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MEDICINE

From the beginning of their history until modern times Jews have exercised a tremendous influence on the development of medical science. They have always been solicitous in their care for the sick and held the medical profession in great esteem. In ancient times medicine and religion were closely connected. The priests were the custodians of public health. The dispute as to the propriety of human interference in sickness – regarded as divine retribution – ceased to trouble the Jews, because they came to regard the physician as the instrument through whom God could effect the cure. Jewish physicians therefore considered their vocation as spiritually endowed and not merely an ordinary profession. By the same token, great demands were made of them, and the ethical standards have always been very high.

The importance of medicine and physicians among the Jews is best seen in the long line of rabbi-physicians, that started during the talmudic period and continued until comparatively recently. Various factors were responsible for this combination of professions. Medicine was sanctioned by biblical and talmudic law and had an important bearing upon religious matters. Since teaching or studying the word of God for reward was not considered ethical, the practice of medicine was most often chosen as a means of livelihood. This trend was further strengthened by the fact that during the greater part of the Middle Ages the Jews were excluded from almost all other occupations, including public office, and medicine was left as one of the few dignified occupations by which they could earn their living.

Jews have contributed to medicine both by the creation of new medical concepts and by the transmission of medical knowledge. It was through the medieval Jewish physician-translators that the medical knowledge of the East and much of ancient Greek medical lore was preserved and transmitted to the West. A general survey of Jews in medicine may be divided into three broad periods:

(a) biblical and talmudic times, which covers the period from antiquity until roughly the fourth to fifth centuries c.e.;

(b) a middle period from approximately the sixth century c.e. to the beginning of the 19th century; and

(c) the 19th and 20th centuries, during which Jews throughout the world have excelled not only in the practice of medicine but in all fields of medical research and teaching. It is significant that over 20% of all winners of the Nobel Prize for medicine up to the end of the 1960s were Jewish.

The high standard of medical science in Israel must be mentioned. Not only have Israeli physicians successfully met the challenge of medical problems in a developing country with a mixed population, but they have continued the ancient Jewish medical tradition by teaching and giving practical aid to those developing countries striving to attain the scientific levels of the 20th and 21st century.

in the bible

The main source of information on ancient Hebrew medicine is the Bible, which refers to medicine as it pertains to religious or civil laws or when important characters are involved. No general ancient Hebrew medical documents are extant, although the Talmud reports that King *Hezekiah canceled the "Medical Book" (Ber. 10b; Pes. 56a) and that a scroll on pharmacology was lost. From earliest times, the Jewish faith sought to suppress *magic customs and practices in every field of life, including those concerned with the health of its members. The Hebrews were doubtlessly influenced in their medical concepts and practices by the surrounding nations, particularly by Egypt, where medical knowledge was highly developed. Prevailing superstitions and beliefs in magic medicine were far less accepted and practiced by the Jews, however, than by their neighbors. But like their contemporaries, the ancient Hebrews attributed health and disease to a divine source.

Healing was in the hands of God and the role of doctors was that of helpers or instruments of God. There are numerous references to physicians and men of healing throughout the Bible. It is always implied, however, that although man may administer treatment, it is God who heals: "I am the Lord that healeth thee" (Ex. 15:26). The title rofe ("healer") was therefore never adopted by ancient Jewish physicians; where it occurs it invariably refers to foreign doctors, who were usually assumed to be helpless because they were not aided by God. Pharmacists and midwives are also mentioned. Hebrew priests had no authority as physicians but rather held the position of health wardens of the community, charged with enforcing the laws pertaining to social hygiene.

The uniqueness of biblical medicine lies in its regulations for social hygiene, which are remarkable not only for their period but even by present-day standards. Hygiene and prophylaxis became religious dogmas intended for the welfare and preservation of the nation. Of the 613 commandments, 213 are of a medical nature. Prevention of epidemics, suppression of prostitution and venereal diseases, frequent washing, care of the skin, strict dietary and sanitary regulations, rules for sexual life, isolation and quarantine, the observance of a day of rest – the Sabbath – these and other provisions inhibited the spread of many of the diseases prevalent in neighboring countries.

The Hebrews were aware of the fact that contagious diseases are spread by direct contact as well as by clothing, household utensils, etc. To prevent the spread of epidemics or infectious maladies they therefore compiled a series of sanitary regulations. These included precautionary or temporary isolation, quarantine, burning or scalding of infected garments and utensils, thorough scrubbing and smoking out of houses suspected of infection, and scrupulous inspection and purification of the diseased person after recovery (Lev. 13–14). Anyone coming into contact with a corpse or carrion, or suffering from purulent discharges from any part of his body, also required a thorough cleansing of himself and his belongings before being allowed back into the encampment (Num. 19:7–16; Lev. 15:2–13). The garments, weapons, and utensils of soldiers returning to the camp after a battle had to be thoroughly cleansed and disinfected to prevent the spread of diseases possibly picked up during contact with the enemy (Num. 31:20, 22–24). The danger of infectious bowel diseases spreading through excrement was also recognized and the Bible instructs how to keep the camp clean (Deut. 23:13–14).

Diseases and Remedies

Many diseases are mentioned in the Bible. Among them are shaḥefet – phthisis (Lev. 26:16); ʿafolim – leishmaniasis (Deut. 28:27); yerakon (yeraqon) – ikterus (Deut. 28:22); sheḥin pore'aḥ aʾvʿabuʾot – pemphigus (Ex. 9:9); zav – gonorrhealeukorrhea (Lev. 15); dever – pest (Deut. 28:21); shivron motnayim – lumbago (Ezek. 21:11); nofel ve-galui ʿenayim – epilepsy (Num. 24:4); rekav (reqav) ʿaẓamot – osteomyelitis (Prov. 14:30). Although not specifically mentioned by name, eye diseases such as blepharitis ciliaris and gonorrheal ophthalmia undoubtedly existed, and senile cataract probably occurred frequently among the ancient Hebrews: "Now the eyes of Israel (Jacob) were dim for age so that he could not see" (Gen. 48:10). The dimness of sight rather than blindness is indicative of cataract. Various forms of skin disease are referred to in Deuteronomy: "The Lord will smite thee with the boil of Egypt, and with the emerods, and with the scab, and with the itch, whereof thou canst not be healed" (Deut. 28:27). The Hebrew word ẓaraʿat, which has been translated as leprosy, was probably a generic term for a number of skin ailments, many of which were considered curable (Lev. 13). However, leprosy in the modern sense was also known, and rigid quarantine, which did not exclude kings (ii Chron. 26:21), was imposed on lepers. The term maggefah refers to plague, epidemics, and contagious diseases in general, very often of a venereal type. A bubonic plague described in i Samuel 5 mentions rodents, who are known to be carriers of the disease. Various types of wounds are mentioned: makkah is the generic term for wound; makkah t'eriyyah is a festering wound; makkah ʾanushah, a wound which will not heal, often fatal; peẓaʿ, a stab wound; ḥabburah, a boil or hematoma; and mazor, a septic boil.

With the one exception of the incurable serpent bite (Num. 21:9), biblical remedies and treatments are all of a rational character and do not involve incantations or magic rites, nor do they include the so-called "filth pharmacy." Biblical therapeutics consisted of washing; the use of oils, balsams, and bandages for wounds and bone fractures; bathing in therapeutic waters (ii Kings 5:10), especially in the case of skin diseases; sun rays, medicated drinks, etc. Among medicaments mentioned by name are myrrh, sweet cinnamon, cassia, galbanum, niter, and the mandrake (dudaʾim) which was considered to possess aphrodisiac properties. The modern method of mouth-to-mouth artificial respiration was also known, as testified by the accounts of Elijah and Elisha (i Kings 17:22; ii Kings 4:34–35). The only surgical operations mentioned are circumcision and castration, and these were not specifically Jewish practices. *Embalming, though unusual, was not forbidden.

Anatomical Knowledge

The Hebrew had more than a passing knowledge of anatomy. This is attested by the language used in instructions concerning methods of sacrifice and by passages of poetry where the names of organs and limbs are used metaphorically. The heart is mentioned frequently as the seat of emotion and intellect, and the functions now ascribed to the brain were then thought to emanate from the heart. No word for brain is mentioned; the word mo'aḥ in Job refers to marrowbone.

It is interesting to note that the Bible has a distinctive nomenclature for parts of the body and types of illnesses. Thus, for example, body defects or deformities are described solely by words constructed in the piʿel grammatical form: ʾiṭṭer – paralyzed, left-handed; ʾillem – dumb; ʿivver – blind; pisse'aḥ –lame; gibben – hunchback. Descriptions of mental or nervous diseases appear in the piʿalon-form: dikkaʾon – depression; shiggaʿon – madness; iẓẓavon – nervousness; ʿivvaron – mental blindness; shikkaron – drunkenness. Somatic illnesses appear in the paʿelet (paʿalat) form: dalleket (dalleqet) – inflammation; shaḥefet – tuberculosis; yabbelet – acne; ʿaẓẓevet – neuritis; baḥeret – leukoderma, vitiligo; sappaḥat – psoriasis; ẓaraʿat – lepra, skin diseases; gabbaḥat – loss of hair. Trauma of the body is formed according to the paʿul model: shavur – fractured; ḥaruẓ – split; maʿukh – crushed; natuk (natuq) – disjointed; raẓuẓ – smashed; ẓaruʿa – infected; paẓuʿa – wounded. Many anatomical terms have the ancient two-letter root, while most Hebrew words derive from three letters. Thus לֵב lev – heart; דָּם dam – blood; פֶּה peh – mouth; חֵךְ ḥekh – gums; שֵׁן shen – tooth; יָד yad – hand.

the talmudic era

The period surveyed in this section extends roughly from the second century b.c.e. to the sixth century c.e. The historical events of that period had a profound influence on the thought and way of life of the Jews and consequently on the development of Jewish medical art as well. As a result of the Babylonian Exile, of Greek rule followed by the Hasmonean Wars, the rise of Christianity and the Exile after the destruction of the Second Temple, the Jewish community became wide open to influences from neighboring countries and to foreign philosophies, which had their effect on every walk of life, including medicine.

Sources and Influences

The sources for this period are the Apocryphal books, Greco-Roman writings of Jews and non-Jews, the Mishnah, the Jerusalem and Babylonian Talmuds, the Midrashim, and, in part, the recently discovered Dead Sea Scrolls. None of these sources is a medical book as such. Except for a few cases, such as the praise of medicine and the physician by *Ben Sira, medical matters are dealt with mainly to illustrate points of ritual, or civil and criminal law. In the Talmud, a few medical matters are dealt with extensively in the tractates Ḥullin, Nega'im, and Bekhorot. The influence of Persian and Babylonian magic medicine is clear from references to *amulets, the *evil eye, *demons, etc. The Greek influence on Jewish medical thought was considerable, but we find that the scholars were not blind adherents of the humoral pathology, but rather followers of anatomic pathology. This was doubtless based on their experiments and observations of sick animals before and after slaughter, as well as on their studies of human bodies and corpses. One of the interpretations given to the name of the sect known as *Essenes is איסיים, "healers." Their medicine mainly influenced Christian medicine and medical thought. They studied and collected herbs and roots for healing purposes, though their chief remedies were prayer, mystic formulas, and amulets. Abiding faith was all that was considered necessary for curing physical and mental diseases as well as chronic defects such as blindness, lameness, and deafness. The medicine mentioned in the New Testament is almost entirely of this type of miracle cure. By contrast, the attitude of Jewish scholars of the time, and later those of the Talmud, is generally a scientific one.

The talmudic attitude toward the sanctity of human life and the importance of health is expressed in numerous statements: "The saving of life (pikku'aḥ nefesh) takes precedence over Sabbath" (Yoma 85a). "Whoever is overzealous in fasting should be regarded as a sinner" (Ta'an. 11a). It was also decreed that when treating the sick or a woman in childbirth, even though no danger to life was involved, the sanctity of the Sabbath could be profaned.

Status of the Physician

The Talmud does not regard calling upon a physician for medical aid as a failure to rely upon God to restore health: "Whoever is in pain, let him go to the physician" (bk 46b). The profession of physician – as an instrument of God – was held in high esteem: "Honor the physician before need of him. Him also hath God apportioned.… The skill of a physician shall lift up his head; and he shall stand before nobles …" (Ecclus. 38). The Talmud enumerated ten things that must be in a city where a scholar lives, and these include a physician and a surgeon. From this statement it may also be concluded that the number of practicing physicians was relatively great.

Specialists as known in Egypt did not exist. However, the Talmud names two types of physician, rofe and rofe umman ("skilled physician" and "surgeon"). Patients visited the physician in his home and not, as in Greece, in the marketplace. A special regulation was therefore enacted which required anyone renting premises to a physician to obtain the prior agreement of his neighbors, since the cries and noise of visiting patients might disturb them (bb 21a). *Hospitals were apparently nonexistent in this period, although certain temple halls, and later on, parts of the poorhouses and synagogues, were set aside for the sick. However, mention is made of operation rooms, which had to be walled with marble for cleanliness – "battei shayish." There were communal or district physicians, whose duties included assessing the character and extent of any physical disability sustained in cases of injury in order to determine damages (Sanh. 78a). They were also required to judge the degree of physical endurance of a person sentenced to corporal punishment (Mak. 22b). "The victim of an assault could refuse to be treated by a physician coming from a distance since he would not be sufficiently concerned with the welfare of his patient" (bk 85a).

A physician had to receive adequate fees, and free medical service was not approved because "a physician who takes nothing is worth nothing" (bk 85a). At the same time, Jewish physicians had special consideration for the poor and needy – a tradition which was maintained throughout the centuries. Abba Umana (fourth century c.e.) was reputed as a physician and a charitable man. In order not to discourage needy patients he would hang a box on the wall where anyone could put in, unnoticed, the fee he thought he could afford for medical treatment. Abba Umana refused to take fees from poor students and would return them their money so that they could use it for convalescence (Ta'an. 21b). If, in spite of every care, a licensed physician injured a patient or caused his death, he was not – as among many other peoples – held guilty (Sanh. 84b). Jewish physicians were apparently organized in some type of guild which had as its insignia the ḥarut – the branch of a palm or a balsam bush (Jews at that time regarded balsam as the best remedy for wounds; cf. Pliny, Hist. Nat., 12:54).

Jewish doctors had an excellent reputation and practiced throughout the then-known civilized world. A physician Theudas is mentioned in Bekhorot (4:4) as a famous doctor from Alexandria. Aulus Cornelius *Celsus, writing in the first century c.e., refers to salves compounded by skilled Jewish physicians. *Galen reports on the Jewish physician Rufus Samaritanus in Rome in the first-second centuries c.e. Similar references are made by Marcellus Empiricus, Aetius of Amida, and Paulus of Aegina. Pliny (Hist. Nat., 37.60.10) mentions a "Babylonian physician – Zechariah," undoubtedly a Jew, who dedicated his medical book to King Mithridates. The emperor Antoninus Pius (86–161 c.e.) requested R. Judah ha-Nasi to supply him with a physician for his house slaves from among his circle of students. The personal physician of St. Basil (c. 300 c.e.) was the Jew, Ephraim. The bishop Gelasius refers to his Jewish physician Telesinus as his "trusted friend." At the same time, numerous restrictions against Jewish doctors were already being promulgated by Christian bishops and emperors. These only serve to show how large the number of practicing Jewish physicians was at the time.

The study of medicine was included in the curriculum of talmudic schools and many Talmud scholars were themselves physicians. Among them were R. Ishmael, R. Hanina b. Dosa, R. Hananiah b. Hama, Joseph ha-Rofe of Gamla, Tobiah ha-Rofe of Modi'in, and Minjomi (Benjamin). The most distinguished of them was *Samuel b. Abba ha-Kohen, also called Mar Samuel Yarḥina'ah (165–257), to whom many remedies and much anatomical knowledge is attributed. He was also the personal physician of the Persian king, Sapur. In addition, the Talmud mentions askan bi-devarim, which might be described as a research scientist, who occupied himself more with the study of animal and human anatomy and physiology than with the actual practice of medicine.

Talmudic Anatomy

The preoccupation with regulations concerning ritually unclean meat, the physical qualifications for priesthood, rules concerning menstruous women, defilement, etc., accounts for the extraordinary anatomical knowledge of talmudic scholars. For full details see *Anatomy.

Talmudic Embryology

A great deal of material on this subject can be found in the Talmud and in the Midrashim, some of it of an imaginary or legendary character but most of it surprisingly accurate. Abba Saul describes the development of an embryo in its sixth week (Nid. 25b). Simlai describes the parts, posture, and nourishment of an embryo in the womb. Scholars accepted the opinion that the embryo is a living organism from the time of conception (Sanh. 91b). In contrast to Aristotle, who regarded the seed as a mosaic of individual creative factors corresponding to each of the parts of the human body and assumed that each limb is derived from the parallel limb of the father, the talmudic scholars regarded the seed as one single summary of all the creative forces of the organism and did not acknowledge the individual influence of one limb on the embryo. "The seed is mixed, otherwise blind would beget blind and one-limbed a one-limbed" (Ḥul. 69a). The Talmud also accepts the equal share of the male and female in forming the organism.

Pathology and Etiology

In examining the ritual fitness of animals and the cleanliness and purity of members of the community, talmudic scholars had numerous opportunities of observing and diagnosing diseases. They described various pathological conditions of the lungs and knew the existence of pulmonary infections (Ḥul. 47b). Disturbances of the circulatory system were recognized by the paleness or flush of the body (Yev. 64b). The diagnosis of certain skin diseases was determined according to the form, temperature, and secretion of the wound and the color of the hair round it. The observation of such a wound could last up to three weeks (Neg. 10). Scholars were able to recognize macula of the cornea, keratitis, and detached retina (Bekh. 38a). R. Ishmael describes diphtheria as an epidemic disease which causes painful death through strangulation. The pathology of hemophilia as a lack of viscosity in the blood preventing coagulation is described, and the circumcision of an infant in a hemophilic family was forbidden. It was also recognized that the female is the transmitter of this disease (Yev. 64a; Ḥul. 47b). A large number of lung, liver, kidney, and stomach diseases were described as being caused by worms (Ḥul. 48a; Shab. 109b; Git. 70a). Lack of fluids was thought to lead to digestive disturbances (Shab. 41a). It was recognized that fear accelerates the pulse and causes heartbeats (Sanh. 100b); that falling from a great height may cause fatal internal injury (Ḥul. 42a); that injury to the spinal cord causes paralysis (Ḥul. 51a); and that restraint of the gall causes jaundice. Fevers and colds were thought to be caused by negligence (bm 107b). According to R. Eleazar the gall (humor) and according to Mar Samuel the air (pneuma) could cause disease. It was generally accepted that blood is the chief cause of disease (bb 58b). Overeating, excessive drinking of intoxicants, and sexual excesses were also thought to cause disease. It was realized that animals and insects, in particular flies, are carriers and transmitters of infectious diseases (Ket. 77a), and that contaminated water may also cause illness (Av. Zar. 30a).

Remedies, Treatments, and Surgery

The medicines mentioned in the Talmud include powders, medicated drinks, juices, balsams, bandages, compresses, and incense. Meat and eggs were considered to be the most nourishing foods (Ber. 44b); fried food or food containing fat was regarded as difficult to digest (57b). The eating of vegetables throughout the year and the drinking of fresh water at every meal were recommended (ibid. 57b; 40a). Baths and mineral waters were regarded as general strengthening tonics and as therapeutics for certain skin diseases (Shab. 40a; 109a; Ket. 77b). Herbs were used for constipation and purges were recommended in serious cases, except for pregnant women (Pes. 42b). The use of opium as an analgetic and hypnotic drug was known, and warning was given against overdosing (tj, Av. Zar. 2:2, 40d). Anything useful for healing purposes was permitted at any time, even on the Sabbath (Ḥul. 77b). Surgeons operated in special halls – "battei shayish" (see above). "Sleeping drugs" – sammei de-shinta – were used as anesthetics. From descriptions of operations we learn of trepannings, amputations, and removal of the spleen (cf. Sanh. 21b; Ḥul. 57a; Git. 56a). A cesarean was also performed, but it is not clear whether the operation was done on a living or on an already dead body. In general, the life of the mother had priority and therefore the killing of a fetus during a difficult birth was allowed (Tosef., Yev. 9:4). Wound edges were cut in order to ensure complete and clean healing (Ḥul. 54a). Surgeons wore special operation aprons (Kelim 26:5).

Hygiene and Prophylaxis

The main contribution of talmudic medicine lies not so much in the treatment of illness but rather, as in the Bible, in the prevention of disease and the care of community health. The hygienic measures advocated were of a practical as well as of a religious, ethical nature. A principle which recurs a number of times is that "bodily cleanliness leads to spiritual cleanliness" (Av. Zar. 20b; tj, Shab. 1:3, 3b). Hygienic regulations applied among other things to town planning, climatic conditions, social community life, family life, and care of the body. Mention is made of a disinfectant composed of seven ingredients used for cleansing infected clothing (Zev. 95a). A town was required to have a physician and a bathhouse. Clothing had to be changed before eating. Mar Samuel declared that diseases may be carried by caravans from land to land (Ta'an. 21b). Members of a family with a sick person among them were to be avoided. The digging of wells in the neighborhood of cemeteries or refuse dumps was forbidden (Tosef., bb 1:10). It was forbidden to drink uncovered water for fear of snake venom (Av. Zar. 30a). Food had to be fresh and served in clean dishes. Kissing on the mouth was discouraged, and kissing only on the back of the hand was recommended in order to prevent contagion. During epidemics, the population was advised to avoid crowding in narrow alleyways because of the danger of contagion in the air. For body care, the Talmud recommends physical exercises, massage, sunlight, employment, and above all cleanliness. Mar Samuel states: "The washing of hands and feet in the morning is more effective than any remedy in the world" (Shab. 108b). Excesses of any kind were regarded as harmful. The Talmud also concerned itself with the health of future generations and forbade marriage to epileptics or the mentally retarded (Yev. 64b; 112b). Surprisingly enough, talmudic pathology had very little influence on medieval medicine, not even on such outstanding physicians as *Maimonides and Isaac *Israeli, who were certainly well versed in the Talmud. The medical authority of Galen was so preeminent that all other medical theories and practice were regarded as banalities or even heresy. Scholars warned against the unselective use of talmudic remedies because they are not equally effective in all countries and at all times. Nonetheless, the hygienic laws and regulations of the Talmud, as well as many of its anatomical and pathological findings, appear in the light of modern knowledge to have enduring validity.

the middle period

The medieval period of Jewish history does not coincide exactly with the common historical definition of the Middle Ages in Western civilization, but may be said to extend from the second-third centuries c.e. until the 19th century when, in most Western countries, Jews were granted full emancipation.

The large variety of climates, environments, and customs to which the Jewish people were exposed during their migrations in exile naturally had a profound influence on the development of their medical thought and knowledge. Thus, for example, there is a description of diabetes mellitus in the writings of Maimonides. According to him, this was a disease quite common in the warm Mediterranean countries with which he was acquainted but practically unknown in Northern Europe. Talmudic scholars give a precise description of ratan ("filariasis") and its treatment – a malady unknown in Europe. Similarly, the prevalence of eye diseases in the Orient greatly encouraged the development of ophthalmology and, when Jewish eye doctors migrated to Europe, they quickly acquired an excellent reputation among their Christian colleagues.

However, the merit of Jewish doctors of that period lay not only in their individual achievements as physicians, but in their work as translators and transmitters of Greek medicine to the Arabs and later on of Arab medicine to Europe. Jewish scholars, and among them physicians, had command of the three most important scholastic languages of the time – Latin, Arabic, and Hebrew – and, in some cases, Greek. This enabled them to translate most of the Arab and Greek medical works into Hebrew and Latin or vice versa. Knowledge of Hebrew was considered extremely important in the study of medicine. The English scholar Roger *Bacon (c. 1220–c. 1292) declared that Christian physicians were ignorant in comparison with their Jewish colleagues because they lacked knowledge of the Hebrew and Arabic in which most of the medical works were written. Vesalius, the great 16th-century anatomist, made a point of learning Hebrew to facilitate his studies, and gives Hebrew terms together with their Greek equivalents in his work Fabrica (see also *Frigeis, Lazaro De). Mosellanus, in his rectorial address at the University of Leipzig in 1518, urged Christian medical students to learn Hebrew so that they might study the medical lore "hidden in the libraries of the Jews." The close religious and family ties linking the various Jewish communities also helped to spread medical knowledge and facilitate rapid communication. As merchants and travelers the Jews met the best minds of their period and became acquainted with drugs, plants, and remedies from many parts of the world.

Nevertheless, although Jewish physicians were frequently held in great esteem by their non-Jewish colleagues as well as by kings and bishops, they suffered from persecution and restrictions, especially in the Christian world. From the fourth century c.e. onward there were innumerable regulations, papal bulls, and royal ordinances forbidding Jewish physicians to practice among non-Jews, to hold official positions and, later on, to study at universities. The fact that, despite these threats and restrictions, Jewish physicians continued in their profession and even held high positions at the courts of the very authorities who preached against them, attests to the esteem with which they were regarded for their medical skill. In this respect the Muslims were much more tolerant: although persecutions of Jews erupted from time to time in Muslim territories, physicians were not singled out, and consulting them was not forbidden.

The large number of Jewish physicians during these centuries may also be explained by the fact that Jews still regarded the medical profession as a spiritual vocation compatible with the career of a rabbi. Many scholars took up the medical profession as an honorable way of earning a living. This was made comparatively easy because the curriculum of talmudic schools often included the philosophies and sciences of ancient and contemporary times. Very often, therefore, medieval Jewish physicians were simultaneously rabbis, scholars, scientists, translators, grammarians, or poets, and as men of wide general knowledge they frequently attained high official positions in the countries in which they lived.

The Byzantine Era

While Greek science and culture declined in the Byzantine Empire and the Jews living there suffered under oppression, Jewish, as well as Nestorian and Jacobite, physicians and scholars sought to save what they could of Hellenistic science. The Babylonian talmudic centers of Sura and Pumbedita flourished at this period. Although the teaching languages of the period were Hebrew, Syrio-Aramaic, and Persian, it was Greek medicine which was taught, strongly influenced by Hebrew, Babylonian, Persian, and Indian traditions. This becomes apparent from the medical work left by Asaph b. Berechiah, called *Asaph ha-Rofe or Asaph Judaeus, who lived about the sixth century c.e. somewhere in the Middle East. Together with Johanan b. Zavda, Judah ha-Yarḥoni, and other Jewish scholars, he founded a medical school. His work, the oldest known medical book written in Hebrew, encompasses all the then-known wisdom of Greek, Babylonian, Egyptian, and Persian medicine, as well as something of Indian medicine. His medical technique is based on old Hebrew traditions. No Arab influence is apparent, which points to the fact that the book was composed before the seventh century. Most of the remedies mentioned were known in the Middle East generally. The book includes chapters on anatomy, embryology, physiology, hygiene, fever and pulse lore, urology, and a rich antidotarium. The oldest known Hebrew translation of the Aphorisms of Hippocrates, as well as chapters of Dioscorides and Galen, are also to be found in it. The book contains a "physician's oath," modeled on Hippocrates but far surpassing it in ethical content. The book of Asaph is not only significant to modern historians: it had considerable influence on medical history, particularly as far as Hebrew medical terms are concerned.

