The Medicine Book

ANCIENT AND MEDIEVAL MEDICINE 51 See also: Greek medicine 28–29 ■ Herbal medicine 36–37 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Pharmacy 54–59 ■ Anatomy 60–63 ■ Midwifery 76–77 ■ Women in medicine 120–21 ■ Pandemics 306–13 texts by Islamic physicians al-Razi An illustration showing a cranial and legs. Rogerius’s pioneering work (854–925) and Ibn Sina (980–1037), operation, taken from Rogerius’s Practica included methods for detecting and other texts from Montecassino Chirurgiae. His work brought academic tears in the cerebral membrane (the reflecting the teachings of ancient respect to the discipline of surgery. Valsalva manoeuvre) and realigning Greece and Rome. The school damaged tissues (reanastomosis). provided thorough curriculum-based Women were welcomed as students teaching, typically with three years and teachers at Salerno. In the early Medical schools spread of study followed by four years of or mid-12th century, the most By the 12th century, other medical hands-on training. prominent of these was Trota (or schools had been set up in Europe, Trocta), a physician, educator, and including those at Montpellier in writer. Her specialities were France, Bologna and Padua in Italy, gynaecology and midwifery, but Combria in Portugal, Vienna in she gave students a grounding in a Austria, and Heidelberg in range of diagnostic tools, including Germany – all modelled on Salerno. how to analyse urine, check pulse rates, and examine skin tone. French surgeon Guy de Chauliac (c. 1300–68) studied at Montpellier Roger of Salerno and Bologna, and was appointed Salerno’s reputation peaked in the to the most prestigious position in late 12th century, when Rogerius Europe – personal physician to Pope (c. 1140–95) became its most famous Clement VI. Chauliac’s Chirurgia teacher and surgeon. His Practica Magna (Great [work on] Surgery) Chirurgiae (Practice of Surgery) covered an array of subjects, was considered a standard text for including anatomy, anaesthetics, at least 300 years. Written in 1180, bloodletting, drugs, fractures, and it was the first work to deal with wounds. The seven-volume text treatments arranged anatomically, was translated from Latin into describing diagnoses and treatments many languages and became a for diseases and disorders of the new authority for surgeons until the head, neck, arms, chest, abdomen, 17th century, when new medical theories began to emerge. ■ The Black Death to 50,000 during this period. Most A 14th-century depiction of Death people who contracted the disease strangling a victim of bubonic plague. One of the deadliest pandemics died within days. Guy de Chauliac distinguished in human history, the Black between this and pneumonic plague. Death was a devastating At the time, the cause of the outbreak of bubonic plague that plague was not understood, but killed 25 to 200 million people in some physicians blamed “a great Asia, Europe, and North Africa pestilence in the air” (the miasma in the mid-14th century. It theory). It is now known that the probably originated in Central bacteria responsible for it were or East Asia and spread west, carried by rat fleas. Rats were peaking in Europe between 1347 commonplace in overcrowded, and 1351. Up to half of Europe’s unhygienic cities, and they were population perished, with cities also transported from port to port faring particularly badly. For on boats. The idea of quarantine instance, the population of first emerged in the city-state of Florence, Italy, fell from 110,000 Ragusa (modern Dubrovnik, Croatia) in 1377.

52 OTHFEMVEADMICPIINREE BLOODLETTING AND LEECHES IN CONTEXT T he practice of medicinal bloodletting should not be left to bloodletting – the removal barber-surgeons alone. Bloodletting BEFORE of blood to cure disease – then became a central medical tool c.400 bce Hippocrates is thought to have originated in until the 19th century: one French promotes his theory of the ancient Egypt around 3000 bce. It doctor, François Broussais (1772– four humours, which becomes passed into ancient Greek culture 1838), was branded the “Vampire the basis for bloodletting. during the 5th century bce, and was of Medicine” for his leech-mania. formalized as a procedure after the c.1000 ce Al-Zahrawi physician Hippocrates declared Today, leeches are still used to describes surgical instruments blood to be one of the four bodily remove congested blood in some for use in bloodletting. humours that must remain in operations, and bloodletting plays balance to preserve health. a role in treating conditions such AFTER as haemochromatosis (a disorder 1411 French healer Peretta Bloodletting was widespread in causing an accumulation of excess Peronne is prosecuted for Europe by the medieval era. In 1163, iron in the blood). ■ carrying out bloodletting, a the Church forbade clerics carrying practice forbidden to women. out the procedure, so barbers Bloodletting performed bloodletting and other frequently strangles fever … 1719 Austrian surgeon surgery, using instruments such Lorenz Heister develops as fleams (blades with handles), it imparts strength the spring lancet. lancets (needles), or the medicinal to the body. leech (Hirudo medicinalis) to suck 1799 First US president blood and anaesthetise the wound. Benjamin Rush George Washington dies from shock and loss of blood Bridging the gap American physician (1746–1813) after being bled excessively The divide between physicians, by his doctors. who dispensed cures, and barber- surgeons, who operated directly on 1828 Research by French the body, only began to close in the doctor Pierre Louis suggests 1250s when doctors such as Italy’s the medicinal use of leeches Bruno da Longobucco argued that is of little value, leading to a reduction in the procedure. See also: Greek medicine 28–29 ■ Roman medicine 38–43 ■ Medieval medical schools and surgery 50–51 ■ Blood circulation 68–73

ANCIENT AND MEDIEVAL MEDICINE 53 HWTHEAAERLPSIRNHOGAGAVRREETFSUSROTFHETRHEED BATTLEFIELD MEDICINE IN CONTEXT W ounds inflicted in battle have engaged doctors BEFORE since ancient times. The c.500 bce Sushruta describes Edwin Smith papyrus, an Egyptian a form of tourniquet that can surgical text from c. 17th century prevent arterial bleeding bce, details treatments for injuries during amputations. sustained in battle. The Roman army gained significant expertise c.150 bce Galen advises in battlefield medicine. Yet by the against tourniquets, claiming medieval era techniques had barely that they increase bleeding. progressed, and most serious wounds resulted in death, either c.1380 ce The use of a wicker from shock or bacterial infection. stretcher to carry a casualty from the battlefield to safety Pioneering techniques Ambroise Paré’s ligature technique is recorded in France. During a battle in 1537, French (tying arteries during amputations to army barber-surgeon Ambroise stop haemorrhaging) represented a AFTER Paré ran out of the boiling oil significant surgical breakthrough. 1847 Russian surgeon Nikolai traditionally used to treat gunshot Pirogov introduces ether to be wounds (it was believed to purge the procedure. His many other used as an anaesthetic in the the body of poisonous gunpowder). advances include long forceps to Crimean War. Resorting to a folk remedy of egg extract bullets from wounds and yolk, rose oil, and turpentine, he the use of pain relief in surgery. 1916 In World War I, British found that the wounds healed more chemist Henry Dakin designs rapidly and with much less pain. Paré’s work inspired others such a disinfectant to kill bacteria Paré later pioneered the use of as Dominique-Jean Larrey, a French without damaging the flesh. ligatures rather than cauterization surgeon in the Napoleonic Wars, who to seal amputations, and developed introduced military ambulances to 1937 In the Spanish Civil War, the Bec de corbin (“crow’s beak”), transport casualties to safety, and Canadian surgeon Norman a clamp to fix the ligature during pioneered the concept of “triage” Bethune’s refrigerated trucks, to assess the urgency of cases. ■ the first mobile blood banks, allow blood transfusions to See also: Plastic surgery 26–27 ■ Roman medicine 38–43 ■ Scientific take place near the front line. surgery 88–89 ■ Triage 90 ■ Blood transfusion and blood groups 108–11

THE ART OF PRESCRIBING LIES IN NATURE PHARMACY



56 PHARMACY IN CONTEXT The body and its illness are chemical entities. BEFORE Illness may therefore be cured c. 70 ce Dioscorides writes with the aid of the right chemical. De Materia Medica. The pharmacist The pharmacist c. 780 Jabir ibn Hayyan may find that may have to create develops ways of purifying the right chemical a new compound by and mixing drugs. already exists joining or synthesizing 1498 The first official in nature. chemicals. pharmacopeia, Ricettario Fiorentino, is issued in Italy. concepts, but in placing chemistry military surgeon Dioscorides at the heart of treatment for produced De Materia Medica – AFTER disease, he characterized the new a compendium of known medical 1785 British physician William focus of Renaissance science and treatments, mostly plant-based – Withering conducts one of the initiated the field of pharmacology. which remained the go-to book for first clinical drug trials, proving medicaments until the 18th century. the efficacy of digitalin. Ancient origins The idea of using particular Knowledge like this depended 1803 The first known substances to heal ailments goes on finding naturally occurring alkaloid, morphine, is back to prehistoric times, and even substances, especially herbs. The isolated by Louis Derosne. animals often know instinctively to idea of creating chemical drugs home in on certain plants or minerals emerged in the Muslim world around 1828 Friedrich Wöhler when sick. Surviving papyri tell the 8th century ce. Persian polymath synthesizes urea from us that ancient Egyptian physicians Jabir ibn Hayyan (known as Geber non-organic compounds. wrote healing recipes for their in Europe) began to experiment with patients and recognized the 1860s Claude Bernard purgative qualities of plant materials proves drugs have specific such as senna and castor oil. Folk sites of action in the body. healers also passed down knowledge about the curative properties of P harmacy is the idea that herbs, and in Greek and Roman certain substances can be times, physicians began noting used to treat or prevent these down. Around 70ce, the Greek disease, or to correct bodily functions. Today, people take it for Jabir ibn Hayyan, known as the granted that if they are ill, a doctor “father of early chemistry”, promoted will prescribe drugs to make them greater understanding of chemical better. Such demand has made the processes through his teaching, texts, production of pharmaceuticals one and experiments in the 8th century ce. of the world’s biggest industries, with an estimated worth of around US$1.5 trillion. One of the first major proponents of pharmacy was the 16th-century Swiss physician Philippus von Hohenheim, who went by the name of Paracelsus. Paracelsus was an alchemist, not a modern scientist, and his theories involved occult

ANCIENT AND MEDIEVAL MEDICINE 57 See also: Herbal medicine 36–37 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Aspirin 86–87 ■ Homeopathy 102 ■ Germ theory 138–45 ■ Physiology 152–53 ■ Targeted drug delivery 198–99 ■ Antibiotics 216–23 processes such as crystallization and physicians today, pharmacopeias of Galen and Ibn Sina (Avicenna) distillation in his laboratory, creating are official lists of medicinal drugs, and rejected the concept of the concoctions which, as a physician, giving their effects and directions four humours. he tested on his patients. He was for their use. chiefly interested in the chemistry Instead of an imbalance in of poisons and how they react in The “Luther of medicine” bodily fluids, Paracelsus regarded the body. Among the hundreds of During the 16th century, Paracelsus disease as an intrusion into the texts attributed to him is the oldest revolutionized the preparation and body – in some ways anticipating known systematic classification of prescription of chemical compounds. germ theory. He also argued that chemical substances. A contemporary of Martin Luther, book learning is of little use when the iconoclastic German priest who treating patients: what matters is The first pharmacopeias challenged the prevailing orthodoxy learning from observation and ❯❯ Most physicians in medieval of the Church, Paracelsus was Europe had little interest in drugs labelled the “Luther of medicine” Alchemists prepared cures that and still adhered to the ancient for his attempts to reform orthodox often included tiny amounts of toxic teachings of Galen on rebalancing medical opinion. He challenged its ingredients, and used processes the body’s humours in order to treat reliance on the traditional teachings such as distillation, which prefigured illness. It was left to apothecaries to modern drug production. dispense chemical remedies, many of which were ineffective, and some even harmful. In 1478, however, the printing of Dioscorides’s De Materia Medica, previously only circulated as hand-copied manuscripts, sparked new interest in the concept of using formulations for healing. In 1498, keen to regulate the apothecary trade and banish quack remedies, the medical authorities in Florence, Italy, published the Ricettario Fiorentino (Florentine Book of Prescriptions) – the first pharmacopeia. Still utilized by The patients are your textbook, the sickbed is your study. Motto of Paracelsus

