1. Medicine in Antiquity: Egypt, Mesopotamia, and Greece

2. Map of Mesopotamia and Ancient Egypt

3. Mesopotamia: Life Between the Rivers Mesopotamian (‘land between the rivers’ [Tigris and Euphrates]) kingdoms of the ancient world after beginning of Bronze Age (4000 BC), includes the kingdoms of Ur (founded by the Sumerians), and Babylon on the Euphrates River, and then Assyria and Nineveh on the Tigris River. Clay tablets written using cuneiform give some indication of early medical knowledge: disease descriptions of tuberculosis and vitamin-deficiency diseases associated with grain economies and diets. Disease interpretation was largely omen-based. Use of divination (inspection of livers [‘seat of life’] of sacrificed animals). Three types of healers: Seer (divination); Priest (performed incantations and exorcisms); and Physician (used drugs, and did surgery and bandaging). Hammurabi, sixth king of the first dynasty of Babylon, left legal code of 282 laws regulating society, family life and occupations. These codes on a 2-metre high stele set rules for physicians governing: fees for treatment (sliding scale based on patient’s rank), as well as fines for incompetence or failure. Gods were everywhere and involved in daily life— spirit invasions, sorcery, breaking of taboos, all could led to sickness as judgement and punishment. Astrology was important—use of horoscopes and soothsaying—disease was supernatural. Patients treated by empirical remedies using ingredients from materia medica (120 mineral drugs, and +250 vegetable items). Hammurabi Law Code Stele, 18 th Century BC (Louvre, Paris) Hammurabi (1728-1686 BC)

4. Ancient Egypt: Life and Afterlife Beginning of Egyptian civilization dates to third millennium BC, and by 2000 BC pharaohs were constructing the great pyramids in the Valley of the Kings. In the medical field, Egyptians believed that health or illness resulted from both earthly and supernatural forces. Health was associated with proper living, being at peace with the gods/spirits/dead; while illness was a matter of an imbalance that could be restored to equilibrium through treatment and prayer and spells. Anatomical knowledge was limited to bones and major organs, but was relatively good as there were no taboos against investigating corpses. (However, mummification— performed by a members of a lower caste—did not result in leaps in knowledge as the process was to preserve the body, and thus organs removed by small incisions (therefore no looking around inside the body cavity).) Believed that humans were born healthy, but were susceptible to disorders caused by demons as well as intestinal putrefaction—key focus of ‘health’ was a period of three days each month dedicated to evacuating the body with enemas and laxatives. Ancient Egyptian Illustration of the Goddess Ritho Giving Birth to the Sun God Ra

5. Egyptian Physicians and Their Skills As with other aspects of Egyptian society, medical practice was hierarchical and under state control. Physicians were appointed to work for the army, public works, burial grounds and the royal palace. Court physicians were at the top of the medical pyramid. Physicians also specialized in treating particular diseases, or treating specific body parts or organs (eyes, head, teeth, bowels). Three divisions of healers: 1) physicians (including some women); 2) priests; and 3) sorcerers. One of most famous physicians was Imhotep—a chief doctor of a pharaoh in the 27 th century BC. He was high priest at Heliopolis, an astrologer, priest, sage and pyramid designer as well as a physician. Within a few generations he was deified and by 300 BC a cult emerged around him. As with later Greek figure of Asclepius—Imhotep was associated with healing shrines and temples. Egyptians had a great variety of cures using ingredients such as vegetables, fruits, tree resins, plant extracts, minerals, metals and animal parts. In field of gynaecology there were methods for detecting pregnancies, and for contraception (pessaries of pulverized crocodile dung, honey and mixed herbs)—very effective Egyptians had stable family sizes and did not practice infanticide. Egyptian God Anubis— The God of Healers and Embalmers

6. Map of Ancient Greek, Asia Minor and the Hellenistic World Hippocrates

7. Greek Medicine: Gods and Healing Sacred nature of healing: Apollo the ‘god of healing’ and his half-mortal son, Asclepius who was taught herbal remedies by Chiron the centaur, and then killed by a thunder-bolt from Zeus on behalf of Hades who was being robbed of new recruits for his underworld. Asclepius was often portrayed with beard, staff and snake—origin of the caduceus? Greek physicians believed in the healing power of nature and were against heroic interventions and procedures. The Hippocratic Oath forbid cutting, and surgery was reserved for treating war injuries—surgeons (working with their hands) were inferior to physicians. Traditional Latin term for surgery was chirurgia—from the Greek words cheiros (hand) and ergon (work)—implying that it was a manual and not a mental skill. Greek, Hippocratic, healing was patient-oriented, and tied to observation which identified illness patterns. The paradigm acute disease was fever (probably malarial), and was tied to the humours and seasons. Airs, Waters and Places would later re-emerge in early modern beliefs in miasmas. Prognostic ability was also important—created good impression as someone who knew a great deal, and by predicting outcome, particularly death, a healer could escape blame for apparent failures. The Asklepieion Temple in Corinth (Temple to the Divine Physician) [right] The Caduceus—Originally the Symbol of Hermes, the Greek God of Commerce