The Arab Period in the East

Following the Arab conquest of the Middle East and Spain, Jewish communities and centers of learning started to flourish at Faiyum in Egypt, Kairouan in Tunisia, and Cordova in Spain. Studies often included ethics, philosophy, sciences, and medicine. Students acquired experience in medicine by assisting practicing physicians. About a hundred years after the Arab conquest of the Middle East, the name of the Jewish physician Māsarjuwayh of Basra is mentioned as the first of a long list of men who translated a great number of Greek and Syrian works into Arabic. Unfortunately all his works have been lost, and he only appears as a frequent reference. Rabbān al-Ṭabarī (Sahl), a Jew converted to Islam who lived in Persia at the beginning of the ninth century, was a noted physician, mathematician, and astronomer. He was the first to translate *Ptolemy's Almagest into Arabic. His son Ali al-Tabarī Abu al-Ḥasan, also a convert, served as court physician to caliphs from 833 to 861, and was renowned as an ophthalmologist. His Paradise of Wisdom dealt with medicine, embryology, astronomy, and zoology and was one of the first original Arabic medical textbooks. He is best known as the teacher of the Arab physician Rhazes. One of the most outstanding medical personalities of the period was Isaac Judaeus (Isaac Israeli). He is believed to have been the first medical author in Arabic whose works were brought to Europe, and his books on fever, diet, uroscopy, and the ethical conduct of physicians were regarded as classics for several hundred years. His outstanding pupils were Abu al-Jazzār (a non-Jew) and *Dunash b. Tamim. It was said of him that he "lived a hundred years, was unmarried, shunned riches, and wrote important books more precious than silver or gold" (Saʿid b. Ahmad, tenth-century Arab scholar). Israeli's books were first translated into Latin by the monk Constantinus Africanus (1020–1087) and were all printed in Lyons in 1515.

Jewish physicians also flourished in Europe during this period. Among them was Zedekias (d. 880), the first registered Jewish doctor in Franco-Germany. He was personal physician to Louis the Pious and to his son Charles the Bald, and was known as the "wonderful physician" (Muenz).

The School of Salerno

From the ninth to the 12th century a medical study center existed in Salerno in southern Italy uninfluenced, either deliberately or by accident, by the Arab culture which penetrated into Southern Europe. The beginnings of the School of Salerno are associated with the name of the distinguished Jewish physician Shabbetai *Donnolo, of Oria, Calabria. His most famous medical work, Sefer ha-Yakar, lists 120 different remedies and their composition. Greek medicine is often referred to and Hebrew terms such as those used by Asaph ha-Rofe are frequently found in it. There is, however, no evidence that the author knew or accepted Arab medical wisdom, even though by that time many Arabic medical works had reached southern Italy by way of the Saracens of Sicily. It is interesting to note that Sefer ha-Yakar was also the first Hebrew prose written on European soil. References to other Jewish physicians practicing in Salerno and to Hebrew as a language of instruction are to be found in various records of the time. Benjamin of Tudela (12th century) refers to the physician Elijah whom he met when visiting Salerno. On the whole, however, the Jews who transmitted Arab philosophy and medical science had little influence on the School of Salerno, which endeavored to uphold the Greek medical tradition.

The Arab-Spanish Period

The Jews played an influential part in the cultural history of the period, starting with the Arab conquest of Spain in the eighth century and ending with their final expulsion from Granada in the 15th century. As statesmen, physicians, mathematicians, philosophers, and poets they attained high positions at the courts of both Moorish and Christian princes. At the Caliphate of Cordova (tenth century) was *Ḥasdai ibn Shaprut who, together with a monk, translated Dioscorides from Greek into Arabic. About a century later, Ephraim b. al-Zafran served as physician to the caliph of Egypt. Zafran was a renowned author and bibliophile and left a library of over 20,000 books. Another famous Jewish physician of the 11th century was Salāma ibn Ramḥamūn who lived in Cairo and whose works include a treatise on the causes of scant rainfall in Egypt and another discussing why Egyptian women grow stout early in life. *Judah Halevi (end of 11th century), the famous Spanish poet-physician, exerted great influence on his contemporaries and on later generations. Jonah ibn Bikhlarish (11th century) of Andalusia, court physician to the sultan of Saragossa, was one of the first Jewish scholars to learn Latin. In about 1080 he compiled a dictionary of drugs in Syriac, Persian, Greek, Latin, and Spanish which is believed to be the earliest work of its kind. Sheshet b. Isaac *Benveniste, who served as court physician to the king of Barcelona, was the author of a famous gynecological treatise in Arabic. The most important Jewish physician-philosopher of the period was Maimonides. Born in Cordova, he fled with his family to North Africa and soon attained a worldwide reputation as a religious legislator, philosopher, and physician. In 1170 he became personal physician to the family of Sultan Saladin of Egypt and continued to serve them until his death. Maimonides wrote ten medical works, of which the most important ones were Pirkei Moshe ("Aphorisms of Moshe") and Regimen Sanitatis. Maimonides' whole concept of medicine is based on the conviction that a healthy body is the prerequisite for a healthy soul. This enables a man to develop his intellectual and moral capabilities and leads him toward the knowledge of God and thus to a more ethical life. He regards healing as the art of repairing both the defects of the body and the turmoil of the mind. A physician must therefore have not only the technical knowledge of his profession, but also the intuition and skill to understand the patient's personality and environment. Maimonides divides medicine into three main fields: preventive medicine – the care of the healthy; the curing of the sick; and the care and treatment of the convalescent, including the aged. Though leaning heavily on the medical teachings of the ancient Greeks, Maimonides warns against blind belief in so-called authorities and upholds the value of clear thought and experiments. His medical observations, diagnoses, and methods of healing mentioned in his works on asthma, poisons, his medical responsa, and commentaries on the Aphorisms of Hippocrates contain innovations in their day and many of them are still valid. Maimonides wrote his medical books in Arabic: most of them were soon translated into Hebrew and Latin.

Southern France

At the end of the 12th and the beginning of the 13th century, Jewish centers of learning were established in southern France – in Avignon, Lunel, Montpellier, Béziers, and Carcassonne. Conditions for Jews in these regions were generally somewhat better than those in Spain, although they did not escape restrictions, expulsion, and persecution. For a period of two to three hundred years, papal bulls and Synod decrees alternated in forbidding and then allowing Jewish physicians to practice their profession. The principal service rendered by Jewish scholars of southern France, many of whom had emigrated from Spain and Portugal, was the translation of Arabic works into Hebrew and Latin. Since some of the original Arabic works had been lost, it was only through their Hebrew translations that they were preserved. The important early 11th-century medical work, the Canon of *Avicenna, was translated into Latin and Hebrew a number of times. The work of translation was accompanied by great scholarly activity. The medical school of Montpellier owed its foundation largely to Jewish scholars, and various records mention "private" schools in which Hebrew law, science, and medicine were taught for a stipulated fee. During the 15th and 16th centuries, when certain universities were closed to Jews, Hebrew translations of Arabic and Greek medical works were made specifically for Jewish medical students.

The most notable of the long list of distinguished translators was the *Tibbon family (Judah b. Saul, Samuel, Moses), who during the 12th and 13th centuries translated most of the well-known scientific and philosophic works, including those of Maimonides, from Arabic into Hebrew. Other eminent translators of the period were Jacob b. Makhir (Prophatius Judaeus), a member of the Tibbon family; Zerahiah ibn Shealtiel Ḥen; and Jacob ha-Katan, translator into Hebrew of Nicolai's antidotarium and of Averroes' treatise on diarrhea. Of special interest is Abraham Shem Tov of Tortosa, who practiced in Marseilles toward the end of the 13th century. His works, especially his translation of Abu al-Qāsim al-Zahrāwī's al-Tatzrif, are of particular importance because he introduced a new Hebrew terminology based mainly on terms used in the Talmud. In other works he deals with the necessity of studying basic sciences with apprenticeships in hospitals, and with the behavior required of the physician when visiting patients, especially poor ones. Another distinguished translator-physician was Moses Farrachi b. Salem (Ferragut) of the 13th century. He studied medicine at Salerno, and at the request of the king of Naples translated Rhazes' Continens and other Arabic medical works into Latin.

Jewish influence was so strong that in Montpellier, portraits of Jews were included in the marble plaques commemorating the early masters of the university. Apparently there was also a Jewish school of medicine in Lunel, which did not, however, attain the eminence of the University of Montpellier. A large part of the information on the early history of the latter and its relations with Jewish scholars is to be found in the history written by one of its graduates, Jean *Astruc (1684–1766), a man of Spanish-Jewish descent, later professor of medicine there and subsequently physician to Louis XV. The Saporta family, also of Marrano descent, has a prominent place in the history of Montpellier during the 16th century. Louis (i) Saporta came from Lerida, was appointed city physician in Marseilles in 1490, and from 1506 to 1529 served as professor at Montpellier University. His son Louis (ii) studied medicine there, and his grandson Antoine became successively royal professor, dean, and chancellor of the university (1560). His great-grandson Jean became professor in 1577 and vice chancellor in 1603. The family then immigrated to the French colonies of America and the name does not appear in the later history of Montpellier. The Sanchez family, already well-known in Portugal and Spain, also became prominent in medicine in southern France. The most distinguished member was Francisco *Sanchez (1562–1632), who was appointed professor of medicine and philosophy at Montpellier and later at Toulouse, and published many medical treatises. Jean Baptiste Silva (1682–1742), a native of Bordeaux who graduated in medicine from Montpellier, became physician to the grand duke of Bavaria, Prince Luis Henry of Conde, and Voltaire.

Benvenutus Grapheus, from Jerusalem, one of the most famous eye doctors of the Middle Ages, lived in the 12th century. He taught and practiced in Southern Europe and probably also in Salerno. His observations of and recommended cures for eye diseases prevailing in Southern Europe and other Mediterranean countries are of extraordinary accuracy and his works, which were translated into many European languages, were the most popular textbooks on ophthalmology of the period. There were also Jewish women physicians practicing at this time. Among them was Sarah La Migresse, who lived and practiced in Paris toward the end of the 13th century. In Marseilles a record has been found of an agreement signed in 1326 between Sara de Saint Gilles, widow of Abraham, and Salvet de Bourgneuf, whereby the former undertook to teach the latter "Artem medicine et physice," and to clothe and care for him for a period of seven months. In return, Salvet agreed to turn over to his teacher all his fees as physician during that period. Sarah of Wuerzburg received a license from Archbishop Johann ii in 1419 and developed a lucrative medical practice. Rebekah Zerlin of Frankfurt (c. 1430) became famous as an oculist.

Christian Spain and Portugal

During the major part of the 13th and 14th centuries Jewish physicians in Catholic Spain enjoyed the protection and support of the reigning monarchs though toward the end of that period the Inquisition became more active. The list of prominent physicians of that period is a long one and only a few can be mentioned here. One of the most important was al-Fakhār (d. 1235), who received the title of nasi ("prince") at the court of Ferdinand iii in Toledo. Another, Nathan b. Joel *Falaquera (second half of 13th century), wrote a medical book in Hebrew on the theory and practice of medicine, therapeutics, herbs and drugs, and hygiene. He used medical and botanical terms found in the Talmud. Abraham b. David Caslari of Narbonne and Béziers was the author of Aleh Refu'ah ("The Leaf of Healing," 1326), a treatise on fevers, divided into five books, to be used as a vademecum on these matters, and of a treatise on pestilential and other fevers, written in 1349 when the Black Death decimated the population of Provence, Catalonia, and Aragon. In 1360, Meir b. Isaac *Aldabi, a native of Toledo who went to Jerusalem in the middle of the 14th century, completed his comprehensive Shevilei Emunah, a collection of philosophic, mystic, and talmudic teachings including chapters on human embryology, anatomy, physiology, pathology, and rules of health.

after the expulsion

At the end of the 15th century the Jews were expelled from Spain and Portugal. Even before that many eminent physicians had immigrated to North Africa, Turkey, Greece, Italy, and Holland. Many were forced converts and some continued to practice in Spain and Portugal until the 18th century, despite their precarious position in those countries, where they were under constant threat of persecution. It is a historical fact that the Marranos and their descendants were leaders and pioneers in medicine in Europe and Asia for several centuries, from the Renaissance until modern times. Many of them distinguished themselves particularly in medical literature. The 16th century was a time of immense exploration, discovery, and progress. During this period – the beginning of the medical renaissance – many distinguished Jewish physicians, fleeing the Iberian Peninsula, won a worldwide reputation in other lands. Among them was *Amatus Lusitanus, who studied and practiced in Salamanca, Lisbon, Antwerp, Italy, and Greece and whose life was a saga of adventurous flights from one country to another. His principal works were Centuria, the description of 700 cases of disease, and a translation of and commentary on Dioscorides. He is also famous for his unrelenting battle against superstition and medical quackery.

some distinguished families

Abraham b. Samuel *Zacuto, called Diego Roderigo, was born in the Spanish city of Salamanca in 1452 and immigrated to Portugal and Tunis, where he became famous as a physician and astronomer. His great grandson, *Zacutus Lusitanus, born in Lisbon in 1575, became a physician in Salamanca and later fled to Amsterdam, where he became one of the foremost critics of his time. He wrote a history of medicine in 12 volumes, De medicorum Principum, and was also known for his code of ethics for physicians, Introitus medici ad praxim.

Dionysus Brudus (1470–1540), a physician at the Portuguese court who later lived in Antwerp, wrote important works on Galenism and on phlebotomy. His son Manuel Brudus practiced in Venice, England, and Flanders and published works on diet for febrile diseases which were widely read. Luiz Mercado (16th–17th century) of Valladolid wrote a medicophilosophical work De Veritate (1604), as well as numerous works on fevers, gynecology, pediatrics, hereditary diseases, and infectious maladies. Isaac *Cardozo, born in Portugal in 1610, became court physician to King Philip iv in Madrid. The 15th-century physician and poet Francesco Lopez de Villalobos was one of the first to describe lues (syphilis). In 1498 he also published a description of bubonic plague. Roderigo *Lopez was an internist and anatomist who fled the Inquisition in 1559 and became physician to Queen Elizabeth i of England. In 1594 he was accused of plotting to poison Elizabeth and sentenced to death.

The family of de *Castro produced many distinguished physicians. The most famous was Roderigo de Castro (c. 1550–1627), author of a gynecological work, Universa Muliebrium Medicina, and physician to the king of Denmark and various German dukes and princes. His son Benedict de Castro (b. 1597) started practicing in Hamburg and later became physician to the queen of Sweden. He was the author of Apologia, a medico-historical work which described the achievements of Jewish doctors and defended them against antisemitic charges. Orobio de Castro fled the Inquisition and settled in Amsterdam, where he became a famous physician and leader of the Jewish community. Jacob de Castro Sarmento (1692–1762), born in Portugal, settled in England and was admitted as a fellow of the Royal Society in 1730. His work Agua de Inglaterra reveals a profound knowledge of the therapeutic properties of quinine. The 18th-century Jacob Rodrigues *Pereira was a pioneer in the education of deaf-mutes. Born in Spain, of Marrano parents, he escaped the Inquisition, settled in Bordeaux, and embraced Judaism. At the age of 19 he started his campaign for improving the status of the deaf-mute, and continued in his chosen task for 46 years, showing great ability in teaching speech to the congenital deaf-mute. He invented a sign language for the deaf and dumb. The fate of Antonio Ribeira Sanchez illustrates how far-reaching was the influence of Jewish physicians at that period. A Portuguese Marrano, he fled from the Inquisition to Holland at the beginning of the 18th century and became the pupil of the famous Dutch physician, Boerhaven. In 1740 he went to Russia as personal physician to the czarinas Elizabeth and Catherine ii. However, when his Jewish origin became known he was threatened with death and with great difficulty escaped to Paris, where he became an eminent physician and introduced soblimat into the therapy of syphilis.

A large number of Jewish physicians also settled in Turkey, where private citizens as well as sultans, viziers, and pashas valued their skill and medical knowledge and their high standard of ethics. In the 15th century Joseph *Hamon, a Granada physician, went at an advanced age to Constantinople, where he became court physician. For almost a century some member of the Hamon family held the position of court physician and exercised great public influence. Marrano physicians were also among the East India pioneers. Foremost among them was Garcia de *Orta, born in Portugal. In 1534 he went to India and there studied and collected Oriental plants and drugs. His Colloquios dos simples Drogas e cosas medicinas de India, which appeared in 1563 in the form of dialogues, is not only the first but also the most important contribution on this subject to European medicine of that time. Twelve years after his death his body was exhumed and burnt by the Inquisition as a suspected Jew. To this same group belongs Cristoval d'*Acosta (1515–1580), a Marrano physician and botanist born in Mozambique, who lived and traveled in India and in the Middle East. He completed and enlarged the work of de Orta.

Italy

Numerous Italian Jewish physicians were also rabbis and leaders of their communities, especially in Rome, Ferrara, Mantua, and Genoa. The Italian universities, notably those of Padua and Perugia, were among the few that allowed Jews to enter the medical faculties at a time when most other European universities were closed to them. The Jewish communities of Italy were also enriched by the influx of Jewish and Marrano scholars and physicians fleeing the persecution of the Inquisition in other countries. At various periods Jews acted as personal physicians to popes, cardinals, bishops, and dukes. Thus Pope Nicholas iv (1287–92) had at his court the physician Isaac b. Mordecai, better known as Maestro Gajota. In 1392 Boniface ix made Angelo, son of Manuele the Jew, his physician and familiar. Immanuel b. Solomon, known as *Immanuel of Rome, was a practicing physician of note, who wrote on various physical and psychic ailments. *Hillel b. Samuel of Verona, who practiced in Ferrara, was a physician and translator of distinction. Another famous physician and translator was *Kalonymus b. Kalonymus, a native of Arles in southern France who later moved to Rome. He translated some of Galen's writings from Arabic into Hebrew and became famous for his accuracy and literary style. Special privileges and tax exemptions usually accompanied the appointment of court physicians. However, the periods of leniency to Jews were usually followed by periods of restriction and persecution. It has been suggested that the popularity of Jewish physicians in Italy in spite of the innumerable restrictions, the bitter attacks, and the calumnies was due to the superstitious belief of Christians in the "magic" arts of the Jews. They also admired Jewish doctors for their unselfish devotion to their calling, and it is not irrelevant that there was a scarcity of Christian physicians, especially during times of epidemic.

the 15th and 16th centuries

A number of distinguished Italian Jews appeared in the field of medicine during the 15th and 16th centuries. Saladino Ferro d'Ascoli (15th–16th century) was acknowledged as the leading pharmacist of his time, and his work on pharmacology was the basic textbook for all pharmacists until the 18th century. Bonet de *Lattes (d. 1515), a native of Provence, became physician to Popes Alexander vi and Leo x. He also served as judge of the highest Italian court of appeal and rabbi to the Jewish community of Rome. Philotheus Eliajus Montalto (d. 1616) fled to Italy from the Portuguese Inquisition. In 1606 he became physician to the Grand Duke Ferdinand of Florence and in 1611 personal physician to Queen Marie de Medici of France. By order of the queen he was buried in a Jewish cemetery in Amsterdam. His work Archipathologia, dealing with diseases of the nervous system and mental disturbances, was widely used in his time and often referred to by later medical writers. Roderigo de Fonseca in the 16th century earned his reputation by his clear diagnoses and descriptions of internal diseases, fevers, surgery, and pharmacology. Benjamin *Mussafia distinguished himself as physician, philologist, scholar, and rabbi. He served as personal physician to the Danish king Christian iv. One of the most outstanding personalities of the time was Rabbi Jacob *Ẓahalon, born in Rome and later physician in Ferrara. In his book Oẓar ha-Ḥayyim he described contemporary hygienic measures as well as the bubonic plague in Rome in 1656. He used numerous new Hebrew medical terms and redefined the moral obligations of the Jewish physician to his profession. Joseph Solomon *Delmedigo studied medicine in Padua and was a pupil of Galileo. After many years of study and travel he settled in Poland and became personal physician to Prince Radziwill. He is famous as a rabbi, physician, philosopher, and mathematician. During the 17th and 18th centuries the family of Conegliano became prominent as physicians and medical teachers in Venice. David de Pomis (1525–1593) of Spoleto became physician to Pope Pius IV. Apart from various medical treatises, he wrote the famous De Medico Hebreo Enarratio Apologica, a scholarly defense of the Jewish physician. The Jewish community in Italy, however, declined during the second half of the 17th and the 18th centuries. Only with the French Revolution and the conquest of Italy by Napoleon did the Jews of Italy come into their own again.

The Northern Countries

In the northern countries – Germany, Poland, Russia – there were Jewish physicians of note only from the middle of the 17th century onward, many of them refugees from the countries of the Inquisition. However, as early as the 11th century a medical book had been written in Hebrew by R. Saadiah of Worms. Gradually, the universities of the German states opened their doors to Jews. Around the middle of the 17th century the grand duke of Brandenburg permitted Jews to enter the University of Frankfurt on the Oder. One of the first to study there was Tobias b. Moses *Cohn of Metz. However, he was unable to obtain his degree and therefore went to Padua to receive his M.D. He practiced in Poland and later became physician to five successive sultans in Constantinople. His Ma'aseh Tuviyyah is almost an encyclopedia and includes medicine, sciences, philosophy, and part of a dictionary. From the beginning of the 18th century the number of practicing Jewish physicians in Germany, Czechoslovakia, England, and Poland increased. Jewish physicians of that period include Marcus Eliezer *Bloch, a famous general practitioner in Berlin during the mid-18th century; Gumperz (Georg) Levison, who distinguished himself as a practitioner, medical author, and organizer in England and in Sweden during the second half of the 18th century; Elias Henschel, a pioneer in modern obstetrics; and Marcus *Herz, an outstanding philosopher, teacher, and physician.

[Suesmann Muntner]

the modern era

19th Century

When Joseph ii of Austria proclaimed the Act of Tolerance in 1782 and when, shortly thereafter, the French Revolution brought in its wake emancipation to Jews throughout Western Europe, the gates of European medical schools were thrown open to Jewish students. The importance of the contribution made by Jewish doctors to subsequent medical progress is enormous. The quality and quantity of this contribution is reflected in rosters of Nobel laureates and winners of other awards, dictionaries of eponymic syndromes and diseases, and lists of medical authors and investigators. Spanning nearly two centuries and extending over many lands, Jewish participation in modern medicine defies rigid categorization within frameworks of countries and centuries. Frequent demographic changes have occurred as a result of global events which did not always coincide with the "turn" of a century. In fact, a future historian might choose the 1930s as the watershed decade, during which the mainstream of Jewish medical activity became diverted from Europe to America, coinciding with the rise of American medicine vis-à-vis that of Europe.

The geographic distribution of Jews practicing medicine in the 19th century reflected the incongruity between the size of Jewish communities and their number of medical practitioners and scientists. Because of restrictions practiced by Russian medical schools, the youth of the world's largest Jewish community went abroad to pursue their medical studies. Those who returned had to pass special examinations in order to obtain a license. Not until 1861 were they admitted to the army and civil service, and only in 1879 were they granted permission to live beyond the *Pale of Settlement. Even when Jewish physicians successfully overcame the main restrictions and hardships, they were rarely permitted to participate fully in university-centered medical activities.

On the other hand, Jewish doctors were extensively involved in the academic-scientific life of Central and Western Europe. In Austria and Germany, this involvement did not, however, come about suddenly. Although the gates of the universities were open for admission, the inner doors to academic recognition remained partially closed during the first half of the century. At best, a Jew could hope to become a privatdocent or a "titular" professor. And even after the struggle for academic recognition had been won, Jews were not welcome in "establishment"-controlled specialties, such as surgery. As a result they tended to cultivate fields that did not attract their non-Jewish colleagues.

An outstanding example of this trend is dermatology-ve-nereology. When Ferdinand von Hebra took over the Kraetze Klinik in Vienna, he was able to recruit only Jewish assistants, some of whom – Moritz *Kaposi, Isador Neumann (1832–1906), and Heinrich Auspitz (1835–1886) – became world famous. In Germany, where dermatology was often referred to disdainfully as "Judenhaut," Paul *Unna, Oskar *Lassar, and Josef *Jadassohn established reputations as pathfinders in their specialty. In Switzerland Bruno Bloch (1878–1933) made Zurich an international teaching center. The predilection for neglected fields may also account for Jewish preeminence in biochemistry, immunology, *psychiatry, and in hematology, histology, and microscopic pathology – sciences which were collectively referred to at the time as "microscopy." The microscope attracted Jewish physicians, many of whom combined the study of microscopy with the practice and teaching of clinical medicine. Outstanding among these men were Ludwig *Traube, a great teacher and pioneer of experimental pathology, anatomy, and neurohistology; Robert *Remak, a pathfinder in embryology, neurohistology, and electro-therapy; Moritz *Romberg, the founder of neuropathology; and the surgeon Benedict *Stilling, whose discovery of nerve nuclei was a turning point in basic neurology. These investigators laid the foundation of modern neurology, which numbered among its great names Leopold *Auerbach, Ludwig *Edinger, and Herman *Oppenheim – discoverers of many neurologic disorders now bearing their names.

Microscopy was also pursued by investigators who were exclusively devoted to basic science. To this category belong the histologist-anatomist Jacob *Henle, who anticipated the germ theory of infection; Gabriel *Valentin, who enriched every branch of basic science; the histologist-pathologist Julius *Cohnheim, who proved that pus cells are derived from the blood; the physiologists Hugo *Kronecker, Rudolf *Heidenhain, Nathan Zuntz, and Hermann *Munk, who were trail-blazers in this field; and Carl *Weigert, whose novel concepts and staining techniques advanced many sciences, particularly bacteriology. Jewish contributions to bacteriology date back to the botanist Ferdinand Cohn (1828–1898), who established the vegetable nature of bacteria (1853). These contributions increased during the latter part of the century when bacteriology and the allied science of immunology became integral parts of medicine. Jews became conspicuous in the discovery of bacteria and the development of immunologic methods for diagnosing and preventing bacterial infection. Prominent in this field were Fernand *Widal, who devised a test for typhoid fever and for its prevention; Mordecai Waldemar *Haffkine, who prepared vaccines against cholera and plague; August von *Wasserman, who researched anti-toxins and antisera; and Nobel laureate Paul *Ehrlich, the father of hematology, chemotherapy, and theoretical immunology.

At the same time, clinical medicine was also receiving Jewish contributions. Among the outstanding internists were Heinrich von *Bamberger, for his contributions to cardiology; Hermann *Senator, for his work on the kidney; and Ottomar Rosenbach (1851–1907), for his researches in functional disease and psychotherapy. Outstanding pediatricians were Edward Henoch (1820–1910) who described a bleeding disease named after him; Adolf *Baginsky who investigated nutrition and infectious diseases; and Max Kassowitz (1842–1913) who shed light on congenital syphilis and rickets. Jews were also prominent in otolaryngology, a specialty founded by Adam *Politzer, and in ophthalmology, with the contributions extending from 1810, when George Gerson (1788–1844) investigated astigmatism, to the close of the century, when Karl *Koller began to use local anesthesia in the treatment of eye diseases. Obstetrics and gynecology owe much to Samuel *Kristeller, Wilhelm Freund (1833–1917), and Leopold *Landau for new concepts, observations, and operative techniques. X-ray therapy was founded in 1897 by Leopold Freund (1868–1944). Even surgery, a specialty not too accessible to Jews, numbered many notables. Anton Wolfeer (1850–1917) performed the first gastroenterostomy in 1881, James Israel (1848–1926) pioneered urologic surgery, and Leopold Von Dittel (1815–1898) devised new surgical techniques and instruments. Jewish doctors also contributed to the history of medicine. Noted historians were August *Hirsch, Judah *Katzenelson, and Julius *Pagel.

