Medicine: Europe and the United States

Harry W Paul. New Dictionary of the History of Ideas. Editor: Maryanne Cline Horowitz. Volume 4. Detroit: Charles Scribner’s Sons, 2005.

Organized societies such as Babylon and ancient Egypt supported the practice of professional medicine, including surgery, but it was in Greece that European or, more cosmically, Western medicine first emerged after the fifth century B.C.E., when the classic texts began to appear.

Ancient Greece and Rome

The ancient Greeks had many ways of healing the sick. Plant gatherers and drug sellers, especially of herbal medicines, were the key people in the establishment of the vast Greek pharmacopoeia. Women healers had their own special categorization. And there were two groups making up a motley crew specializing in diagnosis and treatment calling on the gods and their evil relatives. One constant in Greek medicine was the existence of religious medicine, practiced in the sanctuaries of Asclepius, the Greco-Roman god of medicine. The heritage of Asclepius continues to survive in his professional symbol, the caduceus (one snake only). The medicine of the gods used declamation, singing, and music to speed up the healing process. Ancient Greeks, heavily invested in the “irrational, had more in common with Catholics who go to Lourdes for cures than with rationalist skeptics.

Hippocratic medicine

The most famous document in medical history, the Hippocratic Oath (c. 400 B.C.E.), which established a model of ethical and professional behavior for healers, invoked all the gods, beginning with Apollo. When did the epistemological rupture between mythical thinking and the sort of thinking flattered as scientific, implying a rupture between sacred and scientific healing, take place? The traditional answer is that the change occurred or at least is evident in the Hippocratic corpus, a diverse collection of sixty-odd works by different authors beginning in the sixth century B.C.E., cobbled together about 250 B.C.E. in the library at Alexandria. (A scholarly industry keeps changing the dates of composition of the works and squabbling about textual authenticity.) In the ongoing creation of the Western medical myth it is Hippocrates (the mythic father, also a real person living c. 460-370 B.C.E.) and his followers, who are given credit for establishing the rationalistic basis of scientific medicine. The text On the Sacred Disease (c. 410 B.C.E.) denies that epilepsy is a sacred disease, assigning it a natural etiology within the humoral paradigm based on the four body fluids: phlegm, yellow bile, black bile, and blood. (Epilepsy was caused by phlegm convulsing the body as it struggled to free itself from being blocked in the air passages.)

This Hippocratic corpus is notorious for having developed the theory of humors (chymoi), which provided a grid for many medical systems over the centuries. On the Nature of Man, an anatomical and physiological treatise, went farthest among the Hippocratic writings in the acceptance of the theory of the four humors. According to humoralism, a person’s physical and mental qualities are determined by the four chief fluids of the body, thus making it possible to explain health and disease in humoral terms, with health being an overall balance of the four humors. An upset in this balance, with too much or too little of a humor or two, produces disease. The grid of the system was composed of the humors associated with four organs and the qualities or nature of their products. The heart is associated with blood, warm and moist; the brain with phlegm, cold and moist; the liver with yellow bile, warm and dry; and the spleen with black bile, cold and dry. A sick person could correct an imbalance by taking substances characterized by the opposite qualities. In this scheme both people and medicinal substances had complexions and temperaments, that is, a defining humoral composition. The qualities of the humors were thought to correspond to the qualities of the basic elements of the universe: air, water, fire, and earth. This unified theory of humanity in the universe proved so satisfactory to the Western mind that the medical part of the theory was accepted, though much mangled, up through the eighteenth century. The theory “provided the ‘reasons’ for techniques of evacuation … such as venesection [blood-letting], cupping, cathartics, emetics, sneezing, sweating, [and] urination and so on” (Ackerknecht, p. 53). In the flexible Hippocratic humoral grammar the number of humors varied from one text to another. These humors also existed in a healthy person, though invisible to the medical gaze in this case.

The Hippocratic treatise On Regimen gave a great deal of attention to diet in the context of an active, well-regulated life. People absorb food and air, which become part of them and are also the main cause of internal diseases. Wine, which Louis Pasteur later classified as a food, was also an ideal item of medication, for it could be prescribed in many forms and was the best of excipients for the many herbs at the doctor’s disposal. Taken pure or mixed with other ingredients, wine could be tailored to individual constitutions. The text Affections praised wine and honey for both sick and healthy people. Wine could be mixed with honey or even milk. Greek civilization generally required that wine be cut with two or three parts water to one part wine, but the medical canon permitted the doctor to prescribe it pure or in a variety of mixtures, according to the seasons. In winter the heat and dryness of a small amount of pure wine could counter the baleful effects of humidity and cold. Sometimes doses were quantified, sometimes not.

Galen

By the third century B.C.E., Greek civilization had spread through the Mediterranean basin, blossoming brilliantly in Alexandria, where Ptolemy I ruled from 323 to 285 B.C.E. Hellenistic or Alexandrian medicine placed much emphasis on anatomy and physiology, with Herophilus of Chalcedon (c. 330-c. 260 B.C.E.) and Erasistratus of Chios (fl. 330-250B.C.E.) providing a mechanistic description of the organs of the human body; humoral theory played only a minor role. Dissection became an important tool in the advancement of medical knowledge, leading to the discovery of new organs such as the prostate and establishing the importance of the brain within the newly represented nervous system. Both theories and sects pullulated in Greek medicine, including groups now classified as empiricists, rationalists, and methodists. Healers became more clearly professional, though they were still trained privately rather than institutionally. By the time Rome conquered the Greek world in the second century B.C.E., Greek medicine was already leavening the simpler medical thought of the conqueror. Greek was a technical language designating diseases, remedies, and instruments for which words had not yet been invented in Latin, but sometimes with the arrival of new works in medicine and in botany Greek terms drove out Latin words in professional discourse. Many of the Roman healers were not citizens, and some were even slaves without civil rights, thus ensuring low social status for most physicians.

