The basic needs of societies are food, shelter and health. To obtain food security, science developed the calendar to determine the right season for planting. Shelter was the domain of technology, which provided the techniques to build houses from bricks, wood, straw and mortar. But sufficient food and adequate shelter cannot be enjoyed without a healthy body, and the development of medicine and surgery occurred therefore as early as the development of astronomy and the introduction of building materials for houses.
It is generally accepted today that medicine and surgery are relatives of applied science. Chemistry schools in all universities offer courses in "designer drugs", synthetic chemical compounds for the treatment of diseases. Most modern surgery would not be possible without detailed knowledge of the human anatomy and the functions of the various parts of the human body.
Early societies saw this in a very different light. Performing detailed observations of the stars was one thing; making observations of bodily functions and trying to study the human anatomy was quite a different affair. Even the earliest attempts to cure a sick person from illness had led to the experience that the success of the attempted treatment often depends as much on the patient's cooperation and will to recover as on the actual treatment itself. This indicated that illness is not only a physico-chemical event but has a psychological dimension as well.
The fact that living beings are not machines but endowed with feelings led early societies to postulate the existence of the soul. Different societies located the centre for feelings in different parts of the body, such as the heart, the brain, the liver or the bones. Burial practices were designed to guarantee the undisturbed transition of the soul from this earth to another place of rest.
All religions had one rule in common: Dissecting a human body to study its parts was unacceptable. This placed a severe constraint on the development of medicine as a science. As a consequence, treatment of diseases was often more a religious ritual than application of scientific knowledge, and the connection between science and religion was much stronger in the area of medicine than in any other branch of science.
Before we dismiss the situation as superstition of uneducated societies it is worth reflecting on medical science today. Our definition of science in Lecture 1 was that science is systematic knowledge of nature through repeatable observation and experimentation. Medicine can only be scientific if it is based on observation and experiment, and in medicine this invariably involves experimentation with the human body (or animals as substitutes).
We no longer place restrictions on the dissection of bodies. But our ability to experiment has long advanced past the simple dissection of bodies, and we have to define acceptable limits to medical experimentation. What should these limits be? Is it acceptable to do to living animals what we would not do to ourselves? Can we alter genetic structures for experimental reasons?
These are not questions of scientific or technological possibility. They are questions of morality, in other words, questions of philosophical and religious dimension. We may have advanced in our scientific knowledge and successfully separated science from religion, but we are still confronted with the same questions that the ancient societies had to answer: Does science provide its own justification for possible experiments, or do we, the promoters and users of science, set its boundaries? In 3000 BC - 1000 BC the boundary was the dissection of the human body; today it has to be defined in the area of genetic engineering. Lecture 35, the last lecture of this course, will therefore have to come back to the ethical problems of medicine and try to find answers.
With the exception of the common cold, constipation and similar inconveniences, which were regarded as part of normal life, early societies associated illness with supernatural intervention. Some societies saw a sick person as invaded by demons, others blamed a spell cast by some enemy. Another belief was that a god had been offended by some act of the sick person and had either placed an object into the sick body or removed its soul.
Whatever the belief was, it was logical that treatment always combined the application of (mostly herbal) remedies, often in the form of potions, with incantations, dancing, songs and counterspells, and pharmacies in early civilizations stocked not only herbs, minerals and potions but also quite unpleasant products made from animal faeces and urine for use in magic. Medicine was the domain of the "medicine man" and the "witch doctor." The practice is still alive where mystical belief coexists with rational thought.
Another element that survived from pre-civilization times, which has a much more rational foundation than talismans and charms, is folk medicine or domestic medicine. Knowledge about the healing properties or poisonous effects of plants and mineral salts had accumulated from earliest times, and the use of herbs to provide health predates all other medical treatment.
The taboo on anatomical studies of dead bodies meant that early medicine was restricted to descriptive science until the link between science and religion was broken. As discussed in the previous lecture, this break occurred in Greece around 600 BC. The 6th century BC is thus a decisive moment in the development of medicine.
