ANNALSOF MEDICALHISTORY VOLUMEIV SPRING,SUMMER,AUTUMN AND WINTER 1922 ANNALSOF EDITOR:FRANCISR.PACKARDM.D.Philadelphia,Pa ASSOCIATEEDITORS HORACEMANCHESTERBROWN,M.D. HARVEYCUSHING,M.D. CHARLESLDANA,M.D. GEORGEDOCK,M.D.. FIELDINGH.GARRISON,M.D. HENRYBARTONJACOBS,M.D.. HOWARDA.KEU.Y,M.D. THOMASMd:RAE. Milwaukee Boston New York .Pasadena .W uhington Baltimore .Baltimore Philadelphia LEWISSfEPHENPILCHER,M.D.Brooklyn SIRD'ARCYPOWER,K.B.E.,F.R.C.S.(ENG.)F.S.A.London DAVIDRIESMAN,M.D.Philadelphia JOHNRUHRAH,M.D. CHARLESSINGER,M.D. EDWARDC.STREETER,M.D. CASEYA.WOOD,M.D. VOLUMEIV NEWYORK PAULB.HOEBER,PUBLISHER 67-{;gEAST.s9thSTREET .Baltimore Chford .Boston .Chicago COPYRIGHT,192:1 BYPAUL B. HOEBER ANNALSOFMEDICALHISTORY CONTENTS:VOLUMEIV ORIGINALARTia.ES NOSOGRAPHYINMODERNINTERNALMEDICINE USPAR WISTAR. JUNIOR THE FRENCH ScHooL OF SuRGERY IN THEREIGN OF Louis PHILIPPE LoNDONSURGERYINTHEEARLYPARTOFTHENINETEENTH CENnJay THEDuBLINMEDICALScHooLANDITsINFLUENCEUPONMEDI- . CINEIN AMERICA THEHISTORYOFPuLSETIMINGWITHSOMEREMARKsoNSIR JoHNFLOYER ANDHis PHYSICIAN'sPuLSE WATCH. DE STATICISExPERIMENTISOFNICOLAUSCUSANUS GUYPATIN AND THE MEDICALPROFESSIONINPARISINTHE SEVEN-TEENTHCENTuRY,PARTSI,n,m. LoUIS DANIEL BEAUPERTHUY. BENJAMINFRANKLIN,INVENTOROFBIFOCALSPECI"ACLES WIU.LUI AND JoHN HuNTER. SIRRICHARDBLACKMORE,M.D. THE TREATMENT OF CoNVULSIONS(TETANY)WITHCALCIUMIN THE SEVENTEENTHCENTuRY.. WHAT WASKAPPALAMBDA........... RoBERT T ALBOR.MADAMEDESvrGNi, ANDTHEINTRODUCTIONoF CINCHONA. REGULATINGPHYSICIANSINCoLONIALVIRGINIA. SoMEENGLISHWORTHIESOFSciENCEOFINTERESTTOOPHTHAL-MOLOGISTS. THEEARLYHISTORYOF ANATOMYINTHEUNITEDSTATES. SoMEEARLYOBSERVERSOF ALBUMINURIA MEDICALMAGIC. THE CAouaus ANDITs SYMBOLISM DR.GEORGE CHEYNEAND THE"ENGLISHMALADY". ANOTEONTHE"LIBER DEMEDICINISExPERTIS"ATTRIBUTEDTO GALEN. MEDICINEANDTHEHUMANITIES(WEIRMITCHELL ORATION) WILLIAMHEBERDEN,M.DF.R.S CHRISTOPHERWIDMER. ASIXTEENTHCENTuRYLATINPoEMONTHEDISEASESoFNuRs-LING&"PAEDOTROPHIA" BYScE.voLE DESAINTE-MARTHE. EDITORIALS PAGE KnudFabtrI WiUi4mSbainlineMiddleton64 J. Cbalmns DaCosta 77 JolmH.Gibbon8o Dallid Riesman86 Jo.cobRosmbloom 97 HenryViets.IIS FrancisR. PackardI36.25I,357 CaseyA. WoodI66 I74 TbOJ'IlG$McCraeI75 TbotnasNoxonToomey.I8o Paul GalpinSbipley.I89 CbaunceyD.LtalctI92 GeorgeDock24I Edwardlngle . 248 BurtonChance25I EdwardB.Krumbbaar27I WiUi4mDock287 IsadorH.Coriat29I RobertWilson.30I William Rmwick RiddeU304 ErnestWickersbeimer P3 CharlesL.Dana.328 PercyD.Dallidson336 M.Cbarlton346 CharlesGremeCumston.351 SELECI"IONSFROMVESALIUS,SHOWINGIMPROVEMENTSINTRODUCEDINTO. 2ND'Eo.OFTHE FABRICA(I555).100 THE CuSTODIANSHIPCABINET oF THECoLLEGE oFPHYSICIANSOFPHILADELPHIAI02 THIRDINTERNATIONALCoNGRESSOFHISTORYOFMEDICINE.I03 THEPINEAL GLAND ANDSNUFF207 ANUNIQUEENGRAVING(FUNFZIGCHIRURGISCHE0BSERVATIONEN,HiiTTER)209 Lours PASTEUR311 RICHARDBRIGHT.313 ANEGYPTIANTREATISEOF THESEVENTEENTHCENtuRYB.c.314 REPORTOF THIRD INTERNATIONALCoNGRESSOF HISTORYOF MEDICINE386 DR.ERNEST WICKERSHEIMER,UBRARIANOF THEUNIVERSITYOF STRASBURG389 ANNALSOFMEDICALHISTORY.394 CONTENTS CORRESPONDENCE MARTIAL'sEPIGRAMSRELATINGTOMEDICALPRAcriCE ANDMEDI-CALMEN. ANGINAPEcroRis DESCRIBEDIN THE"MEMoiRs" OF THEEARL oF Cu.RENooN ORIGIN OF THE WoRD "SYPHILis" ExPERIMENTS ON THE EFFEcrsoFTHE PoisoN oF THERATTLEsNAKE FRANCISCO loPEZ DE VILLALOBOS BOOKREVIEWS THE DAWN oF MoDERN MEDICINE,BucK HENRY QuiN,M.D.,1718-1791, KIRKPATRICK EARLY SciENCEIN OxFORD,GUNTHER STUDIESINTHE PALEOPATHOLOGYOFEGYPT,RUFFER HISTORY OFMEDICINE,GARRISON THE LIFE OFJACOBHENLE,ROBINSON LIFE ANDTIMES OF AMBROISEPARE {ljiG-1590).PACKARD. THE EvoLUTIONoF MoDERN MEDICINE,OsLER. LrFE oF EuE METCHNIKOFF,METCHNIKOFF AHISTORYoF THENATIONAL TUBERCULOSIS AssociATION,KNoPF PHYSIC ANDFicrioN, SPRIGGE PASTEUR AND H1s WoRK,DESCOUR Jo.cobRosmbloom J a.cobRosmbloom G.D.Delpra.t Ja.cobRosmbloom Charles Perry Fisbn. MoDERNITALIANSURGERYAND OLDUNIVERSITIEsOFITALY,DEVECCHI DES MErSTERSARNoLD voN VILLANovA,DIEPGEN. ALBRECHTRu.t.ER, SUDHOFF FAMous CHEMISTS:THEMEN AND THEIR WoRK,TrLDEN SELEcrED WoRKs OF THoMAs SYDENHAM,CoMRIE. INDEX. .. PAGE 105 210 211 396 398 108 109 110 Ill 112 113 113 212 214 317 319 319 320 321 400 400 401 402 403 LISTOFILLUSTRATIONS PORTRAITSPAGETITLEPAGESPAGE ABERNETHY,JOHN. BLACKMORE,Sra RICHARD CAowALADER, THoMAs CooPER,Sra Asn.y PASl'ON CaruGNO,0oMENJCO CuSANUS,NrcoLAus DALTON,JoHN DEKKERS,FREDERIK DuPUYTREN, GurLLAUME. FomERGIU., JoHN GufNAULT,FRANcors. HEBERDEN,WILLIAM HUNTER, JoHN Cot1erNo.4 HUNTER, WrLLIAMCotJerNo.2 83 r8r 272 8r 28g 119 200 288 77 276 147 336 177 76.284 145 VAN DER LrNDEN, JoHANNES AmoNrus. MAZARJN,CARDINAL142 Facing323 146 267 MJTCHEU.,s. WEIR NAUDE.GABRIEL NEWTON,SraISAAC PASTEUR, Lours PATJN,CHARLES PATIN,GUY. DERrCHELIEU,CARDINAL RroLAN, JEAN, THEYoUNGER DE LAROCHE,RENE DE SAINTE-MARmE, ScboLE DE SivrGNE, MADAME SHIPPEN,Wrl.LIAM STOKES,wILLIAM. VELPEAU, A. A.LM.Cowr No.r, WICKERSHEIKER,ERNEST WrDMER,CHRISTOPHER WISTAR,CASPAR WoLLASTON,WrLLIAMHYDE . YoUNG,THOMAS TllLE PAGES 227 137.223 140 144 195 351 241 278 87 Facin11 391 347 6s 259 263 HrSTORY OFCoLD BAmiNG(1709)g8 MANUALOFANATOMYBYJEANRroLAN (r64g)Facin1115 KAPPAl....u.mDA JoURNAL VoLr(1826).197 KAPPA l....u.mDA JoURNAL VoL v(r8a8).199 "REPORT"oPTHENEwYoaxMEDICAL SociETY's CoMMITTEE(1831)201 "LYCEUMPATAVINUM,CHARLESPATIN .. (1682)226 "DEANTIQUJTATE," GABRIEL NAUDE (1628)236 CADWALADER's "EssAY oN THE WEST-INDIA DaY-GRIPES"(1745).273 "DEISCHIADENERVOSACoMMENTARIUS" (17fta).28g MISCEllANEOUSILLUSTRATIONS THE WrsTAR CoAT oP Aaws66 WISTARINSTITUTE, PHILADELPHIA67 THE CUSTODIANSHIPCABINET OPTHECoL-LEGE OFPHYsiCIANS OFPHILADELPHIA102 lmRARY IN THE HosPITAL AT CuES121 THEHousEINWHICHNrcoLAusCuSANUS WASBoRN123 HOSPITAL AT CUES125 TABLET MARKING GRAVE oF Lours DANIEL BEAUPERTHUY168 GRAVE OF Lours DANIEL BEAUPERTHUYr6g HUT ON KAow IsLAND170 VrEw OPKAow lsLAI'm.171 Fa.\NXLIN's BIFOCAL SPEcrACLES174 CovEROFpAMPHLETExPOSINGKAPPA l....u.mDA202 FrRSTPAGEoF mEr8s8REPRINToF1831 "REPORT" TO N. Y. MEDICAL SociETY203 FRoNTISPIECE HihTER's "FtlNFZIG CHraua-GISCHE 0aSERVATIONEN".209 PASTEUR IN HIS lABoRATORY..Facin1215 FRONTISPIECE,PHrUBERTGUYBERT's"LE MEDECIN CHARITABLE..229 APAGE oF CAowALADEa's Ms. "AN EssAY ON THE WEST-INDIA DaY-GRIPES":273 THE GYPSUM CASTS.277 THE FOTHERGILL CRAYONSONWHICHSHIP-PEN's ANATOMICAL LECTURES WERE BASED 279. 28o,281 CERTIFICATE OF ATTENDANCEAT WARREN'S LECTURES.283 CERTIFICATEOFATTENDANCEATSHJPPEN'S LEcrURES.284 THOMASWooD'sANNoUNCEMENTOFTHE FIRST CoURSEOPANATOMICALLECTURES GIVEN IN BamsH AMERICA286 INSERTION OF AWICK FOR THE DRAINAGE OF AsciTES288 PAGE OF THE EoWJNSMITH PAPYRUS315 HEADBANDANDINmAL "A" FROM GALEN's "DE SIMPLICIUM..323 PAGEFROMHEBERDEN'S AUTOBIOGRAPHY338 Da. WmMER's HousE349 GENERAL HosPITAL AT Yoax (ToaoNTO)350 TAILPIBCEFROMMERCURIAUS( r6o3)3J6 ANNALSOFMEDICALHISTORY ANNALSOF MEDICALHISTORY PUBLISHEDQUARTERLY VoLUMEIV,No.IMARCH,I922SERIALNo.I 3 EDITOR FRANCISR.PACKARD,M.D.,PHILADELPHIA,PA. -ASSOCIATEEDITORS HORACEMANCHESTERBROWN,M.D. HARVEYCUSHING,M.D. CHARLESLDANA,M.D. GEORGE[')()CK,M.D.. FIELDINGH.GARRISON,M.D. HENRYBARTONJACOBS,M.D. Milwaukee Boston NewYork .St.Louis .Washington Baltimore HOWARDA.KEU.Y,M.D..Baltimore THOMASMcCRAE.Philadelphia LEWISSTEPHENPILCHER,M.D.Brooklyn SIRD'ARCYPOWER,K.B.E.,F.R.C.S.(ENG.)F.S.A.London DA VIDRIESMAN,M.D.Philadelphia JOHNRUHRAH,M.D.Baltimore CHARLESSINGER,M.D.Orlord EDWARDC.STREETER,M.D..Boston CASEYA.WOOD,M.D..Chicago SPRINGNUMBER NEWYORK PAULB.HOEBER,PUBLISHER 67-69EAST59thSTREET c :OPYII.IGHT,1922 BYPAUL B. HOEBER ANNALS OF MEDICAL.HISTORY CONTENTS PoRTRAITOFVELPEAU NOSOGRAPHYINMoDERNINTERNALMEDICINE CAsPARWISTAR,JuNIOR. THE FRENCH ScHooL OF SuRGERY IN THE REIGN oF LouisPHILIPPE LoNDONSuRGERYINTHEEARLYPARTOFTHE NINETEENTHCENTURY. THE DUBLIN MEDICAL ScHOOL ANDhs INFLUENCE UPONMEDICINEINAMERICA THEHISTORYOFPuLSETIMINGWITHSOMERE-MARKSONSIRJoHNFLOYERANDH1sPHYSI-CIAN'SPuLSE WATCH EDITORIALS PAGE Cover and Frontispiece KNUDFABERI WILLIAMSHAINLINEMIDDLETON64 J. CHALMERSDA CosTA77 JoHNH.GIBBON8o DAVIDRIESMAN86 JACOBRosENBLOOM.97 SELECTIONSFROMVESALIUS,SHOWINGTHEIMPROVEMENTSINTRODUCEDINTO THESECONDEDITIONOFTHEFABRICA(1555).100 THE CusToDIANSHIP CABINET oF THE CoLLEGE oF PHYSICIANSOFPHILADELPHIA102 THIRDINTERNATIONALCoNGRESSOF THEHISTORYOFMEDICINE103 CoRRESPONDENCE MARTIAL'sEPIGRAMSRELATINGToMEDICALPRACTICEANDMEDICALMEN105 BooKREVIEws THE DAWN OF MoDERN MEDICINE, AN AccouNT oF THE REVIVAL OF THE SciENCE ANDARToFMEDICINEWHICHTooKPLAcEINWESTERNEuRoPEDuRING THE UTTER HALF OF THEEIGHTEENTHCENTURYANDTHEFIRSTPART OF THE NINETEENTH108 HENRYQuiN,M.D.,PRESIDENTANDFELLowoFTHEKINGANDQuEEN's CoLLEGEoFPHYSICIANSINIRELAND,ANDKING'sPRoFESSOROFTHEPRAC-TICEOFPHYSIC1718-1791109 EARLYSciENCEINOxFORD110 STUDIESINTHEPALEOPATHOLOGYOFEGYPTIll HISTORYOFMEDICINE.112 THELIFEOFJA.coBHENLE1 13 PARACELSUS.113 QrisiDalarticlesaftpublishedonlywiththeunderstandingthattheyaftcontributedexclusivelytotheANNALSOF MEDICALHISTORY.Manuacriptl offeredforpublication,booksforreview,and aUcorrespondencerelating to the editorial m8JY8e111entshouldbe addreaeedto the Editor,Dr.FRANCISR.PACKARD,302 South19th Street,Philadelphia,Pa. Communicationsregardingsubscriptions,reprinu,andaUmattersregardingthebusinessmanagementof the ANNALS OFMEDICALHISTORYshouldbeaddressedto thepublisher,PAULB.HoEBER,67-69Eut 59th Street,NewYork City. The ANNALS OF MEDICAL HISTORYiapublishedquarterly,the fourissues comprising one volume.No advertiaiugil canied.The subscriptionprice is$8.00 ayear.Singlenumben,aafaras available,$2 ..soper copy.AfewRta of Vols.I,11 andIll afe availablein parte aapublishedat $8.00per volume;$1o._soper volume,bouadincloth. BritishRepresentatives:Bailliere,TindaU&Cox,8HenriettaSt.,CoventGarden,London,W.C.2.Subecriptionin Great Britain.2,21avolume. Entered u.conc:klaa matter, June2,1917,at the Post Office,NewYork,N.Y.,under the Act of March3,1879. Copyright,1922,byPaul B.Hoeber. ANNALS OF MEDICAL HISTORY VOLUMEIVSPRING1922NUMBERI NOSOGRAPHYINMODERNINTERNALMEDICINE ByKNUDFABER,M.D. PROFESSOROFINTERNALMEDICINE UniversityofCopenhagen,COPENHAGEN,DENMARK SvDENHAMANDTHENosoLOGISTS ENinterestinpro-mot ingmedical sciencebyindepend-entresearchhad beenrevivedwith theRenaissance, anatomicalinvesti-gationsweremade thechiefstartingpointinthequestfor widerknowledge.Inthebeginningofthe fourteenthcenturythepracticeofhuman dissectionswasbegunattheItalianuni-versitiesofPaduaandBologna,and with thesteadilyincreasingnumberofdissec-tions,aknowledgeofanatomywasgrad-uallygained,whichreacheditsclimaxin thecrowningachievementsofVesalius. Modernphysiologyhaditsbeginningin Harvey'sdiscoveryofthecirculationof thebloodandinMalpighi's demonstration of thecapillarysystem.Through the work ofthesethreegreatmenthefoundations ofhumananatomyandphysiologywere laid.Inpathologyitprovedafarmore difficultandlaborioustasktoprovidea basisforascientificstructure. Intheearlystudiesofnormalanatomy someinterestwasexhibitedinthepatho-logicalchangesoccurringintheviscera; Vesaliushimselfisevensupposedtohave leftanimportantworkonthissubject, whichhas,however,beenlostto posterity. Otheranatomistshadtheireyesopen,too, butwhattheysawremainedtothemdis-connectedobservations,curiosities,and ab-normalities,fromwhichweredrawnno conclusionsof importance forgeneralpath-ology.Inthisfieldtheauthorityofthe ancients,oftheArabianphilosophers,of GalenandHippocrates,wasstill dominant, and when the first attempt at emancipation wasmade,theprocessconsistedchiefly inmakingmoreorlessvaguedeductions, basedonlytoaslightextentonactual observation.Scientistsrevelledintheories and systems,moreparticularlyinthehazy chemicaltheoriesoftheArabians,which hadbeendisseminatedamongthephy-siciansthroughoutEuropebyParacelsus. Thesetheoriesformtheearliestbeginning ofchemicalphysiologyandthechemical conceptionof pathologicalphenomena. 