It is apparent from some of the aforementioned names that Jewish contributions to medicine were not confined to German-speaking countries. In France, many Jewish doctors attained eminence. Julius Sichel (1802–1868) established the first eye clinic in Paris in 1830; Michel Levy (1809–1872) introduced new concepts in the field of public health; Georges Hayem (1841–1933) pioneered hematology; and Fernand Widal made a world impact with his work on the detection and prevention of typhoid fever. In Denmark the great anatomist Ludvig *Jacobson and the pioneer in occupational diseases, Adolph *Hannover, were active during the first half of the century; and the epidemiologists Carl *Salomonsen and "the father of pediatrics in Denmark," Harold Hirschprung (1830–1916), during the second. Holland was the home of the physiologist Van Deen (1804–1869); Italy of the anatomist-physiologist-psychiatrist, Cesare *Lombroso, whose views on criminology have now been discredited; and Poland, of the anatomist Ludwig *Hirszfeld, the neurologist Samuel Goldflam (1852–1930), and the ophthalmologist Ludwig *Zamenhof, the creator of Esperanto. England knighted its greatest laryngologist Sir Felix *Semon. Even restrictive Russia honored the distinguished ophthalmologist Max *Mandelstamm with the title "Privatdocent" and the physiologist, Elie de-*Cyon, with a professorship (1872).

In America, where the Jewish community was small and medical science was not yet advanced, Jewish contributions to medicine were modest, and as often related to organization, administration, and the foundation of hospitals as to scientific pursuits. The ophthalmic surgeon Isaac Hays (1796–1879) was editor of the influential American Journal of Medical Sciences (1827) and one of the founders of the American Medical Association. Jacob da Silva *Solis-Cohen, a pioneer in laryngology who performed the first laryngectomy for laryngeal cancer (1867), was the acknowledged "father" of organized instruction in his specialty. Another "father" – that of American pediatrics – Abraham Jacobi was the founder of the American Pediatric Society and in his later years (1910), the president of the American Medical Association. Jewish doctors were also active in establishing and staffing Jewish hospitals that provided training for Jewish interns and residents. In time these hospitals became important research centers affiliated with medical schools that absorbed many Jewish students.

Challenges to Jewish Medical Scientists and Clinicians

Medicine has undergone profound changes since the start of the 20th century. Advances in medical science have gradually transformed clinical practice from a largely pragmatic skill based on anecdotal experience into a discipline underwritten by verified laboratory and clinical observations. The increasing pace of scientific discovery continues to offer therapeutic possibilities of unprecedented complexity and expense. Medical teaching has changed from apprenticeship to individual teachers with varying degrees of skill and knowledge to organized instruction in universities with courses and teachers with appropriate academic credentials. Before the 1950s patients were rarely given explanations for their illnesses and treatment. Patients now have ready access to medical knowledge and expect to be involved in decisions about their clinical management. They also have increasing expectations in terms of the standards of medical care. Change in attitude and technical advances have made ethics an integral part of clinical practice. In general, an overview of the Jewish contribution to medicine in modern times must consider advances in scientific knowledge, the application of this knowledge to clinical practice, medical education, the organization of medical practice, and the proper education and participation of patients.

Medicine in the Jewish world must take account of four special factors. Firstly, clinical decisions are often influenced by Jewish ethics that differ in varying degree from the constraints related to other forms of religious adherence. Secondly, antisemitism culminating in the Holocaust profoundly affected the lives of Jewish medical scientists and doctors. Thirdly, there is a strong incentive to apply research and clinical skills to diseases to which Jews are genetically predisposed (see *Hereditary Diseases). Finally, the establishment of the State of Israel created the need for sophisticated medical research, teaching, and services in a region of initially endemic infectious diseases in the face of massive immigration, wars, and continuing terrorism.

Conctributions to Medical Science

Advances in clinical medicine have followed progress in the biomedical sciences and the development of novel technologies. Biomedical research in the last quarter of the 20th and the beginning of the 21st centuries is characterized by better understanding of the molecular and pathological processes, the deciphering of the human genome, and the elucidation of complex intra-cellular processes. These have led to the engineering of disease-specific and targeted therapies and the development of non-invasive technologies. Jewish researchers and clinicians have made significant contributions to these advances.

Jewish contributions to the advances in basic science that have transformed medical practice are considered in the entry *Life Sciences. Often the implications of these discoveries for medicine are not initially apparent. There are additional areas of scientific research that are from the outset more clearly relevant to medicine to which Jews have made important contributions. However in medical as in scientific research it has become increasingly difficult to single out specifically Jewish contributors to a global enterprise that is for the most part now carried out by large, interdisciplinary teams, often working in different institutes.

infectious diseases

At the beginning of the 20th century infections were the major causes of human morbidity and mortality. Increased understanding of immunity and natural resistance to infection lead to diagnostic and eventually therapeutic advances. August von *Wasserman introduced the first diagnostic test for syphilis (1906).

Bela *Schick devised a diagnostic test for detecting exposure to C. diphtheriae, the cause of diphtheria. Michael *Heidelberger's work on antibody structure and function laid the basis for protection against and treatment of infections with preformed antibody (passive immunization). Developments in vaccine production (active immunization) made it possible for Jonas *Salk and Albert *Sabin to produce vaccines with the potential ability to eliminate poliomyelitis.

Advances in drug production also reduced the threat of infection. *Ehrlich's dream of a "magic bullet," which would selectively destroy bacteria as salvarsan does spirochetes, has been partially realized by the discovery of sulfonamides and antibiotics. In 1940 Sir Ernst Boris *Chain isolated penicillin, the first naturally occurring antibiotic to be discovered. Streptomycin was isolated in 1944 and neomycin in 1948 by Selman *Waksman of Rutgers University. Harry Eagle (1905–1992) and Maxwell Finland (1902–1987) made important contributions to progress in antibiotic therapy by devising accurate methods for measuring the potency, anti-bacterial specificity, and safety of antibiotics. Unfortunately, microbial resistance to antibiotics threatens to reverse the relative security achieved in the golden age of drug treatment. Stanley Farber discovered one important mechanism in the development of antibiotic resistance, namely the ability of gene fragments called plasmids to confer resistance on previously susceptible bacteria. Combating infection also depends on the efforts of scientists who understand the biology and epidemiology of infection, as exemplified by the research of Baruch *Blumberg and Barry Bloom. Astute clinical observation is also part of the process of controlling infections, as illustrated by Saul Krugman's elucidation of the many causes of "infectious hepatitis."

cell biology and cancer

The links between cell biology and cancer research are prime examples of the contributions of basic research to medicine. For example the formation of new blood vessels (angiogenesis) is essential for tumor growth and metastasis. Judah *Folkman's discoveries in this field point the way to new forms of treatment that may interdict this process. The application of basic genetics to the biology of malignant cells has illuminated many areas of cancer research where inherited or acquired mutations are fundamentally important. A pertinent example is the work of Bert Vogelstein (1949– ) in understanding the molecular basis of colo-rectal cancer. Long-held hopes of manipulating patients' immune system to reject cancer have been greatly encouraged by the innovative work of George *Klein.

blood disorders

Advances in immunology have improved our understanding of many hematological diseases and have also influenced clinical practice. Gerald *Edelman's research on immunoglobulin structure clarified the nature of myeloma and other neoplastic diseases characterized by abnormal immunoglobulin production. The discovery and classification of blood groups by Karl *Landsteiner, and his associates Philip *Levine and Alexander Wiener (1907–1976), rationalized the hitherto haphazard and dangerous practice of blood transfusion. Their findings also revealed the nature of blood disorders resulting from immune attacks on blood group antigens, notably hemolytic disease of the newborn. Jewish investigators have contributed to the solution of other hematological problems. William *Damashek was responsible for the logical classification of many immune-mediated and neoplastic blood diseases and was also an innovator in treating leukemia with anti-proliferative drugs. Robert B. Epstein (1928– ) collaborated with E.D. Thomas in the first successful bone marrow transplantation. Louis Klein *Diamond made major advances in classifying and characterizing many blood disorders of infancy and childhood. Ernest Jaffe (1925– ) contributed to the understanding of hemoglobin synthesis. Ernest Beutler (1928– ) elucidated many facets of iron metabolism in red cell formation and proposed a means of tracing the cellular origin of many bone marrow-derived diseases. Maxwell *Wintrobe developed hematology as a laboratory and clinical discipline.

immunological diseases

Jewish scientists have made outstanding contributions to understanding the molecular basis and clinical manifestations of disordered immunity, a field that has assumed increasing importance in allergy, transplantation medicine, and auto-immunity. Alexander *Besredka of the Pasteur Institute in Paris was a pioneer in allergy research. Current understanding of the pharmacological basis of allergic disorders owed much to the findings of Baruj *Benacerraf. Ernest Witebsky (1901–1969) and Felix Milgrom (1919– ) made important observations on immune mechanisms underlying autoimmune diseases. Robert Schwarz (1928– ) introduced new experimental and therapeutic strategies based on the concept that the immune system in auto-immunity loses the ability to distinguish between self and non-self, a defect termed "loss of tolerance." Peter *Lachmann helped delineate the role of a disturbed complement system in these diseases. Fred *Rosen (1930–2005) was a world authority on the management of inherited immunodeficiency diseases in childhood. The availability of monoclonal antibodies arising from Cesar *Milstein's work has provided immense benefits for research and clinical practice in many fields.

nutritional diseases

Casimir *Funk introduced the idea of vitamin (which he called "vitamines") deficiency to nutrition and medicine. He recognized that beriberi is caused by nutritional deficiency and he also isolated nicotinic acid, a member of the vitamin b complex. Joseph *Goldberger deduced that pellagra is a disease resulting from vitamin deficiency. In the 1920s Alfred Hess, working in parallel with Harry Steenbock, started the important field delineating the relationship between vitamin d deficiencies, rickets, and other bone disorders.

metabolic diseases

Progress in understanding metabolic diseases went through many transformations of approach and technique in the 20th century to which Jewish scientists and physicians made crucially important contributions. Mapping biochemical pathways in health and disease has depended on laboratory discoveries in experimental animals, the introduction of ethically acceptable methods of investigation in humans, improved techniques of laboratory analysis, and the adaptation of molecular genetics to this field.

The high prevalence rate of many metabolic diseases in Jewish populations makes this an area of especial Jewish interest. Diabetes mellitus, now recognized as occurring in two main forms, is a compelling example. In 1899, Oskar Minkowski (1855–1931) demonstrated the association of diabetes with the pancreas, and in 1920 Moses Barron (1883–1961) described observations of the pancreas that suggested the experimental approach that led to Banting and Best's momentous discovery of insulin. Rachmiel Levine (1910–1998) showed that insulin promotes the transport of glucose from blood to cells, a process termed "the Levine effect." Progress in other fields was helped by observations by Jewish biochemists such as Seymour Reichlin and more fundamentally by the description of major metabolic pathways by Max *Meyerhof and Hans *Krebs and many others. A key example of the interrelationship between genetic predisposition to metabolic problems such as type ii diabetes, disorders of lipid metabolism, and obesity is provided by the observations of Jeffrey Friedman, Sir Philip *Cohen, and other investigators.

endocrine diseases

Endocrine diseases illustrate the need to draw together many disciplinary themes in order to understand disease mechanisms and predisposition to these diseases. Jewish medical scientists have contributed to the genetic, metabolic, pharmacological, and immunological studies needed to explore the basis of endocrine diseases such as diabetes and thyroid disease. However, central to advances in this field was the development of precise methods for measuring hormone levels for research and clinical purposes. Rosalyn Sussman *Yalow and Andrew *Schally were largely responsible for the assay techniques that made these measurements possible and which also accelerated research in many other fields.

heart, lung, and kidney diseases

The fields of cardiovascular, pulmonary, and renal diseases have many pioneering Jewish contributors. Arthur *Master introduced the concept of coronary insufficiency and the "Master Step Test" for its detection; Louis Katz (1897–1973) elucidated the principles of cardiovascular hemodynamics, metabolism, and electro-physiology, research fields also enriched by Simon Dack (1908–1994), Richard Bing (1909– ), Eugene Braunwald (1929– ), and Eliot Corday (1913–1999). Michel Mirowski (1924–1990) invented the automatic implantable cardiodefibrillator (aicd) which transformed the management of life-threatening cardiac arrhythmias. The gradual introduction of surgical methods of treating cardiovascular problems necessitated the development of increasingly sophisticated biotechnology to which Adrian Kantrowitz (1918– ) has made many indispensable contributions. New approaches to the study of pulmonary circulation have been introduced by Alfred P. Fishman (1918– ). Arthur Maurice Fishberg (1898–1992) correlated the pathological and clinical manifestations of kidney disease. In 1934 Harry Goldblatt (1891–1977) demonstrated the mechanism of secondary hypertension caused by renal vascular disease. Kurt Lange (1906–?) investigated immunologic, biochemical, and pathological facets of kidney disease in children.

gastroenterology

At the turn of the 20th century, Max Einhorn (1862–1953) and Samuel Weiss (1885–?) were amongst the first clinicians to develop gastroenterology as a medical specialty. In 1931 Burrill *Crohn described the inflammatory bowel disease named after him and Heinrich Necheles (1897–1979), Joseph Kirsner (1909–?), and Leon Schiff (1901–?) extended our understanding of the pathophysiology and therapy of many gastrointestinal and liver diseases. Increasing knowledge produced a need to establish departments devoted to research and treatment of patients with these disorders of the kind set up by Henry *Janowitz at Mount Sinai Hospital, New York.

neurology

Progress in clinical neurology is largely dependent on increased understanding of brain structure and function. Jewish scientists have participated in this problem from the early days of Joseph *Erlanger's research on nerve conduction to Richard *Axel's dissection of the pathways relevant to olfactory function. Among the clinical neurologists who made the first attempts to correlate disease and basic pathology were Bernard Alpers, who studied neuro-syphilis and vascular degenerative diseases; Benjamin Boshes, who investigated Parkinson's disease; and Leo Alexander who investigated multiple sclerosis. Israel *Wechsler compiled one of the first systematic textbooks on clinical neurology (1927) which became a standard work.

dermatology

The longstanding interest of Jewish physicians in skin diseases might traditionally be said to have begun with the Bible. Marion Sulzberger (1895–1983), a pupil of Bruno Bloch of Zurich, Stephen Rothman (1894–1963), Herman Pinkus (1905–1985), and Louis Forman were amongst the first dermatologists to appreciate the need to underpin merely descriptive diagnosis with systematic observations of pathological changes readily observed in this most accessible of human organs. Edmund Klein (1922–1999) was an early winner of the Lasker Award for Clinical Medical Research in recognition of his pioneering treatment of skin diseases, and especially pre-malignant diseases.

rheumatology

Rheumatology is a relatively young but important clinical specialty because of the high incidence of debilitating joint diseases especially in the elderly. The prospects for controlling rheumatoid arthritis have been greatly increased by the successful application of monoclonal antibody techniques. Morris *Ziff was influential worldwide in establishing the essential links between basic science and clinical practice in this discipline.

pediatrics

The demanding technical and psychological challenges of health care in infancy and childhood have intrigued many Jewish scientists and clinicians. In the early stages of its development, Abraham Jacobi (1830–1919) was largely responsible for the emergence of pediatrics in the U.S. Isaac A. *Abt and Julius Hess (1876–1995) were pioneers in child nutrition and care of the premature infant. Henry *Koplik added to knowledge of infectious diseases in children, and Louis *Diamond contributed to pediatric hematology. Sidney Farber (1903–1973) transformed the outlook for childhood leukemia by introducing new anti-proliferative drugs and a regime of comprehensive management. The universally known Dana-Farber Cancer Institute commemorates his achievements. In addition, Alexander Nadas (1913–2000) was a pioneer in pediatric cardiology and Henry Shwachman (1910–1986) was among the first clinical scientists to appreciate the complexities of cystic fibrosis.

surgery, obstetrics, and gynecology

Jewish doctors have made many contributions to the rapidly developing scope of surgery, obstetrics, and gynecology. Charles Elsberg (1871–1948) introduced new methods in the treatment of spinal-cord tumors. Markus *Hajek of Vienna devised new techniques in nasal and laryngeal surgery. A pioneer in thoracic surgery, Max Thorek (1880–1960) founded the International College of Surgeons, and Irving Cooper (1922–1985) introduced an operative procedure for the treatment of Parkinson's disease. In obstetrics, Joseph de Lee (1869–1942) contributed an authoritative textbook and original papers and was an outstanding teacher and clinician. Isidor S. Rubin (1883–1958) made many important contributions to gynecology, including the test for fallopian tube patency when investigating sterility. Lord Robert *Winston's achievements include a worldwide reputation for his contributions to solving the problems of female infertility.

radiology

U.S. Jewish radiologists have enriched every branch of their specialty. Outstanding contributions have been made by Hymer Friedell (1911– ) to radiation biology, by Harold G. Jacobson (1912–2001) to neuroradiology, and Leo Rigler (1896–1979), who was president of the American Radiologic Society, to the radiology of the chest and abdomen. Gustav *Bucky invented the X-ray diaphragm that bears his name.

drugs and therapeutics

Advances in pharmacological knowledge and drug design, testing, and production have transformed the management of virtually every acute and chronic disease. In addition to the development of anti-microbial agents, this is an area to which Jewish scientists and clinicians have made so many contributions that selected examples must suffice. Isidor Ravdin (1894–1972) was a pioneer in anti-cancer chemotherapy. Gertrude *Elion developed the immunosuppressive drug azathioprine, the first anti-viral drug acyclovir, and allopurinol used to treat gout. Ralph Alexander *Raphael's discoveries illustrate how a profound understanding of organic chemistry can be translated into innovative drug design active against a wide range of diseases. Josef Fried (1914–2001) developed anti-inflammatory steroids and Gregory Goodwin *Pincus (1903–1967) and Carl *Djerassi developed the first successful female, oral contraceptive drugs. The successful career of Max *Tishler (1906–1989) also showed the increasing importance of combining scientific and entrepreneurial skills in drug development. This point is emphasized by the increasing dominance of bioengineering companies able to exploit advances in genetics and other fields. The innovative achievements of Robert S. *Langer are a pertinent example. Jewish scientists have also made key contributions to anti-hiv treatment. They include Jerome Horwitz, who synthesized the first drug that inhibits the viral enzyme reverse transcriptase, and Irving Sigal (1953–1988), who first showed the efficacy of drugs which inhibit viral proteases. Sigal died in the terrorist bombing of Pan Am flight 103.

pathology

Jewish pathologists made important contributions at the stage when pathology was developing from an observational skill into one demanding more widely based scientific insight and knowledge. The efforts of Hans Popper (1905–1988) and Fenton Schaffner (1920–2000) clarified the pathology of liver disease. David Spain (1913– ) in cardiac pathology and Averill Liebow (1911–1978) in pulmonary pathology performed a similar service. Benjamin Castleman (1906–1982) described the pathology of the parathyroid glands and a proliferative disease of the immune system which bears his name and is a paradigm for many, more common diseases of a similar nature. Paul *Klemperer's imaginative interpretation of the damage inflicted by "connective tissue diseases" laid the basis for what are now known as multi-system autoimmune diseases.

public health

Jews helped to lay the foundations of public health and hygiene in the U.S. and elsewhere. Sigmund Goldwater (1873–1942) founded the first occupational disease clinic in New York in 1915. His contemporary Milton J. Rosenau (1869–1946) promoted important measures for preventing epidemics of infectious diseases in the Americas and elsewhere. Jeremiah Stamler (1919– ) was one of the first investigators to conduct epidemiologic studies on environmental factors influencing coronary heart disease.

history of medicine

While many Jewish doctors were making history, some were writing it. Outstanding early historians were Max Neuberger (1868–1955) in Austria, Charles *Singer in England, Arturo Castiglioni (1874–1953) in Italy, and Harry *Friedenwald, Victor Robinson (1886–1947), and Saul Jarcho (1906–2000) in the U.S.

education and publication

Jews have played a prominent part in the interrelated fields of medical education and publication. Abraham *Flexner is still remembered for his "Flexner Report" (1906), which charted the subsequent course of medical education in the United States. After World War ii a steadily increasing number of Jews have joined the teaching staffs of medical schools. Many have also contributed to teaching as textbook authors and by editing medical journals. The well-known medical editor, Morris *Fishbein, edited the Journal of the American Medical Association (1924–49) and played a leading role in shaping American healthcare policies. Alexander Gutman (1902–1973) edited the American Journal of Medicine and Alfred Soffer (1922– ) was editor of Chest. Subsequently there has been an at least commensurate increase in the numbers of Jewish medical scientists and teachers needed to meet the enormous demand for journals, books, and education at all levels.

Advances in research and education have also created a demand for medical scientists with the rare combination of the research expertise and administrative skills needed to run vast institutions of unprecedented complexity. Jewish scientists with these capabilities include Arnold Levine at the Rockefeller, Walter *Bodmer, Sir Gustav *Nossal, Harold *Varmus, and Philip Fialkow at the University of Seattle.

Jewish Medicine in the Diaspora

united states

The early years of the 20th century witnessed a continued immigration to the U.S. that changed the "ethnic" and cultural pattern of American Jewry and its medical representation. The first Jewish doctors in the U.S. were of Sephardi origin. During the second part of the 19th century Jewish immigrants from Germany assumed leading roles in communal affairs and medicine. Russian Jews, who began emigrating after the pogroms of the 1880s, added a third element, which was destined to grow in numbers and influence. Later, the U.S. gained new immigrants from the Jewish population that had moved to East European countries when these broke away from the Russian and Austro-Hungarian empires after World War i. These Jews were again unsettled by unfavorable economic and political conditions.

Jewish emigration from Europe to the U.S. yet again increased sharply in the 1930s with the rise of the Nazi Party. After World War ii the majority of those who escaped the Holocaust immigrated to the United States or Israel. Physicians who found refuge in America arrived at a propitious time. The 1930s and 1940s marked the beginning of the current golden age of scientific medicine, ushered in by the discovery of antibiotics and cortisone and advances in molecular biology and medical technology. With the decline of traditional European centers, the United States became the new world center of scientific and medical activity with Jewish immigrants joining the country's extraordinarily creative universities and institutes. Rid of vestiges of intolerance and receptive to new talent, the country's medical establishment and public welcomed the newcomers. Jewish hospitals, such as Mount Sinai in New York and Michael Reese and Mount Sinai in Chicago, as well as non-Jewish hospitals, research foundations, and universities absorbed many of them into the mainstream of medical progress. By the 1980s Jewish physicians in the United States greatly outnumbered those in other countries. In the State of New York alone there were 7,500 practicing Jewish doctors compared with 5,500 in Israel and 3,000 in France. Overall 9% of U.S. physicians were Jewish, compared with a 3% representation in the general population. More than 17,000 of the approximately 27,000 U.S. Jewish physicians in private practice resided in the thickly populated states of New York, California, Illinois, Pennsylvania, New Jersey, and Massachusetts. Of these, approximately 4,700 were general practitioners, 6,500 specialists in general medicine and its branches, 3,000 in surgery, 2,900 in obstetrics and gynecology, 1,000 in ophthalmology, 800 in radiology, 650 in dermatology, and 600 in otolaryngology. However the distribution among medical specialties was uneven. Whereas only 5% of doctors in occupational medicine were Jewish, they comprised 20% of general physicians and more than 30% of psychiatrists. This predominance in numerical terms is likely to have persisted but is difficult to quantify and compare with earlier periods. There has been increasing specialization marking the virtual demise of the "general internist" and the current Jewish population is less homogeneous compared with the initial immigrant Jewish population. However, the Jewish contribution to U.S. and thereby to medicine worldwide should not be assessed simply in terms of the numbers of practicing physicians but should also take account of Jewish contributions to medical science and education.

canada

Jewish doctors and medical scientists in Canada also benefited from the opportunities available in the U.S. to improve the provision of medical services and education. Their numbers included the pediatrician Alton Goldbloom (1890–1962) and Arthur Vineberg (1903–1988), who developed techniques for improving blood circulation to diseased heart muscle.

western europe

The countries of Western Europe other than Germany and Austria had long settled Jewish communities whose numbers were increased by refugees from Russia at the beginning of the 20th century and from Nazi persecution in the 1930s. Jewish doctors are well represented in clinical practice and in academic centers. Their contributions to medicine and medical science in the United Kingdom are reflected by the high national honors accorded to Sir Ludwig *Guttmann for his work on rehabilitation, and to Lord *Cohen, Lord Rosenheim, Lord Turnberg, Sir Raymond Hoffenberg, and Sir George Alberti for their achievements in clinical medicine, teaching, and research. French scientists made important contributions to the formative stages of molecular biology and the contributions of Jewish medical scientists in France are illustrated by the achievements of Jean Hamburger (1909–1992) in renal transplantation. Switzerland's Jewish community of indigenous and refugee medical scientists has included Tadeus *Reichstein, who isolated cortisone, and Pierre Rentchnick (1923– ), the foremost authority on public health and hygiene in a country which traditionally takes these subjects very seriously. Sweden sheltered the Nobel Prize winner Robert *Barany and is now the home of the cancer research specialist George *Klein and of the endocrinologist Carl Luft, well-known for his research on diabetes. The Jewish medical academic communities of Germany and Austria were extinguished by the Nazis and the preeminence of these countries in research and practice thereby passed to the countries where Jewish refugees settled.

russia and the former soviet union

World War i, the Russian Revolution, and the *Balfour declaration had demographic and political consequences that profoundly influenced Jewish participation in medicine. Many Russian Jews moved to large university centers, where they had been forbidden to reside. As a result of this movement and of the new policy of open university admissions, the number of Jewish doctors greatly increased. Unofficial admission quotas reappeared during the later years of Stalin's rule. However, neither their number nor their achievements can be readily determined because of the isolation of Russian Jewry from the Western world.

POLAND AND EASTERN EUROPE

Despite poor economic conditions, Jews in pre-Hitler Poland maintained 40 hospitals where many of the country's 3,500 Jewish doctors provided services. Poverty, backward technology, and a hostile academic environment prevented Jewish scientists from attaining the achievements reached by their colleagues in Western Europe. Still, their contributions were far from negligible. Edward Platau, the doyen of Polish neurologists, researched meningitis and brain tumors. Adolf Beck investigated nerve physiology and Henry K. Higier explored the autonomic nervous system. Samuel Goldflam studied reflexes and the diseases myasthenia gravis and periodic paralysis. Zygmunt Bychowski investigated traumatic epilepsy and multiple sclerosis. Anastaszy Landau was prominent in metabolic research, Stanislaus Klein in hematology, Seweryn Sterling in social medicine, and Gerszon Lewin in tuberculosis. Aron Solowiesczyk, who was killed during the Warsaw ghetto rising, was prominent in surgical research. But the scientific potential of Jewish doctors in Poland was not destined to develop. During the German occupation, Jewish doctors devoted their energies to caring for people doomed to starvation, torture, and death. Many distinguished themselves by acts of dedication and heroism and over 2,800 were killed. The tragic events in Poland were paralleled by similar developments in other German-occupied territories.

south america and mexico

In the early part of the 20th century, geographic remoteness meant that Jewish contributions to medicine in Latin America received less recognition abroad than they deserved. Nevertheless, the large communities in South America were reinforced by immigration from Europe ensuring that Jewish medical scholarship thrived, even if not to the extent enjoyed by colleagues in North America. Since World War ii the opportunities to contribute to advances in medical research have suffered from political instability and periods of economic decline. In Argentina, where Jewish immigration began in 1889, the figure of the pioneer physician Noah Yarchi is still remembered and revered. The doctors who followed in his footsteps helped sustain the health and morale of the colonists and the early settlers in the cities. With the establishment of the Ezra Hospital in Buenos Aires in 1921, a center was provided for medical activity; it grew in importance as the Jewish population increased. Jews have been prominent in every phase of the professional and academic life of the country; Professor Quiroga was president of the Academy of Medicine of Buenos Aires and Ricardo Rodriguez dean of the Medical Faculty of La Plata. Jewish physicians published the Journal Archives de Medicina Argentina-Israel.

