American Journal of Respiratory and Critical Care Medicine

The National Association for the Study and Prevention of Tuberculosis, forerunner of the American Lung Association, was founded in 1904, with Edward Trudeau (1848–1915) as president, and William Osler vice-president (1, 2). During the first two meetings, some sanatorium physicians decided to found a small association as an appendage to the parent organization. On December 1, 1905, 17 (of 49 invited) sanatorium physicians met at the Natural History Museum of New York, and the American Sanatorium Association was formed (1). In 1939, membership was broadened to include physicians with an interest in tuberculosis who did not work in sanatoria, and the name was changed to American Trudeau Society (1). The name was later changed to American Thoracic Society in 1960. To celebrate our Society's founding, the Journal is publishing a series of articles covering the history of pulmonary and critical care medicine over the last century.

The formation of a society of medical specialists at the turn of the twentieth century arose from three historical currents: the heritage of scientific societies that had been in existence for four centuries; the maturation of medicine as a profession; and justification for specialization. I will not cover the history of pulmonary and critical care medicine over the last century—that is the subject of the upcoming articles. Instead, this editorial serves as prologue, tracing three overlapping, yet unique, historical currents that led to the emergence of phthisiology as a subspecialty.

The Scientific Revolution was the time of greatest change in the last millennium, reducing the Renaissance and Reformation to the rank of mere internal displacements within medieval Europe (3). Though indebted to the tradition of Greco-Islamic thought, scholars recognized the incompleteness of inherited knowledge. Shaking off the shackles of scholasticism, a vanguard of thinkers made a fresh start at scholarship: henceforth, new observations were to be criticized, validated, and replicated before being incorporated into the body of knowledge (3, 4). The first known scientific society was the Accademia dei Lincei (Academy of the Lynxes), founded in Rome by Duke Federico Cesi in 1601 (3, 5). Galileo (1564–1642), the originator of the empirical method, joined as a corresponding member in 1609 and the Accademia published two of his works (5). When its patron died in 1630, the Accademia ceased. In Florence, two Medici brothers, Prince Leopoldo and Grand Duke Ferdinand II, founded the Accademia del Cimento (Academy of Experimentation) in 1657 (5). When Leopoldo received a cardinal's hat in 1667, the Accademia ended. The closing of these Accademias together with the obscurantist reaction to new thinking at the trial of Galileo caused the Scientific Revolution to peter out in Italy (3, 5).

On the death of Galileo in 1642, the Scientific Revolution moved to a more hospitable climate in England, at that time in revolt against a dictatorial king. English nonconformists gave a sharper meaning to irreverence for inherited authority when they cut off the head of Charles I in 1649 (6). Enthusiasts for science had started weekly meetings in 1645. The “invisible college” was the name Robert Boyle (1627–1691) gave to these informal gatherings (7). In 1660, the monarchy was restored and later that year the Royal Society of London for Improving Natural Knowledge was founded. Charles II granted a royal charter in 1662, but provided no money; he assigned the society claims on Irish lands, but these proved impossible to realize (5). Membership was open to anyone, not because of egalitarian principles but through financial necessity (8). Early members included Robert Boyle and Robert Hooke, Thomas Willis and Edmund Halley, and Isaac Newton (9). Without a government grant, the society had constant financial difficulties. They thought of raising money through teaching but Boyle blocked the idea, seeing it as a distraction from experimentation (5). Instead, they decided to publish periodic reports of work done under their auspices or by other scientists. And so, the first scientific journal, the Philosophical Transactions, was published in 1665 (10).

In Paris, Louis XIV (1638–1715) founded the Académie Royale des Sciences in 1666, holding the inaugural meeting in his private library (8). Unlike the penurious English king, Louis provided substantial financial support for full-time investigation. After the death in 1683 of Colbert, Louis' controller-general of finances, the Académie declined (5). The ending of religious toleration, with the revocation of the Edict of Nantes in 1685, accelerated France's decline (6).

The new approach to scholarship, involving telescopes and microscopes, was expensive. As such, there were cogent reasons to form unions (3). Describing the ideal research institute in the New Atlantis (1626), Francis Bacon—acknowledged as the inspiration for the new movement—stressed that progress could best be achieved through cooperation (communism he called it) (8, 11). And after 1660 unions of researchers dominated science. That the discoveries of men such as Newton and Boyle, and Huygens and Leibniz were closely connected with scientific societies, contributed hugely to the societies' immediate success (5). In contrast to art—the other field of creativity—science is of value only when used by other scientists. Claude Bernard made the distinction pithily: “Art is I; science is we.” In 1600, science is in the Middle Ages; by 1660, with the inception of the scientific societies, it is in modern times (5). The advances to learning in the seventeenth century outshine those of any other (3, 5).

