| |
Ars
Medicina: Quo Vadis?
--
PROF J. MANRAKHAN
I
roamed the infinite sky, and
Soared
in the ideal world, and
Floated
through the firmament But
Here
I am, prisoner of measurement
--
Kahlil Gibran (1883 – 1931)
Just
where is the art of medicine heading? It arose with early
humans, before Civilisation had even emerged in the great
river valleys, and elsewhere, it enriched many a myth and
folklore: from the Epic of Gilgamesh (2750 – 2500
BCE), where the Sumarian ruler attempted to discover
immortality, to an early Persian goddess, named precisely Immortality;
from the Greek goddess, Hygeia (leading to the word
‘hygiene’); to the celebrated Code of Hammurabi, in
Babylon, prescribing fees and penalties for the medical
profession, from the ‘demonic theory’ in Mesopotamia and
the Nile Valley, whereby illness was caused by ‘evil
spirits’; to the Ebers Medical papyrus (1600 BCE) listing
47 diseases with their symptoms, diagnoses and
prescriptions, and the earlier Edwin Smith surgical papyrus;
‘yin’ and ‘yang’ interactions and the search of the
pill of immortality in China and elsewhere; Vedic medicine,
leading to Charaka (2nd century) and surgical Surusta
(5th century).
From
time immemorial, humanity has been deeply preoccupied with Good
Health, over and above ‘Know –Thyself, and
beyond the shear absence of ailment, malady, physical and
mental disability, all the while abundantly fascinated with
the lure, and lore, of immortality.
Round
About A Name
But
what is ‘Medicine’? It is a term from the Latin ars
medicina, meaning ‘the art of healing’, an art based
on natural and social sciences. Even so, the Concise Oxford
Dictionary is rather ambiguous concerning whether surgery is
strictly part of medicine or not:
Medicine:
1. The science or practice of the diagnosis, treatment and
prevention of disease, esp. as distinct from surgical
methods;
2. any drug or preparation used for the treatment or
prevention of disease, esp. one taken by mouth;
3. a spell, charm, or fetish which is thought to cure
afflictions
Surgery:
the branch of medicine concerned with treatment of
disorders of the body by incision, manipulation or
alteration of organs etc, with the hands or with
instruments.
Oh,
Oath! Hail Humours!
The
first truly (Western) scientific medical doctor was Hippocrates
of Cos (b. 460 BC) whose ideas – and celebrated Oath
-- have prevailed even unto modern times. Medical
practitioners, by the Oath, would swear to treat their
patients with all the skill they possessed, to help the sick
and abstain from harming or wronging them, to never betray
secrets, and inter alia be ‘chaste and
religious’. GER Lloyd: Hippocratia Writings;
Pelican, 1972; p 65).
A
major premise of his was the existence of four fluids or
humours in humans and higher animals: (i) blood; (ii)
phlegm; (iii) yellow bile or choler; and (iv) black bile or
melancholy, in counterpart to the four basic ‘elements’
thought to characterise nature (fire, air, water and earth).
A perfectly sane and healthy person was meant to have an
exact balance of humours. Most people, however, would have
more of the one than of the others. Thereby, ‘complexions
or temperaments’ arose, thus ‘sanguine’ (confident and
hopeful); ‘phlegmatic’, (cold, not easily exited);
‘choleric’ (angry, excitable); and melancholic
(depressed, sad). Indeed failure of humours to balance was
thought to lead to breakdowns in sanity and physical health;
the duty of medicine was to bring about a better balance.
The theory of Humours lasted until the 19th
century and constituted the most important feature of
ancient Western medicine.
Schools
and Revolutions
Medicine,
then, has had a long, proud and glorious history, spanning
various approaches, Schools and Revolutions. Not excluding
controversies, to which we next turn.
Socio-Medical
Ethnics
However,
medical progress also leads to poignant decisions:
health-for-all or expensive high-tech medicine for a few?
Caring for how many very old (again expensive)? Or
euthanasia? How far are we from the old Greek tradition of
complete well-being, social, spiritual and physical? To what
extent will a human remain a collection of mechanical parts
rather than an organic whole in terms of medical and health
services practitioners? And, as the New Scientist (12
July 2008 p3) remarked ‘If it is OK for a mother to pass
on a kidney to a daughter, how can we object to her pass on
a womb?’ And what about Quality of Life -- and of Death:
Who decides? Indeed, Who decides Who Should Decide? How?
