First do no harm Thomas Inman, 1860

17 May

Three simple arguments run through this book. The first is that if we define medicine as the ability to cure diseases, then there was very little medicine before 1865. The long tradition that descended from Hippocrates, symbolized by a reliance on bloodletting, purges, and emetics, was almost totally ineffectual, indeed positively deleterious, except in so far as it mobilized the placebo effect. The second is that effective medicine could only begin when doctors began to count and to compare. They had to count the number of patients that lived and the number that died, and then compare different treatments to see if they resulted in improved sur- vival rates. The idea of counting and comparing seems a very simple one, and yet doctors were very slow to put it into practice. This is partly because counting and comparing is in fact a rather complex cultural activity, much facilitated by the introduction of devices such as the table for organizing information. It is also because before you can count and compare you need to have a conception of disease that makes counting and comparing possible. By the beginning of the nineteenth century counting and comparing was inescapable, and within fifty years medicine was in crisis because it was clear that conventional therapies did not work. Thirdly, the key development that made modern medicine possible is the germ theory of disease. More specifically, the first breakthrough took place with the germ theory of putrefaction. The great puzzle here is the long delay before anyone formulated a germ theory that had a medical application. As early as 1597, Felix Platter had formulated a sophisticated germ theory of contagion. In 1677 Leeuwenhoek had seen germs through his microscope. A series of scientists, including Leeuwenhoek himself, had denied that germs were spontaneously generated. By 1714, if not earlier, the old seeds of disease theories had been fully adapted in the light of Leeuwenhoek’s discoveries. In 1752 Pringle was working on antiseptics. As early as 1810 it was evident that there was something seriously wrong with existing theories of putrefaction. Yet the first disease caused by a germ (in silkworms) was not identified until 1833; the germ theory of putrefaction was not formulated until 1837; and the first application of germ theory to medicine did not occur until 1865. How to explain this delay? Some have attributed it in large part to the inadequacy of early microscopes, but the evidence suggests they are wrong. It is true that there were conceptual obstacles to be overcome, but it is difficult to see that those obstacles were major ones. All the evidence suggests that the delay in formulating a practical germ theory has its origin not within microbiology but outside it. The chief obstacle was that doctors were satisfied with their existing therapies; the barriers to progress were psychological and cultural not intellectual. In pursuing these arguments I have deliberately broken one written and a number of unwritten rules. I have focused on progress, which historians are not supposed to do. That rule is written in places where all historians have read it. The unwritten rules are harder to identify, but here are two. First, a history book should have a homo- geneous character, so that one can easily say this book is about therapy, or this book is about the origins of the germ theory of disease. I have quite deliberately not written a book like that. My model has, let me confess, been Fernand Braudel’s great work, The Mediterranean in the Age of Philip II (1949), written in a prisoner-of-war camp, without access to books or notes. His book is really three books in one. The first deals with continuity, with things that changed hardly at all between the ancient Romans and the eight- eenth century: trade routes, the distribution of crops, the technology of transport. The second deals with things that changed over the course of decades: inflation, banditry, styles of architecture. And the third deals with a political crisis and a military campaign, with events that changed from day to day. This book, while less ambitious, still amounts to three books in one. In the first part, I have surveyed a tradition of therapy that survived from Hippocrates until the early twentieth century. In the second part and the beginnings of the third I have given an account of a world which begins with Vesalius and ends with Claude Bernard, a world in which medical knowledge progressed, but in which that knowledge had little or no significance for therapy. Then in the rest of the third part I have described, in very brief outline, the emergence of a world in which medical knowledge established a positive feed- back loop with medical therapy: progress in knowledge led to pro- gress in therapy, which led to more investment in research. That is the world in which we still live, and in the last chapter I discussed how much we have gained as a result of medical progress. And that brings me to the second unwritten rule that I have broken. History books on big subjects are supposed to be ‘big’ books. This is not a big book, in that sense, but a book which makes an argument. What counts is getting the basic framework right. If that framework is correct, then it becomes evident where we may need a longer and more detailed story of what actually happened: we may need to know more, for example, about theories of animate con- tagion before Pasteur (a field in which research effectively stopped twenty years ago), more about the renaissance of microscopy in the 1830s, more about the crisis in medical therapy between the 1830s and the 1890s. In this way Braudel’s Mediterranean amounted to a programme for research, and it doubled in size between its first publi- cation in 1949 and the revised 2nd edition in 1966. Perhaps this book too has the potential for future growth. So what kind of argument have I developed here? In 1962, Thomas Kuhn published The Structure of Scientific Revolutions. In that book he introduced a number of key concepts. He distinguished sharply between ‘normal science’ and the science that takes place during periods of crisis. His argument was that major intellectual advances only take place in the context of a crisis within existing ways of thinking and doing: my argument is that something that we may call ‘normal medicine’ was carried on from Hippocrates until the 1850s. Intellectual and practical problems were solved, new ideas such as the circulation of the blood were incorporated, but the foundational assumption, the Hippocratic method of therapy, went largely unquestioned (despite the efforts of Paracelsus and van Helmont). Real progress began only when that assumption began to be questioned. Kuhn also argued that what held science together were what he called ‘paradigms’. He used the word in a number of different senses.

