The Far Beginnings: A Brief History of Medicine
Dr. Ian Carr
Professor Emeritus, Faculty of Medicine, University of Manitoba
This is a selective and incomplete account of the history of medicine, from the beginning to about 1975. It and the author have a bias, towards "Western" medicine, as practised by formally qualified physicians, because this is what is taught and practised by our Faculty. The word "physician" or "doctor" is used to mean a practitioner endorsed by the medical qualifying institutions of the time, and the word "medicine" unqualified to mean the practice of such a physician.
This bias includes the common attitude that life for most people in most Western societies, has steadily improved and that while social improvements, in diet, housing and sanitation have played a large part in this, preventive and therapeutic medicine have played significant parts. It includes the professional attitude that while most physicians do well by doing good, for most physicians the ideal of doing good is more important than doing well. The bias is admitted. Often significant ethical and social differences between older and recent societies will appear; these will be noted without justification or criticism. It is further admitted that western medicine is the medicine of a society which is not indefinitely sustainable, and that its cost effectiveness is falling off. Partly because it is not sustainable, the healing practices of other, perhaps more sustainable societies will be briefly considered. Some attention will be given to folk medicine, from which some "alternative medicine" arises.
Disease must have existed since the beginning, but only skeletal pathology lasts. Osteoarthritic lipping of bones was found in Neanderthal man and osteoarthritis and tuberculosis in Ancient Egypt. Trephining of the skull was a widespread habit - perhaps partly religious, partly medical. Until the invention of cities it is likely that early primitive human communities had similar disease patterns to modern non-industrial societies. Five or six thousand years ago, a human creation which sparked off many other human discoveries, humankind invented the city. With the aggregation of people came the opportunity for infections to spread. The ancient plagues arose in over-crowded polluted cities as do the modern plagues, cigarette disease and road accidents. Also with the city came the possibility that individuals could be liberated from the tasks of growing or hunting their own food to care for others.
The function of medicine or healing, was at first not limited to a single profession but was carried out by many people of either gender. As time passed it became closely associated with religion, and as professionalization developed medicine was restricted to some degree to men. This restriction may have been exaggerated by male historians; there is no question that by the 18th century A.D. there was considerable restriction of formal medical training to men. The nursing function and much informal healing devolved on women. The institutionalization of medicine progressed to very formal training and organization which at times has been interpreted as preserving the privileges of the physician as much as the welfare of the patient.
The life pattern of a preindustrial society is well seen in the lives of the recent population of St. Kilda, an isolated Scottish island community now abandoned. Its records are available for several centuries back. Around 1900 families on St. Kilda lived a very simple existence. They lived on fish and mutton; they imported oats, as very little was grown on the island. Many children died within the first week of life, of cord infections probably because of neonatal tetanus acquired from the dressing for the umbilical cord. A boat came from the mainland about twice a year and a crop of deaths would usually follow in about ten days from the boat sickness, pneumonia due to infection brought in with the boat. Others would die of drowning, trauma or in labor. Some few lived to an extreme old age. This pattern is rather akin to that of preconquest Canadian Native Indian populations. Such must have been the pattern of hunting and agrarian societies. Their medicine was folk healing.
Sumer & Egypt
The earliest civilizations were those of Sumeria and Egypt. The city states of Sumer and Akkad, Babylon and Assyria grew up in fertile Mesopotamia around 3000BC. They were cruel civilizations ravaged by wars and powered by slavery. They recorded their history in cuneiform writing on clay.
Their medicine and religion were closely inter-related. Their drugs were largely of vegetable origin and usually ineffective. They practised haruspicy--divination by examination of entrails. They treated strictures due to gonorrhoea by catheterization, and used fumigations and inhalations. Some physicians' seals persist; the Code of Hamurabi records the way in which the state regulated medical practice. Lack of success was punished in a manner related to the social status of the patient.
