Lesson 1bzhzhhzhzhzhzhzbshzhzhyJHGHz.pptx

Course “Approach to patient”
Module: History of Medicine
Prof. Fabio Zampieri
University of Padua Medical School
Dept. of Cardiac, Thoracic, Vascular Sciences and Public Health
Unit of Medical Humanities
fabio.Zampieri@unipd.it

The course: Professor
Fabio Zampieri: Associate Professor of History of Medicine
University of Padua Medical School
Department of Cardiac, Thoracic, Vascular Sciences and Public Health
Unit of Medical Humanities
Email: fabio.zampieri@unipd.it
Mobile: 349 93 03 549
Office: Institute of Legal Medicine, via Falloppio 50, 35131 Padova
Office hours for reception: reception by appointment by email

The course: schedule
Module: History of Medicine
Frontal lectures: 5 lessons of 2 hours
Interactive activities (optional)
Visit tour:
• Bo Palace of the University of Padua (ancient Anatomical Theatre, first of
this kind in the world, inaugurated in 1595 and still preserved)
• Morgagni Museum of Pathology of the University of Padua

Frontal lectures
Course Approach to Patient
The question is: How did ancient doctors approach their patients?
1. “Possessed patients”. The concept of disease as a demoniac possession
during prehistory and ancient times.
2. “Unbalanced patients”. The concept of disease as an unbalance in the
humoral composition of the body from classic times to the Renaissance.
3. “Injured patients”. The anatomo-clinical concept of disease in modern
medicine. The dawn of pathology. The invention of the stethoscope.
4. “Dissected patients”. The dissection of living patients through medical
imaging techniques in contemporary medicine.

Interactive activities
Bo Palace
Palazzo del Bo is the oldest
building of the University of
Padua.
Between 1500 and 1860 it was the
only seat of all the faculties.
Today it is the seat of
representation and of the
Rectorate.

Bo Palace
• Aula Magna
• Hall of Medicine
• Anatomical Theatre
• Hall of the Forty

• About 1300 specimens of human tissues and organs preserved dry
(tannization) or in liquid (formalin), most of them dating back to a period from
about 1850 to 1940.
• Specimens divided by apparatus: skeletal, cardiovascular, digestive, urinary,
genital system, and teratology.
• Most common diseases of this period of time: tuberculosis, syphilis, cancer.
• Most rare diseases: ectopia cordis, tumors with huge masses.
• The Museum shows the progress that medicine has made in the fight against
disease, because today we no longer see certain diseases reaching such
dramatic conditions of gravity (masses of tumors, third stage of syphilis, lungs
lesions in TBC).

Skeletal system Cardiovascular system Teratology

The course: exam
1 question on history of medicine within the general exam
for the course “Approach to patient”
Exam:
Study material: ppt slides of the course on moodle.
On moodle there is also available supplement material (articles,
book chapters and so on) related to specific arguments covered
during the course

Frontal lectures
1. “Possessed patients”. The concept of disease as a demoniac possession
during prehistory and ancient times.
2. “Unbalanced patients”. The concept of disease as an unbalance in the
humoral composition of the body from classic times to the Renaissance.
3. “Injured patients”. The anatomo-clinical concept of disease in modern
medicine. The dawn of pathology. The introduction of stethoscope.
4. “Dissected patients”. The dissection of living patients through medical
imaging techniques in contemporary medicine.

First lecture
PREHISTORY
Prehistory is the period that begins
with the appearance of the human
being, about three million years ago,
and finishes with the invention of
agriculture, breeding, stable
settlement, and writing, about 6.000
years ago.
ANCIENT TIMES
Beginning of agriculture and breeding.
First forms of stable settlements.
Period of the so-called “cradle of
civilizations”: Sumer in Mesopotamia;
Pharaonic Egypt.
From 3000 BCE to about 500 BCE.
Predominance of chronic parasitic diseases
(low population density), surgical diseases
(trauma), and food poisoning (dysentery,
vomiting)
Predominance of acute infectious diseases
favored by the intense man-animal
relationship (breeding) and by the high
population density

