Babylon to Birmingham

A short journey through medicine to the end of the 18th Century

Marion Roberts

That the intelligent man desires health above all else is both a platitude and a fundamental truth. The fact that we seek health implies the fact of disease.

The Roman School put forth the idea of a Golden Age, healthy happy and wise. Science coldly brushes this aside, announcing that germs are as old as earthly life itself and that bacteria can be traced right back to the Carboniferous Period, some 16 million years ago and there is evidence to show that disease was a factor before man appeared. Bone tumours have been found in animal fossil bones and micrococcus and diplococcus types of bacteria have been discovered in coal deposits in the Carboniferous Period.

When we come to prehistoric man, though, it becomes somewhat more difficult. Pathological evidence is scanty and is limited to bone changes. Actual prehistoric medicine was practically non-existent although evidence exists of trephining of the skull (in Neolithic times), spondylitis deformans, a painful stiffening of the spine, tuberculosis of the spine, fractures, great evidence of arthritic afflictions and dental caries.

It is hard to believe that prehistoric man made no attempt to deal with these conditions. If early man was intelligent enough to fashion tools and weapons, it is not unreasonable to argue that he would devise or discover some methods of dealing with disease.

Natural phenomena would first come to mind: thunder, lightning, storm – magical forces, to be harnessed and used by the medicine man or priest. Witchcraft, against the evil spirits whose name is Legion, to be used alongside “domestic” remedies which did not require the specialist’s attention: herbal poultices for wounds, bleeding for headaches, leeches for local pain, vapour baths for rheumatism, chants and amulets tied onto the patient and lotions for the skin.

If there is one fact that stands out more clearly than any other throughout the history of medicine, it is that magic and superstition are inevitably associated with it in all civilizations and in all ages, with a few brief centuries standing out: the 4th and 5th of the Greeks. The 1st BC and 1st AD of the Romans and our own from the 18th century.

The Sumerians of Babylon were skilled in their knowledge and exploitation of desert herbs: frankincense, myrrh, balm of Gilead, laudenam and many others and this knowledge must have been at the disposal of the highly cultured men of Ur, Kish and Akkad, that seat of the most wealthy and cultured dynasty.

In the Indus Valley, hygienic ideas of an astonishingly high level have been discovered – bathrooms with waterproofed brick floors, latrines in private homes, socketted drain pipes to carry sewage away to holding tanks, when in England at this time, Bronze Age people were living in mud huts.

Their physicians dealt with diseases of the head, mouth, nose, eyes, ears, stomach and digestive system, with ulcers, poisons, swellings, the condition of the urine and with childbirth. Their medicine declared it was “necessary to confuse and disgust the demon”. For “demon” read “microbe”, so a genuine remedy was compounded to that effect: turpentine with a green frog, sesame with doves dung, cherry with antimony, even powdered old shoes!

The Sumerians knew about enemata and suppositories, poultices, mustard plasters, compresses, salves, eye washes, ointments, liniments, and aperients. They used opium, artemesia, balsam, sagapenum, licorice root, mandrake, sumach, fennel, plantain and solanum.

The physicians of Babylon had reached and passed the border of the land of genuine medical science and they should receive great credit for the development of true medicine and hygiene.

The Egyptians, on the other hand, did not advance the science of medicine to any great degree. As in Babylon, the priest and physician were closely associated. Physicians were men of honour, becoming, in some cases, demi-gods. The early Egyptian, Imhotep, physician to Zoser, (2000 BC), was such a man, as were Nenekh and Sekaret in the 5th Dynasty. Women were also now becoming physicians.

The Egyptians great art of mummification shows their detailed knowledge of the human body and its functions, and most of the diseases and conditions from earliest times down to the present day are still in evidence as shown in papyri discovered about 140 years ago. Again, magic and treatment go hand in hand.

The Egyptian pharmacopaeia was elaborate and highly developed. Some of the crude vegetable drugs are still in today’s pharmacopaeia: aloes, carraway, castor oil, coriander, dill, fennel, juniper, mint, myrrh and turpentine. These were also known in antiquity.