The Code of Hamurabi states:
If a physician performed a major operation on a seignior with a bronze lancet and has saved the seignior's life, or he opened the eye-socket of a seignior with a bronze lancet and has saved the seignior's eye, he shall receive ten shekels of silver. If it was a member of the commonalty, he shall receive five shekels. If it was a seignior's slave, the owner of the slave shall give two shekels of silver to the physician. If a physician performed a major operation on a seignior with a bronze lancet and has caused the seignior's death, or he opened the eye-socket of a seignior and has destroyed the seignior's eye, they shall cut off his hand. If a physician performed a major operation on a commoner's slave with a bronze lancet and caused (his) death, he shall make good slave for slave. If he opened up his eye-socket with a bronze lancet and has destroyed his eye, he shall pay one-half his value in silver.
We know more about ancient Egyptian medicine because of the large amount of preserved hieroglyphic material (Ebers & Smith papyri, c. 1500 BC) and because they mummified the bodies of the dead. Their concept of disease included the idea that disease was caused by spirits, by worms and by intestinal decay. They suffered from gout, arthritis, tuberculosis, urinary stone, and schistosomiasis. The connection between medicine and religion was close. Some Egyptian surgical instruments have been preserved; the Egyptians lanced abscesses, used the cautery and used many drugs of vegetable origin. Copper salts, wine and frankincense were used as antiseptics. They understood the synchrony of the pulse with the heart.
A good account of cervical dislocation is found in the Edwin Smith Papyrus:
Instruction concerning a dislocation of a vertebra of his neck: If you examine a man having a dislocation of a vertebra of his neck, should you find him unconscious of his arms and legs on account of it, while his phallus is erected on account of it and sperm drops from his member without his knowing; his flesh has received wind; his eyes are blood-shot -- then you should say concerning him: He has a dislocation of a vertebra of his neck, since he is unconscious of his legs and arms, and his sperm dribbles. An ailment which cannot be treated.
Two names of individual physicians have survived --the earliest names in the medical profession: Sekhetenanach and Imhotep, physician to Pharaoh, Grand Vizier, pyramid builder, and apparently the first proctologist, possessing the picturesque title of Shepherd of the Anus.
Greece and Rome
Western medicine really began in ancient Greece. Greek history was over-shadowed by war; in the Iliad and the Odyssey, there are numerous mentions of the treatment of arrow and sword wounds by individuals defined as doctors. Several warrior heroes were described as being skilled in medicine. A priestly connection was initially strong but gradually waned. The earliest mythical doctor was Aesculapius. Various diseases were treated by incubation or temple sleeping. The patient made a request of the god, usually for cure, and; while the patient slept within the confines of the temple, probably aided by an opiate, the god visited in a dream. The snakes would crawl over the patient during the night and the patient would wake in the morning cured.
Hippocrates of Cos (460-360 B.C.) founded a school of physicians whose writings have been preserved. There seems to have been systematic training of both men and women as physicians, then and in later Greek times. There is no evidence that the human body was dissected. He recorded clear histories, and made accurate clinical observations. He regarded prognosis as important and attempted to tell the patient or relatives what was likely to happen. His drugs were mainly herbal, and mainly ineffective; he practised cupping, and prescribed diet, baths, fomentations and gruel. Disease was a natural phenomenon, related often to an imbalance of the humours, the black bile, the yellow bile, the phlegm and the blood. He believed in the power of Nature to heal, and in the importance of geographic influence. His surgery was simple, suturing wounds, trephining , and the draining of pus.
His case histories ring clear over the centuries. From the book of Prognostics:
1. Thus a man will be the more esteemed to be a good physician, for he will be the better able to treat those aright who can be saved, from having anticipated everything; and by seeing and announcing beforehand those who will live and those who will die, he will thus escape censure.
2. He would observe thus in acute diseases; first, the countenance of the patient, if it be like those of persons in health, and more so, if like itself, for this is the best of all; whereas the most opposite to it is the worst, such as the following: a sharp nose, hollow eyes, collapsed temples; the ears cold, contracted, and their lobes turned out; the skin about the forehead being rough, distended, and parched; the color of the whole face being green, black, livid, or lead-colored. If the countenance be such at the commencement of the disease, and if this cannot be accounted for from the other symptoms, inquiry must be made whether the patient has long wanted sleep; whether his bowels have been very loose; and whether he has suffered from want of food; and if any of these causes be confessed to, the danger is to be reckoned so far less; and it becomes obvious, in the course of a day and a night, whether or not the appearance of the countenance proceeded from these causes. But if none of these be said to exist, and if the symptoms do not subside in the aforesaid time, it is to be known that certain death is at hand. (This description of the Hippocratic facies has guided physicians in prognosis ever since).
