Note: This was a dramatic monologue given by Ed at a meeting of the Group for Resesarch in Pathology Education, Hershey, Pennsylvania. Direct quotations from the real Dr. Virchow are given in CAPITAL LETTERS.
Our next speaker is the founder of modern pathology. By age 25, he had already discovered fibrinogen, leukocytosis, leukemia, and myelin, worked out the conditions that predispose to thrombosis, explained and named pulmonary embolization, and refuted the current fad theory of disease -- the humoralism of "crases" and "dyscrasias" which prohibited surgery for localized lesions. He went on to establish the true nature of pus, necrotic cells, sarcomas, red infarcts, amyloid, metastatic calcification, erythrophagocytosis, uterine fibromyomas, brown induration of the lung, malaria pigment, trichinosis, echinococcal cysts, uric acid nephropathy, and psammoma bodies. He discovered and named neuroglia, gliomas, and giant cells. He coined the words "hyperplasia" and "ischemia", and named many of our common tumors. He wrote the first descriptions of the systemic fungal diseases, and discovered the amino acids leucine and tyrosine. He established that all cells today arise from pre-existing cells. In 1859, his book Cell Pathology became the foundation for all microscopic study of disease. Throughout the last third of the nineteenth century, he was the world's leading physician, plus Germany's leading anthropologist, sanitarian, and liberal politician. It was through his efforts that anatomic pathology became a required subject in medical schools. He is the author of over two thousand books and papers. It is a pleasure to introduce Dr. Rudolf Karl Ludwig Virchow.
Honored friends of the late twentieth-century, it is a great pleasure to visit you today and to be able to share some thoughts about disease, medicine, politics, and the critical role of pathology teachers in your world. I am amazed by the wonderful progress of pathology and of all science. I am thrilled by the growth of education and democratic institutions throughout most of the world. I am pleased that my ARCHIVES are now in their 411th volume. I see you still have THAT CRITICAL TURN OF MIND THAT (I always said) CHARACTERIZES PATHOLOGISTS MORE THAN ANY OTHER GROUP. I am also surprised that I can speak English without my German accent, and that I am suddenly ten inches taller.
What impressed me first was your extraordinary staining and photographic technology. I certainly enjoyed viewing the GRIPE slide collection -- the best of it's kind, I'm told. I learned your names for structures I discovered, and saw some new marvels. (I was intrigued by that contraceptive device inside a uterus in Slide 1375.) I never imagined that medical students would each have a microscope. When I lectured, I sent my microscope and slides from student to student on a specially-built model train.
In my time, I remarked that THE INTERVALS BETWEEN THE GREAT REVOLUTIONS OF MANKIND MUST BE SHORTENING. In visiting the late 20th century, I see scientific medicine has progressed far beyond what I thought possible in so short a time. HOW SATISFYING, HOW ENJOYABLE IT MUST BE TO SEE HOW, TO THE SEARCHING MIND, THE MIRACULOUS FORCES OF NATURE WILL REVEAL THEMSELVES! HOW HAPPY WILL THE SCHOLAR BE, WHEN AFTER NUMEROUS FUTILE ATTEMPTS HE DISCOVERS THE GREAT POWERS HIDDEN IN A SMALL PLANT WHICH GROWS, FLOWERS AND FADES UNNOTICED BY MOST! (When I first wrote these words, I never imagined that you would derive all of your most famous wonder drug, penicillin, from one moldy cantaloupe.) AND IT MUST BE AN EVEN MORE ELEVATING THOUGHT TO FINALLY HAVE ACHIEVED, AFTER YEARS OF EFFORT, A COMPLETE KNOWLEDGE OF THE HUMAN BODY, THIS MOST MIRACULOUS MASTERPIECE OF NATURE UNKNOWN TO SO MANY!
I titled my high school oration: "A LIFE FILLED WITH TOIL AND WORK IS NOT A BURDEN, BUT A BLESSING." I announced that my life's goal was to acquire "AN ALL-ROUND KNOWLEDGE OF NATURE -- FROM GOD DOWN TO THE STONES." In my era, I realized this dream through much hard work. In your own time, thanks to the growth of knowledge and education, it is easily within the reach of any interested layman.