The most famous doctor in the history of medicine between Hippocrates and Sigmund Freud was a Greek practicing in the Roman Empire. Other names (Aretaeus of Cappadocia and Soranus and Rufus of Ephesus, for example) earn a paragraph or so in medical history books but only in the shadow of Galen (129-216 C.E.). After arriving in Rome in 161 he gained a reputation in treating upper-class patients, became physician to the imperial family, and pioneered in sports medicine as official physician to the gladiatorial school. He was one of the greatest scribblers in the history of medicine; the classical philologist Ulrich von Wilamowitz-Moellendorff (1848-1931) called him a windbag. He produced works running the gamut from On Bones for Beginners to his more philosophical work, On the Therapeutic Method. Much was just lifted wholesale from other authors. Galen believed that the physician is a philosopher as well as a healer. A good case can be made for Galen’s being “the central figure in the development of the Western tradition of medicine,” as Vivian Nutton points out, especially in his transmission of a Galenized Hippocratic gospel to posterity (p. 58). The great clinician, perpetuator of the tradition of bedside medicine, at least for his wealthy clients, stands out also for his discoveries through experiments on animals and for diagnosis and surgery. Dissection of human corpses and, possibly, vivisection of living criminals had gone out of style, with animals replacing the cadavers and victims. Galen left significant errors for other great minds to correct—in clinical medicine as well as in physiology and anatomy. His legacy was eclipsed by the breakup of the empire accompanied by economic and urban decline.

The Medieval World

With the rise of Christianity in late antiquity, medicine gave a greater role to religion; miracles became more important than enemas. Earlier medieval Christianity did preserve a certain amount of learned medicine in encyclopedias, and the creation of “great texts” gave a coherence and canonic orthodoxy to an ossified Galenism that survived into the seventeenth century. Folk or popular medicine was also incorporated into medical literature, though it is doubtful that it was practiced more widely than in antiquity. In terms of remedies, there was a great deal of overlap between popular and professional medicine. The Liber simplicis medicinae (Book of simple medicine, c. 1150-1160) by the famous healer Hildegard von Bingen provided an encyclopedia of these traditional remedies, many herbal and some fantastic, for numerous ailments.

Arabic-Islamic medicine

During the Middle Ages the most dynamic and learned European medicine was Arabic or Arabic-Islamic, though there is little in the Koran about medicine. Arabic medicine down to the eighth century was based on popular practices using amateria medica of natural items, organic and inorganic, including camel urine as a general tonic. Urine (along with feces) was also an important ingredient of European Dreckapotheke (filth pharmacy). Greek humoral medicine, based on a secular culture, probably survived among the elite in cities of the eastern part of the Roman Empire, even after the Arab conquests. Greek medicine revived in ninth-century Baghdad, chiefly as a result of a the translation of Greek texts into Arabic. The works of Galen, the medical culture hero, became the vehicle of Hippocratic medicine in the Eastern and Western caliphates, especially in Muslim Spain.

By the eleventh century, a vast body of translations with commentaries was augmented by an original medical literature in Arabic. Arab-Islamic medicine produced remarkable summas based on a wide range of sources. As in the written history of Western medicine, historiography tends to emphasize the importance of great physicians, both for their clinical acumen and for the famous works they spawned. Among the great Persians were the philosopher-physician al-Razi (c. 865-925), a critical disciple of Galen; the prolific Avicenna, (Ibn Sina; 980-1037), author of the Canon or the medical code, a million-word everything-you-need-to-know for doctors; al-Zahrawi, who wrote a classic text on surgery (mostly cautery in Arab-Islamic medicine); Averroës (Ibn Rushd; 1126-1198); and Moses ben Maimon (Maimonides; 1135-1204), who ended up in Cairo as court physician to Saladin (1138-1193). Razi’s work On Measles and Smallpoxwas still useful enough to be published in English by the Sydenham Society in 1848. Spread over a vast empire, Arab-Islamic medicine vastly expanded the healer’s pharmacological arsenal with drugs and remedies from Persian and Indian sources, created the first pharmacies, and laid the chemical (alchemical) foundations of modern pharmacy. The vocabulary of European languages was considerably enriched by this activity and by the creation of medical discourse. Medical education was still mostly a private affair, except in the hospital, an important fixture in cities. Roman hospitals had been restricted to soldiers and slaves; Islamic hospitals open to all (a pious hope) were real medical institutions. In 1365 Granada established the first European mental hospital, following the pioneering institutions in other Islamic countries. It looked as if Greek medical glories had been restored and improved.

How it all came to an end is open to debate. Erwin Ackerknecht explained the decline of Arab-Islamic medicine in Gibbonian terms: early Arab tolerance was submerged in Islamic fanaticism. Just add the triumph of the barbarians and one has a crude version of Edward Gibbon’s (1737-1794) model of the decline and fall of the Roman Empire. Christians conquered Cordova in 1236; the Mongols sacked Baghdad in 1258; the Ottoman Turks conquered the Levant—Constantinople fell in 1453—and swept into the Balkans and the Mediterranean. Arab civilization declined after the thirteenth century, but the old medical system survived, especially in the Ottoman Empire, until the nineteenth century and continues to survive in a form known as Yunani medicine (Unani tibb, Greek medicine) on the Indian sub-continent. What influence Arab-Islamic medicine had on the rise of the medical profession in medieval Europe is open to speculation, but it is clear that Arab medicine exercised a powerful intellectual influence on the revival of Greek medicine in the early medieval period.

