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The History of Medicine: A Very Short Introduction (Very Short

Introductions)
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Very Short Introductions a&aila+le no.:
A#V>8TISI/G 4inston 9letcher
A98ICA/ HISTO80 :ohn $ar1er and 8ichard 8ath+one
AG/OSTICISM 8o+in 3e $oide&in
AM>8ICA/ $O3ITICA3 $A8TI>S A/# >3>CTIO/S 3) Sandy Maisel
TH> AM>8ICA/ $8>SI#>/C0 Charles O) :ones
A/A8CHISM Colin 4ard
A/CI>/T >G0$T Ian Sha.
A/CI>/T $HI3OSO$H0 :ulia Annas
A/CI>/T 4A89A8> Harry Side+otto(
A/G3ICA/ISM Mar1 Cha'(an
TH> A/G3OGSAO/ AG> :ohn 6lair
A/IMA3 8IGHTS #a&id #eGra7ia
A/TIS>MITISM Ste&en 6eller
TH> A$OC80$HA3 GOS$>3S $aul 9oster
A8CHA>O3OG0 $aul 6ahn
A8CHIT>CT%8> Andre. 6allantyne
A8ISTOC8AC0 4illia( #oyle
A8ISTOT3> :onathan 6arnes
A8T HISTO80 #ana Arnold
A8T TH>O80 Cynthia 9reeland
ATH>ISM :ulian 6a--ini
A%G%STI/> Henry Chad.ic1
A%TISM %ta 9rith
6A8TH>S :onathan Culler
6>STS>33>8S :ohn Sutherland
TH> 6I63> :ohn 8iches
6I63ICA3 A8CH>O3OG0 >ric H) Cline
6IOG8A$H0 Her(ione 3ee
TH> 6OO2 O9 MO8MO/ Terryl Gi&ens
TH> 68AI/ Michael OHShea
68ITISH $O3ITICS Anthony 4ri-ht
6%##HA Michael Carrithers
6%##HISM #a(ien 2eo.n
6%##HIST >THICS #a(ien 2eo.n
CA$ITA3ISM :a(es 9ulcher
CATHO3ICISM Gerald OHCollins
TH> C>3TS 6arry CunliIe
CHAOS 3eonard S(ith
CHOIC> TH>O80 Michael Allin-ha(
CH8ISTIA/ A8T 6eth 4illia(son
CH8ISTIA/ >THICS #) Ste'hen 3on-
CH8ISTIA/IT0 3inda 4oodhead
CITIJ>/SHI$ 8ichard 6ella(y
C3ASSICA3 M0THO3OG0 Helen Morales
C3ASSICS Mary 6eard and :ohn Henderson
C3A%S>4ITJ Michael Ho.ard
TH> CO3# 4A8 8o+ert McMahon
COMM%/ISM 3eslie Hol(es
CO/SCIO%S/>SS Susan 6lac1(ore
CO/T>M$O8A80 A8T :ulian Stalla+rass
CO/TI/>/TA3 $HI3OSO$H0 Si(on Critchley
COSMO3OG0 $eter Coles
TH> C8%SA#>S Christo'her Tyer(an
C80$TOG8A$H0 9red $i'er and Sean Mur'hy
#A#A A/# S%88>A3ISM #a&id Ho'1ins
#A84I/ :onathan Ho.ard
TH> #>A# S>A SC8O33S Ti(othy 3i(
#>MOC8AC0 6ernard Cric1
#>SCA8T>S To( Sorell
#>S>8TS /ic1 Middleton
#>SIG/ :ohn Hes1ett
#I/OSA%8S #a&id /or(an
#I$3OMAC0 :ose'h M) Siracusa
#OC%M>/TA80 9I3M $atricia Aufderheide
#8>AMI/G :) Allan Ho+son
#8%GS 3eslie I&ersen
#8%I#S 6arry CunliIe
TH> >A8TH Martin 8edfern
>CO/OMICS $artha #as-u'ta
>G0$TIA/ M0TH Geraldine $inch
>IGHT>>/THGC>/T%80 68ITAI/ $aul 3an-ford
TH> >3>M>/TS $hili' 6all
>MOTIO/ #ylan >&ans
>M$I8> Ste'hen Ho.e
>/G>3S Terrell Car&er
>/G3ISH 3IT>8AT%8> :onathan 6ate
>$I#>MIO3OG0 8oldolfo Saracci
>THICS Si(on 6lac1+urn
TH> >%8O$>A/ %/IO/ :ohn $inder and Si(on %sher.ood
>VO3%TIO/ 6rian and #e+orah Charles.orth
>IST>/TIA3ISM Tho(as 9lynn
9ASCISM 2e&in $ass(ore
9ASHIO/ 8e+ecca Arnold
9>MI/ISM Mar-aret 4alters
9I3M M%SIC 2athryn 2alina1
TH> 9I8ST 4O83# 4A8 Michael Ho.ard
9O8>/SIC $S0CHO3OG0 #a&id Canter
9O8>/SIC SCI>/C> :i( 9raser
9OSSI3S 2eith Tho(son
9O%CA%3T Gary Guttin-
98>> S$>>CH /i-el 4ar+urton
98>> 4I33 Tho(as $in1
98>/CH 3IT>8AT%8> :ohn #) 3yons
TH> 98>/CH 8>VO3%TIO/ 4illia( #oyle
98>%# Anthony Storr
9%/#AM>/TA3ISM Malise 8uth&en
GA3AI>S :ohn Gri++in
GA3I3>O Still(an #ra1e
GAM> TH>O80 2en 6in(ore
GA/#HI 6hi1hu $are1h
G>OG8A$H0 :ohn Matthe.s and #a&id Her+ert
G>O$O3ITICS 2laus #odds
G>8MA/ 3IT>8AT%8> /icholas 6oyle
G>8MA/ $HI3OSO$H0 Andre. 6o.ie
G3O6A3 CATAST8O$H>S 6ill McGuire
G3O6A3 4A8MI/G Mar1 Maslin
G3O6A3IJATIO/ Manfred Ste-er
TH> G8>AT #>$8>SSIO/ A/# TH> />4 #>A3 >ric 8auch.ay
HA6>8MAS :a(es Gordon 9inlayson
H>G>3 $eter Sin-er
H>I#>GG>8 Michael In.ood
HI>8OG30$HS $enelo'e 4ilson
HI/#%ISM 2i( 2nott
HISTO80 :ohn H) Arnold
TH> HISTO80 O9 AST8O/OM0 Michael Hos1in
TH> HISTO80 O9 3I9> Michael 6enton
TH> HISTO80 O9 M>#ICI/> 4illia( 6ynu(
TH> HISTO80 O9 TIM> 3eofranc HolfordGStre&ens
HIVKAI#S Alan 4hiteside
HO66>S 8ichard Tuc1
H%MA/ >VO3%TIO/ 6ernard 4ood
H%MA/ 8IGHTS Andre. Cla'ha(
H%M> A) :) Ayer
I#>O3OG0 Michael 9reeden
I/#IA/ $HI3OSO$H0 Sue Ha(ilton
I/9O8MATIO/ 3uciano 9loridi
I//OVATIO/ Mar1 #od-son and #a&id Gann
I/T>33IG>/C> Ian :) #eary
I/T>8/ATIO/A3 MIG8ATIO/ 2halid 2oser
I/T>8/ATIO/A3 8>3ATIO/S $aul 4il1inson
IS3AM Malise 8uth&en
IS3AMIC HISTO80 Ada( Sil&erstein
:O%8/A3ISM Ian Har-rea&es
:%#AISM /or(an Solo(on
:%/G Anthony Ste&ens
2A66A3AH :ose'h #an
2A92A 8itchie 8o+ertson
2A/T 8o-er Scruton
2>0/>S 8o+ert S1idels1y
2I>82>GAA8# $atric1 Gardiner
TH> 2O8A/ Michael Coo1
3A/#SCA$>S A/# C>OMO8$HO3OG0 Andre. Goudie and
Heather Viles
3A4 8ay(ond 4ac1s
TH> 3A4S O9 TH>8MO#0/AMICS $eter At1ins
3>A#>8SHI$ 2eth Grint
3I/CO3/ Allen C) Guel7o
3I/G%ISTICS $eter Matthe.s
3IT>8A80 TH>O80 :onathan Culler
3OC2> :ohn #unn
3OGIC Graha( $riest
MACHIAV>33I Luentin S1inner
MA8TI/ 3%TH>8 Scott H) Hendrix
TH> MA8L%IS #> SA#> :ohn $hilli's
MA8 $eter Sin-er
MATH>MATICS Ti(othy Go.ers
TH> M>A/I/G O9 3I9> Terry >a-leton
M>#ICA3 >THICS Tony Ho'e
M>#I>VA3 68ITAI/ :ohn Gillin-ha( and 8al'h A) Gri5ths
M>MO80 :onathan 2) 9oster
MICHA>3 9A8A#A0 9ran1 A) :) 3) :a(es
MO#>8/ A8T #a&id Cottin-ton
MO#>8/ CHI/A 8ana Mitter
MO#>8/ I8>3A/# Senia $aseta
MO#>8/ :A$A/ Christo'her GotoG:ones
MO#>8/ISM Christo'her 6utler
MO3>C%3>S $hili' 6all
MO8MO/ISM 8ichard 3y(an 6ush(an
M%SIC /icholas Coo1
M0TH 8o+ert A) Se-al
/ATIO/A3ISM Ste&en Gros+y
/>3SO/ MA/#>3A >lle1e 6oeh(er
/>O3I6>8A3ISM Manfred Ste-er and 8a&i 8oy
TH> />4 T>STAM>/T 3u1e Ti(othy :ohnson
TH> />4 T>STAM>/T AS 3IT>8AT%8> 2yle 2eefer
/>4TO/ 8o+ert IliIe
/I>TJSCH> Michael Tanner
/I/>T>>/THGC>/T%80 68ITAI/ Christo'her Har&ie and H) C) G)
Matthe.
TH> /O8MA/ CO/L%>ST Geor-e Garnett
/O8TH>8/ I8>3A/# Marc Mulholland
/OTHI/G 9ran1 Close
/%C3>A8 4>A$O/S :ose'h M) Siracusa
TH> O3# T>STAM>/T Michael #) Coo-an
$A8TIC3> $H0SICS 9ran1 Close
$A%3 >) $) Sanders
$>/T>COSTA3ISM 4illia( 2) 2ay
$HI3OSO$H0 >d.ard Crai-
$HI3OSO$H0 O9 3A4 8ay(ond 4ac1s
$HI3OSO$H0 O9 SCI>/C> Sa(ir O1asha
$HOTOG8A$H0 Ste&e >d.ards
$3A/>TS #a&id A) 8othery
$3ATO :ulia Annas
$O3ITICA3 $HI3OSO$H0 #a&id Miller
$O3ITICS 2enneth Mino-ue
$OSTCO3O/IA3ISM 8o+ert 0oun-
$OSTMO#>8/ISM Christo'her 6utler
$OSTST8%CT%8A3ISM Catherine 6elsey
$8>HISTO80 Chris Gosden
$8>SOC8ATIC $HI3OSO$H0 Catherine Os+orne
$8IVAC0 8ay(ond 4ac1s
$8OG8>SSIVISM 4alter /u-ent
$S0CHIAT80 To( 6urns
$S0CHO3OG0 Gillian 6utler and 9reda McManus
$%8ITA/ISM 9rancis :) 6re(er
TH> L%A2>8S $in1 #andelion
L%A/T%M TH>O80 :ohn $ol1in-horne
8ACISM Ali 8attansi
TH> 8>AGA/ 8>VO3%TIO/ Gil Troy
TH> 8>9O8MATIO/ $eter Marshall
8>3ATIVIT0 8ussell Stannard
8>3IGIO/ I/ AM>8ICA Ti(othy 6eal
TH> 8>/AISSA/C> :erry 6rotton
8>/AISSA/C> A8T Geraldine A) :ohnson
8OMA/ 68ITAI/ $eter Sal.ay
TH> 8OMA/ >M$I8> Christo'her 2elly
8OMA/TICISM Michael 9er+er
8O%SS>A% 8o+ert 4o1ler
8%SS>33 A) C) Graylin-
8%SSIA/ 3IT>8AT%8> Catriona 2elly
TH> 8%SSIA/ 8>VO3%TIO/ S) A) S(ith
SCHIJO$H8>/IA Chris 9rith and >&e :ohnstone
SCHO$>/HA%>8 Christo'her :ana.ay
SCI>/C> A/# 8>3IGIO/ Tho(as #ixon
SCOT3A/# 8a+ Houston
S>%A3IT0 VMroni?ue Mottier
SHA2>S$>A8> Ger(aine Greer
SI2HISM >leanor /es+itt
SOCIA3 A/# C%3T%8A3 A/TH8O$O3OG0 :ohn Mona-han and
$eter :ust
SOCIA3ISM Michael /e.(an
SOCIO3OG0 Ste&e 6ruce
SOC8AT>S C) C) 4) Taylor
TH> SOVI>T %/IO/ Ste'hen 3o&ell
TH> S$A/ISH CIVI3 4A8 Helen Graha(
S$A/ISH 3IT>8AT%8> :o 3a+anyi
S$I/OJA 8o-er Scruton
STATISTICS #a&id :) Hand
ST%A8T 68ITAI/ :ohn Morrill
S%$>8CO/#%CTIVIT0 Ste'hen 6lundell
T>88O8ISM Charles To.nshend
TH>O3OG0 #a&id 9) 9ord
THOMAS AL%I/AS 9er-us 2err
TOCL%>VI33> Har&ey C) MansNeld
T8AG>#0 Adrian $oole
TH> T%#O8S :ohn Guy
T4>/TI>THGC>/T%80 68ITAI/ 2enneth O) Mor-an
TH> %/IT># /ATIO/S :ussi M) Hanhi(O1i
TH> %)S) CO/C8>SS #onald A) 8itchie
%TO$IA/ISM 3y(an To.er Sar-ent
TH> VI2I/GS :ulian 8ichards
4ITCHC8A9T Malcol( Gas1ill
4ITTG>/ST>I/ A) C) Graylin-
4O83# M%SIC $hili' 6ohl(an
TH> 4O83# T8A#> O8GA/IJATIO/ A(rita /arli1ar
48ITI/G A/# SC8I$T Andre. 8o+inson
AVAI3A63> SOO/:
3AT> A/TIL%IT0 Gillian Clar1
M%HAMMA# :onathan A) 6ro.n
G>/I%S Andre. 8o+inson
/%M6>8S $eter M) Hi--ins
O8GA/IJATIO/S Mary :o Hatch V>80 SHO8T I/T8O#%CTIO/S
V>80 SHO8T I/T8O#%CTIO/S are for anyone .antin- a
sti(ulatin- and accessi+le .ay in to a ne. su+,ect) They are
.ritten +y ex'erts, and ha&e +een 'u+lished in (ore than !D
lan-ua-es .orld.ide)
The series +e-an in C@@D, and no. re'resents a .ide &ariety
of to'ics in history, 'hiloso'hy, reli-ion, science, and the
hu(anities) The VSI 3i+rary no. contains o&er !<< &olu(esGa
Very Short Introduction to e&erythin- fro( ancient >-y't and
Indian 'hiloso'hy to conce'tual art and cos(olo-yGand .ill
continue to -ro. to a li+rary of around F<< titles)
V>80 SHO8T I/T8O#%CTIO/S AVAI3A63> /O4
9or (ore infor(ation &isit our .e+ site
...)ou')co)u1K-eneralK&siK
TH> HISTO80 O9 M>#ICI/> A Very Short Introduction
4illia( 6ynu(
9or Helen Sine ?ua non
Contents
Ac1no.led-e(ents 3ist of illustrations Introduction: the 1inds
of (edicine C Medicine at the +edside
! Medicine in the li+rary
F Medicine in the hos'ital
E Medicine in the co((unity
D Medicine in the la+oratory
" Medicine in the (odern .orld
8eferences
9urther readin-
Index
Ac1no.led-e(ents
I ha&e -i&en a short lecture +ased on the structure of this +oo1
to (any -rou's of students) The feed+ac1 has +een &alua+le
in hel'in- (e sort out the forest fro( the trees)
The staI at Oxford %ni&ersity $ress ha&e handled this +oo1
.ith ad(ira+le e5ciency) The co((ents of Andrea 2ee-an
and an anony(ous referee ha&e i('ro&ed the style and
content) :a(es Tho('son has +een a (odel editor) My than1s
to the( all)
My -reatest de+t is al.ays to Helen 6ynu(, .ho has read the
(anuscri't .ith .onderful care and ex'ertise) Many years
a-o, she e&en heard (e -i&e the lecture of the +oo1) She
1no.s ho. (uch of this +oo1 is hers)
3ist of illustrations
C The 1inds of (edicine
! The hu(ours
F Galen*s P'hysiolo-ical syste(*
; The 4ellco(e 3i+rary, 3ondon
E Classical (edical N-ures
; The 4ellco(e 3i+rary, 3ondon
D Galen at .or1, fro( O'era o(nia, dissection of a 'i-
; The 4ellco(e 3i+rary, 3ondon
" #ra.in- of the +rain, Vesalius, CDEF
; The 4ellco(e 3i+rary, 3ondon
A >n-ra&in- of (en .or1in- at a 'rintin- 'ress, CD=<
; The 4ellco(e 3i+rary, 3ondon
= >n-ra&in- sho.in- a 'hysician -i&in- (edicine to a sic1 (an
in +ed and
su'er&isin- sur-ery, C"E"
; The 4ellco(e 3i+rary, 3ondon
@ Her(ann 6oerhaa&e -i&in- a lecture
; The 4ellco(e 3i+rary, 3ondon
C< HQtel #ieu Hos'ital, $aris
; The 4ellco(e 3i+rary, 3ondon
CC 3aennec and the use of the stethosco'e at the /ec1er
Hos'ital
; The 4ellco(e 3i+rary, 3ondon
C! The $arisian sur-eon and anato(ist Alfred Vel'eau
; The 4ellco(e 3i+rary, 3ondon
CF The County 3unatic Asylu(, 6rent.ood, >ssex
; The 4ellco(e 3i+rary, 3ondon
CE An e'isode durin- the 'la-ue at Milan
; The 4ellco(e 3i+rary, 3ondon
CD The 3ondon 6oard of Health see1s out cholera
; The 4ellco(e 3i+rary, 3ondon
C" 3ondon slu(s, fro( Gusta&e #ore, 3ondon: A $il-ri(a-e,
C=A!
; The 4ellco(e 3i+rary, 3ondon
CA PThe $u+lic Vaccinator*, 3ance Cal1in, c) C@<C
; The 4ellco(e 3i+rary, 3ondon
C= Microsco'e .ith three tu+es
; The 4ellco(e 3i+rary, 3ondon
C@ 3ouis $asteur .ith t.o .hite ra++its, C==A
; The 4ellco(e 3i+rary, 3ondon
!< 8o+ert 2och in his la+oratory, C=@"KA
; The 4ellco(e 3i+rary, 3ondon
!C 3ister s'ray in use, fro( Cheyne*s Antise'tic Sur-ery, C==!
; The 4ellco(e 3i+rary, 3ondon
!! :ose'h 3ister acclai(s 3ouis $asteur, C=@!
; The 4ellco(e 3i+rary, 3ondon
!F Gray thera'y, C@<!
; The 4ellco(e 3i+rary, 3ondon
!E Illu(inated tra(Gcar, PGlas-o.*s Gray ca('ai-n*, C@DA
; The 4ellco(e 3i+rary, 3ondon
!D Health exhi+its, 're&entin- conta(inated (il1, Central
Council for Health
>ducation
; The 4ellco(e 3i+rary, 3ondon
!" Messa-e on (alaria 're&ention to soldiers durin- 4orld
4ar II
; The 4ellco(e 3i+rary, 3ondon
!A AntiGo+esity and alcohol 'oster ca('ai-n, C@@!
; The 4ellco(e 3i+rary, 3ondon
!= 4illia( Osler at the +edside of 'atients
; The 4ellco(e 3i+rary, 3ondon
The 'u+lisher and the author a'olo-i7e for any errors or
o(issions in the a+o&e list) If contacted they .ill +e 'leased to
rectify these at the earliest o''ortunity) Introduction: the 1inds
of (edicine
This is a short +oo1 on a &ery +i- su+,ect) I ha&e tried to
'ro&ide a -eneral fra(e.or1 for understandin- the history of
(edicine since the ancient Gree1s esta+lished .hat can +e
called the 4estern (edical tradition) I 'resent (y history
throu-h a ty'olo-y of the P1inds* of (edicine) These are
su((ari7ed in the follo.in- ta+le, and ex'ounded in the Nrst
N&e cha'ters)
The N&e 1inds of (edicine in 9i-ure C B +edside, li+rary,
hos'ital, co((unity, and la+oratory B re'resent diIerent -oals
of doctors, as .ell as reRectin- the diIerin- sites in .hich they
.or1) Althou-h their a''earance allo.s a rou-hly
chronolo-ical narrati&e, these 1inds of (edicine are
cu(ulati&e) 6edside (edicine, +e-innin- .ith the
Hi''ocratics, still has resonances in (odern 'ri(ary care, and
the li+rary (edicine of the Middle A-es is rele&ant to the
infor(ation ex'losion that characteri7es the (odern (edical
.orld (and not, of course, si('ly the (edical one)) In the C@th
century, hos'ital (edicine .as in one sense +edside (edicine
.rit lar-e, .ith ne. dia-nostic and thera'eutic tools, and the
(edical ex'ertise .e ex'ect fro( the (odern hos'ital)
Medicine in the co((unity enco('asses the en&iron(ental
infrastructure of clean .ater, .aste dis'osal, &accination
'ro-ra((es, health and safety in our chosen .or1'laces,
alon- .ith the analysis of disease 'atterns and their
relationshi's to diet, ha+its, or ex'osure to a-ents in the
en&iron(ent) 3a+oratory (edicine ta1es 'lace (ostly in the
la+oratory, and (ay +e translated into +etter dru-s, and
understandin- of +odily (echanis(s that can i('ro&e
dia-nosis or treat(ent)
C) The 1inds of (edicine) A sche(atic re'resentation of the
diIerent P1inds* of (edicine, hi-hli-htin- the &arious units of
analysis, .or1'lace, and ai(s that doctors (ay ha&e) The Nrst
N&e cha'ters of this +oo1 exa(ine these 1inds of (edicine in
their historical contexts
These historical cate-ories are thus still &i+rant ones, and they
allo. a .ay of thin1in- a+out (edical history that still
resonates .ith today*s citi7ens .ho are also tax'ayers,
consu(ers of healthcare, and +eneNciaries of 'u+lic health
strate-ies) These P1inds* of (edicine 'ro&ide +oth the +road
headin-s for conte('orary health +ud-ets, and, es'ecially
.ithin the A(erican scene, .here s'ecialGinterest ad&ocacy
inRuences health s'endin-, the identity of interest -rou's)
$ri(ary care, hos'ital ser&ices, 'u+lic health, +io(edical
research, and infor(ation creation and 'ro&ision: a(on- (a,or
health de(ands, there is not (uch else that a (odern health
(inister need +other a+out) The trou+le of course is that these
cate-ories in so(e sense co('ete .ith each other, since
health +ud-ets are al.ays li(ited) The (ore you s'end on
research, the less you (ay ha&e for hos'ital sta5n- or 'u+lic
health, and &ice &ersa)
The cate-ories o&erla' historically) In their o.n .ays, the
ancient Gree1s and 8o(ans de&elo'ed the .hole ran-e of
a''roaches to healthGrelated 'ro+le(s: they tried to 're&ent
diseases .ithin the co((unity, had si('le institutions to care
for sla&es and soldiers, needed 'laces .here (edical texts
.ere -athered to-ether, tried to add to (edical 1no.led-e
throu-h en?uiry, and of course, cared for 'atients at the
+edside) 6ut the (odern cate-ories of hos'ital, co((unity,
and la+oratory (edicine e(er-ed in their current for(s .ithin
the C@th century, and are .hat .e thin1 of as P(odernity*) In
the Nnal cha'ter, I use the ty'olo-y to fra(e a +rief account of
(a,or de&elo'(ents in the !<th and !Cst centuries, .hen the
P1inds* of (edicine ha&e +eco(e intert.ined)
The .ay I ha&e structured this short account 'ri&ile-es the
4estern (edical tradition, .hich do(inates health
consu('tion and ex'enditure in the 4est, and is a (a,or force
e&ery.here) There are (any other .ays in .hich historians
ha&e constructed the story, +ut I ha&e chosen this one
+ecause I +elie&e it has a historically coherent for( and is
useful in introducin- the su+,ect to curious readers)
4ere I su+(ittin- this (anuscri't to a (edical ,ournal, I .ould
+e re?uired to state any co('etin- interests .hich (i-ht
colour ho. I ha&e inter'reted (y data) I ha&e +een a (edical
historian for al(ost four decades, +ut I also trained in
(edicine, durin- the P-olden a-e* that is identiNed in Cha'ter
") My (edical education has certainly inRuenced the .ay I
inter'ret (edicine*s 'ast, +ut I ha&e tried here to a&oid either
the oldGfashioned P4hi--is(*, .hich &ie.ed all history as
'ro-ress and a series of ste's leadin- ine&ita+ly to the
'resent, or the ne.er &ersion, .hich has su+stituted
conte('orary (oral &alues for intellectual ones and there+y
casti-ates the sexis(, racis(, and other Gis(s of our
fore+ears) It see(s to (e that those in the 'ast .ho had
access ha&e -enerally sou-ht the (edical care that .as on
oIer, and +elie&ed that there .ere -ood doctors and +ad
doctors) They .anted a -ood doctor to ta1e care of the() So
do .e) 4hat has chan-ed is .hat constitutes a P-ood* doctor)
Cha'ter C Medicine at the +edside
Hi''ocrates and all that
Hi''ocrates has +eco(e the fa&oured 9ather for healers of all
stri'es) Ho(oeo'athists Nnd in the Hi''ocratic .ritin-s the
roots of their doctrines) /aturo'aths, chiro'ractors, her+alists,
and osteo'aths in&o1e hi( as the founder of the ideals that
underlie their o.n a''roaches to health, disease, and healin-)
So do (odern hos'ital consultants, (any of .ho( .ould ha&e
re'eated his Oath, or a &ersion of it, .hen they too1 their
(edical de-rees)
The reasons for this curious state of aIairs can +e found in
history) 9or one thin-, the historical Hi''ocrates is su5ciently
shado.y to allo. a (ulti'licity of inter'retations to +e hun-
fro( hi() He is shado.y +ut real) He li&ed on the island of
Cos, oI the coast of 'resentGday Tur1ey, fro( a+out E"< 6C>
to FA< 6C>) This (a1es hi( a +it older than $lato, Aristotle,
and the other cos(o'olitan creators of classical Gree1 culture,
centred in Athens) His anti?uity (a1es the sur&i&al of so (any
PHi''ocratic* .or1s that (uch (ore re(ar1a+leS 'eo'le sa&e
.hat they 'articularly &alue)
6esides .here and a''roxi(ately .hen he li&ed, .e 1no. only
a little (ore) He 'ractised (edicine, too1 'u'ils for a fee, and
had a son) He also achie&ed a fair de-ree of fa(e, since $lato
(entioned hi() 4hether he actually .rote any of the .or1s
attri+uted to hi( is less clear) He certainly did not .rite the(
all, for they .ere co('osed o&er a+out t.o centuries +y
&arious un1no.n hands) This (eans that the Hi''ocratic
Cor'us, the "< or so .or1s and fra-(ents that sur&i&e, contain
(uch inconsistency and (any 'oints of &ie.) These
PHi''ocratic* .ritin-s co&er (any as'ects of (edicine and
sur-ery, as .ell as dia-nostics, thera'eutics, and disease
're&ention) The Hi''ocratics oIered ad&ice on diet and other
as'ects of healthy li&in-, and there is a 'articularly inRuential
treatise on the role of the en&iron(ent in health and disease)
There .ere thus (any PHi''ocratic* stances, and our
PHi''ocratic (edicine* is a historical construct, achie&ed +y
'ic1in- out certain the(es and theories, and 'uttin- the(
to-ether in a fra(e.or1 that .as un1no.n durin- the
centuries of the co('osition of the treatises)
A(idst this (ulti'licity, ho.e&er, there is one strand that runs
throu-h the .hole cor'us, and (a1es Hi''ocrates so
attracti&e to so (any (odern healers) Hi''ocratic (edicine is
holistic) The Hi''ocratic a''roach is al.ays to the .hole
'atient and the (odern yearnin- for a holistic (edicine Nnds a
natural restin- 'lace there) #es'ite its ad(ira+le, 'ositi&e
characteristics, this holis( .as also rooted in cultural &alues
.ides'read in Gree1 society) The ancient Gree1s disli1ed
dissection of hu(an +odies) They 'erfor(ed no auto'sies to
deter(ine the cause of death, and Gree1 doctors tau-ht no
dee' anato(y to their a''rentices) There .ere no (edical
schools in the (odern sense of the ter() Students learned
throu-h their (asters, and .hat they 1ne. .as surface
anato(y and a shre.d sense of loo1in- carefully at their
'atients for si-ns su--estin- the li1ely course of the disease,
that is its 'ro-nosis, and, es'ecially, .hether the 'atient .as
li1ely to reco&er or not) That there .ere no hos'itals (eant
that the +edside of this cha'ter*s title .as literally the
'atient*s, in his or her o.n ho(e)
These structures of ancient Gree1 (edicine (a1e it the
'rototy'e of (odern 'ri(ary care) The Hi''ocratic doctor
needed to 1no. his 'atient thorou-hly: .hat his social,
econo(ic, and fa(ilial circu(stances .ere, ho. he li&ed, .hat
he usually ate and dran1, .hether he had tra&elled or not,
.hether he .as a sla&e or free, and .hat his tendencies to
disease .ere) The theoretical reasons for this .ere e(+edded
in the Hi''ocratic .ritin-s, of .hich (ore +elo.)
If the holis( attracts (odern co('le(entary healers to the
Gree1, there are other attri+utes to Hi''ocratic (edicine that
resonate .ithin conte('orary scientiNc (edicine) The (ost
i('ortant of these is its underlyin- naturalis() The (edical
syste(s of the ancient /ear >ast B >-y't, Syria, Meso'ota(ia,
6a+ylonia B co(+ine theolo-y and healin-) The 'riestG
'hysician is a co((on tro'e) #isease .as .idely assu(ed to
+e the result of di&ine dis'leasure, trans-ressions of &arious
1inds, or (a-ical forces) #ia-nosis (i-ht in&ol&e 'rayer,
inter'retin- ani(al entrails, or deter(inin- ho. the 'atient
had trans-ressed) This (ix of (a-icoGreli-ious (edicine .as
also 'art of the Gree1 landsca'e durin- the Hi''ocratic 'eriod)
Healin- te('les dedicated to the Gree1 -od of (edicine,
Ascle'ius, .ere dotted all o&er the Gree1 s'here of inRuence,
includin-, ironically, a fa(ous one in Hi''ocrates* o.n
+ac1yard, Cos itself) The (ost su+stantial one .as on the
(ainland, at >'idaurus, the extensi&e re(ains of .hich are
still extant) These te('les .ere in the hands of resident
'riests .ho recei&ed 'atients and inter'reted illness on the
+asis of drea(s that 'atients re'orted to the() The drea(s
.ere 'ro+a+ly aIected +y the 'resence of holy sna1es, .hich
undou+tedly distur+ed slee' 'atterns) 6y slou-hin- its s1in,
the sna1e .as an exa('le of rene.al, and a 'ro(inent 'art of
the caduceus, sy(+ol of the Gree1 -od of healin- (see 9i-ure
E)) Curiously, Ascle'ius and the caduceus, +oth redolent of
(a-ic and reli-ion, ha&e +een naturali7ed as an e(+le( of
(odern (edicine)
These healin- te('les .ere an i('ortant 'art of Gree1
(edical care +ut the &alues they e(+odied had little i('act
on the Hi''ocratic Cor'us) The treatises that for( it assu(e
that disease has a natural cause, +ut only once does a
Hi''ocratic author ex'licitly attac1 su'ernatural ex'lanations
of disease) This occurs at the +e-innin- of a treatise on
e'ile'sy, called PThe Sacred #isease* in co((on Gree1
'arlance) It .as dee(ed sacred +ecause e'ile'tic attac1s
.ere dra(atic, causin- as they do a loss of consciousness,
foa(in- at the (outh, relaxation of (uscle, +ladder, and
s'hincter control, +ut also included 'sycholo-ical sy('to(s
.hich suIerers could so(eti(es turn to their ad&anta-e)
Alexander the Great and (later) :ulius Caesar .ere 'o.erful
e'ile'tics in anti?uity) The o'enin- sentences of PThe Sacred
#isease* ha&e +een inter'reted as a clarion call for a co('lete
naturalis( .ithin (edicine) They are still co('ellin-, .ritten
as they .ere (ore than t.o (illennia a-o:
It is thus .ith re-ard to the disease called Sacred: it a''ears to
(e to +e
no.ise (ore di&ine nor (ore sacred than other diseases, +ut
has a natural
cause fro( .hich it ori-inates li1e other aIections) Men re-ard
its nature
and cause as di&ine fro( i-norance and .onder, +ecause it is
not at all li1e
to other diseases) And this notion of di&inity is 1e't u' +y their
ina+ility
to co('rehend it, and the si('licity of the (ode +y .hich it is
cured, for (en
are freed fro( it +y 'uriNcations and incantations) 6ut if it is
rec1oned
di&ine +ecause it is .onderful, instead of one there are (any
diseases .hich
.ould +e sacred)
It is si-niNcant that the stance is not irreli-ious (Pno.ise (ore
di&ine nor (ore sacred than other diseases*), +ut couched
.ithin a fra(e.or1 that could oIer an ex'lanation .ithin
naturalist ter(s of the ori-ins of this soGcalled sacred disease)
The Hi''ocratic author -oes on to oIer such an ex'lanation:
e'ile'sy is caused +y +loc1a-e .ithin the +rain, so that the
re-ular ex'ulsion of 'hle-( is sto''ed, there+y 'roducin-
(alfunctionin- of the +rain, and the dra(atic sy('to(s of the
e'ile'tic sei7ure) T.o further i('lications are .orth notin-)
9irst, this Hi''ocratic author located consciousness and other
(ental functions to the +rain)
And (en ou-ht to 1no. that fro( nothin- else +ut the +rain
co(e ,oys,
deli-hts, lau-hter and s'orts, and sorro.s, -riefs,
des'ondency, and
la(entations) And +y this, in an es'ecial (anner, .e ac?uire
.isdo( and
1no.led-e, and see and hear, and 1no. .hat are foul and
.hat are fair, .hat
are +ad and .hat are -ood, .hat are s.eet, and .hat
unsa&ouryS so(e .e
discri(inate +y ha+it, and so(e .e 'ercei&e +y their utility)
The centrality of the +rain is of course no. a co((on'lace in
scientiNc thin1in-, +ut it .as not so .ith the Gree1s) $lato
follo.ed Hi''ocrates in &ie.in- the +rain as the seat of
'sycholo-ical acti&ity, +ut $lato*s 'u'il Aristotle +elie&ed that
the heart is the centre of e(otion and other (ental functions)
After all, .hen .e are anxious or in lo&e, it is in the +reast, or
heart, not the +rain, that .e ex'erience such e&ents) The
heart, not the +rain, +eats faster .hen .e are (ost ali&e)
6esides, Aristotle, an ex'erienced student of e(+ryolo-ical
de&elo'(ent, noted that the Nrst si-n of life in the de&elo'in-
chic1 e(+ryo .as the (otion .ithin the 'ri(iti&e heart)
Al(ost t.o (illennia later, Sha1es'eare .as to recall this old
de+ate:
Tell (e .here is fancy +red)
Or in the heart or in the headT
#es'ite our lan-ua-e, .hich still attri+utes (uch to the
Pheart*, Hi''ocrates and $lato .on that de+ate)
The second si-niNcant 'oint to tease out of this treatise relates
to the Hi''ocratic cause of e'ile'sy: +loc1ed 'hle-() $hle-(
(i-ht see( the si-n of a co((on cold to us, +ut it .as for the
Hi''ocratics one of four hu(ours, .hich .ere constituti&e of
health and disease, and thus at the heart of Hi''ocratic
'hysiolo-y and 'atholo-y) Althou-h hu(oral doctrine .as not
contained in all of the Hi''ocratic treatises, it can +e 'ieced
to-ether and .as inter'reted +y the other -iant of ancient
Gree1 (edicine, Galen (A# C!@Bc) !C<), as central to (edical
theory) Galen -a&e hu(oral (edicine such 'resti-e that it
do(inated (edical thin1in- until the C=th century)
Hu(ours: the co('lete syste(
The four hu(ours .ere +lood, yello. +ile, +lac1 +ile, and
'hle-(, and as can +e seen fro( the sche(atic dia-ra( in
9i-ure !, they constituted a for(ida+le fra(e.or1 for
understandin- health and disease, and (uch else +esides)
They e&entually e(+odied a theory of te('era(ents, .hich
'ro&ided a -uide to hu(an 'ersonality and susce'ti+ility to
disease) The 'ro'erties of the hu(ours B heat, cold, dryness,
(oistness B oIered a 'arallel readin- of the course of
diseases, and of the sta-es of the indi&idual life cycle) >ach of
the hu(ours .as also lin1ed to one of the four ele(ents B air,
Nre, earth, .ater B .hich Gree1 natural 'hiloso'hy 'osited as
the constituents of all the thin-s in the su+lunary .orld) 6elo.
