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Objectives (a)
evolution of professionalism as a field of study (b) historical factors that
contributed to the development of professionalism as a field of study (d) importance
of professional bodies (e) compare and contrast different professional bodies
around the world
1.2.2 HISTORICAL EVOLUTION OF
CLINICAL MEDICINE
A. ANCIENT MEDICINE
In Pre-historic times
humans tried to understand the causes of disease and tried to find cures for
them. Often magic and superstitions were mixed with medical care and were
closely related to the prevailing belief systems.
Much is known about
Mesopotamian medicine from cuneiform texts. It was magico-religious with
priests serving also as physicians. Divination was used. The materia medica
contained vegetables, animals, and minerals. However no texts were found on
surgical procedures. Sumerians practiced magical and priestly medicine. Babylonians
inherited Sumerian customs and knowledge. Babylonian medicine was in the hands
of priests. Their surgeons were slaves of physicians. Babylonian astrology had
an impact on the practice of medicine. They believed that the destiny of man
was determined by the movement of stars. They believed that blood carried all
vital functions. The liver was considered an essential organ. In their writings
they mentioned apoplexy, fevers, phthisis, plague, ENT diseases, eye diseases,
rheumatism, tumors, abscesses, diseases of the heart, venereal diseases. They
thought that toothache was due to gnawing of a worm. Hammurabi defined
professional responsibilities of physicians and severe penalties were set for
morbidity and mortality following surgical operations. Hammurabi’s codes
contain the earliest mention of medical ethics.
Early Egyptian medicine
was mystical and priestly. Imotep was a grand vizier and priest but at the same
time a magician-physician. He instituted a medical cult as early as 2750 BC. By
525 BC he was worshipped as a deity. A papyrus discovered at Luxor in 1862 CE
and written in 1700 BC summarized Imotep’s writings about paralysis of the
bladder and intestines due to spinal lesions. Imotep's medical teachings were
recorded in another papyrus written in 1553-1550 BC. Egyptians knew about the
human body from their practice of embalming the dead into mummies but they did
not develop a systematic knowledge of anatomy. Papyri contain mention of drugs
in the form of pills, potions, suppositories, purgatives, enemas, emetics,
inhalants, and ointments. In the field of surgery Egyptians knew circumcision,
plaster for closing wounds, cautery to achieve hemostasis, and incision &
drainage for abscesses. They however did not prescribe diet as a treatment.
Chinese medicine can be
traced back to Fu Hse in about 3322BC.
Traditional Indian Medicine and surgery was developed. Vedic practice written from the 2nd
millennium BC used charms to control demons. In the period 800BC – 1000 AD
Brahmanian medicine predominated and the following diseases were described:
tuberculosis, cancer, diabetes mellitus, leprosy, and smallpox. Diagnoses were
made by listening to the breath sounds, observing the color of eyes, the
tongue, and the skin; feeling the pulse; tasting the sweetness of urine. Stress
was put on diet, hygiene, and mental preparation. Herbs were used. Rauwolfia
serpentina and opium were used as drugs. The following surgical operations were
known: excision, suturing, drainage, cauterization, laparatomy, removal of
bladder stones, repair of fistulae, cesarean section, and cataract removal. The
ancient Indian medicine is what has grown into Ayurdevic medicine of India
today.
B. GREEK and ROMAN MEDICINE
The Greeks learned from Asia
Minor, Mesopotamia, and Egypt. Greeks made contributions to anatomy,
physiology, and pathology. A lot of modern medical nomenclature is from the
Greeks. Many medical traditions were inherited from the Greeks. Greek medicine
was closely related to religions and the temples. Asklepos a physician became a
cult and was worshipped. The major figures of Greco-Roman medicine were
Hippocrates, Galen, and Aristotle.
The Hippocratic corpus, a
collection of textbooks, lectures, and works by various authors, contains the
earliest Greek writings on medicine and includes elements even before
Hippocrates. After 300 BC the Hippocratic collection consisted of Hippocratic
medicine, and teachings of the Sicilian, Athenian, Alexandrian, Persian, and
Indian schools of medicine. Hippocratic medicine had Minoan, Mesopotamian,
Egyptian, and Ionian sources. Its main contribution to medicine was that it was
experiential. After years of medical decline, the renaissance of medicine
started with the rediscovery of Hippocratic traditions of careful observation,
recording, and inference. Actual clinical cases were described. Hippocratic
physicians placed a lot of emphasis on the 4 humors. Rest was the most applied
method of treatment. Great emphasis was also put on diet.
Aristotle (384-322 BC), a
student of Plato and a teacher of Alexander the Great, wrote many biological
works. He is credited with founding the discipline of comparative anatomy but
he did not dissect humans. His philosophy had an impact on medicine for 2000
years. He taught the 4 qualities of hot vs. cold and wet vs. dry. He taught the
4 element of earth, air, fire, and water. To these were added the Hippocratic
humors of blood, phlegm, yellow bile, and black bile.