3. Respecting the movement of the hands I have these observations to make: when in acute fevers, pneumonia, phrenitis, or headache, the hands are waved before the face, hunting through empty space, as if gathering bits of straw, picking the nap from the coverlet, or beating chaff from the wall -- all such symptoms are bad and deadly. Philiscus, who lived by the Wall, took to bed on the first day of acute fever; he sweated; towards night was uneasy. On the second day all the symptoms were exacerbated; late in the evening had a proper stool from a small clyster, the night quiet. On the third day, early in the morning and until noon, he appeared to be free from fever; towards evening, acute fever, with sweating, thirst, tongue parched; passed black urine; night uncomfortable, no sleep; he was delirious on all subjects. On the fourth, all the symptoms exacerbated, urine black; night more comfortable, urine of a better colour. On the fifth, about mid-day, had a slight trickling of pure blood from the nose; urine varied in character, having floating in it round bodies, resembling semen, and scattered, but which did not fall to the bottom; a suppository having been applied, some scanty, flatulent matters were passed; night uncomfortable, little sleep, talking incoherently; extremities altogether cold, and could not be warmed; urine black; slept a little towards day; loss of speech, cold sweats; extremities livid; about the middle of the sixth day he died. The respiration throughout, like that of a person recollecting himself, was rare, and large, the spleen was swelled up in a round tumour, the sweats cold throughout, the paroxysms on the even days.
Hippocrates set out a set of ethical rules by which practitioners should abide. The original Hippocratic Oath resembles its modern counterpart -- with some significant differences. His physiology included the doctrine of the humours (blood, phlegm, yellow bile, black bile) which arose from the doctrines of Empedocles (earth, air, fire, water). It was repeated over many centuries and led to the grim ritual of 'bleeding, starving, purging'.
The scene shifted from Greece itself to the Alexandria of the Ptolemaic dynasty, ruled by the descendants of Alexander's generals. Medicine practised here in the third century B.C. was Greek medicine with an Egyptian flavor and was as advanced as any in seventeenth century A.D. Europe. Herophilus dissected the human body and described the torcular (transverse and sigmoid sinuses) and the duodenum. Erasistratus described the convolutions of the cerebrum, distinguished cerebrum and cerebellum and observed that organs had arteries, veins and nerves. He thought however, that arteries contained not blood but pneuma or vital spirit. There are charges that human vivisection was practised.
Medicine as practiced in Rome was largely of Greek origin. Physicians were both male and female and were often Greek slaves or freedmen. Aretaeus of Cappadocia (2nd century AD) gave recognizable descriptions of many diseases, diabetes, pneumonia, pleurisy, tuberculosis, tetany, diphtheria and paralysis among them:
Diabetes is a wonderful affection, not very frequent among men, being a melting down of the flesh and limbs into urine. Its cause is of a cold and humid nature, as in dropsy. The course is the common one, namely, the kidneys and the bladder; for the patients never stop making water, but the flow is incessant, as if from the opening of aqueducts. The nature of the disease, then, is chronic, and it takes a long period to form; but the patient is short-lived, if the constitution of the disease be completely established; for the melting is rapid, the death speedy. Moreover, life is disgusting and painful; thirst unquenchable; excessive drinking, which, however, is disproportionate to the large quantity of urine, for more urine is passed; and one cannot stop them either from drinking or making water.
Treatment was largely ineffective. There were several philosophic schools; those which did the least harm were those which were dependent on such common sense measures as diet, rest and sea voyages. Blood letting was common. The best known names were those of Celsus and Galen.
Cornelius Celsus (25 BC-40 AD): an encyclopaedist, who described the cardinal signs of inflammation, calor, rubor, tumor and dolor. He wrote a detailed account of medical practice and left a picture of surgery which includes ligatures, thyroidectomy, removal of arrow heads, phlebotomy, cataract , tonsillectomy , treatment of bladder stones, and amputation.
