The Medicine Book

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MEDTIHCE INE BOOK

DK LONDON DK DELHI original styling by SENIOR ART EDITOR SENIOR ART EDITORS STUDIO 8 Helen Spencer Ira Sharma, Vikas Sachdeva, First published in Great Britain in 2021 by SENIOR EDITORS Vinita Venugopal Dorling Kindersley Limited Camilla Hallinan, Kathryn Hennessy, PROJECT ART EDITOR DK, One Embassy Gardens, Laura Sandford Sourabh Challariya 8 Viaduct Gardens, London, SW11 7BW ART EDITORS Copyright © 2021 Dorling Kindersley Limited EDITORS Anna Cheifetz, Lydia Halliday, Shipra Jain, Noopur Dalal, Anukriti Arora A Penguin Random House Company Joanna Micklem, Victoria Pyke, ASSISTANT ART EDITORS 10 9 8 7 6 5 4 3 2 1 001–322083–Mar/2021 Dorothy Stannard, Ankita Das, Bandana Paul, Adhithi Priya All rights reserved. Rachel Warren Chadd SENIOR EDITOR Janashree Singha No part of this publication may be ILLUSTRATIONS EDITORS reproduced, stored in or introduced into a James Graham Nandini D. Tripathy, Rishi Bryan, retrieval system, or transmitted, in any JACKET DESIGN Avanika form, or by any means (electronic, DEVELOPMENT MANAGER MANAGING EDITOR mechanical, photocopying, recording, or Sophia MTT Soma B. Chowdhury otherwise), without the prior written SENIOR MANAGING ART EDITOR permission of the copyright owner. PRODUCTION EDITOR Arunesh Talapatra A CIP catalogue record for this book George Nimmo SENIOR JACKET DESIGNER is available from the British Library. ISBN: 978-0-2414-7125-8 PRODUCER Suhita Dharamjit Printed in China Nancy-Jane Maun DTP DESIGNERS Ashok Kumar, Mrinmoy Mazumdar www.dk.com SENIOR MANAGING ART EDITOR PICTURE RESEARCH COORDINATOR Lee Griffiths Sumita Khatwani This book was made with ASSISTANT PICTURE RESEARCHER Forest Stewardship Council ™ MANAGING EDITOR Sneha Murchavade certified paper – one small step in Gareth Jones PICTURE RESEARCH MANAGER DK’s commitment to a sustainable Taiyaba Khatoon future. For more information go to ASSOCIATE PUBLISHING DIRECTOR PRE-PRODUCTION MANAGER www.dk.com/our-green-pledge Liz Wheeler Balwant Singh ART DIRECTOR PRODUCTION MANAGER Karen Self Pankaj Sharma DESIGN DIRECTOR Philip Ormerod PUBLISHING DIRECTOR Jonathan Metcalf

CONTRIBUTORS STEVE PARKER, CONSULTANT EDITOR BEN HUBBARD Steve Parker is a writer and editor of more than 300 Ben Hubbard is an accomplished non-fiction author of information books specializing in science, particularly books for children and adults. He has more than 120 titles biology and medicine, and allied life sciences. He holds a to his name and has written on everything from space, the BSc in Zoology, is a senior scientific fellow of the Zoological samurai, and sharks, to poison, pets, and the Plantagenets. Society of London, and has authored titles for a range of His books have been translated into more than a dozen ages and publishers. Among Steve’s recent accolades is languages and can be found in libraries around the world. the British Medical Association’s Award for the Public Understanding of Science for Kill or Cure: An Illustrated PHILIP PARKER History of Medicine. Philip Parker is a critically acclaimed author, award-winning JOHN FARNDON editor, and historian specializing in the classical and medieval world. He is author of the DK Companion Guide John Farndon is a science writer, whose books have to World History, The Empire Stops Here: A Journey been shortlisted for the Royal Society’s Young People’s around the Frontiers of the Roman Empire, and A History Science Book Prize five times, including for The Complete of Britain in Maps, and he was a contributor to DK’s Book of the Brain and Project Body. A widely published Medicine. He was previously a diplomat working on author, he has written or contributed to around 1,000 books the UK’s relations with Greece and Cyprus and holds on a range of subjects, including the history of medicine, a diploma in international relations from Johns Hopkins and has contributed to major books such as Science and University’s School of Advanced International Studies. Science Year By Year and the Nobel Prize in Physiology or Medicine website. ROBERT SNEDDEN TIM HARRIS Robert Snedden has been involved in publishing for over 40 years, researching and writing science and technology Tim Harris is a widely published author on science books for young people on topics ranging from medical and nature for both children and adults. He has written ethics, autism, cell biology, nutrition, and the human body more than 100 mostly educational reference books to space exploration, engineering, computers, and the and contributed to many others, including Knowledge internet. He has also contributed to histories of mathematics, Encyclopedia Human Body!, An Illustrated History engineering, biology, and evolution, and written books for of Engineering, Physics Matters, Great Scientists, an adult audience on breakthroughs in mathematics and Exploring the Solar System, and Routes of Science. medicine and the works of Albert Einstein.

6 CONTENTS 10 INTRODUCTION 36 Nature itself is the 76 Hope of a good, speedy best physician deliverance ANCIENT AND Herbal medicine Midwifery MEDIEVAL MEDICINE 38 To diagnose, one must 78 The harvest of diseases observe and reason reaped by workers PREHISTORY TO 1600 Roman medicine Occupational medicine 18 A shaman to combat 44 Know the causes of 80 The peculiar disease and death sickness and health circumstances Prehistoric medicine Islamic medicine of the patient Case history 20 A healer of one disease 50 Learned, expert, ingenious, and no more and able to adapt 82 To restore the sick Ancient Egyptian medicine Medieval medical schools to health as speedily and surgery as possible 22 The balance of the doshas Hospitals is freedom from disease 52 The vampire of medicine Ayurvedic medicine Bloodletting and leeches 84 Great and unknown virtue in this fruit 26 We rebuild what fortune 53 Wars have furthered the Preventing scurvy has taken away progress of the healing art Plastic surgery Battlefield medicine 28 First, do no harm 54 The art of prescribing Greek medicine lies in nature Pharmacy 30 A body in balance Traditional Chinese medicine 60 Teach not from books but from dissections Anatomy THE SCIENTIFIC BODY 1600–1820 68 The blood is driven 86 The bark of a tree is into a round very efficacious Blood circulation Aspirin 74 A disease known is 88 Surgery has become half cured a science Nosology Scientific surgery

7 90 The dangerously wounded 112 Soothing, quieting, must be tended first and delightful beyond measure Triage Anaesthesia 91 A peculiarity in my 118 Wash your hands vision Colour vision deficiency Hygiene 92 No longer feared, but 120 Medicine needs men understood and women Humane mental health care Women in medicine 94 Training the immune 122 All cells come from cells 154 Defence against system Histology intruders Vaccination The immune system 124 They mistook the smoke 102 Like cures like for the fire 162 A single mosquito bite Homeopathy Epidemiology is all it takes Malaria 103 To hear the beating 128 A hospital should do the of the heart sick no harm VACCINES, The stethoscope Nursing and sanitation SERUMS, AND ANTIBIOTICS CELLS AND 134 Disturbances at the MICROBES cellular level 1890–1945 Cellular pathology 1820–1890 168 Solving the puzzle 136 Make yourselves masters of cancer 108 Let healthy blood leap of anatomy Cancer therapy into the sick man Gray’s Anatomy Blood transfusion and blood 176 The darker shadow groups 137 One must replace the of the bones scarring tissue X-rays Skin grafts 177 Viruses are alpha 138 Life is at the mercy of predators these minute bodies Virology Germ theory 178 Dreams are the royal 146 A genetic misprint road to the unconscious Inheritance and hereditary Psychoanalysis conditions 148 It is from particles that all the mischief arises Antiseptics in surgery 152 The field of vital phenomena Physiology

8 184 It must be a 214 No woman is free who 240 The quietening effect chemical reflex does not own her body Lithium and bipolar disorder Hormones and Birth control endocrinology 241 A psychic penicillin 216 Marvellous mould that Chlorpromazine and 188 The action currents saves lives antipsychotics of the heart Antibiotics Electrocardiography 242 Changing the way 224 New windows into you think 190 Strings of flashing and the brain Behavioural and travelling sparks Electroencephalography cognitive therapy The nervous system 226 Silent disease can be 244 A new diagnostic 196 A peculiar disease of found early dimension the cerebral cortex Cancer screening Ultrasound Alzheimer’s disease GLOBAL HEALTH 245 All the cells had 47 198 Magic bullets chromosomes Targeted drug delivery 1945–1970 Chromosomes and Down syndrome 200 Unknown substances 232 We defend everyone’s essential for life right to health 246 Death becomes life Vitamins and diet The World Health Transplant surgery Organization 204 An invisible, 254 A promising but unruly antagonistic microbe 234 The artificial kidney can molecule Bacteriophages and save a life Interferon phage therapy Dialysis 255 A sensation for the patient 206 A weakened form 236 Nature’s dramatic Pacemakers of the germ antidote Attenuated vaccines Steroids and cortisone 256 The centre of our immune response 210 To imitate the action Lymphocytes and lymphatics of the pancreas Diabetes and its 258 The power to decide treatment Hormonal contraception

9 259 Asking for proof of safety 305 The barriers of space and The FDA and thalidomide distance have collapsed Robotics and telesurgery 260 A return to function Orthopaedic surgery 306 Public health enemy number one 266 Smoking kills Pandemics Tobacco and lung cancer 314 To reprogram a cell 268 Help to live until you die Regenerative medicine Palliative care 315 This is my new face GENES AND 286 Victory over smallpox Face transplants TECHNOLOGY Global eradication of disease 316 DIRECTORY 1970 ONWARDS 288 Our fate lies in our genes Genetics and medicine 324 GLOSSARY 276 Randomize till it hurts Evidence-based medicine 294 This is everybody’s 328 INDEX problem 278 Seeing inside the body HIV and autoimmune 335 QUOTE ATTRIBUTIONS MRI and medical scanning diseases 336 ACKNOWLEDGMENTS 282 Antibodies on demand Monoclonal antibodies 284 Nature could not, so we did 298 A revolution through the keyhole In vitro fertilization Minimally invasive surgery 299 The first glimpse of our own instruction book The Human Genome Project 300 Fixing a broken gene Gene therapy 301 The power of light Laser eye surgery 302 Hope for new therapies Stem cell research 304 Smaller is better Nanomedicine

