The History of Medicine a Very Short Introduction (Very Short Introductions)

8/11/2019 The History of Medicine a Very Short Introduction (Very Short Introductions)

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A98ICA/ HISTO80 ohn $ar1er and 8ichard 8ath+one

AG/OSTICISM 8o+in 3e $oide&in

AM>8ICA/ $O3ITICA3 $A8TI>S A/# >3>CTIO/S 3 Sandy Maisel

TH> AM>8ICA/ $8>SI#>/C0 Charles O ones

A/A8CHISM Colin 4ard

A/CI>/T >G0$T Ian Sha.

A/CI>/T $HI3OSO$H0 ulia Annas

A/CI>/T 4A89A8> Harry Side+otto

A/G3ICA/ISM Mar1 Cha' an

TH> A/G3O SA O/ AG> ohn 6lair

A/IMA3 8IGHTS #a&id #eGra7ia

A/TIS>MITISM Ste&en 6eller

TH> A$OC80$HA3 GOS$>3S $aul 9oster

A8CHA>O3OG0 $aul 6ahn

A8CHIT>CT%8> Andre. 6allantyne

A8ISTOC8AC0 4illia #oyle

A8ISTOT3> onathan 6arnes

A8T HISTO80 #ana Arnold

A8T TH>O80 Cynthia 9reeland


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ATH>ISM ulian 6a--ini

A%G%STI/> Henry Chad.ic1

A%TISM %ta 9rith

6A8TH>S onathan Culler

6>STS>33>8S ohn Sutherland

TH> 6I63> ohn 8iches

6I63ICA3 A8CH>O3OG0 >ric H Cline

6IOG8A$H0 Her ione 3ee

TH> 6OO2 O9 MO8MO/ Terryl Gi&ens

TH> 68AI/ Michael O Shea

68ITISH $O3ITICS Anthony 4ri-ht

6%##HA Michael Carrithers

6%##HISM #a ien 2eo.n

6%##HIST >THICS #a ien 2eo.n

CA$ITA3ISM a es 9ulcher

CATHO3ICISM Gerald O Collins

TH> C>3TS 6arry Cunli e

CHAOS 3eonard S ith

CHOIC> TH>O80 Michael Allin-ha


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CH8ISTIA/ A8T 6eth 4illia son

CH8ISTIA/ >THICS # Ste'hen 3on-

CH8ISTIA/IT0 3inda 4oodhead

CITIJ>/SHI$ 8ichard 6ella y

C3ASSICA3 M0THO3OG0 Helen Morales

C3ASSICS Mary 6eard and ohn Henderson

C3A%S>4ITJ Michael Ho.ard

TH> CO3# 4A8 8o+ert McMahon

COMM%/ISM 3eslie Hol es

CO/SCIO%S/>SS Susan 6lac1 ore

CO/T>M$O8A80 A8T ulian Stalla+rass

CO/TI/>/TA3 $HI3OSO$H0 Si on Critchley

COSMO3OG0 $eter Coles

TH> C8%SA#>S Christo'her Tyer an

C80$TOG8A$H0 9red $i'er and Sean Mur'hy

#A#A A/# S%88>A3ISM #a&id Ho'1ins

#A84I/ onathan Ho.ard

TH> #>A# S>A SC8O33S Ti othy 3i

#>MOC8AC0 6ernard Cric1


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#>SCA8T>S To Sorell

#>S>8TS /ic1 Middleton

#>SIG/ ohn Hes1ett

#I/OSA%8S #a&id /or an

#I$3OMAC0 ose'h M Siracusa

#OC%M>/TA80 9I3M $atricia Aufderheide

#8>AMI/G Allan Ho+son

#8%GS 3eslie I&ersen

#8%I#S 6arry Cunli e

TH> >A8TH Martin 8edfern

>CO/OMICS $artha #as-u'ta

>G0$TIA/ M0TH Geraldine $inch

>IGHT>>/TH C>/T%80 68ITAI/ $aul 3an-ford

TH> >3>M>/TS $hili' 6all

>MOTIO/ #ylan >&ans

>M$I8> Ste'hen Ho.e

>/G>3S Terrell Car&er

>/G3ISH 3IT>8AT%8> onathan 6ate

>$I#>MIO3OG0 8oldolfo Saracci


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>THICS Si on 6lac1+urn

TH> >%8O$>A/ %/IO/ ohn $inder and Si on %sher.ood

>VO3%TIO/ 6rian and #e+orah Charles.orth

> IST>/TIA3ISM Tho as 9lynn

9ASCISM 2e&in $ass ore

9ASHIO/ 8e+ecca Arnold

9>MI/ISM Mar-aret 4alters

9I3M M%SIC 2athryn 2alina1

TH> 9I8ST 4O83# 4A8 Michael Ho.ard

9O8>/SIC $S0CHO3OG0 #a&id Canter

9O8>/SIC SCI>/C> i 9raser

9OSSI3S 2eith Tho son

9O%CA%3T Gary Guttin-

98>> S$>>CH /i-el 4ar+urton

98>> 4I33 Tho as $in1

98>/CH 3IT>8AT%8> ohn # 3yons

TH> 98>/CH 8>VO3%TIO/ 4illia #oyle

98>%# Anthony Storr

9%/#AM>/TA3ISM Malise 8uth&en


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GA3A I>S ohn Gri++in

GA3I3>O Still an #ra1e

GAM> TH>O80 2en 6in ore

GA/#HI 6hi1hu $are1h

G>OG8A$H0 ohn Matthe.s and #a&id Her+ert

G>O$O3ITICS 2laus #odds

G>8MA/ 3IT>8AT%8> /icholas 6oyle

G>8MA/ $HI3OSO$H0 Andre. 6o.ie

G3O6A3 CATAST8O$H>S 6ill McGuire

G3O6A3 4A8MI/G Mar1 Maslin

G3O6A3IJATIO/ Manfred Ste-er

TH> G8>AT #>$8>SSIO/ A/# TH> />4 #>A3 >ric 8auch.ay

HA6>8MAS a es Gordon 9inlayson

H>G>3 $eter Sin-er

H>I#>GG>8 Michael In.ood

HI>8OG30$HS $enelo'e 4ilson

HI/#%ISM 2i 2nott

HISTO80 ohn H Arnold

TH> HISTO80 O9 AST8O/OM0 Michael Hos1in


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TH> HISTO80 O9 3I9> Michael 6enton

TH> HISTO80 O9 M>#ICI/> 4illia 6ynu

TH> HISTO80 O9 TIM> 3eofranc Holford Stre&ens

HIVKAI#S Alan 4hiteside

HO66>S 8ichard Tuc1

H%MA/ >VO3%TIO/ 6ernard 4ood

H%MA/ 8IGHTS Andre. Cla'ha

H%M> A Ayer

I#>O3OG0 Michael 9reeden

I/#IA/ $HI3OSO$H0 Sue Ha ilton

I/9O8MATIO/ 3uciano 9loridi

I//OVATIO/ Mar1 #od-son and #a&id Gann

I/T>33IG>/C> Ian #eary

I/T>8/ATIO/A3 MIG8ATIO/ 2halid 2oser

I/T>8/ATIO/A3 8>3ATIO/S $aul 4il1inson

IS3AM Malise 8uth&en

IS3AMIC HISTO80 Ada Sil&erstein

O%8/A3ISM Ian Har-rea&es

%#AISM /or an Solo on


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%/G Anthony Ste&ens

2A66A3AH ose'h #an

2A92A 8itchie 8o+ertson

2A/T 8o-er Scruton

2>0/>S 8o+ert S1idels1y

2I>82>GAA8# $atric1 Gardiner

TH> 2O8A/ Michael Coo1

3A/#SCA$>S A/# C>OMO8$HO3OG0 Andre. Goudie andHeather Viles

3A4 8ay ond 4ac1s

TH> 3A4S O9 TH>8MO#0/AMICS $eter At1ins

3>A#>8SHI$ 2eth Grint

3I/CO3/ Allen C Guel7o

3I/G%ISTICS $eter Matthe.s

3IT>8A80 TH>O80 onathan Culler

3OC2> ohn #unn

3OGIC Graha $riest

MACHIAV>33I Luentin S1inner

MA8TI/ 3%TH>8 Scott H Hendrix

TH> MA8L%IS #> SA#> ohn $hilli's


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MA8 $eter Sin-er

MATH>MATICS Ti othy Go.ers

TH> M>A/I/G O9 3I9> Terry >a-leton

M>#ICA3 >THICS Tony Ho'e

M>#I>VA3 68ITAI/ ohn Gillin-ha and 8al'h A Gri5ths

M>MO80 onathan 2 9oster

MICHA>3 9A8A#A0 9ran1 A 3 a es

MO#>8/ A8T #a&id Cottin-ton

MO#>8/ CHI/A 8ana Mitter

MO#>8/ I8>3A/# Senia $aseta

MO#>8/ A$A/ Christo'her Goto ones

MO#>8/ISM Christo'her 6utler

MO3>C%3>S $hili' 6all

MO8MO/ISM 8ichard 3y an 6ush an

M%SIC /icholas Coo1

M0TH 8o+ert A Se-al

/ATIO/A3ISM Ste&en Gros+y

/>3SO/ MA/#>3A >lle1e 6oeh er

/>O3I6>8A3ISM Manfred Ste-er and 8a&i 8oy


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TH> />4 T>STAM>/T 3u1e Ti othy ohnson

TH> />4 T>STAM>/T AS 3IT>8AT%8> 2yle 2eefer

/>4TO/ 8o+ert Ili e

/I>TJSCH> Michael Tanner

/I/>T>>/TH C>/T%80 68ITAI/ Christo'her Har&ie and H C GMatthe.