the (oon, in our .orld, thin-s chan-e, -ro. old, and die)
A+o&e the (oon, 'erfect circular (otion .as 'ostulated as the
nor(, .ith stars (ade of a Nfth ele(ent, the P?uintessence*)
!) The hu(ours: the .onderful si('licity of the Hi''ocratic
sche(e is easily reco-ni7ed, .ith the e?ually i('ortant
?ualities (heat, cold, dryness, (oistness) .hich the hu(ours
'ossessed
Ta1en as a .hole 'ac1a-e, Gree1 hu(oralis( .as the (ost
'o.erful ex'lanatory fra(e.or1 of health and disease
a&aila+le to doctors and lay(en until scientiNc (edicine +e-an
-radually to re'lace it durin- the C@th century)
6odily Ruids and their eIects are features that so(eone carin-
for a sic1 'erson notices) The s1in +eco(es Rushed .hen the
sic1 'erson is fe+rileS 'eo'le cou-h u' 'hle-( or +loodS eyes
.ater and noses runS the urine turns dar1 if there is ,aundice
or dehydrationS the s1in can +eco(e cla((y, s.eaty, or 'aleS
and diarrhoea or &o(itin- (ay +e 'ro(inent features of
illness) Gree1 cultural 'rohi+itions a-ainst dissectin- hu(an
+odies (eant that the Hi''ocratics had relati&ely little
1no.led-e of dee' anato(y, or it .as inferred fro( ani(al
dissections or 1no.led-e ac?uired throu-h 're'aration of
ani(als for eatin-) This did not see( to +other the
Hi''ocratics &ery (uch, althou-h Galen later tried &ery hard
to 'ro&ide anato(ical 1no.led-e, lar-ely throu-h dissectin-
ani(als)
Hu(oral (edicine does not re?uire all that (uch 1no.led-e of
anato(y, since the o'erati&e ele(ents are the +odily Ruids,
not the solids) >ach of the hu(ours .as identiNed .ith a
+odily or-an, ho.e&er: 'hle-( .ith the +rain, +lood .ith the
heart, yello. +ile .ith the li&er, and +lac1 +ile .ith the s'leen)
9urther, in the sur-ical treatises of the Hi''ocratic .ritin-s,
these doctors also discussed the settin- of fractures, reduction
of dislocated ,oints, .ound treat(ent, and si('le o'erations
for &arious s'eciNc conditions) Sur-ical .or1, then as no.,
re?uires a (uch (ore focused orientation on a 'articular area
of the +ody) 6ut Hi''ocratic (edicine re(ained holistic and
'reoccu'ied .ith inter'retin- the chan-es of the hu(ours)
Hu(oralis( +rou-ht .ith it t.o related and endurin- the(es
.ithin 4estern (edicine: +alance and (oderation) The
Hi''ocratics &ie.ed health as the result of a sound +alance of
the hu(ours) I(+alance, too (uch or too little of one or (ore
of the(, or an i('erfect ?uality (often descri+ed as a
corru'tion) of one of the( 'roduced disease) The +ody .as
so(eti(es re-arded as a 1ind of o&en, .ith coo1in-
(eta'hors 'ro(inent in Hi''ocratic descri'tions of disease)
>xcretions in disease B 'us, s.eat, ex'ectorated 'hle-(,
concentrated urine, &o(itus, diarrhoea B .ere inter'reted as
the 'roducts of natural defence (echanis(s) The +ody often
coo1ed, or concocted, corru't or excess hu(ours, to ena+le
the +etter re(o&al of the surfeit or the 'eccant hu(ours, and
restore a +alance)
The Hi''ocratics inter'reted this +edside o+ser&ation B of the
+ody -ettin- rid of hu(ours B as e&idence of .hat they called
the &ix (edicatrix naturae, the healin- 'o.er of nature) This
doctrine has lon- +een de+ated .ithin (edicine, and it .as
codiNed in the C@th century .ith the conce't of PselfGli(ited
disease*) A 'o.erful (odern (edicine is a+le easily to
acco((odate it: (ost disease, treated or untreated, is selfG
li(ited) Treatin- the sy('to(s of a cold, for exa('le, (ay
(a1e one feel +etter, +ut it ne&er really touches the cause,
.hich in due course the +ody -enerally deals .ith) >&ery
doctor 1no.s this, +ut they also 1no. that the 'rescri'tion
that (a1es the 'atient feel +etter is often inter'reted as
curati&e) $ost hoc, er-o 'ro'ter hoc: Pafter, therefore, +ecause
of*: a lot of clinical (edicine has al.ays relied on this lo-ical
fallacy)
The Hi''ocratics .ere (ore (odest, and the doctrine of the
healin- 'o.er of nature -a&e rise to t.o of their (ost
i('ortant a'horis(s: P/atural forces are the healers of
disease*, and PAs to diseases, (a1e a ha+it of t.o thin-s B to
hel', or at least do no har(*) Thera'y .as thus ai(ed
'ri(arily at assistin- the 'atient*s +ody do its Pnatural* .or1)
So(e of their 'rocedures ,ar .ith (odern senti(ent)
6loodlettin-, for exa('le, had a rational +asis, since local
inRa((ation, or the Rush of fe&er, .as easily inter'reted as
e&idence that the +ody had too (uch +lood, and therefore
needed aid in riddin- itself of it) 6loodlettin- is one of the
oldest and (ost 'ersistent thera'ies, and the one (ost often
held u' as e&idence of the crude +ar+arity of (edicine until
the (odern 'eriod) It continued to +e a (ainstay of
thera'eutics until the (idGC@th century, and .as a+andoned
only -radually and reluctantly +y ran1 and Nle 'ractitioners)
$atients often de(anded it, and (any of the( re'orted +ein-
hel'ed +y ha&in- +lood let, so(eti(es so (uch that the
doctor sto''ed only .hen the 'atient .as on the 'oint of
faintin-) As another Hi''ocratic a'horis( 'ut it, P9or extre(e
diseases, extre(e strictness of treat(ent is (ost e5cacious*,
often (ade (ore 'un-ent: P#an-erous diseases re?uire
dan-erous re(edies*)
In -eneral, ho.e&er, hu(oral thera'y .as (ixed, and included
diet, exercise, (assa-e, and other (odalities that .ere ai(ed
at the indi&idual needs of the indi&idual 'atient) It .as this
holistic indi&idualis( that .as the core feature of their (edical
'ractice) Althou-h Hi''ocratic .ritin-s contain descri'tions of
(any diseases to .hich .e can -i&e (odern la+els, they
ne&er se'arated the disease fro( the indi&idual suIerer) Thus,
althou-h .e can Nnd accounts of diseases .e (i-ht call
consu('tion (tu+erculosis), stro1e, (alaria, e'ile'sy, hysteria,
and dysentery, these are 'resented as e&ents that ha''ened
to indi&idual 'eo'le) They used these ex'eriences to co(e to
-enerali7ations a+out ho. to deal .ith these diseases,
'resented as a'horis(s and .hat .e .ould no. call Pclinical
'earls*) Their hu(oral ex'lanatory fra(e.or1 al.ays
encoura-ed the( to tailor 'articular treat(ents to uni?ue
cases)
The Hi''ocratics .ere also acutely a.are that diseases often
s.ee' throu-h a co((unity, aIectin- the old and youn-, rich
and 'oor, thin and cor'ulent, (ale and fe(ale: ,ust those
attri+utes that at the +edside they stro&e to ta1e into account
.hen (a1in- a dia-nosis and reco((endin- a thera'eutic
re-i(en) In t.o 'articularly inRuential treatises, a series of
+oo1s on >'ide(ics, and one entitled Airs, 4aters, $laces, the
Hi''ocratic .riters oIered reRections a+out these .ider
as'ects of disease) Airs, 4aters, $laces is essentially the
foundation state(ent of 4estern en&iron(entalis(, es'ecially
as it relates to health and disease) It oIered ad&ice on .here
to +uild one*s house (.ellGdrained soil, 'rotected fro( chillin-
.inds), and analysed the health of co((unities in ter(s of
the en&iron(ental factors that i('in-ed on their inha+itants)
3i1e (ost (edical and +iolo-ical thin1in- until the late C@th
century, it es'oused .hat is no. called (anachronistically)
P3a(arc1ianis(*S that is, the Hi''ocratics +elie&ed that
en&iron(ental factors could chan-e the +asic characteristics
of hu(an +ein-s (s1in colour, +ody sha'e, and so on), and that
these chan-es could +e 'assed on to oIs'rin-) This is an
o'ti(istic 'hiloso'hy of hu(an (allea+ility, consonant .ith
the -eneral Hi''ocratic conNdence that their thera'eutic
re-i(en had (uch to oIer to its 'atients) At the sa(e ti(e,
their .ritin-s are full of occasions .hen ex'erience tau-ht that
the disease .as so far ad&anced or serious that there .as little
to +e done)
4ider Hi''ocratic re&er+erations
The hu(ours 'ro&ided a theoretical fra(e.or1 that lasted) 4e
still use the idea of the te('era(ents in casual s'eech (Pa
naturally san-uine 'erson*, P-enerally (elancholic*), and the
hotBcold, .etBdry axes of the hu(ours re-ulate ho. .e see
co((on acute co('laints) $o'ular +elief has it that .e catch
colds +y -oin- out .ithout our hats on, or -ettin- our feet .et)
#octors, .ho ou-ht to 1no. +etter, fall in .ith 'o'ular disease
conce'tions a+out the nature and treat(ent of colds, 'artly
+ecause that is .hat 'atients ex'ect, 'artly +ecause it sa&es
ti(e in the 'atientBdoctor encounter, 'artly +ecause doctors,
too, are all too hu(an) More recently, #ar.inian (edicine has
used the Hi''ocratic &ix (edicatrix naturae to ?uestion the
treat(ent of sy('to(s) Is it +etter to su''ress the cou-h, or
dry u' the nasal secretions, .hen they are 'art of a naturally
e&ol&ed defenceT
Much of the Hi''ocratic le-acy .as actually trans(itted to the
4est throu-h the .ritin-s of Galen, .ho do(inated (edical
thin1in- for (ore than a (illenniu() Galen sa. hi(self as
extendin- and co('letin- the fra(e.or1 of the Hi''ocratics)
4e 1no. (uch (ore a+out hi( than any other doctor of
anti?uity: (ore .ords of his sur&i&e than any other ancient
.riter, (edical or other.ise, and his .or1s are laced .ith
auto+io-ra'hical sni''ets) He .rote a+out all as'ects of
(edicine: dia-nosis, thera'y, re-i(en, and the 'hiloso'hy of
(edicine) He codiNed the Hi''ocratic doctrine of the hu(ours,
+ut also consolidated an ex'eri(ental di(ension to (edicine)
4hereas the Hi''ocratics .ere content .ith careful
o+ser&ation, Galen .ent (uch further, oIerin- anato(ical and
'hysiolo-ical accounts of .hat ha''ened in health and
disease) He .as +i- on e-oGstren-th and see(ed to assu(e
that his .as the last .ord on &irtually e&erythin-) He cannot
+e +la(ed that (ost doctors for (ore than a thousand years
a-reed .ith hi()
Hu(oralis( ser&ed Galen &ery .ell at the +edside, ex'lainin-
disease, +ut he also de&elo'ed a co('licated 'hysiolo-y to
ex'lain nor(al +odily function, .hich relied on s'irits
('neu(a) rather than hu(ours) 4ithin his (odel, food .as
ta1en into the sto(ach, .hence it .as turned into chyle) This
chyle .ent to the li&er &ia the 'ortal &ein, .here it .as
con&erted into +lood suIused .ith natural 'neu(a) So(e of
this +lood then .as con&eyed to the heart) $art of the +lood
fro( the heart .ent to the lun-s to nourish this essential
or-an) Other 'ortions of the heart*s +lood 'assed throu-h
in&isi+le 'ores fro( the ri-ht to the left &entricle, .here it
(ixed .ith &ital 'neu(a, ac?uired fro( the lun-s and
ulti(ately throu-h +reathin- air) This &ital +lood then .ent &ia
the aorta and carotid artery to the +rain, .here it had its last
reNne(ent, .ith ani(al 'neu(a, and then &ia the ner&es to
initiate (otion and sensation)
F) Galen*s P'hysiolo-ical syste(*) Galen accounted for (any
+asic 'hysiolo-ical 'heno(ena +y i('licatin- the li&er, heart,
and +rain in the ela+oration and distri+ution of three 1inds of
Ps'irit*, the natural, &ital, and ani(al
This (odel of hu(an 'hysiolo-y +eca(e -os'el for (ore than
a (illenniu() So, too, did Galen*s co((ents on anato(y,
often (throu-h no fault of his o.n) 'erfor(ed on 'i-s, a'es,
and other ani(als) The 'rohi+ition on hu(an dissection .as
out of Galen*s control, and his only (ista1e .as not to tell his
readers .here he -ot his anato(ical 1no.led-e fro() This
o(ission encoura-ed later .orshi''ers of Galen to assu(e
that the hu(an +ody (ust ha&e chan-ed since the (aster
dissected, +ut e&entually left hi( a sittin- tar-et for
'ro-ressi&es .ho +elie&ed their o.n eyes)
More than D<< years se'arated Hi''ocrates and Galen, and
there .ere of course (any doctors and syste(s of treat(ent
afoot +et.een the() One -rou' of doctors in 8o(e
e('hasi7ed (assa-e, .ar( or cool +aths, and other thera'ies
to relax or constrict the +ody*s 'ores, their 'reternatural state
of tension 'osited as the cause of disease) Other doctors
ado'ted their o.n a''roach to dia-nosis and treat(ent) So(e
of these alternati&e syste(s sur&i&ed Galen*s do(inance, +ut
Galen +estrode the (illenniu( after his death far (ore
co('rehensi&ely than Hi''ocrates had done in the centuries
after his follo.ers sto''ed .ritin-) These (edical di(ensions
are .orth studyin- for their o.n sa1e, +ut Gree1 (edicine as a
.hole left three +asic 'rinci'les that for(ed (edicine until the
(odern 'eriod)
The Nrst 'rinci'le, as .e ha&e already seen, .as hu(oralis()
The second .as the +otanical +asis of (ost dru-s) #octors
loo1ed to the +otanical 1in-do( for (edicines to co(+at
disease) One doctor in 'articular or-ani7ed the ancient
'har(aco'oeia into a for( that others found useful for
centuries) #ioscorides (R) c) E<B=<) .rote a treatise on Materia
Medica .hich incor'orated the (edicalG+otanical .ritin-s of
earlier authors +ut also included (uch that he hi(self had
disco&ered a+out 'lants and their (edicinal ?ualities) Althou-h
he descri+ed a fe. ani(al 'roducts, 'lants do(inated, as they
did for (ost other doctors in anti?uity and +eyond) $lants
could yield su+stances that .ould +rin- on a s.eat, induce
&o(itin- or a 'ur-e, 'roduce slee', or control 'ain) Many
+otanical 're'arations, such as o'iu( and helle+ore, had
-reat stayin- 'o.er, +ut unli1e the core theoretical content of
ancient (edicine, 'lants ha&e deNnite -eo-ra'hical
distri+utions, and the search for the( (eant that later doctors
had to do their o.n huntin-, in their local forests and
hed-ero.s) If you ha&e a 'articular 'lant in your area, you can
su''ly it to others .ho don*t, and i('ortin- and ex'ortin-
dru-s +eca(e an acti&e +usiness in later centuries) Galen
incor'orated (uch of #ioscorides* .or1 in his o.n &olu(inous
.ritin-s, and the latter*s Materia Medica .as still 'ri7ed in the
8enaissance)
The third le-acy B a secular a''roach to disease B .as (ore
elusi&e +ut ,ust as i('ortant for all that) 6oth reli-ion and
(a-ic continued to inRuence thin1in- a+out health and
disease +y doctors and lay(en) They still do) 6ut the ancient
healers .hose .ritin-s sur&i&ed and .ere 'ri7ed +elie&ed that
disease could +e understood in natural ter(s) This is not to
say that ancient doctors .ere not reli-ious: Galen had a notion
of (onotheis( that later co((entators turned into a 1ind of
reco-nition of the reli-ious (o&e(ent that .as -ainin- -round
durin- his lifeti(e B Christianity) 6ut .hen Hi''ocrates or
Galen .as confronted .ith a sic1 'atient, they dre. on their
o.n 1no.led-e and s1ills in an atte('t to +rin- a+out an act
of healin- at the +edside) 9or all this, disease still fre?uently
.as and is ex'erienced .ithin a reli-ious or (oral fra(e.or1,
seen as a result of sin, 'unish(ent, or, li1e :o+, trial B .hy (eT
These -losses do not ne-ate the fact that the fra(e.or1 of
ancient (edicine .as a naturalistic one) $hysician and 'hysics
deri&e fro( the sa(e Gree1 root, (eanin- Pnature*, and
atte('tin- to understand the .ay the +ody functions in health
and disease has e&er +een a s'ur for the curious doctor and
.orried 'atient)
Cha'ter ! Medicine in the li+rary
The (iracle of sur&i&al
4hen one sto's to thin1 a+out it, it is a (iracle that anythin-
.ritten sur&i&es fro( anti?uity) Ho. is it that .e can en,oy
Ho(er*s e'ic 'oe(s, $lato*s and Aristotle*s .or1s, or the !<
&olu(es (in their inco('lete (odern edition) of Galen*s
.ritin-sT Manuscri'ts .ere la+oriously co'ied +y hand, on
'arch(ent or other (ediu(s, .ere scarce and ex'ensi&e
co((odities, and .ere then su+,ected to the ra&a-es of ti(e,
the destruction of .ar, natural decay, or si('le carelessness)
The ite(s that sur&i&e today are usually later co'ies, (ade
centuries after the ori-inal text, 're'ared +ecause so(eone
.anted a &ersion for hi(self) In -eneral, the (ore 'ri7ed a text
.as, the -reater the chance of sur&i&al, si('ly +ecause there
.ere (ore &ersions of it (ade) 6ut far (ore .ords .ritten in
anti?uity ha&e 'erished than ha&e co(e do.n to us) The
lar-est li+rary and (useu( in the ancient .orld .as in
Alexandria, >-y't) It housed tens of thousands of scrolls and
'arch(ents, +ut suIered serial destruction and continuous
decay fro( the !nd century and .as nothin- +ut ruins +y the
Ath)
Thus, .e are inde+ted to the anony(ous scri+es in -reat
households, reli-ious esta+lish(ents, and royal courts for
(uch of .hat .e 1no. of the thou-hts of 'eo'le .ho li&ed
t.o (illennia and (ore a-o) The .ritin-s of Hi''ocrates,
Galen, and other doctors of anti?uity 'ro&ided the for(al
foundations of (edical 'ractice into the C=th century)
Conse?uently, the 'eriod of a''reciation, 'reser&ation, and
co((entaries u'on their .or1s that characteri7es the
(illenniu( +et.een the fall of 8o(e in EDD and the
(o&e(ent .e call the 8enaissance deser&es its o.n 'lace in
the history of (edicine) It has +een called the 'eriod of Pli+rary
(edicine*) In this cha'ter, I shall (a1e little distinction
+et.een the 3atin 4est and the 'oly-lot >ast, .hich includes
6y7antiu(, the Isla(ic >('ire, and :e.ish and Christian
contri+utions to (edical life in the areas in .hich Isla( ca(e
to do(inate) #octors in these .idely se'arated -eo-ra'hical
and cultural (ilieus all shared one characteristic: a &eneration
of the (edical .isdo( of the Gree1s, and a desire to +ase
their o.n (edical theories and 'ractices on these ancient
'rece'ts) Of course, they added (uch alon- the .ay)
Alon- .ith this essential contri+ution of 'reser&in- and addin-
to the Gree1 (edical herita-e, this e'och, fro( the Dth
century to the in&ention of the 'rintin- 'ress, also
funda(entally chan-ed the nature of (edical structures) It
+e?ueathed to us three i('ortant thin-s: the hos'ital, the
hierarchical di&ision of (edical 'ractitioners, and the
uni&ersity, .here the elites of (edicine .ere educated)
$reser&ation, trans(ission, ada'tation
In late anti?uity >uro'e, (edical care .as (ostly in the hands
of indi&iduals .ithout access to any of the .ritin-s of the
classical 'eriod) 3ocal traditions, includin- infor(al care,
(a-icoGreli-ious re(edies, and su'erstitions do(inated, +ut
the 're&ailin- .orld &ie. of the Christian era encoura-ed
indi&iduals to .ait for the end of the .orld, and in any case, to
see disease as a 'art of a .ider 'ro&idence, and tri&ial
co('ared to the 'otential ,oys of the .orld to co(e) The fe.
literate doctors .ould ha&e had access to so(e EthG and DthG
century .ritin-s .ithin the classical tradition) Caelius
Aurelianus (R) Eth or early Dth century) 'roduced a co('ilation
on acute and chronic diseases, +ased lar-ely on the .or1s of
an earlier 'hysician, Soranus) Caelius*s .or1 .as rational, full
of (edical insi-hts, and sur&i&ed throu-hout the (edie&al
'eriod as a su((ary of diseases and their treat(ents) 9or
exa('le, he descri+ed (i-raine, sciatica, and a nu(+er of
co((on diseases) His treat(ents .ere (ostly -entle,
su--estin- (assa-e, +ed rest, heat, and 'assi&e exercise for
dealin- .ith sciatica)
A fe. other (edical .or1s .ere also around in the 3atin 4est:
so(e (inor .or1s of Galen, includin- s'urious treatises
attri+uted to hi(, the Hi''ocratic A'horis(s, as .ell as +its of
other ancient authors) The centre of -ra&ity had shifted east,
ho.e&er, to the 6y7antine >('ire, the ca'ital of .hich .as
Constantino'le, no. Istan+ul) A lot of ancient (anuscri'ts had
already found their .ay east, and 'hysicians in the Christian
>ast 'reser&ed, translated, and co((ented on the() The rise
of Isla( sa. 6y7antiu( decline in inRuence and territory, +ut
those sa(e lands, no. .ithin Isla(ic do(inion, .ere also
si-niNcant for the trans(ission of the ancient cor'us of
(edicine)
Isla( .as a .onderfully 'oly-lot culture, and a nu(+er of
Gree1 (anuscri'ts sur&i&ed only in the lan-ua-es of the area
of Isla(ic con?uest, es'ecially Ara+ic, $ersian, and Syriac) A
(a,or translation (o&e(ent .as under.ay +y the late =th
century, and this continued for three centuries) The (edie&al
Isla(ic (edical tradition is often seen 'ri(arily as a conduit
for the 'reser&ation and trans(ission of ancient Gree1 texts,
.hich .ere translated into the Middle >astern lan-ua-es, then
in turn rendered +ac1 into 3atin, and Nnally into (odern
>uro'ean lan-ua-es)
Medie&al Isla(ic (edicine .as (ore than an interlude,
ho.e&er) There .as also a &i-orous learned (edical culture
.hich not only refor(ulated Gree1 (edical ideas to its o.n
context +ut also added ne. o+ser&ations, (edica(ents, and
'rocedures) Three of the -reat na(es of Isla(ic (edicine,
8ha7es (c) ="DB@!DKF!), A&icenna (@=<BC<FA), and A&erroes
(CC!"B@=), s'an al(ost four centuries, and +et.een the(
'roduced a cor'us of .or1 that assi(ilated Gree1 ideas and
'assed the(, 'ro'erly transfor(ed, +ac1 to the 4est) All of
the( .ere (en of .ide interests) 8ha7es, acti&e in .hat is
(odernGday Iran, .rote on alche(y, (usic, and 'hiloso'hy,
+ut his actual (edical 'ractice .as extensi&e, and his
dia-nostic acu(en .as (uch ad(ired durin- his lifeti(e) He
distin-uished s(all'ox fro( (easles for the Nrst ti(e
((easles he ,ud-ed the -ra&er illness), and oIered shre.d
(edical ad&ice for tra&ellers)
3i1e 8ha7es, A&icenna (I+n Sina) .as a (an .ith (any
interests outside of (edicine) Aristotle .as the do(inant
'hiloso'hical inRuence on hi(, and infused his (edical
.ritin-s) A 'recocious youth, A&icenna 'roduced (ore than
!D< titles in the course of an ad&enturous life) His Canon of
Medicine (AlGLanu( N lGti++) has +een descri+ed as the (ost
studied (edical treatise of all ti(e, and its N&e 6oo1s co&er
the .hole of (edical theory, treat(ent, and hy-iene, as .ell
as associated sur-ical and 'har(acolo-ical di(ensions of
(edical 'ractice) 3i1e Galen, A&icenna .as a cle&er (an .ho
did not hesitate to tell his readers a+out his talents, +ut the
Canon +rilliantly assi(ilates and 'ac1a-es Gree1 (edical
.isdo( and Isla(ic (edical ex'erience, in a lo-ical and .ellG
ordered for() It .as ideal as a co('lete (edical text+oo1, for
.hich it .as lon- used in >uro'e, in 3atin translation, and
continues to +e assi-ned to students of unani ti++ (traditional
Isla(ic) (edicine)
A&erroes (I+n 8ushd), li1e A&icenna .ell &ersed in Aristotelian
'hiloso'hy, .or1ed in Isla(ic S'ain and in Morocco) His (a,or
(edical .or1 (he also 'u+lished on 'hiloso'hy, astrono(y,
and ,uris'rudence) .as an encyclo'aedic one, in the style of
A&icenna*s Canon) Variously rendered in >n-lish as PThe 6oo1
of %ni&ersals*, or PGeneralities of Medicine*, A&erroes* text+oo1
in se&en sections co&ered the .hole -a(ut of (edicine, fro(
anato(y to thera'y) Its 3atin translations 'resented a GalenicG
Aristotelian synthesis to -enerations of doctors in late
(edie&al >uro'e)
:ust as the Isla(ic doctors had instituted a 'ro-ra((e of
translation of ancient texts into Middle >astern lan-ua-es, so
the 'rocess of translatin- these translations +ac1 into 3atin
.as initiated +y Constantine the African (d) +efore C<@=), and
continued +y (any other scholars) These ne.ly a&aila+le 3atin
texts for(ed the +asis of the curriculu( of the earliest
>uro'ean (edical schools, +e-innin- .ith the fa(ous one at
Salerno, southern Italy, esta+lished a+out C<=<, and ado'ted
+y (edie&al uni&ersity (edical faculties durin- the follo.in-
centuries)
Hos'itals, uni&ersities, doctors
#e'endin- on .hat counts as a Phos'ital*, this central
institution of (odernity can +e traced to &arious +e-innin-s)
The 8o(ans used s'ecial +uildin-s called Valetudinaria (fro(
the sa(e root as our .ord for so(eone .ho is .orried .ell, a
&aletudinarian) to house and care for .ounded and sic1
soldiers) There is one 1no.n to date fro( a+out C> @) Sli-htly
earlier, sla&es .ere also +ein- housed to-ether .hen they
.ere sic1, a reRection of their &alue) These structures .ere
'ra-(atically desi-ned to contain a nu(+er of +eds and
related facilities, +ut they .ere also -enerally related to the
necessity of a 'articular ca('ai-n or out+rea1 of illness and
.ere not concei&ed of as 'er(anent institutions in the (odern
sense)
Our .ord Phos'ital* co(es fro( the sa(e root .ord as do
hos'itality, hostel, and hotel) In Christendo(, early Phos'itals*
.ere reli-ious esta+lish(ents, (aintained +y reli-ious orders
and a&aila+le as 'laces of refu-e or hos'itality for 'il-ri(s, +ut
also for the needy) Their function .as not ex'licitly (edical,
althou-h (li1e (onasteries or nunneries) the Phos'ital* (i-ht
also contain an PinNr(ary* ('lace for the sic1 or inNr(), .here
those .ith s'eciNc (edical needs could +e loo1ed after) More
co((on and lar-er in the /ear >ast (:erusale( contained one
.ith !<< +eds +y DD<) than in the 3atin 4est, they -radually
+e-an to dot the landsca'e of 'resentGday >uro'e) Many of
the fa(ous >uro'ean hos'itals of the 'resent date +ac1 to
(edie&al ti(es and their na(es testify to their reli-ious
ori-ins: HQtel #ieu in $aris, St 6artholo(e.*s Hos'ital in
3ondon, Sta Maria /uo&a in 9lorence)
4ithin the Isla(ic lands, hos'itals also attained considera+le
si7e and i('ortance +y the CCth century) They so(eti(es had
s'ecial di&isions, such as .ards for 'atients suIerin- fro( eye
diseases, or the insane, and attracted students .ishin- to
learn ho. to 'ractise (edicine) They .ere 'ro+a+ly (ore
o&ertly P(edical* than their Christian counter'arts, +ut they
shared the sa(e ran-e of 'hilanthro'ic or charita+le fundin-,
and, in ti(es of e'ide(ic, the sa(e function of isolation and
se-re-ation) Co((unity leaders (ade use of hos'itals for t.o
diseases in 'articular: 'la-ue and le'rosy) Often called
Pla7arettos* B fro( 3a7arus, the 'oor (an .hose sores the
do-s lic1ed in :esus* 'ara+le in 3u1e*s Gos'el B these isolation
hos'itals .ere ada'ted for 'la-ue after the 6lac1 #eath, fro(
their earlier use for 'eo'le dia-nosed as le'ers) /o disease
+etter than le'rosy ca'tures the co(+ination of +rutality and
lo&e infusin- (edie&al Christendo() The dia-nosis itself, often
for conditions that (odern doctors .ould -i&e another na(e,
carried .ith it total social ostracis( and le-al death, .ith
di&orce +y the le'er*s s'ouse 'er(itted) It conde(ned its
&icti( to a life of isolation and +e--in-, -enerally conNned to a
la7aretto and needin- to carry the fa(iliar le'er*s rattle .hen
-oin- outside, so that 'assersG+y .ere alerted to the
onco(in- source of 'hysical (and (oral) conta-ion) At the
sa(e ti(e, so(e (on1s, nuns, and other reli-iously (oti&ated
indi&iduals freely li&ed a(on- these outcasts and de&oted
their li&es to the()
The le'rosy dia-nosis .as co((on fro( the C!th to the CEth
centuries, in (ost 'arts of >uro'e, and le'rosy*s decline (ay
ha&e +een catalysed +y the fact that 'eo'le li&in- to-ether in
closely conNned ?uarters .ere 'articularly &ulnera+le to the
6lac1 #eath and the re'eated 'la-ue e'ide(ics that follo.ed)
Certainly a nu(+er of le'er hos'itals .ere turned into 'la-ue
hos'itals, for (any of the sa(e reasons, sa&e that 'la-ue .as
an acute disease, fro( .hich so(e indi&iduals reco&ered, and
le'rosy .as a chronic disease and -enerally a lifeGlon-
sentence) $la-ue hos'itals, es'ecially in southern >uro'e,
.ere con&erted to other (edical uses after that disease
disa''eared fro( >uro'e in the CAth centuryS in the Middle
>ast, .here 'la-ue continued, they .ere 1e't as 'laces for
?uarantinin- tra&ellers and others on the (o&e .hen 'la-ue
.as near)
E) Classical (edical N-ures) This earlyG(odern i(a-e, in the
classical style, de'icts Ascle'ius on the left, holdin- a
caduceus, and Galen exa(inin- a s1eleton
Another (edie&al institution i('ortant for (edicine .as the
uni&ersity) The (edical school at Salerno fro( the late CCth
century .as si('ly that: a school to train doctors) A uni&ersity
follo.ed there a cou'le of centuries later) In the (eanti(e,
(any others .ere founded throu-hout >uro'e, +e-innin- .ith
6olo-na (founded c) CC=<), and follo.ed +y those in $aris
(C!<<), Oxford (C!<<), and Sala(anca (c) C!C=)) 6y the late
CDth century, there .ere D< in >uro'e, dottin- the north and
south, east and .est) A uni&ersity has diIerent faculties, and
(ost of these either had fro( the +e-innin- or de&elo'ed
(edical faculties, to co('le(ent those of arts, 'hiloso'hy
(includin- .hat .e .ould call science), theolo-y, and la.)
Althou-h (any of the (edical faculties .ere &ery s(all, and
the nu(+er of -raduates (iniscule, the (o&e(ent -a&e +irth
to learned (edicine, and the uni&ersityGeducated 'hysician) It
re'resented the ?uintessence of Pli+rary (edicine*, since the
teachin- .as initially +ased on texts, of classical and Isla(ic
authors, and dis'utation rather than 'ractical trainin- or
ex'eri(ent .as the 1ey)
One conse?uence of the ne.ly -raduated 'hysician .as the
for(ali7ation of the occu'ational hierarchy .ithin (edicine
that 'ersisted until the C@th century) 4ith an ex'ensi&e and
len-thy education that the uni&ersities oIered ca(e the
-entle(anly status that 'hysicians lon- 'rided the(sel&es on)
(%ntil a decade a-o, 9ello.s of the 8oyal Colle-e of $hysicians
of 3ondon could not sue for the reco&ery of fees)) As
-entle(en, (anual .or1 .as +eneath the() That .as the ,o+
of the sur-eon and a'othecary, +oth occu'ational niches that
already existed +ut .ere (ore for(ally Nxed .ith the co(in-
of the uni&ersity) Sur-eons and a'othecaries .ere trained +y
a''renticeshi's, or +y infor(ally learnin- their craft +y
associatin- the(sel&es .ith an older 'ractitioner) It .as the
Hi''ocratic .ay, +ut it +e-an to ac?uire a lo.er social (and,
-enerally, econo(ic) status .hen co('ared .ith 'hysicians
.ho could read 3atin and dis'ute the niceties of Galen and
A&icenna)
There .ere, to +e sure, a fe. sur-eons .ith uni&ersity
ex'osure, and a(on- +oth sur-eons and a'othecaries,
indi&iduals .ith learnin- and .ealth) The +oundaries .ere not
al.ays Nxed and, in the countryside, (any 'hysicians
co('ounded their o.n dru-s and 'erfor(ed sur-ery) In other
.ords, they acted as -eneral 'ractitioners) In ur+an areas,
ho.e&er, the di&isions .ere retained and re-ulated +y colle-es
and co('anies of 'hysicians, or +y the uni&ersity faculty)
Sur-eons in ur+an areas often esta+lished -uilds, on a 'ar .ith
those re-ulatin- other (anual occu'ations, such as
+utcherin-, +a1in-, or candlestic1 (a1in-) The (edical
re-ulation .as 'atchy, +ut the i(a-e of the three occu'ational
hierarchies re(ained 'art of 'u+lic 'erce'tion until later
de&elo'(ents in (edical 1no.led-e also chan-ed .hat
doctors could do)
The disco&ery of anato(y
Galen and a nu(+er of other ancient and Ara+ic authors had
had a -ood deal to say on the internal structures and functions
of the hu(an +ody) Since then, the occasional auto'sy, (ostly
'erfor(ed .hen an i('ortant 'erson died suddenly or in
sus'icious circu(stances, had re&ealed (ore of .hat the +ody
loo1s li1e .hen it is cut o'en) 9or all that, it .as a +old ste'
.hen the (edical faculties -radually +e-an to oIer 'u+lic
de(onstrations of dissected +odies in the CEth century)
9re?uently, a (enial 'rosector .ould o'en the cor'se (often of
an executed cri(inal) .hile the 'rofessor read rele&ant
'assa-es fro( Galen or another authority) These Panato(ies*,
as the .hole 'rocess .as called, .ere scheduled for the .inter
(onths, .hen the colder .eather slo.ed do.n the +ody*s
'utrefactionS the order of ex'osin- the internal 'arts .as also
dictated +y the s'eed of decay: a+do(en Nrst, follo.ed +y the
contents of the thorax, then the +rain, and Nnally, the li(+s)
D) Galen at .or1) This illustration fro( a CD"D edition of
Galen*s .or1s su+tly reinforces the fact that so(e of Galen*s
1no.led-e of anato(y ca(e fro( dissectin- 'i-s) Althou-h
(any of the classical N-ures a''ear +lissfully uninterested,
the co('osition in&o1es a ty'ical 'u+lic dissection in the
8enaissance
The Nrst recorded 'u+lic dissection .as 'erfor(ed in 6olo-na
in a+out CFCD, +y Mondino de* 3iu77i (c) C!A<BCF!"), .ho also
.rote the Nrst (odern +oo1 de&oted to anato(y, in a+out
CFC") It too1 al(ost a century for dissections to +eco(e
relati&ely co((on, a co(+ination of the di5culty of o+tainin-
cor'ses, and the theoretical +ias of (ost (edical education)
9ro( the CDth century, ho.e&er, the 'ace ?uic1ened, .ith
(ore dissections and (ore .or1s de&oted to hu(an anato(y)
8enaissance artists .anted to a''reciate .hat the hu(an
+ody loo1ed li1e on +oth the outside and insideS 3eonardo da
Vinci*s (CED!BCDC@) anato(ical dra.in-s are so(e of the (ost
fa(ous of the 'eriod, althou-h they had re(ained &irtually
un1no.n, and therefore .ithout inRuence)
The -reatest of the early anato(ists .as Andreas Vesalius
(CDCEB"E), 6el-iu( +orn +ut 'rofessor of anato(y and sur-ery
in $adua) His -reat .or1 #e hu(ani cor'oris fa+rica (CDEF: POn
the fa+ric of the hu(an +ody*) is the Nrst (edical +oo1 in
.hich the illustrations are (ore i('ortant than the text)
4hat Vesalius, hi(self an ardent dissector rather than si('ly
a reader of Galen, had noticed .as that the hu(an +ody .as
not al.ays as Galen had descri+ed it) 4hile others had done
so +efore, Vesalius not only said so B di5dently at Nrst, (ore
forcefully as he -ained conNdence B +ut he de(onstrated it
throu-h the (a-niNcent 'lates that acco('anied his lar-e
+oo1) The (uscular .alls +et.een the ri-ht and left side of the
heart, for instance, .ere dense, .ith no .ay for +lood to 'ass
throu-h, as Galen*s 'hysiolo-y re?uired) The hu(an li&er did
not ha&e the four or N&e lo+es that Galen assi-ned it (throu-h
dissectin- 'i-s and other ani(als)S the sternu(, uterus, and
(any other anato(ical structures .ere accurately descri+ed
+y Vesalius for the Nrst ti(e)
") In addition to the fa(ous (uscleG(en, Vesalius*s 9a+rica of
CDEF de'icted other 'arts of the hu(an +ody, al.ays
dra(atically re'resented
4e di&ide the history of anato(y into 'reGVesalian and 'ostG
Vesalian, .ith Vesalius as the fulcru() This 'ro+a+ly
exa--erates the i((ediate i('act of Vesalius* +oo1, for he
left $adua and anato(y shortly after its 'u+lication for a
lucrati&e ,o+ at the S'anish court) 6y the (idGC"th century,
ho.e&er, the anato(ical re&olution .as .ell under.ay, and
the desire to see for oneself, instead of ta1in- the ancients on
childli1e trust, .as .ides'read)
Anato(y .as the ?ueen of the (edical sciences for so(e
three centuries, and no +ranch of (edical 1no.led-e
+eneNted (ore fro( that catalyst of social and intellectual
chan-e, the 'rintin- 'ress) A Ger(an artisan, :ohannes
Guten+er- (c) CE<<B"=), introduced the (o&a+le ty'e 'rintin-
'ress into >uro'e in a+out CEF@ (the Chinese already had
the()) The i('act on all as'ects of hu(an life .as enor(ous)
Medical +oo1s .ere .ell re'resented in the early incuna+ula
(+oo1s 'rinted +efore CD<C), althou-h 6i+les, .or1s of
theolo-y, and editions and translations of ancient authors
do(inated) 6oo1s could then +e (assG'roduced, and e&en
ordinary doctors could o.n a fe. of the()
In addition to the texts, .oodcuts and en-ra&in-s allo.ed
+oo1s to +e illustrated, so not only could 'eo'le read a+out
the hu(an +ody, they could see its 'arts dis'layed on the
'a-e) Vesalius* #e 9a+rica .as not the Nrst illustrated anato(y
text, +ut it set standards for dra(atic artistic re'resentation as
.ell as anato(ical accuracy) O&er the follo.in- centuries,
anato(y +oo1s crystalli7e a dee' 'aradox in earlyG(odern
(edicine) Anato(y .as an as'ect of (edical acti&ity that
attracted re&ulsion fro( (any (e(+ers of the 'u+lic:
dissectin- .as seen as (orally de+asin-, dis-ustin-, and
cruel) It led e&entually to an under-round trade in the su''ly
of +odies +y ille-al (eans, -enerally -ra&eGro++in- +ut
so(eti(es (urder) It certainly .as s(elly +efore 'reser&ation
(ethods i('ro&ed, althou-h the sic1ly s.eet aro(a of
for(aldehyde (ade (odern (edical students easy to identify
on the street, 'er(eatin- as it does their clothes and s1in)
#issection .as thus +ad for (edicine*s 'u+lic i(a-e) It .as
also the su+,ect of ela+orate, ex'ensi&e, and +eautifully
'roduced and illustrated +oo1s, .ith the u''er end of the
(ar1et ai(ed at the connoisseur) 9or the (edical student,
there .ere s(all text+oo1s .ith crude illustrations and a 'rice
to (atch) /o other disci'line .ithin (edicine so co(+ined art
and science, or 1no.led-e and 'resentation) Increasin-ly,
e&en .ouldG+e 'hysicians dissected, their curiosity -ettin- the
+etter of their -entle(anly 'retensions) Many of the -reat
na(es in earlyG(odern anato(y B Ga+riele 9allo'io (CDF!B"!),
9a+ricius a+ Ac?ua'endente (CDFFBC"C@), 9rederi1 8uysch
(C"F=BCAFC), 4illia( Cheselden (C"==BCAD!), 4illia( Hunter
(CAC=B=F) B had a5liations .ith sur-ery or o+stetrics, +ut
curious 'hysicians, such as 4illia( Har&ey (CDA=BC"DA), also
used their hands in their research) Har&ey*s -reat treatise
announcin- his disco&ery of the circulation of the +lood (C"!=)
is actually entitled an Panato(ical exercise* on de Motu Cordis
(On the (otion of the heart))
A) This Victorian en-ra&in- of a .oodcut +y Stradanus fro(
a+out CD=< sho.s (any sta-es of +oo1 'roduction, includin-
settin- ty'e, in1in- it, 'rintin- the sheets, and 'roofGreadin-
Gi&en the nature of (edical (or e&en sur-ical) 'ractice in the
'eriod, doctors learned (ore anato(y than they could actually
use) 6ut the 'arts of the +ody .ere 'al'a+le and it .as easier
to a-ree on an anato(ical structure than on so(e theoretical
nicety) And anato(y .as a disci'line in .hich 'ro-ress .as
discerni+le) /e. 'arts .ere re-ularly +ein- descri+ed, such as
the lacteal &essels, the &al&es of the &eins, or the Pcircle of
4illis* B the arterial anasto(osis at the +ase of the +rain,
na(ed after Tho(as 4illis (C"!CBAD)) 6y the early CAth
century, fe. anato(ists .ould ha&e deferred to Galen, and in
the P+attle of the +oo1s*, that .ides'read de+ate co&erin- all
Nelds of natural 1no.led-e a+out .hether the ancients or the
(oderns 1no. the (ost a+out the .orld .e inha+it, anato(y
.as one Neld in .hich the (oderns .on handsGdo.n)
The che(ical, the 'hysical, and the clinical
The li+eration eIected +y the in,unction to loo1 for oneself
touched (any as'ects of (edicine as .ell as natural
'hiloso'hy) The 8enaissance coincided .ith the 'eriod that
later historians ha&e na(ed the ScientiNc 8e&olution, .hich
inRuenced (edicine as .ell as astrono(y, cos(olo-y, 'hysics,
and other sciences) The t.o natural sciences that (ost closely
i('in-ed on (edicine .ere che(istry and 'hysics)
The che(ical (o&e(ent .ithin (edicine had its roots in an
eccentric S.iss -enius, $aracelsus (c) CE@FBCDEC)) $aracelsus
.as ho. he .as 1no.n to his follo.ers: his full na(e,
Theo'hrastus $hili''us Aureolus 6o(+astus &on Hohenhei(,
.as so(ethin- of a (outhful) The story that he (eant his
ado'ted na(e to (ean P-reater than Celsus*, the 8o(an
author .ho .rote an inRuential co('endiu( on (edicine, is
'ro+a+ly (ythical, +ut it e(+odies one of t.o 'articularly
stri1in- and inRuential characteristics of his che?uered career)
He .as 'assionate a+out the fact that (edicine (and science)
needed to +e founded a-ain on Nrst 'rinci'les, +y the
(oderns) He had little use for the .isdo( of Hi''ocrates or
Galen, 'u+licly +urnin- one of the latter*s +oo1s in a deNant
dis'lay durin- a (+rief) stint as a 'rofessor in 6asel) Althou-h
he 'ro+a+ly ne&er con&erted to the ne. $rotestantis(,
$aracelsus .as o+&iously inRuenced +y the intellectual and
e(otional fer(ent that Martin 3uther*s (o&e(ent for(ally
inau-urated early in his life) $aracelsus re'eatedly said that
learnin- .as to +e found in nature, not +oo1s, althou-h this
did not sto' hi( fro( 'ennin- do7ens of +oo1s hi(self, (any
of .hich .ere 'rinted in his lifeti(e) $erha's he really (eant
that learnin- .as to +e found in his +oo1s, not those of his
'redecessors)
His second lastin- contri+ution .as his e('hasis on che(istry,
as a .ay of understandin- the .ay the hu(an +ody .or1s,
and as a source of dru-s to treat disease) He used (etals such
as (ercury and arsenic as (uch as the traditional +otanicals
in his treat(ents, and his follo.ers, the iatroche(ists (literally,
che(ical doctors), continued in his .a1e) His notion of
disease, as so(ethin- external to the +ody, is so(eti(es
rather ina''ro'riately descri+ed as a forerunner of -er(
theory, +ut it .as in fact rooted in his (ystical, alche(ical
notions of the .ay nature o'erates) There is (ore to the
thin1in- of this stran-e (an, .ho 'ro&o1ed contro&ersy in his
lifeti(e and after.ards) His follo.ers, of .hich there .ere
(any for .ell o&er a century, atte('ted to re.rite the theory
and 'ractice of (edicine, in a che(ical lan-ua-e)
Another -rou', the iatro'hysicists, sli-htly later and dra.in-
on the triu('hs of astrono(y and 'hysics, sa. the +ody as a
.onderful (echanical contri&ance) 4hereas the iatroche(ists
considered di-estion as a che(ical 'rocess, the iatro'hysicists
sa. it as a (echanical -rindin- do.n) These later ad&ocates
analysed (uscular (o&e(ent, calculatin- the forces
-enerated +y contraction, and sou-ht to re'resent hu(an
'hysiolo-y (athe(atically .hene&er 'ossi+le) Their heroes
.ere Galileo, and later /e.ton, (en .ho had re'laced
Aristotle*s &ie. of the uni&erse .ith a (uch (ore 'o.erful
(odel, in .hich (atter and force .ere the o'erati&e thin-s to
+e (easured) Throu-hout the C=th century, /e.ton*s notion of
-ra&ity as a force that extended throu-hout the uni&erse and
ex'lained so (uch .as a s'ur to doctors see1in- si(ilar
'rinci'les in (edicine)
The ne. relationshi' to en?uiry introduced a 'eriod of -reat
fer(ent .ithin (edicine (and science)) Theories a+ounded and
o'ti(is( 're&ailed) The a''roach to understandin- health and
disease altered dra(atically, +ut chan-es in .hat doctors
actually did in treatin- 'atients .ere less stri1in-) To +e sure,
the che(icals introduced +y $aracelsus and his follo.ers .ere
(ostly ne., and the 're&alence of sy'hilis (eant that
(ercury had a 'ro(inent (edical 'resence) Sy'hilis had ta1en
>uro'e +y stor( in the CE@<s) A''earin- Nrst in /a'les, .here
so(e of the S'anish (ercenaries had +een to the /e. 4orld
.ith Colu(+us, the assu('tion that it .as a ne. disease
i('orted .ith Colu(+us .as a natural conclusion) Historians
are still de+atin- this scenario, +ut the fact re(ains that
sy'hilis in the late CEth and early CDth centuries +eha&ed li1e
a ne. disease, in its &irulence and ra'idity of s'read) 6ecause
of the rash caused +y sy'hilis, (ercury, a standard treat(ent
for s1in diseases, .as used, and it see(ed eIecti&e in
su''ressin- sy('to(s, e&en if it .as toxic for the suIerer,
'roducin- intense sali&ation, loss of teeth, and other side
eIects) The (etallic odour to the 'atient*s +reath .as di5cult
to conceal, and althou-h 'o'es, artists, and doctors suIered
fro( it, its sexual trans(ission .as sus'ected early on (the
-enital lesions .ere usually the Nrst si-n), and the introduction
of the +ar1 of the -uaiacu( tree, fro( South A(erica, soon
+eca(e the fa&oured thera'y for those .ho could aIord it) It
reinforced the notion that sy'hilis had co(e fro( the /e.
