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The history of osteoarthritis - Episode 5

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17th and 18th centuries: at the dawn of modern medicine

osteoarthritis an middle age

While the scholars of the Renaissance, despite their innovations, kept one foot in Antiquity those of these two centuries seem entirely focused on new ideas.
Descartes in France, but also Francis Bacon in England suggested a rationalism free from the religious dogma of the time as a means of advancing science.

Here we are at the beginning of a scientific approach that would lead to significant advances in the fields of physiology, the study of body tissues and the discovery of bacteria. Therapeutics follow in a rather timid way with the exception of the remarkable event of the first vaccination. One still had to wait to dispose of effective treatments against osteoarthritis, but medicine and surgery were getting organised, progress was set in motion and it was never to stop.

  • Cartesian thought and the origins of the scientific revolution
  • A new idea: medical studies attested by a diploma
  • Was osteoarthritis less common than today?
  • First description of Heberden's nodes
  • From the reign of Henry IV to the First Empire, medicine was still powerless against osteoarthritis
  • The Lame Devil was a believer in thermal cures

It was in his Discourse on the Method of Rightly Conducting One's Reason and of Seeking Truth in the Sciences that
René Descartes (1596-1650) laid the foundations of rationalism.

His "method" was based on four fundamental principles

  • "The first of these was to accept nothing as true which I did not clearly recognise to be so: that is to say, carefully to avoid precipitation and prejudice in judgements and to accept in them nothing more than what was presented to my mind so clearly and distinctly that I could have no occasion to doubt it.
  • The second was to divide up each of the difficulties which I examined into as many parts as possible, and as seemed requisite in order that it might be resolved in the best manner possible.
  • The third was to carry on my reflections in due order, commencing with objects that were the most simple and easy to understand, in order to rise little by little, or by degrees, to knowledge of the most complex, assuming an order, even if a fictitious one, among those which do not follow a natural sequence relatively to one another.
  • The last was in all cases to make enumerations so complete and reviews so general that I should be certain of having omitted nothing."

osteoarthritis an middle age

By proposing a logical and almost mathematical sequence of ideas from indisputable evidence, Descartes broke definitively with scholastic thought and inaugurated the reign of scientific thought. 
He contributed himself to the advancement of science by inventing analytic geometry and discovering the law of optical refraction. Defender of modern ideas, he was to become a firm believer in the theory of blood circulation proposed by the Englishman Harvey. His biological theories, however, show that his method could still be improved: he has the soul residing in the pineal gland by which it communicates with the body, which now seems strange. However, one can find a distant echo of the thought of Descartes in the concept currently in vogue, particularly in rheumatology, of "evidence-based medicine." 

(1) Doctrine according to the dogmas of the Church, incorporating the philosophy of Aristotle in the twelfth century, taught in universities until the 17th century. Scholastic knowledge was based only on knowledge of the texts.

A new idea: medical studies attested by a diploma

In 1794, a decree of the National Convention ordered the establishment of three Schools of Health in Paris, Bordeaux and Montpellier. However, it was under the Consulate that the degree of Doctor of Medicine obtained in one of these schools became necessary for exercising medicine. The cardiologist Jean-Nicolas Corvisart was behind this reform.

The recognition of surgery

The Royal Academy of Surgery was founded in 1731. Physicians and Surgeons would subsequently study in the same Schools of Medicine where they would obtain the title of Doctor.

The creation of major hospitals

Henri IV had the Hospital of St. Louis constructed; Louis XIV decided that each major city should have its hospital. Originally intended for the accommodation of the poor, hospitals were quickly to become a place of medical education at the patients' bedside. Some hospital doctors specialised, such as Philippe Pinel (1745-1826), psychiatrist (then called alienist) known to have been the first to order that the mentally ill were no longer put in chains. Pinel exercised his talents at the Salpetriere hospice and prison for women which did not become a hospital until the early 19th century.

Was osteoarthritis less common than today?

The study of skeletons exhumed from the crypt of Christ Church, located in East London and used from 1729 to 1869 showed that men suffered more from osteoarthritis than women (2). The most common sites of osteoarthritis lesions were the shoulder, spine and hands. By contrast, osteoarthritis of large joints was uncommon, affecting 1.1% of men and 2.9% of women in the hips, 0.8% of men and 5.2% of women in the knees. The incidence of osteoarthritis is more common in the population currently living in the same area of London.

