A Brief Introduction to the History of Medicine

C.E. Pringle MD, FRCPC

University of Ottawa

Vita Brevis, Ars Longa

O βίος βραχύς, ἡ δὲ τέχνη μακρή, ὁ δὲ καιρὸς ὀξύς, ἡ δὲ πεῖρα σφαλερή, ἡ δὲ κρίσις χαλεπή.

Vita brevis, ars longa, occasio praeceps, experimentum periculosum, iudicium difficile.

La vie est brève, l'art est long, l'occasion fugitive, l'expérience incertaine, le jugement difficile.

Life is short, the Art long, opportunity fleeting, experience perilous, and judgment difficult.

Hippocrates, Aphorisms

"Medicine is not a science; rather, it is an applied technology or an art that makes extensive use of science."

Jacalyn Duffin MD FRCPC

An Overview of the History of Medicine

“Doc, I have an earache.” 2000 BCE: “Here, eat this root.” 1000 BCE: “That root is heathen, say this prayer.” 1400: “Prayer is superstition, let me bleed you a bit.” 1750: “Bleeding’s no good, drink this potion.” 1900: “That potion is snake oil, let me operate.” 1950: “Cutting won’t help, take this antibiotic.” 2015: “That antibiotic isn’t covered…here, eat this

root.”

State of the Art: 2015 “Half of what you’ll learn in medical school

will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half–so the most important thing to learn is how to learn on your own.”

David Sackett MD

The Ancient Greeks

built on older traditions which overlapped extensively with religion/superstition Greeks separated medicine from religion

(eventually)

dominated medicine for > 8 centuries much of our medical nomenclature is

derived from Greek βιος = bios = life καρδια = cardia = heart οφθαλμος = ophthalmos = eye πνευμα = pneuma = breath

medical traditions

Rod of Aesclepius Aesclepius = God of medicine and

healing in ancient Greece daughters

Hygiei, goddess of cleanliness, sanitation Iaso, goddess of recuperation Aceso, goddess of healing process Panacea, goddess of remedies

cult of Aesclepius healing temples (or asclepieions)

caduceus

Hippocrates of Cos (c. 460 BCE – c. 370 BCE)

“Father of Medicine” Hippocratic School

led medicine away from the supernatural

art of clinical inspection & observation

established medicine as a profession

Hippocratic Corpus Hippocratic Oath

Hippocratic Oath/ Serment d’Hippocrate

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgment, I will keep this Oath and this contract:

To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.

I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

In purity and according to divine law will I carry out my life and my art.

I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.

Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.

Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.

So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.

The Quotable Greek

“As to diseases make a habit of two things - to help, or at least, to do no harm”

(primum non nocere)

“It is far more important to know what person the disease has than what disease the person has.”

21st century “new idea” = patient-centered medicine

The Quotable Greek: Everything Old is New Again

“There are in fact, two things: science and opinion; the

former begets knowledge, the latter ignorance.”

21st century “new idea” = evidence based medicine

The Quotable Greek: Everything Old is New Again

“The art has three factors: the disease, the patient, the physician. The physician is the servant of the art. The patient must cooperate with the physician in combatting the

disease.”

21st century “new idea”

= patient as partner

The Quotable Greek: Everything Old is New Again

FIRE

AIREARTH

WATER

HOT

MOISTCOLD

DRY

BLOOD

PHLEGM

BLACK BILE

YELLOW BILE

Early Physiology:The Four Humors

sanguine

phlegmatic

melancholy

choleric/bilious

Rx = bleeding

Rx = emetic

Rx = expectorant

Rx = purge

State of the Art: 360 BCE “Healing is a matter of time, but it is

sometimes also a matter of opportunity.” hygiene, diet herbs, botanicals wine, opium, mandrake (atropine)

“Walking is man’s best medicine” “First, do no harm.”

Galen of Pergamon (Claudius Galenus) 129–c. 200

considered the ultimate authority on medicine for nearly 2 millennia

creative new theories based on his own observations and extensive animal experimentation

but NO human dissections spectacularly wrong about nearly

everything*

State of the Art: alcohol, opium washes, baths, rubs,

poultices, fumigations and ointments

hartshorn (ammonia) turpentine senna kykeon (barley water)

hyocyamus (scopolamine) theriacs laudable pus BLEEDING!!

2nd century1500

crumbling Roman Empire breakdown of civilization ecclesiastical takeover

“doctrinal mindset” = failure of imagination

“Galen as God” The Great Plagues

Middle (Dark) Ages

but I don’t see any pores in the heart…I must be stupid!