4orld, the assu('tion +ein- that God 'laced re(edies near to
the ori-ins of diseases, to encoura-e us to loo1 for the()
=) The diIerin- social status and (edical functions of the
'hysician and sur-eon are sho.n in this en-ra&in- fro( C"E")
In these t.o scenes, the for(ally dressed 'hysician on the left
hands a (edicine to a sic1 (an in +edS on the ri-ht, he
su'er&ises the (ore rou-hly attired sur-eon .ho is
a('utatin- a (an*s le-
#es'ite these ne. diseases and ne. re(edies, Hi''ocrates
.ould not ha&e +een sur'rised at (ost (edical (inistration to
suIerers) 6loodlettin-, e(etics (to in&o1e &o(itin-), cathartics
(to induce 'ur-in-), and the -a(ut of re(edies associated
.ith hu(oralis( continued as the (ainstay of doctors) Indeed,
as Galen*s star .aned, that of Hi''ocrates still shone +ri-htly)
A(on- clinicians of the CAth century, Tho(as Sydenha(
(C"!EB=@) still co((ands res'ect) Called the P>n-lish
Hi''ocrates*, he sou-ht to return (edicine to the e('irical art
that he identiNed .ith the 9ather of (edicine) Medicine, he
.rote, should concern itself .ith careful clinical descri'tions of
disease (he left -ra'hic accounts of -out, hysteria, and
s(all'ox, a(on- other illnesses)) 4ith the security of correctly
dia-nosin- a disease, re(edies could +e e('irically sou-ht)
He .as instru(ental in ad&ocatin- another /e. 4orld
re(edy, ?uinine (&ariously called $eru&ian +ar1, or :esuit*s
+ar1, reRectin- its ori-in), in the treat(ent of inter(ittent
fe&ers)
Sydenha(*s ex'erience .ith $eru&ian +ar1 funda(entally
chan-ed his .hole conce't of disease) Althou-h he .as still
co(forta+le .ith Hi''ocratic hu(ours, ?uinine see(ed
co('letely to sta(' out inter(ittent fe&ers, root and +ranch)
It see(ed to +e a s'eciNc, dra(atically eIecti&e a-ainst this
one disorder in all 'atients) It encoura-ed hi( to +elie&e that
diseases could +e classiNed, li1e +otanists classify 'lants, and
that the &ariation of a disease and its sy('to(s in indi&iduals
.as ad&entitious, li1e the diIerences in indi&idual &iolets or
other Ro.ers) As he fa(ously .rote:
/ature, in the 'roduction of disease, is unifor( and consistent,
so (uch so,
that for the sa(e disease in diIerent 'ersons the sy('to(s
are for the (ost
'art the sa(eS and the selfsa(e 'heno(ena that you .ould
o+ser&e in the
sic1ness of a Socrates you .ould o+ser&e in the sic1ness of a
si('leton)
Sydenha(*s reRection can +e seen as a 1ind of turnin- 'oint in
clinical thin1in-) It encoura-ed doctors in the -enerations that
follo.ed to classify diseasesS (ore si-niNcantly, it +e-an the
(odern 'rocess of teasin- out the diIerence +et.een the
disease and the 'erson suIerin- fro( the disease, and of
identifyin- those uni&ersal features of each 1ind of disease
that could (a1e a s'eciNc thera'y rational) The irony is,
Sydenha( ne&er sa. hi(self as anythin- +ut a -ood
Hi''ocratic, +ut his thin1in- had 'osed the (odern (edical
dile((a: ho. to retain a +elief in the uni?ue indi&iduality of
each 'atient, and still a''ly the (ore -eneral Nndin-s of a
scientiNcally -rounded dia-nosis and thera'y)
>nli-htened (edicineT
Sydenha( en,oyed a -ood re'utation in the century that
follo.ed his death) His .or1s .ere ori-inally 'u+lished in
3atin, still the lin-ua franca, +ut also a''eared in (any
translated editions, in >n-lish, 9rench, Ger(an, S'anish, and
other >uro'ean lan-ua-es) The (ost fa(ous (edical teacher
of the C=th century, Her(ann 6oerhaa&e (C""=BCAF=),
re'utedly ne&er (entioned Sydenha( in his lectures .ithout
liftin- his hat in salute) 6oerhaa&e .as the leadin- li-ht at the
%ni&ersity of 3eiden for (ore than E< years, and his 'u'ils
ca(e fro( all o&er >uro'e, and inRuenced educational
initiati&es in >din+ur-h, Vienna, GUttin-en, Gene&a, and
else.here)
6oerhaa&e .as intellectually an eclectic, dra.in- his (edical
ideas fro( che(istry, 'hysics, +otany, and other disci'lines,
+ut also 'ossessin- a .onderful co((on sense and dia-nostic
acu(en) 6oth his lectures and his +edside teachin- .ere
fa(ous, and he had an extensi&e 'ri&ate 'ractice, includin-,
as .as still co((on, a lar-e 'ostal consultation, +oth .ith
'u77led doctors and .orried 'atients) >?ually i('ortant,
6oerhaa&e .rote a strin- of text+oo1s in che(istry, (ateria
(edica (i)e) (edical thera'eutics), and (edicine, as .ell as
nu(erous 'u+lications in anato(y, +otany, and &enereal
disease) He inRuenced t.o or three -enerations of doctors,
e&en if his forte .as synthesis rather than funda(ental
disco&ery) #es'ite his fascination .ith the natural .orld
(es'ecially his +elo&ed +otanical -arden), he re(ains a 'art of
the learned tradition of li+rary (edicine: Hi''ocrates .as still
a &ital N-ure for hi(, and he continued to loo1 +ac1 for facts
and a''roaches to (edicine, e&en .hile retainin- the
conNdence in 'ro-ress that had +een .on in the 're&ious
century)
@) Her(ann 6oerhaa&e .as the (ost fa(ous (edical teacher
of his day, and althou-h he trained (any youn- doctors, he
'ro+a+ly did not often lecture to ?uite such lar-e audiences
6oerhaa&e*s 'u'ils included the (ost fa(ous naturalist of the
C=th century, Carl 3innaeus (CA<ABA=)) 3innaeus turned
classiNcation into an a&antG-arde science, introducin- the
syste( of +ino(ial no(enclature, .here+y or-anis(s are
1no.n +y their -enus and s'ecies) 3innaeus de&oted his life to
orderin- the o+,ects of the natural .orld, es'ecially 'lants) He
sa. hi(self as a second Ada(, the Nrst ha&in- +een char-ed
.ith the tas1 of na(in- the ani(als and 'lants in the Garden
of >den) %''sala, .here 3innaeus .as 'rofessor of (edicine,
.as no >den, +ut he orchestrated a series of ex'editions +y
his students to (any exotic 'arts of the .orld fro( .hich they
dutifully +rou-ht +ac1 (if they sur&i&ed) natural s'eci(ens of
all 1inds for hi( to classify) 3innaeus also 'roduced a
classiNcation of diseases, +ut his nosolo-y .as less inRuential
than se&eral other >nli-hten(ent ones, includin- those of
9ranVois 6oissier de la Croix de Sau&a-es (CA<"B"A) of
Mont'ellier, 4illia( Cullen (CAC<B@<) of >din+ur-h, and
>ras(us #ar.in (CAFCBC=<!), a 'oet, +otanist, in&entor, and
(edical 'ractitioner in 3ichNeld and other 'laces in the >n-lish
Midlands) All these nosolo-ies .ere ela+orate aIairs, and
+ased 'ri(arily on .hat .e .ould call sy('to(s, rather than
si-ns or causes) 9e&er .as a disease in itself) Most tellin-ly,
'ain .as (inutely classiNed, accordin- to its characteristics,
intensity, and location)
These (a''in-s of disease re&ealed a 'ro(inent as'ect of
>nli-hten(ent (edicine, in that it .as 'atientGorientated, thus
continuin- the Hi''ocratic tradition) #octors relied on 'atients*
accounts of their o.n feelin-s and sy('to(s to (a1e their
dia-noses, and .ithin this scenario, 'atients are -enerally
descri+ed +y historians as do(inatin- the encounter) It is
'ossi+le to exa--erate this, ,ust as it is 'ossi+le to descri+e
the (edicine of the C@th century and +eyond as uni&ersally
doctorGdo(inated) /e&ertheless, +efore the dia-nostic
(ethods of (odern ti(es, 'atients .ould not ha&e ta1en a.ay
fro( their encounter the +ad ne.s that their +lood 'ressure or
+lood su-ar .as too hi-h (or too lo.), or that there .as a
sus'icious shado. on a chest Gray) In the ancien rM-i(e,
'atients and their doctors s'o1e the sa(e lan-ua-e and had
si(ilar conce'tions of disease and its causes) They (i-ht -o
a.ay .ith a -ra&e or a fa&oura+le 'ro-nosis, +ut it .ould ha&e
+een directly related to the sy('to(s that led the( to see1
(edical ad&ice in the Nrst 'lace)
T.o further as'ects of >nli-hten(ent (edical 'ractice ou-ht
to +e (entioned) 9irst, it .as a ti(e of i('ressi&e (edical
entre'reneurialis() Health (attered, and 'eo'le .ere
're'ared to 'ay for it) This (eant that a(+itious (or de&ious)
healers of all stri'es could see1 to car&e out their niche in the
(edical (ar1et 'lace) Tellin- the diIerence +et.een the
P?uac1s* and the Pre-ulars* .as not al.ays easy, since (any
soGcalled ?uac1s also -enerally o'erated .ithin the cultural
cos(olo-y of (edicine, and Pre-ulars* (i-ht ad&ertise their
thera'ies, use secret re(edies, and culti&ate notoriety as a
(eans of attractin- attention, and there+y 'atients) The
co('le(entary (edicine of the 'resent, +ased as it usually is
on an alternati&e set of causal ex'lanations of health and
disease, had little resonance in earlier centuries) Indi&idual
?uac1s (i-ht ha&e had their o.n idiosyncratic notions of .hat
caused disease, or ho. it (i-ht +est +e treated, +ut as often
as not they .ould also assi(ilate i('ortant historical N-ures
.ithin (edicine B Hi''ocrates and Galen +oth feature in the
ad&ertise(ents of irre-ular healers of the 'eriod) $aracelsus is
a nota+le exce'tion, in re,ectin- not only the theories +ut also
the .hole tradition of (edicine) His .as a -enuinely ahistorical
(entalityS (ost P?uac1s* relied instead on the fa(iliar and
traditional, slyly turnin- it to their o.n ad&anta-e, in .hat
they 'ro(ised or in ho. they 'lied their .ares and ser&ices)
The second stri1in- characteristic of >nli-hten(ent (edicine
.as its +usy o'ti(is() It .as an a-e of 'ro,ects and
institutions) Hos'itals .ere esta+lished .ith -reat re-ularity,
atte('ts .ere (ade throu-hout >uro'e to refor( (ilitary
(edical ser&ices, and (edically orientated 'hilanthro'y .as
co((on) The idea of 'ro-ress, includin- (edical 'ro-ress,
.as ta1en for -ranted, and doctors and their 'atients +oth
+elie&ed that the (edicine of the future could do e&en (ore
than the (edicine of the 'ast or 'resent) At the sa(e ti(e,
learned 'hysicians and sur-eons still loo1ed to Hi''ocrates or
Sydenha(, not si('ly for ins'iration +ut for infor(ation and
exa('le) 9or 6oerhaa&e or Cullen, the history of (edicine .as
not of (ere anti?uarian interest, +ut a source of li&in- .isdo()
#urin- the C@th century, the old doctors .ere consi-ned to
history, as a ne. -eneration of doctors +e-an increasin-ly to
loo1 to the future)
Cha'ter F Medicine in the hos'ital
Vi&e la 9rance
The 'hrase Phos'ital (edicine* has ac?uired a s'eciNc
(eanin- for (edical historians) Hos'itals e(er-ed in the early
(edie&al 'eriod, and P(edicine*, in the sense of (edical
'ractice, has an e&en lon-er history) /e&ertheless, Phos'ital
(edicine* is a con&enient shorthand for the &alues that
Rourished .ithin the (edical co((unity in 9rance, and
es'ecially $aris, +et.een the re&olutions of CA=@ and C=E=)
This 'eriod constitutes an e'och, durin- .hich $aris +eca(e
the Mecca of the (edical .orld) It .as centred s?uarely .ithin
the $arisian hos'itals and the tools and attitudes that
do(inated (edical education and 'ractice there resonated
throu-hout the 4estern .orld)
This 9rench 'eriod has so(eti(es +een descri+ed as a
P(edical re&olution*, a''ro'riate since it -re. out of a 'olitical
re&olution) Historians .ho ha&e (inutely un'ac1ed the
educational structures, (edical 'rocedures, and doctorB
'atient relationshi's ha&e unco&ered su5cient 'recedent to
ar-ue for e&olution rather than re&olution .ithin (edicine, +ut
the fact re(ains that doctors in the C=E<s had ac?uired a ne.
conNdence, .hen co('ared to their 'redecessors a cou'le of
-enerations +efore, and (uch of this can +e ascri+ed to the
inRuence of $aris)
3i1e (any re&olutions, the $arisian (edical one +e-an s(all,
and could ha&e hardly +een 'redicted durin- the tur+ulent
days of the Terror) As the 'olitical and (ilitary forces of the
8e&olution -ained 'o.er, the institutions of (edicine B
'hysicians, sur-eons, hos'itals, the old acade(ies and
faculties B .ere s.e't a.ay, alon- .ith the other detritus of
the Ancien 8M-i(e) 9or a cou'le of heady years in the early
CA@<s, it see(ed +est for e&eryone to +e his or her o.n
doctor, and re&olutionary leaders 'ro(ised that uni&ersal
health .ould ine&ita+ly follo. the a+olition of 'ri&ile-e and
corru'tion associated .ith the old hierarchies and ine?ualities)
The o'ti(is( did not last lon-) #isease did not disa''ear, and
the 8e&olutionary -o&ern(ent soon disco&ered that its
soldiers and sailors de(anded (edical care .hen they .ere
sic1 or .ounded) The ar(y needed its doctors, and, (ore
'articularly, doctors trained in +oth (edicine and sur-ery) The
old dichoto(y .as ine5cient in the (idst of ca('ai-ns and
+attles, and in CA@E, three (edical schools .ere reo'ened,
'ri(arily to 'roduce (en to ser&e the (ilitary needs of the
ne. re'u+lic)
9ortunately, the 1ey (an on the co((ission a''ointed +y the
8e&olutionary Asse(+ly to consider the (edical re?uire(ents
of the ne. era .as a doctor and che(ist sy('athetic to the
ai(s of the 8e&olution) Antoine 9ourcroy (CADDBC=<@) had
(ade his na(e as a che(ist, and ser&ed as 'rofessor of
che(istry in the ne. $arisian school he hel'ed create)
$olitically astute and -enuinely .ellG(eanin-, he
(aster(inded the +lue'rint for the schools in $aris,
Stras+our-, and Mont'ellier) The re'ort he lar-ely 'roduced
reco-ni7ed the (ilitary needs of the conte('orary 'olitical
situation and stressed three as'ects of the ne. (edical
education) 9irst, it ou-ht to +e intensely 'ractical fro( the Nrst
day of the student*s trainin-) In his rin-in- .ords, the student
ou-ht to Pread little, see (uch, do (uch*) /o theory and (uch
'ractice .ere the orders of the day) Second, the ne. (edical
education .as to +e +ased s?uarely .ithin the hos'ital, .here
the o''ortunities for ex'erience .ere (uch -reater and (ore
intense than in the lecture theatre or 'ractice outside the
hos'ital) 9inally, the ne. (edical -raduate should +e trained
in +oth (edicine and sur-ery) In eIect, this (eant the
i('ortation of sur-ical thin1in- into (edicine 'ro'er) 4hereas
'hysicians had traditionally +een concerned .ith the .hole
+ody, .ith hu(ours, s'irits, or other -eneralist conce'tions of
disease, sur-eons had al.ays +een confronted .ith the local:
.ith a+scesses, +ro1en +ones, s'eciNc a+nor(alities re?uirin-
deNniti&e inter&ention at a 'articular site) 4ith the rise of the
9rench (edical schools, the lesion ac?uired (edical
si-niNcance) A lesion is a 'atholo-ical chan-e, induced +y
disease) It could thus +e seen, either .ith or .ithout a
(icrosco'e) $hysicians learned to thin1 sur-ically, and the
solid 'arts of the +ody ca(e into their o.n .ithin (edicine)
C<) The (assi&e ediNce of the HQtel #ieu Hos'ital, $aris, in the
early C@th century, scene of so (uch (edical inno&ation) The
t.o N-ures on the left see( to +e +earin- a co5n, and the
cart in front of the entrance (ay .ell +e 're'arin- to ta1e
a.ay +odies for +urial
9rench hos'ital (edicine ca(e to +e +ased on three 'illars,
none entirely ne., +ut .hich to-ether constituted a ne. .ay
of loo1in- at disease) The three 'illars .ere 'hysical dia-nosis,
'atholo-icoGclinical correlation, and the use of lar-e nu(+ers
of cases to elucidate dia-nostic cate-ories and to e&aluate
thera'y)
4ith (any (odiNcations, these ha&e re(ained funda(ental to
(edicine, as has the centrality of the hos'ital)
$hysical dia-nosis: the ne. inti(acy
An encounter .ith a doctor has its o.n eti?uette and inti(acy)
He or she can as1 the 'atient to undress, can touch and feel in
.ays -enerally reser&ed for s'ouses or 'artners, and can
cause disco(fort) 9or the 'ast t.o centuries or so, (ost
'atients ha&e acce'ted this relationshi' .ith doctors, on the
assu('tion that this de'endency is for their o.n -ood) The
relationshi' +eca(e routini7ed in the $arisian hos'itals in the
early C@th century, as a conse?uence of the 'hysical
exa(ination that doctors de&elo'ed in the ne.ly o'ened
hos'ital (edical schools)
This is not to su--est that doctors, al.ays (ale until the late
C@th century, had ne&er exa(ined na1ed 'atients +efore) The
&a-inal s'eculu(, for instance, .as de&elo'ed in 8o(an
ti(es, and o'erations for +ladder stones or anal Nstulae, the
treat(ent of -enital lesions, or deli&eries of +a+ies +y (ale
'ractitioners had occurred .ith so(e re-ularity in earlier
centuries) /e&ertheless, (ost (edical encounters did not
in&ol&e (uch 'hysical contact .ith the doctor, other than his
feelin- the 'ulse and loo1in- at the ton-ue) 6odily excretions
such as the urine and faeces (i-ht also N-ure in (edical
dia-noses, +ut the doctor so(eti(es exa(ined these .ithout
e&er seein- his 'atient)
The doctorB'atient encounter shifted in the $arisian hos'itals
of the early C@th century) Hos'ital 'atients .ere (ostly the
'oor and uneducated, and therefore 'o.erless to ha&e (uch
say in the .ay they .ere treated) 9urther, the ne. (edical
ideolo-y encoura-ed doctors to loo1 for o+,ecti&e si-ns of
disease, rather than si('ly rely on the 'atient*s account of his
or her sy('to(s) A sy('to(, such as 'ain or tiredness, is
'ri&ate to the indi&idualS si-ns, such as (uscle .astin- or an
a+scess, are (ore 'u+lic (atters, and the leaders of 9rench
hos'ital (edicine .anted to +ase their 'ractice on the
o+,ecti&ity of si-ns and lesions)
$hysical dia-nosis .as central to this endea&our) The four
cardinal di(ensions of 'hysical dia-noses, still tau-ht to
(edical students, are ins'ection, 'al'ation, 'ercussion, and
auscultation) In &arious for(s, all had +een used occasionally
+y doctors since the Hi''ocratics) The 9rench hos'ital doctors
'ut the( to-ether, (ade the( routine and syste(atic, and
fore&er chan-ed doctorB'atient relationshi's)
Ins'ection is the (ost +asic: loo1 at the 'atient) PStic1 out your
ton-ue* has +een a fa(iliar (edical co((and for a-es) 9urred
ton-ues .ere dee(ed to +e the 1ey to fe&ers and other acute
disorders) 0ello. eye+alls 'ointed to ,aundice, and Rushed
faces also indicated fe&ers or the end sta-es of a Phectic* (a
late sta-e of consu('tion, or tu+erculosis), or the 'lethora of
-out) A -reen tint to a 'ale face (ade the doctor thin1 of
chlorosis, a disease of youn- -irls .hich (ysteriously
disa''eared in the early !<th century, a+out the sa(e ti(e as
hysteria, and 'ossi+ly for the sa(e reasons) 9or the (ost 'art,
ho.e&er, ins'ection .as conNned to the P'u+lic* 'arts of our
+odies: the face, hands, and other 'arts ex'osed .ithout
+reech of con&ention) 4hen a doctor loo1ed else.here, there
had to +e a -ood reason, and sur-eons .ere (ore li1ely to
ha&e a reason than 'hysicians)
The 9rench (ade ins'ection syste(atic, 'art of a -eneral
assess(ent of a 'atient*s health) They did the sa(e thin- for
'al'ation, an e&en (ore inti(ate (anoeu&re, since it in&ol&es
touchin-) A tender s'ot, lu(', or enlar-ed or-an can
so(eti(es +e o+ser&ed, +ut it can (ore often +e felt) The
Hi''ocratics 1ne. that inter(ittent fe&ers often 'roduced an
enlar-ed s'leen, occasionally so 'ro(inent that it could +e
seen, +ut (ore often it could +e detected +y 'al'ation) 4ithin
the -entle(anly culture of 'hysicians in the earlyG(odern
'eriod, ho.e&er, 'ro+in- the 'atient*s +ody .ith one*s hands
s(ac1ed of (anual la+our) $al'ation .as thus another as'ect
of dia-nosis i('orted +ac1 into (edicine +y the 9rench
in,unction to inte-rate (edicine and sur-ery) 6y locatin-
disease 'rocesses .ithin the or-ans, and e('hasi7in- the
i('ortance of the lesion, 9rench (edical students .ere tau-ht
to use their hands as 'art of their dia-nostic tools)
$ercussion (ta''in- the chest or a+do(en) .as the third 'art
of routine 'hysical exa(ination) #es'ite isolated co((ents in
earlier case histories, the Viennese 'hysician 3eo'old
Auen+ru--er (CA!!BC=<@) .as .ithin his ri-hts .hen he called
his CA"C treatise on the techni?ue In&entu( no&u( (/e.
#isco&ery)) The son of an inn1ee'er, the youn- Auen+ru--er
re'utedly learned the &alue of 'ercussion .hen, sent +y his
father to the cellar to disco&er ho. (uch .ine and +eer .ere
left in the cas1s, he disco&ered the techni?ue .hile ta''in- on
the sides) At the 'oint of the Ruid le&el, the sound chan-ed)
This (eant he did not ha&e to ta1e oI the co&ers and 'eer,
.ith the aid of a candle, into the +arrels) As a 'ractisin-
'hysician, he ado'ted the 'rocedure, to hel' deter(ine .hen
the heart, li&er, or any other or-an .as enlar-ed, or .hen
accu(ulations of Ruids in the chest or a+do(en (eant that
nor(ally resonant +ody ca&ities .ere chan-ed throu-h
disease)
Auen+ru--er*s (odest little &olu(e is an excellent exa('le of
the fact that classics are (ade, not +orn) It .as +arely noticed
after 'u+lication, and only a handful of references to it in the
follo.in- four decades ha&e +een reco&ered +y historians)
#octors of the C=th century .ere si('ly not attuned to
.orryin- too (uch a+out the solid 'arts of the +ody to aid
their dia-noses) All this chan-ed .ith the co(in- of the 9rench
.ay of teachin- and learnin- (edicine)
Auen+ru--er*s 3atin treatise .as redisco&ered +y :eanG/icolas
Cor&isart (CADDBC=!C), /a'oleon*s 'ri&ate 'hysician and
'rofessor of (edicine in the $aris school) Cor&isart .as .ell
attuned to the ne. or-anG+ased orientation of early C@thG
century 9rench (edicine, and 'articularly interested in
diseases of the heart) He reco-ni7ed the &alue of 'ercussion in
cases of heart enlar-e(ent, collections of Ruid around the
heart, and other cardiac diseases) He +e-an teachin-
'ercussion to his students and translated Auen+ru--er*s
treatise in C=<= into 9rench, addin- extensi&e notes that
?uadru'led its len-th) His notes (ade it &ery clear ho.
i('ortant this ne. techni?ue could +e in assistin- the doctor
in dia-noses) T.o years earlier, his treatise on heart diseases
had +een 'u+lished, lar-ely throu-h notes ta1en +y one of his
'u'ils) The case histories in this inno&ati&e &olu(e (a1e
so+er readin-: Cor&isart 'essi(istically concluded that or-anic
diseases of the heart could rarely +e eIecti&ely treated .ith
the thera'ies a&aila+le to hi() It could +e dia-nosed, ho.e&er,
and one -ets a s'ectru( of the 'atients in the $arisian
hos'itals fro( these histories: .or1in-Gclass (en and .o(en
.ith -ra&e disease, forced to see1 the sanctuary of the
hos'ital as a last resort) Mortality rates in the $aris hos'itals
.ere &ery hi-h, and hos'itals then .ere so(eti(es seen as
P-ate.ays to death*)
To Cor&isart*s 'o'ulari7ation of 'ercussion .as added the
fourth, and (ost inno&ati&e, dia-nostic tool: (ediate
auscultation) #octors had so(eti(es listened to sounds
co(in- fro( .ithin their 'atients* +odies) 4hee7in- can +e
heard +y other 'eo'le, and not si('ly the indi&idual ha&in-
di5culty +reathin-S so(e heart (ur(urs are so loud that they
can also +e audi+le to othersS an o&erGacti&e intestine (a1es
'ro(inent noises) Sounds li1e these 'ro&ide clues to .hat is
-oin- on inside a 'erson*s +ody, and they had +een noted +y
doctors for hundreds of years) Occasionally, doctors had noted
that they had 'ut their ears directly on the 'atient*s chest or
a+do(en, the +etter to hear) This is i((ediate auscultation,
listenin- directly .ith the ear) Mediate auscultation in&ol&ed
so(ethin- +et.een the 'atient*s +ody and the doctor*s ear)
This .as the stethosco'e, the in&ention of 8) T) H) 3aennec
(CA=CBC=!"), one of the (ost co('lex and -ifted of the 9rench
clinicians)
3aennec*s career .ell illustrates the i('ortance of external
considerations in .ho*s in and .ho*s out) As a Catholic and
8oyalist, his career lan-uished durin- the secular at(os'here
that 'er(eated the 8e'u+lic and /a'oleonic e'ochs) A
hos'ital a''oint(ent and, e&entually, a chair ca(e only after
the fall of /a'oleon and the restoration of the (onarchy) He
had already i(+i+ed the ideals of the 9rench school, and
contri+uted (uch as a ,ournalist, editor, and 'ractisin- doctor)
His ori-inal stethosco'e .as no (ore than a ti-htly rolled
note+oo1, constructed +ecause he .anted to listen to the
chest sounds of a 'lu(' youn- .o(an, and decoru( (eant
that he could not 'lace his ear directly on her chest) He .as
deli-hted to disco&er that the sound .as trans(itted e&en
(ore clearly than it .ould ha&e +een had he e('loyed
i((ediate auscultation) He ?uic1ly de&ised a si('le
stethosco'e (his .ord), a hollo. .ooden tu+e, .ith t.o Nttin-s
at the end, a +ell and a dia'hra-(, the +etter to re'roduce
sounds of diIerent 'itches (he .as a s1illed (usician))
His encounter .ith his fe(ale 'atient occurred in C=C", at the
/ec1er Hos'ital, in $aris) 3aennec*s three years +et.een C=C"
and C=C@ constitute one of the (ost creati&e 'eriods for any
indi&idual in the .hole history of (edicine) 6y the ti(e he
'u+lished his treatise on (ediate auscultation in the latter
year, he .as an acco('lished stethosco'ist) He created (uch
of the &oca+ulary that doctors still use to descri+e +reath
sounds and ar-ued co-ently that he could dia-nose (any
diseases of the heart and lun-s +y the s'eciNc auditory
'atterns re&ealed +y his stethosco'e) He .as es'ecially
interested in the auscultory si-ns of 'hthisis, or consu('tion,
the leadin- 1iller of 3aennec*s era) His .ards .ere Nlled .ith
its &icti(s, and the disease e&entually clai(ed hi( as another
one)
CC) The late C@thGcentury reconstruction of 3aennec
de(onstratin- his stethosco'e ca'tures a +edside scene in a
.ard at the /ec1er Hos'ital) The 'atient is 'assi&e and
extre(ely cachectic, su--esti&e of 'hthisis
3aennec*s C=C@ treatise consisted of t.o 'arts, one on the art
of usin- the stethosco'e, the other on the 'atholo-ical
anato(y of the or-ans of the thorax) He .as a true disci'le of
the 9rench school, &ersed not only in the nuances of dia-nosis,
+ut also routinely follo.in- his deceased 'atients fro( their
+edside to the (or-ue, .here he conducted the auto'sy and
co('ared the Nndin-s he had dia-nosed in life .ith the lesions
that .ere in the dead +ody)
Ins'ection, 'al'ation, 'ercussion, auscultation: these four
ste's in syste(atic (edical exa(ination .ere not ado'ted
instantaneously and uni&ersally) More than a decade se'arates
Cor&isart*s translation of Auen+ru--er (C=<") and 3aennec*s
treatise on his stethosco'e (C=C@)) 3aennec tau-ht
stethosco'y to a nu(+er of 9rench and forei-n students, and
the &alue of his dia-nostic instru(ent .as reco-ni7ed +y a
-rou' of inRuential 'hysicians) His >n-lish translator a5r(ed
that 'ri&ate 'atients .ould not .illin-ly su+(it to the inti(acy
of a stethosco'ic exa(ination, +ut it .ould +e useful in
Pca'ti&e* 'o'ulations, that is, 'oor 'eo'le in hos'itals and
(ilitary 'ersonnel) In fact, the 'o.er that doctors ac?uired in
hos'itals only -radually 'er(eated out.ards) He .ho 'ays the
'i'er has e&er called the tune, and 'ayin- 'atients had to +e
con&inced that doctor 1no.s +est) A co('lete (edical history
and exa(ination of the 1ind that 9rench hos'ital doctors
initiated is still a rare e&ent outside of hos'itals and dia-nostic
clinics) /e&ertheless, the ideal ela+orated +y 9rench clinicians
in the $aris (edical school still resonates and ou-ht to +e 'art
of the (indset that doctors +rin- to the +edside)
To the (or-ue: clinicoG'atholo-ical correlation
The $aris (edical school .as reo'ened .ith its refor(ed
curriculu( in CA@E) Ar-ua+ly, it .as rooted earlier, in CA"C)
Auen+ru--er*s descri'tion of 'ercussion a''eared that yearS
so did Gio&anni 6attista Mor-a-ni*s #e sedi+us et causis
(or+oru( (On the Seats and Causes of #iseases), a .or1 that
under'inned the 9rench 'atholo-ical a''roach, ,ust as
Auen+ru--er*s little +oo1 contri+uted to its clinical one)
Mor-a-ni*s (assi&e treatise .as (ore an encyclo'aedia than
a text+oo1, or-ani7ed in the traditional .ay of headGtoGfoot
'resentation) It oIered case histories and auto'sies of so(e
A<< 'atients, (any of the( his o.n) 6e-innin- .ith diseases
of the head and .or1in- his .ay throu-h the hu(an +ody,
Mor-a-ni focused on the 'atholo-ical chan-es that occur in
the or-ans in disease) His case histories relied on the 'atient*s
o.n account of their illness, in .ays that .ould ha&e +een
fa(iliar to the Hi''ocratics, and they also share the concern
.ith close attention to detail) In addition, Mor-a-ni +rou-ht
that sa(e case to the auto'sy roo(, and his descri'tions of
(or+id chan-es .ent .ell +eyond the ancients, .ho of course
'erfor(ed no 'ostG(orte( exa(inations) Mor-a-ni*s .or1
contains a nu(+er of ori-inal o+ser&ations, +ut it .as its
(ethod that re&er+erated) It .as translated into (ost
>uro'ean lan-ua-es and sti(ulated the use of the auto'sy to
learn a+out disease +efore the 9rench school routini7ed it)
Mor-a-ni (C"=!BCAAC) tau-ht +oth anato(y and (edicine at
the %ni&ersity of $adua for (ore than D< years) Many of the
'atients .hose cases he included in #e sedi+us ca(e fro( his
extensi&e 'ri&ate 'ractice, and althou-h Mor-a-ni*s series of
auto'sies .as i('ressi&e, it .as soon d.arfed +y the $aris
school, .hose clinicians 'ractically li&ed in the hos'itals and
could accu(ulate in a cou'le of years as (any 'ostG(orte(
records as Mor-a-ni collected durin- his lon- life) Hos'itals
oIered concentrations of diseased hu(anity and the 9rench
ex'loited the conditions to the hilt)
If 'hysical dia-noses hel'ed the doctor Nnd the lesion, the
auto'sy ena+led hi( to inter'ret his earlier dia-noses and
(odify or reinforce the() ClinicoG'atholo-ical correlation .as
thus a t.oG.ay street, .ith the re'eated +edside o+ser&ations
-i&in- the o''ortunity of follo.in- the 'atient*s illness durin-
his or her life, and these records +ein- discussed in the li-ht of
the Nnal o+ser&ations on the cor'se) The clinician .as his o.n
'atholo-ist, carin- for his 'atients in death as in life) Thus,
Cor&isart, 3aennec, and the other leaders of the 9rench school
.ere e?ually at ho(e at the +edside and the (or-ue)
They .ere dri&en +y the search for the lesion, those
'atholo-ical chan-es 'roduced +y disease) The 'hiloso'her
9rancis 6acon (CD"CBC"!") called these chan-es Pthe footste's
of disease*, and the i(a-e is a''osite, of so(e 'ersoniNed
Pdisease* .al1in- throu-h the or-ans of our +odies, lea&in-
+ehind traces of its &isit) Identifyin- these traces .as the 'oint
of the 'ostG(orte( exa(ination)
$ostG(orte(s .ere conducted +y 9rench clinicians in the sa(e
s'irit as the 'hysical exa(ination: to o+,ectify the 'heno(ena
of disease, and there+y re'lace the s'eculations of !,<<<
years .ith the hard, 'al'a+le, &isi+le, .ei-ha+le, (aterial
conse?uences of 'atholo-y) PO'en a fe. cor'ses*, a&ier
6ichat (CAACBC=<!) had exclai(ed, and the airy theories of
the ancients .ould disa''ear) He hi(self o'ened (ore than
,ust a fe. in his short life (he .as FC .hen he died), dis'layin-
ne&ertheless the 'erfect tra,ectory for .hat $aris (edicine
.as all a+out) He had ser&ed in the (ilitary, and .as a
sur-eon turned 'hysician, there+y li&in- that inte-ration of the
localist thin1in- of sur-ery .ith the (ore 'hiloso'hical,
thou-htful 'ers'ecti&e of the 'hysician) His death .as .idely
(ourned, and he ?uic1ly +eca(e a hero of the ne. (edical
.ays of thin1in-)
He is re(e(+ered today (ostly as the Pfather of histolo-y*,
since he reco-ni7ed that 'atholo-ical 'rocesses are co((on
in the sa(e 1inds of tissue .here&er they occur) Thus the
serous (e(+ranes that line the heart, +rain, thorax, and
a+do(en react in si(ilar .ays to disease 'rocesses) 4or1in-
.ith the na1ed eye and a si('le hand lens, he identiNed !C
such ty'es of tissue, such as osseous, ner&ous, N+rous, or
(ucous) He also considered &eins and arteries as s'ecial
Ptissues*) 6ichat .as (ore intri-ued +y 'rocess than (any of
the 9rench clinicians .ho .ere ins'ired +y hi(, and +rou-ht a
(ore theoretical 'ers'ecti&e to his .or1 than the RatGfooted
e('iricis( that characteri7ed (uch of 9rench hos'ital
(edicine) 6ut he li&ed and died in the hos'ital, di&idin- his
ti(e +et.een the +edside and dead roo(, and he ins'ired
others +oth +y his ideas and his ener-y, the latter
extin-uished too soon)
The hos'itals of $aris (there .ere far (ore +eds there than in
the .hole of Great 6ritain) oIered an un'aralleled o''ortunity
to o+ser&e des'erately sic1 'eo'le, dra.n fro( the needy
classes and re?uired to oIer their +odies, in life and in death,
to the ser&ice of clinical (edicine, in return for .hate&er care
.as on oIer) The 9rench co(+ination of 'hysical dia-noses
and clinicoG'atholo-ical correlation constituted a ne.
a''roach to disease, and e(+odied ne. 'o.er structures
.ithin the hos'ital) It -radually 'roduced a ne. or-ani7ation
(nosolo-y) of disease, -rounded in the or-ans, and ele&atin-
the solid 'arts of the +ody to 'ole 'osition) It .as ar-ua+ly the
Hi''ocratic a''roach .rit lar-e, +ut +ased in the hos'ital and
situatin- disease in the or-ans rather than the hu(ours)
C!) Alfred Vel'eau (CA@DBC="A) .as 'rofessor of clinical
sur-ery in the $aris Medical 9aculty, +ut he also (ade
contri+utions to sur-ical anato(y, e(+ryolo-y, 'hysiolo-y,
and diseases of the +reast) This so(+re etchin- 'oi-nantly
co((e(orates the uses of the dead for the li&in-
Or-an 'atholo-y +eca(e the do(inant the(e) Mono-ra'hs on
the diseases of the heart, lun-s, 1idneys, +rain and ner&ous
syste(, sto(ach and intestines, li&er, s1in, and re'roducti&e
or-ans +eca(e the .ay 9rench clinicians (ade na(es for
the(sel&es) Cor&isart*s (ono-ra'h on diseases of the heart
and 3aennec*s on diseases of the lun-s .ere lin1ed to their
dia-nostic inno&ations) Others B Ali+ert on the s1in, 8ayer on
the 1idneys, Andral on the +lood, 8icord on the re'roducti&e
or-ans B extended the a''roach to other 'arts of the +ody)
Of all diseases, 'hthisis .as undou+tedly the (ost .ritten
a+out, and (ost co((only encountered a(on- the 'atients
(and their doctors) in the 9rench hos'itals) It .as the leadin-
cause of death throu-hout >uro'e in the early C@th century)
P$hthisis* (consu('tion) .as descri+ed +y the Hi''ocratics as
a dan-erous .astin- disease .ith fe&er, chronic cou-h, and
other 'ul(onary sy('to(s, and there is -ood
'alaeo'atholo-ical e&idence that tu+erculosis has +een
co((on in hu(an societies for (illennia) $hthisis +eca(e
u+i?uitous fro( the late C=th century, and there is reason to
su''ose that (ost cases of P'hthisis* .ould today +e
dia-nosed as tu+erculosis) The latter disease cate-ory
recei&ed its (odern deNnition only .hen 8o+ert 2och
identiNed the +acteriu(, the tu+ercle +acillus, as the causati&e
a-ent of tu+erculosis in C==!) /e&ertheless, 3aennec and his
collea-ues deNned P'hthisis* 'atholo-ically, and their
descri'tions of +oth the clinical sy('to(s and the 'ostG
(orte( Nndin-s conNr( the assu('tion that 'hthisis and
tu+erculosis are for the (ost 'art t.o na(es for the sa(e
disease)
3aennec clai(ed to +e a+le to dia-nose 'hthisis .ith his
stethosco'e, ar-uin- for P'atho-no(onic* (i)e) uni?ue to that
condition) sounds in the u''er chest in 'atients .ith the
aWiction) He ar-ued on +oth clinical and 'ostG(orte( -rounds
that the tiny lesion called the Ptu+ercle* (literally, a s(all
s.ellin-) .as the hall(ar1 of a sin-le disease, no (atter
.here the lesion .as found) He thus uniNed a nu(+er of
diIerent dia-noses, such as scrofula, tu+erculous (enin-itis,
or tu+ercles of the intestine) He li1ened the de&elo'(ent of
lar-er -ranular lesions fro( the initial tu+ercles to the ri'enin-
of fruit) His -rou'in- diseases of (any or-ans containin-
tu+ercles into a sin-le entity .as &indicated +y 2och*s .or1 on
the +acillus, +ut .ithin the 'atholo-ical tradition, it too1 a lea'
of the i(a-ination and .as counterGintuiti&e -i&en the or-anG
+ased 'aradi-( .ithin .hich he .or1ed) As for the cause of
'hthisis, 3aennec sus'ected that it .ould ne&er +e 1no.n for
certain, althou-h his o.n causati&e fra(e.or1 &eered to.ards
the 'sychoso(atic) Stron- 'assions .ere often associated
.ith the disease, and he ?uietly assi-ned the( causati&e
si-niNcance)
3aennec*s +rilliant dia-nostic .or1 underscores +oth the
stren-ths and .ea1nesses of the clinicoG'atholo-ical
a''roach: +y concentratin- on the endGsta-e of disease, the
lesions, 9rench clinicians .ere often left short on +oth the
'rocesses +y .hich the lesions .ere for(ed, and the aetiolo-y
(cause) of the chan-es) More 'ositi&ely, +y loo1in- closely at
the correlations +et.een clinical si-ns and 'atholo-ical
chan-es, they .ere a+le to diIerentiate (any diseases that
ha&e re(ained in the (edical &oca+ulary, e&en after -er(
theory and other later de&elo'(ents oIered diIerent sets of
dia-nostic criteria)
One -ood exa('le .as the se'aration of ty'hus and ty'hoid
fe&ers) The t.o .ords are si(ilar and their clinical
'resentations could +e close enou-h that it is so(eti(es
di5cult in the older (edical literature to sort out one fro( the
other, or fro( alternati&e conditions that (i-ht +e dia-nosed
today) They .ere t.o &arieties of fe&er, a disease in its o.n
ri-ht in earlier ti(es) In the C=thGcentury disease
classiNcations, Pfe&er* .as the disease, +ro1en u' into &arious
1inds .ith ad,ecti&es such as inter(ittent, continued, ty'hus,
ty'hoid, lo., ner&ous, 'utrid, hectic) PTy'hoid fe&er* still
sounds acce'ta+le to us, and Pyello. fe&er* is the full na(e .e
use for the disease caused +y a &irus) These na(es lin-er
e&en after C@thGcentury doctors -radually ca(e to deNne
Pfe&er* as a si-n of disease (ele&ated +ody te('erature,
(easured +y a ther(o(eter), rather than a disease itself)
The diIerentiation of ty'hus and ty'hoid .as eIected (ore or
less inde'endently +y se&eral doctors, each under the s'ell of
the 9rench .ay of doin- (edicine, +ut .or1in- in 6ritain and
the %nited States as .ell as 9rance) In 9rance, $ierre 3ouis
(CA=ABC=A!) esta+lished 'atholo-ical criteria for ty'hoid in
C=!@) His career e'ito(i7es the 9rench era) 0oun- enou-h to
train in the Pne.* (edicine, he s'ent a fe. years in 8ussia
+efore returnin- to $aris in C=!<, con&inced that he did not
1no. enou-h a+out disease) He -a&e u' 'ri&ate 'ractice and
attached hi(self to the CharitM hos'ital, carryin- out (ore
than !,<<< auto'sies o&er a sixGyear 'eriod and 1ee'in-
ela+orate records of +oth clinical and 'atholo-ical Nndin-s)
These +eca(e the +asis of his su+se?uent (ono-ra'hs on
'hthisis and enteric fe&er (ty'hoid)) 3ouis identiNed the
s.ollen ly('h nodes ($eyer*s 'atches) in the (e(+rane of the
lar-e intestine, ar-uin- that they are 'atho-no(onic for
enteric fe&er) 4illia( :enner (C=CDB@=) in 3ondon, 4) 4)
Gerhard (C=<@BA!) in $hiladel'hia, and se&eral others
co('leted the diIerentiation of the t.o diseases)
#urin- the Nrst half of the C@th century, 'atholo-ical anato(y
.as the ?ueen of the (edical sciences) It 'ro&ided doctors
.ith 'al'a+le e&idence of the conse?uences of disease, .hich
led to a strea(linin- of the ela+orate nosolo-ies of earlier
ti(es) It .ould not ha&e +een 'ossi+le .ithout the &ast
collections of 'atients in hos'itals, allo.in- doctors to (a1e
clinical and 'atholo-ical o+ser&ations on so (uch P(aterial*,
as they often dis'ara-in-ly called it) The nu(+ers -a(e
constituted the third 'illar, called +y 3ouis, its (ost syste(atic
'ractitioner, the (Mthode nu(Mri?ue (nu(erical (ethod)) He
a''lied it to hel' -ather his 'ictures of dia-nostic cate-ories,
+ut also to e&aluate thera'y)
3earnin- to count
3i1e so (uch else in the $arisian hos'itals, dealin- .ith lar-e
nu(+ers of 'atients .as not entirely ne. to (edicine) Military
doctors of all nationalities had +een 'ressed to 'ro&ide
statistics, and the doctors in hos'itals, +oth (ilitary and
ci&ilian, had reco-ni7ed the duty of 'resentin- annual
su((aries of cases, dia-noses, treat(ents, and cures) One
(i-ht &ie. 3ouis as si('ly the cul(ination of the
>nli-hten(ent e('hasis on facts and o'enness) This (ista1es
inno&ation for i('act: of the later clinicians in the heyday of
$aris (edicine, 3ouis had the -reatest international i('act) He
tau-ht (any forei-n students and, (ore than any other,
+rou-ht the insi-hts of the 9rench school to-ether) His short
essay on Clinical Instruction, translated into >n-lish in C=FE, is
a +rilliant su((ary of .hat teachin- and learnin- in $aris
stro&e to +e)
He is so(eti(es credited .ith al(ost sin-leGhandedly
con&incin- doctors to a+andon the ancient 'ractice of
+loodlettin- for all (anner of diseases) His short (ono-ra'h
on the su+,ect (C=FD) re(ains his +estG1no.n .or1, +ut its
le-acy lies (ore .ith the (ethod than the (essa-e) In
8esearches on the >Iects of 6loodlettin- in So(e
InRa((atory #iseases, 3ouis e&aluated the eIect of diIerent
ti(in- (early or late) and ?uantity (a little or (ore &i-orous) of
thera'eutic 'hle+oto(y in cases of 'neu(onia) The sa(e
(ono-ra'h also exa(ined the use of diIerent doses of tartar
e(etic (a (edicine containin- anti(ony)) 4hat is
re(e(+ered today is the .ay 3ouis atte('ted to e&aluate
these thera'ies +y di&idin- si(ilar 'atients into -rou's and
co('arin- the results of his &arious treat(ents) In eIect,
3ouis .as usin- a clinical trial, thou-h hardly .ith a 'rotocol
that .ould no. +e ,ud-ed ade?uate) /otice that 3ouis did not
include no +loodlettin- as an o'tion, +ut (erely e&aluated
ti(in- and ?uantity)
3ouis* little (ono-ra'h, des'ite its classic status, .as actually
'art of a 'ole(ical ca('ai-n +et.een 3ouis and 9) :) V)
6roussais (CAA!BC=F=)) The latter had de&elo'ed a syste( of
P'hysiolo-ical (edicine* to counter the static, anato(ical
a''roach of (ost 9rench clinicians) 6roussais had noticed ho.