For a long period the Jewish population in Brazil was 140,000, and much lower in other Latin American countries. Jewish participation in medicine increased significantly after the arrival in the 1930s and 1940s of refugee doctors who brought the sophisticated approach of European medicine. Many Jewish physicians rose to eminence. Victor Soriano of Montevideo, Uruguay, was the editor of the World Journal of Neurology. Mexico had 120 Jewish doctors in 1970, many of whom attained professional distinction. Characteristic of the medical pioneers' sense of Jewish identity was their publication of the medical journal Ars Medici early in the century, when their numbers were very small.

south africa

At the peak of communal activity South Africa had about 750 Jewish doctors who made major contributions to medical research, education, and practice. Among these were Philip *Tobias, president of the Royal Society of South Africa, Maurice Shapiro, the immuno-hematologist who became head of the country's transfusion services, the gynecologist S. Joel Cohen, the physician M.M. Sussman, the cardiologist Valva Shrir, and the surgeon Jack Wolfowitz. The plastic surgeon Jack Penn (1909–1996) carried out many facial reconstruction operations on Israeli soldiers wounded in the War of Independence and subsequently became honorary visiting professor of plastic surgery at the Hebrew University of Jerusalem. During the period of political uncertainty before the country achieved independence many doctors immigrated to the United Kingdom, the U.S., and Israel. Those achieving distinction include Israel Chanarin, the hematologist and expert on megaloblastic anemias, and Anthony Segal, the authority on the white blood cells called neutrophils.

Medical Science and Practice in Israel

Sussman *Muntner, Joshua O. *Leibowitz (1895–1993), who was professor of medical history in the Hebrew University of Jerusalem, and David Margalit have fully described the history of medicine in Palestine under the Mandate and in the early years of the State of Israel. At the beginning of the 20th century infectious diseases were rampant in Palestine. Clinics established by European Jewish communities provided medical care for the Jewish population of Jerusalem. These clinics became hospitals that expanded to meet the needs of a modern city, notably Bikkur Ḥolim, established in 1843, and Sha'arei Ẓedek, established in 1902. Fortunately for the needs of the Jewish population, physicians were prominent in the Zionist movement since its inception. The first Jewish physician in Palestine, Simon Fraenkel, was sent to Jerusalem in 1843 by Moses Montefiore. Menahem Stein was the first Jewish doctor in Jaffa (1882), Hillel *Joffe the first in Haifa (1890), and Bathsheba Yunis (1880–1947) the first in Tel Aviv. Leib Pashkovsky was the first surgeon to settle in Palestine (1906). In 1912, the year a medical association was founded in Tel Aviv, there were 35 Jewish doctors in the country, the majority specially trained in ophthalmology, dermatology, and parasitology in order to cope with the country's most prevalent diseases. Prominent among the early specialists were the ophthalmologist Aryeh *Feigenbaum, the dermatologist Aryeh Dostrovsky (d. 1975), and the bacteriologist and founder of the Pasteur Institute in Jerusalem (1913), Israel J. Kligler. Other notable doctors were Aryeh Boehm, who was responsible for many improvements in public health, and the otorhinolarynglogist Moshe Sherman, founding president of the country's first Medical Association. Although public health remained a major preoccupation, increased control of malaria, rabies, trachoma, and other infectious diseases allowed more scope for other specialties to develop.

After the Balfour Declaration, the number of Jewish physicians in Palestine increased sharply and their pace of immigration accelerated with each wave of persecution in Europe. Health services improved under the Mandate with an expanded network of clinics and public health measures including an immunization program. Thus a medical infrastructure was in place when the State was established which could cope with the added demands of immigration and the War of Independence. With subsequent expansion, Israel had approximately 27,000 physicians in the early 21st century, so that the ratio of doctors to population has become one of the most favorable in the world. The country had some 47,000 nurses, of whom 50% were registered. As a result Israel had a very low infant mortality rate (7.5 per 1,000 live births) and long life expectancy (79.1 years on the average for women and 75.3 years for men). Medical care is provided by a network of hospitals and clinics, many affiliated to the health funds, the Ministry of Health, or other organizations like *Hadassah and *Magen David Adom. The hospitals and medical services are also geared to deal with the emergencies arising from wars or terrorist attacks.

Mental health, rehabilitation, and social support services are also highly developed.

Advanced methods of treatment developed elsewhere in the world have also been promptly introduced into Israeli clinical practice. The Hadassah Hospital carried out its first successful in vitro fertilization ("test-tube baby") in 1982 and heart transplantation in 1983.

The Israel Medical Association, founded in 1929, helped to raise the standards of the profession and to improve service to the public during the difficult years of economic hardship and political and military tension. The Association's official organ, Harefuah, founded in 1913, has maintained a high scientific and journalistic standard. The Non-Resident Fellow Project of the Association has helped forge close links with Jewish doctors in the Diaspora. There is also an extensive network of academic exchanges and collaboration between institutes and individuals in Israel and other countries.

Medical research and education have had a consistently high priority, even before the establishment of the State. Moshe Prywes (d. 1999), editor of the Israel Journal of Medical Sciences, founded in 1965, contributed to medical education, and Hanoch Midwidsky to the promotion of postgraduate studies. Most medical research is now carried out at the country's four medical schools, namely the *Hebrew University of Jerusalem (founded in 1949), *Tel Aviv University (founded in 1965), *Ben-Gurion University (founded in 1974), the *Haifa Technion (founded in 1969), and their affiliated hospitals. Biomedical science is performed in the relevant faculties of these universities, at *Bar-Ilan University, which does not have a medical school, and at the *Weizmann Institute of Science.

The first research priority was the control of infectious diseases. Saul *Adler, a world authority on parasitology and tropical medicine, directed research on amebiasis, leishmaniasis, and relapsing fever. Zvi *Saliternik was responsible for the elimination of malaria and the parasitic disease schistosomiasis. Subsequently attention could be turned to the disorders prevalent in the developed world and to genetic disorders prevalent in various Israeli populations. Clinical research was linked to improving teaching and patient care in all branches of medicine.

Chaim Sheba, surgeon-general of the Israeli army, over-saw the rise in medical standards. Bernhard and Hermann *Zondek continued their endocrinologic research, interrupted by the European upheaval, and Moshe *Rachmilewitz, professor of medicine at Hadassah Hospital Medical School, carried out much-cited studies of folate and vitamin b12 deficiency and metabolism. Bracha *Ramot organized a modern hematological service at the Tel Hashomer (Sheba) Hospital and undertook a systematic program of investigation of the prevalence and management of inherited disorders of hemoglobin synthesis. Andre de Vries (1911–1996) was a distinguished physician and hematologist at the Beilinson (Rabin) Hospital. Karl Braun initiated research programs in cardiology and Lipman *Halpern in neurology. Under the leadership of Bruno Lunenfeld (1927– ), the Tel Hashomer (Sheba) Hospital became a world center in research and treatment for female infertility. In the same institute Baruch Padeh had laid the foundations for clinical genetics in the country. David Erlick in Haifa improved techniques of renal transplantation. Isaac Michaelson developed ophthalmological services at Hadassah Hospital and used his expertise to treat patients with trachoma and other sight-threatening diseases in Africa. Michaelson was thereby amongst the first who initiated Israel's continuing medical collaboration with disadvantaged countries. He was also amongst the first clinical scientists to realize the importance of angiogenesis (new blood vessel formation) in retinal disease; an international medal and series of conferences have been named in his memory.

Latterly the pace of research has quickened and there is room to mention only a few of the outstanding contributors. Rina *Zaizov (1932–2005) organized a national center for pediatric oncology. Marcel *Eliakim of Hadassah Hospital has made important advances in the field of liver diseases. Yehezkiel *Stein of the same hospital is an international authority on lipids and atherosclerosis (vascular degeneration). Mordechai Pras of Tel Hashomer Hospital is an international expert on amyloidosis and Rami *Rahamimoff's work on nerve transmission in health and disease is also universally respected. The advances in basic immunology made by Michael *Sela and Ruth *Arnon at the Weizmann Institute have been adapted to many promising strategies for treating multiple sclerosis and autoimmune diseases. Michel *Revel's research on the antiviral interferon system also has important clinical implications. Irun Cohen's immunological studies at the Weizmann Institute on experimental and clinical autoimmune diseases and novel ideas on treating these diseases have attracted continued international attention. Stem cell research is an active area of research carried out in a fully coordinated program involving the country's major academic research centers and biotechnology companies. Sophisticated medical bioengineering is also an area of intense research activity.

The current organization of medical departments in acute care hospitals in Israel has changed from the classical European model with its fully autonomous medical wards to broader-based departments in which all medical sub-specialties are represented, providing comprehensive, multi-disciplinary medical care. In parallel with the remarkable developments in new therapeutic approaches a more realistic view has grown of scientific medicine's limitations and an understanding of the patient's rights. This has introduced a new field in medicine that includes palliative care, safeguarding the quality of life of patients and their families, and their right to be involved in decisions affecting medical management and the end of life. This progressive approach is now being adopted by the Israeli public and medical community with appropriate legal backing. There has also been striking progress in the provision of medical teams able to participate in disaster relief anywhere in the world.

[Samuel Vaisrub /

Michael A. Denman,

Yaakov Naparstek, and

Dan Gilon (2nd ed.)]

bibliography:

sources: S. Muntner, in rhmh, 11 (1951), 23–38; 12 (1952), 21–23; idem, in: Miscellanea Mediaevalia, 4 (1966); idem, in: Korot, 1:1–2 (1952); idem, in: Sinai: Sefer Yovel (1958), 321–37; Saladino di Ascoli, Sefer ha-Rokeḥim (1953); C. Roth, in: Speculum, 28 (1953); Steinschneider, Uebersetzungen. general: H. Friedenwald, Jews and Medicine, 2 vols. (1944); S. Muntner, Le-Korot ha-Safah ha-Ivrit ki-Sefat ha-Limmud be-Ḥokhmat ha-Refu'ah (1940); J. Seide, Toledot ha-Refu'ah (1954); R. Kagan, Jewish Medicine (1952). in bible and talmud: C.J. Brim, Medicine in the Bible (1936); J.L. Katzenelson, Ha-Talmud ve-Ḥokhmat ha-Refu'ah (1928); S. Muntner, in: Leshonenu, 14 (1946); idem, Sexology in the Bible and the Talmud (1961); idem, in: Refu'ah Veterinarit (1944), 6–22; (1945), 5–22; M. Perlman, Midrash ha-Refu'ah (1926); J. Preuss, Biblisch-Talmudische Medizin (1911); W. Steinberg, in: International Record of Medicine, 12 (1960); 2 and 4 (1961). MIDDLE PERIOD: E.A.W. Budge, Syrian Anatomy, Pathology and Therapeutics (1913); A. Feigenbaum, in: Acta Medica Orientalia, 14 (1955), 26–29, 75–82; J. Leibowitz, in: Dappim Refu'iyyim, 11:3 (1952); D. Margalit, Ḥakhamei Yisrael ke-Rofe'im (1962); S. Muntner, in: Leshonenu, 10 (1939/40), 135–49, 300–17; idem, Alilot al Rofe'im Yehudiyyim be-Aspaklaryah shel Toledot ha Refu'ah (1953); idem, Mavo le-Sefer Asaf ha-Rofe (1957); S. Donnolo, Kitvei Refu'ah, 2 vols. (1949); I. Judaeus, Hebrew Physician (1963). modern period: R. Landau, Geschichte der juedischen Aerzte (1895); H. Friedenwald, Jewish Physicians and the Contributions of the Jews to the Science of Medicine (1897); F.H. Garrison, An Introduction to the History of Medicine (19294); S.R. Kagan, Jewish Medicine (1952); idem, The Jewish Contribution to Medicine in America (1934); idem, American Jewish Physicians of Note (1942); L. Falstein (ed.), The Martyrdom of Jewish Physicians in Poland (1963); L. Šik, Juedische Aerzte in Jugoslawien (1931); L. Gershenfeld, The Jews in Science (1934); C. Roth, The Jewish Contribution to Civilization (19563); V. Robinson, Pathfinders in Medicine (1912); R. Taton (ed.), A General History of Science, 3 (1965), 494–548; 4 (1966), 502–62; M. Einhorn (ed.), Harofé Haivri (1928–65); I. Simon (ed.), Revue d'Histoire de la Médicine Hebraïque (1948–68); Medical Leaves, 5 vols. (1937–43); Harefuah (1920–70); A. Castiglioni, in: L. Finkelstein (ed.), Jews, Their History, Culture, and Religion, 2 (19603), ch. 31, 1349–75.

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MEDICINE

MEDICINE. Medicine in the early modern era was characterized by several distinctive features. First, the understanding of illness and its treatment was based on assumptions that were inherited from antiquity and differed conspicuously from our own ideas. Second, physicians comprised but one group among a host of healers who routinely competed with each other for access to patients. Thus, in contrast to medicine today, physicians neither dominated nor directed the care of most of the sick. Third, the delivery of health care was not centered in hospitals or specialized clinics. Hospitals certainly were a feature of early modern medicine, but their role in the delivery of health care was minor. Last, and perhaps most important, people in early modern Europe inhabited a social, cultural, and demographic environment in which death intruded itself far more frequently in the everyday lives of Europeans than it does for people living in the developed world today.

PATTERNS OF DISEASE

Death was a common occurrence in the early modern period, a fact that colored nearly every aspect of social and cultural life. Nor was it just the elderly who expected to die; infants and children died at such high rates that someone could be counted fortunate just to reach the age of twenty-one, not to mention sixty or seventy. This depressing fact was not lost on contemporaries. "Of each 1,000 people born," wrote a German physician in 1797, "24 die during birth itself; the business of teething disposes of another 50; in the first two years, convulsions and other illnesses remove another 277; smallpox . . . carries off 80 or 90, and measles 10 more." Of every 1,000 people born, he concluded, "one can expect that only 78 will die of old age or in old age." Although we cannot verify the accuracy of these numbers, there is no disputing the appallingly high mortality rates they indicate. Available records of baptisms and burials from local churches suggest that in countries such as France and Denmark, deaths of infants (that is, children under the age of two) from all causes could climb as high as two hundred or more deaths per thousand births.

A variety of factors contributed to these high mortality rates, including the prevalence of malnutrition and intestinal parasites. Although these may have only rarely caused death directly, they undoubtedly weakened the body's defenses against disease. More directly responsible were infectious diseases like smallpox and measles, mentioned in the quotation above, along with other serious childhood diseases like diphtheria, whooping cough, and dysentery.

The most dangerous disease of all was the plague, which first struck various parts of Europe between 1347 and 1351 and returned to afflict almost every generation until the very end of the seventeenth century. The disease is believed to have begun in China and then spread along trade routes in Central Asia in the early 1340s. By 1346 it had reached the Crimean city of Caffa, and from there it was brought to Sicily and southern Italy. Once established there, plague spread, again along trade routes, to other parts of Europe. Skepticism has grown in recent years over whether the plague (caused by the bacterium Yersina pestis ) was exclusively bubonic plague, induced in its victims by the bite of a flea, or whether it was mixed with a more dangerous airborne form known as pneumonic plague. It is possible too that one or more other diseases were also part of the mix. Whatever its precise cause, there can be no question that plague hit many parts of Europe hard. Over the entirety of Europe, it is estimated that the first onset of plague killed approximately 25 percent of the population, although actual mortality varied considerably from place to place. Even as late as the seventeenth century, outbreaks of plague continued to hit with devastating impact. In 16561657, the Italian city of Genoa lost 60 percent of its population of 75,000 to plaguea horrific, although unusually high, mortality ratewhile between 1609 and 1611 about 42 percent of the residents of the Swiss city of Basel (population 15,000) caught the plague and 62 percent of those victims died.

A second serious disease, syphilis, appeared for the first time in Europe at the very end of the fifteenth century. While having nowhere near the demographic impact of plague in terms of deaths caused by it, syphilis was serious enough, especially in the virulent form in which it first appeared. The disease was first reported during the French army's campaigns in Italy during 14941495 (hence the common name given it, the "French Pox"), and from there it spread rapidly throughout Europe. Sufferers from syphilis, reported the German scholar Ulrich von Hutten in the early sixteenth century, "had boils that stood out like acorns, from which issued such filthy stinking matter, that whosoever came within the scent believed himself infected." The stinking stain described by von Hutten could have been more than just physical, for it was soon determined that syphilis was sexually transmitted, thus giving the disease extra significance as an apparent punishment for sinful promiscuity.

THE ORIGINS OF PUBLIC HEALTH

Historians once commonly believed that plague was a primary cause of the breakdown of medieval society and the transition to the modern era. Although this is no longer widely accepted, there is no denying that plague did have a powerful impact. Arguably the most significant of its effects was the stimulus it provided to the development of public health, and, more speculatively perhaps, to the more general idea that the purpose of government was to formulate policy, not just maintain order. The idea that the government could exercise a regulatory and policy-making function was certainly not unprecedented in the late fourteenth and early fifteenth centuries, but the horrific consequences of repeated plague outbreaks made matters of health a particular focal point of concern and regulation.

As early as 1348, the town council of Venice appointed three of its members as a special commission to devise measures against the plague that had broken out there, and, in general, highly developed Italian cities like Florence, Milan, and Genoa were among the earliest to formulate measures against the plague. Many European cities and principalities north of the Alps followed suit during the next 150 years. The measures taken by these boards included the institution of quarantine, a practice whereby plague victims were shut up in their houses, together with their families and servants, if they had any. Quarantine could also be placed on entire towns and cities, and because such bans could last for weeks or even months, a declaration of quarantine had serious consequences for trade and economic well-being. Plague ordinances further specified how those who had died of plague should be buried and what should be done with their personal possessionsclothing and bedding could be burned, for example. More controversially, they also prohibited public gatherings of different kinds, including church processions. Since such public gatherings were a major component of medieval Catholic spirituality, their prohibition by secular authorities was a recurrent source of conflict with the church.

Throughout the fifteenth century, most of the health commissions charged with dealing with plague remained temporary institutions, dissolving as soon as the threat posed by the current epidemic had subsided. But during the sixteenth century, more permanent health magistracies began appearing in northern Italian cities. The responsibilities given these boards gradually evolved to cover not only times of emergency but also the more routine supervision of public health. Justified by a desire to forestall future outbreaks of plague and building on prior medieval attempts to enforce sanitary standards in larger cities (in some cases dating much further back than the 1340s), these health boards began formulating more comprehensive sanitary measures to control such things as the cleaning of streets and dumping of wastes. Beggars and Jews, who were suspected of being transmitters of disease, were often singled out for unwelcome attention.

A somewhat different system evolved in German-speaking central Europe during the sixteenth and seventeenth centuries. There, towns and principalities began appointing a local physician or surgeon to the partially salaried post of physicus. Their primary responsibility normally involved providing medical care for the poor, but physici were also charged with enforcing sanitary regulations, instructing and supervising other practitioners, and conducting medical-forensic inquiries, among other functions. In effect, these practitioners served as the instruments for the enforcement of public health ordinances, while at the same time gathering information about local health conditions that could be transmitted back to the political authorities.

THE INSTITUTIONS OF CARE

To the extent that early modern medical care was centered in institutions of any kind and did not simply take place at the patient's bedside or in the practitioner's shop, hospitals provided that institutional setting. But this statement must be immediately qualified by noting that hospitals served almost exclusively the needs of the poor. Not until the early twentieth century, in fact, would people who were not poor begin using hospitals in any considerable numbers. Moreover, hospitals in the early modern era were not devoted exclusively to medical care, offering instead a spectrum of charitable support for the poor.

The roots of hospitals as integrated charitable/medical institutions go back many centuries, on the one hand to the social welfare needs of large urban centers of late antiquity and the early Middle Ages, such as Constantinople (modern-day Istanbul) and Baghdad, and on the other hand to the hospices established for travelers and the poor by early Christian communities. As monastic communities spread across the Christian world during the Middle Ages, many of them, especially those located on important trade routes or destinations for pilgrimages, established small infirmaries for sick members of their communities and travelers who had no other support during times of illness. Eventually, hospitals of varying sizes became an established feature of the urban landscape, funded by the charitable endowments of individual patrons or local religious organizations, such as confraternities.

By the sixteenth century, and especially in the wake of the Reformation, hospitals were confronted by significant new challenges. First, conversion to Protestantism often involved confiscation by the ruler of church properties, which deprived hospitals both of the assets that supported their operation and sometimes of the personnel who ran them. In England, Henry VIII's break with the Roman Church in the 1530s led to wholesale seizure of church properties, including those supporting the three London hospitals of St. Thomas, St. Bartholomew, and Bethlehem. This immediately threw the city's charitable services into chaos, and the city's leaders implored the crown to restore the funds necessary to operate the hospitals. This the crown did over the course of the next twenty years, yielding for London a total of five major hospitals: St. Thomas's and St. Bartholomew's for the sick poor; Christ's for orphans; Bridewell for the shiftless poor, and finally, Bethlehem (known later as "Bedlam") for the mentally ill.

The functional "specialization" displayed by different London hospitals was by no means the standard in the period, and many hospitals, such as the huge Allgemeines Krankenhaus in Vienna or the Julius-Spital in Würzburg, folded various charitable services into one institution. What they did share with the London hospitals was the specific range of charitable activities. Just as importantly, the hospitals of the sixteenth and seventeenth centuries displayed a new attitude about the poor. This attitude was reflected in a separation made between the "virtuous" poor, such as the aged, widows, and children, and the "shiftless" or "lazy" poor, a separation that still resonates in welfare today. In a period when the poor were increasingly viewed as a possible threat to social order, hospitals became places for housing the poor and removing them and their supposed threat from the streets. By 1700, this thinking had led in France to the founding of more than one hundred so-called hôpitaux-généraux (general hospitals), institutions in which the deserving and undeserving poor were rounded up together, with the former supposedly receiving benevolent shelter in their time of need and the latter corrected and improved by a combination of enforced labor and religious discipline.

All of these institutions, even those resembling prisons and workhouses, offered treatment for the sick. By the eighteenth century, the curing of patients and their return to useful roles in society became more clearly the focal point of the hospital's identity. Although they remained charitable institutions, supported largely by private philanthropy or government subventions instead of patient fees, hospitals discouraged the admission of the chronically sick or aged, pregnant women and childrenin short, the traditional clientele who had populated hospitals in previous eras. Instead, they focused on curing and releasing what came to be known later as the "laboring poor," those who held regular jobs and had fallen ill.

MEDICAL PRACTITIONERS

Today, the treatment of illness is usually given by a physician, that is, someone with a university medical education in possession of an M.D. Although other people, such as nurses or pharmacists may be involved in this process, physicians direct it. In the early modern era, that was decidedly not the case. Physicians formed but one small group among a variety of healers, any of whom could be consulted in time of sickness.

Among the other healers who competed for access to patients, surgeons were probably the most prominent. Like physicians, surgeons were a recognized occupation, often organized in larger towns into guilds that supervised professional standards and trained apprentices in the craft. In both the popular imagination and in their own professional identities, physicians and surgeons were separated by their domains of practice: physicians treated internal ailments, while surgeons handled external maladies, including wounds. Physicians were not trained to cut patients most of the time, while surgeons made liberal use of the knife, even if they also administered medications. Their use of the knife is a principal reason why surgeons often were grouped together occupationally with lower-status barbers, who not only cut hair but also performed routine medical procedures such as bloodletting.

However, because the boundary between "internal" and "external" is by no means obvious in every case, many diseases, such as cancerous tumors and syphilis, were often treated by surgeons. Therefore, rather than seeing physicians and surgeons as having clearly demarcated areas of competence, it would be more accurate to understand them as having overlapping spheres of practice, where the choice of healer more often depended on factors such as personal acquaintance, reputation, and availability, and not on a calculation of which healer was most appropriate for any particular illness. Part of the distinction between physicians and surgeons can be explained in terms of social hierarchy. Because physicians were university educated and participated in the literate, Latinate culture of the urban and courtly elites, they tended to enjoy higher social status than surgeons. But neither the status of healers nor the choice of healer by patients was determined along a gradient of social hierarchy. Kings and bishops were just as likely as a common artisan to consult a surgeon when the need arosealthough not, of course, necessarily the same surgeon.

The same point could be made for other established healing occupations, midwives and apothecaries. Midwives were women who attended births and cared for the mother and newborn child during the first days after birth. In principle, they were not supposed to treat patients outside the context of birthing or to administer drugs, apart from those useful during or immediately after labor. But, in fact, midwives were consulted more widely, especially by women, whose trust in the midwife would have been cemented by her assistance during their children's births. Apothecaries were dealers in herbal medications, grocers who knew how to extract the healing virtues from natural products. Physicians expected apothecaries to dispense medications to patients only on the orders of a physician. But here too, the prescribed division of labor was easily breached by apothecaries who believed that they could just as well (or better) determine the appropriate medicines to give people suffering from particular ailments. From the patient's point of view, the decision to consult an apothecary or midwife might depend on the same considerations as those mentioned abovepersonal acquaintance, local reputation and accessibilityas well as cost. In most cases, it cost considerably less to bring a midwife or apothecary in than a physician.

During the later seventeenth and eighteenth centuries, governments in various parts of Europe began paying a great deal of attention to how practitioners were trained and to keeping practitioners from infringing on others' domain of work. Surgeons, whose training had always swung between guild apprenticeships and university-based anatomy theaters (although surgeons did not routinely hold M.D. degrees), increasingly saw their training based in the newer hospitals or specially instituted surgical academies. The training and qualifications of midwives and apothecaries likewise came under closer scrutiny, and in a number of places they were required to submit to licensing examinations. The establishment of a separate licensing examination for physicians after awarding the M.D. also came into much wider use, when, for example, in 1651 the electorate of Bavaria created a collegium medicum that was authorized to examine every physician who wished to practice in its territory.

The practitioners described here by no means exhaust the full range of healers present in early modern society. These other healers are represented, in part, by folk healers, who deployed a wide range of traditional therapies. The use of magical or religious invocations in treating illness, of course, was probably not a rare occurrence at this time. In addition, the early modern period was populated by a host of itinerant drug peddlers, stonecutters, and sundry charlatans who sold special talents or products in the medical marketplace. By the mid-eighteenth century, and as a result of the dramatic expansion of the press, medical products and services participated in a booming advertising market.

