An incredibly brief history of medicine



hello I'm John Gaeta I started my professional career in the Himalayas of all places many years ago and then I fell in love with general practice in New Zealand and returned eventually to the UK where again I pursued a career in general practice and in training future general practitioners and since what reasons it started I have been the international director of prime partnerships in international medical education which has taken me to many parts of the world meeting many wonderful and inspiring people and seeing the vast potential there is for really developing the full understanding of whole person medicine within excellent scientific clinical practice now they say that the the past helps us understand the present and may be a guide to the future the things to aspire to in the future the things to avoid in the future and so what I thought we would do in this presentation is to take an incredibly brief look at the entire history of medicine principally in the Western world and of necessity I mean the history of medicine such a vast topic we're going to make huge time leaps huge cultural things and huge assumptions and miss out many details but I hope in this short presentation we will start to see where medicine has come from how we've got to where we are now and where the future might lie so an incredibly brief history of medicine if we go back to the very earliest recorded times of mankind we find that illness was due to divine displeasure when I was working in Bhutan they they put green branches in front of the houses to keep out the the evil spirits that would cause disease and and throughout history this is the the concept in other words you got sick because you made God angry to certain extent this this attitude it's a prevailed in the time of Jesus 2,000 years ago because they asked him who sinned this man or his parents to which he replied neither we get sick because we're human even when I had cancer people said is not right it's happening to a good person like you and whilst I quite please they thought I was good then I thought maybe I didn't think I was good because I got sick but we still have these inherent attitudes about deserving illness and it being some sort of judgment what have I done to deserve this many people say into this world is animistic world of disease being due to this divine displeasure claim Hippocrates now we're going back two and a half thousand years Hippocrates called the father of modern medicine he introduced the concept that we should always look for natural causes of illness that it doesn't say they're always caused by natural causes but we should always look for them we should seek to prevent disease by lifestyle changes and of course moderation in all things except the zeal to be a good health care practitioner he also brought in the concept of ethics up till the time of Hippocrates the doctors apothecaries the witch doctors of the time it could not be trusted they might give you a poison because they've been paid that way by an enemy or they might give you something they hoped would make you better he brought in the concept of integrity in concept of the patient's good being the absolute be-all and end-all of what we practice and he didn't just make this a good code he actually said I swear by the great god Apollo and all the other gods and goddesses this is something intrinsically in the relationship between man and God when the Christian era began we didn't change the Hippocratic oath except we attribute his I swear by Almighty God when we enter into health care we enter into something which is more than just a medical practice just a job we enter into something which it's fundamental at the roots of humankind Aristotle coming slightly later he sought to marry the natural causes that Hippocrates had talked about with with philosophy he taught that the liver was the organ that was to do with food the brain to do with motion because after all if you hit somebody on the head they stop moving and the heart the heart was the the seat of the Spirit the source of life the passion and feeling we still use this word heart absolutely interchangeable with with with spirits with with life Galen took this thought further now he observed of course that red blood came from the heart through the aorta black blood came through the portal system from the liver so Blackbird was something negative the spirit the life was carried in the red blood and of course from that derived the concept of bleeding if the black blood was a greater proportion and predominance to the red blood then you were sick so you bled out the venous blood and it shows the danger of making observations but not fully understanding them and from this mismatch of observation and and concept and extrapolating it just a stage too far came a thousand years or more well over a thousand years of the practice of leeches venesection which actually made people worse rather than better we have to be careful even in this modern era that we don't make such assumptions and so for a thousand years or more medicine health care became an eclectic mixture of divine displeasure demons and curses I've had people come to me and say that someone has cursed them and they are ill deficiencies in spiritual devotion you're not godly enough and then physical causes the time of the plague I thought it was the dab foul air rising from the River Thames and the treatments were equally eclectic prayer priestly intercession pilgrimages to the bones of saints you know to some of these things to apply penances poultices and applications because leeches and then some of the predecessors of our modern pharmacopoeia those sort of potions and herbal remedies from which eventually have derived so much of our modern therapeutic armament and I said I save this this is poor science and it's very doubtful theology but it's a recognition of the essential makeup of human beings body mind and spirit meanwhile in the Arab world the Arab scholars had preserved the writings of the Greeks the scientists translated many of them into Arabic and developed practices of surgery practices of therapeutics they had a formulary and some of this knowledge then started to filter back where the Islamic and the Christian worlds met in place like solano in Sicily in Toledo in Spain and here is Constantine the African as he was known who studied in the north african countries and then brought some of that knowledge back into the medical centers run by the churches in the south of europe and here's a picture of him examining urine very much they thought they could discern an awful lot from the examination of urine as very often we can so what do medical care look like in the first part of the second millennium it was of great mixture here is probably at its best the hospitality to Santa Maria della Scala opposite the great Cathedral in Siena in Italy so one of the places that this marriage of Christian caring and an Arab science had come together and in the middle of the 11th century the church built a hospital to serve the needs of the poor for beggars orphans and for pilgrims they said the rich could afford their own doctors but the poor