1757: Boerhaave improves image of medicine

Herman Boerhaave's impact on medicine was to improve respect
and dignity for the medical profession by returning to the gentle
practices taught by Hippocrates, and treating patients by assessing
them and making observations about their surroundings. 

Herman Boerhaave was among the well established physicians of the 17th century who helped sway the profession away from the humoral theory of medicine and toward science. He "sought to fix the sciences of medicine on the basis of observation, experiment, and the consequent inferences, "said medical historian Thomas Bradford.  (1, page 127)

Samuel Johnson was the first person to write a biography of Boerhaave, and this was published in subsequent editions of Gentleman's Magazine from January to April in 1739. Johnson said Boerhaave was born in 1668 at Voorhout, a village two miles from Leyden, in the Netherlands. (2, page 307)

His mother was Hagar Daelder, a tradesman's daughter from Amsterdam, and so she had knowledge of medicine. She was unable to share this wisdom with her son because she died at a young age. His father, James, then married Eve du Bois, daughter of a minister in Leyden, in order so she could help James raise his seven children.

Meanwhile, James Boerhaave was preparing his son Herman for the ministry, although at the age of 12 an accident occurred that left such an impression upon the boy that he developed an interest in medicine. Johnson said: (2, page 307)

In the twelfth year of his age, a stubborn, painful, and malignant ulcer, broke out upon his left thigh; which, for near five years, defeated all the art of the surgeons and physicians, and not only afflicted him with most excruciating pains, but exposed him to such sharp and tormenting applications, that the disease and remedies were equally insufferable. Then it was, that his own pain taught him to compassionate others, and his experience of the inefficacy of the methods then in use, incited him to attempt the dscovery of others more certain. (2, page 307)

He began to practise, at least, honestly, for he began upon himself; and his first essay was a prelude to his future success, for having laid aside all the prescriptions of his physicians, and all the applications of his surgeons, he at last, by tormenting the part with salt and urine, effected a cure. (2, page 307)

Until he was fourteen he was educated by his father, and then his father started him in school at Leyden.  He was such an impressive student that he graduated from each class at a time, completing his studies in only six months.  He was then ready for a university education.  It was here, however, that his father died in November of 1692, leaving a 17 year old Boerhaave to tend to his step mother and siblings. (2, pages 307-308)

Eventually he was able to start school at the University of Leyden, the same university where Francois de la Boe (Sylvius) started a medical clinic in 1658. He started studying mathematics in 1687, although in 1690 he obtained a degree in philosophy. Up to this point the objective of all his studies was the ministry. Through his studies he became discontent with the ministry, and decided to study physick (medicine) and chemistry.  (2, page 308)(6, page 68)

It was here where he studied with great interest great anatomists like Vesalius, Fallopius and Bartholin.  He also observed public dissections in the theater.  He also visited slaughter houses "to observe the different structures of animals," said Bradford  All of this gave the young genius an impressive understanding of the inner workings of the human body, at least what was known up to that time.  (1, page 126-127)(2, page 308)

He then delved deep into medical theory, studying the works of ancient physicians such as Hippocrates and Galen.  Then he studied the works of modern physicians, with, said Johnson, none impressing him more than Thomas Sydenham (1624-1689).

He yearned to become a physician just like Sydenham, who believed in the humoral theories of medicine.  Sydenham was said to be the first physician of his era to return to the Hippocratic idea of using the art and skill of the physician to cure patients, as opposed to relying on science and theory.  (2, page 308)

He then went to Hardenwhich, where he obtained his degree in physick in July of 1693.  He then set up his practice in Leyden, and spent the majority of his career as professor of botany and medicine at the University of Leyden.  He soon became very popular both as a physician and professor.  (3) (2, page 309)

He actually returned to Leyten to pursue the ministry, but he was accused of being a practiced atheist, and so he was unable to do this.  Even though the accusations were untrue, he decided not to fight them, and to pursue his other passion, of which was physick. He continued his studies of medicine, started visiting patients, performing chemical experiments, teaching mathematics, and reading scripture.  (2, page 309)

Johnson said this was how Boerhaave lived until 1701 when he was recommended to fill a vacancy as professor of physick at the University of Leyden.  The first thing he observed as professor was that students were not well read in Hippocrates, and so he made sure his students were well read in Hippocrates.  He also read his lectures in public, and also encouraged his students to learn chemistry.  (2, page 310

It wasn't so much the theories of Hippocrates that he was concerned with, but his method of taking care of the sick.  He loved the gentle approach Hippocrates had with his patients, and his gentle remedies.  No more did he want patient's to fear a doctor's poor approach and his painful remedies.

