Indian medicine has a long history. Its earliest concepts are set out in the sacred writings called the Vedas, especially in the metrical passages of the Atharvaveda, which may possibly date as far back as the 2nd millennium BCE. According to a later writer, the system of medicine called Ayurveda was received by a certain Dhanvantari from the god Brahma, and Dhanvantari was deified as the god of medicine. In later times his status was gradually reduced, until he was credited with having been an earthly king who died of snakebite.
The period of Vedic medicine lasted until about 800 BCE. The Vedas are rich in magical practices for the treatment of diseases and in charms for the expulsion of the demons traditionally supposed to cause diseases. The chief conditions mentioned are fever(takman), cough, consumption, diarrhea, edema, abscesses, seizures, tumours, and skin diseases (including leprosy). The herbs recommended for treatment are numerous.
The golden age of Indian medicine, from 800 BCE until about 1000 CE, was marked especially by the production of the medical treatises known as the Charaka-samhita and Sushruta-samhita, attributed respectively to Charaka, a physician, and Sushruta, a surgeon. Estimates place the Charaka-samhita in its present form as dating from the 1st century CE, although there were earlier versions. The Sushruta-samhita probably originated in the last centuries BCE and had become fixed in its present form by the 7th century CE. Of somewhat lesser importance are the treatises attributed to Vagbhata. All later writings on Indian medicine were based on these works.
Because Hindus were prohibited by their religion from cutting the dead body, their knowledge of anatomy was limited. The Sushruta-samhita recommends that a body be placed in a basket and sunk in a river for seven days. On its removal the parts could be easily separated without cutting. As a result of these crude methods, the emphasis in Hindu anatomy was given first to the bones and then to the muscles, ligaments, and joints. The nerves, blood vessels, and internal organs were very imperfectly known.
The Hindus believed that the body contains three elementary substances, microcosmic representatives of the three divine universal forces, which they called spirit (air), phlegm, and bile (comparable to the humours of the Greeks). Health depends on the normal balance of these three elementary substances. The seven primary constituents of the body—blood, flesh, fat, bone, marrow, chyle, and semen—are produced by the action of the elementary substances. Semen was thought to be produced from all parts of the body and not from any individual part or organ.
Both Charaka and Sushruta state the existence of a large number of diseases (Sushruta says 1,120). Rough classifications of diseases are given. In all texts, “fever,” of which numerous types are described, is regarded as important. Phthisis (wasting disease, especially pulmonary tuberculosis) was apparently prevalent, and the Hindu physicians knew the symptoms of cases likely to terminate fatally. Smallpox was common, and it is probable that smallpox inoculation was practiced.
Hindu physicians employed all five senses in diagnosis. Hearing was used to distinguish the nature of the breathing, alteration in voice, and the grinding sound produced by the rubbing together of broken ends of bones. They appear to have had a good clinical sense, and their discourses on prognosis contain acute references to symptoms that have grave import. Magical beliefs still persisted, however, until late in the classical period; thus, the prognosis could be affected by such fortuitous factors as the cleanliness of the messenger sent to fetch the physician, the nature of his conveyance, or the types of persons the physician met on his journey to the patient.
Dietetic treatment was important and preceded any medicinal treatment. Fats were much used, internally and externally. The most important methods of active treatment were referred to as the “five procedures”: the administration of emetics, purgatives, water enemas, oil enemas, and sneezing powders. Inhalations were frequently administered, as were leeching, cupping, and bleeding.
The Indian materia medica was extensive and consisted mainly of vegetable drugs, all of which were from indigenous plants. Charaka knew 500 medicinal plants, and Sushruta knew 760. But animal remedies (such as the milk of various animals, bones, gallstones) and minerals (sulfur, arsenic, lead, copper sulfate, gold) were also employed. The physicians collected and prepared their own vegetable drugs. Among those that eventually appeared in Western pharmacopoeias were cardamom and cinnamon.
As a result of the strict religious beliefs of the Hindus, hygienic measures were important in treatment. Two meals a day were decreed, with indications of the nature of the diet, the amount of water to be drunk before and after the meal, and the use of condiments. Bathing and care of the skin were carefully prescribed, as were cleansing of the teeth with twigs from named trees, anointing of the body with oil, and the use of eyewashes.
In surgery, ancient Hindu medicine reached its zenith. Operations performed by Hindu surgeons included excision of tumours, incision and draining of abscesses, punctures to release fluid in the abdomen, extraction of foreign bodies, repair of anal fistulas, splinting of fractures, amputations, cesarean sections, and stitching of wounds.
A broad array of surgical instruments were used. According to Sushruta, the surgeon should be equipped with 20 sharp and 101 blunt instruments of various descriptions. The instruments were largely of steel. Alcohol seems to have been used as a narcotic during operations, and bleeding was stopped by hot oils and tar.
In two types of operations especially, the Hindus were outstanding. Stone in the bladder(vesical calculus) was common in ancient India, and the surgeons frequently removed the stones by lateral lithotomy. They also introduced plastic surgery. Amputation of the nose was one of the prescribed punishments for adultery, and repair was carried out by cutting from the patient’s cheek or forehead a piece of tissue of the required size and shape and applying it to the stump of the nose. The results appear to have been tolerably satisfactory, and the modern operation is certainly derived indirectly from this ancient source. Hindu surgeons also operated on cataracts by couching, or displacing the lens to improve vision.
The Chinese system of medicine is of great antiquity and is independent of any recorded external influences. According to tradition, Huangdi (the “Yellow Emperor”), one of the legendary founders of Chinese civilization, wrote the canon of internal medicine called the Huangdi neijing (Yellow Emperor’s Inner Classic) in the 3rd millennium BCE; there is some evidence that in its present form it dates from no earlier than the 3rd century BCE. Most of the Chinese medical literature is founded on the Huangdi neijing, and it is still regarded as a great authority. Other famous works are the Mojing (known in the West as the “Pulse Classic”), composed about 300 CE, and the Yuzhuan yizong jinjian (“Imperially Commissioned Golden Mirror of the Orthodox Lineage of Medicine,” also known in English as the Golden Mirror), a compilation made in 1742 of medical writings of the Han dynasty (202 BCE–220 CE). European medicine began to obtain a footing in China early in the 19th century, but the native system is still widely practiced.