A paradigm might be a laboratory activity, learnt by generations of students, such as cultivating a pure sample of a bacterium in a petri dish. It might be a model solution to a problem, such as Pasteur’s development of a vaccine against anthrax, a model that could then be adapted and applied to other diseases. It might be the epitome of something you needed to know to belong to an intellectual com- munity: you could not hope to understand the publications of the Institut Pasteur without some knowledge of Pasteur’s work on anthrax and rabies, and of the work his followers had done on diphtheria, because that provided the common stock of references that others relied on in explaining their own work. Thus one could give an account of a paradigm that related it to a practice, a theory, or a sociological community. As a consequence Kuhn’s account of sci- ence was radically unstable –– one could conclude from it that in order to understand science one needed to look closely at what scientists actually did in laboratories; or to study closely the way in which textbooks evolved over time; or to look at the structure of authority that held a community together –– at what happened, for example, when an outsider submitted a paper to the Institut Pasteur to be published. The argument I have presented here represents one choice amongst these three options, each of which can claim to have been endorsed by Kuhn. The primary obstacle to progress, as I have argued, was not practical (Leeuwenhoek’s microscopes worked well), nor theoretical (the germ theory of putrefaction was not difficult to for- mulate), but psychological and cultural. It lay in doctors’ sense of themselves, their awareness of their own traditions, their habit of conferring authority upon an established canon and upon established therapies. Doctors successfully pushed the microscope, and all the questions that it generated, out of medicine in the 1690s, and kept it

First do no harm Thomas Inman

32. W. Eugene Smith, Dr Ceriani Making a House Call, 1948. From a photographic essay entitled ‘The Country Doctor’ published in Life. out until the 1830s. They did so because they saw it as a threat to traditional medicine, and they dealt with that threat so successfully that they extended the life of traditional medicine by a century and a half. Medicine is an activity that is deeply embedded in institutions and in social practices, and that makes heavy demands on the psyche. For other forms of knowledge, a quite dierent type of account may be necessary. In physics, the key barriers to progress may be theoretical. In oceanography they may be practical. So too, in other periods of medicine a different type of account may be necessary. It is too soon to tell, for example, what the obstacles to making progress in curing cancer have been; they may prove to be quite different in character to the obstacles encountered by germ theory. I have chosen to place my argument in the context of Kuhn because history of medicine, as I understand it, is largely post- Foucauldian when it ought to be post-Kuhnian. Under the influence of a historical profession opposed to the discussion of progress on the one hand and a postmodernist intellectual tradition committed to relativism on the other, historians of medicine have been unable to think about the different types of progress that can occur in medicine, and have failed to ask what keeps the crucial paradigms shared by doctors in place. Let me turn my own method of argument against myself. Why was the book that I have just written not written thirty or forty years ago? There was perhaps a window of opportunity, between 1962 and 1976, and it would be interesting to go back and review the histories of medicine written in those years to see if any of them are similar to this. But that window was only ajar: it was still easy, in those years, to think that Leeuwenhoek’s microscopes were inferior to those of the 1830s. And it was soon closed. Under the triple impact of Foucault, of Illich, and of McKeown, the very idea of progress in medicine came to seem a naïve and simplistic one. Of those three authors, Illich and McKeown no longer have the influence they once had; only Foucault remains as a major obstacle. The idea of progress now needs to be rescued from the condescension of Butterfield and of Foucault.