(any of the 'atients that he auto'sied sho.ed si-ns of
chronic -astric irritation and his syste( 'osited that all
disease ori-inated in the sto(ach, and that local lesions
else.here resulted fro( the 'ri(ary irritation .ithin the
sto(ach) The standard treat(ent for irritation or inRa((ation
.as +loodlettin-) He fa&oured leeches rather than the lancet,
and he and 3ouis exchan-ed a series of shar' 'ole(ics durin-
the C=F<s) 6roussais .as a thera'eutic enthusiast, .hereas
3ouis .as ?uietly 'essi(istic a+out the ca'acity of (edicine to
do (uch to arrest the 'ro-ress of disease) 3ouis*s role as a
'ioneer of clinical trials .as located .ithin this on-oin- feud
.ith his ri&al 6roussais)
Althou-h 6roussais* dyna(ic, 'hysiolo-ical notions of disease
continued to resonate, his central idea of all disease as a
secondary conse?uence of -astric irritation did not lon-
sur&i&e) On the other hand, 3ouis*s nu(erical (ethod has
+eco(e essential to (odern (edicine) There .as certainty in
nu(+ers, +oth in esta+lishin- clear dia-nostic cate-ories and
in e&aluatin- thera'y) A nu(+er of his students assi(ilated his
thera'eutic sce'ticis(, already co((on in the $aris hos'itals
.here doctors .ere (ost concerned .ith accurate dia-nosis
and its &eriNcation throu-h the 'ostG(orte() $atients had
al(ost al.ays entered hos'itals .ith li(ited ex'ectations, +ut
the 'o.er relationshi's shifted in $aris, .ith doctors on to')
They re(ained that .ay until recently, .hen -reater 'atient
autono(y, the tyranny of econo(ics, and the rise of the
(edical (ana-er ha&e reali-ned 'o.er structures .ithin
(edicine)
3ouis*s reco-nition that he did not ha&e (uch to oIer his
'atients .ith the dru-s at his dis'osal (ust +e &ie.ed not as a
cons'iracy a-ainst his hel'less 'atients, +ut as a -enuine
disco&ery) It .as (ade 'ossi+le +ecause he counted,
e&aluated, and co('ared: acti&ities that could +e done (ost
easily in the hos'ital)
The 'hysical and the (ental
6y C=D< or so, 9rench hos'ital (edicine had +eco(e fa(iliar)
/e. a''roaches to understandin- disease, the -reater use of
ex'eri(ent rather than (ere o+ser&ation, and di(inishin-
returns on .hat could +e disco&ered +y yet one (ore auto'sy,
rendered the (iracle of 9rench clinical (edicine so(ethin-
(ore 'edestrian) #urin- its heyday, ho.e&er, thousands of
students had co(e to $aris fro( all o&er the 4estern .orld)
They returned to 6ritain, Ger(any, Austria, Italy, the %nited
States, and the /etherlands, .here so(e of the( founded
(edical schools and hos'itals) 6y the early C@th century, a
(edical school .ithout an attached hos'ital .as second rate)
4hen the ne. %ni&ersity of 3ondon (no. %ni&ersity Colle-e
3ondon) +e-an its (edical school in the late C=!<s, the Nrst
thin- to do .as to esta+lish a hos'ital) The 'attern .as
re'eated throu-hout >uro'e, e&en in s(all Ger(an to.ns
.here clinical instruction .as often +y de(onstration, not +y
doin-)
In (idGcentury A(erica, a nu(+er of 'ro'rietary schools
'ros'ered .ithout a hos'ital or la+oratory, oIerin- (edical
de-rees in return for a fe. (onths* tuition fees) Althou-h
returnin- students fro( $aris and -raduates fro( the
esta+lished >ast Coast (edical schools, such as the %ni&ersity
of $ennsyl&ania, des'aired of .hat this did to the 'rofession,
A(erican &alues 'rotected entre'reneurialis() Only in the
later decades of the century .as the 'attern +ro1en) The :ohns
Ho'1ins %ni&ersity, esta+lished as a researchGorientated
uni&ersity in C=A", introduced the Ger(an (odel of hi-her
education to A(erica) #es'ite a -enerous initial endo.(ent
+y :ohns Ho'1ins, a Lua1er rail.ay (a-nate, the (edical
school too1 al(ost t.o decades to +e reali7ed, so extensi&e
.ere the re?uire(ents) The hos'ital o'ened in C=@F, .ith the
ener-etic faculty introducin- a co(+ination of Ger(an
research and 9rench e('hasis on 'ractical trainin-) The
'rofessor of (edicine, 4illia( Osler (C=E@BC@C@), .as the
(ost fa(ous of the P6i- 9our* B the initial senior (edical
faculty) He still co((ands adulation fro( doctors, as a
scientiNcally attuned +ut hu(ane clinician, +oo1 collector,
historian, essayist, and teacher) The assi(ilation of Ger(an
science infused the Ho'1ins a''roach to disease, +ut 9rench
inno&ations 'er(anently left teachin- hos'itals .ith t.o
re-ular e&ents: the daily .ard round, in .hich a senior
clinician, follo.ed +y ,unior doctors, (edical students, and a
nurse, .ould see and discuss each 'atient at his or her
+edsideS and -rand rounds, in .hich interestin- Pcases* .ould
+e 'resented +y a (e(+er of the ,unior staI and analysed +y
so(eone fro( the senior hierarchy, in front of a lar-e
-atherin- of students and doctors at all le&els of ex'erience)
Often, after the 'resentation of the 'atient*s history and
clinical course, and the discussion of the diIerential dia-nosis,
the auto'sy Nndin-s .ould +e re&ealed +y a 'atholo-ist, and
the .hole life and death of the 'atient 'ut to-ether in a
sea(less .hole)
In the lar-e teachin- hos'itals, the (edical and sur-ical
s'ecialties, such as 'aediatrics, cardiolo-y, neurolo-y,
o+stetrics, ortho'aedic sur-ery, or otolaryn-olo-y (diseases of
the ear, nose, and throat), .ould each ha&e their o.n chief, a
nu(+er of dedicated +eds, and re-ular rounds, +oth .ard and
-rand) One s'eciality lon- underGre'resented in (ost -eneral
hos'itals .as 'sychiatry, e&en if 'sychiatry has +een called
Phalf of (edicine*, so co((on are 'sychiatric disorders)
Instead, those suIerin- fro( serious 'sychiatric illness B
earlier called (adness or lunacy B had their o.n 1ind of
institutional settin-) The institutional 'ro&ision for the (ad
de&elo'ed inde'endently fro( the scattered 'ro&ision of
ordinary hos'itals in the earlyG(odern 'eriod) Madhouses, as
they .ere +rutally called, .ere usually s(all esta+lish(ents,
for 'roNt, and as often as not run +y a nonG(edical 'erson)
%nli1e -eneral hos'itals, they .ere (ostly for the .ellGtoGdo,
so e(+arrassin- .as the +eha&iour of a seriously eccentric or
hallucinationG'rone relati&e) The (ost fa(ous 'sychiatric
institution in 6ritain -a&e its na(e to the lan-ua-e: 6edla(, a
short for( of its full na(e, 6ethlehe(, or St Mary 6ethlehe()
PTo(GoG6edla(* +eca(e a stoc1 Nctional character, used +y
Sha1es'eare in 2in- 3ear, and sy('to(atic of the isolation
that 'sychiatric 'atients ha&e al.ays felt)
6edla( .as unusual a(on- 'sychiatric institutions, funded +y
endo.(ents and .ith -o&ernors o&erseein- its o'erations)
Most (adhouses .ere s(all 'ri&ate aIairs .hose records
ha&e lon- since disa''eared fro( &ie.) 6ut they entered
'u+lic consciousness, since (adness .as the (ost feared
disorder of earlier centuries (de(entia often occu'ies that
'lace no., e&en (ore than cancer for (any 'eo'le))
Madhouses, not usually di-niNed +y the na(e Phos'ital*,
occu'ied the o''osite end of the scale fro( ordinary hos'itals)
#ia-nosis relied on .hat the nei-h+ours or fa(ily re'orted, or
o+ser&ations a+out the 'atient*s +eha&iour) #octors .ho
loo1ed for lesions, the +asis of $aris (edicine, .ere usually
disa''ointed) The +rains of lunatics rarely 'ointed to so(e
s'eciNc reason .hy the 'atient dis'layed sy('to(s) Madness
.as (ental, not 'hysical, e&en if that 'osed di5culties for a
culture .hich assu(ed that the distinctly hu(an
characteristics of reason, (oral res'onsi+ility, and the
ca'acity to 1no. ri-ht fro( .ron- .ere the conse?uences of
our i((ortal, GodG-i&en souls) 3oss of reason (eant loss of
hu(anity)
These 'hiloso'hical and theolo-ical niceties .ere ne-otiated
in &arious .ays, +ut as doctors +eca(e increasin-ly in&ol&ed
in the Ptrade in lunacy*, the disease (odel +eca(e (ore
attracti&e) After all, disease is .hat doctors deal .ith) 9ittin-ly,
one of the fatherGN-ures of $arisian (edicine is often called
the founder of (odern 'sychiatry) $hili''e $inel (CAEDBC=!")
(ade his na(e +efore the 8e&olution, as the author of a
successful nosolo-y of all diseases (he coined the .ord
Pneurosis*) and a (edical 'ractitioner) He also .rote a little
treatise on the i('ortance of hos'itals for clinical instruction)
#urin- the 8e&olution, he .as -i&en the 'ost of 'hysician to
the 6icXtre ((ale), and then the Sal'XtriYre (fe(ale), each a
lar-e HQ'ital GMnMral .hich housed a &ariety of in(ates)
These included 'rostitutes, &a-a+onds, 'etty cri(inals,
or'hans, the a-ed, decre'it, and de(ented, as .ell as other
indi&iduals dee(ed a dan-er to the .ider 'u+lic or una+le to
fend for the(sel&es in society at lar-e) The 8e&olution turned
these institutions into hos'itals for 'sychiatric 'atients, and
durin- his tenure at the Sal'XtriYre, $inel -radually instituted a
'ro-ra((e of P(oral thera'y*, slo.ly releasin- conNned
.o(en and treatin- the( .ith Nr( hu(anity) In >n-land, a
Lua1er fa(ily, the Tu1es, founded the 0or1 8etreat) It .as
+ased on si(ilar thera'eutic 'rinci'les of (oral thera'y, .hich
.ere also e('loyed at rou-hly the sa(e ti(e in Italy, +y
Vincen7io Chiaru-i (CAD@BC=!<))
The nuances of (oral thera'y ha&e +een (uch de+ated +y
historians, +ut there is little dou+t that this for( of treat(ent
+rou-ht the lunatic into the 'u+lic -a7e, and hel'ed create a
'sychiatric s'ecialty .ithin (edicine) #urin- the (iddle third
of the C@th century, 'sychiatric associations .ere esta+lished
in (ost >uro'ean countries and the %nited States, and they
successfully ca('ai-ned for the esta+lish(ent of net.or1s of
'sychiatric hos'itals (-enerally called Pasylu(s*)) The
traditional treat(ent of 'sychiatric disorders .ith ordinary
(edica(ents B+loodlettin-, e(etics, cathartics B .as re'laced
+y P(oral* (eans, and the actual for( of the +uildin-s .as
held to aid in the healin- 'rocess) 9ro( the C=F<s, nonG
restraint +eca(e the rallyin- cry, as doctors ar-ued that the
.ellGdesi-ned and .ellGrun 'sychiatric institution had no need
to use 'hysical restraint .ith its 'atients)
Althou-h the asylu(s .ere +uilt in the na(e of hu(anity and
treat(ent, they hardly ,ustiNed the early o'ti(is(, +y .hich
early dia-noses and the ex'ert use of (oral and other
thera'ies .ere 'redicted to 'roduce cures) Instead, the
asylu(s -re. lar-er and silted u' .ith incura+le 'atientsS they
+eca(e, in the .ords of one conte('orary co((entator,
(ere P(useu(s of (adness*) The s'ecial nature of these
institutions reinforced the distance +et.een 'sychiatry and
ordinary (edicine and sur-ery, a +reach that still exists,
des'ite (odern 1no.led-e of the +rain and ho. it functions)
In the late C@th century, the Ger(an 'sychiatrist >(il
2rae'elin (C=D"BC@!") atte('ted to +rin- (edicine and
'sychiatry closer to-ether, throu-h a 'sychiatric clinic .ithin
an acade(ic settin-) 2rae'elin, an al(ost exact conte('orary
of the founder of 'sychoanalysis, Si-(und 9reud (C=D"BC@F@),
de&elo'ed the +road classiNcation of 'sychiatric disorders that
for(ed the +asis of (odern 'sychiatric nosolo-y) He
diIerentiated the (a,or 'sychoses fro( the neuroses, and
'ro&ided a funda(ental characteri7ation of .hat is no. called
schi7o'hrenia) 2rae'elin called it de(entia 'raecox, the
de(entia of youn-er 'eo'le, and his eIorts hel'ed to create
acade(ic 'sychiatry)
The -a' +et.een (edicine and 'sychiatry still exists, +ut the
tra,ectory of the disci'line fro( asylu( to clinic hi-hli-hts the
faith that 4estern societies ha&e 'ut in hos'itals as healin-
institutions, as .ell as the increasin- (edicali7ation of (any
as'ects of li&in-, fro( sadness to cri(inality, fro( re+ellious
+eha&iour to attention deNcit disorder syndro(e) $uttin- a
na(e on so(ethin- is in itself co(fortin-, and 2rae'elin
sou-ht to i('ose a dia-nostic order on (ental distur+ances
,ust as the 9rench clinicians had earlier used 'hysical dia-nosis
to understand the diseases of our +odies)
CF) The (o&e(ent to esta+lish 'sychiatric hos'itals in the
early C@th century initially .as an o'ti(istic oneS as these
asylu(s +eca(e lar-er and silted u' .ith chronic cases, the
o'ti(is( e&a'orated) This 'lan of the lunatic asylu( at
6rent.ood in >ssex, >n-land, -ra'hically de(onstrates ho.
these institutions +eca(e little .orlds of their o.n, isolated
and selfGcontained
Cha'ter E Medicine in the co((unity
The 'eo'le*s health
The (odern 'u+lic health (o&e(ent +e-an in the C@th
century) It .as +uilt, of course, on earlier 'olitical, social, and
(edical structures, +ut the for( in .hich .e 1no. it e(er-ed
only a cou'le of centuries a-o) If the relationshi' +et.een
'atients and their doctors situates hos'ital (edicine, 'u+lic
health is a+out the state and the indi&idual) It is at once the
(ost anony(ous 'art of (edicine and the (ost &isi+le) 4hen
.e -o to the hos'ital, not (any 'eo'le notice) 4hen there is
an out+rea1 of inRuen7a, or the .ater su''ly is conta(inated,
it is ne.s.orthy)
As the na(e i('lies, 'u+lic health is concerned .ith
(aintainin- health and 're&entin- or containin- disease) Its
traditional +rief .as .ith e'ide(ic disease, +ut there .as
al.ays another strand of disease 're&ention, ai(ed at
'reser&in- the health of the indi&idual, and ter(ed hy-iene)
Althou-h these re'resent t.o diIerent traditions .ithin
(edicine, they are often intert.ined, sharin- the o+,ect of
're&entin- disease) Increasin-ly, hy-iene has +een colla'sed
into the 'hrase Plifestyle (edicine*) In +oth strands, the state
'lays a crucial role)
6efore the industrial state
There are (any references to e'ide(ic diseases in ancient
literature) Indeed, +efore (odern ti(es, hu(an 'o'ulations
.ere 'eriodically thinned +y the Malthusian horse(en of the
a'ocaly'se, su+sistence crises and disease) Much life .as
nasty, +rutish, and short) In the lon- history of the Malthusian
'ressures of destitution and disease, the 'la-ue years, fro(
the (idGCEth to the (idGCAth centuries, stand out as
'articularly -ri()
The 6lac1 #eath, as the Victorians called it, .as ar-ua+ly the
Nrst 'ande(ic (intercontinental or .orld.ide e'ide(ic) in
history) Most earlier 'la-ues .ere (ore conNned in s'ace, and
-enerally also in ti(e) The 6lac1 #eath too1 (ore than four
years to (a1e its .ay &ia the Sil1 8oad fro( the Ste''es of
Central Asia to the .estern(ost 'arts of >uro'e, the Middle
>ast, and the northern shores of Africa) It .i'ed out +et.een
one ?uarter and one half of the 'o'ulation of >uro'e, and .as
the Nrst of a series of de&astatin- e'ide(ics that lost its
4estern >uro'ean hold only in the C""<s (an out+rea1 in the
CA!<s in Marseilles .as contained))
It is certain that the 6lac1 #eath .as a 'la-ue, since that .ord
refers to any hi-hly &irulent e'ide(ic) It has recently +eco(e
fashiona+le to ar-ue that the 'la-ue of the CFE<s .as not
caused +y the 'la-ue +acillus, 0ersinia 'estis, identiNed in
Hon- 2on- durin- the last 'ande(ic in the C=@<s) Various
other or-anis(s ha&e +een su--ested, since the 6lac1 #eath
had so(e features that do not confor( to .hat .e 1no. a+out
the e'ide(iolo-y of (odern +u+onic 'la-ue) Its rate of s'read,
seasonality, and (ortality 'atterns, to-ether .ith the fact that
no+ody noticed a lot of dead rats ((odern hu(an 'la-ue
out+rea1s are acco('anied .ith rat or other rodent 'la-ues),
ha&e led so(e co((entators to 'ostulate that anthrax, an
un1no.n &irus, or other infectious a-ent .as the actual cause)
>r-ot 'oisonin- has also +een in&o1ed)
The 'ro+le( .ith these alternati&e inter'retations is that they
concentrate al(ost exclusi&ely on the ori-inal 'ande(ic, the
6lac1 #eath) If one loo1s at the 'la-ue years as a .hole, fro(
CFED to C""", the 'attern is (ore certain) 6y the later years,
the 'la-ue (for instance, the Great $la-ue of 3ondon in C""D)
is (ore easily reco-ni7a+le throu-h (edical and other
accounts) 9urther(ore, the disease .as 'ercei&ed +y those
.ho li&ed throu-h the &arious e'ide(ics as a sin-le entity, and
.hile of course no one ex'erienced the( all, there .ere
al.ays doctors .ho had li&ed throu-h the 're&ious e'ide(ic
or t.o) The collecti&e historical ex'erience is of a sin-le,
re'eated disease, al(ost certainly Pour* 'la-ueS that is, the
disease caused +y the 'la-ue +acillus) The Nrst e'ide(ic
attac1ed a 'o'ulation .ith no 're&ious i((unolo-ical
ex'erience, and there are (any instances of such de&astatin-
out+rea1s of other diseases (for instance, s(all'ox and
(easles) in &ir-in 'o'ulations)
CE) This (odern litho-ra'h +y 9elix :ene.ein ca'tures the
desolation and 'anic that the re'eated e'ide(ics of +u+onic
'la-ue created durin- the late Middle A-es and earlyG(odern
'eriod) Our o.n fears of inRuen7a or a terroristGinduced
'ande(ic of s(all'ox or anthrax (aintain the 'o.er of such
i(a-es
The ran-e of causes 'ut for.ard at the ti(e ran-ed fro( the
.rath of God to hu(an sinfulness and sloth, (ar-inal hu(an
-rou's such as :e.s and .itches, to +ad air) Astrolo-ical
causes .ere also fre?uently in&o1ed) #es'ite the ran-e of
su'ernatural ex'lanations on oIer, the re'eated 'la-ue
e'ide(ics also hei-htened a.areness of co((unal health
issues and called out a nu(+er of (easures desi-ned to
're&ent or contain the disease) Isolation, enforced +order
controls, co('ulsory hos'itali7ation, and other (easures
ai(ed at the indi&idual .ho (i-ht +e aWicted .ere co(+ined
.ith (ore -eneral (easures such as routine ?uarantine of
shi's co(in- fro( 'la-ue areas, control of the (o&e(ent of
'ersons and -oods, and (edical ins'ection) The disease
tested the li(its of earlyG(odern 'u+lic health acti&ity and
de(onstrates the ine&ita+le nexus of the state and (edicine
durin- such ti(es of crisis) So(e historical scholarshi' has
su--ested that the cordon sanitaire alon- the southern and
eastern ed-es of the AustroGHun-arian >('ire (i-ht ha&e had
so(e eIect in li(itin- the introduction of 'la-ue fro( the
Middle >ast, .here it re(ained ende(ic, and 'eriodically
e'ide(ic, lon- after it disa''eared fro( 4estern >uro'eS C@thG
century >uro'ean tra&ellers in the area acce'ted the
'ossi+ility of ?uarantine in one of the la7arettos (aintained for
control of its s'read)
At the &ery least, 'la-ue ensured that issues of co((unal
health and disease re(ained) The extent to .hich it led to any
'er(anent 'u+lic health infrastructure is de+ata+le, althou-h
'la-ue hos'itals .ere +uilt throu-hout >uro'e, and these .ere
often used for isolatin- and treatin- other infectious diseases
after 'la-ue disa''eared) In -eneral, the a+solutist states of
>uro'e de&elo'ed so(e for(al 'u+lic health acti&ities as 'art
of the +ureaucratic tentacles of the state) 9ro( the late CAth
century, the notion of P(edical 'olice* .as de&elo'ed in the
Ger(anGs'ea1in- states) It reached its a'o-ee .ith the nineG
&olu(e Syste( der &ollstOndi-en (edicinischen $oli7ey
(CAA@BC=!A) +y :ohann $eter 9ran1 (CAEDBC=!C), the
cos(o'olitan 'hysician and 'u+lic health refor(er) The
Ger(an .ord P$oli7eyK$oli7ei* is usually translated as P'olice* in
>n-lish, and 9ran1 +elie&ed that for(ida+le 'o.ers should +e
-i&en to this de'art(ent of -o&ern(ent) His (assi&e .or1
dealt .ith &irtually the .hole of life, fro( cradle to -ra&e:
(aternal, infant, and child care, dress, housin-, 'a&in-,
li-htin-, and the dis'osal of the dead) 4e are hardly the Nrst
to reali7e ho. (uch of hu(an life has a direct +earin- on
health)
9ran1*s latter &olu(es a''eared 'osthu(ously, and the set
extended o&er the ti(e .hen &accination (.hich 9ran1
enthusiastically es'oused) +e-an syste(atically to re'lace
inoculation, as a s'eciNc 're&entati&e a-ainst s(all'ox) These
t.o (easures .ere the Nrst s'eciNc 're&entati&es, and
althou-h +oth .ere ado'ted +y doctors, their ori-ins .ere in
fol1 (edicine) Inoculation (the >n-lish .ord .as ta1en fro(
horticulture, and rou-hly is e?ui&alent to -raftin-) in&ol&ed the
introduction of (aterial ta1en fro( a 'ustule of so(eone
suIerin- fro( s(all'ox, and introducin- it into the +ody of
so(eone .ho had not had the disease) It (ade sense on t.o
counts) 9irst, s(all'ox .as a &irtually uni&ersal disease, .ith a
si-niNcant (ortality, ran-in- accordin- to circu(stances
+et.een DZ and !<Z) The analo-y .ith chic1en'ox 'arties,
.here 'arents see1 to ex'ose their children to another child
.ith the disease, to -et it o&er .ith, is only 'artially a''osite,
since inoculation carried a si-niNcant ris1, +ut the strate-y .as
the sa(e, e&en if the sta1es .ere hi-her) Second, it .as
reco-ni7ed that a sin-le e'isode of the disease conferred lifeG
lon- i((unity, and +y selectin- a (ild case to o+tain the
(aterial for inoculation, the lifeGlon- chances of dyin- fro( the
disease .ere reduced)
Inoculation .as an ancient >astern 'rocedure) The Chinese
'ractised it, usin- a 'o.der of the 'ox (aterial and ta1in- it
li1e snuI) In Tur1ey, the (aterial .as introduced throu-h a
scratch in the s1in, and it .as this techni?ue that 3ady 4ortley
Monta-ue (C"=@BCA"!) learned a+out .hen she .as in
Constantino'le as the .ife of the 6ritish a(+assador) She had
her children, .ho had not had s(all'ox, inoculated, and they
ac?uired (ild cases of the disease) She and the 'hysician to
the 6ritish >(+assy +oth (ade this inno&ation 1no.n in
3ondon, .here it .as ta1en u', after the (onarch, Geor-e II,
had his o.n children inoculated +y the royal sur-eon) :a(es
:urin, a 'ro(inent 3ondon 'hysician and disci'le of Isaac
/e.ton, collected statistics fro( a nu(+er of inoculators and
sho.ed (athe(atically that the chances of dyin- fro( the
disease .ere si-niNcantly di(inished +y the 'ractice)
6y the (idGC=th century, inoculation had +een si('liNed and
+eca(e (ore .ides'read, es'ecially after the 2in- of 9rance,
3ouis V, died of s(all'ox and his son, the illGfated 3ouis VI,
.as successfully inoculated in CAAE) The 'rocedure .as ne&er
.ithout di5culties, ho.e&er, since 'atients so(eti(es died of
the disease after +ein- inoculated, and in any case, they
+eca(e 'ossi+le sources of s'read to others)
3i1e (any other -eneral 'ractitioners, >d.ard :enner (CAE@B
C=!F) occasionally inoculated his 'atients) In the
Gloucestershire countryside near his 'ractice, it .as 1no.n
that an occasional aWiction of cattle, co.'ox, so(eti(es
'roduced .hat loo1ed li1e a sin-le 'oc1 on the hands of the
(il1(aids, and that they see(ed 'rotected fro( the (ore
serious s(all'ox) Althou-h a far(er na(ed :esty and other
'eo'le had 're&iously in,ected the co.'ox (aterial into
indi&iduals .ith the intent of 're&entin- s(all'ox, :enner
'erfor(ed the crucial ex'eri(ent in CA@" and 'u+lici7ed the
ne. 're&entati&e) He too1 so(e (atter fro( a co.'ox lesion
on the hand of a (il1(aid, Sarah /el(es, and in,ected it into
the ar( of a youn- +oy, :a(es $hi''s, .ho had not had
natural s(all'ox) He de&elo'ed a soreness and sca+ on his
ar( +ut, exce't for a day*s fe&er, re(ained .ell) Six .ee1s
later, :enner inoculated hi( .ith ordinary s(all'ox (aterial)
He failed to de&elo' the disease, sho.in- that he .as
i((une)
The 8oyal Society declined to 'u+lish his ori-inal 'a'er, so in
CA@= :enner 'ri&ately 'u+lished his short treatise on the
'rocedure he called P&accination*, after the 3atin .ord for co.)
%nsur'risin-ly, the no&el a''roach attracted so(e ad&erse
co((ent, es'ecially a+out the Pconta(ination* of hu(an
+ein-s .ith ani(al (aterial, and historians ha&e 'u77led
a+out so(e of the outco(es of early &accinations (so(e of the
Ply('h*, as the &accinatin- (aterial .as called, (ay ha&e
+een conta(inated .ith ordinary s(all'ox (atter))
/e&ertheless, :enner*s .or1 .as ta1en u' ?uic1ly in 6ritain
and a+road) He recei&ed t.o handso(e -rants fro( the 6ritish
$arlia(ent and could de&ote hi(self to furtherin- the
&accination cause)
PIf 're&enta+le, .hy not 're&entedT*, the future 2in- >d.ard
VII once as1ed of doctors) It .as a -ood ?uestion, +ut the
de'ressin- ans.er is that it (i-ht cost too (uch, there (i-ht
not +e su5cient 'olitical or (edical .ill, or that 'eo'le (and
their doctors) ha&e to +e educated a+out 're&ention, and
education ne&er ta1es uni&ersally) Althou-h the s(all'ox story
e&entually ended as :enner hi(self foresa., .ith the
eradication of the disease, in C@A@, it .as the exce'tion rather
than the rule) $re&ention has e&er +een the 'oor relation of
other for(s of doctorin-, des'ite the ur-ency of the case in
industriali7in- societies)
Cholera and 'o&erty: (otors of 'u+lic health
Historians traditionally &ie.ed the C@thGcentury 'u+lic health
(o&e(ent as a direct res'onse to the series of cholera
'ande(ics of the 'eriod) The Nrst e'ide(ic to reach >uro'e
(the Nrst 'ande(ic of C=CAB!F 'etered out after it s'read fro(
India to the Middle >ast and northern Africa) certainly raised
consciousness a+out co((unal disease) 9ro( C=!A, .hen the
second 'ande(ic +e-an to s'read out fro( its ordinary ho(e
in eastern India, >uro'e .atched anxiously as the disease
(o&ed e&er closer) Many >uro'ean nations sent dele-ates at
so(e sta-e durin- the fourGyear .aitin- -a(e, to in&esti-ate
the disease and (a1e reco((endations on ho. +est to
're&ent its reachin- >uro'e)
There .ere t.o (ain sources of concern) 9irst, the disease .as
ne. to the 4est, an Pexotic* disease .ith .hich only tro'ical
colonials .ould ha&e had 're&ious ex'erience) The second
'ande(ic (o&ed throu-hout >uro'e and into /orth A(erica,
and introduced the (edical 'rofession to a serious ne.
disorder .ith alar(in- sy('to(s and (ortality rate) Its
ne.ness and e'ide(ic character led (any co((entators to
s'ea1 of the return of the 'la-ue, all the (ore distur+in- since
oldGstyle +u+onic 'la-ue see(ed to ha&e disa''eared
'er(anently fro( the 4est)
Second, the 'attern of s'read .as 'u77lin-) T.o 'olari7ed
ex'lanatory 'aradi-(s .ere current to ex'lain e'ide(ic
diseases: (ias(atic and conta-ious) Mias(atists ar-ued that
co((unal diseases .ere s'read throu-h the air, the result of
at(os'heric conditions or 'articles contained in the air) The
(ost co((only 'ostulated source of the disease .as rottin-
or-anic (atter, such as refuse, faeces B anythin-, in fact, that
.as o''ressi&e or s(elled +adly) The 'o.er of this 'aradi-( is
easily a''reciated: the air is a co((on feature of a locality
and could ex'lain .hy (any indi&iduals (i-ht +e aIected) It
also hel'ed diIerentiate Phealthy* fro( Punhealthy* localities,
.ithin a 'aradi-( that .ould ha&e +een fa(iliar to the author
of the Hi''ocratic treatise Airs, 4aters, $laces) It .as the
do(inant ex'lanation for the co('lex of diseases, (any of
the( un1no.n in the Old 4orld, .hich >uro'eans encountered
in tro'ical areas) They .ere -enerally 1no.n si('ly as
Pdiseases of .ar( cli(ates*, and o''ressi&e heat and hu(idity
and exotic &e-etation .ere so o+&ious that e&o1in- the( to
ex'lain disease 'atterns (ade rational sense)
Conta-ionists 'ostulated that e'ide(ic diseases .ere s'read
fro( one aWicted indi&idual to another) This could account for
(any as'ects of e'ide(ic disease, such as the fact that
'eo'le nursin- sic1 indi&iduals often ca(e do.n .ith the
disease the(sel&es) Conta-ionis( ,ustiNed the instincti&e .ish
to a&oid contact .ith 'eo'le suIerin- fro( dan-erous
diseases, and underlay the 'ractice of ?uarantine) It also
'reyed on collecti&e fears of the ori-in of 'la-ue and other
fri-htful diseases in (ar-inali7ed -rou's)
A (iddle 'osition, Pcontin-ent conta-ionis(*, .as less hardG
line, and (ore easily ada'ta+le to the ano(alies that +oth the
(ain 'ositions had di5culty ex'lainin-) Contin-ent
conta-ionists ar-ued that diseases (i-ht +e either (ias(atic
or conta-ious, de'endin- on the circu(stances) 9or instance,
a disease (i-ht enter the co((unity throu-h corru't air +ut
so(e indi&iduals could de&elo' the disease in such a .ay that
they then +eca(e foci of conta-ious s'read) This (ixed the
cate-ories in .ays that the o+ser&ations re?uired, and co&ered
all fronts) %nfortunately, theories that ex'lain e&erythin- often
ex'lain &ery little)
A fe. diseases, such as s(all'ox and (easles, .ere al.ays
&ie.ed as conta-ious, +ut (ost co((unica+le diseases had
'atterns of incidence and s'read that .ere su5ciently
co('licated to lea&e (uch roo( for de+ate) Ger( theory .as
later to oIer a ne. 'aradi-( for co((unica+le and e'ide(ic
diseases, althou-h there .ere still ano(alies: .hy could t.o
'eo'le ex'osed to the sa(e source of infection react in such
diIerent .ays, so that one ca(e do.n .ith the disease and
the other re(ained co('letely .ellT
6efore -er( theory, there .as little consensus, and in 'ractice
co((unities often co&ered +oth alternati&es) In 'la-ue
out+rea1s, for instance, ?uarantine and isolation .ere
acco('anied .ith Nres, to 'urify the air, and nose-ays,
infusin- the i((ediate inhalations) 4hen in dou+t, do +oth)
Cholera thre. u' these a-eGold issues in an ur-ent (anner)
The o+ser&ers .ho .ent to .atch its .est.ard (arch ca(e
+ac1 .ith (ixed reactions) So(e thou-ht that it .as
conta-ious and >uro'e*s +est res'onse .as isolation and
?uarantine) Others +elie&ed that the air .as the &ehicle and
that ordinary sanitary i('ro&e(ents B i('ro&in- draina-e,
1ee'in- the streets clean B .ere the +est defence) >uro'ean
-o&ern(ents listened to the &ariety of o'inions +ut (ostly fell
+ac1 on the ti(eGhonoured solution of ?uarantine and
ins'ection of 'eo'le and -oods arri&in- fro( the infected
areas)
>&en 6ritain, ho(e of laisse7Gfaire, da++led .ith ?uarantine
durin- the Nrst 'ande(ic to reach 4estern >uro'e, fro( C=F<)
Cholera arri&ed in 6ritain in late C=FC, in Sunderland, a 'ort in
the northGeast, and then tra&elled -radually in all directions,
reachin- 3ondon in early C=F!) Its 'attern of s'read con&inced
(ias(atists that the air .as the cul'rit, and conta-ionists that
it .as 'ro'a-ated +y hu(an +ein-s) Al(ost e&eryone had to
conclude, after the e'ide(ic had 'layed itself out, that the
syste( of ?uarantine had not done its ,o+) Thereafter, 6ritish
'olicy relied 'ri(arily on 'ort ins'ection and isolation of
sus'icious cases, co&erin- +oth 'aradi-(s) 6ritain had then +y
far the lar-est (ariti(e co((it(ent, and therefore the (ost
to lose +y costly and disru'ti&e e('loy(ent of ?uarantine) A
re-ular series of International Sanitary conferences .ere held
fro( C=DC, 'ri(arily concerned .ith cholera) 6ritain and
6ritish India stood Nr( to-ether in o''osin- ?uarantine as a
routine a-ent of disease control) The econo(ic conse?uences
of such a 'olicy .ere clear to all, and 6ritain*s scientiNc 'olicy
.as +latantly dictated +y co((ercial considerations)
CD) >&en durin- the Nrst cholera e'ide(ic of the C=F<s, it .as
'ossi+le to ta1e a li-htGhearted loo1 at o5cial res'onses) Here,
+ureaucrats in to' hats see1 out the incri(inatin- s(ells, as a
+e(used 'i- loo1s on
The (ias(atic 'osition .as consolidated +y the leadin- N-ure
in the early 6ritish 'u+lic health (o&e(ent, >d.in Chad.ic1
(C=<<B@<)) A la.yer +y trainin-, Chad.ic1 had +een the last
secretary of the utilitarian 'hiloso'her and refor(er :ere(y
6entha( (CAE=BC=F!)) 9ro( 6entha(, Chad.ic1 a+sor+ed the
doctrines of e5ciency and the si('le e?uation of -ood .ith
ha''iness (Pthe -reatest -ood for the -reatest nu(+er* is the
slo-an of utilitarianis()) Chad.ic1 ca(e to 'u+lic health
throu-h his concern .ith 'o&erty, and in 'articular the
o'eration of the $oor 3a., the le-islati&e (eans of dealin-
.ith issues relatin- to the relief of 'o&erty and destitution) The
Old $oor 3a., datin- +ac1 to the late C"th century, had
+eco(e .oefully inade?uate in a society under-oin- ra'id
industriali7ation and ur+ani7ation) 6ritain .as the Nrst
industrial nation, and the older .ays of dealin- .ith the 'oor
.ere ina''ro'riate in an industrial .a-e econo(y, .ith
seasonal une('loy(ent, ur+an 'o&erty, and a -ro.in- class
consciousness)
The +runt of the Nrst >uro'ean cholera e'ide(ic .as felt in
C=F!, an e&entful year in other .ays) A 8efor( 6ill in
$arlia(ent .ent so(e .ay to.ards redressin- une?ual
$arlia(entary re'resentation, the result of 'o'ulation shifts
conse?uent on the ra'id -ro.th of industrial citiesS the 6ill also
extended the franchise) $arlia(ent set u' a $oor 3a.
Co((ission to exa(ine ho. the Old $oor 3a. o'erated and
(a1e reco((endations for its refor() This ca(e after years of
intense de+ate, 'art of it sti(ulated +y T) 8) Malthus*s >ssay
on the $rinci'le of $o'ulation (Nrst edition, CA@=S sixth edition,
C=!")) Malthus had 'ointed out the dou+leGed-ed nature of
'oor relief: 1ee'in- the 'oor ali&e could si('ly co('ound the
(isery of 'enury in later -enerations, .hen +reedin- 'au'ers
re'roduced yet (ore de'endency) The Pla. of 'o'ulation* that
Malthus ela+orated stated that throu-hout nature, the
ca'acities of or-anis(s to re'roduce al.ays outstri''ed the
nu(+er of oIs'rin- that could actually sur&i&e) Hu(an +ein-s
.ere not exe('t fro( this stern la., .ith the dis'arity caused
+y -eo(etrical 'o'ulation increase set a-ainst the
arith(etical increase in the (eans of su+sistence) #isease,
(isery, .ar, &ice, and .ant 1e't hu(an 'o'ulations do.n,
and interferin- .ith the syste( +y 1ee'in- (ore 'au'er
children ali&e did no -ood in the lon- run)
C") Gusta&e #ore*s 3ondon: A $il-ri(a-e (C=A!) +rilliantly
ca'tured the o&ercro.din- and 'o&erty of the lar-est and
richest city in >uro'e
The Malthusian dile((a .as (erely one of the issues that the
C=F! $oor 3a. Co((ission had to consider) Chad.ic1 .as its
secretary and do(inant N-ure, (aster(indin- the syste(atic
sur&ey of ho. the CD,<<< local 'arishes actually ad(inistered
the Old $oor 3a.) Initiated in the ti(e of >li7a+eth I, in the late
C"th century, this statute .as desi-ned to 'ro&ide, fro( local
taxes, a last safe-uard for 'eo'le .ho could not su''ort
the(sel&es, throu-h sic1ness, in,ury, une('loy(ent, or other
(isfortunes) #esi-ned for an o&er.hel(in-ly static, rural
society, the 3a. had +eco(e increasin-ly inade?uate, as
6ritain +eca(e (ore (o+ile, industrial, and ur+an, and
reached a crisis after the close of the /a'oleonic 4ars in the
C=C<s, .hen thousands of (ilitary (en returned ho(e and
could not Nnd .or1) 4ith CD,<<< diIerent local authorities
ad(inisterin- it, there .as .ide dis'arity, so(ethin- .hich
dee'ly oIended Chad.ic1*s utilitarian leanin-s) The
Co((issioners* 8e'ort, 'u+lished in C=FE and the +asis for
the /e. $oor 3a. of the sa(e year, reco((ended
strea(linin- and unifyin- its o'erations, so that si(ilar rules
and re-ulations extended o&er the .hole country)
This /e. $oor 3a., so hated +y (any for its harshness, ser&ed
as the (echanis( for 'oor relief until its a+olition in C@!@)
Chad.ic1 .anted to +e a Co((issioner of the ne.
