Reflections on nineteenth century German medicine

Reflections on Nineteenth Century German Medicine

Richard Warren, MD, Boston, Massachusetts

German Influence on American Medicine

In 1929 when I entered medical school the tradition of German leadership in medicine was very much accepted. Many of the professors still alive, and some still teaching, had received part of their education in Germany. (The term Germany as used here includes also Austria and German Switzerland.) Furthermore, texts in the anatomy, histology, and physiology li- braries were either written in German or full of references to German literature.

As Ben-David and Zloczower [I] wrote: “The education of an American or British scientist was not considered complete until he had spent some time in Germany.” Bonner I.21 states: “During the interval between 1870 and 1914 it is estimated that 15,000 American medical persons, students, young physicians, older practitioners, undertook some kind of serious study in a German university.” Even in the summer of 1914 there were several thousand foreign medical students in Germany.

The medical share of the pilgrimage was only a fraction of the total. Benjamin Franklin visited Gijttingen in 1766-some have said to get pointers on the founding of the University of Pennsylvania, but one third of the population of Pennsylvania at that time was German and that could have in- fluenced him. It must further be admitted, as some have contended, that he went there just for his health. Thwing [3] has recorded the stimulus that four young Harvard graduates derived from studying in Giittingen in the early nineteenth century: Edward Everett, later President of Harvard College; George Ticknor, eminent expert in Spanish literature and founder of the Boston Public Library; George Ban- croft, author of a great History of the United States and later Ambassador to Berlin; and Joseph Green Cogswell, scholar and Harvard Librarian.

In describing Johns Hopkins University founded in 1876, Viereck [4] writes: “The University faculty numbers 53 professors and lecturers; with but few exceptions all have spent more or less time in German

Professor of Surgery Emeritus, Harvard Medical School, Boston, Massa- chusetts.

From the Boston Medical Library, Boston, Massachusetts. Adapted from an address given before the Goethe Institute of Boston,

universities.” Daniel Coit Gilman, first President of Johns Hopkins had visited several European universities before organizing the new Hopkins and took the best of the German system. He did not, however, set up a “German university on Chesapeake Bay,” any more than Charles W. Eliot did on the Charles River, although both were accused of doing just that.

But let us focus on the doctors themselves. Because making complete lists of students and teachers to illustrate a mass pilgrimage of fifty years’ duration would be overwhelming, I will paint a brief picture of the experience of one eager student, my grandfather, J. Collins Warren, later Moseley Professor of Surgery at the Massachusetts General Hospital. (Figure 1.) Dr. Edward Churchill [5] brilliantly edited his reminiscences, a labor of love on behalf of one of his predecessors in the Moseley Chair.

In three years abroad from 1866 to 1869, my grandfather went first to Vienna where he initially

Figure 1. J. Collins Warren, 1842-1927 October 5. 1976.

Volume 135, March 1976 461

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Flame 2. Johannes van Onnolzer. 1808-1871 _ .=-._ -_ _- .__.... -- ._.. _,~,~~ ~~ ,

Figure 3. James C. White, 1833- 79 18

Figure 4. Carl Rokitansky, 1804- 1878 Figure 5. Rudolf Ludwig Karl Virchow, 182 l- 1902

462 The American Journal of Surgery

Nineteenth Century German Medicine

Figure 6. Warren’s Arbeit “Uber Keloid”

studied nonsurgical subjects: dermatology, laryn- gology, auscultation and percussion, and topogra- phical anatomy. For clinical medicine he worked under von Oppolzer (Figure 2), a brilliant clinician and bedside lecturer who had, according to most re- ports, a quaint appearance. Dr. James C. White (Figure 3) (another Bostonian) who introduced the specialty of dermatology in the United States, had said of him in 1856: “He had made a hasty toilette, had forgotten his collar and had not made the same use of the Danube as we do of the Cochituate” [6].