The development of cities in the early civilizations created the possibility to compare symptoms among a large population. This increased the statistical data base for medical observations and brought about a significant improvement in diagnosis, at least in the sense that identical illnesses were associated with identical causes. The degree to which this led to the discovery of the correct causes (for example bad hygiene) and eliminated irrational beliefs is one of the differences between the early civilizations.
A discussion of medicine and surgery before 600 BC begins with a return to the timeline of civilizations, which shows that there were four major independent developments. What follows is a very brief discussion of medicine and surgery in these early civilizations.
Very little is known about medical practices in the Sumerian civilization. The earliest relevant document is the Code of Hammurabi, one of the first kings of Babylon, who reigned 1792 - 1750 BC. It contains laws to regulate the medical profession, including admissible fees and penalties for incorrect treatment, such as: "If the doctor, in opening an abscess, kills the patient, his hands shall be cut off." If the patient was a slave, the doctor had to provide a slave of equal value.
Such measures appear severe by today's standards; but by Babylonian standards they were actually rather lenient. The Code of Hammurabi was based on the principle "an eye for an eye, a tooth for a tooth," and death was generally punished by death. To give an example, a builder who caused the death of a person through the collapse of a house incurred the death penalty.
The doctor's less severe penalty for the death of a patient has to be seen as an acknowledgment that it is more difficult to heal a person than to build a house. The principle "an eye for an eye" still applied for lesser maltreatment; loss of a patient's eye meant the loss of an eye for the doctor.
As discussed above, the treatment of the sick was based on medication as well as incantation. It is remarkable in this context that the two activities were separate professions very early in Mesopotamian history. The âshipûtu was responsible for the magic, the âsûtu for the science. By about 1400 BC Babylonian âsûtu (physicians) were held in highest regard throughout the eastern Mediterranean and all of Mesopotamia. Rulers in every kingdom competed for their services and paid substantial retainers to keep them at their courts.
The physicians wrote detailed reports on their patients twice daily. But they were not much inclined to systematic scientific writing, and most of the information we have today comes from medical handbooks compiled by medically untrained scribes. An exception was a list of over 150 medical essences prepared by the physician Nabu-le'u. In three columns it described the names and parts of the plants to be used, the diseases against which they are prescribed and at what temperature, time of day and at which frequency they are to be administered.
A substantial number of compendia survived on clay tablets from the Akkadian civilization. They give a description of symptoms, sometimes followed by a diagnosis and a prognosis. Diagnosis was complicated by the fact that symptoms were not ordered according to illness but according to parts of the body. Diagnosing a patient thus involved going through different parts of the compendium and piecing together the various symptoms. Where a diagnosis is given it is accompanied by recommended treatment.
Surgery was severely handicapped by the lack of knowledge of the human anatomy. The only observational information obtainable came from haruspicy (the practice of divination by inspection of the entrails of sacrificial animals). Despite of this, Mesopotamian surgeons were successful in setting broken bones. There is also evidence that cataracts were treated by eye surgeons.
As in other early civilizations medical treatment was only accessible to members of the wealthy ruling class and - if the owner considered the expense justified - its slaves. This may explain the observation of the Greek travel writer and historian Herodotus that in Babylon the sick were usually laid in the street in the hope that passers-by would offer advice. According to Herodotus all Babylonians were amateur physicians.
As in Mesopotamia, treatment of illnesses in Egypt involved medical procedures and magic. Administratively both activities were often combined; the official in charge of the Hatnub quarries had the title "Chief Priest of Sekhmet, Chief of Magicians, Physician-in-Chief of the King."
Egyptian medical knowledge was, however, much more advanced than Babylonian medicine, and most Egyptian doctors were specialists. According to Herodotus "the practice of medicine is so divided among the Egyptians that each physician is a healer of one disease and no more. All the country is full of physicians, some of the eye, some of the teeth, some of what pertains to the belly, and some of the hidden diseases."