2AnnalsofMedicalHistory It wasnot untilthe seventeenthcenturydiffusedhistheoriesthroughoutEurope, that scientific enquiry was seriously broughtwherehisdisciplesfurtherelaboratedhis tobearonpathologicalproblems,andansystem.InEnglandhehadafamoussue-attempt wasmadeto advancebymeans ofcessorinthephysician,ThomasWillis, anatomicalandphysiologicalresearches.and about the same time there also appeared Asoneof the mostnotedrepresentativesanumber of prominent experimentalists,as of the anatomical schoolmaybementionedRobertBoyle,Hooke,Lower,andMayow, theDane,ThomasBartholin.Hewaswhoinitiatedtheaccumulationofknowl-amongthefirsttopublishlargecollectionsedgeconcerningthephysiologyof respira-of pathologicalobservations,partlyreportstionandgavefurthersupport to the iatro-of clinical cases and partly post mortem find- chemicalschool.ItwasalsoinEngland, ings,inhis"Historiarumanatomicarum ethowever,duringthisstirringperiod,so medicarum rariorum centurife v et VI" and insignificanttoEnglishintellectuallife,that his "Epistolfe."Inhis last years heplannedthemanlivedandworkedwhowasthe and made studies for a large work, an "Ana- severest opponent of the speculations of the tomiapractica"whichwastocontainaiatrochemists,andwhofirstconsciously collection of the post-mortem findingsinallandclearlygaveclinicalobservationits organs.Thesestudieswerelostinafireplaceofhonorasascientificmethod-whichdestroyedhishouse,andBonetusinThomas Sydenham. his"Sepulchretum"accomplishedthe taskIn contrast withthe leadingpathologists whichBartholinhad set himself.Bartholin,on the continent, Sydenham was exclusively however,madeonlydisconnectedobserva- aclinician,andstrictlyconfinedhimself tions, and we may search his published worktothe immediateobservationof pathologi-invainforanygeneralpathologicalpointscal phenomena. He was,not without reason, ofview.Azealousbutratheruncriticaltheintimatefriendofthephilosopher, endeavortocollectcuriouscasesstampedJohnLocke,whowasbutafewyearshis Bartholin'sactivityasapathologist,andjunior, and whoisgenerally regarded asthe thisisgenerally characteristic of the schoolfounderofempiricalphilosophy;andhe he represents.wasanardentadmirerofhiscountryman, Hiscontemporaryandcloseacquain- FrancisBacon.Thelatter,inhisbookon tance,FranciscusdeleBoe,orSylvius,atthe"AdvancementofLearning,"had Leyden,sought,o ~the other hand,to con- pointed out the twochief waysinwhichhe structapathologyoutoftheanatomicalthought medical science might be advanced. andphysiologicalknowledgeandtheoriesInthefirstplace,headvisedarevivalof of hisage.LikeBartholin,SylviusstudiedHippocrates'oldmethodofrecordingan bothnormalandpathologicalanatomy,accountofthevariouscases,withtheir but first and foremost he was the representa- coursetowardsrecoveryordeathinorder tiveoftheiatrochemicalschool.Hecon- that, through such observations, the descrip-tinued the work of Paracelsus and especiallytion of diseases,whichhad been undertaken ofvanHelmontindevelopingchemicalinancientGreekmedicinebuthadsince physiology, and he deduced his pathologicalbeen quite discontinued,might be amplified systemandhistreatmentof patientsfromandextended.Inthesecondplaceheheld theories in which the notion of the acid andthat the pathological changes in the organs, alkalinefluidsofthebody,andmorbidthe"footstepsofdiseases"shouldbe changesbroughtaboutbyfermentation,studiedbyanatomicalinvestigationsand played the chief part.thefindingscomparedwiththemanifesta-Throughhisassiduousactivityasationsandsymptomsof diseaseduringlife. teacherinHolland,towhichcountryallAsalreadymentioned,medicalscience learnedmedicalmenflocked,Sylviuswas.fairlylaunchedonthis latter roadbe-NosOGRAPHYINMoDERNINTERNALMEDICINE 3 foreBacon's time,but bedside observations were not very frequent. The various theories concerningthecharacterandnatureof diseases still formedthe center of interest. Asagainstthis,Sydenhamadvocated asoberobservationofmorbidnatural phenomena,andhethusreestablishedthe brokenconnectionbetweenancientand modernmedicalscience.Hisinfluencewas enormous,andthemostinterestingthing inhiswork isthe clarity with whichhe set forthhismethodof research,onlyequalled inimportancebytheresultsheobtained and the advances he inaugurated.For these reasonshemaybecalledthefounderof scientific nosography. In the introduction to the third edition of Sydenham'schiefworkonacutediseases which appeared inI675, he gives an account oftheprinciplesonwhichhisscientific activity was mainly based.His first passage isasfollows:"Afterlongdeliberationand manyyears'closeandfaithfulobservation, Iresolved(1)to communicate my thoughts relatingtothemannerofmakingfarther advancesinphysicand(2)topublisha specimenofmyendeavorsinthisway." In his view the best manner of advancing "physic" wouldconsist in the firstplace in providingagenuineandnaturaldescrip-tionorhistoryofalldiseases,asortof natural history of disease, and in the second place,inlaying downafixedand complete method of cure for each disease. The proper descriptionof the diseasesheheld to be far moredifficultthangenerallysupposed. Thefollowingprinciplesoughttobe observed: Inthefirstplace,alldiseasesshouldbe reducedto certain definite specieswiththe samecare whichwe see exhibited by botan-istsintheir description of plants. Next,allhypothesesandphilosophical systems should be entirely set aside and the pathological phenomena should be described withthesameaccuracythatapainter observesinpaintingaportrait.Nothing hasdonesomuchharmasthosephysio-logicalhypotheses which permi(the authors to ascribe to the diseasescertain symptoms whichexistonlyintheirownbrains,or allow themto exaggerate certain symptoms whichhappentofitinwiththeirown theories.Whilereferringtothesesymp-toms,theymagnifyratsintoelephants, they entirelyneglect other symptoms which donot fitinto their systems. In the third place, inmaking the descrip-tion, the particular and constant symptoms shouldbewelldistinguishedfromthe accidentalphenomena,whichmayvary with the age and constitution of the patient, or depend upon different forms oftreatment. Finallyitshouldbeobservedatwhat seasonoftheyearthediseaseoccurs,as somediseasesfollowtheseasonassurely asmanybirdsandplants.Thisisnotthe casewithalldiseases,butwhenitdoes occur,knowledgeregardingthispoint isof greataidindeterminingtheirspeciesand in effecting their extirpation. BehindtheseprinciplesofSydenham's forevolvingascientificnosographythere isthe firmconvictionof thepossibilityof drawingupacompletepictureofeach disease,aconvictionwhichwasnotthen current."And,intruth,"saysSydenham, "it ismy opinion that the principal reason ofourbeingyetdestituteofanaccurate historyof diseases,proceeds fromageneral suppositionthat diseasesarenomorethan theconfusedandirregularoperationsof disorderedand debilitatednature, and con-sequentlythatitisafruitlesslabor toendeavortogiveajustdescriptionof them."In oppositiontothispoint of view heinsiststhatmorbidphenomenaare subjecttolaws.The symptoms"observed inSocratesinhisillnessmaygenerallybe appliedtoanyotherpersonafflictedwith the same disease,in the same manner as the generalmarksof plantsjustlyrunthrough thesameplantsofeverykind.Thus,for instance, whoever describes aviolet exactly as to its colour, taste, smell, form,and other properties,willfindthe descriptionagrees, inmostparticulars,withalltheviolets inthe universe." 4 AnnalsofMedicalHistory ThesceneofSydenham'slaborswas unusuallyfavorableforhisobservations, since the sickrate of London inhis day was enormouslyhighcomparedwiththatof moderntimes.Onemurderousepidemic succeeded another,and all the more chronic diseasesflourishedluxuriantly.In1667, outof thesoo,oooinhabitantsof thecity, some16,ooodied,whileonlyII,ooowere born,andtwoyearsbeforethisthe plague hadsweptaway1oo,oooinhabitants.By 1667theplaguehadceased,butabout 1,300diedofsmallpox,2,oooofcholera, 3,000 of.phthisis, etc., and onlyI,oooof old age. Sydenham'sfirstworkdealtwiththe acute diseases,andbynotingthe course of theepidemicsandtheoccurrenceofthe diseaseat different seasonshewasaidedin layingdownthechiefsymptomsofthese diseases.Hisdescriptionofthesmallpox isamodelof concisenessandhasretained itsworthuntilourday,andhemade admirabledescriptionsofdysentery,chol-era,theplague,etc.Hewasthefirstto diagnosemeaslesandscarlatinaasdistinct diseases. The task of describing the chronic diseases seemedtohimfarmoredifficult.Herehe wasdeprivedoftheassistancefurnished bytheepidemicoccurrenceof thedisease. It washisconstanthope,however,tolive longenoughtoprovideadescriptionof thesechronicdiseasesaswell.Hehadonly timetogivefragments,buttheseareof greatvalue.Famousishisdescriptionof thegout(podagra)fromwhichhewas himselfasufferer.It wasnotuntilSyden-ham described this disease that it was finally clearly differentiatedfromrheumatism.His descriptionof hysteria,the psychiccharac-terof whichheestablished,isclassical;his treatisesondropsy,onsyphilis,etc.,are alsoimportant.Healsogavethefirst descriptionofSt.Vitus'dance(chorea minor).Dispersedthroughouthiswritings, wefindtherecordof manyothernewand importantobservations.Sydenham'sde-scription of diseasesis concise and lucid. We neverfindhimquoting other authors,asis so frequently done,forinstance, by Bartho-lin.Whenayoungphysicianaskedhim whatheshouldreadinordertoimprove himselfinhisprofession,heanswered: Read"DonQuixote."Solittledidhe respectcontemporarylearning.Hede-mandedindependentobservationwhich tooknothingforgranted.Hisdescription of symptomsisnever detailedandverbose. Thathisdescriptionshavesolongbeen regarded as- classicisbecause heunderstood sowellhowtopointoutthefundamental charactersofadiseasetogetherwithdue considerationofitscourseanddevelop-ment.Hepossessedtheartisticinstinctof the great clinician,the power of seeing what isessentialandofpassingbyimmaterial details,and,aswehavealreadyseen,with himthiswasaconsciouspurpose,apro-gramme,amethod. Twoclassesofpeopleequallyretarded the advance of medical science after Syden-ham.One classconsistedof those who,idle themselves,considered even the least efforts of othersobjectionableandexcusedthem-selveswiththeirgreatrespectfortheold authors.To theotherclassbelongedthose who, desirous of posing as superior intellects, brought forwarda wealth of arguments and speculations,quitefutilewhenitcameto curingdisease.Thesespeculativeandcon-structivephysicianswerethechiefbuttof Sydenham'spolemics,andinhisviewson thispointhewaswarmlysupportedbyhis friendJohn Locke. Lockehadhimselfbeentrainedforthe medicalprofessionandhadpracticedasa physicianinhisyouth.In hisworkhewas intimately associated with Sydenham. They visited patients together,forinstance small-poxcases,andin the preface to hisbook on theacutediseasesSydenhamexpressly states that L o c k ~fully endorsed his opinions. Among Locke's posthumous papers wehave