needed the care of the church they set this up it functioned as a hospital till 1930 must be a absolute record in the Great Hall in 1452 1451 artist painted life in the hospital at the time and here we see some of the care being given it was run by a Christian Brotherhood some of whom would classify as doctors some as a pastor's son as carers but here we see a beggar obviously who's been seriously injured we look at his face he is terrified he's received a huge wound which in many times would have killed a person in those days and this attendant is washing his feet watching you feet partly because it's touch and touch is healing but partly because Jesus washed the feet of his disciples and he following in the example of Jesus is doing exactly the same saying here am I an educated man learners here am i washing your fees a beggar not because it was a ritual but because he was devoted to the care of those who had nothing and the interesting thing is you can see the surgeon in the background with his forceps and his sponge not pushing the attendant out of the way saying here I'm busy get out of my way he's recognizing that dealing with this person's inner hurt is every bit as important as dealing with that wound now that bleeding has stopped that the dealing with the spiritual the mental emotional aspects of his injury and that's what we're finding more and more in how to treat victims of disaster the the need to avoid post-traumatic stress disorder if ever possible here we see in another corner there's a a a one of the Leigh brothers attached to this order listening to the spiritual problems of a patient and then the medical relationship didn't stop there here they're restoring this healed beggar to dignity they gave everyone discharge new clothes not secondhand ones not rags they sent them out newly clothes healed in body but now able to hold a head up with respect within society and so often we forget this need our duty to our patients doesn't just end when we've given the right medical treatment they're only fully healed when they are restored that's what healing means wholeness and here they took this task very seriously we talked about body mind and spirit and the way I view this is is that we have a physical body we're aware of that but we also have a spiritual body we have a mind that links the two together and these components are as integrally linked as this mosaic on the floor of a late Roman Church probably about the third or fourth century showing it interlinking of the component parts of our human nature and also as they saw it the nature of God totally integrated we can't separate it and if we try to we end up with bad medicine let me explain it this way I often teach overseas and when I go home one of my eight grandchildren usually comes running up to me and flings their arms around me and says granddad I love you it's one of the great things about growing old you have grandchildren and the physical air vibrates the tympanic membrane physically vibrates this is my body the ossicles vibrate and then there's a a chemical physical electrical reaction which transfers that vibration into an electrical impulse travels to the acoustic cortex of my brain but there my mind transforms it into a thought a concept but as my spirit that rejoices it's me my inner me and out of that rejoicing of my spirit my mind transforms that rejoicing into a electrical impulse travels down my laryngeal nerve my vocal cords vibrate and I say I love you too whether we like it or not whatever our theology whatever our worldview we all function as body mind and spirit the inner being communicating with the outside world through the mind and all diseases actually contain all these three components we call it psycho spiritual because where the mind ends and the spirit begins is difficult to say where the body ends and the mind begins is again difficult to say but some diseases are essentially biological biophysical a fractured bone but a fractured bone why has it been fractured what was the cause the person who has it has anxiety they feel guilty that they've done this thing that they're going to be unable to work that their family's welfare their family's income might suffer so a a fractured femur has all sorts of psychological and even deep spiritual attachments to it and then of course something like anxiety State and all that of the mind well anxiety state arises maybe because of a lack of trust like trust in yourself in your surroundings in God but even that it has physical effects and you can think of some of them palpitations raised catecholamine levels in the blood tremor sweating pallor you see we our body mind and spirit now Along Came this gentleman his picture William Harvey now William Harvey as we I think most of us know was reputedly the first person to describe the accurate circulation of the blood that arteries carry the blood away from the heart veins bring it to the heart and it's hard for us in 21st century to to imagine the impact that had on society at the time they were still under this Aristotle and concept that the heart was the seat of the Spirit the source of life is where where we exist and then suddenly it became a mechanical pump now that doesn't cause us great problems today but it has great impact at the beginning of the 18th century which was the time of what's called the Enlightenment cross Western Europe the concept came that if we divided humanities from science if we took away the religion music literature art these were things which actually were if heat there were things which were not real and there were things that caused disagreement and it would put things the hard science the physics the chemistry the biology where you could actually observe and measure things nobody can disagree about a measurement and so this concept came that the the one was real and the other one was illusory the BSC and the BA and medicine came firmly in the camp of the science leaving behind the humanity of the person so medicine is investigative its material is the real world it's it's biology whereas the humanities communication the spiritual the understanding what makes us human that is different now what followed what followed we started to develop organ centered medicine that's good I suffered cancer I'm glad that this organ censored medicine we got increasing specialization in smaller and smaller areas we started having hospitals for eyes hospitals for skins and students were selected for their scientific ability medicine and indeed in nursing now science rules a concept within the medical profession develop the top doctor is the top scientist professorships are given on research rather than communication top doctor is always a specialist communication skills were not important now in UK thankfully and many other countries they are starting to come back into the curriculum but generalism generalism was devalued how did this affect the way that we educate our doctors and nowadays increasingly our nurses my introduction to a patient was some 45 years ago when I was starting medicine at Blenheim University it was a great medical school still is and the introduction said report at 9:00 a.m. on the 1st of October to the dissection