IDEAS OF HEALTH AND ILLNESS

The dominant medical thinking of the early modern period saw health as dependent on a particular balance in the body's four humors, known conventionally as blood, phlegm, black bile, and yellow bile. Each individual humor, in turn, manifested a distinctive combination of qualities from the pairs wet/dry and cold/hot. Thus, blood was believed to be hot and wet, yellow bile, hot and dry, and so on. The balance of humors required to maintain health was highly individual, depending on someone's age, sex, local environment, diet, work, lifestylein principle, almost anything could influence health. Excessive exercise, for example, could cause the body to heat up, resulting in an excess of blood or yellow bile. Scholars, on the other hand, were thought to suffer from particular diseases resulting from their having too little exercise and too much brainwork. The prevention of illness and its cure depended in principle on the same idea, whereby the practitioner sought to maintain or restore the proper humoral balance. The application of many treatments, such as the use of bloodletting or emetics (agents that cause vomiting), can be understood as working in this way.

Over against these doctrines concerning pathology and therapeutics must be set a partially separate set of ideas concerning what we now call physiology, the functions of the living body. The body's functions were thought to be governed by three principal organs: the liver, which converted nutritive juices produced by digestion into blood, which was then sent via the venous system to all parts of the body and nourished it; the heart, which mixed air taken in by the lungs with some blood, producing vital spirit, which was distributed throughout the body by the arteries and governed vital processes such as motion, breathing, and digestion; and the brain, which produced animal spirits, responsible for the higher functions of sensation and consciousness, and which traveled throughout the body via the nerves. Although not entirely divorced from the humoral doctrines that molded thinking about health and illness, the theories governing physiology were formulated to answer a distinctive and separate set of questions, such as what breathing does or how the movement of muscles occurs.

The source of many of these ideas was a collection of writings attributed to the ancient Greek physician Hippocrates (c. 460 b.c.e.375 b.c.e.), especially as interpreted by the later Greek physician Galen (129199? c.e.). Very few of Hippocrates' and Galen's writings were available in Latin translation during the early Middle Ages, but a far richer view of Hippocratic and Galenic medicine started appearing in Latin-speaking Europe at the end of the eleventh century, when translations of Arabic medical writings were made in southern Italy and Spain. These encyclopedic compendia of ancient medicine became the basis for medical teaching in the universities that began appearing at the end of the twelfth century.

By the early sixteenth century, medicine was a widely accepted part of the university curriculum, with the teaching of theory and practice based largely on Hippocratic and Galenic precepts, as interpreted and synthesized by medieval Muslim scholars. A second wave of translations, beginning in the late fourteenth century and inspired by the humanist cultural program for the restoration of classical antiquity, produced a wave of Latin translations from ancient Greek manuscripts, bypassing the mediation and (so the humanists claimed) the barbarism of earlier Muslim translators and commentators. The output from all this effort is astonishing: between 1500 and 1600, there are said to have been approximately 590 different editions of Galen's writings. To a surprising extent, these new translations from Greek sources did little to change the curriculum or the dominant medical theories. Yet in one important area, anatomy, the recovery of Galen's writings, especially his On Anatomical Procedures (first published in 1531), a guide to dissection, did lead to dramatic changes in medical thinking.

The conduct of dissections as part of the teaching of anatomy was a well-established, if also a sporadic, part of the medical curriculum. Well before 1500, medical scholars had used dissection as a means of engaging in critical dialogue with their ancient and medieval Muslim predecessors, to the extent that these sources were available to them. The appearance of On Anatomical Procedures in Latin translation, however, gave to humanistically inclined physicians an impeccably ancient source of authority for the practice of dissection, as well as practical tips for doing so. Consequently, anatomy and the practice of dissection acquired a status far exceeding what it had enjoyed before, and knowledge of human anatomical structure became a focal point of research interest. This burst of activity culminated with the publication of De Humani Corporis Fabrica (1543; On the structure of the human body), by Andreas Vesalius, the most renowned anatomist of the era. Vesalius's richly illustrated text presented itself as an extended critique of Galen's claims about anatomy, offering its readers a far more visually concrete picture of the body than anything previously available.

The critique of Galen's anatomical ideas, however, did not translate immediately into a broader abandonment of his physiology, in part because his theories about the body's functions made a great deal of sense in the context of physicians' experiences with the bodies of their patients. Only in the greatly changed circumstances of the seventeenth century, when a new generation of scholars deployed a new "mechanical" philosophy based on experiment to overthrow the entire edifice of ancient natural philosophy and the kinds of explanations it offered, did physicians shift from engaging in their centuries-long critical dialogue with their ancient sources to thinking about the body's functions in ways that departed significantly from ancient models. The most important among these later physicians was William Harvey (15781657), a highly skilled anatomist and experimentalist whose carefully designed investigations into the function of the heartbeat, published in 1628 as Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (An anatomical essay on the motion of the heart and blood in animals), directly attacked the physiological role assigned to the heart by Galen, suggesting instead that the heart acts as a pump, distributing blood to the body through the arteries and receiving it back again from the veins.

See also Alchemy ; Anatomy and Physiology ; Death and Dying ; Harvey, William ; Hospitals ; Midwives ; Plague ; Public Health ; Vesalius, Andreas .

BIBLIOGRAPHY

Brockliss, Laurence, and Colin Jones. The Medical World of Early Modern France. Oxford, 1977.

Conrad, Lawrence I., et al., eds. The Western Medical Tradition 800 B . C . to 1800 A . D . Cambridge, U.K., 1995.

Cook, Harold, J. "The New Philosophy and Medicine in Seventeenth-Century England." In Reappraisals of the Scientific Revolution, edited by David C. Lindberg and Robert S. Westman. Cambridge, U.K., 1990.

French, Roger, and Andrew Wear, eds. The Medical Revolution of the Seventeenth Century. Cambridge, U.K., 1989.

Grell, Ole Peter, Andrew Cunningham, and Jon Arrizabalaga, eds. Health Care and Poor Relief in Counter-Reformation Europe. London and New York, 1999.

Lindemann, Mary. Health and Healing in Eighteenth-Century Germany. Baltimore, 1996.

. Medicine and Society in Early Modern Europe. Cambridge, U.K., 1999.

Pelling, Margaret. The Common Lot: Sickness, Medical Occupations and the Urban Poor in Early Modern England. London and New York, 1998.

Siraisi, Nancy G. Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice. Chicago, 1990.

Wear, A., R. K. French, and I. M. Lonie, eds. The Medical Renaissance of the Sixteenth Century. Cambridge, U.K., 1985.

Thomas H. Broman

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Medicine

APICIUS’S RECIPE FOR CAULIFLOWER OR BROCCOLI IN CELERY MINT SAUCE

Sources

Diseases Then Unknown. Diseases were common in the ancient world, but, because medical practitioners of these times described symptoms rather than grouping diseases by classification, and because infectious disease-causing microorganisms alter through mutation, many diseases with which we are afflicted were not known or experienced. Some diseases of this period one cannot identify, probably because the organisms causing them mutated or the human immune system became invulnerable to their infections. Likely the Romans were not affected by smallpox, measles, diphtheria (although this malady was possibly described by Aretaeus of Cappadocia, circa 150-200 c.e., but osteological evidence for it is not found), scarlet fever, and influenza. Neither were they afflicted with the ravaging plagues of pandemic diseases, such as the notorious bubonic plague of 1347 c.e. or syphilis, introduced to Europe in the late fifteenth century. The greatest exception came with a plague that arrived in Rome in 170 c.e., supposedly spread by Roman troops transferred from the eastern frontier. Mortality rates were high, but data or even detailed descriptions are lacking. Modern scholars generate various hypotheses as to what type of disease it was—a microorganism ancestor to smallpox and typhus are two leading contenders—but no definitive answer has been forthcoming. Leprosy, identified in biblical and classical texts, is not the disease known in modern times by that name (the organism for which evolved during the Middle Ages). The ancients’ leprosy was elephantiasis in some cases, and other nonfatal skin afflictions as well. Helping to understand why the Romans had a less-restrictive attitude toward sexuality is the fact that they were not subject to potentially fatal venereal diseases. Certainly the Romans were inflicted with pneumonia (in various forms), cancer, typhus, gout (although a cluster of afflictions passed under its name, podagra), tuberculosis, pinta, yaws (the microorganism of which eventually evolved into the one causing endemic syphilis), and malaria, the latter being prevalent. Indeed, one theory for the fall of the Roman Empire was the sustained, corrosive effects of malaria as it sapped lives and energies, especially in the Mediterranean areas. Additionally they had many degenerative chest, skin, and eye diseases. Nothing that we know about ancient Roman medicine indicates that their physicians could have intervened to the extent of curing most major diseases. In those cases, the most that they did was to provide symptomatic relief and comfort.

Medical Knowledge. Two features characterize early Roman medicine: the ideal of the head of the family (paterfamilias) having sufficient medical knowledge to treat his family, slaves, and clients; and the handbook tradition of summarizing empirical cures for written transmission to supplement oral lore. Knowledge passed from father to son, mother to daughter, and wise woman to young woman or man probably accounted for medical therapies that most Romans received, especially those living during the Republic. Supplementary medical knowledge derived from herbalists and other pharmaceutical vendors as they plied their wares. Beginning in the third century b.c.e., Greek physicians established medical practices in Rome and other Latin-speaking areas, and, with them, the face of Roman medicine was altered—not without protest, however, from conservative-minded Romans, such as Cato the Elder and Pliny the Elder. Part of the reason for the Romans’ negative reaction to Greek medicine might be attributed to the fact that early Greek physicians tended to be slaves or freedmen.

Ambivalence to Greek Medicine. Easily, Cato the Elder (234-149 b.c.e.) epitomizes Rome’s love/hate relationship with Greek medicine. On one hand, he warns his sons to beware the Greeks bearing medicine, and yet, in his handbook on agriculture he proudly displays his knowledge of theoretical medicine from Greek authorities. Pliny the Elder exhibited the same ambivalence. Caustically, Pliny charged that the physicians are the only people who can murder with impunity. Greek medicine had some advantages, Cato thought, but the father of a Roman family ought to have enough native intelligence together with experience with illnesses, injuries, and cures to be able to practice medicine effectively. Cato’s only surviving work, De agricultura (160 b.c.e.), contains some of the medical lore expected to be known by a Roman. The older Romans considered the maintenance of good health an individual responsibility. Echoing Cato, Marcus Terentius Varro (116-27 b.c.e.) gave practical advice on farming that included medical and nutritional lore. Varro’s work, De re rustica (37 b.c.e., three books), exemplified the Roman handbook tradition with respect to medicine.

APICIUS’S RECIPE FOR CAULIFLOWER OR BROCCOLI IN CELERY MINT SAUCE

(Adapted for the modern kitchen: t = teaspoon, equivalent to 6 Roman scruples; T = tablespoon, equivalent to 1 Roman cyathus):

1 cauliflower, cabbage, or

bunch of broccoliFirst Sauce:

1/4 t cumin

pinch of salt

2 T. white wine

1 T. olive oil

Take cauliflower, cabbage, or broccoli, quarter them, and put in a saucepan. For the first sauce, combine the cumin, salt, wine, olive oil, and enough water to steam the vegetables. Add the vegetables, bring to a boil, then simmer gently.

Second Sauce:

1/4 t, ground pepper

1/2 t. celery seed (or lovage)

1/2 t. mint

pinch of rosemary (or rue)

1/4 t. coriander

1/2 c. vegetable stock

2 T. white wine vinegar

1 T. olive oil or butter

Meanwhile, in a mortar, grind pepper, celery seed (or lovage), mint, rosemary (or rue) and coriander. Add to stock, vinegar, and olive oil or butter. Bring to a boil, then simmer to reduce for 25 minutes. Serve over the cooked strained vegetables.

Source: Apicius, The Roman Cookery of Apicius; A Treasury of Gourmet Recipes & Herbal Cookery, translated by John Edwards (Port Roberts, Wash.: Hartley & Marks, 1984).

Surgery. A procedure that ancient physicians considered the last resort, surgery was used only when regimen or drug therapy was deemed not to be effective. Most physicians practiced minor surgery, but, at least in populous areas, there were specialized surgeons—some of whom had reputations for certain procedures. Celsus, in a first century c.e. treatise on medicine, described the ideal surgeon. Surgical instruments found in archaeological sites have familiar functions, such as scalpels, forceps, hooks, and probes, designs similar to those used in modern surgeries. Anesthetics were not totally lacking, although patients must have experienced pain in many instances. Physicians employed plants containing atropine and hyoscyamine to reduce pain, and Dioscorides mentions the Memphis stone that surgeons employed so that

the patients would have no pain during operations. It is not known what that mineral was. Although powerful antiseptics were lacking, surgeons used plant resins to treat wounds and heal sutures, and these had mild antiseptic qualities.

The Humors. By the third century b.c.e. many physicians had adopted an evolving theory of medicine based on humors, or body fluids. Blood, phlegm, yellow bile, and black bile were believed to correspond respectively to the four elements of air, water, fire, and earth.

Schools of Medicine. Medical education in Rome, before and after Hellenistic influences, was achieved the same way as all the craftsmanship skills, namely, with master practitioners training young men as apprentices. A school of medicine, not as the familiar institution for medical education in the late medieval and modern worlds, was a group of like-minded people who shared common perspectives and theories. Despite some measure of agreement, not all physicians accepted the existence of four humors—some espousing the existence of more humors, some fewer, as well as disputing their relative importance. After the great medical researchers Herophilus and Erasistratos, Greek medicine broke up into competing, and often contentious, schools, beginning with the conflict between the Empiricists and the Dogmatists. Empiricists insisted that it was impossible for the physician to penetrate the mysteries of the body and, consequently, viewed each disease as a unique event. They based their therapies on empirical cures and, along the way, rejected anatomy as irrelevant to medical practice. Autopsies could not inform one about a live body, they argued, and, besides, dissections were disgusting. In contrast, the Dogmatists appealed to theory and reason, regarded rigorous study as necessary, especially in anatomy, and believed that ultimately diseases had causes that were ascertainable.

Methodists and Empiricists. Between these two poles of the Empiricists and the Dogmatists, other schools of medicine developed whose influence was felt in Rome and, presumably, throughout the empire. One such school was that of the Methodists, who, like the Empiricists, rejected causation and anatomy but embraced a theory that all illnesses were based on an imbalance of moisture. An affliction caused too great an increase in wetness or dryness, either generally throughout the body or in specific locations. The physician’s duty was to learn

the cause and restore the balance by the administration of diet and/or drugs, according to opposites. Thus, a drying drug would restore an excessively moist condition. Allegedly Thessalus, a leading Methodist, claimed that he could train a full-fledged physician in six months!

Pneumatist School. Athenaeus of Attaleia (dated variously in the first centuries b.c.e. or c.e.) founded another school, the Pneumatists, but, although influential, none of its early adherents’ works have survived. Closely associated with the Stoic school of philosophy, the Pneumatists postulated the existence of pneuma (literally, “breath”) that gave vital spirits to all forms of animal life. Medicine, as they regarded it, was an essential part of a liberal education. The Pneumatists influenced Roman medicine specifically by an emphasis on diet.

Asclepiadian School. Practicing in Rome for at least part of his career, Asclepiades of Prusias and Mare (first century b.c.e.) developed a corpuscular theory of physiology. He believed that the body functioned through its composition of tiny, fragile corpuscles that moved through ducts. When the free movement was halted through injury or disease, the blockages caused morbid elements. Asclepiades and his followers attempted to employ noninvasive therapies that opened these ducts. Diet, fasting, massage, exercise, and baths were preferred to drugs and were considered the first avenues of address. Drugs could be administered in critical afflictions, however, and surgery was rarely prescribed. Their theme was “To cure, safely, swiftly, and pleasantly.” Needless to say, the Asclepiadian school had some popularity among the Romans.

Cold Baths. A follower of Asclepiades, freedman Antonius Musa (flourishing 20s b.c.e.) achieved a celebrated reputation as a physician. He devised a cold-bath therapy that attained fame when he cured Augustus Caesar in 23 b.c.e. So successful was he with his cold hydrotherapy that he won not only a fortune but also immunity from taxation both for himself and his profession. He wrote on pharmacy, but his work does not survive.

Greatest Medical Authority. Interestingly, Rome’s greatest native writer on medicine in Latin may not have been a physician. A member of the famous Cornelian family, we know that Aulus Cornelius Celsus (flourishing 25 c.e.) wrote a large encyclopedia titled Artes and, as part of it, there were eight books on medicine. The only sections of the work surviving are the medical books. The technical skill with which he presented medicine causes modern scholars and physicians to believe that only a practitioner of medicine could have written with such clinical exactitude. Pointing to the fact that medical learning was expected of Senatorial and Equestrian class Romans, other scholars argue that, despite the sophisticated, practical erudition, Celsus’s work indicates the level of knowledge that at least one well-educated Roman had. Whatever their persuasion on this dispute, Celsus is generally regarded as the best general medical writer in Latin.

History of Medicine. The surviving section of his work is called De medicina (” On Medicine”). After a learned introduction, Celsus gave an extraordinarily valuable history of medicine, especially concerning the Greek Alexandrians, Herophilus and Erasistratus. He had an ambivalent attitude toward the Greeks, among whom “this art [of medicine] has been cultivated much more than in other nations.” In the introduction to his work, however, he asserted that even “the most uncivilized nations have had a knowledge of herbs, and other things to hand for the aiding of wounds and diseases” (1-2). After the introductory historical section, Celsus begins his summary of medicine with general dietetics and discusses pathology, general and special therapies, drugs, surgery, and bone diseases. The work is so well written that some scholars were led to claim that Celsus must have simply translated an unknown, lost work from Greek to Latin. Most scholars now agree that the work reflects no indications of having been a translation and that Celsus was an author of great literary and medical skills.

Greek Medical Writers. Even during the empire, if elite attitudes are indicated from surviving works, the Romans distrusted Greek medicine, and yet, the greatest medical writers of antiquity in terms of influence on later generations lived and practiced medicine in Greece. Most of what we know of Roman medicine comes through the writings of three such persons: Dioscorides, Soranus, and Galen.

Pharmacy. Nothing is distinctive about the actual drugs that the Romans employed. Generally, the Romans used many of the same drugs that were known by ancient Mediterranean peoples. The various plants, minerals, and animal products were much the same whether found in Greek or Latin texts. Indeed, most of the drugs are the same as those found in the various medical papyri of the ancient Egyptians, some of which date back to the New Kingdom, circa 3000 b.c.e., and various Sumerian, Akkadian, and Assyrian pharmaceutical tablets. Laxatives are one example. Most of the laxatives employed today are the same as those used for four thousand years. Among the drugs the Romans used were almond oil, aloes, ammoniacum, belladonna, calamine, calcium hydrate, castor oil, cherry syrup, cinnamon, copper oxide, coriander, galbanum, galls, ginger, St. John’s wort, juniper, lavender, lead acetate, marjoram, mastic, mercury, olive oil, opium, pepper, pine bark, storax, sulfur, terebinth, thyme, willow bark, and wormwood. Cato the Censor and Pliny the Elder both championed old-fashioned Roman home remedies in preference to the drugs of foreigners, especially Greeks, but in truth most of the drugs were herbs, and most of them were similarly used regardless of culture. The Romans employed drugs primarily to treat symptoms, and they had few drugs that truly were pathological cures. Occasionally new drugs or new uses for known drugs, were discovered. For example, sometime in the Roman period, likely during the Roman Empire, they discovered that the plant autumn crocus cured gout. This plant contains colchicine, the drug currently employed for gout. Colchicine functions to break the chemical chain reaction that leads to inflammation in joint tissue. Many of the drugs the Romans employed came from east Africa, India, and even Malaysia and China, thereby producing an unfavorable balance of trade and causing money to flow out of the empire. The only drug that East Asians imported from Rome was saffron, but soon the Indians and Chinese learned to cultivate it themselves, so it was no longer imported.

Standard Authority. The empirical science of taking certain drugs for specific maladies constituted most of pharmaceutical medicine until Pedanius Dioscorides of Anazarbus (flourishing 50-70 c.e.), a Greek physician, traveled widely in search of new drugs among various ethnic groups. Dioscorides was the author of a five-book work on pharmacy called Pêri hules iatrikes, or, in Latin, De materia medica. So thorough, precise, and authoritative was Dioscorides that his work remained the standard authority on pharmacy through the sixteenth century. While in a medical practice, his keen observational powers, diligence in scholarship, and critical faculties resulted in a study of around one thousand pharmaka, or drugs. Most of the drugs were from the plant kingdom, loosely called herbs, but two sections (part of book 4 and all of book 5) discuss drugs derived from the animal and mineral kingdoms, respectively. His method, as he explained it, was to read in the libraries what every authority had written on the subject of a particular drug, to observe the drug in its environment, in particular habitats and growing conditions, to inquire among the natives of each region where he traveled regarding their use and experiences with the drug, and, finally, to test the drugs himself in clinical trials. Only when a detail had received that level of attention did he have a “fact” to relate. In library research, Dioscorides names some twenty-seven authorities. Each chapter of his work is devoted to a single plant, although he would group related “kinds” or what we would call species or subspecies, within the same genera. He followed (or devised) a method for relating the material that would subsequently be adopted as the format for herbals: (1) picture; (2) name of plant, sometimes with synonyms; (3) botanical descriptions; (4) habitats; (5) drug properties or types of actions, such as “astringent”“drying” and “cooling”; (6) medicinal uses; (7) harmful side effects; (8) quantities and dosages; (9) harvesting, preparation, and storage instructions; (10) adulteration, methods, and tests for detection; and (11) veterinary uses. In his introductory letter, Dioscorides boasted that his work surpassed previous pharmaceutical writings because of his superior organization. He did not explain what his organizing scheme was; thus, it was left to readers to discern. The overall organization is apparent: book one, for example, begins with aromatic herbs, followed by oils, ointments, resins, shrubs, trees, and fruit trees; book two starts with animal drugs, first with specific animals and ending with animal products (such as milk, fats, and blood), then cereals, pot herbs, and sharp herbs. Within each category, however, there appears some order, fore-shadowing the modern scientific binomial classification scheme devised by the Swedish botanist Carolus Linnaeus in the eighteenth century. Dioscorides appeared to have classified plants by linking together related species within the same genus. At other times there are inconsistent interruptions in how the chapters are arranged. Recent scholarship discloses that Dioscorides was arranging his chapters by how the total medicinal uses related to other similar drugs, or, in other words, by drug affinities. This organization explains why there appears some botanical scheme, because related plants tend to have similar chemistries. Because Dioscorides’ scheme was little appreciated or understood by later imitators who otherwise followed his methods, his organizational genius had little subsequent influence.

Gynecology. During the period of the writings attributed to Hippocrates, circa 460-330 b.c.e., there were several gynecological works produced. They were written by men and were mostly compilations of midwife practices. During the Roman Empire, a writer on gynecology truly elevated the art of women’s medicine. In the words of Owsei Temkin, Soranus of Ephesus (flourishing early second century c.e.) was “one of the most learned, critical, and lucid authors of antiquity.” He wrote on many medical subjects, such as acute and chronic diseases, causes of diseases, medicaments, surgery, bandages, ophthalmology, and, more philosophically, on the soul. None of those works survived except for portions preserved in the texts of later writers. What survived was influential—a masterful treatise on gynecology, called Gynaecia, in four books. Details of his life are few: we know that he practiced in Rome during the reigns of Trajan and Hadrian and that he received some medical training in Alexandria. Indirect evidence indicates that he learned medicine also in Ephesus. Clearly he subscribed to the Methodist School, but he was not dogmatic in applying its theoretical constructs when he saw clinical evidence pointing elsewhere. Soranus used some theoretical constructs derived from the Alexandrian physiologists and anatomists as a basis for his observations.

Women’s Health. Book one defines the ideal midwife (sober, literate, displaying integrity, free from superstition, knowledgeable both in theory and practice, compassionate, and charging no excessive fees). Soranus eschewed the magic and superstition that pervaded midwifery practices, but he said that such practices, when they resulted in no harm, could be useful in gaining a

patient’s confidence and reducing stress. The remainder of his book discusses feminine physiology and hygiene, menstruation, conception, pregnancy, and birth control. About the latter, Soranus clearly distinguished between contraception and abortion, saying that the former was safer than the latter. He said that pessary birth-control agents are less safe and effective than oral drugs. Book 2 deals with obstetrics, including regular and abnormal deliveries, nursing, infant hygiene, and childhood diseases. Book 3 concerns women’s diseases, where he asserts that women have some afflictions that men do not. The fourth and final book concerns diseases that are addressed pharmaceutically and surgically. During the Middle Ages, Soranus’s gynecology was not translated into Latin, and so his influence was confined to derived influence through other writers, that is, until the Renaissance.

Medicine, Physiology, and Anatomy. Most of the ancient medical theory regarding physiology and therapeutics we know through the incredibly detailed works Galen of Pergamum (circa 129/130 c.e. -post 204). Galen was the practitioner who casts the greatest shadow on Western, Islamic, and Hellenistic medical science. Because of his dominance and strongly stated, somewhat egocentric opinions, we often do not know what is original in Galen and how much he was summarizing consensus opinions about medicine. In reading Galen’s works, one can be certain that medicine after him was dominated by his assertions. Son of Nikon, an architect and geometer, Galen began studies in philosophy at the age of fourteen but two years later turned to what was to be his life’s profession. His grounding in geometry is said to have guided his logical mind in a life of practice, research, and writing. Galen came to value the anatomical and physiological studies of Herophilus and Erasistratus, as well as the earlier basic studies attributed to Hippocrates. Although human dissection was no longer a permissible study in his era, Galen conducted comparative anatomical studies on a variety of animals, including monkeys, sheep, and, once, even an elephant. When he was twenty-eight, he returned to Pergamum where he was engaged as a physician to a gladiator company. His practice enabled him to explore human anatomy as he attempted to reconstruct and heal the injured and maimed. Galen’s intense interest in anatomy and physiology extended to some experimentation such as ligating or severing a spinal cord and inserting a tube in an artery to test for pulse. Galen not only accepted the scheme that included the four humors, but also he gave logical structure and evidence for their operation, such that medical science was persuaded by his theories for the next fifteen hundred years. Galen connected some illnesses with the mind and said that it could make a healthy body sick and a sick body healthy. Dreams, he stated, were one of the means by which the body informed the mind about what was wrong with it.

Distinguished Career. Galen’s greatest anatomical writings were produced in Rome, where he went to practice in 161; there he acquired a great reputation. Galen regarded the body as centering on three organs, with ancillary dependence on them by other organs. The heart, brain, and liver control systems throughout the body. While borrowing from his predecessors, Galen was at once a synthesizer of previous works, a marvelous organizer, a severe critic, and a true contributor to medicine through his own research. He explained well the processes of digestion, assimilation (what is called metabolism), nerve and respiration function, blood formation, and embryological developments.

Circulatory Theory. While accepting Erasistratus’s assertion that the arteries function to provide pneuma (literally, “breath” but more broadly,“vital spirits”) pumped by the heart from the left ventricle, Galen added that the arteries normally carried blood as well. The Alexandrians believed that arteries contained blood in times of disease and that the spurts of blood apparently issuing from a severed artery were the consequence of a vacuum and venal blood rushing to fill it. Galen claimed that the arterial and venal systems exchanged blood through tiny, invisible pores in the ventral walls. Not until English anatomist William Harvey’s theory of blood circulation published in 1628 was Galen disproved.