INTRODU

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12 INTRODUCTION I llness and disease have always to patients. This ideal, enshrined in blood, yellow bile, phlegm, and black been with us, and the need to the Hippocratic Oath, continues to bile. This idea persisted in Europe find ways to prevent and treat inform medical ethics and practice. even into the 19th century. them can often be literally a matter of life and death. Over time, many The Greeks had few cures and, Scientific investigation new techniques have been tried, because dissecting bodies was When the Roman Empire fell, the and a number of key discoveries, taboo, knew little anatomy, but the teachings of Galen were kept alive such as vaccines and antibiotics, Romans’ military campaigns helped in the Islamic world by a succession have made a lasting impact, saved physicians to develop new surgical of scholar–physicians who developed countless lives, or restored many skills. The celebrated Roman new surgical skills and introduced people to health. physician Claudius Galen greatly many innovative medicines. Al-Razi advanced anatomical knowledge pioneered chemical drug treatments Early practice by learning from animal dissections, and Ibn Sina wrote the definitive In prehistoric times, people relied and from gladiators’ wounds. work The Canon of Medicine. on traditional knowledge, healers, and even magic when they fell ill. Galen’s medical approach was In the later medieval period, More systematic approaches detailed and thorough, and he wrote medical ideas from Islam and Galen gradually evolved, with Ayurvedic the first great manuals of medicine. filtered back into Europe. Dedicated healing emerging in ancient India However, his theories were based medical schools, based on Galenic around 3,000BCE. It still has many on the mistaken idea, originating in and Islamic practices, were set up adherents, as does the ancient ancient Greece, that illnesses are alongside universities in cities such Chinese system of medicine, which caused by an imbalance between as Salerno and Padua. Medicine includes acupuncture. While these four body fluids called humours – was recognized for the first time medical practices have endured, the as a legitimate subject of academic ideas that led to today’s science- Cure sometimes, study, and the Renaissance that based medicine developed in treat often, followed ushered in a new age of ancient Greece. discovery based on inquiry and comfort always. first-hand observations. In the late 5th century BCE, Hippocrates the Greek physician Hippocrates In the mid-16th century, the insisted that illness has natural (c. 460–c. 375 bce) detailed dissections conducted by causes, and so might also have Flemish physician Andreas Vesalius natural cures. This has been the began to build an accurate picture guiding principle of medicine ever of human anatomy. Physicians also since. Hippocrates also founded a started to learn about physiology – school of medicine where students the science of how the body works. undertook to act with a duty of care A major breakthrough was the demonstration by English physician

INTRODUCTION 13 William Harvey in 1628 that the bacteria that causes tuberculosis develop, and fuelled new methods to heart is a pump that circulates blood inspired Russian scientist Élie fight them. The field of biomedical around the body. Metchnikoff to identify cells in engineering has also produced the body that fight against germs. solutions in all areas of healthcare, Progress in treating disease was The gradual revelation of the body’s from noninvasive imaging to robotic slow. In the 16th century, the Swiss intricate immune system over the surgery and implantable medical physician and alchemist Paracelsus last century has been one of devices such as pacemakers and pioneered the idea of the body as a medicine’s most remarkable stories. replacement joints. chemical system that could be treated with chemical cures. While In the early 20th century, new Whether a flash of individual his use of mercury for syphilis was approaches in microbiology and insight or the result of several a standard treatment for nearly 400 chemistry transformed ideas about years of research and testing by years, it took until the 20th century how to treat disease. Identifying large teams of people, new ideas for his chemical approach to be tiny immune particles in the body in medicine have saved millions applied in modern drug therapies. called antibodies, German scientist from suffering and death. Yet the Paul Ehrlich developed the idea of innovations of medical science Tackling disease targeted drugs, which hit germs are also tempered by more caution The fight against disease received but leave the body unharmed. His and regulation than many other a major boost in 1796 when British success in developing Salvarsan, disciplines – after all, human lives physician Edward Jenner developed the first effective drug for syphilis, are at stake. ■ a vaccination for smallpox. In 1881, in 1910 marked the beginning of a French chemist Louis Pasteur global pharmaceutical industry. Advances in medicine showed that vaccination could work and agriculture have for other diseases too, and the Modern medicine saved vastly more lives search for vaccines is now a major Scottish bacteriologist Alexander than have been lost in all area of medical research. Fleming’s discovery of penicillin in the wars in history. 1928 marked a new era of medicine. Pasteur, with German physician For the first time, physicians had Carl Sagan Robert Koch, also led the way to an an effective treatment for a range of understanding of what disease is. previously life-threatening diseases. American scientist (1934–96) They ended belief in the humours by Antibiotics also facilitated one of proving germ theory – the idea that the miracles of modern surgery, infectious diseases are caused by organ transplants, which had often microscopic organisms such as failed as a result of infection. bacteria. Their discovery generated a new field of research, as scientists Since the 1950s, advances such hunted for the germ responsible for as the deciphering of genetic code each disease. Koch’s isolation of the have shed new light on how diseases

MAANNEDCDIIMECNEITND PREHISTORY TO

IEEVAL 1600

16 INTRODUCTION Human skulls found in Egypt’s Edwin Smith Hippocrates, a physician Roman soldier–physician Europe have holes papyrus, one of the in ancient Greece, Pedanius Dioscorides earliest surviving compiles his De Materia chipped or drilled into medical documents, embarks on his medical Medica (On Medicinal them, a practice called describes 48 cases of career. He and his trepanning, possibly trauma to the body. followers develop an Substances), listing to treat pain or let out hundreds of herbal, and ethical code for doctors, “evil spirits”. later known as the other, medications. Hippocratic Oath. 6TH MILLENNIUM BCE C. 17TH CENTURY BCE C. 440 BCE C. 70 CE 27TH CENTURY BCE C. 500 BCE C. 300 BCE In ancient Egypt, the In India, the physician In China, the Huangdi architect, high priest, vizier, Sushruta begins compiling Neijing (The Yellow Emperor’s Classic of and physician Imhotep the Sushruta Samhita, Internal Medicine) sets rises to fame. Centuries a compendium of out the principles and methods of traditional later, he is deified Ayurvedic surgical Chinese medicine. as the god-on-Earth of methods that include reconstructive procedures. medical practices. P rehistoric evidence such with them for the relief of illness and In India, Ayurvedic medicine as skeletons, tools, and rock disease. Such practices still exist in developed from around 800 BCE. art indicate that humans some Indigenous societies. Still practised by some physicians were practising medicine more today, its central premise is that than 40,000 years ago. Early humans Medical systems illness is caused by an imbalance were aware that certain minerals, Each of the ancient civilizations between the body’s three elemental herbs, and parts of animals had developed medical practices, many doshas: vata (wind), pitta (bile), and health-giving properties. People of them linked to religious rituals. kapha (phlegm). The task of the who possessed such knowledge In Egypt, in the 4th millennium BCE, vaidya, the Ayurvedic physician, were sought-after specialists, whose serious disease was regarded as is to detect imbalances and correct ability to heal was often associated the work of the gods – probably as them using herbal and mineral with myths, magic, and the worship a punishment for a misdemeanour remedies, bloodletting, laxatives, of supernatural powers. in the current or past life. Temple enemas, emetics, and massage. priests administered herbal Many regions – North and South medications, carried out healing Ancient China developed a America, Africa, and large parts of rituals, and placated the gods with theory of health based on balance Asia and Australasia – cultivated offerings. By the 2nd millennium BCE, within the body between the spiritual practices in which there were Egyptian doctors who oppositions of yin and yang, the five individuals believed to have access specialized in disorders of the eyes, elements of fire, water, earth, wood, to supernatural beings entered a digestion, joints, and teeth, and and metal, and the life-sustaining trance-like state in order to contact in surgery that was informed by energy of qi flowing along the body’s and even join with those spirits. many centuries of experience in many meridians (channels). Chinese Practitioners channelled the healing mummification and embalming. medicine included some remedies powers of the spirits or bargained that were common to other ancient

ANCIENT AND MEDIEVAL MEDICINE 17 Medicine develops Islamic physician French physician and Andreas Vesalius in the Islamic world, Ibn al-Nafis rightly surgeon Guy de revolutionizes led by the physician asserts that there are no pores between the Chauliac completes medicine with his al-Razi in Baghdad ventricles of the heart his influential treatise book De Humani and later by Ibn Sina and discovers Chirurgia Magna Corporis in Persia. pulmonary (Great Surgery). Fabrica (On the circulation. Structure of the Human Body). 9TH–11TH CENTURY 1242 1363 1543 162 CE 1180 1347 1530S Physician Claudius In Italy, Rogerius, a The Black Death Paracelsus prepares Galen moves to Rome teacher at the Schola reaches Genoa, Italy. and uses chemical and champions the theory Medica Salernitana, Ending in 1353, it kills remedies to treat of four humours and the Europe’s first medical up to 200 million disease, founding importance of first-hand school, writes Practica people in Asia, Europe, pharmacology – the observation, experiment, Chirurgiae (Practice and anatomical knowledge. and North Africa. science of drugs. of Surgery). civilizations, such as herbs, diets, Claudius Galen became hugely In the 14th century, the European and massage, but it also developed respected, especially for anatomy, Renaissance (“rebirth”) arose in its own practices. It placed great and physicians consulted his works Italy, inspired by the rediscovery of emphasis on the pulse for diagnosis, until well into the 16th century. Greco–Roman culture and learning. and on acupuncture – the insertion It spread across Europe, with an of needles along the meridians – to As the Roman Empire declined explosion of new ideas in the arts, correct imbalances in the body. and eventually fell in 476CE, Europe education, politics, religion, science, entered a period of fragmentation. and medicine. New insights Much medical knowledge was lost, Medicine flourished in ancient and for most of the medieval era Scientists and physicians now Greece in the 1st millennium BCE. (c. 500–1400), medical care was the turned to first-hand observation, Its many celebrated physicians preserve of monasteries. However, experimentation, and rational included Hippocrates of Cos, whose with the spread of Islam, the Arabic analysis rather than relying solely caring attitude towards patients and world made significant advances in on the pronouncements of ancient rational approach to diagnosis and many areas of science, including texts such as Galen’s. Two towering treatment still influence medicine medicine. During Islam’s Golden figures of the period were the today. The Romans made strides in Age (c. 750–1258), scholars at the Swiss physician Paracelsus, who many areas of medicine, especially Abbasid court in Baghdad translated founded pharmacology, and Flemish surgery. They too believed that good and studied the medical texts of anatomist Andreas Vesalius, whose health depended on balance – in this the ancient world, and physicians masterwork De Humani Corporis case, four bodily fluids, or humours: such as al-Razi and Ibn Sina added Fabrica (On the Structure of blood, phlegm, yellow bile, and black influential works of their own, the Human Body) transformed the bile. In the 2nd century CE, physician which were later translated into medical profession’s understanding Latin by scholars in Europe. of the human body. ■

18 CAANOSDMHBADAMETAATDNHISTOEASE PREHISTORIC MEDICINE IN CONTEXT E arly humans faced with and even enter the spirit world to injuries and disease began influence the forces there, and BEFORE to self-medicate with herbs bring peace and healing to the 47000 bce Evidence from the and clays, a behaviour similar to suffering and sick. teeth of Neanderthal skeletons that of chimpanzees or apes. They found at El Sidrón, a cave in also turned to the supernatural to Prehistoric rock art in Africa northern Spain, suggests the explain misfortune, blaming injuries and cave paintings in Europe are early use of medicinal plants. and ill health on the operation of thought to represent ancient ritual malevolent spirits. practices, including the healer’s AFTER transformation into a creature form. 7000–5000 bce Cave art in Magical healing The burial of what may be a female Tassili n’Ajjer, Algeria, depicts Around 15,000 to 20,000 years spiritual healer at Hilazon Tachtit shaman-like figures carrying or ago, a new figure emerged in the in Israel, from around 11,000 bce, covered in Psilocybe mairei prehistoric world. Part healer and contains the wings of a golden eagle, mushrooms, known for their part magician, this shape-shifter a leopard pelvis, and a severed psychedelic effects. was believed to be able to access human foot – artefacts believed to suggest the healer’s ability to c.3300bce Studies of the body of Ötzi the Iceman, found in the People suffer, and blame evil spirits for their misfortune. Ötztal Alps on the Austrian- Italian border in 1991, indicate Their magical healers can communicate with spirits. that he took medicinal herbs. The healers When disorders c. 1000 ce Spiritual healers persuade evil spirits are fatal, the healers in southwest Bolivia use transport the soul psychoactive drugs, including to leave the body, cocaine; chemical traces of the restoring health. out of the body. drugs were found in Lípez Altiplano in 2010. 2000 Chuonnasuan, one of the last practising shamans in Siberia, dies.