In all likelihood, these figures reflect both the difficulty of manual labour at the time (laundry washing could be responsible for affecting the knees in women) and, as in previous eras, a reduced life expectancy lowering apparent frequency of this disease which is, in part, due to ageing.

(2): Waldron HA. Prevalence and distribution of osteoarthritis in a population from Georgian and early Victorian London. Ann Rheum Dis 1991 ; 50 : 301-307.

The first description of Heberden's nodes.

The 17th and 18th centuries abound in descriptions of signs and symptoms of disease and it was in his Commentaries on the History and Cure of Diseases that William Heberden (1710-1801) described the digitorum nodi, signs of osteoarthritis now known as Heberden's nodes:

"What are these little hard nodules, with roughly the size of a pea, frequently observed on the fingers, especially just below the tip, near the joint? They have nothing to do with gout ... "

Heberden was thus the first to distinguish "his" famous nodes, affecting the distal interphalangeal joints, other rheumatic lesions of the fingers and gouty tophi.

From the reign of Henry IV to the First Empire, medicine was still powerless against osteoarthritis

Description of the circulation of blood by William Harvey in 1628, then the lymphatic circulation by Jean Pequet, first histological descriptions (study of body tissues) by the inventor of the microscope Anthony Van Leeuvenhoek and then by Marcello Malpighi and Xavier Bichat. The list of new knowledge acquired during these two centuries in the area of human physiology is truly impressive. Remember that Van Leeuvenhoek, once again, identified bacteria in 1683 after having discovered sperm in 1677.

These discoveries were sometimes difficult to impose when they were published. We know that Descartes was one of the protagonists of Harvey's theory of the circulatory system which was very rational and in which he no doubt recognised an application of his own "method". He had to differ on this point with two "anti-circulatory system" doctors, Riolan Jean and Guy Patin, for whom the arteries contained air and not blood. It can be assumed that the discussions were especially lively since it took the intervention of Louis XIV for the theory of the circulatory system to be imposed in France for good!

It was in the guise of Dr. Diafoirus, a professed anti-circulatory system doctor that Drs Riolan and Patin, but perhaps all of their colleagues as well, were ridiculed by Molière. If one believes the retorts of the Imaginary Invalid, the therapists of the time knew only three remedies: purges, bloodletting and enemas. As for the doctors described by Voltaire, they seriously wonder whether bleeding should be done on the healthy side or the diseased side.

These authors produced good caricatures of the medicine of the time. However, it is true that despite the striking evolution in physiological knowledge, advances in treatment were few and far between.

The reality is somewhat more nuanced, but it must be said that the lack of progress in treatment contrasts with the striking evolution in physiological knowledge.

osteoarthritis an middle age

Two notable exceptions are the use of digitalis (from which digitalin would be drawn later on) for certain heart conditions and, above all, the development in 1796 by Edward Jenner of the first vaccination successfully used against smallpox. One also notes the appearance of some new drugs (quinine for fever, ipecac used as an anti-diarrhoeal drug and tea and coffee used as psychostimulants).
All this did not do much for patients with osteoarthritis who, to ease their pain, only had recourse to the old (and ancient) concoction of willow bark, and for the wealthy, thermal cures. Unless they had recourse to homeopathy, the first "alternative" medicine (synonym of non-Cartesian?) proposed in 1796 by Christian Samuel Hahnemann. Visceral surgery had advanced (the first appendectomy was performed in 1763) but we are not yet in the era of the hip or knee prosthesis.

Edward Jenner

 

 

The Lame Devil was a believer in thermal cures

Prince Charles-Maurice de Talleyrand-Périgord (1754-1838), an exceptional diplomat and opportunistic enough to serve all regimes from the beginning of the Revolution to the Restoration, was affected by a consecutive club foot. Some dispute this version and now lean more towards a congenital club foot. The fact remains that the Lame Devil, who wore an orthopaedic shoe, took the waters at Bourbon l'Archambault for 30 consecutive years. No doubt he sought to relieve osteoarthritis of mechanical origin?