Chapter 1The Origins of the History

Chapter 1The Origins of the History and Physical Examination
H. Kenneth Walker.

Each of us should strive "to rise above the routines of the daily ward round and to see in every patient an opportunity not only to serve mankind in the best tradition of medical excellence, but to add to the store of medical knowledge."

—A. McGehee Harvey (1973)

Ten individuals are responsible for the development of modern physical diagnosis: Hippocrates, Vesalius, Morgagni, Sydenham, Auenbrugger, Corvisart, Laennec, Louis, Mueller, and Osler. Their accomplishments form a "golden thread [that runs] throughout the history of the world, consecutive and continuous, the work of the best men in successive ages" (Moxon, quoted by William Osler). The pool of information presented in this book has been created by the scholarship of these ten men. They were physicians going about the daily practice of medicine. The story of their achievements serves to stimulate the spirit of inquiry in each of us and underscores the obligation we have to add to this pool of knowledge. This chapter traces the historical evolution of modern clinical diagnosis. Knowledge of this evolution provides the student with a foundation upon which to build mastery of the art and science of diagnosis.

Seven crucial developments over the past 3000 years shaped physical diagnosis as we know it today. Hippocrates and his colleagues laid the foundations by establishing medicine as a profession and by declaring that it has a rational basis. The second development was the resumption of the dissection of human bodies for educational purposes, beginning in the thirteenth century in Italy. Vesalius was thereby able to publish an accurate human anatomy text in 1543, and Morgagni to establish morbid anatomy, or pathology, as a discipline in 1761. The third development was Sydenham's definition of disease between 1666 and 1683, leading to the nosological concept of disease. The actual beginnings of physical diagnosis occurred with the discovery of percussion by Auenbrugger in 1760, and its dissemination by Corvisart in 1808. Laennec invented the stethoscope in 1816, beginning a century of explosive development in physical diagnosis. The French School, exemplified by Pierre Louis, synthesized the previous developments and put physical diagnosis on a secure footing at the bedside and in the autopsy room during the period 1800 until 1850. The German School, epitomized by Johannes Mueller, laid the foundation for experimental laboratory science from 1830 until 1900. These six developments were applied to medical education by William Osler in the medical clinic at Johns Hopkins University in 1893, thereby revolutionizing medical education and the practice of medicine in America and the Western world. Table 1.1 summarizes these developments.

Table 1.1. Crucial Developments in the History of Physical Diagnosis.
Table 1.1

Crucial Developments in the History of Physical Diagnosis.
There were a number of important developments in addition to the seven crucial ones outlined above: the model of bedside teaching developed by Boerhaave at Leyden about 1700; the development of precision instruments such as the thermometer, microscope, ophthalmoscope, kymograph, and sphygmomanometer; and the discovery of the x-ray. The urban migration in Europe in the late 1700s and early 1800s, coupled with the development of the French hospital system, made available to physicians a concentration of human illness never seen before. The ascendance of the German and American university had a profound influence on medicine. Once again, the genius of William Osler wove all these threads into the fabric that established clinical diagnosis and medical education as it exists today.

Go to:
Hippocrates: A Rational Profession 460–370 b.c

Physical diagnosis had its origins in Grecian medicine. Clinical medicine flourished before the Greeks, especially in Egypt, Crete, and Babylonia, and undoubtedly the Greeks were influenced by these earlier physicians. But writings from these countries did not become part of the mainstream of Western civilization, as did those of the Greeks. Table 1.2 contains two quotations that illustrate the level of medicine practiced by the Greeks. They took a careful history and practiced direct auscultation. They were masters of observation: their descriptions of patients could fit modern texts without much change.

Table 1.2. Quotations Illustrating the Level of Greek Medicine.
Table 1.2

Quotations Illustrating the Level of Greek Medicine.
Greek medicine flourished early. Homer in the Iliad (ca 1200 b.c.) described 141 wounds and used 150 anatomic terms. Hippocrates (ca 460—370 b.c.) lived during the Golden Age of Greece. His contemporaries included Plato, Socrates, Aeschylus, Sophocles, Euripides, Aristophanes, and Pericles. Medicine "became in his hands an art, a science, a profession" (Major, 1954). The Hippocratic writings are probably a collection from a number of individuals, including the master, from the period during which he was the dominant medical figure. They were collected after the death of Hippocrates and stored in Alexandria. From there, they were disseminated to all parts of the civilized world. The surviving collection contains 42 clinical cases, the likes of which are not encountered again for 1700 years. These cases demonstrate a high level of medicine that included a careful history, inspection, palpation, direct auscultation, and examination of the sputum and urine.

