History of Medicine Research Paper

1. The Scientific and Conceptual History of Modern Western Medicine

The magical–mythical art of healing of indigenous cultures is part of a world in which human relationships with nature and with societal structures are not understood as objects in their own right. In hunter– gatherer societies and in the early agriculturally determined cultures, diseases were seen as the results of violated taboos, offended demons or neglected ancestors. Therapies aimed at restoring the old order: exorcism was practiced, demons and ancestors were pacified. With this, the spiritual, physical, and social order were restored. This animistic–demonic medicine presented a closed rational system of thinking and acting.

Magical conceptions of the world were not confined to prescientific times. Rather, iatro-magic (‘iatro’ from ancient Greek iatros, ‘the physician’) influenced medical theory and even practical medical action far into the seventeenth century. Even today, simile magic (e.g., the use of ginseng roots) or singularity magic (e.g., the use of charms, symbols, spells) are found in popular medicine, nature healing, and so-called complementary medicine.

The highly developed medicine of the ancient cultures of Mesopotamia, Egypt, and Asia Minor was characterized by a religious world order. This order was underpinned by (national) deities and the (divine) ruler. Diseases were seen as conscious or unconscious violations of the world order with which the healers were familiar. These healers possessed practical as well as prophetic skills. Thus physicians and priests were hardly distinguishable. There was an abundance of empirical practices both in magical–mythical medicine and in the archaic art of healing. The one criterion that clearly distinguishes the latter from medicine in the narrow sense was that the entire art of healing remained metaphysically oriented. Even those treatments which worked in the modern sense as well were in their time assigned to a magical–mythical, i.e., religious, domain. This also applied to rules of hygiene such as sanitary and dietary laws.

It was Hippocrates of Kos (ca. 460–375 BC) who took the decisive step towards scientific medicine of classical antiquity. Hippocrates and his school emancipated medicine from religious concepts. Diseases came to be explained ‘according to nature.’ Natural philosophical elements (fire, water, air, earth) and their qualities (warm, humid, cold, dry) were combined with the teachings of the body fluids (blood, phlegm, yellow and black bile) to produce a theory of humoral pathology. Apart from this concept, ancient medicine also developed a wide spectrum of theories and methods associated with various philosophical schools. The spectrum ranged from the pathology of the body fluids (humoral pathology, humoralism) to the pathology of solid body parts (solid pathology). This included, for example, functional anatomy (including vivisections), surgery (e.g., vascular ligatures), and pharmacy (as practiced by Dioscorides Pedanius, first century BC). The Alexandrine medical schools of Herophilus of Chalcedon (ca. 330–250 BC) and Erasistratus of Kos (ca. 320–245 BC) followed empirical, partly experimental concepts in the modern sense. With that, almost all possible patterns of modern medical thinking had already been put into practice, or at least anticipated, in classical antiquity.

Galen of Pergamum (AD 130–200) subsumed the theory and practice of ancient medicine under a humoral pathological view. Authoritative Hippocratic– Galenian medicine entered Persian and Arabian medicine via Byzantium (e.g., Onbasius of Pergamum, ca. 325–400, and Alexander of Tralles (ca. 525–600). As a result of Islamization, Persian–Arabian medicine spread eastward to South-east Asia and westward to the Iberian Peninsula. In the heyday of Arabian– Islamic culture between the seventh and twelfth centuries, ancient medicine was transformed into practice-oriented compendia in a process of independent scientific work. Far beyond the high Middle Ages, the Canon Medicinae of Ibn Sina (980–1037) (known in the West as Avicenna) was the handbook even of Western European physicians.

For approximately 1,500 years humoralism was the dominating medical concept from India to Europe. The original theory of the four body fluids, qualities, and elements was constantly expanded: by the four temperaments (sanguine, phlegmatic, choleric, melancholic), by the four seasons, the 12 signs of the zodiac, then later by the four evangelists, certain musical scales, etc. This concept allowed the physician to put the patient with his her respective symptoms at the center of a comprehensive model: the powers of the macrocosm and the microcosm influenced one another within the individual on a continuous basis. By means of thorough anamnesis, prognoses, and dietary instructions (‘contraria contrariis’; allopathy), physicians supported the healing powers of nature (‘vis medicatrix naturae’; ‘medicus curat, natura sanat’), a model which—according to the principle of ‘similia similibus’—is still valid today in homeopathy.