The reputation of Egyptian medicine can be understood when we realize that during the high period of the Greek civilization Greek physicians came to Egypt to consult the library of the temple of Imhotep in Egypt's ancient capital Memphis. Imhotep had practiced medicine around 2630 BC, some 2200 years earlier. He had been such an outstanding physician for his time that he was later elevated to the Egyptian god of medicine.
Papyrus manuscripts dedicated to the treatment of diseases contain a combination of prescriptions, treatments and incantations. The lack of knowledge of the organs and their function and the use of magic potion ingredients such as pelican dung or crocodile excrement did not produce many effective treatments. Nevertheless, some prescriptions were based on pure experience of their effectiveness.
Thus, it is known today that night blindness is caused by a deficiency in vitamin A. The recommended treatment was "ox liver placed over a fire of grain or barley stems and suffused with the vapours they emit, the resulting liquid to be pressed on the eyes." (Lefebre, 1957) Liver of any animal is rich in vitamin A, so the Egyptian treatment must have been effective.
The Egyptian climate with its heat, desert dust and flies meant that eye diseases were widespread. Medicines for their treatment often involved the blood of bats. The magical connotations may have helped the healing process, but we now know that bat excrement and probably blood as well contains very high levels of vitamin A (in higher concentrations than cod liver, which is often used today). Other ingredients of prescription medicine were the bile of birds, pigs and tortoises, which have been shown to be a natural source of cholic acid, the basis of cortisone.
Egyptian surgery was based on case histories documented in papyri. The embalming of important people, practiced since early times, was a religious act, and although it involved the removal of the inner organs from the body, nothing was learnt from the procedure. The success of some of the surgical practices described in the papyri is all the more impressive. Surgeons used lint and bindings comparable to our plaster, wooden splints for the support of fractures, and sutures to tie the lips of wounds.
Indian physicians had found a way to partially circumvent the taboo imposed on dissecting the human body. Indian religion allowed the placing of the dead in rivers. The surgeon Susruta noted in his Susruta-samhita" ("compendium of Susruta") that if a body is placed in water for seven days its parts can be separated easily without cutting. While this did not allow detailed study of organs, ligaments and muscles, Indian knowledge of the human anatomy was excellent.
The earliest documents that refer to the treatment of diseases are found in the Vedas, poetic epics from the period 1500 - 800 BC. They consist mainly of hymns and ritual prescriptions and list symptoms of a range of diseases.
The two fundamental works in Indian medicine are the Susruta-samhita and the Atreya-samhita. Both were written around 600 BC but report knowledge that goes back considerably further. (The Atreya-samhita is known only from the Caraka-samhita, the compendium of Caraka, court physician to king Kanishka, who lived c. 100 AD.) They are based on the analogy between the inert world and the living body.
Indian science considered the inert world to be made of earth, water, fire, wind and space. Correspondingly the living body was thought to be made up of tissue, mucus, bile, breath and organic cavities. Diseases were considered disturbances of the equilibrium between the five elementary substances.
Indian medicine used many herbs and other plants, both as medicine for internal use and for external use as ointments. The Susruta-samhita lists 760 medical plants, the Caraka-samhita some 500. Unlike other early civilizations it did not know the use of minerals. There are indications that smallpox inoculation was practiced at Susruta's time.
The strength of Indian medicine was in surgery. Indian surgeons performed cataract operations like their Egyptian colleagues. Assisted by their detailed knowledge of the human anatomy, they also went well beyond the surgical practices of Mesopotamia or Egypt. Their surgical manuals included instructions for the removal of bladder stones, excision of tumours, draining of abscesses, removal of foreign bodies, amputations, Caesarean sections, repair of anal fistulas and other procedures.