Drug Dosage. In many ways Galen disrupted Dioscorides’ organization of drugs by affinities, when in three major works on pharmacy he proposed an alternate theory of drug behavior, one closely related to the Empedoclean theory of the four elements. Galen noted that minute amounts of drugs have little or no perceptible effect, but with increased amounts, benefits are perceived. Continue increasing the amount, he argued, and at some point the benefits diminish. This phenomenon is called dosage. According to Galen each drug had a potential of up to four degrees of activity in each of two ways: either warming or cooling (derived from its active quality) and either moistening or drying (its passive quality). The strongest drugs had four degrees of activity either actively or passively. A fourth-degree drug was potentially life-threatening and should be employed for only the most severe cases, whereas one degree of activity was almost imperceptibly mild. Thus, applying by opposites, a fever needed a cooling drug. A high fever in a child required a less strong drug than the same fever in an old person. To complicate the matter—nature is not simple—a drug that is, for example, three degrees cooling will have a passive quality that is one of four degrees of moistening or cooling. In prescribing medicines, Galen’s theory is intellectually challenging, but it worked according to the ancients’ perceptions of healing and curing. Galen warned that only experience demonstrated a drug’s actions, not logic derived from sense perception. Seawater, for example, is sensibly moistening, and yet, internally as a drug it is drying. This pharmaceutical theory replaced Dioscorides’ more clinical approach. Finally, Galen organized his order in relating drugs by the alphabet, a system that medieval copyists and simple medical personnel found more attractive because of its convenience.

Lasting Influence. Galen’s influence was tremendous because of the volume of his writings, the logical structure of his observations (fitting within the framework of accepted scientific or philosophical principles), and the authority with which he wrote. Even serious attacks on his systems during the sixteenth century did not eliminate his influence on medicine altogether.

Late Roman Medicine. Toward the end of the Roman Empire, more public support was given to medical education. Alexander Severus (208-235 c.e.) granted privileges for medical instruction, and those who taught it were granted citizenship. In the fourth century c.e., medical students were supervised and required to attend lectures in the gymnasia. Julian (361-363 c.e.) decreed that physicians needed to be a member of a guild and licensed to practice. Although seemingly progressive, such measures were doubtlessly a response to abuse and a general decline in medical practice. After Galen, Roman medicine declined along with the infrastructure of the ancient state. This deterioration of medical practice is not to say that there were not physicians who delivered learned and dedicated services, nor was there a lack of medical writers who contributed to knowledge.

Medical Advances. Rufus of Ephesus (second century c.e.) wrote a Latin work on anatomy, dietetics, and pathology from which came important contributions on the pulse, kidney diseases, satyriasis, jaundice, gout, and gonorrhea. Oribasius (circa 320-400 C.E.), a friend and physician to the Emperor Julian, wrote a medical encyclopedia in the Roman handbook tradition that preserves large sections of medical writings that otherwise would have been lost. For example, the contributions to surgery by Archigenes (flourishing under Trajan) and Heliodorus (dates unknown), both advocates for the Pneumatic school, were incorporated in Oribasius’s work. Portions of Heliodorus’s surgery are known in Latin manuscript texts. Antyllus (second century c.e.) described aneurysms; these contributions would have been unknown or unattributed were it not for the references in Oribasius. He even included some works by Galen that were otherwise lost.

Acute and Chronic. In the early Roman Empire several medical works were produced on acute and chronic diseases—the latter supposedly being untreatable. Themison (late first century b.c.e.) of the Methodist School first set forth treatments for chronic diseases. Whereas Themison’s works did not survive, those of his followers did, among which were Aretaeus of Cappadocia (flourishing during the time of Trajan, 98-117 c.e.), Caelius Aurelianus (circa fifth century c.e.), and an anonymous author whose influence was felt strongly in the Middle Ages. Although some ancients recognized a bifurcation of diseases, by the time Aretaeus wrote, both types received therapeutic intervention by physicians. Written in Greek, Aretaeus’s nosology (the science of disease description) was especially good (for example, his description of pleurisy), and he is the first physician to describe elephantiasis. Aretaeus’s devotion to a physician’s compassionate duty earned for him a high reputation. Caelius wrote separately on acute and chronic diseases. Both Aretaeus and Caelius were also reportedly members of the Pneumatic School. An unknown author wrote a similar treatise, perhaps around the fifth century C.E. He is known as Anonymous Parisinus, because the major surviving manuscript is located in Paris. Similar in arrangement with Aretaeus and Caelius, the text begins by concentrating on sixteen acute diseases, followed by thirty-nine chronic diseases, with both sections arranged by the “from head to foot” format. The acute diseases are: head (phrenitis, lethargy, epilepsy, apoplexy, cephalea), neck (angina, tetanus), chest (pleuritis, peripneumonia, syncope), esophagus (hydrophobia), peritoneum (cholera), intestines (ileus, colic), and sexual organs (satyriasis). Chronic diseases begin with vertigo, madness, fanaticism, and various forms of paralysis (for the head) and end with sciatica, arthritis, gout (joints), and elephantiasis.

Head-to-Foot Pharmacology. Marcellus Empiricus (flourishing late fourth century c.e.) wrote a work on pharmacy that combined learned Greek and Roman medical knowledge with traditional Roman lore and popular Celtic and other folk knowledge. Cassius Felix (died circa 447 c.e.) wrote a similar work, but one that was more based on learned medicine especially derived from Galen. Theodorus Priscianus served as a physician to the emperor Gratian (367-383 c.e.) and wrote Euphoriston, in three books. Organized “from head to foot”, book one deals with external ailments, two with internal medicine, and three with female disorders. Primarily, Theodorus’s value lies in the variety of his pharmaceutical prescriptions. With the pseudonym of Apuleius, an anonymous writer, probably in the fourth century, wrote a Latin herbal, with colored drawings of the plants, that enjoyed great popularity in the Middle Ages. Similarly, another writer about the same time composed an illustrated herbal titled De herbis femininis (On Female Herbs) that was popular and passed under the name of Dioscorides.

Women’s Issues. Enjoying popularity during the Middle Ages was a medical poem in hexameters, called Liber medicinalis, written by Quintus Serenus (Sammonicus) in the late second to fourth century c.e. In gynecology, Moschion (sixth century c.e.) wrote De mulieribus passionibus, largely based on Soranus. Passing under the erroneous name of Cleopatra (in an allusion to the famous Egyptian queen), an unknown author (possibly fourth or fifth century C.E.) wrote a treatise in Greek called Genesia; an early Latin translation listed several abortifacients but, curiously, no contraceptives.

Sources

Lawrence J. Bliquez, Roman Surgical Instruments and Other Minor Objects in the National Archaeological Museum of Naples (Mainz, Germany: Verlag Phlipp von Zabern, 1994).

Mirko D. Grmek, Diseases in the Ancient World, translated by Mireille Muellner and Leonard Muellner (Baltimore: Johns Hopkins University Press, 1989).

Ralph Jackson, Doctors and Diseases in the Roman Empire (London: British Museum Publications, 1988).

John M. Riddle, Dioscorides on Pharmacy and Medicine (Austin: University of Texas Press, 1985).

Guy Sabbah and others, eds., Bibliographie des textes medicaux latins: antiquitiét haut Moyen Age (Saint-Etienne: Universite de Saint-Etienne, 1987).

John Scarborough, Roman Medicine (London: Thames & Hudson, 1969; Ithaca, N.Y.: Cornell University Press, 1969).

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medicine according to The Shorter Oxford English Dictionary, is ‘the science and art concerned with the cure, alleviation, and prevention of disease, and with the restoration and preservation of health’. From its ancient origins as a barely-tolerated trade on the margins of early human society, medicine has grown in stature and status to become a vast, professional enterprise that commands increasing proportions of the resources of modern, developed countries. The main driving force behind this process has been the claim by the medical profession to possess unique, privileged knowledge of the human body, of its functioning in health and disease, and of the ways in which natural healing processes can be imitated, accelerated, or augmented.

In modern Western medicine, the conventional way of acquiring medical knowledge about the body involves the telling and retelling of patients' stories (the history), and the gathering of physical evidence, both immediate (the examination) and hidden (the further investigations). From this information, patients' conditions are given names (the diagnosis) or, if their doctors cannot be specific, several possible names (the differential diagnosis). Armed with a diagnosis, doctors can inform their patients about what will happen to them (the prognosis), and begin treatment.

History

Even in the age of high technology medicine, nothing improves the efficiency and efficacy of medical intervention more than an accurate and complete history, detailing a patient's medical problems, past and present, their family's medical history, and their social circumstances. Histories, however extended and refined, have been an integral part of Western medicine for 2500 years. The works ascribed to the Greek physician Hippocrates (sc. 460–370 bc) notably include the Epidemics, in which the author notes details of patients' circumstances before and during their illness, as well as the presence and nature of any change in their condition, mental or physical. These works may have been little more than an aide-memoire for the author in his practice, or possibly in his teaching, but, as the author of the first book of Epidemics describes, ‘learning from the common nature of all and the particular nature of the individual, from the disease, the patient, the regimen prescribed and the prescriber’ allowed him to make more accurate judgements about the likely outcome of the case. Case histories are written repositories of the collective experience of the medical profession.

The ultimate purpose of the history is to understand the patient, their environment, and their place in society. At various times in history it has been considered important to know where patients live (Hippocratic doctors believed that each locality was prone to particular diseases because of its climate); when they were born (Arabic and medieval Western medicine placed much emphasis on the astrological portents accompanying illness); or what their job is (many occupational diseases have been identified since the English surgeon Percival Pott (1714–88) first described cancer of the scrotum in chimney sweeps).

Besides being good listeners, doctors are also natural storytellers. Recent scholarship by physicians, literary critics, and anthropolgists has drawn attention to the narrative structure of medical knowledge, in particular how patients' endlessly varied and complex ‘stories of sickness’ are translated into more strictly regimented ‘doctors’ stories'. Medical students are taught to ask specific questions in order to elicit information for all the categories of the ideal case history: the presenting complaint, the history of that complaint, the patient's past medical history, their past medications and allergies, their family history, and their social circumstances (including their smoking and drinking habits). They are taught to interpret patients' symptoms and organize them into systems — cardiovascular, respiratory, gastrointestinal, nervous, and so on. As critics of medicine have pointed out, the resulting narrative bears little resemblance to that presented by the patient, and there is a danger that the story may lose something — the patient as an individual — in translation if the doctor is not alive to that possibility. The taking of accurate and full histories is vital for the science of medicine; the art of medicine is to construct, within the bounds of accepted form, a vibrant history which retains the concerns and character of the patient while stressing those aspects of the illness which are amenable to medical intervention.

Examination

Clinical examination of patients' bodies creates, not least by the symbolism of laying on of hands, a special relationship between doctors and their patients. Clinical examination, like history-taking, has a long history. The author of the Epidemics, for example, paid as much attention to the physical state of his patients' bodies as to the symptoms of which they complained. He regularly noted the presence of fever, jaundice, or enlargement of the spleen, and the character of any sputum, urine, and faeces. Many other Hippocratic texts record physical findings, such as the sweet taste of diabetic urine. Indeed, Hippocratic medicine was based around semiotics — the recognition and interpretation of signs — and it is startling to realize that these skills were for the most part held in abeyance by the medical profession for over 2000 years, until the creation of clinical medicine in the late eighteenth century. Social mores conspired to keep doctors away from the body, though such taboos did not apply to substances excreted from it. While the doctor would often be limited in his examination to feeling the patient's pulse, he usually had free access to the urine, faeces, and other excreted matter. The interpretation of pulses and urines became highly refined skills: Chinese doctors, for example, used a silk thread held between the thumb and forefinger to feel the oscillations of six pulses in the wrist, each one of which was thought to correspond to a specific internal organ; medieval Western doctors carried specially designed urine bottles, and charts showing the colours and character of morbid urines.

At the end of the eighteenth century a new form of medicine was created in European hospitals. Clinical medicine required immediate access to patients' bodies, both in life and after death, in order to elicit signs of disease and to correlate those signs with morbid changes seen post mortem. The egalitarian hospitals of Paris, crowded with soldiers returned from the Napoleonic wars, proved an ideal environment in which this new approach to the body could flourish. Old, rarely used skills, such as percussion (first described in the 1730s by the Austrian physician Leopald Auenbrugger (1722–1809), were rediscovered and refined. New skills were introduced, most notably auscultation of patients' hearts and lungs by means of the stethoscope, an instrument which has become emblematic of modern medicine. The stethoscope signifies both doctors' intimacy with, and their detachment from, their patients' bodies: immediate auscultation — putting one's ear directly to the patient's chest — was often physically unpleasant or socially unacceptable. Mediate auscultation (listening to the chest through a tube), invented by the French physician René-Théophile-Hyacinthe Laënnec (1781–1826) in 1816, spared the sensibilities of both doctors and their patients, as well as improving the acoustics of the technique.

Modern doctors are heir to the spirit as well as the skills of the first clinicians. Medical students learn, and repeatedly practice, the four central skills: inspection, palpation, percussion, and auscultation. The spirit of clinical examination was captured by the English surgeon George Humphry (1821–96) in the aphorism ‘eyes first and most, hands next and little, tongue not at all’. Of these perhaps the most important is the first. Few diseases produce pathognomonic signs — the ‘spot diagnosis’ beloved of senior students and junior doctors — but experienced clinicians can sometimes determine much of what they need to know about their patients' health simply by observing them carefully. Arthur Conan Doyle (1859–1930) modelled his fictional detective Sherlock Holmes, the epitome of skilled observation, on the Edinburgh physician Joseph Bell (1837–1911), a doctor of tremendous clinical acumen who insisted that successful diagnosis was due to the ‘precise and intelligent recognition and appreciation of minor differences’.

Investigations

Clinical medicine, created at the end of the eighteenth century, enjoyed a golden age in the flourishing hospitals of the nineteenth century. Yet doctors still had to cope with the unyielding complexity and variability of the human body, and the fundamental uncertainty of medical practice. In their quest for certainty, doctors in Europe and the US turned to science for answers. Science itself was a new, fragile discipline at this time: experimental physiology, pathology, and pharmacology first flourished in Berlin and Paris in the 1820s. As scientists delved ever deeper into the anatomy and physiology of the human body, they devised new methods of investigation, which soon entered medical practice. Chemical tests for the presence of sugar or protein in urine, supplanting previous methods such as close inspection or tasting, entered practice in the 1840s and 1850s, at a time when the chemical study of biological processes was being pioneered by the German chemist Justus Liebig (1803–73). The investigation of blood and other tissues under the microscope became necessary in the context of the cell theory, first propounded in 1838 by the German physiologist Theodor Schwann (1810–82) but vastly extended and modified by the German pathologist Rudolf Virchow (1821–1902). With the advent of the germ theories of disease — created and implemented by the French chemist Louis Pasteur (1822–95) and the German bacteriologist Robert Koch (1843–1910) — finding, fixing, and staining bacteria became part of standard medical practice. By 1914, public institutions and private companies were providing extensive diagnostic laboratory services for doctors throughout Europe and the US.

The discovery of X-rays, in 1895, by the German physicist Wilhelm Röntgen (1845–1923), was immediately exploited by the medical profession to examine areas of the human body which were previously inaccessible in life. X-rays proved especially useful in diagnosing fractures and chest diseases. Since World War II several new imaging techniques have been developed: ultrasound began to be used to diagnose diseases of the brain, heart, and abdomen in the 1950s; computerized axial tomography (the CAT scan, now known simply as computed tomography, or CT), invented by the British electrical engineer Godfrey Hounsfield (1919– ), was introduced commercially into practice in 1972; more recently still, magnetic resonance imaging (MRI) and positron emission topography (PET) technology are providing detailed information about the anatomy and physiology of the body.

Imaging technology primarily provides information about the structure of the body. Information about its function comes from other investigations, the earliest and most widely used of which is the electrocardiograph (ECG), which records the electrical activity of the heart. The ECG was first described in 1903 by the Dutch physiologist Willem Einthoven (1860–1927). Similar technology was applied to the recording of brain waves when in the 1930s the American physicist Alfred Loomis (1887–1975) and his colleagues showed that electroencephalograph (EEG) recordings varied during a night's sleep.

Patients entering hospital today, for whatever reason, can expect to have blood taken for simple tests, their ECG recorded, and a chest X-ray taken. Those with suggestive findings in their histories or examinations may then have more complex investigations undertaken. In many cases these investigations will allow a firm diagnosis to be made; in others they may simply confirm a diagnosis already arrived at by clinical reasoning, while giving some indication of the prognosis of the individual patient's illness; in yet others they may provide little or no information to confirm or rule out a diagnosis. Despite the enormous incursion of science into medicine over the last two hundred years, medicine remains an enterprise best characterized by the Hippocratic aphorism, ‘Life is short, the art long, opportunity fleeting, experience treacherous, judgement difficult’.

Diagnosis, prognosis, and therapy

And what do doctors do when they have taken their patient's history, examined them, and made all the necessary investigations? In modern medicine the goal of all these activities is the making of a diagnosis and, ideally, the implementation of therapy. Diagnosis is so central to modern medicine that it is difficult to believe that in earlier eras it could be a matter of little or no interest. The goal of Hippocratic medicine, for example, was to establish the patient's prognosis, that is, the likely future course and outcome of their illness given their past course and present state. Prognosis was important for the Hippocratic doctor, partly because he would only take on cases that he thought would recover (his reputation and even his life being in danger if his patient died), and partly because he had little to offer his patients in the way of specific treatment for disease, believing that diseases arose from an imbalance within the body, or between the body and its environment. Very occasionally some surgical manipulation was indicated, usually to replace a dislocated or broken bone, but otherwise Hippocratic therapy required a change of regimen (in modern terms, lifestyle, including food, drink, and exercise, both physical and mental) to restore the lost equilibrium.

In those cases which Hippocratic doctors did take on, the goal of therapy was to cure the patient completely. This remained the sole goal of therapeutics until the late eighteenth and early nineteenth centuries. Specifics — single drugs which cured specific diseases, hence their name — were highly valued and very rare. As doctors, and in many cases their patients, became increasingly sceptical about the value of long-used remedies, new schools of thought both within and outside the medical establishment began to preach that nature alone cured disease, and that doctors could at best hope to treat the patient by promoting and aiding nature's best efforts. Within orthodox medicine this sceptical attitude fostered experimental research into the actions of drugs: in the 1820s, for example, the French physiologist François Magendie (1783–1855) and pharmacist Pierre-Joseph Pelletier (1788–1842) isolated strychnine from nux vomica, morphine from opium, and quinine from Peruvian bark; around 1900 the German pharmacologist Paul Ehrlich (1854–1915) investigated hundreds of chemicals in his search for antimicrobial agents, before the 606th (christened ‘Salvarsan’) proved to be effective against the spirochaete that caused syphilis; and in 1941, the Australian pathologist Howard Florey (1898–1968) and the British biochemist Ernst Chain (1906–79) purified penicillin from the Penicillium mould first described in 1928 by the British physician Alexander Fleming (1881–1955). Today, new drugs are evaluated in thousands of patients at dozens of hospitals, the results of trials being subjected to sophisticated statistical analysis on powerful computers. Armed with these results, however, an individual physician must still decide whether they apply to each individual patient; often a policy of watching and waiting, without giving drugs may be the most appropriate. Outside orthodox medicine a natural scepticism reached its acme in the doctrine of homœopathy, invented by the German physician Samuel Hahnemann (1755–1843), according to which diseases are treated with drugs at infinitesimal dilutions.

surgery — which prior to the nineteenth century had hardly been regarded as part of medicine at all (in mediaeval times surgeons shared their guild, and their work, with barbers) — flourished as pills and potions fell out of favour. The development of anaesthesia by the American dentists William Morton (1819–68) and Horace Wells (1815–48), and its rapid uptake by surgeons across the world, revolutionized surgical practice, allowing longer and more complex operations to be carried out. This however was of little importance if the majority of those operated upon died of infection soon afterwards; the introduction of antiseptic technique by the Scottish surgeon Joseph Lister (1827–1912), and the subsequent development of aseptic operating theatres, was of equal importance in raising the prestige and effectiveness of surgical treatment of disease. By providing a scientific basis for personal hygiene, these developments also transformed preventive medicine by adding new weapons to its previous armoury of quarantine and sewers.

The contributions of scientific research to medicine in the twentieth century were legion, but scientific progress has often brought with it new ethical, social, and financial dilemmas for medicine. In cardiology, for example, the development of basic and advanced life support techniques, and of new drugs designed to prevent and treat heart disease, have significantly reduced the chances of dying from a heart attack. But the cost of the equipment needed for advanced life support, and of drugs (such as those that lower cholesterol in the blood) that improve survival, mean that these therapies are largely confined to well-funded hospitals in wealthy countries. Again, one of the most significant discoveries of all occurred in 1921 when the Canadian physiologists Frederick Banting (1891–1941) and Charles Best (1899–1978) isolated the hormone insulin. At last it seemed that there would be a cure for diabetes mellitus, a disease recognized since Hippocratic times. But seventy-five years of experience with insulin has taught us that it does not cure the disease. The pancreatic b-cells whose destruction is the defining stage in the disease are not restored by giving insulin. Instead, insulin allows diabetes to be managed, a difficult, time-consuming, often frustrating process that requires doctors and their patients to co-operate over long periods. Nothing could demonstrate the difference between the science and the art of medicine more clearly: scientists push on, trying to understand the pathological processes that take place in the body of a patient with diabetes, elucidating the genetics of both common and rare forms of the disease, and producing new therapies such as recombinant human insulin; doctors, meanwhile, continue to wrestle, as their ancestors did for thousands of years, with the complexity, variability, and uncertainty of their patients' bodies, and their patients' minds.

Mark Weatherall

D. J. Weatherall


See also diagnosis; disease.
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Medicine


Religion and medicine are twin traditions of healing. Although they have overlapped for most of their history, in the past three hundred years the two traditions have become separate and have often been in competition with one another. At the close of the twentieth century, serious consideration began to be given to reintegrating religion and medicine. In this discussion, a review of the historical connection between these two traditions will be offered. Research that has led to a possible rapprochement will be examined as will the implications for practicing clinicians.


Historical background

There is a long historical tradition that connects religion and medicine. The first hospitals in western civilization for care of the sick in the general population, particularly for those unable to pay for their own care, were built by religious groups. In the fourth century, Basil, the Bishop of Caesarea established one of the earliest hospitals based upon the good Samaritan story in the Bible. This building was resurrected in present-day Turkey among almshouses and leper colonies. For the next thousand years, the church would build and staff most hospitals throughout the western world. Many early physicians, especially those in Europe during the Middle Ages and in the New England colonies of the United States during the seventeenth and eighteenth centuries, were also members of the clergy. In Europe, licenses to practice medicine were in fact controlled by the church and church-sponsored universities.

Similarly, the profession of nursing was to emerge out of the Christian church in the 1600s and 1700s with the Daughters of Charity of St. Vincent de Paul, an order of Catholic sisters devoted to the care of the sick. The Daughters of Charity also established the first nursing profession in the United States in Emmitsville, Maryland, in the early 1800s, modeled after nursing in France. Florence Nightingale (17881849), after receiving a "calling" from God, would later receive nurses training from the Daughters of Charity and the Protestant deaconesses (started up by Lutherans in Germany). After the Crimean War, Nightingale applied what she learned to a secular setting. Interestingly, though, up until the early 1900s, most hospitals in Europe and the United States continued to be staffed by nurses who were primarily from religious orders.

Beginning in the fifteenth century, the profession of medicine began to split away from the church, and the state took over the role of administering licenses to practice medicine. That separation would continue to widen until the early 1800s when it was nearly complete. For the last two hundred years, religion and medicine have been divided into separate healing disciplines, with very little overlap and very little communication between the two. However, since about the mid-1990s, especially in the United States, there has been active dialogue about bringing religion and medicine together once again. This movement has been highly controversial and has met with considerable resistance. A growing volume of research showing a connection between religion and health, however, has been breaking down the resistance.

Although the history reviewed above applies primarily to the Christian church, there has been similar interest in health and healing running through nearly all the major world religious traditions, including Judaism, Hinduism, Buddhism, Islam, and Chinese religions. Space does not allow for an adequate discussion of historical connections with medicine for each of these traditions, although resources that do so include Lawrence Sullivan's Healing and Restoring: Health and Medicine in the World's Religious Traditions (1989) and Caring and Curing: Health and Medicine in the Western Religious Traditions (1998) by Ronald Numbers and Darrel Amundsen.

Research on religion and health

The recent trend towards integration of religion and medicine has been stirred primarily by medical research demonstrating intimate and often complex relationships between religion and health. First, many patients indicate that religious beliefs and practices help them to cope with the stress of medical illness. In some areas of the United States, nearly ninety percent of hospitalized patients report that they use religious beliefs to at least a moderate degree to help them to cope. Nearly fifty percent of this group indicate that religion is the most important factor that enables them to cope with medical conditions and the stress they cause. Over one hundred studies have now documented the high prevalence of religious coping among persons with a variety of diseases ranging from diabetes, kidney disease, heart disease, cancer, arthritis, and cystic fibrosis, to more general conditions such as chronic pain.

There is also research demonstrating that persons who are religious end up coping better with physical health problems and disabling conditions. Of nearly one hundred studies conducted during the twentieth century on the relationship between religion and emotional well-being (happiness, life satisfaction, optimism, and hope), nearly eighty percent find that the religious person experiences significantly greater well-being. This is particularly true when populations of medically ill subjects have been studied. The religious are less likely to become depressed or anxious, and if they do develop these mental conditions, they recover more quickly. Suicide is less common among the more religious, as is marital dissatisfaction and divorce, and alcohol and drug use. Nearly 850 studies have now examined these associations, with between two-thirds and three-quarters of these finding that the religious person tends to be healthier and better able to cope with illness.

Of course, a number of studies also report that religion can be associated with worse mental health, more depression, and greater anxiety. This is particularly true for practitioners of religions that are repressive, controlling, and do not emphasize caring for self and others in a responsible way. Religion can be used to justify hatred, aggression, prejudice, and social exclusion. It may induce excessive guilt in situations where guilt is not healthy. Religion may also be used to replace professional psychiatric care for serious mental or emotional problems that require medication and biological therapies. In all of these ways, religion may do a disservice to mental health. In most cases, however, the emotional benefits of religious faith tend to outweigh the negative effects.

There is also a growing volume of research suggesting that religious belief and practices are related to healthier lifestyles, better overall physical health, and longer survival. Studies demonstrate stronger immune functioning among religious persons who are older, who are HIV positive or have AIDS, or have breast cancer. Death rates from coronary artery disease are lower among the more religious, even when health behaviors, diet, and social factors are taken into account. The same applies to mortality from all causes. Since 1990, over a dozen careful studies have demonstrated that the religious person lives longer than the person who is less religiously involved. In these studies, religion is measured by frequency of church attendance, private prayer and scripture study, meditation, and religious coping. Studies have not demonstrated that the broader aspect of religion called spirituality is associated with greater longevity. Spirituality is a broad concept, making it difficult to measure, whereas religious beliefs, practices, and commitment can be more easily assessed and quantified.

Why does religious belief and practice correlate with and predict greater physical health? The answer may lie in the mind-body relationship. There is growing evidence suggesting that emotions influence physiological processes. Psychological stress, anxiety, and depression have been related to impairments in immune functioning, delayed wound healing, and increased risk for cardiovascular morbidity. If religious beliefs and practices reduce emotional stress, counter anxiety, and prevent or facilitate recovery from depression, then religion may help to neutralize the health-impairing effects that these negative emotions have on physical health, and do so through known biological pathways. Mainstream scientists in the field of psychoneuroimmunology are beginning to explore these connections more seriously.