variousunfinishedmanuscripts dating from this period of cooperation in which he further supports Sydenham's ideas. His criticism, too, wasprincipally directed against the "chemi-NosOGRAPHYiNMoDERNINTERNALMEDICINE 5 atrical"speculativetendencyinmedicine. Inhis"Arsmedica"(1669)hewritesthat hewhothinkshewillbecomeanable physicianbystudyingthedoctrines of the humors,orthathisknowledgeofsulphur andmercurywillhelphiminhistreatment of afever,"may asrationallybelievethat his cook owes his skill in roasting and boiling tohisstudyof theelements,andthathis speculationsaboutfireandwaterhave taughthimthatthesameseethingliquor thatboilstheegghardmakesthehen tender." Sydenhamhadaverylowopinionof the chemicalschool."Heblamedthosewho believethat medicineistobepromotedby thenewchemicalinventionsofourday, morethanbyanyotherprocesswhatso-ever."Stillhefullyrecognizedtheutility ofchemistrywhenitcametopreparing medicines.Famousarehiswords:"How I canmakeapatientvomit,andhowIcan purgeorsweathim,arematterswhicha druggist' sshopboycantellmeoffhand. When,however,Imustuseonesortof medicineinpreferencetoanother,requires an informant of a different kind-a man who hasnolittlepracticeinthearenaofhis profession."He assignedfargreater impor-tancetoanatomyasaguidetothe physi-cian: "He whowants thisknowledgeislike amanfightingblindfold,andamariner withoutacompass.Moreover,theknowl-edgeiseasilyattained.Nevertheless,inall acutediseases-andtwo-thirds are acute-wemustfairlyownthatthereisintheir nature something divine-some specific prop-ertywhichnospeculationsdeducedfrom the contemplationof the humanframewill everbeenabledtodiscoverandexhibit. " Lockemadequitesimilarremarksinhis fragment" Anatomica" dating from1668. Thus wesee,alreadyat the firstappear-anceofnosography,thattendencytoa divergencebetweenclinicalandanalytical scienceontheonehand,andtheoretical anddeductivescienceontheother,which hascharacterizedsomanydiscussionsin thepastcenturiesandhasrenderedthem particularlyacrimoniousbecauseofthe failuretodistinguishsharplybetweenthe theory and practice of medicine. The theorist drawsunjustifiableinferencesandapplies thempractically,andtheclinician,noting withgriefallthedisappointmentsand disasterscausedbysuchunjustifiableand immaturedeductions,indignantlyturns againstthetheorist.Andif therehasbeen anytimeinwhichanunjustifiableapplica-tionof theoriesandspeculationsflourished it wasduringSydenham's time.Inhisday there wasawidechasmbetweenthe scien-tificanatomicalenquiriesandchemical theoriesofthelearnedphysiciansandthe doctor's practice at the bedside. In Sydenham's writings we therefore again and again find severe polemical sallies against thespeculativetheorists.Sydenhamwas, aboveall,thephysician,andtherapeutic directions fill a very large space in his works. He wasnot,however,entirely freefroma speculative bias inhisowntherapy, though hissystemwassimpleandlucid.It started with the conception that in ague theorgan-ism,throughfever,"boiled"thedisease-provoking substance and dischargedit with the perspiration.He adhered to the notion, inherited fromthe ancients,of the inherent healing power of nature,and hismethod of cure consisted inaiding nature with various evacuants.Attentionshouldbecalledto his later doctrine of specifics, because it is so intimatelyconnectedwithhiswholecon-ceptionofdiseasesasspecific"natural phenomena subject to particularlaws.The startingpointofthisconceptionseemsto havebeenhisexperienceswithquinine. Quinquinahadjustthenbeenbroughtto Europe fromPeru. Sydenham soon observed its effectintheagueandsawthat it acted entirelywithout the assistance of the usual evacuations.Thus it hadactuallyaspecific effectinthisparticulardisease,andhence-forwarditmustbeconsideredthechief taskofphysicianstofindsuchspecific remedies,however difficult this might seem. Sydenhamhimselfdeclaredthatheknew of no other specific than quinine.He did not 6AnnalsofMedicalHistory considermercuryand sarsaparilla specifics, for,althoughtheycuredsyphilis,their effectwasprobably dueonlyto the saliva-tion and perspiration they promoted. Syden-ham entertainednodoubt that the Creator hadprovidedspecificremediesforthe chiefdiseases,andreferredtothecircum-stance that sofewof all the many different plants had been examined fortheir curative effects. AfterthedeathofSydenham,in1682, JohnLocke,inalettertoDr.Th.Moly-neux, wrote the following slightly pessimistic testimonialwhichgivesusagoodideaof Sydenham'saspirations: Ihopethe agehasmanywhowillfollowhis example,andbythe wayof accuratepractical observation,whichhehassohappilybegun, enlarge the history of diseases,and improve the artofphysic,andnot,by speculative hypoth-eses,filltheworldwithuselessthoughpleasing visions.Iwonderthat,afterthepatternDr. Sydenhamhassetthemof abetterway,men shouldreturnagaintotheromancewayof physic.ButIseeit iseasierandmorenatural formento buildcastlesinthe air of their own than to surveywellthosethat aretobefound standing.Nicelytoobservethehistoryof diseasesinalltheirchangesandcircumstances isaworkof time,accurateness,attentionand judgment,andwherein,ifmenthroughpre-possessionorobstinacymistake, theymaybe convinced of their error by unerring nature and matteroffact,whichleaveslessroomforthe subtlety and dispute of words. Sydenhamhimselfregardedhiswork merelyasan initial stage inthe description ofdiseases.Forthedescriptionofacute diseasesalone"theworkofcenturies wouldnotsuffice,"buthethoughthehad pointedouttherightwaytoproceed."I amlikeagrindstone,"hesays,"which withoutitselfbeingabletocut,yetcon-tinually whetsthe iron." Despite thisplainindicationof theroad to be followed, Sydenham had no immediate successor.Thiswashardlyduealoneto that propensity inscientists to build castles intheair,towhichLockealluded,but rathertothefactthattheprogramlaid downbySydenhamwasnotsoeasyto followaswouldatfirstsightappear.Asa matter of facthisdirections concerning the methodto befollowedinthe descriptionof diseaseswerequite insufficient.They might befollowed,atanyrateinpart,inthe differentiationofvariousacuteepidemic diseaseswhicharecharacterizedbyoccur-ring at different ages and at different seasons, buthowshouldthephysicianbeableto drawupdistinctpicturesfromthevaried massofsymptomspresentinpatients sufferingfromnon-epidemicandespecially fromchronicdiseases. Advancemightbemadeonsomefew pointsthroughunusualpowersofclinical observation,suchasSydenhamhimself possessed,butamethodrenderingsys-tematicworkpossiblehadnot been found. And so we see the pathological investigators ofthenextcenturytakingothercourses. LeadingclinicianssuchasBoerhaave, HoffmannandStahlwerechieHyoccupied with general pathological deductions and the framingofingeniouspathologicalsystems. ItistruethatBoerhaavewasawarm admirerof Sydenhamandspreadhisfame all over Europe,but he himself was rather a brilliant teacher than anindependentclini-calinvestigator,andhedidnotinheritthe chair of de leBot!(Sylvius) at Leyden with-outbeinginsomemeasureinHuencedby the chemiatricspeculations of the humoro-pathologicalcastof the latter.At anyrate wecannot assignanyimportant advance in clinicalknowledgetoBoerhaave,however greathisfame,andthesamemaybesaid inthemainabouthisnumerouspupils. Butinhiscenturyamassofmaterialwas collectedthroughindividualpathological andanatomicalinvestigationwhichgradu-allyprovidedasubstructureforlater pathologicalknowledgeand clinicalreason-ing.Assaidbefore,ThomasBartholinhad alreadyinauguratedthisdirectionof clini-calprogressbyhissedulousactivityin collectingpathologicalobservations,and furtherexperiencewassteadilygainedin NosOGRAPHYINMoDERNINTERNALMEDICINE 7 theeighteenthcenturyuntilMorgagniin 1700publishedhisgreat work"De sedibus et causismorborum." Therewasasyet,however,nointimate connectionbetween these anatomical obser-vationsandclinicalconceptsorpicturesof diseases.Throughthestudyofepidemic diseases(varicella,influenza),and of blood-poisoning (ergotism, lead-poisoning, scurvy), an ever widening knowledge of clinical medi-cinewasattained;variousnervousdiseases suchassciatica(Cotugno),trigeminusneu-ralgia(Fothergill),paraplegiainspinal caries(Pott),anginapectoris(Heberden), etc.,weredescribed,but these additionsto knowledgeweremadeindependentlyof the simultaneousdevelopmentoftheoretical knowledgeandtheymustbelookedupon ascasualgleamsof lightrather than asthe resultsof amethodical effort. Inthebeginningoftheeighteenth century,however,therewasonemanwho attemptedadirectcontinuationof Syden-ham'snosologicalworkandmoreparticu-larlysoughttocarryoutSydenham'sidea of describingthediseasesinthesameway asbotanists.describeplants.Thiswas F r a n ~ i sBoissierdeSauvages,ascholar who flourished at Montpellier and published asmallbook,"TraitedesClassesdes Maladies," in1731.He was himself a botan-ist besidesbeing a physician and inhisbook henowsoughttogroupthediseasesin classes,ordersandgenera,justasnatural scientistswereatthattimeoccupiedin arranging plants and animalsinaperspicu-ous system. Suchanattempttoplaceandgroupall diseases in a definite system was quite a new departure,thoughafewveryimperfect attemptsinthisdirectionhadbeenpre-viouslymade,suchasthosebythe Swiss physician,FelixPlater,in1002,andthe Amsterdamphyscian, Johnston, in1644. It isdifficult tojudge at the present time oftheamountofsensationcausedby Sauvages' sworkat thetime of its appear-ance,butonemanatleastwasgreatly impressedbyit,namely,theSwede,CarI linne.linne wasthen studying inHolland wherehe graduated asadoctor of medicine in1735, the same year in which he published his"Systemanaturae."Fromthemoment of firstreadingSauvages'sbookhebecame deeplyinterestedinthisman,inwhomhe discoveredthe same capacity for systematic arrangementasinhimself,andforthirty yearsthese twomen carried on an extensive correspondence,becameclosefriends,and weremutuallygreatlyinfluencedbyeach other,althoughtheyneverbecameperson-allyacquainted.In1737Linnecommenced the correspondencebyrequestingSauvages to sendhimhisbook whichhe had "sought invainthroughoutSweden,Lapland,Nor-way,Denmark,Germany,Hollandand England,"butwhichhadmadehismind teemwithnewthoughtssincehehadseen itatthehouseofaphysicianinLeyden. "My dullbraincanonlytakeinandcom-prehend that whichcanbeconceived syste-matically.Anyonewithabent formethod willfindtruthsinyourworkwhichwill livetill distant times." Inlaterlettershefurtherventedhis enthusiasm."Youaretheonlysystemati-cianamongphysicians,youalonehave brokentheiceandclearedtheway.You alonehave thrown open the road whichthe blind molesrefuse to enter." Hence,whenLinnebecameprofessorof theoreticalandpracticalmedicineatUp-sala,hebasedhislecturesonSauvages's system. After more than thirty years of work withhissystemSauvagespublishedhis greatmainworkin1763withthetitle, "Nosologiamethodicasistensmorborum classes,generaetspecies,"andthiswork exertedawideinfluenceinthecontem-poraryworld.Sauvagesenumeratesinall 2,400differentkindsofdiseasesinhis nosology.Theyaredividedbotanicalwise intoclasses(toinall),theselatteragain intoorders(40inall),theordersinto genera(thefirstclassalonecontains78 genera),andthe generaagainintospecies, theirnumber,assaidbefore,amounting to 2,400.In the preface he examines various ./ 8AnnalsofMedicalHistory principles for classifying diseases. A division basedupontheanatomicalchangeswould notbefeasible,andstilllessfeasibleany