With the political decline of the Western Roman Empire during the fifth and sixth centuries, a Christian art of healing came to the fore in Western Europe. In this, the traditions of ancient practice (Cassiodor, 487–583) mingled with a magic-influenced popular art of healing and Christian cosmology to create a world of ‘Christus Medicus.’ Such a theological–soteriological concept of medicine was able to take up the ancient cult of Asclepius. In early Christian and medieval iatro-theology diseases were interpreted as the result of sin or as a divine act of providence. This still continues to have an effect on contemporary religious practices, such as the use of votive tablets, intercessions, and pilgrimages. In her medical writings (e.g., Physica; Causae et Curae), Hildegard of Bingen (1098–1179) left abundant evidence of the medieval art of healing.

The so-called monastic medicine, or pre-Salernitarian medicine (sixth to twelfth century) was superseded in southern Italy and Spain by the adoption of ancient traditions from Arabian medicine. Beginning in Salerno in the eleventh century with Constantinus Africanus (1018–87) and Toledo in the twelfth century with Gerhard of Cremona (1114–87) and his followers, the era of scientifically oriented medicine taught at universities began. Northern Italy, Montpellier, and Paris became major centers of medical study at this time. Hippocratic–Galenian medicine became the all-embracing and generally binding concept.

Neoplatonism and astrology (of which Marsilius Ficino, 1433–99 was a prominent practitioner), contributed to shaping Hippocratic–Galenian medicine into an all-encompassing model during the Renaissance. Modern medicine has been gradually developing ever since. This development was furthered by the discovery of numerous ancient texts, e.g., the De re medicina of Celsus, discovered in 1455. Andreas Vesalius (1514–64), in his secular anatomical work De humani corporis fabrica (1543), wanted to purify the ancient authorities of errors that had arisen through mistranslation. More and more, medicine based itself on its own experience, on its own theories, and on its own ‘experiments.’ Theophrast of Hohenheim known by the name of Paracelsus (1493 94–1541) introduced a chemistry-oriented way of thinking into medicine, while Rene Descartes (1596–1650) contributed a mathematical–mechanical thought pattern; both were complemented by Francis Bacon’s (1561–1626) model of empirical thinking. The human body was released from religious cosmology and gradually became the outstanding subject of scientific examination. This initially took the form of anatomical explorations.

A secular step was taken at the end of the eighteenth century and early in the nineteenth century in English and French hospitals: the focus of medicine and of the physicians shifted from the patient to his her disease. The sick man disappeared from medical cosmology. Seventeenth-century attempts at scientific systematization led to extensive nosologies in medicine, e.g., that of Thomas Sydenham (1624–89). Hippocratic– Galenian symptomatology, which was directed at the individual patient, was replaced by described syndromes. These syndromes became detached from the individual sick person, who turned into a mere ‘case.’ With this, a scientific–experimental field of separate research into disease entities opened up for medicine.

The man-machine model of iatro-physics and the man-reagent model of iatro-chemistry finally introduced modern scientific thinking into medicine. As medical theory was progressively freed from any religious or metaphysical reasoning, the question as to the source of life was raised. It was answered by dynamic concepts of disease, by psychodynamism and biodynamism. These concepts finally led, via Brownianism, to modern psychopathology and psychotherapy. In contrast to that, iatro-morphology built on the visible and observable. Georgio Baglivi (1668–1708) paved the way from humoral to solid pathology. Pathology improved from Giovanni Battista Morgagni’s (1682–1771) organ pathology via Francois-Xavier Bichat’s (1771–1802) tissue pathology to the functional cellular pathology of Rudolf Virchow (1821–1902). Cellular pathology established the physiological and pathological fundamentals of scientific medicine.