ANCIENT AND MEDIEVAL MEDICINE 19 See also: Ancient Egyptian medicine 20–21 ■ Ayurvedic medicine 22–25 ■ Greek medicine 28–29 ■ Traditional Chinese medicine 30–35 ■ Herbal medicine 36–37 ■ Medieval medical schools and surgery 50–51 The Bird Man from the Lascaux caves in France, created c.15000bce, may depict a shaman. His head, four-fingered hands, and the bird beside him suggest he can take an avian form. transform and transcend the normal human state. Such spiritual healers may well have developed practical healing skills, too, as archaeologists have found ample evidence not only of the use of medicinal plants, but also of surgical procedures such as trepanning and attempts to reset broken bones. Meeting a need trance state in which they receive Today, varying forms of spiritual Belief in supernatural healing gave a vision of the spirit world. The healing continue in East Asia, way to other spiritual and medical most powerful healers are thought Africa, and among Indigenous practices, but never died out. In the to project themselves (often guided peoples in Australia, the Arctic, 17th century, European travellers by a spirit animal) into the other and the Americas. For millennia, rediscovered the Siberian spiritual world to persuade the evil spirit these beliefs have answered a healers called “shamans” – from the causing the disease to release the primal need to explain why disease word šaman (“one who knows”) in sick person and restore their health. occurs and why – where the spirits their Tungusic language – and the Where healing is not possible, a prove too strong or intractable – it term shamanism was often applied shaman conducts a similar ritual cannot be cured. If less widespread to spiritual practices elsewhere. to lead the soul of the dying person as populations of Indigenous people safely into the afterlife. decline, the beliefs still live on. ■ In Siberia, a dwindling number of shamans still use hallucinogens, drumming, and chants to promote a Prehistoric trepanning One of the earliest examples, a 7,000-year-old skull of a man An 11th-century skull discovered Archaeologists have unearthed unearthed at Ensisheim in below the Market Square in Krakow, thousands of skulls with a small France in the 1990s, had been Poland, indicates the therapeutic use hole drilled or sawn into them – a trepanned twice. Here and of trepanning in the medieval era. practice called trepanning dating elsewhere, new bone growth from around 8000 bce. Probably shows that trepanned patients performed by community healers, often survived for some years. trepanning was possibly a ritual to drive out evil spirits; the bone Healers and physicians removed was sometimes worn as practised trepanning in the an amulet. As these skulls often ancient civilizations of Egypt, show signs of earlier injuries or Greece, Rome, China, and South disease, it also seems likely that America. Later, in Europe and healers used the procedure to the US, surgeons used it to treat repair injuries, relieve head pain, concussion, brain inflammation, and treat neurological diseases. and to clean head wounds (as in the American Civil War).

20 OAANNHDEEADNLIOSEEMRAOOSRFEE ANCIENT EGYPTIAN MEDICINE IN CONTEXT T he prevailing view in the is known of his medical views, yet earliest societies was that he is believed to have been a skilful BEFORE disease was caused by practitioner, and was later deified c.3500 bce Trepanning supernatural influence. As a result, as a god of medicine. (drilling or sawing holes in the in many cultures healing was the skull) is used to relieve cranial domain of shamans or priests. In Egyptian specialization pressure in Egypt. ancient Mesopotamia, a person Imhotep started a tradition of afflicted by venereal disease was medicine that implemented practical c.2700 bce Egyptians begin said to be struck “by the hand of measures to preserve patients’ the mummification of royal Lilith”, a storm demon, while the lives, and marked the divergence corpses, giving the embalmers first Egyptian doctors were based between priests and doctors. In the knowledge of internal organs. in areas of temples known as Per- 5th century bce, the Greek historian Ankh, or houses of healing. AFTER Surgical instruments on a wall c.2600 bce Death of the In ancient Egypt, the first carving in the Kom Ombo Temple first known dentist, Hesy-Re, physician whose name survives near Aswan show the significance of revered as “chief of the was Imhotep, vizier to the pharaoh surgery in ancient Egyptian culture. ivory cutters”. Djoser in the 27th century bce. Little c. 17th century bce The Edwin Smith papyrus (named after the dealer who bought it in 1862) shows a knowledge of surgery to treat wounds, fractures, and other trauma. c.440 bce Herodotus notes the high level of specialization among Egyptian doctors. 1805 ce The Moorfields Eye Hospital, one of the first modern specialist hospitals, opens in London, UK.

ANCIENT AND MEDIEVAL MEDICINE 21 See also: Prehistoric medicine 18–19 ■ Greek medicine 28–29 ■ Hospitals 82–83 ■ Orthopaedic surgery 260–65 Physicians in ancient Egypt begin to diversify and treat specific ailments and body parts. This becomes the first known example of specialization within medicine. The Egyptian concept of medical specialization Imhotep is the foundation of the specialisms recognized Much biographical information in modern medicine today. about Imhotep dates from more than 1,000 years after Herodotus wrote that Egyptian dislocations. The practical approach his death, and few details are medicine was notable for the suggests that it was composed known for certain. His name existence of specialist practitioners for use by a military doctor, unlike appears on a statue of the Old in various disciplines, such as documents such as the Ebers Kingdom pharaoh Djoser, held dentistry, the stomach, and “hidden papyrus (c. 1550 bce), which proposes in the Cairo Museum. Born in diseases”. Egyptian documents folk remedies and healing magic for the 27th century bce, he was a of the time support Herodotus’s the treatment of infectious diseases. commoner who rose in the view, and the tomb of Hesy-Re (an service of Djoser and became Egyptian official and contemporary Although they were considered his vizier (chancellor). He was of Imhotep) reveals his title “chief of specialists, Egyptian physicians’ believed to have been the dentists”. Further records mention understanding of internal anatomy architect of the step-pyramid swnw (who practised general was rudimentary. They appreciated at Saqqara, a style of tomb medicine), others who specialized that the heart played a central that prefigured the pyramids in eye or intestinal disorders, and role in the healthy workings of built at Giza a century later. female physicians, such as Merit- the body, but believed that veins, He was also the high priest Ptah, who lived around 2700 bce, as arteries, and nerves operated as of Ra at Heliopolis. well as midwives and surgeons. part of 46 “channels” allowing energy to pass through the body. Imhotep’s reputation as a Egyptian surgery However, it was their innovative physician has led to attempts Surgery was among the most specializing in medical fields that to identify him as either the developed specialisms in Egypt, had the most lasting impact, author of the Edwin Smith at least for external operations passing from Egyptian to Roman papyrus or as the source of the (operating on internal organs physicians and later into Arabic surgical techniques it contains. invariably risked fatal infections). and medieval European medicine. However, there is no direct The oldest surviving Egyptian This differentiation accelerated evidence to support this, and surgical text, the Edwin Smith during the 19th century with he was not associated with papyrus written c. 17th century bce, the founding of many specialist medicine until the 4th century describes trauma surgery, detailing hospitals, such as London’s bce. After his death, Imhotep 48 case studies with instructions Moorfields Eye Hospital in 1805 – was revered as a god of given for fractures, wounds, and by the 1860s, London had more medicine and as the son of than 60 specialist centres. ■ Sekhmet, a healing goddess. He was sometimes associated with Asclepios, the Greek god of medicine, and also became identified with Thoth, the god of architecture and wisdom.

22 IN CONTEXT IFOTSRHFOFETRMHBEEADELDIDSAOOENMSACHSEAES BEFORE c.3000 bce In legend, the AYURVEDIC MEDICINE rishis (seers) of India are gifted Ayurveda by Dhanvantari, the physician of the gods. c.1000 bce The Atharvaveda is the first major Indian text to contain medical guidance. AFTER 13th century ce The Dhanvantari Nighantu, a comprehensive lexicon of herbal and mineral Ayurvedic remedies, is compiled. 1971 The Central Council of Indian Medicine is established to oversee training at recognized institutions and to develop good practice. 1980s Ayurvedic practitioners Dr Vasant Lad and Dr Robert Svoboda and American Vedic scholar David Frawley spread the teachings of Ayurveda throughout the US. A preventive and curative medical system infused with a strong philosophy emerged in India between 800 and 600 bce. Called Ayurveda from the Sanskrit words for life (ayur) and knowledge (veda), it was based on the theory that disease is caused by an imbalance in the elements that make up the human body. Interventions and therapies aimed to restore and maintain the body’s equilibrium, and were adapted to patients’ personal physical, mental, and spiritual requirements. The roots of Ayurveda lie in the Atharvaveda, one of four sacred texts – the Vedas – which enshrine

ANCIENT AND MEDIEVAL MEDICINE 23 See also: Greek medicine 28–29 ■ Traditional Chinese medicine 30–35 ■ Herbal medicine 36–37 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Medieval medical schools and surgery 50–51 An imbalance in To make a diagnosis, the body causes the vaidya (practitioner) observes, examines, a disorder. and questions the patient. After diagnosing The vaidya According to Hindu tradition, the disorder, the vaidya identifies the Ayurveda was communicated to imbalance in the body’s Dhanvantari by the creator god Brahma. prescribes an three doshas – vata (wind), In India, Dhanvantari’s birthday is Ayurvedic treatment pitta (bile), and kapha celebrated as National Ayurveda Day. tailored to the patient, (phlegm) – that govern different such as internal physiological purification or a activities. herbal remedy. The treatment restores balance in the Hridayam, both written by doshas, curing the disorder. Vagbhata, a disciple of Charaka, and the Bower manuscript, named the core beliefs of the civilization compendium of shalya chikitsa or after Hamilton Bower, the British that emerged in India in the second Ayurvedic surgical methods. It officer who acquired it in 1890. millennium bce. Providing formulae includes guidance on such complex Together, all six texts constitute and rituals for everyday living, the procedures as cataract removal, the Ayurvedic medical tradition Atharvaveda contains a number hernia repair, and setting broken that has flourished for centuries in of magico-religious prescriptions bones, alongside hundreds of herbal Asia and more recently in the West. for treating disease, such as the remedies. The Charaka Samhita, exorcism of evil spirits, but also compiled around 300 bce and The elements and doshas features less mystical cures, such attributed to Charaka, a court as the use of herbal remedies. physician, takes a more theoretical At the heart of Ayurvedic medicine approach. Dealing with kaya is the notion of harmony and Two later treatises, the Sushruta chikitsa or “internal medicine”, it balance between all components Samhita and the Charaka Samhita, focuses on the origins of disease. of the human body. It is the primary further developed the key tenets role of the vaidya, or Ayurvedic of Ayurvedic medical theory and In the 5th century ce, the body physician, to diagnose and correct practice. The Sushruta Samhita – of Ayurvedic knowledge was any imbalances. The body (like attributed to the physician Sushruta, increased by the creation of three the material world) is said to be who practised around 500 bce in more scholarly works: the Ashtanga made up of five elements: akash Varanasi, northern India – is a Sangraha and the Ashtanga (space), vayu (air), jala (water), prithvi (earth), and teja (fire). In the body, certain combinations of these elements manifest themselves as three doshas (roughly analogous ❯❯

