DOCTORS, THE BIOGRAPHY OF MEDICINE, by Sherwin B. Nuland, Vintage, 489 pages, $15.
Dr. Nuland is a fine writer of the Yale group of medical historians. Former head of the department of neurosurgery at Yale Medical School, he has hung up his scalpel for his word processor, much to the edification of his readers.
He traces the development of medical practice, “The Biography of Medicine,” not through a dry history but through lively biographies of the practitioners who were there when the great developments took place.
Hippocrates is the logical first. It was he and his followers who took the care of the ill out of the hands of the pantheists of Roman mythology. Before Hippocrates, illness was attributed to an offense the patient had given to one of the gods. Cure could be effected only by appeasing that god. The Hippocratics had the notion that illness has discoverable natural causes and it is up to the physician to discover the cause in order to provide a cure. Diseases were thought to be caused by imbalances among the four “humors” — blood, black bile, yellow bile and phlegm. Cures were attempted by bringing these humors into balance by bleeding, purging, diet, fresh air and so on. In a sense, the Hippocratics were the first holistic practitioners. They saw disease as the result of being out of sorts with one’s environment and attempted to correct that. Their descriptions of the diseases they saw were so detailed and accurate that most of the diseases are recognizable to modern pratitioners.
Hippocrates’ other great contribution to the development of medical practice was his beneficial influence on medical ethics. He was a firm believer in the tenet “Primum non nocere” — “Above all, do no harm.” This is the third paragraph of the Hippocratic Oath: “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” Not all physicians can always follow the Hippocratic Oath, but everything physicians are taught is deeply colored by that adage, “Primun non nocere.”
Hippocrates lived in the fifth century B.C. His writings, and perhaps those of some of his followers, are contained in the “Hippocratic Corpus.” Over the next 600 years this was the only medical text available and was translated into most known languages, including Arabic. Then Galen was born in Pergamon, northern Italy, in 130 A.D. Galen of Pergamon is the next great physician profiled by Dr. Nuland.
To the teachings of Hippocrates, Galen added the idea that a knowledge of the anatomy of the body and how the body works are important in correct diagnosis and treatment. He had two problems. First, he wasn’t allowed to dissect human bodies, so he had to dissect animals and infer from those dissections the anatomy of humans. He made mistakes. His second problem was his penchant for theorizing about the function of body parts and then doing only enough investigation to bolster his theories. More mistakes. Dr. Nuland portrays Galen as “vain, petulant, contentious, impatient, and quick to take offense.” Mercilessly he attacked anyone who disagreed with him.
Galen’s teachings were based on the incorrect humoral theory of disease, on flawed concepts of anatomy and on equally flawed theories of physiology, yet they were the foundation for the practice of medicine for another 15 centuries. Was it because he wrote as though he was so sure he was right, or because he so effectively beat down opposition or because of the intellectual climate of the Dark Ages? Whatever the reason, medical progress slumbered for the next 1,500 years.
The awakening came at the hands of the Belgian anatomist Andreas Vesalius. The young surgeon, obsessed with the need to produce an accurate anatomical text, became aware of the errors of Galen’s teachings and concluded that Galen’s knowledge of anatomy did not come from human dissections. In 1543, when Vesalius was 28, his monumental “De Humani Corporis Fabrica” was published. In it he pointed out more than 200 of Galen’s errors and exposed Galen’s reliance on animal dissection. Beautifully illustrated by a real artist, Jan Stephan van Calcar, the book was a sensation, mostly for its technical excellence. However, it also brought down upon Vesalius the wrath of the old guard, disciples of the revered Galen. Perhaps this is the reason he left academic medicine and became physician to Emperor Charles V.
Ambroise Pare was a contemporary of Vesalius but not an acquaintance. He was a lowly barber-surgeon, not on the same social level as a real physician. Pare was instrumental in changing all that and making France the center of surgical practice for years. He was an astute observer of nature, technically proficient, an innovator and an independent thinker, but most important, he was a writer. At a time when there were no surgical texts, he filled the void and through his texts elevated himself and his fellow barber-surgeons in the eyes of their medical colleagues.
Dr. Nuland declares Dr. William Harvey’s discovery of the circulation of the blood as “the greatest gift ever made by one man to the science and art of medicine.”
After Vesalius and Harvey came Giovanni Morgagni, the Italian physician who provided the third and final nail for the coffin in which the old medicine of Galen was buried. He taught that disease originated in specific organs instead of mysterious humors. Symptoms were the anguished cries of the diseased organ seeking attention. Thus began the era of scientific medicine, the movement away from the holistic view of the Hippocratics. Hippocrates focused on the plight of the sick patient. Scientific medicine focused on the cause of the sickness.
From this point, the biographies move into more familiar ground — John Hunter, the genius who never let school interfere with his education; Rene Laennec, the tiny wisp of a man who invented the stethoscope; and Ignac Semmelweis, who proved that unwashed physicians caused the deaths of thousands of women after childbirth and then threw away all the benefits of his work, perhaps because of Alzheimer’s disease.
There is an excellent chapter on the development of general anesthesia and its shameful aftermath in the scramble for credit for its development.
Rudolf Virchow, “Hippocrates with a microscope,” moved the cause of disease from an organ to the cells within the organ. In the chapter on Joseph Lister, the father of antiseptic surgery, you can almost smell the carbolic acid being sprayed in the operating room. If you wonder why physicians are the strange way they are and do the mysterious things they do, read about William Stewart Halsted. He is the father of the medical schools we know today.
The biography of Helen Taussig illustrates the difficulty women had in breaking into the fraternity of male physicians. Dr. Nuland feels women physicians have done away with the traditional aloofness, the wall male physicians were taught to keep between themselves and their patients. Dr. Taussig unabashedly loved her little blue baby patients and their families, and they reciprocated. He also credits the entrance of women into the profession with moving us back toward the holistic view of the Hippocratics. Modern physicians are taught that the exact cause of an illness is important, but important also is the impact of the illness on the patient.
In the final chapter, Dr. Nuland uses the present status of organic transplantation to take off into uncharted territory, the future of medical care. His knowledge of where medicine has come from makes his vision for the future well worth pondering.
Robert A. Graves, M.D., is a retired physician and NEWS columnist who lives in Orono.
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