Galen of Pergamum (AD 131-200): after studying medicine at Alexandria became surgeon to the school of gladiators of Pergamum and subsequently physician to Emperor Marcus Aurelius. His pharmacopoieia included myrrh, nitre, saffron, mandrake and poppy. The term Galenical persisted as a name for a drug. Galen was a proponent of the doctrine of Humours.
The basic principle of life was a spirit (pneuma) drawn from the general World-spirit in the act of breathing. It encountered the body through the windpipe (trachea) and so passed to the lung and thence, through the arteria venalis (our pulmonary vein) to the left ventricle, where it encountered the blood. The food-substance from the intestines was carried as chyle by the portal vein to the liver. There it was converted into blood and endowed with a particular pneuma, the natural spirit, which bestowed the power of growth and nutrition. This venous blood then entered the vena cava, from which it passed upwards and downwards to the tissues of the body. A portion of this venous blood entered the right ventricle of the heart, from which most of it passed by way of the vena arterialis (our pulmonary artery) and its valve to the lungs for their nutrition. The small remaining part of the blood in the right ventricle passed by way of invisible pores in the interventricular septum into the left ventricle. There it mixed with the air, drawn in through the pulmonary vein, to produce arterial blood, which was there charged with a second type of pneuma, the vital spirit.
Blood containing this pneuma passed into the arteries, endowing the various organs with activity. Such arterial blood as reached the brain became there charged with the third and noblest pneuma, the animal spirit, which passed through the hollow nerves to initiate motion and sensation in the organism. But the active mingling of the blood and the vital spirit in the left ventricle gave rise to injurious vapours. The vital spirit passed with the blood from the left ventricle into the arteries. The mitral valve, having only two cusps, was always slightly incompetent; so that blood mixed with vital spirit and injurious vapours passed back into the pulmonary vein and the lungs, by which the vapours were exhaled. (Singer)
Galen believed that pus coming from wounds was Alaudable. He employed diet, massage exercise and simple vegetable drugs a few of which were effective. Some of his treatment was heroic -- bleeding, purging, cupping and blistering. His fame as anatomist and experimental physiologist was based on the anatomy of the pig. He studied the effects of transection of the spinal cord and knew of the cranial nerves, the difference between sensory and motor nerves, and the significance of the laryngeal nerve. He knew that the heart moved blood, but not that blood circulated.
Herbal medicine was important from early days. Dioscorides who flourished about AD60 described over 600 plants and plant extracts. His book was copied and recopied and first printed in 1478. It had many successors. Herbal medicines still form more than a quarter of the pharmacopoieia; they include morphine, cocaine, atropine, digitalis, salicylate, ergot, quinine, ephedrine, vinca. Some of these are now synthetic, and the fact that they are effective in modern purified form does not necessarily mean that they significantly affected the course of disease in pre-modern medicine in herbal form.
Rome's greatest contribution to medicine was the organization of medical schools, teachers, of public physicians or archiatri, of public and military hospitals, of clean water supplies and of city drainage. Rome fell partly because of failure of drainage, and consequent disease, notably malaria. Only in the 18th century did standards of urban sanitation climb back to those of Rome in its heyday.
The Salerno School
Several traditions led to modern medicine. With the fall of Rome, the major Greco-Roman tradition disappeared into the silence of the monasteries for several centuries. The School of Salerno in southern Italy derived from classic Jewish and Arabic medicine and flourished between the ninth to thirteenth centuries; it then lapsed into obscurity, to be closed ultimately by Napoleon in 1811. It was an organized medical school, with a final examination; its products called themselves not medicus but doctor, the learned one. The Emperor Frederick II would not allow physicians to practise in his dominions unless certified by the School of Salerno.
Several names have persisted. Michael Scot used as an anaesthetic spongia somnifera, sponges soaked in opium and other soporifics. Trotula the Dame Trot of nursery rhyme practised mid-wifery. Roger of Salerno wrote a classic mediaeval surgical text.