I have organized this short guide to further reading according to the Parts into which the book is divided. Further bibliography, references, and links to other websites can be found at


The late Roy Porter is undoubtedly the most influential medical historian of the last few decades. See in particular his The Greatest Benet to Mankind:

A Medical History of Humanity  from Antiquity  to the Present (London, 1997). Another very useful standard history is Irvine Loudon (ed.), Western Medi- cine: An Illustrated History (Oxford, 1997). For a doctor’s view of the history of medicine see Raymond Tallis, ‘The Miracle of Scientific Medicine’, in his Hippocratic Oaths: Medicine and its Discontents (London, 2004), 17–24. The key critique of modern medicine is Ivan Illich, Limits to Medicine (London,1976).


The  main primary sources are: Hippocratic Writings,  ed. G. E. R. Lloyd (London, 1978); Galen, Selected Works, tr. P. N. Singer (Oxford, 1997); Charles Singer, Galen, On Anatomical   Procedures (Oxford, 1956). Highly recommended is Jacques Jouanna, Hippocrates (Baltimore, 1999). Shigeshisa Kuriyama, The Expressiveness   of the Body and the Divergence  of Greek and Chinese Medicine (New York, 1999) is exceptionally  thought-provoking.

For a survey of the Middle Ages, Nancy G. Siraisi, Medieval and Early Renaissance Medicine (Chicago, 1990). A wonderful book on pre-scientific medicine is Barbara Duden, The Woman beneath the Skin: A Doctor’s Patients in Eighteenth-Century  Germany (Cambridge Mass., 1991). To  understand what doctors were really doing, read Daniel Moerman, Meaning, Medicine and the ‘Placebo Eect’ (Cambridge, 2002), or, more briefly, chapter 2 of Harry Collins and Trevor Pinch, Dr Golem: How to Think about Medicine (Chicago, 2005).


For a good general survey of the early modern period, see Roger French, Medicine  before Science: The Business  of Medicine  from the Middle Ages to the Enlightenment (Cambridge, 2003). There are a number of helpful books on Renaissance advances in anatomy: Bernard Schultz, Art and Anatomy in Renaissance Italy (Ann Arbor, 1985); Andrew Cunningham, The Anatomical Renaissance (Aldershot, 1997); Andrea Carlino, Books of the Body (Chicago,1999); R. K. French, Dissection and Vivisection in the European Renaissance (Aldershot, 1999). Also on vivisection, see Anita Guerini, ‘The Ethics of Animal Experimentation in Seventeenth-Century England’, Journal of the History of Ideas, 50 (1989), 391–407.

There is a fine digital replica of Vesalius’s Fabrica available from The standard authority is C. D. O’Malley, Andreas Vesalius of Brussels, 1514-1564 (Berkeley, Calif., 1964). A valuable article is Katharine Park, ‘The Criminal and the Saintly Body: Autopsy and Dissection in Renaissance Italy’, Renaissance Quarterly, 47 (1994), 1–33. Harvey can be read in William Harvey, The Circulation of the Blood and Other Writings (London, 1963). An excellent short introduction to the extensive literature on Harvey is Andrew Gregory, Harvey’s Heart (Cambridge, 2001). C. R. S. Harris, The Heart and the Vascular System in Ancient Greek Medicine (Oxford, 1973) puzzles over why the ancient Greeks (including Galen) did not discover the circulation of the blood. On theories of contagion, see Carlo M. Cipolla, Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age (New Haven, 1992); Vivian Nutton, ‘The Seeds of Disease: An Explanation of Con- tagion and Infection from the Greeks to the Renaissance’, Medical History, 27 (1983), 1–34; Vivian Nutton, ‘The Reception of Fracastoro’s Theory of Contagion: The Seed that Fell among Thorns?’, Osiris, 6 (1990), 196–234; and Lise Wilkinson, ‘Rinderpest and Mainstream Infec- tious Disease Concepts in the Eighteenth Century’, Medical History, 28 (1984), 129–50.

