The Roots Of Scientific Medicine
Dr. P. Warren
Professor, Faculty of Medicine, University of Manitoba
Medicine and Religion have always worked hand in hand to care for the sick, to heal the ill and to explain the mysteries of life and disease. Both are examples of humanity's highest ideals and intellectual efforts to understand our world, the nature of man and to reach the truth. The modern medical school emphasizes science as the path to wisdom and the application of scientific knowledge as the most effective way of healing and caring for the patient. But there are many other alternative approaches to illness such as chiropractic, herbalism and traditional Chinese medicine, all of which are attractive to the general public. The purpose of this lecture is to examine the emergence of scientific medicine and religious medicine will be discussed as an alternative. Scientific Medicine is often called Western Medicine- if anything it might be called Mediterranean Medicine, for it arose in the lands that encircle that sea.
The cave paintings of Neolithic people 9,000 BC show figures who could be "Medicine Men", bones reveal healed fractures and holes in skulls from the practice of trephining, although why this was done is unknown. Certainly these early "brain surgeons" were competent because the skulls show that the hole healed. Records reveal evidence of medicine in the earliest urban societies that surround the Mediterranean e.g. Assyria, Sumeria 3000 BC, Egypt 1500 BC. These were warlike civilizations whose history touches on the Old Testament. Their medicine was a mixture of magic and religion. They prescribed with spells but did use plants and herbs for treatment. They wrote on clay tablets that have been preserved.
Sumerian Incantation about 3000 BC trans. Campbell Thompson 1903
Fashion a figure of him in dough,
Put water upon the man and
Pour forth water of the Incantation;
Bring forth a censer and a torch
As the water trickleth away from his body
So may the pestilence in his body trickle away.
Several deities were associated with medicine. Thoth was the patron of physicians, Isis was invoked for magical cures and her son Horus was a protector against harm. Imhotep 2,700 BC is the name of the first physician known to us and he was deified. Much information on Egyptian medicine is available in wall paintings, carvings and papyri.
Eber's Papyrus, 1300 BC (trans Majno 1975), "O Isis, great in sorcery! Mayest thou loosen me, mayest thou deliver me from everything evil and vicious and red, from the spell of a god.." was recited as a bandage was removed. Such practice is incomprehensible to us.
On the other hand Edwin Smith Papyrus, "Instruction concerning a dislocation of a vertebra of the neck: If you examine a man having a dislocation of the a vertebra of his neck, should you find him unconscious of his arms and legs on account of it......then you should say an ailment which cannot be treated" describes quadriplegia and is familiar to us.
Surgical instruments have been found and operations on lumps, bumps, breaks and cuts were performed. Surgery has always been a more practical down to earth discipline.
The symbol of the god Horus is still used for prescriptions today.
The Egyptians embalmed the dead and so some knowledge of human anatomy must have existed.
The origins of Greek medicine are similar to Egyptian. The god Apollo is associated with science. Aesclepius, whose staff is the symbol of medicine, is the first known Greek associated with medicine. He was probably derived from Egypt's Imhotep. Aesclepius was:
Either the son of the god Apollo and the mortal Coronis. He was taught herbal remedies by the centaur Chiron. When Aesclepius resuscitated too many dead he was slain by Pluto Lord of the Underworld. He had sons and two daughters- Hygeia and Panacea (Hygiene and the Panacea of ills).
Or a tribal chief and skilled wound healer whose sons, Machaon and Podalirius, became physicians and appear in Homer's Iliad.
The Cult of Aesclepius
The worship of Aesclepius became established in the 3rd cent BC and many cult temples were built. They were a religious and therapeutic spa, with entertainment, such as theatres, provided. The most famous Aesclepian centre was at Epidaurus, Southern Greece. Patients would spend the night in the god's sanctuary "sleeping in " (incubatio) The priests would interpret the dreams experienced. The cured would leave votive inscriptions and offerings.
A woman had a worm and the cleverest of the physicians despaired of curing her. So she went to Epidaurus and begged the god to free her from the parasite. The god was not there, but the attendants made her lie down where the god was in the habit of healing the suppliants. The attendants removed her head, pulled out the worm but could not replace her head. The god returned and was angry with them for attempting a task beyond their wisdom, and he himself with the irresistible power of a god restored the head to the body."
