MEDICINE, HISTORY OF

the development of the prevention and treatment of disease from prehistoric and ancient times to the 20th century. Additional reading The literature on the history of medicine covers all topics and periods and includes biographies as well as descriptions of the development of hospitals, research institutes, health care, and medical education in different countries. Introductory studies include George T. Bettany, Eminent Doctors: Their Lives and Their Work, 2 vol. (1885, reprinted 1972); Arturo Castiglioni, A History of Medicine, 2nd rev. ed. (1947; originally published in Italian, 1927), a classic work; Fielding H. Garrison, An Introduction to the History of Medicine, 4th rev. ed. (1929, reprinted 1967), a scholarly history; Douglas Guthrie, A History of Medicine, rev. ed. (1958); Howard W. Haggard, Devils, Drugs, and Doctors: The Story of the Science of Healing from Medicine-Man to Doctor (1929, reprinted 1980); Richard H. Meade, An Introduction to the History of General Surgery (1968), a well-documented work on developments in surgery on separate organs; Charles Singer and E. Ashworth Underwood, A Short History of Medicine, 2nd ed. (1962); and Philip Rhodes, An Outline History of Medicine (1985). The Oxford Companion to Medicine, 2 vol., edited by John Walton, Paul B. Beeson, and Ronald Bodley Scott (1986), is a comprehensive text of 20th-century developments and persons.Ancient traditions of non-Western medicine are presented in P. Kutumbiah, Ancient Indian Medicine (1962); Heinrich R. Zimmer, Hindu Medicine (1948, reprinted 1979); Edward H. Hume, The Chinese Way in Medicine (1940, reprinted 1975); Paul U. Unschuld, Medicine in China: A History of Ideas (1985; originally published in German, 1980); and Edward G. Browne, Arabian Medicine (1921, reprinted 1983).For developments from the origin of Western medicine to the end of the 18th century, see William G. Black, Folk-Medicine: A Chapter in the History of Culture (1883, reprinted 1970); W.H.R. Rivers, Medicine, Magic, and Religion (1924, reprinted 1979), a comprehensive treatment of primitive medicine; John Scarborough, Roman Medicine (1969, reprinted 1976); Robert S. Gottfried, Doctors and Medicine in Medieval England, 13401530 (1986); A. Wear, R.K. French, and I.M. Lonie (eds.), The Medical Renaissance of the Sixteenth Century (1985); Katharine Park, Doctors and Medicine in Early Renaissance Florence (1985); and Guy Williams, The Age of Agony: The Art of Healing, c. 17001800 (1975, reprinted 1986).Medicine and surgery during the 19th and 20th centuries are the subject of Carl J. Pfeiffer, The Art and Practice of Western Medicine in the Early Nineteenth Century (1985); Thomas E. Keys, The History of Surgical Anesthesia, rev. ed. (1963, reprinted 1978); M.H. Armstrong Davison, The Evolution of Anesthesia (1965); Robert G. Richardson, The Scalpel and the Heart (1970; U.K. title, The Surgeon's Heart: A History of Cardiac Surgery, 1969); John S. Haller, Jr., American Medicine in Transition, 18401910 (1981); Ruth J. Abram (ed.), Send Us a Lady Physician: Women Doctors in America, 18351920 (1985); George Rosen, The Structure of American Medical Practice, 1875-1941 (1983); A. McGehee Harvey, Science at the Bedside: Clinical Research in American Medicine, 19051945 (1981), a discussion of the institutionalization of clinical research; and Lawrence Galton, Med Tech: The Layperson's Guide to Today's Medical Miracles (1985), a historical dictionary. Surgery in the 20th century The opening phase Three seemingly insuperable obstacles beset the surgeon in the years before the mid-19th century: pain, infection, and shock. Once these were overcome, the surgeon believed that he could burst the bonds of centuries and become the master of his craft. There is more, however, to anesthesia than putting the patient to sleep. Infection, despite first antisepsis (destruction of microorganisms present) and later asepsis (avoidance of contamination), is still an ever-present menace; and shock continues to perplex physicians. But in the 20th century, surgery has progressed farther, faster, and more dramatically than in all preceding ages. The situation encountered The shape of surgery that entered the new century was clearly recognizable as the forerunner of today's, blurred and hazy though the outlines may now seem. The operating theatre still retained an aura of the past, when the surgeon played to his audience and the patient was little more than a stage prop. In most hospitals it was a high room lit by a skylight, with tiers of benches rising above the narrow, wooden operating table. The instruments, kept in glazed or wooden cupboards around the walls, were of forged steel, unplated, and with handles of wood or ivory. The means to combat infection hovered between antisepsis and asepsis. Instruments and dressings were mostly sterilized by soaking them in dilute carbolic acid (or other antiseptic), and the surgeon often endured a gown freshly wrung out in the same solution. Asepsis gained ground fast, however. It had been born in the Berlin clinic of Ernst von Bergmann where, in 1886, steam sterilization had been introduced. Gradually, this led to the complete aseptic ritual, which has as its basis the bacterial cleanliness (as opposed to social cleanliness) of everything that comes in contact with the wound. Hermann Kmmell, of Hamburg, devised the routine of scrubbing up. In 1890 William Stewart Halsted, of Johns Hopkins University, had rubber gloves specially made for operating, and in 1896 Johannes von Mikulicz-Radecki, a Pole working at Breslau, Ger., invented the gauze mask. Many surgeons, brought up in a confused misunderstanding of the antiseptic principlebelieving that carbolic would cover a