24 AYURVEDIC MEDICINE to the humours of the ancient Greek is as important as its anatomy. tissues – the dhatus. The dhatus and Roman medical traditions). Each dosha is associated with a are rasa (fluids including plasma These tridosha are vata (wind), pitta particular form of energy: vata with and lymph), rakta (blood), mamsa (bile), and kapha (phlegm). A state movement, governing the action of (muscle), meda (fat), asthi (bones), of good health and wellbeing muscles, the flow of breath, and the majja (marrow and nerve tissue), occurs when all three doshas are heartbeat; pitta with the metabolic and shukra (reproductive tissue). well balanced, but the ideal system, digestion, and nutrition; The internal balance of the body proportions may vary from person and kapha with the structure of the is also controlled by agni (“biological to person. Disease and damaging body, including the bones. fire”), the energy that fuels the metabolic conditions occur when body’s metabolic processes. The the doshas are not in balance. An The doshas flow from one part of most important aspect of agni is excess of vata, for example, can the body to another along porous jatharagni, or “digestive fire”, which cause problems such as indigestion channels known as srotas. There ensures the elimination of waste and flatulence, while a surfeit of are 16 main srotas, three of which products. If this is too low, urine, kapha may bring on lung disorders bring nourishment into the body in faeces, and sweat will build up, or breathing problems. the form of breath, food, and water; causing issues such as urinary three allow for the elimination of tract infections. In Ayurvedic medicine, the metabolic waste products; two body is viewed as a dynamic system carry breast milk and menses; one Diagnosis and treatment rather than a static one, and the is the conduit for thought; and Practitioners of Ayurvedic medicine way energies flow through the body seven link directly with the body’s evaluate the signs of disease by directly observing and questioning The seven dhatus, or body tissues, function sequentially. the patient in order to devise an This means if one dhatu is affected by a disorder (caused appropriate treatment. The main by an imbalance in one of the three doshas – vata, pitta, or methods of physical diagnosis are kapha), it will directly affect the nutritional support and measuring the pulse; analysing the function of the next dhatu. urine and stools; inspecting the tongue; checking the voice and Shukra Rasa speech; examining the skin and (reproductive tissue) (fluids) eyes; and assessing the patient’s overall appearance. Kapha The physician may also examine the marma points on a patient’s body. These 108 points are where Vata Majja Pitta Rakta (bone (blood marrow, tissue) When diet is wrong, nerve medicine is of no use. tissue) When diet is correct, medicine is of no need. Ancient Ayurvedic proverb Asthi Mamsa (bone tissue) (muscle tissue) Meda (fat)

ANCIENT AND MEDIEVAL MEDICINE 25 Ayurvedic medicines are widely purification process that employs It is more important available across India in shops and steam treatment, massage therapy, to prevent the occurrence pharmacies. Over 3,000 years, around virechana (the use of laxatives), 1,500 medicinal plants have become vamana (induced vomiting), of disease than to part of Ayurveda’s pharmacopoeia. raktamokshana (bloodletting), seek a cure. basti (enemas), and nasya (a nasal body tissues (veins, muscles, joints, treatment) to eliminate excess Charaka Samhita ligaments, tendons, and bones) waste products. Also prescribed intersect. They are also junctions are herbal remedies, which act in a The 11th-century arrival of Islamic between the physical body itself, more direct way on the doshas. Of medicine (incorporating earlier consciousness, and the energy that the numerous plant, animal, and Greco-Roman concepts) introduced flows in the body. mineral ingredients used in these, a new approach, as did the founding garlic is considered especially of scientific medical schools and Following a diagnosis, Ayurvedic potent. It is used to treat a wide modern hospitals in the 19th and practitioners select from a number range of conditions, including 20th centuries. Yet Ayurvedic of therapies aimed at correcting colds, coughs, and digestive practitioners remained the primary imbalances between the doshas or disorders, and as an emollient for healthcare providers in India. Today other elements in the Ayurvedic sores, bites, and stings. they cater for around 500 million physiological systems. Among patients in India alone, who use these are panchakarma, a multistep Foodstuffs, including spices, Ayurveda exclusively or along with play a major role in Ayurvedic conventional Western medicine. practice by supporting the body’s healing processes. Vaidya may Safety concerns prescribe dietary changes as part In the West, Ayurveda is used as a of their holistic (whole-person) complementary therapy alongside approach to restoring a balance conventional medical care. A few between the body, mind, spirit, and studies and trials have suggested the environment. Dietary regulation that its approaches are effective, considers the patient’s physical but there are concerns about the and emotional makeup and their safety of Ayurvedic medicines. dominant dosha, and practitioners Sold largely as food supplements, draw on six principal “tastes” as the presence of metals in some the basis for their recommended makes them potentially harmful. regimens: astringent, sour, sweet, A 2004 study found that 20 per salty, pungent, and bitter. cent of 70 Ayurvedic medicines produced by 27 South Asian Other Indian medical traditions manufacturers contained toxic levels of lead, mercury, and arsenic. Ayurveda is not the only Bala vahatam (paediatrics), They have also been shown to traditional Indian medical Nanjunool (toxicology), and work against the effects of Western system. The practice of Siddha Nayan vidhi (ophthalmology). medicines, so their use should medicine (its name derives always be supervised by a trained from the Tamil siddhi, which Unani medicine (from a Hindi Ayurvedic practitioner. ■ means “attaining perfection”) word meaning “Greek”) is a is particularly strong in South descendant of ancient Greek India. While also seeking to and Islamic medical practices. restore balance in the body, it It aims to keep the humours espouses a duality of matter (blood, phlegm, black bile, and and energy in the Universe yellow bile) in balance. Unani that needs to be kept in also places great value on the harmony. Siddha’s treatment examination of the patient, but system has three branches: regards measurement of the pulse as particularly important.

26 HWWAEHSARTTEAFBKOUERINLTDAUWNEAY PLASTIC SURGERY IN CONTEXT In accidents, torture, and F or most of human history, times of war, countless doctors could do little for BEFORE individuals receive patients who suffered c. 17th century bce The disfiguring injuries. disfiguring accidents, disease, Egyptian Edwin Smith A disfiguring injury or congenital conditions. Minor papyrus shows how to treat can have damaging blemishes could be concealed wounds to reduce scarring. psychological effects. with cosmetics, and prostheses were used to replace missing limbs, c. 950 bce An artificial wooden Innovative, compassionate but those more severely affected toe in an Egyptian tomb is the surgeons devise suffered social ostracism. The first known prosthesis. medical culture that arose in new reconstructive India in the 1st millennium bce AFTER procedures. gave rise to techniques that c. 40 ce In his De Medicina, offered hope to such patients. Celsus refers to operations to Successful plastic surgery repair damaged earlobes. conceals or rebuilds Ayurvedic surgery damaged facial and Early references to operations – 1460 Heinrich von Pfolspeundt other features. alleged to have restored severed describes an operation to These procedures help heads – feature in the Vedas, the rebuild a nose (rhinoplasty). heal physical and ancient religious texts that form psychological wounds, the basis of Hindu religion and 1814 The first rhinoplasty boost confidence, and philosophy. However, the first clear operation using Sushruta’s transform lives. evidence of reconstructive surgery techniques is carried out comes from the Sushruta Samhita, in Western Europe. (Sushruta’s Compendium), written around 500 bce. 1914–18 During World War I, New Zealand-born surgeon Belonging to a tradition of Harold Gillies specializes in Shalya, or Ayurvedic surgery, this performing facial repairs. Sanskrit text is believed to be the work of Sushruta, a physician from 2008 French surgeon Laurent Varanasi, northern India. Sushruta’s Lantieri claims to have carried medical approach was advanced for out the first full face transplant. his time; he urged students to gain a knowledge of internal anatomy

ANCIENT AND MEDIEVAL MEDICINE 27 See also: Ayurvedic medicine 22–25 ■ Greek medicine 28–29 ■ Battlefield medicine 53 ■ Anatomy 60–63 ■ Gray’s Anatomy 136 ■ Skin grafts 137 ■ Face transplants 315 Plastic surgery and World War II through dissecting dead bodies. The Sushruta Samhita has strikingly New Zealand-born plastic His key innovation lies in his modern ideas about surgical training, surgeon Archibald McIndoe descriptions of reconstructive instruments, and procedures. This became chief plastic surgery procedures, and he is often referred 12th- or 13th-century version was found consultant to Britain’s Royal to as the “father of plastic surgery”. in Nepal. Air Force in 1938. When World War II broke out in 1939, he Among 300 surgical operations operations were in great demand. was called to treat aircrew described in the Sushruta Samhita Sushruta also recommended the with severe burns. are instructions for nasa sandhan use of wine as an anaesthetic for (rhinoplasty – rebuilding the nose) such painful operations. Most burn treatments and ostha sandhan (otoplasty – at the time used tannic jelly, reconstruction of the ear). Sushruta Spread of plastic surgery resulting in severe contraction explains how a flap of skin should Indian plastic surgery remained of the wound tissue as well as be excised from the cheek and then more advanced than anything in permanent scarring. McIndoe turned backwards to cover the nose Europe for more than two millennia. devised new techniques, while still attached to the cheek – In the 1st century ce, the Roman including saline burn baths a technique later modified using physician Aulus Celsus outlined and flap reconstruction to skin from the forehead. At the time, how otoplasty corrected earlobes repair the faces and hands of the mutilation of the nose was a damaged by heavy earrings. In injured airmen. McIndoe also common punishment, so these the 15th century, German surgeon understood the importance of Heinrich von Pfolspeundt described post-operative rehabilitation, The surgeon should … how to reconstruct a nose “which and he set up the Guinea Pig treat the patient is off entirely”. It was only when Club, a support network made as his own son. Europeans colonized India in the up of more than 600 service Sushruta 17th and 18th centuries that they personnel who had undergone encountered sophisticated Indian operations at McIndoe’s burns Sushruta Samhita, rhinoplasty techniques. British unit at the Queen Victoria 6th century bce surgeon Joseph Carpue was the Hospital in East Grinstead. first to adopt them, in 1814. to the development of skin grafts. Plastic surgery progressed Plastic surgery techniques to fix swiftly in the West; by 1827, the accidental and congenital defects first operation to correct a cleft became increasingly sophisticated palate had been carried out in the during the 1900s. Cosmetic surgery US. The demands of treating severe also became widespread. The first wounds during two World Wars led facelift was performed in 1901, and by the end of the 1900s, a range of facial and body enhancements were available. Plastic surgeons performed more than 10 million aesthetic surgical procedures in 2018. The same year, a 64-year-old Canadian Maurice Desjardins, who had suffered a shot wound to the face, became the oldest person ever to have a full facial transplant. ■