Galen (129-199 CE) wrote on
anatomy, physiology, and compiled earlier writings. Later authors copied or
abstracted his writings. Galen’s writings can be considered as the synthesis of
all ancient medical knowledge. He described bones, muscles, the brain, vessels
but many of his physiological ideas were wrong. With his death in 199 BC
Greco-Roman medicine entered its dark ages.
De Medica was written in about 30 CE by Aulius
Cornelius Celsius as a compilation of previous writings. It formulated the 4
cardinal signs of inflammation: pain, redness, heat, and swelling and described
various surgical operations.
By the 6th century BC
Greek medical schools were operating in Cos (where Hippocrates was born) and
Cnidos. The Alexandrian school was established in about 300 BC and became
famous in anatomy and physiology. Human dissection was undertaken. With the
absorption of Alexandria into the Roman Empire, the medical school continued
for centuries but with restricted activity and lack of originality.
Romans made practical but no
theoretical contributions to the development of medicine. The Roman Empire did
not produce great physicians. Rome became a center of medical teaching after
the reign of Emperor Vespassan (70-79 CE). Medical schools in Rome and other
parts of the empire were mainly for training army surgeons. Romans organized
medical services, sanitation, aqueducts, public latrines, and food supplies.
Public physicians were appointed to various towns. They organized general and
military hospitals. The Church preserved medical knowledge during the Byzantine
Empire.
C. MUSLIM MEDICINE
Nestorians had translated Greek
medical works into the Syriac language. Muslims translated these Greek works
into the Arabic language. They in addition made their own observations and
discoveries. Abubakar al Razi described measles and wrote al Hawi. Ibn Sina
wrote al Qanun fi al Tibb. Zahrawi wrote on surgery.
D. EUROPEAN MEDICINE
THE MIDDLE AGES
The middle ages were a period of
general decay with the Christian Church being a major contributor to lack of
scientific growth. The negative role of the Church became more intense ever
since Christianity became the state religion of the Roman Empire. During the
Middle Ages superstition became wide spread. Muslim medicine was transferred to
Europe through Andalusia (modern Spain) and Sicily in Italy creating the
medieval medical reawakening (800-1500 CE). As a result of contacts with Muslims,
the Salermo medical school emerged in Southern Italy in the 9th
century CE. Muslim medical writings were translated into Latin by Constantine
Africanus (1010-1087 CE) at Salermo. Muslim works were expanded and annotated
by Europeans and were taught at Universities in Bologne and elsewhere.
DEVELOPMENT OF BASIC MEDICAL
SCIENCES
Anatomy: The Renaissance
(1500-1700 CE) was a period of the rise of anatomical knowledge. Besides
translations of Muslim writings, Europeans undertook human dissections and
disproved many of Galen’s teachings. Leonardo Da Vinci (1452 – 1519 CE)
dissected human bodies and produced anatomical drawings. Andreas Vesalius
(1514-1564 CE) made contributions to anatomy through his dissections and
published De Humanis Corporis Fabrica
in 1543 CE rejecting many of Galen’s ideas. Renaissance anatomists extended
anatomical knowledge of the brain and the nervous system: Leonardo da Vinci
(1452 – 1519 CE), Jacopo Beranganio de Capi (d. 1550 CE), Johannes Dryander
(1500-1560 CE), Charles Etienne (1503-1564 CE), Andreas Vesalius (1514-1564
CE), Bartolommeo Eustachi (1520-1574 CE), Constanzio Verolio (1543-1578 CE).
Further work on the nervous system and neurology was done in the 17th
century CE by Thomas Willis (1621-1675 CE) and Raymond Vieussans (1641-1715
CE). Contributions to anatomical knowledge of the nervous system were made in
the 18th century CE by Jakob Benignus Winslow (1669-1760 CE), Samuel
Thomas Von Soemmering (1755-1830 CE), Munro (
), and Antonio Scarpa (1747-1832 CE),
Johannes Evangelista Purkinje
(1787-1869) who described nerve cells, Heinrich Wilhem Gottfried Waldayer-Hertz
(1836-1921 CE) proposed the neuron theory, Wilhem His (1831-1904 CE) described
the axon, Camelio Golgi (1843-1826 CE) described the Golgi apparatus. Gaspare
Melli (1581-1626 CE) discovered lacteals that carry lymph. Jean Pecquet
(1622-1674 CE) discovered the thoracic duct. Marcello Malphighi (1628-1694 CE)
described capillaries. Better knowledge of anatomy led to better surgery and
surgery rose from a despised profession of barbers to a position of respect. In
1665 CE Robert Hooke (1635-1707 CE) published Micrographia in which he described cells. John Hunter collected
many anatomical specimens.
Physiology: Santorio
Santorio (1561-1636 CE) measured the pulse rate, discovered the thermometer,
and carried out experiments on metabolism. William Harvey (1578-1652 CE)
described blood circulation in 1628 CE but Ibn Nafis (1210-1288 CE) had
discovered blood circulation much earlier but his views were not known in Europe.