Medieval physic

This revival of formal medicine in the West began in the southern Italian town of Salerno, a dynamic, multiethnic place under Norman power; the town is a hundred miles south of the great monastery of Monte Cassino, whose library held a collection of medical texts, and which stimulated an interaction with Salerno. The teachers at the medical school in Salerno developed a good curriculum, founded on their translations of the great texts of Greek (from Arabic) and on Arab medicine. Constantine the African (Constantinus Africanus; c. 1020-1087) was instrumental in transmitting a Galenized Hippocrates to the Latin world with its new concepts, couched in a new technical vocabulary, in anatomy and physiology. By the thirteenth century, an enriched Arabic-tinted medical Latin identified medicine as a separate and elite discipline—and a few centuries later provided medical discourse for Molière. The new medical canon, flattered as the Little Art of Medicine (Articella) in the sixteenth century, was based on a group of translated works, especially Constantine’s version of the Liber ysagogarum (Medical questions) or introduction of Hunayn ibn Ishaq al ibadi(Johannicius). This work became the basis for the medical teaching of the difficult art of diagnosis and of the gamble of therapy—Constantine’s book on drugs, the Antidotarium, expanded the therapeutic repertoire. This introductory book emphasized the therapeutic need to regulate Galen’s “six nonnaturals” (food and drink; sleep and waking; environment; evacuation, including sexual; exercise; and mental state) in order to preserve the natural humoral balance in the body, thus avoiding illness, or to restore balance, thus curing an illness. This emphasis on regimen or lifestyle was made famous in the popular Regimen sanitatis salernitanum, a book of verses perhaps concocted by Arnau de Villanova (c. 1235-1312), physician to the high and mighty (popes and kings) and professor at the University of Montpellier. Many popular works adopted this holistic framework in giving advice to the sick and those trying to stay healthy.

With the economic revival of Europe in the period 1200-1350, there appeared an age of construction in hospitals and universities as society invested in the care of the sick and the production of clergy, lawyers, teachers, and doctors. Medical education, when it was organized in places such as Bologna and Montpellier, was a long, tedious affair (about ten years) attempted by few. Padua, degree mill of the age, granted nine medical and surgical degrees in 1450; it had a large faculty of sixteen. Europe probably produced enough physicians to treat elite patients and to discourse with them in the Aristotelian lingo they both had ingested in the faculties. The rest of the population cured themselves or depended on charlatans (not necessarily a pejorative designation) or empirics of varying degrees of ignorance and skill. Neither doctor nor empiric could do much in dealing with smallpox, influenza, insanity, leprosy (a popular diagnosis in the eleventh and twelfth centuries), and the Bubonic plague (1347-1351), which killed off about a quarter of the European population. The wise doctor limited himself to dietetics, according to the Galenic gospel of the “nonnaturals,” some drugs, and a bit of minor surgery. With a degree and well-heeled patients, he could become rich. There was not much competition. In 1454 Vienna, with a population of fifty thousand, had eleven M.D.s.

Medieval surgery

Surgery, often identified as a craft, has sometimes been promoted to the status of an intellectual adventure. It was certainly a dangerous though not necessarily fatal adventure to have surgery in pre-Listerian times. Roman surgery can appear “remarkably modern,” meaning comparable to the surgery of the 1970s (Nutton, p. 57). Great surgeons such as John Bradmore (d. 1402), John of Arderne (c. 1307-1370, and Henri de Mondeville (c. 1260-1320) were remarkably successful in carrying out dangerous operations, some on the battlefield, often improving on ancient techniques. It is not surprising that mortality rates were high; what is surprising is the survival of a patient exposed to massive infection. The ancient technique of using wine to irrigate wounds and incisions is probably one part of the explanation. Surgeons liked to write as well as cut. The leading surgeons produced classic texts, thus following in the literary Hippocratic-Galenic tradition. Outside Italy surgery may not have been a respectable part of the curriculum, but from the twelfth century on, leading surgeons were closer to physicians than to barber-surgeons and empirics; in some towns cooperation between all groups was more striking than clashes. Even snarling Parisian surgeons and physicians could come to a limited agreement in 1210 over dissections. While the doctor envied the surgeon’s skill, the surgeon lusted after the doctor’s cultural capital and academic baggage. The social status of surgery was helped by the official role of the surgeon in autopsies for investigations of homicide and in the public dissection of criminals. The growing importance of anatomy (including the dissection of human corpses) in medical education during the fourteenth century also promoted the surgeon. Medicine and surgery had become part of society in an unprecedented way as a result of the new governmental function of practitioners and the related development of institutions.

Renaissance Medicine

In the sixteenth century, Greek medicine was reborn yet again but with a difference. The upside of the fall of Constantinople was an influx of Greek scholars and manuscripts into Italy. A scholarly industry soon developed for the study of ancient Greece and for the publication of the works forming the basis of Western civilization, including medicine. In 1525 the Aldine Press in Venice published Galen’s complete works in Greek. (In the sixteenth century 590 different editions of Galen were published.) The next year Aldine also published the Hippocratic corpus. New Latin translations soon appeared for the Greekless. Medical humanism was on a solid footing; what the return to a true Galenism meant for the practitioner and patient is not clear, except for a new emphasis on the etiology of disease and the tailoring of therapy to a profile of the individual patient. Clinical bedside teaching—its origins are piously traced back to Hippocrates—was integrated into medical education at Padua in 1578 by Giambatista da Monte (1498-1552), who was also keen on method as the key to knowledge and practice. Galen’s Method of Healing, brought up to date by the professors, could put doctors on an infallible path to correct diagnosis and treatment. All they had to do was look in apractica, or crude physician’s handbook, whose professorial prolixity often reduced its usefulness.

