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The development of medicine from ancient times until the 15th c.

The philosophical dispute in the 19th c. about the extent to which medicine was a mere practical skill, the artistry of skilful hands and a cool eye, or in contrast to what degree it was a science where the decisive factors were hard knowledge and the ability to reason logically, is still unresolved. And it cannot in fact be resolved because medicine relies equally upon both art and science; they coexist and influence one another. One is tempted to agree with Władysław Szumowski who said that across different epochs what varied was only the degree to which one or the other contributed to the continuous search for remedies to the illnesses that afflict humankind.

When contemplating the beginnings of medicine, we enter a twilight zone of conjecture and speculation and, relying only on rudimentary knowledge, we are forced to look for support in hypothetical reconstructions rather than in hard facts. A few remaining fragments of human bones with visible signs of healed fractures, skulls with marks of trepanation, rock engravings and paintings, and microscopic traces of healing herbs found on archaeological sites might roughly be the only links we have to the healing practices of our Palaeolithic and Neolithic ancestors. There is not really very much to hold on to. Therefore, we go to traditional Siberian and African cultures to look for clues from anthropological studies in order, however sketchily, to reconstruct our past.

If we have not made any dreadful mistakes and our conclusions are by analogy correct, the prehistoric beginnings of medicine would have been closely connected with human belief in supernatural forces. Supernaturalism and the accompanying conviction that deities are the real givers of life and death, good health and sickness, this theurgy might have constituted the most characteristic features of the manner in which the world was then perceived. Most probably instinct and direct sensory experience (empiricism) played the predominant role in the human perception and apprehension of reality. In those times wounds could be dressed and fractures set with some degree of skill, whereas herbal medicine was only at an initial stage of development.

Owing to the discovery of writing, we are able to catch a first glimpse of the lives of the people who inhabited Mesopotamia and the Nile Valley, their health problems included. Egyptian papyri record achievements of advanced surgery, gynaecology, obstetrics and, above all, ophthalmology. The Egyptians could remove cataracts and, as we learn from later Greek and Roman written accounts, they displayed expertise in this field. They already knew several plant- and animal-derived medications and would also stock their medicine boxes with powdered minerals. Although they followed quite sophisticated formulae, we have grounds to doubt miraculous effects on the health of the patients. By contrast, human anatomy was practically unknown on the Nile. Despite the fact that all intestines and inner organs were removed prior to mummification, there is no evidence of interest in their functions in the living organism. It seems that their symbolic or even magical dimension was much more important than human physical nature. Besides, there was no real need to take such interest because of the strong belief that all available knowledge had been written down many centuries before by Thot, the god of wisdom. Forty books were believed sufficient to give an entire factual representation of the world, including knowledge of health and illness. The Greeks called Thots writings hermetic.

The ancient people of Mesopotamia also entrusted their fate to the gods searching the night sky for answers to puzzling questions. Astronomy, and its less developed sister astrology, were the foundation for all kinds of science including medicine. Diagnosis which should always be seen as a prerequisite for any treatment, was entrusted to the stars, signs seen in the sky, and the shape and colour of the liver of sacrificed animals from which the prognosis of the patient was determined; as on the Nile, patients delirious dreams were interpreted. From messages written on cuneiform tablets emerges a hazy picture of recognizable disorders and doctors prescriptions. The famous Code of Hammurabi (18th c. BC) includes several pieces of information of the utmost importance, with some that would interest any historian of medicine. We might learn and visualise what the Babylonian medical profession involved, what risks it entailed and, last but not least, what status physicians enjoyed in that society. It is very difficult, however, to learn anything from the code about medicine itself and what techniques of medical treatment were used. We owe our knowledge of the medicine practised in ancient Mesopotamia and Egypt mainly to Herodotus of Halicarnassus (5th c. BC), the Greek traveller and historian who wrote detailed accounts of customs observed in the countries he had visited.

