Medicine

If the role of the systematic model in chemistry was centered on the problem of nomenclature, its influence in medicine was most clearly perceptible in questions of definition, description, and classification of disease. The desire to bring order to a large and ill-integrated body of knowledge, disillusionment with the results of mechanistic or chemical physiology in practical therapeutics, and a need to overcome the opposite extreme of radical skepticism, were among the factors behind the development of nosology, as medical systematics came to be called.

[45] Encyclopédie méthodique, chimie, pharmacie, metallurgie, 2 , articles "Alkalis," "Axiomes chimiques," and "Caractères," on 20–9, 455–89, 784–5, resp. The formlessness that Fourcroy found in chemistry when he began to teach the subject in the 1770s had also been noted by J.H. Lambert, who pointed to chemistry textbooks as examples of "a very inferior degree of order" in the arrangement of the different parts of a science. Lambert, "Essai de taxéometrie," 337. The importance of generic categories in shaping chemical perception and research is discussed for a particular case in John E. Lesch, "Conceptual change in an empirical science: The discovery of the first alkaloids," Historical studies in the physical sciences, 11 (1981), 305–28.

The beginnings of the systematic model in medicine appear early in the writings of the English physician of the late 17th century, Thomas Sydenham. A friend of Locke and admirer of Francis Bacon, Sydenham called for the setting aside of hypotheses and philosophical systems in favor of "a natural description or history of all diseases." He took the significant step of asserting that as there were species of plants, so too there were species of disease. This implied that diseases were distinct entities, not merely disturbances blending into one another, and that these distinct entities could be systematically grouped or classified. In practice Sydenham concentrated on exact definition and description. He gave concise accounts of smallpox, dysentery, cholera, plague, and other diseases. He was the first to differentiate between measles and scarlet fever, and his description of gout made possible its separation from rheumatism. For Sydenham specificity of disease implied specificity of remedy, and it was this idea, as much as the example of cinchona bark for malaria, that was behind his doctrine of specific medicines.^[46]

The 18th century continued Sydenham's botanical approach while shifting its emphasis from description of individual species to comprehensive classifications using higher taxonomic categories. The first such effort was made by François Boissier de Sauvages, a professor at the medical school of Montpellier familiar with contemporary botany. Sauvages' Treatise on the classes of diseases of 1731 arranged its objects in classes, orders, and genera as well as species. His major work carried the instructive title Methodical nosology, in which diseases are arranged by classes according to the system of Sydenham and the order of the botanists . Like Sydenham, Sauvages distrusted contemporary physiological theories and rejected the idea that a classification of diseases could be based on knowledge of their

[46] Knud Faber, Nosography in modern internal medicine (New York: Hoeber, 1923), 5–49; Lester S. King, The medical world of the 18th century (Huntington, N.Y.: Krieger), 193–226; Michel Foucault, The birth of the clinic. An archeology of medical perception (New York: Pantheon Books, 1973), 3–21; and Sergio Moravia, "Philosophie et médecine en France à la fin du XVIIIe siècle," Studies on Voltaire and the 18th century, 89 (1972), 1089–1151, esp. 1129–38. On Sydenham, see also The works of Thomas Sydenham , 2 vols. (London: The Sydenham Society, 1848–50), 1 , 3–24.

underlying causes. He insisted that classification be based instead on study of directly observable symptoms. Species definition depended largely on designation of the various circumstances in which symptoms might appear. Species proliferated accordingly, finally reaching 2,400, divided into 315 genera, 44 orders, and 10 classes.^[47]

Sauvages set the pattern for the nosology of the latter 18th century. Linnaeus had been a medical student when Sauvages' first book appeared in 1731. Subsequently the two men corresponded, became friends, and influenced one another. When he became professor of medicine at Uppsala, Linnaeus based his lectures on Sauvages' nosological system. In 1763, the year that Sauvages' Methodical nosology appeared, Linnaeus published his own work on Genera morborum . Given the long-standing botanical association of nosology, the increasing success and prestige of Linnaeus' botanical system after midcentury no doubt strengthened the appeal of the nosological approach to medicine. There is a clustering of nosological treatises in the 1760s and 1770s. Vogel published at Göttingen in 1764; Cullen, at Edinburgh in 1772; Macbride, at Dublin in 1775; Sagar, at Vienna in 1776; and Vitel, at Lyons in 1778. All of these works followed Sauvages in departing from Sydenham's original emphasis within the systematic program. Rather than seeking new, more accurate descriptions of disease, the nosologists of the latter 18th century took existing descriptions and tried to catalogue and group them, usually on the basis of symptoms.^[48]