By the time of Newton's death in 1727, the Royal Society had degenerated into a group dominated by intellectual snobbery (6). Fellows nursed their awards, hobnobbed with amateur scientists among the aristocracy, and were more concerned with status than with making original discoveries (6). The most famous example of conservative caution was the rejection of Edward Jenner's experiments on vaccination by the Philosophical Transactions in 1796 (12). As such, the inventions of the Industrial Revolution during the eighteenth century were made outside the scientific societies and universities (6, 10).

Medical knowledge, the second of our three historical currents, was slow to build on the discovery of a Newtonian universe involving clockwork motion produced by discoverable laws (3, 13). In the early eighteenth century, the Dutch city of Leiden was preeminent, thanks to Hermann Boerhaave (1668–1738), who promoted clinical teaching on the wards of the local charity hospital (13). Boerhaave's trainees brought Leiden methods to Edinburgh, which dominated British medicine for decades (13). And Edinburgh served as the model for the founding of medical schools in Britain's North American colonies in the latter eighteenth century (13, 14). In 1761, Giovanni Battista Morgagni of Padua, waiting till his seventy-ninth year to publish his major work (15), showed how symptoms could be traced back to diseased organs, opening the way for logical diagnosis. Throughout the eighteenth century, medicine was still operating more like a trade than the lofty profession to which it aspired (13).

If blood from the head of Charles I spurred on English science, the decapitation of Louis XVI did the same for French medicine. The French Revolution moved hospitals out of ecclesiastical control and into the hands of the nation (13). Salaried physicians turned the large public hospitals of Paris into institutions for medical research and teaching (16). Homage to yesterday's authorities went the way of the ancien regime, and hands-on experience replaced book learning. Symptoms were seen as superficial, and diseases as conditions with laws of their own to be disclosed through autopsies. Xavier Bichat (1771–1802) performed 600 autopsies and built a new system of tissue pathology (though never obtaining a major hospital post) (13). The shift from symptoms to pathological lesions emphasized the ontological model of disease: diseases as discrete entities, real things. At a minor and peripheral institution, Hopital Necker, René Laennec (1781–1826) invented the stethoscope in 1816 (15), which remained medicine's chief diagnostic tool until the discovery of X-rays in 1895. Vast numbers of students from Europe and North America (up to 5,000 at a time) were flocking to early nineteenth-century Paris, with Laennec alone teaching some 300 foreign pupils (13, 14).

Around the mid-nineteenth century, preeminence in medicine crossed to the German states where it stayed till dissipated by twentieth-century war (13, 15). At last, science moved into the universities. The first laboratory for teaching science was established at the University of Giessen by Justus von Liebig in 1824 (11). Germans established the first research organizations that were both large-scale and self-consciously professional (17). Johannes Muller (1801–1858) is regarded as the greatest physiologist—less for his discoveries than for developing a systematic approach to experimental physiology. Muller's trainees included Schwann, Traube, Henle (through him, Koch and Waldeyer), Ludwig (through him, Welch), Helmholtz (through him, Hertz, Planck, and Michelson), and Virchow (through him, Ehrlich and Pavlov) (11, 18). Rudolf Virchow (1821–1902) gave pride of place to the cell, as Morgagni had done for the organ and Bichat the tissue (15). Several factors contributed to the success of German science (14). The universities were engines of inquiry, whereas English and French universities served more as finishing schools for gentlemen (13). Shunning the dilettante attitude of the latter, German faculty recognized that the war on ignorance would be won by painstaking, if pedestrian, investigations, thoroughness, and attention to detail (17). Their approach calls to mind the words of Carlyle that genius “means transcendent capacity for taking trouble.” For the first time, universities promoted faculty on the basis of original research. Academic freedom, originating out of the failed Revolution of 1848, became paramount: professors pursued research without constraint (19). Germany served as the model for reform of American universities, still intellectual backwaters in the late 1800s (16). About half of future leaders of American medicine graduating around this time studied in a German-speaking country (20). And Germany was the first to introduce socialized medicine when Chancellor Bismarck embarked on a national system of compulsory sickness insurance in 1883 (13).

By the late nineteenth century few therapies had been introduced: opium (around 3,000 BC), cinchona bark (1677), digitalis (1785), morphine (1805), quinine (1820), salicin (1826), ether (1842), chloroform (1847), and cocaine (1859) (21). New diagnostic techniques, however, were strengthening the authority of medicine and altering the patient–doctor relationship. Early in the nineteenth century, diagnosis depended on a patient's recitation of symptoms (15). By mid-century, the stethoscope had been joined by the ophthalmoscope and laryngoscope, the thermometer and spirometer (16). The discovery of X-rays by Wilhelm Konrad Roentgen in 1895 revolutionized the perception of physicians by patients. Whereas an ophthalmoscope could be used by only one physician at a time, and thus at risk of subjective distortion, X-rays could be viewed by several physicians simultaneously, bolstering claims to objective judgment (16). By the mid-1800s, successful peasants and petit bourgeois of Europe were routinely visiting a doctor, whereas they would rarely have done so in 1700 (13).