groupingdependinguponthecausesof diseases,because,asarule,thecausesare quite unknown.Hence he choosesa classifi-cationbaseduponsymptomsastheonly onepossibleandnatural.Buttohismind nearlyeverysymptommustbeconceived asaseparatedisease,asaconsequenceof whichhe wasable to enumerate the before-mentionedenormousnumberofdiseases. ViewedwithmoderneyesSauvages's system soonrevealsthe great shortcomings ofthisfirstattemptataclassificationof morbidconditionsaswellasthegreat difficultiesitinvolvedbothfortheauthor andforthephysicianwhowastouseit. ThusnolessthanI 8kindsofanginaare described,I 9 of asthma,20 of pleurodynia, 20of phthisis,etc. Thegroupingof the symptomsreferable tothedigestiveorgans,forinstance,is specially confusing. Sauvages's seventh class comprisespainsandissubdividedintofive orders:Thevaguepains,thepainsinthe head,chest,abdomenandextremities. Amongthe33generaoftheclasswefind dysphagia,cardialgia,andgastrodynia. ThereareI 9speciesofdysphagia,6of pyrosis,I 3ofcardialgiaand20different kindsofgastrodynia;further,underthe sixthclass(thedebilities)occursagenus calledanorexiahavingI3differentspecies; underthethirdclass(inflammations)we find7speciesofgastritis,andunderthe ninthclass(theevacuatingmaladies)are foundI 2speciesofnauseaand29species of vomiting. Inrealityhisnosologyconsistedessenti-allyinadescriptionofsymptoms,the variousspeciesofdiseasedependingupon the variouscircumstancesunderwhichthe symptomsappear.Suchadescriptionof symptomswasveryfarfromSydenham's ideaofgivingaproperdescriptionofthe diseases.That,however,agreatwanthad beenm e t ~ b ySauvages' s nosology is testified by the appearance of anumber of imitators andsuccessorsinthefollowingyears.In I 763Linnepublishedabrief"Genera morborum"fortheuseofhisstudents, andinthefollowingyearsextensive nosologiesmodelledonSauvages'ssystem appearedinseveral countries. Thus a nosol-ogybyVogelwaspublishedatGottingen inI 764,alsoonebyCulleninEdinburgh inI772,onebyMacbrideinDublinin I775,onebySagarat ViennainI776,one byVitelat LyonsinI 778,etc. Theonlyoneofthesenosologieswhich markedarealadvance wasthat of Cullen. Inthisanextensivesimplificationofthe systemwasattempted,thenumberof specieswasreducedandsymptomswere groupedasfaraspossibleintowhatwe shouldnowcallcomplexes.Forinstance, hecollectedthenumerousformsofano-rexia,pyrosis,cardialgia,etc.,underthe headof dyspepsia. Neverthelesshissystem doesnotdifferessentiallyfromtheothers we have mentioned,his divisions,too,being basedentirelyondifferencesinsymptoms. Thisisalsothecasewiththe" Praxis medicasystematiceexposita,selectisdiarii nosocomiiF ridericianiillustrata" published byBangatCopenhageninI 789.Like Cullen's,thisDanishnosologygreatly sim-plifiesmatters by avoiding an undue elabor-ationoftheindividualsymptoms.It was translatedintoGermanandenjoyeda wide popularity. Althoughthesenosologiespretendedto carry out Sydenham'sidea and programme byprovidingadescriptionof diseasessimi-lartothatusedforplantsinbotanical systems,yettheprinciplesunderlyingall these attempts differed essentially fromthat recommendedbySydenham.Whenhede-scribedadiseasehestrove to characterize it by its specific course and the specific corn-. binationofsymptomsexhibited.Inthis wayhe,in a manner, created newindividual diseases.Thenosologistsoftheeighteenth century,ontheotherhand,formedno newclinicalpicturesof diseases;theyonly cataloguedandgroupedthedescriptions alreadyknownandlefttheproblemof NosoGRAPHYINMoDERNINTERNALMEDICINE9 nosographyatmuchthesamepointasitTheearliernosologiesallexhibiteda wasinSydenham's time.certainresemblancetoLinne'ssystemfor Onthewhole,whatdifferencewasthereanimalsandplants.JustasLinneoften betweenasymptomandadisease?Thisemployedquitesuperficialcharactersin problemhadnotevenbeenproposed,aarranginghisclassifications,sointhese solution much less attempted. Linne had cer- nosologiessymptomshavingasuperficial tainly given it as his view that "symptomataresemblance,but differingwidelyinpatho-sehabentadmorbumutfoliaetfulteragenesisandsignificance,weregroupedto-adplantam,,but noattempt wasmade together.Duringthelatercenturiesthe collectthe symptomsintodefiniteunits.attempthasbeenmadetosupersedethese However, at that time methodical nosolo- moreorlessartificialsystemsbya more gies,suchasthosementioned,wereofnaturalnosologicalsystem,byonemorein muchuseandweremuchneeded.Theyaccordwiththenatureofthephenomena stimulated amoreaccurate descriptionandconcerned. namingofsymptomsandamoresecureBeforethisproblemcouldbesuccessful, basiswasthusobtainedforalldiscussionshowever,acompleterevolutionofclinical andclinicalstudies.Inreality,nosologies,medicinewasrequired.Sucharevolution onceattempted,havesincebeenindispens- tookplaceinFrancesimultaneouslywith able.It isindeednecessarytohaveasys- and shortlyafter the greatpolitical revolu-tematic expositionof allknown"diseases,,tionduringwhichallsciencesbrokeaway butthemodernsystemscertainlydiffermoreorlessfromtraditionandanew inevery particular fromthose of the past.intellectuallifebegan. 11 THEPARISScHooL.ANATOMICDIAGNosis Theschoolofmedicinewhichflourished at Parisinthebeginningof thenineteenth centuryisgenerallycalledthe pathologico- anatomicalschool, asitchieflycultivated pathologicalanatomy,but inrealityit was aclinicalschoolinwhichanatomywas alwaysheldsubservienttoclinicalends. Indeed,wemaysaythat with the develop-mentofthisschool,clinicalmedicinewas firstraisedtothedignityofanactual science. Themovementwasinauguratedbytwo menwhosescientificviewsexertedan exceedinglystimulatingeffectupontheir contemporarieseventhoughtheirachieve-mentsinthedomainofclinicalmedicine itself werenot of specialimportance.These two menwerePinel and Bichat. Pinelinsofarstoodhalfwayinthe past, ashischiefworkisanosologyonthe patternofthemanynosologiesofthe eighteenthcentury.ButPinel's"Nosologic philosophique,,whichwaspublishedin 1798,differedwidelyfromtheolderdes-criptivecollectionsofsymptoms.Helaid particular stress onthe importance of disre-gardingthe individual,continuallyvarying symptomsof diseaseandconsideringeach maladyasanindivisiblewholetakinga coursesubjecttofixedlaws.Settingaside allincidentalandindividualphenomena, he sought to arrive at the typical picture of the disease.In accordance with this principle heestablished inhissystemvarious typical "essential,fevers,eachcharacterizedbya different course and characteristic symptoms. Hisgreatpersonalcontributionto clinical medicine,however,consistsinanattempt toclassifyacuteinflammationonakind ofanatomicalbasishithertodisregarded. While in earlier times diseases were grouped onananatomicalbasisasdiseasesofthe head,chest,abdomen, etc., and of the vari-ousorgans,henowdividedinflammations, "lesphlegmasies,,intothefollowingfive orders.The diseasesof (1)the skin,(2)the 10Annals of MedicalHistory mucousmembranes,(3)theserousmem-branes,(4)theconnectivetissue,(5)the musclesandjoints.Forthefirsttimethe attempt was made to demonstrate aconnec-tion and an agreement between all diseases of the mucous membranes, between those of the serousmembranes,etc.He succeeded only veryimperfectlyinthispurpose,butthe ideaprovedfertileandwastakenupby Bichat who brought it to greater perfection. Xavier Bichat is usually, and with justice, mentionedasthe man who set up the land-mark between the two centuries in medicine. Thisyounggeniussucceeded,inthefew years of his life work, not only in completely revolutionizinganatomyandphysiology byhis"Anatomiegenerale,"butalsoin bringingthe newanatomy of the tissuesto bearuponpathologicalanatomyandclin-icalmedicine.Heshowedhoweach of the tissues described by him could be separately affected,andhowtheinvolvementof each tissuegivesrisetodifferentmorbidsymp-toms.Previously,studentsofpathology, suchasMorgagni,conceivedofwhole organsbeingdiseased.Nowthemorbid changesinanorganweredissociatedinto diseasesofthevarioustissues,eachof whichfollowsanentirelydifferentcourse. Thesubstanceofthebrainanditsmem-branesmaybeseparatelyaffected,the variousmembranesoftheeyehaveeach their diseases,the bronchi,lungs and pleura likewise, and the diseases of the pericardium aredifferentfromthoseof theheartitself. The different tissues become diseasedin the samemannerquiteindependentlyofthe organtowhichtheybelong.Thereforein allinflammations there occur two groups of symptoms.Onegroupisdependentupon the nature of the inflamedtissue,the other groupistheresultof disturbanceinfunc-tionof theorganconcerned.Forinstance, certainsymptoms,suchaspainandfever, arealwayspresentandthedurationand issueofthediseasearemuchthesame, whicheverserousmembraneisattacked, butifitispleurathatisinvolved,the patientwillsufferfromcoughandrespira-torydifficulties;ifitistheperitoneum, vomiting and obstipation are present; if the arachnoida,psychicsymptoms,etc.He says inconclusion: 11me semble que noussommesa uneepoque, ouI'anatomiepathologiquedoitprendreun essor nouveau.Otez certains genres de fievreset d'affectionsnerveuses,toutestpresquealors enpathologieduressortdecettescience.La medecinefutlongtempsrepousseduseindes sciencesexactes,elleauradroitdeleurassocieeaumoinspourlediagnosticdes maladies,quandonaurapartoutunia la rigoureuseobservation,I'examendesaltera-tionsqu'eprouventnosorganes... qu'est l'observation,sionignorela,ousiegelemal? ThewholeofBichat'spathologicaldoc-trineandprincipleof researchwasexceed-inglystimulatingandfruitfulonaccount of its many new points ofviewandsugges-tive starting points,andhiswholeperson-ality seems to have had the same stimulating effect.There isafireandenthusiasminhis writingswhichcannotfailtoarousethe reader.He spent the whole of his day in the dissectingroomandwroteatnight,and only in this way didhe accomplish somuch beforehediedin18o2,inhisthirty-first year.Hisexamplenodoubtgreatlyinflu-encedthemanygiftedyoungphysicians whosetoutontheirscientificcareersjust at this period. Bichat's ideasfoundthe greatest number offollowersattheclinicalschoolatthe HotelDieuwhereCorvisarteagerlyculti-vatedpathologicalanatomyinconnection withclinicalmedicine,andwherethe post-mortemroomsweredailyvisitedbythe young students,Bayle and Corvisart haslaiddownhisprinciplesof researchintheintroductiontothe"Essai surIesmaladiesetleslesionsorganiques ducoeuretdesgrosvaisseaux"which appearedin18o6. With Corvisart the olderaof systematic nosologycomestoanend.Afterthis, medicalprogressnolongerdepends merely ongroupingthesymptomsofdisease.In ordertoincreaseexistingknowledgecon-' NosOGRAPHYINMoDERNINTERNALMEDICINEIl cerning the realnature of disease Corvisart laid stress upon the study of the pathological changesintheorgans.Suchstudieshad beenprosecutedsincetheRenaissanceand hadresultedinMorgagni'sfamedbook, "but," he says,"this fineworkhasserved more to adorn the works of other physicians than to advancethe art of recognizingthe organicdiseases.Itshouldnotbeour objectto search,out of abarren curiosity, forwhat the corpsesmayofferintheway of remarkablethings,but torecognizethe diseasesbydefinitesignsandconstantly recurring symptoms."He therefore thought thattheproblemmightbeformulatedin much the same way as Morgagni formulated itinthetitleofhisbook,butconversely. Morgagni had called his work,"De sedibus etcausismorborumpersignadiagnostica investigatisetperanatomenconfirmatis," butadded Corvisart,"it