Tuesday, 25 April 2017

Medicine in Ancient Greece

Medicine in Ancient Greece

The advances made in medical knowledge during the time of ancient Greece were quite remarkable. The knowledge was recorded in paintings and in writings. Many of the original writings were later destroyed but second-hand accounts survived.

Figure 1. Physician treating patient, 480–470 BC

Terminology

The term “physician” was introduced, meaning “healer”, and physician is a  term that remains in use today. The term “doctor” is a later term, Roman and meaning “teacher” ( docere = to teach).

The term “surgeon” comes from old French “serurgien”, originally from the Latin “chirurgia”. This is why the usual form of the UK medical degree is MB ChB, Bachelor of Medicine, Bachelor of Surgery.

There is also an ancient Greek origin of surgery, “kheirourgia” meaning “handiwork”.

Apollo

Apollo was the god of medicine, plague and knowledge, among other things. Apollo was therefore in control of illness and healing.

Homer describes in the Iliad (about 700 BC) that during the Trojan War, plague fell upon the Achaean soldiers. The plague was considered to be the result of  Agamemnon taking Chryseis, the daughter of Chryses, and refusing to release her, despite the offer of a ransom. 

Figure 2. Chryses pleading with Agamemnon for the release of his daughter

As the plague, some form of epidemic, was considered to be under the control of Apollo, the end of the plague would also be under the control of Apollo. The "treatment" would therefore be to plead to Apollo, with prayer and human sacrifice.

However in this story Agamemnon released Chryseis and so the plague came to an end without the need for sacrifice. But the general principle remained that health and sickness, life and death were under the control of the the gods. The treatment therefore had to be prayer and sacrifice. 

In fact both are still used to this day, 2500 years later. Sacrifice has gone out of fashion in our society but prayer is still used extensively, in an attempt to save lives as well as souls. Prayer can in this respect be dangerous as some people (fortunately vey few) will use prayer to the exclusion of current medical practice. We only know about it when it does not work, but perhaps sometimes it does work. However, natural healing is impossible to distinguish from supernatural intervention.

In ancient Greece the new medical philosophers were sceptical of supernatural intervention, taking the pragmatic view that if gods controlled illness, then there was no place for physicians.

The discovery of ignorance

It was the rejection of divine intervention in all things that led to arguably the greatest discovery by humankind: the discovery of ignorance. It led to scientific development, seeking after knowledge.

The important contribution of the ancient Greeks was to try to understand health and illness, whereas other ancient cultures tried to develop medicines from herbs without scientific understanding.

The medical/scientific development of the era of ancient Greece came to an end with the appearance of the Roman empire, especially after its Christianisation. European civilisation had to wait until the late 18th century for ignorance to be rediscovered, in what we know as the Age of Enlightenment. It is important to note that this was the second Age of Enlightenment, the first having been in ancient Greece.

Cnidus (Knidos)

Figure 3. Cnidus
Ancient Greece had its physicians and the fist medical school was established in 700 BC, in Cnidus (Knidos). It was situated on the south west coast Asia Minor, and its remains can be seen today.

Figure 4. Location of Cnidus
The illnesses dealt with at the time were diseases, dog bites and war injuries. The treatments offered were restricted to herbs, bandages and wine, a modest contribution from prayer.

The treatment of war injuries was of great importance as it gave the opportunity to study the inside of the body, its structures and organs, leading to the development of anatomy.

Asclepius

Figure 5. Temple of Asclepius
Pergamon (Pergamum) was the next important centre of medical development, specifically the Temple of Asclepius (Asklepios). This is located on the northerly part of the west coast of present-day Turkey. The innovation at the Temple of Asclepius was "taking the waters".
Figure 6. Location of Pergamon

Asclepius was “the healing god”, the god of medicine, healing, rejuvenation, and physicians. He was depicted with a rod around which a snake was coiled. The Rod of Asclepius became the symbol of medicine, still in use today.
Figure 7. Asclepius
The Rod of Asclepius is often, but is not to be confused with the Caduceus, the Symbol of Hermes, in which two snakes are coiled around a rod.

