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Doctors May Not Know It All

Life itself, healthy life, is so unarguable a boon that the medical profession-the profession of health and healing-must always have seemed indispensable. And yet the doctor's high status is a relatively recent phenomenon. For most of our history, doctors had so little ability to deal with disease and injury that they were lucky to earn a living, let alone be seen as wise and worthy. Thanks to the advances of science and the standards of the profession, doctors now can be both effective and rich-a phenomenon that is at once a source of pride and some trepidation to them. They are aware that when so much hope and trust is invested in another human being, any lapse-real or perceived-is met with anger, incomprehension, and loss of confidence. With the glory of curative power comes a rise in malpractice suits. Doctors may not know it all (only quacks pretend to), but we're very grateful for what they do know.

The understanding of prehistoric medical practice is derived from paleopathology, which involves the study of skulls and skeletons, of surgical tools, and of pictographs showing medical procedures. Although such study is properly the concern of anthropology, some of the practices have survived into modern times, justifying their consideration in the history of medicine.

Serious diseases were of primary interest to early humans although they did not have the knowledge needed to treat these illnesses adequately. Most diseases were attributed to the influence of malevolent demons, who were believed to project an alien spirit, a stone, or a worm into the body of the unsuspecting patient. These diseases were typically treated by incantation, dancing, magic effects, charms and talismans, and various other measures. If the demon managed to enter the body of its victim, either in the absence of such precautions or despite them, efforts were made to make the body uninhabitable to the demon by beating, torturing, and starving the patient. The alien spirit could also be expelled by potions that caused violent vomiting, or could be driven out through a hole bored in the skull. The latter procedure, called trepanning, was also a remedy for fractured skulls, convulsions, and insanity.

In some cases therapy was mounted directly against a disability, and these treatments were usually more successful. Operative procedures practiced in ancient societies included cleaning and treating wounds by cautery (the burning or searing of tissue), poultices, and sutures; resetting dislocations and fractures; and using splints. Additional therapy included the use of purges, diuretics, laxatives, emetics, and enemas. Perhaps the greatest success was achieved by the use of plant extracts with narcotic or stimulating properties. So successful were these that 50 or more continue to be used today, such as digitalis, a heart stimulant extracted from foxglove.

Several prescientific systems of medicine, based primarily on magic, folk remedies, and elementary surgery, existed in various diverse societies before the coming of the more advanced Greek medicine about the 6th century bc. Two distinct trends are discernible in Egyptian medicine, the magico-religious, embodying primitive elements, and the empirico-rational, based on experience and observation and lacking in mystical features. Common diseases of the eyes and skin were usually treated rationally by the physician because of their favorable location; less accessible disorders continued to be treated by the spells and incantations of the priest-magician. In the 3d Dynasty the physician emerged as an early form of scientist, a type distinct from the sorcerer and priest. The earliest physician whose name has survived is Imhotep (fl. 27th cent. bc), renowned equally as vizier to the pharaoh, a pyramid builder, and an astrologer.

The physician normally spent years of arduous training at temple schools in the arts of interrogation, inspection, and palpation (examining the body by touch). Prescriptions contained some drugs that have continued in use through the centuries. Favorite laxatives were figs, dates, and castor oil. Tannic acid, derived principally from the acacia nut, was valued in the treatment of burns.

Although Egyptians practiced embalming, their anatomical knowledge remained at a low level; as a result, they attempted only minor surgical procedures. An exception was the practice of trepanning. According to reports of the Greek historian Herodotus, the ancient Egyptians recognized dentistry as an important surgical specialty. Some evidence suggests that Egyptian studies of physiology and pathology, based on the work of Imhotep, and the later vivisection of criminals by the Greek anatomist and surgeon Herophilus may have influenced the Greek philosopher Thales of Miletus, who is known to have traveled in Egypt in the 7th century bc.