First lecture
PREHISTORY
Prehistory is the period that begins
with the appearance of the human
being, about three million years ago,
and finishes with the invention of
agriculture, breeding, stable
settlement, and writing, about 6.000
years ago.
ANCIENT TIMES
Beginning of agriculture and breeding.
First forms of stable settlements.
Period of the so-called “cradle of
civilizations”: Sumer in Mesopotamia;
Pharaonic Egypt.
From 3000 BCE to about 500 BCE.
However, prehistoric and ancient medicines shared the fundamental
conception of disease as a demoniac possession

Common characteristics
• Prehistoric medicine: 3 million years to 3000 BCE
• Ancient Medicine
• Mesopotamian Medicine: 3000 BC – 539 BC (fall of Babylon, when it was conquered
by the Achaemenid Empire).
• Egyptian Medicine: 3000 BC – 525 BC (conquered by the Achaemenid Empire).
• Archaic Greece: VII-V cent. BC (before Hippocratic School)
• Common characteristics
• Medicine and Religion. Diseases were caused by supernatural agents: demons and
gods. Medicine was practices in sacred spaces (temples).
• Medicine and Magic. Given the supernatural origins of diseases, the cure was magic
and performed by priests, magicians, sorcerers, shamans combining empirical
treatment with magic rituals

Common characteristics: MEDICINE MAN
“Strong is magic in combination with medicine and vice versa”
Ebers Papyrus 1500 BC
Prehistory: shaman who was skilled in using herbs and performing
magico-therapeutic rituals

Common characteristics: MEDICINE MAN
Drugs
Prayers
Mind-body approach

Where does medicine come from?
• The term medicine means “to cure”
• This means that medicine born for curing diseases
• How ancient are diseases?
• Living beings are product of evolution: they are not perfect
machines! So disease exist because organisms are intimately
characterized by structural and physiological vulnerabilities
evolutionary determined.
• All livings get sick: bacteria, insect, bird and mammalian.
• Oldest skeletal remains showing signs of diseases.

Disease and Evolution
Biological traits are optimal, not perfect

Disease and evolution
Biological traits are optimal, not perfect
SQUID HOMO
SAPIENS

Standing upright is an extraordinary adaptation
of the human species: broader vision of the
environment, hands free to grasp objects.
However, its evolution has led to several
vulnerabilities:
• back pain: the spine depends on proper
muscle development;
• obstetric difficulties: the pelvic canal has
narrowed to allow the legs to stand upright,
but it causes difficulties in childbirth.

In the human eye, the optic
nerve runs through the retina,
enveloping it from within.
This causes a blind spot and the
eye’s vulnerability to retinal
detachment!
The squid eye, from this point
of view, is better designed,
because the optic nerve
surrounds the retina from the
outside without any holes.

All livings get sick
Bacteria, insect, bird and mammalian

Bacteria get sick
It can be used for treating antibiotic resistant diseases

The oldest signs of diseases
Dinosaurs and Homo

Dinosaurs get sick
Osteosarcoma in the femur of
an ancestor of current turtle
(Pappochelys rosinae) dating
back to 240 million years ago.

Human and their ancestors get sick
In humans and their ancestors, some of the earliest skeletal evidences for
disease include the same classes of disease that affected dinosaurs, and
continue to affect us today.
The earliest neoplastic-like tumors of bone have been found on an
Australopithecine ancestor from almost 2 million years ago, and on Homo
ergaster from 1.5 million years ago (cancer has been a curse on planet earth
for a long time).
Tuberculosis-like infectious lesions have been found on a Homo erectus fossil
from 500.000 years ago. Tuberculosis is still active across the globe today,
with the worrying development of highly infectious antibiotic-resistant strains
of TBC that no longer respond to any known treatments.

