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LECTURE 1 Archaic Medicine Medicine in the Ancient Eastern/Oriental Countries: Egypt, Mesopotamia Archaic medicine in ancient India Archaic medicine in ancient China Medicine in the Ancient Eastern/Oriental Countries: Egypt, Mesopotamia Ancient Egypt Until the medical papyruses were discovered during the last century, our knowledge of ancient Egyptian medicine came principally from the writings of Greek and Roman commentators such as Homer, Herodotus and Pliny the Elder. The oldest of the medical papyruses is the Kahun Papyrus, which deals with veterinary medicine and gynaecology. All deities were associated with some aspect of health or illness. Ra, the sungod, held the highest place. Isis, a sort of primal earth-mother was a healing goddess. Ancient Egypt The attitude towards death contains many paradoxes. Life was considered a preparation for afterlife. An important ritual called "the opening of the mouth" was described in the "Book of the Dead", a guidebook to the afterlife and regulator of all funerary practices. The extent of embalming was determined by the status of the deceased. The cranial content was removed through the nostrils with hooks and the skull and abdominal cavity were then washed out with spices. The body was soaked for seventy days in natron (a mixture of clay and salts of carbonate, sulfate and chloride) and then thoroughly washed. The Egyptians believed that the human body has a system of channels (metu). The heart was at the centre of the system and the propagation of its beats throughout the body was known. Air came in through the nose but also the ears, entered the channels, was delivered to the heart and from there was sent to all parts of the body. However, the metu also carried blood, urine, tears, sperm and feces. Around the anus, the channels coalesced into a sort of collecting system where the contents of the rectum could enter the network. The channels were considered the main cause of disease if allowed to built up. Hence, the intestinal contents were cleaned out regularly by purges and the anus became a prime target of medical treatment. Ancient Egypt The ancient Egyptians paid much attention to cleanliness of body and home, probably for religious reasons. Washing was practiced every morning, evening and before each meal. Some diseases can be reasonably well identified from descriptive reports in papyruses and mummies. Diseases resulting from water and food contamination were common. Parasitic infestations have been discovered in mummies. Although malaria seems not to have been as common nor as severe as in neighbouring countries, fevers of all kinds were a problem. Diseases of the eye were frequent and included infections such as trachoma, cataract and nictalopia (night blindness). Leprosy may well have been present, but was probably often confused with other skin conditions. Acute illnesses were certainly well known. Pneumonia and appendicitis clearly can be reconstruct from the information available. Arthritis, gout, kidney and bladder stones, tumours of the ovaries and of bone have been identified. Cirrhosis of the liver was frequent, probably related to large consumption of beer and wine. Ancient Egypt The Egyptian pharmacopoeia was vast. Many of the medications and plants that later were found in the herbals of Dioscorides, Galen and Pliny the Elder came from Egyptian sources. The Egyptians administered medications in many forms: as pills, suppositories, ointments, drops, fumigations, baths. The liquid vehicles were water, milk, beer and wine, each sweeten with honey. The physicians used a wide variety of medicinal plants, but the most numerous remedies were purgatives and emetics. Minerals in the pharmacopoeia included antimony, copper, salt, carbon and possibly iron from meteorites Women's diseases occupy an important place in the medical writings. An exceptional method was used for diagnosing pregnancy. A woman would urinate over a mixture of wheat and barley seeds. If any grains later sprouted, the woman was sure to give birth. Ancient Egypt Contraceptive methods were described in the medical papyruses. Dung, honey and a carbonate salt made up one contraceptive combination. The reputation of medical practitioners was high throughout Egypt and the Mediterranean world. Egyptian physicians were often called to treat members of the ruling classes in other countries. As in other societies the healer set himself apart from the general population, but was also responsible in case of malpractice. He was warned to use only the methods promulgated in ancient treatises. In this case, even if the results were poor, he would be above reproach. The standards of training and practice seem to have been set by . pharaoh's physician, who stood at the apex of the hierarchy. Beneath him were the palace physicians, among whom one may have been the supervisor of physicians. The others were inspectors of physicians and a lower order of physicians comprising