The Greatest Benefit to Mankind: A Medical History of Humanity

MODERN DEVELOPMENTS

Until the nineteenth century, Chinese medicine more or less matched its European counterpart in authority and efficacy. Chinese physicians showed little interest in European medicine, but the Japanese became familiar with western science through the Europeans allowed to reside in the port of Nagasaki, and what was called ‘Dutch scholarship’ (rangaku) flourished. Japanese rangaku physicians took up anatomy and surgery, introducing Jennerian vaccination in 1824. These developments helped undermine the prestige of kanpo, and schools of western medicine began to spring up. International politics, however, was a greater force of change than curative efficacy: by 1850, both Japan and China were confronted by European gunboats, and by a western medicine daily more confident of its own scientific superiority.

In 1869, the Japanese Meiji rulers resolved to adopt the German system of medical training and, while kanpo was not banned, its practice was subject to restrictions. Japan established a state system of western medical education and services, and by 1900 three imperial and eleven other state colleges of western medicine existed, which by 1912 had trained 14,552 physicians – around two-thirds of all those in practice. Many Japanese medical students were sent to Germany for their education.

The Chinese were exposed to western medicine through the missionaries who streamed in after the treaties following the Opium Wars. Some reformers held Chinese medicine partly responsible for the Empire’s backwardness and defeats, while others sought not to scrap but to reinforce it. In any case, the weak late Qing regime was in no position to effect Meiji-style reforms. In the end the chief force for change came not from the state but from the hated foreigners, above all the Chinese Medical Missionary Association, founded in 1886, which, together with the Rockefeller-funded Chinese Medical Commission, aimed to transform medical services and training, partly through the ‘union medical colleges’, established in Peking (Beijing) and other key cities after 1903. Yet by 1913, there were still only 500 Chinese medical students receiving training in all the mission services throughout the empire.

Republican China (1911–49) sought to establish a modern state medical system. By 1926 about one hundred cities had western-style medical services, which the Nanjing-based Nationalist government turned into the nuclei for health institutions, organizing a chain of medical education, hospitals and health centres stretching from the capital right down to rural paramedics. Peasant health-care was given priority: village health workers received training in smallpox, typhoid and diphtheria vaccination, in hygiene, the diagnosis and treatment of minor complaints, and referral of serious illnesses to specialists. The system drew upon western medicine and, whilst Chinese medicine was not banned, it came to be seen as old-fashioned, not least by Marxist revolutionaries.

After 1948, this nationalist health-care structure was taken over wholesale by the new People’s Republic, though under the Marxist regime Chinese medicine could also be depicted as ‘socialist’ and integrated into the Communist system. Science was exalted as the key to the future, yet patriotic sentiment, reinforced by anti-capitalist ideology, also gave Chinese medicine a renewed symbolic authority, leading to professional parity with western medicine (readily condemned as ‘bourgeois’). The emphasis on functions and holism within traditional Chinese medicine could be squared with the ‘dialectical materialism’ of Marxism-Leninism.

At the top of the tree, Chinese-style physicians are today required to have a basic training in western-style medicine, and vice versa. Indeed, in the late 1950s, when China was desperately short of skilled medical practitioners, thousands of doctors were withdrawn from regular medical practice for a three-year study of traditional medicine, and Beijing invested heavily in clinics and medical schools for Chinese medicine. The ‘barefoot doctors’ of the Mao era included amongst their skills simple acupuncture and a knowledge of Chinese materia medica.

The balance between western and Chinese practice has fluctuated, and the ideal of a ‘syncretic medicine’, combining the best of both, has become an attractive one. Attempts have been made to set Chinese medicine on an experimental, scientific footing. In line with this, there has been a move from functionalism to materialism in medical thinking, accompanied by tendencies to reduce traditional terms of Chinese medical art to their modern biomedical equivalents: thus xue classically ranges over a spectrum of meanings, only one of which corresponds to the biomedical concept of ‘blood’. While most practitioners continue to recognize this distinction, the trend is towards using the readings interchangeably. Materialism thus provides a way of translating Chinese medical theory and therapeutics into western scientific terms, and thence of mobilizing experimental laboratory techniques. The pharmacological effects of Chinese drugs have been tested, the siting of the acupuncture tracts investigated, and explanations advanced of the effects of acupuncture anaesthesia in terms of endorphins.