Osteosarcoma in Australopiteco sediba dated to 1.98 million years ago

Benign fibrous dysplasia in a rib of a Neanderthal dating back to 120.000 BCE

Most ancient proof of “cure” in humans
Castello di Dmanisi, Georgia
Skull of Homo habilis, called
Homo georgicus, dating
back to 1,85-1,75 million
years ago, of a man died at
very old age (toothless).
This means that the group
of this individual took care
of him, because he was
unable to obtain his own
food by hunting.
Why he was cured?
Probably because he was
an old wiseman.

PREHISTORIC MEDICINE:
MAGIC, SURGERY AND PHYTOTERAPY

Magic medicine
MAGICO-
THERAPEUTIC
CHARMS
MAGIC SPELLING
RITUAL MUSIC
RITUAL DANCE
We will return on that point

Prehistoric
surgery
• Amputation to treat infection
• Cauterization to treat infection
• Sutures: use of insects to suture small wounds
• Acupuncture to treat joint pain
• Trepanation

Surface porosity demonstrates necrosis
following amputation
Bone remodeling demonstrates the healing
process after the amputation

Sutures
Ant heads used as wound closure devices

Ötzi, also called the Iceman, is the
natural mummy of a man who lived
some time between 3350 and 3105
BCE, discovered in 1991 in the Ötztal
Alps on the border between Austria
and Italy.
A number of tattoos were found on
the mummy’s body.

• Due to their shape and anatomical location,
these tattoos did not have an aesthetic
function.
• Being in correspondence with the joints and
the spine, therefore, they could have an
antalgic function, to treat joint pain.
• Indeed, the individual suffered suffered from
arthrosis of the lumbar spine.
• Acupuncture points used for treatment of
this condition coincide with tattoos found
along the “UB channel”, that is, the meridian
through which, according to Chinese
Traditional Medicine, flow the vital energy
Qi.

Trepanation
A widespread practice from the late
Palaeolithic, which flourished in Neolithic
Europe (c.7.000 years ago), was trepanation:
making a hole through the frontal or
parietal bones of the skull.
Whilst the reasons for this practice are
unknown, the high survival rate of patients,
indicated by the healing and remodelling of
bone, proves great technical skill.
This procedure was widely used also in
historic times: it is described in Greek and
Middle Age medicines, as well as in pre-
hispanic cultures (Inca, Peru).

Trepanation
«Terebra», used by ancient
Greek
Peruvian
instruments
Some instruments
described by Lorenz
Heister (1683-1758)

Trepanation
Paul Broca (1824-1880), French physician and
anthropologist (Broca’s area of the brain with
functions linked to speech production), was the
first to examine a skull with signs of trepanation
coming from Peru.
He demonstrated that the “patient” survived for a
while after trepanation.
He experimented trepanation on cadavers, for
understanding if the procedure was realizable in
reasonable times. Trepanation of the skull of a
cadaver of a young individual took about 30
minutes, while in an adult tool a couple of hours.

Why trepanation?
• It is commonly believed that trepanation was practised in
“psychiatric” patients for driving out a malignant spirit from his
head.
• “Proto-surgical” interventions:
• Depressed skull fractures: a hole could be useful for restoring bones
fragments in their anatomical position;
• Head trauma and epidural hematoma: a hole might be useful for
reducing the hematoma and intracranial pressure;
• “Madness stone”: cysticercosis?

Why trepanation?
• The cause is typically head injury, which is
typical condition of ancient times due to
hunting, battle and so on.
• Head injury might results in bleeding from a
meningeal artery (1-4% of cases).
• The brain may be injured by prominences on
the inside of the skull.
• If not treated promptly, epidural hematomas
can cause respiratory arrest.
• Treatment is generally by urgent surgery in the
form of a craniotomy.

Why trepanation?
Morgagni Museum of Pathology, Padua

Why trepanation?
Neurocysticercosis
Neurocysticercosis occurs when cysts formed by the infection take hold
within the brain, causing neurologic syndromes such as epileptic
seizures. It is a common cause of seizures worldwide. It has been called a
“hidden epidemic” and “arguably the most common parasitic disease of
the human nervous system”.
Cysts may calcify: madness stone?