the great bulk of practitioners. Temple physicians, possibly of lower social standing, were available to all and visited patients' home as well. Army doctors accompanied military expeditions and gave service to soldiers in the barracks. Ancient Egypt The Egyptian physician, whether a priest or a specially chosen layman, was considered to possess divine knowledge and have special access to the deities and demons. Some of this tendency to ascribe possession of unimpartable information to professionals of the healing art has continued to permeate medical practice in all countries throughout the centuries. This divine self-image has had a detrimental effect because it encouraged arrogance, excessive secrecy and unwillingness to recognize limitations. Ancient Mesopotamia Mesopotamia, the ancient region of southwest Asia, localized between the rivers Tigris and Euphrates has also been called the Cradle of civilization. Here, about five thousand years ago, man first developed a system of writing and here the first cities in the world were built. The next major civilization was centred on Babylon, and the most famous ruler was Hammurabi (r.l 728-1 686 B.C.). His code of laws is the most prominent work of the period. Many thousands of inscribed clay tablets from this era still exist and make it one of the best-known culture of Near Eastern antiquity. The civilizations of Mesopotamia exerted powerful influences on their neighbours not only in their own time, but also in subsequent centuries. Some of the most famous early Bible stories have precursors in venerable Sumerian legend. Probably Mesopotamia's most important contribution to mankind was the introduction of a writing system, attributed to the Sumerians of about 3000 B.C. Ancient Mesopotamia Among the various Mesopotamian cultures illness was considered a punishment by the gods on the sinner who had violated a moral code. The three principal deities of Sumer were Anu, Enlil and Enki. Enlil had a son, Ninib, who was a healing god. An important Babylonian god was Ea, lord of Water and the first great cosmic ancestor of physicians. Mesopotamian doctors depended on divination to uncover the sin committed by a sick person, but they also observed the patient's symptoms. The liver was regarded as the seat of life and hepatoscopy -- detailed examination of the liver of sacrificed animals-- was one method of divination. Clay tablets that reported illness with their symptoms, diagnosis, prognosis and treatment were found. Other clay tablets listed drugs and their appropriate uses. Hundreds of plants, minerals and animal substances were the therapeutic agents. The medications were administered according to rituals, the time of the day and the position of constellations. Medical practice seems to have been in the hands of three types of priests Ancient Mesopotamia The baru as a diviner dealt with diagnosis and prognosis. He also had to discover the causes and probable outcome of many other kinds of catastrophe. The ashipu, as an exorcist, was called to drive out evil demons. The asp acted principally as a physician, employing charms and divination, but also drugs and operations. Medical practice, as well as other professional activities, was regulated by laws. The Code of Hammurabi devotes ten short statements to the fees due to medical practitioners and their punishments for failure. Here are some of them: If a doctor has treated a freeman with a metal knife for a severe wound, and has cured the freeman, or has opened a freeman's tumour with a metal knife, and cured a freeman's eye, then he shall receive ten shekels of silver. If the son of a plebeian, he shall receive five shekels of silver. If a man's slave, the owner of the slave shall give two shekels of silver to the doctor. If a doctor has treated a man with a metal knife for a severe wound, and has caused the man to die, or has opened a man's tumour with a metal knife and destroyed the man's eye, his hands shall be cut off. If a doctor has treated the slave of a plebeian with a metal knife for a severe wound and caused him to die, he shall render slave for slave. Ancient Mesopotamia Comparing the fees in the Code with the five shekels of silver yearly rent for a middle-class house indicates a generally high schedule of medical fees. The ailments were not grouped together as disease entities, as they are today, but were classified according to the location of the symptoms. For instance, chest problems were cough, pain and the spitting of blood. Epidemics must have occurred often. Certain plagues and fevers were reported in the cuneiform tablets. The shaking chills which Alexander the Great suffered during his campaign in Mesopotamia in the fourth century B.C. may have been due to malaria. A sick person of any rank was in a special category and was excused from work and from service to the king. Since disease was caused by spirits the sick person was isolated as much as possible to avoid transference of the offending demon. This was