Their methods of treatment and application of remedies are worthy of great respect. Directions found in papers as to the administration of drugs are entirely modern. Quantities are minutely specified in prescriptions and instructions to the patient are very detailed.

The physician co-operated with Nature, often doing nothing but putting the patient on a normal diet and awaiting results. But if their system of drug treatment was sensible and soundly based, their appreciation of hygiene ran alongside, reaching a high stage of development.

The priests set the standard: six hourly baths, body shaving at 3 – day intervals and spotless white clothing. They knew the value of fresh, clean air and the custom of administering emetics and enemata for 3 consecutive days each month.

But it was to be the curious, eager Greeks who pushed the boundaries of knowledge and experience which we now know as science. They built on the foundations laid down by those who went before. In Greek thought, everything is clear cut, sharp and defined. They took all knowledge into their domain, pursuing it by such scientific means, that succeeding ages have found no need for improvement.

It was Empedocles of Agrigentum, physician, physiologist, poet and traveller, who took the primary principle of “pneuma” as the breath of life and heat and moisture as the fundamental qualities of the body. He taught the 4 Elements: earth, air, fire and water, and the 4 Qualities: heat, cold, moisture and dryness, to produce his doctrine of the ‘Humours’ of the body which came to dominate medicine till the Renaissance, when Greek science came to light again.

Empedocles developed the important principle that health depends upon harmony of the elements within the body, disease depends on its discord. He regarded the heart as the centre of the body system and that blood was the life and seat of innate heat. He seems to have earned great fame in 480 BC, by draining the marshes in the Sicilian town of Selinos, staying the plague of malaria which was devastating the town.

Public medical services were started and state physicians were appointed, their services being much esteemed and keenly sought.

Temples to the divine Asklepios were built and included ablutons and airy, sleeping places for the sick, where, after performing ritual washings and sacrifices, the patient lay down at night. The priest recited ritual prayers for divine help and according to inscriptions, the god frequently appeared in the dreams or in person at the patient’s side, diagnosing the ailment and suggesting the treatment. Just how drugged the patient was, or how often the ‘god’ was the priest in disguise, is not mentioned!

It is thought the Asklepaeion was probably the prototype of the modern hospital, since patients were received for differing periods of time, attention was paid to diet, exercise, massage and bathing.

Greek hygiene was advanced. Each big house had an outside room, with a large stone basin for bathing and windows were open to all points of the eastern horizon to ensure that the house was bright, sunny and well-aired. Town planning, street arrangement, water supply and sewage disposal were all considered and regulated.

The father of all medicine, the great Hippocrates, was behind all Greek medical writing and best practice until barbarian darkness descended. He knew nothing of bacteria or infection. His store of medical knowledge was small, but he did know something of disease and of its cure. His ethic established the highest set of ideals which are still acclaimed by the profession today. The essential simplicity of Hippocrates treatment is its unpretentious nature, its complete lack of diagnostic boasting or loud promises of cure.

The regimen is mild. A few drugs: hellebore and other simple purges, herbal drinks made from raisins, wheat, saffron and pomegranates, barley gruel and barley water with hydromel (honey and water), as a soothing drink and oxymel, (honey and vinegar), as an expectorant. Bathing, wet and dry fomentations, bran poultices, enemata and suppositories, were used, all under careful direction.

Malaria he considered the greatest foe. Mental and physical prostration, was named melancholia. Other named diseases were: diarrhoea, dysentery, pleurisy, pneumonia, consumption and ophthalmia.

After the passing of the Hippocratic School of Common Sense, the scientific spirit seemed to weaken. Sectarian disputes and charlatanism appeared, quacks of all grades did a roaring trade, paying lip-service to the Master. Nevertheless, the next centuries saw progressive ideas and advancement was made through such colossal figures as Aristotle, who gave medicine its real beginnings in botany, comparative anatomy, embryology, and physiology. His ideas were to determine the direction of medical thought. His doctrine of the four qualities and elements, together with the Hippocratic ‘humours’, remained the medical ‘arch’ for well over 2000 years.