Prehistoric Phytotherapy
In a cave in Spain was discovered an important Neanderthal site dating back to 40.000 BC. Tooth of skeletal
remains were analysed for studying the diet of this ancient group (by analysing the DNA of the biological
material in the tartar of tooth). Traces of chamomile and yarrow were found, plant with no nutritive value, but
with therapeutic properties. Chamomile: remedy for stress and digestive problems. Yarrow: antiseptic and
antipyretic.
Hardy K. et al. Neanderthal medics? Evidence for food, cooking, and medicinal plants entrapped in dental calculus. Naturwissenschaften 2012

Hardy K. et al. Neanderthal medics? Evidence for food, cooking, and medicinal plants entrapped in dental calculus. Naturwissenschaften 2012
In the tartar of a young traces of poplar bark (Populus trichocarpa, from which is extracted the acetylsalicylic
acid: aspirin) and Penicillium mushroom (antibiotic penicillin) were found. This individual had an abscess in a
tooth and a probable intestinal infection (in his tooth were found traces of bacterium Enterocytozoon bieneusi,
which causes diarrhoea).

Mesolithic cemetery at Al Khiday, in Sudan
(6580-6440 BC), re-used in Neolithic (4360-4250
BC).
Archeo-botanic investigations demonstrated
that a fundamental element of the diet of this
prehistoric population was the Cyperus
rotundus, probably used as medicinal plant.
We know now that this plant could be effective
against bacteria causing dental caries.
Interestingly, the tooth of the skeletal remains in
this cemetery were almost all healthy, without
caries.

ANCIENT MEDICINES
MESOPOTAMIA
EGYPT
GREECE

Mesopotamian medical texts
The Code of Hammurabi
Babylonian legal text composed c. 1755–1750
BCE by the Babylonian king Hammurabi (c.
1810 – c. 1750 BCE).
Here, there are also laws that establish the
tariff of the doctor-surgeon.
This means that medicine was already a
profession within one of the first complex
civilizations in history.

Assurbanipal, king of Assyrian from 667 to
626 BC. Named also in the Bible.
He collected at Nineveh, capital of his
empire, a huge library containing clay
tablets with almost the whole
Mesopotamian science and literature.
Among them, about 2000 tablets are of
medical content.

1. Texts characterized by a connection between symptoms of diseases and
their respective prognosis, generally labelled as “prognostic-diagnostic”:
Babylonian Diagnostic Handbook.
2. Therapeutic or recipe texts which give detailed information about preparing
and administering a variety of remedies, usually based on medicinal plants.
These prescriptions consist of a symptoms list, a set of instructions as to
what the healer and/or the patient is supposed to do, and/or a set text to
be recited a specified number of times at appropriate points in the
procedure.
3. Texts of pharmaceutical content.

Pharmaceutical texts
“If a man has pain in his kidney, his groin constantly hurts him, and
his urine is white like donkey-urine, and later on his urine shows
blood, that man suffers from discharge (musû-disease). You boil 2
shekels of myrrh, 2 shekels f baluhhu-resin, (and) 2 sila-measures of
vinegar together in a jug; cool it and mix it in equal measure in
pressed oil. You pour half into his urethra via a copper tube, half mix
in premium beer, you leave it out overnight and he drinks it on a
empty stomach and he will get better”.
Description of the symptoms

Diagnosis

Preparation of the drug and treatment

Prognosis

It is probably a urinary infection treated with a catheter through
which introducing an antibiotic and anti-inflammatory!

Demons and diseases
Pazuzu: evil spirit of air, he could cause pestilences. His wife,
Lamaštu, could cause fevers and abortion in pregnant women
More than 6000 demons causing diseases are listed in Mesopotamian clay tablets

Egyptian medical texts
We dispose of a dozen of medical papyri, more or less completes, all dating
back to a period between 1850 and 1200 BCE.
Among the most significant medical papyri, there are the Edwin Smith
papyrus, compiled around 1550 BCE and preserved at the New York
Academy of Medicine, and the Ebers papyrus, composed around 1300 BCE
and conserved at the University Library of Leipzig.
They represent collections of clinical and surgical cases, and prescriptions,
sometimes improved with explanatory glosses which indicate that the
original content was probably older than the period of compilation of the
texts.