Since about 1980, people have become increasingly disillusioned with medical care that relies solely on high technology and focuses on the biology of disease, while neglecting the care of the whole person. That disillusionment has caused many patients to express a desire to have their spiritual and emotional needs met, as well as their physical needs. Between one-third and two-thirds of patients consistently indicate that they wish their physicians to address religious or spiritual needs in addition to medical needs, particularly when they experience serious medical problems or terminal illness.

Furthermore, there is research indicating that religious and spiritual beliefs impact medical decision making and may even affect compliance with medical treatment, making it essential for physicians to know about these beliefs. Some patients may use religion instead of traditional medical care to treat their illnesses. For example, they may decide to pray for their illnesses and stop taking their medications. There is also research showing that certain types of negative religious beliefs may adversely affect physical health and recovery from medical illness. Patients who feel punished or deserted by God, who question God's power and love, or who feel abandoned by their spiritual community, experience greater mortality and worse mental health outcomes.


Application to medical practice

The growing body of research on religion and health suggests at least the following four applications to medical practice in the West. First, in light of this research, some have argued that physicians should consider taking a spiritual history on patients with serious, terminal, or chronic medical illness. In the United States, only about one in ten physicians consistently addresses spiritual issues by taking a religious history, despite suggestions by a consensus panel of the American College of Physicians and American Society of Internal Medicine that such a history can be obtained by asking a few simple questions. Such questions include the following:

  1. Are religious beliefs a sense of comfort or a source of stress for the patient?
  2. Is the patient a member of a spiritual community and is this a source of support for the patient?
  3. Does the patient have any religious belief that may influence medical decisions or conflict with medical care?
  4. There any religious or spiritual needs present that need addressing?

Taking a spiritual history should be done in addition to (not instead of) competently and completely addressing the medical issues for which the patient seeks help from the physician. Thus, a spiritual history is most appropriate when there is more time in the schedule, such as during a new patient evaluation or during a hospital admission workup.

Second, if spiritual needs are identified when the spiritual history is taken, then the research suggests that addressing those needs should improve the health and coping capacity of the patient. This can be done in a couple of ways. The patient can be referred to a trained clergyperson or chaplain. Chaplains in the United States are required to undergo extensive training that prepares them to address such issues in the medical setting. Before a chaplain is certified in the Association of Professional Chaplains, he or she must complete four years of college, three years of divinity school, one to four years of clinical pastoral education, and must take written and oral examinations. Thus, chaplains are skilled professionals with much to offer in this area. Sometimes, however, patients do not wish to speak with a chaplain or clergyperson. In that case, if the patient already has a trusting relationship with the physician, then the physician may need to be prepared to address such issues, even if this involves only listening and showing respect and concern. Nearly two-thirds of the medical schools in the United States have elective or required courses on religion, spirituality, and medicine. In these courses, medical students are trained to take a spiritual history and to address spiritual issues in a sensitive and appropriate manner.

Third, in addition to taking a spiritual history and, if necessary, addressing spiritual issues, the physician may choose to support healthy religious beliefs or practices that the patient finds helpful in coping with illness. Physicians should not prescribe religion for patients who are not interested in religion. There may be benefits, however, in physicians learning about the religious beliefs and practices of their patients and supporting those beliefs that the patient finds helpful and that do not conflict with medical care. Even when religious beliefs conflict with medical care, the patient is likely to profit when the physician tries to understand those beliefs and keep open lines of communication about religious issues with the patient. By way of supporting religious practice, some physicians have decided to pray with their patients. This activity is highly controversial in the medical setting. Conditions for its appropriateness include that:

  1. A spiritual history has been taken and the physician knows about the religious background of the patient.
  2. Religion is important to the patient and is used in coping.
  3. The religious background of the patient and the physician are similar.
  4. Either the patient asks the physician to pray (i.e., patient initiates the prayer) or, if the physician initiates it, the physician is certain that the patient would appreciate this activity.
  5. The situation calls for prayer (i.e., a difficult, uncontrollable, or stressful situation, severe medical condition, or terminal illness).

Under such circumstances, it may be helpful for a physician and patient to engage in prayer together, enhancing the doctor-patient relationship by increasing trust.

Finally, the research suggests that new social arrangements for medical care may prove beneficial. For example, physicians might develop a communication network with local clergy, both to facilitate a referral base and to allow physicians to assess the community resources that are available to the patient. Religious communities often already provide volunteers to assist with homemaker services, rides to the doctor, respite for exhausted family members caring for the patient, and emotional support to the patient and the patient's family. Religious communities may also monitor the patient to ensure that the medical regimen is being followed and that medical problems are detected early and treatment is obtained promptly. Such a system works especially well when volunteers are appropriately trained and coordinated by a parish or congregational nursea registered nurse who is a member of and works professionally as a nurse within the congregation. A parish nurse can coordinate health programs within the congregation that involve screening for high blood pressure, diabetes, depression, and other diseases. A parish nurse can also provide spiritual care, communicate with physicians and nurses within the formal healthcare setting about the health condition of members of the congregation, train and mobilize volunteers within the religious community to meet the needs of sick members, and provide health education to keep healthy members well.

Religion and Western medicine are indeed coming closer and closer together. The research suggests that this is a positive trendgood for the health of patients and for the maintenance of the health of the community. It is also arguably good for the profession of medicine in the West, which is truest to its most basic aims when its practices support the health of the patients in every dimension.


See also Mind-body Theories; Placebo Effect; Spirituality and Health; Spirituality and Faith Healing


Bibliography

carson, verna benner, and koenig, harold g. parish nursing: stories of service and care. radnor, pa.: templeton foundation press, 2002.

koenig, harold g. "religion, spirituality and medicine: application to clinical practice." journal of the american medical association 284 (2000): 1708.

koenig, harold g; mccullough, michael e.; and larson, david b. handbook of religion and health. new york: oxford university press, 2001.

koenig, harold g. spirituality in patient care: why, how, when, and what. radnor, pa.: templeton foundation press, 2002.

koenig, harold g., and cohen, harvey j. the link between religion and health: psychoneuroimmunology and the faith factor. new york: oxford university press, 2002.

lo, bernard; quill, timothy; and tulsky, james. "discussing palliative care with patients." annals of internal medicine 130 (1999): 744749.

mueller, paul s.; plevak, david j.; and rummans, teresa a. "religious involvement, spirituality, and medicine: implications for clinical practice." mayo clinic proceedings 76 (2001): 12251235.

numbers, ronald l., and amundsen, darrel w., eds. caring and curing: health and medicine in the western religious traditions. baltimore, md.: johns hopkins university press, 1998.

sloan, richrd p.; bagiella, emilia.; and powell, t. "religion, spirituality, and medicine." the lancet 353 (1999): 664667.

sloan, richard p.; bagiella, emilia; vandecreek, larry.; et al. "should physicians prescribe religious activities?" new england journal of medicine 342 (2000): 19131916.

sullivan, lawrence e. healing and restoring: health and medicine in the world's religious traditions. new york: macmillan, 1989.

harold g. koenig

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MEDICINE

Between 1754 and 1829, medicine in what would become the United States passed through three stages. All of the stages originated in Europe, and American medicine remained in a colonial relationship with that continent, regardless of what was going on in politics and economics.

stages of development

At first, physicians and educated people who knew medical texts tended to think in very traditional terms and formulations that had been honored since the time of Galen in the second century a.d. People fell ill because of an imbalance in the humors—black bile, yellow bile, phlegm, and blood. To this basic scheme were added alchemical ideas, folk wisdom, and sometimes ideas about the body as a chemical or physical organism.

The second stage came in the late eighteenth century, when a number of physicians took up Enlightenment teachings. The most conspicuous and important was Benjamin Rush, a physician and teacher in

Philadelphia. Rush based his ideas on those of William Cullen of Edinburgh, who in turn inspired John Brown, also of Edinburgh, where a significant number of American physicians studied. All three of them taught highly rational systems of medicine, as was appropriate to the Age of Reason. Disease in their eyes represented either too much or too little irritability or excitability. Rush in particular held that pathology grew out of a morbid tension in the walls of the arteries.

After the War of 1812, leading American physicians began to study in France. By 1830 the French clinical school was deeply influencing the way physicians viewed and treated ill health. By correlating symptoms with local lesions found during autopsy, and by introducing a measure of skepticism concerning traditional therapies, French clinicians gave a small but growing number of American physicians a sense that empirical investigation could lead to much better understanding of disease.

ideas about disease

Except for the theories of Rush and others, and then the slow incursion of notions of localized pathology, ideas of what a disease was did not change greatly in the two-thirds of a century after 1763. Epidemics were sent by God, but individuals had some control over their own health. Something, it was held, went awry with "the system," a more or less mechanical entity that nevertheless had a vital spirit infusing it and was sensitive to the ordinary inputs of eating and sleeping and the more ominous influences from the environment (often airborne "miasmas"). Because the ideas of both the human system and inputs and environments were vague and contested, medicine remained at best an inexact science and one that was difficult to explain in that time or this. Certain features did stand out, however.

While a few diseases were distinctive, such as syphilis, cancers, stroke, and smallpox, most acute diseases were just varieties of general categories, chiefly fluxes (that is, diarrheas) and fevers. And that was what practitioners ordinarily saw the most of. But fever could come in many varieties, such as long fever (typhoid), malarial fever, putrid sore throat, and the like. In general, diseases were classified by symptoms. One of the most common diseases, for example, tuberculosis of the lungs, was described in a term suggesting the way patients wasted away: consumption.

What people at the time especially noted was how illnesses varied with season and geography. The measles of one year would be different from that of the next. Even epidemics came at different seasons—everyone knew that malaria was a disease of hot weather, that respiratory and arthritic ailments were worse in the winter. Moreover, there was serious doubt that the disease of one place was the same as that of another. It was a surprise in 1800–1801, for example, that the smallpox of New England would respond to vaccination just as would the smallpox of Old England.

As sectional identities began to develop, sectional differences appeared among physicians. Southerners encountered diseases such as malaria and yellow fever that were seldom found in the North. Northern physicians had to deal with diseases of cold weather, not only frostbite but arthritic disorders, which appeared in young as well as older adults. The trans-Appalachian West even acquired a significant disease, first described in 1809–1811. Called the milk sick, it later was found to be poisoning that came when cattle ate a common weed, white snakeroot, so that the illness was both geographical and seasonal. As settlers filtered into the West, the milk sick was a serious and sometimes epidemic disease. (The mother of Abraham Lincoln died of the milk sick in 1818.) On the basis of these different types of illnesses, physicians began to describe special regional medicines, especially southern medicine.

treating illnesses

To a remarkable extent, the therapies available then were general, designed to set the system back onto a natural course so that it had humors in balance or the amount of irritability or tenseness balanced. There could not be a specific cure until there was a specific disease to be cured. From an earlier period, there was a specific cure for the disease of syphilis: mercury. And in the 1730s, Europeans started using cinchona bark, which contained quinine, a specific for malaria. But since the bark affected one fever, many physicians used it for all fevers, since "fever" was the working category. Then, beginning in 1785, foxglove (containing digitalis) was imported from England, where it was discovered to counter dropsy (congestive heart failure). Thus, the list of specifics was a very short one, without significant additions until after 1830.

Physicians often prescribed very powerful drugs—usually herbs, including opium. Each practitioner had his or her favorites. Diet and other, more homely, devices were also used. Sweating was common. The gastrointestinal system was kept as active as possible, and stimulating medications were administered from both ends of the GI system, causing diarrheas and vomiting. "Trust in God, and keep the bowels open," was common wisdom.

Treatments were described in general terms according to the effects that they had on the system. There were stimulants (people most importantly and incorrectly imagined that alcohol was a stimulant). There were depletives, of which the most commonly employed was bleeding. And there were alteratives, such as violent purges that wracked the system and left it in a new rhythm or state after the effects had run their course.

Physicians and people practicing on themselves utilized other techniques as well. In addition to bleeding, a variety of instrumentalities existed to produce running sores and pus by means of which the body would throw off "moribific matter" or undesirable elements in the blood. The skin could be blistered with irritants such as cantharides (Spanish fly) or cupping (burning paper in a cup applied to the skin and creating a vacuum). "Issues" could be created by inserting a pea or bean under the skin to obtain a discharge. Or a seton could be made: a thread was run under the skin and then coated with an irritant and pulled back and forth, which usually produced a satisfactory discharge (done in the neck for headache, for example).

Since treatment modalities tended to persist from the late eighteenth into the nineteenth century, the style of treatment rather more than the specific details defined changes in medicine. Beginning in the 1790s, and especially under the leadership of Benjamin Rush, who thought his extreme measures had some effect against the yellow fever epidemic in Philadelphia in 1793, so-called heroic medicine flourished in the United States. The more serious the symptoms, the more powerful were the treatments. "It is but trifling with the life of a man to give him less of a remedy than his disease calls for," wrote a southern physician in 1828.

Heroic treatment consisted of the usual therapies carried out with more than usual vigor and dosage. "Copious bleedings" took place—to an extent that scandalized later generations. Although extremely violent purgatives were used, "the Samson of the material medica" was mercurous chloride, or calomel. Calomel was used as a stimulant, and it did stimulate the gastrointestinal system. Calomel also caused classic symptoms of mercury poisoning. The mouth could turn ash gray, ulcers of the oral area appeared, and teeth could become loosened. Patients often took calomel until they "salivated"—another sign of mercury poisoning.

Heroic treatment spread most famously to the West and South. The practice of many New Englanders and other physicians was often relatively restrained and mild—and empirical. But already by the 1820s, a popular reaction had set in, and many lay people as well as medical practitioners were criticizing heroic styles of practice. At the same time, an active stance regarding an individual patient's disease was part of a professional identity.

surgery

In colonial medicine, physicians, even those trained in England as surgeons, did only limited kinds of surgery. Since there was no anesthesia, and since infection almost invariably followed cutting into the body, only in urgent cases would anyone resort to surgery. A competent practitioner would set a simple fracture or correct a dislocation. He would lance abscesses and extirpate growths on the skin. He might couch a cataract. In a case of a compound fracture, or in warfare when a bullet broke the skin, amputation of the limb was called for. Infection otherwise would almost certainly kill the patient. The only generally accepted procedure that involved cutting below the skin on the body or head came when a patient was dying with bladder stones that prevented urination. Then a physician could "cut for stone"—often with considerable success.

Occasionally some foolhardy or desperate practitioner would attempt to intrude into the thorax to cut a dangerous growth or condition, though such incidents became more common in the nineteenth century. The most famous instance was that of Ephraim McDowell, a practitioner of Danville, Kentucky, who in 1809 operated on a woman with a large ovarian tumor. He subsequently repeated the operation successfully, reporting his cases in 1817. And all through the late eighteenth and early nineteenth centuries, many practitioners ingeniously invented or copied new and better surgical instruments, many of which have survived in museum collections.

medical practice and self-treatment

Almost all practice was carried out in patients' homes or, to a lesser extent, the physician's home office. Charitable hospitals appeared only slowly. The Pennsylvania Hospital had been founded in 1751 (and the New Orleans Charity Hospital in 1736), and others came and went. But no one would willingly choose a hospital over home care. Nursing, either institutional or domestic, was carried out by servants or relatives.

Because of the isolated life of many settlers, and because a large and growing proportion of the population was literate, many Americans avoided the expense of seeking medical advice and used their own means to treat their illnesses. Sometimes family recipes or folk healing sufficed. A growing number of advice books was available, either imported from Europe or printed in America in pirated editions. Throughout the period, almanacs like those compiled by Benjamin Franklin contained medical advice. Most notably, proprietary or "patent" medicines, offered commercially, attracted many customers. Newspaper ads for English preparations first appeared in significant numbers during the 1750s, and by the 1820s Thomas Dyott of Philadelphia, a former bootblack, was becoming one of the richest men in the country by marketing nostrums.

In 1830 American medicine was poised for great changes. For the first time, Americans would be contributing significantly to world medicine. (The physiology of digestion, surgical anesthesia, and landmark therapeutic skepticism all came in the 1830s.) Cholera, which terrorized the population and stimulated changes in medical practice; health reform movements; and the railroad, which enabled professionals to organize, all lay in the future. Meantime, in the 1820s, many signs of the future were already in place. Sulfate of quinine—in place of "bark"—came in. A national pharmacopeia appeared in 1820, with a promise of revision every ten years. The Philadelphia College of Pharmacy was established in 1821. The first state mental hospital to signal a wave of reform that swept the country, the Eastern Lunatic Asylum (later Eastern State Hospital), was established in 1824 in Lexington, Kentucky. And by 1829, 105 American physicians had returned from studying in Paris. Of course, they still had to practice right alongside a very large number of practitioners of various degrees of education, apprentice training, self-education, and simple commercial cupidity.

See alsoAsylums; Epidemics; Health and Disease; Malaria; Mental Illness; Pain; Patent Medicines; Professions: Physicians; Smallpox .

bibliography

Estes, J. Worth. Hall Jackson and the Purple Foxglove: Medical Practice and Research in Revolutionary America, 1760–1820. Hanover, N.H.: University Press of New England, 1979.

Estes, J. Worth, Philip Cash, and Eric H. Christianson, eds. Medicine in Colonial Massachusetts, 1620–1820. Boston: Colonial Society of Massachusetts, 1980.

Gevitz, Norman, ed. Other Healers: Unorthodox Medicine in America. Baltimore: Johns Hopkins University Press, 1988.

Kett, Joseph F. The Formation of the American Medical Profession: The Role of Institutions, 1780–1860. New Haven, Conn.: Yale University Press, 1968.

Reiss, Oscar. Medicine in Colonial America. Lanham, Md.: University Press of America, 2000.

Rothstein, William G. American Physicians in the Nineteenth Century: From Sects to Science. Baltimore: Johns Hopkins University Press, 1972.

Shyrock, Richard Harrison. Medicine and Society in America, 1660–1860. New York: New York University Press, 1960.

Warner, John Harley. The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820–1885. Princeton, N.J.: Princeton University Press, 1997.

John C. Burnham

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Medicine

HISTORY OF MEDICINE

MEDICINE TODAY

BIBLIOGRAPHY

In its broadest sense, medicine denotes ideas relating to diagnoses, causes, and cures of illness, as well as the practice of restoring and maintaining health, and the substances used in the treatment of disease. Medicine is both a domain of knowledge and the application of that knowledge. Medical ideas and practices as well as the social institutions relating to health compose a medical system. Medical systems include ways of classifying disease (cancer, a cold, soul loss, and spirit possession), health specialists (doctors, herbalists, and shamans), and therapies to end illness (pharmaceuticals, meditation, acupuncture, and divination).

Western medicine, or biomedicine, is currently the most widespread medical system, but thousands of others exist throughout the world. Although each tradition is different, diagnosis and treatment often consist of both magical and herbal components. For instance, many societies believe that ill health can be attributed to supernatural forces, which can be meted out by spirits, gods, ancestors, sorcerers, or witches. These forces are capable of causing both the body and the soul to become ill. To combat disease, patients and healers can also invoke magical substances, rituals, or supernatural beings. Another common method of healing is herbalism, using plants to treat illness. An immense variety of plant species are employed as remedies and include decongestants, pain relievers, and antiseptics. Plants in the Americas have been used to derive important drugs including aspirin, quinine, and novocaine. Although nonbiomedical traditions were once regarded as ineffective and superstitious, they are now acknowledged as providing new sources of medicinal plants as well as information regarding the social lives, environments, and experiences of humans.

Medical ideas and practices both constitute and are constituted by social and cultural beliefs and concerns. Arthur Kleinman notes that medicine is a cultural system of symbolic meanings anchored in particular arrangements of social institutions and patterns of interpersonal interactions (1990, p. 24). Illness dialogues, diagnoses, and treatments can express ideas regarding religion, morality, power, politics, identity, economics, and gender. Consequently, social scientists are able to examine medical systems and their components as one method of understanding societal norms, attitudes, and practices. For instance, in The Birth of the Clinic (1973) Michel Foucault examines what he calls the clinical gaze, to show how medicine is linked to power. In AIDS and Accusation (1992) Paul Farmer explores how AIDS dialogues in the United States and Haiti reflect attitudes of colonialism, capitalism, and poverty. Social science research regarding the conceptions and use of medicine can focus on both local environments and global ones.

HISTORY OF MEDICINE

The purposeful treatment of illness has probably occurred throughout the entire span of human existence. However, without written records, it is impossible to know for certain what the earliest types of medical treatment were. The first written evidence of medical knowledge, including lists of symptoms, diagnoses, and treatments, comes from Mesopotamia and Egypt, dating to more than four thousand years ago. In ancient Mesopotamia 250 vegetable and 120 mineral drugs were documented (Magner 1992, p. 19). But it is ancient Egypt that can claim both the first real physician known by name, Imhotep (c. 2980 BCE), and later, the first formalized medical system, which included medical schools, medical insurance, sick leave, and registered physicians of both sexes. The ancient Mesopotamian and the Egyptian medical systems also incorporated magical remedies. These were the first of a number of codified medical traditions that developed around the world.

The ancient medical systems of India and China were developed later than those of Mesopotamia and Egypt but they are still practiced today. In India, Ayurveda (the science of life) was intended to maintain health, not simply treat disease. Ayurvedic practitioners believe that health is the result of the balance of three doshas (elemental manifestations in the physical body) that govern body processes. Magner notes that ancient texts list more than one thousand diseases and almost one thousand drugs, and describe advanced surgical procedures including cesarean section, amputation, lithotomy, cauterization, tonsillectomy, and plastic surgery (p. 43). Like Ayurveda, traditional Chinese medicine also views disease as the result of an imbalance in the body, which is composed of yin and yang elements. Doctors often made diagnoses by studying the pulses of patients and were aware that the heart was responsible for circulating blood long before Europeans were. Chinese medicine employs a variety of treatments including more than five thousand medicinal herbs (such as ginseng), acupuncture (inserting needles into the body at specific points), and moxibustion (applying a burning tinder to the skin).

In classical Greece, Hippocrates (460361 BCE), sometimes called the Father of Medicine, wrote that health was the result of a balance between the four humors (basic bodily fluids) of phlegm, yellow bile, black bile, and blood. During the Roman Empire the humoral approach was used by many physicians, including Galen (130200 CE). His writings were used as important medical texts throughout Rome, the Islamic world, and Europe for centuries. Islamic doctors further embraced and modified the Greek tradition and spread it from Spain to India. The medical writings of the doctor and philosopher Ibn Sina (Avicenna, 9801037) became standard texts throughout the Arab conquests and Medieval Europe. In Europe it was not until the scientific revolution of the sixteenth and seventeenth centuries that the Greco-Islamic tradition was fully abandoned.

In 1628 William Harvey (15781657) challenged the Galenic tradition when he published what was then an unorthodox idea: that the pumping heart moved a continuous flow of blood through the body. Almost one hundred years later the Turkish and African practice of purposefully exposing individuals to mild strains of smallpox to achieve inoculation caught the attention of Europeans and Americans, leading to the development of the first vaccine. Nonetheless, it was not until the nineteenth century that advances in chemistry and medical technology led to the discovery of microbial sources of disease and their cures. This allowed researchers to isolate, treat, and create vaccines for diseases such as tuberculosis, tetanus, cholera, and rabies. The introduction of general anesthesia (1840s) and antisepsis (1870s) precipitated the growth of surgery and hospitals, but it was not until the twentieth century that significant advances were made.

MEDICINE TODAY

The product of a specific historic and cultural past, bio-medicine is currently used around the globe. The biomedical system includes professional, scientific, educational, legal, financial, and ethical frameworks. Biomedicine can be characterized by a number of features. One is its almost exclusive use of science and technology to fight disease. Unlike many other traditions, biomedicine views disease as caused by only natural factors. Supernatural or magical sources of illness or treatments are absent. Most biomedical treatments involve the use of synthesized pharmaceuticals and some require hospitalization. Furthermore, the physical body, not the soul, is considered to be the only locus of illness. Given its early history, biomedical practitioners often have a tendency to look for and find a single cause of an illness (such as a microbe) and then to treat it with a single cure (such as antibiotics). Deborah Gordon (1988) notes that the scientific approach of biomedicine is not only a way to treat illness; it is also a way of conceptualizing the world.

The focus of biomedicine is illness and not health, which is often defined as the absence of disease. Critics charge that because biomedicine almost exclusively treats the body and disease, it lacks a holistic approach to well-being that engages with the social individual. Patients who feel that biomedicine is not meeting their needs have a number of other therapeutic options from which to choose. In developed counties such as the United States, complementary and alternative medicines are widely used. In 1998 Eisenberg et al. estimated that number of visits to alternative medicine practitioners exceeded the total number of consultations with primary care physicians in the United States. These therapies, which include herbalism, meditation, yoga, massage, acupuncture, aromatherapy, and chiropractic medicine, are used either in conjunction with, or as a substitute for, biomedical treatment. They are often provided by nonlicensed healers and can incorporate religious or non-Western traditions.

Throughout much of the world, the majority of medical consultations are still with traditional healers and not biomedical personnel. Nevertheless, indigenous and local healing traditions are often used in conjunction with bio-medicine. For instance, in India and China, Ayurveda and traditional Chinese medicine, respectively, continue to play important roles in the public health care systems alongside biomedicine. Magner notes that in the 1960s acupuncture anesthesia was used in 60 percent of all surgeries in China (1992, p. 59). Australian Aboriginal people have the choice of going to a biomedical clinic, using local plants as remedies, or consulting local healers to cure spiritual sickness. In Africa herbalists and diviners, as well as doctors and nurses, are regularly consulted. Throughout our history, humans have employed a variety of techniques to treat illness, and this process continues today.

SEE ALSO AIDS; AIDS/HIV in Developing Countries, Impact of; Anthropology, Medical; Disease; Magic; Medicaid; Medicare; Medicine, Socialized; Public Health

BIBLIOGRAPHY

Eisenberg, David, Rodger Davis, Susan Ettner, et al. 1998. Trends in Alternative Medicine Use in the United States, 19901997: Results of a Follow-Up National Survey. Journal of the American Medical Association 280 (18): 15691575.

Farmer, Paul. 1992. AIDS and Accusation. Berkeley: University of California Press.

Foucault, Michel. 1973. The Birth of the Clinic: An Archaeology of Medical Perception. London: Routledge.

Gordon, Deborah. 1988. Tenacious Assumptions in Western Medicine. In Biomedicine Examined, ed. Margaret Lock and Deborah Gordon, 1956. Dordrecht, Netherlands: Kluwer Academic Publishers.

Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press.

Magner, Lois. 1992. A History of Medicine. New York: Marcel Dekker.

Eirik J. Saethre

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MEDICINE

Medicine has been an integral part of Islamic intellectual life and social institutions from the time of the Prophet. This brief description will touch on the diverse origins of medical knowledge in Islam; the development of hospitals, medical practice, and medical knowledge during the Islamic "Golden Age" (the latter half of the seventh century through the thirteenth century c.e.); the role of the Islamic world in protecting, elaborating, and reintroducing Hellenic medicine to Europe after the Dark Ages; and contemporary issues including the development of Islamic medical organizations dedicated to the assertion and protection of the religious context of the practice of medicine.

