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Shamen and pagan priests used a blend of rituals and medical techniques, to cure ailments. Amongst the ritual and magic, they sometimes arrived at a cure that passed into oral tradition and memory.
Herbs, acupuncture and prayer were commonly used to heal and, whilst eastern practitioners certainly contributed greatly and participated in the sharing of knowledge along the ancient Silk Route, the scope of this article will concentrate on a Euro-centric approach. This western bias also includes the Ancient Egyptian medicine and the Middle East.
The History of Medicine and Ancient Egyptian Medicine
Due to the hot and dry climate in Egypt, ancient papyri have survived intact, allowing historians to study the sophisticated techniques employed by Ancient Egyptian physicians. Whilst couched in magic and ritual, the Egyptians possessed a great deal of knowledge of healing herbs and repairing physical injuries, amongst the normal population and the workers responsible for building the great monuments of that nation.
|Cropped version of image of a prosthetic toe from ancient Egypt, now in the Egyptian Museum in Cairo (Released from Copyright)|
Modern research has shown that these builders were not slaves but highly respected and well-treated freemen, and the care and treatment given for injuries and afflictions was centuries ahead of its time. Early paid retirement, in case of injury, and sick leave were some of the farsighted policies adopted by Ancient Egyptian medicine, luxuries that would rarely be enjoyed by most workers until well into the 20th Century.
The Egyptians made sure that the laborers were fed a diet rich in radish, garlic and onion, which modern researchers have found to be extremely rich in Raphanin, Allicin and Allistatin. These powerful natural antibiotics would certainly help to prevent outbreaks of disease in the often-crowded conditions of the workcamps.
|The Edwin Smith papyrus, the world’s oldest surviving surgical document. Written in hieratic script in ancient Egypt around 1600 B.C. (Public Domain)|
Ancient Egyptian practitioners were also adept at performing eye-surgery, no surprise in the desert where foreign objects blown into the eye could cause irritation. Innovatively, the Egyptian doctors cured Night-Blindness by feeding the patient powdered liver, rich in Vitamin A.
The physicians drew upon a great store of knowledge in the Peri-Ankh, the Houses of Life; here, students were taught and papyri documenting procedures were stored. Physiotherapy and heat-therapy were used to treat aches and pains, and Ancient Egyptian medicine included repairing and splinting broken bones, as shown by successfully healed skeletons. Priest-doctors also practiced amputation, using linens and antiseptics to reduce the chance of infection and gangrene, and there is some evidence that they employed prosthetics where needed.
|Georg Ebers papyrus from the U. S. National Medical Library at the National Institutes of Health. This papyrus recounts the case of a “tumor against the god Xenus.” The recommendation is to “do thou nothing there against.” It is also noted that the heart is the center of the blood supply, with vessels attached for every member of the body. (Public Domain)|
Anecdotal evidence shows that the Ancient Egyptian physicians adopted an ethical code centuries before the Hippocratic Oath, with one such inscription stating that ‘Never did I do evil towards any person’ on the tomb of Nenkh-Sekhmet, chief of the Physicians during the 5th Dynasty.
The information remaining about the medicines and herbs used by the Egyptian physicians is remarkable. Whilst some of the most outlandish cures had little effect, many of the herbs they used have been shown to have positive effects upon ailments and are still used by modern herbalists, thousands of years later.
- Honey: An excellent antiseptic, used to treat wounds, and an ancient cure that is now increasingly used by the British Military to treat burns.
- Willow: A concoction of this was used to treat toothache and willow bark formed the basis of modern aspirin.
- Mint: Used to treat gastric ailments and mint is another cure that is still used today.
- Pomegranate: Used to treat infestations of parasitic worms, and modern scientists have found that the high tannin content of this fruit actually does paralyze worms, known to Ancient Egyptian medicine as the ‘snakes of the digestive system.
|Hippocratic Oath. ‘Twelfth-century Byzantine manuscript the oath was written out in the form of a cross, relating it visually to Christian ideas’ from the Folio Biblioteca Vaticana. (Public Domain)|
The Ancient Egyptians also practiced dentistry and were fully aware of draining abscesses, extracting teeth, and even making false teeth.
