Ancient Egypt: Medicine and History
Medicine in the hospital
Learning to count
Like so much else in the Parisian hospitals, dealing with large numbers of patients was not entirely new to medicine. Military doctors of all nationalities had been pressed to provide statistics, and the doctors in hospitals, both military and civilian, had recognized the duty of presenting annual summaries of cases, diagnoses, treatments, and cures. One might view Louis as simply the culmination of the Enlightenment emphasis on facts and openness. This mistakes innovation for impact: of the later clinicians in the heyday of Paris medicine, Louis had the greatest international impact. He taught many foreign students and, more than any other, brought the insights of the French school together. His short essay on Clinical Instruction, translated into English in 1834, is a brilliant summary of what teaching and learning in Paris strove to be.
He is sometimes credited with almost single-handedly convincing doctors to abandon the ancient practice of bloodletting for all manner of diseases. His short monograph on the subject (1835) remains his best-known work, but its legacy lies more with the method than the message. In Researches on the Effects of Bloodletting in Some Inflammatory Diseases, Louis evaluated the effect of different timing (early or late) and quantity (a little or more vigorous) of therapeutic phlebotomy in cases of pneumonia. The same monograph also examined the use of different doses of tartar emetic (a medicine containing antimony). What is remembered today is the way Louis attempted to evaluate these therapies by dividing similar patients into groups and comparing the results of his various treatments. In effect, Louis was using a clinical trial, though hardly with a protocol that would now be judged adequate. Notice that Louis did not include no bloodletting as an option, but merely evaluated timing and quantity.
Louis’ little monograph, despite its classic status, was actually part of a polemical campaign between Louis and F. J. V. Broussais (1772–1838). The latter had developed a system of ‘physiological medicine’ to counter the static, anatomical approach of most French clinicians.
Broussais had noticed how many of the patients that he autopsied showed signs of chronic gastric irritation and his system posited that all disease originated in the stomach, and that local lesions elsewhere resulted from the primary irritation within the stomach. The standard treatment for irritation or inflammation was bloodletting. He favoured leeches rather than the lancet, and he and Louis exchanged a series of sharp polemics during the 1830s. Broussais was a therapeutic enthusiast, whereas Louis was quietly pessimistic about the capacity of medicine to do much to arrest the progress of disease. Louis’s role as a pioneer of clinical trials was located within this ongoing feud with his rival Broussais.
Although Broussais’ dynamic, physiological notions of disease continued to resonate, his central idea of all disease as a secondary consequence of gastric irritation did not long survive. On the other hand, Louis’s numerical method has become essential to modern medicine. There was certainty in numbers, both in establishing clear diagnostic categories and in evaluating therapy. A number of his students assimilated his therapeutic scepticism, already common in the Paris hospitals where doctors were most concerned with accurate diagnosis and its verification through the post-mortem. Patients had almost always entered hospitals with limited expectations, but the power relationships shifted in Paris, with doctors on top. They remained that way until recently, when greater patient autonomy, the tyranny of economics, and the rise of the medical manager have realigned power structures within medicine.
Louis’s recognition that he did not have much to offer his patients with the drugs at his disposal must be viewed not as a conspiracy against his helpless patients, but as a genuine discovery. It was made possible because he counted, evaluated, and compared: activities that could be done most easily in the hospital.
The physical and the mental
By 1850 or so, French hospital medicine had become familiar. New approaches to understanding disease, the greater use of experiment rather than mere observation, and diminishing returns on what could be discovered by yet one more autopsy, rendered the miracle of French clinical medicine something more pedestrian. During its heyday, however, thousands of students had come to Paris from all over the Western world. They returned to Britain, Germany, Austria, Italy, the United States, and the Netherlands, where some of them founded medical schools and hospitals. By the early 19th century, a medical school without an attached hospital was second rate. When the new University of London (now University College London) began its medical school in the late 1820s, the first thing to do was to establish a hospital. The pattern was repeated throughout Europe, even in small German towns where clinical instruction was often by demonstration, not by doing.