Fall
and Rise
But,
undoubtedly, one of the major cases of social injustice in
medicine has been in the treatment of women in the various
professions involved. The ancient Greeks, and therefrom, the
Roman Empire, were both relatively fair towards women
doctors matrons, midwives and others. Then the Dark Ages
descended and seemingly lasted until close to the 20th
century for those professionals not only in terms of
university medical and health studies, as well as careers.
Even now, promotions and top posts are unevenly distributed
by gender, and otherwise, in most countries, bar a few.
Literary
Light
From
Chaucer’s doctour of Phisik who knew the causes of
‘everich maladye’ and loved ‘gold in special’
(1340-1400) to Ode to Dr Harvey by Abraham Cowley
(1618-67) and ‘In memory of Sigmud Freud (d, Sep 1938)’
by W. H. Auden (1907-73), not to mention Morris Bishop
(1893-1973 and his Adventures of Id, concerning Ego
and Super Ego, while psychoanalysis, often regarded
as the nearest medicine comes to natural science, is deemed
as ‘the treatment of the id by the odd’ (New
Scientist 18 Sep 1989 pp 49 – 53) -- we have travelled
a long way. In ‘The Belly and the Limbs’ William
Shakespeare (1564-1616) apparently drawing from Hindu
sources, traced the flows feeding heart, brain, ‘strongest
nerves and mall inferior veins’. Indeed all the works of
the Great Bard have been scrutinized to unravel the medical
complaints and aliments described in them so as to examine
the state of knowledge and the practice of medicine for the
periods concerned.
Much
more recently Isaac Asimov and George Randall in The
Misunderstood Clone showed present-day relevance in the
following lines (quoted from Scientific American, May
1997).
Then my
own little clone
Will
be of the opposite sex.
Will
the change of sex become a mere routine? Will the male
become redundant? What about Medical Nemesis – the
counterattack of Ivam Illich against large-scale animal
experimentation to discover safe pharmaceuticals for humans?
And societal accountability?
The
Twaining of East and West
On
a more constructive note, let us listen to Professor Robert
Winston, somewhat away from Fertility studies at the
University of London, in his highly sensitive and
informative text “The Story of God’ (BBC; pp 107
– 108) Yoga, through disciplines of posture, breath
control, fasting, exercise and meditation sought to
discipline the senses, detaching them from the external
world and turning them in upon the mind, and the reality
that lay behind the mind itself. And then there are
wholesale benefits from acupuncture, to unblock ‘chi-flows’
(breath, energy, life force); as well as herbal medicine.
East and West now appear to the meeting ever faster with
growing medical tourism (see later) And who knows, the
twaining way may be also more symbiotically beneficial,
between analysis and synthesis, the mind – brain – soul
interactions baffling science, philosophy and religion.
WHO
The
World Health Organisation (WHO), has over its long
existence, encountered many a critic, opponent and supporter
(eg. tobacco smoking; radiation and cancer; cannabis;
antibiotic; tolerance and resistance). Research, development
and extension areas which appear to be of vital importance
world-wide: first, the search for cheap cures for diseases
of greater significance for the developing world for which
pharmaceutical firms have little or no financial incentives;
second, HIV, malaria and other vaccines; third, global flu
epidemics and their containment; fourth, re-emerging old
diseases (e.g. diphtheria and tuberculosis); fifth,
auto-immune diseases; and so on. Strong stands taken by the
WHO and certain governments have led to a more constructive
approach towards cheaper pharmaceutical products from
multinational firms.
Patients’
Power: Medical Tourism
The
Human Genome Project is already proving its worth, with a
whole range of genetic diseases being tracked and analysed,
whether monogenic (e.g. muscular dystrophy) or multigenic
(diabetes, hypertension, various cancers, psychiatric
disorders). Hopefully these and other projects will lead
towards a customized and personalized medicine, within a
much wider knowledge base, another medical revolution.
And
yet another. Fed up with all the rows (and expenses)
relating to new medicines, patents, and the like, patients
are now movipg in to support and perhaps, ultimately,
control medical research (New Scientist Feb 2001).
And the medical profession speaks, increasingly, of patient-centred
health care. Already registering successes patients’
power is simply another form of consumer strength, with
a global voice, demanding a seat at the negotiating table,
empowered to speak clearly and forcefully for the
application of 'good' science for alleviating problems of
ill health And who knows where this dual revolution might
not lead? Patients’ power has now moved into imports and
exports (see The Economist, 16 Aug 2008; pp10, 65 –
78). The leader entitled ‘globalisation on health’;
ended if governments make the best of the boom then
medical tourism should improve the health of rich and poor
alike, people and countries right across -- Mauritius
included, obviously.