The Egyptian physicians knew how to suture wound, placing raw meat upon the wound to aid healing and stimulate blood production. They also used honey, known for its antiseptic qualities and ability to stimulate the secretion of infection-fighting white blood cells. Ancient Egyptian priest-doctors used moldy bread as an antibiotic, thousands of years before Fleming discovered penicillin.
Much of the Egyptian knowledge of physiology undoubtedly derived from their practice of embalming the dead, which allowed them to study the structure of the body. They made some accurate observations about which part of the body was responsible for certain tasks and, despite some inaccuracies due to the limitations of their equipment, they were fine physicians and were unrivalled until the Islamic Golden Age. Ancient Egyptian medicine outstripped both the Romans and Greeks in the level of knowledge and sophistication.
The History of Medicine and Ancient Greek Medicine
The Ancient Greeks, some 1000 years before the birth of Christ, recognized the importance of physicians, as related in the works of Homer, injured warriors were treated by physicians. They continued to develop the art of medicine and made many advances, although they were not as skilled as the Ancient Egyptians, whom even Homer recognized as the greatest healers in the world. Whilst they imported much of their medical knowledge from the Egyptians, they did develop some skills of their own and certainly influenced the course of the Western history of medicine.
The Greeks tended to believe that most ailments could be healed by prayers to the God of Medicine, Asclepius, and the great temples, known as Aesclepions, were where many Greeks went to seek healing, making sacrifices and prayer to the god in return for having their ailments healed.
|Hippocrates Bust (Public Domain)|
However, this all changed with Hippocrates, one of the most famous of all physicians, and his famous oath is still used by doctors today, as they pledge to ‘Do No Harm.’ His most telling contribution to the history of medicine was the separation of medicine from the divine, and he believed that checking symptoms, giving diagnoses and administering treatment should be separated from the rituals of the priests, although most Greeks were happy to combine the two and hedge their bets.
Greek doctors, influenced by Hippocratic thought, would study the case history of patients, asking questions and attempting to find out as much as possible from the patient before arriving at a diagnosis. This two-way interaction between patient and doctor became a foundation of the history of medicine, still used by modern practitioners.
The Ancient Greeks believed that there were four humors making up the body, and an imbalance in these would lead to both mental and physical illnesses and ailments. The balance of these humors would be affected by diet, location, age, climate and a range of other factors, and Ancient Greek medicine was based upon restoring the balance.
The Four Humors were:
- Sanguine: The blood, related to the element of air and the liver, dictated courage, hope and love.
- Choleric: Yellow bile, related to the element of fire and the Gall Bladder, could lead to bad temper and anger, if in excess.
- Melancholic: Black bile, associated with the element of earth and the spleen, would lead to sleeplessness and irritation if it dominated the body.
- Phlegmatic: Phlegm, associated with the element of water and the brain, was responsible for rationality, but would dull the emotions if allowed to become dominant.
Many of the Greek herbal remedies and medicines were based around restoring the balance of humors, and this belief continued in European thought well into the Middle Ages.
The Greeks were also surgeons and some of the equipment they used is recognizable today. Some of the tools of the Greek physicians included forceps, scalpels, tooth-extraction forceps and catheters, and there were even syringes for drawing pus from wounds. One instrument, the spoon of Diocles, was used by the surgeon Kritoboulos, to remove the injured eye of Phillip of Macedon without undue scarring. Finally, the Greeks knew how to splint and treat bone fractures, as well as add compresses to prevent infection.
The Egyptians and the Greeks lay at the root of the modern history of medicine, understanding the value of cleanliness, medicines and the finer arts of surgery. Their knowledge passed down to the Romans, who preserved the medical skills and refined them.