In Egypt, medicine was an important profession.
For physicians there were a medical insurance,
permit for illness, retirement, and working day of 8
hours.
Medical profession passed from father to son. The
young physicians finally studied at the “House of
Life”, schools for scribes.
Physicians did not performed embalming, so the
knowledge of internal anatomy was scarce.
Salt Papyrus (British
Museum), planimetry of the
House of Life

Salt Papyrus (British
Museum), planimetry of the
House of Life

• General practitioners with various offices at the court
and in the temples
• Specialist
o Abdomen and digestion
o Eye Specialist
o Tooth Specialist
o Surgeon
All physicians prepared themselves
the drugs for therapy. Herbs, animal
products (honey), and minerals
were used for preparing drugs

Anatomo-physiology
1. Heart as the spiritual centre:
intelligence, emotion and will
3. Heart-ib: internal organs
connected by the channels metu
Ib means also awareness
2. Heart-haty: the cardiac muscle
Trachea/oesophagus which
bringing air and food to the
heart. The air became Ka (vital
energy)
Channels met bringing to the anus

Anatomo-physiology
The heart was also the main container
and storage of the physiological liquids of
the body: air, blood, sweat, tears, urine
and feces.

Ebers papyrus (ca 1550 BC)
“The beginning of the physician’s secret: knowledge of
the heart’s movement and knowledge of the heart.
There are vessels from it [the heart] to every limb. As to
this, when any physician, any surgeon or any exorcist
applies the hands or his fingers to the head, to the back
of the head, to the hands, to the place of the stomach,
to the arms or to the feet, then he examines the heart,
because all the limbs possess its vessels, that is: the
heart speaks out of the vessels of every limb”.
“As for the air that enters into the nose, it enters to the
heart and lungs. It is they that provide (it) to the entire
body”.

Hieroglyphic used in Smith papyrus for designating
the examination of the patient (Kha)
Instrument (a sort of eye-
dropper) for “measuring” the
pulse

Ebers Papyrus
“Angina pectoris”
“If you examines a man for illness in his cardia and
he has pains in his arm, in his breast and in one
side of his cardia, and it is said of him: it is (wadj)
illness, then you shalt say thereof : it is (due to)
something entering into the mouth, it is death
that threatens him. Thou shalt prepare for him
stimulating herbal remedies”

The Weighing of the Heart Ceremony

The Weighing of the Heart Ceremony
The heart was the witness of the
individual for his judgment in the
after-life

Egyptian Medicine (3200-300 BC)
The heart was the only organ not
extracted from the cadaver during
mummification. Above the heart was
often placed an amulet

Archaic Greece (IIV-V cent. BC)
Hereditary Aristocracy
Culture dominated by religion and poetry
Classic Greece (V-IV cent. BC)
Democracy: first time in the history of human culture
Dawn of philosophy, form of rational knowledge emancipated from religion:
first time in the history of human culture
Dawn of rational medicine: clinics and physiology (theory of humours)
Hellenistic period (III-I cent. BC)
Alexander the Great (356-323 BC)
Hellenistic Empire
Dawn of human anatomy: School of Alexandria

Asclepius (Áσκληπιός, Aesculapius in Latin) was
a semigod, son of Apollo and of Coronis, a
mortal woman. He is the god of medicine and of
snakes.
His blood had healing power and could even
resuscitate dead people. His supernatural
powers came from natural forces.
The cock was the sacred animal to Asclepius and
cocks were sacrificed for him, probably because
as the cock announces the new day, the
physician announces the restoring of health
from disease.