wouldrequireno lessthanasecondMorgagnitoproduce such awork."The whole programme of the newschooliscontainedintheabovesen-tence,andtherewasreallynolack of men whowereMorgagni'sequals.Corvisart himselfmadeabeginninginhisbook alreadymentioned,whichdealswiththe generalsymptomatologyofheartdiseases fromthispointofview.Inthisbookhe givesaclassicaldescriptionofcardiac dyspnea.Headoptedthe"Inventumnov-um"publishedbyAuenbriiggerin1761, i.e.,directpercussion,inordertodemon-stratehypertrophyoftheheart,andhe soughttocorrecthisdiagnosesthrough succeeding post-mortem examinations.But allthiswasonlythe beginning. The geniuswhoreallybroke newground wasLai!nnec,whose"Traite deI' ausculta-tionmediate"belongsamongtheworks whichhavemarkedanepochinmedicine andmoreparticularlyininternalclinical medicine. It is now just one hundred years since this book sawthe light,andfromthe time of its appearancethephysiciansawhistaskat thebedsidechange.Thephysicianbegan nownotonlytoobserve,buttoexamine thepatient.Laennec'sworkproducedalso arevolutioninnosography,arevolutionin themannerof describingandclassingthe morbidphenomena. Inhisprefacetothe 2ndeditionof his book( 1826)Laennecdescribeshismethod inthe followingwords: Lebutque jeme suisconstamment propose dansmesetudeset recherchesa ete lasolution des trois problemes suivants: 1.Distinguersur lecadavre un caspatholo-gique,auxcaracteresphysiquesquepresente !'alteration desorganes; 2.Lereconnaitresurlevivant,a des signes certains,etautantquepossiblephysiqueset independantdessymptomes,c' est-a-dire dutroublevariabledesactionsvitalesqui I'accompagnent; 3Combattre lamaladiepar lesmoyensque I' experienceamontreetrelesplusefficaces: en unmot,j'ai tAchede mettre, sous lerapport dudiagnostic,leslesionsorganiquesintemes sur la meme ligne que les maladies chirurgicales. Aswillbeseen,hisscieqtificprogramme coincidesverynearlywiththatofhis teacherCorvisart.He carried on pathologi-co-anatomical investigations, but constantly hadinmindtheutilityofpathological anatomyforclinicalmedicine."C'estle flambeaudelanosologie,"heexclaimsin 1812,greatlypreferringtheanatomicalto theetiologicalorsymptomaticmethodfor distinguishing the variousdiseases,because hebelievedtheanatomicalcharactersto bethemostconstantandtheeasiestto recognize. Butwhenitcametorecognizinginthe livingpatientstheanatomicalchanges foundinthe dead,there wasstill farto go. It waswhileconsideringthisthat hemade thegreatestadvancewhen,in1816,he conceivedtheideaof indirect auscultation, andthisresultedintheinventionofthe stethoscope.Byauscultationhewasable to demonstrate the signs of morbid changes inthe organsmuchmoreperfectlythanhe couldbypercuSJionalone,andthesub-jectivesymptoms,therefore,becameof secondaryimportance. 12 AnnalsofMedicalHistory Afterhavingdescribedandclassifiedallempyema,gangrene of the lungs,etc., were thephenomenaobservedbymeansofhisconfused with phthisis,and the early stages stethoscope,heexplainedinhis"Traite deof the diseasewerelittle known.Onpurely I' auscultationmediate,theanatomicalsymptomatic groundsvariouskindsof con-changesinthelungscorrespondingtothesumptionhadbeendemonstrated,asmany stethoscopic phenomena, basing his explana- astwentyvarietiesbySauvages,fourteen tionsuponpost-mortemfindings.BeforebyPascal,etc.Anatomicaltubercleswere timeaphysician'sexaminationknown since the time of Sylvius and Morton, of his patient consisted entirely in observingandtheconceptionhadgraduallygained hisappearance,feelinghispulse,lookinggroundthattuberclespossessedacertain at histongue,examiningthe urineandthesignificanceinthe development of phthisis. like.Nowareallyobjective examination ofcontemporary,Bayle,gotsofar certainorganscouldbemade,at anyrate,insimplificationoftheproblemasto oftheorgansofthethorax.Objective. describe only sixdifferentkinds of phthisis. criteriawerehenceforthdemanded,andLaennec was,however,the first to recognize nosographyhadthusbeenplacedonquitethatallthesevarietieswerebutstagesin anewandfirmerfooting.Laenneccausedonedisease,tuberculosis,andto showhow the germs providedbyPinel' s andBichat' sto distinguishit fromsimilar morbid states. anatomical ideas to spring into life in clinicalMoreover, he showed that miliary tubercles, medicine.the larger yellow tubercles and the grey and Bycomparingtheconditionspresentyellow infiltration are all but different stages in the patient with the course of the diseaseofthesameprocess.Clinicallyhedemon-and the lesions found at post-mortem exami- stratedthattheprocessusuallybeginsin nations Laenneccreated a seriesof entirelytheapexof thelung,andthat thevarious newandclassicalpicturesof disease.Thusanatomicalchangesmaybedemonstrated hewasthefirsttodescribeemphysema,bymeansofstethoscopy,andfinallyhe acuteandchronicedemaofthelungs,conceivedanddescribedtuberculosisof bronchiectasisandgangreneofthelungs.the lungsasa special disease differingfrom Hefurtherdescribedpneumothorax,andallotherdiseaseprocesses.Healsorecog-hedistinguishedpneumoniafromthenizedthat tuberculosisinother organsand variouskindsofbronchitisandfromalsoscrofulawerevarietiesofthesame pleuritis.Beforehistimephysicianshadgeneral disease. notbeenableto distinguishbetweenthesedied in 1821, only forty-five years variousaffections,butmergedthemallold,butanumberof clinicianscarriedon underthetermperi-pneumonia whichhadthe work in accordance with the programme beeninheritedfromtheancients.HavinglaiddownbyCorvisartandbyhim.Inall made these distinctionshewasableto givefieldsof internal clinical medicine there was aclinicalandanatomicaldescription . ofaregeneration,andanosographywas pneumonia whichholds goodto this day.createdofhithertounknowncomprehen-Hisgreatestaccomplishment,however,siveness and certitude. The most prominent washisdescriptionof tuberculosis.It maynames of this French school are G. L. Bayle, be said that he was the first to establish theAndral,Louis,Bretonneau,A.L.Bayle, conceptionoftuberculosisasamorbidBouillaud,Cruveilhier,Chomel,Alibert, unity.Phthisiswas,of course,knownfromRayer,andPiorry.Theirworksand thetimeoftheancients.Theadvancedinfluence have sooftenbeendescribedthat stagewithconsumption,theexpectorationwemayherecontent ourselves withabrief of pus or blood, fever and_ diarrhea, had beenmention.Withregardtothem all,it holds known and described,but a number of othergood that it wasthe careful examination of chroniclungdiseasessuchasbronchitis,thepatientsandtheexactpost-mortem NOSOGRAPHYINMoDERNINTERNALMEDICINE13 examinationswhichledtothe advancesinParis school.For eight yearshe gave up all knowledgewhichtheymadeandtotheirprivatepractice,spentfourorfivehours continualdiscoveryofnewdiseases,ordailyat the hospitaland gaveat least two rather,tothecontinualestablishmentofhourstoeverypost-mortemexamination. new categories of disease,all of whichhad aHisfirstworkontuberculosisofthe pathologico-anatomicalbasis,and had clin- lungswasbasedon167clinicalcasesof icalfeaturescharacterizingthemaswell- pulmonarytuberculosiswithautopsyex-markedindividualdiseases.Astypicalaminations,hisworkontyphoidfeveron examplesof theirworkmaybementioned138caseswithdissections.1 In theprefaces Bretonneau' sdescriptionofdiphtheria,tohisworksinwhich,likemostofthe Louis'andAndral' sstudiesontyphoidauthorsofthisperiod,hediffuselydis-fever,A.L.Bayle'sdiscoveryof dementiacussedhisprinciplesofresearch,he paretica,Cruveilhier' sdiscovery. of chronicemphasizedhowimportantitisforthe ulcerof the stomach,Bouillaud'sestablish- physician to question his patientscarefully, mentofmitralinsufficiencyandofrheu- ascertainingwhatsymptomswerepresent, matic endocarditis.andlackingthese,beingcarefulnotto Bacon'ssentencearsmedicatotainexertanysuggestiveinfluenceonthepa-observationibus which Laennec had employedtient while taking the history. The next step asamotto,becameaguideto the school.shouldconsistindeterminingwhetherthe Theimportanceofhospitalfacilitiesfororgan to which the symptoms are referable, makingthesecarefulobservationsattheasindicatedbythedisturbancesinrune-bedsideandatthepost-mortemtablestion,showslesionsatthepost-mortem causedhospitalworksuddenlytogainaexaminationthat satisfactorilyexplainthe significance whichit hadneverhadbefore.symptoms.Inthisthe greatestobjectivity It wasonlyinthewardsofthehospitalsshouldbe observed.Andasamotto forhis thatthecarefulexaminationofpatientsworkontyphoidfeverhecitesRousseau' s whichwasnowrequiredcouldtakeplace;familiarwordsfrom"Emile":"Jesais, itwasinthepost-mortemroomsthatque la verite est clans les choses et nond ans BichatandLaennechadcarriedontheirmonespritquilesjuge,etquemoinsje anatomicalstudies.metsdumienclansIesjugementsquej'en It was the results of such careful examina- porteplusjesuiss11rd' approcherdela tionsof patientsandjustascarefulpost- verite." mortemobservationswhichwerecollectedAsmaybeinferredfromthisquotation byAndralin1823inhisclassic"Ciiniquehewasmethodicalratherthaningenious. Medicale"whichbecamethe modelforallHewasalmostpedanticallyexactandcan worksonclinicalnosographyduringthehardly becalledan innovator.He therefore followingdecades.Themodeof expositiongradually invested the school with a certain whichheemployedinthis work was unusu- tendency to dryness,givingmoreand more allylucidandmethodical.Indiscussingweight to a numerical registration of morbid eachdiseasehefirstdescribesaseriesofphenomena.Heintroducedthestatistical, casesendingfatallyanddescribesthenumericalmethodintoclinicalresearch, anatomicalfindings,thenhedescribesabut ina certain degree this occurred at the seriesofcasesterminatinginrecovery,cost of direct biologicalobservation. andfinallyhecollectstheanatomicalasOnthis point hewasinmarkedcontrast wellastheclinicalfindings,anddrawsawithanotherofthemostprominent pictureofthediseaseinitsentirecoursemembersoftheschool,Bretonneau.This andinits differentphases.remarkableandgiftedclinicianspenthis The samemethod wasfollowedby Louis1 Garrison states that his research on phthisis was whograduallybecametheleaderofthebasedupon358dissectionsandtg6oclinicalcases. 