A unique Indian invention was applied for the treatment of intestinal wounds: Because normal sutures lead to constriction of the intestines, bull ants were set on the wounds; the ant bodies were then cut off and the mandibles left as clamps. When the Islamic empires expanded east during the Middle Ages the method was brought to Africa, where it is still successfully used along the Somali coast.
The introduction of plastic surgery was another Indian specialty, caused by the legal practice to punish adultery by amputation of the nose. Nose replacement involved the cutting of a suitable piece of tissue from the cheek and its application to the stump of the nose.
Indian surgery remained at the leading edge of world-wide medical practice well into the Middle Ages. Veterinary medicine and surgery flourished as well, particularly for the treatment of horses and elephants.
Although Chinese legend associates the oldest medical compendium, the Nei ching, with the legendary emperor Huang Ti, who is said to have lived around 2700 BC, more reliable documents indicate that at least in its known form the Nei ching was written around 300 BC. Nothing reliable can thus be said about Chinese medicine before 600 BC, and further discussion of medical achievements in China is postponed to Lecture 15.
Our knowledge of ancient American medical practice is severely limited by the nearly complete destruction of all documents during the European invasion; Christian priests burnt all but a few of the Indigenous Indian documents as "pagan superstition". Our main sources of information are writings produced shortly after the arrival of the conquistadors, which report on the medical knowledge of the indigenous population of the time. Because American civilizations developed in isolation from all other civilizations it is appropriate to include here a brief discussion of American medical knowledge.
The fall of Tlatelolco to the Spanish under Cortés in 1521 marked the end of the Aztec empire and civilization in Mexico. 31 years later, in 1552, two Aztec students at the College of Santa Cruz in Tlatelolco, who had been given the names Martinus de la Cruz and Juannes Badianus, compiled a list of herbs used in Aztec medicine. Martinus wrote and probably illustrated the original Aztec text, and Badianus translated the work into Latin.
The Badianus manuscript documents the extensive use of herbal medicines, intoxicating drugs and poisons. (Much of it is taken up by modern "shamans" who advertise their services on the internet; one such site lists over 120 Aztec herbs.) One source of energy and general health was the chocolatl drink, produced from the fruit of the cocoa tree.
A practice widely documented for ancient South America is trepanning or trephining. It involves the drilling of a hole, between 2.5 and 5 cm in diameter, into the patient's skull. Archaeological finds indicate that trepanning was practiced as early as 4000 years ago with stone age tools such as obsidian and quartz flakes.
There has been much guessing about the purpose of the practice, and it is likely that it was often not practiced for good medical reasons (to remove a tumour or relieve pressure on the brain caused by a blood clot) but to let a foreign object or evil spirit escape. It can also be assumed that trepanning was often used only as a last resort, ie in cases that defied other known treatment methods. What is clear from the archaeological evidence is that the survival rate for patients was quite high in South America. Estimates from thousands of skulls excavated in the Peruvian highlands indicate that 2 out of 3 patients survived.
The success of South and Central American trepanning contrasts strongly with the success rate of European "surgeons" during medieval times, who claimed that trepanning could be used to treat mental illnesses. Most medieval trepanning ended with the loss of the patient due to infection.
We saw in our last lecture that the social revolution of the 7th century BC in the Greek merchant city states created the conditions for a revolution in the general approach to science. Nowhere were science and religion more closely linked than in the medical profession. It is thus obvious that the separation of science and religion during the years 600 - 400 BC had profound consequences for medicine as well.
The new approach to science led to the establishment of medical schools on the three islands Cnidus, Cos and Sicily. During a brief initial period the schools provided training in public speaking for physicians, and travelling orators practiced "show treatments" and medical stunts. This soon gave way to serious scientific investigation in the medical field.