28 NFIORSHTA,RDMO GREEK MEDICINE IN CONTEXT A ncient medical practice An early attempt to regulate was largely rooted in the medical practice was set out by BEFORE belief that disease was the Babylonian king Hammurabi c. 1750 bce Hammurabi’s Code caused by malign spirits or inflicted around 1750 bce. His wide-ranging stipulates payments for as a punishment by the gods. Most law code included a scale of fees physicians, and penalties attempts to heal an illness usually that doctors could charge – such as for their failures. involved ritual and prayer rather ten shekels for excising a tumour than any real attempt at medicinal from a nobleman. It also laid down c. 500 bce Alcmaeon of Croton cure. Although drug recipes, using harsh punishments for botched identifies the brain as the seat various plants, had been concocted operations – a surgeon could lose of intelligence. by Egyptian and Sumerian healers, his hands for causing the death of their efficacy was questionable. a patient. Yet Babylonian medicine AFTER 4th century bce The great In ancient Greece, Hippocrates rejects philosoper Aristotle expands disease is widely superstition, emphasizes on the humours theory, but sees the heart as the seat of considered to have a disease as a natural vitality, intellect, and feeling. supernatural basis, phenomenon, and seeks c. 260 bce Herophilus of and is seen as to find its causes. Alexandria establishes the punishment from science of anatomy, describing nerves, arteries, and veins. the gods. c. 70 bce Asclepiades of This lays the foundation Hippocrates applies Bithynia states the body is for a new, holistic a rational approach composed of molecules, and style of medicine, to medicine, using powers disease occurs if their pattern with an emphasis on of logic and observation is disrupted. prognosis and treatment. to assess disease. c. 70 ce Dioscorides writes De Materia Medica, which remains the core text for plant-based medicine for 16 centuries.

ANCIENT AND MEDIEVAL MEDICINE 29 See also: Ancient Egyptian medicine 20–21 ■ Herbal medicine 36–37 The Hippocratic Oath ■ Roman medicine 38–43 ■ Pharmacy 54–59 ■ Anatomy 60–63 Traditionally attributed to Hippocrates, the founding father of Hippocrates and named after Western medicine, is depicted with a him, the oath required new copy of his works in this 14th-century physicians to swear to uphold portrait. Widely translated, his theories a code of ethics. As a revered greatly influenced medieval learning. teacher and physician who had travelled widely, still employed exorcists to chase physiology. He had founded a Hippocrates had great away disease-causing spirits, and medical school on his native Cos, influence. The oath set a high it was not until the ancient Greeks where he developed and taught the standard of expertise and began to try to explain the nature of theory of the four humours (blood, etiquette, and established the Universe in philosophical rather phlegm, yellow bile, and black bile), medicine as a profession that than divine terms that medical whose equilibrium in the body was ordinary people could trust. practice began to change. necessary for good health. Unlike It separated physicians from rival medical schools such as the other “healers” and included a Philosophy and medicine Cnidian school, he saw the body promise not to poison patients, Among the first to adopt a more as a single system, not a collection and to protect confidentiality. rational approach to medicine was of isolated parts, and insisted on Hippocrates himself insisted the philosopher–scientist Alcmaeon observation of symptoms of disease that physicians be of a good of Croton. In the 5th century bce, he to inform diagnosis and treatment. appearance, as patients could identified the brain as the seat of not trust a doctor who did not intelligence, and also conducted A rational approach look capable of taking care of scientific experiments, such as The Hippocratic Corpus is a body himself. According to the oath, dissecting an eye to establish the of more than 60 works (including the physician must be calm, structure of the optic nerve. He Epidemics and On Fractures and honest, and understanding. believed the body was governed Joints) attributed to Hippocrates and by opposing influences (dry/hot or his followers. Along with detailed The oath became a basis sweet/bitter) that must be balanced. case studies, it includes neatly for medical ethics in the Empedocles, another 5th-century defined disease categories that are Western world and many of its Greek philosopher, believed that the still used today, such as epidemic, clauses are still relevant today, human body was ruled by the four chronic, and acute. Hippocrates such as patient confidentiality elements – earth, air, fire, and water. promoted holistic treatment of his and respect for patients. patients, with as much emphasis These two theories were then placed on diet, exercise, massage, A medieval Greek copy of the synthesized by Hippocrates and hygiene as on drugs. This Hippocratic Oath. The original was (c. 460 bce–c. 375 bce), the greatest professional approach was reflected probably written by a follower of physician in the ancient Greek in his school’s later insistence that Hippocrates, c. 400 bce or later. world, in order to produce an all- its students take an oath promising encompassing theory of human to avoid doing patients harm and to respect patient confidentiality. Hippocrates’ rationalism laid the foundations for later physicians such as Galen and Dioscorides to establish medicine as a respected and vitally important profession. Its key advances would stem from science rather than the shady practices and old superstitions of itinerant healers and exorcists. ■

BAABLOADNYCINE TRADITIONAL CHINESE MEDICINE



32 TRADITIONAL CHINESE MEDICINE IN CONTEXT An imbalance of the two complementary forces yin and yang, which influence the body’s organs, causes BEFORE 2697 bce As legend has it, a disease or disorder. Huangdi, the Yellow Emperor, Each organ is aligned with one of the five elements, begins his reign and founds traditional Chinese medicine. or phases – fire, water, wood, metal, and earth. Six excesses associated with the elements 1700–1100 bce Oracle bones provoke symptoms. For example, an excess of huo (fire) from the Shang dynasty describe diseases, wine as a causes a fever. medicine, and surgical knives and needles. After assessing the symptoms, the physician uses eight principles to diagnose the cause of the imbalance. c. 1600 bce Shang official Yi Yin invents decoction Prescribed treatments such as acupuncture, (boiling ingredients in water medicines, diet, or exercise restore balance. or spirits to create a purified, concentrated medicine). T he foundational text of the fundamental components of traditional Chinese reality (Heaven, Earth, Water, Fire, AFTER medicine is the Huangdi Wind, Thunder, Mountain, and Lake). 113 ce Four gold and five silver Neijing (The Yellow Emperor’s Each symbol is made up of three acupuncture needles – the Classic of Internal Medicine). It was lines that are either broken (yin) or oldest known – are buried in written around 300 bce, during the unbroken (yang). Shennong, the Red the tomb of Prince Liu Sheng, Warring States period before China Emperor, discovered which plants which is rediscovered in 1968. was unified under a single emperor, had medicinal uses and which but it includes earlier ideas, such as were toxic. Huangdi, the Yellow 2nd century Hua Tuo the diagnostic methods of legendary Emperor, invented acupuncture and pioneers an early anaesthetic, physician Bian Qiao, described in was taught by the gods how to mix new surgical techniques, his Nanjing (Classic of Difficulties). magical healing powders and use and exercises based on the the pulse for diagnosis. movements of the tiger, deer, The core principles of traditional bear, ape, and crane. Chinese medicine are far older. They Whatever their origins, yin and are attributed to three mythical yang (the universal concept on 1929 As Western influence emperors. Emperor Fuxi created the which Chinese medical philosophy increases, China’s ministry of bagua, eight symbols that represent is based), examination and diagnosis health tries to ban acupuncture and other forms of traditional Chinese medicine. 1950s Chairman Mao Zedong promotes traditional Chinese medicine and establishes acupuncture research institutes across China. 2018 The World Health Organization (WHO) includes traditional Chinese medicine in its 11th International Classification of Diseases.

ANCIENT AND MEDIEVAL MEDICINE 33 See also: Ayurvedic medicine 22–25 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Medieval medical schools and surgery 50–51 ■ Pharmacy 54–59 ■ Anaesthesia 112–17 ■ Vitamins and diet 200–03 If the authentic qi most akin to water, while yang is sheng (generating or nurturing), flows easily … hot, bright, active, and masculine, ke (controlling), cheng (overacting), with a kinship to fire. An imbalance and wu (rebelling). The vital force how could illness arise? between them causes disease. qi passes through the meridians, Huangdi Neijing animating the organs. Taking in Each of the major internal food and air replenishes qi. Without (the procedure for healing), and organs is influenced either by yin it, the body will die, and where it acupuncture and herbs (the means or yang. The yin organs – the heart, is deficient, the body will sicken. of healing), are the essence of spleen, lungs, kidney, liver, and traditional Chinese medicine, pericardium (a thin sac around Diagnosing disease brought together in the Huangdi the heart) – are seen as solid, with Traditional Chinese medicine aims Neijing. Its text takes the form of functions that include regulating to identify and correct imbalances discussions between the Yellow and storing key substances such in the body’s yin and yang, wu-xing, Emperor and his ministers. Huangdi as blood and qi. The yang organs – and qi. A deficit of yin, for example, asks questions about medical the small intestine, large intestine, might appear as insomnia, night problems, and his advisers reply, gallbladder, stomach, and urinary sweats, or a rapid pulse, while a setting out the core tenets of bladder – are considered hollow; lack of yang could cause cold limbs, Chinese medical knowledge. their function is to digest nutrients a pale tongue, or a sluggish pulse. and eliminate waste. At a basic level, eight diagnostic The key principles principles help identify the complex The Huangdi Neijing describes the The five elements, interacting patterns of disharmony. The first oppositions of yin and yang, the five in a system termed wu-xing, each two principles are yin and yang, elements (fire, water, wood, metal, correspond to a yin and yang organ – which help define the six other and earth), and qi – the energy that fire to the heart/small intestine, principles – deficiency, cold, interior, flows along channels (meridians) of water to the kidney/bladder, wood excess, heat, and exterior. the body, sustaining life. The text to the liver/gallbladder, metal to the also sets out diagnostic procedures, lungs/large intestine, and earth to A physician can further diagnose such as taking the pulse or looking the spleen/stomach. Interactions the cause of external disorders at the patient’s tongue, as well as between the elements create a according to six excesses (wind, ❯❯ treatments, including acupuncture, dynamic, self-adjusting cycle of the prescription of herbs, massage, diets, and physical exercise. Deficiency Excess (weak resistance (such as acute The concept of balance between or immunity) pain or an yin and yang is key; they are seen aggressive pathogen) as opposed yet complementary forces that govern different aspects Cold Yang Heat of the body and manifest their (such as pallor, Yin (such as a fever influences in different ways. Yin is nausea, or or a headache) cool, dark, passive, feminine, and slow pulse) Exterior Interior (for instance, (problems of affecting the skin, the blood or hair, or meridians) internal organs) Traditional Chinese medicine uses eight principles to define disorders during diagnosis. They are yin and yang, and the six principles they govern: the yin principles are deficiency, cold, and interior; the opposite yang principles are excess, heat, and exterior.