The nosologists' insistence on observable symptoms as criteria of classification reveals in several ways the kinship of their enterprise with contemporaneous systematic endeavors in other fields. It is analogous to the use of visible external characters in botany and

[47] François Boissier de Sauvages, Nouvelles classes de maladies, qui dans un ordre semblable à celui des botanistes, comprennent les genres et les especes de toutes les maladies, avec leurs signes et leurs indications (Avignon, 1731), and Nosologia methodica sistens morborum classes, genera et species juxta Sydenhami mentem et botanicorum ordinem , 2 vols. (Amsterdam: De Tournes, 1763). See also King, The medical world , 205–14.

[48] Linnaeus, Genera morborum, in auditorum usum (Uppsala, 1763); Fredrik Berg, "Linnés systema morborum," Uppsala Universitets Årsskrift , 1957:3, 1–132; King, The medical world , 198–204; Faber, Nosography , 25–6.

mineralogy and appears consonant with their empiricist philosophical posture. It is also artificial, not in the sense of limiting the numbers of external characteristics to be considered, but in the sense of ruling out, at least for the moment, consideration of the structural and functional processes underlying disease.

The Paris clinical school of the early 19th century would challenge what it took to be the superficiality of this approach and insist that diseases be studied in anatomical depth, in the structural changes they produced in the organs and tissues of the body. The transition can be seen in the work of the Paris physician Philippe Pinel. Pinel's Nosographie philosophique, ou la méthode de l'analyse appliquée à la médicine , first appeared in 1798, and went through six editions in two decades (fig. 3.4). On the surface it is a work of the 18th century. To be sure, Pinel was critical of the "overloaded tables" and "arbitrary and vacillating" classifications of his predecessors. He granted, however, that there was an "absolute necessity" for some such method to save physicians from uncertainty, perplexities, risk, and precipitous decisions, and to save patients from mistakes. Pinel accepted the validity of the systematic model for medicine, and attempted to describe and classify the full range of known diseases.

In making his nosography "philosophical" and in citing the "method of analysis," he referred to the same views of Condillac that had helped motivate Lavoisier's reform of chemical nomenclature and Haüy's revision of the language of mineralogy. He declared that he would replace the earlier medical motto, "Given a disease, find the remedy," with a new motto of his own: "Given a disease, determine its true character, and the rank that it must occupy in a nosological table." Viewed more closely, however, Pinel's approach does not exactly correspond to that of his predecessors:

We must make every effort [he wrote] to introduce into medicine the method now followed in all the other parts of natural history, that is, a severe exactitude in descriptions, precision and uniformity in nomenclature, a wise reserve in rising to general views without giving reality to abstract terms, and a simple, regular classification founded invariably on the relation of the structure or organic functions of the parts.

The last crucial phrase separates Pinel's work from the nosologies of the 18th century. For Pinel a valid classification had to be based not only on symptoms but also on pathological anatomy. The class of inflammations—to give only one example—Pinel divided into orders on the basis not of symptoms but of the kind of membrane that was attacked. The result was a system greatly simplified by comparison with earlier nosologies. It included 5 classes, 80 genera, and fewer than 200 species of disease. As Pinel's Nosography went through successive editions, the classificatory scheme itself became less and less prominent. With the last edition of 1818, the 18th-century tradition of nosology came to an end.^[49]

The varied expressions of the systematic model in mineralogy, chemistry, and medicine only begin to indicate the omnipresence and diversity of its applications in the late Enlightenment. Some idea of this variety may be gained from a brief look at several of the model's less predictable incarnations, in mathematics, physics, mechanics, the theory of machines, physiology, anatomy, and materia medica.