With the dawn of Greek civilization, the lands on the Nile and those between the Euphrates and the Tigris became models to be followed by all those engaging in their own search and adventures. This trend is clearly visible in ancient Greek architecture, sculpture, the motifs decorating earthenware where imitation of Near-Eastern form and content was not only deemed appropriate but an obligation of the higher classes and the intellectual elite. The medical profession naturally joined in, blindly adopting and advocating all that came from there, mixing the new with the domestic folk tradition. Oneiroscopy (dream analysis) practised in the temples of Apollo and his son Asclepius, medical prognoses based on astronomy, number symbolism, complex medical formulations with a magical element added - such is the image of the Greek medicine of that era.

All that changed, however, with Hippocrates of Cos (ca 460-370), traditionally referred to as the father of medicine, whose famous oath has remained the basis for medical deontology. Neither renouncing the faith of his ancestors nor challenging divine authority, Hippocrates demonstrated a new source of human disease by allying philosophy to medicine and creating the first rational model of the functioning of the human body. Following the lead of Greek natural philosophers in search of the principle of all things (apeiron), Hippocrates held that four fluids were responsible for the health of the human body. Maintaining their mutual balance was a prerequisite of good health while an overabundance of any led to disease. The term used in referring to these four fluids (humours) was soon applied to the new branch of medicine created by Hippocrates: humoral pathology. This was when we might with increasing certainty speak of the birth of medicine as a branch of science. Those who followed in Hippocrates footsteps were adherents of empirical medicine, and physicians from the Alexandrian school of medicine were the first to conduct anatomical observations on a human corpse. By compiling Hippocrates writings into one code, referred to as the Hippocratic Corpusippocratic , Alexandrian scholars established and preserved his status as the father of medicine and laid the foundation of present-day European practice.

While Hippocrates is perceived as the founder of medical science, Claudius Galen (130-200 AD) might be seen as the first medical researcher to fully confirm its scientific nature. Galen, a physician attending gladiators and Roman emperors, became a legend while still alive and, after his death, a true icon for many generations of physicians to come. His account of the medical anatomy of the human body held good for the following thirteen centuries, until Andreas Vesalius proved that it was created solely on the basis of the dissections of a variety of animal cadavers and is therefore the anatomy of a nonexistent hybrid. However false, it still constituted the first attempt at a comprehensive description of the human body. Similarly, Galens account of the origins and the circulation of blood in the human body was finally proved untrue, and his claim that blood originates from food consumed and, in its upward movement is enriched with a nutritional element or pneuma, from the point of view of present-day medicine, seems nothing but naïve. It took as long as fourteen centuries to discredit the only fairly consistent existing physiological theory when in 1628 William Harvey produced tangible proof of the circulation of the blood in the human body. However, Galens description of inflammatory diseases, as well as his description of how a medication might affect a patient depending on the manner and time it is administered (in addition to the size of the dose) have stood the test of time. Galens fundamental principles on dressing open and closed fractures were not questioned until the late 19th c.

The Middle Ages, though generally characterized by a critical stance towards the pagan legacy of ancient times, nevertheless fully accepted the teachings of Hippocrates and Galen not only as binding but beyond question as well. Both the medicine practised in the seclusion of monasteries and cloisters, and that taught in university lecture halls, shied away from doubting their theories. Even in such a unique and advanced institution as the Salerno School of Medicine where, apart from Greek and Roman writings, scholars studied Arabic and Jewish texts and, what is more, women were allowed not only to enrol but lecture, and even for Trotula of Salerno (11th c.) the most famous, the principles of Hippocrates and Galen held firm. Diagnosis was limited to checking the general condition of the patient through taking the pulse and uroscopy. A horoscope reading, combined with a detailed anamnesis (or case history), was common practice, whereas surgery was treated as an outcast practice undeserving to be called true medicine. From then on surgery became reduced to the domain of artisans known as barber-surgeons. The more time that passed the more impregnable this ivory tower of knowledge would become and Europe had to wait until the 16th c. until a breakthrough came which could bring about some advancement in medical science.

Ryszard W. Gryglewski
Collegium Medicum
Jagiellonian University