34 TRADITIONAL CHINESE MEDICINE Bian Qiao coldness, summer heat, dampness, The skipping pulse dryness, and fire) that are allied to is a pulse coming and going Born in the 5th century bce, the elements. Internal problems are with occasional interruption. Bian Qiao is the first Chinese related to seven emotions (anger, physician of whom anything is happiness, thoughtfulness, sadness, Wang Shuhe known – largely thanks to a fear, surprise, and anxiety). biography written some 300 people with different symptoms years after his death by In the 4th century bce, Bian may require the same treatment, historian Sima Qian. The story Qiao’s Nanjing set out four key while treatments for those with goes that a mysterious figure stages of diagnosis: observing a similar symptoms may differ. gave the young Qiao a book of patient (especially the face and medical secrets and a bunch of tongue); listening to the voice and A cure by needles herbs, and then disappeared. internal sounds (and smelling the The aim of acupuncture is to After taking the herbs in a breath and body odours); asking correct the body’s imbalances by solution for 30 days, Bian Qiao the patient about symptoms; and inserting needles into the skin at could see through the human taking the pulse. In the late 3rd key points to redirect the flow of body to diagnose disease. century ce, Wang Shuhe wrote the qi along the body’s 12 principal Maijing (Pulse Classic), explaining meridians and a host of minor ones. As Bian Qiao travelled where the pulse should be taken on These points may be at some across the country, treating the wrist – at the cun (close to the distance from the area where the disorders and performing hand), the guan (slightly higher on problem appears; to remedy pain surgery, his fame as a gifted the arm), or the chi (furthest up the healer grew. Among the many arm). Taking a reading on the right Chinese physicians prescribed many near-miraculous cures was wrist, he advised, was best for exercises to help restore the body’s that of Zhao Jianzi, chief measuring yin, and on the left balance. This image is part of a silk minister of the kingdom of Jin, for yang. To gauge the health of manuscript from the 2nd century bce, whom Ban Qiao revived by different organs, he recommended found in a tomb in south central China. using acupuncture after he taking two pulse measurements – had fallen into a coma and first by pressing lightly, then more was believed dead. heavily – at each pulse point. In 310 ce, Bian Qiao was In traditional Chinese medicine, assassinated by a rival – Li Mi, every diagnosis is tailored to the a royal medical officer. individual patient, as reflected in the saying yin bing tong zhi; tong bin yi zhi, or “different diseases, the same treatment; the same disease, different treatments”. In other words, Key works Nanjing (Classic of Difficulties) Bian Qiao Neijing (Bian Qiao’s Classic of Internal Medicine)

ANCIENT AND MEDIEVAL MEDICINE 35 Back Front Needling and moxa … Urinary bladder meridian Lung meridian cure the corpse that is Triple warmer Kidney meridian numb [unconscious]. meridian Pericardium meridian Liver meridian Bian Qiao (energy regulator) Colon meridian Stomach meridian Spleen meridian Small intestine meridian Heart meridian Gallbladder meridian in the lower back, for instance, the The qi life force flows Key: acupuncture points are located on through 12 major meridians the hand. The first key text, listing (divided into yin and yang Yin meridian 349 points, was the Systematic groups), which supply health Classic of Acupuncture and and vitality to the major Yang meridian Moxibustion, written around organs. Any disruption of 260 ce by Huangfu Mi and revised this flow causes disease. establishment of the People’s around 630 ce by Zhen Quan. By During acupuncture, needles Republic in 1949, partly because 1030, there were 657 points, as set are inserted in points along the new Communist government out by Wang Weiyi, a renowned the basic 12 and other pledged to provide wider healthcare acupuncturist who made life-sized specialized meridians to to a population of over 500 million, bronze models to illustrate the release blockages. for whom there were only 15,000 location of the points. physicians trained in Western With the advent of European medicine. The combination of Moxibustion and more medicine, introduced by Jesuit modern and traditional medicine A further key component of Chinese missionaries in the late 16th century, became known as the “walking-on- medicine is moxibustion – burning imperial China increasingly viewed two-legs policy”. the herb mugwort (moxa) on or acupuncture as mere superstition, very near the surface of the skin to and herbal treatments became the While scientists still point out stimulate qi. As with acupuncture, chief therapeutic tool of Chinese the lack of clinical evidence for herbal medicine, dietary rules, and doctors. Physician Li Shizhen’s its efficacy, traditional Chinese other treatments were all refined 53-volume Bencao Gengmu medicine (TCM) is thriving today. during the first millennium ce. (Compendium of Materia Medica) Acupuncture is widely used to treat Leading Han dynasty physician of 1576 lists 1,892 herbs and more pain, and the inclusion of TCM in a Zhang Zhongjing (150–219 ce) wrote than 11,000 combinations of herbs 2018 World Health Organization about diet and typhoid, but is best to prescribe for specific diseases. diagnostic compendium looks set known for Shang han za bing lun to further boost its influence. ■ (Treatise on Fevers and Other Walking on two legs Diseases). His contemporary Hua As Western influence increased from Tuo is considered to be China’s first the mid-19th century, traditional anaesthetist; he used a powder Chinese medicine was criticized for called mafeisan (thought to have its perceived lack of scientific basis. contained opium, cannabis, and It underwent a revival after the small quantities of toxic herbs), which was dissolved in water and given to patients before surgery.

36 INPSHATTYUSHIRECEBIAIETNSSTELF HERBAL MEDICINE IN CONTEXT M any ancient societies Iliad and Odyssey, both composed employed herbs in around 800 bce, mention more BEFORE medicinal treatment and than 60 plants with medicinal c. 2400 bce A Sumerian recorded their uses. The Egyptian uses. However, it was only with the cuneiform tablet records 12 Ebers papyrus, a collection of advent of a more scientific approach recipes for drugs including medical texts compiled around to medicine, initiated by the work of plant sources. 1550 bce, cites 700 plant species Hippocrates in the 5th century bce, to be used as herbal remedies that a more consistent method of c.1550 bce The Ebers papyrus and applications. In ancient Greek classifying plants according to includes more than 700 plant culture, Homer’s epic poems the their therapeutic action was taken. species used by the ancient Egyptians to create medicines. Ancient societies make regular use of plants for treatments. c.300 bce In ancient Greece, Theophrastus’s Historia Dioscorides compiles De Materia Medica, Plantarum classifies over the first comprehensive classification system 500 medicinal plants. of plants and their medicinal properties. AFTER 512 ce The oldest surviving De Materia Medica Dioscorides’ work copy of De Materia Medica is gives rise to establishes produced for the daughter of the practice of the modern the Roman emperor Olybrius. traditional herbal practice of using c.1012 The Canon of Medicine medicine. plants as a by Islamic physician Ibn Sina compiles material from many source of drugs. sources including Dioscorides. 1554 Italian botanist and physician Pier Andrea Mattioli writes a lengthy commentary on De Materia Medica.

ANCIENT AND MEDIEVAL MEDICINE 37 See also: Greek medicine 28–29 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Medieval medical schools and surgery 50–51 ■ Pharmacy 54–59 ■ Aspirin 86–87 ■ Homeopathy 102 Pedanius Dioscorides Born in Anazarbus (modern-day substances he included. When Turkey) around 40 ce, Dioscorides it was later translated into served as a surgeon in the Roman Latin and Arabic, its neat army during the reign of Emperor organization was obscured by Nero. This enabled him to travel the editors’ habit of alphabetizing extensively throughout the his original lists of drugs. In eastern Mediterranean, and to illustrated form, it became a collect information on medically favourite of medieval manuscript useful plants that grew in the copyists, and of publishers of region. By about 70ce, he had used early printed books during the this knowledge to produce his De late Renaissance. Dioscorides Materia Medica, a comprehensive died around 90 ce. five-volume textbook on herbal medicine. Written in his native Key work Greek, it was organized according to the therapeutic properties of c. 70 ce De Materia Medica (On the plants as well as the other Medicinal Substances) Pioneering botanist Theophrastus of their medicinal effect, and the to copies that were made by Lesbos (a pupil of Aristotle) refined diseases against which they were scholars in the Byzantine and then classification systems in the late effective. Many of these plants, such Islamic empires. Dioscorides’ work 4th century bce. In his Historia as willow and camomile, treated a was widely translated and became Plantarum (Enquiry into Plants), he range of conditions, and became the prime means by which classical devised a method for categorizing the mainstays of medieval herbals. medical knowledge was transmitted. 500 medicinal plants according to detailed groupings such as physical The rise of herbals During the medieval period, features, habitats, and practical use. De Materia Medica was influential De Materia Medica inspired a during Roman times, and even new genre of herbals – extensive De Materia Medica after the fall of the Roman Empire compilations of medically useful in the 5th century it remained a plants. In the Renaissance, it had a The full development of herbal key text. When Rome fell and its further revival with the publication medicine came with the work libraries were destroyed, many of lavish printed editions, including of the Roman soldier–physician other medical works were lost, yet commentaries by scholars. Dioscorides in the 1st century ce. De Materia Medica survived thanks His seminal text De Materia De Materia Medica established Medica (On Medicinal Substances), the modern scientific appreciation assimilated his knowledge of plants of plants as a crucial source of new based on years of observing their drugs (leading, for example, to the medicinal uses. Dioscorides’ key extraction of medicinal quinine insight was to arrange the work in 1820). It also bolstered the according to the physiological continuing practice of traditional effect each drug had on the body, herbal medicine, using plants and such as a diuretic effect (increased plant preparations directly for their production of urine) or an emetic therapeutic value. ■ effect (causing vomiting). He recorded 944 drugs, of which more De Materia Medica became the than 650 have a plant origin, and foundation text for herbal medicine detailed their physical properties as and pharmacology for 16 centuries. well as how they should be prepared, These hand-drawn sweet violets are from a 15th-century illustrated edition.

ROOTOBNESDEEAIRAMGSVNEUOOASSNNETD, ROMAN MEDICINE



40 ROMAN MEDICINE IN CONTEXT In ancient Rome, three competing approaches to medicine hinder treatment. BEFORE 753 bce Rome is founded. Later For Methodists, Empiricists For Dogmatists, rulers will conquer Greek medicine is a believe that or Rationalists, territories and build one of the matter of experience and theories on the greatest empires in history. physics and observation rules, not matter more than cause of 219bce Archagathus of Sparta observing each disease matter becomes the first Greek doctor patient. theories. to practise in Rome. more than observation. 2nd century bce Rome builds its first public baths, where Galen’s approach largely rejects the Methodist school and combines people flock to wash and clinical observations (Empiricist method) with the need to socialize, but disease is rife. understand causes of illness (Rationalist method). AFTER This synthesis leads to a better understanding c.390ce The first general of disease and to new medical theories. hospital is built in Rome. theoretical and scientific approaches or military hospitals, and he c.400 Oribasius, personal that had evolved in Greece since the popularized Greek medical theories. physician to Emperor Julian, 5th century bce. At first, the principal The most important of these was the compiles the Medical borrowings from the Greek medical theory of the humours, developed Collections, one of the last world were religious, in particular by the Greek physician Hippocrates great Roman medical works. the adoption of the Greek deity in the 5th century bce. It proposed Asclepios as the Roman god of that the body was composed of four c.900 Al-Razi writes the healing. Then in 219 bce, the Spartan vital fluids – blood, yellow bile, black Doubts about Galen. doctor Archagathus arrived in Rome, bile, and phlegm – and that an marking the start of a change in the excess or lack of any of these was c.1150 Burgundio of Pisa Roman attitude towards medicine. a sign of illness. The physician’s role produces the first Latin Archagathus was renowned for his was to identify an imbalance and translations of Galen’s works. ability to cure skin ailments and to restore the patient to balance, which heal wounds received in battle – a would ensure their continued health. T he Roman Empire, at its valuable skill at a time when the peak under the emperor Romans knew little of surgery but Schools of thought Trajan in the 2nd century ce, were becoming embroiled in the As Greek medical tradition became stretched 5 million sq km (1.9 million Second Punic War against Carthage. accepted into Roman culture, Greek sq miles) across Europe, North Africa, doctors came to Rome in increasing the Middle East, and western Asia. Although some in Rome called numbers. However, they met with Its citizens took pride in their bath Archagathus “the Butcher”, his varying levels of hostility. Historian houses and aqueducts, but in reality treatment centres for soldiers paved and senator Cato the Elder, writing streets were insanitary and disease the way for Rome’s valetudinaria, common. Yet Rome made strides in hygiene, and its contributions to medicine have had a lasting impact. Greek roots Roman medicine arose out of a synthesis of traditional practices, such as herbal healing, and the more

