Autopsy and Case Reports ISSN: 2236-1960 São Paulo, SP: Universidade de São Paulo, Hospital Universitário

Ferraz de Campos, Fernando Peixoto The Dawn of Modern Pathology Autopsy and Case Reports, vol. 6, no. 1, 2016, January-March, pp. 1-5 São Paulo, SP: Universidade de São Paulo, Hospital Universitário

DOI: 10.4322/acr.2016.019

Available in: http://www.redalyc.org/articulo.oa?id=576061726001

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The Dawn of Modern Pathology

Fernando Peixoto Ferraz de Camposa

Campos FPF. The Dawn of Modern Pathology [editorial]. Autopsy Case Rep [Internet]. 2016;6(1):1-5. http://dx.doi.org/10.4322/acr.2016.019

Karl von Rokitansky (1804-1878)

The declining rate of autopsies worldwide, and age, the medical procedure of autopsy is often which has been observed in recent decades, has been considered to be unimportant and sometimes even extensively debated. Although many reasons have been worthless. suggested for the genesis of this unfortunate process, Surprisingly, in the 19th century–more than none is convincing. 200 years ago–the practice of autopsy was met with The history of medicine is far from being a linear hostility, not only from the general public but also progression of discoveries. Twists and turns occurred, from some of the medical community. It would take which, over time, completely changed the current the untiring work of a remarkable man, in Vienna, to concepts. One of these turns was based on the wealth change the future of medicine thanks to the knowledge of knowledge acquired through the observation of he gained through his determination, dedication, and thousands of autopsies. Paradoxically, in our day belief of the truth that autopsy would reveal. a Internal Medicine Division - Hospital Universitário - University of São Paulo, São Paulo/SP – Brazil.

Autopsy and Case Reports. ISSN 2236-1960. Copyright © 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided article is properly cited. The Dawn of Modern Pathology

Maria Theresa (1717-1780), sovereign of the and is part of the Czech Republic. He lost his father Austro–Hungarian Empire, started her 40-year reign early in childhood and sustained significant financial in the middle of the 18th century after the death of difficulties during that time along with his mother and her father, Emperor Charles VI (1685-1740). She ruled three siblings by the counsel of her advisors and contributed to In spite of those difficulties, he completed primary financial and educational reforms as well as promoted school at his hometown before moving to Prague greater unification of the Habsburg monarchy. where he continued his education and graduated from According to recommendations by Dr. Gerard van secondary school at the age of 14 (in 1818). He started Swieten [long‑time student of Hermann Boerhaave his advanced studies in philosophy, which was the (1668‑1738), brought from Leyden University – usual preliminary to a course in medicine, and was Holland, imperial personal physician], the Vienna greatly influenced by the contemporary philosophers General Hospital (The Algemeines Krankenhaus) Kant, Schopenhauer, and Schiller. In 1822, still in was rebuilt. Viennese medicine had first attained Prague, he began his medical studies, but two years international significance through its incentives. later he moved to Vienna to live with his uncle and Similarly, following van Swieten’s advice, Maria Theresa finish his medical studies there. signed a decree making it mandatory to autopsy every Highly dedicated, self-taught, and skeptical hospital death (the motivation for this decree was the of ancient medical concepts, early on Rokitansky high infant mortality in Austria, mostly in the city of focused his interest in anatomy, and was substantially Graz). This practice continued—especially for forensic influenced by the publications of Jean-Frédéric Lobstein cases—into the following century. This decree (still (1777-1835), Johann Friedrich Meckel (1781-1833), theoretically in effect in Austria, but no longer strictly and Gabriel Andral (1797-1876). He started working as followed) led to many morphologic observations that a trainee in the poorly equipped and underdeveloped contributed immeasurably to the development and pathological institute of the Vienna General Hospital. progress of modern medicine. At the age of 24 he attained a doctorate in medicine In the early part of the 19th century, the after defending a thesis dedicated to the vaccination Austro‑Hungarian Empire showed many societal against smallpox (De variolide vaccinica), which had defects precipitated by the Napoleonic wars. Emperor been a plague in Europe until the end of the 18th Francis II (who succeeded his father, Leopold II, the century, when Edward Jenner’s experiment was King of Belgium, who was the son of Maria Theresa) successfully developed (the cowpox inoculation — the dissolved the Holy Roman Empire, and suffered cradle of immunology). various defeats until Napoleon’s abdication in 1815. The professional debut of Rokitansky took place in When Francis II died, his son, Ferdinand, who tried the morbid anatomy institute, which was considered as unsuccessfully to enhance the power of the throne by little better than a hut in a corner of the Vienna General leaving an heir, was depicted as feeble-minded and Hospital (described by Rokitansky as “a cabin inhabited incapable of ruling, which left the actual carrying out of by few settlers”). The young Dr. Johann Wagner, who government affairs to the austere Klemens Wenzel von found the institute entrusted to a museum servant, Metternich. Ferdinand eventually abdicated in favor of had been recently put in charge. his nephew, Franz Josef, who, somehow — and despite As assistant to Dr. Johann Wagner (1800‑1832), many military disputes — proved to be a progressive he helped to perform the autopsy of Ludwig van and powerful ruler of the Austro–Hungarian Empire Beethoven (1770-1827). Aloys Rudolph Vetter during the second half of the 19th century. Metternich (1765-1806) and Lorenz Biermayer (1778-1843), and Franz Josef concentrated on military initiatives to previous physicians in charge of the morbid anatomy reinforce the Empire, while allowing society to pursue institute, had abandoned their posts of prosectors a variety of intellectual activities. many years before, because of the indifference of the In the midst of this political scenario, in 1804 profession and the opposition by many at that time. Karl von Rokitansky was born in Königgrätz, a city Adolf Kussmaul (1822-1902), in a visit to Rokitansky in Bohemia (formerly part of the Austro–Hungarian described the prosecutory as a small house, where— Empire), which is currently called Hradec Králové, besides a chamber to store the corpses — there was