Many sectarians were to arise over subsequent time:

Empiricists, who despised anatomy and rejected theorizing, producing instead the idea that medicine could be reduced to a ‘rule of thumb’ treatment for classified sets of symptoms and specific drugs that of themselves could cure these particular symptoms and diseases.

Methodists, whose theories were that diseases could be put into ‘communities’ of symptoms and that they could be treated with astringents or laxatives accordingly, without reference to cause. They also despised anatomy.

Dogmatists, who indulged in great speculation based only on a very small amount of theory and who declared there were 11 ‘humours’, instead of the Hippocratic 4.

Eclectics, a general philosophical, dilettante school who did little for the progress of medicine.

Moving ever westwards, now from Greece to Rome, the medical men discovered that not only were they despised, there was no science or medicine allowed – the Roman religious system forbade it.

All symptoms and diseases were under deities and the head of the household was his own physician, using just a few, simple herbal remedies.

Almost anyone could be a doctor, a medicus. No qualifications were necessary, just reputation. In Rome, even the half-educated and untrained man could be a specialist, all that was needed was a little surface knowledge of a portion of a subject!

And so the stage is set for the last great figure in ancient medicine.

Claudius Galen, who, though inferior to his master, Hippocrates, knew that all his world had knowledge and he set about systemising medicine, anatomy, physiology and disease, thereby giving to the world the ‘law’ in these ‘departments’, which no-one was able to improve on for 1200 years.

Galen attached considerable importance to clinical observation. His method is scientific, but, being obscured too often by his methods of study, he never gives a clinical history, such as was had from Hippocrates. Nevertheless, he paid close attention to dietetics, gymnastics, massage and a great variety of baths and is accepted as being the greatest master of the scientific method.

As with the theory and practice of medicine in Rome at that time, their system of hygiene and hospital is excellent. 14 great aqueducts supplied the capital with its daily drinking water. Every private house had its service pipes, cistern and taps. Drainage was at a high stage of development and the river Tiber received it all.

The hospital system, which grew out of the Health Temples of earlier times, was an organisation which grew out of military needs. There were hospitals already open to the public, rich or poor, often of considerable size, but it was the Roman military, with its long campaigns in far countries who laid down the rules.

They had their appointed surgeons and medical officers, wards were arranged around long corridors, with administration, kitchens, an apothecary’s shop, dining area and orderlies all at one end. No expense was spared in the medical care of the army!

Then came the Barbarian, who made a wilderness. The Dark Ages had arrived.

All classical knowledge was condemned as pagan. Science and investigation was declared unnecessary. Although monks, as part of their rule of charity relieved the sick, playing the part of physician, they were, in general, forbidden to do so. Even when they, themselves were sick, they were forbidden to have anything to with physic(k) and must not use earthly remedies to ensure salvation. Prayer was all that was required.

Simple medicine – by the use of a ‘simple’ – a medicine derived from one plant – were starting to be used extensively. Magic and superstition again abounded. Magicians and quacks were everywhere once more, with their charms, exorcism or their disgusting remedies used to ‘nauseate and drive out the demons’. Yet in the background, the 4 ‘humours’ remain.

In Europe, the Dark Ages finally came to an end. Fears and thoughts of an early end to the world died down and the spirit of humanity began to make its vigorous rise, with new movements, social, political, religious and intellectual, yet advancements in science and in medicine in particular, were small.

The new Arabic translations were eagerly accepted and studied, but, over time, little substance of the Greek originals was left. The 13th and 14th centuries knew and practised very little of the work of Hippocrates and Galen. Their texts were corrupted, their words being twisted out of all real meaning by practitioners, yet these translations and commentaries were responsible for the first revival of learning, leading to the beginnings of the universities, teaching being by word of mouth for it was a bookless age.

Medicine, at this time, ranked low in university faculties, so the great figures in medicine studied, not at one university, but at all. This was a significant change. Before, learning hardly existed outside the Church. Literate man was in Holy Orders of some kind, but knowledge was now opening its bounds, and it was free. At most universities, medical degrees of bachelor, licentiate and doctor were given. All over Europe, medical learning was on the rise, but at this time, was not worth following.