The 17th -18th centuries CE witnessed the rise of
physiology. Robert Boyle (1627-1691 CE), the father of chemistry, published The
Skeptical Chymist in 1661 and by then alchemy had become chemistry. Jean
Baptiste Von Helmont (1577-1644 CE) was the father of chemical physiology.
Albrecht Von Haller (1708-1777 CE) published books on physiology covering
various issues. Sir Charles Bell (1774-1842 CE) studied the nervous system.
Rene Antoine Ferchault Reamur (1683-1757 CE) studied gastric juices. These studies
were extended by Abbate Lazaro Spallanzani (1729-1799 CE). William Prout
(1785-1850 CE) demonstrated hydrochloric acid in the stomach. William Beaumont
(1785-1853) studied gastric digestion in a wounded man with an open wound. Emil
de Bois Reymond showed that a nervous impulse was accompanied by change of
electrical potential. In 1771 CE Joseph Priestly (1733-1804 CE) discovered
oxygen. Antoine Laurent Lavoisier (1743-1794 CE) discovered combustion and
explained respiration. Edward Frederick Wilhelm Pflinger (1829-1910 CE) showed
that chemical reactions of respiration took place in the lungs. Tustus Von
Liebig (1803 – 1873 CE) elucidated many chemical processes of life and first
described the concepts that underlie the nitrogen and carbon cycles. Sir John Floyer
(1649-1734 CE) invented the pulse watch. In 1761 CE, Leopold Auenbrugger
(1722-1809 CE) introduced percussion. Rene Theophile Hyacinthe Laennec
(1781-1826 CE) invented the stethoscope. Johannes Muller (1841-1858 CE), was a
great physiologist who studied the electrical phenomena of nerves and was the
teacher of Humann Ludwig Ferdinand Von Helmholtz (1821-1894 CE). Claude Bernard
(1813-1878 CE) founded experimental medicine, studied liver glycogen and
pancreatic juices, and introduced the concept of milieu interieur in 1857 CE. Karl Friedrich Wilhem Ludwig
(1816-1895 CE) invented the kymograph and studied salivary glands and their
innervations. Later physiologists were William Beaumont (1785-1853 CE), Ivan
Pavlov (1849-1936 CE), Sir William Maddock Bayliss (1860-1924 CE), Ernest Henry
Sterling (1866-1927 CE), and Walter Bradford Canon (1871-1945 CE).
Microbiology: However
many erroneous Greek concepts of disease persisted. Fracastoros (1478-1553 CE)
developed ideas on infectious disease. Antoni Leeuwenhoek (1635-1723 CE) saw
micro organisms under the microscope.
Pathology: The 19th
century witnessed the rise of pathology. Percival Potts (1714-1788) described
Pott’s fracture, Pott’s disease, congenital hernia, and occupational cancer in
chimney sweeps.
Pharmacology: In the era
of reformation, herbal remedies became popular as botanical knowledge expanded.
Mercury was used to treat syphilis.
DEVELOPMENT OF CLINICAL SCIENCES
Internal medicine:
Internal medicine lagged behind surgery for a long time. De Bailbou (1538-1616
CE) described whooping cough. Thomas Syndenham (1624-1689), considered the
father of modern medicine, published Methodus
Curandi Febres (The Method of Treating Fevers) in 1666 CE. Bleeding using
leeches was a common treatment in the 18th century CE.
Obstetrics and Gynecology:
Peter Chamberlain (d. 1631 CE) discovered the obstetric forceps.
DEVELOPMENT OF MEDICAL EDUCATION
In 1636 CE clinical teaching of
medicine started at Leyden. Schools of medicine developed in the 18th
century in Vienna, Paris, Edinburgh, and Dublin. In London clinical teaching
was at Guy’s Hospital and St Thomas Hospital. Famous clinical teachers at Guy’s
Hospital were Sir Aitley Pastor Cooper (1768-1841 CE), Richard Bright
(1789-1858 CE), Thomas Addison (1798-1866 CE), and Thomas Hodgkins (1798-1866
CE).
HOSPITALS
The industrial revolution
witnessed building of new hospitals.
E. MODERN MEDICINE (20th century onwards)
HUMAN EXPERIMENTATION
Ibn Sina suggested clinical
trials in his Qanun fi al Tibb including comparisons of 2 patients. Ambrose
Pare (1510-1590) experimented with a new treatment for bullet wounds instead of
the traditional method of using burning oil. In 1721 smallpox inoculation was
tried in 21 convicts. In 1747 a comparative trial of lemon for cure of scurvy
was carried out by James Lind (1716-1794). He selected 12 patients with scurvy
who lay together and had the same diet. Two were given lemons and oranges
daily. Two were given a quart of cider. Two were given vinegar and an elixir of
vitriol. The rest were given nothing. After 6 days those who were given oranges
were well enough to look after the other sick. The cider seemed to have some
benefit. The other remedies were not beneficial. William Wuthering carried out
a large study involving 163 subjects to investigate digitalis as a treatment
for dropsy. Edward Jenner experimented with vaccination. Sir Austin Bradford
Hill in 1946 carried out a trial of streptomycin in the treatment of pulmonary
TB.