When I was a young pathologist, the Berlin government assigned me to explain the 1847 epidemic in the province of Upper Silesia. I called the disease "typhus". It was probably the louse-borne rickettsial disease, or perhaps borreliosis -- relapsing fever. The province was home to several million peasants living in abject squalor. I reported, "THE UPPER SILESIAN IN GENERAL DOES NOT WASH HIMSELF AT ALL, BUT LEAVES IT TO CELESTIAL PROVIDENCE TO FREE HIS BODY OCCASIONALLY BY A HEAVY SHOWER OF RAIN FROM THE CRUSTS OF DIRT ACCUMULATED ON IT. VERMIN OF ALL KINDS, ESPECIALLY LICE, ARE PERMANENT GUESTS ON HIS BODY." The people subsisted on potatoes and vodka, with rare milk or sauerkraut, and were kept impoverished by absentee landlordism. Education in Upper Silesia was nonexistent because the people spoke only Polish while the teachers sent by the government spoke only German. Malaria and dysentery were endemic, and I also described what you call "kwashiorkor". The potato harvest had just failed, and it was during the famine that typhus appeared.
My study documented that, in Upper Silesia and elsewhere, epidemic disease reflected social problems. Typhus appeared when people were crowded or hungry. In my report, I said the problem and its solution were obvious. The cause of typhus was . . . misgovernment of the region by the stupid reactionary politicians in Berlin! I commented, "THE GOVERNMENT HAS DONE NOTHING FOR UPPER SILESIA". My only treatment plan was FULL AND UNLIMITED DEMOCRACY for the region. This would include admission of Polish as the official language, separation of church and state, shifting of taxes from the poor to the rich, improvement of agriculture, building of roads, forming of farming cooperatives, reopening of homes for orphans, and local administration of relief funds. MY POLITICS WERE THOSE OF PROPHYLAXIS, MY OPPONENTS PREFERRED THOSE OF PALLIATION. Of course the Berlin government fired me. I continued my research in a different pathology department.
By your standards, my politics were very moderate, but in my time I was a radical. In the revolution of 1848 I flourished my pistol, called my colleagues, "TO THE BARRICADES!" and fought in the streets. For us, the street fighting was THE GREAT FIGHT OF CRITICISM AGAINST AUTHORITY, OF NATURAL SCIENCE AGAINST DOGMA, OF THE ETERNAL RIGHTS AGAINST RULES OF HUMAN ARBITRARIENESS. THIS FIGHT WHICH HAD ALREADY TWICE SHAKEN THE EUROPEAN WORLD, BROKE OUT FOR THE THIRD TIME AND VICTORY WAS OURS. After we won, I served in the German parliament as a leader of the progressives, while continuing my medical work. I led the opposition to Bismarck's 1865 demand for an inflated military budget. Bismark was so angry that he challenged me to a duel. This entitled me to select the weapons, and I chose "two pork sausages -- a healthy cooked sausage, to be eaten by me, and an uncooked sausage loaded with trichinella larvae, to be eaten by Bismark."
When I called myself a "socialist" and a member of the "extreme left", I meant only that I knew things work best if people have a say in their own government, with access to education, good medical care, and other social services. I agitated for accurate vital statistics, secular nursing schools, free choice of physicians for charity patients, prohibition of child labor, decent custodial care for mental patients, adequate ventilation in worksites, hospitals, and barracks, compulsory meat inspection, and science education for all children in elementary school. I designed Germany's sewage systems, and used cost-benefit analysis to persuade the government to build them. I also performed the racial survey of German school children that refuted the myth of the blonde-haired, blue-eyed German race. I was very sorry to learn that some people in your century did not listen to my findings. Much of what I wrote sounds simplistic or commonplace to you, but my theme was always the same -- it is pathologists who need to educate people about the health consequences of their decisions.
In my era, pathology teachers had to contend with the ancient belief that disease was a spiritual process, or at least something that cannot be understood in terms of natural science. Throughout my career I maintained this was wrong. DISEASE IS NOT SOMETHING PERSONAL AND SPECIAL, BUT ONLY A MANIFESTATION OF LIFE UNDER MODIFIED CONDITIONS, OPERATING ACCORDING TO THE SAME LAWS AS APPLY TO THE LIVING BODY AT ALL TIMES, FROM THE FIRST MOMENT UNTIL DEATH. In turn, LIFE itself IS BUT THE EXPRESSION OF A SUM OF PHENOMENA, EACH OF WHICH FOLLOWS THE ORDINARY PHYSICAL AND CHEMICAL LAWS. I specifically denied THE EXISTENCE OF AN AUTOCRATIC VITAL OR HEALING FORCE. Medicine and science are things that every educated person should be able to understand. All this sounds familiar to you, but to many of my colleagues it was radical in the extreme.