The medicine, Scientific Medicine, that we teach began with Hippocrates (460 - 377 BC). He published 60 or so works called the Corpus. These range from philosophy to case notes. What makes these works unique is that health and disease are considered to be capable of rational explanation following the same physical laws as govern the universe. Supernatural interference is not needed to explain illnesses. Hippocrates had a sound knowledge of surface anatomy but not about the structure of the body below the skin. He was particularly accurate on wounds/ trauma e.g. On Head Injuries. Hippocratic Medicine dominated European medicine for over two thousand. Careful observation and the symptoms and appearance of the sick were recorded. Case histories were common in the publications.
In Meliboea a youth who had been feverish for a long time because of drunkenness and much sexual indulgence took to his bed. His symptoms were shivering, nausea, insomnia and lack of thirst.
On the first day there passed from his bowels a large quantity of solid stools with much fluid.
During the following day he passed a large quantity of watery green excrement. His urine was then, sparse, and of bad colour. His respiration was at long intervals and deep after a time. There was a rather flabby tension of the upper part of the abdomen extending to both sides. Cardiac palpitation was continuous throughout. The urine was oily.
Tenth day. He was delirious, but calm, well-behaved, and silent. Skin dry and taut; stools either copious and thin or bilious and greasy.
Fourteenth day: all symptoms exacerbated. Delirious with much rambling speech.
Twentieth day. Out of his mind; much tossing about. No urine passed: small amounts of fluid retained.
Twenty fourth day: died.
Hippocrates criticized some of the beliefs on the divine origin of disease. His most famous doctrine on this subject is his treatise on Epilepsy, The Sacred Disease.
I do not believe that the so-called 'Sacred Disease' is any more divine or sacred than any other. It has its own specific nature and cause; but because it is completely different from other diseases men through their inexperience and wonder at its peculiar symptoms have believed it to be of divine origin. This theory of divine origin is kept alive by the difficulty of understanding the malady, but is really destroyed by the facile method of healing, which they adopt, consisting as it does of purification's and incantations.'
He goes on to say, "the brain is the cause of this condition as it is of other most serious diseases."
The Humoral Theory of Diseases
Medicine was equated with philosophy and three Greek philosophers Hippocrates, Plato (427-348 BC) and Aristotle (384-322 BC) contributed to the vision of health, disease and the functions of the body. Although they had differences in general they saw health as an equilibrium of the body as determined by the four humors.
Sap in plants and the blood in animals is the fount of life. Other body fluids- phlegm, bile, faeces, became visible in illness when the balance is disturbed. For instance, epilepsy, the sacred disease was due to phlegm blocking the airways that caused the body to struggle and convulse to free itself. Mania was due to bile boiling in the brain. Black bile was a late addition to disease theory and was associated with melancholy. Aristotle was a philosopher, scientist, and the father of biology. He emphasized the importance of the senses in the investigations of science. He considered the generation of life and of evolution. He dissected animals and produced comparative anatomy. He studied embryology of the dogfish and chick Some of his names continue e.g. Hystera for the uterus.. His physiology was weak -unlike his contemporaries he thought the mind was in the heart and the brain simply cooled the blood. But his physiology dominated medical thought for 2000 years.
Examples of these concepts are descriptions of the function of the lungs and heart. They were aware that breath was essential for life and viewed it as a nutriment. Aristotle thought that air kept the soul in the body.
Diseases of the Lungs
Some diseases of the lungs described by Hippocrates included pleurisy and empyema as well as tuberculosis.
Was recognized as a vital organ and the lungs cooled the blood that was hottest in the heart. Aristotle placed the soul in the heart while Plato put it in the brain. Their description of the anatomy of the heart was generally wrong. Heart disease is hard to identify in Hippocrates' works but it is thought that he described a case of rheumatic fever.
Alexandria, 331 BC
Founded by Alexander the Great and supported by the Ptolemies. Greek thought was established in the intellectual life of the Mediterrenean countries. After the political decline of Athens the centre of learning moved again to Egypt.