In mid-century America, a number of proprietary schools prospered without a hospital or laboratory, offering medical degrees in return for a few months’ tuition fees. Although returning students from Paris and graduates from the established East Coast medical schools, such as the University of Pennsylvania, despaired of what this did to the profession, American values protected entrepreneurialism. Only in the later decades of the century was the pattern broken. The Johns Hopkins University, established as a research-orientated university in 1876, introduced the German model of higher education to America. Despite a generous initial endowment by Johns Hopkins, a Quaker railway magnate, the medical school took almost two decades to be realized, so extensive were the requirements. The hospital opened in 1893, with the energetic faculty introducing a combination of German research and French emphasis on practical training. The professor of medicine, William Osler (1849–1919), was the most famous of the ‘Big Four’ – the initial senior medical faculty. He still commands adulation from doctors, as a scientifically attuned but humane clinician, book collector, historian, essayist, and teacher. The assimilation of German science infused the Hopkins approach to disease, but French innovations permanently left teaching hospitals with two regular events: the daily ward round, in which a senior clinician, followed by junior doctors, medical students, and a nurse, would see and discuss each patient at his or her bedside; and grand rounds, in which interesting ‘cases’ would be presented by a member of the junior staff and analyzed by someone from the senior hierarchy, in front of a large gathering of students and doctors at all levels of experience. Often, after the presentation of the patient’s history and clinical course, and the discussion of the differential diagnosis, the autopsy findings would be revealed by a pathologist, and the whole life and death of the patient put together in a seamless whole.
In the large teaching hospitals, the medical and surgical specialties, such as paediatrics, cardiology, neurology, obstetrics, orthopaedic surgery, or otolaryngology (diseases of the ear, nose, and throat), would each have their own chief, a number of dedicated beds, and regular rounds, both ward and grand. One specialty long under-represented in most general hospitals was psychiatry, even if psychiatry has been called ‘half of medicine’, so common are psychiatric disorders. Instead, those suffering from serious psychiatric illness – earlier called madness or lunacy – had their own kind of institutional setting. The institutional provision for the mad developed independently from the scattered provision of ordinary hospitals in the early-modern period. Madhouses, as they were brutally called, were usually small establishments, for profit, and as often as not run by a non-medical person.
Unlike general hospitals, they were mostly for the well-to-do, so embarrassing was the behavior of a seriously eccentric or hallucination-prone relative. The most famous psychiatric institution in Britain gave its name to the language: Bedlam, a short form of its full name, Bethlehem, or St Mary Bethlehem. ‘Tom-o-Bedlam’ became a stock fictional character, used by Shakespeare in King Lear, and symptomatic of the isolation that psychiatric patients have always felt.
Bedlam was unusual among psychiatric institutions, funded by endowments and with governors overseeing its operations. Most madhouses were small private affairs whose records have long since disappeared from view. But they entered public consciousness, since madness was the most feared disorder of earlier centuries (dementia often occupies that place now, even more than cancer for many people). Madhouses, not usually dignified by the name ‘hospital’, occupied the opposite end of the scale from ordinary hospitals. Diagnosis relied on what the neighbors or family reported, or observations about the patient’s behaviour. Doctors who looked for lesions, the basis of Paris medicine, were usually disappointed. The brains of lunatics rarely pointed to some specific reason why the patient displayed symptoms. Madness was mental, not physical, even if that posed difficulties for a culture which assumed that the distinctly human characteristics of reason, moral responsibility, and the capacity to know right from wrong were the consequences of our immortal, God-given souls.
Loss of reason meant loss of humanity
These philosophical and theological niceties were negotiated in various ways, but as doctors became increasingly involved in the ‘trade in lunacy’, the disease model became more attractive.
