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> Medicine - Past, Present & Future
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post Oct 21, 2008, 11:22 AM
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Medicine - Past, Present & Future
Pre-Classical Period
1500 BCE
Mycenaean Greece was organized around large architectural complexes
referred to as “palaces.” These structures held many rooms, often
elaborately decorated with wall paintings, and were outfitted with
baths. The society lived well, in communal comfort, health and style.
The Greeks of this time believed that there was a supernatural element
to disease. In the Iliad, the plague that sweeps the Greek encampment is
sent by the god Apollo because of his displeasure at the maltreatment of
one of his priestesses by Agamemnon. The epidemic does not pass until
Apollo is placated. This supernatural element to medicine is also seen in
the Odyssey. When the young Odysseus is wounded at a boar hunt his
cousins bandage his wound and staunch the flow of blood with holy
incantations to the Gods.
The power and prosperity of Mycenaean Greece was lost in a period of
violent conflict following a natural disaster around 1200 BCE that
encompassed not only Greece but also most of the eastern
Mediterranean region of the Near East. Only Athens seems to have
escaped wholesale destruction.
500 BCE
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Virtually nothing is known of the first physician named Hippocrates, but
there are considered to have been several, all of them teachers at the
famous medical school on the Mediterranean island of Cos. It was in the
5th century BCE, however, that Hippocrates’ name and image began to
emerge as a leader in medical research and thought.
Hippocrates is generally credited with turning away from divine notions
of medicine and using observation of the body as a basis for medical
knowledge. Prayers and sacrifices to the gods did not hold a central place
in his theories, but changes in diet, beneficial drugs, and keeping the
body "in balance" were the key.
Central to his physiology and ideas on illness was the humoral theory of
health, whereby the four bodily fluids, or humors, of blood, phlegm,
yellow bile, and black bile needed to be kept in balance. Illness was
caused when these fluids became out of balance, sometimes requiring
the reduction in the body of a humor through bloodletting or purging.
The Hippocratic Corpus, or the collected writings attributed to
Hippocrates, contains about sixty works on a variety of medical topics,
including diagnosis, epidemics, obstetrics, pediatrics, nutrition, and
surgery. There are assumed to be several authors, however, probably
scattered over several centuries, and different treatises often give
contradictory advice.
Hippocratic Oath — Classical Version
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and
all the gods and goddesses, making them my witnesses, that I will fulfill
according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to
live my life in partnership with him, and if he is in need of money to
give him a share of mine, and to regard his offspring as equal to my
brothers in male lineage and to teach them this art - if they desire to
learn it - without fee and covenant; to give a share of precepts and oral
instruction and all the other learning to my sons and to the sons of him
who has instructed me and to pupils who have signed the covenant and
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have taken an oath according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my
ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I
make a suggestion to this effect. Similarly I will not give to a woman an
abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will
withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick,
remaining free of all intentional injustice, of all mischief and in
particular of sexual relations with both female and male persons, be
they free or slaves.
What I may see or hear in the course of the treatment or even outside
of the treatment in regard to the life of men, which on no account one
must spread abroad, I will keep to myself, holding such things shameful
to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to
enjoy life and art, being honored with fame among all men for all time
to come; if I transgress it and swear falsely, may the opposite of all this
be my lot.
Born in 384 BCE, the son of a physician at Stageira in Macedonia,
Aristotle was one of the most noted philosophers and scientists of the
ancient world. Once a student of Plato at his Academy in Athens,
Aristotle adopted his own methods of inquiry different from that of his
teacher. Unlike Plato, Aristotle felt that one could, and in fact must,
trust one's senses in the investigation of knowledge and reality.
At Plato's death, Aristotle was not chosen to be his successor as head of
the Academy and he left Athens. He eventually returned to Macedonia,
where he was teacher to the young Alexander the Great. After Alexander
conquered Athens and the rest of the Middle East and Egypt, Aristotle
returned to Athens to found the Lyceum, a school similar to Plato's
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Academy. After Alexander's death, Aristotle was forced to flee Athens to
the nearby island of Euboea, where he died soon afterwards in 322 BCE.