ANCIENT AND MEDIEVAL MEDICINE 41 See also: Greek medicine 28–29 ■ Islamic medicine 44–49 ■ Medieval medical schools and surgery 50–51 ■ Pharmacy 54–59 ■ Anatomy 60–63 ■ Blood circulation 68–73 ■ Nosology 74–75 ■ Case history 80–81 in the 2nd century bce, rejected be advanced by observing patients It is impossible Greek innovations in favour of more and identifying the visible signs of for anyone to find traditional remedies, such as the disease. However, they also believed the correct function use of cabbage: he recommended it that nature was fundamentally of a part unless he is for ailments ranging from stomach incomprehensible, and that perfectly acquainted disorders to deafness. speculation on the causes of illness with the action of the was pointless, so they had little whole instrument. Despite its opponents, Greek interest in exploring the internal Claudius Galen medicine became well established human anatomy. in Rome. Its results were clearly De Usu Partium Corporis too effective to ignore. Over time, A third medical school, the Humani, c.165–75 ce however, its followers fractured into Rationalists or Dogmatists, placed a number of competing schools. greatest importance in physicians Turkey), was such a man. By drawing devising an underlying theory to on specific aspects of each school The Methodists, founded by the guide their treatment of a disease. that aligned with his own theories, Greek physician Asclepiades in This was valued above examining he created a medical approach that 50 bce, applied a philosophical the patient’s particular symptoms. would remain orthodoxy for over a approach. This was based on the The Rationalists were more able thousand years. work of the philosopher Democritus, than the Empiricists to devise who had theorized that the Universe general principles in dealing with Galen absorbed Greek philosophy was made of atoms. Methodists diseases, but did not promote any and medical theories in his native believed the body was simply a close clinical observation of specific Pergamum, but after he had moved physical construct and that with cases. If a theory proved incorrect, to Rome in 162ce, he developed them good hygiene, diet, and drugs, it it could lead to disastrous results. further. Like Hippocrates, he saw could be easily put back into order. the human body as one complete They decried the medical profession, Combined theories system that should not be treated believing that the basics of medicine It took a physician of rare ability as a collection of isolated organs could be learnt in a few months. to create a synthesis from these that yielded disparate sets of competing schools of thought. symptoms. To understand disease By contrast, the Empiricists – Claudius Galen, a Roman physician and to treat patients, Galen believed founded by the Greek physician from Pergamum (in modern-day the physician must closely observe Philinus of Cos in c. 250 bce – both inside and outside the human believed medical knowledge could body. Only then could he apply a theoretical framework, based on ❯❯ When serving as physician for a gladiatorial school, Galen gained first-hand experience of the internal human anatomy through treating the wounded and examining the dead.

42 ROMAN MEDICINE the humours of Hippocrates, when contained blood. During one proposing cures. With this approach, experiment, he severed the Claudius Galen Galen combined Rationalist and laryngeal nerve of a live pig, which Empiricist thought – but he remained continued to struggle but was no Born in Pergamum (in modern- sceptical of the Methodist school. longer able to squeal. This confirmed day Turkey) in 129 ce, Galen Galen’s own hypothesis concerning decided to become a doctor Clinical observation the nerve’s role in vocalization. after the healing god Asclepios Galen believed an understanding appeared to his father in of anatomy together with direct Galen’s emphasis on observation a dream. He studied at observation and experiment were extended to the clinical examination Pergamum, Smyrna, and then fundamental medical requirements. of patients’ external symptoms as a Alexandria, where he had During his time as chief physician means to diagnose and to prescribe access to medical texts in the to a Pergamum gladiatorial school, correct cures. During the Antonine Great Library. he had observed elements of the Plague, which erupted in 165 ce, musculature and internal organs Galen recorded symptoms of After five years as chief exposed by wounds. Yet, human patients he examined. In all cases physician to the gladiatorial dissection was forbidden by Roman he saw vomiting, upset stomachs, school in Pergamum, Galen law, so he was confined to the and foul breath, but the patients moved to Rome in 162 ce. dissection of animals. Galen’s whose bodies became covered in There, his growing medical experiments on barbary apes, black scabs that fell off after a few reputation and abrasive cattle, and pigs enabled him to days tended to survive. In contrast, personality won him enemies. make certain advances such as patients who excreted dark black Forced to leave in 166, he understanding that the arteries stools would usually die. Galen did was brought back by Emperor not understand the cause of this Marcus Aurelius in 169 to serve as imperial physician – “Phlegmatic” Air “Sanguine” a post he also held under temperament; Spring temperament; Commodus and Septimius influenced by cold Blood influenced by heat Severus. Galen died in and wet; associated Sanguine and wet; associated c. 216. A prolific writer, with apathy. with optimism. he left around 300 works, including books on linguistics, Water Winter Wet Hot Summer Fire logic, and philosophy, as well Phlegm Temperament Yellow bile as medicine, but only about Phlegmatic half of these have survived. Cold Dry Choleric Key work “Melancholic” Autumn “Choleric” temperament; Black bile temperament; c. 165–75 ce De Usu Partium influenced by Melancholic influenced by Corporis Humani (On the cold and dry; heat and dry; Usefulness of the Parts of associated with Earth associated the Human Body) sadness. with anger. Galen linked each of the four humours to a season, an element (such as air), and a temperament (such as sanguine). Ideally, humours remained balanced; an excess or lack of one could result in illness.

ANCIENT AND MEDIEVAL MEDICINE 43 Although separated by centuries, with high levels of cold and dry, medical authority that impeded Galen and Hippocrates are portrayed for example, would most likely be progress in both areas. He had together in this 13th-century Byzantine melancholic. Galen also claimed carried out most of his anatomical fresco in Italy as the most significant that high levels of yellow bile would research on animals, and many of physicians of the ancient world. contribute to intelligence. his results were invalid for humans. Yet Galen’s authority meant later disease, which may have been Lasting fame practitioners were so certain of smallpox, and little could be done Although Galen was Rome’s most his work that for centuries those other than to make the patients famous physician, there were others performing dissections simply comfortable. However, his detailed who carried out groundbreaking rejected any contradictory evidence recording of the symptoms is a work. The mid-1st century ce saw before them. As more physicians testament to his commitment to Aulus Celsus, who dealt with diet attempted to replicate Galen’s understanding the signs of disease. and surgery, and identified many experiments, the flaws in his skin disorders. Soranus of Ephesus theories appeared. With the work Galen’s medical ideas were in the early 2nd century was of Flemish physician Andreas rooted in his development of a pioneer of obstetrics and Vesalius in 1543, Galen’s authority Hippocrates’ theory of humours. gynaecology. Yet it was Galen’s as an anatomist collapsed. He expanded Hippocrates’ idea work that survived the fall of on the variables of hot and cold, Rome in 476, in books that were Despite this fall from grace, and wet and dry – each of which translated and transmitted via Galen’s contribution to medicine was played a role in the equilibrium Islamic physicians from the 7th immense. The Islamic physician of the body. A person who has a century, to become the basis of al-Razi (854–925), who wrote Doubts tendency to coldness and dryness, medieval European medicine. about Galen, was still supportive of Galen believed, would have a soft his methods rather than his findings. constitution and be slim. He Ironically, despite his emphasis Modern physicians work on the also considered that the relative on practical experimentation and basis that an accurate knowledge combinations of these factors clinical observation, it was Galen’s of human anatomy combined affected temperament. The person elevation to the status of ultimate with close clinical observation of symptoms is essential to treating disease. As such, Galen continues to be a towering influence on the practice of medicine. ■ In the course of a single dissection … Galen has departed on two hundred or more occasions from the true description of the harmony, function, and action of the human parts. Andreas Vesalius De Humani Corporis Fabrica, 1543

KSCANICUOKSWNESETSHOSEF AND HEALTH ISLAMIC MEDICINE



46 ISLAMIC MEDICINE IN CONTEXT Truth in medicine become a renowned centre of is an unattainable goal, and medical treatment and learning. BEFORE the art as described in books Islam’s first documented general 4th–6th century ce The is far beneath the knowledge hospital – or bimaristan (Persian for world’s first medical centre “place of the sick”) – was founded develops at Gondeshapur of an experienced and around 805 by caliph al-Rashid in under the patronage of thoughtful physician. Baghdad and quickly achieved fame. Sassanian kings from Shapur I. Within a century, another five had Al-Razi been built and more were later 627 The first mobile hospital established around the Middle East. is a tent for the Muslim worked in the medical centre at wounded, set up during the Gondeshapur in Iran under the Medical schools had close links Ghazwah Khandaq (Battle Persian Sasanian emperors. to such hospitals, and students of the Ditch). could observe patients being treated This interest continued under by qualified doctors. Some hospitals c. 770 Caliph al-Mansur the Islamic caliphs, particularly the had separate wards for infectious founds the Bayt-al Hikma Abbasids, whose capital Baghdad diseases, gastrointestinal problems, (House of Wisdom), where (founded in 762) became a vibrant eye ailments, and mental illnesses. many ancient medical texts economic, cultural, and scientific As a result of such first-hand are translated into Arabic. centre. In the late 8th century, clinical experience, early Islamic caliph al-Mansur established the physicians made important AFTER Bayt al-Hikma, or House of Wisdom, advances in identifying disorders 12th–13th century In Spain, which became a base for the and devising effective cures. the first Latin translation of Ibn translation of ancient texts into Sina’s Al-Qanun fi al-Tibb (The Arabic. Men such as Ibn Ishaq Clinical expertise Canon of Medicine) appears. (808–73), the court physician who In the 9th century, al-Razi, the chief translated the works of Hippocrates physician to the caliph in Baghdad, 1362 After the Black Death and Galen, ensured that Islamic wrote more than 200 texts and ravages Europe, Ibn al-Khatib physicians had access to the medical commentaries developing the of Granada writes a treatise theories of the Greek and Roman principles of earlier Greek, Roman, on contagious infections. world. A new era of Islamic medicine Syrian, Islamic, and Indian medical developed, fuelled by luminaries 1697 Ibn Sina’s Qanun is still such as al-Razi (854–925) and Ibn Al-Razi examines a patient and on the curriculum at the Sina (980–1037), known in the West holds up a matula, a vessel for collecting medical school in Padua, Italy. as Rhazes and Avicenna respectively. urine, in a French image from the 13th century. Al-Razi pioneered a scientific T he fall of the western Early Islamic hospitals approach to uroscopy, the study of urine. Roman Empire in the late From the first, Islamic medicine 5th century ce led to a embraced the practicalities of steep decline in the level of medical treatment as well as medical knowledge and practice in Europe, theory. In the 7th century, Islam’s but Hellenistic (Greek) culture had first mobile hospital had treated survived in the empire’s eastern battlefield injuries, and the provinces, conquered by the armies academy at Gondeshapur had of a new religion – Islam – in the 7th century. There, the medical theories from ancient Greece and ancient Rome were transmitted to early Islamic physicians by Nestorian (Eastern) Christians who