Figure 8. Rod of Asclepius
Hygieia

Figure 9. Hygieia
Asclepius and Epione had five children. Their daughter Hygieia became the goddess of good health, cleanliness, and sanitation. Her name lives on as “hygiene” in our present day. A statue of Hygieia by Alexander Handys stands outside the College of Physicians in Queen Street, Edinburgh.
Figure 10. Hygieia, in Edinburgh
The Bowl of Hygieia remains in use today as a symbol of the pharmacy profession, and there are several forms of it in use in Europe.


Figures 11,12 The Bowl of Hygieia

Panacea

Asclepius and Epione had a second daughter who continued the family tradition. She was Panacea, the goddess of universal health. We use the term “panacea” today as meaning a medicine that treats everything, a cure-all. It is usually an illusion but a sign of medical optimism, or possibly now the sign of a charlatan.

Figure 13. Panacea tending the sick

Hippocrates

Hippocrates (460–370 BC) is regarded as the father of modern medicine. His home was on the island of Kos and a later mosaic illustrates a visit by Asclepius.

Figure 14.  Asclepius visits Hippocrates on Kos
Hippocrates was revolutionary in that he defined a new way of thinking. He rejected the divine cause of disease, replacing it with what we would recognise today as biological, chemical, and physical causes of disease.

He was aware of the importance of the sun in respect of human health. He recommended living on the south side of the hill (in the northern hemisphere). He established a solarium on the island of Kos (Cos).

Hippocrates defined the “humoral” cause of disease, the humors (Latin for “body fluids”) being blood, yellow bile, black bile, and phlegm. Hippocrates emphasised that good health was the result of the balance of humors within the body. For example the body could be too hot or too cold, too wet or too dry. It was the balance between the extremes that was of the greatest importance.

In this respect his ideas predated by more than two millennia those of Claude Bernard, who in 1854 published his concept of the “milieu intérieur”. This is the metabolic control of the functioning of the body, for example how body temperature remains constant. Also body weight and blood levels of calcium, sodium, potassium, the pH of the blood and many others. 

It is all a matter of balance, as defined by Hippocrates, what is now called homeostasis, a term introduced in 1926 by Walter Bradford Cannon, professor of physiology at Harvard medical school.

As well as the interior environment of the body, Hippocrates also drew attention to the environment in which we live. He was concerned about bad water and bad air. The direction of the wind was also important. 

The miasma theory

This led to a new concept, the miasma theory (μίασμα in ancient Greek), which persisted to 1854. Miasma means bad air, an unhealthy smell or vapour, that will cause disease. There was no useful intervention, just hoping for a change of wind. Fortunately the population densities were low at that time.

But population density was not low in London 1854 when yet another epidemic of cholera occurred. The air was bad and so miasma was assumed to be responsible. It was the physician John Snow who, through careful mapping of the outbreak, realised that the disease came from an individual water pump in Broad Street, Soho. Removal of the handle of the pump brought an end to the epidemic of cholera, and also an end to the miasma theory. The microbiological explanation of much disease then followed.

The Hippocratic Oath

Figure 15. Hippocrates
Hippocrates produced a Hippocratic Corpus, a written body of knowledge. In addition he produced the Hippocratic Oath, a code of conduct for physicians:

“I swear by Apollo The Healer, by Asclepius, by Hygieia, by Panacea, and by all the Gods and Goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture ….
“To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else.
“I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.
“Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
“Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me.”

 The Hippocratic Oath has been modified many times and most doctors on graduation do not take it these days. However they are aware of its basic ideals.

Figure 16. The Hippocratic Oath
There are two aspects that are controversial today. First is the prohibition of active termination of pregnancy. Second, there is prohibition of assisted dying.

kheirourgia

More interesting is the prohibition on “using the knife” and transferring care to “craftsmen” who would the knife when necessary. This became the standard model of care, that surgeons (craftsmen, “kheirourgia” = handicraft) were not required to have medical qualification. In the UK their craft was ultimately controlled by the Royal College of Surgeons (1800) and a medical degree was enforced by the Medicines Act of 1858. There is still a rather quaint and uniquely UK tradition of referring to surgeons (members of the Royal College of Surgeons) as “Mr” rather than the more appropriate “Dr”.