14Annalsof MedicalHistory lifeasahospitalphysicianatTours.demonstrationofthespecificcharacter of Veryfertileinoriginalideaswithwhichadiseasethatdiagnosis,prognosisand heorallyenrichedhispupils,heseemstotreatmentdepend.SinceBretonneau,the havebeenindisposedtocommitthemtospecificityofdiseaseshasinfactalways paper.Hehasinfactleftbehindhimonlybeenimplied; this is shownby the different onelargerwork,hisbookondiphtheria,namesgiventothecutaneousinflamma-whichappearedin1826.Itmaybesaidtions,"eventhephysicianswhorefuseto thatthescientifichistoryofdiphtheriaacceptitbecauseitisopposedtotheir beganwithBretonneau,sincehewasthetheories,defer to it inpractice." firstto writediphtheria!anginaandcroupOf special interest isthe manner in which intoanetiologicalandclinicalentity.HisBretonneausoughttogiveexperimental secondgreatsubjectofinvestigationwassupporttohistheoryofspecificity.By typhoidfeverinwhichhedemonstratedapplicationof the extract of cantharideshe theintestinallesions,andhethereforesucceededinproducingamembranous namedthisdisease"Dothienenterie."Ininflammation in the mouth and throat or in 1826 Bretonneau's disciple, Trousseau, gavetheconjunctivaofdogs.Theappearance anexpositionofthelatter'sideasandofthelesionwasexactlysimilartothat observations concerning dothienenterie, andofrealdiphtheria,butthecourseofthe Bretonneau's own great work on this subjectdiseasewasquitedifferent,the processwas seemedtobenearingitscompletionwhenlocalized,extremelybenign,andwasnot LouisandAndralin1829broughtforwardaccompaniedbyfeverorothergeneral theirworksontyphoidfeverandthusmanifestations."Ce quelquechosedespe-renderedBretonneau'sbookunnecessary,cial,ce'quiddivinum,'quinepeut~ t r e orat anyrate,deprivedhimof thedesiresaisi, et qui, de I' aveu d'Hippocrate, echappe of finishingit.a touteexplication"waswanting.Like Our ownspecial interest inBretonneau isSydenham he stops at this "quid divinum," excited chieflyby his general points of viewthismysteriousfactorwhichdetermines concerningspecificinflammationsand spe- the course of adisease,its specificity. cificdiseases.AccordingtoBretonneauitBretonneauhadnotthesameinfluence isthe specificity of the inflammationmuchonhiscontemporariesasLouis,and,under more than its intensity or seat in the variousthe leadership of the latter, purely anatomi-tissueswhichinfluencesthemorbidphe- caldiagnosisbecamemoreandmoredomi-nomena:"C'esta laspecificitedeI' en- nant,butitwillbeeasilyseenthatthe flammation,queserapportentladuree, lapointsofviewandattitudeofmindre-graviteetledangerdelaplupartdesvealedbyBretonneauinhiswritings pyrexies."Hestatesthatalltissuesseemindicate that inhima further andconsider-liable tobeaffectedbyvariouskindsofabledevelopmentofLaennec'sideascon-inflammations,buttheinflammationsofcerningnosography,hadtakenplace.The theskinofferthegreatestvariety;theFrench physicians of thisperiodwerecon-mucousmembranes,however,mayalsobestantlyengagedinisolatinganddescrib-the seat of differentkindsof inflammation.ingnewtypesofdisease,andthisaided Asan example of a specificinflammationgreatly in maintaining and developingLaen-he refers to the membranaceous diphthereticnee's ideas. inflammationofthethroat;intyphoidItmustnot,however,beunderstood feverthere occursanother variety inwhichthattherewerenodifficultiestobeover-akindofpustulousexanthemaoccursincome.Onthe contrary,the newschool met themucousmembranesoftheintestine,withkeenopposition,andLaennecand justasinsmallpoxaspecialtypeof exan- Louis,especially,foundabitteradversary thema is present on the skin.It isupon theinthesomewhatfancifulBroussais,who NosOGRAPHYINMooERNINTERNALMEDICINEI 5 was,however,agiftedagitator.Theirchangeablemorbidcondition,andwhichwe controversiesplayedagreatpartatPariscannotbecertainoffindinginnature.They inthefirstpartof thecenturyand finallyarefactitiousentities(entittsfactices},andall ended inthe defeat of Broussais.Neverthe- thosewhostudymedicineaccordingtothis less,it isnot unimportant to draw attentionmethodare ontologists. tosomeof theviewswhichheadvocated,Toregardthesuccessionofsymptomsobserved asthenecessaryandunchangeablecourse of a becausetheyrepresentcertainprinciplesdisease,means the creation of a factitious entity, inclinicalresearchwhichhaveretained ameans the making of ontology. certainvitality,especiallyinGermany. Broussaiscalledhisdoctrine"physio-logicalmedicine"becausehewishedto attachmoreweighttothefunctionaldis-ordersof the diseasedorgansthan to their anatomical alterations. He was the disciple of Bichatinsofarashesoughttolocatethe diseasesintheseparateorgans,buthe opposedthe tendency of the modernschool todrawupdefiniteclinicalpicturesof diseaseascribingtoeachdiseaseatypical courseandsufficientlywell-markedcharac-teristicsastojustifyitsdesignationasa distinct entity. He maintained that symptoms are subject tonolaw,butcombineinevervarying groups,notwo cases being ever foundalike. It was,therefore,necessarytoinvestigate closelythe physiologicalconditionspresent ineachseparatecase.It wasunjustifiable toregardtuberculosisasamorbidentity. Viewedanatomically,tuberculosis wasonly achronicinflammationofthelungs,a chronicpneumonia,withoutparticular characters.Inflammation,whereveroccur-ring,wasdueto adiminishedorincreased degreeofthat"irritation"whichwas,to him,thevitalprinciple.Accordingto Broussais,thepracticeof thepathologico-anatomical school of setting up diseases was infactonlythe continuation of the infelic-itousideaoftheoldernosologistsof con-ceivingofdiseasesasspecialbeingslike plants.Thiswas"ontology,"anditwas chieflythisandtheaccompanying"fatal-istic" conception.of the course of the diseases whichhepersecutedwithallhishateand scorn. Thosegroupsofsymptomswhicharegiven outasdiseasesaremetaphysical. abstractions whichbynomeansrepresentaconstantun-Broussaisinawayhitstheverycenter of themarkinhiscriticismof theaimsof the Paris school, since in all the coryphes of theschool,fromPinelwithhisessential fevers,toLaennecwithtuberculosisand Bretonneauwiththespecificmaladiesof the mucousmembranes,wemeet withthis tendencytosetup"factitiousentities," typical diseases,and these aims are diamet-ricallyopposedtoBroussais'physiological medicinewhichfanaticallyopposesevery-thingspecific.Itisthesameantagonism whichwefoundbetweenthemenofthe chemiatricalschoolontheonehandand SydenhamandLockeonthe other,andin one shape or another weshall meet it again during the whole of the nineteenth century. Broussaiswasofcourserightinhis argumentthatallentitiesofdiseaseare abstractconceptscreatedbythehuman brain, but he did not see that the same holds trueofallspecies,evenofbotanicaland zoologicalspecies,thoughBroussaisdrew a contrast between these and what he called the"factitious"entitiesinmedicine.Even afterthezoologicalspecieshavebeen deprivedof theirPlatonicdivineness,they arestillasnecessaryasbeforeinbiology, andan analogoussituation existsinrespect to diseasesinmedicine.It isonlywhenwe forget that species is a concept derived from individualobservations,and assignto it an absolutevalue,thatwecanbedubbed ontologists. The habit of regarding diseases as entities, asakind of beings, forced itself on the clini-cianswithirresistiblepowerfromSyden-hamtoBretonneau.Thisgave support to thecriticismthattherewasacomplete failuretorecognizetheessentialprinciple 16Annalsof MedicalHistory inthedelimitationof a given pathological speciesfromother pathological conditions. Althoughanatomicalchangeswerecon-sideredof greatimportancebythemenof Laennec's school,thesemenwere too much clinicianstorelyonthemalonein classi-fyingdiseases.They understoodthatthere existedlawsrelatingtothecombination andcourseofsymptomswhichcouldnot beneglected.Aspreviouslymentioned, suggestionsappearedintheworksofBre-tonneauastomethodsforsolvingthe problem, and his suggestions were extremely fruitfulin later times. Theclinicalscientificmovementspread quicklyfromParistoothercountries. From all parts of the world young physicians flockedto Parisinorder to learn the art of stethoscopy as well as anatomical diagnosis, andcentersoflearningaroseinwhich the new teaching was not only applied in the practice of diagnosis,but alsoinwhichthe principlesofresearchactuatingtheParis school were employed in further independent investigations along similar lines. Thefirstplaceinwhichsuchaclinical school arose was Dublin. About 1820 Ireland wasbeginningtorecoverfromaseriesof violentanddisastroussocialandpolitical shocks,andabout thistime the physicians ofDublin founda leader inRobert Graves. Afterpursuing hisstudiesonthe continent for several years, Graves had been appointed chief physician to the small Meath hospital, andherealsoshortlyafterwardsWilliam Stokes obtained apost.These twoeminent cliniciansformthecenterofagroupof physicianswhosenamesarestillfamiliar onaccountof theclinicaldiscoverieswith whichtheywereassociated.Amongthese physicianswereCheyne,Adams,Corrigan, and others. These clinicians are nowchiefly remembered as having described the "new" diseasesorcomplexesofsymptomswith whichtheirnamesareassociated,as,for example,Graves'disease,Adams-Stokes' disease,Cheyne-Stokes'respiration,Cor-rigan'sdisease,etc. Almost simultaneously new clinical schools appearedinLondon,thatatSt.George' s Hospital,whereHopeworked,andthe schoolofGuy'sHospitalbeingofspecial importance.AtthelatterschoolThomas AddisonandRichardBrightwerethe leadersandtheybecame the mostnoted of the"greatmenofGuy's,"amongwhom wasalsoHodgkin.In Bright's"Reports of MedicalCases,"publishedin1827,he showedforthefirsttimetheconnection between anatomical changesin the kidneys anddropsy,andalbuminuria,andthus createdtheclinicalpicture of that chronic inflammationofthekidneyswhichstill bearshisname,andthenosographyof whichhefurtherelaboratedinhislater works.The names of Addison and Hodgkin alsobecameattachedtodefinitediseases, andthe sameistrue of thenamesof other physicianswhowerethenpracticingin Londonand Edinburgh,such asParkinson, Abercrombieandothers. AlltheseEnglishcliniciansworked accordingtothesameprinciplesasthose thatguidedtheParisschool,andtheir chief contributionsweretonosography.It wasthecombinationofanatomicaland clinicalinvestigationwhichledtothe resultswhichthey obtained,andtheyheld theopinion,perhapsevenmorestrongly than the French physicians, that pathologi-calanatomywasmerelyanaidtoclinical medicineandmust alwaysbe subordinated to the latter.Wefindthis clearly expressed byGraves inhisfamousclinicallectures: In order justly to estimate the importance of morbidanatomy,weshouldrecollectthatthe first alteration in the picture of apart is not the causebuttheconsequenceofdisease.... Thusthephysicalalterationswhichattend externalinflammation,thetumefaction,the heat,therednessarenotthecausesbutthe consequencesof disease.Butinthusreducing them to the rank of symptoms, dowediminish theirimportance?Certainlynot.Forbeing immediatelyconnected,aseffects,witbthe primary cause, they prove the most useful of all symptoms,inenablingustoascertainthe seat and progress of diseasedaction. NOSOGRAPHYINMoDERNINTERNALMEDICINE 17 Graves,of course, fully acknowledged the importanceofLaennec'sanatomicaldiag-nosis,butheheldtheconceptionof "disease"asofprimarysignificanceand was therefore inharmony with Sydenham's and Bretonneau's doctrine of the specificity of disease. ThustheFrenchandEnglishclinicians became eo-workers, starting with very simi-lar points or view, and as a result, an entirely newclinicalmedicinedevelopedduringthe first part of the nineteenth century.A series of new diseases was described and these were madeeasy to recognizeby the discoveryof "pathognomonic" symptoms and character-isticobjective signs.The courseandwhole characteristic picture of these diseaseswere definitely outlined. The violence with which clinicalmedicinewascompletelyrevolu-tionizedinthecourseof afewdecadesby theseimportantandstrikingdiscoveries willalwaysremainoneofthewonders of medical history. The stir of this scientific movement spread quicklytoothercountries.In Americathe brilliantpupilofLouis,W.W.Gerhard, besidesotheraccomplishments,described tubercularmeningitisinchildren,andhe wasalsothefirstclearlytodifferentiate typhusandtyphoidfevers.InDenmark, Seligman Trier, head physician at Frederiks Hospital in Copenhagen, introduced stethos-copyasadiagnosticmethodintoScandi-navia,andin1830publishedabookof "DirectionsintheArtofStethoscopy." Scientificworkinthisfieldwasnotcon-tinuedinScandinavia,however,andonly later,throughtheeffortsof C.E.Fenger, whodemonstrated"the echointhe human lungs,"weretheFrenchideas,moreparti-cularlyLouis'statisticalmethod,adopted