The classics continue to shape the thinking of contemporary practitioners: no Chinese medicine practitioner can be trained without becoming familiar with the canonical works. But, linguistically, classical Chinese is no longer essential for medical education, and physicians may cull their knowledge of the medical canon from selections in modern textbooks. Utilitarian priorities mean that many practitioners today gain only a smattering of the theoretical rationales underpinning therapy. Formerly Chinese medical practitioners won their prestige through textual erudition; now they assume the trappings of western medicine, and even traditional physicians wear white coats.

From a wider perspective, it is evident that there has been a great parting of the ways between eastern and western medicine. Initially they shared certain common assumptions, inscribed in hallowed texts, about the harmonies and balance of the healthy body. Western medicine alone radically broke with this. An entirely new practice grew up in Europe – scientific medicine – building upon the new sorts of knowledge, programmes and power which followed from dissection and the pathological anatomy it made possible.

Tensions thus opened up between the western and the eastern traditions which remain unresolved to this day. As early as the late eighteenth century, European surgeons visiting China were already expressing open contempt for traditional Chinese medicine; it was ignorant of anatomy and hence had no ‘scientific’ basis. Westerners found it laughable that Chinese doctors thought they could diagnose illness on the basis of the pulse alone. And though acupuncture gained some devotees in nineteenth-century France and Britain, it has been only in recent years that the claims of Chinese medicine have found a broader acceptance in the West. This is due partly to a new multiculturalism, and partly to rejection in some quarters of high-tech values; but it also owes much to ‘scientific’ explanations of acupuncture anaesthesia and other aspects of Chinese practices. Whether East and West will ever meet or even converge, medically, remains unclear, and only time will tell whether the current popularity in the West of acupuncture and Chinese medical outlooks will last.

CHAPTER VIII RENAISSANCE

THE OLD WORLD AND THE NEW

THE MOST MOMENTOUS EVENT FOR HUMAN HEALTH was Columbus’s landfall in 1492 on Hispaniola (now the Dominican Republic and Haiti). The Europeans’ discovery of America forged contact between two human populations isolated from each other for thousands of years, and the biological consequences were devastating, unleashing the worst health disaster there has ever been, and precipitating the conquest of the New World by the Old World’s diseases.

The forebears of the ‘Indians’ Columbus encountered in his attempt to find a short-cut to the ‘Indies’ or China were hunter-gatherers. Before or around 10,000 BC such people had crossed the Bering Straits from Asia to Alaska via a land bridge created by the fall in sea levels during the last Ice Age. They were relatively disease-free; lacking domesticated animals, they had no walking disease-carriers except themselves, and on their travels they encountered no other humans.

The melting of the great North American glaciers isolated that continent while opening it up to the newcomers, who spread south. In time the Maya, Aztec and Inca to the south and the Mississippian peoples of North America settled into sedentary agriculture, cultivating maize and beans, cassava and potatoes, and in some cases building complex civilizations centred on vast cities – which spawned all the familiar health problems. Tuberculosis developed, as did pinta and other treponemal infections, including non-venereal syphilis, various disorders caused by intestinal parasites, and Chagas’ disease. With agriculture came the nutritional maladies typical of monocultures.

The Amerindian peoples developed their own forms of medicine, with priests, shamans and sorcerers conducting healing rituals. Supernatural powers were believed to inflict pestilence to punish misdeeds, and in Mexico and Peru disease was connected with witchcraft and the malevolent shades of dead animals, demons and deities. Native Americans acquired knowledge of the healing properties of various vegetable products: Peruvian Indians chewed coca leaves against hunger and fatigue, while cacao (cocoa) was the Aztecs’ most important tonic and medicinal beverage, powdered and boiled in water with honey, vanilla and pepper. The Incas had herbs for headaches and other pains; and they used scopolamine, a poison from the datura plant, as an anaesthetic. Broken bones were treated with fat from the ñandu, an ostrich-like bird, and llama kidney juice was dropped into aching ears.