At the time of Hippocrates the main function of the physician in respect of disease was the assessment of prognosis, the outlook of the disease. Was it likely to be fatal? Or was it expected to be recoverable? Little or usually nothing could be done to alter the prognosis, or perhaps recoverable could be changed to fatal!

There were some descriptions of draining abdominal abscesses and removal of foreign material. The procedures would have been undertaken by the “craftsmen”, but under the observation of the physicians, who would have learned much from such interventions.

Aristotle

Aristotle continued the Hippocratic tradition of observation and empiricism, also maintaining concept of the biological causation of disease.

Figure 17. Aristotle

Aristotle stated that:

"There are three factors in the practice of medicine: the disease, the patient and the physician.” 

This has been very relevant in present-day medical practice. An important book “The Doctor, the Patient and the Illness” by Michael Balint (1896–1970) was first published in 1957. 

And also that:

“The physician is the servant of science, and the patient must do what he can to fight the disease with the assistance of the physician".

This follows, emphasising the complex dynamics of the medical consultation and intervention. Medicine in ancient Greece emphasised the importance of medical science, an understanding of disease (pathology), the person who is ill, and the physician who must be knowledgable and honest in his / her treatment of the patient. This is the empiricism emphasised by Aristotle.

Theophrastus

Theophrastus (371–287 BC) was based in Lesbos.

Figure 18. Theophrastus
Theophrastus wrote “A History of Plants”. In this he identified the role of sex in reproduction, applying this also to human reproduction, a major step in understanding. 

The prevailing view before Theophrastus and for more than 2000 years afterwards was that the father supplied the seed from which the offspring grew, and that the mother was merely the host, the receptacle, both the pre-natal and the post-natal nurse. The father was thus the natural “owner” of the child, and this attitude continued into the 20th century. It was not until the development of microscopy in the 19th century that the female “seed”, the ovum, was clearly identified and the process of human fertilisation understood.

Theophrastus was ahead of his time, but his wisdom, like so much, was lost with the rise of the Roman Empire.

Herophilus

Herophilus of Chalcedon (335–280 BC) is described as the first anatomist. 

Figure 19. Herophilus

He identified the distinction between arteries and veins. He defined the brain as being the seat of intelligence. He also made the important discovery that movement is controlled by the nervous system.

Erastistratus

Erastistartus of Ceos (304–250 BC) made further anatomical advances. He mapped the arteries and veins. He identified the importance of the convolutions of the brain.

Much of the knowledge of Erastistratus was obtained by the rather barbaric vivisection of criminals.

Figure 20.  Erastistratus and the illness of Antiochus
He is also famous for diagnosing the cause of the illness of Antiochus, son of the King of Syria. Erastistratus identified the illness being the result of love for his young stepmother Stratonice. He persuaded the old king to give his young wife to his son, who then fully recovered.

Dioscorides

Figure 21. Dioscorides
Pedonius Dioscorides (30–90 AD) was described as an army surgeon. He wrote a “Materia Medica”, a body of therapeutic knowledge. The term continued in use until into the 20th century, but it has now been replaced by the term “pharmacology”.

Galen

Aelius Galenus (129–210 AD) , otherwise known as Galen of Pergamon, was an important Greek physician in the Roman Empire.

Figure 22. Galen
Galen was also an anatomist and one important observation was that injury to one side of the brain results in paralysis of the opposite side of the body.

He also developed the concept of what is now called heteropathic or allopathic medicine. The term was “contraria contrariis”, meaning that the opposite is cured by the opposite. An example is treating fever by cooling. It is generally the antithesis of homeopathic medicine.

Galen was the last of the great ancient Greek physicians. The Roman Empire was established. It would shortly be Christianised, by Constantine the Great’s Edict of Milan in 313 AD.

 The final  triumph of science over superstition

Europe then entered the Dark Ages, with medical science suppressed until the second Age of Enlightenment. 

The English physician William Harvey (1578–1657) initiated a new era of medical investigations by his identification of the circulation of the blood.

Figure 23. William Harvey
Less well known is Harvey's important assertion that “witchcraft is a fallacy”, thus once again attempting to consign to history the notion of the supernatural cause of illness and death. This conclusion was reached after he was invited to attend the Pendle witch trials of 1633–34, set in a location just a few miles from where I live.