in this country. ThefirstplaceintheGermanicworld inwhichtoanyextentCorvisart'sand Laennec's and other exact methods of physi-calexaminationwereadopted, was Vienna. HereAuenbriiggerhadformerlydeveloped the method of percussion,and here nowthe clinician,Skoda, and the pathologist,Roki-tansky,becametheleadersofthe"new schoolof Vienna." Theyfollowedlargelyalongthelines laid downbythe Paris school.Rokitansky, drawingonanimmensebodyofmaterial, mostindustriouslyandsystematicallycon-tinued the study of the pathologico-anatom-icalchangesinthe organswhichhad been undertakenbytheFrenchpathological anatomists,whileSkodaextendedand developedLaennec'sstethoscopy.Byinti-mate cooperation these two scientists greatly advancedtheartofanatomicaldiagnosis, and the Allgemeines Krankenhaus of Vienna was long a gathering-place foryoung physi-cians. Therewas,however,anessentialdiffer-ence between the French and Vienna clinical schools.In Skoda's chief work on percussion andauscultationwhichappearedin1839, thereismuchcriticismof Laennec'sviews, particularlyofhisviewsconcerningthe significanceofcertainsigns.Laennechad attemptedtocharacterizethevarious diseasesbydefinitestethoscopicfindings, andhad,forinstance,pronouncedcrepita-tion"pathognomonic"ofpneumonia. Skodawasopposedtothisview.Skoda attemptedtoexplainthephenomenaob-servedbypercussionandauscultationby purelyphysicallawsandheemployedthe methodsofauscultationandpercussionto demonstrateanatomicalchangesinthe lungs,buthewouldhearofnodefinite diseasesorpathognomonicsignsofsuch. In these views he accorded with Rokitansky, and likehim,placedanatomicalalterations firstintheclassificationofmorbidpro-cesses,andheldthatthetaskofclinical medicinewasconfinedtodemonstrating theseanatomicalchangesinpatients.He thus entirely subordinated clinical medicine to pathological anatomy and made anatom-icaldiagnosisintheliteralsenseofthe wordthe end and object of his efforts.Asa matter of fact, Laennec, too,had seen quite clearlythatonlycertainpurelyphysical changesinthe lungs could be demonstrated byauscultation,but he utilized the findings 18Annalsof MedicalHistory as part of the morbid picture and described, forinstance,atypicalstethoscopic finding inpneumoniaasacharacteristicfeatureof that disease.Skoda raised strong objections to this, and he seems to have lost the power of seeing precisely what was clinically typical inproportion ashebecame absorbedinthe studyofthephysicallawsunderlying the percussiveandauscultatoryphenomena. Indeed,hequitedeferredtoRokitansky who,inhistextbookof 1846,drewthe oft-citedconclusion"thatpathologicalana-tomyshouldbethebasenotonlyofthe knowledgeofphysiciansbutalsooftheir practice,asitcontainsallthereisin medicineofpositiveknowledgeandthe foundation of it I" With such views scientists hadwanderedfarfromthenosographyof theEnglishandFrench,andlandedin anatomicaldiagnosisof thepurestand dryestsort.Isittobewonderedthatit Ill broughtwithitacompletetherapeutic nihilismininternal medicine? AtBerlinitwasSchtsnleinwhohadthe meritofintroducingLaennec'sdiagnostic methods.Throughhisvigorouspersonality he greatly influenced the younger generation of physicians,thoughasa scientific worker hewasnotveryproductive.Inhisearlier yearshe wasgreatly influencedbyGerman "Naturphilosophie,"andbytheearlier cliniciansof the eighteenthcentury, and he alsobecameengrossedindevisingnoso-logicalsystems.The systemsoriginatedby himandhisdisciples(Eisenmann,Juchs andothers)hadastrongphilosophical characterandwereofnolastingvalue. Only whenhecame to La Charite at Berlin in1839andat thesametimeadoptedthe Frenchmethodsofphysicaldiagnosisdid hegrowto bethehighlyvaluedteacher of the risinggenerationinthe medicalworld. GERMANPHYSIOLOGICALMEDICINE WhilethenewschoolofViennawasstudied by the same exact methods. Through developing clinical medicine on pathologico- pathological anatomy alone complete knowl-anatomicallines,anothertendencybeganedgeconcerningdiseasecouldneverbe toassertitselfinGermany.Thiswasacquired.The changesfoundintheorgans manifested by a disregard of the nosographyafterdeathcannotexplainallthephe-oftheParisschool,accompaniedbyannomena observed before death, and the local efforttoreconstructclinicalmedicineonlesionis,asarule,onlythe outcome of an physiologicallines.action onthe economy of the whole system. ThismovementhadindeedalreadybeenInGermanyit waschieflythephysiolo-initiatedinFrancebytheexperimentalgist,Joh.Muller,whoadvocatedsimilar physiologist,Magendie.Inhislecturesofviews,andhisdisciplescarriedonthe 1836onthe"Phenomenesphysiquesdelamovementwithvigor.Asaphysiologisthe vie,"hediscussedtheproblembothfromcontinuedtheworkbegunbyMagendie, thephysiologicalandthepathologicalbuthisinfluenceextendedfarbeyond standpointandpublishedhisownviewsphysiologyonaccountoftheconsistency concerning the best methods to be employedwithwhichhedemandedexactnessand inincreasingknowledgeconcerningmorbidconciseness,notonlyinphysiology,but phenomena.Headmittednoessentialdif- alsoinpathology,andhisimportance for ferencebetweenphysiologyand pathology;Germanmedicalsciencemaybestbecon-theyappearedtohimasonescience;veyedbymentioning someof the menwho pathologicalphenomenaareonlymodifiedcountedthemselveshisdisciples,suchas physiologicalphenomena."LamedecineSchwann,Remak,Wunderlich,Henle, n'estquelaphysiologiedel'hommemal- Traube,Virchow,Helmholtz,Ktslliker,du ade."Bothsciencesshould,therefore,beBois-Reymond,Briicke andmany others .. NosOGRAPHYINMoDERNINTERNALMEDICINE19 Inthebeginningofthefortiessomeofhistory"inmedicine,asit wasnamedby theseenthusiasticyoungphysicianssetK.W.Stark.Hehasrelated,moreorless highthebannerofscienceinmedicine.vaguely, certain notions held by this school, Almostsimultaneouslythreeperiodicalssuchasthatdiseasesshouldberegarded werestartedasorgansforthenewschool.asparasites,notasproducedbyparasites, In1842WunderlichandRoserbeganthebut asbeingthemselvesakindof parasite publicationof the Arcbiv furpbysiologiscbeexisting on the sound organism in which they Heilkundeat Wiirzburgandin1847Henledevelop.Thediseasedorganistobecon-atZUrichestablishedtheZeitscbriftfursiderednotonlyasadegeneratedpartof rationelle Medizin. At Berlin LudwigTraubethebody,butisitselfaspecialorganism inI846 began the publication of his Beitrilgewithitsownlawsofdevelopment,akind zurexperimentellenPatbologieundPbysi- ofparasite.Thedifferencebetweenthe ologie, which, in its first numbers,containedcauseofthediseaseandthediseaseitself hisownwell-knowninvestigationsonthewasoverlooked,andthusan"ontology" consequencesofcuttingthevagusnervesof a much more stalwart character than had andthe pathogenesisof the resulting pneu- hithertobeenknownwasestablished. monias (Scbluckpneumonien), and Virchow'sBysomeofthedisciplesofthisschool stillmorefamousworkonembolismandthesenotionswerecarriedtothevergeof thrombosis.TheseBeitrilgeonlyappearedthegrotesque.ThusKarlR.Hoffmann, foroneyear,however,astheyweresuper- influencedbycertainideasinSchelling's seded by the famous Arcbiv fur patbologiscbe"Naturphilosophie," describedin his "ideal AnatomieundpatbologiscbePbysiologieundpathology"thevariousmorbidconditions furkliniscbe Medizin which was foundedbyasakindofretrogressiontolowergrades VirchowandReinhardtin1847.of evolution.Rachitissignifiedareturnto Evenifthesethreejournalsdifferedthe mollusca because the bones became soft. somewhat in character they all sounded theHethoughtindividualssufferingfromcer-samenote,demandingareallyscientifictaindigestivedisordershaddescendedto treatmentoftheproblemsinmedicine,therankofcattle.Thatthetonguegot basedonexperienceandexperiment.Thewhite,theurine sedimented and eructation descriptionofphenomenawasnolongerandvomitingoccurred,allindicateda sufficient;anattemptshouldbemadetotendencytorumination.Afinerexample understand their interrelation,theirgenesisof "false analogies" can hardly be adduced. anddevelopment,andtheprinciplefirstInthefaceofsuchunscientificviews, enunciatedbyMagendie,thatpathologythenewmovementhadtheeffectof arev-is the physiology of the diseasedindividual,olution,andthe two"Swabian reformers," wasconstantly emphasized.WunderlichandRoser,whowerethe first Thescientificlifewhichnowunfoldedinthe arena,created an enormous sensation itselfwasallthemoreeffectivebecauseinthe medical world. priortothistherehadbeenanabsolutelyThe title whichWunderlichhad givento barrenperiodformedicineinGermany.hisArcbivledtothename"physiological Germansciencewasgreatlyunderthemedicine"soonbecomingacceptedas 'the influenceof"Naturphilosophie"atthenameof theschool.Inhis "Geschichte der beginningof thenineteenthcentury.Med- Medizin,"publishedin186g,Wunderlich icalsciencewasdominatedbySchelling' ssaysthatthisnamewaschosen"onthe philosophyanda priorideductionsandone hand to express the fact that pathology, superficialanalogiesreplacedscientificincontrast to all ontological and personify-observation.ingconceptions,isonlythephysiologyof FromJena,thehomeofromanticism,diseasedman,onthe otherhand,to callto hadissuedthe so-called"school of naturalmindthefactthat pathologyrequiresthe 20AnnalsofMedicalHistory same means and methods to establish facts, andthesamelogicinargumentation,as werealreadyrecognizedinthescienceof healthyman."Wethusseethatthe selectionof thename"physiologicalmedi-cine"hadadoublesignificance.Fromthe verybeginningthereexistedtheintention toreplaceanatomicalresearchentirelyby physiological investigation, to pass from the purelydescriptivemethodtoaconsidera-tion of the relations existing between various morbidphenomena,andtoestablisha pathologicalphysiologysuchashadbeen suggestedbyHunter,Dupuytren and Ma-gendie.Butinadditionthere was also the firmresolveto abandonthe "ontology"of earlier times;above allasit displayed itself intheGermanschoolofnaturalhistory withitsalmostpersonifyingconceptionof diseases.Thisattitude,however,involved astrongly antagonistic position towards the wholedoctrineof theFrenchpathologico-anatomicalschoolwhichBroussais,aswe haveseen,haddeclaredtobeadangerous ontology.OnthewholeBroussaisand Magendiewerecultivatedandcorn-mendedatthecostofLouisandhisfel-lows,andBretonneau'sviews were entirely disregarded. Onreadingtheintroductoryarticles containingtheprogrammesofthe above-men-tioned periodicals we receive a vivid impres-sion of the excessive enthusiasm with which Germanmedicine,after longlanguishment, woketothevigorousactivitywhichwas soontogiveitaleadingpositioninthe world,aleadershiptoberetainedunder the guidance of Virchow during the remain-derofthecentury.Butfromthesesame articleswealsoreceivethe impressionthat thereprevailedextremelynarrowand limitedviewsconcerningclinicalmedicine, andwecanalsodetectthe germsof these opinionswhichweresoontoleadGerman medicineastray on certain important points. Asalreadysaid,themembersofthis schoolfromtheverybeginningresisted everyendeavor to establishdefiniteclinical pictures,or to describeindividual diseases, andallmentionof specificcharacterswas opposedanddubbedontology,orcharac-terizedasarelicofanunscientificand antiquated age.. Some passagesfromWunderlich'sintro-ductoryarticletothefirstnumberof ArcbivfurpbysiologiscbeHeilkundeareof interestin this connection: Suchaviewwhichtakesabstractconcepts forthings,implyingtheiractualexistenceand atoncetreatingthemasentities,iscalled