The microscope had helped the specialties of histology and pathology outstrip gross anatomy as the exciting forefront of medical science. Rokitansky (Figure 4) was the great Viennese leader in the field of cellular pathology, which Virchow (Figure 5) had fathered. Rokitansky was an older man when my grandfather was there, but a Polish student of his,

Figure 7. Bernard Rudolph Conrad von Langenbeck, 1610-1667

Biesiadecki, had taken over the research activities of the clinic. His interest was the pathology of the skin and my grandfather worked under him on an “Ar- beit” on keloid [ 71. (Figure 6.) From him also he derived a good concept of the classification of tumors, a subject that interested him all his life and led him to the chairmanship of the Harvard Cancer Com- mission and the Collis P. Huntington Memorial Hospital.

My grandfather then went to Berlin where he studied with von Langenbeck (Figure 7), the leading surgeon of Germany, who gave courses in operative surgery on cadavers from 600 to 8:00 in the morning. While in Berlin he also basked in the glow of Virchow, who by then had returned triumphantly to that city after his semibanishment to Krakow as a political protestor in 1849. His studies in pathology, however, were with Cohnheim (Figure 8), the great pioneer on the migration of white cells and on the pathophysiology of inflammation. Grandfather was going to return to spend another year with him, but Cohn- heim was transferred to Kiel the next year and the plan fell through. Already evident is a similarity with the United States as embodied in the peripatetic professor.


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Flgure 8. Julius Friedrich Cohnheim, 1839- 1884 Figure 9. Willlam Henry Welch, 1850-1934

I could go on with lists of teachers and students.

William H. Welch of Johns Hopkins (Figure 9), the leading pathologist in America in the last century, worked with Cohnheim, now in Breslau, ten years

after my grandfather, and with Klebs in Prague. He then moved to Strasbourg to sit at the feet of von

Recklinghausen who made many major contributions (the lymphatics, neurofibromatosis, osteitis-fibrosa

cystica). It was an exciting period in the development of medicine. Simon Flexner [8] remarked, “the 1870s in Europe showed a rapid shift from the cellular pathology of Virchow through the pathophysiology of

Cohnheim to bacteriology, of which the leader was Koch.” (Figure 10.)

Dr. Reginald H. Fitz of Boston (Figure ll), who described appendicitis and pancreatitis, worked with Virchow, Rokitansky, Oppolzer, and Skoda. Halsted of Baltimore, another one of Hopkins’ pioneer great four, studied in Vienna, Leipzig, and Berne and persuaded his prize pupil, Harvey Cushing, to go to Berne to sit at the feet of Kocher. (Figure 12.)

A delightful appraisal of the forces and a descrip- tion of the people and clinics that attracted Ameri- cans to Germany and Vienna 100 years ago is given by Dr. E. H. Bradford [9], in an address published in

1923. He points out that the two cities, Berlin and

Vienna, rivaled each other in eminence, but that

Vienna was easier for Americans, elective courses being more available. An American Medical Associ-

ation in Vienna was organized in 1904, was revived

after World War I, and lasted until 1939. It had a directory of courses, was a pleasant meeting place for

exchange of ideas, and invited various professors to

meet and talk. A Guide to American Medical Students in Europe

was written by Henry Hun [IO] of Albany who suc- cinctly stated that Vienna was preferred for clinical

work and Germany for laboratory work. (One of

Hun’s helpful admonitions was that students should get a University identification card immediately, the

main advantage of which was to avoid getting into a civil prison which was very stark. The University had its own prison.)

The Rise of German Medicine and Its Contribution

Considering the ascendancy of nineteenth century German medicine, no precise date marks its begin- ning. At some point in the first half of the nineteenth century, however, the position of preeminence seems

to have passed to Germany from France. In the eighteenth century, and in the early nineteenth,



Figure IO. Robert Koch, 1843-1910

French science and medicine, having in turn taken the torch from England, had become outstanding. The concentration of talent and facilities was largely in one city, Paris [3]. The contributions to the physical sciences of men such as Laplace and Lavo- isier stimulated a group of young physicians emerging from the Revolution. (Lavoisier was guillotined as an artistocrat, not as a scientist [12].) The concentrated population in Paris during the eighteenth century had necessitated development of her great hospitals, such as the Hotel Dieu and the Charite. After the early part of the Revolution a denigration of intel- lectualism, including that of science and scientists, the inevitable accompaniment of such social con- vulsions, gave over under Napoleon to a climate where the new young physician could develop. Within it Bichat first oriented pathology toward the study of tissues rather than of organs and became the father of modern pathologic anatomy. Other French names standing out at that time were Magendie, Larrey, Laennec, Cruveilhier, Broussais, and Lis- franc.