Basic to traditional Chinese medicine is the dualistic cosmic theory of yinyang. The yang, the male principle, is active and light and is represented by the heavens. The yin, the female principle, is passive and dark and is represented by the earth. The human body, like matter in general, is made up of five elements: wood, fire, earth, metal, and water. With these are associated other groups of five, such as the five planets, the five conditions of the atmosphere, the five colours, and the five tones. Health, character, and the success of all political and private ventures are determined by the preponderance, at the time, of the yin or the yang, and the great aim of ancient Chinese medicine is to control their proportions in the body.
The teachings of the religious sects forbade the mutilation of the dead human body; hence, traditional anatomy rests on no sure scientific foundation. One of the most important writers on anatomy, Wang Qingren, gained his knowledge from the inspection of dog-torn children who had died in a plague epidemic in 1798 CE. Traditional Chinese anatomy is based on the cosmic system, which postulates the presence of such hypothetical structures as the 12 channels and the three so-called burning spaces. The body contains five organs (heart, lungs, liver, spleen, and kidneys), which store up but do not eliminate, and five viscera (such as the stomach, intestines, gallbladder, and bladder), which eliminate but do not store up. Each organ is associated with one of the planets, colours, tones, smells, and tastes. There are 365 bones and 365 joints in the body.
According to the physiology of traditional Chinese medicine, the blood vessels contain blood and air, in proportions varying with those of the yin and the yang. These two cosmicprinciples circulate in the 12 channels and control the blood vessels and hence the pulse. The Huangdi neijing says that “the blood current flows continuously in a circle and never stops. It may be compared to a circle without beginning or end.” On this insubstantial evidence it has been claimed that the Chinese anticipated Harvey’s discovery of the circulation of the blood. Traditional Chinese pathology is also dependent on the theory of the yin and the yang; this led to an elaborate classification of diseases in which most of the types listed are without scientific foundation.
In diagnosis, detailed questions are asked about the history of the illness and about such things as the patient’s taste, smell, and dreams. Conclusions are drawn from the quality of the voice, and note is made of the colour of the face and of the tongue. The most important part of the investigation, however, is the examination of the pulse. Wang Shuhe, who wrote the “Pulse Classic,” lived in the 3rd century BCE, and innumerable commentaries were written on his work. The pulse is examined in several places, at different times, and with varying degrees of pressure. The operation may take as long as three hours. It is often the only examination made, and it is used both for diagnosis and for prognosis. Not only are the diseased organs ascertained, but the time of death or recovery may be foretold.
The Chinese materia medica has always been extensive and consists of vegetable, animal (including human), and mineral remedies. There were famous herbals from ancient times, but all these, to the number of about 1,000, were embodied by Li Shijen in the compilation of Bencao gangmu (the “Great Pharmacopoeia”) in the 16th century CE. This work, in 52 volumes, has been frequently revised and reprinted and is still authoritative. The use of drugs is mainly to restore the harmony of the yin and the yang and is also related to such matters as the five organs, the five planets, and the five colours. The art of prescribing is therefore complex.
Among the drugs taken over by Western medicine from the Chinese are rhubarb, iron (for anemia), castor oil, kaolin, aconite, camphor, and Cannabis sativa (Indian hemp). Chaulmoogra oil was used by the Chinese for leprosy from at least the 14th century, and about the 19th century it began to be used for this purpose by Western physicians. The herb mahuang (Ephedra vulgaris) has been used in China for at least 4,000 years, and the isolation of the alkaloid ephedrine from it has greatly improved the Western treatment of asthma and similar conditions.
The most famous and expensive of Chinese remedies is ginseng. Western analysis has shown that it has diuretic and other properties but is of doubtful value. Reserpine, the active principle of the Chinese plant Rauwolfia, has also been isolated and has been effectively used in the treatment of hypertension (high blood pressure) and some emotional and mental conditions.
Hydrotherapy is probably of Chinese origin, since cold baths were used for fevers as early as 180 BCE. The inoculation of smallpox matter, in order to produce a mild but immunizing attack of the disease, was practiced in China from ancient times and came to Europe about 1720. Another treatment is moxibustion, which consists in making a small, moistened cone (moxa) of powdered leaves of mugwort, or wormwood (Artemisiaspecies), applying it to the skin, igniting it, and then crushing it into the blister so formed. Other substances are also used for the moxa. Dozens of these are sometimes applied at one sitting. The practice is often associated with acupuncture.
Acupuncture consists of the insertion into the skin and underlying tissues of a metal needle, either hot or cold. The theory is that the needle affects the distribution of the yin and the yang in the hypothetical channels and burning spaces of the body. The site of the insertion is chosen to affect a particular organ or organs. The practice of acupuncture dates from before 2500 BCE and is peculiarly Chinese. Little of practical importance has been added since that date, although there have been many well-known treatises on the subject.
A bronze model circa 860 CE shows the hundreds of specified points for the insertion of the needle; this was the forerunner of countless later models and diagrams. The needles used are 3 to 24 cm (about 1 to 9 inches) in length. They are often inserted with considerable force and after insertion may be agitated or screwed to the left or right. Acupuncture, often combined with moxibustion, is still widely used for many diseases, including fractures. Patients in the Western world have turned to acupuncturists for relief from pain and other symptoms. There is some speculation that the treatment may trigger the brain to release morphinelike substances called endorphins, which presumably reduce the feeling of pain and its concomitant emotions.
The most interesting features of Japanese medicine are the extent to which it was derivative and the rapidity with which, after a slow start, it became Westernized and scientific. In early times disease was regarded as sent by the gods or produced by the influence of evil spirits. Treatment and prevention were based largely on religious practices, such as prayers, incantations, and exorcism; at a later date drugs and bloodletting were also employed.
Beginning in 608 CE, when young Japanese physicians were sent to China for a long period of study, Chinese influence on Japanese medicine was paramount. In 982, Tamba Yasuyori completed the 30-volume Ishinhō, the oldest Japanese medical work still extant. This work discusses diseases and their treatment, classified mainly according to the affected organs or parts. It is based entirely on older Chinese medical works, with the concept of yin and yang underlying the theory of disease causation.