The “Caduceus”, the staff
carried by Hermes, god of trade
The “Rod of Asclepius” is a serpent-entwined rod wielded,
associated with medicine and health care
It is frequently confused with the staff of the god Hermes, the caduceus

According to some authors, both the
“Caduceus” and the “Rod of Asclepius”
were the symbol of an ancient “surgical”
procedure for extracting a parasite from
the skin, the Dracunculus medinensis,
which was extracted by gently rolling up
the worm in a little wood stink. This
method is still in use in some African
populations.

Asclepeion
Asclepeion were healing temples dedicated to Asclepius,
where magic rituals and medical practices were combined for
the cure of the sick.
In these temples, the practice of incubation was performed,
also known as “temple sleep”. This was a process by which
patients would go to sleep in the temple (probably taking an
hypnotic or hallucinogen drug) with the expectation that they
would be visited by Asclepius. The priest would then
interpret the dream of the patient and prescribe a cure, often
a visit to the baths or a gymnasium.
During the dream of the patients, it seems that real
therapeutic procedures were done. They had to remain
secrets, so that the patients would think to having been
miraculously healed.
Sanctuaries included a stadium, gymnasium, library, and
theatre, which promoted self-therapy through rest,
relaxation, and exercise.

Asclepeion
Asclepeion were healing temples dedicated to Asclepius,
where magic rituals and medical practices were combined for
the cure of the sick.
In these temples, the practice of incubation was performed,
also known as “temple sleep”. This was a process by which
patients would go to sleep in the temple (probably taking an
hypnotic or hallucinogen drug) with the expectation that they
would be visited by Asclepius. The priest would then
interpret the dream of the patient and prescribe a cure, often
a visit to the baths or a gymnasium.
During the dream of the patients, it seems that real
therapeutic procedures were done. They had to remain
secrets, so that the patients would think to having been
miraculously healed.
Sanctuaries included a stadium, gymnasium, library, and
theatre, which promoted self-therapy through rest,
relaxation, and exercise.
Mind-body approach

Asclepeion
In Rome the cult of
Asclepius was
introduced in 293 BC
at the Tiber Island. The
temple was shaped as
a ship because the
legend told that
Asclepion arrived from
the sky to the earth
with a ship.

Ex voto found in the Asclepeion at Corinth, Greek
Patients donated a reproduction of the diseased part of their body for asking
the “grace” of being healed or for thanking the god for the recovery.

The “rational” behind
magic medicine

Magico-medical rituals, music and dances favoured the
perception of an environment favourable to recovery and
stimulated a state of deep relaxation.
1. Placebo. The perception of the environment affects the function of
the immune system (nervous system vagus nerve immune
system).
2. Relaxation Response. Cognitive and emotional relaxation has
healthy effects by activating the parasympathetic nervous system.
Relaxation can be stimulated through slow breathing and mental
exercises.

• Recent studies have discovered that human body
disposes of an important psycho-physiological
mechanism known under the name of Relaxation
response.
• By activating the parasympathetic nervous system
through slow breathing and some meditation techniques
(a simple word or phrase to repeat to keep the mind from
wandering), it induces physiological reactions that are
proving to be healthy for the body and, in particular, the
cardiovascular system.

PARASYMPATHETIC NERVOUS SYSTEM
SLOW BREATHING
RIPETITION OF A WORD OR PHRASE

Incantesimi magico-terapeutici
This frequency of breathing (6/min) coincides with the subjects’ spontaneous Mayer wave
frequency and thus enhanced this cardiovascular oscillation by synchronizing sympathetic
and vagalout flow.
Mayer waves are cyclic changes or waves in arterial blood pressure brought about by
oscillations in baroreceptor and chemoreceptor reflex control systems. The waves are
seen both in the ECG and in continuous blood pressure curves and have a frequency
about 0.1 Hz (10 second waves).

• It might be not a chance if ancient religious and medical practices
are often based on rituals which favors a state of relaxation
probably eliciting the relaxation response.
• Prayers, religious charms and songs are often repetitive and
monotonous and their play seems to induce slow breathing and a
state of focused mind.

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