The actual step towards modern scientific medicine was taken in the late eighteenth and early nineteenth centuries. Chemical, physical, and then biological thinking has been determining the theories of medicine ever since. Deliberately reproducible (research) results led to a ‘triumphal victory’ for modern medicine in the second half of the nineteenth century with developments such as anesthesia (nitric oxide 1844–6; ether 1846; chloroform 1847), antisepsis (Joseph Lister, 1827–1912), asepsis (Ernst von Bergmann, 1836–1907; Curt Schimmelbusch 1860–95), immunology, serum therapy, and the diagnostic (1895–6) and therapeutic (1896) possibilities of x-rays. With acetylsalicylic acid (asprin), the first chemically representable feverreducing drug was introduced into medicine in 1873.

Modern scientific medicine follows the iatro-technical concept pathophysiology, a causal analysis of distinguishable disease entities, objectifying and gauging methods, and causal therapy characterize such medicine. The driving force of this scientifically and technically oriented medicine is its endeavor to put physiology, pathology, and therapy on a scientific footing; first chemistry, then physics became central guiding sciences, and laboratories and experiments were introduced even into clinical practice. With the animal model, bacteriology launched a biological experimental situation. From the start, the iatrotechnical concept created specific tensions in medicine: on the one hand, the scientific fundamentals which aim at general insights get into the maelstrom of the physician’s need for action (consequence: the ‘autisticundisciplined thinking’ and acting, as denounced by Eugen Bleuler, 1857–1915). On the other hand, medical action directed at the sick individual patient as a subject gets caught in the maelstrom of generalized technical applications and scientifically justifiable therapies (consequence: the ‘therapeutic nihilism’ of the Second Viennese School, i.e., proscription of any insecure therapeutical measures; Josef Skoda, 1805–81). As a result, since the 1840s both patients and medical practitioners have been turning to and from homeopathy and nature healing over and over again.

2. The Institutional and Organizational History of Western Medicine

Medicine is a science built neither on pure knowledge nor on mere empiricism. It is rather an action-based science directed at the sick individual. As already formulated in Hippocrates’ first aphorism, the patient and his her environment are granted equal parts in medicine. Therefore, a scientific and conceptional internal perspective can only partly explain the significance of medicine. From a historical perspective, diachronic questions are necessary which are directed at medicine from outside, i.e., from society. Consequently, a comprehensive history of medicine also demands socio–historical, historico–sociological, and anthropological perspectives.

The interaction between scientific knowledge and practical experience has been part of medicine since ancient times. In the course of the scientification of medicine during the nineteenth century, the historical argument simply disappeared from scientific reasoning. As a well-aimed counter-reaction against the purely scientific–technical concept, the history of medicine was reintroduced into the medical curriculum in the early twentieth century. Far into the 1990s, the history of medicine was considered in medical faculties and schools to be the substantial representative of the humane aspects of medicine. However, just as the objects and methods of the historical sciences began to expand in the late twentieth century, medicine also became an object of general history, i.e., especially one of social and cultural history. Yet, although methodological professionalization raised the academic standards of the history of medicine, the position of medical history within medicine has been impeded by the emphasis on professional historiography, including its technical jargon. Since the 1990s, humanist issues of medicine have come increasingly under the category of ethics in medicine. As a result, the existence of history as an academic subject within medical faculties and schools has been called into question. If history in medicine wants to survive, it has to meet the expectations of its humanist– pragmatic task which the rapid progress in medicine dictates. Due to the different tasks—which partly refer to the current problems of legitimization and action, partly to the debate about contents and methods in historiography—it is necessary to make a distinction between a ‘history of medicine’ and a ‘history in medicine.’

Within the doctor–patient encounter, the patients receive special attention due to their special need for help, as do doctors due to their specific need for action. From antiquity to the beginnings of scientific– technical medicine, the conceptual world of medicine and the patients’ lay interpretations overlapped in large areas. Humoral pathological medicine lives on in popular medicine, in nature healing, and in alternative medicine. With the advent of the scientific concept, the world of medicine and that of the patient drifted apart. From the eighteenth century, the physician as an expert began to face the patient as a layperson. At the same time, medicine came to hold the monopoly of definition and action over the human body. In the sociogenesis of health as a social good and value, medicine and the physicians were endowed with an exclusive task; and they were thus given a special position in society. The historical and sociological discussion of the 1970s called this process ‘the professionalization of medicine.’