58 PHARMACY experimentation. Prefiguring toxicity of some of the substances modern pharmaceutical methods, used), but in late 17th-century Paracelsus he conducted experiments to make France, scientists began to follow medicinal compounds, heating and up on Paracelsus’s assertion that Born in Einsiedeln, Switzerland, distilling metals to transform them there is an active principle or key in 1493, Philippus Aureolus into substances that might defeat chemical in plants that gives Theophrastus Bombastus von disease. Among his discoveries them medicinal qualities. They Hohenheim took the name was laudanum, derived from hypothesized that if they could Paracelsus (meaning “beyond powdered opium and alcohol, which extract or harvest this, as Paracelsus Celsus”, the Roman physician) became the prime relief for people suggested, they might be able to to show his rejection of ancient in severe pain until the discovery of reproduce it in large amounts. Roman teaching after studying morphine in the 19th century. He medicine at universities in was also one of the first physicians In 1803, French pharmacist Austria, Switzerland, and Italy. to treat syphilis with mercury, which Louis Charles Derosne found that remained almost the only treatment morphine was the active ingredient Paracelsus found university for the disease until the 20th century in opium. In 1809, Louis Vauquelin learning so out of touch that he despite its dreadful side effects. isolated nicotine in tobacco. spent years travelling widely, Soon after, Pierre-Joseph Pelletier learning from folk healers and The active principle and Joseph-Beinamé Caventou alchemists. By the time he After his death, Paracelsus’s ideas identified quinine in cinchona, returned to Austria in 1524, he continued to circulate through his caffeine in coffee, and strychnine was famous for his miraculous written works. For two centuries, in the seeds of the “poison nut” cures. He opened his lectures his followers developed the field of tree, Strychnos nux-vomica. to all, burned ancient medical iatrochemistry, a form of medicinal texts, and stressed the value chemistry. Regarding the body as The isolation of these organic of practical learning. He looked a chemical system and disease as a compounds led to the realization to chemistry and metals for disturbance in this framework, they that they all contained nitrogen and cures, but his iconoclastic style used chemical processes to extract behaved as bases, which form salts and interest in the occult made the “active principle” from natural when combined with acids. In 1819, him enemies. He redeemed his substances, which was then German pharmacist Wilhelm reputation with his book Der administered to rebalance the body. Meissner dubbed them “alkaloids”. grossen Wundartzney (The Soon another class of active Great Surgery Book) in 1536, Resistance to iatrochemistry organic compounds was identified: and became sought after and persisted in some medical circles glycosides. These included digitalin, wealthy, but died in the White (not least because of the high a heart stimulant extracted from Horse Inn in Salzburg in 1541 foxgloves, and salicin, the painkiller in mysterious circumstances. Low dose Doctors calculate level of Key works cures disease safe but effective dose 1536 The Great Surgery Book Substance “The dose makes the poison” 1538 Third Defence contains level was Paracelsus’s key idea that substances that are toxic in large of toxins amounts could be therapeutic in small doses. In pharmacology today High dose this principle is seen in drugs such as causes organ warfarin, a rat poison, which is used damage or death in low dosages to prevent blood clots.

ANCIENT AND MEDIEVAL MEDICINE 59 The pharmaceutical industry today uses new technologies to mass-produce drugs, but the research, testing, and development of formulations still reflect the processes developed by Paracelsus. discovered in willow bark by British cleric Edward Stone in the 1760s and later manufactured as aspirin, the first mass-market painkiller. Drug action Bernard’s research demonstrated By the mid-19th century, it was While chemists isolated organic that drugs interact with chemical clear that many of these dyes had compounds in the early 19th century, structures in or on cells (later called medical applications and large physiologists began to pin down receptors). Understanding this dye-making companies, such as their effects in the body. In France, chemical action forms the basis of CIBA and Geigy in Switzerland, François Magendie showed the drug development and testing today. and Hoechst and Bayer in painkilling effect of morphine in Germany, began to market them as 1818, and the spasms caused by Big business pharmaceuticals, redirecting their strychnine in 1819. Drugs at that As the 19th century progressed, chemical capabilities towards the time were presumed to have a advances in chemical and industrial production of synthesized drugs. general action throughout the body, processes enabled the manufacture but in 1864, Magendie’s assistant of drugs to treat the ailments of the Bayer began producing aspirin Claude Bernard found that curare, large populations crowding into new in 1899, and Hoechst launched a poison used by South American urban centres. In 1828, German Salvarsan, the first effective drug Indigenous peoples, had a specific chemist Friedrich Wöhler for syphilis, in 1910. Salvarsan local effect. Although it is carried synthesized an organic substance, marked the development of a new through the body in the bloodstream, urea, from inorganic elements. This range of “magic bullet” targeted curare acts only at the point where refuted the prevailing belief that chemical drugs. Designed to lock nerves contact muscles, preventing organic substances could only be on to specific disease-causing them from moving. In this way, the produced from living organisms. It pathogens, these drugs left the poison causes paralysis and, when also suggested that medicines based rest of the body unharmed. it hits the chest muscles, inhibits on organic compounds could be breathing, resulting in death. synthesized from inorganic materials. During the 20th century, the development of synthetic insulin Poisons and medicines A breakthrough moment came formulas to manage diabetes, are oftentimes in 1856, when 18-year-old British the production of vaccines, and the chemistry student William Henry manufacture of antibiotics, such as the same substances Perkin, tasked with finding a way penicillin, turned pharmaceuticals given with different intents. to synthesize quinine, accidentally into a lucrative global industry. Yet made the first synthetic dye, a the use of drugs as a core treatment Peter Mere Latham deep purple which he called for ailments, the methods of their mauveine. Other synthetic dyes production, and the essence of British physician soon followed, fuelling a major new their action, still draw on the basic (1789–1875) dyestuff and fashion industry. approach and principles outlined by Paracelsus. ■

60 IN CONTEXT BDFTREIUSOATSCMFEHRCBONTOIMOOOTKNSS BEFORE c. 1600 bce In ancient Egypt, ANATOMY the Edwin Smith papyrus, the oldest known medical treatise, lists traumas to the organs. 2nd century ce Galen publishes works on anatomy that are largely based on his dissections of animals. c. 1012 Persian physician Ibn Sina completes The Canon of Medicine, which includes a classification of organs. 1490s Leonardo da Vinci begins his anatomical studies based on direct observation of the human form. AFTER 1832 The Anatomy Act is passed in Britain, enabling doctors and students to dissect donated bodies. 1858 Henry Gray publishes his influential work Anatomy: Descriptive and Surgical. U ntil the discovery of X-rays in 1895 ushered in medical imaging, the only way to see inside the whole human body was by dissecting the dead. As cultural taboos hindered this, physicians based their knowledge of bones and organs on animal dissection. Flemish anatomist Andreas Vesalius revolutionized anatomical study in the 16th century when he proved through his own dissections of the human body that many earlier theories were wrong. Using corpses from public hangings, he established the importance of accurate anatomical knowledge gained from first-hand observation.

ANCIENT AND MEDIEVAL MEDICINE 61 See also: Ancient Egyptian medicine 20–21 ■ Greek medicine 28–29 ■ Roman medicine 38–43 ■ Blood circulation 68–73 ■ Scientific surgery 88–89 ■ Gray’s Anatomy 136 ■ The nervous system 190–95 Dissection of This inaccurate view Dissection became a regular part human beings is very of human anatomy of university courses. In general, rarely carried out. Ideas becomes received assistant barber-surgeons rather of human anatomy wisdom. than professors performed human are therefore based dissections, while junior academic on the anatomy of When Andreas staff read out relevant sections from Vesalius conducts Galen. In 1315, Mondino de Luzzi, animals. human dissections, professor of anatomy at the he finds that much of this University of Bologna, presided over Personal received wisdom his first public dissection of a human observation body. He published Anathomia in leads to accurate is wrong. 1316, but, like other anatomy texts knowledge of the time, it espoused the of the body. other animals, and from examining hallowed anatomical texts of Galen. wounded gladiators when he was Physicians had long known that they chief physician to the gladiator The study of anatomy began to needed to understand the structure school in Pergamum. Galen’s texts change in the late 15th century, after and placement of organs in order became established orthodoxy for Renaissance artists introduced a to treat disease. Ancient Egyptian more than 1,300 years. The work of more realistic style of portraiture, texts display knowledge of human Islamic physician Ibn al-Nafis, who involving a closer study of the human organs, probably gained from carried out dissections in Egypt in form. From around 1490, Italy’s mummification. The word anatomy the 13th century, and contradicted famous artist, scientist, and engineer (from the Greek ana-tome meaning Galen with his correct description of Leonardo da Vinci performed “a cutting up”) was coined in the pulmonary circulation, was not dissections in Florence, Milan, 4th century bce by Aristotle, who translated into Latin until 1547. Rome, and Pavia and made detailed dissected animals and made anatomical sketches of the human generalizations from his findings. New interest skeleton, muscles, and organs. The Greek physician Herophilus As new universities sprang up in It was Leonardo who provided the took this a stage further around Europe, interest in anatomy revived, first clinical description of cirrhosis 275 bce by dissecting hundreds beginning at the medical school in of the liver. of human corpses. Allegations that Salerno, Italy, founded in the 9th he had dissected live bodies led to century. A Church ban on clergy In Bologna, Giacomo Berengario public revulsion for anatomy, and performing surgery did not extend da Carpi produced a book in 1521 the practice largely stopped. to human dissection, and in 1231, that amended Mondino’s work. Holy Roman Emperor Frederick II Venetian anatomist Niccolò ❯❯ Galen’s legacy ruled that a human dissection should Until Vesalius, the most influential take place every five years. In 1240, Through dissection early anatomist was the Roman he also decreed that all surgeons had of the dead we gain doctor Galen, in the 2nd century ce. to study anatomy for at least a year. accurate knowledge. Galen derived his knowledge from Andreas Vesalius the dissection of dogs, apes, and De Humani Corporis Fabrica

62 ANATOMY I myself cannot wonder enough at my own stupidity and too great trust in the writings of Galen. Andreas Vesalius De Humani Corporis Fabrica Massa included his own Dissections were part tutorial, part about human anatomy were wrong observations in Liber Introductorius public spectacle, as the title page of De on several important points. For Anatomiae (Introductory Book of Humani Corporis Fabrica Libri Septem example, Vesalius found that the Anatomy), published in 1536. shows. Audiences included dignitaries, human breastbone is made up of Generally, however, conclusions members of the public, and students. three segments, not seven as Galen drawn from dissections were still had said; the human liver has four made to fit the theories of Galen. Italy at the University of Padua, lobes, not five; and the mandible which had a longstanding tradition (lower jaw) is made up of a single Anatomical revolution of practical anatomy, Vesalius bone, not two. Vesalius also Andreas Vesalius established the carried out the dissections himself established that the humerus principle that proper understanding and produced charts to illustrate (the upper arm’s bone) was not the of the human body can only come his lessons for students. He second-longest bone in the body, from direct observation. Working in discovered that Galen’s theories as Galen had maintained – the tibia and fibula are longer. Trailblazing masterpiece In 1543, Vesalius published De Humani Corporis Fabrica Libri Septem (Seven Books on the Structure of the Human Body), the first comprehensive illustrated work on anatomy. Printed to exacting standards in Basel, Switzerland, the seven sections on the skeleton, musculature, vascular system, nerves, gastrointestinal system, heart and lungs, and brain were illustrated with 82 plates and around 400 separate drawings. The artists are unnamed, but may have come from the studio of the great Venetian painter Titian. Vesalius’s book provoked a storm