ANCIENT AND MEDIEVAL MEDICINE 47 See also: Greek medicine 28–29 ■ Herbal medicine 36–37 ■ Roman medicine 38–43 ■ Medieval medical schools and surgery 50–51 ■ Pharmacy 54–59 ■ Hospitals 82–83 ■ Hygiene 118–19 ■ Women in medicine 120–21 The physician … must At the start of the Islamic Golden Age, newly translated always make the patient Greek, Roman, and ancient Indian texts reveal a wealth believe that he will recover, for the state of the body of medical principles and remedies. Islamic physicians study the theories and gain practical is linked to the state of the mind. experience from examining patients in hospitals. Kitab al-Hawi fi al-Tibb, c.900 By recording and comparing patients’ symptoms, physicians make more accurate diagnoses. theorists. He emphasized the need Treatments become more effective as physicians observe to develop diagnoses by examining how patients respond to drugs and other therapies. patients and interviewing them, and to administer treatments based Physician-scholars set down new findings and refine on past experience of their efficacy. earlier principles. Medicine progresses. In his Kitab al-Hawi fi al-Tibb (The Comprehensive Book of Medicine), therapies involving diet, medicines, 931, caliph al-Muqtadir ordered the he recorded the symptoms of a huge and even music and aromatherapy. licensing of all physicians when he range of diseases and became one He also urged that patients should heard that an error had caused a of the first doctors to distinguish be encouraged to believe in the patient’s death. When medical between smallpox and measles, possibility of improvement and the students passed their examinations, which doctors had previously efficacy of a treatment, as this was they took the Hippocratic Oath and considered to be the same infection. likely to produce better outcomes. received a licence from a muhtasib Insistence on close observation (inspector general). also led him to identify gout as a Licensed to practise single condition (and not a variety Al-Razi was revered as not only a A great medical manual of conditions, as the Greeks had model practitioner but also as a The idea that medicine should be supposed), and he concluded from teacher. Not everyone matched his based on a comprehensive system his clinical experience that many high standards, however, and in of observation, experimentation, ❯❯ diseases did not follow the course that Galen, the great Roman physician, had suggested. Among al-Razi’s many insights were his views on mental illness and the connection between mind and body. He championed the idea that mental disorders should be treated in the same way as physical diseases, and prescribed

48 ISLAMIC MEDICINE [Medicine] has both of the person). Ibn Sina believed doses at first to observe the effect. a theoretical and a that the four humours interacted In the third and fourth books, Ibn with the “elements” (earth, air, Sina covers disorders of specific practical side. fire, and water) and the patient’s parts of the body, from head to toe, Ibn Sina anatomy to cause disease. An including tuberculosis affecting excess of moisture, for example, the lungs (correctly identified as and testing in order to establish might cause tiredness or digestive contagious) and cataracts of the diagnoses and devise the best disorders, while elevated heat could eye, and those that affect the whole treatment reached its most induce thirst or a racing pulse. body or several different parts, such developed form in the work of Ibn Like Galen and Hippocrates, he as fevers, ulcers, fractures, and skin Sina. His Al-Qanun fi al-Tibb (The considered that direct observation conditions. The fifth and final book Canon of Medicine), published of a patient could determine which describes a number of complex around 1012, gathered knowledge factor was out of balance. preparations and treatments, and a from Greek, Roman, Persian, and collection of preventive measures, Arabic works and combined it with Drugs, diseases, and cures including diet and exercise. Ibn his own clinical observations to The second book of the Qanun Sina’s recognition that prevention create the most comprehensive catalogued about 800 remedies and is better than cure set him several medical manual of the medieval medicines from plant, animal, centuries ahead of medieval era. In the 12th century, it was and mineral sources, together with European physicians. translated into Latin and became the diseases they could treat most an essential part of the training for effectively. Ibn Sina drew from Built on earlier advances medical students in Europe for Indian and Greek authorities, then Before Ibn Sina, a constellation of some 400 years. offered his own opinions of the Islamic physicians had contributed efficacy of remedies, their differing to the advancement of medical The Qanun ran to more than a strengths, and certain variations in science. In the late 8th century, million words in five volumes. The recipes from different sources. Jabir Ibn Hayyan (known in first book dealt with the origins of Europe as Geber), who was diseases. Drawing much from the With advice partly taken from the court physician to caliph Hippocratic and Galenic theory of Galen, Ibn Sina also set down seven al-Rashid, formalized the study humours, Ibn Sina classified the rules for experimenting with new of pharmacology. Although many of possible causes of disease, both drugs. He cautioned that medicines the 500 works attributed to him extrinsic (such as the climate of should not be exposed to excessive were probably written by his later the region) and intrinsic (such as heat or cold, and that a drug should followers, Jabir himself brought whether the patient has excessive be tested on a patient who suffered experimental rigour to the traditional sleep/rest or excessive movement/ from one, rather than multiple practice of alchemy, which sought activity), alongside other causes conditions, and given only in small (such as the habits and constitution A pharmacist weighs out a medicine for a patient suffering from smallpox in this illustration from Ibn Sina’s Canon of Medicine. Islamic pharmacists – like doctors – were trained and licensed.

ANCIENT AND MEDIEVAL MEDICINE 49 Ibn Sina Born in 980 ce near Bukhara (in Iran. There he was court present-day Uzbekistan), Ibn Sina, physician and vizier to the Buyid the son of a government official, ruler Shams ad-Dawla. In 1022, studied Islamic philosophy, law, Ibn Sina moved to Isfahan, and medicine. At the age of 18, under the patronage of Persian he successfully treated Nuh Ibn prince Ala al-Dawlah, and Mansur, the Samanid sultan of completed his major works. He Bukhara, which gained him a died in 1037 from the after-effects position at court and access to of a slave adding excessive the extensive royal library. opium to one of his remedies. The collapse of the Samanids Key works in 999 forced Ibn Sina to flee, and he spent several years in c.1012 Al-Qanun fi al-Tibb Khorasan, a region covering parts (The Canon of Medicine) of northeast Iran, Afghanistan, c.1027 Kitab al-Shifa (Book and Central Asia, before moving of Healing) to Hamadan, a city in west central to transform one substance into Egypt, was renowned for his basis for diagnosis, the keeping of another (notably base metals extensive knowledge of medicinal detailed patient records, the inclusive into gold). A brilliant chemist, herbs, for his guide to nutrition, nature of its hospitals that treated he catalogued key processes such plants, and minerals (al-Murshid), all members of society, the training as crystallization and evaporation, and for an antidote for snakebite so of doctors, and the employment of and invented the alembic, a jar successful that he called it tiryaq female physicians and nurses. Its used for distillation. Jabir’s work al-faruq (“the cure of salvation”). teaching lives on, especially in the gave pharmacists of his time the Unani system of medicine practised tools to develop new drugs. In Cordoba, Spain, Andalusian in Iran, Pakistan, and India. ■ court physician and the medieval Other notable precursors to Ibn era’s greatest surgeon al-Zahrawi Sina include al-Tabari, a 9th-century compiled the 30-part Kitab al-Tasrif Persian physician who taught al-Razi (The Methods of Medicine) in the and wrote the seven-part Firdous late 10th century. It included a al-Hikmah (Paradise of Wisdom) – surgical treatise outlining many one of the earliest encyclopedias sophisticated techniques, such as of Islamic medicine. Al-Tamimi, a the removal of bladder stones, the 10th-century physician in Cairo, excision of cancerous tumours from breasts, as well as gynaecological operations and an early form of plastic surgery to mitigate damage caused by wounds. If the physician is able Lasting influence to treat with nutrients, A product of the Islamic Golden Age, Islamic medicine had a significant not medication, impact on Western Europe from the then he has succeeded. medieval era until the 17th century, when new scientific ideas emerged Kitab al-Hawi fi during the Age of Enlightenment. al-Tibb, c.900 Islamic medicine was advanced in many ways, with its emphasis on wellbeing, its insistence on Ibn Sina teaches his students the observation of the patient as the principles of hygiene in this image from a 17th-century Ottoman manuscript. Ibn Sina taught daily at a local medical school during his later life in Isfahan.

50 ILANEBGALERENNTIEOODUA,SED,XAAPPNETDRT, MEDIEVAL MEDICAL SCHOOLS AND SURGERY IN CONTEXT A fter the fall of the Roman monasteries had their own medicinal Empire, what remained garden for herbal remedies. Some BEFORE of Greco-Roman medical had qualified apothecaries and 9th century ce The Salerno knowledge in Western Europe their in-depth knowledge of plants medical school is founded, retreated into monasteries. The enabled them to prescribe a range reviving medical studies in Benedictine monastic order of the of herbal or mineral remedies, as Western Europe. Catholic Church, founded in the they carried out basic procedures 6th century ce, insisted that each such as bloodletting. Beyond the c.1012 Ibn Sina writes The of its monasteries had an infirmary monasteries, medical schools Canon of Medicine, which with a monk in charge. One of the advanced new ideas and skills, remains essential reading at first of these was Montecassino, in epitomized in the late 12th century medical schools until the southern Italy. In the early 800s, the by the master surgeon Roger of 16th century. Holy Roman Emperor Charlemagne Salerno, or Rogerius. decreed that every cathedral and 1130 The Catholic Church monastery in his kingdom should Schola Medica Salernitana forbids clergy from practising have a hospital attached. Monks The first formal medical teaching medicine for fees, accelerating provided palliative care and treated school emerged from the European the move to secular medicine. a wide range of ailments. Many Dark Ages in the 9th century ce in Salerno, southern Italy. It drew AFTER Paris for the sciences, on influences from Islamic, Jewish, 1363 Guy de Chauliac writes Salerno for medicine, Greek, and Roman medicine. the authoritative and wide- For four centuries, the reputation ranging Chirurgia Magna. Bologna for law… of this school, Schola Medica Thomas Aquinas Salernitana, as a centre of teaching c.1440 The invention of the excellence was probably unrivalled printing press rapidly expands Italian theologian and philosopher in medieval Europe. Students, the spread of knowledge, (c. 1225 –74) teachers, and those seeking medical including key medical texts. treatment travelled long distances to reach Salerno. In 1099, for 1543 Andreas Vesalius’s example, Robert II of Normandy De Humani Corporis Fabrica travelled from northern France to (On the Structure of the receive medical attention. Human Body) marks a new Salerno had the world’s most advance in medical anatomy. extensive medical library, with