In 1570 a 15-volume medical work was published by Menase Dōsan, who also wrote at least five other works. In the most significant of these, the Keitekishū (1574; a manual of the practice of medicine), diseases—or sometimes merely symptoms—are classified and described in 51 groups; the work is unusual in that it includes a section on the diseases of old age. Another distinguished physician and teacher of the period, Nagata Tokuhun, whose important books were the I-no-ben (1585) and the Baika mujinzo (1611), held that the chief aim of the medical art was to support the natural force and, consequently, that it was useless to persist with stereotyped methods of treatment unless the physician had the cooperation of the patient.
European medicine was introduced into Japan in the 16th century by Jesuit missionaries and again in the 17th century by Dutch physicians. Translations of European books on anatomy and internal medicine were made in the 18th century, and in 1836 an influential Japanese work on physiology appeared. In 1857 a group of Dutch-trained Japanese physicians founded a medical school in Edo (later Tokyo) that is regarded as the beginning of the medical faculty of the Imperial University of Tokyo.
During the last third of the 18th century it became government policy to Westernize Japanese medicine, and great progress was made in the foundation of medical schools and the encouragement of research. Important medical breakthroughs by the Japanese followed, among them the discovery of the plague bacillus in 1894, the discovery of a dysentery bacillus in 1897, the isolation of adrenaline (epinephrine) in crystalline form in 1901, and the first experimental production of a tar-induced cancer in 1918.
The roots of Western medicine
The transition from magic to science was a gradual process that lasted for centuries, and there is little doubt that ancient Greece inherited much from Babylonia and Egypt and even from India and China. Modern readers of the Homeric tales the Iliad and the Odyssey may well be bewildered by the narrow distinction between gods and humans among the characters and between historical fact and poetic fancy in the story. Two characters, military surgeons Podaleirius and Machaon, are said to have been sons of Asclepius, the god of medicine. The divine Asclepius may have originated in a human Asclepius who lived about 1200 BCE and is said to have performed many miracles of healing.
Asclepius was worshipped in hundreds of temples throughout Greece, the remains of which may still be seen at Epidaurus, Cos, Athens, and elsewhere. To these resorts, or hospitals, sick persons went for the healing ritual known as incubation, or temple sleep. They lay down to sleep in the dormitory, or abaton, and were visited in their dreams by Asclepius or by one of his priests, who gave advice. In the morning the patient often is said to have departed cured. There are at Epidaurus many inscriptions recording cures, though there is no mention of failures or deaths.
Diet, baths, and exercises played their part in the treatment, and it would appear that these temples were the prototype of modern health resorts. Situated in a peaceful spot, with gardens and fountains, each had its theatre for amusements and its stadium for athletic contests. The cult of incubation continued far into the Christian era. In Greece, some of the Aegean islands, Sardinia, and Sicily, sick persons are still taken to spend a night in certain churches in the hope of a cure.
It was, however, the work of the early philosophers, rather than that of the priests of Asclepius, that impelled Greeks to refuse to be guided solely by supernatural influence and moved them to seek out for themselves the causes and reasons for the strange ways of nature. The 6th-century philosopher Pythagoras, whose chief discovery was the importance of numbers, also investigated the physics of sound, and his views influenced the medical thought of his time. In the 5th century BCE Empedocles set forth the view that the universe is composed of four elements—fire, air, earth, and water—and this conceptionled to the doctrine of the four bodily humours: blood; phlegm; choler, or yellow bile; and melancholy, or black bile. The maintenance of health was held to depend upon the harmony of the four humours.
Medical thought had reached this stage and had partially discarded the conceptions based upon magic and religion by 460 BCE, the year that Hippocrates is said to have been born. Although he has been called the father of medicine, little is known of his life, and there may in fact have been several men of this name, or Hippocrates may have been the author of only some, or none, of the books that make up the Hippocratic Collection (Corpus Hippocraticum). Ancient writers held that Hippocrates taught and practiced medicine in Cos, the island of his birth, and in other parts of Greece, including Athens, and that he died at an advanced age.
Whether Hippocrates was one man or several, the works attributed to him mark the stage in Western medicine where disease was coming to be regarded as a natural rather than a supernatural phenomenon and doctors were encouraged to look for physical causes of illness. Some of the works, notably the Aphorismi (Aphorisms), were used as textbooks until the 19th century. The first and best-known aphorism is “Life is Short, Art long, Occasion sudden and dangerous, Experience deceitful, and Judgment difficult” (often shortened to the Latin tag “Ars longa, vita brevis”). This is followed by brief comments on diseases and symptoms, many of which remain valid.
The thermometer and the stethoscope were not then known, nor indeed did Hippocrates employ any aid to diagnosis beyond his own powers of observation and logical reasoning. He had an extraordinary ability to foretell the course of a malady, and he laid more stress upon the expected outcome, or prognosis, of a disease than upon its identification, or diagnosis. He had no patience with the idea that disease was a punishment sent by the gods. Writing of epilepsy, then called “the sacred disease,” he said, “It is not any more sacred than other diseases, but has a natural cause, and its supposed divine origin is due to human inexperience. Every disease,” he continued, “has its own nature, and arises from external causes.”
Hippocrates noted the effect of food, of occupation, and especially of climate in causing disease, and one of his most interesting books, entitled De aëre, aquis et locis (Air, Waters and Places), would today be classed as a treatise on human ecology. Pursuing this line of thought, Hippocrates stated that “our natures are the physicians of our diseases” and advocated that this tendency to natural cure should be fostered. He laid much stress on diet and the use of few drugs. He knew well how to describe illness clearly and concisely and recorded failures as well as successes; he viewed disease with the eye of the naturalist and studied the entire patient in his environment.
Perhaps the greatest legacy of Hippocrates is the charter of medical conduct embodied in the so-called Hippocratic oath, which has been adopted as a pattern by physicians throughout the ages:
I swear by Apollo the physician, and Asclepius, and Health, and All-heal, and all the gods and goddesses…to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion…Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.
Not strictly an oath, it was, rather, an ethical code or ideal, an appeal for right conduct. In one or other of its many versions, it has guided the practice of medicine throughout the world for more than 2,000 years.
Hellenistic and Roman medicine
In the following century the work of Aristotle, regarded as the first great biologist, was of inestimable value to medicine. A pupil of Plato at Athens and tutor to Alexander the Great, Aristotle studied the entire world of living things. He laid what can be identified as the foundations of comparative anatomy and embryology, and his views influenced scientific thinking for the next 2,000 years.