The personification of the new medicine was Hippocrates, who rose beyond a historical personality to a mythical figure. There is no doubt about Hippocrates' existence as a physician; but his ability and fame had the result that much of the written material on the new medicine was later attributed to him as well. This Corpus Hippocraticum or Hippocratic Collection is the best evidence that the change that occurred in medicine is equally revolutionary as the changes that occurred in mathematics and cosmology.
Probably the most lucid declaration of the departure of scientific medicine from religion is found in On the Sacred Disease (epilepsy), one of the works of the Hippocratic Collection believed to have been written by Hippocrates himself:
This is not only the separation of medical science from religion but the declaration of the superiority of scientific methods over incantations and magic. Before Hippocrates magicians were seen as members of an honoured profession; now they are on the same level with charlatans and quacks.
This does of course not mean that Hippocrates regarded all medical treatises of the past as outdated and useless. On the contrary, he studied them all carefully and tried to extract from them as much practical information as possible. He was one of the Greek physicians who visited the library of Imhotep's temple in Egypt and incorporated much Egyptian and Mesopotamian knowledge into his writings. But he did it with a scientific attitude and tried to come to explanations for observed effects.
The logical consequence of the scientific approach to medicine was dissection. Just as scientific astronomy required the study of the stars and planets, scientific medicine required the study of the human body. This was a dangerous subject even in Greece with its humanised gods and goddesses. Diocles, a successor of Hippocrates at the medical school of Cos, dissected animal corpses (he is reported to have studied the womb of a mule) and wrote a textbook on anatomy; but that was about as far as a scientist could go in Greece.
But surgery required textbooks on the human anatomy. There was always a need for surgery; as Hippocrates said: "To become a surgeon, follow the army", and "manual work" was not frowned upon in the medical profession.
In the next lecture we shall see how the Greek civilization was transplanted to Alexandria, Egypt's new capital from 334 BC onward. During the 3rd century BC Greek scientists, among them many physicians and surgeons, went to Alexandria for studies. The medical profession found the conditions particularly attractive because Egypt had no objection against the dissection of human corpses - Egyptians had practiced it for millennia when they embalmed their kings. Alexandria and Cyrene developed into new centres of medicine with famous medical schools.
The first Greek to take advantage of the situation in Egypt was Herophilus. By dissecting human corpses he was able to describe the human anatomy and many organs, including the brain, the eye and the genital organs of both sexes in great detail. His works were lost, but several of the terms he introduced for parts of the human anatomy are still used today.
Science had overcome the ban on dissection of the human body at last. Should a new limit be imposed? Erasistratos, the successor of Herophilus as director of the school, is sometimes called the "father of comparative anatomy and of pathological anatomy" (the study of changes under morbid conditions). The Roman medical author Celsus, who lived in the 1st century AD, accused him of practicing vivisection (dissection of live bodies) on prisoners on death row. Would Erasistratos try to do the same today, he would end up in prison himself.
A fair judgement of Erasistratos has to take into account the practices and norms of his time. The civilizations of antiquity did not only tolerate cruelty, their justice system often applied much needless cruelty in legal judgement. Crucifixion, a common method of imposing the death penalty, was immensely cruel: The crucified could live on the cross for days, while the weight of the body would slowly rip the wounds apart. Suffering on the cross or under vivisection would probably not have made much difference.
This does of course not mean that vivisection is ethically acceptable. Celus's commentary is proof that 300 years after Erasistratos physicians agreed that he had passed the boundaries of professional ethics. The medical profession had a defined ethical code, known today as the Hippocratic Oath, well before Erasistratos practiced in Alexandria. It is unlikely that Hippocrates formulated it himself, but it applied to the Greek medical schools and therefore also to Erasistratos.
It is often said that medical practitioners adhere to the principles of the Hippocratic oath. This is only true in the sense that modern medicine shares several of the ethical principles on which the oath is based. Not all detail of the Hippocratic oath is accepted today, as becomes evident through a closer inspection of its clauses.