ANCIENT AND MEDIEVAL MEDICINE 63 of criticism for contradicting Galen, The lavish illustration in De Humani this comprehensive manual with not least from his own professor, Corporis Fabrica was designed to annotated illustrations has been an Jacobus Sylvius, who had taught entertain and amaze as well as instruct essential handbook for medical Vesalius dissection in Paris. Some readers. Its lively figures are often set students ever since. critics attacked the book for its against imaginary landscapes. scandalous nudity, but most of Vesalius’s legacy to anatomy was Vesalius’s peers soon accepted his tube, connecting the middle ear and not just De Humani Corporis Fabrica ideas. In 1561, however, Gabriele the upper throat, which he identified itself, but the principle behind it – Fallopio, professor of anatomy at and described. that true knowledge of the human Padua, who may have been taught body can only be gained from direct by Vesalius, published his own New tool, new texts and careful examination. ■ book, Observationes Anatomicae The invention of the microscope (Anatomical Observations), in which in the early 17th century enabled he corrected some of Vesalius’s scientists to examine aspects of errors. Vesalius replied by criticizing the human anatomy that are Fallopio, who is now largely forgotten invisible to the naked eye. By the save for the tubes connecting each 18th century, the study of anatomy ovary to the uterus, which he had revolutionized medical and identified in the book and which surgical education. William Hunter, bear his name to this day. a Scottish anatomist, obstetrician, and physician to Queen Charlotte In the 1550s, a professor of from 1764, used his observations anatomy at Rome, Bartolomeo of childbirth to understand the Eustachi, prepared plates with 47 structure of the uterus. In 1768, anatomical drawings – intended for Hunter established an influential a book called De Dissensionibus private school of medicine at his ac Controversiis Anatomicus – that home in London. were just as detailed as those in De Humani Corporis Fabrica. If The publication of Anatomy: Eustachi had not died before the Descriptive and Surgical by British book was published, he might have surgeon Henry Gray in 1858 marked shared the title of Father of Anatomy the moment when the study of with Vesalius. Instead, his fame is anatomy became mainstream. In largely confined to the eustachian due course retitled Gray’s Anatomy, Andreas Vesalius Born in Brussels, Belgium (which possibly to avoid a charge of was then part of the Habsburg heresy. While on a pilgrimage to Netherlands), in 1514, Vesalius the Holy Land, Vesalius heard he was the son of the apothecary to had been reappointed to his Holy Roman emperors Charles V Padua post, but on the voyage to and Maximilian I. He studied Italy, he was shipwrecked on the medicine at Louvain, Paris, and Greek island of Zakynthos. Short Padua. The day after graduating of funds, he died there in 1564. in 1538, he became professor of surgery at Padua. Key works Vesalius’s presentation of 1538 Six Anatomical Plates De Humani Corporis Fabrica to 1543 De Humani Corporis Charles V earned him a post as Fabrica Libri Septem (Seven imperial physician in 1544. He Books on the Structure of the secured the same position with Human Body) Philip II in 1559. This took him to Spain, but he left five years later,

BTHOEDYSCIE 1600–1820

NTIFIC

66 INTRODUCTION William Harvey English doctor Bernardino Ramazzini’s British writer and provides the first full Thomas Sydenham, Diseases of Workers diplomat’s wife Lady Mary Wortley Montagu and accurate a major contributor links ill health to the has her five-year-old description of blood to nosology (how workplace, laying the circulation in the diseases are classified), son inoculated publishes his Method of foundations for against smallpox. human body. occupational Curing Fevers. medicine. 1628 1666 1700 1718 1661 1671 1700s–20s 1725 Marcello Malpighi uses a In The Midwives In Holland, Herman Guy’s Hospital opens microscope to identify tiny Book, Jane Sharp Boerhaave reforms in London, UK, with provides wide-ranging, patient examination capillaries connecting practical guidance for an initial aim of treating arteries and veins – the pregnancy and procedures and “the incurably ill and “missing link” in William introduces organized childbirth. case history notes. hopelessly insane”. Harvey’s theory of blood circulation. A s the Scientific Revolution of leading European scientists, the scientific research, Malpighi gathered pace during the concept of scientific method began identified capillaries that are ten 17th century, major to take shape: the idea of formulating times thinner than human hairs, medical advances arrived with a hypothesis; designing a trial or and link arteries and veins. increasing rapidity, fuelled by experiment to test it; analysing the ingenious inventions, innovative results; and drawing conclusions. Many physicians had resisted procedures, and new philosophies Medical practitioners began to adopt Harvey’s conclusions at first because from other scientific fields. The new this approach to assess diagnoses, they contradicted Galen’s theory scientific approach also influenced treatments, and outcomes. that blood was produced by the the Enlightenment, or the Age of liver, but the evidence was now Reason, which advocated the In 1628, after almost 20 years irrefutable. Harvey’s approach also application of rational thought of personal research and scientific encouraged more physicians to use and observation to every aspect experiments, English physician their own observations rather than of society and incited political William Harvey published De Motu remain bound to ancient texts. revolution in 18th-century North Cordis et Sanguinis (On the Motion America, France, and beyond. of the Heart and Blood), which Benefits across society described for the first time how English midwife Jane Sharp used Scientific approach the heart pumps blood around the her decades of observation and The doctrines of the 2nd-century whole body. In 1661, Italian biologist hands-on experience to inform Roman physician Claudius Galen Marcello Malpighi supplied the one The Midwives Book (1671), which that had ruled European medicine missing link in Harvey’s account – advanced understanding of the birth for some 1,500 years would now be how blood in the arteries passes process, breastfeeding, and infant steadily eroded. Under the influence into the veins. Using a microscope, care. Italian professor of medicine the instrument that revolutionized Bernadino Ramazzini carefully

THE SCIENTIFIC BODY 67 Scottish naval surgeon John Hunter founds British chemist In An Inquiry into the James Lind publishes an anatomy school John Dalton gives a Causes and Effects of in London, where he scientific description the Variolae Vaccinae, A Treatise on the advocates his new Scurvy, reporting his scientific approach of colour vision Edward Jenner deficiency, which explains his life-saving 1747 clinical trial to the discipline becomes known on sailors aboard of surgery. technique of HMS Salisbury. as Daltonism. vaccination against the deadly smallpox. 1753 1764 1794 1798 1763 1793 1794 1816 In Britain, Edward French military surgeon In his Memoir French physician Stone’s report on the Dominique-Jean on Madness, French René Laënnec invents benefits of willow bark Larrey devises the doctor Philippe Pinel for fevers stimulates the stethoscope the search for its active system of triage to sort calls for more to listen more effectively ingredient and the the battlefield wounded compassionate, development of aspirin. into immediate, urgent, supportive regimes for to a patient’s and non-urgent cases. the mentally ill. chest and lungs to diagnose disease. researched disorders encountered his work. At his school of anatomy, in the 18th century, the emergence in 54 different types of work, in the he refined the practice of surgery, of hospitals that treated all who first major study of occupational which he would perform only after were sick, regardless of wealth or diseases, published in 1700. detailed observation of his patients’ religion, improved the lives of many conditions, often practising on ordinary people. By the end of the Scottish doctor James Lind animals before he operated to test century, kinder healthcare had also carried out the earliest controlled the efficacy of an intervention. been extended to the mentally ill, clinical experiment in 1747 when he spurred by the work of Philippe methodically administered different Hunter had honed his skills as a Pinel in France and William Tuke remedies to sailors with scurvy; his military surgeon in the Seven Years’ in Britain. experiment established that what War of the 1760s. In France, at the we now know as vitamin C could end of the century, another military The birth of vaccination cure the disease, which is fatal if surgeon – Dominique-Jean Larrey – Perhaps the greatest medical untreated. Clergyman Edward conceived the idea of triaging the advance of this era was vaccination. Stone reasoned that willow bark, battlefield wounded to ensure those British physician Edward Jenner’s the precursor of aspirin, might help most seriously injured were treated experiments in 1796, using cowpox reduce fevers and similarly proved first. Triage became widely used inoculation to protect against his hypothesis by observing its during wars and was then more smallpox, laid the basis for the beneficial effects on patients. generally adopted in hospitals from procedure, since used to prevent around 1900. killer diseases such as polio or At a time when surgeons were diphtheria. Vaccination currently often barbers and not medically Unlike scientific discoveries, prevents between two and three qualified, Scottish surgeon John which take time to trickle down, million deaths globally each year. ■ Hunter took a rigorous approach practical advances such as triage to the study of anatomy to inform have an immediate benefit. Early

ROUNDDTRHIEVEBNLOINOTDOISA BLOOD CIRCULATION



70 BLOOD CIRCULATION IN CONTEXT BEFORE 2nd century ce Claudius Galen asserts that blood is produced in the liver and then consumed by the organs. 1242 Ibn al-Nafis describes pulmonary circulation of blood. 1553 The idea of pulmonary circulation is put forward by Michael Servetus in his book Christianismi Restitutio (Christianity Restored). AFTER 1661 Marcello Malpighi discovers capillaries, the missing link in the double circulatory system. 1733 Stephen Hales describes and measures blood pressure (the pressure of arterial blood). 1953 American surgeon John Gibbon performs the first successful operation on a human using the heart-lung machine (the first heart bypass machine). I n 1628, English physician process was unclear to them. In Galen’s theory that blood came from William Harvey published ancient China, the Huangdi Neijing the liver is illustrated in De Arte Phisicali a new theory about the (The Yellow Emperor’s Classic of et de Cirugia (On the Art of Medicine circulation of the blood. Through Medicine) hypothesized that blood and Surgery) by English master surgeon rigorous experiments over ten became mixed with qi (life force) John Arderne (1307–c. 1390). years, he had discovered the source and spread energy around the body. and route of blood in the body. His In Greece, Hippocrates believed in the liver and was then carried ideas challenged theories that had that the arteries carried air from the through the body by the veins. prevailed for almost 1,500 years. lungs and that the heart had three Crucially, Galen argued that blood chambers, or ventricles. was absorbed by body tissues and Early theories had to be constantly replenished; Ancient doctors understood that The most influential theories he did not believe that it returned blood was essential for human life, were those of the 2nd-century-ce to the liver or the heart, or that it that it moved around the body in Roman doctor Claudius Galen. He circulated around the body. Even some way, and that the heart played understood that the body had both so, he did surmise that the right an essential role in this, but the arteries and veins but thought, side of the heart nourished the lungs incorrectly, that blood was produced

THE SCIENTIFIC BODY 71 See also: Greek medicine 28–29 ■ Traditional Chinese medicine 30–35 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Bloodletting and leeches 52 ■ Anatomy 60–63 ■ Blood transfusion and blood groups 108–11 The penetration of the blood The right ventricle Brain Harvey’s dual into the left ventricle of the heart pumps Lungs circulation is from the lung, blood that is low in theory noted that Heart blood is driven after it has been heated oxygen to the around the body within the right ventricle. lungs, where it in a circular picks up oxygen. motion and Ibn al-Nafis passes through the heart twice. Commentary on Anatomy in The oxygen-rich Ibn Sina’s Canon, 1242 blood (dark orange) flows to the left ventricle (chamber) of the heart. in some way and that blood entered Now low in Liver The heart pumps the left side of the heart through tiny oxygen, the used Gut the oxygen-rich pores. This “venal” blood then mixed blood (light orange) blood to the rest of with air from the lungs and entered returns to the heart the body’s organs the arteries, where it delivered and tissues via the pneuma or “vital spirit” to the body. via the veins. arteries. Challenging orthodoxy Rest Galen’s views formed the basis of of body medical knowledge for well over 1,000 years, but his theories did not problem of how blood circulated Things Anatomical) in 1559. In the go unchallenged. In the 13th through the body as a whole. In 16th century, human dissection century, Syrian doctor Ibn al-Nafis 1553, Spanish anatomist and became more popular in Europe. established that there are no pores theologian Michael Servetus However, acquiring corpses for this between the right and left ventricles restated the concept of pulmonary purpose was limited, and it was not of the heart, as Galen had supposed, circulation, but he was burnt as sanctioned by the Catholic Church. and that blood must travel between a heretic at the age of 42 and his the two sides of the heart by some books were suppressed, so his Dual system other means. He suggested that this theories were not widely known. William Harvey may have known must be the lungs, establishing the of Colombo’s work, since he studied principle of pulmonary circulation At around the same time, at Padua University in Italy. He also and solving one of the biggest Italian anatomist Realdo Colombo had access to the anatomical mysteries of blood circulation. rediscovered the principle of drawings of Flemish physician and pulmonary circulation. Colombo artist Andreas Vesalius. Harvey Al-Nafis’s theory was a major published his observations, based expanded on Colombo’s ideas by step forward, but the manuscript on dissections of human and animal considering the wider matter of ❯❯ in which he explained his theory cadavers, in De Re Anatomica (On was not known to European scholars until it was translated into Latin in 1547, nor did it solve the

72 BLOOD CIRCULATION blood’s circulation beyond the lungs. would have to produce and consume Harvey explains his theories In 1628, he came up with the theory about 235 litres (414 pt) of blood to his patron, King Charles I. After that the body has a dual circulatory each day. This seemed impossible. Charles I’s execution in 1649, Harvey system and that the blood passes lost his position as chief physician through the heart twice. He realized In another experiment, Harvey at St Bartholomew’s Hospital. that blood passed between the heart opened up a live snake and and the lungs, and from the heart to compressed the vein entering the pushed through the blockage in the rest of the body. This discovery heart, which then emptied of blood, the direction of the heart but it is was crucial, facilitating many future proving that he had stopped the impossible to push it backwards. medical advances. circulation of the snake’s blood. Harvey also demonstrated that Harvey’s experiments proved Practical experiments when a tourniquet is applied to that blood not only circulates Harvey came to his conclusions the arm of a human, and the veins throughout the body, but does so in through a series of experiments. become engorged, the blood can be a one-way direction. He calculated First, he concentrated on Galen’s that blood must circulate outwards assertion that blood was produced from the left ventricle through the in the liver. He drained the blood arteries, inwards to the right from sheep and pigs and measured ventricle through the heart, and their left ventricles. He calculated back to the left ventricle by means that if each heartbeat emptied the of the lungs. He realized there must ventricle of blood – and if Galen be small connections between the was right in saying that blood was arteries and veins to allow this to constantly being created rather happen, but he could not observe than circulated through the body – any himself. then the amount of blood pumped daily would be around ten times Hostile reception the volume of the entire animal. In 1628, Harvey published his The body of a dog, for example, theories in De Motu Cordis et Sanguinis (On the Motion of the Before Harvey established that Experimenting on different-sized animals, blood circulated around the body, Harvey calculated the amount doctors thought the body produced of blood in their bodies. and consumed blood. He concluded that the amount of blood He then calculated the volume passing through the heart could not of their heart chambers and the be manufactured and consumed by the rate at which they pumped blood. body as quickly as it was pumped. Harvey established that the same blood circulates.