An enduring contribution of the Hippocratic school was the conviction that disease is natural and not divine. Consider the remarks about epilepsy: "It is thus with regard to the disease called Sacred: It appears to me to be no wise more divine nor more sacred than other diseases, but has a natural cause from which it originates like other affections" (Delp and Manning, 1981). This was a major conceptual leap. Natural phenomena can be studied and their course predicted. This concept was a necessary prerequisite to the development of physical diagnosis.

The Greeks did not develop an accurate knowledge of human anatomy and pathology. Dissection of human bodies did not occur except for a brief time at Alexandria in the third century b.c. The Greeks had no concept of nosology. They felt that disease was caused by an imbalance of the four humors of the body; blood, yellow bile, black bile, and phlegm. Developments on these three fronts—anatomy, pathology, and the nosology of disease—did not begin to occur until the thirteenth century.

The next great Greek physician after Hippocrates was Galen (ca a.d. 130–201), who was born in Pergamum. He spent most of his professional life in Rome, becoming physician to the Emperor Marcus Aurelius. He was a prolific author. Many of his works have been lost; the surviving ones fill twenty-two volumes. He studied and wrote extensively about anatomy based upon pigs and monkeys. He was the first experimental physiologist. He supplemented his findings by speculation. His written work was accepted as the ultimate truth until the time of Vesalius. This enshrinement of knowledge, much of which was incorrect, hampered medical progress for the next 1500 years.

Go to:
Vesalius: Establishment of an Accurate Anatomy, 1543

Andreas Vesalius founded modern anatomy with the publication of De Humanis Corporis Fabrica (On the Structure of the Human Body) in June 1543. His book was based upon personal dissection of human bodies. This represented a remarkable departure from the zoological anatomy of Galen. The accomplishments of Vesalius were possible because of the resumption of the dissection of human bodies that began in the thirteenth century.

Human dissection was rare before the thirteenth century. The Egyptians knew the body organs, but only after extracting them through tiny incisions made for the purposes of embalming. There is continuing controversy about human dissection during the Hippocratic period. A knowledge of anatomy, except the skeleton, is scanty in the Corpus Hippocraticum. The consensus is that human dissection was not practiced during the Hippocratic period, either because of reverence for the human body or belief in a life after death that required an intact body.

Dissection for the purpose of acquiring a knowledge of the human body probably originated in Alexandria, Egypt, in the fourth century b.c., 100 years after Hippocrates. Herophilus studied the nervous system and gastrointestinal tract, describing the cerebrum, cerebellum, meninges, fourth ventricle of the brain, duodenum, and the eye. He counted the pulse with a water-clock, and analyzed the rate and rhythm. Erasistratus (ca 310–250 b.c.) described the aortic and pulmonic valves and the chordae tendineae of the heart. He clearly saw that the heart was a pump, although he had the direction of circulation backward.

The practice of human dissection in antiquity was confined largely to Alexandria. Some dissection apparently occurred in Rome until the second century a.d., but it must have been sparse. Galen (a.d. 129–200) said Alexandria, where he had studied, was the only place where anatomy could be learned. There is no good evidence that Galen himself practiced human dissection.

Human dissection began again in the thirteenth century in Bologna, one of the great medieval universities, and has continued uninterrupted through the present time. Several occurrences during the early thirteenth century set the stage for the lifting of the taboo against disturbing the human body. Emperor Frederic II issued an imperial decree in 1238 authorizing the performance of public "anatomes" on the bodies of executed criminals for teaching purposes. Legend has it that Frederick II also had the stomachs of two of his subjects opened in order to determine if digestion was enhanced by exercise or by rest. Another sign of the relaxation of the concept of the sanctity of the human body during the thirteenth century was

Результаты (русский) 3:

глава 1 истоки истории и осмотр
н кеннет уокер.

каждый из нас должен стремиться "подняться выше мероприятий ежедневно уорд раунда и смотреть на каждого пациента, возможность не только служить человечеству в лучших традициях медицинского опыта, но добавить к магазину медицинских знаний".

- а. mcgehee харви (1973)

десять человек, ответственный за развитие современного физического диагноз: гиппократа, везалий, Morgagni, сиденгам, auenbrugger, corvisart, laennec, луис, мюллер и ослер.их достижения в форме "золотой нитью проходит] [, что на всем протяжении мировой истории, последовательных и непрерывной работы лучших людей в своих возрастных групп" (moxon, quoted by уильям ослер).