-o&ern(ent de'art(ent +ut had to content hi(self .ith +ein-
its 'aid Secretary) Ad(inisterin- the /e. $oor 3a. on a daily
+asis ine&ita+ly confronted Chad.ic1 .ith the relationshi's
+et.een 'o&erty and disease) #octors had lon- noticed that
e'ide(ic diseases -enerally aWicted the 'oor (ore than the
rich, and assu(ed that this .as associated .ith their
o&ercro.ded li&in- conditions, s'arse diet, and other tra''in-s
of .ant) Chad.ic1*s initial concern .as .ith the fact that (any
of the de(ands on the $oor 3a. .ere +ecause the
+read.inner had fallen sic1 and could not .or1)
#isease could thus i('o&erish a fa(ily) The re&erse
'ro'osition .as (ore su+tle: does 'o&erty itself cause
diseaseT Chad.ic1 and (any of his conte('oraries 'referred
to 'ut a (oral s'in on 'o&erty 'er se, ar-uin- that its ulti(ate
cause lay in indi&idual failin-: i('rudent (arria-es, failure to
sa&e, s'endin- on drin1 and other &ices) /e&ertheless, since
disease .as a (a,or factor in the causation of 'o&erty, it
follo.ed that 're&entin- .hat he called PNlth diseases* .ould
ease the +urden on the $oor 8ate) As an ardent (ias(atist, he
attri+uted Nlth diseases such as cholera, ty'hus, and scarlet
fe&er to the +ad s(ells of rottin- or-anic (atter) The solution
.as easy: cleanliness) #irt caused diseaseS cleanliness
're&ented it)
Chad.ic1*s ,ourney fro( a $oor 3a. refor(er to one o+sessed
.ith 're&entin- disease occurred o&er the fe. years fro(
C=FE to C=E!, .hen he 'u+lished a classic text of the early
'u+lic health (o&e(ent: 8e'ort on the Sanitary Condition of
the 3a+ourin- $o'ulation of Great 6ritain) He used the ne.
statistical a''roaches of the day (the ci&il re-istration of
+irths, (arria-es, and deaths had started in C=FA) to ?uantify
the sta--erin- diIerences of (ortality rates and a&era-e
ex'ectation of years at +irth +et.een o&ercro.ded, ur+an
areas and rural ones, and +et.een the rich and the 'oor) To
sol&e the 'ro+le( of Nlth diseases, Chad.ic1 'ro'osed .hat
he called an arterioG&enous syste( of .ater su''ly and
se.a-e dis'osal) If runnin- .ater under 'ressure .ere
su''lied to households, cleanliness .ould +e easierS if se.a-e
.ere ta1en a.ay in -la7ed 'i'es i('er&ious to lea1a-e, the
'ro+le(s of cess'its and -round conta(ination .ould +e
sol&ed) 9urther, if the se.a-e .ere ta1en a.ay fro( cities to
treat(ent 'lants, it could +e turned to -uano, sold to far(ers
at a 'roNt, and cro's .ould +e increased, there+y i('ro&in-
nutrition) It .as a neat en-ineerin- solution to 'u+lic health,
-ood in its context, thou-h not sol&in- all the 'ro+le(s that
Chad.ic1*s li(ited &ie. of disease causation en&isioned)
He -ot his chance to inRuence 'u+lic health in C=E=, .hen
cholera returned, and a 6oard of Health .as esta+lished, .ith
Chad.ic1 one of three (e(+ers (a fourth, a doctor, .as added
later)) The $arlia(entary Act settin- u' the 6oard .as lar-ely
'er(issi&e, allo.in- co((unities to a''oint a Medical O5cer
of Health (MoH) if C<Z of their rateG'ayers 'etitioned for it)
The MoH .as o+li-atory only if the crude death rate in the
area .as -reater than !F 'er C,<<<) The 'er(issi&e clause
.as so(ethin- of a Tro,an Horse, since the MoHs raised the
'roNle of 're&ention, and a-itated for such o5cers throu-hout
the country, on a statutory +asis) This 'assa-e fro(
'er(issi&e to statutory le-islation +eca(e the 'attern in
li+eral, laisse7Gfaire societies, in .ays that are still resonant)
In&esti-atin- al(ost any social issue unco&ers others that
need attention)
Throu-hout his lon- life, Chad.ic1 ne&er a+andoned his notion
of Nlth disease, nor of the healin- 'o.er of cleanliness) He left
o5ce a-ainst his .ill, in C=DE, des'ite the return of cholera)
His dictatorial style (ade too (any ene(ies, and he .anted
co('ulsory le-islation to enter throu-h the front door) It ca(e,
'iece(eal and -radually, throu-h the +ac1 one)
In the (eanti(e, the nature of Nlth diseases .as +ein-
reconce'tuali7ed) Only in hindsi-ht did 'eo'le reali7e that the
Italian (icrosco'ist 9ili''o $acini (C=C!B=F) had descri+ed
durin- the C=DE 'ande(ic the causati&e or-anis( of cholera)
Of e?ual (o(ent, the 3ondon anaesthetist, e'ide(iolo-ist,
and -eneral 'ractitioner :ohn Sno. (C=CFBD=) de(onstrated
that cholera is not air +ut .ater +orne) Sno. .as a (edical
a''rentice durin- the ori-inal cholera out+rea1 in C=FCB!, and
studied the disease as an esta+lished and a(+itious
'ractitioner durin- the C=E= and C=DE 3ondon e'ide(ics) He
'ro&ided -ood e&idence fro( the C=E= e'ide(ic that the
disease .as trans(itted throu-h .ater conta(inated +y
faecesS he nailed his case throu-h t.o classic co((unity
ex'eri(ents durin- C=DE) The 6road Street $u(' is the (ost
fa(ous B the stuI of le-ends) This 'u(', in Soho, central
3ondon (the street is no. called 6road.ic1 Street), ser&ed
(any houses, (ost of .hich had no direct access to runnin-
.ater) 6y syste(atically in&esti-atin- house to house the
cases that occurred in the area of a sin-le .ater 'u(', and
tracin- cases further aNeld fro( 'eo'le .ho had drun1 .ater
fro( the 'u(', he incri(inated it as the source of the disease)
An o'en se.er drained into it) The dra(atic re(o&al of the
'u(' handle .as (ore sy(+olic than eIecti&e, since the
e'ide(ic .as already on the .ane, +ut the incident attracted
a -ood deal of attention)
His second e'ide(iolo-ical in&esti-ation .as (ore i('ressi&e)
He co('ared the incidence of 'eo'le +uyin- Tha(es .ater
fro( t.o se'arate co('anies: one Nltered their .ater and
dre. it u'strea(, +efore the se.ers of 3ondon had e('tied
into itS the other used unNltered .ater fro( do.nstrea(,
se.era-e and all) In so(e instances, 'eo'le in the sa(e
streets, li&in- in si(ilar housin- and +reathin- the sa(e air,
had contracts .ith each of the t.o co('anies) He sho.ed that
'eo'le usin- the .ater of the P+ad* co('any had CF ti(es the
chance of co(in- do.n .ith cholera than 'eo'le usin- the
+etter su''lies)
Sno.*s e&idence see(s o+&ious to us) It .asn*t to (ost of his
conte('oraries, and the nature and cause of cholera
continued to +e de+ated for decades, e&en, it turns out, after
8o+ert 2och descri+ed the or-anis( in C==E, in an a-e of
+acteriolo-y) Old .ays of thin1in- die hard, althou-h .hen
cholera struc1 Ha(+ur- durin- the C=@<s 'ande(ic, (ore
'eo'le listened to 2och than had to Sno. four decades
're&iously) His e&idence .as i('ressi&e, +ut so .as Sno.*s) As
the next cha'ter .ill sho., only .ith the co(in- of science did
real heroes e(er-e .ithin (odern (edicine)
>sta+lishin- the 'u+lic health +ureaucracy
PIn the +e-innin- .as the 4ord*, St :ohn*s Gos'el has it) /o.,
there is (ostly the nu(+er) 4e li&e +y the cloc1, follo. the
u's and do.ns of the stoc1 (ar1ets or (ort-a-e rates,
ex'erience the hottest, or .ettest, (onth since records +e-an)
Conte('orary society is 'er(eated .ith nu(+ersS they rule
our li&es)
$u+lic health e&idence is ine&ita+ly nu(erical) If the 'u+lic
health (o&e(ent .as in lar-e (easure a 'roduct of the
industriali7ation and ur+ani7ation that transfor(ed the
4estern .orld fro( the late C=th century, it also relied on the
nu(erical (entality that acco('anied the 'roNts and losses of
the factory syste(, the harnessin- of stea(, dou+leGentry
+oo1G1ee'in-, and the national census) 3i1e us, the Victorians
felt o&er.hel(ed .ith facts and data)
Three di(ensions to the ?uantiNcation of (edicine (and
society (ore -enerally) should +e hi-hli-hted: sur&eys,
sur&eillance, and si-niNcance)
The sur&ey is the (ost +asic) The C=F! $oor 3a. Co((ission
has +een descri+ed as the 'ioneerin- national sur&ey, and it
certainly .as no&el for its ti(es) Chad.ic1 and his fello.
co((issioners sent out a detailed ?uestionnaire to each of the
'arishes res'onsi+le for $oor 3a. relief, and atte('ted to
coordinate the re'lies) In the late C=F<s, Chad.ic1
co((issioned sur&eys of the relationshi' +et.een 'o&erty,
o&ercro.din-, and Nlth diseases) One of the Nrst acts of
Chad.ic1*s successor as leader of the 6ritish $u+lic Health
Mo&e(ent, :ohn Si(on (C=C"BC@<E), .as a >uro'eanG.ide
sur&ey of &accination and its eIecti&eness, in relation to the
issue of enforcin- co('ulsory &accination) This sur&ey
con&inced hi( that the .ay to 're&ent s(all'ox .as to ha&e
an acti&e 'olicy of free &accination) #urin- his years in o5ce,
Si(on -radually +eca(e disillusioned .ith 'ersuasion as a
tool to achie&e 'u+lic health ends, and under his leadershi',
6ritain ac?uired a &accination syste( that .as 'u+licly
funded, free, uni&ersal, and co('ulsory, .ith 'enalties for
nonGco('liance)
Throu-hout the de&elo'ed .orld, durin- the (iddle decades of
the C@th century, the 'o.er of the nu(+er +eca(e
a''reciated) Social issues .ith (edical ra(iNcations .ere
re'eatedly in&esti-ated +y sur&eys) Issues of 'o&erty, child
la+our, factory conditions, food adulteration, .ater su''ly,
'rostitution, +uildin- standards, and, of course, e'ide(ic
diseases, all ca(e under scrutiny) In&esti-atin- one issue often
thre. u' others that called out for attention) 9or instance,
concern .ith the e('loy(ent of youn- children in 'oorly 'aid
and -rindin- ,o+s raised (ore -eneral issues of education and
child health) Charles #ic1ens*s Mr Grad-rind .as not the only
one in C@thGcentury >uro'e .ho .anted Pthe facts*, and Pfacts*
increasin-ly ca(e in a ta+le or other ?uantitati&e for()
CA) In contrast to 9i-ure CD, .hen the intrusion of the state
into 'u+lic aIairs is treated as an o+,ect of satire, here, in this
i(a-e +y 3ance Cal1in (c) C@<C), the 'u+lic &accinator is seen
as a N-ure of authority, ?uietly -oin- a+out his .or1 of
'rotectin- these youn- -irls fro( s(all'ox
If sur&eys thre. u' all 1inds of (edical and social issues,
sur&eillance .as a co('le(entary strate-y, ai(ed at
syste(atically follo.in- trends or follo.in- u' on trou+lin-
'ro+le(s) Many sur&eillance structures ha&e lon- histories) 9or
exa('le, fro( (edie&al ti(es, 9rench +utchers could ex'ect
'eriodic &isits fro( ins'ectors exa(inin- the (eat they .ere
sellin-) Mar1ets and fairs .ere conducted under re-ulations)
6orders, 'orts, and .alled to.ns .ere (anned, es'ecially
durin- out+rea1s of 'la-ue and other e'ide(ic diseasesS
'eo'le and -oods could ex'ect to +e ins'ected) In any case,
a+solute (onarchs and des'ots needed infor(ation a+out the
co(in-s and -oin-s of their ene(ies) The 96I, CIA, MID, and
2G6 ha&e (any forerunners, althou-h (ost earlier net.or1s of
sur&eillance .ere concerned .ith security and control rather
than .ith health)
Once statutes are on the +oo1s, they need to +e 'oliced, and
Medical O5cers of Health, factory sur-eons, 'ort (edical
authorities, and the host of other indi&iduals concerned .ith
the 'u+lic*s health +eca(e a &isi+le 'art of C@thGcentury
4estern society) The star1est instance of the 'olice functions
of 'u+lic health o5cials, as .ell as ordinary (edical
'ractitioners, is seen in the de&elo'(ent of the conce't of the
notiNa+le disease) A nu(+er of local co((unities had insisted
that cases of s(all'ox had to +e re'orted to central
authorities) 9ro( the C==<s, in the .a1e of +acteriolo-y,
national sche(es .ere inau-urated and se&eral diseases .ere
identiNed as conta-ious and 'u+lic health ris1s) S(all'ox,
scarlet fe&er, ty'hoid fe&er, and, e&entually, tu+erculosis and
sy'hilis +eca(e diseases in .hich the ris1 to the -eneral
'u+lic .as dee(ed -reater than the &alue of 'ri&acy and
indi&idual treat(ent +y a (edical (an) Medical 'ractitioners
.ere re?uired to add sur&eillance to their other tas1s
(resistance to the +ureaucracy lessened after they .ere 'aid
for Nllin- out the for(s), and althou-h MoHs and e?ui&alent
o5cials in diIerent countries occu'ied the front line, all
doctors .ere ex'ected to ser&e in the ran1s)
The ran-e of le-al, (edical, and ethical issues in&ol&ed in
sur&eillance is star1ly seen in the fa(ous case of Mary Mallon
(C="@BC@F@), PTy'hoid Mary*) This IrishG+orn .o(an ser&ed as
a coo1 for a series of .ealthy /e. 0or1 fa(ilies in the Nrst
decade of the !<th century) She .as co('letely .ell +ut
dis'layed all the characteristics that 8o+ert 2och had recently
identiNed as the Pcarrier state*, that is, she shed the +acteria of
ty'hoid fe&er .ithout suIerin- fro( the sy('to(s herself)
She infected (e(+ers of se&eral fa(ilies, and the isolated
out+rea1s .ere in&esti-ated +y 'u+lic health o5cials) A
fe(ale i((i-rant, .ith li(ited education, and conscious of no
.ron-Gdoin-, Mary .as ne&ertheless a 'u+lic health ha7ard,
and incarcerated for her Pcri(e*)
Sur&eyin- .as the acti&ity of o5cials intent on unco&erin-
ne. associationsS sur&eillance +eca(e the duty of all doctors
.ho encountered a 'atient .ith a notiNa+le disease) Statistics
+eca(e the ex'ertise of those es'ecially trained to
understand the nature of correlations and causations) The
(odern 'u+lic health (o&e(ent e(er-ed si(ultaneously .ith
statistical societies, and for (any of the sa(e reasons) 6oth
.ere res'onses to industriali7ation, and the (o&e(ent and
the societies .ere 'eo'led +y (any of the sa(e concerned
indi&iduals)
Althou-h the (athe(atics of 'ro+a+ility had +een de&elo'ed
fro( the late CAth century, its conte('orary (athe(atical
'artner Pstatistics* .as in the early C@th century (uch less
so'histicated) Statistical societies .ere (ostly de&oted to
collectin- (any o+ser&ations and 'resentin- these in ta+ular
for() The introduction of ci&il death re-istration in (any
>uro'ean countries led to annual 'resentation of ta+ular
causes of death, and at the sa(e ti(e re?uired international
atte('ts to standardi7e dia-nostic cate-ories) Althou-h (any
of the sy('to(G+ased disease cate-ories (such as Pfe&er* or
P,aundice*) had to +e a+andoned as diseases in their o.n ri-ht,
nosolo-y still (aintained its i('ortance, as doctors +oth
nationally and internationally .anted to +e certain of the
diseases that .ere 'ut on death certiNcates or annual hos'ital
re'orts)
Of e?ual lastin- i('ortance, Psi-niNcance* entered statistics,
ori-inally throu-h the .or1 of Charles #ar.in*s cousin, 9rancis
Galton (C=!!BC@CC)) Galton +eca(e intri-ued .ith the nature
of heredity, and de&elo'ed (athe(atical (ethods to exa(ine
the relati&e contri+utions of +oth 'arents, as .ell as
-rand'arents and other ancestors, to the inherited (a1eu' of
an indi&idual) As the father of eu-enics, he .as es'ecially
concerned .ith .hat he 'ercei&ed as the diIerential +irth rate
+et.een fec1less 'oor and res'onsi+le (iddleGclass 'arents)
He (easured (any hu(an attri+utes, such as hei-ht,
lon-e&ity, (uscle stren-th, and Psuccess* in life) He 'ut
inheritance into the 'u+lic health e?uation, in a Neld that had
hitherto (ostly concerned itself .ith en&iron(ental issues
such as o&ercro.din- and dirt) After Galton, +oth Pnature* and
Pnurture* had to +e considered)
Althou-h Galton trained in (athe(atics and (edicine (he
ne&er 'ractised), it .as his disci'le 2arl $earson (C=DABC@F")
.ho 'laced statistics at the centre of +oth ex'eri(ental
science and clinical (edicine) Our notions of si-niNcance, .ith
its P'* &alue (the le&el of @DZ conNdence that the &aria+le
+ein- (easured is correct), o.e (uch to $earson) He studied
inheritance in tu+erculosis and alcoholis(, +ut he .as (ostly
interested in the role of inheritance in e&olutionary +iolo-y) His
'u'ils and follo.ers 'laced (athe(atics at the centre of
e'ide(iolo-y and the e&aluation of ne. thera'ies throu-h the
de&elo'(ent of the clinical trial)
These !<thGcentury de&elo'(ents ha&e transfor(ed the
si('le sur&eys and ta+ulations of earlier 'u+lic health
ad&ocates) 6ut the C@thGcentury (essa-e of those concerned
.ith diseases .ithin the co((unity has stuc1: facts are
i('ortant, and so are nu(+ers) The (Mthode nu(Mri?ue that
3ouis had used so .ell .ithin the hos'ital had resonance
outside of it) #ata had to +e e&aluated, in the hos'ital,
co((unity and the la+oratory, and the (athe(atical and
statistical tools to eIect this ha&e -ained increasin-
i('ortance in (odern health research and disease 're&ention)
Cha'ter D Medicine in the la+oratory
Ma1in- (edicine scientiNc
4estern (edicine has al.ays fancied that it .as PscientiNc*,
+ut .hat that (eans has chan-ed) The Hi''ocratics .ould
ha&e counted the(sel&es in the ran1s of science (the Gree1s
.ould ha&e used .ords li1e Pnatural 'hiloso'hy*)) So .ould the
(any follo.ers of Galen) The (edicine they 'ractised had t.o
funda(ental PscientiNc* attri+utes)
The Nrst .as an underlyin- rationality, .hich sur(ised that,
-i&en their .orld &ie.s, their actions B the dia-noses and
thera'ies B (ade sense) This is of course a relati&istic &ie. of
science, since astrolo-ical (edicine is also rational, assu(in-
that one acce'ts the inRuence of the 'lanets and stars on
hu(an +eha&iour and earthly e&ents) To dis(iss it, one needs
to discount the underlyin- 'rinci'les, not the rationality that
-o&erned the .hole 'rocess of reasonin-)
The second .as that (edical 'ractice has al.ays +een rooted
in Pex'erience*, fro( .hich .e also deri&e the .ord
Pex'eri(ent*) P>x'erience* told doctors and their 'atients that
+loodlettin-, for instance, hel'ed, or that a thousand other
re(edies that see( ineIecti&e, e&en dis-ustin-, to us, .ere
,ust .hat the doctor ordered) Historians can attri+ute these
encounters to the healin- 'o.er of nature, to the 'atient
-ettin- +etter des'ite, not +ecause of, his or her treat(ent, or
to the old lo-ical fallacy .e ha&e already encountered: 'ost
hoc, er-o 'ro'ter hoc) These retros'ecti&e ,ud-e(ents do not
in&alidate .hat historical 'artici'ants inter'reted as Prational*,
PscientiNc* (edicine)
9ro( the earlyG(odern 'eriod, ho.e&er, ex'erience ca(e
increasin-ly to incor'orate ex'eri(ent, .hich .as often
situated in a la+oratory) The .ord literally (eans a 'lace
.here so(eone .or1s, and la+oratories .ere initially in
'eo'le*s ho(es, and .ere si('ly roo(s set aside +y those
.ith su5cient leisure to en?uire into the secrets of nature) The
?uintessential early la+oratory, and the one (ost fre?uently
illustrated, .as that of the alche(ist, as natural 'hiloso'hers
sou-ht to learn ho. to turn +ase (etals into -old) The
alche(ist*s tools .ere the furnace, distiller, rea-ents, +alance,
and Ras1s of &arious si7es) Those interested in anato(y,
'hysiolo-y, and other life sciences .ould 'ossess dissectin-
ta+les, sur-ical instru(ents, and other e?ui'(ent to (easure
.hate&er 'ara(eter .as under in&esti-ation) The 6el-ian
'hysician :) 6) Van Hel(ont (CDA@BC"EE) 1e't a youn- sa'lin-
in a 'ot for N&e years, .aterin- it re-ularly .ith rain .ater) He
then .ei-hed the tree and its surroundin- soil) The soil .as
(ore or less the sa(e .ei-ht as .hen he had 'lanted the
sa'lin-, .hereas the tree then .ei-hed C"E 'ounds, an
increase Van Hel(ont attri+uted to the .ater) In Italy, Santorio
Santorio (CD"CBC"F") desi-ned a chair in .hich he could
carefully .ei-h hi(self, 1ee'in- a thorou-h tally of the .ei-ht
of food and drin1 he in-ested, and the .ei-ht of his excreta)
The diIerence .as .hat he lost in Pinsensi+le 'ers'iration*, as
he called it) 4illia( Har&ey dissected sna1es, toads, and other
coldG+looded creatures, the +etter to o+ser&e the details of the
heartG+eat, in his ?uest to understand the P(otion of the heart*
and circulation of the +lood) Al+recht &on Haller (CA<=BAA)
conducted an extensi&e series of ex'eri(ents on li&in-
ani(als in his diIerentiation of irrita+ility (the ca'acity to react
to external sti(uli, a 'ro'erty of (uscles) and sensiti&ity (the
ca'acity to feel, the result of ner&ous function)) The
ex'eri(ental i('ulse in (edicine has a lon- tradition, often
in&ol&in- the ?uantitati&e s'irit) 4hat could +e (easured
could +e 1no.n)
One tool a(on- (any that (i-ht +e found in these early
scientiNc .or1'laces .as the (icrosco'e) There .ere
'ro+le(s, reali7ed at the ti(e, of distortion and a+erration,
and historians ha&e so(eti(es dis(issed (icrosco'y +efore
the C@th century as a 'laythin- of rich dilettantes) 8ecent
scholarshi' has sho.n ho. i('ortant (icrosco'y .as in
serious scientiNc de+ates fro( its early use in the CAth
century, a+o&e all +y Antoni &an 3eeu.enhoe1 (C"F!BCA!F), a
selfGtau-ht (icrosco'ist .ho .or1ed as a dra'er in the
/etherlands, and 8o+ert Hoo1e (C"FDBCA<F), also fro( hu(+le
ori-ins +ut a (an .ho ri&alled Isaac /e.ton in the +readth of
his research) Hoo1e coined the .ord Pcell* in his Micro-ra'hia
(C""D)) Once the (icrosco'e allo.ed indi&iduals to .itness
the ne. .orld that it re&ealed, the technical 'ro+le(s .ere
set aside as an incon&enience, co('ared to the 'ossi+ilities its
use o'ened u') In the C@th century, the (icrosco'e +eca(e
the sy(+ol of the (edical scientist, occu'yin- the identical
role that the stethosco'e had for the 'ro-ressi&e clinician)
Cells: e&er s(aller
The +asic unit of (edical understandin- of disease has
+eco(e steadily (ore reNned) Hu(oralis( .or1ed .ith .hole
+odiesS Mor-a-ni used the or-ans as his default (odeS 6ichat
noticed ho. i('ortant tissues .ere for classifyin- and
analysin- 'atholo-ical chan-es) Cells then +eca(e the 1ey,
and ha&e re(ained central, e&en as su+Gcellular units and
(olecules ha&e since +een identiNed as crucial constituents of
the dyna(ics of disease 'rocesses)
The cell theory that Nnally triu('hed fro( the C=F<s can +e
seen as the foundation stone of +oth (odern (edical science
and +iolo-y) The .ord P+iolo-y* dates fro( C=<C, .hereas
Pscientist* .as not coined until C=FF) These t.o .ords su--est
that so(ethin- funda(ental chan-ed durin- those decades) In
the early C@th century, se&eral theories 'ro'osed so(e 1ind of
(icrosco'ic unit fro( .hich .hole or-anis(s .ere co('osed)
So(e of these units, such as P-lo+ules*, .ere actually artefacts
of the (icrosco'es then in use) The technical 'ro+le(s .ere
lar-ely resol&ed in the late C=!<s) #escri'tions a''eared
re-ularly of units that are reco-ni7a+le as our Pcells*, as .ell as
their contents, es'ecially the nucleus) Then, in the successi&e
years of C=F= and C=F@, t.o Ger(an scientists, Mathias
Schleiden (C=<EB=C) and Theodor Sch.ann (C=C<B=!),
'ro'osed that cells are the +uildin- +loc1s of 'lants and
ani(als, res'ecti&ely) That they .ere +oth Ger(an is no
accident, for (uch of (odern +io(edical research ori-inated
in Ger(any, .ithin the Ger(an uni&ersity syste() Schleiden
.as an acade(ic +otanist, +ut Sch.ann, trained as a doctor,
.as the 'u'il of the (ost i('ortant teacher of (edical
science, :ohannes M[ller (C=<CBD=)) Sch.ann had a fa+ulously
successful early research career, (a1in- funda(ental
disco&eries a+out the nature of fer(entation and di-estion, as
.ell as ela+oratin- his cell theory) He ar-ued that co('lex
or-anis(s .ere collections of inte-rated cells, and that
therefore function, +oth nor(al and 'atholo-ical, had to +e
understood in ter(s of the li&in- characteristics of these
entities) He +elie&ed that 'ri(iti&e cells, for instance, in early
e(+ryolo-ical de&elo'(ent, or in tissues that .ere inRa(ed,
could crystalli7e out fro( an a(or'hous Ruid .hich he called
the P+laste(a*) This theory see(ed to s?uare .hat the
(icrosco'e could re&eal .ith his notion that life .as the
'roduct of essentially a 'hysical 'rocess)
C=) One of the on-oin- 'ro+le(s .ith (icrosco'y .as the fact
that only one 'erson could loo1 at the i(a-e at a ti(e) 8o+ert
2och (ade it (uch (ore 'u+lic +y usin- the ca(era to record
i(a-esS a (ore co('aniona+le solution, fro( C=AC, .as this
(icrosco'e, .ith three tu+es, so 'ro&idin- o+,ecti&e
&eriNcation of the (a-niNed i(a-e
Sch.ann soon a+andoned his conNdent (aterialis( and s'ent
the last decades of his life in reli-ious and 'hiloso'hical
s'eculations) His cell theory found -eneral fa&our, ho.e&er,
and .as (odiNed and a''lied to (edicine +y others,
es'ecially +y 8udolf Vircho. (C=!CBC@<!), the do(inant N-ure
.ithin C@thGcentury Ger(an (edical science) Vircho. .as a
lifeGlon- li+eral in an increasin-ly (ilitant Ger(an society, and
in his youth had a touch of the 'olitical radical a+out hi() He
s'earheaded a refor(ist -rou' of youn- doctors durin- the
re&olutions that acco('anied the C=E= cholera e'ide(ic,
s'endin- a +it of ti(e on the +arricades that .ere thro.n u'
+y re&olutionaries in 6erlin) To re(o&e hi( to a +ac1.ater, the
$russian authorities sent hi( to in&esti-ate an e'ide(ic of
ty'hus in %''er Silesia, no. 'art of $oland +ut then .ithin the
$russian s'here of inRuence) He .rote a re'ort that the
authorities did not .ish to read, +la(in- the e'ide(ic on
social de'ri&ation, 'o&erty, illiteracy, and 'olitical ine?uality)
These and si(ilar e'ide(ics .ere +est controlled, he ar-ued,
throu-h de(ocracy, education, and econo(ic ,ustice) He
+elie&ed that one i('ortant role of doctors .as si('ly to
ca('ai-n for such refor(s) #octors .ere the natural
ad&ocates of the 'oor, since their 'rofession +rou-ht the( into
inti(ate contact .ith the econo(ic and social causes of
disease)
Vircho. al.ays (aintained his interest in 'olitics and sanitary
refor(, ser&in- in the Ger(an 'arlia(ent and the 6erlin 'u+lic
health council) He li1ed to co('are the +ody 'olitic .ith the
hu(an +ody, cells +eco(in- the +ody*s citi7ens) #octors had
to confront in their daily .or1 the ad&erse eIects on health of
'o&erty) This (an of incredi+le ener-y also 'ursued his
interests in anthro'olo-y and archaeolo-y, as .ell as editin-
se&eral ,ournals and (ultiG&olu(e +oo1s) The 'atholo-y
,ournal he founded and edited for (ore than half a century is
still 'u+lished, 1no.n as Vircho.s Archi&) And it .as 'ri(arily
as a 'atholo-ist that he is re(e(+ered) Al.ays con&inced that
the (icrosco'e .as central to understandin- disease
'rocesses (P3earn to see (icrosco'ically*, he tau-ht his
students), Vircho. too1 're&ious cell theories and a''lied
the( to (edicine) He ca(e to dou+t that Sch.ann*s
P+laste(a* .as the source of ne. cells, such as those in early
e(+ryolo-ical de&elo'(ent, or in inRa((atory res'onses in
the tissues, ar-uin- instead that all cells co(e fro( (other
cells (O(nis cellula e cellula)) Althou-h the slo-an .as not
ori-inally his, Vircho. con&inced the scientiNc .orld that cells
do not crystalli7e or other.ise ori-inate s'ontaneously, +ut
that they are al.ays the result of cell di&ision) He ela+orated
his cellular 'atholo-y in the C=D<s, in a series of articles,
(ostly in his o.n ,ournals, and in C=D=, then +ac1 in 6erlin
after se&en years as 'rofessor of 'atholo-y in 4[r7+ur-,
'u+lished a series of lectures, as Cellular $atholo-ie) In it he
sho.ed ho. cells .ere the funda(ental units of 'hysiolo-ical
and 'atholo-ical acti&ity, and that routine clinical e&ents, such
as acute and chronic inRa((ation, cancer -ro.th and s'read,
and +odily reactions to external sti(ulation such as irritation
or 'ressure, could +e fruitfully conce'tuali7ed in cellular ter(s)
He 'laced the cell at the centre of 'atholo-y, e&en as he
ela+orated a (ore -eneral +iolo-ical 'rinci'le)
Vircho. (ade (any i('ortant o+ser&ations on a &ariety of
diseases, such as 'hle+itis, e(+olis(, cancers, and
a(yloidosis, a rare disease that is still not .ell understood) He
also .as the (ost inRuential teacher of 'atholo-y in the C@th
century, and (any of the su+se?uent leaders in the Neld
'assed throu-h his Institute in 6erlin) He carried out so(e
acti&e ani(al ex'eri(ents, +ut (uch of his .or1 .as s'ent
exa(inin- 'atholo-ical tissues and cells, and relatin- his o.n
Nndin-s to the clinical issues that had occurred durin- the
'atient*s lifeti(e) He .itnessed the de&elo'(ent of ne.
(icrosco'ical techni?ues, such as usin- (icroto(es to cut
thin slices of tissues, the +etter to o+ser&e the(, and stains to
hi-hli-ht features of cells, such as their nucleus and +odies in
the cyto'las() Althou-h he .as so(ethin- of an
ex'eri(entalist, ex'eri(ental 'atholo-y ca(e into its o.n
only late in Vircho.*s life, .ith +acteriolo-y) Vircho. follo.ed
this disci'line .ith interest +ut ne&er .holeheartedly endorsed
-er( theory)
Ger(s: the ne. -os'el
In the (edical 'antheon, there are fe. saints (ore re&ered
than St 3ouis B 3ouis $asteur (C=!!B@D)) That he .as not e&en
a ?ualiNed doctor, +ut trained in 'hysics and che(istry, says
(uch a+out the increasin- i('ortance of science for (edicine)
That he .or1ed (ostly in the la+oratory, co(in- to the
+edside only late in his life, to .atch .hile doctors in,ected his
ra+ies &accine, re(inds us of the 'lace of the la+oratory in our
total 'icture of (odern (edicine)
Traditionally, the -er( theory has +een seen as the +e-innin-s
of eIecti&e, and therefore (odern, (edicine) 8e&isionist
historians so(eti(es 'oint out that the disco&ery that (icroG
or-anis(s cause (any of the (ost i('ortant historical
diseases B ty'hus, tu+erculosis, sy'hilis, cholera, (alaria,
s(all'ox, inRuen7a, and (any others B too1 decades of de+ate
+efore so(e sort of consensus .as reached) 9urther, so this
re&isionist account e('hasi7es, (edicine re(ained
thera'eutically ine't lon- after $asteur .as dead) The
e(er-ence of ne. diseases, such as HIV infection, 3assa fe&er,
and le-ionnaires* disease, the .ides'read de&elo'(ent of
dru- resistance a(on- (icroGor-anis(s, and the increasin-
're&alence of nonGinfectious chronic diseases in 4estern
societies, ha&e 'ut -er( theory into another 'ers'ecti&e) 9ro(
the C@D<s, Tho(as Mc2eo.n (C@C!B==), a 'rofessor of social
(edicine at 6ir(in-ha(, 'u+lished a series of inRuential
studies ar-uin- that the decline in (ortality rates in 4estern
societies .as 'ri(arily aIected +y i('ro&e(ents in nutrition
and -eneral standards of li&in-, and that or-ani7ed (edicine
had contri+uted little, at least until the &ery recent 'ast)
4ithin these readin-s of C@thGcentury (edicine, the .or1 of
$asteur, 8o+ert 2och (C=EFBC@C<), and the other 'ro'onents
of (icro+iolo-y, +acteriolo-y, and their attendant la+oratory
disci'lines (i-ht ha&e +een doin- interestin- research, +ut its
funda(ental si-niNcance for 'atients and life ex'ectancies
had +een exa--erated) 4hat exactly did they Nnd out, and did
it (atter all that (uchT
$asteur .as not the Nrst to see +acteria and other (icroG
or-anis(s, nor the Nrst to tal1 a+out the P-er(s of disease*)
6ut his researches, fro( the late C=D<s, had a .onderful lo-ic
to the(, and for fe. scientists is it easier to connect the entire
career as a series of chance o+ser&ations and o''ortunities for
.hich the .hole is -reater than the considera+le su( of its
'arts) He +eca(e interested in (icroGor-anis(s .hile
studyin- crystalli7ation, and sho.ed that crystals of tartaric
acid (a +yG'roduct of the tannin- industry) (ade +y ordinary
che(ical (eans .ere al.ays o'tically neutral, .hereas those
he o+tained after (icroGor-anis(s had +een at .or1 rotated
'olari7ed li-ht) This con&inced hi( that li&in- or-anis(s had
s'ecial ca'acities, and led hi( to study the 'ro'erties of yeast
and other industrially i('ortant or-anis(s used in +a1in-,
+re.in-, and fer(entation) His iconic ex'eri(ents on
s'ontaneous -eneration occu'ied hi( for se&eral years in the
early C="<s, and had s'ecial resonance in the .a1e of
#ar.in*s Ori-in of S'ecies (C=D@)) His fa(ous s.anGnec1ed
Ras1s, to exclude airG+orne conta(ination after the solutions
had +een +oiled to sterili7e the(, are 'art of our aIectionate
i(a-e of hi()
To hi(, these ex'eri(ents sho.ed that s'ontaneous
-eneration of (icroGor-anis(s does not occur, and he .on the
'u+lic de+ates .ith a collea-ue, .ho re'eated his ex'eri(ents
and often found or-anis(s s.ar(in- in the Ruid) Analysis of
$asteur*s la+oratory note+oo1s has sho.n that $asteur*s
ex'eri(ents also so(eti(es Pfailed* (i)e) had Ras1s .ith
or-anis(s in the(), +ut that he ?uietly discarded these
results) He .as .or1in- .ith the hay +acillus (a1in to the
causati&e a-ent of anthrax) and the s'ore for( of this
+acteriu( is resistant to heat, so one .ould ex'ect Pne-ati&e*
results to $asteur*s ex'eri(ents) 6y su''ressin- these,
$asteur -ot the +etter of his o''onents) He al.ays had the
(ost a(a7in- 1nac1 of +ac1in- the ri-ht horse, and stic1in- to
his -uns)
Alon-side his s'ontaneous -eneration ex'eri(ents, $asteur
.or1ed acti&ely .ith the role of yeasts and other (icroG
or-anis(s as the cause of &arious fer(entations: of +eer,
.ine, or the sourin- of (il1) Sch.ann and other Ger(an
scientists had concluded that these i('ortant e&eryday
reactions .ere (erely che(ical, +ut $asteur insisted that they
need li&in- or-anis(s to 'roduce, and hence .ere &ital
'rocesses) He 'ro&ided i('ortant 'ractical 1no.led-e for
.ineG(a1ers and +re.ers, as .ell as introducin-
P'asteuri7ation* as a (eans of sterili7in- su+stances li1e (il1,
to retard their s'oila-e)
Such .as his re'utation +y a+out C=A< that he .as as1ed +y
the 9rench -o&ern(ent to in&esti-ate an a''arently infectious
disease of sil1.or(s that .as threatenin- the sil1 industry) He
too1 his fa(ily .ith hi(, 'ut the( to .or1, and identiNed the
t.o (icroGor-anis(s res'onsi+le, then sho.ed ho. they could
+e 're&ented fro( doin- their (ischief) After this .or1, he
increasin-ly +e-an to tal1 a+out a P-er( theory* of disease,
and to .or1 on the diseaseGcausin- ca'acity of +acteria)
9ittin-ly, for this nonG(edically ?ualiNed scientist, he tac1led a
disease co((on to ani(als and (an, anthrax) Anthrax is
unusual: unli1e (ost +acterial infections, .hen ani(als or
hu(an +ein-s suIer fro( anthrax, the +acteriu( can routinely
+e seen on slides (ade fro( the +lood (the P+lood s(ear*))
Acce'tin- that these +acteria .ere the causati&e a-ents, he
(and se&eral ri&al .or1ers) sou-ht .ays to Pattenuate* the
+acteriu(, so that it (i-ht 'roduce i((unity .ithout causin-
the disease) Ha&in- .hat he thou-ht .as a satisfactory
anthrax &accine, $asteur did a darin- thin- (he .as a s1illed
'u+licist, 'erha's the Nrst (a,or scientist to court the (edia):
he in&ited ,ournalists to see the inoculation of far( ani(als
.ith his &accine, then to .itness the in,ection of li&e, &irulent
anthrax +acillae) The 'u+lic result .as the death of (any of
the un'rotected ani(als, +ut not those &accinated (he coined
this ter( as a -eneral one in honour of :enner)) It .as re'orted
.orld.ide)
After anthrax, $asteur li&ed in the 'u+lic do(ain) He .as ready
for it, for his Nnal (a,or disco&ery .as a treat(ent for ra+ies,
a relati&ely rare disease, +ut one .hich 1illed so horri+ly that it
'ro&o1ed fear and tre(+lin-) $asteur had to .or1 at ra+ies
+lind, for ra+ies is (.e no. 1no.) caused +y &iruses, tiny
or-anis(s .hich in $asteur*s ti(e .ere 1no.n only throu-h
their eIects) S(all'ox, yello. fe&er, (easles, inRuen7a, and a
host of other &iral diseases had already (ade their 'resence
1no.n) The .ord P&irus* had lon- +een used in a -eneral
sense, as a P'oison* that caused disease, +ut it .as -i&en its
(ore 'recise +iolo-ical (eanin- early in the !<th century, as a
PNltera+le &irus*, that is, a s(all a-ent that 'assed throu-h
Nlters that .ould tra' +acteria and other lar-er +iolo-ical
causes of disease) Tissue culture (ethods and, e&entually, the
electron (icrosco'e (ade identiNcation and classiNcation of
&iruses 'ossi+le)
9or $asteur, dealin- .ith the ra+ies P&irus* also (eant .or1in-
.ith an a-ent that he did not 1no. ho. to culti&ate) Instead,
reco-ni7in- that the sy('to(s of ra+ies 'ointed to so(e 1ind
of infection of the ner&ous syste(, he .or1ed .ith the s'inal
cords of ra++its, and +y 'assin- the infected (aterial serially,
learned ho. to (a1e the P'oison* of ra+ies (ore or less
&irulent) The latent ti(e +et.een the +ite of a ra+id do- or
other ani(al, and the de&elo'(ent of sy('to(s in the &icti(,
(eant that there (i-ht +e ti(e to sti(ulate resistance in the
'erson .ho had +een +itten) There .ere so (any
i('ondera+les that such a -rant a''lication .ould not -et
'ast the Nrst hurdle of a (odern fundin- a-ency, and $asteur*s
.hole enter'rise, -i&en .hat he and his conte('oraries 1ne.
a+out ra+ies and &iruses, .ould ha&e +een atte('ted only +y
a 'erson 'ossessed .ith .hat the Gree1s called hu+ris) %nli1e
Gree1 tra-ic heroes, ho.e&er, $asteur +rou-ht oI his ra+ies
treat(ent, and .ent fro( scientiNc stardo( to scientiNc
sainthood) His Nrst 'u+lic 'atient, :ose'h Meister, sur&i&ed
after +ein- +itten +y a do- .hich .as 'ro+a+ly ra+id, and
other 'atients .ere soon treated) The ra+ies treat(ent
created international acclai(, .ith 'atients co(in- to $aris
fro( all o&er >uro'e (ti(e .as of the essence) to recei&e the
course of in,ections) It also con&inced (any (e(+ers of the
'u+lic that (edical research .as .orth.hile, and they &oted
.ith their 'oc1et+oo1s) The $asteur Institute in $aris .as
funded lar-ely +y 'u+lic su+scri'tion) It o'ened in C=== to
-reat fanfare and .as follo.ed +y (any (ore, throu-hout the
9rench area of inRuence and +eyond) Many of these 'eri'heral
Instituts $asteur .ere de&oted lar-ely to (a1in- &accines and
other +iolo-ical 'roducts: the $aris head?uarters
(anufactured &accines, +ut it also had (and has) (edical
research as its 'ri(ary o+,ecti&e) $asteur s'ent the last se&en
years of his life 'residin- o&er his e'ony(ous institute, .here
he also li&ed, died, and is +uried)
8o+ert 2och headed a cou'le of institutes as .ell, althou-h his
.ere (ostly funded +y the Ger(an state, sy('to(atic of the
diIerences in outloo1 to.ards scientiNc research +et.een
Ger(any and the rest of the .orld) 8elations +et.een 9rance
and Ger(any .ere frosty after the s.ift defeat of 9rance +y
6is(arc1*s $russian forces in the 9rancoG$russian 4ar (C=A<B
=C)) Science .as (and is) su''osed to +e international and
o+,ecti&e, cuttin- across +arriers of race, reli-ion, nationality,
or -ender) The reality has al.ays +een diIerent, and 2och and
$asteur actually 'layed out these national anti'athies in their
'ersonal and 'rofessional relationshi's) $asteur sent +ac1 his
honours fro( Ger(an states after the 9rancoG$russian 4ar,
and refused to drin1 Ger(an +eer, and 2och .as ea-er to
score as (any 'oints as he could .hen confronted .ith 9rench
(icro+iolo-ical and i((unolo-ical Nndin-s) Their (eetin-s at
international conferences .ere for(al +ut frosty)
C@) 3ouis $asteur .as one of the (ost illustrated scientists of
the C@th century) Here, he is seen, in a Vanity 9air 'rint of
C==A, holdin- t.o ra++its, so i('ortant for his ra+ies research)
Only the (ost fa(ous .ere chosen for the series of 'ortraits in
this 'o'ular .ee1ly (a-a7ine, 'u+lished fro( C="= to C@CE
There .ere a('le scientiNc s'oils to satisfy the( +oth in the
rich 'ic1in-s of early +acteriolo-y, +ut they 'ossessed
co('letely diIerent scientiNc styles) $asteur 'referred to
culti&ate his (icroGor-anis(s in Ras1s, constantly chan-in-
the nutrients in the culture sou') He 1e't (uch of his research
'ri&ate to hi(self and his closest collea-ues) 2och, a
-eneration youn-er, .as (uch (ore 'recise in his techni?ues)
He introduced 'hoto(icro-ra'hy, the +etter to 'resent
o+,ecti&e data to the .orld) He culti&ated +acteria on a-arG
a-ar, a solid (ediu( that (ini(i7ed the 'ro+le(s of
conta(ination) He 'ioneered the use of sterili7ation
e?ui'(ent, and his 'u'il $etri introduced the e'ony(ous dish)
2och .as a (edical +acteriolo-istS $asteur .as a
(icro+iolo-ist .hose fascination .as .ith this .orld of the
&ery s(all) $asteur .ent fro( triu('h to triu('h, .hereas
2och en,oyed a cou'le of decades of +rilliant achie&e(ent and
an old a-e in .hich he could not reca'ture the -lories of his
scientiNc youth)
2och*s Nrst si-niNcant .or1 in&ol&ed anthrax, and as a -eneral
'ractitioner ,ust after the 9rancoG$russian 4ar, he .or1ed out
this co('lex +acteriu(*s life cycle, .hich has a s'ore for(
accountin- for its a+ility to lie dor(ant in the soil for (any
years) The research so i('ressed one of his old teachers that
he secured research facilities for 2och) The early results .ere
little short of a(a7in-: the technical inno&ations (entioned
a+o&e, i('ortant .or1 on the role of +acteria in the -enesis of
.ound infections, and, cro.nin- it all, the identiNcation of the
causati&e or-anis(s of the (ost i('ortant disease of the C@th
century, tu+erculosis (C==!), and of the (ost anxietyG
'ro&o1in-, cholera (C==E)) 6oth identiNcations .ere
considera+le technical achie&e(ents) The tu+ercle +acillus is
fastidious, slo.G-ro.in-, and di5cult to stain) It .as not an
o+&ious candidate for a +acteriolo-ical cause, as a chronic
disease .ith an extensi&e literature relatin- it to a &ariety of
constitutional and en&iron(ental factors)
2och re'orted his cholera .or1 fro( India, .hence he had
-one after 9rench and Ger(an ex'editions had tra&elled to
>-y't in C==F, to in&esti-ate a cholera out+rea1 there) The
9rench ex'edition .as disastrous, one of its 'ro(isin- youn-
$asteurians dyin-, and the ex'edition returnin- .ithout any
'ositi&e results) 2och +elie&ed that he and his -rou' had
identiNed the cholera or-anis( in >-y't, +ut +ein- certain of
any s'eciNc or-anis( in the -ut is tric1y, since there are so
(any +acteria al.ays li&in- there) 2och then .ent to India, the
traditional ho(e of cholera, and identiNed a co((aGsha'ed
or-anis( in +oth .ater su''lies and the excretions of cholera
&icti(s) Cholera had +een 'ercei&ed so (uch as a disease of
Nlth, foul .ater, and hi-h .ater ta+les that 2och*s
identiNcation of a s'eciNc or-anis( .as only slo.ly acce'ted)
The leadin- Ger(an hy-ienist, Max &on $etten1ofer (C=C=B
C@<C), had his o.n theory of the necessary interaction of
se&eral causati&e factors, of .hich the P-er(* .as only one) In
a fa(ous -esture, he 'u+licly s.allo.ed a Ras1 of 2och*s
+acillus, and de&elo'ed only (ild diarrhoea, +ut nothin- li1e
the fullG+lo.n disease of cholera) The 'ros and cons of 2och*s
+acillus .ere still +ein- learnedly de+ated in the C=@<s) A
'artially eIecti&e cholera &accine 're'ared in India fro( the
+acillus +y the 8ussianG+orn +acteriolo-ist 4alde(ar HaI1ine
(C="<BC@F<) hel'ed to turn the tide, and its s'read +y the
oralGfaecal route see(ed to ans.er (ost of the
e'ide(iolo-ical issues)
6y the C=@<s, scientiNcally attuned (edical o'inion on -er(
theory had shifted, and (ost de+ates .ere .hether so(e
s'eciNc or-anis( caused so(e s'eciNc disease, or, as (ore
.as learned a+out i((unolo-y and the 'atho'hysiolo-y of
infection, a+out the nature of +acterial toxins) The 'rinci'le of
the -er( theory had +een inte-rated into (edical text+oo1s,
and (ost (edical students .ould ha&e learned it in their
studies) So(e (edical (en still re,ected it, of course, and
others thou-ht that +acteria (i-ht +e 'artially instru(ental in
infectious diseases, +ut hardly su5cient) The -old standard of
causation .as 2och*s 'ostulates, i('lied +ut ne&er as
concisely articulated +y hi( as +y his student 9riedrich 3UWer
(C=D!BC@CD), .ho .rote of di'htheria:
!<) 8o+ert 2och .as often de'icted .ith his (icrosco'e) Here,
in South Africa in C=@"BA, he is sho.n as a studious scientist in
his la+oratory, surrounded +y the other tools of +acteriolo-y,
such as Ras1s and $etri dishes) The la+oratory could +e
any.here .here 4estern science .as 'ractised
If di'htheria is a disease caused +y a (icroGor-anis(, it is
essential that
three 'ostulates are fulNlled) The fulNl(ent of these 'ostulates
is
necessary in order to de(onstrate strictly the 'arasitic nature
of a disease:
C) The or-anis( (ust +e sho.n to +e constantly 'resent in
characteristic for(
and arran-e(ent in the diseased tissue)
!) The or-anis( .hich, fro( its +eha&iour a''ears to +e
res'onsi+le for the
disease, (ust +e isolated and -ro.n in 'ure culture)
F) The 'ure culture (ust +e sho.n to induce the disease
ex'eri(entally)
6ut the -old standard .as hard to achie&e in (any diseases,
and the (ore +acteriolo-ists and i((unolo-ists learned a+out
the 'atho'hysiolo-y of infection, the (ore su+tle the .hole
'rocess .as re&ealed to +e) 6acteria could easily +e culti&ated
fro( the s1in, -ut, 'harynx, or +odily Ruids of 'eo'le .ith no
o+&ious si-ns of disease, and (any of these +acteria .ere
identical .ith those that in other indi&iduals .ere i('licated in
disease) Sce'tics of the .hole 'rocess could 'oint to the fact
that (any -er(s .hich one doctor identiNed as causati&e,
other doctors dou+ted) Ger(s .ere associated .ith (any
conditions that .ere later assi-ned to other causes) 2och
hi(self identiNed the Pcarrier* state, i('ortant in the case of
Ty'hoid Mary, in .hich a 'atho-enic -er( .as Phar+oured* +y
a co('letely healthy indi&idual) Out+rea1s of (any diseases,
.hen in&esti-ated, thre. u' intricate issues of .hy so(e
'eo'le succu(+ed to a disease, and others, si(ilarly ex'osed,
.ent scotGfree) The &iral diseases +eha&ed li1e P-er(* ones,
+ut their a-ents could not +e seen) A nu(+er of diseases that
.e no. reco-ni7e as &iral had +acteria 'ro'osed as their
causati&e a-ents) Much had to +e ta1en on trust, and doctors
did disa-ree)
Ger(s, (edicine, and sur-ery
#es'ite the disa-ree(ents and no little nonsense in the na(e
of science, the trust .as ,ustiNed, for t.o theoretical and t.o
'ractical reasons) Of the theoretical, neither .as entirely ne.,
+ut +oth found their full reali7ation after -er( theory) The Nrst
.as the se'aration +et.een the cause of disease and the
'atient*s +ody) Ger(s .ere external, and althou-h the
indi&idual*s res'onse needed to +e understood throu-h e&ents
inside the +ody, the cause had to +e identiNed else.here) The
disease .as so(ethin- that ha''ened to the 'atient, and
althou-h the +la(e culture of illness hardly disa''eared (and
is still stron-, es'ecially for sexually trans(itted and soGcalled
lifestyle diseases), the -a' +et.een 'atient and cause (ade it
easier for doctors to de&elo' o+,ecti&e criteria for dia-nosis)
The second theoretical i('lication for -er(s .as the
hei-htened notion of disease s'eciNcity) The earlier sanitarian
(o&e(ent a''roached (ost e'ide(ic diseases as of a 'iece,
ca'a+le of chan-in- their character as they (o&ed throu-h a
co((unity) P9ilth disease* .as for >d.in Chad.ic1 a sin-le
dia-nostic cate-ory, .hether it (anifested itself as ty'hus,
ty'hoid, cholera, erysi'elas, scarlet fe&er, or any other of the
e'ide(ic diseases that s'read throu-h the o&ercro.ded,
ur+an 'oor) Ger(s 'ro&ided a +iolo-ical +asis for the
distincti&eness of the diIerent Pfe&ers*, and Nnally rendered
fe&er a si-n of disease, not the disease itself) #isease
classiNcation had +eco(e a (a,or (edical issue after routine
re-istration of death (and its causes) +eca(e co((on
throu-hout industriali7ed nations) International interest in
(a,or e'ide(ics, a+o&e all cholera, increased the need for
these re-isters of causes of death to +e understanda+le across
national +oundaries, and concern .ith nosolo-y .as (erely
'art of the extensi&e eIort to (a1e scientiNc and (edical
&oca+ularies (ore 'recise)
The 'ractical re&er+erations of -er( theory .ere extensi&e,
+ut t.o ou-ht to +e hi-hli-hted) The Nrst .as antise'tic,
follo.ed +y ase'tic, sur-ery) The use of the anaesthetic a-ents
ether and chlorofor( fro( the C=E<s had transfor(ed the
'riorities of the sur-eon, no. that 'ain could +e controlled)
That these t.o su+stances .ere the 'roducts of che(ical
in&esti-ations hi-hli-hts the on-oin- i('ortance of the
la+oratory for clinical 'ractice) >ther anaesthesia .as,
incidentally, the Nrst (a,or A(erican +rea1throu-h in
(edicine, althou-h its introduction .as frau-ht .ith -othic
tales of 'riority dis'utes, failed atte('ts at 'atents, and sordid
ends to 'ro(isin- careers) The Nrst 'u+lic de(onstration of
sur-ery under ether too1 'lace in the Massachusetts General
Hos'ital on C" Octo+er C=E") /e.s s'read to >uro'e as fast as
+oats could carry it, and national (edical histories are full of
local PNrst* o'erations usin- the ne. su+stance) Chlorofor(
follo.ed .ithin a year, and the search .as on for other a-ents
that could render 'atients 'ainGfree)
/o (edical inno&ation is e&er .ithout contention, and
anaesthesia .as no exce'tion) Its use in child+irth .as
resisted +y a fe. .ho +elie&ed that the 6i+lical in,unction to
>&e (eant that child+irth should +e 'ainfulS so(e (ilitary
doctors thou-ht that .ounded soldiers needed the sti(ulus of
'ain the +etter to endure the o'erationS and a fe. deaths
durin- anaesthetic ad(inistration alerted doctors to the
dan-ers of the su+stances) These issues are so(eti(es
e('hasi7ed in the historical literature, +ut the ra'idity .ith
.hich the ne. 'ossi+ility of 'ain control s'read, +oth a(on-
doctors and their 'atients, is the (ost stri1in- as'ect of
anaesthesia*s early history) Gi&in- sur-eons (ore ti(e to
o'erate (ade conser&in- tissue easier, +ut the lon-er
ex'osure of the o'en .ounds to the air also increased the
'ossi+ility of 'ostGo'erati&e infection) Conse?uently,
anaesthesia enlar-ed the ran-e of o'erations sur-eons could
'erfor(, +ut not necessarily the chances of a 'atient*s
sur&i&in- the ordeal)
Anaesthesia 'ro&ided the +asis of one as'ect of (odern
sur-ery) Antise'sis, and es'ecially ase'sis, 'ro&ided the
second) Antise'tic sur-ery .as 'ioneered in the late C="<s +y
:ose'h 3ister (C=!ABC@C!)) 3ister .as of Lua1er stoc1) His
father hel'ed de&elo' the achro(atic (icrosco'e, so he -re.