THE SCIENTIFIC BODY 73 The animal’s heart is piece in the dual circulation theory William Harvey the basis of its life, its vindicated Harvey, albeit four years chief member, the sun of after his death. By the late 17th Born in 1578, William Harvey its microcosm; on the heart century, the double circulation of was the son of a Kent farmer. all its activity depends, the blood in the cardiovascular After studying medicine at from the heart all its liveliness system had itself become medical Cambridge University, he orthodoxy, entirely replacing the enrolled at the University of and strength arise. long-held Galenic view. Padua, where he studied William Harvey under celebrated anatomist Harvey’s discovery led to a long Hieronymus Fabricius. De Motu Cordis et Sanguinis series of medical advances, starting with the rejection of the age-old Returning to London in Heart and Blood). They were not theory that bloodletting and the 1602, Harvey became chief very well received to begin with. application of blood-sucking leeches physician at St Bartholomew’s Physicians were so steeped in were helpful in removing “excess” Hospital in 1609 and Lumleian Galen’s doctrines that they resisted blood from the system. The lecturer of the Royal College the idea of double circulation, and importance of blood pressure, as of Physicians in 1615. His many mocked Harvey’s practical first described by British clergyman appointment as chief physician approach through experimentation. and scientist Stephen Hales in the to James I in 1618 (and to his 1730s, and of hypertension (high successor Charles I in 1625) Harvey’s failure to find the blood pressure), outlined by Thomas gave him considerable prestige means by which blood passed from Young in 1808, were breakthroughs and partly shielded him from the arterial to the venous system in knowledge of the cardiovascular critics when he published his provided his critics with a specific system. In the 1890s, the new cuff theory of double circulation in loophole, which they used to sphygmomanometer (an inflatable 1628. His other important work undermine his theory. In 1648, arm band for measuring blood concerned the development French physician Jean Riolan pressure) gave doctors a powerful of animal embryos, in which pointed out that the animal diagnostic tool when assessing the Harvey disproved the long- anatomy, on which Harvey had health of the heart. held theory of spontaneous based many of his findings, might generation of life. He died not operate in the same way as In finding the solution to an in 1657. the human body and questioned enduring medical mystery and “how such a circulation takes replacing outmoded theories with Key works place without causing upset and firm evidence-based ideas about mixing of the body’s humours”. the circulation of the blood, William 1628 De Motu Cordis et Harvey ranks among the most Sanguinis (On the Motion important medical pioneers. ■ of the Heart and Blood) 1651 Exercitationes de New understandings To prove that venal blood flowed Generatione Animalium It was not until 1661, after the towards the heart, Harvey ligatured an (On Animal Generation) recently invented microscope had arm to make the veins obvious. He then been sufficiently improved, that tried to push the blood in the vein away Italian biologist Marcello Malpighi from the heart, to no avail. observed the network of tiny capillaries that connect the arterial and venous systems. This missing

74 HKANADLOIFSWECNAUSIRSEED NOSOLOGY IN CONTEXT F rom the time of Hippocrates and signs, and used the same in ancient Greece until approach to classify disorders. The BEFORE the mid-17th century, when classification of diseases was later c.175 ce Galen develops English doctor Thomas Sydenham termed nosology. Hippocrates’ idea of the four began his work, physicians in humours, which becomes the Europe had based diagnoses on Sydenham’s endeavours were basis for diagnosing disease. the erroneous theory of the four timely in an era when infectious humours. The theory attributed diseases and epidemics, such as the 1532 In England, the City of disease to excesses of phlegm, Great Plague of 1665, had decimated London begins to issue Bills blood, yellow bile, or black bile, and urban populations. The ability to of Mortality. grouped disorders accordingly. distinguish between different types of illness in order to treat them 1554 Jean Fernel outlines an When diagnosing his patients’ effectively was urgently required. early scientific approach to complaints, Sydenham, by contrast, nosology in Universa Medicina. based his conclusions on careful, Objective observation objective observation of symptoms One practical effort to monitor AFTER disease was the City of London’s 1853 In Brussels, Belgium, the Bills of Mortality, which listed first International Statistical generic causes of death (such as Congress calls for a uniform, “pox”), but these were not based international classification of on detailed medical examinations. causes of death. French physician Jean Fernel had included a section on types of 1883 German psychiatrist disease in his Universa Medicina Emil Kraepelin publishes an (1554), but Sydenham’s work marked influential classification the true start of modern nosology. system for mental disorders. Sydenham was among the first 1949 American scientist Linus to describe scarlet fever, which he Pauling suggests that some distinguished from measles. He diseases can be classified according to the molecular The Bills of Mortality, published structure of the microorganism weekly, listed who had died, what causing them. they had (allegedly) died of, and where outbreaks of diseases had occurred to help people avoid areas of infection.

THE SCIENTIFIC BODY 75 See also: Greek medicine 28–29 ■ Roman medicine 38–43 ■ Medieval medical schools and surgery 50–51 ■ Pharmacy 54–59 ■ Histology 122–23 ■ The World Health Organization 232–33 ■ Pandemics 306–13 also identified chronic and acute Like flora and Disregarding forms of gout and separated them fauna, diseases philosophical hypotheses, from other rheumatic disorders. His should be grouped a disease must be described recognition that symptoms, such by “species” (type). objectively in the greatest as fever, were not the disease itself but the body’s reaction to disease possible detail. was also a significant contribution to medicine. His Medical Observations Diseases must be accurately classified. of 1676 became a standard textbook for the next 200 years. Nosology after Sydenham It is important to Symptoms specific The concept of classifying diseases record when the to a disease should be gained momentum. In 1763, French disease occurs, as distinguished from others specific physician François Boissier de some disorders are to the patient, such as age Sauvages published Nosologia Methodica, which grouped 2,400 seasonal. and constitution. physical and mental disorders in 10 major classes, with more than At a meeting in Chicago, US, in now updates and manages. The 200 genera. Six years later, Scottish 1893, the International Statistical ICD classifies all known diseases, physician William Cullen published Institute adopted the International disorders, and injuries, establishes Synopsis Nosologiae Methodicae, List of Causes of Death, compiled universally comparable statistics on which became widely used. by French statistician Jacques cause of death, categorizes newly Bertillon. It was later renamed the identified diseases, and, crucially, By 1869, when the Royal College International Classification of allows health information to be of Physicians in London published Diseases (ICD), which the WHO shared and compared worldwide. ■ its monumental The Nomenclature of Diseases, more countries were recognizing the need for a uniform system for classifying disease. Thomas Sydenham Born in 1624, Sydenham served and cinchona bark (which in the army of Oliver Cromwell in contains quinine) for malaria. the English Civil War before and Many physicians opposed his after completing medical studies ideas, but prominent supporters at Oxford University. In 1663, he included philosopher John Locke passed the College of Physician and scientist Robert Boyle. examinations, allowing him to practise as a doctor in London. Long after his death in 1689, Sydenham’s innovative work on In his 1666 treatise on fevers nosology won him recognition as and later works, Sydenham began the “English Hippocrates”. to develop his nosological system, which reflected his belief that Key works close examination of patients and the course of an illness were 1666 The Method of crucial for classifying disease. He Curing Fevers also championed effective herbal 1676 Medical Observations treatments, such as willow bark 1683 The Management of (the source of aspirin) for fevers Arthritis and Dropsy

76 DHGEOOLPOIEDV,EOSRFPAAENECDEY MIDWIFERY IN CONTEXT Women learn to be midwives from other women. They are not formally trained or educated. BEFORE 1540 The first midwifery Early books on midwifery are written by men, manual printed in England and books on medicine and human biology are in Greek or is The Byrth of Mankynd, a translation of German Latin. Few women can read in these languages. physician Eucharius Rösslin’s Der Rosengarten. Jane Sharp writes The Midwives Book in English to educate women in “the conception, breeding, 1651 Nicholas Culpeper publishes his practical and bearing, and nursing of children”. wide-ranging Directory for Midwives. J ane Sharp’s 1671 The by comparison, had been a Midwives Book is a “practitioner in the art of midwifery” AFTER comprehensive manual on for more than 30 years. Although 1902 In Britain, the Midwives pregnancy and childbirth that little else is known about her, the Act establishes the Central provided a badly needed female knowledge and understanding of Midwives Board to train and voice of experience. Previously, medicine and human biology that license midwives. every British book on childbirth is evident in her book indicate that had been written by men. They she had been formally educated. 1920s Mary Breckinridge included A Directory for Midwives, founds the Frontier Nursing a popular text by English herbalist Invaluable advice Service (FNS) in Kentucky, Nicholas Culpeper, later known as Sharp’s book is divided into US. She demonstrates that the father of midwifery, despite sections. They include: male and midwives can achieve safer Culpeper’s own admission that he female anatomy; conceiving and births than doctors. had never attended a birth. Sharp, the problems doing so; the different 1956 The Natural Childbirth Trust (later the National Childbirth Trust) is founded in the UK to promote natural childbirth led by midwives.

THE SCIENTIFIC BODY 77 See also: Women in medicine 120–21 ■ Nursing and sanitation 128–33 ■ Birth control 214–15 ■ Hormonal contraception 258 ■ In vitro fertilization 284–85 “put to as little trouble as you can, for she has endured enough pain already”. The Midwives Book contains Women only Midwifery is doubtless illustrations of the womb. This one The Midwives Book clearly states one of the most useful shows how “the child lies therein that midwifery should be an and necessary of all arts near the time of its birth” and the exclusively female occupation. role of the placenta. When Sharp refers to the books for the being and of male rivals, including Culpeper’s wellbeing of mankind. stages of foetal development; and Directory for Midwives, she is childbirth and the complications quick to point out any errors. Jane Sharp that can arise during labour. In She also gives female midwives the childbirth section, Sharp career advice, urging them to seek The Midwives Book refutes the common advice that out a formal education in order women should lie in one position to understand the many texts in content and approach. Sharp used during labour and suggests that Greek and Latin that could further science to dismiss unfounded they move around, choosing their knowledge of biology and religious and paternalistic beliefs, whatever position feels best. Sharp medicine, and recommends that while offering practical advice and also puts paid to the then popular they learn basic surgical procedures, arguing for the betterment of notion that any physical deformities so that a physician may not need women. The text is testament in offspring were God’s retribution to be called in when complications to a woman who broke into the or punishment for the sins of their arise in childbirth. male-dominated field of printed parents, and instead explains knowledge on the subjects of the biological causes of some of Ahead of its time science and medicine. Remarkably, these conditions. The Midwives Book had run to four The Midwives Book is still in separate editions by 1725, and print today. ■ A final section in the book remained the go-to text for midwives provides practical advice on life and doctors for many decades Sharp celebrates the female after childbirth, including guidance afterwards. It was visionary in its reproductive organs, marvelling on breastfeeding and the correct at the vagina and cervix’s ability way to handle infants, who are Sharp and sexuality to expand, open, and close as described as “tender twigs”. There “the works of the Lord”. She also is also advice, perhaps aimed at Jane Sharp’s writing is clear, emphasizes the importance of fathers, for the comfort and care witty, and often ironic in tone, clitoral stimulation and female of a new mother, who should be not least when it discusses male orgasm in conception – ideas and female sexuality. Sharp that were virtually unheard of dismisses the common notion in the 17th century. Sharp’s that the female reproductive candid views represent an organs are responsible for important, progressive voice at sexual dissatisfaction and a time when gender roles and places the blame on men notions of women’s sexuality instead, explaining: “True it is were extremely limited. that … motion [an erection] is always necessary, but the Yard moves only at some times, and riseth sometimes to small purpose.”