Aristotle's writings cover a wide variety of subjects, from human and
animal anatomy, to metaphysics, statesmanship, and poetry. His
treatises on human anatomy are lost, but his many works on animals
advocate direct observation and anatomical comparisons between
species through dissection. He wrote extensively on the soul, classifying
the souls of different forms of life and inanimate objects, including the
earth and the heavens. Aristotle wrote extensively on animal life and
both sexual and asexual reproduction, making him in many ways the
founder of Western natural philosophy.
In the fourth century BCE, the locus of medical thought and practice was
not Cos, the island home of Hippocrates. Instead, it was the great center
of Greek learning at Alexandria, founded in 331 BCE by Alexander the
Great and governed by a dynasty stemming from his general Ptolemy. The
Ptolemaic rulers gave lavish financial support to the library and museum
at Alexandria, which consequently attracted researchers in all fields.
Medical research in the Alexandrian museum became world renowned.
Two of its most influential investigators were Herophilos of Chalcedon
(280 BCE) and Erasistratos of Ceos (250 BCE). They linked the function of
brain, spinal cord and nervous system, described the function of the eye
and its connection to the brain. Cause of disease due to nature not from
angry gods.
Alexandria had a large population of Hellenistic, Greek-speaking Jews.
The books of the Hebrew tribes and their best scholars were brought to
Alexandria during this period. The ancient texts were translated into
Greek over a 200 year time span. This work is known as The Bible. It
happened to survive the burning of the library because so many copies
had been produced for Jewish communities in the Mediterranean area.
Classical Period
Galen was born in Pergamos in Asia Minor in the year 131 . After receiving
medical training in Smyrna and Alexandria, he gained fame as a surgeon
to the gladiators of Pergamos. He was eventually summoned to Rome to
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be the physician of the Emperor Marcus Aurelius. Galen spent the rest of
his life at the Court writing an enormous corpus of medical works until
his death in 201.
Taking Hippocrates’ notions of the humors and pathology, Galen
incorporated the anatomical knowledge of noted Alexandrians such as
Herophilus of Chalcedon. A supporter of observation and reasoning, he
was one of the first experimental physiologists, researching the function
of the kidneys and the spinal cord in controlled experiments.
Galen’s works in many ways came to symbolize Greek medicine to the
medical scholars of Europe and the Middle East for the next fifteen
centuries. His message of observation and experimentation were largely
lost, however, while his theories became dogma throughout the West. In
the mid-16th century, however, his message that observation and
investigation were required for medical research began to emerge, and
modern methods of such research finally arose.
While Christian Church fathers and the Gnostics fought for dominance of
the new religion, the books of the New Testament were being written.
Some were destroyed or hidden. The greater Hellenistic (Pagan) Greek
culture embraced a non-secular Neo-Platonist philosophy. One part
consisted of exoteric, publicly taught ethical codes. Another part was
privately taught to only a few, the esoteric mysteries.
Starting from the Absolute, Transcendent, and Indescribable One, the
Human Soul emanates from the Universal Soul. From this universal ethical
and spiritual foundation, by learning and experiencing the expression of
timeless wisdom, the individual could experience divinity. The teaching
was eclectic, capable of embracing all religious and philosophical systems,
underpinning classical education until the 1400s. It helped spark the
humanistic movement of the Renaissance.
AD 323 - 325: Byzantium becomes the capital of the Roman empire.
Council of Nicea & Nicene Creed. Non-Christian texts by heretics are
banned. Disease is linked to evil. Much ancient material is purged and
lost.
AD 350: Oribasius, physician to the Emperor Julian the Apostate, writes
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the medical encyclopedia Corpus Medicorum, a massive compilation of
existing excerpts from other medical writers of the ancient world.
AD 450: Nestorius, Patriarch of Constantinople, preaches that there are
two natures of Christ: human and divine. He is banished to Syria, and
removes the once again banned classical texts to Baghdad. They are
translated into Arabic, then Hebrew, and finally Latin. Later these
writings form much of the basis for the Renaissance in Western Europe.
Mediaeval Period
AD 500 -1450
Byzantine physicians introduce the hospital system interpolated with
Christian teaching, used for warfare and the dying. The Plague of
Constantinople of 541-543 ushers in the first quarantine. Bubonic plague
kills a third of Europeans by 1348. Trade routes to the far East collapse.