Disease results when natural body processes occur at the wrong times and places. ALL PATHOLOGICAL FORMATIONS ARE EITHER DEGENERATIONS, TRANSFORMATIONS, OR REPETITIONS OF TYPICAL PHYSIOLOGICAL STRUCTURES. Pathology is really the study of physiology under abnormal circumstances. DISEASES ARE NEITHER SELF-SUBSISTENT, CIRCUMSCRIBED, AUTONOMOUS ORGANISMS, NOR ENTITIES WHICH HAVE FORCED THEIR WAY INTO THE BODY, NOR PARASITES ROOTED ON IT, BUT THEY REPRESENT ONLY THE COURSE OF PHYSIOLOGICAL PHENOMENA UNDER ALTERED CONDITIONS. THE GOAL OF THERAPY HAS TO BE THE MAINTENANCE OR THE REESTABLISHMENT OF NORMAL PHYSIOLOGICAL CONDITIONS. As medical students contemplate the failure of cancer chemotherapy for most of the common tumors, we can remind them that cancers are not parasites with selective vulnerability to certain antibiotics. In most cases, disease is not "other", it is "us". Because I focused on disease as altered "self", I rejected the idea that it could be caused by micro-organisms. I lived to see Louis Pasteur prove me wrong. Then I gave him the encouragement that led to his prevention of rabies -- the first use of laboratory science to actually conquer a disease.
Medicine is applied pathophysiology, and I always thought of politics, social science, and education as application of the techniques of medicine to the "body politic". The medical model made me think of the body itself as a republic. I liked to say that in both sickness and health, THE BODY IS A FREE STATE OF EQUAL INDIVIDUALS, A FEDERATION OF CELLS, A DEMOCRATIC CELL STATE. Cells FORM A FREE STATE OF INDIVIDUALS WITH EQUAL RIGHTS, THOUGH NOT EQUAL ABILITIES, WHICH PERSISTS BECAUSE THE INDIVIDUALS DEPEND ON EACH OTHER. Sometimes I was whimsical. I rejected various forms of vitalism as "MONARCHISM", and I protested when another pathologist called WBC's "sheriffs" rather than "health workers". Because the body can only be understood as a free and healthy community, I wrote that ONLY THE LIBERAL-MINDED CAN GAIN INSIGHT INTO THE NATURE OF MEDICINE. Further, AS A NATURAL SCIENTIST I CAN ONLY BE A REPUBLICAN -- in my time, this meant an advocate of parliamentary democracy, government by consent of the governed. THE REPUBLIC IS THE ONLY FORM of government IN WHICH THE CLAIMS DERIVED FROM THE LAWS OF NATURE AND THE NATURE OF MAN CAN BE REALIZED. MEDICINE IS A SOCIAL SCIENCE, AND POLITICS IS NOTHING ELSE BUT MEDICINE ON A LARGE SCALE. MEDICINE, AS A SOCIAL SCIENCE, AS THE SCIENCE OF HUMAN BEINGS, HAS THE OBLIGATION TO POINT OUT PROBLEMS AND TO ATTEMPT THEIR THEORETICAL SOLUTION: THE POLITICIAN, THE PRACTICAL ANTHROPOLOGIST, MUST FIND THE MEANS FOR THEIR ACTUAL SOLUTION.For me, even basic research is applied science. SCIENCE FOR ITS OWN SAKE, SCIENCE FOR THE SAKE OF MERE KNOWING I called theology. SCIENCE FOR ITS OWN SAKE USUALLY MEANS NOTHING MORE THAN SCIENCE FOR THE SAKE OF THE PEOPLE WHO HAPPEN TO BE PURSUING IT. KNOWLEDGE WHICH IS UNABLE TO SUPPORT ACTION IS NOT GENUINE -- AND HOW UNSURE IS ACTIVITY WITHOUT UNDERSTANDING. My goal as a scientist is TO EXPLORE THE NATURE OF MAN, AND TO GIVE TO THE INDIVIDUAL THE LARGEST POSSIBLE OPPORTUNITIES FOR NATURAL DEVELOPMENT. FROM THIS CERTAIN CONSEQUENCES DO STEM FOR PUBLIC AND PRIVATE LIFE, FOR EDUCATION AND HANDLING OF PEOPLE, THEREFORE ALSO FOR THERAPEUTICS AND PROPHYLAXIS. I urged medical educators to focus on the physiological and social aspects of disease and on using the methods of science to solve problems. I would not make medical students memorize vast numbers of scientific facts. This emphasis was restated in your own recent GPEP report.