The Romans and the History of Medicine
The Roman contribution to the history of medicine is often overlooked, with only Galen, of Greek origin, believed to be notable of mention. However, this does the Romans a great disservice and they put their excellent engineering skills to use in preventative medicine. The Romans understood the role of dirt and poor hygiene in spreading disease and created aqueducts to ensure that the inhabitants of a city received clean water. The Roman engineers also installed elaborate sewage systems to carry away waste. This is something that Europeans did not fully understand until the 19th Century; before this period, sewage was still discharged close to drinking water.
The Romans may not have understood the exact mechanisms behind disease but their superb level of personal hygiene and obsession with cleanliness certainly acted to reduce the number of epidemics in the major cities. Otherwise, they continued the tradition of the Greeks although, due to the fact that a Roman soldier was seen as a highly trained and expensive commodity, the military surgeons developed into fine practitioners of their art. Their refined procedures ensured that Roman soldiers had a much lower chance of dying from infection than those in other armies.
When mentioning the Roman influence on the history of medicine, the physician Galen is the most illustrious name. This Greek, granted an expensive education by his merchant father, studied in the medical school at Pergamum and frequented the Aesclepions. In AD161, Galen moved to Rome, where he acted as physician to the gladiators, which allowed him to study physiology and the human body.
Later he committed his findings into writing and produced many works about human physiology and the treatment of ailments. As his fame grew, as a physician and lecturer, he became the personal physician of three emperors, Marcus Aurelius, Commodus and Septimus Severus.
When the Roman Empire split into the Western and Eastern Empires, the Western Empire, centered on Rome, went into a deep decline and the art of medicine slowly slipped away, with the physicians becoming pale shadows of their illustrious predecessors and generally causing more harm than good. Western Europe would not appear again in the history of medicine until long after the decline of Islam.
In the Eastern Empire, based on Byzantium, physicians kept the knowledge and the skills passed from the Romans and the Greeks. This knowledge would form the basis of the Islamic medicine that would refine and improve medial techniques during the Islamic domination of the Mediterranean and Middle East. The history of Medicine would center on the Middle East and Asia for the next few centuries.
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Hay fever is a misnomer. Hay is not a usual cause of this problem, and it does not cause fever. Early descriptions of sneezing, nasal congestion, and eye irritation while harvesting field hay promoted this popular term. Allergic rhinitis is the correct term used to describe this allergic reaction, and many different substances cause the allergic symptoms noted in hay fever. Rhinitis means “irritation of the nose” and is a derivative of rhino, meaning nose. Allergic rhinitis which occurs during a specific season is called “seasonal allergic rhinitis.” When it occurs throughout the year, it is called “perennial allergic rhinitis.” Rhinosinusitis is the medical term that refers to inflammation of the nasal lining as well as the lining tissues of the sinuses. This term is sometime used because the two conditions frequently occur together.
Symptoms of allergic rhinitis, or hay fever, frequently include nasal congestion, a clear runny nose, sneezing, nose and eye itching, and excess tear production in the eyes. Postnasal dripping of clear mucus frequently causes a cough. Loss of the sense of smell is common, and loss of taste sense occurs occasionally. Nose bleeding may occur if the condition is severe. Eye itching, redness, and excess tears in the eyes frequently accompany the nasal symptoms. The eye symptoms are referred to as “allergic conjunctivitis” (inflammation of the whites of the eyes). These allergic symptoms often interfere with one’s quality of life and overall health.
Allergic rhinitis can lead to other diseases such as sinusitis and asthma. Many people with allergies have difficulty with social and physical activities. For example, concentration is often difficult while experiencing allergic rhinitis.
The idea of replacing a bad organ with a good one has been documented in ancient mythology. The first real organ transplants were probably skin grafts that may have been done in India as early as the second century B.C. The first heart transplant in any animal is credited to Vladimer Demikhov. Working in Moscow in 1946, Demikhov switched the hearts between two dogs. The dogs survived the surgery. The first heart transplant in human beings was done in South Africa in 1967 by Dr. Christiaan Barnard; the patient only lived 18 days. Most of the research that led to successful heart transplantation took place in the United States at Stanford University under the leadership of Dr. Norman Shumway. Once Stanford started reporting better results, other centers started doing heart transplants. However, successful transplantation of a human heart was not ready for widespread clinical application until medications were developed to prevent the recipient from “rejecting” the donor heart. This happened in 1983 when the Food and Drug Administration (FDA) approved a drug called cyclosporine (Gengraf, Neoral). Before the advent of cyclosporine, overall results of heart transplant were not very good.