TH> /O8MA/ CO/L%>ST Geor-e Garnett

/O8TH>8/ I8>3A/# Marc Mulholland

/OTHI/G 9ran1 Close

/%C3>A8 4>A$O/S ose'h M Siracusa

TH> O3# T>STAM>/T Michael # Coo-an

$A8TIC3> $H0SICS 9ran1 Close

$A%3 > $ Sanders

$>/T>COSTA3ISM 4illia 2 2ay

$HI3OSO$H0 >d.ard Crai-

$HI3OSO$H0 O9 3A4 8ay ond 4ac1s

$HI3OSO$H0 O9 SCI>/C> Sa ir O1asha

$HOTOG8A$H0 Ste&e >d.ards

$3A/>TS #a&id A 8othery


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8>3IGIO/ I/ AM>8ICA Ti othy 6eal

TH> 8>/AISSA/C> erry 6rotton

8>/AISSA/C> A8T Geraldine A ohnson

8OMA/ 68ITAI/ $eter Sal.ay

TH> 8OMA/ >M$I8> Christo'her 2elly

8OMA/TICISM Michael 9er+er

8O%SS>A% 8o+ert 4o1ler

8%SS>33 A C Graylin-

8%SSIA/ 3IT>8AT%8> Catriona 2elly

TH> 8%SSIA/ 8>VO3%TIO/ S A S ith

SCHIJO$H8>/IA Chris 9rith and >&e ohnstone

SCHO$>/HA%>8 Christo'her ana.ay

SCI>/C> A/# 8>3IGIO/ Tho as #ixon

SCOT3A/# 8a+ Houston

S> %A3IT0 V roni?ue Mottier

SHA2>S$>A8> Ger aine Greer

SI2HISM >leanor /es+itt

SOCIA3 A/# C%3T%8A3 A/TH8O$O3OG0 ohn Mona-han and$eter ust

SOCIA3ISM Michael /e. an


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SOCIO3OG0 Ste&e 6ruce

SOC8AT>S C C 4 Taylor

TH> SOVI>T %/IO/ Ste'hen 3o&ell

TH> S$A/ISH CIVI3 4A8 Helen Graha

S$A/ISH 3IT>8AT%8> o 3a+anyi

S$I/OJA 8o-er Scruton

STATISTICS #a&id Hand

ST%A8T 68ITAI/ ohn Morrill

S%$>8CO/#%CTIVIT0 Ste'hen 6lundell

T>88O8ISM Charles To.nshend

TH>O3OG0 #a&id 9 9ord

THOMAS AL%I/AS 9er-us 2err

TOCL%>VI33> Har&ey C MansNeld

T8AG>#0 Adrian $oole

TH> T%#O8S ohn Guy

T4>/TI>TH C>/T%80 68ITAI/ 2enneth O Mor-an

TH> %/IT># /ATIO/S ussi M Hanhi 1i

TH> % S CO/C8>SS #onald A 8itchie

%TO$IA/ISM 3y an To.er Sar-ent


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TH> VI2I/GS ulian 8ichards

4ITCHC8A9T Malcol Gas1ill

4ITTG>/ST>I/ A C Graylin-

4O83# M%SIC $hili' 6ohl an

TH> 4O83# T8A#> O8GA/IJATIO/ A rita /arli1ar

48ITI/G A/# SC8I$T Andre. 8o+inson

AVAI3A63> SOO/:

3AT> A/TIL%IT0 Gillian Clar1

M%HAMMA# onathan A 6ro.n

G>/I%S Andre. 8o+inson

/%M6>8S $eter M Hi--ins

O8GA/IJATIO/S Mary o Hatch V>80 SHO8T I/T8O#%CTIO/SV>80 SHO8T I/T8O#%CTIO/S are for anyone .antin- asti ulatin- and accessi+le .ay in to a ne. su+ ect They are.ritten +y ex'erts, and ha&e +een 'u+lished in ore than !Dlan-ua-es .orld.ide

The series +e-an in @@D, and no. re'resents a .ide &arietyof to'ics in history, 'hiloso'hy, reli-ion, science, and thehu anities The VSI 3i+rary no. contains o&er !-y't andIndian 'hiloso'hy to conce'tual art and cos olo-y and .illcontinue to -ro. to a li+rary of around F80 SHO8T I/T8O#%CTIO/S AVAI3A63> /O4


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9or ore infor ation &isit our .e+ site... ou' co u1K-eneralK&siK

TH> HISTO80 O9 M>#ICI/> A Very Short Introduction

4illia 6ynu

9or Helen Sine ?ua non

Contents

Ac1no.led-e ents 3ist of illustrations Introduction: the 1indsof edicine Medicine at the +edside

! Medicine in the li+rary

F Medicine in the hos'ital

E Medicine in the co unity

D Medicine in the la+oratory

" Medicine in the odern .orld

8eferences

9urther readin-

Index

Ac1no.led-e ents

I ha&e -i&en a short lecture +ased on the structure of this +oo1to any -rou's of students The feed+ac1 has +een &alua+lein hel'in- e sort out the forest fro the trees

The sta at Oxford %ni&ersity $ress ha&e handled this +oo1.ith ad ira+le e5ciency The co ents of Andrea 2ee-an


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and an anony ous referee ha&e i 'ro&ed the style andcontent a es Tho 'son has +een a odel editor My than1sto the all

My -reatest de+t is al.ays to Helen 6ynu , .ho has read theanuscri't .ith .onderful care and ex'ertise Many yearsa-o, she e&en heard e -i&e the lecture of the +oo1 She1no.s ho. uch of this +oo1 is hers

3ist of illustrations

The 1inds of edicine

! The hu ours

F Galen*s P'hysiolo-ical syste *

; The 4ellco e 3i+rary, 3ondon

E Classical edical N-ures


D Galen at .or1, fro O'era o nia, dissection of a 'i-


" #ra.in- of the +rain, Vesalius, DEF


>n-ra&in- of en .or1in- at a 'rintin- 'ress, D=n-ra&in- sho.in- a 'hysician -i&in- edicine to a sic1 an

in +ed and


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su'er&isin- sur-ery, "E"


@ Her ann 6oerhaa&e -i&in- a lecture


< HQtel #ieu Hos'ital, $aris


3aennec and the use of the stethosco'e at the /ec1erHos'ital


! The $arisian sur-eon and anato ist Alfred Vel'eau


F The County 3unatic Asylu , 6rent.ood, >ssex


E An e'isode durin- the 'la-ue at Milan


D The 3ondon 6oard of Health see1s out cholera


" 3ondon slu s, fro Gusta&e #ore, 3ondon: A $il-ri a-e,= !



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PThe $u+lic Vaccinator*, 3ance Cal1in, c @n-lish as PThe 6oo1of %ni&ersals*, or PGeneralities of Medicine*, A&erroes* text+oo1in se&en sections co&ered the .hole -a ut of edicine, fro

anato y to thera'y Its 3atin translations 'resented a GalenicAristotelian synthesis to -enerations of doctors in lateedie&al >uro'e

ust as the Isla ic doctors had instituted a 'ro-ra e oftranslation of ancient texts into Middle >astern lan-ua-es, sothe 'rocess of translatin- these translations +ac1 into 3atin.as initiated +y Constantine the African (d +efore


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>uro'ean edical schools, +e-innin- .ith the fa ous one atSalerno, southern Italy, esta+lished a+out uro'ean hos'itals of the 'resent date +ac1 toedie&al ti es and their na es testify to their reli-iousori-ins: HQtel #ieu in $aris, St 6artholo e.*s Hos'ital in3ondon, Sta Maria /uo&a in 9lorence

4ithin the Isla ic lands, hos'itals also attained considera+le


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si7e and i 'ortance +y the th century They so eti es hads'ecial di&isions, such as .ards for 'atients su erin- fro eyediseases, or the insane, and attracted students .ishin- to

learn ho. to 'ractise edicine They .ere 'ro+a+ly oreo&ertly P edical* than their Christian counter'arts, +ut theyshared the sa e ran-e of 'hilanthro'ic or charita+le fundin-,and, in ti es of e'ide ic, the sa e function of isolation andse-re-ation Co unity leaders ade use of hos'itals for t.odiseases in 'articular: 'la-ue and le'rosy Often calledPla7arettos* B fro 3a7arus, the 'oor an .hose sores thedo-s lic1ed in esus* 'ara+le in 3u1e*s Gos'el B these isolationhos'itals .ere ada'ted for 'la-ue after the 6lac1 #eath, frotheir earlier use for 'eo'le dia-nosed as le'ers /o disease+etter than le'rosy ca'tures the co +ination of +rutality andlo&e infusin- edie&al Christendo The dia-nosis itself, oftenfor conditions that odern doctors .ould -i&e another na e,carried .ith it total social ostracis and le-al death, .ithdi&orce +y the le'er*s s'ouse 'er itted It conde ned its&icti to a life of isolation and +e--in-, -enerally conNned to ala7aretto and needin- to carry the fa iliar le'er*s rattle .hen-oin- outside, so that 'assers +y .ere alerted to theonco in- source of 'hysical (and oral) conta-ion At thesa e ti e, so e on1s, nuns, and other reli-iously oti&atedindi&iduals freely li&ed a on- these outcasts and de&otedtheir li&es to the

The le'rosy dia-nosis .as co on fro the !th to the Ethcenturies, in ost 'arts of >uro'e, and le'rosy*s decline ay

ha&e +een catalysed +y the fact that 'eo'le li&in- to-ether inclosely conNned ?uarters .ere 'articularly &ulnera+le to the6lac1 #eath and the re'eated 'la-ue e'ide ics that follo.edCertainly a nu +er of le'er hos'itals .ere turned into 'la-uehos'itals, for any of the sa e reasons, sa&e that 'la-ue .asan acute disease, fro .hich so e indi&iduals reco&ered, andle'rosy .as a chronic disease and -enerally a life lon-sentence $la-ue hos'itals, es'ecially in southern >uro'e,

.ere con&erted to other edical uses after that diseasedisa''eared fro >uro'e in the th century in the Middle


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>ast, .here 'la-ue continued, they .ere 1e't as 'laces for?uarantinin- tra&ellers and others on the o&e .hen 'la-ue.as near

E Classical edical N-ures This early odern i a-e, in theclassical style, de'icts Ascle'ius on the left, holdin- acaduceus, and Galen exa inin- a s1eleton

Another edie&al institution i 'ortant for edicine .as theuni&ersity The edical school at Salerno fro the late thcentury .as si 'ly that: a school to train doctors A uni&ersityfollo.ed there a cou'le of centuries later In the eanti e,any others .ere founded throu-hout >uro'e, +e-innin- .ith6olo-na (founded c =


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of the uni&ersity Sur-eons and a'othecaries .ere trained +ya''renticeshi's, or +y infor ally learnin- their craft +yassociatin- the sel&es .ith an older 'ractitioner It .as the

Hi''ocratic .ay, +ut it +e-an to ac?uire a lo.er social (and,-enerally, econo ic) status .hen co 'ared .ith 'hysicians.ho could read 3atin and dis'ute the niceties of Galen andA&icenna

There .ere, to +e sure, a fe. sur-eons .ith uni&ersityex'osure, and a on- +oth sur-eons and a'othecaries,indi&iduals .ith learnin- and .ealth The +oundaries .ere notal.ays Nxed and, in the countryside, any 'hysiciansco 'ounded their o.n dru-s and 'erfor ed sur-ery In other.ords, they acted as -eneral 'ractitioners In ur+an areas,ho.e&er, the di&isions .ere retained and re-ulated +y colle-esand co 'anies of 'hysicians, or +y the uni&ersity facultySur-eons in ur+an areas often esta+lished -uilds, on a 'ar .iththose re-ulatin- other anual occu'ations, such as+utcherin-, +a1in-, or candlestic1 a1in- The edicalre-ulation .as 'atchy, +ut the i a-e of the three occu'ationalhierarchies re ained 'art of 'u+lic 'erce'tion until laterde&elo' ents in edical 1no.led-e also chan-ed .hatdoctors could do

The disco&ery of anato y

Galen and a nu +er of other ancient and Ara+ic authors hadhad a -ood deal to say on the internal structures and functions

of the hu an +ody Since then, the occasional auto'sy, ostly'erfor ed .hen an i 'ortant 'erson died suddenly or insus'icious circu stances, had re&ealed ore of .hat the +odyloo1s li1e .hen it is cut o'en 9or all that, it .as a +old ste'.hen the edical faculties -radually +e-an to o er 'u+licde onstrations of dissected +odies in the Eth century9re?uently, a enial 'rosector .ould o'en the cor'se (often of an executed cri inal) .hile the 'rofessor read rele&ant

'assa-es fro Galen or another authority These Panato ies*,as the .hole 'rocess .as called, .ere scheduled for the .inter


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onths, .hen the colder .eather slo.ed do.n the +ody*s'utrefaction the order of ex'osin- the internal 'arts .as alsodictated +y the s'eed of decay: a+do en Nrst, follo.ed +y the

contents of the thorax, then the +rain, and Nnally, the li +s

D Galen at .or1 This illustration fro a D"D edition ofGalen*s .or1s su+tly reinforces the fact that so e of Galen*s1no.led-e of anato y ca e fro dissectin- 'i-s Althou-hany of the classical N-ures a''ear +lissfully uninterested,the co 'osition in&o1es a ty'ical 'u+lic dissection in the8enaissance

The Nrst recorded 'u+lic dissection .as 'erfor ed in 6olo-nain a+out F D, +y Mondino de* 3iu77i (c !