The Regimen Sanitatis Salernitanum was a rhymed programme of advice on health:
The Salerne Schoole doth by these lines impart
All health to Englands King, and doth aduise
From care his head to keep, from wrath his heart,
Drinke not much wine, sup light, and soone arise,
From care his head to keepe, from wrath his heart,
When meate is gone, long sitting breedeth smart:
And after-noone still waking keepe your eyes.
When mou'd you find your selfe to Natures Needs,
Forbeare them not, for that much danger breeds,
Vse three Physicians still; first Doctor Quiet,
Next Doctor Merry-man, and Doctor Dyet.
A medical school then appeared in the University of Bologna where Mundinus (1275-1376) dissected the human body. William of Salicet (1210-1277), distinguished for the first time between venous and arterial haemorrhage. A medical school was founded in Montpellier. Arnold of Villanova, (1235-1315) first extracted the active principles of drugs with alcohol to make tinctures and wrote a book on toxicology. Guy de Chauliac (1300-1367) treated hernia. All over Europe, hospitals, medical schools and leper houses were founded.
The common supposition about the Renaissance is that there was a rapid increase in intellectual creativity in many fields, including medicine: first in Italy and then in France, Holland and England, the lights came on, people came no longer to accept authority but began to look, listen and ask and draw and think for themselves. Among all this came the beginnings of modern scientific medicine - dissection; and thence hypotheses and experimentation on how the structures worked.
Leonardo da Vinci (1452-1519): a genius and polymath, a gifted artist and theoretical engineer who dissected the human body, demonstrated for the first time the maxillary sinus and the moderator band and depicted the fetus in utero. He intended to produce a major anatomical work but this was abandoned on the death of his artist collaborator.
Andreas Vesalius (1514-1564): inaugurated the new science of anatomy. He grew up in Brussels, studied at the University of Louvain then proceeded to Paris where he studied medicine. He then went to Italy and in Venice met one of his pupils who drew many of the excellent engravings which illustrate his work. Vesalius became professor of anatomy and surgery at Padua 1537, and in 1543 when he was 28 published the De Humani Corporis Fabrica. He corrected many of the misapprehensions of Galenic anatomy, which was based on the study of the pig, noting for instance that only one bone formed the mandible, and that the sternum was in only three parts. He identified the venous valves although apparently not appreciating their importance. In the second edition of his work he observed the absence of connection between the two ventricles; blood therefore could not pass from one to the other (in contradiction to Galenic views). This work raised bitter controversy largely because he contradicted Galenic doctrine. He then moved to Madrid and became physician to the Emperor, at the age of 30, his scientific work finished. In 1564 he went on a pilgrimage to the Holy Sepulchre possibly because the body of a nobleman on whom he was performing a necropsy showed signs of life; the Inquisition objected and the pilgrimage was the condition of his pardon. On returning his ship was wrecked near Corinth and he was drowned. Other major anatomists, Servetus, Fabricius, Fallopius & Eustachius extended his work and attached their names to numerous structures.
The Circulation of Blood
Anatomy led to physiology. William Harvey, son of the mayor of Folkestone was educated at Cambridge and trained in medicine at Padua. There he was taught by Fabricius who wrote the De Venarum Ostiolis, perhaps the genesis of Harvey's discovery . Harvey returned to London and became physician to St. Bartholomew's Hospital. In a lecture on anatomy in 1616 he said:
He later became court physician, and in 1628 published his great work De Motu Cordis dedicated to Charles I. His views were based on experimental ligation of veins and arteries and the demonstration of the function of venous valves and on calculations of stroke volume of the heart. He showed that if the blood did not circulate it had to be very rapidly consumed. He didn't know why it circulated -- whether for the sake of nourishment or for the communication of heat. But the discovery was revolutionary, and marked the beginning of modern medicine.
Medical training was now being organized; medical schools were set up all over western Europe, e.g. in 1575 William of Orange rewarded Leyden for its successful defence against the Spaniards - offering the choice between remission of taxes and a University. The burghers chose a University; and within a short time it was attracting scholars from all over Western Europe. Of many great physicians - the most famous was Herman Boerhaave, trained first in divinity then in medicine, and subsequently Professor of Medicine. He practised the classical Hippocratic methods; his pupils had a dominant influence in British medicine, and in particular on the development of the Edinburgh medical school.