After all, disease is what doctors deal with. Fittingly, one of the father-figures of Parisian medicine is often called the founder of modern psychiatry. Philippe Pinel (1745–1826) made his name before the Revolution, as the author of a successful nosology of all diseases (he coined the word ‘neurosis’) and a medical practitioner. He also wrote a little treatise on the importance of hospitals for clinical instruction. During the Revolution, he was given the post of physician to the Bicêtre (male), and then the Salpêtrière (female), each a large Hôpital Général which housed a variety of inmates. These included prostitutes, vagabonds, petty criminals, orphans, the aged, decrepit, and demented, as well as other individuals deemed a danger to the wider public or unable to fend for themselves in society at large. The Revolution turned these institutions into hospitals for psychiatric patients, and during his tenure at the Salpêtrière, Pinel gradually instituted a programme of ‘moral therapy’, slowly releasing confined women and treating them with firm humanity. In England, a Quaker family, the Tukes, founded the York Retreat. It was based on similar therapeutic principles of moral therapy, which were also employed at roughly the same time in Italy, by Vincenzio Chiarugi (1759–1820). The nuances of moral therapy have been much debated by historians, but there is little doubt that this form of treatment brought the lunatic into the public gaze, and helped create a psychiatric specialty within medicine. During the middle third of the 19th century, psychiatric association’s were established in most European countries and the United States, and they successfully campaigned for the establishment of networks of psychiatric hospitals (generally called ‘asylums’). The traditional treatment of psychiatric disorders with ordinary medicaments –bloodletting, emetics, and cathartics – was replaced by ‘moral’ means, and the actual form of the buildings was held to aid in the healing process.
From the 1830s, non-restraint became the rallying cry, as doctors argued that the well-designed and well-run psychiatric institution had no need to use physical restraint with its patients. Although the asylums were built in the name of humanity and treatment, they hardly justified the early optimism, by which early diagnoses and the expert use of moral and other therapies were predicted to produce cures. Instead, the asylums grew larger and silted up with incurable patients; they became, in the words of one contemporary commentator, mere ‘museums of madness’. The special nature of these institutions reinforced the distance between psychiatry and ordinary medicine and surgery, a breach that still exists, despite modern knowledge of the brain and how it functions.
In the late 19th century, the German psychiatrist Emil Kraepelin (1856–1926) attempted to bring medicine and psychiatry closer together, through a psychiatric clinic within an academic setting. Kraepelin, an almost exact contemporary of the founder of psychoanalysis, Sigmund Freud (1856-1939), developed the broad classification of psychiatric disorders that formed the basis of modern psychiatric nosology. He differentiated the major psychoses from the neuroses, and provided a fundamental characterization of what is now called schizophrenia. Kraepelin called it dementia praecox, the dementia of younger people, and his efforts helped to create academic psychiatry.
The gap between medicine and psychiatry still exists, but the trajectory of the discipline from asylum to clinic highlights the faith that Western societies have put in hospitals as healing institutions, as well as the increasing medicalization of many aspects of living, from sadness to criminality, from rebellious behaviour to attention deficit disorder syndrome. Putting a name on something is in itself comforting, and Kraepelin sought to impose a diagnostic order on mental disturbances just as th the French clinicians had earlier used physical diagnosis to understand the diseases of our bodies.
Medicine in the community
The people’s health
The modern public health movement began in the 19th century. It was built, of course, on earlier political, social, and medical structures, but the form in which we know it emerged only a couple of centuries ago. If the relationship between patients and their doctors situates hospital medicine, public health is about the state and the individual. It is at once the most anonymous part of medicine and the most visible. When we go to the hospital, not many people notice. When there is an outbreak of influenza, or the water supply is contaminated, it is newsworthy.
As the name implies, public health is concerned with maintaining health and preventing or containing disease. Its traditional brief was with epidemic disease, but there was always another strand of disease prevention, aimed at preserving the health of the individual, and termed hygiene. Although these represent two different traditions within medicine, they are often intertwined, sharing the object of preventing disease. Increasingly, hygiene has been collapsed into the phrase ‘lifestyle medicine’. In both strands, the state plays a crucial role.