IF MEDICINE IS TO FULFILL HER GREAT TASK, THEN SHE MUST ENTER THE POLITICAL AND SOCIAL LIFE. DO WE NOT ALWAYS FIND THE DISEASES OF THE POPULACE TRACEABLE TO DEFECTS IN SOCIETY? In my listing, "CROWD DISEASES" or "ARTIFICIAL DISEASES" caused by poverty included typhus, scurvy, TB, leprosy, cholera, relapsing fever, and mental illness. IF DISEASE IS AN EXPRESSION OF INDIVIDUAL LIFE UNDER UNFAVORABLE CIRCUMSTANCES, THEN EPIDEMICS MUST BE INDICATIVE OF MASS DISTURBANCES.
Since disease so often results from poverty, THE PHYSICIANS ARE THE NATURAL ATTORNEYS OF THE POOR, AND THE SOCIAL PROBLEMS SHOULD LARGELY BE SOLVED BY THEM. THE MEDICAL REFORM OF WHICH I often spoke WAS A REFORM OF SCIENCE AND SOCIETY. I urged that people treat criminal justice, education, unemployment, and occupational safety as if they are medical problems rather than political ones. Your era is beginning to do this.
I am happy to observe in your time that the health of people around the world is improving. This is due primarily to EDUCATION, WITH ITS DAUGHTERS, LIBERTY AND PROSPERITY. All of the public health measures I advocated now exist in your nation. In 1986, revolutions overthrew two notorious dictators who, rather than deal with the problems of poverty, systematically kept large numbers of people in chronic ill-health. Since my era, social and political progress has led to a revolution in the nature of disease in the developed world. In my autopsy series, more people died of rheumatic fever than of myocardial infarction, and more people died of pediatric respiratory infections such as whooping cough than died as adults of cancer. The change is due in part to the availability of doctors, hospitals, and antibiotics. But even more important are improved housing, mosquito abatement, sanitation, refrigeration, immunization, and nutrition -- the kind of interventions that I advocated.
For people to plan intelligently for the health of the community, they need accurate information about the causes and natures of diseases and injuries. Thanks to the efforts of pathologists and other physicians, the public is somewhat better informed. In some areas, physicians have taken the lead. For example, I am encouraged that physicians have taken a lead in warning people about the dangers of nuclear war.
Of course, you still have much work to do. In less prosperous nations, infectious diseases are still killing most people before maturity. One billion people are disabled by tropical parasites. Despite a world food glut, even more people suffer from chronic malnutrition. Ten thousand children die every day of diarrhea, and many nations accept this as the cheapest means of population control. IT IS THE CURSE OF HUMANITY THAT IT LEARNS TO TOLERATE EVEN THE MOST HORRIBLE SITUATIONS BY HABITUATION. I always maintained that the problems of poverty -- including population control -- will finally be solved only by democratization. EDUCATION, WEALTH AND FREEDOM ARE THE ONLY GUARANTEE FOR THE PERMANENT HEALTH OF A POPULATION. Like you, I recognized that many barriers remain before this is accomplished, and that implementing solutions to social problems will always be very difficult.
In your wealthy country, though, most of the principal killer diseases are related to the lifestyles of their victims. I once doubted that micro-organisms caused disease, but your own pathogens are obvious. Your "ARTIFICIAL DISEASES" result from addictions to tobacco, ethanol, and street drugs, unprotected and promiscuous sex, widespread breakdown of law, and acquired tastes for salt, grease, and physical idleness. Many people in your country consider these to be individual moral problems. I could never bring myself to believe this. I always maintained that they are social problems to be overcome by education and enlightened legislation.
