Concepts Instruments and Institutions Nineteenth Century Legacy

The heartbeat and its relation to the pulse have interested physicians for some 3,000 years or more. The intellectual history of heart rhythm disorders customarily begins with the mention of the pulse by the Edwin Smith papyrus of 3500 B.C. and by the Ebers papyrus of 1500 B.C.:

When the heart is diseased, its work is imperfectly performed: the vessels proceeding from the heart become inactive, so that you cannot feel them. ...If the heart trembles, has little power and sinks, the disease is advancing and death is near.2

To begin the history with the Egyptian papyri, mythical in large part, or with William Harvey's De Motu Cordis, is to construct a respectable, positive lineage for a modern complex of medical ideas, practices, and institutions, and to assert the continuity of modern studies with those of the predecessors. 3 A system of medical ideas that dominated Western medicine up to 1800 in large part went back to the writings of Hippocrates (circa 400 B.C.) and Galen (circa 130-201 A.D.) and played a major role in the understanding and treatment of health and disease.4

By the nineteenth century, however, this tradition no longer carried the same force or occupied so central a position within medicine. The difference between the medical world of twenty-first century and that of the turn of the eighteenth century, to go no further back, is so dramatically different that one can think of discontinuity between the modern medical science and the past. Yet, paradoxically, few writers of medical papers can resist the temptation to look at the previous developments in their field in retrospect that set their current studies in its historical context. Although there is little or nothing in the ancient medical writings that points to any knowledge of heart disease as we understand it today, this must not be taken to imply that the ancient physicians did not observe accurately enough symptoms and syndromes that would suggest heart rhythm disorders to the modern physician. For instance, the description of a pulse caprizans by Herophilus (circa 300 B.C.), the leading anatomist of Alexandrian school, is suggestive that he observed extrasystole.5 Galen's description of the irregularity of the pulse and his diagnosis of blockage as the result of a narrowing of the passage of a large artery in the lung point unequivocally to the atrial fibrillation associated with mitral valve stenosis.6 The De morbis acutis of the Roman physician Caelius Aurelianus (fifth century A.D.) contains an exact description of the vascular collapse from ventricular fibrillation.7 However, we shall use the second half of the nineteenth century as a working landmark for the beginning of new science, when the emerging field of experimental physiology began to reshape and restructure the perception of cardiac diseases, arrhythmias, in particular.

By the mid-nineteenth century there had been a rich investigative and explanatory structure for the study of heart diseases composed largely of physical diagnosis and pathological anatomy. Bedside techniques for localizing cardiac pathology, which form the basis for many modern concepts of heart diseases, had been developed mainly in France by the Paris school. Although symptoms associated with an irregular pulse could not be correlated with postmortem findings, irregular pulse was a subject of attention for the eighteenth-century French clinician, Jean Baptiste de Senac, physician to King Louis XV, and for the early nineteenth-century doctors Jean Nicolas Corvisart and Jean Baptiste Bouillaud. Senac's rebellious palpitatio'n (later known as delirium cordis and pulsus irregularis perpetuus) was often associated with mitral valve disease and heart failure and observed to respond to digitalis.8 The introduction of the stethoscope in the 1820s by Rene Laennec allowed synchronization of the audible cardiac rhythm with palpation of the pulse, and Bouillaud applied the new instrument to the heart. Both Corvisart, who reintroduced Leopold Auenbrugger's method of percussion and applied it to the heart, and Bouillaud published influential treatises on cardiac pathologies.9 These texts, however, did not include descriptions of heart rhythm disorders, which were recognized clinically but could not be defined anatomically. The same tendency persisted into the end of the nineteenth century. William Osler's The Principles and Practice of Medicine of 1892 included such conditions as palpitation and arrhythmias, but it largely treated heart diseases as structural rather than functional entities.10 Palpation, percussion and auscultation of the chest, and the volume and strength of the pulse, rather than its rhythm, were still the cornerstone of cardiac practice. Until the turn of the twentieth century, clinical practice was still essentially perceived as an art, to which the basic science and instruments and methods associated with them had little to offer.11

Paris teachings of the 1820s-1840s turned the hospital morgue into a site for cutting-edge pathological anatomy, for which the Paris school became so famous. By the 1850s, the laboratory had begun to challenge the hospital as the major site of medical discovery. The new laboratory disciplines, experimental physiology, and cellular pathology offered perspectives on bodily functions and malfunctions that previously seemed impossible. Nineteenth-century laboratory leaders created a distinct scientific medicine based on microscopy, vivisection, and chemical investigations in uniquely controlled experimental environments. They used sophisticated instruments, devices, and methods translated from mechanics, optics, physics, and organic chemistry that began to reshape medical education and clinical medicine. The changes in nineteenth-century medicine that made it emblematic of modern development have often been explained through medicine's close relationship with the basic sciences. One reason for this trend was that, by 1840, the two physical sciences in which quantitative methods became most pervasive—physics and chemistry—offered methods and technologies more effectively applicable to physiological phenomena than had ever before been available.12

There were also related institutional developments. Technological improvements mean little without matching career opportunities, and German universities provided such openings. Specialized scientific institutes within the university system developed into prestigious research centers, excellently staffed, equipped, and lavishly funded by the government on a level that was unthinkable for the institutions in France and Britain. From 1847 onward German physiology was dominated by Hermann Helmholtz in Heidelberg, Emil du Bois-Reymond in Berlin, and Ernst Brücke in Vienna, all three students of the brilliant and versatile Johannes Müller and Carl Ludwig in Leipzig. All of them in turn taught large numbers of students who propagated their methods wherever physiology was practiced. This group of physiologist-physicists took a reductionist approach based primarily on qualitative, analytic, and physicochemical methods and techniques that was the centerpiece of their experimental practice. Among German physiologists, it was Carl Ludwig who became the supreme teacher at the Physiological Institute in Leipzig, an institution on a grand scale that housed departments of histology, anatomy, physical physiology, and physiological chemistry. In France, Claude Bernard, the premier physiologist and teacher, despite severe budgetary and institutional limitations, ran the laboratory at the Paris College de France, which, like the best German laboratories, attracted many young investigators. Bernard powerfully influenced physiological research and practice on a very broad range of problems and developed an explicit methodological and epistemological discussion of experimental medicine in his famous Introduction à l'étude de la medecine expérimentale of 1865.13

Nineteenth-century physiology had multiple relationships with clinical medicine. With its experimental approach, instruments, and measuring devices, which reflected the ideals of quantification, precision, and objectivity, physiology became a model for clinical medicine, although it was never fully accepted or applied in all its aspects. Entire generations of doctors acquired an idea of scientific medicine through laboratory work, and in this respect the laboratory served as a site of medical innovation and acquired an increasing significance in medical practice. Clinicians who had worked in the laboratories of Claude Bernard in Paris, Carl Ludwig in Leipzig, or Michael Foster in Cambridge oriented their clinical practices toward the laboratory, formulating new scientific questions and promoting new research projects relevant to the clinic.

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