After the Napoleonic Wars the Germans were naturally not quick to recognize French scientific leadership. Their university faculties, well developed by the turn of the century (there were 20 universities at that time [12]), were pursuing their traditional

Figure I I. Reginald Heber Fitz, 1843- I9 I3

Figure 12. Emil Theodor Kocher, 184 I- I9 I7


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Figure 13. Wilhelm von Humboldt, 1767-1835

philosophic and classical subjects and stood apart from applied science, which was studied in separate academies. But occasional young Germans, such as Liebig and Wilhelm von Humboldt (Figure 13), went to Paris and brought back new attitudes and methods. Von Humboldt’s influence was responsible for the founding of the University of Berlin in 1809. His concept was to replace the old idea of “Burger,” or the useful citizen, not supposed to think for himself, with “Mensch” personifying the new idea of individual freedom of thought [13]. A second, equally important innovation was the emphasis on the necessity of the union of teaching and research. Johannes Mueller, taking a lead from the work of Magendie and also from Berzelius in Sweden, developed neurophysiol- ogy using the new scientific approach and thus appeared as the person most responsible for turning the interest of German scientific faculties towards pos- itive experimentation.

Unifying Influence of Government. As the universities had emerged from the medieval period, their liberation from tight ecclesiastical dogma caused conflicts between the conservative members of their faculties and the men who sought freedom to intro-

duce humanistic studies and new methods. The conflict fell into the lap of the governments of the German states, which took control early, and the new relationship between government and university became stabilized [14]. The universities thus were founded, supported, and controlled by the rulers of the many states, who looked upon their universities as their sources for lawyers, doctors, and other pro- fessionals.

Through her lack of central authority Germany had been excluded from world markets and the op- portunities of Empire. The nineteenth century uni- fication under Prussian leadership developed these outlets as well as intellectual ones. But as the new Germany presented her face to other nations, it was to the universities, her major source of pride, that she turned for her world image.

Universities as the Sites of National Research. The interest of the government in the universities led to recognition of them rather than separate institutes as the seats of scientific work. Productive research became a sine qua non of an academic career and was expected of both senior and junior faculties. To quote Abraham Flexner [15]: “Both England and France were scientifically productive before Germany woke up from its metaphysical trance. But in neither have productive scientists been long or consistently con- nected with universities. They have labored as indi- viduals. Davy, Faraday, Darwin, and Tyndale were all their lives without university station, recognition, or even whole hearted toleration.”

New Tool. A main boost to the flourishing of German science was the microscope. Around 1840 it reached its first state of development to the point where it could be applied to human histology and pathology.

Competition. Competition among the score of university centers in Germany and Austria exerted an important influence. No other country of that period could claim this catalytic force [12]. The free communication between these centers, the periodi- cals that appeared following the lead of Virchow’s Archiv (founded in 1847 when he was 27 years old), becoming the forums for cooperative scrutiny and progress, and the national and regional medical meetings remind us of our present day.

Premedical Training. The German system held other advantages. Secondary education as a prepa- ration for professional training was carried forward in the Gymnasium. The education of those who achieved the Gymnasium was advanced to a point where at graduation the German student was two years ahead of the American high school graduate. This system was, of course, not unique to Germany

The American Journal of Surgery


[15,16]. The European system, then as now, required commitment to a profession at an earlier age than in the United States.

“Lehr- and Lernfreiheit.” The German reaching the university found, in contrast to the rigidity of the Gymnasium, an unprecedented amount of freedom both for teachers and students. The teacher, once he had become an Ordinary (regular or full) Professor could cover whatever topic he liked. The student could, within wide limits, take what course he liked and shift from one university to another. This was commonly done, and to encourage or allow this the universities had developed comparable curricula.