The 4 ‘humours’ were still there but were now elaborately sub-divided. Nearly all diseases were bled, the drugs used were experimental and, in the main, had no effective result. The drug most widely used was:  Therias or Universal Antidote – the name given to Venice Treacle, a celebrated mixture of 64 drugs, prescribed for poisons and as a preventive of disease.

Hygiene had reverted to the semi-barbaric. Everywhere was squalor and quackery. There was a lack of drains and a poor water supply and it was only at the end of the 14th. century, after plague had struck, that the first Sanitary Act was passed. Scavengers and Sanitary Watchmen were appointed. Care of the sick was now being developed into the semblance of a hospital system.

The 15th century brought a tide of humanity from East to West, accentuating the change in intellectual development. Clerks became busy, copying out the new marvels. The actual words of the classical Masters could be read and there were, at last, men of the Greek tongue, ready and able to interpret the documents and to teach.

The advance in scholarship, though, was not equalled by the advance in medicine. Here, the dead hand of medievalism persisted. Oxford slept while Avicenna ruled. Astrology and horoscopy required that the medical man should possess mathematical skills.

Uroscopy, diagnosis by inspection of the patient’s urine, another medieval factor, was still to the fore and was used as a means of cloaking the physician’s ignorance.

So was the general condition of medicine.

It took men like Thomas Linacre, who became physician to Henry V111th. and from whom he obtained a charter constituting the Royal College of Physicians. Nine years earlier Henry, who was much concerned with the medical profession, had issued the first English Actregulating medicine, requiring examination and licensing, and forbiddding others: empirics, quacks and illiterate monks, to practice. Now, licenced persons were allowed to practice within an area of 7 miles around the City of London. He also incorporated the Barber Surgeons and the Apothecaries.

John Cairns (or Kaye), was another such physician. He was acknowledged as the founder of the study of Anatomy and author of a treatise on Clinical Medicine.

So the world, once again, was in possession of the true wisdom of the ancients, even though such knowledge did not materially alter the current medical practice. What it did was, indirectly, to arouse a spirit of enquiry which brought medical science into being.

The Elizabethan period brought great activity and military adventure. Surgeons were attached to the Crown forces, there was public concern for the purity of water, the prevention of nuisance and the cleanliness of roads and streets. Town Ordinances were issued dealing with these matters.

The Renaissance may have been an age of enlightenment but with medicine it was still a dark age, clinging to sorcery, astrology and religion.

Prescriptions at this time often seem like those from Ancient Egypt: bile, dung, urine and sweat were features, to be taken according to astrological indications. Even Boyle, the first great chemist, suggested powdered mistletoe for the ‘falling sickness’ – ‘as much as will sit on a sixpence, taken early in the morning in black cherry water, for some days before the full moon.’ Whilst in Paris, the King’s physician asserted that it was ‘absolutely necessary, in medical practice, to have a knowledge and understanding of astrology,’

The ‘touching for the King’s Evil’ (Scrofula or Tuberculous Glands of Neck), continued until stopped by William of Orange.

The 17th century saw the birth of modern physiology and in particular, the discovery, by William Harvey of the Circulation of the Blood. Until then, Galen’s theory still held: that the body continually manufactured fresh blood to replace the old, stagnant blood, which was then eliminated. Harvey believed through his research, that blood circulated, but he was loath to publish his findings in case they jeopardised his future. He waited for over 10 years before doing so and his treatise, Exercitatio de Moto Cordis et Sanguinis is considered to be one of the greatest landmarks in medical research. He was made a professsor in 1615 and later became the King’s physician.

The year that Harvey’s research was published, Marcello Malpighi, was born in Italy. He was destined to become Professor of Theoretical Medicine in Pisa while still in his 20’s. He was the first to use the microscope for systematic anatomical research, to investigate the individual organs of the body and, in the process, to complete Harvey’s work by discovering how blood flows from arteries to veins.