The new anatomy

Historians agree on the main developments in Renaissance medicine: first, the revival of a modestly revised Galenism; second, the related renewal of anatomy, which was linked to the flourishing artistic culture in Italy. Artists used the knowledge from dissection as the conceptual foundation of the new art. Anatomical texts illustrated by artists displayed a representational, natural body rather than the pedagogical schematic model of medieval texts. Michelangelo collaborated with Realdo Colombo (1516-1559), who in 1548 became professor of anatomy at the Papal University in Rome. A great deal of the new work in anatomy was concerned with modifying Galen, who had sometimes extrapolated from animal to human anatomy, as in the case of the five-lobed liver. The major demolition job on Galen was done by one of his most fervent disciples, Andreas Vesalius (1514-1564), who in 1537 moved to Padua, took his degree and, though an academic physician, became lecturer in anatomy and surgery. Influenced by the Bolognese model, Vesalius increased his dissecting activity—a sympathetic judge increased his supply of cadavers of executed criminals—and by lecturing while dissecting, he integrated physician, anatomist, and surgeon and gave a coherence to the subject. In 1543 Vesalius published De humani corporis fabrica (On the fabric of the human body), a great classic of descriptive anatomy. This book was “the first proper account of human anatomy” (Wear, p. 275); the artistic but scientifically precise illustrations were a key part of the text. By his teaching and book, Vesalius eventually changed the way doctors understood the human body, ensured the triumph of an anatomical method based on dissection and observation, and left future investigators plenty of problems to solve within the emerging physiological paradigm. Galenic views on the blood and the heart, or his cardiovascular system, came to be recognized as seriously flawed. The new model was completed grosso modo in 1628, when William Harvey (1578-1657) published An Anatomical Essay Concerning the Movement of the Heart and Blood in Animals (De motu cordis).

The Harveian Revolution (Seventeenth Century)

Until the seventeenth century, medicine operated within the context of the Galenic blood system, or rather, two blood systems. Using chyle (concocted in the stomach from food), the liver produced venous blood, which moved through the veins to various parts of the body to provide for nourishment and growth. The heart was the source of arterial blood, a concoction of venous blood, and pneuma (vital air, the stuff of life), which also moved through the body as needed. The venous blood seeped from the right side to the left side of the heart through invisible pores in the interventricular septum. The air came from the lungs via the venal artery (today’s pulmonary vein). Blood did not return to the heart but was consumed: no circulation. This coherent, rational system, concordant with major therapies, also explained mental functions by diverting a little arterial blood for conversion into animal spirits (highly refined spirituous air) to flow though the nervous system.

Movement of the heart and blood

Harvey was a Cambridge man who took his medical degree at Padua, where he worked under Girolamo Fabrici (Fabricius ab Aquapendente; c. 1533-1619), the first anatomist to discuss the venous valves (De venarum ostiolis; 1603). By the time Harvey arrived in Padua, Galen’s model had been seriously damaged, though no one had thrown Galen’s works into a bonfire, as Paracelsus had supposedly done with Avicenna’s Canon in 1527. Vesalius had denied the origin of the vena cava in the liver and, in the second edition of De humani corporis fabrica, the theory of the porous septum in the heart. After some vivisectionist experiments, Columbo argued for the pulmonary transit, or movement of blood though the lungs, and also described accurately the action of the heart in systole and diastole. Other anatomists confirmed these discoveries.

On his return to England, Harvey practiced in London, becoming one of the city’s most famous doctors and after 1618 one of the royal physicians. De motu cordis does not introduce its great novelty, the circulation of the blood, until chapter eight, and then only apologetically in an Aristotelian, vitalistic framework. Unlike René Descartes (1596-1650), Harvey was not a mechanist. His work was based on dissection, vivi-section, and a famous quantitative experiment in which he measured the amount of blood passing thorough the heart in a given time, thus showing that the system had to circulate the same blood or explode. Of course Harvey’s argument on circulation was incomplete because he could not see the capillaries, though he inferred their existence; Marcello Malphighi (1628-1694) used a microscope to discover them in a frog’s lungs (On the Lungs, 1661). Robert Hooke (1635-1703) as well as an Oxford group pinpointed the importance of the mixing of air and blood in the lungs. (An explanation of respiration, completing the system, was not possible before the chemical revolution of the late eighteenth century.) Galenic physiology, with the liver as a blood-making organ, became untenable, as Jean Riolan the Younger (1580-1657) recognized in a weak scientific attack on Harvey, who had little trouble in showing it to be nonobservational nonsense. Physicians were too conservative to abandon the Galenic practice of venesection, and this points to a problem of new medical science: the development of a related therapy is usually in the future, leaving doctor and patient both victims of the old science with its traditional therapeutics.

Paracelsus: Crude chemotherapy

The end of Galen’s iconic status was balanced by a revival of Hippocrates, the perfect cover for an attack on orthodoxy. Paracelsus (Bombast von Hohenheim; 1493-1541) denounced learned medicine but praised Hippocrates, a curious patron for his brand of medicine based on the Christian religion, magic, astrology, observation, and personal experience. Ackerknecht called him a “medical Doctor Faustus” (p. 108). Paracelsus’s cosmic “doctrine of signatures” identified the curative power of plants according to their resemblance to the organ affected; this was a pretty standard belief in popular medicine as well. In his natural philosophy, the Aristotelian-Galenic system of qualities, elements, and humors was replaced by a chemical fantasy associating substances with principles of solidity (salt), inflammability (sulfur), and spirituousness (mercury). Specific remedies of this chemical therapy cured specific diseases, whose agents might be poisons from the stars or from minerals on earth. Paradoxically, the advocate of the idea of a chemical etiology of and cure for diseases is the culture hero of alternative medicine. He was antiestablishment. Reading deeply into the book of nature, he concluded that therapy should be based on the principle of “like cures like”: applying what is suitable to the affected part, rather than following Galenic therapeutics based on the principle of opposition. Paracelsus had many followers, the most famous being Jan Baptista van Helmont (1579-1644), master of medical chemistry (iatrochemistry) and defender of the ontological concept of disease, meaning that every disease has its own unique principle and therefore a specific treatment. The theory was useful in attacking blood-letting as a debilitating practice based on the erroneous idea that plethora causes disease. But like its Galenic enemy, Paracelsan iatrochemistry declined in the second half of the seventeenth century. The choleric Harvey, no friend of chemistry, regarded the Paracelsans as “shitt-breeches.”