The medical marketplace has always been characterized by enormous competition. Because of that, the healing professions have almost always depended on their clients, the patients. In medieval and early modern times, the patronage system made the academically trained physician subject to his socially superior patron-client. This was only inverted with the gradual scientification of medicine in the eighteenth century. With the compulsory linkage to scientific medicine, orthodox medicine has developed since the 1840s. Orthodox medicine was confronted with traditional or modern alternatives as kinds of ‘outsider medicine’; healers who applied these methods were both internally and externally discriminated against as quack doctors. Industrial societies with their various social security systems and their general claim of social inclusion opened up a new clientele of the working class and the lower strata for medicine.

A significant medical institution both in the Western and in the Islamic tradition is the hospital. Hospitals were established partly for pilgrims, partly for anybody in need of help, in order to fulfill the Christian ideal of ‘caritas.’ Having migrated eastwards along with ancient medicine, the hospital became the place of training for physicians in Islam around the turn of the first millennium. Within the European tradition, the charitably oriented hospital changed only in the late eighteenth century: the modern hospital came to be a place to which only sick people were admitted, with the purpose of discharging them after a well-directed treatment within a calculable period of time. Such was initially the responsibility of proficient nursing. Around the same time selected hospitals had become places of practical training for future physicians. Scientific–medical research was also conducted in these university hospitals from the 1840s onwards; only as a result of this, antisepsis medicine entered the General Hospitals in the 1860s. This was the beginning of the history of modern nursing, of scientifically oriented medical training, of the many medical disciplines, of the modern Medical Departments and Schools, and of the hospitals which only then became medically oriented.

At first sight, diseases embody the biological reality in the encounter between physician and patient. As a study of leprosy or plagues shows, diseases have had a number of different names over the course of time. Therefore it is hardly possible to determine with certainty which diseases were referred to in reports handed down to us. However culturally interpreted, diseases induce the encounter between physician and patient. It is therefore the sick human being who accounts for the existence of medicine. Over and above the conceptual and institutional interpretations, disease has always been experienced as a crisis in human existence. In different cultures and eras sick people and their environment interpreted diseases with reference to their metaphysical reasoning. Diseases are given a cultural meaning as a divine trial or as a retaliation for violated principles of life and nature. The scientific–analytical notion of disease in the iatrotechnical concept is not capable of taking the patient’s quest for meaning into account. The chronically ill, the terminally ill, and the dying therefore present a constant challenge for scientific–technical medicine— including its necessarily inherent thoughts of progress. The result is a continuous push towards alternative and complementary medicine as well as towards lay and self-help.

From a historical and sociological point of view, even the interpretations of health take place in a repetitive process. In antiquity, health resulted from the philosophical ideal of the beautiful and good human being (ancient Greek: ‘kalokagathia’. The Islamic world and the Christian Middle Ages assigned the health of the body to religious categories. In the sciences of early modern times, the nature-bound human body came to be understood as an objectified body. In early rationalism, Gottfried Wilhelm Leibniz (1646–1716) elevated medicine to a means of ordering private and public life according to scientific rules: the order of the soul, the order of the body and the order of society corresponded with piety, health, and justice; they had to be guaranteed by the church, by medicine, and the judiciary. In critical rationalism, reason, physics, and morality were declared a unity. In the early nineteenth century, the interpretation of the concept of health became a scientific activity. The question of the meaning of health was excluded from medicine. Within the iatro-technical concept, health as a chemical, physical, or statistical norm measured by percussion, auscultation, the thermometer, etc., became a negative definition of scientific notions of disease. Those values and ideas of order which were inextricably bound up with the notion of health seem to have disappeared in the course of scientific–rational progress.

With the scientific notion of health and disease, modern medicine was finally granted the monopoly of interpretation and action for a rational design of the biological human resources in modern societies. Disease is the cause for medical action, health is its aim. Via the societal value of health medical knowledge and medical action are integrated into their societal surroundings. The definition of health mediates in its valid interpretation of a particular civilization between the individual, the social, and the ‘natural’ nature of mankind. Thus, health integrates the ‘natural’ biological basis, the social basis and the individuality— the ‘I’ and ‘me’—of human existence. In terms of philosophical anthropology, the valid notions of health mediate between the outer world nature, the social world society, and the inner world individuality with regard to the body living corpse. The place and the scope of medical action in society are defined via the interpretation and the effect of the valid definitions of health.