North American Indian tribes had a less extensive materia medica. They used sassafras, holly, sunflower seeds and infusions of flaxseed, inhaled the smoke from burning twigs to treat chest conditions, and used decoctions of mushrooms and peyote as hallucinogens. A Spanish explorer, Cabeza de Vaca, travelling in the 1520s through what is now Texas, observed the healing practices of the native Indians: ‘their method of cure is to blow on the sick, the breath and the laying-on of hands supposedly casting out the infirmity.’ He had no doubt what to think of that: ‘We scoffed at their cures.’

The New World peoples were not living in a golden age, but they had been spared Eurasian afflictions. Thus they were vulnerable virgin soil, entirely without resistance to epidemics imported by the conquistadores. This was not the first time Spanish conquest had brought diseases to a virgin population. In the fifteenth century, the Iberian conquest of the Canary islands had meant total devastation of the native inhabitants, the Guanches, whose immune systems were helpless against European infections. Originally there were some 100,000 Guanches; by 1530 only a handful was left, and in the seventeenth century they became extinct, spectacular victims of what has been called ecological imperialism.

The first epidemic, which struck Hispaniola in 1493, may have been swine influenza, carried by pigs aboard Columbus’s ships. Other deadly diseases then struck in hammerblows, so that New World populations were reeling even before smallpox reached the Caribbean in 1518. That outbreak killed one third to one half of the Arawaks on Hispaniola and spread from there to Puerto Rico and Cuba. A few Spaniards fell sick but none died and, as ever, all was attributed to God’s will, in support of the Christian conquest.

Smallpox accompanied Hernan Cortés (1485–1547) to Montezuma’s Aztec Mexico, where the main town was Tenochtitlan (modern Mexico City); with some 300,000 people, it was three times the size of Seville. Contact spread the disease among the natives outside the city and then within. In 1521, Cortés attacked with 300 Spaniards. Three months later, when the city fell, the conqueror learned that half its people had died, including Montezuma and his successor: ‘a man could not put his foot down unless on the corpse of an Indian.’ The same happened when Pizarro (c. 1475–1541) took on the Incas: smallpox ran ahead of him to Peru. By 1533, when he entered Cuzco to plunder its treasure, the Incas were incapable of serious resistance.

Infections thus primed and sped conquest, rippling outwards to fell countless indigenes the Spanish troops did not have to butcher. The consequent epidemics did not merely exterminate vast numbers, they destroyed the will to resist – the psychological impact was as devastating as the physical. Between 1518 and 1531, perhaps one third of the total Indian population died of smallpox, while the Spanish hardly suffered. With allies like microbes, the Europeans did not require many soldiers or much military acumen.

These initial smallpox outbreaks were only the beginning of a long, mainly unintentional, but almost genocidal germ onslaught unleashed against the Amerindians. Waves of measles – 1519 (Santa Domingo), 1523 (Guatemala) and 1531 (Mexico) – influenza, and finally typhus followed, all bringing devastating mortalities. In 1529 measles killed two thirds of those who had just survived smallpox; two years later it had killed half the Hondurans, ravaged Mexico, raced through Central America and attacked the Incas. Repeated epidemics followed, one of the worst being that of typhus, which towards 1600 killed about two million people in the Mexican highlands. By then, 90 per cent of the local inhabitants had died in successive outbreaks, and the fabric of life had fallen to pieces.

Though the mainland populations of Mexico and the Andes gradually recovered, in the Caribbean and in parts of Brazil decline verged upon extinction; from as early as 1520, the Spanish imported slaves from Africa to meet the labour shortages in their lucrative Peruvian silver mines. African slaves, in turn, brought malaria and yellow fever, creating further disasters. Guns and germs enabled small European bands to conquer half a continent in what might be called, to echo Gibbon, another victory of barbarism over civilization.