The Arab Influence Arab & Jewish scholars preserved & expanded on the Ancient Greek learning Latin translations of Arabic medical works had a significant influence on the development of medicine in the early Renaissance

al-Razi (Rhazes of Basra) Ibn al-Nafis al-Zahrawi (Albucaisis) Ibn Sinna (Avicenna) Isaac Judaeus (Isaac Israeli) Moses Maimonides

Renaissance revival of learning rediscovery of the ancient Greeks

from Arabic translations printing press Age of the Anatomists

autopsy/dissection Renaissance artists as anatomists

Michelangelo, Raphael, Titian Leonardo DaVinci

Andreus Vesalius (1514-64)

De humani corporis fabrica 1543 directly challenged Galen created an atmosphere of inquiry based on

direct observation

William Harvey (1578-1657)

“father of Physiology” first to describe systemic

circulation “De Motu Cordis” 1628

came into direct conflict with Galen some doctors affirmed they

would "rather err with Galen than proclaim the truth with Harvey.”

since a disease well-known is a disease half cured, for ignoti nulla est curatio morbis, it will not be difficult for you to conclude what are the remedies needed by our patient. First of all, to remedy this obdurate plethora, and this luxuriant cacochymy throughout the body, I opine that he should be freely phlebotomised; by which I mean that there should be frequent and abundant bleedings, first in the basilic vein, then in the cephalic vein; and if the disease be obstinate, that even the vein of the forehead should be opened, and that the orifice be large, so that the thick blood may issue out; and, at the same time, that he should be purged, deobstructed, and evacuated by fit and suitable purgatives, i.e. by chologues and melanogogues.

State of the Art: 1669

puisqu'une maladie bien connue est à demi guérie, car ignoti nulla est curatio morbi, il ne vous sera pas difficile de convenir des remèdes que nous devons faire à Monsieur. Premièrement, pour remédier à cette pléthore obturante, et à cette cacochymie luxuriante par tout le corps, je suis d'avis qu'il soit phlébotomisé libéralement, c'est-à-dire que les saignées soient fréquentes et plantureuses : en premier lieu de la basilique, puis de la céphalique ; et même, si le mal est opiniâtre, de lui ouvrir la veine du front, et que l'ouverture soit large, afin que le gros sang puisse sortir ; et en même temps, de le purger, désopiler, et évacuer par purgatifs propres et convenables, c'est-à-dire par cholagogues, mélanogogues.

Moliere: M. de Pourceaugnac; Act I,sc x

The Paris School: La Faculté de Médecine Universelle

“Peu lire, beaucoup voir, beaucoup faire” correlation of patient’s symptoms with

physical signs and pathology (at autopsy)

Phillippe Pinel Jean-Nicolas Corvisart Rene Laennec Pierre Louis Guillaume Duchenne Claude Bernard

Les Sensualistes: The Golden Age of French Medicine

John Snow & the Broad Street Pump 1854

Louis Pasteur germ theory 1860’s

Joseph Lister introduces antisepsis 1865

Germ Theory & Antisepsis

Hmmm…it says here in this 9 year old copy of “The Lancet” that he

ought to be using antiseptic technique…guess he’s a little

behind on his reading!

State of the Art: 1875

Germ Theory & Antisepsis Ignaz Semmelweis 1847

Vienna's Allgemeines Krankenhaus

The Emergence of Laboratory Medicine

shift from gross to microscopic pathology Germany at the forefront “pathologic physiology” Rudolf Virchow (1821-1902)

“Father of modern pathology” “Father of social medicine”

Micro-Virchow: “think microscopically”

leukemia, thrombosis, embolus introduced the terms

chromatin, agenesis, heterotopia, parenchyma, osteoid, ochronosis,

1st descriptions of microinvasion by carcinoma, amyloid degeneration of the kidney,

myelin, neurologia, melanoma of the meninges, congenital encephalitis, spina bifida, leontiasis ossea, strawberry gallbladder, teratomatous (dermoid) cyst of the ovary, and Virchow-Robin space

founded Virchow’s Archiv 1847 the cell theory 1855

the whole organism doesn’t get sick, only certain cells “omnis cellula e cellula”

inspiring, innovative & influential teacher landmark text “Cellular Pathology” 1858

Macro-Virchow: “physicians are the natural attorneys of the poor”

an outspoken advocate for public health report on the Silesian typhus epidemic 1847 on the barricades in 1848 Revolution elected to many political offices

Berlin City councillor 1859-1901 Prussian House of Deputies 1862 founder of the “radical” German Progressive Party Reichstag 1880-93

“If Medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?”

“the sausage duel” 1865

Robert Koch (1843-1910)

identified responsible organisms anthrax(1877), tuberculosis(1882), cholera(1883)

pupils identified diphtheria, typhoid, pneumonia, gonorrhoea,

cerebrospinal meningitis, leprosy, bubonic plague, tetanus, and syphilis

Koch’s postulates (1884) to establish an organism as the cause of a disease, it must:

1. be found in all cases of the disease, absent in healthy

2. be isolated from diseased host and grown in pure culture

3. reproduce the disease when pure culture inoculated into a healthy susceptible host

4. be retrievable from the inoculated animal and cultured again.

tuberculin scandal (1890)

The Ages of Medicine

Hippocrates: sickbed medicine Middle Ages: library medicine Renaissance: dissection room medicine Paris school: hospital medicine German school: laboratory medicine Osler: modern medicine (all of the above)

William Osler (1849-1919)

“Father of Modern Medicine” brought medical students out of

the lecture halls and back to the bedside

The Flexner Report 1910

damning report on medical education in US & Canada criticized proprietary schools’ lax standards for

admission & graduation concluded too many medical schools graduating

too many doctors sited Johns Hopkins as the standard recommended medical schools appoint full-time

clinical professors

triggered much needed-reforms more than half med schools would close

Physic: alcohol/opium/morphine

cocaine (1880)

emetics/laxatives/purgatives/poultices/plasters

digitalis (1785)

placebo (c1811)

potassium bromide (1857)

chloral hydrate (1869)

amyl nitrate (1879)

Diptheria antitoxin (1891)

salicylate (1899)

State of the Art: 1910: What’s in Osler’s Black Bag?