Against this background arose the concept of the seminar in which the professor did not profess but sat with a small group of a dozen students to explore the forefront of a subject [3]. Here a student often knew more than the professor, but attitudes and directions for further thought and investigation were hammered out in a way that could not be accomplished other- wise. Henry Adams [I 71 in The Education of Henry Adams describes his delight with the reaction of his students when he transplanted the method to his classes at Harvard.

Bedside Teaching. The Allegemeine Krankenhaus in Vienna and the Charite Hospital in Berlin com- peted with France for foreign graduate students. Their “clinical material” (an unfortunate expression, used freely then, as it is now) was one of the factors that attracted visiting graduate students from other lands. H. K. Oliver [18] of Boston described the practice of assigning a patient to the responsibility of each student who followed him or her through his hospital course. Furthermore, Vienna gave “touch” courses in obstetrics in which patients were examined by small groups of students [5].

No organization of human institutions can operate without defects. Here are some problems that arose from the system.

Isolation of the Professor. One problem was the swing of the pendulum away from application of the knowledge acquired and from undergraduate teaching to the pursuit of science for its own sake and the training of investigators.

According to Ben-David and Zloczower [I], “the creation of research institutes early in the century was inspired, but the system it set up was resistant to future change. There could only be one professor to a discipline and he had control of the Institute. TO create a new professor a new specialty was needed. Thus a rigidity soon became apparent that worked against the modern idea itself of a university where interdisciplinary boundaries are easily crossed by the developing young scientists.”

Imbalance in Numbers of Student Bodies. The

freedom of to-and-fro migration of students led to crowding in some schools. Flexner [15] points out that in 1909 and 1910 the student enrollment in Munich was 2,148 whereas the average of all twenty-one schools was 533, the lowest being 172.

Specialization. Also the specialization of interest within the profession, the inevitable result of focused productive research, furthered the creation of “schools and sects” which were relatively impervious to outsiders.

Fealty to Government. The German academic professors were an elite corps called by Ringer [19] “The German Mandarins.” Their training, their national position, and their authority rightly gave them a sense of intellectual supremacy. Despite their desire to be a law unto themselves, however, they realized they owed their positions and their basic incomes to the authority of the State. As aspirations of world empire and militarism proceeded, most found themselves supporting these views. Actually they seem to have welcomed the onset of World War I as a means of reuniting in “a rebirth of idealism” [19] a Germany they had found increasingly threat- ened by commercialism. Ben-David and Zloczower [1 J write: “University professors were civil servants and considered it a privilege to be part of this important corps. They were therefore expected to be loyal to the state, which under absolutist rule implied a great deal. . . identification with the politics of the state often meant fanatical nationalism and obscu- rantism.” This statement is harsh. There were those who rebelled. Virchow was one. Paulson, according to Flexner [15], refused the designation of Geheimrat (“privy councillor”) because he did not want “to crook his knee to the gentlemen of the court.”

Visitors. Problems arising from the attraction of German medicine to visitors were the arrangements necessary to accommodate them and the financial considerations involved. The payments for courses within the university itself were, according to the medieval tradition, from the student directly to the teacher. These fees constituted much of his income. It was difficult not to prevent commercial motives from sullying university activities. The possible evils of this system were recognized, but it was so in- grained that, despite these,the general opinion, even of objective observers, was that the professors would lose incentive if the fees were abandoned [ZO].

Conclusion

Such a brief vignette of medical history stimulates

the question: what have we learned from it? During the period of German ascendancy admiring observers in the New World repeatedly asked the question whether the egalitarian social structure of the United


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States could accept transplantation of the German medical system. The answer was always, “No, our society is different.” The,origins of the two cultures are dissimilar. In Germany, as Roberg [21] puts it, !‘For six centuries the character of the German universities was a contract between an absolute ruler who needed educated men for his kingdom and the faculties which tried to insure their academic freedom against royal intrusion.” Charles W. Eliot remarked that the German university would suit the 150 young men who enter as freshmen (at Harvard) every year “about as well as a barnyard would suit a whale” [5]. As Conant [22] has said, the difference lies between fluidity in the American system and the stratification of the German.