2 Autopsy and Case Reports 2016;6(1):1-5 Campos FPF one room for autopsies and another for the court. such as “in most cases, the necropsy relates to the Rokitansky subsequently devoted his whole life clinical history like glasses to a blind eye; they have no to pathologic anatomy, almost entirely in Vienna, meaning for one another” (written in 1809, cited by and ultimately became one of the most important Erna Lesky); and “I set but little value on the minute physicians of his time. examination of the traces left by disease on our Wagner’s teaching led Rokitansky to develop the organs though that pursuit has been pompously styled techniques he subsequently used in the performance pathologic anatomy. The lesions found at our autopsies of as many as 30,000 autopsies. After the early death are frequently produced after death, and consequently of Wagner from tuberculosis in 1832, Rokitansky the plan hitherto followed in such inquiries is fallacious, succeeded him and in 1834 was appointed as a and can only lead to vague information and error.” temporary Professor of Pathologic Anatomy. (François Magendie’s declaration in 1839). The Viennese School of Medicine that had Unlike the practice in all other European an North flourished in the previous century was in decline, American medical centers, where dissections were and morbid anatomy had scarcely bloomed at all. restricted, Rokitansky had the unique situation of Rokitansky was also appointed Associated Professor of having endless study material since all diseases and Pathological Anatomy of the Vienna School of Medicine. cases for autopsy were referred to the Vienna General The health service was under imperial sponsorship (in a Hospital. period of constant territorial disputes), and although He developed a special technique to expedite the the general hospital was rebuilt and expanded, the old examination and dissection of many corpses brought Vienna School somewhat stagnated. daily to the autopsy room, particularly because At the beginning of the 19th century, autopsies there was neither a preservation mechanism nor any generally concentrated on one organ, typically chosen refrigeration. It has been estimated that he performed by a clinician, and, as a general rule, were carried out more than 30,000 autopsies and reviewed another without a specific methodology and left many organs similar amount — if not more. These estimations are unexamined. Rokitansky accepted the challenge to based on the number of hospital beds, the mortality develop pathology to serve clinical science in keeping rate, and uninterrupted work for 6 days of the week with the Giovanni Batista Morgagni (1682-1771) for the period that Rokitansky was in charge of the practice of clinico-pathological correlations — an prosectory. However, this number is considered to approach augmented by Mathew Baillie (1761-1823). be underestimated by John Talbot and Erna Lesky, Even as a novice pathologist, Rokitansky began two renowned medicine historians, attesting that observing the appearance of morbid diseases at this number did not take into account: (i) the period different stages and developed new concepts of when Rokitansky was busy with many administrative pathogenesis, which were of great value for physicians duties; and (ii) the forensic autopsies. The burden at the bedside. He demanded that the autopsy of knowledge stemming from such experience was findings be integral to clinicopathological correlation, translated and immortalized in the three-volume and developed advanced nosology — attempting Handbook of Pathological Anatomy (Handbuch der to understand the process of disease from the Pathologuischen Anatomie), published in Vienna beginning to the end. Years later, he demonstrated during 1841-1846, the subsequent editions of which the applicability of clinicopathological correlation to were less successful since they were not in keeping accurately diagnose patients. Rokitansky descriptions with Virchow’s groundbreaking concepts. not only contained the pathological epicrisis but also The New or Second Vienna Medical School was the implications on diagnosis and therapeutics. founded and centered on Rokitansky’s autopsy table, At first he was confronted with persistent which also counted on the aid of the clinician and opposition; however, as the validity of his concepts his lifelong friend, Joseph Skoda; the dermatologist, became better understood, he ultimately became Ferdinand von Hebra; the surgeons, Franz Schuh pre-eminent in the Viennese physician community. and Theodor Billroth, who laid the foundations of Destructive comments and some written statements modern surgery; and Ignaz Philipp Semmelweis, threatened the development of Rokitansky’s work, the pioneer on antisepsis with the discovery of the