Gadgets: bandages, tourniquets, lancets stethoscope (Laennec1816)

carbolic hypodermic needle (1857)

thermometer (1867)

sphygmomanometer (1881/1901)

surgical gloves (1890)

XRay requisitions (1895)

The Age of Therapeutics: Materia Medica Yields to Pharmacology

salvarsan 1910 insulin 1921 prontosil 1932 penicillin* 1928 (1945)

sulfanilamides 1936Fabriqué au Québec

State of the Art: 1957 tonsillectomy antibiotics for URTI’s frontal lobotomies/leukotomies insulin shock therapy radiating “enlarged thymus glands” in

newborns thalidomide for morning sickness

Frances Oldham Kelsey & Helen Taussig

In Summary Medicine is an art that makes use of science YOU are now part of a profession with a proud tradition as the heirs of Hippocrates, Avicenna, Virchow, Osler,

Taussig et al, we are called on to help and not harm comfort the individual, challenge the society only accept “because I said so” from your patients, never

your professors (and never from the drug reps) be teachers as well as perpetual students

Wherever the art of Medicine is loved, there is also a love of

Humanity” Hippocrates

Fildes “The Doctor” 1887

THE END

5

Pringle’s Rule if asked “who was [insert eponymous name

here]?” if the eponym refers to a clinical sign, the answer

is usually “a French [insert name of appropriate specialty] from the 19th century.”*

if the eponym refers to an anatomic/histologic structure, the answer is usually “a German pathologist from the 19th century.”

* unless the name sounds unmistakenly British (eg Cullen’s sign, McBirney’s point)

Examples Who was His? (of the bundle of

His) Who was Waller? (of Wallerian

degeneration) Who was Henle? (of the Loop of

Henle)

Who was Dupuytren? (of Dupuytren’s contracture)

Who was L’Hermitte? (of L’Hermitte’s sign)

Who was Babinski? (of the Babinski sign)

a German pathologist from the 19th century

a French surgeon from the 19th century

a French neurologist from the 19th century

Galen’s Mixed Legacy arteries filled with blood, not pneuma urine is formed by the kidneys, not

the bladder chest expansion from diaphragmatic

& thoracic muscle action precede ventilation, not the reverse

spinal cord & spinal nerves control specific neuromuscular function sensory nerves are distinguishable

from motor nerves the heart is the origin of blood vessels

and the brain the source of nerves, not the converse

voice originates in the larynx (via the recurrent laryngeal nerve), not the heart

flawed anatomy based on animal dissections mistaken views of

circulation & brain too authoritative

theories dominated & influenced Western medicine for nearly two millenia

stagnation of the Middle Ages

Ambrose Paré (1510-1590)

“Father of Surgery” apprenticed to a barber battlefield surgeon

ended the cautery of gunshot wounds with red-hot iron & hot oil

vascular ligature, prostheses writings in vernacular (incl.

Vesalius translation)

Thomas Sydenham (1624-1689)

“Father of Internal Medicine” “the English Hippocrates” the natural history of disease

Sydenham’s chorea the idea of contagion

introduced laudanum, quinine

William Hunter (1718-1783)

“Father of Obstetrics”

John Hunter (1728-1793)

“Father of Scientific Surgery” landmark studies of

inflammation “he found surgery a

mechanical art and left it an experimental science.”

Hunterian collection

Edward Jenner (1749-1823)

“Father of Immunology” inventor of the smallpox vaccine

millions of deaths 1/3 cases of blindness WHO declared eradicated 1979

Osler’s “Girls” “This is right: if any woman feels that the medical

profession is her vocation, no obstacles should be placed in the way of her obtaining the best possible education, and every facility should be offered so that, as a practitioner, she should have a fair start in the race.”

“…my sympathies are entirely with them in the attempt to work out the problem as to how far they can succeed in such an arduous profession as that of medicine.”

3 women & 15 men enrolled in original class

Worth Reading (after you graduate and have all that spare time….)

“History of Medicine: A Scandalously Short Introduction” by Jacalyn Duffin

“Doctors: The Biography of Medicine” by Sherwin Nuland

“Osler: A Life in Medicine” by Michael Bliss “The Youngest Science: Notes of a Medicine-

Watcher” by Lewis Thomas “Partners of the Heart” by Vivien Thomas

Univerity of Padua Alumni

Andreas Vesalius De Humani Corporis Fabrica

William Harvey De Motu Cordis

Giovanni Morgagni De Sedibus et Causis Morborum

Giovanni Battista Morgagni (1682-1771)

“symptoms are the cry of the suffering organs”

Ubi est morbus? (where is the disease?)