Because of the theocratic system prevailing in Assyria and Babylonia, medicine in these countries could not break away from the influence of demonology and magical practices. Surviving cuneiform tablets present an extensive series of well-classified case histories. Surprisingly accurate terra-cotta models of the liver, then considered the seat of the soul, indicate the importance attached to the study of that organ in determining the intentions of the gods. Dreams also were studied to learn the gods' intentions. A large number of medical remedies were used in Mesopotamia, including more than 500 drugs, some of which were of mineral origin. Incantations chanted by the priests served as a form of psychotherapy.

Hebrew medicine derived much from contact with Mesopotamian medicine during the Assyrian and Babylonian captivities. Disease was considered evidence of the wrath of God. The priesthood acquired the responsibility for compiling hygienic regulations, and the status of the midwife as an assistant in childbirth was clearly defined. Although the Old Testament contains a few references to diseases caused by the intrusion of spirits, the tone of biblical medicine is modern in its marked emphasis on preventing disease. The Book of Leviticus includes precise instructions on such varied subjects as feminine hygiene, segregation of the sick, and disinfection of materials capable of harboring and transmitting germs. Although circumcision is the only surgical procedure clearly described, fractures were treated with the roller bandage, and wounds were dressed with oil, wine, and balsam. The leprosy so frequently mentioned in the Bible is now believed to have embraced many skin diseases, including psoriasis.

The practices of ancient Hindu, or Vedantic, medicine (1500 to 1000 bc) are described in the works of two later physicians, Caraka (fl. 1st or 2d cent. ad) and Susruta (fl. 4th cent. ad). Susruta gave recognizable descriptions of malaria, tuberculosis, and diabetes. He also wrote about Indian hemp, cannabis, and henbane, Hyoscyamus, for inducing anesthesia, and included specific antidotes and highly skilled treatments for bites of venomous snakes. An ancient Hindu drug derived from the root of the Indian plant Rauwolfia serpentina was the source of the first modern tranquilizer. In the field of operative surgery, the Hindus are acknowledged to have attained the highest skill in all antiquity. They were probably the first to perform successful skin grafting and plastic surgery for the nose.

With the rise of Buddhism the study of anatomy was prohibited, and with the Muslim conquest the field of medicine further declined and ultimately stagnated. Nevertheless, much valuable knowledge concerning hygiene, diet, and surgery was transmitted to the West through the writings of the Arab physician Avicenna and others.

In ancient China religious prohibitions against dissection resulted in an inadequate knowledge of body structure and function. As a consequence, surgical technique remained elementary. External treatments included massage and dry cupping, a form of counterirritation in which blood is drawn to the skin surface by application of a cup from which air is then exhausted to create a partial vacuum. Two special forms of counterirritation used in rheumatic and other disorders were acupuncture, or puncture of the skin by needles to relieve pain and congestion—a technique still used in modern medicine; and cautery of the skin by the application of burning moxa, a preparation of oil-soaked leaves of Chinese wormwood. Important Chinese drugs included rhubarb, aconite, sulfur, arsenic, and most important, opium. Concoctions of animal organs and excretions, survivals of ancient ritual, were also used.

The earliest Greek medicine depended on magic and spells. Homer considered Apollo the god of healing. Homer's Iliad, however, reveals a considerable knowledge of the treatment of wounds and other injuries by surgery, already recognized as a specialty distinct from internal medicine.

Asclepius subsequently supplanted Apollo as the god of healing, and the priests practiced the healing art in his temples. Still later, a semipriestly sect, the Asclepiades, although claiming to be descendants of the god of medicine, practiced a form of psychotherapy called incubation.

By the 6th century bc, Greek medicine had become thoroughly secular, stressing clinical observation and experience. In the Greek colony of Crotona the biologist Alcmaeon (fl. about 535–500 bc) identified the brain as the physiological seat of the senses. The Greek philosopher Empedocles elaborated the concept that disease is primarily an expression of a disturbance in the perfect harmony of the four elements—fire, air, water, and earth—and formulated a rudimentary theory of evolution.