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+oo1 The uscular .alls +et.een the ri-ht and left side of theheart, for instance, .ere dense, .ith no .ay for +lood to 'assthrou-h, as Galen*s 'hysiolo-y re?uired The hu an li&er did

not ha&e the four or N&e lo+es that Galen assi-ned it (throu-hdissectin- 'i-s and other ani als) the sternu , uterus, andany other anato ical structures .ere accurately descri+ed+y Vesalius for the Nrst ti e

" In addition to the fa ous uscle en, Vesalius*s 9a+rica ofDEF de'icted other 'arts of the hu an +ody, al.aysdra atically re'resented

4e di&ide the history of anato y into 're Vesalian and 'ostVesalian, .ith Vesalius as the fulcru This 'ro+a+lyexa--erates the i ediate i 'act of Vesalius* +oo1, for heleft $adua and anato y shortly after its 'u+lication for alucrati&e o+ at the S'anish court 6y the id "th century,ho.e&er, the anato ical re&olution .as .ell under.ay, andthe desire to see for oneself, instead of ta1in- the ancients onchildli1e trust, .as .ides'read

Anato y .as the ?ueen of the edical sciences for so ethree centuries, and no +ranch of edical 1no.led-e+eneNted ore fro that catalyst of social and intellectualchan-e, the 'rintin- 'ress A Ger an artisan, ohannesGuten+er- (c E


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text, +ut it set standards for dra atic artistic re'resentation as.ell as anato ical accuracy O&er the follo.in- centuries,anato y +oo1s crystalli7e a dee' 'aradox in early odern

edicine Anato y .as an as'ect of edical acti&ity thatattracted re&ulsion fro any e +ers of the 'u+lic:dissectin- .as seen as orally de+asin-, dis-ustin-, andcruel It led e&entually to an under-round trade in the su''lyof +odies +y ille-al eans, -enerally -ra&e ro++in- +utso eti es urder It certainly .as s elly +efore 'reser&ationethods i 'ro&ed, althou-h the sic1ly s.eet aro a offor aldehyde ade odern edical students easy to identifyon the street, 'er eatin- as it does their clothes and s1in

#issection .as thus +ad for edicine*s 'u+lic i a-e It .asalso the su+ ect of ela+orate, ex'ensi&e, and +eautifully'roduced and illustrated +oo1s, .ith the u''er end of thear1et ai ed at the connoisseur 9or the edical student,there .ere s all text+oo1s .ith crude illustrations and a 'riceto atch /o other disci'line .ithin edicine so co +ined artand science, or 1no.led-e and 'resentation Increasin-ly,e&en .ould +e 'hysicians dissected, their curiosity -ettin- the+etter of their -entle anly 'retensions Many of the -reatna es in early odern anato y B Ga+riele 9allo'io ( DF!B"!),9a+ricius a+ Ac?ua'endente ( DFFB " @), 9rederi1 8uysch( "F=B F ), 4illia Cheselden ( "==B D!), 4illia Hunter( =B=F) B had a5liations .ith sur-ery or o+stetrics, +utcurious 'hysicians, such as 4illia Har&ey ( D =B "D ), alsoused their hands in their research Har&ey*s -reat treatise

announcin- his disco&ery of the circulation of the +lood ( "!=)is actually entitled an Panato ical exercise* on de Motu Cordis(On the otion of the heart)

This Victorian en-ra&in- of a .oodcut +y Stradanus froa+out D=< sho.s any sta-es of +oo1 'roduction, includin-settin- ty'e, in1in- it, 'rintin- the sheets, and 'roof readin-

Gi&en the nature of edical (or e&en sur-ical) 'ractice in the'eriod, doctors learned ore anato y than they could actually


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$aracelsus .as o+&iously inRuenced +y the intellectual ande otional fer ent that Martin 3uther*s o&e ent for allyinau-urated early in his life $aracelsus re'eatedly said that

learnin- .as to +e found in nature, not +oo1s, althou-h thisdid not sto' hi fro 'ennin- do7ens of +oo1s hi self, anyof .hich .ere 'rinted in his lifeti e $erha's he really eantthat learnin- .as to +e found in his +oo1s, not those of his'redecessors

His second lastin- contri+ution .as his e 'hasis on che istry,as a .ay of understandin- the .ay the hu an +ody .or1s,and as a source of dru-s to treat disease He used etals suchas ercury and arsenic as uch as the traditional +otanicalsin his treat ents, and his follo.ers, the iatroche ists (literally,che ical doctors), continued in his .a1e His notion ofdisease, as so ethin- external to the +ody, is so eti esrather ina''ro'riately descri+ed as a forerunner of -ertheory, +ut it .as in fact rooted in his ystical, alche icalnotions of the .ay nature o'erates There is ore to thethin1in- of this stran-e an, .ho 'ro&o1ed contro&ersy in hislifeti e and after.ards His follo.ers, of .hich there .ereany for .ell o&er a century, atte 'ted to re.rite the theoryand 'ractice of edicine, in a che ical lan-ua-e

Another -rou', the iatro'hysicists, sli-htly later and dra.in-on the triu 'hs of astrono y and 'hysics, sa. the +ody as a.onderful echanical contri&ance 4hereas the iatroche istsconsidered di-estion as a che ical 'rocess, the iatro'hysicists

sa. it as a echanical -rindin- do.n These later ad&ocatesanalysed uscular o&e ent, calculatin- the forces-enerated +y contraction, and sou-ht to re'resent hu an'hysiolo-y athe atically .hene&er 'ossi+le Their heroes.ere Galileo, and later /e.ton, en .ho had re'lacedAristotle*s &ie. of the uni&erse .ith a uch ore 'o.erfulodel, in .hich atter and force .ere the o'erati&e thin-s to+e easured Throu-hout the =th century, /e.ton*s notion of

-ra&ity as a force that extended throu-hout the uni&erse andex'lained so uch .as a s'ur to doctors see1in- si ilar


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'rinci'les in edicine

The ne. relationshi' to en?uiry introduced a 'eriod of -reat

fer ent .ithin edicine (and science) Theories a+ounded ando'ti is 're&ailed The a''roach to understandin- health anddisease altered dra atically, +ut chan-es in .hat doctorsactually did in treatin- 'atients .ere less stri1in- To +e sure,the che icals introduced +y $aracelsus and his follo.ers .ereostly ne., and the 're&alence of sy'hilis eant thatercury had a 'ro inent edical 'resence Sy'hilis had ta1en>uro'e +y stor in the E@


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#es'ite these ne. diseases and ne. re edies, Hi''ocrates.ould not ha&e +een sur'rised at ost edical inistration tosu erers 6loodlettin-, e etics (to in&o1e &o itin-), cathartics

(to induce 'ur-in-), and the -a ut of re edies associated.ith hu oralis continued as the ainstay of doctors Indeed,as Galen*s star .aned, that of Hi''ocrates still shone +ri-htlyA on- clinicians of the th century, Tho as Sydenha( "!EB=@) still co ands res'ect Called the P>n-lishHi''ocrates*, he sou-ht to return edicine to the e 'irical artthat he identiNed .ith the 9ather of edicine Medicine, he.rote, should concern itself .ith careful clinical descri'tions of disease (he left -ra'hic accounts of -out, hysteria, ands all'ox, a on- other illnesses) 4ith the security of correctlydia-nosin- a disease, re edies could +e e 'irically sou-htHe .as instru ental in ad&ocatin- another /e. 4orldre edy, ?uinine (&ariously called $eru&ian +ar1, or esuit*s+ar1, reRectin- its ori-in), in the treat ent of inter ittentfe&ers

Sydenha *s ex'erience .ith $eru&ian +ar1 funda entallychan-ed his .hole conce't of disease Althou-h he .as stillco forta+le .ith Hi''ocratic hu ours, ?uinine see edco 'letely to sta ' out inter ittent fe&ers, root and +ranchIt see ed to +e a s'eciNc, dra atically e ecti&e a-ainst thisone disorder in all 'atients It encoura-ed hi to +elie&e thatdiseases could +e classiNed, li1e +otanists classify 'lants, andthat the &ariation of a disease and its sy 'to s in indi&iduals.as ad&entitious, li1e the di erences in indi&idual &iolets or

other Ro.ers As he fa ously .rote:

/ature, in the 'roduction of disease, is unifor and consistent,so uch so,

that for the sa e disease in di erent 'ersons the sy 'to sare for the ost

'art the sa e and the selfsa e 'heno ena that you .ouldo+ser&e in the


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'u77led doctors and .orried 'atients >?ually i 'ortant,6oerhaa&e .rote a strin- of text+oo1s in che istry, ateriaedica (i e edical thera'eutics), and edicine, as .ell as

nu erous 'u+lications in anato y, +otany, and &enerealdisease He inRuenced t.o or three -enerations of doctors,e&en if his forte .as synthesis rather than funda entaldisco&ery #es'ite his fascination .ith the natural .orld(es'ecially his +elo&ed +otanical -arden), he re ains a 'art ofthe learned tradition of li+rary edicine: Hi''ocrates .as stilla &ital N-ure for hi , and he continued to loo1 +ac1 for factsand a''roaches to edicine, e&en .hile retainin- theconNdence in 'ro-ress that had +een .on in the 're&iouscentury

@ Her ann 6oerhaa&e .as the ost fa ous edical teacherof his day, and althou-h he trained any youn- doctors, he'ro+a+ly did not often lecture to ?uite such lar-e audiences

6oerhaa&e*s 'u'ils included the ost fa ous naturalist of the=th century, Carl 3innaeus ( < B =) 3innaeus turnedclassiNcation into an a&ant -arde science, introducin- thesyste of +ino ial no enclature, .here+y or-anis s are1no.n +y their -enus and s'ecies 3innaeus de&oted his life toorderin- the o+ ects of the natural .orld, es'ecially 'lants Hesa. hi self as a second Ada , the Nrst ha&in- +een char-ed.ith the tas1 of na in- the ani als and 'lants in the Gardenof >den %''sala, .here 3innaeus .as 'rofessor of edicine,.as no >den, +ut he orchestrated a series of ex'editions +y

his students to any exotic 'arts of the .orld fro .hich theydutifully +rou-ht +ac1 (if they sur&i&ed) natural s'eci ens ofall 1inds for hi to classify 3innaeus also 'roduced aclassiNcation of diseases, +ut his nosolo-y .as less inRuentialthan se&eral other >nli-hten ent ones, includin- those of9ran ois 6oissier de la Croix de Sau&a-es (

edical 'ractitioner in 3ichNeld and other 'laces in the >n-lishMidlands All these nosolo-ies .ere ela+orate a airs, and