78 DBTHIYSEWEHAOSARREKSVEERRSESTAPOEFD OCCUPATIONAL MEDICINE IN CONTEXT I n 1700, while professor of and injuries, and, for his work medicine at Modena University, in this area, Ramazzini is often BEFORE Italian physician Bernardino referred to as the father of 4th century bce Hippocrates Ramazzini published his pioneering occupational medicine. comments on occupational book Diseases of Workers. It detailed health after discovering the disorders encountered in 54 Ramazzini’s research took place the link between poisoning different occupations, and warned during a time of economic recession and mining. against the factors that could cause in Italy and, in particular, a crisis in them, including the hazards of poor the agricultural sector in northern 1st century ce Roman author posture, repetitive and strenuous Italy where he was based. He Pliny the Elder recommends movements, and the dangers of believed that workers’ disorders workers wear masks to protect abrasive and irritating substances, had a significant socioeconomic against dust. such as dust, mercury, and sulphur. impact, and began to investigate Diseases of Workers represented a ways to minimize their risk and 1533 The Swiss physician breakthrough in the treatment and improve workers’ health. To do this, Paracelsus publishes his prevention of workplace disease Ramazzini visited workplaces, findings on the diseases investigated conditions, and talked of miners. Occupational cancer AFTER 1842 British social reformer Bernardino Ramazzini observed populations. The theory of Edwin Chadwick publishes the potential link between occupational cancer was later guidance on sanitary certain occupations and cancer confirmed in 1775 by British conditions for workers. while investigating job-related surgeon Percivall Pott, who risks among women, including found that exposure to soot was 1910 American physician midwives, wet nurses, and nuns. causing scrotal cancer among Alice Hamilton is appointed He found that nuns were more chimney sweeps. In 1788, an Act as a state investigator of likely to develop breast cancer of Parliament forbade the use of occupational diseases, and than other women, but less likely young boys as sweeps, but – compiles a report on the to get cervical cancer, which he unlike countries where sweeps effects of industrial poisons attributed to the nuns’ celibacy. wore protective clothing – death on workers in Illinois. rates remained high in Britain Published in 1713, this until the mid-20th century, study was an early example of when new heating and cooking epidemiology, which compares technology became the norm. the risks of illnesses in different

THE SCIENTIFIC BODY 79 See also: Greek medicine 28–29 ■ Roman medicine 38–43 ■ Pharmacy 54–59 ■ Case history 80–81 ■ Epidemiology 124–27 ■ Evidence-based medicine 276–77 … in this curious branch outdoors; cleaners of cesspits Occupational diseases of medicine … should wear protective masks; and hazards are described and blacksmiths should not stare the clear waters of truth too long at molten substances. for the first time are so often muddied by in Bernardino Ramazzini’s mutual antagonisms, quarrels In the science we now call Diseases of Workers (1700). over wages and hours, ergonomics, Ramazzini suggested Rapid industrialization and over unionization. that workers should not sit or stand from the mid-18th century for too long, that those performing Alice Hamilton repetitive or strenuous tasks take leads to an increase regular breaks, and that those in dangerous American physician (1869–1970) performing “activities requiring an intense effort of the eyes … now working conditions. to the workers about what they did and again drop their work and Occupational medicine and the health problems afflicting turn their eyes elsewhere”. Where them. This approach was unusual preventive measures were not becomes an at a time when medical attention possible, or poor occupational established field was almost exclusively the domain health had caused a lasting problem, as social reform campaigners of the rich and powerful, but Ramazzini also recommended the and labour movements Ramazzini considered talking to worker be found alternative forms lobby for improvements workers essential to the scientific of employment. to prevent workplace success of his studies. He famously diseases and injuries. recommended that all physicians Published during the Age Legislation attempts add a new diagnostic question to of Reason, Diseases of Workers those suggested by Hippocrates: signalled the slow emergence to minimize “What is your occupation?”. of a wider focus on public health occupational hazards issues. Translated into several and ensure employers languages, its advice soon gained further relevance when the create safe working Industrial Revolution radically environments. affected the way people lived and worked. ■ Prevent and protect In his book, Ramazzini highlighted the dangerous and often exploitative conditions workers were subjected to, and recommended a range of protective measures. Starch makers, for example, should limit their exposure to dust by working Reports on industrial poisoning in the early 20th century highlighted the plight of workers such as these pottery manufacturers, whose exposure to lead glazes resulted in chronic illness.

80 OCTHIFRETCHPUEEMCPSUATLTAIIANERCNETS CASE HISTORY IN CONTEXT T he classical medical approach meant that one patient’s tradition that began with symptoms could not be measured BEFORE Hippocrates in the 5th against another’s: differences or c. 175 ce Rufus of Ephesus century bce emphasized the key common characteristics between writes On the Interrogation importance of examining patients, cases could not be compared, and of the Patient. with both questions and the careful there was no attempt to keep noting of symptoms. In the 2nd records for future reference. c. 900 Al-Razi stresses the century ce, the Roman physician need for physicians to develop Rufus of Ephesus championed The birth of case notes diagnoses based on interviews interrogating patients and taking A shift in attitude was established with patients. a pulse as a diagnostic measure. by the work of Herman Boerhaave, a Dutch physician who lectured 1529 The Italian physicist and During the medieval era, doctors and was a professor at the University astronomer Galileo invents a further refined their assessments of of Leiden, the Netherlands, from primitive form of thermometer. patients, by introducing techniques 1701 to 1729. such as examining the urine. Yet AFTER a general lack of consistency in As part of Boerhaave’s reform 1761 Leopold Auenbrugger of the university’s medical faculty, develops the “percussion” he insisted that students observe technique as a means of their instructors examining the examining patients. patients and making records of their diagnoses. Boerhaave made 1827 French doctor Louis daily rounds with his students: Martinet publishes A Manual he performed new examinations, of Pathology, including a guide including examinations of patients’ to the optimal method of urine, and reviewed and amended drawing up case notes. the notes that had previously been recorded. Boerhaave emphasized in 1893 The Johns Hopkins particular the usefulness of post- Medical School in the US opens, with a curriculum that Boerhaave was a gifted lecturer, insists on two years of clinical and taught the importance of clinical experience in wards, including examination and patient records to the taking of patient histories. a wide audience, disseminating his knowledge throughout Europe.

THE SCIENTIFIC BODY 81 See also: Greek medicine 28–29 ■ Roman medicine 38–43 ■ Islamic medicine 44–49 ■ Nosology 74–75 ■ Hospitals 82–83 ■ The stethoscope 103 ■ Cancer screening 226–27 mortems as a means of a final A patient provides their personal details and diagnosis. He used the technique main concerns or symptoms, details of medical to find the cause of death of Baron and surgical history, and any current medications. van Wassenaer, a Dutch admiral who had torn his oesophagus while overeating (an affliction that was later named Boerhaave syndrome). New techniques A physician compiles all these details into a formalized The new discipline of taking case case history, and updates them as treatment progresses. histories (known as anamnesis) to diagnose patients spread from the The patient’s case history notes are made available to Netherlands throughout Europe, other physicians in case further treatment is required. thanks to the many foreign students who studied under Boerhaave. Yet In the mid-19th century, French health of a patient, their occupation he and his successors found their physician Pierre Charles Alexandre and family history, and the details examinations were hampered by Louis furthered Boerhaave’s work. of their present symptoms – all this the lack of diagnostic tools: even In a Paris hospital, Louis carried was recorded and updated during thermometers, for example, were out detailed clinical research into the patient’s treatment, and referred still not advanced enough to take patients, and by comparing the to in the case of a post-mortem. accurate readings. data he collected, he was able to make informed assessments of The routine taking of patients’ In 1761, Austrian physician their conditions. Louis insisted that clinical histories today shows that Leopold Auenbrugger invented the physicians discover the previous Boerhaave’s insight still lies at the technique of percussion – tapping on heart of modern medical practice. ■ the surface of the body as a means of diagnosis. Then in the early 19th century, instruments such as the reflex hammer, stethoscope, and pleximeter were developed, enabling physicians to refine their diagnoses. Herman Boerhaave Sometimes known as the “Dutch editions of works such as De Hippocrates”, Herman Boerhaave Humani Corporis Fabrica by was born in the Netherlands in Andreas Vesalius. Boerhaave 1668. He studied philosophy and believed that fluids circulated medicine and spent his career at in the body via elastic vessels, the University of Leiden, serving and that disease occurred when as lecturer; professor of botany, this flow was disturbed, and he medicine, and chemistry; and frequently diagnosed purging to rector of the university. remove excess blood. Boerhaave died in 1738. Boerhaave’s teaching and innovative diagnostic practices Key works attracted students from all over Europe and enhanced Leiden’s 1708 Institutes of Medicine reputation. Aiming to systematize 1709 Aphorisms on the the medical developments that Recognition and Treatment had occurred over the previous of Diseases two centuries, he produced new

82 PSTAOOSICSRSKSEPITSEBOETLDOEHIRELEAYLTATHSHE HOSPITALS IN CONTEXT T hroughout much of human army began building valetudinaria, history, the sick have been medical establishments to treat BEFORE cared for at home. Temple- sick and wounded legionnaries. c.50 ce A valetudinarium is based healing, practised in ancient constructed at the Roman Greece, is the earliest evidence of Hospitals, complete with wards, military camp at Vindonissa some form of community healthcare appeared in the Islamic world from (now Windisch, Switzerland). provision. However, nothing like the 9th century, some also offering the modern idea of a hospital – a care for the elderly and for those 805 The first recorded dedicated building staffed with with mental illness. In Christian general hospital is founded medical personnel – emerged until Europe, care for the sick in the in Baghdad by the caliph the 1st century ce, when the Roman medieval period was associated Harun al-Rashid. with spiritual care and poor relief. 1123 St Bartholomew’s Medieval healthcare is primarily linked to religious institutions monastic hospital is founded and concepts of spiritual health and charity. in London, the oldest surviving medical establishment in Scientific advances boost The founding of the UK. the concept of professional secular institutions by philanthropic individuals and AFTER medical care, separate civic authorities increases 1725 Prussia’s Medical Edict from religious institutions, regulates the curriculum for the availability, and medical degrees. and the provision of improves the standards, social support. 1790 As part of a movement to of hospital care for all. provide free medical treatment to all, the New York Dispensary Hospitals become centres for education, is founded. innovation, and research. 1824 The first specialist hospital in the US, the Massachusetts Eye and Ear Infirmary, is established.