Kos and Cnidus are the most famous of the Greek medical schools that flourished in the 5th century bc under the Asclepiades. Students of both schools probably contributed to the Corpus Hippocraticum (Hippocratic Collection), an anthology of the writings of several authors, although popularly attributed to Hippocrates of Kos, known as the father of medicine. None of these works mentions supernatural cures. The highest ethical standards were imposed on the physicians, who took the celebrated oath usually attributed to Hippocrates and still in use today. Knowledge of human anatomy was based mainly on the dissection of animals. Physiology was based on the four cardinal humors, or fluids, of the body: This concept was derived from Empedocles' theory of the four elements. Pain and disease were attributed to imbalance of these humors. The true genius of Hippocrates is shown in the Aphorisms and Prognostics, containing pithy summaries of vast clinical experience that inspired countless commentaries until well into the 18th century. Of unusual excellence also is the Hippocratic work Fractures, Dislocations, and Wounds.

Although not a practicing physician, the Greek philosopher Aristotle contributed greatly to the development of medicine by his dissections of numerous animals. He is known as the founder of comparative anatomy. By the 3d century bc, Alexandria, Egypt, the seat of a famous medical school and library, was firmly established as the center of Greek medical science. In Alexandria the anatomist Herophilus performed the first recorded public dissection, and the physiologist Erasistratus did important work on the anatomy of the brain, nerves, veins, and arteries. The followers of these men divided into many contending sects; the most notable were the empiricists, who based their doctrine on experience gained by trial and error. The empiricists excelled in surgery and pharmacology; a royal student of empiricism, Mithradates VI Eupator, king of Pontus, developed the concept of inducing tolerance of poisons by the administration of gradually increased dosages.

Alexandrian Greek medicine influenced conquering Rome despite initial resistance from the Romans. Asclepiades of Bithynea was important in establishing Greek medicine in Rome in the 1st century bc. Opposed to the theory of humors, Asclepiades taught that the body was composed of disconnected particles, or atoms, separated by pores. Disease was caused by restriction of the orderly motion of the atoms or by the blocking of the pores, which he attempted to cure by exercise, bathing, and variations in diet, rather than by drugs. This theory was revived periodically and in various forms as late as the 18th century.

The chief medical writers of the 1st and 2d centuries ad, apart from Galen of Pergamum, were the Roman Aulus Cornelius Celsus, who wrote an encyclopedia of medicine; the Greek physician Pedanius Dioscorides, the first scientific medical botanist; the Greek physician Artaeus of Cappadocia (fl. 2d cent.), a disciple of Hippocrates; the Greek anatomist Rufus of Ephesus (fl. early 2d cent.), renowned for his investigations of the heart and eye; and Soranus of Ephesus (fl. 98–138), another Greek physician, who recorded information concerning obstetrics and gynecology, apparently based on human dissection. Although an adherent of the school of Asclepiades, he distinguished among diseases by their symptoms and course.

Galen of Pergamum, also a Greek, was the most important physician of this period and is second only to Hippocrates in the medical history of antiquity. In view of his undisputed authority over medicine in the Middle Ages, his principal doctrines require some elaboration. Galen described the four classic symptoms of inflammation and added much to the knowledge of infectious disease and pharmacology. His anatomic knowledge of humans was defective because it was based on dissection of apes. Some of Galen's teachings tended to hold back medical progress. His theory, for example, that the blood carried the pneuma, or life spirit, which gave it its red color, coupled with the erroneous notion that the blood passed through a porous wall between the ventricles of the heart, delayed the understanding of circulation and did much to discourage research in physiology. His most important work, however, was in the field of the form and function of muscles and the function of the areas of the spinal cord. He also excelled in diagnosis and prognosis. The importance of Galen's work cannot be overestimated, for through his writings knowledge of Greek medicine was subsequently transmitted to the Western world by the Arabs.

Original Roman contributions were made in the fields of public health and hygiene. In the organization of street sanitation, water supply, and public hospitals, the methods of the Romans were not surpassed until modern times. The gradual infiltration of the Roman world by a succession of barbarian tribes was followed by a period of stagnation in the sciences.



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