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?uac1s i-ht ha&e had their o.n idiosyncratic notions of .hatcaused disease, or ho. it i-ht +est +e treated, +ut as oftenas not they .ould also assi ilate i 'ortant historical N-ures

.ithin edicine B Hi''ocrates and Galen +oth feature in thead&ertise ents of irre-ular healers of the 'eriod $aracelsus isa nota+le exce'tion, in re ectin- not only the theories +ut alsothe .hole tradition of edicine His .as a -enuinely ahistoricalentality ost P?uac1s* relied instead on the fa iliar andtraditional, slyly turnin- it to their o.n ad&anta-e, in .hatthey 'ro ised or in ho. they 'lied their .ares and ser&ices

The second stri1in- characteristic of >nli-hten ent edicine.as its +usy o'ti is It .as an a-e of 'ro ects andinstitutions Hos'itals .ere esta+lished .ith -reat re-ularity,atte 'ts .ere ade throu-hout >uro'e to refor ilitaryedical ser&ices, and edically orientated 'hilanthro'y .asco on The idea of 'ro-ress, includin- edical 'ro-ress,.as ta1en for -ranted, and doctors and their 'atients +oth+elie&ed that the edicine of the future could do e&en orethan the edicine of the 'ast or 'resent At the sa e ti e,learned 'hysicians and sur-eons still loo1ed to Hi''ocrates orSydenha , not si 'ly for ins'iration +ut for infor ation andexa 'le 9or 6oerhaa&e or Cullen, the history of edicine .asnot of ere anti?uarian interest, +ut a source of li&in- .isdo#urin- the @th century, the old doctors .ere consi-ned tohistory, as a ne. -eneration of doctors +e-an increasin-ly toloo1 to the future

Cha'ter F Medicine in the hos'ital

Vi&e la 9rance

The 'hrase Phos'ital edicine* has ac?uired a s'eciNceanin- for edical historians Hos'itals e er-ed in the earlyedie&al 'eriod, and P edicine*, in the sense of edical'ractice, has an e&en lon-er history /e&ertheless, Phos'ital

edicine* is a con&enient shorthand for the &alues thatRourished .ithin the edical co unity in 9rance, and


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es'ecially $aris, +et.een the re&olutions of =@ and =E= This 'eriod constitutes an e'och, durin- .hich $aris +eca ethe Mecca of the edical .orld It .as centred s?uarely .ithin

the $arisian hos'itals and the tools and attitudes thatdo inated edical education and 'ractice there resonatedthrou-hout the 4estern .orld

This 9rench 'eriod has so eti es +een descri+ed as aP edical re&olution*, a''ro'riate since it -re. out of a 'oliticalre&olution Historians .ho ha&e inutely un'ac1ed theeducational structures, edical 'rocedures, and doctorB'atient relationshi's ha&e unco&ered su5cient 'recedent toar-ue for e&olution rather than re&olution .ithin edicine, +utthe fact re ains that doctors in the =E


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ne. re'u+lic

9ortunately, the 1ey an on the co ission a''ointed +y the

8e&olutionary Asse +ly to consider the edical re?uire entsof the ne. era .as a doctor and che ist sy 'athetic to theai s of the 8e&olution Antoine 9ourcroy ( DDB =


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The doctorB'atient encounter shifted in the $arisian hos'italsof the early @th century Hos'ital 'atients .ere ostly the'oor and uneducated, and therefore 'o.erless to ha&e uch

say in the .ay they .ere treated 9urther, the ne. edicalideolo-y encoura-ed doctors to loo1 for o+ ecti&e si-ns ofdisease, rather than si 'ly rely on the 'atient*s account of hisor her sy 'to s A sy 'to , such as 'ain or tiredness, is'ri&ate to the indi&idual si-ns, such as uscle .astin- or ana+scess, are ore 'u+lic atters, and the leaders of 9renchhos'ital edicine .anted to +ase their 'ractice on theo+ ecti&ity of si-ns and lesions

$hysical dia-nosis .as central to this endea&our The fourcardinal di ensions of 'hysical dia-noses, still tau-ht toedical students, are ins'ection, 'al'ation, 'ercussion, andauscultation In &arious for s, all had +een used occasionally+y doctors since the Hi''ocratics The 9rench hos'ital doctors'ut the to-ether, ade the routine and syste atic, andfore&er chan-ed doctorB'atient relationshi's

Ins'ection is the ost +asic: loo1 at the 'atient PStic1 out yourton-ue* has +een a fa iliar edical co and for a-es 9urredton-ues .ere dee ed to +e the 1ey to fe&ers and other acutedisorders 0ello. eye+alls 'ointed to aundice, and Rushedfaces also indicated fe&ers or the end sta-es of a Phectic* (alate sta-e of consu 'tion, or tu+erculosis), or the 'lethora of-out A -reen tint to a 'ale face ade the doctor thin1 ofchlorosis, a disease of youn- -irls .hich ysteriously

disa''eared in the early !


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'al'ation, an e&en ore inti ate anoeu&re, since it in&ol&estouchin- A tender s'ot, lu ', or enlar-ed or-an canso eti es +e o+ser&ed, +ut it can ore often +e felt The

Hi''ocratics 1ne. that inter ittent fe&ers often 'roduced anenlar-ed s'leen, occasionally so 'ro inent that it could +eseen, +ut ore often it could +e detected +y 'al'ation 4ithinthe -entle anly culture of 'hysicians in the early odern'eriod, ho.e&er, 'ro+in- the 'atient*s +ody .ith one*s handss ac1ed of anual la+our $al'ation .as thus another as'ectof dia-nosis i 'orted +ac1 into edicine +y the 9renchin unction to inte-rate edicine and sur-ery 6y locatin-disease 'rocesses .ithin the or-ans, and e 'hasi7in- thei 'ortance of the lesion, 9rench edical students .ere tau-htto use their hands as 'art of their dia-nostic tools

$ercussion (ta''in- the chest or a+do en) .as the third 'artof routine 'hysical exa ination #es'ite isolated co ents inearlier case histories, the Viennese 'hysician 3eo'oldAuen+ru--er ( !!B =


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.orryin- too uch a+out the solid 'arts of the +ody to aidtheir dia-noses All this chan-ed .ith the co in- of the 9rench.ay of teachin- and learnin- edicine

Auen+ru--er*s 3atin treatise .as redisco&ered +y ean /icolasCor&isart ( DDB =! ), /a'oleon*s 'ri&ate 'hysician and'rofessor of edicine in the $aris school Cor&isart .as .ellattuned to the ne. or-an +ased orientation of early @thcentury 9rench edicine, and 'articularly interested indiseases of the heart He reco-ni7ed the &alue of 'ercussion incases of heart enlar-e ent, collections of Ruid around theheart, and other cardiac diseases He +e-an teachin-'ercussion to his students and translated Auen+ru--er*streatise in =


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doctors for hundreds of years Occasionally, doctors had notedthat they had 'ut their ears directly on the 'atient*s chest ora+do en, the +etter to hear This is i ediate auscultation,

listenin- directly .ith the ear Mediate auscultation in&ol&edso ethin- +et.een the 'atient*s +ody and the doctor*s ear This .as the stethosco'e, the in&ention of 8 T H 3aennec( = B =!"), one of the ost co 'lex and -ifted of the 9renchclinicians

3aennec*s career .ell illustrates the i 'ortance of externalconsiderations in .ho*s in and .ho*s out As a Catholic and8oyalist, his career lan-uished durin- the secular at os'herethat 'er eated the 8e'u+lic and /a'oleonic e'ochs Ahos'ital a''oint ent and, e&entually, a chair ca e only afterthe fall of /a'oleon and the restoration of the onarchy Hehad already i +i+ed the ideals of the 9rench school, andcontri+uted uch as a ournalist, editor, and 'ractisin- doctorHis ori-inal stethosco'e .as no ore than a ti-htly rollednote+oo1, constructed +ecause he .anted to listen to thechest sounds of a 'lu ' youn- .o an, and decoru eantthat he could not 'lace his ear directly on her chest He .asdeli-hted to disco&er that the sound .as trans itted e&enore clearly than it .ould ha&e +een had he e 'loyedi ediate auscultation He ?uic1ly de&ised a si 'lestethosco'e (his .ord), a hollo. .ooden tu+e, .ith t.o Nttin-sat the end, a +ell and a dia'hra- , the +etter to re'roducesounds of di erent 'itches (he .as a s1illed usician)

His encounter .ith his fe ale 'atient occurred in = ", at the/ec1er Hos'ital, in $aris 3aennec*s three years +et.een = "and = @ constitute one of the ost creati&e 'eriods for anyindi&idual in the .hole history of edicine 6y the ti e he'u+lished his treatise on ediate auscultation in the latteryear, he .as an acco 'lished stethosco'ist He created uchof the &oca+ulary that doctors still use to descri+e +reathsounds and ar-ued co-ently that he could dia-nose any

diseases of the heart and lun-s +y the s'eciNc auditory'atterns re&ealed +y his stethosco'e He .as es'ecially


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of the indset that doctors +rin- to the +edside

To the or-ue: clinico 'atholo-ical correlation

The $aris edical school .as reo'ened .ith its refor edcurriculu in @E Ar-ua+ly, it .as rooted earlier, in "Auen+ru--er*s descri'tion of 'ercussion a''eared that yearso did Gio&anni 6attista Mor-a-ni*s #e sedi+us et causisor+oru (On the Seats and Causes of #iseases), a .or1 thatunder'inned the 9rench 'atholo-ical a''roach, ust asAuen+ru--er*s little +oo1 contri+uted to its clinical one

Mor-a-ni*s assi&e treatise .as ore an encyclo'aedia thana text+oo1, or-ani7ed in the traditional .ay of head to foot'resentation It o ered case histories and auto'sies of so e


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o ered concentrations of diseased hu anity and the 9renchex'loited the conditions to the hilt

If 'hysical dia-noses hel'ed the doctor Nnd the lesion, theauto'sy ena+led hi to inter'ret his earlier dia-noses andodify or reinforce the Clinico 'atholo-ical correlation .asthus a t.o .ay street, .ith the re'eated +edside o+ser&ations-i&in- the o''ortunity of follo.in- the 'atient*s illness durin-his or her life, and these records +ein- discussed in the li-ht of the Nnal o+ser&ations on the cor'se The clinician .as his o.n'atholo-ist, carin- for his 'atients in death as in life Thus,Cor&isart, 3aennec, and the other leaders of the 9rench school.ere e?ually at ho e at the +edside and the or-ue

They .ere dri&en +y the search for the lesion, those'atholo-ical chan-es 'roduced +y disease The 'hiloso'her9rancis 6acon ( D" B "!") called these chan-es Pthe footste'sof disease*, and the i a-e is a''osite, of so e 'ersoniNedPdisease* .al1in- throu-h the or-ans of our +odies, lea&in-+ehind traces of its &isit Identifyin- these traces .as the 'ointof the 'ost orte exa ination

$ost orte s .ere conducted +y 9rench clinicians in the sa es'irit as the 'hysical exa ination: to o+ ectify the 'heno enaof disease, and there+y re'lace the s'eculations of !,