Dodoland
Musings
It
is commonplace to blame politicians or much-harassed staff
for all ills, medical and otherwise. But that is too easy,
far too much for real comfort. And instead of finding
ready-made, if unrealistic, answers, why not focus on some
questions instead. Let us begin with three, to be further
reshaped and refined, at popular will:
-
Who really and effectively ‘guards the guardians’ of the
famous Hippocratic Oath….?!!! Ah well, there is always the
private – radio network.
-
Should the Government of Mauritius not think in terms of
‘buying, borrowing or stealing’ a pure mathematician
from WHO or a friendly country, to monitor periodically our
health-systems’ analysis – and -- forecasting processes,
now more than a decade old?
-
What about plain truth, plus bringing health consumers on
board on any Health PR exercise, rather than massive
spin-doctoring which generally boomerangs -- sooner or
later?
Towards
Immortality?
The
alchemist’s dream of an elixir of life depended crucially
on finding out appropriate answers to the question of why
living organisms age. Today, it appears that while medical
science may not be able to ‘abolish death’, it may yet
succeed in postponing it for much longer than is presently
the case, essentially through a remedial strategy involving
management, stem-cell therapy and proper diets and exercise,
among others, but all the time working with nature rather
than against the latter. As The Economist stated the
unlikely dream to live forever ‘no longer looks
impossible’ (9 January 5th 2008, pp 64-66).
Of course there is always the other way: is there not? That
would be the very special way described by Robert Browning
(1812-89) concerning a ‘sanguine proportioned… wholly
laudable’ fifty-year old man who died. And was then ‘restored
to life by a Nazarene physician of his tribe’. The
man? Lazarus, no less.
A
whole range of ‘promises to keep’, for medicine no
doubt. But should the related responsibilities lie with
medicine alone?
Annex
from Galen to Nano-Robots: A Brief History of (Western)
Medicine
Greek
medical knowledge spread with Alexander the Great (4th
century BCE). The first of the world’s great medical
schools (as far as we know) was the one at Alexandria, with
unique knowledge on embalming, even if it shunned anatomy.
On mainland Greece, by the 3rd century BCE,
arteries and veins were being distinguished, ideas on the
nervous system developed, and explanations provided on
respiration (breathing), while bleeding became a standard
technique. The Empiric School had begun, based on
observations, records and judgments reached by analogy or
comparison. It was to underlie much of Roman medicine, whose
earliest work De Medicina (concerning Medicine), was
written by Cornelius around the year 30. Highly proficient
in surgery and nutrition, Roman medicine, with public
hospitals, constituted a kind of National Health Scheme,
with an even more comprehensive service for the armed
forces. The Greek Galen (c129-199) was the most famous of
the doctors of Rome. His theories became conventional wisdom
in Europe until the 17th century. Elsewhere, in the
countries of Islam, medical knowledge developed along new
lines (and texts) from the 9th to the 12th
century and served to gradually enrich Western medicine,
which also interacted subsequently, with Vedic and Chinese
medicine.
More
medical schools were set up to achieve fame at Salerno (11th
century), Bologna (12th century)
and Montpellier (13th century). From the 13th to the 16th
century there were small, yet important, advances; more
accurate knowledge, more widely practised, and somewhat
safer, surgery along with the making, and recording of case
– histories. But it was also the period of the bubonic
plague (the ‘Black Death’) which decimated one-quarter
of the population of Europe, and against which medical
knowledge then appeared powerless.
By
the 15th century, with the Renaissance, ancient Greek and
Roman medical texts, long forgotten, were revived. Thomas
Linacre (1460? – 1524), founded the Royal College of
Physicians; Andreas Vesalius (1514-64) at Padua wrote the
most reliable textbook on anatomy of the time De Humani
Corpus Fabrica, 1543. Pharmacopeia (lists of drugs and
their uses) became considerably enlarged; while improvements
took place in metal instruments (including surgical ones)
and techniques (e.g. ligature of blood vessels, late 1536).
The medical profession could then follow either the Arabic
tradition, or the (newly rediscovered) ancient Graeco-Roman
one.
The
early part of the 16th century saw Paracelsus (1493-1541)
providing a third broad option, in which the human body was
perceived as a ‘microcosm’ (little world) to mirror the
wider universe. Disease treatment should tackle the
spiritual roots of the problem, not merely the latter’s
physical symptoms. In his book On Long Life, 1560,
Paracelsus stressed the importance of public health and
proper environmental measures, e.g. draining swamps and
controlling harbour pollution in Venice. Although his
followers were harassed, the views of Paracelsus were to be
reviewed and expanded until they became part of conventional
medical thought in the 17th century.