room and so my introduction to a patient was to actually peel the skin off the back of a cadaver and we do this we peel the skin off the face we study the course of the jugular vein so the courses trigeminal nerve but so often we actually forget to put the skin back on and to look for that flicker of emotion look for what the expression means look for the eyes the anxiety the distress that is there we learn our physiology from frogs at least I did and inevitably you start to think of yourself and others really as overgrown frogs it's subtle but pervasive we learn krebs cycle now when I show this usually people laugh because it's a nightmare to me and we spend a lot of time learning theirs now I'm glad we've got correct cycle we all need it to exist but we learn this and yet tend to leave behind the chemistry of relationship which is I think much more important than learning some of these names and formulas okay how does that affect how we see our patients well here we have the patient 48 year-old man he presents with breathlessness when lying flat he has chest pain on exertion he has this pain it radiates into his left arm and he's got a history of hypertension and unfortunately his defaulted from follow-up now you can think of the diagnosis most probably it's M it's left ventricular failure it's the heart is developed at atherosclerosis s which has led on to angina so we learn the anatomy of the heart we can picture the left ventricle we've also I hope learned the process of atherosclerosis and we need to know these things these are things we really need to understand the process that is affecting our patients but when the patient now let's give him a name we don't just have the patient the thyroid case in the fifth bed down on the right a patient has a name and he isn't going to be saying to you when he comes at least he's not going to say in his head what stage of atherosclerosis have I got are the calcium deposits he's going to have other questions just think if you are mr. Smith and you've come in because you've got the symptom and they say you've got advanced heart disease what questions are you going to ask am I going to die am I going to die will my wife leave me for a younger fitter man can I have sex with my wife there are so many questions that are in the patient's mind and we tend to think asterisk rhotic process and referrals and stenting and tablets maybe he's got a little child will I see my little boy grow up what happens to his education if I'm not there to provide for him will he be able to continue at school will he be able to go to university and mr. Smith has parents maybe they're alive maybe they've died and they will have endowed him with things they will have endowed you not just with the genes which may have given him the propensity to develop the heart disease but they'll have given him attitudes one prevailing attitude in so many countries is big boys don't cry many men think it's unmanly to seek treatment maybe that's why mr. Smith didn't have his blood pressure followed up it's not manly to be ill they give him attitudes to diet which may be a causative factor or maybe he's got to look after them maybe their age it and how is he going to care for them as they get increasingly frail in old age maybe his laborer will he be able to work at all or maybe it's his job and the stress that have contributed to his heart disease now all these are important questions they're all relational questions they're all to do with the social environment the relational environment in which our patients live and we've studied the trigeminal nerve and not built the skin back on the face this is an article from the British Medical Journal of 2004 and here it says medical training seems focused onto how to deal with things a liver and MRI scan rather than how to deal with people such as patients and colleagues and then it goes on to say this lack of training on how to deal with people could mean doctors are ill-equipped to do this vital part of their jobs and explains much of their subsequent stress if we're any treating half the patient with half of us then we are going to develop stress because we need to be the same inside as out we need to be practicing as whole people with whole patience we're very good at being trained to use our biophysical component to use our hands to palpate our ears to auscultate a chest our eyes to look at x-rays to look with an ophthalmoscope at the fundus we're very good at that to use our rational brain our left brain if you like to run through differential diagnosis to make action plans but we tend to keep our own inner being a relational part our psychological our spiritual component we tend to keep that away so we don't meet great relationships I was actually taught keep yourself apart from the patient because you can't bear their pain well I think part of the skill of being a really good doctor or nurse is to actually learn how to share that pain with the patient but then shed that pain but that's another topic so what we are doing is using our biophysical component to treat the biological part of our patient what we really need to do is to be able to be flexible to been run be excellent at medical science we owe that to our patients but we also need to be able to meet heart-to-heart with our patients we need to be able to look deeper than just that which presents on the surface or even deep inside but the biological thing is relatively easy to discern MRI scans are brilliant but we can't have an MRI scan of the of the real things which cause patients to present the way their illness affects them the things that will lead to compliance the things that will help them feel better and give them more hope in the future and that's where we need to use that machinery that's been given to us our own intrinsic understanding of human nature and indeed this is now widely recognized the World Health Organization in 1998 said the mechanistic view of patience which focuses on medicine and surgery is no longer satisfactory patients and physicians have begun to realize the value of elements such as faith hope and compassion in the healing process faith hope and compassion vital elements in healing where do we learn them do we lose them during our training or are they increased it makes good medicine it makes for a far better understanding of ourselves it makes our practice much more enjoyable Lister did 9 when I retired some years ago I had over 200 letters from patients and what some of them said thanks to your brilliant diagnosis whether it was brilliant or not I don't know but thanks to your diagnosis I'm still here today but more of them said when my mother died you were there when my marriage broke apart you gave me such hope for the future when my child was born I was so glad you were there and were able to see them grow up this relational aspect of medicine must be one that goes on into the future as its learned from the past let us take the wonderful advance of science that has given us so many medical cures let's excel at it but let's not soot lose sight of the fact as the World Health Organization said that faith hope and compassion are vital ingredients of what we do thank you