.ays of thin1in-


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He is re e +ered today ostly as the Pfather of histolo-y*,since he reco-ni7ed that 'atholo-ical 'rocesses are co onin the sa e 1inds of tissue .here&er they occur Thus the

serous e +ranes that line the heart, +rain, thorax, anda+do en react in si ilar .ays to disease 'rocesses 4or1in-.ith the na1ed eye and a si 'le hand lens, he identiNed !such ty'es of tissue, such as osseous, ner&ous, N+rous, orucous He also considered &eins and arteries as s'ecialPtissues* 6ichat .as ore intri-ued +y 'rocess than any ofthe 9rench clinicians .ho .ere ins'ired +y hi , and +rou-ht aore theoretical 'ers'ecti&e to his .or1 than the Rat footede 'iricis that characteri7ed uch of 9rench hos'italedicine 6ut he li&ed and died in the hos'ital, di&idin- histi e +et.een the +edside and dead roo , and he ins'iredothers +oth +y his ideas and his ener-y, the latterextin-uished too soon

The hos'itals of $aris (there .ere far ore +eds there than inthe .hole of Great 6ritain) o ered an un'aralleled o''ortunityto o+ser&e des'erately sic1 'eo'le, dra.n fro the needyclasses and re?uired to o er their +odies, in life and in death,to the ser&ice of clinical edicine, in return for .hate&er care.as on o er The 9rench co +ination of 'hysical dia-nosesand clinico 'atholo-ical correlation constituted a ne.a''roach to disease, and e +odied ne. 'o.er structures.ithin the hos'ital It -radually 'roduced a ne. or-ani7ation(nosolo-y) of disease, -rounded in the or-ans, and ele&atin-the solid 'arts of the +ody to 'ole 'osition It .as ar-ua+ly the

Hi''ocratic a''roach .rit lar-e, +ut +ased in the hos'ital andsituatin- disease in the or-ans rather than the hu ours

! Alfred Vel'eau ( @DB =" ) .as 'rofessor of clinicalsur-ery in the $aris Medical 9aculty, +ut he also adecontri+utions to sur-ical anato y, e +ryolo-y, 'hysiolo-y,and diseases of the +reast This so +re etchin- 'oi-nantlyco e orates the uses of the dead for the li&in-

Or-an 'atholo-y +eca e the do inant the e Mono-ra'hs on


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the diseases of the heart, lun-s, 1idneys, +rain and ner&oussyste , sto ach and intestines, li&er, s1in, and re'roducti&eor-ans +eca e the .ay 9rench clinicians ade na es for

the sel&es Cor&isart*s ono-ra'h on diseases of the heartand 3aennec*s on diseases of the lun-s .ere lin1ed to theirdia-nostic inno&ations Others B Ali+ert on the s1in, 8ayer onthe 1idneys, Andral on the +lood, 8icord on the re'roducti&eor-ans B extended the a''roach to other 'arts of the +ody

Of all diseases, 'hthisis .as undou+tedly the ost .rittena+out, and ost co only encountered a on- the 'atients(and their doctors) in the 9rench hos'itals It .as the leadin-cause of death throu-hout >uro'e in the early @th centuryP$hthisis* (consu 'tion) .as descri+ed +y the Hi''ocratics asa dan-erous .astin- disease .ith fe&er, chronic cou-h, andother 'ul onary sy 'to s, and there is -ood'alaeo'atholo-ical e&idence that tu+erculosis has +eenco on in hu an societies for illennia $hthisis +eca eu+i?uitous fro the late =th century, and there is reason tosu''ose that ost cases of P'hthisis* .ould today +edia-nosed as tu+erculosis The latter disease cate-oryrecei&ed its odern deNnition only .hen 8o+ert 2ochidentiNed the +acteriu , the tu+ercle +acillus, as the causati&ea-ent of tu+erculosis in ==! /e&ertheless, 3aennec and hiscollea-ues deNned P'hthisis* 'atholo-ically, and theirdescri'tions of +oth the clinical sy 'to s and the 'ostorte Nndin-s conNr the assu 'tion that 'hthisis andtu+erculosis are for the ost 'art t.o na es for the sa e

disease

3aennec clai ed to +e a+le to dia-nose 'hthisis .ith hisstethosco'e, ar-uin- for P'atho-no onic* (i e uni?ue to thatcondition) sounds in the u''er chest in 'atients .ith theaWiction He ar-ued on +oth clinical and 'ost orte -roundsthat the tiny lesion called the Ptu+ercle* (literally, a s alls.ellin-) .as the hall ar1 of a sin-le disease, no atter

.here the lesion .as found He thus uniNed a nu +er ofdi erent dia-noses, such as scrofula, tu+erculous enin-itis,


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or tu+ercles of the intestine He li1ened the de&elo' ent oflar-er -ranular lesions fro the initial tu+ercles to the ri'enin-of fruit His -rou'indiseases of any or-ans containin-

tu+ercles into a sin-le entity .as &indicated +y 2och*s .or1 onthe +acillus, +ut .ithin the 'atholo-ical tradition, it too1 a lea'of the i a-ination and .as counter intuiti&e -i&en the or-an+ased 'aradi- .ithin .hich he .or1ed As for the cause of'hthisis, 3aennec sus'ected that it .ould ne&er +e 1no.n forcertain, althou-h his o.n causati&e fra e.or1 &eered to.ardsthe 'sychoso atic Stron- 'assions .ere often associated.ith the disease, and he ?uietly assi-ned the causati&esi-niNcance

3aennec*s +rilliant dia-nostic .or1 underscores +oth thestren-ths and .ea1nesses of the clinico 'atholo-icala''roach: +y concentratin- on the end sta-e of disease, thelesions, 9rench clinicians .ere often left short on +oth the'rocesses +y .hich the lesions .ere for ed, and the aetiolo-y(cause) of the chan-es More 'ositi&ely, +y loo1in- closely atthe correlations +et.een clinical si-ns and 'atholo-icalchan-es, they .ere a+le to di erentiate any diseases thatha&e re ained in the edical &oca+ulary, e&en after -ertheory and other later de&elo' ents o ered di erent sets ofdia-nostic criteria

One -ood exa 'le .as the se'aration of ty'hus and ty'hoidfe&ers The t.o .ords are si ilar and their clinical'resentations could +e close enou-h that it is so eti es

di5cult in the older edical literature to sort out one fro theother, or fro alternati&e conditions that i-ht +e dia-nosedtoday They .ere t.o &arieties of fe&er, a disease in its o.nri-ht in earlier ti es In the =th century diseaseclassiNcations, Pfe&er* .as the disease, +ro1en u' into &arious1inds .ith ad ecti&es such as inter ittent, continued, ty'hus,ty'hoid, lo., ner&ous, 'utrid, hectic PTy'hoid fe&er* stillsounds acce'ta+le to us, and Pyello. fe&er* is the full na e .e

use for the disease caused +y a &irus These na es lin-ere&en after @th century doctors -radually ca e to deNne


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Pfe&er* as a si-n of disease (ele&ated +ody te 'erature,easured +y a ther o eter), rather than a disease itself

The di erentiation of ty'hus and ty'hoid .as e ected ore orless inde'endently +y se&eral doctors, each under the s'ell ofthe 9rench .ay of doin- edicine, +ut .or1in- in 6ritain andthe %nited States as .ell as 9rance In 9rance, $ierre 3ouis( = B = !) esta+lished 'atholo-ical criteria for ty'hoid in=!@ His career e'ito i7es the 9rench era 0oun- enou-h totrain in the Pne.* edicine, he s'ent a fe. years in 8ussia+efore returnin- to $aris in =!


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3i1e so uch else in the $arisian hos'itals, dealin- .ith lar-enu +ers of 'atients .as not entirely ne. to edicine Militarydoctors of all nationalities had +een 'ressed to 'ro&ide

statistics, and the doctors in hos'itals, +oth ilitary andci&ilian, had reco-ni7ed the duty of 'resentin- annualsu aries of cases, dia-noses, treat ents, and cures Onei-ht &ie. 3ouis as si 'ly the cul ination of the>nli-hten ent e 'hasis on facts and o'enness This ista1esinno&ation for i 'act: of the later clinicians in the heyday of$aris edicine, 3ouis had the -reatest international i 'act Hetau-ht any forei-n students and, ore than any other,+rou-ht the insi-hts of the 9rench school to-ether His shortessay on Clinical Instruction, translated into >n-lish in =FE, isa +rilliant su ary of .hat teachin- and learnin- in $arisstro&e to +e

He is so eti es credited .ith al ost sin-le handedlycon&incin- doctors to a+andon the ancient 'ractice of+loodlettin- for all anner of diseases His short ono-ra'hon the su+ ect ( =FD) re ains his +est 1no.n .or1, +ut itsle-acy lies ore .ith the ethod than the essa-e In8esearches on the > ects of 6loodlettin- in So eInRa atory #iseases, 3ouis e&aluated the e ect of di erentti in- (early or late) and ?uantity (a little or ore &i-orous) ofthera'eutic 'hle+oto y in cases of 'neu onia The sa eono-ra'h also exa ined the use of di erent doses of tartare etic (a edicine containin- anti ony) 4hat isre e +ered today is the .ay 3ouis atte 'ted to e&aluate

these thera'ies +y di&idin- si ilar 'atients into -rou's andco 'arin- the results of his &arious treat ents In e ect,3ouis .as usin- a clinical trial, thou-h hardly .ith a 'rotocolthat .ould no. +e ud-ed ade?uate /otice that 3ouis did notinclude no +loodlettin- as an o'tion, +ut erely e&aluatedti in- and ?uantity

3ouis* little ono-ra'h, des'ite its classic status, .as actually

'art of a 'ole ical ca 'ai-n +et.een 3ouis and 9 V6roussais ( !B =F=) The latter had de&elo'ed a syste of


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P'hysiolo-ical edicine* to counter the static, anato icala''roach of ost 9rench clinicians 6roussais had noticed ho.any of the 'atients that he auto'sied sho.ed si-ns of

chronic -astric irritation and his syste 'osited that alldisease ori-inated in the sto ach, and that local lesionselse.here resulted fro the 'ri ary irritation .ithin thesto ach The standard treat ent for irritation or inRa ation.as +loodlettin- He fa&oured leeches rather than the lancet,and he and 3ouis exchan-ed a series of shar' 'ole ics durin-the =F


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The 'hysical and the ental

6y =D< or so, 9rench hos'ital edicine had +eco e fa iliar/e. a''roaches to understandin- disease, the -reater use ofex'eri ent rather than ere o+ser&ation, and di inishin-returns on .hat could +e disco&ered +y yet one ore auto'sy,rendered the iracle of 9rench clinical edicine so ethin-ore 'edestrian #urin- its heyday, ho.e&er, thousands ofstudents had co e to $aris fro all o&er the 4estern .orld

They returned to 6ritain, Ger any, Austria, Italy, the %nitedStates, and the /etherlands, .here so e of the foundededical schools and hos'itals 6y the early @th century, aedical school .ithout an attached hos'ital .as second rate4hen the ne. %ni&ersity of 3ondon (no. %ni&ersity Colle-e3ondon) +e-an its edical school in the late =!


