instance the ringing of bell) that the dog had learned to associate with food. • These learnt responses he called conditioned reflexes. In 1904 Pavlov received a Nobel Prize for his work on digestion. • The discovery of haemoglobin by Felix Hoppe-Seyler (1825-1895) in 1862 was a milestone in medicine. • Among the pupils of Johannes Muller who contributed to an understanding of the microscopic structure of organs was Jacob Henle (1809-1885). He was also responsible for early ideas concerning microorganisms as causes of disease.

7. The nineteenth century • Carl von Rokitansky (1804-1878), a Czech who worked in Vienna at the Institute of Pathology, was the most outstanding morphological pathologist in the world. • The outstanding characteristic of the nineteenth century medicine was the correlation of discoveries in the laboratory and autopsy room with observations at the bedside. • Rene-Theophile-Hyacinthe Laennec (1781-1826) was one of the greatest clinicians of all time. He made outstanding contributions to the pathological and clinical understanding of diseases of the heart and lungs, in particular of tuberculosis. • Laennec is best remembered as the inventor of the stethoscope, with the help of which he was able to recognize disorders in the chest much more accurately than anyone before him. Today the stethoscope is a regular tool of every clinician. • Guillaume B.A. Duchenne (1806-1875) and Jean-Marie Charcot (1825-1893) were the virtual founders of neurology in France. Duchenne, who started as a country practitioner, made use of the new electrical current reported by Michael Faraday to treat patients with rheumatism and to study the actions of muscles. Charcot became famous through his clinical teachings at the Salpetriere Hospital of Paris.

8. The nineteenth century • In the early years of the nineteenth century many plant and mineral drugs were available. However, only a few were based on physiological or even empirical observations: quinine for malaria, digitalis for heart failure, colchicine for gout, opiates for pain. • Probably the most influential system was homoeopathy, a creation of Samuel Hahnemann (1755-1843) in Germany • He observed that an overdose of quinine causes symptoms like those of malaria. But a moderate dose of quinine cures malaria. • Another medical therapy, which arose in the eighteenth century but had a strong impact in the following century, was cranioscopy. Also called phrenology, the doctrine was promulgated by Franz Joseph Gall (1758-1828), a clinician born in Germany and educated in France and Austria. He thought that the shape and irregularities of the skull were projections of the underlying brain and consequently indications of a person's mental characteristics.

9. The nineteenth century • Chiropractic, founded in 1895 by Daniel D. Palmer (1845-1913), was another healing system which ascribes disease to derangements in structure and function of the vertebrae. Proper adjustments of the spinal column are supposed to cure the ailments of the internal organs. • Another healing cult which was more religious than medical was Christian Science which viewed health and recovery from disease as dependent entirely on following God's divine laws. • There were also many quack cults whose objective was to attract money from the people. For instance, James Morison created in England the "Hygeian" system. He considered that the cure of disease and the maintenance of health was possible by freeing the blood of all impurities through the use of secret-formula pills. Later it was proved that the "Universal Pills" were a combination of strong laxatives. • Although many personalities within the medical profession condemned Morison as a charlatan, sales of the pills spread all over Europe.

10. The nineteenth century • Numerous systems of therapy and explanations for illness flourished in the 19th century. • Homeopathy – a creation of Samuel Hahnemann • Hydrotheraphy – was based on the ancient concepts of humours • Cranioscopy, a doctrine promulgated by F. Joseph Gall who thought that the shape and irregularities of the skull indicated a person’s mental characteristics. • Osteopathy – considered that the human body contains all remedies necessary to protect against disease. • Christian science – a healing and religious cult which viewed health and recovery, as dependent on God’s divine laws. • Surgery made a step forward very slowly, limited by the lack of effective pain control, during operations and by post operative infections. Both of these obstacles were lifted by the discoveries of anaesthesia and the proof that germs caused infections.

11. The nineteenth century • When anaesthesia had become commonplace and the limitations of pain had disappeared, surgical procedures multiplied in number and complexity. No longer did the surgeon have to place the first emphasis on speed and to limit his manipulations mainly to surface areas of the body and the skeletal system. Yet the potential benefits of surgery were overshadowed by the frequent, devastating infections which often resulted in death. Only when the bacterial origin of disease had been discovered and the necessity for keeping germs away from the operative field had been proved could surgery enter with safety the interior regions of the body. • Jacob Henle, in the mid-nineteenth century deduced from earlier published reports that living organisms were the cause of infections. In promulgating a series of precise requirements for a specific organism to be considered the causative agent, he antedated by several decades the postulates of his pupil Robert Koch. • The first studies of the pathogenic nature of bacteria were on a relatively large-sized and easily seen bacterium, the bacillus of anthrax, a fatal disease in sheep and horses. Casimir Davaine and Pierre Rayer in 1850 produced the deadly disease in healthy animals by injecting them with the blood of dying sheep. They subsequently found the anthrax organism in the blood of the sheep so killed.