Sydenham: Bedside medicine

Unlike Harvey, Thomas Sydenham (1624-1689) was on the winning side in the English Civil War. Unlike Harvey, he did not have any scientific manuscripts for soldiers to destroy. Sydenham, an Oxford man scornful of learned medicine, advocated observation and the bedside tradition. His hero was Hippocrates, reinvented as an inspiring clinical spirit at the bedside. The “English Hippocrates” believed in specific remedies for diseases; cinchona bark against the ague (benign tertian malaria), for example. Unlike Harvey, Sydenham, accepting Francis Bacon’s (1561-1626) philosophy of science, was interested in classifying diseases, epidemic fevers in particular; the botanical model was useful here in his attempt to develop a clinical medicine for the London masses who suffered from the ague from March to July. In the midst of these conceptual upheavals on the functioning of the body and the nature of diseases, therapeutics changed little, except that a “new” disease like syphilis might require a “new” and horrible treatment (mercury). Herbal remedies continued in both popular and professional use. The old humoral procedures of bleeding, purging, induced vomiting, blistering, and cupping survived in the medical repertory. No wonder Sydenham admitted that without opium, medicine was a cripple. (Sydenham’s laudanum contained 200 grams of opium, 100 grams of saffron, and 15 grams each of cinnamon and of cloves in 100 grams of Malaga wine.) Sydenham doubted that using the microscope or studying anatomy would advance medicine. Prophecy should be left to the prophets.

From Enlightened to Clinical Medicine

The age of Enlightenment (and revolution), even in medicine, is how historians conceive of the eighteenth century. Centers of new or innovative medicine shifted over the centuries: ancient Athens and Rome, Salerno, Montpellier, Edinburgh, Leiden, Vienna, London, Paris, New York, and so forth. After the medieval creation of universities, learned or academic medicine, often connected to a clinic or a hospital, played a major role in reorienting medicine in theory and sometimes in practice. In spite of the profession’s hero worship of Hippocrates, what was going on in faculties of medicine by the late seventeenth century had little to do with classical medicine. At Leiden, then “the medical center of the world” (Ackerknecht, p. 130), teaching was organized on the basis of subjects rather than the teachings of the great doctors; bedside teaching and the dissection of corpses had also become important. Hermann Boerhaave (1668-1738) was at the center of the new dispensation. His students included the founders of the great centers of clinical medicine in Edinburgh and Vienna. Boerhaave, inspired by experimental natural philosophy, concocted a hydraulic model of the body with a corresponding mechanistic explanation of disease. His mighty text The Institutes of Medicine (1708) ran through ten editions and endured a few translations into vernacular tongues. In 1724 Boerhaave wrote up a famous case history of a male who had died of a ruptured esophagus. It can been argued that this was the first modern form of this literary genre, covering the patient’s history, a physical examination, a diagnosis, the course of disease, and an autopsy. Boerhaave developed a modern medical curriculum with a sequence of natural science, anatomy, physiology, and pathology, complemented by clinical instruction in a twelve-bed ward. This looks like the birth of that elusive entity the clinic; Michel Foucault insists that it was a protoclinic, for Boerhaave still struggled in the “old age of the clinic” (Foucault, ch. 4).

Pathological anatomy

It had become clear that death could give insight into disease, possibly even establish its cause. Though tedious to use because of its two correlating indexes, the prolix work On the Sites and Causes of Disease (1761), by the Paduan anatomist Giovanni Battista Morgagni (1682-1771), achieved part of its noble aim of establishing a connection between the patient’s symptoms and the lesions of the diseased organ in the corpse. Morgagni logged in some seven hundred autopsies. A new etiology of disease shifted it from a general theory to a specific organ, a site, where lesions produced by morbid changes in the organ could be matched with symptoms of disease in the patient. The London doctor Matthew Baillie (1761-1823) carried this anatomo-pathology further in a famous work on Morbid Anatomy … (1793), which provided classic textbook descriptions of diseases, including cirrhosis of the liver and emphysema.

In Paris the hospital came to dominate medicine through surgery and teaching. At the gigantic Hôtel-Dieu, Xavier Bichat (1771-1802) did six hundred autopsies as a basis for his Treatise on Membranes and his book General Anatomy applied to Physiology and Medicine (3 vols., 1801). Bichat’s famous, complex theory of tissues, or membranes, shifted the etiology of localized disease from the organ to lesions of specific tissues. This shift allowed a lesion to be more precisely identified according to the particular tissue affected rather than the whole organ: inflammation of the heart was replaced by identification of inflammation of membranes or the muscle itself. “Life, disease and death now form[ed] a technical and conceptual trinity,” as Michel Foucault put it in consecrating “death [as] the great analyst” (p. 144). Death, formerly the domain of the priest, had become part of medicine, and, along with life and disease, integrated into the medical gaze. Or, as Roy Porter puts it in ordinary discourse, Bichat’s “work laid the foundations for nineteenth-century patho[logical] anatomy” (p. 265). Medicine could become a science enabling diagnosis to be more precise. The tool was the modern physical examination (still the doctor’s best diagnostic tool), which consecrated the techniques of inspection, palpation, percussion, and auscultation. The patient’s symptoms and the signs detected by the doctor could be related to the lesions that had been observed in diseased organs. With a galaxy of stars—Jean-Nicolas Corvisart des Marets (1755-1821), René Laennec (1781-1826), and Pierre Louis (1787-1872) prominent among them—Parisian hospital medicine enjoyed its day in the sun as a model having considerable influence on medical thought and education.