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ost fa ous of the P6i- 9our* B the initial senior edicalfaculty He still co ands adulation fro doctors, as ascientiNcally attuned +ut hu ane clinician, +oo1 collector,

historian, essayist, and teacher The assi ilation of Ger anscience infused the Ho'1ins a''roach to disease, +ut 9renchinno&ations 'er anently left teachin- hos'itals .ith t.ore-ular e&ents: the daily .ard round, in .hich a seniorclinician, follo.ed +y unior doctors, edical students, and anurse, .ould see and discuss each 'atient at his or her+edside and -rand rounds, in .hich interestin- Pcases* .ould+e 'resented +y a e +er of the unior sta and analysed +yso eone fro the senior hierarchy, in front of a lar-e-atherin- of students and doctors at all le&els of ex'erienceOften, after the 'resentation of the 'atient*s history andclinical course, and the discussion of the di erential dia-nosis,the auto'sy Nndin-s .ould +e re&ealed +y a 'atholo-ist, andthe .hole life and death of the 'atient 'ut to-ether in asea less .hole

In the lar-e teachin- hos'itals, the edical and sur-icals'ecialties, such as 'aediatrics, cardiolo-y, neurolo-y,o+stetrics, ortho'aedic sur-ery, or otolaryn-olo-y (diseases ofthe ear, nose, and throat), .ould each ha&e their o.n chief, anu +er of dedicated +eds, and re-ular rounds, +oth .ard and-rand One s'eciality lon- under re'resented in ost -eneralhos'itals .as 'sychiatry, e&en if 'sychiatry has +een calledPhalf of edicine*, so co on are 'sychiatric disordersInstead, those su erin- fro serious 'sychiatric illness B

earlier called adness or lunacy B had their o.n 1ind ofinstitutional settin- The institutional 'ro&ision for the adde&elo'ed inde'endently fro the scattered 'ro&ision ofordinary hos'itals in the early odern 'eriod Madhouses, asthey .ere +rutally called, .ere usually s all esta+lish ents,for 'roNt, and as often as not run +y a non edical 'erson%nli1e -eneral hos'itals, they .ere ostly for the .ell to do,so e +arrassin- .as the +eha&iour of a seriously eccentric or

hallucination 'rone relati&e The ost fa ous 'sychiatricinstitution in 6ritain -a&e its na e to the lan-ua-e: 6edla , a


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short for of its full na e, 6ethlehe , or St Mary 6ethlehePTo o 6edla * +eca e a stoc1 Nctional character, used +ySha1es'eare in 2in- 3ear, and sy 'to atic of the isolation

that 'sychiatric 'atients ha&e al.ays felt

6edla .as unusual a on- 'sychiatric institutions, funded +yendo. ents and .ith -o&ernors o&erseein- its o'erationsMost adhouses .ere s all 'ri&ate a airs .hose recordsha&e lon- since disa''eared fro &ie. 6ut they entered'u+lic consciousness, since adness .as the ost feareddisorder of earlier centuries (de entia often occu'ies that'lace no., e&en ore than cancer for any 'eo'le)Madhouses, not usually di-niNed +y the na e Phos'ital*,occu'ied the o''osite end of the scale fro ordinary hos'itals#ia-nosis relied on .hat the nei-h+ours or fa ily re'orted, oro+ser&ations a+out the 'atient*s +eha&iour #octors .holoo1ed for lesions, the +asis of $aris edicine, .ere usuallydisa''ointed The +rains of lunatics rarely 'ointed to so es'eciNc reason .hy the 'atient dis'layed sy 'to s Madness.as ental, not 'hysical, e&en if that 'osed di5culties for aculture .hich assu ed that the distinctly hu ancharacteristics of reason, oral res'onsi+ility, and theca'acity to 1no. ri-ht fro .ron- .ere the conse?uences ofour i ortal, God -i&en souls 3oss of reason eant loss ofhu anity

These 'hiloso'hical and theolo-ical niceties .ere ne-otiatedin &arious .ays, +ut as doctors +eca e increasin-ly in&ol&ed

in the Ptrade in lunacy*, the disease odel +eca e oreattracti&e After all, disease is .hat doctors deal .ith 9ittin-ly,one of the father N-ures of $arisian edicine is often calledthe founder of odern 'sychiatry $hili''e $inel ( EDB =!")ade his na e +efore the 8e&olution, as the author of asuccessful nosolo-y of all diseases (he coined the .ordPneurosis*) and a edical 'ractitioner He also .rote a littletreatise on the i 'ortance of hos'itals for clinical instruction

#urin- the 8e&olution, he .as -i&en the 'ost of 'hysician tothe 6icXtre ( ale), and then the Sal'XtriYre (fe ale), each a


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lar-e HQ'ital G n ral .hich housed a &ariety of in ates These included 'rostitutes, &a-a+onds, 'etty cri inals,or'hans, the a-ed, decre'it, and de ented, as .ell as other

indi&iduals dee ed a dan-er to the .ider 'u+lic or una+le tofend for the sel&es in society at lar-e The 8e&olution turnedthese institutions into hos'itals for 'sychiatric 'atients, anddurin- his tenure at the Sal'XtriYre, $inel -radually instituted a'ro-ra e of P oral thera'y*, slo.ly releasin- conNned.o en and treatin- the .ith Nr hu anity In >n-land, aLua1er fa ily, the Tu1es, founded the 0or1 8etreat It .as+ased on si ilar thera'eutic 'rinci'les of oral thera'y, .hich.ere also e 'loyed at rou-hly the sa e ti e in Italy, +yVincen7io Chiaru-i ( D@B =!uro'ean countries and the %nited States, and theysuccessfully ca 'ai-ned for the esta+lish ent of net.or1s of'sychiatric hos'itals (-enerally called Pasylu s*) Thetraditional treat ent of 'sychiatric disorders .ith ordinaryedica ents B+loodlettin-, e etics, cathartics B .as re'laced+y P oral* eans, and the actual for of the +uildin-s .asheld to aid in the healin- 'rocess 9ro the =F


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ordinary edicine and sur-ery, a +reach that still exists,des'ite odern 1no.led-e of the +rain and ho. it functions

In the late @th century, the Ger an 'sychiatrist > il2rae'elin ( =D"B @!") atte 'ted to +rin- edicine and'sychiatry closer to-ether, throu-h a 'sychiatric clinic .ithinan acade ic settin- 2rae'elin, an al ost exact conte 'oraryof the founder of 'sychoanalysis, Si- und 9reud ( =D"B @F@),de&elo'ed the +road classiNcation of 'sychiatric disorders thatfor ed the +asis of odern 'sychiatric nosolo-y Hedi erentiated the a or 'sychoses fro the neuroses, and'ro&ided a funda ental characteri7ation of .hat is no. calledschi7o'hrenia 2rae'elin called it de entia 'raecox, thede entia of youn-er 'eo'le, and his e orts hel'ed to createacade ic 'sychiatry

The -a' +et.een edicine and 'sychiatry still exists, +ut thetra ectory of the disci'line fro asylu to clinic hi-hli-hts thefaith that 4estern societies ha&e 'ut in hos'itals as healin-institutions, as .ell as the increasin- edicali7ation of anyas'ects of li&in-, fro sadness to cri inality, fro re+ellious+eha&iour to attention deNcit disorder syndro e $uttin- ana e on so ethin- is in itself co fortin-, and 2rae'elinsou-ht to i 'ose a dia-nostic order on ental distur+ances

ust as the 9rench clinicians had earlier used 'hysical dia-nosisto understand the diseases of our +odies

F The o&e ent to esta+lish 'sychiatric hos'itals in the

early @th century initially .as an o'ti istic one as theseasylu s +eca e lar-er and silted u' .ith chronic cases, theo'ti is e&a'orated This 'lan of the lunatic asylu at6rent.ood in >ssex, >n-land, -ra'hically de onstrates ho.these institutions +eca e little .orlds of their o.n, isolatedand self contained

Cha'ter E Medicine in the co unity

The 'eo'le*s health


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The odern 'u+lic health o&e ent +e-an in the @thcentury It .as +uilt, of course, on earlier 'olitical, social, and

edical structures, +ut the for in .hich .e 1no. it e er-edonly a cou'le of centuries a-o If the relationshi' +et.een'atients and their doctors situates hos'ital edicine, 'u+lichealth is a+out the state and the indi&idual It is at once theost anony ous 'art of edicine and the ost &isi+le 4hen.e -o to the hos'ital, not any 'eo'le notice 4hen there isan out+rea1 of inRuen7a, or the .ater su''ly is conta inated,it is ne.s.orthy

As the na e i 'lies, 'u+lic health is concerned .ithaintainin- health and 're&entin- or containin- disease Itstraditional +rief .as .ith e'ide ic disease, +ut there .asal.ays another strand of disease 're&ention, ai ed at'reser&in- the health of the indi&idual, and ter ed hy-ieneAlthou-h these re'resent t.o di erent traditions .ithinedicine, they are often intert.ined, sharin- the o+ ect of're&entin- disease Increasin-ly, hy-iene has +een colla'sedinto the 'hrase Plifestyle edicine* In +oth strands, the state'lays a crucial role

6efore the industrial state

There are any references to e'ide ic diseases in ancientliterature Indeed, +efore odern ti es, hu an 'o'ulations.ere 'eriodically thinned +y the Malthusian horse en of the

a'ocaly'se, su+sistence crises and disease Much life .asnasty, +rutish, and short In the lon- history of the Malthusian'ressures of destitution and disease, the 'la-ue years, frothe id Eth to the id th centuries, stand out as'articularly -ri

The 6lac1 #eath, as the Victorians called it, .as ar-ua+ly theNrst 'ande ic (intercontinental or .orld.ide e'ide ic) in

history Most earlier 'la-ues .ere ore conNned in s'ace, and-enerally also in ti e The 6lac1 #eath too1 ore than four


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out+rea1s of other diseases (for instance, s all'ox andeasles) in &ir-in 'o'ulations

E This odern litho-ra'h +y 9elix ene.ein ca'tures thedesolation and 'anic that the re'eated e'ide ics of +u+onic'la-ue created durin- the late Middle A-es and early odern'eriod Our o.n fears of inRuen7a or a terrorist induced'ande ic of s all'ox or anthrax aintain the 'o.er of suchi a-es

The ran-e of causes 'ut for.ard at the ti e ran-ed fro the.rath of God to hu an sinfulness and sloth, ar-inal hu an-rou's such as e.s and .itches, to +ad air Astrolo-icalcauses .ere also fre?uently in&o1ed #es'ite the ran-e ofsu'ernatural ex'lanations on o er, the re'eated 'la-uee'ide ics also hei-htened a.areness of co unal healthissues and called out a nu +er of easures desi-ned to're&ent or contain the disease Isolation, enforced +ordercontrols, co 'ulsory hos'itali7ation, and other easuresai ed at the indi&idual .ho i-ht +e aWicted .ere co +ined.ith ore -eneral easures such as routine ?uarantine ofshi's co in- fro 'la-ue areas, control of the o&e ent of'ersons and -oods, and edical ins'ection The diseasetested the li its of early odern 'u+lic health acti&ity andde onstrates the ine&ita+le nexus of the state and edicinedurin- such ti es of crisis So e historical scholarshi' hassu--ested that the cordon sanitaire alon- the southern andeastern ed-es of the Austro Hun-arian > 'ire i-ht ha&e had

so e e ect in li itin- the introduction of 'la-ue fro theMiddle >ast, .here it re ained ende ic, and 'eriodicallye'ide ic, lon- after it disa''eared fro 4estern >uro'e @thcentury >uro'ean tra&ellers in the area acce'ted the'ossi+ility of ?uarantine in one of the la7arettos aintained forcontrol of its s'read