Before the industrial state
There are many references to epidemic diseases in ancient literature. Indeed, before modern times, human populations were periodically thinned by the Malthusian horsemen of the apocalypse, subsistence crises and disease. Much life was nasty, brutish, and short. In the long history of the Malthusian pressures of destitution and disease, the plague years, from the mid-14th to the mid-17th centuries, stand out as particularly grim.
The Black Death, as the Victorians called it, was arguably the first pandemic (intercontinental or worldwide epidemic) in history. Most earlier plagues were more confined in space, and generally also in time. The Black Death took more than four years to make its way via the Silk Road from the Steppes of Central Asia to the westernmost parts of Europe, the Middle East, and the northern shores of Africa. It wiped out between one quarter and one half of the population of Europe, and was the first of a series of devastating epidemics that lost its Western European hold only in the 1660s (an outbreak in the 1720s in Marseilles was contained).
It is certain that the Black Death was a plague, since that word refers to any highly virulent epidemic. It has recently become fashionable to argue that the plague of the 1340s was not caused by the plague bacillus, Yersinia pestis, identified in Hong Kong during the last pandemic in the 1890s.
Various other organisms have been suggested, since the Black Death had some features that do not conform to what we know about the epidemiology of modern bubonic plague. Its rate of spread, seasonality, and mortality patterns, together with the fact that nobody noticed a lot of dead rats (modern human plague outbreaks are accompanied with rat or other rodent plagues), have led some commentators to postulate that anthrax, an unknown virus, or other infectious agent was the actual cause. Ergot poisoning has also been invoked.
The problem with these alternative interpretations is that they concentrate almost exclusively on the original pandemic, the Black Death. If one looks at the plague years as a whole, from 1345 to 1666, the pattern is more certain. By the later years, the plague (for instance, the Great Plague of London in 1665) is more easily recognizable through medical and other accounts. Furthermore, the disease was perceived by those who lived through the various epidemics as a single entity, and while of course no one experienced them all, there were always doctors who had lived through the previous epidemic or two. The collective historical experience is of a single, repeated disease, almost certainly ‘our’ plague; that is, the disease caused by the plague bacillus. The first epidemic attacked a population with no previous immunological experience, and there are many instances of such devastating outbreaks of other diseases (for instance, smallpox and measles) in virgin populations. The range of causes put forward at the time ranged from the wrath of God to human sinfulness and sloth, marginal human groups such as Jews and witches, to bad air. Astrological causes were also frequently invoked. Despite the range of supernatural explanations on offer, the repeated plague epidemics also heightened awareness of communal health issues and called out a number of measures designed to prevent or contain the disease. Isolation, enforced border controls, compulsory hospitalization, and other measures aimed at the individual who might be afflicted were combined with more general measures such as routine quarantine of ships coming from plague areas, control of the movement of persons and goods, and medical inspection. The disease tested the limits of early modern public health activity and demonstrates the inevitable nexus of the state and medicine during such times of crisis. Some historical scholarship has suggested that the cordon sanitaire along the southern and eastern edges of the Austro-Hungarian Empire might have had some effect in limiting the introduction of plague from the Middle East, where it remained endemic, and periodically epidemic, long after it disappeared from Western Europe; 19th-century European travelers in the area accepted the possibility of quarantine in one of the lazarettos maintained for control of its spread.
At the very least, plague ensured that issues of communal health and disease remained. The extent to which it led to any permanent public health infrastructure is debatable, although plague hospitals were built throughout Europe, and these were often used for isolating and treating other infectious diseases after plague disappeared. In general, the absolutist states of Europe developed some formal public health activities as part of the bureaucratic tentacles of the state. From the late 17th century, the notion of ‘medical police’ was developed in the German-speaking states. It reached its apogee with the nine-volume System der vollständigen medicinischen Polizey (1779-1827) by Johann Peter Frank (1745-1821), the cosmopolitan physician and public health reformer. The German word ‘Polizey/Polizei’ is usually translated as ‘police’ in English, and Frank believed that formidable powers should be given to this department of government. His massive work dealt with virtually the whole of life, from cradle to grave: maternal, infant, and child care, dress, housing, paving, lighting, and the disposal of the dead. We are hardly the first to realize how much of human life has a direct bearing on health.