After the time of Aristotle, the centre of Greek culture shifted to Alexandria, where a famous medical school was established about 300 BCE. There the two best medical teachers were Herophilus, whose treatise on anatomy may have been the first of its kind, and Erasistratus, regarded by some as the founder of physiology. Erasistratus noted the difference between sensory and motor nerves but thought that the nerves were hollow tubes containing fluid and that air entered the lungs and heart and was carried through the body in the arteries. Alexandria continued as a centre of medical teaching even after the Roman Empire had attained supremacy over the Greek world, and medical knowledge remained predominantly Greek.
Asclepiades of Bithynia (born 124 BCE) differed from Hippocrates in that he denied the healing power of nature and insisted that disease should be treated safely, speedily, and agreeably. An opponent of the humoral theory, he drew upon the atomic theory of 5th-century Greek philosopher Democritus in advocating a doctrine of strictum et laxum—the attribution of disease to the contracted or relaxed condition of the solid particles that he believed make up the body. To restore harmony among the particles and thus effect cures, Asclepiades used typically Greek remedies: massage, poultices, occasional tonics, fresh air, and corrective diet. He gave particular attention to mental disease, clearly distinguishing hallucinations from delusions. He released the insane from confinement in dark cellars and prescribed a regimen of occupational therapy, soothing music, soporifics (especially wine), and exercises to improve the attention and memory.
Asclepiades did much to win acceptance for Greek medicine in Rome. Aulus Cornelius Celsus, the Roman nobleman who wrote De medicina about 30 CE, gave a classic account of Greek medicine of the time, including descriptions of elaborate surgical operations. His book, overlooked in his day, enjoyed a wide reputation during the Renaissance.
During the early centuries of the Christian era, Greek doctors thronged to Rome. The most illustrious of them was Galen, who began practicing there in 161 CE. He acknowledged his debt to Hippocrates and followed the Hippocratic method, accepting the doctrine of the humours. He laid stress on the value of anatomy, and he virtually founded experimental physiology. Galen recognized that the arteries contain blood and not merely air. He showed how the heart sets the blood in motion in an ebb and flow fashion, but he had no idea that the blood circulates. Dissection of the human body was at that time illegal, so that he was forced to base his knowledge upon the examination of animals, particularly apes. A voluminous writer who stated his views forcibly and with confidence, he remained for centuries the undisputed authority from whom no one dared to differ.
Another influential physician of the 2nd century CE was Soranus of Ephesus, who wrote authoritatively on childbirth, infant care, and women’s diseases. An opponent of abortion, he advocated numerous means of contraception. He also described how to assist a difficult delivery by turning the fetus in the uterus (podalic version), a life-saving technique that was subsequently lost sight of until it was revived in the 16th century.
Although the contribution of Rome to the practice of medicine was negligible compared with that of Greece, in matters of public health the Romans set the world a great example. The city of Rome had an unrivaled water supply. Gymnasiums and public baths were provided, and there was even domestic sanitation and adequate disposal of sewage. The army had its medical officers, public physicians were appointed to attend the poor, and hospitals were built; a Roman hospital excavated near Düsseldorf, Germany, was found to be strikingly modern in design.
Christian and Muslim reservoirs of learning
After the fall of Rome, learning was no longer held in high esteem, experiment was discouraged, and originality became a dangerous asset. During the early Middle Agesmedicine passed into the widely diverse hands of the Christian church and Arab scholars.
Translators and saints
It is sometimes stated that the early Christian church had an adverse effect upon medical progress. Disease was regarded as a punishment for sin, and such chastening demanded only prayer and repentance. Moreover, the human body was held sacred and dissection was forbidden. But the infinite care and nursing bestowed upon the sick under Christian auspices must outweigh any intolerance shown toward medicine in the early days.
Perhaps the greatest service rendered to medicine by the church was the preservation and transcription of the Classical Greek medical manuscripts. These were translated into Latin in many medieval monasteries, and the Nestorian Christians (an Eastern church) established a school of translators to render the Greek texts into Arabic. This famous school, and also a great hospital, were located at Jundi Shāhpūr in southwest Persia, where the chief physician was Jurjīs ibn Bukhtīshūʿ, the first of a dynasty of translators and physicians that lasted for six generations. A later translator of great renown was Ḥunayn ibn Isḥāq, or Johannitus (born 809), whose translations were said to be worth their weight in gold.
About this time there appeared a number of saints whose names were associated with miraculous cures. Among the earliest of these were twin brothers, Cosmas and Damian, who suffered martyrdom (c. 303) and became the patron saints of medicine. Other saints were invoked as powerful healers of certain diseases, such as St. Vitus for chorea (or St. Vitus’s dance) and St. Anthony for erysipelas (or St. Anthony’s fire). The cult of these saints was widespread in medieval times, and a later cult, that of St. Roch for plague, was widespread during the plague-ridden years of the 14th century.
A second reservoir of medical learning during those times was the great Muslim empire, which extended from Persia to Spain. Although it is customary to speak of Arabian medicine in describing this period, not all of the physicians were Arabs or natives of Arabia. Nor, indeed, were they all Muslims: some were Jews, some Christians, and they were drawn from all parts of the empire. One of the earliest figures was Rhazes, a Persianborn in the last half of the 9th century near modern Tehrān, who wrote a voluminous treatise on medicine, Kitāb al-hāḳī (“Comprehensive Book”), but whose most famous work, De variolis et morbillis (A Treatise on the Smallpox and Measles), distinguishes between these two diseases and gives a clear description of both.
Of later date was Avicenna (980–1037), a Muslim physician, who has been called the prince of physicians and whose tomb at Hamadan has become a place of pilgrimage. He could repeat the Qurʾān before he was 10 years old and at the age of 18 became court physician. His principal medical work, Al-Qānūn fī aṭ-ṭibb (The Canon of Medicine), became a classic and was used at many medical schools—at Montpellier, France, as late as 1650—and reputedly is still used in the East.