What is a heart transplant?
Believe it or not, heart transplantation is a relatively simple operation for a cardiac surgeon. In fact, the procedure actually consists of three operations.
The first operation is harvesting the heart from the donor. The donor is usually an unfortunate person who has suffered irreversible brain injury, called “brain death”. Very often these are patients who have had major trauma to the head, for example, in an automobile accident. The victim’s organs, other than the brain, are working well with the help of medications and other “life support” that may include a respirator or other devices. A team of physicians, nurses, and technicians goes to the hospital of the donor to remove donated organs once brain death of the donor has been determined. The removed organs are transported on ice to keep them alive until they can be implanted. For the heart, this is optimally less than six hours. So, the organs are often flown by airplane or helicopter to the recipient’s hospital.
The second operation is removing the recipient’s damaged heart. Removing the damaged heart may be very easy or very difficult, depending on whether the recipient has had previous heart surgery (as is often the case). If there has been previous surgery, cutting through the scar tissue may prolong and complicate removal of the heart.
The third operation
is probably the easiest; the implantation of the donor heart. Today, this operation basically involves the creation of only five lines of stitches, or “anastomoses”. These suture lines connect the large blood vessels entering and leaving the heart. Remarkably, if there are no complications, most patients who have had a heart transplant are home about one week after the surgery. The generosity of donors and their families makes organ transplant possible.
Who needs a heart transplant?
Every year in the United States there are about 4,000 people who could benefit from a heart transplant. Unfortunately, there are only about 2,000 donor hearts available. Therefore, there is a careful selection process in place to assure that hearts are distributed fairly and to those who will benefit most from the donor heart. The heart is just a pump, although a complicated pump. Most patients require a transplant because their hearts can no longer pump well enough to supply blood with oxygen and nutrients to the organs of the body. A smaller number of patients have a good pump, but a bad “electrical conduction system” of the heart. This electrical system determines the rate, rhythm and sequence of contraction of the heart muscle. There are all kinds of problems that can occur with the conduction system, including complete interruption of cardiac function causing sudden cardiac death.
While there are many people with “end-stage” heart disease with inadequate function of the heart, not all qualify for a heart transplant. All the other important organs in the body must be in pretty good shape. Transplants cannot be performed in patients with active infection, cancer, or bad diabetes mellitus; patients who smoke or abuse alcohol are also not good candidates. It’s not easy to be a transplant recipient. These patients need to change their lifestyle and take numerous medications (commonly more than 30 different medications). Hence, all potential transplants patients must undergo psychological testing to identify social and behavioral factors that could interfere with recovery, compliance with medications, and lifestyle changes required after transplantation.
Moreover, needing a heart and being a suitable candidate are not enough. The potential donor heart must be compatible with the recipient’s immune system to decrease the chance of problems with rejection. Finally, this precious resource, the donor organ, must be distributed fairly. The United Network for Organ Sharing (UNOS) is in charge of a system that is in place to assure equitable allocation of organs to individuals who will benefit the most from transplantation. These are usually the sickest patients.
What are the results of a heart transplant?
When all potential problems are considered, the results of transplantation are remarkably good. Keep in mind that heart failure is a very serious and life-threatening disease. In patients with severe forms of heart failure that require transplantation, the one year mortality rate (that is the percent of patients who die in within one year) is 80%. Overall, five year survival in patients with any form of heart failure is less than 50%. Compare these outcomes with cardiac transplant. After heart transplant, five year survival averages about 50%-60%. One year survival averages about 85%-90%.
What are the complications of a heart transplant?