The triumph of science over superstition!

Figure 24. Pendle Hill and Clitheroe, Lancashire








Sunday, 19 March 2017

Altitude and health – three towns in East Lancashire.


East Lancashire, from the summit of`Pendle Hill

The sun and susceptibility to coronary heart disease – the experience of Lancashire, UK.


Previous Posts have described the well-defined epidemic of coronary heart disease (CHD) that  occurred during the mid and latter parts of the 20th century. Also the Posts have led to the conclusion that the only realistic (and therefore the most probable) cause of the epidemic appears to be an infection. The actual causative organism has not been defined, but it is usual that the recognition of a microbial cause of a disease precedes the identification of its causative organism.

The presence of a disease depends on a combination of its cause plus the susceptibility of an individual or population to  it. This is often a function of immunity.

However the identification of factors leading to susceptibility are of great importance. We need to determine the difference in the incidence of disease, death rates and life expectancy in various places.

A recent Post looked at the much higher incidence of illness and early death in Belfast in Northern Ireland compared to Toulouse in France. The only answer appeared to be a protective effect of the sun acting on the population of Toulouse, which is almost 1000km closer to the equator. Whereas Belfast is at sea level, Toulouse is a slightly higher altitude, 150m above sea level.

Health inequalities in England

A previous Post has looked at health inequalities in Three English Towns, demonstrating higher death rates those in the north of England. There was no explanation other than latitude. Dietary characteristics were the same in all towns. 

It is now well-known that standardised mortality rates are higher in the north-west of England than the UK average, shown in Figure 1. Mortality rates are lowest in the south, and this conforms to a latitude effect. However London has higher mortality rates than the surrounding rural locations.



Figure 1. Mortality rates in England and Wales

Burnley, Nelson and Colne

Burnley is one of the major towns of Lancashire, and Nelson and Colne are smaller towns just 10 and 20 km to the north-east. All grew during the 19th century as cotton and textile manufacturing towns, an industry undergoing major decline during the second half of the 20th century. Like all industrial towns, they have been characterised by significant but relative socio-economic deprivation, with low incomes, poor housing, low average educational achievement and bad health profiles.


Figure 2. The north-west of England, Burnley Nelson & Colne shaded

The particularly interesting aspects of the health profiles are the differences between theses three towns that are geographically so close together and so similar in respect of employment patterns. This is shown in the infant mortality rates in the early years of the 20th century.


Figure 3. Burnley, Nelson and Colne

With the standardised average England & Wales mortality rate (SMR) of 100, that of Burnley was one of the nation’s highest infant mortality rates at 160. But it was significantly lower at 117 in Nelson, and well below the national average at 78 in Colne. The difference is remarkable and no explanation was offered when the data were first published.


Figure 4. Infant mortality rates, 1911-1913

The study was revisited later in the 20th century, this time looking at adult health profiles. During the years 1968–1978, the SMR for “all cause” mortality was high at 121 in Burnley. Nelson was better at 109, and the SMR in Cone was on the national average at 100. So we see the same pattern as was present more than 50 years earlier.


Figure 5. Mortality rates, all causes

When we look at deaths from “bronchitis” we see an overall high mortality rate in Lancashire, a remarkably high SMR of 188 in Burnley. The populations of Nelson and Colne also show high mortality rates, but once again much less than Burnley, with Colne lowest of the three.


Figure 6. Mortality rates, bronchitis

Deaths from pneumonia show the same pattern, Burnley highest of all at 174, Nelson lower at 125, and Colne lower still at 108, just above the national average.


Figure 7. Mortality rates, pneumonia

Deaths from coronary heart disease (CHD) show the same pattern. All are above the national average, but is this expected for towns in the north-west of England. Again, the highest mortality rate of the three is Burnley, Nelson in the middle and the lowest is Colne.


Figure 8. Mortality rates, coronary heart disease

The importance of geography

So how do we explain this? There is no obvious socio-economic difference between the three towns. No formal research has been undertaken in this respect but no significant population  differences can be anticipated, nothing to account for such major differences in death rates. 