To the same extent to which the human relationship towards nature becomes more scientific and leads to a scientific–technological civilization, more and more aspects become scientific within the combined interplay of the body as a part of oneself and the body as an object. ‘Homo hygienicus,’ i.e., mankind, who defines himself and is defined by others in terms of medical standards, are typical examples of the paradox of modernity: the autonomously progressing discoveries of scientifically oriented medicine liberated the person, communities, and society from the task of having to account for the values and norms of their bodily existence. From this position, the individual and public ‘rationalization of the body’—as stated by Max Weber (1864–1920), amongst others, at the beginning of the twentieth century—could begin their widely welcomed and universally demanded ‘victory march of medicine.’ With the end of the belief in progress, the disadvantages of this process have been perceived since the 1970s. So in historical, sociological, and anthropological debates medicine has turned into an ‘institution of social control.’ Medicalization—as Michel Foucault (1926–84), amongst many others, pointed out from the early 1970s onwards—became the focus of a fundamental critique on the penetrating social impact of modern medicine.

The doctor–patient relationship is no anthropological constant. Rather, this relationship is an integral part of the economic and social organization of a community. This is especially true for public medicine and the health sciences. Early forms of the modern public health service developed from the end of the thirteenth century in northern Italian cities. The driving forces were the endemic plagues which kept returning at regular intervals after the Great Plague of 1347–51. In early modern times those public health measures evolved which then became regular institutions in the great commercial cities: general regulations which also had health effects (such as food inspection and market regulations, etc.); municipal supervision of those practicing medicine; city hospitals for the infirm, and others for special isolation (leprosaria, plague hospitals, etc.); the beginnings of a municipal medical and surgical service.

When the territorial states were thoroughly consolidated on the legal and administrative level, medical and sanitary supervision unfolded in the late seventeenth and early eighteenth century. A public medicine arose which was linked to administrative and political goals. Within the framework of mercantilism one intention in calculating power was to increase the population. The paternalistic welfare state towards the end of the absolutist period developed public health as part of its ‘populating policy.’ This is where the special, still heavily disputed relationship between state, medicine, and women, begins: to the extent to which women were made the ‘human capital’ of a welldirected population policy their role came to be substantially determined by medicine (medicalized midwifery, medicalization of birth and childhood, medicalization of housekeeping, childrearing, etc.).

Through the bourgeois revolutions the nation as sovereign made itself the object of public health. Besides the idea of a qualitative evaluation of the population the idea arose of calculating the value of a human being in terms of money. In a combined act of statistics, epidemiology, physics, geography, metereology, etc., and driven by a paternalistic idea of welfare the first modern health sciences came into being. The nineteenth-century cholera pandemics accelerated this development. Only with the beginning of industrialization was comprehensive healthcare promoted, due to the ‘public value’ of health. The modern health sciences finally defined in a biological chain of causes and effects a closed circle of human hygiene: the environment as conditional hygiene of Michel Levy (1809–72), Jules Guerin (1801–86), Edmund Parkes (1819–76) or Max von Pettenkofer (1818–1901); the microbiology or bacteriology as infectious hygiene of Louis Pasteur (1822–95) or Robert Koch (1843–1910); the dynamic relation of exposition and disposition as constitutional hygiene; the forthcoming human life as racial hygiene and eugenics; and finally health and society as social hygiene—all these combined approaches took hold of basically all areas of human existence in the late nineteenth and early twentieth centuries. This is especially true for unborn life. At this point the historical reflection on public healthcare, medical statistics, and epidemiology, health economics, health laws, and health systems, etc., begins.