8. Alexandrian Medicine City of Alexandria near mouth of the Nile River was capital of the Ptolemy royal family and its library and museum were key sites of learning in ancient world—linked the Greek world to Egypt and its rich history. Archimedes and Euclid taught there, and the library contained more than 700,000 books and had its own observatory, zoological gardens, lecture halls, and research rooms. Due to Alexander’s conquest, the Hellenistic world stretched from Sicily to Persian Gulf (with much knowledge of Central Asia and northern India). Thus, a broad geographic area of knowledge or animals, plants, drugs, minerals and medical techniques. Generally no human dissection was practiced (although some examples were recorded), therefore while surface anatomy was good, first-hand knowledge of insides and living processes depended on wound observations and animal dissection. Famous Alexandrian Physicians: Praxagoras of Cos (c. 340 BC) distinguished arteries [heart and air] from veins [liver and blood]; his student Herophilus who dissected cadavers in public, used pulse in diagnostics, and wrote on mid- wifery, ophthalmology, dietics, and the importance of the brain. Tree Supposedly Planted by Hippocrates in City of Cos (Kos) [Above]; and Roman Image of Greek Surgical Techniques [Image to Right]

9. Hippocrates (460-377 BC) For two millennia has been considered the ‘founding father’ of medicine. Born on the Aegean island of Cos (Kos) towards end of fifth century B.C. He traveled throughout Greece and Asia Minor for several decades as an itinerant physician, then returned when middle-aged to Cos to write, to practice and to teach. Must be careful, however, as there are only two references to his life in Plato’s Dialogues and much of the common narrative is little more than myth. Of the sixty works that comprise the Hippocratic Corpus fewer than ten are now attributed to Hippocrates himself, and he did not write the oath that bears his name. The Corpus was a collective effort like Homer’s Iliad or the books of the Bible. The majority of works in the Corpus were gathered together around 250 BC in the great library at Alexandria. Although varied (from philosophy to case histories of diseases and epidemics), the works of the Corpus do share certain elements: 1) reasoning about nature can lead to explanations of health and disease; 2) man is governed by the same physical laws as the rest of the cosmos; 3) medicine must be empirical and rational. Overall, what marks the approach of the Hippocratics, was the appeal to reason over rules or supernatural forces. Also, it is patient-centred, not disease-centred, and it is concerned with observations and experience more than abstract ideas and theories. Byzantine Icon of Hippocrates

10. Equilibrium of the Humours The key concept in the Hippocratic Corpus was that health was equilibrium and illness was an upset or imbalance. Some variation in this view, as in On Regimen the vision was of the body in perpetual flux and that health was when it was within bounds; while in On the Nature of Man the body was viewed as stable until an illness subverted it. Imbalance was often noted by the concentration of fluid in a particular body zone or part. Egs: i) A flow of humours to the feet would produce gout; or ii) Phlegm from the head to the lungs would be the cause of a cough. A healer’s job was to preserve balance, or to restore it when an illness was present. Balance/upset of the chymoi (humours): 1) Blood [air and infancy]; 2) Yellow Bile [fire and youth]; 3) Black Bile (melancholy) was a harmful if essential humour [earth and adulthood]; and 4) Phlegm [water and old age]. Two fluids or humours most often associated with illness: bile and phlegm (present in the body, but flowed in quantity in sickness)—winter colds due to phlegm and summer diarrhoea and vomiting due to bile; mania due to bile boiling in brain. Aristotlean and Hippocratic View of the Four Humours

11. Traditional Translation of Hippocratic Oath I swear by Apollo the healer, by Aesculapius, Hygeia, and Panacea and all the powers of healing, and call to witness all the gods and goddesses that I may keep this Oath and Promise to the best of my ability and judgement. To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimens for the good of my patients according to my ability and my judgement and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

12. Questioning the Hippocratic Oath Elements of the traditional Hippocratic Oath that have been abandoned: 1) To support my teacher if necessary. Not charging the families of physicians for services was the last trace of this item. 2) To teach medicine to the sons of my teachers. In the past, medical schools gave preferential consideration to the children of physicians—this also has largely disappeared. 3) To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. Overall, this item is followed, but what of the issue of euthanasia? 4) To never attempt to induce an abortion. No longer followed in most Western nations. Hippocratic advice that is still followed: i) To never deliberately do harm to anyone for anyone else’s interest. In most Western nations, physicians and medical associations have denounced physician participation in legal executions. ii) To avoid violating the morals of my community. Many licensing bodies will revoke a physician’s license for offending community morals (‘moral turpitude’). iii) To avoid sexual relationships or other inappropriate entanglements with patients and families. iv) To keep confidential what I learn about my patients. Confidentiality is still a valued element in the doctor-patient relationship. Move to Modern Alternatives: In 1970s, recognition that society’s cultural and social norms had changed, led many North American medical schools to abandon the Hippocratic Oath as part of their graduation ceremony. But, a modified version or alternate pledge was then included— continuation of a ‘sacred vow.