Perhaps it is the geography that is important. We saw this in the comparison between Belfast and Toulouse: geography was the only realistic explanation of the much higher mortality rates in Belfast, the higher latitude with a lower intensity of sunlight being the important factor.

As with Belfast and Toulouse, in Burnley, Nelson and Colne, we are looking not at a case of a disease but of a factor that increases susceptibility to a number of illnesses and results in premature death.

Burnley is located in the valley of the River Calder, a tributary of the River Ribble. The Ribble enters the Irish Sea between Blackpool and Southport. In Burnley the River Calder is joined by the Rivers Brun and Don, and also by Pendle Water. This was an advantage in the pre-steam era, when motive power for factories was provided by gravity acting via running water. 


Figure 9. Burnley

Burnley is therefore relatively low-lying. It is in a valley where four rivers meet, and it is known to be damp. In the industrial era the smoke from domestic and factory chimneys would accumulate in Burnley. When coal and steam came into industrial use, the newer industrial towns of Nelson and Colne could be built away from the rivers. 


Figure 10. Coal mine in Burnley, now closed

Altitude

Burnley lies at 105 metres above sea level. 
Figure 11. Burnley

Nelson is further up the valley of Pendle Water, and is built on higher round above the valley. It lies at 160 metres above sea level. 


Figure 12. Nelson
Colne is even further up the valley and was originally (in the pre-industrial era) a hilltop town, lying at 190 meters above sea level.


Figure 13. Colne

And so here we have the most obvious and the most likely explanation of the variation of indices of health of the populations of the three towns: altitude.


Figure 14. Altitude variation of Burnley, Nelson and Colne

Altitude in the USA

We have seen this phenomenon in a previous post, which described the same feature in the USA. At a latitude of 37–38 degrees north of the equator, between Washington DC and San Fransisco, there is a convincing inverse relationship between altitude and standardised death rates from coronary heart disease (CHD) and cerebro-vascular disease (CVD).
Figure 15: Land mass profile of the USA at 37–38 degrees north, and inverse  CHD/CVD mortality rates

Higher altitude means higher intensity of sunlight at ground level. Of more importance is being above the pollution that is inevitable in an urban environment. An increased altitude of even 30 metres can make a significant difference: the polluted layer of atmosphere is heavier than the atmosphere, and is thus low-lying.

Atmospheric pollution

In a city such as London the polluted layer of atmosphere is only thin, perhaps 20 metres. 


Figure 16. London, looking north from Greenwich

In many cities in China and other rapidly industrialising countries, the atmospheric pollution is very great and its removal by wind and rain is infrequent. The layer of pollution becomes so thick that the sun is totally obscured, despite no natural cloud.


Figure 17. Xian, China, mid-day 

Atmospheric pollution is both chemical and physical. Oxides of nitrogen and sulphur cause irritation to eyes and lungs. These give the chemical component of damage.

The most damaging component is particulate material, tiny particles of dust and unoxidised carbon, giving a physical rather than or as well as a chemical effect. It is the particles that are responsible for the obstruction to the passage of sunlight to ground level.

City versus countryside

It has been known for more than two hundred years that death rates are much higher in people living in industrial cities compared to those living in a rural environment. 


Figure 18. Thomas Percival 1740–1804

It was first demonstrated in a monograph written in 1773 by the Manchester physician Thomas Percival. The monograph was entitled “Observations on the state of the populations of Manchester and other adjacent places”. It recorded that in Manchester (population 27,246) and in Liverpool the death rates were one in 28 of the population each year. This was twice the death rate in surrounding villages in rural locations, one in 56 per year.

It is the same today, standardised death rates being higher in the cities (polluted air) than in rural locations (clean air).


Figure 19. Cloud but clean air in the Ribble Valley, where I live

Conclusion

Life expectancy is greater and death rates lower in the countries of southern Europe compared to countries in northern Europe.

Death rates from a number of diseases are lower with residence at a higher altitude. This demonstrated in the USA and in East Lancashire, UK.

Death rates are lower in rural villages than urban cities.

Pollution blocks the sun much more continuously and much more effectively than natural cloud.

The common factor is that a major determinant of good health and long life is good exposure to the sun.