The greatest contribution of Arabian medicine was in chemistry and in the knowledge and preparation of medicines. The chemists of that time were alchemists, and their pursuit was mainly a search for the philosopher’s stone, which supposedly would turn common metals into gold. In the course of their experiments, however, numerous substances were named and characterized, and some were found to have medicinal value. Many drugs are of Arab origin, as are such processes as sublimation.
In that period, and indeed throughout most historical times, surgery was considered inferior to medicine, and surgeons were held in low regard. Renowned Spanish surgeon Abū al-Qāsim (Albucasis), however, did much to raise the status of surgery in Córdoba, an important centre of commerce and culture with a hospital and medical school equal to those of Cairo and Baghdad. A careful and conservative practitioner, he wrote the first illustrated surgical text, which held wide influence in Europe for centuries.
Another great doctor of Córdoba, born in the 12th century, just as the sun of Arabian culture was setting, was Jewish philosopher Moses Maimonides. Banished from the city because he would not become a Muslim, he eventually went to Cairo, where the law was more lenient and where he acquired a reputation so high that he became physician to Saladin, the Saracen leader. (He was the original of El Hakim in Sir Walter Scott’s Talisman.) A few of his works, written in Hebrew, were eventually translated into Latin and printed.
Medieval and Renaissance Europe
Salerno and the medical schools
At about the same time that Arabian medicine flourished, the first organized medical school in Europe was established at Salerno, in southern Italy. Although the school of Salerno produced no brilliant genius and no startling discovery, it was the outstanding medical institution of its time and the parent of the great medieval schools soon to be founded at Montpellier and Paris, in France, and at Bologna and Padua, in Italy. Salerno drew scholars from near and far. Remarkably liberal in some of its views, Salerno admitted women as medical students. The school owed much to the enlightened Holy Roman emperor Frederick II, who decreed in 1221 that no one should practice medicine until he had been publicly approved by the masters of Salerno.
The Salernitan school also produced a literature of its own. The best-known work, of uncertain date and of composite authorship, was the Regimen Sanitatis Salernitanum(“Salernitan Guide to Health”). Written in verse, it appeared in numerous editions and was translated into many languages. Among its oft-quoted couplets is the following:
Use three physicians still, first Doctor Quiet,
Next Doctor Merryman, and Doctor Diet.
Salerno yielded its place as the premier medical school of Europe to Montpellier about 1200. John of Gaddesden, the model for the “doctour of physick” in Geoffrey Chaucer’sCanterbury Tales, was one of the English students there. That he relied upon astrology and upon the doctrine of the humours is evident from Chaucer’s description:
Well could he guess the ascending of the star
Wherein his patient’s fortunes settled were.
He knew the course of every malady,
Were it of cold or heat or moist or dry.
Medieval physicians analyzed symptoms, examined excreta, and made their diagnoses. Then they might prescribe diet, rest, sleep, exercise, or baths, or they could administer emetics and purgatives or bleed the patient. Surgeons could treat fractures and dislocations, repair hernias, and perform amputations and a few other operations. Some of them prescribed opium, mandragora, or alcohol to deaden pain. Childbirth was left to midwives, who relied on folklore and tradition.
Great hospitals were established during the Middle Ages by religious foundations, and infirmaries were attached to abbeys, monasteries, priories, and convents. Doctors and nurses in these institutions were members of religious orders and combined spiritual with physical healing.
The spread of new learning
Among the teachers of medicine in the medieval universities there were many who clung to the past, but there were not a few who determined to explore new lines of thought. The new learning of the Renaissance, born in Italy, grew and expanded slowly. Two great 13th-century scholars who influenced medicine were Roger Bacon, an active observer and tireless experimenter, and Albertus Magnus, a distinguished philosopher and scientific writer.
About this time Mondino dei Liucci taught at Bologna. Prohibitions against human dissection were slowly lifting, and Mondino performed his own dissections rather than following the customary procedure of entrusting the task to a menial. Although he perpetuated the errors of Galen, his Anothomia, published in 1316, was the first practical manual of anatomy. Foremost among the surgeons of the day was Guy de Chauliac, a physician to three popes at Avignon. His Chirurgia magna (“Great Surgery”), based on observation and experience, had a profound influence upon the progress of surgery.
The Renaissance in the 14th, 15th, and 16th centuries was much more than just a reviving of interest in Greek and Roman culture; it was rather a change of outlook, an eagerness for discovery, a desire to escape from the limitations of tradition and to explore new fields of thought and action. In medicine, it was perhaps natural that anatomy and physiology, the knowledge of the human body and its workings, should be the first aspects of medical learning to receive attention from those who realized the need for reform.
It was in 1543 that Andreas Vesalius, a young Belgian professor of anatomy at the University of Padua, published De humani corporis fabrica (“On the Structure of the Human Body”). Based on his own dissections, this seminal work corrected many of Galen’s errors. By his scientific observations and methods, Vesalius showed that Galen could no longer be regarded as the final authority. His work at Padua was continued by Gabriel Fallopius and, later, by Hieronymus Fabricius ab Aquapendente; it was his work on the valves in the veins, De venarum ostiolis (1603), that suggested to his pupil William Harvey his revolutionary theory of the circulation of the blood, one of the great medical discoveries.
Surgery profited from the new outlook in anatomy, and the great reformer Ambroise Parédominated the field in the 16th century. Paré was surgeon to four kings of France, and he has deservedly been called the father of modern surgery. In his autobiography, written after he had retired from 30 years of service as an army surgeon, Paré described how he had abolished the painful practice of cauterization to stop bleeding and used ligatures and dressings instead. His favourite expression, “I dressed him; God healed him,” is characteristic of this humane and careful doctor.
In Britain during this period, surgery, which was performed by barber-surgeons, was becoming regulated and organized under royal charters. Companies were thus formed that eventually became the royal colleges of surgeons in Scotland and England. Physicians and surgeons united in a joint organization in Glasgow, and a college of physicians was founded in London.
The 16th-century medical scene was enlivened by the enigmatic physician and alchemist who called himself Paracelsus. Born in Switzerland, he traveled extensively throughout Europe, gaining medical skills and practicing and teaching as he went. In the tradition of Hippocrates, Paracelsus stressed the power of nature to heal, but, unlike Hippocrates, he believed also in the power of supernatural forces, and he violently attacked the medical treatments of his day. Eager for reform, he allowed his intolerance to outweigh his discretion, as when he prefaced his lectures at Basel by publicly burning the works of Avicenna and Galen. The authorities and medical men were understandably outraged. Widely famous in his time, Paracelsus remains a controversial figure to this day. Despite his turbulent career, however, he did attempt to bring a more rational approach to diagnosis and treatment, and he introduced the use of chemical drugs in place of herbal remedies.