This leaves clause three, which prohibits abortion and the administration of deadly drugs on a patient's request. The application of this clause to modern society is highly contentious and requires some discussion. The key question is: What has changed since 300 BC, and does that change require a change of attitude to abortion and assisted death? This lecture does not intend to provide all the answers, but we will end it with some relevant observations.
One of the most important consequences of the advances in medical science is the rapid increase of the world population. This increase is of course the result of a combination of factors, such as improved agriculture through advances in science and technology in general. But the rate of the population increase has been supported by medicine through a large reduction of infant mortality and improvements in general health and sanitation.
Abortion is often practiced as a means of birth control. It is obvious that we have to constrain the growth of the human population as much as we can. An abortion is always a traumatic experience for the woman involved. The loss of an infant, or of several children over a few years as it was standard everywhere before the 20th century and still is not unusual in poor countries today, is certainly just as traumatic for the parents.
In an ideal world infant mortality and the abortion rate should both be zero and birth control should secure a stabilization of the total population. The state of medical science allows us to come very close to that aim. The continued population growth must therefore have other reasons than medical ones.
As discussed in the first lecture, the pre-industrial society (which is still the society in which the majority of people live in the rural areas of Asia, Africa and South America) is based on the extended family. Security of support during one's old age comes from having children, who are socially obliged to care for their parents. In a society with high infant mortality the only way to have security of support during one's old age is to have several children.
Governments and humanitarian agencies promote birth control to stem the population increase in the pre-industrial societies. It is, however, debatable whether such initiatives are based on an accurate understanding of the situation. Europe went through a period of rapid population growth during the 19th century, a period that was characterized by extreme poverty and suffering of the working and peasant classes. The European population stabilized eventually as a result of the transition from a pre-industrial to a capitalist society.
The basic structure of the early capitalist society was the two parent family. How did it provide security for those who could no longer work? The answer was the introduction of the old age pension. Once everyone can rest assured that provision is made for his or her old age there is no more need to produce many children, and birth control becomes a part of one's life.
Stabilization of population growth in the developing world will be achieved eventually not through the promotion of birth control but primarily through the introduction of pensions and a system of social security. The individual man and woman may agree that controlling the population growth is a laudable idea, but as long as their children have to provide for their old age they will not volunteer to run the risk of having only one or two children and see them die in their early years.
Once the world has reached the stage of universal social security and old age pensions and practices universal birth control, abortion will have become unnecessary. Until that day it is a necessary evil of our society.
The question of assisted death has a different dimension. Death is part of nature, and the question how a life comes to an end has to be addressed again and again. Medical science created the conditions in which everyone can expect to live to old age. It allows people in a coma to be kept on live-support for years. It has in fact created a situation where the action of the doctor who prolongs a life through life-support technology can come into conflict with the commitment to act only in the interest of the patient.
History knows of more than one case where prominent people found their condition during old age so hard to bear that they died by voluntary starvation. It might well be argued that assistance from a doctor could have shortened their suffering. With the advances of modern medical science the number of people who will find themselves growing old under much suffering is likely to rise, and society will have to deal with the question of assisted death.
The final judgement on clause three of the Hippocratic Oath has to be made by every individual according to his or her conscience. One final observation has to be made, though: Whatever the answer, it has to be based on consistent ethics. The same anti-abortionists who use the "sanctity of human life" to support their position have no problem with the death penalty and do not show much concern about the abject poverty in the less developed countries to which they export their anti-abortion message. It is simple hypocrisy to show concern for the unborn life and indifference towards the fate of the living.
Lefebre, G. (1957) Egyptian medicine. In Taton, R. (ed.) La Science Antique et Médiévale, Presses Universitaires de France; English translation by A. J. Pomerans (1967) "Ancient and Medieval Science", Thames and Hudson, London.551 pp., p. 55. (Volume 1 of "A General History of the Sciences")
Sarton, G. (1959) A History of Science. Harvard University Press, Cambridge Mass. 646 pp., p. 355-356.
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