The clinic

What was the clinic? The teaching clinic meant different things in different countries. In France clinical medicine put an emphasis on surgery, chiefly in large city hospitals. Military demand was a powerful stimulus to medical growth in the eighteenth century, and the need for army doctors rose during the French Revolutionary and Napoleonic wars. British clinical education was also mainly an affair of London institutions and provincial hospitals; Edinburgh and Glasgow resembled more the German model. In the German states small university-affiliated clinics and infirmaries provided practical education. The public hospitals of Paris had twenty thousand beds in which to stack, examine, and perhaps cure—an autopsy was more frequent—the city’s vast diseased population. Medicine in Paris distinguished itself by the accessibility of public hospitals to students wanting instruction from great men like Laennec and experience in bedside medicine and dissection. Lots of corpses were available, for mortality at the Hôtel-Dieu was about 25 percent, two and one half times that of most English hospitals. Foreign students and doctors found Restoration Paris a profitable place in which to learn the latest French medical fashion; on returning home, they carried versions of the French model with them to many cities, including Vienna, Boston, and even London. London, whose population reached a million and a half by 1831, developed large teaching hospitals. Paris, whose population did not reach a million until 1846, was notorious for its concentration of patients and after the 1830s the development of medical specialization. The bedside tradition foundered when dozens or even many more students crowded round the patient’s bed to receive the master’s instruction. More profitable instruction was to be had from private courses organized by Parisian doctors. Limits on numbers were also imposed through elite selection in intern and extern examinations. The lecture shifted to the amphitheater. In spite of the fame of Paris hospital medicine, a student got a better education in private instruction by a great man, perhaps even Laennec, who gave a private course in the small ward of a big hospital, thus providing the advantages of both pedagogical worlds.

From Clinical to Laboratory Medicine

Medicine was transformed institutionally, practically, and intellectually in the century after the 1750s. Medicine evolved from a cultural system to an occupation, as the practitioners of professional medicine grew in prestige and began to dominate their rivals, the charlatans or empirics of popular medicine.

Physiology

One of the striking intellectual developments of this period was the emergence of physiology as an autonomous experimental science, probably first in France through the work of Bichat, François Magendie (1783-1855), and Claude Bernard (1813-1878). Physiology distinguished itself by the use of operative or experimental surgery, which might be seen as a mutation of an ancient tradition running from the Alexandrian school through Galen to the Italian schools and Harvey. Much knowledge was gained; many animals were sacrificed. With the advent of Bernard, the historian passes into a different conceptualization of the development of medicine: from pathological anatomy in the hospital to medicine in the laboratory. Medicine seemed in danger of becoming obsessed with the pathological, always a danger in the doctor’s world of disease. Bernard’s physiological medicine showed how essential it was to understand the normal as well as the pathological, indeed, that there is only a narrow divide between them. Understanding the functions of an organ became central to understanding a disease. For example, Bernard’s experimental demonstration of the role of the liver in making glycogen and in regulating glucose levels in the blood provided the basis for understanding diabetes—an alteration or disorder in a normal function produced the lesion or disease. (The new world of internal secretions later gave rise to the science of endocrinology.) Such discoveries could only occur in a controlled laboratory experiment on an animal. Bernard’s view was similar to that of Rudolf Virchow (1821-1902): “Disease is nothing but life under altered circumstances.” Imitating Virchow, Canguilhem (p. 100) made a brilliant diagnosis: “Diseases are new ways of life.”

Medical science in Germany

In the middle of the nineteenth century the center of medical excitement and interest began to shift from Paris to German centers, where heavy investment in higher education had begun to pay large research dividends. The history of medicine at this point becomes of necessity rather Whiggish as discovery after discovery has to be cataloged, and the practice of medicine itself seems to have improved. Some of the progress was driven by instruments, especially the microscope, which had been of no interest to Bichat but was indispensable to Virchow, pathologist and Progressive politician. The great unifier of physiology and pathology, Virchow developed the medical implications of cell theory. To understand diseases, one had to understand the cell. From Morgagni’s emphasis on the organ to Bichat’s concentration on tissues to Virchow’s consecration of the cell (Cellular Pathology, 1858), medicine, like the other sciences, turned increasingly microscopic. The whole patient would soon be hard to find, but the German model of medical science became universally admired and imitated, especially in a few select American institutions (Johns Hopkins, Harvard, and the Universities of Pennsylvania and of Michigan). Of course it would be a while before the chasm between laboratory and hospital (and physician) would be bridged and the hospital would begin “to resemble a factory” (Porter, p. 347).

The immediate influence that experimental physiology had on the practicing physician is not easy to assess; the impact of sciences such as chemistry (in anesthesiology), microscopy, and bacteriology was much clearer by the end of the nineteenth century. Over the long haul no doubt physicians came to place considerable reliance on various physiological instruments to record and analyze data. Most of these instruments, like the kymograph, were invented and developed in the German states. The stethoscope replaced the urinal as the symbol of the profession. A much-improved microscope became indispensable to medical and biological research in the second half of the nineteenth century and, with the white coat, the accessory of the successful doctor. Wilhelm Conrad Roentgen discovered X-rays in 1895, and by the 1920s diagnostic medicine embraced X-rays for large masses of people. Physics was becoming an essential part of medicine, which by the early 2000s was integrated into the world of engineering and physics through CAT and PET scans and magnetic resonance imaging in order to model the structure and functioning of the body.

Women doctors

The autonomous and monopolistic organization of the medical profession under governmental protection is a late development in the history of medicine, essentially post-Revolutionary (1789). Universities assumed the primary role in medical education, though private schools or institutes and, above all, hospitals played major roles in Britain and France. Medical history teems with women healers, but they were not admitted to medical schools until the late nineteenth century, with resistance holding out until the early twentieth century in Germany. Fortunately for Russian Jewish women, Switzerland’s facilities were open, beginning with the University of Zurich in 1864. The mobilization and slaughter of male doctors in both world wars helped increase the number of women doctors, though Nazi Germany dealt a blow to the movement that had made one-fifth of the German medical profession female by 1933. After World War II, female enrollments in medical schools rose and continued to rise to near equality of the sexes (in numbers only) in the profession by the early twenty-first century. Not welcome in certain specialities such as surgery, women tended to go into general practice and areas of specialization such as bacteriology, anaesthesia, pediatrics, neuropsychiatry, dermatology, and nonsurgical gynecology.