Here the dissection of Human bodies was practiced and possibly even vivisection of criminals quoted by Celsus (60 AD). The knowledge of Egyptian embalmers and the teachings of Plato and then Aristotle that the soul was independent of the body and was immortal meant that the dead body was not sacred and could be "violated". More accurate anatomy emerged.
Herophilus, 330-260 BC, Alexandria
He wrote 11 treatises. He was a pupil of Praxagoras of Cos 340 BC who had identified arteries and veins. They carried the pneuma from the lungs to the body with the veins bringing digested food from the liver as blood to mix with the pneuma in the lungs- blood and the pneuma produced heat.
Herophilus studied and wrote on the pulse, distinguished the thick walled arteries from thin veins and determined that arteries carried blood not pneuma.
Erasistratos 330-225 BC
Distinguished the cerebrum from the cerebellum, showed nerves are solid not filled with pneuma, and differentiated sensory and motor nerves.
The Roman Empire
The next great power was Rome and its empire. The most famous and influential physician of the Roman Empire was Galen 129-216 AD. He was a prolific writer- 350 titles ranging from the soul to bloodletting -and his works dominated medical practice for 1500 years. His ability and erudition was matched by a vast ego; he would boast about his famous patients including the Emperors.
I have done as much for medicine as Trajan did for the Roman Empire. It is I, and I alone, who revealed the true path of medicine. It must be admitted that Hippocrates already staked out this path...he prepared the way, but I have made it passable.
His father was wealthy so he pursued a long education- born in Pergamon (Turkey) he studied in Alexandria, returned home and became physician to the gladiators. In 162 BC he moved to Rome. He advertised himself by public displays- he would vivisect a pig, which would squeal until Galen cut the recurrent laryngeal nerve that supplies the vocal cords.
Galen did fine experimental work on the nervous system, for example on the nervous system:
Transsection of the spinal cord
At cervical vertebra: 1/2 produced instant death.
At cervical vertebra: 3/4 produced respiratory arrest.
At cervical vertebra: 6 paralyzed costal muscles.
At thoracic vertebrae: paraplegia.
Galen dissected apes, sheep, pigs, goats and an elephant's heart BUT not humans so his human anatomy was weak. He knew human skeletal but not organ anatomy. He combined the theory of Plato's three spirits with anatomy. A major weakness was his concept of the circulation of the blood for he believed that the right and left sides of the heart communicated through minute pores and so he had no concept of the circulation of the blood.
Galen presented his work as 'perfecting' Hippocrates' legacy for he fused the theoretical and clinical bases of medicine. Fever might result from an excess of yellow bile or phlegm or of blood (plethora). These superfluous humors accumulating in a body part could cause putrefaction and excessive heat' fever. To remove these superfluous humors and restore humoral balance he advocated energetic blood-letting. Blood letting should also be used prophylactically to prevent diseases. He indicated when and how much blood to let depending on the patient's age, constitution, the season, the weather and the place. Hippocrates had treated fever by starvation, Galen did by bleeding. The theoretical basis for bloodletting was his concept of the pulse.
Galen The Pulse
He wrote 16 books on the pulse. Feeling the pulse was used extensively for diagnosis of diseases. He taught how to examine the pulse- its fullness, rate, rhythm. He explained the nature of pulsation believing that arteries contracted and expanded independently of the heart and this helped the formation of the vital spirit. He wrote books on how various changes in the pulse revealed diseases of the body.
The Arabic Muslim Civilization
His followers, the Arabs, founded the Islamic faith and his disciples conquered the Eastern and Southern shores of the Mediterranean. The Arabs were devoted to learning, civilized behaviour and the advancement of science and included people of all faiths and races in their community. It was the Muslim Arabic culture that swept across the Near East and North Africa and into the two ends of Europe In the 9th century medicine flourished under the Arabs in a scholarly manner starting with translation of the Hippocratic and particularly Galenic texts. With the decline and fall of the Roman Empire Europe is said to have entered the Dark Ages and all this knowledge was lost from it.
Some of the notable Arab-Muslim physicians included:
Al-Razi (Rhazes), 865-925: author of 200 treatises. "he who studies the works of the Ancients gains the experience of their labour as if he himself had lived thousands of years spent on investigation" but "all that is written in books is worth much less than the experience of a wise doctor". He differentiated the infections with rashes in particular Smallpox from Measles.