multitude of sins, many of which they were ignorant of committingfailed to grasp what asepsis was all about. Thomas Annandale, for example, blew through his catheters to make sure that they were clear, and many an instrument, dropped accidentally, was simply given a quick wipe and returned to use. Tradition died hard, and asepsis had an uphill struggle before it was fully accepted. I believe firmly that more patients have died from the use of gloves than have ever been saved from infection by their use, wrote W.P. Carr, an American, in 1911. Over the years, however, a sound technique was evolved as the foundation for the growth of modern surgery. Anesthesia, at the turn of the century, progressed slowly. Few physicians made a career of the subject, and frequently the patient was rendered unconscious by a student, a nurse, or a porter wielding a rag and bottle. Chloroform was overwhelmingly more popular than ether, on account of its ease of administration, despite the fact that it was liable to kill by stopping the heart. Although by the end of the first decade, nitrous oxide (laughing gas) combined with ether had displacedbut by no means entirelythe use of chloroform, the surgical problems were far from ended. For years to come the abdominal surgeon besought the anesthetist to deepen the level of anesthesia and thus relax the abdominal muscles; the anesthetist responded to the best of his ability, acutely aware that the deeper he went, the closer the patient was to death. When other anesthetic agents were discovered, the anesthetist came into his own, and many advances in spheres such as brain and heart surgery would have been impossible without his skill. The third obstacle, shock, is perhaps the most complex and the most difficult to define satisfactorily. The only major cause properly appreciated at the start of the 20th century was loss of blood, and once that had occurred nothing, in those days, could be done. And so, the study of shockits causes, its effects on human physiology, and its prevention and treatmentbecame all-important to the progress of surgery. In the latter part of the 19th century, then, surgeons had been liberated from the age-old bogies of pain, pus, and hospital gangrene. Hitherto, operations had been restricted to amputations, cutting for stone in the bladder, tying off arterial aneurysms (bulging and thinning of artery walls), repairing hernias, and a variety of procedures that could be done without going too deeply beneath the skin. But the anatomical knowledge, a crude skill derived from practice on dead bodies, and above all the enthusiasm, were there waiting. Largely ignoring the mass of problems they uncovered, surgeons launched forth into an exploration of the human body. They acquired a reputation for showmanship; but much of their surgery, though speedy and spectacular, was rough and ready. There were a few who developed supreme skill and dexterity and could have undertaken a modern operation with but little practice; indeed, some devised the very operations still in use today. One such was Theodor Billroth, head of the surgical clinic at Vienna, who collected a formidable list of successful first operations. He represented the best of his generationa surgical genius, an accomplished musician, and a kind, gentle man who brought the breath of humanity to his work. Moreover, the men he trained, including von Mikulicz, Vincenz Czerny, and Anton von Eiselsberg, consolidated the brilliant start that he had given to abdominal surgery in Europe. The rise of scientific medicine in the 19th century The portrayal of the history of medicine becomes more difficult in the 19th century. Discoveries multiply, and the number of eminent doctors is so great that the history is apt to become a series of biographies. Nevertheless, it is possible to discern the leading trends in modern medical thought. Physiology By the beginning of the 19th century, the structure of the human body was almost fully known, due to new methods of microscopy and of injections. Even the body's microscopic structure was understood. But as important as anatomical knowledge was an understanding of physiological processes, which were rapidly being elucidated, especially in Germany. There, physiology became established as a distinct science under the guidance of Johannes Mller, who was a professor at Bonn and then at the University of Berlin. An energetic worker and an inspiring teacher, he described his discoveries in a famous textbook, Handbuch der Physiologie des Menschen (Manual of Human Physiology), published in the 1830s. Among Mller's illustrious pupils were Hermann von Helmholtz, who made significant discoveries relating to sight and hearing and who invented the ophthalmoscope; and Rudolf Virchow, one of the century's great medical scientists, whose outstanding achievement was his conception of the cell as the centre of all pathological changes. Virchow's work Die Cellularpathologie, published in 1858, gave the deathblow to the outmoded view that disease is due to an imbalance of the four humours. In France the most brilliant physiologist of the time was Claude Bernard, whose many important discoveries were the outcome of carefully planned experiments. His researches clarified the role of the pancreas in digestion, revealed the presence of glycogen in the liver, and explained how the contraction and expansion of the blood vessels are controlled by vasomotor nerves. He proposed the concept of the internal environmentthe chemical balance in and around the cellsand the importance of its stability. His Introduction l'tude de la mdecine exprimentale (1865; An Introduction to the Study of Experimental Medicine) is still worthy of study by all who undertake research.