The rise of psychiatry

An enormous number of drugs were available to healers from Hippocrates to Magendie, whose Formulary of 1821 introduced the notion of chemical purity into the pharmacopoeia. In the materia medica in use before the 1950s there is a striking absence of psychotropic drugs; the first, lithium, used to treat manic depression, dates from 1949. (Phenobarbital had been found effective against epileptic seizures in 1912.) So how did doctors treat mental disease? The answer is that they did nothing for most of medical history. “Madness” was generally not the province of the doctor, but of the churches and the family. “Madhouses” were generally charitable or religious institutions with medical connections until the nineteenth century, when the treatment of the insane evolved into a specialized branch of medicine. The development of psychiatry was accompanied by the rise of the “new” asylum—new because of its practice of a humane treatment of the mentally ill. Politicians in the late-eighteenth-century French state, converted to the scientific gospel, became convinced that madness could be cured, with the hospital functioning as a healing machine. Ideologue doctors such as Pierre-Jean-Georges Cabanis (1757-1808) provided epistemological (that is, scientific) respectability for medicine by emphasizing its roots in classification and a content related to sensationalist psychology.

The moral treatment, made famous by Philippe Pinel (1745-1826) at Bicêtre, the Salpêtrière, and Charenton, indulged in sympathetic but firm handling and even theatrical performances by the actor-inmates. “A historic transformation … in Paris” (Weiner, p. 275): the mentally ill were recognized as human beings with natural rights, and mental illness was classified as a curable disease. Doctors soon invented new categories of disease out of the old simple divisions of insanity; perhaps the most notorious new disease was Jean-Etienne Esquirol’s (1772-1840) concoction of monomania. Esquirol’s work Mental Illnesses, a classic text, was published in 1838, the year the government voted to create a national asylum system. The treatment of the insane became a matter of a scientific management of the mind and emotions rather than the traditional bleeding and purging of the body. Psychiatry arrived in the faculty of medicine in Paris in 1882, when the neurologist Jean-Martin Charcot (1825-1893) was appointed professor of diseases of the nervous system. There is no evidence that all this science and institutional growth contributed to a higher cure rate for patients suffering from the old mental diseases or even the new ones such as neurasthenia and hysteria, which some doctors attributed to industrial civilization. A desperate Western psychiatry indulged in thousands of lobotomies between 1935 and 1950.

As with clinical medicine, psychiatry in Germany (and Austria) differed from psychiatry in France and Britain in being connected directly with research-related university medicine, particularly neurology. Wilhelm Griesinger (1817-1868), professor of psychiatry and neurology in Berlin, developed a department for the study of mental disorders and founded the Archiv für Psychiatrie und Nervenkrankheiten (1868). Sigmund Freud (1856-1939) specialized in clinical neurology, but he recognized the bankruptcy of the old organic psychiatry, which attributed mental disorders to structural disease in the brain. Pinel had similarly become disillusioned with the hope of finding lesions in the brains of the mentally diseased. Freud’s new dynamic psychiatry with its radical views of the human personality is probably the most influential and most controversial medical paradigm in the history of Western civilization and its discontents. The success of the “talking cure,” or psychoanalysis, in treating mental disorders provided the basis for modern psychotherapy, but much of psychiatry has since followed the biochemical path to Prozac and other psychotropic drugs. The ideology of most German (and French) psychiatrists was scientific materialism, with their medical science being basically neurological and neuropathological. Medicine loves classification: German psychiatry was obsessed by it. The twenty-first century’s bible of the profession, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 4th edition, 1994) has its origin in the classification of mental disorders done by Emil Kraepelin (1856-1926), who drew on the work of several other men of method. To venture beyond the current DSM paradigm and DSM-IV framework, the powers in mental health issued A Research Agenda for DSM-V in 2002.

Did science matter?

Concluding his book on nineteenth-century scientific medicine, W. F. Bynum asked “Did science matter?” The answer is yes. Consider surgery. No branch of medicine changed more radically than surgery during the second half of the nineteenth century. Surgery itself had been socially and cognitively (through the study of anatomy) transformed by 1790. Surgery joined medicine as a liberal profession, that is, a group in possession of scientific or esoteric knowledge, transmitted through institutions; recognized by the state, the profession also controlled admission to its ranks and tried to control the practice of medicine within certain areas. The French doctorate in surgery, introduced in 1749, required a thesis in Latin, which nicely hid professional secrets from the polloi.

Reform of French medical education in 1794 integrated surgery into the regular training of doctors.

With the growing importance of the hospital and the increasing prestige of pathological anatomy, the professional status of surgeons soon equaled that of physicians. Whether chloroform did “a lot of mischief” by enabling “every fool to become a surgeon” (Sir Patrick Cullen, in Bernard Shaw’s Doctor’s Dilemma, 1906) is open to question. But it is certain that the cult of the surgeon could not have emerged at the end of the nineteenth century without anesthesiology. In 1846 the first amputation with a patient under ether was done in Boston; the next year James Y. Simpson (1811-1870), professor of obstetrics, first administered chloroform at the Infirmary in Edinburgh. The incorporation of bacteriology into surgical practice was equally important to the cult.

Germ theory

The medical acceptance of germ theory is a complex story. Since disease killed more soldiers than bullets, army doctors, desperate for an etiology and a therapy, were among the first to embrace the gospel of germs. The antiseptic, then aseptic practices of Joseph Lister (1827-1912)—Lister’s system—was inspired by his reading a paper on fermentation by Louis Pasteur (1822-1895). Listerism was accepted most enthusiastically in German-speaking areas, where there was also a striking development of surgery of the abdominal, thoracic, and cranial cavities, and, more controversial, the female reproductive system. Pasteur, accepting the idea that fermentation, putrefaction, and infection are related, developed a germ theory of infection. What distinguished his theory was a set of brilliant if controversial experiments on wine diseases, chicken cholera, anthrax, and rabies. Without understanding the immune system—researchers are still investigating how it works—Pasteur and his colleagues developed vaccines to prevent disease. Development of immunization against rabies (such as Creutzfeldt-Jacob disease, a frightening but minor killer) made it possible for Pasteur to collect enough funds to establish the Institut Pasteur (1888).