One might ask, “Why is survival no better than it is after a heart transplant?” Good question. As part of our defense mechanism to fight off infection and even cancer, our bodies have an “immune system” to recognize and eliminate foreign tissues such as viruses and bacteria. Unfortunately, our immune system also attacks transplanted organs. This is what happens when organs are rejected; they are recognized as foreign by the body. Rejection can be controlled with powerful “immunosuppressive” medications. If there is not enough immunosuppression the organ can reject acutely. Even when it seems that there is no active rejection, there may be more subtle chronic rejection that consists of a growth of tissue, something like scar tissue, which causes blockage of the blood vessels of the heart. The blockage of the vessels is the process that ultimately causes the transplanted heart to fail. It is this chronic rejection that is the major limiting factor for the long-term success of heart transplantation.
Unfortunately, immunosuppression is a double-edged sword. While immunosuppression blocks rejection, because it suppresses the immune system, transplant patients are more susceptible to infection and cancers of various types. Among older transplantation patients, as survival has improved, more patients are eventually dying from cancers.
How does a heart transplant patient know if he or she is rejecting the donor organ or developing an infection?
This is not an easy question to answer because many of the symptoms and signs of rejection and infection are the same. These include:
- malaise (feeling lousy),
- fever, and
- “flu-like symptoms”, such as chills, headaches, dizziness, diarrhea, nausea and/or vomiting.
The more specific symptoms and signs of infection will vary greatly depending upon the site of infection within the body. Transplant patients who experience any of these findings need to seek medical attention immediately. The transplant physician will then do tests to determine whether the transplanted heart is functioning normally or not. If there is no evidence of rejection, a thorough search for infection will be performed so that the patient can be treated appropriately.
How is rejection of the organ diagnosed and monitored?
Currently, the gold standard for monitoring rejection is the endomyocardial biopsy. This is a simple operation for the experienced cardiologist and can be done as an outpatient procedure. First, a catheter is put into the jugular vein in the neck. From there, the catheter is advanced into the right side of the heart (right ventricle) using an x-ray method called fluoroscopy for guidance. The catheter has a bioptome at its end, a set of two small cups which can be closed to pinch off and remove small samples of heart muscle. The tissue is processed and placed on glass slides to be reviewed under the microscope by a pathologist. Based on the findings, the pathologist can determine whether or not there is rejection.
Immunosuppressive therapy is then adjusted, for example, increased if rejection is present. Investigators have tried to develop less invasive methods to monitor for rejection. There is a new high-tech analysis that can be done in a sample of blood that is very promising and much easier for the patient than the endomyocardial biopsy. This test looks at the expression of specific genes in cells in the blood. The amount of expression of key genes indicates whether or not rejection is occurring. Nevertheless, so far, no method has replaced the endomyocardial biopsy.
Cost is one reason why more heart transplants aren’t done. The cost is always at least a few hundred thousand dollars. Not all insurers will pay for heart transplant. The longer the recipient lives, the more expensive the transplant. Of course, if the heart lasts longer, the benefit is also greater to the patient and to society. It’s also not easy to qualify for a heart transplant. One has to have a very bad heart but an otherwise healthy body. However, the major limiting factor is the availability of donor hearts. For many reasons, individuals and families refuse to donate organs that could be life-saving to others. Sometimes, even when an organ is available, there is no good match. Other times, there is no way to get the heart to a suitable recipient in time for the organ to still be viable.
What is the future of heart transplant?
There are several ways to help patients with end-stage heart disease. One is to get more donors for heart transplant. This will require teaching people the benefits of transplantation in hope of changing society’s attitudes. Better methods of preserving organs and preventing and treating rejection are constantly being developed. In the end, however, there will never be enough donor hearts. Indeed, artificial hearts already exist but have a limited life-span. Patients with artificial hearts are at high risk of developing infection and blood clots related to the device. Better devices are being developed all the time. What about the use of animal organs, also calledxenotransplantation? These organs are too “foreign” and thus the problemswith rejection are currently insurmountable.