At the &ery least, 'la-ue ensured that issues of co unal

health and disease re ained The extent to .hich it led to any'er anent 'u+lic health infrastructure is de+ata+le, althou-h


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'la-ue hos'itals .ere +uilt throu-hout >uro'e, and these .ereoften used for isolatin- and treatin- other infectious diseasesafter 'la-ue disa''eared In -eneral, the a+solutist states of

>uro'e de&elo'ed so e for al 'u+lic health acti&ities as 'artof the +ureaucratic tentacles of the state 9ro the late thcentury, the notion of P edical 'olice* .as de&elo'ed in theGer an s'ea1in- states It reached its a'o-ee .ith the nine&olu e Syste der &ollst ndi-en edicinischen $oli7ey( @B =! ) +y ohann $eter 9ran1 ( EDB =! ), thecos o'olitan 'hysician and 'u+lic health refor er TheGer an .ord P$oli7eyK$oli7ei* is usually translated as P'olice* in>n-lish, and 9ran1 +elie&ed that for ida+le 'o.ers should +e-i&en to this de'art ent of -o&ern ent His assi&e .or1dealt .ith &irtually the .hole of life, fro cradle to -ra&e:aternal, infant, and child care, dress, housin-, 'a&in-,li-htin-, and the dis'osal of the dead 4e are hardly the Nrstto reali7e ho. uch of hu an life has a direct +earin- onhealth

9ran1*s latter &olu es a''eared 'osthu ously, and the setextended o&er the ti e .hen &accination (.hich 9ran1enthusiastically es'oused) +e-an syste atically to re'laceinoculation, as a s'eciNc 're&entati&e a-ainst s all'ox Theset.o easures .ere the Nrst s'eciNc 're&entati&es, andalthou-h +oth .ere ado'ted +y doctors, their ori-ins .ere infol1 edicine Inoculation (the >n-lish .ord .as ta1en frohorticulture, and rou-hly is e?ui&alent to -raftin-) in&ol&ed theintroduction of aterial ta1en fro a 'ustule of so eone

su erin- fro s all'ox, and introducin- it into the +ody ofso eone .ho had not had the disease It ade sense on t.ocounts 9irst, s all'ox .as a &irtually uni&ersal disease, .ith asi-niNcant ortality, ran-in- accordin- to circu stances+et.een DZ and !


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lon- i unity, and +y selectin- a ild case to o+tain theaterial for inoculation, the life lon- chances of dyin- fro thedisease .ere reduced

Inoculation .as an ancient >astern 'rocedure The Chinese'ractised it, usin- a 'o.der of the 'ox aterial and ta1in- itli1e snu In Tur1ey, the aterial .as introduced throu-h ascratch in the s1in, and it .as this techni?ue that 3ady 4ortleyMonta-ue ( "=@B "!) learned a+out .hen she .as inConstantino'le as the .ife of the 6ritish a +assador She hadher children, .ho had not had s all'ox, inoculated, and theyac?uired ild cases of the disease She and the 'hysician tothe 6ritish > +assy +oth ade this inno&ation 1no.n in3ondon, .here it .as ta1en u', after the onarch, Geor-e II,had his o.n children inoculated +y the royal sur-eon a es

urin, a 'ro inent 3ondon 'hysician and disci'le of Isaac/e.ton, collected statistics fro a nu +er of inoculators andsho.ed athe atically that the chances of dyin- fro thedisease .ere si-niNcantly di inished +y the 'ractice

6y the id =th century, inoculation had +een si 'liNed and+eca e ore .ides'read, es'ecially after the 2in- of 9rance,3ouis V, died of s all'ox and his son, the ill fated 3ouis VI,.as successfully inoculated in E The 'rocedure .as ne&er.ithout di5culties, ho.e&er, since 'atients so eti es died ofthe disease after +ein- inoculated, and in any case, they+eca e 'ossi+le sources of s'read to others

3i1e any other -eneral 'ractitioners, >d.ard enner ( E@B=!F) occasionally inoculated his 'atients In theGloucestershire countryside near his 'ractice, it .as 1no.nthat an occasional aWiction of cattle, co.'ox, so eti es'roduced .hat loo1ed li1e a sin-le 'oc1 on the hands of theil1 aids, and that they see ed 'rotected fro the oreserious s all'ox Althou-h a far er na ed esty and other'eo'le had 're&iously in ected the co.'ox aterial into

indi&iduals .ith the intent of 're&entin- s all'ox, enner'erfor ed the crucial ex'eri ent in @" and 'u+lici7ed the


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ne. 're&entati&e He too1 so e atter fro a co.'ox lesionon the hand of a il1 aid, Sarah /el es, and in ected it intothe ar of a youn- +oy, a es $hi''s, .ho had not had

natural s all'ox He de&elo'ed a soreness and sca+ on hisar +ut, exce't for a day*s fe&er, re ained .ell Six .ee1slater, enner inoculated hi .ith ordinary s all'ox aterialHe failed to de&elo' the disease, sho.in- that he .asi une

The 8oyal Society declined to 'u+lish his ori-inal 'a'er, so in@= enner 'ri&ately 'u+lished his short treatise on the

'rocedure he called P&accination*, after the 3atin .ord for co.%nsur'risin-ly, the no&el a''roach attracted so e ad&erseco ent, es'ecially a+out the Pconta ination* of hu an+ein-s .ith ani al aterial, and historians ha&e 'u77leda+out so e of the outco es of early &accinations (so e of thePly 'h*, as the &accinatin- aterial .as called, ay ha&e+een conta inated .ith ordinary s all'ox atter)/e&ertheless, enner*s .or1 .as ta1en u' ?uic1ly in 6ritainand a+road He recei&ed t.o handso e -rants fro the 6ritish$arlia ent and could de&ote hi self to furtherin- the&accination cause

PIf 're&enta+le, .hy not 're&ented *, the future 2in- >d.ardVII once as1ed of doctors It .as a -ood ?uestion, +ut thede'ressin- ans.er is that it i-ht cost too uch, there i-htnot +e su5cient 'olitical or edical .ill, or that 'eo'le (andtheir doctors) ha&e to +e educated a+out 're&ention, and

education ne&er ta1es uni&ersally Althou-h the s all'ox storye&entually ended as enner hi self foresa., .ith theeradication of the disease, in @ @, it .as the exce'tion ratherthan the rule $re&ention has e&er +een the 'oor relation ofother for s of doctorin-, des'ite the ur-ency of the case inindustriali7in- societies

Cholera and 'o&erty: otors of 'u+lic health

Historians traditionally &ie.ed the @th century 'u+lic health


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o&e ent as a direct res'onse to the series of cholera'ande ics of the 'eriod The Nrst e'ide ic to reach >uro'e(the Nrst 'ande ic of = B!F 'etered out after it s'read fro

India to the Middle >ast and northern Africa) certainly raisedconsciousness a+out co unal disease 9ro =! , .hen thesecond 'ande ic +e-an to s'read out fro its ordinary ho ein eastern India, >uro'e .atched anxiously as the diseaseo&ed e&er closer Many >uro'ean nations sent dele-ates atso e sta-e durin- the four year .aitin- -a e, to in&esti-atethe disease and a1e reco endations on ho. +est to're&ent its reachin- >uro'e

There .ere t.o ain sources of concern 9irst, the disease .asne. to the 4est, an Pexotic* disease .ith .hich only tro'icalcolonials .ould ha&e had 're&ious ex'erience The second'ande ic o&ed throu-hout >uro'e and into /orth A erica,and introduced the edical 'rofession to a serious ne.disorder .ith alar in- sy 'to s and ortality rate Itsne.ness and e'ide ic character led any co entators tos'ea1 of the return of the 'la-ue, all the ore distur+in- sinceold style +u+onic 'la-ue see ed to ha&e disa''eared'er anently fro the 4est

Second, the 'attern of s'read .as 'u77lin- T.o 'olari7edex'lanatory 'aradi- s .ere current to ex'lain e'ide icdiseases: ias atic and conta-ious Mias atists ar-ued thatco unal diseases .ere s'read throu-h the air, the result ofat os'heric conditions or 'articles contained in the air The

ost co only 'ostulated source of the disease .as rottin-or-anic atter, such as refuse, faeces B anythin-, in fact, that.as o''ressi&e or s elled +adly The 'o.er of this 'aradi- iseasily a''reciated: the air is a co on feature of a localityand could ex'lain .hy any indi&iduals i-ht +e a ected Italso hel'ed di erentiate Phealthy* fro Punhealthy* localities,.ithin a 'aradi- that .ould ha&e +een fa iliar to the authorof the Hi''ocratic treatise Airs, 4aters, $laces It .as the

do inant ex'lanation for the co 'lex of diseases, any ofthe un1no.n in the Old 4orld, .hich >uro'eans encountered


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in tro'ical areas They .ere -enerally 1no.n si 'ly asPdiseases of .ar cli ates*, and o''ressi&e heat and hu idityand exotic &e-etation .ere so o+&ious that e&o1in- the to

ex'lain disease 'atterns ade rational sense

Conta-ionists 'ostulated that e'ide ic diseases .ere s'readfro one aWicted indi&idual to another This could account forany as'ects of e'ide ic disease, such as the fact that'eo'le nursin- sic1 indi&iduals often ca e do.n .ith thedisease the sel&es Conta-ionis ustiNed the instincti&e .ishto a&oid contact .ith 'eo'le su erin- fro dan-erousdiseases, and underlay the 'ractice of ?uarantine It also'reyed on collecti&e fears of the ori-in of 'la-ue and otherfri-htful diseases in ar-inali7ed -rou's

A iddle 'osition, Pcontin-ent conta-ionis *, .as less hardline, and ore easily ada'ta+le to the ano alies that +oth theain 'ositions had di5culty ex'lainin- Contin-entconta-ionists ar-ued that diseases i-ht +e either ias aticor conta-ious, de'endin- on the circu stances 9or instance,a disease i-ht enter the co unity throu-h corru't air +utso e indi&iduals could de&elo' the disease in such a .ay thatthey then +eca e foci of conta-ious s'read This ixed thecate-ories in .ays that the o+ser&ations re?uired, and co&eredall fronts %nfortunately, theories that ex'lain e&erythin- oftenex'lain &ery little

A fe. diseases, such as s all'ox and easles, .ere al.ays

&ie.ed as conta-ious, +ut ost co unica+le diseases had'atterns of incidence and s'read that .ere su5cientlyco 'licated to lea&e uch roo for de+ate Ger theory .aslater to o er a ne. 'aradi- for co unica+le and e'ide icdiseases, althou-h there .ere still ano alies: .hy could t.o'eo'le ex'osed to the sa e source of infection react in suchdi erent .ays, so that one ca e do.n .ith the disease andthe other re ained co 'letely .ell