hygienically beneficial to the community although its purpose was based on magical reasons Archaic medicine in ancient India The earliest culture in India of which we have archaeological evidence is centred in the Indus valley. This civilization, which flourished from about 2500 to 1500 B.C. has had an advanced system of public sanitation including public baths and chutes for collecting refuse. Initially, illness was thought to result from punishment by the gods for sinning. Later, the belief in reincarnation developed. Humans were continually reborn until their karma (sum of actions in one existence that determined destiny in the next) entitled them to nirvana, or merging with the cosmic spirit. All the gods affected health and illness, but Dhanvantari was most associated with medicine as its patron deity. Ancient India the Vedas contained references to disease, injuries, fertility, sanity and health. Methods of diagnosis included magical as well as rational approaches. The flights of birds, the sounds of nature and many other observations were interpreted by the Indian physician as clues to the severity of the illness. Nevertheless, the patient was carefully examined, especially his sputum, urine, stool and vomits. Diabetes was detected by the sweet taste of patient's urine. The pulse was also an important diagnostic and prognostic tool. The pharmacopoeia was vast. Charaka described five hundred remedies and Sushruta over seven hundred vegetable medicines. The plant called Rauwolfia serpentina was considered by the Indians to be especially potent against headache, anxiety and snakebite Since cutting off the nose was an official punishment for adultery, Indian surgeons had to develop methods for reconstruction of the nose. The repair procedures described by ancient Indians are essentially the same as in modern plastic surgery. Ancient India Operative methods were described for different kinds of injuries and abnormal states like harelip, hernia and bladder stones. Amputations were a regular part of surgical practice. A large number of instruments were available to the surgeon: forceps, scalpels, scissors, saws, needles, trocars, catheters Early physicians came from the priestly caste. Later, members of the second and third ranking castes embraced the healing profession. Trained physicians, called "vaidya", stood high in the social scheme and were even excepted from taxes. The "Laws of Manu" - a body of rules for ritual and daily life (200 B.C.200 A.D.) - stated that physicians could be penalized for improper treatment. On the other hand, if the cured patient refused to pay, his property could be confiscated in the favour of the doctor. Judging from the written records, epidemics must have been frequent. There is evidence for malaria, dysenteries, cholera, smallpox, typhoid fever, plague, leprosy, tuberculosis Ancient India Traditional medicine recognized the dangers of remaining in an area where an epidemic was raging. Smallpox was prevented by inoculating people with pus from a smallpox skin boil by puncture or scarification. We do not know precisely when first hospitals were built. Among inscriptions dating from the third century B.C. there are statements that hospitals had been established. Charaka summarized ail the attributes of a good hospital, including location in an area free of smoke and protected from the sun, smells and noises. He also discussed an appropriate food supply and the availability of drugs. The personnel should be clean, well-behaved and able to care for the patients. The well-being of the sick was also considered, with provision for attendants who could distract the patient by conversation and entertainment. We do not know whether Charaka's principles represent an actual situation or simply an ideal to be hoped for. Archaic medicine in ancient China In ancient China cosmology, the universe was self-generated from the interplay of nature's basic duality: the active, light, dry, warm, positive, masculine yang and the passive, dark, moist, cold, negative yin. All things, animate and inanimate were a combination of these fundamental. The ultimate principle of the universe was the too, "the way", and it determined the proportion of yin and yang in everything. Anything that altered the relation of yin and yang was considered bad Chinese medicine was focused on the prevention of illness. The legendary Huang Ti, father of Chinese medicine, observed: "the real physicians helps before the budding of disease". Ancient China Buddhism came to China from India and medical concepts and practices were an important part of its teachings Classical Chinese medicine was based primarily on works ascribed to three legendary emperors. The most ancient was Fu Hsi (c.2900 B.C.) Shen Nung, the Red Emperor, compiled the first medical herbal, the Pen-tsao (c.2800 B.C.), in which he reported the effects of 365 drugs, all of them personally tested. The Red Emperor is also said to have drawn up the first charts on acupuncture. The