Medicine today is organized through structures that allow physicians considerable autonomy under state protection, while claiming to protect the public from charlatans and substandard care (13). The rise of any profession depends ultimately on its authority, that is, its claim to the possession of specialized and validated knowledge, technical skills, and rules of behavior that compel trust (16). To acquire authority, a profession needs to achieve consensus among members (as to goals) and be seen as legitimate by the state (16). All this crystallized only in the late nineteenth century.

In ancien regime France, licensure was in the hands of university faculties. The Jacobins judged such practices as efforts to reduce competition and raise rewards, and abolished them (13). In early nineteenth-century America, attempts to introduce licensure were also viewed as efforts to gain a selfish monopoly and failed (14, 16). In 1858, the London Parliament created a single register for all approved practitioners and a council to serve as an ethico-legal watchdog (13, 14). The United States Supreme Court finally ruled in favor of licensing in 1888 (16). A key precondition for the acquisition of medical authority was the construction of large hospitals. Once dreaded as cesspools of infection, hospitals began to be seen as temples of healing and citadels of science, affording them a new moral identity. America had only 178 hospitals in 1872, increasing to 4,000 in 1910 and over 6,000 by 1920 (16).

Adam Smith's views on the division of labor, in his Wealth of Nations, also applied to medicine. As the medical market grew, so did opportunity and incentive to specialize—the last of our three historical currents. The satisfaction of mastering a single field was attractive (22). Pediatrics, neurology, and dermatology emerged as separate specialties by the late 1880s (23). Just as the craft guilds of the 1500s struggled to secure economic advantage, so physicians of the early 1900s battled to define boundaries of authority against emerging ancillary occupations (16). American nurses were strongly established as anesthetists by the 1920s, and non-physicians were sometimes in charge of radiology units (16, 24). Only in the late 1930s did physicians gain control of these two departments. It is no accident that the first certification examinations were developed by two groups that felt the keenest competition from non-physicians: ophthalmologists (in 1917) and otolaryngologists (in 1924) (16, 23, 24). The goals of specialty boards were to provide hallmarks of quality in fields that were prime targets for non-physicians (such as optometrists) and general practitioners, and to establish monopolies based on specialist techniques (23). The American Board of Internal Medicine was established in 1936, partly in response to the challenge of separate boards in tuberculosis and gastroenterology, already in embryonic form. Subspecialty certification in tuberculosis was introduced in 1941 (23).

Tuberculosis has ravaged mankind back to Neolithic times. It is estimated to have caused a seventh to a quarter of deaths of working people in the nineteenth century. Victims have included Frédéric Chopin and Niccolò Paganini, Friedrich Schiller and Franz Kafka, Emily, Anne and Charlotte Bronte, John Keats, Laurence Sterne, Anton Chekhov, D.H. Lawrence, George Orwell, and Simonetta Vespucci (the pale model for Botticelli's Venus) (25). To make sense of such tragic loss of talent, wasting of the flesh was thought to inspire creativity of the soul—so-called spes phthisica. Pianists, poets, and playwrights notwithstanding, tuberculosis mainly affected the urban poor (13).

The great triumph was Koch's discovery of the tubercle bacillus in 1882 (26). The tuberculin test (introduced in 1890 and refined in 1907) revealed that latent infection was widespread. Satisfactory drug therapy would not arrive until the 1940s (and none of the agents was to emerge from a great center of medical research [25]). In 1854, Hermann Brehmer opened a sanatorium in Silesia, and Edward Trudeau opened his cottage in the Adirondacks thirty years later (25). The first pneumothorax operation was attempted by Carlo Forlanini of Pavia in 1888 (13). The operation was taken up by Ferdinand Sauerbruch (1875–1951), who tried solving the problem of lung collapse on opening the thorax through the use of a negative pressure chamber. (Sauerbruch later served on the Committee of the Reich Research Council that approved grants for the Mengele twin experiments in Auschwitz [27]–clear evidence that history, even medical history, does not necessarily represent a progressively upward evolution.) By 1904, negative pressure chambers to contain a patient and full operating team were in use on both sides of the Atlantic. The three historical currents of this prologue—the heritage of scientific societies, the maturation of medicine, and the justification for specialization—now converged in the battle against tuberculosis. Local and national associations sprang up in Europe and America, and one of these was the National Association for the Study and Prevention of Tuberculosis (with the American Sanatorium Association as an appendage) (1, 2). In founding this association, Trudeau, Osler, and assembled phthisiologists were linking each of us, as members of today's ATS, with Galileo, Boyle, Newton, and the first unions of scientists that battled ignorance for the betterment of mankind. The upcoming series takes off from this point and covers the history of pulmonary and critical care medicine in the twentieth century.

History provides us with a scale, and with a time-constant for extrapolating into the future. From our perch in the present, we look back and see how the complexities of today evolved from relatively simple roots. A panoramic perspective of the past enables us to understand change and its significance. Though history is about the past, it is our key to true understanding of the present—which is simply the edge of the past.

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