For the illnesses that result from your peculiar health hazards, your expensive system of health care offers little help. You cannot really treat lung cancer, emphysema, cirrhosis, saddle embolus, immunodeficiency virus, stroke, suicide, or murder. Your elaborate interventions for atherosclerosis are only palliative. Studies among American Indians and in your urban slums show that massive health-care expenditures have little impact on the health of your poor. Even your health care system inflicts economic morbidity. Your society currently wastes $150,000 per year on each of the ten thousand patients you know are in irreversible coma. The medical costs for ten victims of your new epidemic disease, all of whom die, is equal to the total health care budget for many poor nations with several million sick people that could be helped. The usual cause of a well-to-do family's being reduced to poverty is medical bills, and your legal system prevents clinicians from withholding treatment in most cases. You spend twice what your British cousins spend per capita on health care, yet they are healthier. Your health care expenditures are added to the costs of your exports, pricing you out of world markets. Yet services for the mentally ill and for abused children barely exist in most communities. And because of public indifference and lack of prison space, you cannot even lock up most drunk drivers. The adversarial climate of health care, and its limited usefulness for most sick people, takes a great toll on idealistic young physicians as well. Two percent of internal medicine residents commit suicide during their training, and another five percent make attempts on their own lives. At the same time, public funds for basic medical research are now channeled into military spending instead. I once asked an American admirer, "DO THEY THINK IN YOUR COUNTRY THAT NOTHING IS PRACTICAL EXCEPT TO WRITE A PRESCRIPTION?"
Engels and Stalin smeared me, but more recently your Marxists -- including the pathologist Salvator Allende of Chile and the International Journal of Health Services -- have claimed me for their own. But unlike Communist ideologues, I made a practice of actually visiting the farms and factories I wrote about. And when I recommended change, it was based on natural science, not on economic mythology. While governments must fund research, government initiative cannot expect to solve medical problems. I even opposed what you call "socialized medicine". THE REAL CARE FOR THE HEALTH OF AN INDIVIDUAL MUST ALWAYS BE ROOTED IN THE SMALL CIRCLE OF PERSONAL FRIENDS, OF THE FAMILY OR THE COMMUNITY, AND I DO NOT SHARE THE OPINION OF SOME MODERN SOCIALISTS THAT IT SHOULD FALL WITHIN THE PROVINCE OF THE GOVERNMENT OR OF THE STATE. ON THE CONTRARY, I OPPOSE THE CENTRALIZATION OF LIFE IN THE HANDS OF A SUPREME STATE WITH ALL MY MIGHT. The health of people depends on freedom and on education. For this, pathology education holds the key.
During my last few minutes on earth, let me share a few thoughts about pathology education. First, all medical teaching is a humanitarian endeavor. MEDICAL EDUCATION DOES NOT EXIST TO PROVIDE STUDENTS WITH A WAY OF MAKING A LIVING, BUT TO ENSURE THE HEALTH OF THE COMMUNITY. In your era, your job is to educate other physicians, so they may diagnose and treat disease and also educate the public. Understanding pathology is the hardest task of the young physician. Learning treatments is easy -- typically, the treatments that work are simple, while those that don't work are very elaborate.
It is the pathologist who must equip all other physicians to teach patients. In one study from your own era, patients identified two most-desired qualities in a physician -- showing common courtesy, and taking time to educate them about their illnesses. They complained especially that physicians seldom explained what was wrong. Typically, doctors only gave instructions, or merely cited statistics. With so little information transmitted, is it any wonder that many patients don't follow the doctor's advice, and that quackery remains widespread?
Dr. Friedlander shared with me an experience as a junior medical student, when he cared for a noncompliant patient with a ten year history of severe renovascular hypertension associated with old radiation nephritis. On this admission, her BP was 240/180. Across the hall was a victim of a hypertensive cerebral hemorrhage who could only move his eyes and scream gibberish. Dr. Friedlander told the patient that she, too, was likely to burst a blood vessel in her brain, "like a pipe under too much pressure will burst". She immediately exclaimed, "Every doctor I ever saw gave me blood pressure pills, but none of them ever told me why it was important to take them!"
Could it be that physicians cannot come up with simple analogies like comparing a cerebral hemorrhage to "a bursting pipe", simply because they have forgotten most of their basic pathology? There is no need to make an internist into a diagnostic histopathologist. When you teach basic pathology, try to describe basic disease processes simply and vividly. Elementary reviews of basic pathophysiology, at conferences, in the lab, or even at the bedside, can greatly help physicians, and their patients, understand disease and make the right decisions. Patients will appreciate, and will probably act on, their better understanding of illness. And pathologists can help control medical costs by helping clinicians use the lab appropriately.