A contemporary of Paracelsus, Girolamo Fracastoro of Italy was a scholar cast from a very different mold. His account of the disease syphilis, entitled Syphilis sive morbus Gallicus(1530; “Syphilis or the French Disease”), was written in verse. Although Fracastoro called syphilis the French disease, others called it the Neapolitan disease, for it was said to have been brought to Naples from America by the sailors of Christopher Columbus. Its origin is still questioned, however. Fracastoro was interested in epidemic infection, and he offered the first scientific explanation of disease transmission. In his great work, De contagione et contagiosis morbis (1546), he theorized that the seeds of certain diseases are imperceptible particles transmitted by air or by contact.
In the 17th century the natural sciences moved forward on a broad front. There were attempts to grapple with the nature of science, as expressed in the works of thinkers like Francis Bacon, René Descartes, and Sir Isaac Newton. New knowledge of chemistry superseded the theory that all things are made up of earth, air, fire, and water, and the old Aristotelian ideas began to be discarded. The supreme 17th-century achievement in medicine was Harvey’s explanation of the circulation of blood.
Harvey and the experimental method
Born in Folkestone, England, William Harvey studied at Cambridge and then spent several years at Padua, where he came under the influence of Fabricius. He established a successful medical practice in London and, by precise observation and scrupulous reasoning, developed his theory of circulation. In 1628 he published his classic book Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (Concerning the Motion of the Heart and Blood), often called De Motu Cordis.
William Harvey: theory of the circulation of bloodWoodcut depicting William Harvey’s theory of the circulation of blood, from his Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (1628).
There was one gap in Harvey’s argument: he was obliged to assume the existence of the capillary vessels that conveyed the blood from the arteries to the veins. This link in the chain of evidence was supplied by Marcello Malpighi of Bologna (who was born in 1628, the year of publication of De Motu Cordis). With a primitive microscope, Malpighi saw a network of tiny blood vessels in the lung of a frog. Harvey also failed to show why the blood circulated. After Robert Boyle had shown that air is essential to animal life, it was Richard Lower who traced the interaction between air and the blood. Eventually, the importance of oxygen, which was confused for a time by some as phlogiston, was revealed, although it was not until the late 18th century that the great chemist Antoine-Laurent Lavoisier discovered the essential nature of oxygen and clarified its relation to respiration.
Although the compound microscope had been invented slightly earlier, probably in Holland, its development, like that of the telescope, was the work of Galileo. He was the first to insist upon the value of measurement in science and in medicine, thus replacing theory and guesswork with accuracy. The great Dutch microscopist Antonie van Leeuwenhoek devoted his long life to microscopical studies and was probably the first to see and describe bacteria, reporting his results to the Royal Society of London. In England, Robert Hooke, who was Boyle’s assistant and curator to the Royal Society, published his Micrographia in 1665, which discussed and illustrated the microscopic structure of a variety of materials.
The futile search for an easy system
Several attempts were made in the 17th century to discover an easy system that would guide the practice of medicine. A substratum of superstition still remained. Richard Wiseman, surgeon to Charles II, affirmed his belief in the “royal touch” as a cure for king’s evil, or scrofula, while even the learned English physician Thomas Browne stated that witches really existed. There was, however, a general desire to discard the past and adopt new ideas.
The view of French philosopher René Descartes that the human body is a machine and that it functions mechanically had its repercussions in medical thought. One group adopting this explanation called themselves the iatrophysicists; another school, preferring to view life as a series of chemical processes, were called iatrochemists. Santorio Santorio, working at Padua, was an early exponent of the iatrophysical view and a pioneer investigator of metabolism. He was especially concerned with the measurement of what he called “insensible perspiration,” described in his book De Statica Medicina (1614; “On Medical Measurement”). Another Italian, who developed the idea still further, was Giovanni Alfonso Borelli, a professor of mathematics at Pisa, who gave his attention to the mechanics and statics of the body and to the physical laws that govern its movements.
The iatrochemical school was founded at Brussels by Jan Baptist van Helmont, whose writings are tinged with the mysticism of the alchemist. A more logical and intelligible view of iatrochemistry was advanced by Franciscus Sylvius, at Leiden, and in England a leading exponent of the same school was Thomas Willis, who is better known for his description of the brain in his Cerebri Anatome Nervorumque Descriptio et Usus(“Anatomy of the Brain and Descriptions and Functions of the Nerves”), published in 1664 and illustrated by Sir Christopher Wren.
It soon became apparent that no easy road to medical knowledge and practice was to be found along these channels and that the best method was the age-old system of straightforward clinical observation initiated by Hippocrates. The need for a return to these views was strongly urged by Thomas Sydenham, well named “the English Hippocrates.” Sydenham was not a voluminous writer and, indeed, had little patience with book learning in medicine; nevertheless, he gave excellent descriptions of the phenomena of disease. His greatest service, much needed at the time, was to divert physicians’ minds from speculation and lead them back to the bedside, where the true art of medicine could be studied.
Medicine in the 18th century
Even in the 18th century the search for a simple way of healing the sick continued. In Edinburgh the writer and lecturer John Brown expounded his view that there were only two diseases, sthenic (strong) and asthenic (weak), and two treatments, stimulant and sedative; his chief remedies were alcohol and opium. Lively and heated debates took place between his followers, the Brunonians, and the more orthodox Cullenians (followers of William Cullen, a professor of medicine at Glasgow), and the controversy spread to the medical centres of Europe.
At the opposite end of the scale, at least in regard to dosage, was Samuel Hahnemann, of Leipzig, the originator of homeopathy, a system of treatment involving the administration of minute doses of drugs whose effects resemble the effects of the disease being treated. His ideas had a salutary effect upon medical thought at a time when prescriptions were lengthy and doses were large, and his system has had many followers.