7 comments

  1. Very nice presentation, and in keeping with how I teach medicine. There is, however, an essential error at 21:10. The patient presented with a complaint of orthopnea and indeed a history consistent with likely progression to left ventricular failure. The good doctor called this "angina"(chest pain), which is of course incorrect. Though it is entirely possible the patient has atheroscleotic cardiovascular disease he did not present with chest pain. It is perhaps a small infraction in the context of the presentation but important as it is a point I am constantly correcting for medical students and residents.

    The holistic approach has, in my opinion, been a core component of medical practice all along. With the emergence of better scientific understanding there was a shift in concentration and focus on the patient in the larger context fell into the background, but I believe it has always been a core component of the practice of every good physician, including the specialists. That this is being more formally recognized over the past 20 years is extremely important. It is in fact increasingly tested on qualifying exams in the United States (USMLE). Sadly, it is also the most powerful leverage in quackery where the relationship with the patient is primarily abused by charlatans. We in medicine have only ourselves to blame as the profession reduced the human side of medicine to secondary or tertiary for too long.

    Thank you for a very nice presentation.

  2. As a person that aspires to become a doctor I find this man trully inspiring. Besides being an interesting factual documentary, it reminds us that we, the ones that want to become doctors and are doctors, will cure other humans and for that we have to be humans as well. We should never forget that the person we have in front of us has a life, other than the biological and physical componement of it that we can see. I look forward to get in university and be able to study this area of knowledge that has always interested me since a little child. Hopefully I won't ever forget the message this amazing man delivers and I will be able to have the passion he seems to have after a long period of having worked in the medical field.

  3. Yes, qorilla, we fully agree with you that it is vitally important that a doctor in charge of blood transfusions knows about the make up of blood and how to avoid incompatibilities. It is also essential that a cardiac surgeon knows his/her way round the detailed anatomy and physiology of the heart and has taken the time and trouble to acquire the very considerable skills needed – but there is a problem. The Bristol Heart Enquiry into deaths after children's cardiac surgery did not find that the deaths were due to lack of knowledge or technique on the part of the surgeons but rather due to a breakdown in relationships and poor communication amongst the teams they led. Nor were the deaths reported in the North Staffordshire Hospitals due to lack of knowledge but attributable to a lack of care and compassion 

  4. I insist that my heart surgeon know about molecular biology and has his science straight in his head.
    I insist that I get blood transfusion done by a doctor who understands in detail how blood cells work and can confidently make sure no incompatibilities happen!
    He can be a good communicator, he may make me comfy, if he doesn't know his stuff, then get out of the way and let someone do the job who has learned the facts.

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