THE SCIENTIFIC BODY 83 See also: Islamic medicine 44–49 ■ Medieval medical schools and surgery 50–51 ■ Case history 80–81 ■ Scientific surgery 88–89 ■ Triage 90 ■ Hygiene 118–19 ■ Nursing and sanitation 128–33 ■ Palliative care 268–71 Advances in understanding about sanitation transformed the design and organization of many hospitals, including King’s College, London, which moved from cramped conditions to modern, hygienic premises in 1913. Monasteries became centres for Sea Company, which profited from without consideration of religion or healing and the nucleus for proto- the slave trade. Aiming to provide wealth. The first general hospital in hospitals such as St Bartholomew’s, a hospital for the “incurably ill and the US was founded in Philadelphia London, which was founded in 1123. hopelessly insane”, Guy’s state-of- in 1751. New York’s Bellevue Hospital, the-art establishment opened to while originally attached to a A new secular model patients in 1725 with 100 beds and poorhouse, was by 1816 one of The 16th-century Reformation of 50 staff, including a bed-bug killer. a range of American medical the Church weakened the link establishments that offered care between religion and healthcare Similar hospitals founded by and trained physicians. In Germany, in the West, and many monasteries wealthy individuals, charitable or Berlin’s Charité, originally founded and their hospitals disappeared. civic trusts, and universities created as a quarantine hospital for plague While some were taken over by places where, for the first time, victims, became a military hospital, civic authorities, a lingering notion the general public were admitted and then a teaching hospital in 1828. that hospitals were just hospices for the poor meant that surviving Today, we take for granted that institutions became places to shut hospitals are places dedicated to away the destitute and those with excellence in the healing of the infectious diseases. sick, using the most advanced techniques possible. Yet without During the 17th and 18th the establishment of progressive centuries, the emergence of a institutions such as Guy’s Hospital, merchant class with funds and a the marriage of patient care and belief in philanthropic giving, the science they initiated might have growth of cities, and the dawn of occurred far more slowly, if at all. ■ scientific medicine led to the birth of hospitals in their modern form. Centres for education and innovation One of the first, Guy’s Hospital in London, UK, was founded in 1721 In the 18th century, the founding instructing students, and by the by Thomas Guy. A wealthy publisher of new secular institutions such 1770s trainee doctors in Vienna and businessman, he had made his as Guy’s Hospital, London, and were also learning on the wards. fortune through shares in the South the boost to scientific research provided by Enlightenment By the 19th century, hospitals thinkers began to alter the focus had developed into centres for of hospital medicine. innovation as well as education. Advances such as handwashing Prussia’s Medical Edict of to reduce disease transmission, 1725, which set standards for introduced by Hungarian doctor the training of doctors, was a Ignaz Semmelweis in 1847, and first sign that hospitals would, the recommendations proposed as well as caring for the sick, by Florence Nightingale in the become centres for education. 1860s, effected changes in By 1750, Edinburgh’s Royal medical practice that still Infirmary had a clinical ward for underpin modern hospital care.

84 IUGNNRTKEHANTIOSWAFNNRDUVIITRTUE PREVENTING SCURVY IN CONTEXT W hile working as a citrus fruit recovered from the surgeon on the British illness most quickly, and one sailor BEFORE naval vessel HMS was fit for duty after only six days. c.1550 bce The ancient Salisbury in 1747, Scottish physician Those given the other “cures” Egyptian Ebers papyrus James Lind reportedly performed recovered slowly or not at all. describes the symptoms a controlled clinical experiment on of scurvy. 12 sailors who were suffering from Scurvy is now known to result scurvy. The disease, which was from a lack of vitamin C (ascorbic c.400 bce Hippocrates lists ravaging the navy, was not yet acid) in the body, and symptoms scurvy as a disease. understood. Lind divided his begin to develop after about a patients, whose symptoms were month of deprivation. Early signs 1614 John Woodall, Surgeon allegedly similarly advanced, into include extreme lethargy and aching General of the British East six pairs. Each pair was given a joints. If untreated, bleeding gums, India Company, advises using different dietary supplement that loose teeth, and haemorrhaging of oranges, lemons, limes, and had been suggested as a cure: the skin follow, then death. tamarinds as a cure for scurvy. vinegar, sea water, cider, oranges and lemons, diluted sulphuric acid, The disease was endemic AFTER or a mixture of garlic and mustard among sailors, who were often at 1795 Britain’s Royal Navy seeds. He found that those given sea for months at a time and had to agrees to give sailors a ration subsist on an appalling diet lacking of lemon juice, a policy that is in fruit and vegetables. Portuguese implemented in 1800. explorer Ferdinand Magellan lost most of his crew to scurvy on an 1928 Hungarian biochemist expedition across the Pacific Ocean Albert Szent-Györgyi discovers in 1520. By the mid-18th century, the antiscorbutic (anti-scurvy) with increases in shipping, naval compound, which he calls activity, and the length of voyages, hexuronic acid. the scale of the problem was immense. This “plague of the sea” 1932 American medical researcher Charles Glen King James Lind’s experiment in 1747 finally demonstrates the was one of the first controlled medical connection between hexuronic trials. Participants shared the same diet, (ascorbic) acid and scurvy. environment, and symptoms, so Lind could accurately compare the effects of his prescribed supplements on scurvy.

THE SCIENTIFIC BODY 85 See also: Greek medicine 28–29 ■ Roman medicine 38–43 ■ Vitamins and diet 200–03 ■ Evidence-based medicine 276–77 Ancient records Anecdotal evidence of scurvy symptoms exist, grows among seafarers that but its cause remains consuming citrus fruits unknown. will cure and prevent scurvy. James Lind’s controlled The medical James Lind trial of the use of profession maintains the belief that scurvy Born in Edinburgh, Scotland, oranges and lemons is a digestive disorder, in 1716, James Lind was compared to other not a nutritional disease. apprenticed to a surgeon at the age of 15 and joined the supplements proves the Royal Navy in 1739. After efficacy of citrus fruits. conducting experiments with a group of sailors on HMS The specific anti-scurvy compound found in Salisbury who were suffering citrus fruits – hexuronic (ascorbic) acid – is identified. from scurvy, he published his findings in A Treatise probably killed more than 2 million long periods, citrus was not adopted on the Scurvy in 1753. Lind’s sailors between the 15th and the as an antiscorbutic. Shortly after recommendation that sailors 19th centuries – more than died Lind’s death, however, the British be given juice from citrus fruits from storms, combat, and every navy succumbed to pressure from to prevent scurvy led to British other disease combined. naval physicians to supply all sailors sailors being called “limeys”. with lemon juice. A similar policy Long-known disease was adopted by other maritime Lind returned to his The symptoms of scurvy had been nations in the early 19th century. ■ native Edinburgh to practise described by the ancient Egyptians, medicine, but in 1758 he was Hippocrates was aware of the … it is no easy matter persuaded to become the chief disease, and several seafarers had to root out physician at the newly opened suggested that citrus fruit might be Haslar Royal Naval Hospital in preventative before Lind’s trial. One old prejudices … Gosport, Hampshire. From of these was Portuguese explorer James Lind then until his retirement 25 Vasco da Gama, who successfully years later, he proposed many treated his crew with oranges after A Treatise on the Scurvy measures to improve health they succumbed to scurvy in 1497. and hygiene on naval vessels, though he was often frustrated Despite similar reports, the that these were slow to be medical establishment remained implemented. Many historians wedded to the idea that scurvy was regard him as one of the first a digestive complaint caused by a clinical investigators of the lack of “fixed air” in the tissues and, modern era. Lind died in with no way of keeping fruit fresh for Gosport in 1794. Key work 1753 A Treatise on the Scurvy

86 ETAFHTFERICBEAEACRIISKOVUOESFRY ASPIRIN IN CONTEXT A spirin is one of the most prescribed willow leaf tea for fever widely used drugs in the and pain, in particular for women BEFORE world. It has a spectrum in childbirth. c.1600 bce Egyptian medical of applications, from relieving pain papyri refer to willow as having and reducing inflammation to The analgesic (pain-relieving) an anti-inflammatory effect. preventing strokes and treating properties of willow bark were cardiovascular conditions. Its active rediscovered in the 18th century by 1676 English physician ingredient is acetylsalicylic acid, a British clergyman Edward Stone. Thomas Sydenham publishes compound originally derived from Nibbling on a piece of willow bark his recipe for laudanum, a form the willow tree. while out walking, he was struck of opium, to treat pain. by its bitterness. It reminded him A cure for agues of cinchona bark, the source of AFTER The medicinal properties of willow quinine used to treat malaria. Aware 1887 In Germany, physician have been known for thousands of the folk belief that harmful agents Joseph von Mering tries of years. In the 5th century bce, and their panaceas are often found paracetamol on humans for the Greek physician Hippocrates side by side, Stone reasoned that the first time. willow might be a cure for fevers. 1961 British pharmacist Edward Stone In addition to his duties as Stewart Adams discovers a cleric, and his interest in the drug ibuprofen. The son of a gentleman farmer, medicine and science, Stone Edward Stone was born in was appointed a justice of the 1998 In a clinical trial of 18,790 the English town of Princes peace for Oxfordshire in 1755. patients with hypertension in Risborough, Buckinghamshire, 26 countries, aspirin reduces in 1702. At the age of 18, he A fire at Bruern Abbey ended cardiovascular events such as attended Wadham College, Stone’s chaplaincy in 1764. He heart attack and stroke. Oxford and was ordained a died in Chipping Norton in deacon and priest in 1728. He 1768 and was buried in the 2015 The US Preventative became a fellow of the college churchyard at Horsenden. Services Taskforce advocates two years later. low-dosage aspirin for the Key work prevention of cardiovascular In 1745, Stone moved to disease and some cancers. Chipping Norton, Oxfordshire, 1763 “An account of the success as chaplain at Bruern Abbey, of the bark of the willow in the where he also served as priest cure of agues” in several parish churches.

THE SCIENTIFIC BODY 87 See also: Greek medicine 28–29 ■ Herbal medicine 36–37 ■ Pharmacy 54–59 ■ Cancer therapy 168–75 ■ Electrocardiography 188–89 ■ Antibiotics 216–23 The creation of aspirin The analgesic and Chemists isolate the The chemical structure Salicylic acid is modified anti-inflammatory effect active ingredient – of salicylic acid can now to create acetylsalicylic of willow (Salix spp.) is salicylic acid, a natural be determined. This allows acid – a safer form of the discovered by accident compound – that produces chemists to synthesize it – compound, better known when its bark is chewed. the analgesic effect. create it artificially. as aspirin. Fevers (or “agues”) were associated in a landmark paper entitled “An given the name aspirin. Frenchman with damp, marshy environments, account of the success of the bark Charles Gerhardt had treated acetyl such as those in which willow trees of the willow in the cure of agues”. chloride with sodium salicylate in typically grow. 1853, but Hoffmann’s version, which Active ingredient was instigated by his supervisor Over the next few years, Stone After the publication of Stone’s Arthur Eichengrün, was the first treated 50 patients with fevers or findings, more pharmacists began to be suitable for medical use. suspected malaria with small doses using willow bark. In 1827, German of powdered willow bark in water chemist Johann Buchner succeeded Bayer marketed aspirin in 1899, delivered every four hours. He found in isolating the bitter substance. He originally as a powder that reduced the infusion to be very effective and called it salicin, and it contained the temperature and inflammation, and in 1763 he wrote to the president of active ingredient salicylic acid. Two sales of the first analgesic took off the Royal Society about his remedy, years later, French pharmacist Henri across the world. ■ Leroux managed to extract 30 grams That many … remedies (1 oz) of purified salicin from 1.5 kg lie not far from their causes (3.3lbs) of willow bark. The drawback of salicylic acid was that it caused was so very apposite gastrointestinal irritation, which to this particular case that some patients could not tolerate. I could not help applying it. In 1897, at the pharmaceutical Edward Stone company Bayer based in Germany, chemist Felix Hoffmann created a Letter to the Royal Society, 1763 safe form of the drug by altering the structure of salicylic acid. This new chemical, acetylsalicylic acid, was An Italian advertisement from 1935 illustrates the transforming effects of taking aspirin tablets to treat different types of pain.

88 HSAUASSRCGBIEEENRCCYOEME SCIENTIFIC SURGERY IN CONTEXT O ne of the first medical when it came to the long-term disciplines to make real effects of an operation. The success, BEFORE advances was the practice or failure, of a particular procedure c.17th century bce The of surgery. In ancient Egypt, c. 17th might be apparent to the surgeon, Egyptian Edwin Smith century bce, the Edwin Smith but rarely did anyone examine the papyrus describes operations papyrus outlined different surgical impact of surgery in detail. for the treatment of wounds. procedures. Later, Roman military surgeons refined surgical practice Surgical discipline c.1150 ce The Arab surgeon around the 1st century bce, and key In the 18th century, Scottish surgeon Ibn Zuhr (Avenzoar) performs anatomical advances were made John Hunter established a scientific a tracheotomy on a goat, during the Renaissance. However, and methodical basis for surgery. He to prove the safety of the internal surgery was hampered by honed his skills as a military surgeon procedure on humans. a lack of anaesthesia or pain relief. during the Seven Years’ War in the There was also little understanding 1760s. From his studies of gunshot 1543 Andreas Vesalius publishes his De Humani If a traditional The new procedure may Corporis Fabrica, showing surgical technique be tested on animals, depictions of internal human is ineffective, the anatomy in previously surgeon reconsiders then transferred unparalleled detail. the procedure, using to humans. scientific knowledge AFTER 1817 John Hunter’s pupil of anatomy. Astley Cooper carries out the first operation to ligate the The surgical Detailed notes abdominal aorta. technique is refined and post-operative 1846 American dentist Henry on the basis of (or post-mortem) Morton first uses ether as an these observations. observations anaesthetic in an operation. are taken. 2001 The first-ever remote operation using robotic surgery is carried out in the US.