6efore -er theory, there .as little consensus, and in 'ractice


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co unities often co&ered +oth alternati&es In 'la-ueout+rea1s, for instance, ?uarantine and isolation .ereacco 'anied .ith Nres, to 'urify the air, and nose-ays,

infusin- the i ediate inhalations 4hen in dou+t, do +oth

Cholera thre. u' these a-e old issues in an ur-ent anner The o+ser&ers .ho .ent to .atch its .est.ard arch ca e+ac1 .ith ixed reactions So e thou-ht that it .asconta-ious and >uro'e*s +est res'onse .as isolation and?uarantine Others +elie&ed that the air .as the &ehicle andthat ordinary sanitary i 'ro&e ents B i 'ro&in- draina-e,1ee'in- the streets clean B .ere the +est defence >uro'ean-o&ern ents listened to the &ariety of o'inions +ut ostly fell+ac1 on the ti e honoured solution of ?uarantine andins'ection of 'eo'le and -oods arri&in- fro the infectedareas

>&en 6ritain, ho e of laisse7 faire, da++led .ith ?uarantinedurin- the Nrst 'ande ic to reach 4estern >uro'e, fro =Fd.in Chad.ic1( =


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ca'acities of or-anis s to re'roduce al.ays outstri''ed thenu +er of o s'rin- that could actually sur&i&e Hu an +ein-s.ere not exe 't fro this stern la., .ith the dis'arity caused

+y -eo etrical 'o'ulation increase set a-ainst thearith etical increase in the eans of su+sistence #isease,isery, .ar, &ice, and .ant 1e't hu an 'o'ulations do.n,and interferin- .ith the syste +y 1ee'in- ore 'au'erchildren ali&e did no -ood in the lon- run

" Gusta&e #ore*s 3ondon: A $il-ri a-e ( = !) +rilliantlyca'tured the o&ercro.din- and 'o&erty of the lar-est andrichest city in >uro'e

The Malthusian dile a .as erely one of the issues that the=F! $oor 3a. Co ission had to consider Chad.ic1 .as itssecretary and do inant N-ure, aster indin- the syste aticsur&ey of ho. the D,


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its 'aid Secretary Ad inisterin- the /e. $oor 3a. on a daily+asis ine&ita+ly confronted Chad.ic1 .ith the relationshi's+et.een 'o&erty and disease #octors had lon- noticed that

e'ide ic diseases -enerally aWicted the 'oor ore than therich, and assu ed that this .as associated .ith theiro&ercro.ded li&in- conditions, s'arse diet, and other tra''in-sof .ant Chad.ic1*s initial concern .as .ith the fact that anyof the de ands on the $oor 3a. .ere +ecause the+read.inner had fallen sic1 and could not .or1

#isease could thus i 'o&erish a fa ily The re&erse'ro'osition .as ore su+tle: does 'o&erty itself causedisease Chad.ic1 and any of his conte 'oraries 'referredto 'ut a oral s'in on 'o&erty 'er se, ar-uin- that its ulti atecause lay in indi&idual failin-: i 'rudent arria-es, failure tosa&e, s'endin- on drin1 and other &ices /e&ertheless, sincedisease .as a a or factor in the causation of 'o&erty, itfollo.ed that 're&entin- .hat he called PNlth diseases* .ouldease the +urden on the $oor 8ate As an ardent ias atist, heattri+uted Nlth diseases such as cholera, ty'hus, and scarletfe&er to the +ad s ells of rottin- or-anic atter The solution.as easy: cleanliness #irt caused disease cleanliness're&ented it

Chad.ic1*s ourney fro a $oor 3a. refor er to one o+sessed.ith 're&entin- disease occurred o&er the fe. years fro=FE to =E!, .hen he 'u+lished a classic text of the early'u+lic health o&e ent: 8e'ort on the Sanitary Condition of

the 3a+ourin- $o'ulation of Great 6ritain He used the ne.statistical a''roaches of the day (the ci&il re-istration of+irths, arria-es, and deaths had started in =F ) to ?uantifythe sta--erin- di erences of ortality rates and a&era-eex'ectation of years at +irth +et.een o&ercro.ded, ur+anareas and rural ones, and +et.een the rich and the 'oor Tosol&e the 'ro+le of Nlth diseases, Chad.ic1 'ro'osed .hathe called an arterio &enous syste of .ater su''ly and

se.a-e dis'osal If runnin- .ater under 'ressure .eresu''lied to households, cleanliness .ould +e easier if se.a-e


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.ere ta1en a.ay in -la7ed 'i'es i 'er&ious to lea1a-e, the'ro+le s of cess'its and -round conta ination .ould +esol&ed 9urther, if the se.a-e .ere ta1en a.ay fro cities to

treat ent 'lants, it could +e turned to -uano, sold to far ersat a 'roNt, and cro's .ould +e increased, there+y i 'ro&in-nutrition It .as a neat en-ineerin- solution to 'u+lic health,-ood in its context, thou-h not sol&in- all the 'ro+le s thatChad.ic1*s li ited &ie. of disease causation en&isioned

He -ot his chance to inRuence 'u+lic health in =E=, .hencholera returned, and a 6oard of Health .as esta+lished, .ithChad.ic1 one of three e +ers (a fourth, a doctor, .as addedlater) The $arlia entary Act settin- u' the 6oard .as lar-ely'er issi&e, allo.in- co unities to a''oint a Medical O5cerof Health (MoH) if


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'eo'le listened to 2och than had to Sno. four decades're&iously His e&idence .as i 'ressi&e, +ut so .as Sno.*s Asthe next cha'ter .ill sho., only .ith the co in- of science did

real heroes e er-e .ithin odern edicine

>sta+lishin- the 'u+lic health +ureaucracy

PIn the +e-innin- .as the 4ord*, St ohn*s Gos'el has it /o.,there is ostly the nu +er 4e li&e +y the cloc1, follo. theu's and do.ns of the stoc1 ar1ets or ort-a-e rates,ex'erience the hottest, or .ettest, onth since records +e-anConte 'orary society is 'er eated .ith nu +ers they ruleour li&es

$u+lic health e&idence is ine&ita+ly nu erical If the 'u+lichealth o&e ent .as in lar-e easure a 'roduct of theindustriali7ation and ur+ani7ation that transfor ed the4estern .orld fro the late =th century, it also relied on thenu erical entality that acco 'anied the 'roNts and losses of the factory syste , the harnessin- of stea , dou+le entry+oo1 1ee'in-, and the national census 3i1e us, the Victoriansfelt o&er.hel ed .ith facts and data

Three di ensions to the ?uantiNcation of edicine (andsociety ore -enerally) should +e hi-hli-hted: sur&eys,sur&eillance, and si-niNcance

The sur&ey is the ost +asic The =F! $oor 3a. Co ission

has +een descri+ed as the 'ioneerin- national sur&ey, and itcertainly .as no&el for its ti es Chad.ic1 and his fello.co issioners sent out a detailed ?uestionnaire to each of the'arishes res'onsi+le for $oor 3a. relief, and atte 'ted tocoordinate the re'lies In the late =F


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issue of enforcin- co 'ulsory &accination This sur&eycon&inced hi that the .ay to 're&ent s all'ox .as to ha&ean acti&e 'olicy of free &accination #urin- his years in o5ce,

Si on -radually +eca e disillusioned .ith 'ersuasion as atool to achie&e 'u+lic health ends, and under his leadershi',6ritain ac?uired a &accination syste that .as 'u+liclyfunded, free, uni&ersal, and co 'ulsory, .ith 'enalties fornon co 'liance

Throu-hout the de&elo'ed .orld, durin- the iddle decades of the @th century, the 'o.er of the nu +er +eca ea''reciated Social issues .ith edical ra iNcations .erere'eatedly in&esti-ated +y sur&eys Issues of 'o&erty, childla+our, factory conditions, food adulteration, .ater su''ly,'rostitution, +uildin- standards, and, of course, e'ide icdiseases, all ca e under scrutiny In&esti-atin- one issue oftenthre. u' others that called out for attention 9or instance,concern .ith the e 'loy ent of youn- children in 'oorly 'aidand -rindin- o+s raised ore -eneral issues of education andchild health Charles #ic1ens*s Mr Grad-rind .as not the onlyone in @th century >uro'e .ho .anted Pthe facts*, and Pfacts*increasin-ly ca e in a ta+le or other ?uantitati&e for

In contrast to 9i-ure D, .hen the intrusion of the stateinto 'u+lic a airs is treated as an o+ ect of satire, here, in thisi a-e +y 3ance Cal1in (c @< ), the 'u+lic &accinator is seenas a N-ure of authority, ?uietly -oin- a+out his .or1 of'rotectin- these youn- -irls fro s all'ox

If sur&eys thre. u' all 1inds of edical and social issues,sur&eillance .as a co 'le entary strate-y, ai ed atsyste atically follo.in- trends or follo.in- u' on trou+lin-'ro+le s Many sur&eillance structures ha&e lon- histories 9orexa 'le, fro edie&al ti es, 9rench +utchers could ex'ect'eriodic &isits fro ins'ectors exa inin- the eat they .eresellin- Mar1ets and fairs .ere conducted under re-ulations

6orders, 'orts, and .alled to.ns .ere anned, es'eciallydurin- out+rea1s of 'la-ue and other e'ide ic diseases


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'eo'le and -oods could ex'ect to +e ins'ected In any case,a+solute onarchs and des'ots needed infor ation a+out theco in-s and -oin-s of their ene ies The 96I, CIA, MID, and

2G6 ha&e any forerunners, althou-h ost earlier net.or1s of sur&eillance .ere concerned .ith security and control ratherthan .ith health

Once statutes are on the +oo1s, they need to +e 'oliced, andMedical O5cers of Health, factory sur-eons, 'ort edicalauthorities, and the host of other indi&iduals concerned .iththe 'u+lic*s health +eca e a &isi+le 'art of @th century4estern society The star1est instance of the 'olice functionsof 'u+lic health o5cials, as .ell as ordinary edical'ractitioners, is seen in the de&elo' ent of the conce't of thenotiNa+le disease A nu +er of local co unities had insistedthat cases of s all'ox had to +e re'orted to centralauthorities 9ro the ==


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out+rea1s .ere in&esti-ated +y 'u+lic health o5cials Afe ale i i-rant, .ith li ited education, and conscious of no.ron- doin-, Mary .as ne&ertheless a 'u+lic health ha7ard,

and incarcerated for her Pcri e*

Sur&eyin- .as the acti&ity of o5cials intent on unco&erin-ne. associations sur&eillance +eca e the duty of all doctors.ho encountered a 'atient .ith a notiNa+le disease Statistics+eca e the ex'ertise of those es'ecially trained tounderstand the nature of correlations and causations Theodern 'u+lic health o&e ent e er-ed si ultaneously .ithstatistical societies, and for any of the sa e reasons 6oth.ere res'onses to industriali7ation, and the o&e ent andthe societies .ere 'eo'led +y any of the sa e concernedindi&iduals

Althou-h the athe atics of 'ro+a+ility had +een de&elo'edfro the late th century, its conte 'orary athe atical'artner Pstatistics* .as in the early @th century uch lessso'histicated Statistical societies .ere ostly de&oted tocollectin- any o+ser&ations and 'resentin- these in ta+ularfor The introduction of ci&il death re-istration in any>uro'ean countries led to annual 'r

Documents

The History of Medicine a Very Short Introduction (Very Short Introductions)