Three postscripts to my discussion of theories of animate contagion. 1) I am not the first to turn from Nardi to Platter (above, p. 128). The anonym- ous annnotator of the 1714 edition of Creech’s translation of Lucretius (which advertises itself as ‘a complete system of the Epicurean philosophy’ and was reprinted in 1722) added (apparently as an afterthought) a note ‘Of Contagion, the chief Cause of a Plague’ (II, 776–81) in which he reports Platter’s views with care. He stresses that Platter has an account of how ‘resistance’ to disease may vary, and that he argues that there may be asymptomatic carriers of diseases –– in other words he fully recognizes what we would think of as distinctively ‘modern’ aspects of Platter’s theory. 2) I was too quick to accept the Singers’ account of theories of animate contagion after 1725 (above, p. 129). See the excellent article by M. E. De Lacy and A. J. Cain, ‘A Linnean Thesis Concerning Contagium Vivum: the “Exanthemata viva” of John Nyander and its place in contemporary thought’, Medical History, 39 (1995), 159–85 (discussing a text of 1757). Nyander and his contemporary Plenciz provoked William Alexander (who had published Experimental Essays … on the External Application of Antiseptics in 1768) to devise a series of experiments to refute the germ theory of putrefaction. See his An Experimental Enquiry (1771), ch. 8: ‘Of Animalcula, Whether the Cause or the Effect of Putrefaction’, pp. 87–155. See also Anon., Necessary to All Families (1788), which pro- vides a full account of animate contagion. 3) In my discussion of Spallanzani (above p. 131) I suggested it was difficult to grasp that micro- scopic creatures could have macroscopic effects; but this very difficulty was soon to be discussed and overcome by James Tytler, in A Treatise on the Plague and Yellow Fever (1799), 188–9. These three postscripts deepen the puzzle as to why germ theory failed to win support before Pasteur and Lister.

On the microscope, Brian J. Ford, The Leeuwenhoek Legacy (Bristol, 1991) is fundamental, if hard to obtain. Catherine Wilson, The Invisible World: Early Modern  Philosophy  and the Invention  of the Microscope (Princeton, 1995), is an excellent survey. Also useful is Edward G. Ruestow, The Microscope in the Dutch Republic (Cambridge, 1996). The Conclusion draws especially on Andrew Wear, Knowledge and Practice in English Medicine, 1550–1680 (Cambridge, 2000) and on Gianna Pomata, Contracting  a Cure: Patients, Healers and the Law in Early Modern  Bologna (Baltimore, 1998).