Bacteriology was largely a German creation. Robert Koch (1843-1910) identified major killers such as the tuberculosis and cholera bacilli and codified a method for investigating the etiology of infections. His students went on to identify the microorganisms causing a large number of diseases (diphtheria, typhoid, gonorrhea, and syphilis, among others) Koch spent the period from 1896 to 1907 in Africa studying its diseases; partly as a result of European invasions that displaced populations, millions of Africans suffered from helminth (intestinal worm) infections, in addition to germ and viral diseases. Many other medical researchers of the imperial powers also spent time in areas where tropical diseases presented a challenge not to be found in Europe. The germ-theory model of disease with its simple etiology did not work for diseases such as yellow fever and malaria; the parasitological model required the concept of a vector such as the mosquito. If the prion, which has no nucleic acids (DNA and RNA), causes bovine spongiform encephalopathy (BSE, popularly known as “mad cow disease”) and its human form, the “new” Creutzfeld-Jacob disease, then a new model of infection will appear in medicine.

With four institutes named after him, the imperious Koch went on to glory, though not so great as that of Pasteur, with whom he squabbled over the great germs of the day. Supported by well-developed chemical and pharmaceutical industries, German scientists were able to pioneer in serum therapy (antitoxins) and chemotherapy, whose most famous product might have been the arsenical compound salvarsan (not a magic bullet) for treating syphilis. More useful drugs to come out of Germany included chloral hydrate, aspirin, and phenobarbital. But no drug has ever been more useful or cheaper than quinine, the extract of the bark of the cinchona tree, used in fighting malaria, still one of the great killer diseases.

Public health

So what was the effect of all this progress in medical science on public health? Mortality did decline in the second half of the nineteenth century, particularly deaths from tuberculosis, scarlet fever, diphtheria, typhus, typhoid, cholera, and smallpox (mostly before 1850 in this case). The decline started before effective medical means could combat these diseases. Nonmedical factors seem to explain why people lived longer: first, improved nutrition, which made people more resistant to diseases such as tuberculosis; second, the attenuated virulence of some microbes, such as the diphtheria bacillus; third, effective public health measures such as supplying towns and cities with safe water, installing sewage systems, and clearing slums. The effect of the Malthusian check of infectious disease on population growth was severely reduced if not eliminated. The introduction of antibiotics lowered mortality even further. Sulfa drugs, the first effective step toward the control of bacterial diseases, became widely available only in the early1940s and penicillin shortly after.

The Twentieth Century: Science, State, and Business

Whiggish authors justifiably rave about the “stupendous progress” of medicine in the twentieth century; it was also the century that witnessed the greatest medical crimes in history.

Medical murder and human experimentation

Enthusiastically serving scientifically deluded politicians and bureaucrats, a large number of doctors turned medical research into a large-scale immoral and deadly science in the Japanese empire, the United States, and, above all, in Nazi Germany. Adopting eugenic policies, Nazi doctors and their collaborators sterilized hundreds of thousands of mentally handicapped and sick persons, epileptics, and alcoholics. Other countries—Sweden and the United States, for example—also pursued sterilization policies. Patients in mental hospitals were starved and, during World War II, gassed. A racial agenda supported cost-effective medicine. Human experimentation carried out by doctors flourished in certain death camps. Beginning with the postwar Nuremberg Code, international declarations have outlawed such medical horrors. A nonethical medicine has a murderous potential; so it is back to Hippocrates, the phoenix of Western medicine, who was also Heinrich Himmler’s medical hero.

Medical progress

By the end of the twentieth century, European medicine was remarkably similar to but not identical with American medicine in terms of clinical science, medical research, and surgery; it was different in its relations with the market economy, in the state’s provision of universal primary medical care as a basic service, and in its cultural values. For considerably less cost, Europeans were just as healthy and, in many groups, enjoyed greater longevity than Americans. “Big medicine,” which includes giant hospitals, often including extensive imaging and laboratory facilities, enormous bureaucracies, global drug companies, and large medical schools, was of course just as much a feature of the European as the American scene. Nowhere is this clearer than in the “war on cancer,” the most useful of diseases in the promotion of the modernization of medicine; cancerology became the growth model of big medicine. The conceptual basis of medicine has changed radically since the eighteenth century. The changes can all be blamed on discoveries in genetics, immunology, neurology, endocrinology, pharmacology, and, the stepchild of medical education, nutritional science.

Still, science cannot escape being part of culture. Even in the new surgical fields that have opened up in organ transplantation and in cardiology, certain cultural differences distinguish medical practice in different countries. German doctors, loving the heart above all other organs, are much more inclined to use drugs than surgery in treating cardiovascular diseases. The number of coronary bypass operations per 100,000 people in 1998 was 202 for the United States, 90 for Germany, and 35 for the United Kingdom; the last figure probably reflected a generally bad state of cardiovascular care. French doctors seem much more concerned with the functioning of the liver than doctors in other cultures; they are also much more conservative in n recommending hysterectomies. French doctors are too generous with the use of ionizing radiation—825 procedures per 1,000 inhabitants—nearly twice as many procedures as in Britain. Wherever one looks, health is a major European growth industry. There is no shortage of disease, including hypochondria. Every age seems to have its “epidemic”—in the early twenty-first century, it is HIV-AIDS. And with the doctor accepting the modern idea that a well person is only an insufficiently diagnosed patient, and genetic medicine aiming to define genetically determined disease susceptibility in individual patients, the normal may become, as in Jules Roman’s famous play Knock, the profitable pathological.