12. The nineteenth century • It was Ignaz Semmeweis (1818-1865) who assembled the facts and analyzed the happenings on the obstetrical wards of the General Hospital in Vienna to prove the contagious nature of postpartum infection. He noted that the annual mortality rate on one of the wards where medical students were trained was over ten percent and that it reached almost twenty percent during some months, mainly due to puerperal fever. • The next step for Semmelweis was to require the physicians and students under his charge to wash hands with soap and water and soak them in a chlorinated solution before entering the clinic or ward, and to repeat this after each examination. The death rate fell at once. Only one percent of the patients still died. • The role of microbes in causing infection was not yet known. Semmelweis published an account of his work in 1861 . His views were not only not accepted, but he was abused by his colleagues so that he left Vienna and returned to Budapest.

13. The nineteenth century • It was the monumental work of Louis Pasteur (1 822-1895) which firmly established the germ theory of disease. He explained the effectiveness of the asepsis and antisepsis and laid the basis for the biological preventive measures of the future • Trained as a chemist, Pasteur proved that microscopic live creatures were responsible for fermentation. He also observed that some of these tiny organisms grew in the presence of oxygen (aerobic) while others lived in the absence of free oxygen (anaerobic). Pasteur also determined that heating wine for a few moments at about 60°C destroyed the organisms which produced spoilage, a process later called "pasteurization". • Pasteur also treated cultures of the anthrax bacillus in various ways until he found that microbes grown in a particular temperature range became harmless. In a public demonstration made in 1881 he injected virulent cultures of the anthrax bacillus into normal sheep and into an equal number of sheep previously inoculated with attenuated, harmless cultures. In the next few days, all the unprotected sheep died and all of the prepared sheep remained well. The principle of immunity was thus publicly and dramatically launched.

14. The nineteenth century • Pasteur established the fundamental principle that attenuated cultures of an organism could afford protection against the disease caused by the organism. • In 1885 Pasteur produced an effective vaccine against rabies. The success of the antirabies inoculation gained him public acclaim. • A German physician, Robert Koch (1843-1910) revolutionized bacteriology, established the pathogenic character of the anthrax bacillus, developed techniques of culturing bacteria, advanced the method of steam sterilization. He also discovered the causes of many diseases and introduced effective preventive measures in typhoid fever, plague, malaria and other illness. • Probably his two most influential contributions were the isolation of the tubercle bacillus, the cause of tuberculosis and the establishment of the essential steps required to prove that an organism is the cause of disease. His studies with tuberculin (a filtrate from the culture of the tubercle bacillus) convinced Koch and the world that he had found the means of curing tuberculosis. The subsequent failures were a severe blow to him. However, Koch's tuberculin is still used as a diagnostic tool.

15. The nineteenth century • In the last decade of the nineteenth century, two especially important additions were made to the understanding of infections: the development of antitoxins and the discovery of viruses. • The recognition of antibodies in the blood of a person sick with infection became useful in diagnosis: finding the specific antibody, against a particular germ in the blood determined which organism was cause. • The mosquito as an insect vector in malaria was clearly recognised by several observers in the nineteenth century. • The nineteenth century saw the establishment of more uniform rational and licensee requirements. • Dentistry gradually became a separate speciality. The first dental school in the world was established in 1839 as the "Baltimore College of Dental Surgery“.

16. The nineteenth century • Nursing became fully established as a profession in the nineteenth century. In England, Florence Nightingale (1820-1910) was in large measure responsible for the transformation of nursing from a low, unpopular endeavour into a highly respected, essential part of the healing arts. She founded an educational institution for nurses, whose first class was graduated in 1 861. • In the Geneva Convention of 1864, sixteen nations signed a treaty establishing the International Red Cross and specifying the regulations that should apply to the treatment of wounded soldiers. It included the recognition that all hospitals, military and civilian were to be neutral territory.