By the 18th century the medical school at Leiden had grown to rival that of Padua, and many students were attracted there from abroad. Among them was John Monro, an army surgeon, who resolved that his native city of Edinburgh should have a similar medical school. He specially educated his son Alexander with a view to having him appointed professor of anatomy, and the bold plan was successful. Alexander Monro studied at Leiden under Hermann Boerhaave, the central figure of European medicine and the greatest clinical teacher of his time. Subsequently, three generations of the Monro familytaught anatomy at Edinburgh over a continuous period of 126 years. Medical education was increasingly incorporated into the universities of Europe, and Edinburgh became the leading academic centre for medicine in Britain.
In 18th-century London, Scottish doctors were the leaders in surgery and obstetrics. The noted teacher John Hunter conducted extensive researches in comparative anatomy and physiology, founded surgical pathology, and raised surgery to the level of a respectable branch of science. His brother William Hunter, an eminent teacher of anatomy, became famous as an obstetrician. Male doctors were now attending women in childbirth, and the leading obstetrician in London was William Smellie. His well-known Treatise on the Theory and Practice of Midwifery, published in three volumes in 1752–64, contained the first systematic discussion on the safe use of obstetrical forceps, which have since saved countless lives. Smellie placed midwifery on a sound scientific footing and helped to establish obstetrics as a recognized medical discipline.
The science of modern pathology also had its beginnings in this century. Giovanni Battista Morgagni, of Padua, in 1761 published his massive work De Sedibus et Causis Morborum(The Seats and Causes of Diseases Investigated by Anatomy), a description of the appearances found by postmortem examination of almost 700 cases, in which he attempted to correlate the findings after death with the clinical picture in life.
On the basis of work begun in the 18th century, René Laënnec, a native of Brittany, who practiced medicine in Paris, invented a simple stethoscope, or cylindre, as it was originally called. In 1819 he wrote a treatise, De l’auscultation médiate (“On Mediate Auscultation”), describing many of the curious sounds in the heart and lungs that are revealed by the instrument. Meanwhile, a Viennese physician, Leopold Auenbrugger, discovered another method of investigating diseases of the chest, that of percussion. The son of an innkeeper, he is said to have conceived the idea of tapping with the fingers when he recalled that he had used this method to gauge the level of the fluid contents of his father’s casks.
One highly significant medical advance, late in the century, was vaccination. Smallpox, disfiguring and often fatal, was widely prevalent. Inoculation, which had been practiced in the East, was popularized in England in 1721–22 by Lady Mary Wortley Montagu, who is best known for her letters. She observed the practice in Turkey, where it produced a mild form of the disease, thus securing immunity although not without danger. The next step was taken by Edward Jenner, a country practitioner who had been a pupil of John Hunter. In 1796 Jenner began inoculations with material from cowpox (the bovine form of the disease). When he later inoculated the same subject with smallpox, the disease did not appear. This procedure—vaccination—has been responsible for eradicating the disease.
Public health and hygiene were receiving more attention during the 18th century. Population statistics began to be kept, and suggestions arose concerning health legislation. Hospitals were established for a variety of purposes. In Paris, Philippe Pinel initiated bold reforms in the care of the mentally ill, releasing them from their chains and discarding the long-held notion that insanity was caused by demon possession.
Conditions improved for sailors and soldiers as well. James Lind, a British naval surgeon from Edinburgh, recommended fresh fruits and citrus juices to prevent scurvy, a remedy discovered by the Dutch in the 16th century. When the British navy adopted Lind’s advice—decades later—this deficiency disease was eliminated. In 1752 a Scotsman, John Pringle, published his classic Observations on the Diseases of the Army, which contained numerous recommendations for the health and comfort of the troops. Serving with the British forces during the War of the Austrian Succession, he suggested in 1743 that military hospitals on both sides should be regarded as sanctuaries; this plan eventually led to the establishment of the Red Cross organization in 1864.
Two pseudoscientific doctrines relating to medicine emerged from Vienna in the latter part of the century and attained wide notoriety. Mesmerism, a belief in “animal magnetism” sponsored by Franz Anton Mesmer, probably owed any therapeutic value it had to suggestions given while the patient was under hypnosis. Phrenology, propounded by Franz Joseph Gall, held that the contours of the skull are a guide to an individual’s mental faculties and character traits; this theory remained popular throughout the 19th century.
At the same time, sound scientific thinking was making steady progress, and advances in physics, chemistry, and the biological sciences were converging to form a rational scientific basis for every branch of clinical medicine. New knowledge disseminatedthroughout Europe and traveled across the sea, where centres of medical excellence were being established in America.
The rise of scientific medicine in the 19th century
The portrayal of the history of medicine becomes more difficult in the 19th century. Discoveries multiply, and the number of eminent doctors is so great that the history is apt to become a series of biographies. Nevertheless, it is possible to discern the leading trends in modern medical thought.
By the beginning of the 19th century, the structure of the human body was almost fully known, due to new methods of microscopy and of injections. Even the body’s microscopic structure was understood. But as important as anatomical knowledge was an understanding of physiological processes, which were rapidly being elucidated, especially in Germany. There, physiology became established as a distinct science under the guidance of Johannes Müller, who was a professor at Bonn and then at the University of Berlin. An energetic worker and an inspiring teacher, he described his discoveries in a famous textbook, Handbuch der Physiologie des Menschen (“Manual of Human Physiology”), published in the 1830s.
Among Müller’s illustrious pupils were Hermann von Helmholtz, who made significant discoveries relating to sight and hearing and who invented the ophthalmoscope, and Rudolf Virchow, one of the century’s great medical scientists, whose outstanding achievement was his conception of the cell as the centre of all pathological changes. Virchow’s work Die Cellularpathologie, published in 1858, gave the deathblow to the outmoded view that disease is due to an imbalance of the four humours.
In France the most brilliant physiologist of the time was Claude Bernard, whose many important discoveries were the outcome of carefully planned experiments. His researches clarified the role of the pancreas in digestion, revealed the presence of glycogen in the liver, and explained how the contraction and expansion of the blood vessels are controlled by vasomotor nerves. He proposed the concept of the internal environment—the chemical balance in and around the cells—and the importance of its stability. His Introduction à l’étude de la médecine expérimentale (1865; An Introduction to the Study of Experimental Medicine) is still worthy of study by all who undertake research.