u' in a scientiNcally orientated household) He .as re'utedly
'resent at the Nrst 'u+lic o'eration in 6ritain usin- ether,
'erfor(ed +y the 'rofessor of sur-ery at %ni&ersity Colle-e
Hos'ital, 8o+ert 3iston (CA@EBC=EA)) 3ister 'u+lished
su+stantial 'a'ers on (icrosco'y .hile still a (edical student,
and after -raduatin- fro( %ni&ersity Colle-e 3ondon, he
headed to >din+ur-h to further his sur-ical studies) There he
(arried his 'rofessor*s dau-hter and s'ent al(ost t.o
decades in >din+ur-h and Glas-o., durin- .hich ti(e he
introduced his syste( of antise'tic sur-ery, in C="A)
3ister .as ins'ired +y $asteur*s researches on the role of
(icroGor-anis(s in fer(entation, 'utrefaction, and other &ital
'rocesses, and cited $asteur in his ori-inal 'u+lication)
Co(+inin- $asteur*s insi-hts .ith the 1no.led-e that car+olic
acid ('henol) .as successfully used to disinfect se.a-e, he
used car+olic dressin-s on sur-ical .ounds to sho. that
co('ound fractures (that is, .here the +ro1en +one 'erforated
the s1in and .as thus ex'osed to the at(os'here) could +e
successfully closed .ith this treat(ent) The usual alternati&e
for a co('ound fracture .as a('utation, so 'oor .ere the
sur-ical atte('ts to close it and thus sa&e the li(+) 3ister*s
rationale .as co('lex, and he later reconstructed his early
.or1 to (a1e it a''ear that his antise'tic syste( .as rooted
in a -er( theory of .ound infection) It .as actually +ased on a
+elief that dust 'articles in the air trans(itted the sources of
conta(ination ($asteur*s s'ontaneous -eneration ex'eri(ents
had excluded dust fro( his Ras1s), and that +y dressin- the
.ounds .ith car+olicGsoa1ed dressin-s, he excluded the
sources of .ound infection)
!C) The 're'aration of a 'atient for a (astecto(y,
de(onstratin- ho. cu(+erso(e and (essy :ose'h 3ister*s
antise'tic sur-ery actually .as in 'ractice) The illustration is
fro( a +oo1 (C==!) +y one of his disci'les, Sir 4illia( 4atson
Cheyne
3ister*s syste( .or1ed and he +e-an teachin- it to his
students) A nu(+er of sur-eons re,ected it, es'ecially those
.ho had already +een achie&in- -ood sur-ical results throu-h
si('le cleanliness) The 9rancoG$russian 4ar oIered a -ood, if
un'lanned, co('arati&e trial, since Ger(an sur-eons had
+e-un to ta1e u' his (easures, and 9rench ones had (ostly
resisted) The Ger(an sur-ical ex'erience of the .ar .as (uch
su'erior to the 9rench, and 3ister*s na(e +e-an to +e
associated .ith a 'articular 1ind of sur-ical techni?ue) 3ister
hi(self .as al.ays a fairly conser&ati&e sur-eon and
continued to conNne hi(self to the traditional do(ains of
sur-ery: the li(+s, ,oints, +ladder, and su'erNcial 'arts of the
+ody)
3ister continued to (odify his antise'tic re-i(e, introducin- a
car+olic s'ray and chan-in- the routine of afterGcare for the
sur-ical .ound) He continued to -et -ood results and ac?uired
an international re'utation) He and $asteur had -reat res'ect
for each other, fre?uently a''earin- on the sa(e 'latfor( at
international (edical (eetin-s that .ere increasin-ly co((on
in the latter decades of the C@th century) As a''reciation of
the role of +acteria in .ound infections -re., his o.n syste(
-radually chan-ed its theoretical ,ustiNcation and +eca(e
(ore closely identiNed .ith the ne. science of +acteriolo-y)
Antise'tic sur-ery had a li(ited life, in any case) It .as soon
re'laced .ith ase'tic sur-ery, the ai( not +ein- to 1ill
conta(inatin- -er(s, +ut to exclude the( in the Nrst 'lace)
Ase'sis excluded +acteria as co('letely as 'ossi+le, +y
sterili7in- e?ui'(ent, instru(ents, dressin-s, the sur-eon*s
hands, and the 'atient*s s1in) It .or1ed on the -eneral
'rinci'le that the tissues of the +ody are -er(Gfree to +e-in
.ith, and if +acteria could +e excluded durin- the o'eration,
the .ound .ould heal naturally, +y .hat sur-eons had lon-
called PNrst intention*: healin- of the .ound .ithout 'us
for(ation) Ase'tic 'rinci'les Nnally o'ened the three (a,or
+ody ca&ities B a+do(en, thorax, and craniu( B to the sca'el,
and sur-ery +eca(e the -la(our s'eciality durin- the last
third of the century) Techni?ues that 2och and others had
introduced into the +acteriolo-ical la+oratory found their
natural a''lication in the o'eratin- theatre, increasin-ly a
se'arate, carefully re-ulated s'ace in hos'itals)
As sur-eons o'erated on the 're&iously for+idden ca&ities,
their initial success rates .ere &ery lo., as other 'ro+le(s,
such as excessi&e +leedin- and infection, e(er-ed) (The
-astroGintestinal tract, for instance, is o'en to the outside
.orld at +oth ends, so the +o.els are not sterile li1e (ost
internal 'arts of the +ody -enerally are)) 2nifeGha''y sur-eons
+eca(e con&inced of the ada-e PA chance to cut is a chance
to cure*, as (any conditions that 'hysicians had +een a+le to
dia-nose +ut not to do (uch a+out see(ed suddenly to +e
a(ena+le to radical treat(ent) 4e should re(e(+er the early
(ortality of heart trans'lants +efore .e conde(n a 're&ious
a-e, +ut the structures of (odernGday audit .ere not in 'lace,
indi&idual sur-eons had relationshi's .ith indi&idual 'atients,
and conditions that .e .ould not ,ud-e sur-ical .ere
su+,ected to the 1nife) Thus, o&aries .ere re(o&ed for
hysteria or (enstrual 'ain, lar-e se-(ents of +o.els for
consti'ation or chronic tiredness, and tonsils .ere re(o&ed
routinely, as a 'ro'hylaxis a-ainst all sorts of childhood
co('laints) The doctrine of Pfocal infection* en,oyed -reat
&o-ue durin- the early !<th century, and .as used to ,ustify
the re(o&al of 'ortions of +o.el, teeth, tonsils, and other
or-ans for all (anner of ail(ents, includin- insanity)
!!) Medical scientist as hero: 3ouis $asteur*s A<th +irthday in
C=@! .as a focus of international acclai() Here, :ose'h 3ister
-reets the Master, +efore an audience of thousands
Modern sur-ery .as thus +uilt on the ne. 'o.er relations
+et.een sur-eons and 'atients) Sur-eons could do (ore and
'atients needed to +elie&e in their sur-eons) The historical
literature tends to e('hasi7e the outlandish o'erations, or
those .ith hi-h (ortality rates and little chance of success)
3oo1in- at the i('ressi&e technical de&elo'(ents .ithin
sur-ery in the halfGcentury +efore 4orld 4ar I, it can +e seen
that sur-ical techni?ue -re. faster than the su''ort net.or1
(+lood transfusion, anti+iotics to counter infection, intensi&e
care roo( (onitorin-), and that the ethical standards that
((ostly) -o&ern (odern (edical and sur-ical 'ractice .ere
not in 'lace) There .as .ide &ariation in dia-nostic fashions as
.ell as technical a+ility a(on- sur-eons, so it +eho&ed
'atients to choose their sur-eons .ell) It still does)
The second (a,or 'ractical le-acy of +acteriolo-y .as the
a+ility to understand the sources and 'atterns of infections
and e'ide(ic diseases, and to react a''ro'riately: la+oratory
(edicine infor(in- co((unity (edicine) 6acteriolo-ists .ere
Pex'erts* in .ays that oldGstyle sanitarians .ere not, and
therefore they had (ore clout .ith -o&ern(ents and
'oliticians) Chad.ic1 ad&ocated Pclean* .ater, +ut .hat
constituted clean chan-ed .ith the reali7ation that s'eciNc
'atho-enic +acteria .ere trans(itted +y .ater, and therefore
.ater needed to +e analysed +efore 'assin- it Nt to +e drun1)
The sa(e -oes for food additi&es, (eat ?uality, air 'urity, and
the host of other thin-s that .e consu(e) Scientists ha&e
ta1en the lead in deNnin- these thin-s, and ha&e 'ro&ided a
+asis for an allGenco('assin- 'u+lic health)
$hysiolo-y: the ne. ri-our
6acteriolo-y .as the (edical science .ith the (ost i('act on
the li&es of ordinary indi&iduals durin- the late C@th century)
>x'eri(ental 'hysiolo-y aroused the (ost tan-i+le outcry,
since 'hysiolo-ists +e-an syste(atically to o'erate on li&in-
ani(als) 6acteriolo-ists used a lot of ani(als too, +ut their
ex'eri(ents did not arouse the e(otion that ex'eri(ental
'hysiolo-y did, es'ecially in 6ritain, .here 'hysiolo-y .as
+etter de&elo'ed than +acteriolo-y)
The Ger(ans created institutes in all the (edical sciences, the
(ost nota+le one in 'hysiolo-y +ein- that of Carl 3ud.i-
(C=C"B@D) at the %ni&ersity of 3ei'7i-, .here students fro( all
o&er the .orld trained) 3ud.i- .as one of a -rou' of four
youn- 'hysiolo-ists .ho durin- the re&olutionary year C=E=
issued a (anifesto, declarin- that all the 'ro+le(s of
'hysiolo-y could +e sol&ed +y the syste(atic a''lication of
'hysics and che(istry) T.o of the others in the -rou' .ent on
to head 'hysiolo-y institutes in 6erlin and Vienna, and the
fourth, Her(ann &on Hel(holt7, e&entually turned to 'hysics)
In addition to i('ortant .or1 in electro(a-netis( and
conser&ation of ener-y, he .as an ex'ert in the 'hysiolo-y of
the s'ecial sense or-ans, and the 'hysics of hearin-) All four
of the -rou' (aintained their +asic 'hysical orientation to
'hysiolo-y) 3ud.i-*s 'rinci'al research interests .ere the
functions of the heart and 1idneys, and his text+oo1 .as
'o'ular +oth in the Ger(anGs'ea1in- lands and a+road,
throu-h translations) Ger(an .as the lan-ua-e of (edical
science in the 'eriod, so e&en the Ger(an edition had a .ide
international readershi') The la+oratories of these and other
Ger(an 'hysiolo-ists +e-an to ac?uire a (odern loo1, as
scientists a&ailed the(sel&es of the latest technolo-ical aids)
Hel(holt7 in&ented the o'hthal(osco'e, and 3ud.i-
de&elo'ed the 1y(o-ra'h, a turnin- dru( connected to a
recordin- de&ice that allo.ed the (easure(ent of continuous
functional &ariations, such as the 'ulse, (uscle contractions,
or chan-es in tension) The -ra'hical recordin- of &ital e&ents
has increasin-ly characteri7ed +io(edical research and clinical
(edicine)
$hysiolo-y Rourished in Ger(any, althou-h the 'reGe(inent
'hysiolo-ist of the century .as 9rench: Claude 6ernard (C=CFB
A=)) He .ent throu-h the $aris (edical school, and reco-ni7ed
that the clinical orientation that do(inated it could only -o so
far in understandin- disease (echanis(s or in searchin- for
ne. re(edies) An unha''y (arria-e at least +rou-ht hi( a
do.ry to allo. a career in (edical research, althou-h his
ani(al ex'eri(entations further alienated hi( fro( his .ife
and dau-hter) 6ernard .as a+o&e all a -ifted sur-ical
crafts(an .ithin the la+oratory) His early .or1 elucidated the
role of the li&er in su-ar (eta+olis(, and the function of the
'ancreas in di-estion) He (ade further i('ortant disco&eries
in the functions of the 'eri'heral ner&es, elucidated the .ay in
.hich car+on (onoxide 'oisons, and 'roduced a 1ind of
dia+etes throu-h a selecti&e destruction of a 'ortion of the
+rain) He .as a+o&e all intri-ued +y the .ay 'hysiolo-ical
(echanis(s .or1ed to-ether to 'roduce a functional .hole
ani(al) His conce't of the Pinternal (ilieu* hel'ed ex'lain ho.
or-anis(s function +y 1ee'in- .ithin a narro. ran-e (any
'hysiolo-ical 'ara(eters, such as te('erature, the ionic salts
in the +loodstrea(, and +lood su-ar) His conce't .as later
rena(ed Pho(eostasis* +y the A(erican 'hysiolo-ist 4alter
Cannon, and it re(ains funda(ental to our understandin- of
health, disease, and e&olution)
6ernard had a 'hiloso'hical turn of (ind, and he su((ari7ed
his o.n research career, as .ell as de&elo'in- a 'hiloso'hy of
(edical research, in his classic Introduction to the Study of
>x'eri(ental Medicine (C="D)) It re(ains a +oo1 .ell .orth
readin-) In it, 6ernard ar-ued that the la+oratory .as the true
sanctuary of (edical science) In the hos'ital, .here sic1
'atients need care, and the nu(+er of &aria+les (eans that
o+ser&ations are only 'iece(eal, no real ex'eri(ental science
can Rourish) Only in the la+oratory can the ex'eri(enter 1ee'
&aria+les constant, so that chan-es can +e una(+i-uous)
$asteur once o'ined that chance fa&oured the 're'ared (ind,
and 6ernard .as ali&e to the role of chance o+ser&ations
leadin- hi( into fruitful in&esti-ati&e 'aths) 9or instance,
ra++it urine is usually al1aline and tur+idS o+ser&in- the urine
of fastin- ra++its turn acidic, he reasoned that they .ere
(eta+oli7in- their o.n tissues) This led hi( to in&esti-ate the
di-estion of &arious foodstuIs) His 'hiloso'hy of disco&ery .as
.hat is no. called the hy'otheticoGdeducti&e (ethod: a
scientist for(s an hy'othesis a+out so(e 'heno(enon) He
then deduces .hat (i-ht ha''en in conse?uence and
ex'eri(ents to see if his hy'othesis is correct, +ein- careful to
'ut aside his ex'ectations .hile doin- the ex'eri(ent)
6ernard li1ened this to a hat +ein- the thin1in- facility) The
-ood scientist 'uts his hat on the rac1 .hile doin- the
ex'eri(ent, +ut he does not for-et to 'ut it on a-ain .hen
lea&in- the la+oratory, to thin1 a+out .hat he has seen, and
.hat it (eans) On the +asis of his ex'eri(ent, he can conNr(,
re,ect, or (odify his hy'othesis, and then, if necessary, further
test it)
9or 6ernard, the three 'illars of ex'eri(ental (edicine .ere
'hysiolo-y, dealin- .ith nor(al functionS 'atholo-y,
in&esti-atin- a+nor(al functionS and thera'eutics, concerned
.ith disco&erin- eIecti&e re(edies) His o.n researches
contri+uted to each of these Nelds, +ut the i('ortant 'oint
.as that each had to +e ri-orously ex'eri(ental, a -oal
achie&a+le only in the la+oratory) 9ield .or1, auto'sies, and
+edside o+ser&ations could 'ro&ide the ra. data and hel'
for(ulate 'ertinent ?uestions) The essential -oal of science,
ho.e&er, .as to elucidate (echanis(s and causes) 6ernard
and $asteur .ere friends, and the for(er reco-ni7ed the
i('ortance of $asteur*s .or1, e&en if he died +efore its full
'otential .as reali7ed) $asteur sa. in 6ernard an elo?uent
a'olo-ist for the ex'eri(ental (ethod .ithin (edicine: the
future)
Althou-h ex'eri(ental 'hysiolo-y too1 the +runt of the
anti&i&isection (o&e(ent, only in 6ritain .as there le-islation
to re-ulate ani(al ex'eri(entation) The C=A" Cruelty to
Ani(als Act initially .orried (edical researchers, +ut in fact it
'ro&ided a reasona+le fra(e.or1 .ithin .hich to 'ursue
ani(alG+ased research, and +y (o&in- research a.ay fro(
'ri&ate la+oratories .ithin scientists* o.n ho(es, hel'ed to
institutionali7e it .ithin 'u+lic and uni&ersity settin-s) The
(ost i('ortant tool for 'hysiolo-ists .as anaesthesia) /ot
only did it 're&ent 'ain in ex'eri(ental ani(als, it also (ade
o'erati&e conditions easier) Antise'tic and ase'tic techni?ues
also ser&ed 'hysiolo-y, another instance of clinical (edicine
and ex'eri(ental science reinforcin- each other)
A nu(+er of (edical s'ecialties +eneNted fro( 'hysiolo-ical
research) /eurolo-y, for instance, relied on .or1 on cere+ral
locali7ation) Cardiolo-ists (ade use of ani(al research on
cardiac contraction and the re-ulation of the heartG+eat)
>ndocrinolo-y (the (edical s'ecialty of the -lands) .as (ade
'ossi+le +y the disco&ery of the hor(ones, +y t.o
'hysiolo-ists, >rnest Starlin- (C=""BC@!A) and 4illia( 6ayliss
(C="<BC@!E)) Medical and sur-ical s'ecialties .ere not si('ly
Pnatural*S they also relied on the acti&ities of -rou's of
indi&iduals 1een on careers and 'resti-e) 6ut (edicine and
sur-ery +y the out+rea1 of 4orld 4ar I could call u'on (uch
1no.led-e that had +een -ained .ithin the la+oratory, and
increasin-ly +y indi&iduals .hose careers .ere .ithin (edical
science, not clinical (edicine)
Cha'ter " Medicine in the (odern .orld
4hat ha''ened nextT
The Nrst N&e cha'ters ha&e +een rou-hly chronolo-ical, fro(
Hi''ocrates to the out+rea1 of 4orld 4ar I) This cha'ter deals
.ith the (edicine of the 'ast century) In it, .e shall loo1
+rieRy at the current rele&ance of each of the N&e P1inds* of
(edicine: +edside, li+rary, hos'ital, co((unity, and
la+oratory) >ach has a 'lace .ithin the +ud-ets of (odern
healthcare and the li&es of 'atients and doctors)
The dri&in- force +ehind (odern (edicine has +een cost) The
(ost ur-ent ?uestion of (edical care of the last -eneration or
t.o has too often +een: Is it aIorda+leT This ?uestion crosses
national +oundaries, and is a''lica+le to taxG'aid sche(es
such as 6ritain*s /ational Health Ser&ice (/HS), 'ri&ate
insurance and feeG+ased care in the %nited States, or +asic
health functions and (edical aid in Africa) Health Pneed*, no
(atter ho. it is (easured, see(s inNnitely elastic) The (ore
that is a&aila+le, the -reater is the de(and) S'irallin- (edical
costs ha&e sha'ed (odern (edicine) At the sa(e ti(e,
(edical eIecti&eness has increased in .ays that e&en
&isionaries of the 'ast .ould not ha&e ac1no.led-ed) Thus,
concern .ith e5ciency has co(e to the fore) Medical care has
+eco(e +i- +usiness, and has ac?uired (any of the strate-ies
of international cor'orations) Indeed, (any of the su''liers of
(edical care are international cor'orations, dri&en +y 'roNt
(oti&es) 6usiness leaders 'oint out that a cor'oration that
'ro&ides shoddy or o&erG'riced 'roducts .ill lose out to its
co('etitors) Critics of Modern Medicine, Inc), 'oint out that
(endin- +odies and 're&entin- disease should not +e li1e
re'airin- auto(o+iles or sellin- toys) There is on-oin- de+ate
+ut fe. 'oints of a-ree(ent)
6edside (edicine: the Hi''ocratic le-acy
Hi''ocrates re(ains a (uchGin&o1ed N-ure today) Healers of
all stri'es, fro( (ainstrea( 4estern doctors to (any 1inds of
alternati&e healers, clai( hi( as their foundin- father) T.o
interconnected as'ects of the Hi''ocratic i(a-e continue to
attract: the holis( of hu(oralis(, and the i('ortance of the
'atient)
Holis( has once a-ain +eco(e a (antra in recent ti(es) Most
co((entators see it as a reaction to the continued
reductionis( in (odern (edical science) 9irst +odies, then
or-ans, then tissues, then cells, no. (olecules) 4e ha&e
institutes of (olecular (edicine, ,ust as C@thGcentury Ger(an
uni&ersities created institutes of 'hysiolo-y, +acteriolo-y, or
'atholo-y) 3oo1ed at dis'assionately ('eo'le are rarely
dis'assionate a+out their health or healthcare), (olecular
(edicine si('ly re'resents the cul(ination of a trend that had
(oti&ated doctors since at least the CAth century to 'ush +ac1
the le&el of analysis of disease) It is 'art and 'arcel of .hat
can le-iti(ately +e descri+ed as the 'ro-ress of (edicine and
(edical science)
This constant ai( at e&er lo.er le&els of analysis has not (et
.ith uni&ersal a''ro&al, e&en a(on- (edical 'ractitioners)
The feelin- that P.e (urder to dissect* has +een around lon-er
than the author of the sentence, the 8o(antic 'oet 4illia(
4ords.orth (CAA<BC=D<)) The 8o(antics .a-ed .ar a-ainst
the inexora+le analysis of the 'arts at the ex'ense of the
.hole, and follo.in- the horrors of 4orld 4ar I, and the ra'id
-ro.th of s'eciali7ation .ithin (edicine, (any doctors felt
that a ne. foundation .as needed for (edicine) The holis(
(o&e(ent that de&elo'ed ado'ted Hi''ocrates as its N-ureG
head, and atte('ted to concei&e disease in -eneral ter(s
such as the 'atient*s constitution) #octors encoura-ed their
char-es to return to nature, to eat si('le foods, .ear 'ractical
clothes (or none: nudis( .as also 'art of the (o&e(ent), and
li&e li&es that .ere attuned to the dictates of nature) The
(o&e(ent attracted a nu(+er of fa(ous doctors, es'ecially
those sus'icious of ex'eri(ental science and of (edical
s'eciali7ation, and resulted in a nu(+er of concrete
ex'eri(ents) In 6ritain, the (ost fa(ous .as the Health
Centre at $ec1ha(, South 3ondon, o'ened in C@!=) Its
founders ar-ued that (edicine had for too lon- e('hasi7ed
disease, and that the +iolo-y of health ou-ht to +e its 'ri(ary
concern) It encoura-ed fa(ily life, and for fa(ilies to co(e
re-ularly to the centre, to 'artici'ate in its 'hysical and social
acti&ities, not a (illion (iles a.ay fro( those on oIer at the
conte('orary Ntness clu+)
The holis( (o&e(ent .ithin (edicine .as ne&er (ore than a
(inority &oice, and its inRuence ?uic1ly e&a'orated after
4orld 4ar II, 'artly +ecause it had +een es'oused +y a
nu(+er of leadin- /a7i doctors, and 'artly +ecause the ne.
ran-e of +iolo-icals and (iracle dru-s, a+o&e all, insulin,
'enicillin, and cortisone, 'ro(ised that ex'eri(ental research
(i-ht indeed cure all ills) The P-olden a-e* of (odern (edicine
do(inated the (iddle third of the !<th century, and doctors
en,oyed an un'recedented era of 'resti-e and trust) Infectious
diseases .ere +elie&ed to +e (ore or less con?uered,
'sychiatric disorders .ere to +e controlled +y the ne.
thora7ine and the other +rands of anti'sychotic dru-s, and
cures for cancers .ere on the hori7on)
It is no coincidence that -eneral 'ractice, or fa(ily (edicine,
.as at a lo. e++ durin- these decades) In 6ritain, it .as
assu(ed that -eneral 'ractitioners .ere (ade u' of those not
-ood enou-h to +eco(e consultants in the ne. /HS, or
'ri&ate consultants in Harley Street) Medical or sur-ical
s'eciali7ation .as the 'resu(ed ai( of any (edical student,
for s'ecialists .ere the elites .ho ruled the 'rofession)
9ro( the C@"<s, thin-s +e-an to chan-e) The Vietna( 4ar
s'ar1ed a 'rotest -eneration .hich .as sus'icious of all for(s
of 'o.er) At the sa(e ti(e, the attac1s on the 'rofessions, as
cry'tic trade unions, concerned .ith inco(e and freedo( to
do as their (e(+ers 'leased, +e-an to -ather 'ace) The
Austrian social critic I&an Illich (C@!"B!<<!) launched his
attac1 on educationalists, doctors, and other 'rofessionals,
.ith doctors creatin- as (uch disease (Piatro-enesis*) as they
'ur'orted to cure) Illich ur-ed 'eo'le (not P'atients*, or e&en
Pclients* as they ha&e recently +eco(e) to ta1e control of their
+odies and health) Illich .as only one of a nu(+er of
counterculture ad&ocates (in 6ritain, Mrs Thatcher fro( a
ri-htG.in- 'ers'ecti&e +e-an her o.n attac1 on the
'rofessions) .ho forced doctors and other 'rofessionals onto
the +ac1 foot) #octorB'atient relationshi's +e-an to chan-e,
.ith 'o.er shiftin- in the direction of 'atients)
T.o de&elo'(ents a(on- (any can +e (entioned as
e&idence) 9irst, the nature of -eneral 'ractice +e-an to +e
refor(ulated) It had al.ays +een (ore concerned .ith the
P.hole 'atient* than had the s'ecialties, and Michael 6alint
(C=@"BC@A<), a(on- others, hi-hli-hted ho. (any 'sychiatric
disorders (such as de'ression, anxiety, inso(nia) .ere +ein-
dealt .ith +y -eneral 'ractitioners) 6alint .as instru(ental in
the refor(ulation of fa(ily (edicine as a &i+rant and
i('ortant as'ect of (edical care) It +eca(e an acade(ic
disci'line, and -ained 'resti-e .ithin the (edical hierarchy)
The irony that -eneral 'ractice raised itself u' +y +eco(in- a
P-eneral* s'ecialis(, .ith its o.n trainin- 'rotocols,
exa(inations, and (in 6ritain) a 8oyal Colle-e, has not +een
lost on co((entators) The fact re(ains that it .as ada'tin- to
the de(ands of the ti(es)
The second de&elo'(ent .as the e('hasis on 'ri(ary care in
de&elo'in- countries) International (edical aid fro( the ti(e
of the 3ea-ue of /ations, for(ed after 4orld 4ar I, to the
4orld Health Or-ani7ation (4HO) and related international
a-encies created after 4orld 4ar II, had e('hasi7ed &ertical,
technolo-ically dri&en 'ro-ra((es) Malaria, s(all'ox,
schistoso(iasis, hoo1.or(, onchocerciasis (ri&er +lindness),
and other s'eciNc diseases had +een sin-led out for attention)
The s(all'ox ca('ai-n succeeded co('letely, and other
'ro-ra((es had so(e si-niNcant successes, +ut that for
(alaria failed, s'ectacularly)
At an international conference of 4HO held at Al(a Ata,
2a7a1hstan, in C@A=, the e('hasis o5cially shifted to
hori7ontal 'ro-ra((es, that is, 'ri(ary care, education, and
+asic infrastructure, instead of s'eciNc &ertical 'ro-ra((es
ai(ed at indi&idual diseases) Vertical 'ro-ra((es ha&e not
+een co('letely a+andoned, +ut the shift reco-ni7ed the
i('ortance of the -eneral o&er the s'eciNc, in ter(s of
sustaina+ility and e5ciency) It 'rioriti7ed indi&idual health
'ractitioners educatin-, dia-nosin-, and treatin- indi&idual
'atients and their fa(ilies)
Hi''ocrates is a su5ciently secure icon that anyone can
identify .ith hi( .ith i('unity) /e&ertheless, (any of the
&alues of +edside (edicine in the Hi''ocratic cor'us ha&e reG
entered the (ainstrea()
3i+rary (edicine: .hat 'rice infor(ationT
The co(in- of +oo1s in the CDth century transfor(ed (edical
1no.led-e) T.o centuries later, (edical and scientiNc ,ournals
chan-ed the ti(escale) 6oo1s (i-ht +e rushed into 'rint to
co((unicate an excitin- ne. disco&ery or theory, +ut they
(i-ht ,ust as .ell +e the careful 'roduct of a lifeti(e*s
reRections) :ournals, .ith their re-ular 'roduction schedule,
.ere desi-ned to +e u'GtoGdate) The early ,ournals .ere
(ostly the 'roductions of the scientiNc societies of the CAth
century) #octors and (edical to'ics .ere .ell re'resented,
and fro( the next century s'ecial (edical ,ournals +e-an to
a''ear) 6y the C=<<s, the +e-innin-s of an ex'onential -ro.th
had occurred, althou-h since it .as fro( a lo. +ase, it
re'resented fe.er ne. titles each year than .e ha&e +eco(e
accusto(ed to) 4ee1ly ,ournals, such as those no. called The
/e. >n-land :ournal of Medicine (C=C!) and 3ancet (C=!F),
+oth still inRuential &oices .ithin (edicine, allo.ed e&en
s'eedier 'u+lication and also encoura-ed leaders, ne.s ite(s,
and corres'ondence, all i('ortant in the for(ation of the
(odern (edical 'rofession)
The deaths of the +oo1 and the 'rinted ,ournal ha&e +een
re-ularly forecast durin- the 'ast cou'le of decades, .hen the
co('uter, internet, and electronic 'u+lishin- ha&e
transfor(ed the .ay 1no.led-e is disse(inated) /either has
ha''ened, and +oth +oo1s and ,ournals a''ear at an
increasin- rate) The econo(ics of 'u+lishin- (ean that
ulti(ate chan-e .ill undou+tedly +e -radual) /e&ertheless,
Pli+rary (edicine* no. li&es li1e the rest of us in the co('uter
a-e, and it has had at least t.o si-niNcant i('acts on (edical
care)
9irst, the relationshi' +et.een 'atients and their doctors has
+een chan-ed +y the fact that indi&iduals no. ha&e easy
access to (edical infor(ation) $atients curious a+out the
i('lications of a dia-nosis or treat(ent could al.ays as1 their
doctors, or ta1e the(sel&es to a li+rary) The internet has (ade
this easier, and has encoura-ed 'atients to +e (ore in&ol&ed
in their o.n (edical care) This 'heno(enon has (erely
accentuated a .elco(e 'rocess that has +een under.ay for a
-eneration or (ore) It re?uires (edical 'ersonnel to +e (ore
co((unicati&e and co((unication s1ills are no. tau-ht (.ith
&aryin- de-rees of success) in (edical schools) It also creates
'ro+le(s, since the unre-ulated nature of the internet (eans
that 'atients (ay recei&e 'artial, +iased, or si('ly .ron-
infor(ation) Modern concerns .ith 'atients* ri-hts and the
ease of access to infor(ation ha&e shifted the +alance of
'o.er +et.een doctors and (any of their 'atients) 9or the
(ost 'art, this is a healthy situation, and re?uires doctors to
s'end (ore ti(e .ith their 'atients)
Second, 'atient records ha&e +een funda(entally transfor(ed
+y the ne. infor(ation re&olution) There are (a,or issues of
access and conNdentiality, and any national sche(e, such as
the one +ein- atte('ted in the %2, is extre(ely ex'ensi&e
and so far unsuccessful) The ho'e that each 'atient .ould
ha&e his or her o.n (edical record on a chi' is -ood in theory:
it .ould (a1e life for health 'ersonnel in accident and
e(er-ency roo(s (uch easier, and 'ro&ide doctors .ith the
infor(ation they need .here&er the 'atient ha''ens to +e) In
the short ter(, at least, the sche(e .ould .or1 (ostly for
those 'atients .ho are su5ciently concerned .ith their health
to coo'erate) Access to these data +y insurance co('anies
and e('loyers is still an unresol&ed issue, and the uto'ian
ideal is li1ely to re(ain frau-ht)
As li+rarians +eco(e infor(ation o5cers, and doctors stare at
their co('uter screens instead of en-a-in- .ith their 'atients,
the trou+led 'atient (ay +e for-i&en for thin1in- that the
+ra&e ne. .orld is not necessarily for the +est)
Hos'ital (edicine: .hat 'rice careT
Hos'itals ha&e +een central to (edicine since the
transfor(ation in (edical thin1in- and education that
acco('anied the 9rench 8e&olution) They ha&e of course
e&ol&ed durin- the 'ast t.o centuries, in their architectural
for(s, or-ani7ation, fundin-, and (edical and sur-ical
functions)
Hos'ital architecture has +eco(e a s'ecial su+,ect in its o.n
ri-ht, as social, econo(ic, and (edical de(ands ha&e
chan-ed) Many hos'itals in the earlyG(odern 'eriod
deli+erately reRected their reli-ious ori-ins and as'irations)
They .ere often +uilt, li1e cathedrals, in a crucifor( sha'e,
.ith altars and, ine&ita+ly, a cha'el) In (any 'arts of >uro'e,
8o(an Catholicis( 'ro&ided +oth the architectural ins'iration
and the nursin- orders .hich 'ro&ided daily care) In $rotestant
>uro'e, (ore secular for(s de&elo'ed, and (any 'ur'oseG
+uilt hos'itals in >nli-hten(ent 6ritain +ore (ore than a
'assin- rese(+lance to the country house) The s(aller
s'ecialist hos'itals, dealin- .ith such issues as child+irth,
&enereal disease, s(all'ox, diseases of children or of the lun-s
or eyes, .ere often started in an ordinary house, ta1en o&er
for the 'ur'ose) Successful hos'itals .ould (o&e to lar-er
're(ises, so(eti(es si('ly a lar-er house, +ut increasin-ly
into a 'ur'oseG+uilt structure) The s'eciNc de(ands .ere not
&ery diIerent fro( those of a house: a 1itchen, 'ri&ies or other
facilities for .aste dis'osal, roo(s for +eds, and, -enerally,
?uarters for a doctor) Sur-ery or child+irth -enerally too1 'lace
in the 'atient*s ordinary +ed, and so(eti(es this .ould +e
shared .ith other 'atients)
#urin- the C@th century, s'eciNc (edical and sur-ical
re?uire(ents +e-an to deter(ine so(e as'ects of hos'ital
desi-n) $a&ilion .ards, rectan-ular in sha'e .ith tall .indo.s
on +oth sides, had +een a feature of (ilitary hos'itals, and the
/i-htin-ale (o&e(ent .ithin nursin- (ade this style of .ard
standard for lar-e -eneral hos'itals) The 'a&ilion .ard had t.o
desira+le ?ualities: the dou+le ro.s of .indo.s (ade
&entilation easy, in an a-e .hen (ias(atic theories of disease
'redo(inated (9lorence /i-htin-ale .as an ardent (ias(atist
and sanitarian)S and the sha'e (ade nurse sur&eillance easy)
4hen the :ohns Ho'1ins Hos'ital .as +ein- constructed fro(
the late C==<s, it incor'orated the 'a&ilion .ard)
6y then, ho.e&er, there .ere other re?uire(ents) Ger(an
uni&ersity hos'itals had e('hasi7ed the need for a s(all
la+oratory attached to each .ard, .here (edical staI could
'erfor( che(ical and (icrosco'ical analyses of urine, +lood,
and other su+stances) In (ost hos'itals, the acce'tance of
antise'tic, and then ase'tic, sur-ery led to s'ecial o'eratin-
theatres, .ith a''ro'riate sterili7in- e?ui'(ent) Ger( theory
(eant that ad&anced hos'itals needed s'ecial la+oratories for
culti&atin- s'utu(, +lood, urine, and faeces, and cell
'atholo-y (eant that tissue s'eci(ens .ere exa(ined for
cancer and other disorders) 6io'sies ta1en durin- sur-ery
.ere often read +y the resident 'atholo-ist, and the nature of
the o'eration .ould de'end on his readin-) 9ro( the end of
the C@th century, Gray e?ui'(ent +e-an to a''ear in
hos'itals, re?uirin- s'ace and technicians to ta1e Gray i(a-es
and so(eone to inter'ret the() Out'atient de'art(ents also
+eca(e i('ortant features of hos'itals fro( the C=A<s)
>ach of these, and (any (ore, (edical and sur-ical
inno&ations re?uired ada'tation of existin- architectural
arran-e(ents or s'ecial consideration as ne. hos'itals
continued to +e +uilt) One should not 'ush the analo-y too
closely, +ut there are resonances +et.een C@thGcentury
lunatic asylu(s and 'risons, and +et.een !<thGcentury
hos'itals and hotels) 6oth 'risons and Victorian asylu(s .ere
fre?uently +uilt outside of cities, .ith surroundin- .alls and an
e('hasis on security and isolation) Hotel desi-n and
(ana-e(ent structures ha&e inRuenced (odern hos'itals:
+oth ha&e to 'ro&ide food and clean linen for residents stayin-
for &aria+le len-ths of ti(e, and need laundry facilities as .ell
as .holesale su''liers of food for 're'aration) 3on- central
corridors .ith roo(s co(in- oI each side .ere another
co((on feature, to say nothin- of -ettin- chec1Gin 'rocedures
correct, includin-, in the %nited States and 'ri&ate hos'itals
e&ery.here, sortin- out 'ay(ent details)
The or-ani7ational side of hos'ital (ana-e(ent has
increasin-ly ado'ted +usiness (odels) >arly in the !<th
century, A(erican hos'ital ad(inistrators deli+erately loo1ed
to (odes of industrial 'roduction to ins'ire their dri&e for
-reater e5ciency) Throu-hG'ut, costGcuttin-, and oIerin- the
client decent &alue for (oney (ade sense to ad(inistrators
concerned .ith runnin- their institutions at a 'roNt) In >uro'e,
(ost hos'itals .ere still charita+le institutions, +ut the sa(e
&alues could easily 'er(eate, since +ud-ets .ere in&aria+ly
ti-ht, and the (ain feature of all hos'itals durin- the 'ast
century and a half is that of s'irallin- costs) In the clash
+et.een (edical and econo(ic &alues, the latter often
do(inate, no (atter .hat the ulti(ate source of fundin-)
Costs are thus a central feature of the (odern hos'ital, and a
&ariety of .ays ha&e +een ado'ted to (eet the() 4hen
hos'itals .ere lar-ely run +y reli-ious or-ani7ations or 'ri&ate
charity (the &oluntary hos'ital .as the 'rinci'al (ode of
fundin- hos'itals in 6ritain until they .ere nationali7ed in the
context of the /HS), +ud-ets .ere usually the res'onsi+ility of
those .ho funded the(, +ut rarely used the() Modern
sur-ery, Grays, and other dia-nostic features (eant that,
fro( the late C@th century, the rich also had occasion to enter
hos'ital) The 6ritish &oluntary hos'ital solution .as to +uild
'ayin- .ards for the .ellGtoGdo, the 'roNts of .hich su+sidi7ed
the charita+le .ards) In the %nited States, 'ayin- .ards
de&elo'ed earlier, and 'ri&ate hos'itals, such as the Mayo
Clinic, de&elo'ed in Minnesota +y the Mayo clan fro( the
C==<s, oIered ad&anced (edical and sur-ical care, to those
.ho could 'ay or .ho had 'ri&ate insurance) The role of
insurance co('anies in the early !<th century is still
insu5ciently a''reciated in (edical history, and althou-h
(any of the early co('anies e('hasi7ed their 'hilanthro'ic
ai(s, the 'roNt (oti&e .as e&er 'resent)
4hate&er the syste( of (edical care, in 4estern societies,
thirdG'arty arran-e(ents are the nor( in hos'ital 'ay(ents,
so lar-e are the +ills) The costs of +uildin-, heatin-, li-htin-,
(aintainin-, e?ui''in-, and sta5n- these co('lex institutions
ha&e +een an increasin- concern for the 'ast century) The
-uaranteein- +ody has +een &ariously the state, the
(unici'ality, a reli-ious or-ani7ation, an insurance co('any, a
charita+le -rou', indi&idual -o&ernors, a rich +enefactor, or a
co(+ination of these) 9orG'roNt hos'itals, such as those in the
%nited States, attract (uch criticis(, for the draconian
ad(ission 'olicies, in .hich the insurance 'olicy is (ore
i('ortant than the dia-nosis or (edical need) 6ut the dri&e
for e5ciency, and the ado'tion of +usiness (odels,
characteri7es al(ost all (odern hos'itals) In the C@th century,
fear of the inco(e loss that chronic illness +rou-ht .as the
'ri(ary .orry of .or1in- 'eo'le) A de+ilitatin- illness
re?uirin- len-thy hos'itali7ation and not ade?uately co&ered
+y insurance is no. the fear of 'eo'le .ho are co(forta+le as
lon- as they ha&e health)
/e. technolo-ies as .ell as Nnancial constraints ha&e reduced
the a&era-e len-th of hos'ital stays) Gettin- 'eo'le out of +ed
?uic1ly, e&en after (a,or sur-ery, is no. a sur-ical -oal) There
is sound (edical e&idence that this is a -ood idea, as it
reduces thro(+osis, +ed sores, and (uscle .astin-, +ut the
strate-y also has econo(ic rationale, since it reduces hos'ital
stays) #ia-nostic 'rocedures that in an earlier a-e .ould ha&e
(eant a stay in hos'ital are no. conducted in the out'atients
de'art(ent)
#es'ite the 'ro+le(s, hos'itals are here to stay) They ha&e
three 'articular features that (a1e the( indis'ensa+le:
so'histicated dia-nosis, acute care, and sur-ery) #ia-nosis
.as the one thin- that hos'itals in early C@thGcentury 9rance
.ere +est at, and, for diIerent reasons, -oin- into hos'ital for
a +attery of tests is still a co((on (odern ex'erience)
Technolo-y and science co(e to-ether in such 'rocedures as
cardiac catheteri7ation, to e&aluate heart functionS li&er or
1idney +io'sy, to 'rocure a 'iece of tissue for (icrosco'ic
exa(inationS the use of ultrasound to (onitor foetal
de&elo'(ent durin- -estationS or the CAT scan, the
co('uteri7ed axial to(o-ra'hy, or M8I, the (a-netic
resonance i(a-in- (achine, t.o nonGin&asi&e (eans of
&isuali7in- structures .ithin the +ody) The CAT scan and M8I
use diIerent technolo-ical and scientiNc 'rinci'les, the for(er
+uilds u' a 'icture of the interior of the +ody throu-h serial