Ibn Sina (Avicenna), 980-1037: practiced medicine by age 16. He wrote 270 books with two monumental encyclopedia. He wrote on horseback during wars, in hiding, in prison and even after drinking bouts!
Ib rushd (Averroes), died 1198: wrote a useful The Book of General Principles.
Ibn Maimon (Rabbi Moses Maimonides), 1135-1204: Jewish physician who had to flee Spain and eventually became court physician to the Saladin sultan of Egypt and Syria. He wrote a 14 volume religious book and 10 medical works. His is recognized for one of the earliest descriptions of asthma. His religious prayer has been exhorted as a code for physicians.
Arabic-Islamic medicine was particularly strong on pharmacology and rugs were derived from plants, animals and minerals. The Arab culture also saw the establishment of the Hospital. Arabs saw that they had a duty to contribute to the public good and they founded the first one in Baghdad 805 AD. A major hospital was begun in Cairo, 1283 AD- for the rich and poor, old and young, male and female and all faiths. It had wards for physical and mental diseases and surgery. There was a pharmacy, a library and lecture room and a chapel for Christians and a Mosque.
In the 12th and 13th century AD Salerno in Italy became the centre of medical teaching until the 15th century. It drew faculty from Muslim, Jewish and Christian faiths and had women students and teachers. Geoffrey Chaucer describes a typical medieval physician in The Canterbury Tales.
The Doctor of Physic, 1387
With us there was a Doctor of Physic,
In all the world was there none like him
To speak of physic and of surgery,
For he was grounded in astronomy
He knew the cause of every malady,
Were it hot or cold or moist or dry,
And where engendered, and of what humor;
He was a very perfect practitioner.
Full ready had he his apothecaries
To send him drugs and his ointments
His study was but little on the bible Well knew he the old Aesculapius*
And Dioscorides*, and Rufus*
Old Hippocrates*, Alhazen# and Galen**;
Serapion#, Raziz#, and Avicenna#
Averrois#, Damascien#, and Constantine~
Bernard@ and Gatesden+ and Gilbertyn+
For gold in physic is a cordial
Therefore he loved gold in special.
* Greek # Arab/Muslim ** Roman ~ Salerno @ Montpelier + English
* Greek # Arab/Muslim ** Roman ~ Salerno @ Montpelier + English
The Italian Renaissance
All was soon to change- with the Italian Renaissance. Dissection of the body began as part of the Arts e.g Leonardo da Vinci and then as an intellectual exercise in its own right. In due course the abnormalities created by disease in the body were identified and the science of pathology emerged.
The colonizing European physician practiced by the old beliefs of Hippocratic Galenic medicine but in fact they had much in common with the native aboriginal practitioner. The Jesuits who colonized Georgian Bay as missionaries (St. Marie, Midland) recorded the medicine of the Hurons in 1615 AD. Some of it is reminiscent of the Aeschylean beliefs (Elizabeth Tooker, 1964).
The Huron recognized three types of illness:
• due to natural causes treated by natural remedies-herbs, roots, emetics, sweat lodges.
• due to the desires of the soul of the sick person that were cured by supplying those desires- Dreams were much used to identify the nature of the illness. Friends and neighbours supplied the object or a party.
• due to witchcraft that were cured by extracting the sorcerer's spell. Medicine Men could be diagnosticians or apothecaries.
Religion and Medicine
There is still a relationship between medicine and religion in our society. A walk around Mount Royal Park in Montreal can see this. At the east end is the Hospital - Hotel Dieu of the University of Montreal - founded in 1663 by the Religieuses Hospitaliere de St Joseph, an order of nuns who devoted their lives to the care of the sick. The hospital is now a leading research teaching hospital.
At the west end is Oratoire St. Joseph, a massive church commemorating the miracles and healing power of Brother Andre who built a small chapel here 1904. Many miraculous cures have occurred there and the church exhibits the crutches of the lame who now can walk In the middle is the Montreal General Hospital, a major McGill teaching hospital, founded in 1820 and moved to this site in 1955. In front of it is the Church of Christian Science. Mary Baker Eddy started Christian Science in 1866 who viewed matter as an illusion and so there could be no disease of the body. Her believers seek cure through prayer and spurn medical care.