Verification of the germ theory
Perhaps the overarching medical advance of the 19th century, certainly the most spectacular, was the conclusive demonstration that certain diseases, as well as the infection of surgical wounds, were directly caused by minute living organisms. This discovery changed the whole face of pathology and effected a complete revolution in the practice of surgery.
The idea that disease was caused by entry into the body of imperceptible particles is of ancient date. It was expressed by Roman encyclopaedist Marcus Terentius Varro as early as 100 BCE, by Girolamo Fracastoro in 1546, by Athanasius Kircher and Pierre Borel about a century later, and by Francesco Redi, who in 1684 wrote his Osservazioni intorno agli animali viventi che si trovano negli animali viventi (“Observations on Living Animals Which Are to Be Found Within Other Living Animals”), in which he sought to disprove the idea of spontaneous generation. Everything must have a parent, he wrote; only life produces life. A 19th-century pioneer in this field, regarded by some as founder of the parasitic theory of infection, was Agostino Bassi of Italy, who showed that a disease of silkworms was caused by a fungus that could be destroyed by chemical agents.
The main credit for establishing the science of bacteriology must be accorded to French chemist Louis Pasteur. It was Pasteur who, by a brilliant series of experiments, proved that the fermentation of wine and the souring of milk are caused by living microorganisms. His work led to the pasteurization of milk and solved problems of agriculture and industry as well as those of animal and human diseases. He successfully employed inoculations to prevent anthrax in sheep and cattle, chicken cholera in fowl, and finally rabies in humans and dogs. The latter resulted in the widespread establishment of Pasteur institutes.
From Pasteur, Joseph Lister derived the concepts that enabled him to introduce the antiseptic principle into surgery. In 1865 Lister, a professor of surgery at Glasgow University, began placing an antiseptic barrier of carbolic acid between the wound and the germ-containing atmosphere. Infections and deaths fell dramatically, and his pioneering work led to more refined techniques of sterilizing the surgical environment.
Advances in obstetrics had already been made by individuals such as Alexander Gordon at Aberdeen, Scotland, Oliver Wendell Holmes at Boston, and Ignaz Semmelweis at Viennaand Pest (Budapest), who advocated disinfection of the hands and clothing of midwivesand medical students who attended confinements. These measures produced a marked reduction in cases of puerperal fever, the bacterial scourge of women following childbirth.
Another pioneer in bacteriology was German physician Robert Koch, who showed how bacteria could be cultivated, isolated, and examined in the laboratory. A meticulousinvestigator, Koch discovered the organisms of tuberculosis in 1882 and of cholera in 1883. By the end of the century many other disease-producing microorganisms had been identified.
Discoveries in clinical medicine and anesthesia
There was perhaps some danger that in the search for bacteria other causes of disease would escape detection. Many physicians, however, were working along different lines in the 19th century. Among them were a group attached to Guy’s Hospital in London: Richard Bright, Thomas Addison, and Sir William Gull. Bright contributed significantly to the knowledge of kidney diseases, including Bright disease, and Addison gave his name to disorders of the adrenal glands and the blood. Gull, a famous clinical teacher, left a legacyof pithy aphorisms that might well rank with those of Hippocrates.
In Dublin Robert Graves and William Stokes introduced new methods in clinical diagnosisand medical training, while in Paris a leading clinician, Pierre-Charles-Alexandre Louis, was attracting many students from America by the excellence of his teaching. By the early 19th century the United States was ready to send back the results of its own researches and breakthroughs. In 1809, in a small Kentucky town, Ephraim McDowell boldly operated on a woman—without anesthesia or antisepsis—and successfully removed a large ovarian tumour. William Beaumont, in treating a shotgun wound of the stomach, was led to make many original observations that were published in 1833 as Experiments and Observations on the Gastric Juice and the Physiology of Digestion.
The most famous contribution by the United States to medical progress at this period was undoubtedly the introduction of general anesthesia, a procedure that not only liberated the patient from the fearful pain of surgery but also enabled the surgeon to perform more extensive operations. The discovery was marred by controversy. Crawford Long, Gardner Colton, Horace Wells, and Charles Jackson are all claimants for priority; some used nitrous oxide gas, and others employed ether, which was less capricious. There is little doubt, however, that it was William Thomas Green Morton who, on October 16, 1846, at Massachusetts General Hospital in Boston, first demonstrated before a gathering of physicians the use of ether as a general anesthetic. The news quickly reached Europe, and general anesthesia soon became prevalent in surgery. At Edinburgh, the professor of midwifery, James Young Simpson, had been experimenting upon himself and his assistants, inhaling various vapours with the object of discovering an effective anesthetic. In November 1847 chloroform was tried with complete success, and soon it was preferred to ether and became the anesthetic of choice.
Advances at the end of the century
While antisepsis and anesthesia placed surgery on an entirely new footing, similarly important work was carried out in other fields of study, such as parasitology and disease transmission. Patrick Manson, a British pioneer in tropical medicine, showed in China in 1877 how insects can carry disease and how the embryos of the Filaria worm, which can cause elephantiasis, are transmitted by the mosquito. Manson explained his views to British army surgeon Ronald Ross, who was then working on the problem of malaria. Ross discovered the malarial parasite in the stomach of the Anopheles mosquito in 1897.
In Cuba, Carlos Finlay expressed the view in 1881 that yellow fever is carried by the Stegomyia fasciata (later renamed Aedes aegypti) mosquito. Following his lead, American researchers Walter Reed, William Gorgas, and others were able to conquer the scourge of yellow fever in Panama and made possible the completion of the Panama Canalby reducing the death rate there from 176 per 1,000 to 6 per 1,000.
Other victories in preventive medicine ensued, because the maintenance of health was now becoming as important a concern as the cure of disease, and the 20th century was to witness the evolution and progress of national health services in a number of countries. In addition, spectacular advances in diagnosis and treatment followed the discovery of X-rays by Wilhelm Conrad Röntgen, in 1895, and of radium by Pierre and Marie Curie, in 1898. Before the turn of the century, too, the vast new field of psychiatry had been opened up by Sigmund Freud. The tremendous increase in scientific knowledge during the 19th century radically altered and expanded the practice of medicine. Concern for upholding the quality of services led to the establishment of public and professional bodies to govern the standards for medical training and practice.