Medicine in the Time of the Prophet

The tribes that inhabited what is now Saudi Arabia at the time of the prophet Muhammad had a great deal of traditional medicine. As medical thinking and knowledge became explanatory and inductive with the parallel development of scientific thought in general, much of this traditional knowledge was preserved and some of it expressed in religious thinking. At the same time, distinct medical traditions were well developed in India, Persia, China, and Greece. Early Islamic medicine drew upon all of these traditions. The Qur˒an itself contains limited specific medical text, although there is important guidance in prescribing breastfeeding as the right of every child, in proscribing intoxicants and the meat of certain animals, and in commentary on the beneficial health effects of some natural foods. However, the hadith (authenticated sayings and deeds of the Prophet) and its interpretations contain rich and detailed material on preventive and curative medicine, dietetics, and spiritual health. Early in the Islamic tradition these sources were collected and eventually became known as al-Tibb al-Nabawi (Medicine of the Prophet, or Prophetic Medicine). These collections remained distinct from the Persian, Indian, and Greek sources that early Islamic physicians drew upon, although they interacted with these traditions through their work. The best-known version is that of Ibn Qayyim al-Jawziyya, writing in Damascus in the late eleventh century c.e. Translated into many languages and widely accessible to Muslims the world over, the Medicine of the Prophet forms the rationale for many aspects of everyday Muslim life in terms of health protection and promotion—for example, injunctions against overeating; prescriptions for the spiritual and psychological care of the bereaved and traumatized; encouragement of moderation in all things; and much specific instruction on everyday food, drink, rest, and sexual behavior.

The Development of Islamic Medicine

The schisms within European Christianity in the fourth and fifth centuries c.e. paved the way for a shift of focus outside Europe for development of the profession. When Nestorius, the Patriarch of Byzantium, and his followers were forced out of Europe a large pool of intellectuals moved to the Middle East, many to Jund-e Shapur, a city in what is now southwestern Iran that was already home to a thriving intellectual community including Syrians, Persians, and Jews and where a medical school was well established. When Justinian I (527–565 c.e.) expelled "heathen philosophers" from Athens, the Hellenic medical tradition based on Galen and others was transplanted to the fertile soil of Jund-e Shapur where it thrived amid a community of scholars who translated the Greek medical works into Arabic either directly or through translations into Syriac. Manuscripts from other regions including India and China were also translated and when Islam expanded into Egypt, Greek manuscripts from Alexandria also became available. A short time before, the Persians had been conquered by Muslim armies under the first caliph, giving the Muslims access to Jund-e Shapur.

In 765 c.e., an eminent Christian physician who headed the medical school at Jund-e Shapur, Jurjis Bukhtishu, was invited to Baghdad by the caliph al-Mansur to treat him. He did this successfully, and was appointed to the court. Although he returned to Jund-e Shapur, his son migrated to Baghdad and set up a successful medical practice. Other prominent medical men and their offspring soon joined an emigration to Baghdad, which became a medical focal point with many hospitals and medical centers and a great deal of scientific and intellectual activity of all sorts, most of which drew on Greek intellectual tradition. That the medical experts of Jund-e Shapur and later of Baghdad were accomplished linguists who opened the Islamic empire to knowledge from the rest of the world and made Arabic the primary language of the time for documentation in medicine, science, philosophy, and many other fields.

During the several centuries that followed, hospitals and medical schools were established and thrived throughout the Islamic world, with the largest and most notable in Damascus, Cairo, and Cordoba. These facilities established traditions of treatment free of charge to the patient and acceptance of all in need of treatment without regard to means, religion, age, or gender. The development, enrichment, and encyclopedic documentation of medicine in the Islamic world of the time was led by a series of individuals, some of whom were true "Renaissance men" of their times. The guidance of several of these (al-Razi, al-Zaharwi, Ibn Sina) will be briefly mentioned, but they are among many other eminent contributors to medicine from this period.

Abu Bakr Mohammed ibn Zakariyya al-Razi (known as Rhazes in the West) was born near what is now Tehran in middle of the seventh century c.e. Al-Razi was accomplished in many spheres, and came to the study of medicine relatively late in life after a visit to Baghdad and a hospital there, which he later directed. There are many stories about al-Razi's skill as a practitioner. One famous account addresses his knack for environmental health. The story goes that he was asked at some time during his career to choose the location for a new hospital in Baghdad. He did this by observing fresh meat hanging in various parts of the city and choosing the area based on where the meat took the longest to spoil. He was a diligent teacher, a skilled diagnostician, and a prolific writer. His written works number in the hundreds. The largest, which is a huge compilation of case studies and notes edited and published by al-Razi's students after his death, has been called al-Hawa (the Continent); a thirteenth-century Latin translation was entitled Continens. This work summarized essentially all of the medical writings preceding al-Razi's time as well as his own observations. His most famous piece was a much shorter monograph in which he distinguished smallpox, chicken pox, and measles; this work translated to Latin was called de Pestilentia and formed the basis for much future work on these highly contagious diseases.

Several centuries later, the dual influence of al-Zahrawi in the West and Ibn Sina in the East were pivotal. Abu 'l-Qasim al-Zahrawi lived from about 930 to 1013 c.e. and was known as the "greatest surgeon of Islam." Zahrawi lived in the western caliphate, near Cordoba, and attended the University of Cordoba. He is most famous for his command of analgesia and anesthesia, utilizing opium and other natural narcotics and depressants, and the theory and practice of surgery. He invented many surgical instruments and wrote what is no doubt the first textbook of surgery. Although ignored throughout most of the eastern part of the Islamic world at the time, his influence on Europe was very significant.

Ibn Sina (known as Avicenna in the West) lived just a bit later (980–1037 c.e.). He was born in Persia in what is now Isfahan, Iran. Like many medical men of his time, he was an intellectual in a complete sense, writing on philosophy, music, military strategy, mathematics, and other subjects as well as medicine. His greatest medical work was the Qanun fi altibb, a five-volume treatise based on Greek knowledge and including Ayurvedic writings from India, some Chinese medicine, and other available sources. The Qanun included discussions of almost all ailments imaginable, as well as health promotion focusing on diet, the environment, and climate; it also included a huge materia medica including many medicinal plants and the drugs that could be derived from them. His theory of infection by "traces," together with the Prophet's earlier injunction to avoid travel to or from places in which plague was present, led to the introduction of quarantine as a means of limiting the spread of infectious diseases. Although he also wrote in his native Persian, Ibn Sina's medical works were penned in Arabic, which faciliated the reintroduction of scientific medicine in Europe as the Dark Ages gave way to the European Renaissance. This process paralleled a period of decline in Islamic influence and hegemony.

The Re-Introduction of Medical Science to Europe

The Arabic text of Ibn Sina's Qanun was published in Rome in 1593, and was one of the first Arabic books to be printed. The entire text had been translated into Latin two centuries earlier. This encyclopedic work soon became the preeminent medical text in Europe and was depended upon for four hundred years by the major medical schools on the continent. It was published in no less than sixteen editions, in Milan, Padua, and Venice throughout the 1400s and 1500s; the last edition for textbook use was published in 1658. Ibn Sina's writings, and the antecedent Islamic works on which he drew, thus formed the route by which the Arabic repository of Hellenic medicine, greatly expanded and enriched, was reintroduced to Europe. The subsequent major scientific advancements that came with Claude Bernard's (quite compatible) theory of the internal milieu, van Leewenhoek's discovery of the microscope, and other advances quickly pushed medicine to a secular, empirical basis and the importance of the contributions of the Arabic texts was largely forgotten.

Medicine in Contemporary Islam

Today, the infrastructure and content of medicine as it is practiced in the Islamic world is compatible with and even formed in the image of European and other Western models. Ironically, the only part of the world in which the corpus of (largely Greek) theory that constituted the medical knowledge of early Islamic history is still taught is in South Asia, where there are schools and licensure for practitioners of "Tibb Unani" ("Greek Medicine"). In most of the Muslim world, however, medical education and practice is largely consistent with that in the West, with a structure of specialties, supervisory responsibility and liability, curricula, and requirements for continuing medical education for practitioners. However, the last several decades have seen a movement toward development of consciously Muslim perspectives in medicine.

A notable recent change has been the reentry of women into medicine throughout the Muslim world. There has never been a prohibition on female physicians, nor on the treatment of patients of either gender by a male or female doctor. Aside from the doctrine that "necessity overrides prohibition," the hadith states clearly that treatment should depend solely on the needs of the patient and the capability of the doctor. Indeed, the precedent for female doctors was set by the Prophet's own entirely female medical corps that accompanied his armies into battle. As medicine became an intellectual pursuit requiring literacy and education, skills that were the province of men in most Muslim societies, the profession became almost entirely male. As education has more recently included women, they have moved back into medicine without formal barriers and with enthusiasm.

Recently there has been particularly active dialogue and introspection around issues of bioethics and the conduct of the Muslim medical practitioner in the religious context. Noteable in this context is the Islamic Organization for Medical Sciences (IOMS) (<http://www.islamset.com>), established in 1984 in Kuwait with an objective of serving the entire Muslim world. In its brief history IOMS has held multiple conferences on the heritage of Islam in medicine, established a World Health Organization Collaborating Research Center focused on traditional medicinal plants, and published a number of works focusing on ethical issues including Muslim definitions of the beginning and end of life, the use of newer reproductive technologies, care of the aged, and, recently, the impact of globalization on health and health care in the Islamic world. An Islamic Oath of the Doctor was developed by an IOMS conference, and is now widely published and used.

An early anatomical drawing appears in the volume two color insert.

See alsoBody, Significance of ; Ethics and Social Issues ; Falsafa ; Science, Islam and .

BIBLIOGRAPHY

Bakar, Osman. The History and Philosophy of Islamic Science. Cambridge, U.K.: Islamic Texts Society, 1999.

Hathout, Hassan. Islamic Perspectives in Obstetrics and Gynecology. Kuwait: Islamic Organization for Medical Sciences, 1986.

Islamic Organization for Medical Sciences. Overview of the Islamic Organization for Medical Sciences. Kuwait: IOMS, 1987.

Jawziyya, Ibn Quyyim al-. Medicine of the Prophet. Translated by Penelope Johnstone. Cambridge, U.K: Islamic Texts Society, 1998.

Rosenthal, Franz. Science and Medicine in Islam. Brookfield, Vt.: Gower Publishing Company, 1990.

Wright, David Lionel. The Legacy of Arabic Medicine during the Golden Age of Islam. Kuwait: Islamic Organization for Medical Sciences, 1996.

Gail G. Harrison Osman M. Galal

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MEDICINE

MEDICINE. Food plays both a causative and curative role in health and disease. Thus, its role in medicine may be as a risk factor for, protector against, or treatment of an illness. While too much food or exposure to certain foods can reduce someone's health, too little food or inadequate amounts of certain foods can be equally damaging. In the years before modern transportation, packaging, and refrigeration, medicine was primarily concerned with food deficiencies and food spoilage. The focus of medicine was on the identification of critical components of food and common pathogens and on the prevention of nutritional deficiencies and foodborne infections. The role of food in medicine has changed as food production, preservation, and preparation techniques have progressed. Today far more people in developed countries such as the United States suffer from excessive food consumption than from food deficiencies. In addition, certain components of food have been found to have therapeutic or protective properties when administered in levels greater than generally considered necessary. For instance, large quantities of vitamin A are used to treat acne, therapeutic quantities of vitamin E may be protective against heart disease, and extra fiber appears to reduce the risk of colon cancer. However, the problems of malnutrition or inadequate food intake and foodborne illness have not been eliminated. Undernutrition continues to plague developing nations, while the prevention and treatment of foodborne illness is a concern for all nations.

The Basics of Food and Health

Food is fundamental to support life. People get energy, water, and all of the building blocks for growth and proper bodily functioning from the foods they eat and the liquids they drink. The components of food necessary to life are termed "nutrients" and the study of the role of food in health is called nutrition. The goal of medicine is to ensure health, and because adequate nutrition is necessary to accomplish this, nutrition is a crucial component of medicine. Nutritional science combines food science and medical science. Nutrients include protein, fat, carbohydrates, fiber, thirteen vitamins, seventeen minerals, and more substances that are still being identified. The majority of nutrients essential to health are found in a variety of different foods. No one food is absolutely essential to support life. People with access to adequate amounts of food get all of the nutrients they need by eating a varied diet complete with fruits, vegetables, meat or meat alternatives, dairy foods, and grains. However, some people are not able to or do not choose to eat the full variety of foods available. These people may require special foods or supplements to meet their nutritional needs.

The Study of Food in Medicine

All branches of medicine, from pediatrics to geriatrics and from internal medicine to surgery, study food and its role in health and disease. Nutritional scientists in government, industry, and academia are constantly seeking to understand the role food plays in illness and well-being. Meanwhile health-care practitioners treat patients with nutritional plans and food supplements. Registered dietitians are health-care specialists who integrate food into medical treatmentthis is referred to as medical nutrition therapy.

The Role of Food in Maintaining Health

Although the presence of adequate nutrition does not ensure health, it is a significant contributor. The energy contributed by the protein, carbohydrates, and fat in food provides the fuel for every element of body functioning from breathing to thinking to fighting disease to running marathons. Adequate energy intake is crucial to promote proper growth and development as well as to maintain healthy functioning once one is fully grown. Food also provides the materials necessary to build healthy bone, muscle, skin, hair, etc. For example, bone is a complex matrix of calcium, phosphorus, and collagen fibers. A person's bone strength is directly related to their nutrient intake such that inadequate calcium intake is one of the primary reasons for bone disease such as osteoporosis. Nutrients are also necessary to support proper chemical and neurological functioning. For example, fat insulates nerve fibers such that they can conduct electrical signals along the length of the body. Meanwhile, those electrical signals are generated via channeling ions such as sodium, potassium, and calcium into and out of the nerve cells. Finally, the neurotransmitters released from the nerve cells are made from amino acids contributed largely from proteins in the diet. Thus, thinking and feeling are intricately connected to food.

Food for Those Who Can't Feed Themselves

Food is generally eaten, or drunk, and swallowed. However, many people cannot obtain adequate nutritional levels by conventional ways of ingesting food. In the past, these people would suffer and die from malnutrition. Modern nutritional medicine offers people several alternatives to conventional chewing and swallowing of food so that those who cannot do so will not die. Liquid solutions have been manufactured by pharmaceutical companies that are easier to digest than solid food and provide 100 percent of nutritional needs. People who can drink but not eat rely on these formulas just as babies who cannot breast feed rely on baby formula to meet their nutritional needs. People who cannot consume anything orally are fed via a tube inserted into the stomach or intestines. Finally, those whose gastrointestinal tracts cannot absorb even liquids are fed intravenously with solutions that provide 100 percent of human nutritional needs.

Examples of Food as a Cause of Disease

Food allergies and intolerances are common medical reasons for eliminating specific foods from one's diet. An allergy is an immune response to proteins in food that the body identifies as foreign. The most common food allergies include those to peanuts, tree nuts, shellfish, milk, soy, corn, wheat, and eggs. Most allergies appear in childhood and require complete elimination of the offending food if the symptoms are to be eradicated. Childhood food allergies may persist for a lifetime or may resolve a few years after getting rid of the offending food. Symptoms of allergies may include rashes and other skin irritations, gastrointestinal inflammation and bleeding, and respiratory distress, which may even involve arrest of breathing.

Food intolerances are not allergies but rather uncomfortable reactions to food that are not generally considered life threatening. One well-known example is lactose intolerance. Lactose is the carbohydrate in milk and other dairy products. The body requires a specific enzyme if lactose is to be absorbed. As people age their bodies may make less of the enzyme necessary to break down lactose and as a result they may experience gastrointestinal distress, including such symptoms as gas or diarrhea, when they consume milk products containing lactose. Most people with lactose intolerance can tolerate dairy products if they accompany their meal with a lactase enzyme pill or if they consume dairy products pretreated with lactase enzyme. Thus, food technology allows people with intolerances to tolerate the offending foods but avoidance is the only option for people with food allergies.

In countries such as the United States where food is abundant, some of the greatest medical risks result from overeating rather than insufficient eating. For example, an excess intake of energy in the form of food leads to an increased risk of obesity. Obesity increases one's risk of cardiovascular disease, cancer, diabetes, and obstructive pulmonary diseaseamong the most common and most deadly diseases today. Medical practitioners have tried to determine how much food is adequate to support healthy living. People who consume too much food and become obese may seek medical treatment to lose weight and treat diseases resulting from obesity. Treatments may include nutritional therapy, exercise programs, drug therapy, or surgery. Foodborne illness results from eating contaminated food. Foodborne illness can be caused by parasites, bacteria, viruses, toxins, or other pathogens that are harmful to humans. Food is not the direct cause but rather the carrier of the problematic agent. The effects of foodborne illness can range from flulike symptoms to death depending on the type of pathogen and the amount of exposure. Foodborne illnesses are generally prevented by appropriate growing, harvesting, packaging, preparation, cooking, and storage of food. However, many countries lack the technology and resources necessary to accomplish this. Thus, assuring food safety continues to be an area of international concern.

Food as a Treatment

Food is not only necessary to sustain health but it can also help ill people regain health. Although the common advice to "feed a fever" may sound like folklore it is actually based in scientific evidence. A rise in body temperature is required in order to fight disease. People with a fever also require extra energy if they are to have adequate energy to maintain their strength while they battle illness. Likewise, the immune system uses a wide range of nutrients to combat intruders. All infectious diseases result in increased need for nutrition to strengthen the immune system as if fights against invading viruses or bacteria. People who suffer from diseases such as cancer, cystic fibrosis, and acquired immunodeficiency syndrome (AIDS) generally require extraordinarily large amounts of nutrients to battle their disease. Likewise, young children who are ill require extra food to ensure that they have adequate nutrition to ensure normal growth and development. Food is crucial in combating both minor and major illnesses.

Many specific nutrients defend against disease. Calcium, a mineral found mainly in dairy products, is critical in the promotion of bone health and protection against osteoporosis. Fluoride, now added as a supplement to most water supplies, is crucial to tooth development. Iron is most commonly found in meats and protects against anemia. Folic acid prevents neural tube defects such as spina bifida in developing fetuses and has recently been found to protect against cardiovascular disease. In fact, almost every vitamin and mineral is known to be critical to one or more life processes. Nutritional specialists and medical practitioners are constantly studying the role each nutrient plays in protecting the body and investigating further possible cures.

See also Dietetics ; Digestion ; Disease: Metabolic Diseases ; Enteral and Parenteral Nutrition ; Health and Disease ; Hunger, Physiology of ; Immune System Regulation and Nutrients ; Intestinal Flora ; Microbiology ; Nutrient-Drug Interactions ; Nutrients ; Nutrition ; Nutritionists ; Safety, Food.

BIBLIOGRAPHY

Duyff, Roberta Larson. The American Dietetic Association's Complete Food and Nutrition Guide. New York: Wiley, 1998.

Mahan, Kathleen L., and Marian Arlin, eds. Krause's Food, Nutrition and Diet Therapy. 10th ed. Philadelphia: W.B. Saunders; Harcourt Brace Jovanovich, 2000.

Margen, Sheldon, and the editors of the University of California at Berkeley Wellness Letter. The Wellness Encyclopedia of Food and Nutrition: How to Buy, Store, and Prepare Every Variety of Fresh Food. New York: Health Letter Associates, 1992.

Nelson, Jennifer K., Karen E. Moxness, Michael D. Jensen, and Clifford F. Gastineau. Mayo Clinic Diet Manual: A Handbook of Nutrition Practice,. 7th ed. St. Louis: Mosby, 1994.

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Jessica Rae Donze

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Medicine

Medicine is one of the branches of the health sciences. It deals with restoring and maintaining health, but is also used in determining the causes of death. It is a practical science that applies knowledge from biology, chemistry, and physics to treat diseases. Biological knowledge is derived from anatomy, biochemistry, physiology , histology, epidemiology , microbiology, genetics, toxicology , pathology , and many other disciplines. Biology forms the basis for understanding how the human body works and interacts with its environment. An understanding of chemistry is required to determine the interactions between different drugs, to detect chemicals in the body, and design drugs for treatment. Physics has an impact on understanding how the body works and on understanding how the various instruments and equipment are used in diagnosis and treatment. The need to understand interactions between all of these areas makes medicine one of the most complex scientific disciplines.

In its early days medicine was not based on science. Many aspects of it were considered forms of magic, encompassing everything from disease causes to treatments. This was because the disease process was not understood. There was no knowledge of infectious agents (such as bacteria and viruses). Therefore, unless the cause of a disease was obvious and visible, sickness was considered a punishment from gods or an interference of an evil spirit. As a result, some treatments were logical, while others were irrational and often involved magic incantations and spells.

The practice of medicine goes back to at least 3000 b.c., when the first written medical records appeared in Mesopotamia. Babylonian medical texts provided the first anatomical descriptions and an early code of conduct for doctors. Their understanding of diseases was very basic; they recognized trauma and food poisoning , but a lot of the illnesses were still a mystery. Despite advances in anatomy and surgery, ancient Egyptians, as the Babylonians before them, still believed in supernatural causes for many illnesses.

The scientific basis of medicine was laid down by Hippocrates, who rejected magical causes of diseases. He believed in medical examination and keeping detailed records of a disease history. His influence on medicine is present even today, in form of the "Hippocratic Oath," which all new doctors have to take. It sets out ethical guidelines for doctors.

The importance of clinical examination of the patient was made even more important by Claudius Galen, another Greek physician. He worked extensively on anatomy and experimented with live animals.

Great advances in all areas of medicine, especially in epidemiology and hygiene, took place in the middle ages. Avicenna, a Persian physician, was the first to recognize the contagious nature of tuberculosis. In his many works, he gave important advice to surgeons, especially on cancer treatment and advanced use of oral anesthetics (painkillers). Another great advancement of the times was the use of silk thread for stitching wounds, developed by Abul Qasim al-Zahrawi.

A number of scientific discoveries, starting from the late 1800s with the work of E. Jenner, L. Pasteur, R. Koch, A. Flemming and others, established that microbes are the cause of infectious disease; these diseases can be prevented by vaccinations; and there are drugs that can kill the infectious agents (microbes). These findings shaped modern western medicine.

Furthermore, discoveries in physics, such as x rays, ultrasounds, magnetic resonance, and lasers, led to the development of equipment that allows quicker and better diagnosis, as well as easier and safer surgical procedures.

As a result of these scientific and technological changes, the knowledge that medical students have to acquire is immense. Therefore, all doctors learn the same basics but later they have to specialize in narrower areas in order to be highly skilled and able to effectively treat all of the diseases of a particular organ or tissue.

There are doctors specializing in various areas of medicine, such as emergency medicine, intensive care medicine, internal medicine, pediatrics, surgery, neurology, obstetrics, and others. While obstetrics is a relatively narrow area, dealing with childbirth and female health, surgery or internal medicine is further subdivided into sub specializations. Some of those subspecialties are hematology (blood and its diseases), cardiology (heart and cardiovascular system), oncology (cancer), ophthalmology (eyes), orthopedic surgery (mostly skeletal system), or neurosurgery (brain). On the other hand, pediatrics deals with childhood diseases and most of the specialties and subspecialties have their pediatric equivalent. Some doctors specialize in narrow medical fields, while others specialize in areas requiring wide medical knowledge such as sport, aerospace, or forensic medicine.

The most important doctor for the majority of the population is the family doctor (or general practitioner, GP). It is the GP who makes the first examination and keeps a record of the medical history of the patient. He or she also makes an assessment if more tests are required before a diagnosis can be made or if a referral to a specialist is required.

The process of determining the cause of a disease and prescribing treatment is quite complex. It consists of clinical examination, diagnosis, and treatment.

Clinical examination can consist of a number of different aspects, including visual, pathological, toxicological, and genetic analysis. Visual examination addresses the general symptoms: a patient's appearance, heart rate etc. Pathological analysis is often required to identify any non-obvious cause of disease. The tests can include blood or urine analysis, electrocardiogram (ECG), ultrasound, computed tomography (CT) scan, biopsy, histology of removed tissues, or bacteriological analysis of body fluids . Most people have blood and urine tests during their lives. Toxicological analysis is usually carried out on blood, but can be done on tissue samples (bones or hair) and can detect alcohol, certain drugs, toxic metals, and other compounds (for example dioxins). Genetic testing is not usually required for the majority of patients, but in cases of inherited diseases, or genetic predisposition, they can be carried out. Often it is not just the adults that undergo this procedure. Amniotic fluid surrounding the embryo can be tested to determine if a child will develop a life-threatening disease.

Diagnosis is based on the combination of all of the examinations that have been performed and the accumulated knowledge of the doctor. Depending on the illness, it can be quick and simple or time consuming and difficult.

Treatment is the ultimate result of a visit to the doctor. It can include prescription of drugs, surgery, or special diet. Any treatment can be simple or complex depending on the illness.

Not all doctors treat patients. Pathologists study disease processes. They analyze clinical tests and base their diagnosis on the results. They can work with isolated tissues and samples, or, in the case of forensic pathologists, the deceased. Pathological analysis is very important in the diagnosis of an illness in the case of regular pathology and in determining a cause of death in forensic pathology. Forensic pathology is a part of a forensic medicine, a branch of medicine answering questions important to the law.

Forensic medicine is important in determining the cause of death, time of death , and identification of the remains. This allows doctors to determine the cause of death as accident, suicide, or murder . A forensic pathologist describes the state of the body (decomposition if any), and subsequently examines the body for a cause of death, but also notes any abnormalities found on the surface or in the tissues. The surface of the body is initially checked for the presence of trauma injuries (bruises, broken bones), cuts or stab wounds, thermal injuries (burns), firearm injuries (gunshot wounds), or defensive wounds . An internal examination of the body is carried out on organs or isolated tissues (histology). It might reveal presence of water in lungs (drowning), or asphyxia (lack of oxygen).

The analysis of a corpse is often carried out in the same way as for normal patients using x rays, toxicology, and genetics. Forensic medicine requires great attention to detail and a wide medical knowledge, especially in the areas of anatomy and physiology.

Modern western medicine is not the only existing medical system. There is also traditional medicine and complementary or alternative medicine. Traditional medicine includes folk and indigenous practices. The best known and most widely accepted areas are Chinese medicine and western herbal medicine. Complementary medicine uses non-invasive and non-pharmaceutical methods. Examples of alternative treatments include yoga, chiropractic or osteopathic manipulation, or various massage methods, as well as many others.

The first written evidence of Chinese medicine comes from 1766 b.c. The philosophy of medicine and methods used by Chinese doctors differed widely from those of the ancient Mediterranean and current modern medicine. The Chinese have based their medicine on a philosophy of yin and yang, and on The Five Elements (metal, wood, water, fire, and earth). A healthy person would have a harmonious mix of these elements. Among the practices developed in Chinese medicine are acupuncture, moxibustion (a technique that involves the use of heat, through burning specific herbs, to facilitate healing), and traditional herbal medicines. A physical examination with a doctor can include detailed interview, pulse taking, breath analysis, and tongue inspection. Some of the traditional Chinese treatments are quite widely accepted by modern western medicine, for example acupuncture.

A new approach to practicing medicine is the development of integrative medicine. It combines the modern western practices with alternative treatments. It only accepts methods for which there is scientific evidence for safety and effectiveness. Acupuncture, herbal treatment, music, and massage therapy are just some of the accepted treatments. The aim of this approach is not to just treat the illness, but to provide support to patients and induce their general well-being.

see also Autopsy; Epidemiology; Pathology.

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