There were young men, average age 34, who, with Harvey met at The Mitre, Wood Street, London and later elsewhere, where they confined themselves to the study and discussion of Natural Philosophy, Physic, Anatomy, Geometry, Astronomy, Navigation, Statics, Mechanics and Natural Experiments. Men such as: John Wilkins, the great thinker, Seth Ward and Laurence Rook, astronomers, Robert Boyle, chemist, William Petty, who became Cromwell’s first Army physician in Ireland, Matthew Wren, Jonathan Goddard, noted for his drops, Thomas Willis and Ralph Bathurst, physicians, Francis Glisson, who would write a classic work on Rickets and the young Christopher Wren. They took the whole of Natural Science for their field and their meetings became a ‘clearing house’ for scientific information.

Out of this nucleus, in 1662, by Royal Charter, came the Royal Society of London.

To the members, the Natural World must have been like a new and wonderful box of toys and a great spirit of curiosity was abroad. The invention, in Holland, of the microscope, was to open up new and amazing fields of research : bacteriology, histology and protozoology. It was like a miracle! Those things that were hid, were now uncovered.

One name, in this country, associated with bacteriology, is Robert Hooke, curator of experiments at the Royal Society, whose discoveries were the foundation of the Cell Theory. In Holland, Anthony van Leeuwenhook’s work among microscopes was vast and extended over a great many years. He was the first to see the complete Circulation of the Blood which Harvey had described and proved.

In spite of all the research that was going on, the poor patients in English towns and villages saw little or no benefit. The practical application of medicine was lagging far behind. Mountebanks and quacks again were everywhere, physicians, surgeons and apothecaries were in constant war with each other. It was time for examplars of duty, shrewdness, common sense and natural kindness, who thought more of the patient than all the philosophising going on.

One such was Thomas Sydenham – the embodiment of all those virtues. Over 40 when he qualified at Oxford, he did for 17th. century medicine what Hippocrates had done 2000 years before. He believed the life force must be assisted, stimulated and kept in trim. Everything he prescribed, from fresh air to beer, was to be taken in moderation. He used ‘simples’, such as the juice of willow leaves, prescribed for fevers. (We now know it as Salicylic Acid or Aspirin).

He determined that ‘ the patient’s symptoms are not the effects of the disease but of the body’s struggle to overcome it.’

He was a soldier under Cromwell, a Puritan, who saw clearly that the physician had to return to the bedside, to aid, with the help of nature and by direct observation and experience, together with a little patience, to discover what needed to be done. He took copious notes so that they could be of use, not only to him, but to those who came after. He was greatly interested in epidemics and fevers and he wrote detailed accounts, season by season, for 15 years.

He also wrote on Gout, Scarletina, Measles, Pneumonia, Dysentery, Chorea and Hysteria. Writings which have served as models for clinicians and pathologists ever since.

Though no believer in specifics, Sydenham gradually came to use, to a greater degree in the treatment of fevers, Peruvian Bark or Cinchona, from which quinine was extracted.( A recent innovation, it was first brought to notice by the Jesuits in South America and brought to Europe by the Countess of Cinchon in 1640.)

He insisted on well-ventilated sick rooms. He distrusted London water. For him and all his patients the right beverage was small beer. He most certainly possessed the love and friendship of all for whom he cared and all his human qualities were given freely to suffering mankind.

Alive, Sydenham was vilified as an imposter but Time would avenge him. His was to become the most respected name in the history of British Medicine. So simple, so English and so straightforward.

Within the profession, though, dissatisfaction continued. They longed for a better understanding of disease and how to treat it.

The 100 years of the 18th century saw the most extraordinary stirrings of conscience.

It began the modern era of trade and industry almost overnight and physicians had to face all the problems connected with larger towns and a more ‘standardised’ life.

The factory came into being, the battle for hygiene was started and in addition to the questions put by the physician to the patient, another was added: ‘What is your trade?’

Always aware of the dangers of epidemic, City and Town Fathers start to wonder how they could arrest any contagion which may now threaten. Dr. Richard Mead, a good physician, when asked by Government, recommended:

– quarantine methods of precaution, suggesting official ‘Searchers’ should find out where in the neighbourhood pestilence or contagion was to be found,

– that people infected, should be removed from their homes and, after being stripped, washed and shaved of bodily hair, all their goods and even their house, if possible, should be burnt,

– streets should be washed down regularly and nuisance removed

– beggars and idlers should be put into hospital, workhouse or asylum.