Dissection had been forbidden until 1350. Roger Bacon studies Alchemy.
Basic sanitation develops. The Jagiellonian University is founded in 1364
in Krakow, Poland, the University of Heidelberg in 1386, and the
University of Bologna in 1407.
Renaissance Period
AD 1451- 1600
Vesuvius publishes De Humanis Corporis Fabrica and starts modern
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anatomy. Paracelcius launches the humanistic revolution with the
rediscovery of writings by Hippocrates, Celsus and Galen. Holy Scripture
gives way to the “book of nature”. The genius of Leonardo di Vinci
coincides with reestablishment of trade and sharing of knowledge with
the east as far as China. Exploration by Europeans expands to the New
World. Native cultures are wiped out by European viruses and war. New
foods, precious metals, syphilis and tobacco are brought to Europe.
Early Modern Period
AD 1600
Francis Bacon writes Novum Organum. The thermometer is invented,
Antoni van Leeuwenhoek invents the microscope, Robert Hooke writes
Micrographia in 1665. Harvey develops the first complete theory of the
circulation of blood. Isaac Newton studies alchemy while also developing
calculus and modern physics.
AD 1700s
Lavoisier starts modern chemistry. Understanding scurvy and citrus fruits
expands sea trade. Celsius defines a scientific temperature scale.
Orthopedic surgery founded by Venel. Smellie sets down safe rules for
the use of forceps, and imparts to obstetrics the stamp of science.
Priestly discovers oxygen. Black discovers carbon dioxide. Jenner
introduces vaccination. Pinel moves the insane from prisons to asylums.
AD 1800
Claude Bernard develops physiology. "La fixité du milieu intérieur est la
condition d'une vie libre et indépendante" ("The constancy of the
internal environment is the condition for a free and independent life").
This is still the underlying principle of homeostasis today. Experimental
medicine expands its reach. Dupuytren advances surgery. Laennec
defines pulmonary diseases and direct auscultation. Freud develops the
link between mental pathology and science. The Red Cross is founded.
Pasteur advances medical microbiology. Koch’s postulates define
pathogens as a cause of disease. Lister refines antiseptic surgery. Charles
Darwin stumbles upon evolution. Virchow builds pathology as the core of
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medical diagnosis. X-ray imaging is developed. Radium is discovered by
Marie Sklodowska-Curie.
Modern Period
AD 1900
Osler brings modern medicine to the USA, and writes The Principles and
Practice of Medicine.
“The greater the ignorance the greater the dogmatism. The truth of
one age become the absurdities of the next, and the foolishness of
yesterday become the wisdom of tomorrow.”
“ One of the first duties of the physician is to educate the masses not to
take medicine.”
“ Medicine is a science of uncertainty and an art of probability. “
Cancer and chemotherapy. Blood transfusions. Nutrition and vitamins.
EKG, pacemakers and cardiac catheterization. Decline in deaths from
coronary heart disease and stroke. Nuclear medicine. Diagnostic imaging
CT & MRI. Family planning. Healthier mothers and babies. Vaccination &
control of infectious diseases. Safer and healthier foods. Recognition of
tobacco use as a health hazard. Insulin, antibiotics and modern
pharmaceuticals. Trauma care. Transplant surgery. HIV,Virology, DNA
structure, genetics defined. The human genome. Stem cell research.
Cloning. Computer technology and the internet. Medicare, HMO, PPO,
IPA, HIPAA, ICU, NICU, ER, DNR. And so much more...
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Second Millennium and Beyond
After all this time and effort we now have a health care crisis. Funding is
hammered by inflationary costs. Bioethics are hijacked for political gain.
Your value as a person is defined by access to, or lack of access to health
care. Bankruptcy is forced upon families after an illness or accident. We
know so much yet fail to provide the care we should.
Do we continue to allow political deadlock , special interests, an
adversarial legal system, and a profit driven corporate mentality to
dominate our health care system? At the cost of over one third of all
health care dollars being paid out sustain the bloated profits of insurance
“payers”? Another third to cover inefficiencies of hospital systems
(primary care delivered in the ER), malpractice costs, big (multinational)
pharma’s profits and health system CEO’s salaries?