Via Johns Hopkins we did copy, and still revere, the union of teaching, practice, and investigation. The concept has spread widely throughout our health care system. To date we have, however, preserved free enterprise in medicine as in the rest of our social structure.

Human beings change little individually, but social structures evolve. American attitudes and adminis- trative procedures are so different from those of nineteenth century Germany that no retrospective comparative study can provide lessons or guidelines to help us today. Nevertheless, when we pause every so often to examine the foundations of the edifice we continue to build, we must recognize, with William Wartman [23] the following important list of German contributions. German medicine (1) fused.laboratory teaching of anatomy, chemistry, and physiology with clinical bedside teaching, (2) gave us a plan of an in- tegrated curriculum for modern medical schools, (3) demonstrated the necessity of teaching medicine in a university setting, (4) showed the essentiality of advanced training of the student before coming to medical school, (5) established investigation as an integral part of teaching, and (6) set guidelines for the specialties.

Acknowledgment: The help of Dr. Morton H. Roberg is gratefully acknowledged.

References

1.

2.

3.

4.

5.

6.

7. 6.

9.

10.

11.

12.

13. 14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

Ben-David J. Zloczower A: Universities and academic systems in modern societies. Science and Society (Kaplan N. ed). Chicago, Rand McNally, 1965.

Bonner TN: American Doctors and German Universities; a Chapter in International Intellectual Relations 1870-1914. Lincoln, University of Nebraska Press, 1963.

Thwing CF: The American and the German University: One Hundred Years of History. New York, Macmillan, 1928.

Vierlck L: German instruction in American schools, p 43. In

[31. Churchill ED: To Work in the Vineyard of Surgery-The Rem-

iniscences of J. Collins Warren, Cambridge, Harvard Uni- versity Press, 1958.

White JC: Sketches from w Life. Cambridge. Riverside Press, 1914.

Warren JC: Uber Keioid: Virchow’s Arch/v 40: 1, 1868. Flexner S: Introduction to Welch WH: Papers and Addresses.

Baltimore, Johns Hopkins University Press. 1920. Bradford EH: Medical education fifty years ago. Boston A&da&

Surg J 189: 748, 1923. Hun H: A Guide to American Medical Students in Europe. New

York. Wm Wodd, 1883. Ben-David J: Scientific productivity and academic organization

in nineteenth century medicine. Science and Society (Kaplan N, ed). Chicago, Rand McNally, 1965.

Shryock RH: The Development of Modern Medicine, an Inter- pretation of the Social and Scientific Factors Involved. Philadelphia, University of Pennsylvania Press, 1936.

Roberg NH: Personal communication. Paulsen F: The German Universities, Their Character and His-

torical Development. New York, Macmillan. 1895. Flexner A: Medical Education in Europe, Bull #6 of Carnegie

Foundation. A report to the Carnegie Foundation for the advancement of teaching with an introduction by Henry S. Pritchett. New York, Carnegie Foundation, 1912.

Flexner A. Medical Education, A Comparative Study. New York, Macmillan, 1926.

Adams H: ‘The Education of Henry Adams. New York, The Modem Library, 1931.

Oliver JK Jr: The Vienna Hospitals-A Letter from Henry K. Oliver, Jr, MD, of Boston. BostonMedandSurgJ57: 51, 71. 1857.

Ringer FK: The Decline of the German Mandarins. Cambridge, Harvard University Press, 1969.

Billroth T: The Medkzal Sciences in the German Universft&s-A Study in the History of Civilization (American ed). New York, Macmillan, 1924.

Roberg NH: Medical reform in West Germany. JAMA 200: 603.

1967. Conant JB: Education in a Divided World. The Function of the

Public Schools in Our Unique Society. Cambridge, Harvard University Press, 1948.

Wartman WB: Medical Teaching in Western Civilization. Chi- cago, Year Book Medical, 196 1.


Reflections on nineteenth century German medicine

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