He set up a practice in Leyden and began to visit patients.  Bradford said he soon became extremely popular,  "and all the distinguished persons who passed through Leyden visited him." (1, pages 128)

He said Boerhaave treated all his patients, rich and poor, famous and not so famous, as equals.  So even when Peter the Great sought out his services, he was made to wait all day to see the great physician.  (1, pages 128)

Britannica.com said that he was among the first to, instead of doing all his teachings in the classroom, to take his students to the patient's bedside. In this way, he is said to have given birth to the modern system of medical instruction. He was so famous that students traveled from all over Europe to learn from him. (2)

In this way he was among the first physicians to teach by experience and observation as opposed to science and theory. This, coupled with his gentle approach, established Boerhaave as among the various physicians of the 18th century to increase the respect and dignity of the medical profession. Of this, Johnson said:

Yet I cannot but implore, with the greatest earnestness, such as have been conversant with this great man, that they will not so far neglect the common interest of mankind, as to suffer any of these circumstances to be lost to posterity. Men are generally idle, and ready to satisfy themselves, and intimidate the industry of others, by calling that impossible which is only difficult. The skill to which Boerhaave attained, by a long and unwearied observation of nature, ought, therefore, to be transmitted, in all its particulars, to future ages, that his successors may be ashamed to fall below him, and that none may hereafter excuse his ignorance, by pleading the impossibility of clearer knowledge. (2, page 311)

Yet so far was this great master from presumptuous confidence in his abilities, that, in his examinations of the sick, he was remarkably circumstantial and particular. He well knew that the originals of distempers are often at a distance from their visible effects; that to conjecture, where certainty may be obtained, is either vanity or negligence; and that life is not to be sacrificed, either to an affectation of quick discernment, or of crowded practice, but may be required, if trifled away, at the hand of the physician. (2, page 311)

Encyclopedia.com said that "Boerhaave’s reputation as one of the greatest physicians of the 18th century lay partly in his attempts to collect, arrange, and systematize the mass of medical information that had accumulated up to that time." (2)

Medical historian Fielding Hudson Garrison said his writings had "an enormous impact in their day.  (4, page 321)

Future generations would then become acquainted with the teachings of Boerhaave through his writings, as his books were used as texts for medical instruction for several generations after his death.

He is not, however, remembered for his medicine. He was not even popular for his medical treatments. Plus he added nothing new about any particular diseases. His ideas were mainly his own adaptations of the views of Hippocrates and Sydenham.

Through his lectures he explained the curative part of physick generally attempts to do one of four things: (5, page 277)

1. Preserve life
2. Remove the cause of disease
3. Take away the disease itself
4. Expel the present effects or symptoms of the disease (5, page 277)

In order to accomplish these, he said that...

...artificial Change is to be produced in the Body of the Patient, for which Purpose Instruments or Remedies are required; by the Efficacy and Application of which, the Changes necessary for the attainment of the proposed Ends may be excited, whether under the Denomination of Remedies, Medicines, or help of any kind. (5, page 277)

He said the physician must have all the remedies memorized, and know which one to use for which signs. He likewise explained that...

...these Signs are to be taken from the Patient himself, and not from the general Principles of Physic, which when applied to particular Cases are often found deceitful: As for instance, suppose a Case which indicates a Vomit, if the physician does not attend to the particular Habit or Antipathy of the Patient, it may kill him, for there are some who are always thrown into Convulsions by an Emetic." (5, page 279)

Whatever is discovered in the Patient so as to instruct the Mind of the Physician is called Indicans, or the Things that indicates, and the knowledge of the arising in the Mind of the Physician, is called the Indication, as that which is by this knowledge indicated to be done is called Indicatum.  

He specified that the indicans and indications should not be derived from the patient alone, as the Methodists say, but from the patient and his surroundings, or anything which is known to have an influence on the patient. If, for example, the patient presents as having asthma, and it is known to be very hot the next day, great care must be taken to prepare the patient for this.  Or, if a patient has "drank plentifully of Brandy or other Spirituous Liqours, I thence know what is best to be done for his Recovery." (5, page 281)

All of this is done to determine the Methodus Medendi, or the Method of Healing.

Boerhaave said Hippocrates observed that:

"Disease always cures itself, since it is that imperfect life which still remains from Health; that is what Hippocrates calls Nature, and what others call strength; namely the powers of generating motion. (5, page 282)

Which powers being carefully examined, will be found to depend upon the Remaining motion, of the Humours through the vessels, however conditioned that motion may be." (5, page 282)

And though these powers are reduced to the least degree, they yet continue the circulating Motion of the Humours thro' the heart, lungs, and Cerebellum, in which therefore consists every the least Force of Life, which may be increased in various degrees." (5, page 282)

Boerhaave preached basically two rules for what to do once the indicans is discovered.  If it agrees with nature, it should be preserved in the body.  If it disagrees with nature, it should be removed. As far as the homours are concerned, contraries are removed by their contraries, which is the same belief held by Galen. Another belief he held in common with Galen was his belief that mild maladies required mild remedies, and greater maladies required powerful remedies.  (5, page 287)

Boerhaave notes diseases were caused by poisonous vapours entering the body, and that once poisons enter the body they are spread by the veins and not by the arteries.  The arteries resist the entry of poisons because the "Humours resist the Entrance of any kind of Particles." (5, page 332)

So life is the maintained by quality humours being continuously circulated through the vessels, and the remedies are meant to maintain this function within the body, and expectorate the poisons. When the poison enters the body there are a variety of effects that it can have on the body, such as increasing the viscosity of fluids or humours, thus making it so they become occluded.  In this case, the remedy would be thin or loosen the humours and juices to allow them to flow once more in a natural state.