The
‘new’ physics of Galileo, and others, brought in new
instruments, ideas and techniques (thermometer, pulse rate
measurements, effects of different food on health). Jean Van
Helmont (1577-1644) consolidated medical knowledge, helped
by William Harvey (1578-1657; single blood circulation
system, as compared with Galen’s double -system), Marcello
Malpighi (1628-94); blood capillaries), Anton wan
Leenwenkock (1632-1723; red blood corpuscles), as well as
inventions such as the microscope, and discoveries e.g. that
of micro-organisms. Thomas Willis (1621-73) wrote the first
complete treatise on the central nervous system. New
knowledge arose (the eye and the mechanism of sight; the ear
and hearing; reproduction processes).
Thomas
Sydenham. (1624-89) postulated that a disease was the result
of the body trying to rid itself of something harmful to it;
the symptoms constituted the evidence of the fight taking
place between the body and its attacker (a theory still
acceptable today): Medicine should therefore help the body
in its struggle, rather than merely cure the symptoms. By
the mid-17th century, modern inoculation techniques had been
anticipated and tried. Later that century, blood transfusion
reached medical practice.
The
18th century saw the ever-increasing impact of the
Scientific Method to establish the behaviour of human body
in good health, or otherwise. Essentially, the tendency was
to enlist the help of nature to restore the patient to
health. Definite advances concerning the central nervous
system came with Thomas Willis: nerves were not hollow tubes
but sensitive carriers of messages to the brain while
muscular tissues were irritable; hence, the distinction
between conscious and reflex voluntary action on the one
hand, and involuntary action on the other (Albrecht von
Haller, 1708-77).
Homeopathy
(Samuel Hahnemann, 1755-1843: "let likes be treated by
likes") was initiated leading to the long-term notion
of immunology. Blood pressure measurements (Stephen Hales,
1677-1761), and vaccination (Edward Jenner, 1749-1823), as
well as comprehensive sanitation measures, more hospitals
and increased public water supplies began to contribute
significantly towards improving health conditions in Europe
in the 18th century. Even so, there were great problems of
diseases and high death rates associated with the Industrial
Revolution reflecting appalling conditions of work, and bad
sanitation: tuberculosis, cholera, typhoid fever were rife.
The work of Lavoisier (1744-94) on respiration and exercise,
as well as the invention in 1796 of vaccination by Jenner
(1749-1823) paved the way for subsequent progress in
physiology, pharmacology, biochemistry and experimental
medicine. The advent of the stethoscope (for chest sounds,
1819), and the work of Louis Pasteur (1822-95) on
disease-causing germs, their prevention and cure, the use of
anaesthetics (1846) and antiseptics (Lister, 1865) were
landmarks in 19th century medicine.
A
limited number of effective medicinal drugs existed at the
turn into the 20th century: nitrous oxide, ether and
chloroform (to help the surgeon); opium and morphine
(pain-killers), digitalis (heart failure), quinine (malaria)
and aspirin (the all-purpose "wonder" drug).
Gradually the range was extended: sulphonamides (1935) along
with preventive measures such the diphteria immunisation
programme (1940) and the mass vaccination campaign against
poliomyelitis (1956). In the US alone, around 400 new drugs
were appearing on the market every year, sometimes with
highly undesirable side effects (e.g. thalidomide). During
the latter part of the 20th and at the turn into the 21st
century, health problems are no longer infectious diseases,
but cardio-vascular, malignant, psychiatric and old-age
ones, besides AIDS, and the re-emergence of diseases such as
tuberculosis and malaria.
Advances
in medical science and health care increasingly depend upon
a synthesis of many fields e.g. biochemistry and
biotechnology (analysis of body fluids; genomics,
pharmaceuticals); engineering (medical instrumentation and
measurements, computer based bio-information systems,
imaging; robotics); immunology (transplant surgery),
physiology (hormonal action, In-vitro fertilization);
polymer science (valves, hips, hearts, nanotechnology);
psychology (behaviour therapy), mathematics (health
systems’ analyses, epidemiology, modelling, trials). Such
has been the progress that nano-robots are now conducting
surgery (see The Economist Tech Suppl, 6th
September 2008 p 15); Swallow the Surgeon a far cry
from the barber’s craft).
--
PROF J.MANRAKHAN
|