i(a-es that are co(+ined .ith the use of the co('uterS the
latter uses a stron- (a-netic Neld that is (ani'ulated +y a
radiofre?uency .a&e)
!F) Grays ?uic1ly found their uses in +oth dia-nosis and
thera'y) In this i(a-e of Gray thera'y, fro( C@<!, the
a''aratus has a shield around it, an unusual 'recaution at that
ti(e) The doctor hi(self is un'rotected, .ithout e&en a .hite
coat as a +ad-e of o5ce
The t.o techni?ues ha&e (any si(ilarities) >ach inno&ation
has +een re.arded .ith a /o+el $ri7e for its de&elo'ersS each
'roduces a threeGdi(ensional i(a-e .hich also sho.s soft
tissues (uch (ore distinctly than traditional GraysS each has
dra(atically furthered dia-noses and thera'y, allo.in-, for
exa('le, needle +io'sies that .ould 're&iously ha&e re?uired
in&asi&e sur-eryS and each (achine has +een extre(ely
ex'ensi&e to +uild, (aintain, and use) Since the M8I has fe.er
'atient ris1s, and 'roduces a clearer i(a-e of su+tle soft
tissue structures, it has lar-ely re'laced the CAT scan, +ut
each in turn fro( the C@=<s sy(+oli7ed the 'o.er and costs of
(odern technolo-yGdri&en (edicine) Alon- .ith lasers, N+reG
o'tics, and a host of other (odern inno&ations, they ha&e
chan-ed the face of hos'ital (edicine, increasin- .hat
doctors can 1no. and do, +ut also addin- su+stantially to the
costs of (edical care)
The second feature of hos'ital (edicine that .ill re(ain is
acute care) Trau(a, for instance, is not si('ly an i('ortant
+ranch of (ilitary (edicine, +ut also one that (ust deal .ith
tra5c accidents, 1nife and -un .ounds, +urns, and the (yriad
ris1s that (odern society thro.s u') Terroris( has added to
the &isi+ility of the s'ecialty) At the +e-innin- of 4orld 4ar II,
>uro'ean countries (ade routine 're'aration for ho. to deal
.ith a lar-e nu(+er of ci&ilian casualtiesS si(ilar 'lans are
no. in 'lace for lar-eGscale disasters, +ut indi&idual &icti(s of
accidents and acute illnesses .ere al.ays 'art of the
res'onsi+ility of hos'itals)
S'ecial 'laces .ithin hos'itals .ere -radually de&elo'ed to
care for those acutely ill or in,ured) After 3isterian antise'sis
and ase'sis (ade (a,or sur-ery feasi+le, reco&ery roo(s
.ere added to o'eratin- theatres, and nurses .ho s'eciali7ed
in carin- for sur-ical 'atients .ere added to hos'ital
'ersonnel) In the !<th century, +lood 'ressure and other &ital
si-ns could +e (onitored, and .ith the de&elo'(ent of
intra&enous Ruids, and durin- the inter.ar years +lood
transfusion, sur-ical shoc1 and other 'ostGo'erati&e
co('lications .ere dealt .ith (ore eIecti&ely) In the C@D<s,
continuous (onitorin- of the heartG+eat .as added to the
technolo-ical e?ui'(ent 'resent there, and as heart attac1s
+eca(e co((only reco-ni7ed as a (edical e(er-ency,
coronary care units e&ol&ed to care for the acute sta-e) Such
units are far fro( 'eaceful 'laces for 'atients (or staI), and
durin- the C@A<s, it .as seriously de+ated .hether heart
attac1 &icti(s .ere +etter oI at ho(e, si('ly restin-) 6etter
control of irre-ularities of the heartG+eat, a (a,or cause of
death in the acute 'hase of (yocardial infarctions, as .ell as
(odern resuscitation techni?ues, has -uaranteed the
'er(anence of coronary care units, des'ite their costs and
inhu(an en&iron(ent) $atients .ho ha&e ex'erienced stro1es,
dia+etic co(a, or other de+ilitatin- e'isodes are also treated
in such intensi&e care units)
Modern sur-ery is also inextrica+ly sited .ithin the hos'ital)
Mini(ally in&asi&e techni?ues (ean that radiolo-ists,
cardiolo-ists, -astroenterolo-ists, and other nonGsur-ical
s'ecialists often 'erfor( (anual 'rocedures, +ut the sur-eon
still occu'ies a 'ri&ile-ed 'lace in the (odern (edical
hierarchy) If /o+el $ri7es are any (easure of (edical .orth,
sur-eons ha&e +een underGre'resented, es'ecially in (ore
recent ti(es) >arly on, Theodor 2ocher (C=ECBC@CA) .on one
for his .or1 on the sur-ery of the thyroid, and Alexis Carrel
(C=AFBC@EE), .ho 'ioneered &ascular suturin-, -ot one,
althou-h it .as (ostly for his research .ith tissue cultures)
Charles Hu--ins (C@<CB@A), a CanadianG+orn urolo-ist, shared
a /o+el $ri7e (C@"") for sho.in- that tu(ours of the 'rostate
can +e de'endent on hor(ones) His .or1 had +een done a
?uarter of a century 're&iously) The $ortu-uese neurolo-ist
Antonio >-as Moni7 (C=AEBC@DD) shared the C@E@ $ri7e for his
.or1 on 'reGfrontal lo+oto(y, no. so(ethin- of an
e(+arrass(ent) In ter(s of hel'in- hu(anity, :ohn Charnley
(C@CCB=!), the 6ritish ortho'aedic sur-eon, deser&ed +ut did
not recei&e one for his 'ioneerin- research on the technolo-y
and sur-ical a''roaches to hi' re'lace(ent) Cardiac
catheteri7ation also collected one (C@D"), +ut none of the
reci'ients .as a dedicated career sur-eon, reinforcin- the
'oint that sur-ical 'rocedures are no. 'erfor(ed +y a &ariety
of nonGsur-ical s'ecialists)
The only (odern sur-ical $ri7e .ent to three 'ioneers of
trans'lant sur-ery, one of the (ost dra(atic as'ects of
'resentGday sur-ery, +ut one that has in&ol&ed (uch +asic
i((unolo-ical research, to control the tendency of the +ody to
re,ect tissues and or-ans 'ercei&ed as Pforei-n*) 2idneys,
hearts, and li&ers are no. routinely trans'lanted fro( donors
(-enerally dead, althou-h a 'erson .ith t.o healthy 1idneys
can s'are one)) Trans'lant sur-ery can accurately +e
descri+ed as a (iracle of science and sur-ery, +ut it is also
iconic for the dile((as of (odern healthcare) 8ecei&in- a
forei-n or-an -enerally 'uts the reci'ient in a lifeGlon- (edical
relationshi' .ith his or her carers, since 'o.erful
i((unosu''ressant dru-s (ust +e ta1en on a lon-Gter( +asis
and they ha&e unfortunate side eIects, includin- increasin-
the donor*s susce'ti+ility to infections) More o(inously, the
shorta-e of or-ans for trans'lantation has led to an
international +lac1 (ar1et, 'ri(arily throu-h des'erately 'oor
indi&iduals fro( de&elo'in- countries sellin- their or-ans for
use in the richer countries)
Hos'itals sa&e li&es) They are also still at the centre of (edical
education and clinical research, +ut they suIer fro( serious
structural 'ro+le(s) 9undin- is al(ost al.ays an issue, and
althou-h they fre?uently retain the rhetoric of charity and
ser&ice, they (ust +e run li1e the co('lex institutions that
they are) Anti+iotic resistance a(on- (any 'atho-enic (icroG
or-anis(s is co((on today, +ut the anti+ioticGrich
en&iron(ent of hos'itals (a1es the( ideal 'laces for this
e&olutionary 'heno(enon to occur) 8esistance to anti+iotics
ha''ens .hen a rando( -enetic chan-e in a (icroGor-anis(
'roduces so(e characteristic that ena+les it to resist the
anti+iotic) In .ays that #ar.in .ould ha&e understood, the
ne. hereditary characteristic -i&es the (icroGor-anis( an
ad&anta-e, and it thri&es) The sta'hylococcus, a co((on
+acteriu( .hich causes +oils +ut also (ore serious infections,
.as initially susce'ti+le to 'enicillin, the .onder dru- of the
C@E<s) It soon +eca(e resistant, and as other anti+iotics .ere
de&elo'ed, it ac?uired resistance to (any of those too) 4e
no. 1no. it +y its acrony(, M8SA (Meticillin 8esistant
Sta'hylococcus Aureus)) It is a serious 'ro+le( in hos'itals
and, since there is al.ays (o&e(ent +et.een the hos'ital and
the .ider .orld, in the co((unity as .ell) The causati&e
a-ents of (alaria, tu+erculosis, and HIV ha&e all de&elo'ed
resistance to (any of their con&entional treat(ents,
co('licatin- these (a,or .orld diseases)
The hos'ital has not Pcaused* this 'heno(enonS hu(an
a-ency has) 6ut dru-Gresistant 'atho-ens are no. so co((on
that (odern hos'itals so(eti(es lose their desired e'ithet, as
Phouses of healin-*, and re&ert to that old one, P-ate.ays to
death*)
Medicine in the co((unity: our health in our hands
The C@thGcentury ad&ocates of 'u+lic health created an
infrastructure throu-hout the 4estern .orld, de&elo'ed at
diIerent s'eeds and sensiti&e to diIerin- national ideolo-ies)
As .e ha&e seen, the (o&e(ent achie&ed (ore eIecti&eness
after the causation of infectious diseases .as +etter
understood, +ut the infrastructure itself .as ,ust as i('ortant)
The +and of indi&iduals (MoHsS .ater and food analystsS
sanitary, factory, and +uildin- ins'ectorsS &isitin- nurses), and
the e&erG-ro.in- set of re-ulations they .ere e('o.ered to
enforce, .ere necessary to achie&e the refor(s that
-o&ern(ents increasin-ly identiNed as their res'onsi+ilities)
$u+lic health .as su''osed to li&e u' to its na(e, and extend
its +eneNts to all (e(+ers of society)
On the .hole, it did, +ut &ulnera+le -rou's B the 'oor,
children, the a-ed, and .o(en of childG+earin- a-e B .ere
often tar-eted and stood to +eneNt (ost) 4hile this (ay 'ut
an unnecessarily +ene&olent -loss on a -ood deal of late C@thG
and early !<thGcentury 'u+lic health acti&ity, one historian has
ar-ued that .ar is -ood for +a+ies and other youn- children)
The .ar in ?uestion .as the 6oer 4ar, .ith its dis?uiet that so
(any recruits fro( the slu(s of 6ritain had to +e re,ected
fro( ar(y ser&ice on health -rounds, and the unsatisfactory
outco(e of the conRict led to fears that the 6ritish could not
sustain their >('ire .ithout i('ro&in- the health and Ntness
of their 'eo'le) Si(ilar fears fuelled the 'u+lic health and
'ronatalist (o&e(ents in other 4estern countries, e&en if the
s'ectre of racial de-eneration (and a 'ercei&ed +irthGrate
lar-er in the 'roletariat than in the solid (iddle classes) also
sti(ulated the eu-enics (o&e(ent) $u+lic health had
traditionally +een en&iron(entalist in its orientation: -et rid of
dirt, o&ercro.din-, and the slo&enly (orals that they
en-endered, and the 'o'ulace .ould +e healthier) This older
(antra .as diluted +y the e('hasis on +ad heredity, and the
ne.er scenario that only +y sto''in- undesira+les fro(
+reedin- could 4estern nations continue their .orld
do(inance)
!E) Grayin- the (asses as 'art of the ca('ai-n a-ainst
tu+erculosis .as a re-ular feature of 'u+lic health initiati&es
fro( the C@F<s) This Glas-o. tra( fro( C@DA, in&o1in- a fairG
-round ride, tries to (a1e ha&in- an Gray trendy as .ell as
(odest (no undressin-, +ut fast and conNdential)
!D) Conta(inated (il1 .as a co((on source of tu+erculosis
s'read +efore 'asteuri7ation +eca(e (andatory) Other
'otential ha7ards are noticed here in this C@!@ lantern slide,
encoura-in- the 'u+lic to -et in&ol&ed +y re'ortin- to the MoH
and co('lainin- to the (il1(an
As is .ell 1no.n, the eu-enics (o&e(ent reached its a'o-ee
in /a7i Ger(any) Their notions of racial destiny, and the
inherent de-eneracy of :e.s, Gy'sies, and other (ar-inal
-rou's, .ere +ar+aric in the extre(e) The .hole /a7i ideolo-y
.as dri&en +y a ruthless do-(atis(, +ut it ironically included
notions of the i('ortance of fresh air and exercise in
(aintainin- health, and a +elief that to+acco and alcohol .ere
ini(ical to it) There are (any routes to current ideas of a
healthy lifestyle, and not all of the( .orth e(ulatin-)
The /a7is too1 ideas of racial hierarchies to the extre(e, +ut
racis( .as .ides'read in the 'eriod) 4hile de&elo'ed nations
can ta1e the sur&eillance and re-ulations of 'u+lic health for
-ranted, or +e incensed .hen they fail, (any of the tra''in-s
of the older sanitarian (o&e(ent are still +ein- 'layed out in
the de&elo'in- .orld) Much has chan-ed, of course, +ut the
'ro+le(s encountered in 'oorer 'arts of the .orld .ould not
ha&e sur'rised >d.in Chad.ic1 or other ad&ocates in C@thG
century >uro'e) Issues of child and (aternal (ortality,
e'ide(ic diseases, 'o&erty, and 'oor sanitation are still .ith
us) 4hile the 4est co(+ats o+esity and sedentary lifestyles,
(uch of the .orld scra++les for enou-h to eat) OldGfashioned
'u+lic health is still +ein- fou-ht for in (any countries)
Chad.ic1 thou-ht that clean .ater and decent arran-e(ents
for dis'osin- of hu(an .aste .ould sol&e (ost of the
'ro+le(s of Nlth disease) His (edical ideas .ere na\&e, +ut his
ad(ira+le ai(s ha&e yet to +e achie&ed .orld.ide)
I('erial 'o.ers did so(e .or1 on 'u+lic health in their
'ossessions o&erseas) The 6ritish in India, for exa('le, too1
cholera and (alaria &ery seriously indeed) /either .as a
uni?uely Ptro'ical* disease, since +oth .ere 1no.n in >uro'e)
6ut the disco&ery +y 8onald 8oss (C=DABC@F!), .or1in- in the
Indian Medical Ser&ice, of the role of the Ano'heles (os?uito
in the trans(ission of (alaria catalysed the de&elo'(ent of
tro'ical (edicine as a (edical s'ecialty) Malaria occurred in
te('erate cli(ates as .ell as tro'ical ones, +ut in (any .ays
it Ntted the (odel that 8oss*s (entor, $atric1 Manson (C=EEB
C@!!), ela+orated as the distinct features of the diseases that
the s'ecialty had to deal .ith) It .as trans(itted +y an insect,
so had a (ore co('licated life cycle and (ode of s'read than
the +acterial diseases of the Old 4orld) 9urther(ore, its
causati&e or-anis( .as a 'las(odiu(, not a +acteriu(, Nllin-
Manson*s +elief that .or(s, 'arasites, and other 1inds of
or-anis(s .ere the (ain ene(ies in the tro'ics) Manson used
8oss*s .or1, announced in C=@A and C=@=, to con&ince the
6ritish -o&ern(ent to found a School of Tro'ical Medicine in
3ondon, in C=@=) Another one in 3i&er'ool .as esta+lished a
fe. (onths earlier, and a s'ate of institutes and schools of
tro'ical (edicine .ere in existence throu-hout the .orld
+efore the out+rea1 of 4orld 4ar I)
The ai( of these schools .as to train (edical o5cers to deal
.ith the ran-e of diseases that .ould confront the( in Asia,
Africa, and other tro'ical areas of the .orld) Tro'ical (edicine
.as to (a1e these areas safe for >uro'eans, to carry out their
eIort to Christiani7e, ci&ili7e, and co((erciali7e the 'eo'les
under their do(inion) So(e historians ha&e dis(issed the
eIort as co('letely selfGser&in-, carried out +y -o&ern(ents
and indi&iduals .ho had no feelin-s for the Pnati&es*, and .ho
in any case (erely .anted to create safe encla&es for
>uro'ean soldiers, (erchants, 'lanters, and ci&il ser&ants) If
one exa(ines dis'assionately the (oti&es and careers of
(any of the 1ey indi&iduals in&ol&ed in the eIort, a (uch
(ore su+tle scenario is reached) At the &ery least, enli-htened
selfGinterest dictated that diseases needed to +e controlled
a(on- all -rou's) In Asia, in 'articular, >uro'eans often
a''reciated the richness of the cultures they .ere controllin-
and ex'loitin-) In su+GSaharan Africa, a diIerent set of
conditions o+tained, accentuated +y the harshness of the
disease 'roNle in 4estern Africa, in 'articular, and the a+sence
of a .ritten culture) 6ut it is historically distortin- to .rite oI
(edical and 'u+lic health eIorts in I('erial do(inions as
si('ly ex'loitati&e)
Most Ptro'ical (edicine* +efore 4orld 4ar I .as initiated +y
colonial 'o.ers, to ser&e their o.n 'ossessions) The exce'tion
.as (issionary (edicine, nurses and doctors .ho .ere
concerned .ith s'readin- the (essa-e of 4estern health
&alues as .ell as reli-ion) Missionaries .ere res'onsi+le for
settin- u' and (annin- health centres and hos'itals in (any
'arts of the .orld, and .hile they tended to follo. esta+lished
I('erial -eo-ra'hy, there .as so(e (issionary acti&ity
outside of ho(eGcountry s'heres of do(ination) An e(+ryonic
international health (o&e(ent started .ith the for(ation of
the 3ea-ue of /ations after 4orld 4ar I, althou-h (uch of its
healthGrelated acti&ity .as concerned .ith >astern >uro'e and
other 'arts of the .arGtorn continent) Althou-h the %nited
States -o&ern(ent .as reluctant to su''ort the 3ea-ue, the
8oc1efeller 9oundation and its international a-encies .ere
'articularly acti&e durin- the inter.ar years) 8oc1efeller
o5cials .ere 1een to esta+lish 4esternGstyle institutions
((edical schools, research institutions, and teachin- hos'itals)
in areas .here there .as the 'ossi+ility of continued
indi-enous su''ort and, therefore, continuity) >uro'e, Mexico,
and 3atin A(erica .ere the 9oundation*s 'ri(ary areas of
international acti&ity, althou-h its interest in (alaria,
schistoso(iasis, and hoo1.or( too1 8oc1efeller o5cials to
other 'arts of the .orld too)
9ollo.in- the end of 4orld 4ar II, internationalis( .as Nnally
esta+lished throu-h the %nited /ations and sister
or-ani7ations, es'ecially 4HO) 4HO has al.ays had ad(ira+le
-oals, +ut has stru--led .ith the co('lexity of the 'ro+le(s it
sou-ht to confront) The do(inant (ode of attac1in- disease in
the inter.ar years .as &ertical: sin-le diseases .ith s'eciNc
(odes of trans(ission .ere sin-led out as the (ost e5cient
.ay of i('ro&in- health in 'oor countries) S(all'ox and
(alaria .ere the su+,ects of t.o (a,or 4HO ca('ai-ns in the
C@D<s and +eyond) The (alaria 'ro-ra((e, a''ro&ed at the
C@DD General Asse(+ly of 4HO, .as lar-ely ins'ired +y the
a&aila+ility of ##T, the insecticide that .as de&elo'ed durin-
4orld 4ar II and used .ith -reat eIecti&eness a-ainst (alaria
and ty'hus (a louseG+orne disease) in the .ar 7ones)
>&er since 8oss and G) 6) Grassi (C=DEBC@!D) in Italy had
disco&ered the role of the Ano'heles (os?uito in the
trans(ission of (alaria, and elucidated the life cycle of the
'las(odiu( res'onsi+le for the disease, its control see(ed
strai-htfor.ard) >li(inate the (os?uito, throu-h interru'tin-
its +reedin- sites +y drainin-, oilin-, and e('loyin- P(os?uito
+ri-ades* to 'atrol the oIendin- sites, and the disease ou-ht
to disa''ear) 6esides, ?uinine could cure the disease and had
lon- +een sho.n to 'rotect if ta1en re-ularly) 8oss s'ent the
last three decades of his life ar-uin- that (alaria could +e
're&ented, if su5cient resources .ere de&oted to it) The
1no.led-e .as there, only a lac1 of .ill (and (oney)
're&ented this desira+le -oal fro( +ein- achie&ed)
9or 8oss, a''ly the &ertical 'ro-ra((e, eradicate or
(ar-inali7e the disease, and a healthier .or1force .ould
achie&e econo(ic de&elo'(ent i('ossi+le as lon- as the
disease ra-ed) 9or other (alariolo-ists, only a hori7ontal
'ro-ra((e .ould .or1) The decline of (alaria in >uro'e
su--ested that if a reasona+le standard of li&in-, econo(ic
de&elo'(ent, and education .ere in 'lace, (alaria .ould fade
out as a conse?uence) These (alariolo-ists ar-ued that in
hi-hly (alarious areas ((uch of Africa, for instance), the
constant ex'osure fro( +irth 'roduced a 'o'ulation that .as
(ore or less i((une) 8e(o&e this Pnatural* ex'osure, and
hi-hly e'ide(ic for(s of the disease .ould thri&e)
##T see(ed to consi-n these ar-u(ents to history) It .as
chea', had a residual eIect after s'rayin-, and 'ro(ised a
technolo-ical Nx to a co('licated and .ides'read (edical
'ro+le() $arts of .orstGaIected Africa .ere excluded fro( the
(andate, +ut the 'lan .as that the rest of the .orld .ould +e
(alariaGfree in a cou'le of decades) The ca('ai-n .as
a''ro&ed in a Nt of 'ostG.ar o'ti(is(, +ut it .as +ede&illed +y
'ro+le(s fro( the start) S'rayin- e?ui'(ent .ould +e
deli&ered and there .ould +e no ##T, or &ice &ersa) Trainin-
NeldG.or1ers .as slo. and la+orious) The results in diIerent
'arts of the .orld .ere &aria+le) A -ro.in- en&iron(ental
(o&e(ent, s'earheaded +y the 'u+lication of 8achel Carson*s
Silent S'rin- (C@"!), o+,ected to the (ore -eneral eIects that
##T had, and the C@"<s 'rotest (o&e(ent disli1ed the lar-eG
scale or-ani7ation of the ca('ai-n and, es'ecially, the 'roNts
that ((ostly) A(erican Nr(s .ere (a1in- fro( it) 9inally, ##TG
resistant (os?uitoes +e-an to e(er-e)
!") $re&entati&e (edicine 'layed an i('ortant 'art in the
ca('ai-ns of 4orld 4ar II) Here, soldiers are encoura-ed to
ta1e their re-ular doses of ate+rin, the (ost co((only used
anti(alarial dru- of the 'eriod) Malaria .as still an i('ortant
disease in the Middle >ast, southern >uro'e, and the Asian
theatres of .ar
The (alaria eradication 'ro-ra((e .as ?uietly con&erted to a
focus on control in C@"@, .ith (uch less fanfare than its
launch) Its (ista1es ha&e since +een easy tar-ets for critical
analysis, +ut it had achie&ed so(e successes, for instance in
the Mediterranean countries of >uro'e, .here (alaria had
resur-ed durin- the disru'tions of 4orld 4ar II) Italy, S'ain,
$ortu-al, and, nota+ly, Greece, far less de&elo'ed
econo(ically than the others, .ere declared (alariaGfree
durin- the years of the ca('ai-n) Sri 3an1a ca(e close, and
the incidence of the disease in India decreased dra(atically)
6y contrast, the 4HO s(all'ox eradication initiati&e is still
heralded as a triu('h of (odern (edicine) A triu('h it .as,
since the last naturally occurrin- case of s(all'ox .as
re'orted in C@AA, and the disease .as ratiNed as extinct in
hu(an 'o'ulations in May C@=<) It .as in the end the 'roduct
of international coo'eration and -ood .ill, not of (edical
science) It relied on the old (fol1) disco&ery of &accination, and
the ti(eGhonoured (ethods of case trac1in-, isolation, and
(ass &accination of 'o'ulations at ris1) There .as no
treat(ent sa&e su''orti&e (easures) S(all'ox could +e
eradicated since it had no natural ani(al reser&oir, it .as
'assed 'erson to 'erson, and could +e controlled throu-h
isolation and &accination) It .as an ad(inistrati&e ca('ai-n,
althou-h that in no .ay di(inishes its i('ortance)
Vertical, sin-leGdisease ca('ai-ns are still attracti&e, and
se&eral ha&e +een successful) $olio is al(ost eradicated, and
-uinea .or( and onchocerciasis ha&e +een counted as
eIecti&e) #es'ite the -la(our (e&en if the .or1 (ay +e
routine) of sin-leGdisease strate-ies, the i('ortance of
'ri(ary care has also +een reco-ni7ed) The 4HO Al(a Ata
conference o5cially (andated hori7ontal 'ro-ra((es as a
necessary -oal of international healthcare) In essence, this
(erely ratiNed the truis( that a (edical and social
infrastructure is a 'recondition for sustaina+le deli&ery of
(odern 'u+lic health and healthcare) Its reali7ation has +een
slo., as the econo(ic diIerence +et.een the rich and the
'oor has increased in the 'ast fe. decades, and HIV, dru-G
resistant (alaria and tu+erculosis, and .ars ha&e inter&ened)
There ha&e +een so(e -ains, +ut (ore set+ac1s, durin- the
closin- decades of the last century, and the outloo1 is
challen-in- to say the least)
So(e of these 'ro+le(s in 'oorer countries are si('ly
reRections of issues in the 4est, .here alcoholis(, dru-Guse,
resistant tu+erculosis and HIV, and o+esity ha&e +eco(e (a,or
health (atters) One social ha+it, ex'orted fro( the 4est,
threatens to +e a ti(e +o(+ in the co(in- decades: ci-arette
s(o1in-) The disco&ery of the direct lin1 +et.een ci-arettes
and lun- cancer is one of the -reat achie&e(ents of (odern
e'ide(iolo-ical sur&eillance) 3un- cancer .as a rare condition
in earlier centuries, and its -radual increase durin- the
inter.ar years .as noted +y (any clinicians and a fe.
statisticians) 6y the late C@E<s, it .as reco-ni7ed as a serious
disease of (odernity, and the Medical 8esearch Council (M8C)
in 6ritain co((issioned t.o indi&iduals, a (athe(atically
inclined clinician and a statistician, to in&esti-ate its s'read,
and try to deter(ine its cause) The clinician .as 8ichard #oll
(C@C!B!<<D)S the statistician, Austin 6radford Hill (C=@AB
C@@C)) Their o.n .or1in- hunches su--ested that lun- cancer
.as 'ro+a+ly a disease of (odern 'ollution, car exhaust
fu(es, or tar fro( road surfaces)
They +e-an .or1 +y de&isin- a ?uestionnaire for 'atients in
3ondon hos'itals dia-nosed .ith cancer of the lun-, li&er, or
+o.el) The initial stri1in- result .as that hea&y s(o1in- .as
'resent in those .ith lun- cancer, +ut not in those .ith the
other for(s of cancer) At the sa(e ti(e, an A(erican study
(C@D<), +ased on auto'sies of 'atients dyin- of lun- cancer,
also found a hi-h 're&alence of s(o1in- in the &icti(s) 6ased
on these su--esti&e Nndin-s, #oll and Hill de&ised a
'ros'ecti&e study, follo.in- the health fortunes of (ore than
FE,<<< 6ritish doctors .ho a-reed to ta1e 'art in it) 6ecause
doctors (ust -i&e their address chan-es each year to the
Medical 8e-ister, an annual list of ?ualiNed (edical
'ractitioners, #oll and Hill .ere a+le to follo. their cohort o&er
the years, relatin- the indi&idual*s chances of ac?uirin- lun-
cancer to his or her s(o1in- ha+its) Since (any doctors
(includin- #oll hi(self) -a&e u' the ha+it once the ris1s .ere
ex'osed, the study also oIered the o''ortunity to co('ute
statistically the years -ained +y -i&in- u' the sotG.eed) The
Nnal 'art of the study .as 'u+lished in !<<E, D< years later,
and .as .ritten +y #oll hi(self, .ith a collea-ue) It is 'ro+a+ly
the (ost re(ar1a+le Psocial* ex'eri(ent e&er de&ised .ithin
(edicine) It .as si('le in desi-n +ut do--ed in execution, and
the results unfolded in a series of 'a'ers o&er half a century)
6y the ti(e the Pex'eri(ent* ended, (uch other e&idence had
+een 'roduced on the health conse?uences of ci-arette
s(o1in-, +ut #oll and Hill can +e said to ha&e initiated the
(odern (o&e(ent of Plifestyle (edicine*)
The 'hrase is +arely t.o decades old, +ut it see(s here to
stay) Co((unity (edicine in&ol&es sur&eillance, and 'uttin-
the o+ser&ations to-ether has co(e u' .ith a 'icture in .hich
the ordinary indi&idual has a (a,or in'ut on his or her health)
Our choices inRuence our .ellG+ein-) In the -olden a-e of
(edicine, fro( the C@E<s to the early C@A<s, there .as e&ery
conNdence that, .hate&er .e did, doctors could ta1e care of
us) 6et.een sur-ery, anti+iotics, tran?uilli7ers, hor(ones,
contrace'ti&es ((edicine inRuencin- lifestyle rather than
lifestyle (edicine), and the ran-e of other dru-s and
thera'ies, the 'ro(ise of an a-e of health see(ed ,ust around
the corner) Althou-h (edicine is no. e&en (ore 'o.erful, .e
are less conNdent a+out it) Alcoholis(, s(o1in-, dru- a+use,
&enereal disease, o+esity, fatty, hi-hGsalt ta1ea.ays, factory
far(in-, and other di(ensions of (odern 4estern li&in- ha&e
ta1en their toll) Many of these indiscretions are old, althou-h
so(e are ne.) The doctorB'atient relationshi' has chan-ed,
and the co(in- of 'atient 'o.er has +rou-ht .ith it
reco-nition of 'atient res'onsi+ility)
!A) 3ifestyle (edicine fro( C@@!, in a 'oster ai(ed +oth at
counterin- o+esity and the deleterious eIects of excessi&e
alcohol consu('tion
The Hi''ocratic e('hasis on (oderation re(inds us that
doctors ha&e lon- +een (oral 'olice(en) 4hat counts as
(oral, and .hat i((oral, has a tendency to chan-e in
diIerent cultural settin-s) In the earlyG(odern 'eriod, a
sy'hilitic lesion could +e a 1ind of +ad-e of honour a(on-
so(e social -rou'sS in the inter.ar 'eriod, -ood eatin- (eant
lots of red (eat, crea(, and e--sS ci-arette s(o1in- .as an
e(+le( of fe(ale e(anci'ation) Societies chan-e, and so
does (edical ad&ice) There are -ood reasons to thin1 that
ad&ice no. is +etter than it so(eti(es .as in the 'ast, and
e&en those .ho distrust doctors and (edical science still en,oy
the +eneNts of the sur&eillance and e'ide(iolo-ical studies
that try to tease out the har(ful fro( the +eneNcial) 4hen in
dou+t, re(e(+er the Hi''ocratic in,unction that health is (ost
li1ely to +e found in the (iddle .ay)
3a+oratory (edicine: still the 'ro(ise of the ne.
The (odern +io(edical la+oratory has ne&er +een so re(ote,
and yet so close, to the a.are, a&era-e citi7en) Scientists
fre?uently call ne.s conferences .hen they thin1 they ha&e
so(ethin- i('ortant to re'ortS all ne.s a-encies carry
(edical science ite(s on a re-ular +asis) The internet (a1es
so'histicated 1no.led-e a&aila+le to anyone .ho .ants to
ta1e the trou+le) #es'ite our (odern infor(ationGdri&en
culture, sur&eys re&eal that 'rofound i-norance a+out health
and science is .ides'read and .orriso(e) It has 'ro+a+ly
al.ays +een this .ay, and the 'hysicist and no&elist C) $)
Sno.*s criti?ue of the Pt.o cultures* had resonance +efore he
articulated it in C@D@, and still does) Sno. ar-ued that (ost
nonGscientists are less infor(ed a+out the (ain ideas of
science than scientists are a+out those of -eneral culture)
I-norance is e&ery.here, +ut i-norance of science and
(edicine 'articularly so)
If the details elude the(, (ost 'eo'le 1no. that the (edicine
that is 'ractised in the !Cst century has +een hea&ily
inRuenced +y (edical science) A+o&e all, (odern dru-
disco&eries, and, (ore recently, the contro&ersies surroundin-
the Hu(an Geno(e $ro,ect and ste( cell research, ha&e +een
ne.s.orthy) The latter t.o are +eyond the sco'e of this
historical account, +ut conte('orary (edicine has +een
transfor(ed +y the thera'eutic 'o.er of dru-s) Serendi'ity
has 'layed a 'art in the disco&ery of a nu(+er of the(, +ut
the la+oratory has +een the 'ri(ary site .here their
thera'eutic 'otential has +een Nrst o+ser&ed) Claude
6ernard*s co((ent of the C@th century is still true: the
la+oratory is the sanctuary of ex'eri(ental (edicine)
9ro( the late C@th century, a nu(+er of eIecti&e
'har(aceutical a-ents +e-an to Nlter throu-h, .hich ha&e had
stayin- 'o.er) These include as'irin, 'henacetin, choral
hydrate, and the +ar+iturates) They all share the characteristic
of +ein- relati&ely si('le che(ically, a(ena+le to the analytic
(ethods then a&aila+le) As'irin is often (entioned as a dru-
that .ould not 'ass (odern safety standards, -i&en that it is a
-astric irritant and can +e used for suicide) Ironically, in lo.
doses, it has +een sho.n to +e eIecti&e in 're&entin- +lood
clottin-, and so is used to 're&ent heart attac1s and stro1es,
uses re(ote fro( .hat it .as ori-inally introduced for) The
eIect is s(all in the indi&idual +ut si-niNcant in a lar-e
'o'ulation) Its (echanis( of action has +een .or1ed out only
.ithin the last -eneration, decades after its use .as routine,
as an antiGinRa((atory dru- and to relie&e 'ain and fe&er)
6et.een this -rou' of dru-s and the C@!<s ca(e se&eral
che(icals and a nu(+er of +iolo-icals, es'ecially &accines and
antisera) /one of the( could co('are .ith insulin, disco&ered
in C@!C +y a youn- 'hysician turned 'hysiolo-ist and a
(edical student at the %ni&ersity of Toronto) 9rederic1 6antin-
(C=@CBC@EC), the 'hysiolo-ist, o+tained the use of the
la+oratory durin- the su((er holidays, .hile the 'rofessor
.as on holiday) Charles 6est (C=@@BC@A=), the (edical student
.ho su+se?uently +eca(e a distin-uished 'hysiolo-ist
hi(self, hel'ed in the careful isolation of the acti&e hor(one
secreted +y the 'ancreas) A(a7in-ly, the su+stance reduced
the +lood su-ar le&els of dia+etics, and 6antin- and the a+sent
'rofessor, :) :) 8) Macleod (C=A"BC@FD), shared the /o+el $ri7e
al(ost i((ediately) 6antin- and Macleod a''ro'riately shared
their $ri7e (oneys .ith 6est and the che(ist, :) 6) Colli'
(C=@!BC@"D), .ho had hel'ed .ith the 'uriNcation of the
su+stance) This .as a classic oneGoI ex'eri(ent, .ides'read
in its thera'eutic i('lications and fully deser&in- of the $ri7e
that .as ?uic1ly a.arded) 4ithin a year, co((ercial insulin
.as a&aila+le, and for dia+etics the ne. dru- could +e lifeG
sa&in-) Insulin is 'aradi-(atic of +oth ex'eri(ental (edicine
and (odern (edical care) Insulin controlled dia+etes, it did not
Pcure* it, and its &icti(s .ere still left .ith a 'er(anent
aWiction that needed daily (ana-e(ent) #es'ite +etter .ays
of ad(inisterin- the dru- and diIerent 're'arations, insulinG
de'endent dia+etes is a lifeGlon- 'ro+le( .ith (any
co('lications .hich also need to +e (ana-ed as they occur)
Ti(e and a-ain, (odern ho'es of cure ha&e really +een the
sentence of chronic care, +etter than the alternati&e, +ut less
than early ex'ectation) The +rutal truth is that the hu(an
+ody is a .onderfully e&ol&ed (achine, and (edicine rarely
does as .ell as nature)
#es'ite the on-oin- issues relatin- to dia+etes control, insulin
.as a (a,or inno&ation, and seen as such +y 'atients) It
encoura-ed the -eneral 'u+lic to ex'ect (ore fro( la+oratory
in&esti-ations, an attitude reinforced +y success in treatin-
'ernicious anae(ia) The results .ere not so dra(atic as those
of 'atients in dia+etic co(a .a1in- u' .ith the ad(inistration
of insulin and -lucose, +ut 'ernicious anae(ia, as the na(e
su--ests, .as a de+ilitatin-, distressin-, and ulti(ately fatal
aWiction) 3i1e insulin, ho.e&er, the rationale for the thera'y
.as +ased .ithin the la+oratory, in feedin- ex'eri(ents .ith
do-s) The solution, eatin- lar-e ?uantities of ra. li&er, .as not
exactly .hat 'atients (i-ht ha&e chosen, +ut (ost thou-ht it
.as +etter than the conse?uences of their disease)
These and other la+oratory inno&ations B +lood ty'in- (a1in-
transfusions safe, &arious &accines, increased understandin-
of the nature of &iruses B 1e't scientiNc (edicine in the 'u+lic
do(ain) The ta1eGoI occurred in the years surroundin- 4orld
4ar II, 'roducin- ulti(ately the +i- science that .e still ha&e)
The sul'ha dru-s, for instance, .ere eIecti&e a-ainst se&eral
co((on +acteria: one conse?uence .as a ra'id decline in
.o(en*s (ortality fro( 'uer'eral fe&er (the infection all too
fre?uently follo.in- child+irth)) These .ere de&elo'ed ,ust
+efore the .ar (the /a7is refused to let their disco&erer,
Gerhard #o(a-1 (C=@DBC@"E), -o to Stoc1hol( to collect his
/o+el $ri7e), and the .ar itself 'ut 'aid to the international
'atent syste(, so sul'ha dru-s could +e (anufactured outside
of Ger(any) #urin- the early years of the .ar, these dru-s
.ere (uch usedS +y its end, they had +een o&erta1en +y
'enicillin)
$enicillin is 'ro+a+ly the .onderGdru- of all ti(e) Its story adds
to the a''eal, disco&ered in C@!= serendi'itously +y Alexander
9le(in- (C==CBC@DD), throu-h a (ould on an unco&ered $etri
dish, +ut (ore or less ne-lected for a decade (there .ere a
fe. isolated atte('ts to e('loy it thera'eutically)) 4ith the
out+rea1 of 4orld 4ar II, the Oxford 'rofessor of 'atholo-y
Ho.ard 9lorey (C=@=BC@"=) and his tea( .ere char-ed .ith
loo1in- for ne. thera'eutic a-ents a-ainst +acterial infections)
$enicillin .as a(on- the su+stances they chose, and usin-
(a1eshift e?ui'(ent in .arti(e conditions, they isolated
enou-h of the 'recious (ould to sho. that it .as indeed
dra(atically eIecti&e) Their Nrst 'atient, an Oxford 'olice(an
.ith a sta'hylococcus infection follo.in- a roseGthorn 'uncture
.ound, i('ro&ed, +ut there .as not enou-h 'enicillin to
achie&e a cure, des'ite reco&erin- it fro( his urine and
read(inisterin- it) He died)
#urin- the .ar, 9lorey and a collea-ue .ent to the %nited
States, .here 'har(aceutical (anufacturin- .as less
disru'ted) 9lorey had oldGfashioned +eliefs a+out the o'enness
of scientiNc research, so failed to 'ay attention to the 'atent
arran-e(ents) A(erican 'har(aceutical (anufacturers .ere
(uch shre.der, and +y the last t.o years of the .ar .ere
(anufacturin- lar-e ?uantities, and (a1in- lar-e su(s of
(oney) At Nrst, reser&ed essentially for (ilitary use (it .as
eIecti&e a-ainst (any +acterial infections, includin- sy'hilis
and -onorrhoea, as .ell as so(e conta(inants of .ar .ounds
and +acterial 'neu(onias), 'enicillin .as in -eneral ci&ilian
use shortly after the .ar ended, in C@ED)
The 'enicillin story is a thorou-hly (odern one) Hi-hly
'roNta+le, it needed industrial (odes of 'roduction and
distri+ution) It .as &ery eIecti&e a-ainst (any co((on
scour-es, +eca(e chea', sa&ed (any li&es, and -reatly
increased the 'resti-e of the la+oratory and of (odern
(edicine (ore -enerally) It .as a (iracle dru-, e&en if
(iracles don*t last fore&er) $enicillin .as -i&en
indiscri(inately, in doses that .ere not correct, for conditions
that .ere not a''ro'riate, and in courses that .ere not
co('leted) It +e-an to lose its eIecti&eness, as 'enicillinG
resistant +acteria e(er-ed) In the early days, this see(ed
only a (inor 'ro+le(, since other for(s of 'enicillin .ere
(anufactured, and other anti+iotics ca(e on the (ar1et,
includin- stre'to(ycin, eIecti&e a-ainst tu+erculosis, the a-eG
old chronic +acterial 1iller) Stre'to(ycin .as de&elo'ed in the
%nited States, and .hen a s(all su''ly reached 6ritain ,ust
after the .ar, Austin 6radford Hill (soon to turn his attention to
lun- cancer) turned li(ited a&aila+ility to -ood eIect,
desi-nin- a 'ro'er Pdou+leG+lind* controlled trial, in .hich
neither the 'artici'atin- doctors nor the 'atients 1ne. .hich
thera'y .as +ein- tested) In this .ay, the +ias of ex'ectation
could +e re(o&ed) The results de(onstrated the thera'eutic
eIecti&eness of stre'to(ycin) Hill*s ex'eri(ental desi-n has
+eco(e the -old standard for e&aluatin- ne. thera'ies)
Stre'to(ycin, 'enicillin, and the other anti+iotics ushered in a
-olden a-e, .hen ne. eIecti&e dru-s and &accines see(ed to
+e the ine&ita+le result of 'har(aceutical and +io(edical
research) Cortisone a''eared in the late C@E<s, and .as
acco('anied +y Nl(s sho.in- se&erely cri''led &icti(s of
rheu(atoid arthritis -ettin- out of their +eds and .al1in-) /e.