ontology. Frequently as has this logical blunder crept intomedicineandflourishedthere,after Broussais'time it willhardly be heard of again. To the most widespread and the most danger-ousconsequencesofontologybelongsthe practice of setting up speciesof diseaseswhich havebeengroupedin classesin the sameway asplants.Byraisingthemtothedignity ofspeciestheseontologicalpersonifications received,asitwere,thesanctionofnatural history. Thephenomenologistcertainlyusessuch clinical pictures as dysentery, cholera, scrofula, butheonlyassignsimportancetothemasa practical make-shift borrowed from the popular, unscientific view of things.He knows that such agroupisnodefinitephysiologicalwhole,no organic entity.He knowsthat i t ~an impossi-bilitytodecide,orisatanyratequitean arbitrarydecision,wherethelimitistobe drawn between dysentery and enteric diarrhea, betweenrheumatismandarthritis.But to the ontologist the assumed diseaseisadogma; the group oncecollected,it becomesaconcept,an entity.Thusthesemodelpicturesofdiseases arise,which contain no essential mark. no mark which may ever be missed-this compendium of diseasesto whichweonlyexceptionally,or by usingcompulsion,findparallelsin nature. Hereweseehowentirelyhedissociates himselffromtheFrenchclinicalschool, and wefindsimilar pronouncements by the otherrepresentativesofGermanphysio-logicalandrationalmedicinein the forties. For instance,wefindquiteasimilarline ofthoughtexpressedbyTraubeinhis BeitrllgeandbyVirchowinthearticles sketchinghisprogrammeinthefirstnum-bersofhisArcbiv.Intheprefacetohis NosOGRAPHYINMoDERNINTERNALMEDICINE21 periodical Traube states that there was only one means of escaping from the uncertainty andconfusionwhichprevailedinpath-ology, only "experimentation combined with observationcanmakepathologywhatit shouldbe,an exact science.'' Virchow'sviewsofclinicalresearchare found expressed in the prospectus contained inthefirstvolumeofhisArcbiv(1847): The idealweshallstrive torealize,asfaras itisinourpower,is,thatpracticalmedicine shallbecomeappliedtheoreticalmedicine,and theoreticalmedicineshallbecomepathological physiology.Pathologicalanatomyandclinical medicine,thejustnessandindependenceof whichwefullyrecognize,are essential to us as sourcesofnewquestions,theansweringof whichwillfallto pathologicalphysiology. Inafollowingarticle" OberdieStand-punkteinder wissenschaftlichen Medizin" he continues: Pathologicalphysiologytakesitsquestions partly frompathological anatomy,partlyfrom practical medicine; it creates its answerspartly fromobservations at the bedside,and thus it is apartofclinicalmedicine,andpartlyfrom experimentson animals.The experiment isthe ultimateandhighestresortinpathological physiology. LikeWunderlich he repudiatedall ontol-ogy,alltalkof specificdiseasesandasso-ciated specifictherapy.In the next number of the Arcbivhe continues: Indeed therapy knows only too well the giant whosefar-reachingshadowhaswitheredso many freshshoots in allthe provinces of medi cineandmadesomanypleasantflowersfade beforetheirtime.Itisontologywhichhas inflicted wounds of no less depth in pathological microscopythanintherapyanddiagnosis. Consider only how much toil it has cost and still coststoconquerontologyintheso-called physical examination of the thoracic organs, and keep fresh in the consciousness of physicians the fact that weare able to recognize only the con-solidation of the parenchyma of the lung and the contents of the bronchi but not immediately the pneumoniaorbronchialcatarrh;considerfur-ther,hownowadays ontology is againattempt-ing to creep into therapy in all sorts of disguises asweseeitmostmarkedlyintheso-called specificmethodsofcure,andweshallnot wonderthatontologyhasrapidlybeenable to gainsuchcurrencywithinsoyoungascience aspathologicalmicroscopyashaseven threat-enedits existence asa science.The cancer cells areregardedaspathognomonicforcancer,the pus cells as characteristic forpus. Withontologytheentirepathologicaltele-ology will disappear; cancer willnolongerbe a parasiteofindependentvitalitymaintaining its existence at the expense of another life,and againstwhichtheorganismwagesbattlein order to destroyit.Suppurationwillnolonger be acurative measure of the organism,the pus bodieswillnolongerbe gendarmes orderedby the state to escort this or that foreignintruder, whohascomeinwithoutapassport,across thefrontier;thefibroustissuenolongerwill formtheprisonwallswithinwhichtoconfine such aforeigner. In awell-known treatise written in1849, "DieEinheitsbestrebungeninderwissen-schaftlichenMedizin,"Virchowfurther emphasizeshisviewthat"the destruction oftheontologicalconceptionof diseaseis alsoadestructionofontologicaltherapy, of the schoolof the specifics.The subjects of therapyarenot diseasesbut conditions; weareeverywhereonlyconcernedwith changesintheconditionsoflife.Di'tease is nothing but life under altered conditions." Weseehowthecustomofregarding pathology as akind of modifiedphysiology dominatedthewholeGermanschool.The greatadvancemadebythisschoollies inthefactthatitsetasthegoalofall medicalsciencetheattainingof anunder-standing of morbid processes, of the relations between the pathologicalphenomena. "Das Kennen ist wichtig, aber das Begreif-enisdasWichtigereundHohere."With thesewordsWunderlichcharacterizesthe aimsofphysiologicalmedicine,andthus contraststhemwiththepurposesofthe Frenchschoolofmedicinewhichconfined itsattentionchieflytothedescriptionof morbidphenomena,boththeclinicalphe-nomenaandthepathologico-anatomical 22Annalsof MedicalHistory lesions.Aswehaveseen,heandhiscol- scientificcareerasanexperimentalist,and leaguesopposed the effortsof the cliniciansafterhehadobtainedchargeofaclinical to establishclinicalpicturesof thevariousdepartmentattheChariteHospitalin diseases,each disease followinga character- Berlinandwascarryingonhisworkasa isticcourse.Ontheotherhand,suchcon- teacherof"clinicalpropaedeutics,"he ceptionsformedthefoundationoftheretainedhisinterestinexperimentation. flourishingFrenchandEnglishclinicalHemaybesaidtohavefoundedexperi-medicineofthetime.Thisattitudeofmental pathologyinGermanyand hisbest antagonismwhichwasadoptedbytheknownclinicalworkwasperformedin Germanswasnot without consequencesforintimateconnectionwithexperimental thefutureof Germaninternalmedicine.studies.Forinstance,in1856hedeveloped If welookatthewholeevolutionofhisdoctrineof variationinblood-pressure, Germanmedicineinthisfruitfulperiodweandmoreespeciallyofhypertoniaasthe findthat it wasprimarilyinthe theoreticalcauseofthecardiachypertrophywhich branchesofmedicinethatthedevelop- Brighthadobservedtobepresentin menttookplace.Experimentalphysiologychronicnephritis.Hebasedhisconclusion receivedanenormousimpulseandonechieflyuponexperimentsmadebyLudwig physiologicalinstitute after another spranganduponhisownexperiments onanimals. upinthevariousuniversities.Under Vir- Incontinuationof theseinvestigationshe chowandhismanydisciplespathologicaldescribedinterstitial nephritis. anatomydevelopedintoapowerfulandPerhaps,ofstillgreaterimportanceto quiteindependentscience.Asgreatanclinicalmedicinewerehisinvestigations advance in general medical viewsasBichatconcerningclinicalthermometry.Inthis had producedbyhisgeneralanatomy,washefulfilledanotherofthedemandsof nowaffectedby Virchowthroughhiscellu- physiology,thatofexactmeasurementof larpathologyandthroughthethorough- themorbidphenomena.Butitwasnot goingmicroscopicalrevisionofthewholeuntilWunderlichbytheadviceof Traube ofpathologicalanatomywhichnowtookhad taken up this problem that the endeavor place.It is entirely due to the circumstancetointroducethermometryatthebedside that these great branches of science,physi- became successful. To him, above all others, ologyandpathologicalanatomy,nowbe- weoweitthatthedailymeasurementof cameemancipatedfromclinicalmedicinethe temperature graduallybecame aneces-thatitbecamepossible to subject them tosarydetailintheobservationofpatients. thethoroughandaccuraterevisionwhichWeare also chieflyindebted to Wunderlich was needed. Germany thus became a pioneerforthedemonstrationofthetypicaltern-to other countries where such an emancipa- peraturecurvesofthevariousdiseases.It tionwastardyinmakingitsappearanceisinteresting to see howthrough the recog-orhastothis daybeenonlyimperfectlynitionofthesetypicalcurvesandtheir accomplished.significanceindiagnosishewasgradually What,now,wasthepositionofclinicalledmore and more to acknowledge that the researchduringthispowerfulmovement,various diseasesran typical courses,andhe what part wasassignedto it,andhowwaswas,therefore,forcedtoadoptapoint of it furthered?viewnotdissimilarfromthatheldbythe InordertoanswerthisquestionitwillFrenchclinicianswiththeir despisedontol-benaturaltoconsiderthe activitiesof theogy.Indeed,wehavejustheardfromhis twogreatclinicianswhoweretheleadingdisciple,Strilmpell,thatWunderlich,on menatBerlinduringthisperiod,namely,hisrounds,oftenlookedmoreintently Traube andFrerichs.atthetemperaturechartsthanhedidat Asalreadynoted,Traubestarted onhisthe patients. NosOGRAPHYINMoDERNINTERNALMEDICINE Traube'sotherclinicalstudiesconsisted chieflyincontributionsto anatomicallocal diagnosis,especiallyoflungdisease,and clinicalmedicinehas,asweknow,retained hisnameinthedesignation"Traube's space"forthat part of the left pleura which liesbelowthe lung.His system of diagnosis wasbasedchieflyonpathologicalanatomy andespecially onVirchow's teaching. Frerichs,whobecametheleaderof clinicalmedicineattheCharitein1859, beganhisscientificcareerasachemist and physiologistunderLiebig.Nevertheless,in hisfirstimportantclinicalwork,thaton Bright's disease,publishedin1851,helaid stressontheimportanceofindependent clinicalobservations,andsought,onthe whole,morethanTraube,toemphasize theirvalue.Inthisworkonnephritishe wasthe firstaccurately to describeuremia, andheattemptedtodiscoveritspatho-genesis by means of experiments on animals, forhe,too,recognizedthegreatvalue of experimentation,thoughhelookedupon it largely asan aidto clinicalmedicine.He desired that the latter should be founded on thoroughchemicalandanatomicalknowl-edge,togetherwithbedsideobservation. Thisattitudeofmindisrevealedin his greatworkonthediseasesof theliver,in whichhedescribedacuteyellowatrophy. Hemadeothercontributions tomedicine, mainlyofaphysiologico-chemicalnature, suchashisstudiesonleucinandtyrosin. Despitehismarkedchemico-physiological tendenciesandinterests,he,too,largely subordinated his clinical studies to patholo-gicalanatomy.It wasaboveallVirchow's pathologywhichdominatedclinicalmedi-cineeverywhereat thistime,andthiswas butacontinuation of Rokitansky'spatho-logicalanatomyandjustasdogmaticas the latter inregardto clinical problems. Frerichs to acertain degree sawthe mis-takeoflettinganatomypredominate,but made only faint resistance, although he was annoyed by the purely personalantagonism between himself on the one side and Virchow andTraubeontheother.This divergence wassogreatthatTraube'sandFrerichs' numerous and eminent disciples formedtwo separatecampswhichwerefarremoved fromeachother,thoughthey wereequally scientific in their tendencies. The strength of the new German internal medicinelayinitscloseconnectionwith physiologyandthenewpathologicalana-tomy.BeforetheEnglishandtheFrench, the Germansknewhowto turn to acco