THE SCIENTIFIC BODY 89 See also: Plastic surgery 26–27 ■ Battlefield medicine 53 ■ Anaesthesia 112–17 ■ Antiseptics in surgery 148–51 ■ Robotics and telesurgery 305 wounds, Hunter concluded that the later he died of a fever, Hunter’s John Hunter opening of damaged tissue in order post-mortem revealed the aneurysm to extract bullet fragments (which had gone, leaving no sign of infection. Born in Scotland, in 1728, John was common practice at the time) Hunter moved to London aged in fact aggravated infections rather In 1786, Hunter became one of 21 to join his brother William, than diminish them. the first physicians to recognize the an anatomist. Hunter studied process of metastasis in cancer. He surgery at St Bartholomew’s On returning to London, Hunter noted the presence of tumours in Hospital, and gained practical aligned his surgical procedures a male patient’s lungs that were experience when he was then to an understanding of anatomy similar to those on the man’s thigh, commissioned as an army and physiology. He made detailed and in doing so foreshadowed the surgeon in 1760. observations of disease in living clinical discipline of oncology. patients, and also conducted post- Hunter later set up his own mortem dissections. Hunter would Enduring influence anatomy school in London in devise an operation on the basis of Hunter’s focus on direct scientific 1764, and used it as the base his observations, and practise on observation refined the practice of for his wide-ranging interests, animals before conducting it on a surgery, earning him great acclaim. such as comparative anatomy, human patient. This rigorous and Many of his contemporaries and the circulatory system of blood inductive approach made him the pupils, such as Joseph Lister, in pregnant women and the founder of scientific surgery. emulated Hunter’s methods, and foetus, venereal disease, and carried forward his insistence that the transplantation of teeth. In 1785, Hunter carried out his surgery (and the development of new He also taught Edward Jenner, most famous operation on the knee operations) must have a basis in the pioneer of vaccination. of a 45-year-old coachman, who had science, not tradition. This discipline a popliteal aneurysm that swelled continues to inform core surgical Hunter became a fellow of to fill the entire back of his knee. developments in the 21st century. ■ the Royal Society in 1767, and Instead of opening up the wound later personal surgeon to King and scooping out the aneurysm, The Hunter brothers, William and George III in 1776. He died in Hunter opened up the muscles and John, are depicted mid-dissection at 1793, leaving his collection of inserted ligatures (bindings) – these William’s school of anatomy. It was more than 10,000 anatomical pressed against the blood vessels open to anyone who could pay to specimens to the Royal to steady the blood flow. The patient observe and learn surgical techniques. College of Surgeons. was able to walk again and, when Key works 1771 The Natural History of the Human Teeth 1786 A Treatise on the Venereal Disease 1794 A Treatise on the Blood, Inflammation, and Gunshot Wounds

90 BWTHEOETUEDNNADDNEEGDDEMRFOUIRUSSSTTLY TRIAGE IN CONTEXT I n 1793, while on campaign The triage nurse with Napoleon, French military makes quick decisions BEFORE surgeon Dominique-Jean, that can be the difference c.1000–600bce Assyrian Baron Larrey first used a system between life and death. “asu” are the first recorded termed “triage” (“sorting”) to Lynn Sayre Visser military physicians to tend manage the treatment of soldiers the wounded during battles. wounded on the battlefield, American triage nurse and educator separating them into immediate, c.300 bce–400 ce Roman urgent, and non-urgent cases. became more efficiently managed armies develop systems Regardless of rank, the most in the early 1900s, their emergency to evacuate and treat seriously wounded, who in earlier departments developed triage the wounded. campaigns had often been left to systems – both to decide the order die, were taken to nearby medical for treating incoming patients and, 16th century Barber-surgeons tents on another of Larrey’s in the field, to prioritize those work on the battlefield; their innovations – ambulances volantes needing most urgent medical care increasingly skilled treatment (“flying ambulances”), which were after a major accident or disaster. raises the status of surgeons. horse-drawn gun carriages, specially adapted to carry the Today, triage is widely used in AFTER wounded from the battlefield. civilian settings, and, depending 1861–65 Union surgeon on the country, may have three to Jonathan Letterman creates a Larrey’s triage system, together five levels, ranging from immediate new system of battlefield care with the first teams of medical and resuscitation to non-urgent. ■ during the American Civil War. attendants, who stretchered the wounded, greatly reduced the total 1914–18 The Ordre de Triage, fatalities among Napoleon’s men. devised by Belgian doctor Antoine Depage, sets out Triage in civilian settings guidelines for the treatment of The triage concept further evolved soldiers during World War I. in battlefield settings throughout the 19th and 20th centuries. As 1939–45 In World War II, hospitals in Western nations army medics triage injuries in mobile aid stations close See also: Battlefield medicine 53 ■ Hospitals 82–83 ■ Scientific surgery 88–89 to battlefield front lines. ■ Nursing and sanitation 128–33

THE SCIENTIFIC BODY 91 IANPMEYCUVLISIAIORNITY COLOUR VISION DEFICIENCY IN CONTEXT J ohn Dalton was a British deficiency. Lacking M-cones that meteorologist and chemist, react to medium-wave light, he BEFORE but he is also known for his could only distinguish between two c.1040 Islamic scholar Ibn 1794 description of the eye disorder or three colours, rather than the full al-Haytham proposes that light that affected him and his brother. spectrum visible with normal vision. entering the eye enables vision. He found it difficult to detect the Rarer blue-yellow colour deficiencies colour red, while orange, yellow, (tritanomaly and tritanopia) make it 1613 In his Opticorum libri sex and green appeared to merge into hard to distinguish between blue (Six books on optics), Flemish shades of yellow to beige. Later and green, and yellow and red. scientist Francois d’Aguilon dubbed Daltonism, his was a red- identifies red, yellow, and blue green form of the defect better While screening tests now help as primary colours, in addition known as colour blindness, or (more eye experts to identify colour vision to black and white. accurately) colour vision deficiency. deficiency, there is still no remedy. ■ 1704 British scientist Isaac Dalton’s account interested the Newton analyses the nature of scientific community. Within a light in his treatise, Opticks. decade, British physicist Thomas Young proposed that the eye has AFTER three types of cone (photoreceptors 1801 In a Royal Society responsible for colour vision) – one lecture, Thomas Young sets each for blue, green, and red – to out his wave theory of light provide the full colour spectrum. and photoreceptors in the eye. If one type is defective (in Dalton’s case the green receptor), colour 1851 German physicist vision deficiency results. Hermann von Helmholtz invents the ophthalmoscope to Limited colour range This colour dot test plate, devised examine the eye and confirms In 1995, DNA from Dalton’s eye, by Shinobu Ishihara, helps to detect Thomas Young’s theory. preserved after his death, showed red-green colour vision deficiency in he had deuteranopia, one of three those unable to see the figure 57. 1917 The first screening tests types of red-green colour vision for colour vision deficiency are published by ophthalmologist See also: Islamic medicine 44–49 ■ Anatomy 60–63 ■ Inheritance and Shinobu Ishihara in Japan. hereditary conditions 146–47 ■ Physiology 152–53

92 NBUOTLUONNDGEERRSFTEOAORDED, HUMANE MENTAL HEALTH CARE IN CONTEXT Before the 18th century, T he diagnosis and treatment people with mental illness of mental illness raises a BEFORE unique set of problems, c.8000bce A skull unearthed are feared and removed in particular the judgement of at Taforalt, a cave in Morocco, from society. what “normal” means in terms of bears evidence of trepanning behaviour. Throughout the (drilling into the skull), possibly Their humanity is denied medieval period, the belief that to cure a mental disorder. and their condition people could be possessed by becomes worse. demons that had to be driven out 1406 The first mental hospital was common. The world was opens in Valencia, Spain. The Enlightenment fosters dominated by fear of plague, notions of common famine, and war, and superstition AFTER was rife. At best, the mentally ill 1927 Austrian psychiatrist humanity, individual experienced social stigma; at worst, Manfred Sakel introduces liberty, and they were accused of witchcraft. insulin coma therapy. Schizophrenics are injected universal rights. Asylums to house the mentally with insulin to put them into The humane treatment of ill increased in number during the a low blood sugar coma. 16th century. Most of their patients mental illness, were confined against their will 1949 Portuguese neurologist known as traitement moral, and were often chained. They were Egas Moniz receives the Nobel likened to animals, without the Prize for introducing lobotomy is introduced. capacity to reason or experience (severing connections in parts pain. Asylums made no pretence of the brain) to treat serious at helping the mentally ill recover, mental illness. The procedure and patients were expected to is later discredited for causing tolerate their miserable existence personality changes. without complaint. 1950s French scientists Traitement moral develop antipsychotic drugs to treat schizophrenia and Scientific understanding of mental bipolar disorder. illness barely changed during the 17th century, but in the 18th century, social reformers in Europe began to turn their attention to

THE SCIENTIFIC BODY 93 See also: Lithium and bipolar disorder 240 ■ Chlorpromazine and antipsychotics 241 ■ Behavioural and cognitive therapy 242–43 The managers of rehabilitation of patients, who were Philippe Pinel these institutions … encouraged to engage in manual labour and recreational pastimes. Born in Jonquières, France, are frequently By the end of the century, however, in 1745, Philippe Pinel was men of little knowledge moral treatment had largely been the son of a master surgeon. and less humanity … abandoned. Asylums had become Abandoning his studies in overcrowded and individual care theology in 1770, Pinel Philippe Pinel could no longer be provided. attended France’s leading medical school at the Treatise on Insanity, 1801 Mental hygiene University of Montpellier, By the late 19th century, the mental supporting himself during the mentally ill. Italian physician hygiene movement promoted by his training by translating Vincenzo Chiarugi removed the reformer Clifford Beers in the US medical and scientific texts chains from his psychiatric patients was replacing moral treatment. and teaching mathematics. in the 1780s and encouraged good Beers was motivated by the poor hygiene, recreation, and some treatment he had received for his In 1778, Pinel moved to occupational training. In Paris in own depression and anxiety. He Paris, where he edited the the 1790s, Philippe Pinel sought to recommended an approach to medical journal Gazette de prove his hypothesis that mentally mental health that focused on the santé, regularly including ill patients would improve if treated patient’s total wellbeing. Beers’ articles on mental illness. with compassion. He introduced his book A Mind That Found Itself In 1793, he was appointed traitement moral (moral treatment), (1908), and the National Committee superintendent of the Bicêtre a regime of improved nutrition and for Mental Hygiene that he founded hospice and two years later, living conditions. in 1909, influenced mental health became chief physician of the services across the world. Beers’ Salpêtrière hospital, which In Britain, Quaker philanthropist ethos is at the heart of mental had 600 beds for the mentally William Tuke established the York health provision today. ■ ill. It was at Bicêtre and Retreat along similar lines in 1796. Salpêtrière that he devised his Tuke also believed in the therapeutic traitement moral, and chains and moral value of physical work were removed from patients for patients. who had been restrained for decades. Pinel worked at The moral treatment advocated Salpêtrière for the rest of his by Pinel and Tuke reached the US life and died in 1826. in the early 19th century. Again, the focus was on spiritual and moral development as well as the The York Retreat, shown here in Key works 1887, was founded on “moral treatment” 1794 Memoir on Madness of the mentally ill. Patients were 1801 Treatise on Insanity viewed with compassion and treated as guests rather than prisoners.