He also spoke of the dangers of lead for piping or storing liquids, reference being made to Vitruvius and Galen. He also recommended a Police Service. All this was to develop eventually into the English Public Health System.

Sir John Pringle, Physician-General to the Forces, 1742 – 48, knew that Typhus or Jail Fever, a rampant disease, was spread by lice, passing from the sick to the healthy, either directly or by clothing or bedding.

He knew that overcrowding and dirt greatly increased the risk of infection and that personal cleanliness and space, plus ventilation helped get rid of the contagion.

James Lind, physician at the Royal Naval Hospital, Haslar, Portsmouth, for 25 years from 1758, also regarded ventilation, cleanliness and diet as absolutely essential to the care of the sick. It was he, who, concerned about the prevalence of scurvy on long voyages, due to the lack of a vegetable diet, recommended lemon juice as treatment, with amazing results.

At last, we see that innate desire in man, not only to help his brother, but to alleviate the lot of the unfortunate and stricken.

The medical literature of the 18th century is bewildering in its profusion. As medical science continued, so did the written word – if not a book, then a pamphlet – and there are thousands of them!

Edinburgh rose steadily to be among the greatest of the Medical Schools with William Cullen, Professor, whose ‘Lectures on the Materia Medica’ and ‘First Lines on Medical Practice’ sealed his great reputation, and  Alexander Monro, who, at the age of 24, became Professor of Anatomy. He was a pupil of Boerhaave at Leyden, one of the greatest teachers medicine ever had and whose influence we can trace down to today.

John Fothergill, a good Quaker physician, described Diphtheria, William Heberden wrote a book on ‘The History and Cure of Diseases’ and was known as a truly great physician.

The theories of medicine having now been researched, the actual body of man, both living and dead, could be explored.

It was an Italian physician, Giovanni Battista Morgagni who created the science of pathology using clinical detail of the ailment and post-mortem revelation – all recorded in great detail. But it was slow to make an impact in this country. It took the brothers, William and John Hunter, to change all that.

William Hunter had studied anatomy under Monro and became the prime force in anatomical instruction when he came to St George’s in London. Such lectures had never been delivered before. He built the Theatre of Anatomy in Great Windmill Street and so transformed anatomical instruction.

John, his brother, eight years his junior, came to London and became William’s pupil. Later, he, himself, gave lectures on surgery and anatomy. By his detailed work in Nature and Animal Studies, he foreshadowed the concepts of physiology, biology and pathology. He was also at St. George’s Hospital, practising surgery, not as an empirical necessity but as a branch of physiology and pathology. John Hunter was undoubtedly the greatest pathologist the world had seen.

Sir John Floyer of Lichfield, was to study the pulse. To feel it, and to improve it with the help of a Pulse Watch: a watch that divided up the minutes,(watches at this time had no hands), to record the seconds.

The great Erasmus Darwin, also of Lichfield, whose extraordinary insight in physics, chemistry, geology and all aspects of biology was to make him one of the foremost physicians of his time.

Other physicians on the Continent were adding to knowledge:

– Annenbrugger, an unassuming Viennese physician wrote a book on the correct way to examine and sound the chest.

– Réné Laennec, who discovered the stethoscope, helping physicians to listen to the sounds of the lungs, pleura and heart.

And, of course, here, the great Edward Jenner, who studied under John Hunter. Famous for his work on Smallpox, it was he who pioneered vaccination against the disease and whose evidence, when presented, assured his triumph.

So, gradually, the gaps were being filled and the solid basis was being constructed on which would be built the astounding edifice of 19th century medicine.

However, it would not be right to leave the 18th century without reminding ourselves of its achievements. Amid wars and upheavals, science went on to great things – the rise of pathology, the development of the idea of hygiene, specialisation in children’s diseases – this was a century of the practical service of mankind.

Yet there is still one more outstanding achievement to be mentioned. The discovery and use, by William Withering, a Birmingham physician, of Digitalis, obtained from the foxglove and used in the treatment of Heart disease and Dropsy. It has been classed as one of the greatest discoveries in medicine and alongside Aspirin is still in use today.

Marion Roberts.