Autopsy and Case Reports 2016;6(1):1-5 3 The Dawn of Modern Pathology etiology of puerperal fever. In 1848, the doctors’ that disease originated in the cells and not in the four revolution forced the resignation of Metternich, humors. In spite of his greatness, Rokitansky — the transforming the theretofore-reactionary system into last word in pathology at that time—was a humble a “new era” when teaching and the science became man, and recognized the revolutionary correctness of free. From that time on, the Viennese Medical School Virchow’s concepts and publicly proclaimed that he lived the most scientifically fruitful epoch; scientific had been wrong in many of his teachings and that the discussions and publications proliferated with the work young Berliner, Virchow, should be followed. of the younger members of the faculty. The quality of We should not forget that as the Dean of the training, by means to access to patients and corpses, Medical School and the Rector of Vienna University, in the Medical School attracted students from all Rokitansky had enormous influence in improving over Europe and other continents. Rokitansky was medical service and teaching. Prior to the 19th promoted to Chairman of Pathological Anatomy, and century, various hospitals around the world, such the discipline became a compulsory subject in the as the Hôtel‑Dieu Hospital in Paris, the Chelsea University of Vienna. In his inaugural lecture in 1844, and Westminster Hospital and Guy’s Hospital in he insisted on the importance of close contact between London, the Charité Universitätsmedizin in Berlin, the the pathologic anatomy and the clinical departments. Pennsylvania Hospital and the New York Hospital in From then on, he became Dean of the Medical Faculty the USA, were focused on the basic care of the sick. (by open election), President of the Medical Society of Although already rebuilt in the 18th century, in the Vienna, Rector of the Vienna University, and Medical 19th century the 2000-bed Vienna General Hospital Adviser for Culture and Instruction appointed by the became one of the largest hospitals in the world, the Emperor. practices of which affected institutions throughout Rokitansky, a taciturn man of melancholic Europe and the Americas because of its commitment personality and of contemplative and introverted to medical innovation, discoveries, and education. character, was a scientist and a physician who, despite These important changes are also certainly credited having limited resources for most of his professional to Rokitansky’s endeavor. life, achieved scientific excellence through tireless Although Austria was recovering from two dedication. He left his mark in many studies and serious military defeats at the time, Rokitansky’s adult discoveries, and is one of the physicians who changed life took place in the city of Vienna, which became the history of medicine. the greatest cultural city in Europe, attracting nearly Karl Rokitansky died in Vienna on July 23, 1878. 2 million people. Eric Richard Kandel (winner of the He had been greatly bothered by bronchitis and Nobel Prize in Physiology/Medicine in 2000) wrote angina. The uncertain cause of death was reported that “liberal laws, of those days, were responsible for as myocardial ischemia or asthma. Ironically, the man the outstanding cultural and intellectual flowering who performed more than 30,000 autopsies was not in Vienna,” allowing for the free expression of the autopsied himself. ideas and artistry of a diverse group, which included The modern pathology, in fact, started with Sigmund Freud, Arthur Schnitzler, Johann Goethe, Rokitansky’s work, which was essentially based on gross Gustav Mahler, Gustav Klint, and Oscar Kokoschka, pathology. Later, the studies of Rudolph Karl Virchow, as well as the brothers Franz and Ferdinand Schubert which were extensively based on microscopy during and Johann and Richard Strauss. the last quarter of the 19th century, supplemented Physicians in the 19th century occupied the and expanded Rokitansky’s contributions. However, highest rung on the social ladder, although effective Rokitansky used the microscope on a very limited basis therapies were still limited. Bloodletting was the most as this was not the focus of his work. He described common way of treating fever, mercuric chloride was common diseases and recognized new ones as well the most prescribed drug, and surgery was unbearably as establishing the concept of the “disease process” painful until 1846 when ether anesthesia first by observing different stages of pathological change. appeared. Tuberculosis was a dreaded urban disease. However, to a degree, Rokitansky had traditional views It was so prevalent that it was considered by many to of the etiology of diseases until Virchow proclaimed be a hereditary disease.