ISTMRYAIMSNINTUGENTMHEE VACCINATION



96 VACCINATION IN CONTEXT BEFORE c. 590 ce Chinese healers begin to practise inoculation. 1713 Emmanuel Timoni describes mass inoculation in Constantinople. 1718 Lady Mary Wortley Montagu has her young son inoculated in Constantinople. 1721 In the American colonies, pastor Cotton Mather urges variolation to protect against a smallpox epidemic. AFTER 1921 French scientists Albert Calmette and Camille Guérin create BCG, the first vaccine against tuberculosis. 1953 Jonas Salk, an American virologist, discovers a vaccine for polio. 1980 The World Health Organization declares that “Smallpox is dead!” V accines are one of the who are immune to the disease, Yu Hoa Long was the Chinese god of greatest medical success the less it can spread. The key to recovery from smallpox, a disease that stories of all time. In the vaccination’s success is the idea was seen by many cultures as a divine developed world, they have been of the “safe version”, and this was punishment for sins committed. so effective at containing many the great breakthrough made by infectious diseases that it is easy British physician Edward Jenner the disease each year. And as to forget just how terrible diseases in 1796 with his smallpox vaccine. European explorers, traders, and such as smallpox, diphtheria, polio, settlers spread across the globe, and tetanus once were. The deadly pox they took with them smallpox and Smallpox is a highly contagious other diseases, which decimated Vaccination, or immunization, disease that is caused by two forms native populations that had never works by priming the body’s of the variola virus. It has now been before been exposed to these germs. defences with a safe version of completely eradicated from the the germ (or part of the germ) that world, but until Jenner’s vaccine, Those who were lucky enough causes the disease. This enables its effects were devastating. In the to survive smallpox were often the immune system to build up 18th century, nearly half a million scarred for life with pockmarked resistance, or immunity, to the people in Europe alone died from faces, the effect of the terrible disease – and the more people pustules or “pox” that erupt. One

THE SCIENTIFIC BODY 97 See also: Germ theory 138–45 ■ The immune system 154–61 ■ Virology 177 ■ Attenuated vaccines 206–09 ■ Global eradication of disease 286–87 ■ HIV and autoimmune diseases 294–97 ■ Pandemics 306–13 The small-pox, so fatal, full immunity. It was a high-risk In 1736, I lost and so general amongst us, strategy since a significant number one of my sons … of those inoculated would die. Also, by the small-pox. is here entirely harmless children who survived variolation I long regretted bitterly … by the invention of could become carriers of the disease. that I had not given it to him But smallpox was so devastating ingrafting [variolation] … that many people were prepared to by inoculation. Lady Mary risk it. Some, such as girls raised Benjamin Franklin in the Caucasus for the Ottoman Wortley Montagu sultan’s harems in Constantinople American statesman (1706–90) (now Istanbul), had no choice. Letter to a friend, April 1717 Maitland to oversee the inoculation The royal experiment of her five-year-old son Edward by third of survivors went blind. In The idea of inoculation began to one of the Greek female inoculators 18th-century England, largely due catch the attention of European in 1718. She became a prominent to smallpox, just one child in three physicians around 1700. In 1713, advocate of the technique, and on survived beyond the age of five. Greek doctor Emmanuel Timoni their return to Britain, she asked described how he had seen Greek Maitland to inoculate her daughter. It had been known at least as far female inoculators successfully back as Roman times that those who inoculating thousands of children Soon after, in 1721, Maitland survived smallpox somehow gained in Constantinople during a smallpox received a Royal Commission to immunity. Indeed, former smallpox epidemic. Venetian physician Jacob conduct what may have been the victims were often called upon to Pylarini, who practised variolation world’s first clinical trial. The aim nurse the sick. Healers across Asia in the city, wrote a book about it in was to prove to the British royal (especially China), Africa, and 1715. Then, British writer Lady Mary family that inoculation worked. Europe had long tried to replicate Wortley Montagu, who had been Under the watchful eye of the this natural immunity through the left severely disfigured by the country’s leading physician, Hans practice of variolation (inoculation), disease, observed the practice. Sloane, Maitland inoculated six in which healthy people were condemned prisoners in Newgate deliberately infected with matter Impressed by the apparent Prison, who were persuaded to from someone with an apparently success of “ingrafting”, Lady Mary cooperate in return for then being mild version of the disease. asked embassy surgeon Charles released. They survived and, a few months later, Maitland repeated Variolation usually involved the trial with orphaned children, rubbing crushed smallpox scabs who also survived. ❯❯ into cuts on the hand, or blowing them in pellets into the nostrils. In Smallpox survivor Lady Mary Wortley a practice known as “buying the Montagu was instrumental in bringing pox”, parents would purchase scabs the practice of inoculation to the notice or contaminated clothing with of British physicians. She had lost her which to infect their children. brother to the disease when he was 20. With luck, people who had been inoculated would fall moderately ill for a few days, then recover with

98 VACCINATION News of Maitland’s achievements Inoculation works But smallpox is spread quickly, and the practice of by introducing a a dangerous disease inoculation was adopted across and many of those Europe and in the American small sample of infected colonies. In 1721, Massachusetts matter into the body, inoculated with pastor Cotton Mather and doctor smallpox-infected Zabdiel Boylston became forceful which causes illness but advocates. In 1738, with a serious confers immunity. matter die. smallpox epidemic threatening the state of Carolina, around 1,000 Deliberately infecting Exposure to cowpox people were treated. In Britain that people with a safer form causes a mild illness year, nearly 2,000 people were of a disease (such as cowpox) inoculated in Middlesex. gives them immunity to in humans, but the deadly form of the protects them Variolation was a hazardous disease (such as smallpox). from smallpox. procedure, with at least one in 30 dying from the disease as a direct This practice is called vaccination. result, but the introduction of inoculation on a large scale soon demonstrated that the risk was considerably lower than from dying in an epidemic. In 1757, an eight- year-old boy was inoculated with smallpox, one of thousands to be treated that year. His name was Edward Jenner. The safe version inoculated many of his patients In 1796, Sarah Nelmes, a dairymaid, Jenner went on to be dubbed the to protect them from smallpox. went to see Jenner about a rash on “father of immunology”, with an He was intrigued by stories that her right hand. He diagnosed her assured place in the history of people, typically milkmaids, who with cowpox and decided to test medicine. But back in the 1770s, had contracted a mild infection, his theory, using James Phipps, the he was a country physician who, cowpox, from their cows had eight-year-old son of his gardener, like other doctors of the period, acquired an immunity to the much as his guinea pig. Jenner made a deadlier smallpox, and wondered few scratches on one of the boy’s I hope that some day whether cowpox could provide a arms and rubbed in some of the the practice of producing safer method of inoculation. cowpox material he had taken cow pox in human beings will from pockmarks on the infected spread over the world – when One day, Jenner is said to have dairymaid’s hand. Within a few that day comes, there will be overheard a dairymaid boasting, “I days, the boy became mildly ill shall never have smallpox for I have with cowpox but soon recovered. no more small pox. had cowpox. I shall never have an Edward Jenner, 1798 ugly pockmarked face.” He began Having established that cowpox to gather data in earnest. In nearly could be transferred from person to 30 cases, he found examples of person, Jenner proceeded to the previous exposure to cowpox next step in his experiment. This appearing to give immunity to was to test whether the cowpox smallpox. Although Jenner did not would indeed protect James from know it, cowpox is caused by the smallpox. Jenner inoculated the vaccinia virus, which can be boy with material from a fresh transmitted to humans and is smallpox lesion. James did not closely related to the variola virus develop smallpox symptoms, either responsible for smallpox. then or in the future.

THE SCIENTIFIC BODY 99 Jenner continued to collect further annihilation of the smallpox, This painting by Gaston Melingue case histories and also followed up the most dreadful scourge of the shows Jenner vaccinating James his initial experiment with others, human species, must be the final Phipps in 1796. Jenner was so grateful which confirmed his original theory result of this practice”. to the boy that he later built a house that cowpox did indeed protect for him in his home town of Berkeley. against smallpox. In 1798, he Although Jenner was the first published his findings in a book person to carry out a scientific interfere with divine intention was entitled An Inquiry into the Causes investigation into vaccination and blasphemy. There were also those and Effects of the Variolae Vaccinae, its effects, he may not have been who were fearful of having material a Disease Discovered in some of the first to discover the technique. from diseased cows introduced into the Western Counties of England, When a smallpox epidemic hit the their bodies, an objection readily Particularly Gloucestershire, and English county of Dorset in 1774, satirized by the caricaturists of the Known by the Name of the Cow local farmer Benjamin Jesty was day. When vaccination with cowpox Pox. The technique of introducing determined to protect his family. was made compulsory in 1853, it led material under the skin to confer He took material from the udder of to protest marches and impassioned protection against disease became an infected cow and used a small demands for freedom of choice from universally known as vaccination, needle to introduce it into the arms anti-vaccination campaigners. a word derived from the Latin name of his wife and two sons. (Jesty had for the cow (vacca), in recognition had cowpox already, so did not For decades after Jenner’s of Jenner’s discovery. vaccinate himself.) The experiment breakthrough discovery, the source worked, and the family remained of the vaccine continued to be ❯❯ Spreading the word free of smallpox. But it would be Jenner sent vaccine to anyone who a further 25 years before Jenner’s requested it and, with the support experiments and dogged promotion of other doctors, vaccination spread of vaccination changed the way rapidly throughout Britain. By 1800, medicine was practised for ever. it was being practised in most European countries and in the A mixed reception United States. The following year, Jenner’s findings did not meet with Jenner published an article, “On the universal acceptance. Some of the Origin of the Vaccine Inoculation”, most vocal objections came from summarizing his discoveries and the clergy, who reasoned that expressing his hope that “the smallpox was a God-given fact of life and death and any attempt to Edward Jenner Born in Berkeley, Gloucestershire, hut in the garden of his family UK, in 1749, Edward Jenner was home, dubbed the “Temple of orphaned aged five and went to Vaccinia”, he vaccinated the poor live with his older brother. In 1764, for free. Having won widespread he began an apprenticeship with recognition, he died in 1823. a local surgeon, after which, at 21, he became a student of the famous Key works surgeon John Hunter in London. 1798 An Inquiry into the Jenner’s interests were wide: Causes and Effects of the he helped classify new species Variolae Vaccinae brought back from the South 1799 Further Observations Pacific by botanist Joseph Banks; on the Variolæ Vaccinæ, built his own hydrogen balloon; or Cow Pox and studied the life cycle of the 1801 “On the Origin of the cuckoo. He also played the violin Vaccine Inoculation” and wrote poetry. Jenner married in 1788 and had four children. In a

100 VACCINATION Vaccination was feared by many people. This 1802 cartoon by James Gillray depicts Jenner vaccinating a nervous woman, while around her cows sprout from other people’s bodies. the cowpox sores on the arms of Until the 1870s, smallpox was the (weakening) a germ in the laboratory infected dairymaids. Few efforts only disease for which there was a so that it could be used as a safe were made to use cowpox material vaccine. But that all changed when vaccine was a huge breakthrough. taken directly from cattle. In the microbiologists Louis Pasteur in 1840s, Italian physician Giuseppe France and Robert Koch in Germany Other vaccines Negri was one of the first to use showed that diseases are caused Pasteur at once began to look for bovine material to vaccinate people by tiny microbes, or germs. In 1877, other diseases to inoculate against. directly, but it was not until 1864 Pasteur began to argue that if a In 1881, he developed a vaccine that French medics Gustave Lanoix vaccine could be found for smallpox, for anthrax, which he successfully and Ernest Chambon transported then it could for all diseases. used in sheep, goats, and cows. a calf infected with cowpox from Then, in 1885, he began to search Naples in Italy to Paris and set up Weakened germs for a rabies vaccine. an “animal vaccine” service. Eager to prove his theory, Pasteur tried inoculating chickens with Unlike cholera and anthrax, There were obvious advantages cholera bacteria, but most of the rabies (unbeknown to Pasteur) is to animal vaccination. Over the chickens died. In 1879, he made a due to a virus, not a bacterium, so course of a few weeks, one heifer startling discovery. Just before he it cannot be grown easily in the lab. could provide enough vaccine for went away on holiday, he instructed But the virus mutates quickly, and thousands of doses. A small herd his assistant to inoculate the birds its virulence can be reduced by could vaccinate a city. Another using a fresh bacteria culture. The passing it through a different species benefit was that patients no longer assistant forgot, and on his return, before human use. Pasteur was able risked cross-infection with other Pasteur inoculated the chickens to get his attenuated rabies vaccine diseases from a human donor. with the old cultures. The birds by drying the spinal cords of rabbits Chambon took his ideas to the were then mildly ill, survived, and he had infected with the disease. United States, where “virus farms” became immune. became established towards the Following successful trials on end of the century. By 1902, around Pasteur realized that exposing dogs, Pasteur was persuaded to a quarter of the population of New the bacteria to oxygen had made test his vaccine on a nine-year-old York, about 800,000 people, had them less deadly. The idea of using boy, Joseph Meister, who had been been vaccinated. a weakened germ was not new, but bitten by a rabid dog and was likely the idea of purposely “attenuating” to die. Pasteur injected the boy Medicine has with a daily series of progressively never before produced any single improvement of such utility. Thomas Jefferson 3rd US president (1801–09)