In later centuries the North American Indian population was similarly devastated by the English and French, sometimes by the fiendish distribution of smallpox-infected blankets and clothes. In 1645, smallpox killed half the Hurons; the same happened later with the Cherokees in the Charleston area, and with the Omahas and the Mandans. Not one European fell sick of smallpox in 1680, when the Revd Increase Mather (1639–172 3) tersely recorded that ‘the Indians began to be quarrelsome … but God ended the controversy by sending the smallpox among the Indians’. The wholesale destruction of indigenous New World populations continued for over three hundred years; twenty million slaves had to be shipped to America to fill the vacuum, causing cruelty and suffering on a scale not matched until the regimes of Hitler and Stalin.

SYPHILIS

European expansion produced the ‘Columbian exchange’, a highly unequal disease trade-off in which Columbus may have brought one killer disease back from the Americas: syphilis. This broke out in 1493–4 during a war between Spain and France being waged in Italy. When Naples fell to the French, the conquerors indulged in the usual orgy of rape and pillage, and the troops and their camp-followers then scattered throughout Europe. Soon, a terrible venereal epidemic was raging. It began with genital sores, progressing to a general rash, to ulceration, and to revolting abscesses eating into bones and destroying the nose, lips and genitals, and often proving fatal.

Initially, it was called the ‘disease of Naples’, but rapidly became the ‘French Pox’ and other terms accusing this or that nation: the Spanish disease in Holland, the Polish disease in Russia, the Russian disease in Siberia, the Christian disease in Turkey and the Portuguese disease in India and Japan. For their part, the Portuguese called it the Castilian disease, and a couple of centuries later Captain Cook (1728–79), exploring the Pacific, rued that the Tahitians ‘call the venereal disease Apa no Britannia – the British disease’ (he thought they’d caught it from the French).

That some of the Spaniards at the siege of Naples had accompanied Columbus suggested an American origin for the pox (or ‘great pox’, to distinguish it from smallpox). It certainly behaved in Europe like a new disease, spreading like wildfire for a couple of decades. ‘In recent times’, reflected one sufferer, Joseph Gruenpeck (c. 1473–c. 1532):

I have seen scourges, horrible sicknesses and many infirmities affect mankind from all corners of the earth. Amongst them has crept in, from the western shores of Gaul, a disease which is so cruel, so distressing, so appalling that until now nothing so horrifying, nothing more terrible or disgusting, has ever been known on this earth.

Syphilis, we now know, is one of several diseases caused by members of the Treponema group of spirochetes, a corkscrew-shaped bacterium.* There are four clinically distinct human treponematoses (the others are pinta, yaws and bejel) and their causative organisms are virtually identical, suggesting all are descendants of an ancestral spirochete which adapted to different climates and human behaviours.

What caused this terrible outbreak? Many epidemiological possibilities have been mooted. It is feasible that some American treponemal infection merged with a similar European one to become syphilis, with both initial infections subsequently disappearing. Others maintain that venereal infections had long been present in Europe but never properly distinguished from leprosy; treponemal infections (pinta, yaws, endemic and venereal syphilis) had, it is suggested, initially presented as mild childhood illnesses, spread by casual contact and producing a measure of immunity. With improved European living standards, treponemes dependent on skin contact had become disadvantaged, being replaced by hardier, sexually transmitted strains. Thus an initially mild disorder grew more serious. A related theory holds that the spirochete had long been present in both the Old World and the New; what would explain the sixteenth-century explosion were the social disruptions of the time, especially warfare.

Like the pox itself, the debate raged – and remains unresolved to this day. But whatever the precise epidemiology, syphilis, like typhus, should be regarded as typical of the new plagues of an age of conquest and turbulence, one spread by international warfare, rising population density, changed lifestyles and sexual behaviour, the migrations of soldiers and traders, and the ebb and flow of refugees and peasants. While Europeans were establishing their empires and exporting death to aboriginal peoples, they were caught in microbial civil wars at home. Bubonic plague bounced from the Balkans to Britain, malaria was on the increase, smallpox grew more virulent, while typhus and the ‘bloody flux’ (dysentery) became camp-followers of every army. Influenza epidemics raged, especially lethal being the ‘English sweat’ (sudor Anglicus) which struck in 1485 (delaying Henry VII’s coronation), 1507, 1528, 1551 and 1578, and was described by Polydore Vergil, an Italian diplomat in London, as ‘a pestilence horrible indeed, and before which no age could endure’. John Caius’s (1510–73) A Boke of Conseill against the Disease Commonly Called the Sweat or Sweating Sickness (1552) noted the copious sweating, shivering, fever, nausea, headache, cramps, back pain, delirium and stupor. It came to crisis within twenty-four hours, with very high mortality. It was thought even worse than the plague, for plague:

commonly giveth three or four, often seven, sometimes nine … sometimes eleven, and sometimes fourteen days’ respect to whom it vexeth. But that [the sweating sickness] immediately killed some in opening their windows, some in playing with children in their street doors, some in one hour, many in two it destroyed, and at the longest, to they that merrily dined, it gave a sorrowful supper.

The ‘English sweat’ remains a riddle. Such calamities form a doleful backdrop to the Renaissance.

THE MEDICAL RENAISSANCE

From the fourteenth century Europe’s cultural and intellectual life was undergoing a mighty rebirth. First in the bustling commercial cities of Italy and later in transalpine courts, the arts and humanities were being restored to a brilliance unknown for centuries. Glory would be achieved, enthusiasts proclaimed, by burying the immediate past and emulating the ancients. New inventions were changing material culture: gunpowder, the compass and Gutenberg’s printing press. Books multiplied, and were cheered on by propagandists and educators.

Among these was the monk who quit his monastery, Desiderius Erasmus (1466–1536), who led European scholarship and culture for more than three decades. A supreme stylist, it was he who established Greek as the basis for literary and theological studies, not least through production of a restored Greek text for the New Testament. His example prompted others to produce the first Greek editions of the ancient medical authors, and he inspired young scholars and physicians to bring out the great Aldine edition of Galen (1525). He also took a keen personal interest in medicine, both as patient (he suffered from gout, kidney stone and hypochondria) and as author. His Latin versions of three of Galen’s works, The Protrepticus, The Best Method of Teaching, and The Best Doctor is also a Philosopher, were the first to be based on the Greek of the Aldine edition, and enjoyed huge success. Yet, if Erasmus promoted medical learning, he was dubious about doctors, echoing that earlier humanist, Petrarch (1304–74), who had written, ‘I have never believed in doctors nor ever will.’

Painters, philosophers and poets commended the beauty of the human form and the nobility of the human spirit, using the emblem of Vitruvian man, in which the idealized naked male human form was superimposed upon the cosmos at large. Above all perhaps, after centuries when the Church had taught mankind to renounce worldly goods for the sake of eternity, Renaissance man showed an insatiable curiosity for the materiality of the here and now, a Faustian itch to explore, know and possess every nook and cranny of creation. No wonder they became inquisitive about human bodies, which were judged to occupy a privileged status. According to the Venetian surgeon Alessandro Benedetti (c. 1450–1512),

The human body was created for the sake of the soul and stands erect among other animals, as established by divine nature and reason so that it might look upward more comfortably.… The heart was first created since it contains the principle of life and sense. Next came the brain and liver. Then nature, performing like a painter, sketched out the other members with a life-giving fluid; they gradually receive their colours from the blood, which is very abundant in man and stirs up very much heat.

Art and nature thus both drew attention to the body, and in an intellectual climate that revered the classics, no wonder there was a revival of ancient medicine. For centuries, of course, Galen had been god: the Arabs had synthesized his works and the medieval West had translated these into Latin. So why was there a need for a Galen revival?

Admiration for all things Greek was in the air. Spurred by the fall of Constantinople in 1453, Greeks like Theodore Gaza (fl. 1430–80) and his student Demetrius Chalcondylas (d. 1511) went to Italy, taking manuscripts with them and passing their knowledge to Italian humanists eager to believe that truth was at its purest in Greek sources: Plato, Aristotle, the poets and orators. These ideas were obviously applicable to medicine too, for were not its first oracles Greek?