I have only one other suggestion for medical school teaching. Don't leave all mention of the social causes of disease to the social workers and statisticians. Lung cancer and emphysema are caused when ignorant children are lured into a deadly addiction. Endocarditis is caused by the cycle of poverty and lawlessness from which young people seek relief through IV drugs. Alcoholic cirrhosis is caused by frustrations that drive people to drink. I found that the people of Upper Silesia remained drunk to relieve the pain of oppression, just as the people in the Soviet Union and other slave states do in your day. Prematurity is caused by educational and economic barriers that prevent the poor from obtaining prenatal care. Urinary tract infections result when secretaries are forbidden to take unscheduled bathroom breaks, or when people are so accustomed to soda pop that they will not drink adequate water. Reasonable people can differ about solutions, but the underlying pathology is as much society's problem as it is the individual's. The pathology teacher, as a "doctor's doctor", has every right to describe what you call "social pathology".
Most pathologists could be superb public educators. In my era, my job was to educate politicians. In your time, you must educate the public as well. I said SCIENCE SHOULD SPEAK THE LANGUAGE OF THE COMMON PEOPLE. It is a real gratification to find that so many scientists write for the public, and as I predicted, interest runs very high. The public is fascinated by disease, and can understand all but the most technical aspects of medical pathology. I frequently lectured for the public. As community leaders, you have many opportunities to educate people in your communities. To discourage the intemperate drinking of alcohol, Dr. Friedlander tells me he has shown diseased livers and brains into prisons and churches. It is appropriate for you also to speak on local television and radio.
So these are my recommendations. First, keep reminding doctors of the mechanisms of disease, and make your descriptions simple and graphic. Second, remind students of the importance of social factors as causes of disease. Third, take advantage of opportunities to educate your neighbors about health concerns.
Right now, your politicians are considering mandatory lab testing for a new disease that can be avoided by using condoms. I would be in character by strongly opposing such compulsory testing. I am glad that most physicians, beginning with your own surgeon-general, see that disease education, not regimentation, is the best social solution.
In your time, may healthy, educated people around the world avail themselves of the benefits of democracy. MENTAL FREEDOM CANNOT EXIST APART FROM THAT OF THE BODY. FREE THINKERS WANT TO BECOME FREE PEOPLE TOO. Freedom from disease depends on knowledge. And this knowledge is best transmitted by my most special successors -- the world's pathology teachers.
DR. VIRCHOW'S REFERENCES
Ackerknecht, Erwin H., Rudolf Virchow: Doctor, Statesman, Anthropologist, Madison: University of Wisconsin, 1953.
Anonymous, "Rudolf Virchow, M.D. (1821-1902)", CA 25(2): 91-2, Mar.-Apr. 1975.
Anonymous, "Virchow: Gargantuan Appetite for Knowledge, Battles, Causes", Hospital Practice, 13(2): 123, Feb., 1978.
Bronkhous, Kenneth M., and Sommer, Elizabeth, "Why Virchow Became a Physician", Arch. Path. 85: 231, 1968.
Eisenberg, Leon, "Rudolf Ludwig Karl Virchow: Where Are You Now That We Need You?, Am. J. Med. 77(3): 524-32, Sept., 1984.
L.J. Rather, ed., Virchow, Rudolf, Rudolf Virchow: Collected Essays on Public Health and Epidemiology, Canton, Massachusetts: Science History Publications, 1985.
McLendon, William W., "A Historical Perspective as a Compass for the Future of Pathology", Arch. Pathol. Lab. Med. 110(4): 284-8, April, 1986.
Rather, L.J., tr., Disease, Life, and Man: Selected Essays by Rudolf Virchow, Stanford: Stanford University Press, 1958.
Rather, L.J., "Rudolf Virchow's Views on Pathology, Pathological Anatomy, and Cellular Pathology", Arch. Path. 82(3): 197-204, Sept., 1966.
Silver, George, "Virchow as a Role-Model", Lancet 2(8497): 34, July 5, 1986.
Silver, George, "Virchow, The Heroic Model in Medicine: Health Policy by Accolade", Am. J. Pub. Health, 77(1): 82-8, Jan., 1987.
Taylor, Rex, and Rieger, Annelie, "Medicine as Social Science: Rudolf Virchow on the Typhus Epidemic in Upper Silesia", Int. J. Health Services 15(4): 547, 1985.
Waitzkin, Howard, "The Social Origins of Illness: A Neglected History", Int. J. Health Services 11(1): 177-103, 1981.
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