fame of Yu Hsiung (c.2600 B.C.), the Yellow Emperor, rests on his medical compendium, the Nei Ching (Canon of Medicine). Its present form dates from the eighth century A.D., when the last extensive revision was done. A great part of the Nei-Ching, called "Simple Questions", records the discourse of the Yellow Emperor with his prime minister on health and illness, including prevention and treatment. Ancient China Chang Chung-ching, the Chinese Hippocrates, in the third century A.D., wrote the classic treatise "Typhoid and Other Fevers". Sun Szu-miao (581-682 A.D.) wrote "A Thousand Golden Remedies", which summarized in thirty volumes much of the known medical learning. The anatomical knowledge was reached by reasoning and by assumption rather than dissection or direct observation. It was not until the eighteenth century that the Chinese began systematic, direct anatomical studies-Physiology relied on a humoural system much like Greel concepts, except that there were five instead of four essential humours. The medical compendium "Nei Ching" stated that each emotion has its set in a particular organ. For instance, happiness dwelt in the heart, thought in the spleen, sorrow in the lungs and anger in the liver. The Chinese methods of diagnosis included questioning, feeling the pulse, observing the voice and body and in some circumstance touching the affected parts. Ancient China Perhaps the most important diagnostic technique of the ancient Chinese was examination of the pulse. There were hundreds of possible types of pulse. In one treatise ten volumes were necessary to describe all the characteristics of the pulse. According to the Nei Ching, there were five methods of treatment: cure the spirit, nourish the body, give medications, treat the whole body and use acupuncture and moxibustion. Considering that specific mental states caused changes in specific organs, the healer linked certain behavioural and constitutional factors with illness. He had to put the patient back on the right path, the tao. The Chinese pharmacopoeia was rich. Over sixteen thousand prescriptions were described. There are two plant substances associated with Chinese medicine. One is ephedra, the "horsetail" plant. It was used for thousands of years as a stimulant, as a remedy for respiratory diseases, to induce fevers and perspiration. In the nineteenth century Japanese investigators isolated and purified the active principle, ephedrine, and established its pharmacologic action. A second medicinal herb, always popular among the Chinese, is ginseng. Preparations containing ginseng were almost miraculous in delaying old age, restoring sexual powers, stimulating the debilitated. Ancient China Acupuncture and moxibustion have been an integral part of Chinese therapy for thousands of years. The aim of these treatments was to drain off excess yang or yin and thus establish a proper balance. External energy also could be introduced into the body. Acupuncture spread to Korea and Japan by the end of the tenth century A.D. and to Europe about the seventeenth century One surgical procedure was the frequent castration of certain males seeking advancement at court. The aim of this surgical intervention was absolute allegiance to the monarch. It released the eunuch from loyalty to his family and the obligation of having a son. Footbinding is also of medical interest because it caused the development of artificially clubbed feet. Over a period of one thousand years, every young girl of proper family willingly permitted herself to be crippled by her mother and aunts to achieve the tiny foot of ideal feminine beauty Ancient China Some epidemic diseases were understood well enough to allow the development of protective measures. Inoculation against smallpox was effected by putting scabs from smallpox pustules into the nostrils. Wearing the clothing of someone who had the disease was another mean of prevention. Leprosy was described in the "Nei Ching" and fourteenth-century writings referred to chaulmoogra oil as a specific drug for its treatment Venereal diseases, although not well differentiated, received a variety of therapies. In the "Secret Therapy for the Treatment of Venereal Disease", the seventeenth-century physician Chun Szi-sung reported using arsenic, which until the development of penicillin, was the modern medication for venereal diseases In the eleventh century an organization for medical education was set up under imperial auspices Ancient China Ancient Chinese medicine was well-developed long before the beginning of the Christian era. Its influence spread into Korea by the sixth century A.D. At that time, after a severe epidemic had ravaged Japan, Korean doctors were invited to counsel Japanese physicians and introduced them to Chinese medicine. Later, Japanese students and doctors were going directly to China to gain experience. At the end of the eighth century, Chinese medicine was established in Japan and a medical school based on its methodology was founded.