The idea of obligatory collective health was developed after the turn of the twentieth century. In the biologistic ideology of National Socialism it was molded into a highly rational model of future-oriented health. The goal of National Socialist healthcare was a ‘genetically healthy’ and ‘racially pure’ population of ‘Aryan–German blood.’ This genetically and racially cleansed ‘Volk’ should be fit to survive the secular ‘war of races.’ The goal of obligatory national—which really means racial—health was located beyond all individual rights. This model of a totalitarian program of healthcare was based categorically on exclusion. It was carried out in decisive areas: at first sterilization (at least 350,000 victims, all of them Germans), then ‘euthanasia’ (over 100,000 victims, including so-called ‘wild euthanasia,’ probably more than 250,000 victims, all of them Germans), and finally the extermination of ‘Volkerparasiten’ during the Holocaust (approximately 6 million victims, of whom 180,000 were Germans).

Medicine in National Socialism requires special mention here, as it is historically unique in the world. Basically an excluding function is always inherent in medicine. In the daily routine of medicine this becomes apparent wherever decisions have to be made on the allocation of scarce goods and services in short supply (e.g., transplantation medicine, assessment and social medicine, allocation of medical services). As to their forcefully carried out eugenic actions the National Socialists themselves referred to the examples of other countries, especially the USA. Indeed there had been, prior to 1933 and after 1945, an ‘internationale’ of eugenicists. The National Socialist model of health can serve worldwide as an historical example of the conflicting nature of the rationalization process on which modern times are based—a process which is irreversible. National Socialism is therefore to be seen as the Janus-faced flipside of the modern era, which is as obsessed with progress as it is blinded by it. This means that National Socialism and medicine in the National Socialist era are not only particular phenomena of German history. They are rather a problem of our times and thereby a problem of all societies which have built on modernism.

3. Conclusion and Outlook: Western Medicine and the Molecular Health of Tomorrow

In the narrow scientific–practical sense medicine is determined by the dialectics of medical knowledge and medical action. Such dialectics have accompanied medicine from its first historical steps onwards to the scientific–rational establishment in Greek antiquity. The controversy between ‘dogmatists’ and ‘empiricists,’ between ‘medics’ and ‘doctors,’ has raged throughout the entire history of medicine. It is the patient who gives this dialectic a direction: the patient’s need for help constitutes medicine. Because of the patient and the special situation in which the patient and the doctor meet, medicine possesses a domain distinct from that of other sciences. In the encounter between doctor and patient medicine faces the necessity to take action. With this, the doctor–patient encounter is placed within a historical context. This is the starting point of historical reflection as an indispensable aspect both of a history in medicine and a history of medicine.

The position of medicine within society is changing fundamentally. The scientific medicine of the late nineteenth and early twentieth centuries was the reproductive rearguard of industrialization. By contrast, the medicine of the late twentieth and early twenty-first centuries is a forerunner of scientific, economic and social change. Since the 1980s, molecular biology has become the referential discipline of medicine. With that, it has become possible to diagnose diseases in their genetic informational principles and their molecular mechanisms. The molecular transition means a secular change in the concept of medicine. The molecular biological thought pattern transfers the process of health and disease into the informational bases of the production and function of proteins. With that, genetics and information processing in the cellular and extracellular realm step into the limelight.

Historical analysis has shown to what extent medical knowledge and medical action affect society. Thus, experimental hygiene and bacteriology have cleansed and pasteurized conditions and behavior since the middle of the nineteenth century. Since the 1960s the pharmacological possibilities of contraception have altered the self-definition and the role of women. Molecular genetics and clinical reproductive medicine have already started to show their effects on the generative behavior of mankind (in itro and in i o fertilization, preimplantation diagnostics, etc.). The transition to molecular medicine will also change the living world and the social world: molecular medicine leads to a new image of humans. The medicine of the last decades followed the model of ‘exposition,’: in which diseases had an external origin (e.g., bacteria, viruses, stress factors, etc.). Molecular medicine shifts the etiology from exposition (i.e., the outside world of all human beings) to disposition and therefore to the (genetic) inner world of the individual. Predispositions for certain diseases are internalized as an individual (biological) fate. The result is the ‘genetization’ of individual life and of its subsequent societal acts (e.g., life and health insurance). The interpretation of health, including the notion of normality of the body, will in substance be linked with the knowledge of genetically determined dispositions. Such a genetic living world will be as ‘real’ for human beings of the twenty-first century as the bacteriological living world was ‘real’ for the twentieth century.

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