Or do we learn cooperate intelligently as a nation?
Should we perhaps develop a universal health care system that provides
quality care at a cost we can afford afford to live with? Change our
system of insuring and paying for health care? Change the way we
organize and deliver health care? An uniquely American single-payer
system could provide a standard package of benefits to all. Additional
private insurance will still be available for purchase by patients that can
afford the choice to op-out.
We must reduce the exodus from primary care to meet the needs of an
aging population. We must strive to restore collegiality and bring a sense
of fairness among physicians. We must reduce overuse of technology and
inflation of expenditures.
This model would promote medical professional values and control costs
without compromising quality or freedom of choice. Physicians who are
organized within multi specialty groups, and fairly capitated, would be
able to negotiate a sensible cost per diem with hospital systems.
Hospitals would no longer have a rationale to operate a tax free charity
model as all patients would have coverage. Meanwhile the removal of the
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cost of providing the uninsured uncompensated healthcare in the ER
would allow more hospitals to operate in the black. Patients would see
the doctor of their choice instead of going to the ER for routine
problems.
Physicians would not have to write off a large percent their accounts
receivables or turn away patients and families due to their inability to
pay. Physician groups could afford the computer technology needed for
the information process to evolve.
Groups would instead compete to meet quality standards and gain
approval of patients and professional colleagues. This will help reduce
income disparity between primary care, nonprocedural specialists, and
procedure based specialists. Those that choose medicine as a career
could practice in any specialty in any location in the country and be
assured of the possibility of making a decent living.
This arrangement would strike a balance between freedom of choice and
the general public need for a high quality national health care plan. The
road will be challenging but ultimately rewarding.
Some guiding principles - forming a new Hippocratic Oath:
The practice of medicine is a privilege which carries important
responsibilities.
All physicians should observe the core values of the profession which
centers on the duty to help sick people and to avoid harm.
Physicians should promise that medical knowledge will be used to
benefit people's health. This is their first concern.
Physicians should listen and provide the best care they can. Physicians
should be honest, respectful and compassionate towards patients. In
emergencies, physicians should do their best to help someone in
medical crisis.
Physicians should make every effort to ensure that the rights of all
patients are respected, including vulnerable groups who lack means of
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making their needs known, be it through immaturity, mental incapacity,
detention or other circumstance.
If patients have limited mental awareness, physicians should still
encourage them to participate in decisions as much as they feel able and
willing to do so.
Physicians’ professional judgment should be exercised as independently
as possible and not be influenced by political pressures nor by factors
such as the social standing of the patient.
Physicians should not put personal profit or advancement above their
duty to patients.
Physicians should recognize the special value of human life but also
know that the prolongation of human life is not the only aim of
healthcare. Where abortion is permitted, physicians should agree that it
should take place within an ethical and legal framework.
Physicians should not provide treatments which are pointless or harmful
or which an informed and competent patient refuses.
Physicians should ensure patients receive the information and support
they want to make decisions about disease prevention and improvement
of their health.
Physicians should answer as truthfully as they can and respect patients'
decisions unless that puts others at risk of harm. If the physician cannot
agree with their requests, he or she should explain why.
Physicians should do their best to maintain confidentiality about all
patients. If there are overriding reasons which prevent keeping a
patient's confidentiality the physician should explain them.
Physicians should recognize the limits of my knowledge and seek advice
from colleagues when necessary.
Physicians should acknowledge mistakes.
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Physicians should do their best to keep themselves and colleagues
informed of new developments and ensure that poor standards or bad
practices are exposed in order to improve them.
Physicians should show respect for all those with whom they work and
be ready to share knowledge by teaching others what they know.
Physicians should use training and professional standing to improve the
community in which they work.
Physicians should treat patients equitably and support a fair and
humane distribution of health resources.
Physicians should try to influence positively authorities whose policies
affect public health.
Physicians should oppose policies which breach internationally accepted
standards of human rights.
Physicians should strive to change laws which are contrary to patients'
interests or to professional ethics.
JCM 10/18/08
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