Frank’s latter volumes appeared posthumously, and the set extended over the time when vaccination (which Frank enthusiastically espoused) began systematically to replace inoculation, as a specific preventative against smallpox. These two measures were the first specific preventatives, and although both were adopted by doctors, their origins were in folk medicine. Inoculation (the English word was taken from horticulture, and roughly is equivalent to grafting) involved the introduction of material taken from a pustule of someone suffering from smallpox, and introducing it into the body of someone who had not had the disease. It made sense on two counts. First, smallpox was a virtually universal disease, with a significant mortality, ranging according to circumstances between 5% and 20%. The analogy with chickenpox parties, where parents seek to expose their children to another child with the disease, to get it over with, is only partially apposite, since inoculation carried a significant risk, but the strategy was the same, even if the stakes were higher. Second, it was recognized that a single episode of the disease conferred life-long immunity, and by selecting a mild case to obtain the material for inoculation, the life-long chances of dying from the disease were reduced.
Inoculation was an ancient Eastern procedure. The Chinese practised it, using a powder of the pox material and taking it like snuff. In Turkey, the material was introduced through a scratch in the skin, and it was this technique that Lady Wortley Montague (1689–1762) learned about when she was in Constantinople as the wife of the British ambassador. She had her children, who had not had smallpox, inoculated, and they acquired mild cases of the disease. She and the physician to the British Embassy both made this innovation known in London, where it was taken up, after the monarch, George II, had his own children inoculated by the royal surgeon. James Jurin, a prominent London physician and disciple of Isaac Newton, collected statistics from a number of inoculators and showed mathematically that the chances of dying from the disease were significantly diminished by the practice.
By the mid-18th century, inoculation had been simplified and became more widespread, especially after the King of France, Louis XV, died of smallpox and his son, the ill-fated Louis XVI, was successfully inoculated in 1774. The procedure was never without difficulties, however, since patients sometimes died of the disease after being inoculated, and in any case, they became possible sources of spread to others.
Like many other general practitioners, Edward Jenner (1749–1823) occasionally inoculated his patients. In the Gloucestershire countryside near his practice, it was known that an occasional affliction of cattle, cowpox, sometimes produced what looked like a single pock on the hands of the milkmaids, and that they seemed protected from the more serious smallpox. Although a farmer named Jesty and other people had previously injected the cowpox material into individuals with the intent of preventing smallpox, Jenner performed the crucial experiment in 1796 and publicized the new preventative. He took some matter from a cowpox lesion on the hand of a milkmaid, Sarah Nelmes, and injected it into the arm of a young boy, James Phipps, who had not had natural smallpox. He developed a soreness and scab on his arm but, except for a day’s fever, remained well. Six weeks later, Jenner inoculated him with ordinary smallpox material. He failed to develop the disease, showing that he was immune.
The Royal Society declined to publish his original paper, so in 1798 Jenner privately published his short treatise on the procedure he called ‘vaccination’, after the Latin word for cow. Unsurprisingly, the novel approach attracted some adverse comment, especially about the ‘contamination’ of human beings with animal material, and historians have puzzled about some of the outcomes of early vaccinations (some of the ‘lymph’, as the vaccinating material was called, may have been contaminated with ordinary smallpox matter). Nevertheless, Jenner’s work was taken up quickly in Britain and abroad. He received two handsome grants from the British Parliament and could devote himself to furthering the vaccination cause.
‘If preventable, why not prevented?’, the future King Edward VII once asked of doctors. It was a good question, but the depressing answer is that it might cost too much, there might not be sufficient political or medical will, or that people (and their doctors) have to be educated about prevention, and education never takes universally. Although the smallpox story eventually ended as Jenner himself foresaw, with the eradication of the disease, in 1979, it was the exception rather than the rule.
Prevention has ever been the poor relation of other forms of doctoring, despite the urgency of the case in industrializing societies.