Some examples of indicatum (remedies) he might use to accomplish this were: 

• Bleeding: to prevent suffocation (such as in peripneumonia)
• Cardiacs (or Cordials): Increase force of the heart to preserve life.  Some increase the quantity of healthy humours, some increase power and strength into the fibres (increase elasticity), some increase power and quantity and motion of nervous juice, and some stimulate the moving fibres (or agitate sluggish vessels to move forward the stagnant humours).  Examples are liquors, kiln, antimony, etc. (5, pages 293-4)
• Antidotes:  These are the remedies meant to remove the poisons that are causing disease.  An example is spirit of sal ammoniacum to treat and remove poisons inhaled from chemical fumes, and thus prevent suffocation by contraction of the vessels.  Another example is Hippocrates burning the bodies of the dead to remove the poisons, or making a wall of fire so that the poisonous air must pass through the fire wall and become purified before being inhaled by citizens.   (5, pages 314-319)

Other examples of antidotes may be: (5, page 329, 331, 332)

• Fumigations of the air
• Dry or moist vapours conveyed to the lungs
• Draughts
• Baths
• Formentations (poultice)
• Injections (5, page 282)
• Cupping glasses frequently renewed
• Bleeding with a lancet
• Leaches
• Scarification
• Friction (rubbing the skin to provide warmth)
• External warmth (warm blankets, fire, etc.) (5, page 331)
• Cautery (5, page 332)
• Vegetable poisons (such as hellebore, hyacinthi, etc.) 
• Opium
• Many other

The antidote should be taken in by the same means as the poisonous vapours entered the body.  For instance, if a poison entered into the brain, the remedy should be inhaled through the nose.  If the disease entered the mouth to the stomach, the remedy should be swallowed the same way.  (5, page 330)

Antidotes may also be used to prevent disease or, "armed and defended against any poison," as Boerhaave said.  One method of doing this is to "anoint the Part of the Body where the Poison is feared with remedies mild and oily."  (5, page 334-335)

Boerhaave said of antidotes used as preventatives:

But there is not yet any universal Antidote known, which can be safely relied upon... though a great many have boasted of such. (5, page 335)

He does, however, offer the some other options as preventative measures:

1. When you are to enter any Place which you suspect poisonous or infected, it is adviseable to drink first as much Hydromel or Mead, as will almost make one dropsical. (5, page 335)
2. One who is to visit Patients in the time of a Plague, cannot secure himself better, than by anointing his Body naked with Oil before a Fire, and then breathing the Air through a Sponge which has been dipped in the best Wine Vinegar by which means the Pores will be closed or filled up, and the Ingress of a put-rid or contagious Air prevented from taking up its Seat in the Lungs, Saliva and Stomach. (5, page 335)
3. But as to a preventative Diet in this Distemper, I hardly know any; but am apt to believe, that keeping the Stomach empty will give a better opportunity of discharging the Pestilential Virus at times by a gentle Vomit, as it is chiefly swallowed with the-Air and salival Humours of the Mouth. (5, page 335)
4. Bathing the body over with salt, vinegar and water and keeping up a copious perspiration. 
5. Sylvius avoided getting sick during a plague by rinsing his mouth with vinegar in the morning, and by keeping a sponge dipped with vinegar under the nose

Rather than description of disease, and his medicine, he is mostly remembered for his approach to medicine, and reintroducing the gentle approach of Hippocrates to the medical profession.  His approach was not soon forgotten, as they were shared through his students as they set up their practices throughout Europe, thus practicing in his image.  Later in our history we will meet William Cullen, who was one of these students, and who would become one of the more significant contributors to our asthma history.

He retired from his work due to failing health in 1729, and in 1737 he became very short of breath and died of hydrothorax.  He was 70 years old. (1, page 128)

References:

1. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
2. Johnson, Samuel, "Herman Boerhaave," 1739, as printed in the book" "The Works of Samuel Johnson, with an essay on his life and genius," by Arthur Murphy, volume II, 1837, New York, George Dearborn Publisher, pages 307-314; (This biography of Boerhaave by Johnson was first published in January, February, March, and April of 1739 in subsequent issues of The Gentleman's Magazine. To view a version with section titles added for simplicity, you can click here. 
3. "Hermann Boerhaave", Encyclopedia Britannica, http://www.britannica.com/EBchecked/topic/71313/Hermann-Boerhaave, accessed 11/12/13
4. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, 
5. Boerhaave, Herman, "Academical Lectures on the theoryof physic being a genuine translation of his institutes and explanatory comment, collated and adjusted to each other, as they were dictated to his students at the University of Leyden, 1757, Volume II, London, 
6. Foucault, Michael, "The Birth of the Clinic," 2003, Great Britain, Routledge Classics 

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