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The 19th century also saw outstanding medical Bures J. Karel Rokitansky. Chicago: Hektoen Institute of contributions in other cities by physicians who Medicine; 2004 [cited 2016 Jan 16]. Available from: http://www.pro-folia.org/files/1/2004/1/rokitansky.pdf would also be renowned, including Richard Bright (who understood end-stage renal disease), Thomas Castagnoli L, Jonjic N, Rizzardi C, Melato M. Carl von Rokitansky and the Italian translation of the Handbuch Addison (who described pernicious anemia and the der Pathologischen Anatomie: a linguistic and degenerative disease of the adrenal glands), Thomas doctrinal enigma. Pathologica. 2001;93(6):654-61. Hodgkin (who recognized lymphoma and expanded PMid:11785117. the concept of the Morgagni autopsy), George Budd Gilder SSB. Karl von Rokitansky. CMAJ. 1954;71:70-2. (author of one of the first English-language liver disease Jay V. The legacy of Karl von Rokitansky. Arch Pathol Lab texts, describing what would become Budd-Chiari Med. 2000;124(3):345-6. syndrome), and the English naturalist Charles Darwin Lesky E. The Vienna Medical School of the Nineteenth (who published his theory of evolution in 1859). Century. Baltimore: Johns Hopkins University Press; 1976. Karl von Rokitansky was born into a century that Rumpler H, Denk H, Ottner C. Carl Freiher von Rokitansky was ripe for change in many areas. His contribution to (1804-1878): Pathologe – Politiker – Philosoph, Gründer advances in medicine, not only in his lifetime but also der Wiener Medizinischen Schule des 19 Jahrhunderts. in the future, cannot be underestimated. - Das Lebensbild eines Grossen Österreichers. Verlag: Wien – Kóln – Weimar, Böhlau; 2005. Sedivy R. Die Wiener Iniversitätspathologie – eine ACKNOWLEDGEMENTS Chronologie de lezten 200 Jahre. Wien Med Wochenschr. 2013;163:3015-9. The author is very thankful to the professors Sedivy R. Rokitansky und die Wiener Medizinishe Schule von György Miklós Böhm and Steven A Geller for the der Naturphilosophie zur Naturwissenchaft. Wien Med encouragement and corrections. Wochenschr. 2004;145(19-20):443-53. http://dx.doi. org/10.1007/s10354-004-0103-y. PMid:15560466. van den Tweel JG, Taylor CR. A brief history of pathology: BIBLIOGRAPHY preface to a forthcoming series that highlights milestones in the evolution of pathology as a discipline. Virchows American Medical Association. Karl von ROKITANSKY (1804- Arch. 2010;457(1):3-10. http://dx.doi.org/10.1007/ 1878). JAMA. 1963;183(13):1106-6. http://dx.doi. s00428-010-0934-4. PMid:20499087. org/10.1001/jama.1963.03700130073016. Weyers W. Carl Rokitansky: his life, work, and contributions to dermatopathology on the occasion of his 20th Batt RE. A history of endometriosis. Saint Louis Park: London birthday. Am J Dermatopathol. 2004;26(5):431-8. http:// Limited; 2011. http://dx.doi.org/10.1007/978-0-85729- dx.doi.org/10.1097/00000372-200410000-00013. 585-9. PMid:15365376. Buklijas T. Cultures of death and politics of corpse Whonamedit? A dictionary of medical eponyms. 2016 [cited supply: anatomy in Vienna, 1848-1914. Bull Hist 2016 Jan 16]. Karl Freiherr von Rokitansky. Available Med. 2008;82(3):570-607. http://dx.doi.org/10.1353/ from: http://www.whonamedit.com/doctor.cfm/981. bhm.0.0086. PMid:18791297. html

Correspondence Fernando Peixoto Ferraz de Campos Internal Medicine Division - Hospital Universitário - University of São Paulo Avenida Professor Lineu Prestes, 2565 - São Paulo/SP – Brazil CEP: 05508-000 Phone: + 55 (11) 3091-9275 E-mail: [email protected]

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