dru-s 'ro(ised to control those cancers that .ere not .ithin
the reach of increasin-ly so'histicated sur-ery or radiothera'y)
Anti'sychotics dra(atically reduced the sy('to(s of
schi7o'hrenia, se&ere de'ression, and the other aWictions of
'atients .ho had s'ent their li&es in 'sychiatric asylu(s)
Victi(s of ence'halitis lethar-ica, an e'ide(ic of the C@!<s,
.ho had +een in a co(a for decades, .o1e u' in the late
C@D<s after +ein- ad(inistered do'a(ine, a dru- recently
introduced for $ar1inson*s disease (the res'onse .as shortG
li&ed if dra(atic)) 6y the early C@"<s, co((unity 'sychiatry
.as the +u77 .ord, as 'sychiatric 'atients .ere to +e treated
as out'atients, .ith the +elief that they .ould +e a+le to li&e
(oreGorGless nor(al li&es if they si('ly too1 their (edicines)
9or 'eo'le .ith (ild de'ression or anxiety, 3i+riu( and Valiu(
ca(e on the (ar1et) Medicine see(ed truly to ha&e, or shortly
to ha&e, a 'ill for e&ery ill)
6efore the C@E<s, (ost (edical research in the %nited States
.as su''orted +y 'ri&ate foundations and charities, of .hich
the cancer, tu+erculosis, and 'olio charities too1 centreGsta-e)
9ran1lin #) 8oose&elt*s o.n 'olio 1e't this disease in the ne.s)
In e'ide(ic for(, it +eca(e the (a,or cri''ler of youn-
'eo'le, .ith an a&era-e of E<,<<< cases 'er year +et.een
C@DC and C@DD) As a &iral disease, it .as not susce'ti+le to
anti+iotics, and the conse?uence in those .ho sur&i&ed the
disease .as often lifeGlon- disa+ility) Althou-h (ore 're&alent
in the %nited States than any other country, 'olio had a
.orld.ide distri+ution (hi-her in the 4est than in 'oorer
countries), and the e'ide(ic in Co'enha-en in C@D! .as
'oi-nant, not only for its se&erity +ut for the acts of hu(anity
it ins'ired) In order to 1ee' the se&erely aWicted ali&e,
tracheoto(ies and inter(ittent 'ositi&e &entilation .ere used,
.ith so(e C,D<< &olunteers s'endin- C"D,<<< hours
&entilatin- 'olio &icti(s +y hand) $olio did not confor( to the
richK'oor di&ide: it is a disease of decent hy-iene, children in
countries .ithout clean .ater ac?uirin- the &irus in infancy
.hen it does not 'roduce the lastin- neuro(uscular da(a-e
caused .hen older children and youn- adults are Nrst
ex'osed)
The &iral aetiolo-y of 'olio, and the fact that 'eo'le .ho
reco&ered ne&er -ot the disease a-ain, (ade a &accine the
(ost sensi+le strate-y) The March of #i(es 9oundation .as
.ealthy, althou-h -rant a''lications .ere e&aluated +y
standards that .ould +e unacce'ta+le today) Se&eral &accines
.ere 're'ared in the C@E<s, +ut only .ith the Sal1 and Sa+in
&accines of the C@D<s .ere lar-eGscale i((uni7ation
ca('ai-ns 'ut into 'ractice) :onas Sal1 (C@CEB@D) de&elo'ed a
1illedG&irus &accine) #es'ite so(e serious -litches, the &accine
.as eIecti&e, +ut it .as soon su'erseded +y the attenuated
li&eG&irus &accine of Alfred Sa+in (C@<"B@F)) Sa+in*s .as
ad(inistered orally, on a lu(' of su-ar, .hich (ade it easy to
distri+ute and 'o'ular .ith children) It had the ad&anta-e that
the attenuated &irus .as then excreted in the faeces, and
'ro&ided natural 'rotection +y the identical route (oralGfaecal)
throu-h .hich the disease s'reads) 3i1e s(all'ox, 'olio is a
(odern success story and the disease*s .orld.ide eradication
has al(ost +een achie&ed) The 'olio story is full of stron-
'ersonalities, and no s(all a(ount of du'licitous +eha&iour,
+ut the result .as a desira+le one)
Its success encoura-ed (ore (edical research, and the &ast
industrialGscientiNc esta+lish(ent .e still ha&e .as created)
The lar-est (edical research or-ani7ation in the .orld, the
/ational Institutes of Health (/IH), in 6ethesda, Maryland, .as
one +eneNciary) 9ro( the C@D<s, the A(erican -o&ern(ent
+e-an to +e a (a,or 'layer in (edical research, .ith e&er
lar-er la+oratories and (ultiGauthored scientiNc 'a'ers the
nor() 4hate&er 'ara(eter one (easures, +asic (edical
research has increased dra(atically o&er the 'ast fe.
decades) So ha&e i('ro&e(ents in healthcare, at least in the
4est) #octors in the early !Cst century can dia-nose and
(ana-e disease e&en +etter than they could in the C@A<s)
Asth(a, cancer, 'e'tic ulcer, cardio&ascular disease, and
(any others are less li1ely to +e sentences of in&alidis( and
death than they .ere only a -eneration a-o) The chan-in- a-e
'roNle (eans that chronic disease is (ore 'ro(inent, and the
translation of (edical research into clinical 'ractice has (eant
that (any of the -ains of (odern (edicine relate to care, not
cure) The 'ro(ises of health i('ro&e(ents throu-h
se?uencin- the hu(an -eno(e or ste( cell research are so
far lar-ely unreali7ed) As scientiNc ca'a+ility rises, so do
ex'ectations, and (any 'atients no lon-er ha&e 'atience,
ha&in- +een 'ro(ised so (uch)
Modern (edicine: the reality of the ne.
It is 'erce'tion as (uch as reality that dictates (odern
attitudes to (edicine and .hat it can, and cannot, do) The
thalido(ide disaster .as a turnin- 'oint) It see(ed an
excellent dru- in the late C@D<s, a .onderful 're&ention of
(ornin- sic1ness in early 're-nancy) It .as hastily (ar1eted
and not ade?uately tested) A shar'Geyed o5cial in the %nited
States 're&ented its +ein- released there, +ut thousands of
.o(en in (ore than E< countries too1 the dru- durin-
're-nancy +efore the relationshi' +et.een the dru- and +irth
a+nor(alities in the li(+s of their +a+ies +eca(e clear)
Althou-h the e'isode ulti(ately did result in ti-htenin- u'
safety standards on ne. (edica(ents, it dented 'u+lic
conNdence in the 'har(aceutical industry) /o su+se?uent
dru- has +een ?uite so o+&iously deleterious, e&en if se&eral
ha&e +een hastily .ithdra.n after side eIects ha&e e(er-ed)
The (odern 'har(aceutical industry has +een of a 'iece .ith
other (ultinational cor'orations) S(all Nr(s -et s.allo.ed u'
in lar-er ones, and conte('orary +ud-ets for ad&ertisin- and
sales are lar-er than those for research and de&elo'(ent)
#irect ad&ertisin- of 'rescri'tionGonly dru-s in the %nited
States has introduced a ne., distur+in- ele(ent in the
industry, and PaddGon* (edicines, .here s(all chan-es are
(ade to an existin- dru-, occu'y too (uch of the industry*s
ti(e) 8esearch tends to follo. co((on disorders of the 4est,
.ith lucrati&e 'otentials, instead of (a,or diseases of the
'oorer countries, .here there is -reat need +ut little chance of
yieldin- &ast 'roNts) A lon-Gter( chronic disease, in .hich
'atients (ust ta1e their (edications for years, or e&en for the
rest of their li&es, is the ideal -oal for a ne. dru-)
!=) The studious 'hysician at the +edside: Sir 4illia( Osler,
one of the (ost ad(ired 'hysicians of all ti(e, does his stuI
in dia-nosin- and thin1in- a+out .hat he has learned) 6edside
(anner .ith (odern intent
HIV (AI#S) 'ro&ides an o+,ect lesson on the status of (odern
(ar1etGdri&en healthcare) 9ro( its e(er-ence in a 'articularly
&irulent for( in the C@=<s, lar-ely a(on- -ay (en and
in,ectin- dru- users in the %nited States, it has +eco(e a
sy(+ol of the 'o.er and the 'ro+le(s of conte('orary
healthcare) 6ecause it Nrst (anifested itself in a rich country,
+io(edical research .as (arshalled ?uic1ly, althou-h so(e
reli-ious leaders insisted that the disease .as si('ly God*s
'unish(ent for ho(osexuality and other for(s of sin)
$resident 8onald 8ea-an too1 his ti(e utterin- the acrony(
AI#S in 'u+lic and the Catholic Church refuses to countenance
the use of condo(s as a (eans of 're&entin- the s'read of
this sexually trans(itted disease) AI#S still carries the hea&y
+urden of sti-(a)
If those at ris1 thou-ht the o5cial res'onse .as (uted, this
should +e co('ared .ith traditional 4estern lethar-y a+out
diseases of 'oor countries that 'ose no threat to the rich ones)
A ?uarter of a century later, the la'se +et.een the earliest
cases of 2a'osi*s sarco(a, then a rare for( of cancer, and the
a''earance of co('ro(ised i((une syste(s a(on-
're&iously healthy youn- adults, on the one hand, and the
identiNcation of the causati&e or-anis(, in C@=E, on the other,
see(s fairly short) That t.o -rou's, one in the %nited States
and one in 9rance, al(ost si(ultaneously identiNed the
res'onsi+le retro&irus, and each clai(ed the s'oils, is another
si-n of the ti(es, .hen the +i- 'ri7es in science are 1eenly
contested)
HIV .as initially 1no.n so(e.hat condescendin-ly as the
disease of the F H*s B ho(osexuals, heroinGusers, and Haitians)
The 'oor in Haiti .ere identiNed as an early &ulnera+le -rou',
+ut they .ere soon ,oined +y the African 'oor, and it is in
Africa and other de&elo'in- countries that the star1est issues
and the (ost serious social and econo(ic conse?uences of
AI#S are found) In the 4est, the disease has ?uic1ly chan-ed
fro( an acute to a chronic one, althou-h one still .ith a
serious (ortality rate) Anti&iral treat(ents, a&aila+le since the
C@@<s, slo. the 'ro-ress of the disease, +ut they re(ain
ex'ensi&e and ha&e side eIects) Good nursin- care and the
ti(ely treat(ent of infections as they occur are also i('ortant
in increasin- ?uality of life and decreasin- (or+idity and
(ortality) 3i1e so (any diseases caused +y (icroGor-anis(s,
ho.e&er, 'ro+le(s of dru- resistance ha&e co(e to the fore,
and the HIVG'ositi&e ta- is a -ri( one)
In so(e 'arts of Africa, AI#S is a disease co((only
trans(itted +y heterosexual intercourse, and the incidence of
indi&iduals .ho are HIVG'ositi&e, as .ell as those suIerin-
fro( the fullG+lo.n syndro(e, is o&er.hel(in-) Treat(ent is
ex'ensi&e and in any case re?uires a healthcare infrastructure
that is si('ly (issin- in (ost of the continent) Alon- .ith
(alaria and tu+erculosis, AI#S has do(inated the
international health scene for the 'ast cou'le of decades) All
three diseases ha&e strains that resist con&entional che(ical
treat(ent and their 1noc1Gon eIects in ter(s of (or+idity and
(ortality in youn- adults are hu-e) #isease has further
increased the diIerential +et.een the rich and the 'oor and,
des'ite the su+stantial contri+ution of the Gates 9oundation
and other international a-encies, 'ro(ises to do so in the
i((ediate future)
AI#S has +een called a social disease for .hich its suIerers
loo1ed to (edical science for a solution) Science and (edical
'ractice +ased on it are a(on- the (ost si-niNcant
achie&e(ents of 4estern culture) 4e need the(, +ut (edical
science alone cannot sol&e the 'ro+le(s of hu(an +ein-s) 4e
no lon-er li&e in a .orld .here the idea of ine&ita+le 'ro-ress
carries (uch con&iction)
8eferences
Cha'ter C The ?uotations fro( the Hi''ocratic .or1s POn the
Sacred #isease* and PA'horis(s* are ta1en fro( 9rancis Ada(s
(ed)), The Genuine 4or1s of Hi''ocrates, ! &ols (3ondon: The
Sydenha( Society, C=E@)) Sha1es'eare*s ?uestion a+out the
seat of fancy co(es fro( The Merchant of Venice, ActF)
Cha'ter ! Sydenha(*s fa(ous co((ent a+out the constancy
of sy('to(s in diIerent 'ersons suIerin- fro( the sa(e
disease .as (ade in his Medical O+ser&ations) I ha&e used 8)
G) 3atha( (ed)), The 4or1s of Tho(as Sydenha(, ! &ols
(3ondon: The Sydenha( Society, C=E=))
Cha'ter F Antoine 9ourcroy*s su((ary of the +asis of $arisian
(edical education is ?uoted in >r.in Ac1er1necht, Medicine at
the $aris Hos'ital, CA@EBC=E= (6alti(ore: :ohns Ho'1ins
%ni&ersity $ress, C@"A)S 6ichat*s rin-in- in,unction also is
?uoted in Ac1er1necht*s (ono-ra'h) The 'hrase P-ate.ays to
death* as a descri'tion of +ad hos'itals ori-inated .ith the
'hysician and (an of letters :ohn Ai1in (CAEABC=!!), no.
+etter 1no.n as a .riter than a 'hysician) 9rancis 6acon*s
'hrase P9ootste's of diseases* co(es fro( his Ad&ance(ent of
3earnin-, ori-inally 'u+lished in C"<D)
Cha'ter E >d.ard VII*s stirrin- directi&e, said of tu+erculosis, is
?uoted in Tho(as #or(andy, The 4hite #eath: A History of
Tu+erculosis (3ondon: Ha(+ledon $ress, C@@@), .ith the note
that >d.ard .as cri++in- fro( 4illia( 4itherin-, the
'hysician .ho introduced di-italis into clinical (edicine in
CA=D) Mr Grad-rind*s insistence on P9acts* is a recurrin- tro'e
in Charles #ic1ens*s Hard Ti(es, Nrst 'u+lished in C=DE)
Cha'ter D 8o+ert Hoo1e used the .ord Pcell* in his
Micro-ra'hia (C""D)) 3UWer*s su((ary of the ste's .e 1no.
as P2och*s $ostulates* is ?uoted in Tho(as #) 6roc1, 8o+ert
2och: A 3ife in Medicine and 6acteriolo-y (Madison, 4isconsin:
Science Tech $u+lishers, C@==))
Cha'ter " 4illia( 4ords.orth*s (e(ora+le 'hrase Nrst
a''eared in his 'oe( PThe Ta+les Turned*, 'u+lished in CA@=)
I&an Illich ela+orated his notion of Piatro-enesis* in se&eral
.or1s, (ost centrally in Medical /e(esis: The >x'ro'riation of
Health (3ondon: Calder and 6oyars, C@AD)) C) $) Sno.*s lecture
on .hat he called The T.o Cultures .as 'u+lished +y
Ca(+rid-e %ni&ersity $ress in C@D@)
9urther readin-
General
4) 9) 6ynu( and Helen 6ynu( (eds), #ictionary of Medical
6io-ra'hy, D &ols
(4est'ort, Connecticut, and 3ondon: Green.ood $ress, !<<A))
6io-ra'hies of
(a,or (edical N-ures fro( all o&er the .orld .ho ha&e
contri+uted to clinical
(edicine, 'lus introductory essays on the (a,or (edical
traditions)
4) 9) 6ynu( and 8oy $orter (eds), Co('anion >ncyclo'edia of
the History of
Medicine, ! &ols (3ondon: 8outled-e, C@@F)) A collection of
essays co&erin-
the .hole of the Neld)
4) 9) 6ynu(, Anne Hardy, Ste'hen :acyna, Christo'her
3a.rence, and >) M)
(Tilli) Tansey, The 4estern Medical Tradition, C=<<B!<<<
(Ca(+rid-e: Ca(+rid-e
%ni&ersity $ress, !<<")) A -eneral sur&ey of 4estern (edicine
durin- the 'ast
t.o centuries)
3a.rence I) Conrad, Michael /e&e, Vi&ian /utton, 8oy $orter,
and Andre. 4ear,
The 4estern Medical Tradition, =<<6CBA#C=<< (Ca(+rid-e:
Ca(+rid-e %ni&ersity
$ress, C@@D)) A -eneral sur&ey of the history of the 4estern
(edical tradition
u' to C=<<)
:acylyn #u5n, History of Medicine: A Scandalously Short
Introduction
(Toronto: %ni&ersity of Toronto $ress, C@@@)) An excellent
introduction, .ith
-ood co&era-e of (odern /orth A(erican de&elo'(ents)
Ste'hen 3oc1, :ohn M) 3ast, and Geor-e #unea (eds), The
Oxford Illustrated
Co('anion to Medicine (Oxford: Oxford %ni&ersity $ress,
!<<C)) Arran-ed
al'ha+etically, (ost of the articles ha&e -enerous historical
content)
:ohn $ic1stone, 4ays of 2no.in-: A /e. History of Science,
Technolo-y and
Medicine (Manchester: Manchester %ni&ersity $ress, !<<<)) A
sti(ulatin-
introduction to these Nelds +y a leadin- ex'ert)
8oy $orter, The Greatest 6eneNt to Man1ind: A Medical History
of Hu(anity
fro( Anti?uity to the $resent (3ondon: Har'erCollins
$u+lishers, C@@@)) A
.idely ad(ired, al.ays reada+le sur&ey)
Andre. 4ear (ed)), Medicine in Society: Historical >ssays
(Ca(+rid-e:
Ca(+rid-e %ni&ersity $ress, C@@!)) An excellent collection of
.ideGran-in-
essays, es'ecially .ritten for teachin- 'ur'oses)
#a&id 4eatherall, Science and the Luiet Art: Medical 8esearch
and $atient Care
(Oxford: Oxford %ni&ersity $ress, C@@D)) Historically sensiti&e
study +y an
outstandin- clinician and (edical scientist) Cha'ter C:
Medicine at the +edside
/o-a Aro1ha, $assions and Te('ers: A History of the Hu(ours
(/e. 0or1:
Har'erCollins $u+lishers, !<<A)) A full history of the continuin-
inRuence of
the doctrine of the hu(ours .ithin (edicine and science)
M) #) Gr(e1, #iseases in the Ancient Gree1 4orld (6alti(ore:
:ohns Ho'1ins
%ni&ersity $ress, C@=@)) An authoritati&e account of the
e&idence for the
ran-e of diseases 're&alent in classical anti?uity, usin- +oth
.ritten and
(aterial sources)
Helen 2in-, Hi''ocrates* 4o(an: 8eadin- the 9e(ale 6ody in
Ancient Greece
(3ondon: 8outled-e, C@@=)) A sti(ulatin- account of .o(en*s
diseases in
ancient (edical .ritin-s)
G) >) 8) 3loyd (ed)), Hi''ocratic 4ritin-s (Har(onds.orth:
$en-uin, C@A=)) A
&ery useful selection of the Hi''ocratic .ritin-s .ith a Nne
introduction)
Vi&ian /utton, Ancient Medicine (3ondon: 8outled-e, !<<E)) A
full and
.ellG.ritten sur&ey +y a leadin- scholar)
O.sei Te(1in, Galenis(: 8ise and #ecline of a Medical
$hiloso'hy (Ithaca:
Cornell %ni&ersity $ress, C@AF)) An account of Galen*s
continuin- inRuence
for (ore than a (illenniu( after his death) Cha'ter !:
Medicine in the li+rary
3aurence 6roc1liss and Colin :ones, The Medical 4orld of >arly
Modern 9rance
(Oxford: Clarendon $ress, C@@A)) A (onu(ental account of
four centuries of
(edical life in 9rance)
4) 9) 6ynu( and 8oy $orter (eds), 4illia( Hunter and the
>i-hteenthGCentury
Medical 4orld (Ca(+rid-e: Ca(+rid-e %ni&ersity $ress, C=@D))
A .ideGran-in-
collection of essays on >nli-hten(ent (edicine and anato(y)
$eter $or(ann and >(ilie Sa&a-eGS(ith, Medie&al Isla(ic
Medicine (>din+ur-h:
>din+ur-h %ni&ersity $ress, !<<A)) An u'GtoGdate su((ary of a
co('lex su+,ect)
8oy $orter, Luac1s: 9a1ers and Charlatans in >n-lish Medicine
(Stroud,
Gloucestershire: Te('us $u+lishin-, !<<<)) An entertainin-
&olu(e, rich in
anecdote +ut also de&elo'in- $orter*s notion of the continuin-
i('ortance of
the (edical (ar1et'lace)
Carole 8a.cliIe, Medicine and Society in 3ater Medie&al
>n-land (Stroud,
Gloucestershire: A) Sutton, C@@D)) An accessi+le and .ideG
ran-in- sur&ey)
Guenter 6) 8isse, Hos'ital 3ife in >nli-hten(ent Scotland: Care
and Teachin-
in the 8oyal InNr(ary of >din+ur-h (Ca(+rid-e: Ca(+rid-e
%ni&ersity $ress,
C@=")) An outstandin- study of clinical (edicine and (edical
education on the
e&e of the 9rench 8e&olution)
/ancy G) Siraisi, Medie&al and >arly 8enaissance Medicine
(Chica-o: Chica-o
%ni&ersity $ress, C@@<)) An excellent introduction to the
(edicine of the
'eriod) Cha'ter F: Medicine in the hos'ital
>r.in H) Ac1er1necht, Medicine at the $aris Hos'ital, CA@EB
C=E= (6alti(ore:
:ohns Ho'1ins %ni&ersity $ress, C@"A)) The classic study of the
9rench school
in the early C@th century)
4) 9) 6ynu(, Science and the $ractice of Medicine in the
/ineteenth Century
(Ca(+rid-e: Ca(+rid-e %ni&ersity $ress, C@@E)) A -eneral
account of the
increasin- role of science .ithin clinical (edicine)
:acylyn #u5n, To See .ith a 6etter >ye: A 3ife of 8) T) H)
3aennec
($rinceton: $rinceton %ni&ersity $ress, C@@=)) A Nne +io-ra'hy
of the
in&entor of the stethosco'e)
Michel 9oucault, The 6irth of the Clinic: An Archaeolo-y of
Medical
$erce'tion, tr) A) M) Sheridan S(ith (3ondon: Ta&istoc1, C@AF))
One of the
(ost accessi+le +oo1s of this inRuential thin1er, in .hich he
de&elo's his
ideas a+out 'o.er .ithin (edicine, focusin- on the 9rench
clinical school)
Caroline Hanna.ay and Ann 3a 6er-e (eds), Constructin- $aris
Medicine
(A(sterda(: 8odo'i, C@@=)) A -ood series of essays +y leadin-
scholars,
e&aluatin- the 9rench school)
8ussell Maulit7, Mor+id A''earances: The Anato(y of
$atholo-y in the >arly
/ineteenth Century (Ca(+rid-e: Ca(+rid-e %ni&ersity $ress,
C@=A)) A
sti(ulatin- study of the fortunes of 'atholo-y durin- its 'eriod
of do(inance
.ithin clinical (edicine)
Guenter 6) 8isse, Mendin- 6odies, Sa&in- Souls: A History of
Hos'itals
(Oxford: Oxford %ni&ersity $ress, C@@@)) An exce'tionally
ele-ant and
thou-htful study of the hos'ital throu-hout history) 8isse
dissects the 9rench
hos'itals of the early C@th century, discussed in Cha'ter ")
Andre. Scull, The Most Solitary of AWictions: Madness and
Society in
6ritain, CA<<BC@<< (/e. Ha&en and 3ondon: 0ale %ni&ersity
$ress, C@@F))
Althou-h focusin- on 6ritain, Scull*s 'o.erful account
hi-hli-hts (any co((on
features of 'sychiatry and insanity throu-hout >uro'e and
/orth A(erica durin-
this 'eriod) Cha'ter E: Medicine in the co((unity
:ohn #uIy, The Sanitarians: A History of A(erican $u+lic
Health (%r+ana,
Ill): %ni&ersity of Illinois $ress, C@@<)) A sound account of the
'u+lic
health (o&e(ent in the %nited States)
Christo'her Ha(lin, $u+lic Health and Social :ustice in the A-e
of Chad.ic1:
6ritain, C=<<BC=DE (Ca(+rid-e: Ca(+rid-e %ni&ersity $ress,
C@@=)) An i('ortant
study of the relationshi' +et.een 'o&erty and disease)
#aniel 2e&les, In the /a(e of >u-enics: Genetics and the %ses
of Hu(an
Heredity (Har(onds.orth: $en-uin, C@=")) Still the +est
-eneral account of the
eu-enics (o&e(ent)
Ann 3a 6er-e, Mission and Method: The >arly /ineteenthG
Century 9rench $u+lic
Health Mo&e(ent (Ca(+rid-e: Ca(+rid-e %ni&ersity $ress,
C@@!)) An excellent
synthesis of the 9rench (o&e(ent)
Tho(as Mc2eo.n, The 8ole of Medicine: #rea(, Mira-e or
/e(esisT (Oxford:
6lac1.ell, C@A@)) The (ost 'un-ent state(ent of Mc2eo.n*s
&ision of (edicine
and its history)
#orothy $orter, Health, Ci&ili7ation and the State: A History of
$u+lic Health
fro( Ancient to Modern Ti(es (3ondon: 8outled-e, C@@@)) A
-ood synthesis of a
&ast to'ic)
#orothy $orter (ed)), The History of $u+lic Health and the
Modern State
(A(sterda(: 8odo'i, C@@E)) A Nne collection of essays on
(any countries, +y
leadin- ex'erts) Cha'ter D: Medicine in the la+oratory
>r.in H) Ac1er1necht, 8udolf Vircho.: #octor, States(an,
Anthro'olo-ist
(Madison: %ni&ersity of 4isconsin $ress, C@DF)) This old
+io-ra'hy is still an
excellent introduction to the (any facets of Vircho.*s career)
Claude 6ernard, An Introduction to the Study of >x'eri(ental
Medicine, tr)
Henry Co'ley Green (/e. 0or1: #o&er $u+lications, C@DA))
Ori-inally 'u+lished
in C="D, 6ernard*s classic (ono-ra'h is still .ell .orth
readin-)
4illia( Cole(an and 9rederic 3a.rence Hol(es (eds), The
In&esti-ati&e
>nter'rise: >x'eri(ental $hysiolo-y in /ineteenthGCentury
Medicine (6er1eley:
%ni&ersity of California $ress, C@==)) An outstandin- collection
of essays on
ex'eri(ental 'hysiolo-y and its rele&ance for (edical
'ractice)
$atrice #e+rM, 3ouis $asteur, tr) >l+or- 9orster (6alti(ore:
:ohns Ho'1ins
%ni&ersity $ress, C@@=)) A full +io-ra'hy of $asteur,
sy('athetic +ut not
uncritical)
Henry Harris, The 6irth of the Cell (/e. Ha&en and 3ondon:
0ale %ni&ersity
$ress, C@@=)) A -ood introduction to C@thGcentury (icrosco'y)
O.en H) 4an-ensteen and Sarah #) 4an-ensteen, The 8ise of
Sur-ery: 9ro(
>('iric Craft to ScientiNc #isci'line (9ol1estone, 2ent: #a.son,
C@A=))
OldGfashioned and in the heroic (ode, +ut .onderfully
cos(o'olitan and
accurate in its details)
Michael 4or+oys, S'readin- Ger(s: #isease Theories and
Medical $ractice in
6ritain, C="DBC@<< (Ca(+rid-e: Ca(+rid-e %ni&ersity $ress,
!<<<)) A su+tle
in&esti-ation of the i('act of +acteriolo-y and -er(s theories
on 6ritish
(edicine) Cha'ter ": Medicine in the (odern .orld
Michael 6liss, The #isco&ery of Insulin (>din+ur-h: Harris,
C@=F)) A +alanced
account of this fa(ous e'isode in the history of (edicine)
Tho(as /e&ille 6onner, 6eco(in- a $hysician: Medical
>ducation in Great
6ritain, 9rance, Ger(any and the %nited States, CAD<BC@ED
(Oxford and /e.
0or1: Oxford %ni&ersity $ress, C@@D)) A Nne co('arati&e study,
.ith (any
resonances for earlier cha'ters of this Introduction as .ell)
8o-er Cooter and :ohn $ic1stone (eds), Medicine in the
T.entieth Century
(A(sterda(: Har.ood Acade(ic $u+lishers, !<<<)) A lar-e
collection of essays
on (any as'ects of (edicine in the last century)
:ohn 9arley, The International Health #i&ision of the 8oc1efeller
9oundation:
The 8ussell 0ears, C@!<BC@FE (Ca(+rid-e: Ca(+rid-e
%ni&ersity $ress, C@@D)) An
excellent introduction to the i('ortant di(ension of
international health, and
the A(ericani7ation of the .orld)
:oel Ho.ell, Technolo-y in the Hos'ital: Transfor(in- $atient
Care in the
>arly T.entieth Century (6alti(ore: :ohns Ho'1ins %ni&ersity
$ress, C@@D)) A
Nne (ono-ra'h on ho. (edical science and technolo-y
inRuenced .hat doctors
did in the hos'ital)
:a(es 3e 9anu, The 8ise and 9all of Modern Medicine (3ondon:
3ittle, 6ro.n and
Co), C@@@)) A 'erce'ti&e account of !<thGcentury (edicine +y
a shre.d -eneral
'ractitioner and (edical ,ournalist)
Harry Mar1s, The $ro-ress of >x'eri(ent: Science and
Thera'eutic 8efor( in the
%nited States, C@<<BC@@< (Ca(+rid-e: Ca(+rid-e %ni&ersity
$ress, C@@A)) An
excellent introduction to the clinical trial, and (uch else
+esides)
8ose(ary Ste&ens, In Sic1ness and in 4ealth: A(erican
Hos'itals in the
T.entieth Century (/e. 0or1: 6asic 6oo1s, C@=@)) A full
analysis of the
econo(ic and (edical di(ensions of A(erican hos'itals)
Index
A
access to (edical infor(ation C!FBE acute care C!=, CF< AI#S
see HIV anaesthesia C<=B@, CCA anato(y ", CC, CD, CA, !ABFF,
DFBE, D@B"C, @! ani(al ex'eri(ents @!BF, CCEBCA anthrax @@B
C<<, C<F anti+iotics CF!, CE=BDC antise'tics C<=BCC, CCA, C!D,
CF< Aristotle @, !!, FD Ascle'ius A ase'tic techni?ues CCC,
CCA, C!D, CF< as'irin CE"BA asylu(s "FB", C!" Auen+ru--er,
3eo'old E=B@, D!BF auscultation EA, D<BF auto'sies ", DFBD,
D=B@, "! A&erroes !! A&icenna !!BF, !A 6
+acteriolo-y @@BC<<, C<FBCC, CCFBCE, CE=BD< 6alint, Michael
C!C 6antin-, 9rederic1 CEA +edside (edicine C, !, DBC=, CC@B
!!, CDF 6entha(, :ere(y AD 6ernard, Claude !, CCDBCA, CE"
6est, Charles CEA 6ichat, a&ier DEBD, @F +iolo-y @FBE, @",
C!< 6lac1 #eath or 'la-ue !E, !", "@BA!, AA, =A +lood C<, DDB
", CE=
circulation CD, FF, @!
lettin- C!BCF, FA, "< 6oerhaa&e, Her(ann F=BE<, E! +otany
CABC=, FA, F@BE< 6roussais, 9:V "< +ureaucracy,
esta+lish(ent of 'u+lic health A!, =!B@< C
Caelius Aurelianus !C CAT scans C!=B@ cell theory @FBA
Chad.ic1, >d.in A@B=F, =D, C<A, CCFBCE, CF" che(istry FEBD,
@@, C<=, CCE cholera AEB@, =CBF, @D, C<FBE, CF"BA clinical
trials "<, =@, CD< clinicoG'atholo-ical correlation DFB@ Colli', :6
CEA co((unity (edicine C, F, CCFBCE, CFFBED Constantine
the African !F conta-ion A!B=E coronary care units CF<BC
Cor&isart, :eanG/icolas E@BD<, D!, DE, D" costs of (edicine F,
AE, CC=BC@, C!"B=, CF! #
#ar.in, Charles CEBCD, @=B@, CF! ##T CF@, CEC de&elo'in-
countries C!!, CF=B@, CDEB" dia-nosis C, A, E<BC, E"BDA, "CB!,
""BA, C!FBE, C!= #ioscorides CABC= di'htheria C<" diseases
FEBD see also 'articular diseases (e- cholera)
classical .ritin- !C
classiNcation FAB=, E<BC, DD, D=B@, "D, =@, C<AB=
e'ide(ic diseases CFBCE, !E, !", "=B==, @D, C<FBA, CF!, CF"B
@
Nlth diseases =CBF, =D, C<A, CF"
hos'itals C!EBD
hu(ours C<BCD, CA, DD
notiNa+le diseases =AB=
reli-ion AB= #oll, 8ichard CE!BF #o(a-1, Gerhard CE= dru-s
CABC=, FA, @AB=, C!<, CFF, CE"BD!, CDEBD >
>nli-hten(ent (edicine F=BE!, D@B"<, C!D >'ile'sy =
e'ide(ic diseases CFBCE, "=B==, @D, C<FBA, CF!, CF"B@
eu-enics =@, CFDB" ex'eri(ents @!BF, CCEBCA, C!<, CEF, CE"B
A 9
Nlth diseases =CBF, =D, C<A, CF" 9lorey, Ho.ard CE=B@
9ourcroy, Antoine EE 9rance, hos'ital (edicine in EFB"A 9ran1,
:ohann $eter A!, AD G
Galen C<, CC, CDB!F, !D, !ABF<, FF, FE, EC, @C Galton, 9rancis
=@ -er( theory A"BA, @ABC<@, C!" Grassi, G6 CF@ Gree1s "B
CC, C=, !CB!, @C H
Haller, Al+recht &on @!BF Har&ey, 4illia( FF, @! heart @, CC,
F<, FF, E@, D!, D", @!, CCA, CF<BC Hel(holt7, Her(ann &on
CCEBCD Hel(ont, :6 &an @! hereditary conditions =@, CFDB"
Hill, Austin 6radford CE!BF Hi''ocrates and Hi''ocratics C, !,
DBC=, !<BC, !A, FE, FAB=, E<B!, EA, DF, DDBA, AD, @C, CC@B!<,
C!!, CED HIVKAI#S @A, CF!, CE!, CDEB" holistic (edicine "BA,
CF, CC@B!< hos'itals C, !, F, !FBE, C!EBFF
architecture C!EB"
>nli-hten(ent ECB!, C!D
9rance EFB"A
Isla(ic (edical tradition !E
la+oratories C!DB"
(ana-e(ent C!"B=
(edical schools EE, E", "CBF reli-ion C!EBD sur-ery E", E=, "F,
C!DB", C!=, CF<BC technolo-y C!=BF< hu(ours C<BCD, CA, FA,
DD, CC@ hy'otheticoGdeducti&e (ethod CC" I
Illich, I&an C!C infor(ation C, C!FBE, CEDB" inoculation A!BE,
=DB", C<<BC, C<E, CECB!, CEA, CDC ins'ection EAB=, D! insulin
C!<, CEAB= insurance C!AB= internationalis( CF=BE! Internet
C!FBE, CED Isla(ic (edical tradition !<, !CBE :
:enner, >d.ard AFBE, C<< :ohns Ho'1ins %ni&ersity "!, C!D
,ournals C!!BF 2
2och, 8o+ert DA, =E, ==, @E, @=, C<C, C<FB", CCC 2rae'elin,
>(il "D, "A 3
la+oratory (edicine !, F, @!, CCFBCE, C!DB", CEDBD! 3aennec,
8TH !, D<B!, DE, D"B= 3eeu.enhoe1, Antoni &an @F le'rosy !E,
!" li+rary (edicine C, !, C@B!<, !", F@BE<, C!!BE lifestyle
(edicine "=, C<A, CE!BD 3innaeus, Carl E< 3ister, :ose'h C<@B
CF, CF< 3UWer, 9riedrich C<" 3ouis, $ierre D=B"C, @< 3ud.i-,
Carl CCE lun- cancer CE!BF M
Macleod, ::8 CEA (a-icoGreli-ious (edicine A, C= (alaria CF"B
E!, CDD Mallon, Mary (Ty'hoid Mary) ==, C<" Malthus, T8 "@,
A@B=< Manson, $atric1 CFA Mc2eo.n, Tho(as @= (edical
schools EE, E", "CBF (ental illness "FBE, C!<BC, CD< (ias(a
ADB", AAB=, =C, C!D (icroG+iolo-y @AB@, C<F, C<@, CF!
(icrosco'y @F, @EBA (olecular (edicine @F, CC@ Mondino de*
3iu77i !@ (oral thera'y "EBD Mor-a-ni, Gio&anni 6attista DFB
E, @F M8I scans C!=B@ M8SA (Meticillin 8esistant
Sta'hylococcus Aureus) CF!BF /
/ational Institutes of Health (/IH) CD! naturalis( AB=, C=
/e.ton, Isaac FD, =F, @F nu(erical (ethod D@B"C, @< O
Osler, 4illia( "!, CDF $
$acini, 9ili''o =F 'al'ation EA, E=, D! $aracelsus
(Theo'hrastus &on Hohenhei() FEBD, EC $asteur, 3ouis @AB
C<F, C<@BC<, CC!, CC"BCA 'atholo-y D", D@, "!, @"BA, CC",
C!" $earson, 2arl =@ 'enicillin C!<, CE=BD< 'ercussion EA, E=B
D<, D!BF $etten1ofer, Max &on C<E 'hilanthro'y !E, E!, C!A
'har(aco'oeia CA 'hthisis (consu('tion) EAB=, DCB!, D"B@
see also tu+erculosis 'hysiolo-y CDBCA, FD, "<, @!, CCEBCA
$inel, $hili''e "E 'la-ue !E, !", "@BA!, AA, =A 'olio CD<B!
'o'ulation "@, A@B=< 'ostG(orte(s ", DFBD, D=B@, "! 'o&erty
A@B=D, =A, @DB", C<A, CE!, CDEB" 're&ention "=, ACBE, =CBF,
CF@BE< 'ri(ary care "BA, C!!, CE! 'rintin- 'ress, in&ention of
the !<, FC, F! 'ri&ate health care C!A 'rofessions, attac1s on
C!C 'sychiatry "FB", C!<BC, CD< 'u+lic health "=B@<, @DB",
CFFB= L
?uac1s and re-ulars EC ?uarantine ACB!, A", AA ?uinine FA 8
ra+ies C<<BC, C<F racis( CFF, CFD, CF" reli-ion AB=, C=, !<,
!FBE, FE, "E, C!EBD, CFAB= research F, "!, @!BF, @=BC<C, CCEB
CA, C!<, CF!, CEF, CE"BA, CDCBE 8ha7es !! 8oc1efeller
9oundation CF= 8oss, 8onald CFA, CF@ S
sanitary conditions AA, =CB!, C<A, CCFBCE, CFDB" Schleiden,
Mathias @E Sch.ann, Theodor @E, @", @@ scientiNc (edicine
@CBCCA se.a-e dis'osal =!BE, CF" Si(on, :ohn !, =D s(all'ox
A!BE, A", =D, =A, CF=B@, CECB! Sno., :ohn =FBE s'eciali7ation
C!<BC, CFA statistics ==B@< stethosco'es D<BF, DA
stre'to(ycin CE@BD< sur-ery and sur-eons CC, F", D", CCF,
C!=
anaesthesia C<=B@
antise'tics C<=BCC, C!D, CF<
ase'tic sur-ery CCC, C!D, CF<
hos'itals E", E=, "F, C!DB", C!=, CF<BC
trans'lants CFCB!
uni&ersities !A sur&eillance =AB=, CEF, CED sur&eys =DB", ==,
@<, CE" Sydenha(, Tho(as FAB=, E! sy'hilis FDBA T
technolo-y CCD, C!=BF< transnational cor'orations CC=BC@,
CDE trans'lants CFCB! tro'ical (edicine ADB", CF"B=
tu+erculosis D"BA, C<FBE, CFD, CE!, CDD see also 'hthisis
(consu('tion) Ty'hoid Mary see Mallon, Mary ty'hus and
ty'hoid fe&ers D=B@, ==, @D, C<A, CF@ %
uni&ersities !"BA, "D, CC@, C!DB" V
&accination A!BE, =DB", C<<BC, C<E, CECB!, CEA, CDC Vesalius,
Andreas !@BFC Vircho., 8udolf @DBA &iruses C<<BC, C<"BA,
CD<BC 4
.ater su''ly =!BE, CCFBCE, CF" 4orld Health Or-ani7ation
(4HO) C!!, CF=B@, CECB! .ritin-s and +oo1s "B=, CE, C@B!F,
FCBE, F=, C!!BF see also li+rary (edicine
xGrays C!@, CFD #8%GS A Very Short Introduction
3eslie I&erson
The t.entieth century sa. a re(ar1a+le u'sur-e of research
on dru-s, .ith (a,or ad&ances in the treat(ent of +acterial
and &iral infections, heart disease, sto(ach ulcers, cancer, and
(ental illnesses) These, alon- .ith the introduction of the oral
contrace'ti&e, ha&e altered all of our li&es) There has also
+een an increase in the recreational use and a+use of dru-s in
the 4estern .orld) This +oo1 ex'lains .hat dru-s are, ho.
they .or1, and ho. (edicines are de&elo'ed and tested) It
also discusses current ideas a+out .hy so(e dru-s are
addicti&e, and .hether dru- la.s need refor()
Pextre(ely interestin- and ca'a+le ] althou-h called a &ery
short
introduction, it contains a .ealth of infor(ation for the
interested lay(an
and is exe('lary in its accuracy)*
Malcol( 3ader, 2in-*s Colle-e, 3ondon
Pa sli( +ut assured and .ise &olu(e on dru-s) ^It_ ta1es u'
(any contro&ersial
'ositions ] .ith an air of authority that co((ands res'ect) It
is di5cult to
thin1 of a +etter o&er&ie. of the Neld for anyone ne. to it)*
#a&id Healy, %ni&ersity of 4ales Colle-e of Medicine
...)ou')co)u1Kis+n)<GC@G!=DEFCGF

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