James Le Fanu, The Rise and Fall of Modern Medicine (London, 1999) under- stands that modern medicine is fundamentally different from everything that preceded it. On the nineteenth century in general, W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge, 1994). On physiology and vivisection, Claude Bernard, An Introduction to the Study of Experimental Medicine, tr. Henry Copley Greene (New York, 1957); Michel Foucault, The Birth of the Clinic (London, 1973); John E. Lesch, Science and Medicine in France: The Emergence of Experimental Physiology, 1790–1855 (Cambridge, Mass., 1984); Richard D. French, Anti-vivisection and Medical Science in Victorian Society (Princeton, 1975); Stewart Richards, ‘Anaesthetics, Ethics and Aesthetics: Vivisection in the Late Nineteenth-Century British Laboratory’, in Andrew Cunningham and Perry Williams (eds.), The Laboratory Revolution in Medicine (Cambridge, 1992), 142–69. On the birth of controlled trials and of medical statistics, Stephen R. Bown, Scurvy (Chichester, 2003); P. C. A. Louis, Researches on the Effects of Bloodletting in Some Inflammatory Diseases (Birmingham, Ala., 1986); Andrea A. Rusnock, Vital Accounts: Quantifying Health and Population in Eighteenth- Century England and France (Cambridge, 2002). On the survival of blood- letting, Chantal Beauchamp, Le Sang et l’imaginaire médical: Histoire de la saignée aux XVIIIe et XIXe siècles (Paris, 2000), and Guenter B. Risse, ‘The Renaissance of Bloodletting: A Chapter in Modern Therapeutics’, Journal of the History of Medicine, 34 (1979), 3–22. On Haygarth, see Christopher Booth, John Haygarth FRS (Philadelphia, 2005). On spontaneous generation, John Farley, The Spontaneous Generation Con- troversy from Descartes to Oparin (Baltimore, 1974) is more narrowly focused than the title would suggest. On Needham, there is Shirley A. Roe, ‘John Turberville Needham and the Generation of Living Organisms’, Isis, 74 (1983), 159–84. Pasteur and Pouchet are dealt with briefly in chapter 4 of Harry Collins and Trevor Pinch, The Golem: What Everyone Should Know about Science (Cambridge, 1993). John Tyndall has been reprinted: Essays on the Floating-Matter of the Air (Delanco, NJ, 2003). On germ theory, John Waller, The Discovery of the Germ (Cambridge, 2002) provides a quick survey. Margaret Pelling, Cholera, Fever and English Medi- cine, 1825–1865 (Oxford, 1978) has been influential. In the same tradition, Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900 (Cambridge, 2000). On Snow, Peter Vinten-Johansen, Howard Brody, Nigel Paneth, Stephen Rachman, Michael Rip, Cholera, Chloroform and the Science of Medicine: A Life of John Snow (Oxford, 2003), and (rather missing the point), Howard Brody, Michael Rip, Peter Vinten-Johansen, Nigel Paneth, Stephen Rachman, ‘Map-Making and Myth-Making in Broad Street: The London Cholera Epidemic, 1854’, Lancet, 356 (2000), 64–8. On childbed fever, Irvine Loudon, The Tragedy of Childbed Fever (Oxford, 2000), Oliver Wendell Holmes, Medical Essays (Boston, 1911), and Ignaz Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, tr. K. Codell Carter (Madison, 1983). On Pasteur, Gerald L. Geison, The Private Science of Louis Pasteur (Princeton, 1995) and Bruno Latour, The Pasteurization of France (Cambridge, Mass., 1988). On Lister, Richard B. Fisher, Joseph Lister, 1827–1912 (London, 1977). On Fleming, Gwyn MacFarlane, Alexander Fleming: The Man and the Myth (Cambridge, Mass., 1984) and Wai Chen, ‘The Laboratory as Business: Sir Almroth Wright’s Vaccine Programme and the Construction of Penicillin’, in Andrew Cunningham and Perry Williams (eds.), The Laboratory Revolution in Medicine (Cambridge, 1992), 245–92. A useful book for thinking about methodological and theoretical issues is Stanley J. Tambiah, Magic, Science, Religion and the Scope of Rationality (Cambridge, 1990).

On lung cancer, Unfiltered: Conflicts Over Tobacco Policy and Public Health, ed. Erich A. Feldman and Ronald Bayer (Cambridge, Mass., 2004), and Charles Webster, ‘Tobacco Smoking Addiction: A Challenge to the National Health Service’, British Journal of Addiction, 79 (1984), 8–16. For the McKeown thesis, Thomas McKeown, The Modern Rise of Popula- tion (London, 1976). There is a recent survey of the issues in James C. Riley, Rising Life Expectancy: A Global History (Cambridge, 2001). I have found the following particularly helpful for the nineteenth century: Henry Abelove, ‘Some Speculations on the History of Sexual Intercourse during the Long Eighteenth Century in England’, in his Deep Gossip (Minneapolis, 2003), 21–8; Georges Vigarello, Concepts of Cleanliness: Changing Attitudes in France since the Middle Ages (Cambridge, 1988); Simon Szreter, ‘The Importance of Social Intervention in Britain’s Mortality Decline c.1850–1914: A Re-interpretation of the Role of Public Health’, Social History of Medicine, 1 (1988), 1–37, with reply by Sumit Guha, ‘The Importance of Social Intervention in England’s Mortality Decline: The Evidence Reviewed’, Social History of Medicine, 7 (1994), 89–113; Robert W. Fogel, ‘The Con- quest of High Mortality and Hunger in Europe and America: Timing and Mechanisms’, in Patrice Higonnet, David Landes, and Henry Rosovsky (eds.), Favorites of Fortune (Cambridge, Mass., 1991), 33–71. For the twen- tieth century, J. P. Bunker, ‘Medicine Matters After All’, Journal of the Royal College of Physicians of London, 29 (1995), 105–12, and Johan P. Mackenbach, ‘The Contribution of Medical Care to Mortality Decline: McKeown Revisited’, Journal of Clinical Epidemiology, 49 (1996), 1207–13.

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