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This Insitute is dedicated to the dissemination of information about "Alternative Medicine" and how these approaches may beneficially impact upon the quality of life of healthy individuals and interface with "Allopathic Medicine" to improve the care of patients. I must confess, however, that the term "Alternative Medicine" bothers me. It implies that the concepts that you have heard about at this conference in some way developed after so called "Western Medicine". I take objection to this because the precepts of "Alternative Medicine" represent the main stream concepts of Classical Western Medicine and consequently predate the postulates of "Modern Western Medicine" by Millennia. Indeed, the principles of Modem Western Medicine were postulated less than two centuries ago and are supported by a relatively brief period of empirical observations. Thus, I prefer to view "Alternative Medicine" as Traditional Western Medicine and Modem Western Medicine as "Experimental Medicine".
The tradition of Western Medicine is ancient and extends back through out the historical period. We have access to papyri written by physicians and surgeons of the Pharaohs, to the large mass of teachings attributed to Hippocrates during the Golden Age of Greece and the even larger body of knowledge preserved in the writings of Greek physicians and surgeons during the Roman period. These teachings which were based on thousands of years of careful observation were preserved and expanded by Arabic and Persian physicians before being introduced back into Western Europe after the Dark Ages. After the ability to read Latin was reintroduced into Western Europe by Irish and Scottish Monks, this ancient tradition once again flourished in Western Europe during the Renaissance and the Age of Enlightenment. Indeed, the textbooks of the late 18th and early 19th Century proudly proclaim the continuity of this ancient thread of tradition and freely quote from the works of Hippocrates, Celsus, Galen, Aretaeus and Avicenna.
The definition of disease that Hippocrates and Galen used is the antithesis of that taught in Western Medical Schools today. Traditional Western Physicians physicians believed that the symptoms of disease were the normal physiologic response of the body to a noxious stimulus. They called this physiologic response "Vis Medicatrix Naturae" or the tendency of nature to heal. Physicians and Surgeons believed for thousands of years that the body naturally responded in an appropriate manner to noxious agents in the environment. They believed that the body possessed amazing recuperative powers and that the body could normally overcome almost all the noxious elements that were non-nally encountered. They viewed symptoms such as sneezing, coughing, runny noses, vomiting, fever and diarrhea as an effort by the body to rid itself of the offending noxious agent. Thus, Traditional Western Medicine taught that the healthy body naturally combated disease in the best possible manner.
The primary goal of a Traditional Western Physician was to educate his patients on how to maintain a healthy body. The overwhelming majority of the writings of Hippocrates are devoted to this paramount task. In his Dietetics, for example, Hippocrates meticulously explores how diet is a principle determinant of health as well as illness. Hippocrates also promoted exercise and stressed the importance of weather and enviro=ent in the maintenance of a healthy body. He warned of the dangers of mood changes and their role in the genesis of many diseases. Galen focused on the adverse impact of crowded city living in his H ygiene. Thus, the foundation of Traditional Western Medicine is the importan cc of diet, mood, exercise, and the environment in maintaining health. It was only when the Physician failed in his primary task that he was forced to treat an already sick patient.
The Traditional Western Physician assumed that the body fought disease in an appropriate manner. Consequently, their primary charge, and, indeed, one still sworn to by Modem Physicians in the Hippocratic Oath, was "First, do no harm." As a result, the most important role of a Classical Physician when caring for an already ill patient was to predict the outcome of the illness in that individual patient. This was the skill taught in Hippocrates' Proguostics. They observed the pattern of illness in patients and based on this could accurately predict if the individual would recover or succumb to the affliction. The Classical Physician could also try to intervene if the course of the patient's illness did not suggest that they would recover. Under these circumstances the Physician attempted to remove the noxious stimulus that was causing the illness. This could be achieved through changes in diet, environment or exercise. If these methods failed, the Physician could attempt to cleanse the body with emetics, cathartics or purgatives.
The central role played by women in Traditional Western Medicine has been largely forgotten and is now difficult to reconstruct. Our knowledge of the role of Physicians is based on the survival outside of Western Europe of books written by Greek Physicians such as Hippocrates. Unfortunately, the string of oral tradition that had been passed down from mother to daughter over countless millennia was broken and then actively suppressed by first the Inquisition and then the crazed hunt for witches that swept Europe. Only a few fait glimmers of this role have survived. This vague memory is sometimes humorously portrayed in popular television shows. In the Beverly Hillbillies, for example, Granny often mixed up folk remedies for treating various maladies. There is some evidence to suggest that characters of this type played a historical role in Traditional Western Medicine. Woman tended to the health of their families by selecting the diet they used, by regulating the environment in which they lived and by structuring their exercise programs. Moreover, there were apparently specifically trained women who mixed the herbal teas and remedies that treated specific illnesses. Evidently, the body of knowledge possessed by these woman was handed down orally from generation to generation. Unfortunately, it seems that this group of woman were frequently named as witches and were virtually wiped out by the centuries of witch trials that plagued Europe and the American colonies.
During the Renaissance, classical medical authors were warmly embraced. The teachings of Hippocrates, Celsus and Galen once again governed the care given by physicians to their patients. This tradition continued until the beginning of the Industrial Age. While experimental science was generating a blossoming of the mechanical sciences and industries, medicine seemed to be stagnating. Academic Physicians at the beginning of the 19th Century felt that they were oppressed by the weight of the Classical Tradition of Western Medicine. They felt that they were prevented from introducing new approaches to old problems because Galen had not used them. Moreover, they felt as if they were required to use Classical techniques to treat new diseases that had not afflicted the people of the Age of Pericles or the citizens of the Roman Empire. These physicians believed that Medicine could only hope to meet the new challenges of the Industrial Age if the mantle of Classical Medicine was entirely discarded. They accomplished this by changing the definition of disease.
In the beginning of the 19th Century, the definition of disease was changed. In the past, the symptoms produced by an illness were viewed as the natural response of the body to the affliction; an attempt by the body to ward off the noxious stimulus. In contrast, the new definition of disease held that the symptoms were a manifestation of the malady. This altered entirely the role of the physicians in the care of their patients and their basic strategy. This meant that the disease should be treated by suppressing the symptoms. Moreover, it implied that the response of the body to an illness was inappropriate and that it was the obligation of the physician to override these pathologic changes engendered by the illness before they killed the physician's patient.
The modem Physician defines diseases by the compilation of symptoms produced by the individual affliction. Indeed, many illnesses are named for specific symptoms such as whooping cough, scarlet fever, diabetes mellitus (sweet urine), or high blood pressure. The physician then treats the illness by suppressing the symptoms. This strategy of treatment is illustrated by using antihistamines to suppress a runny nose, by the use of aspirin to suppress a fever, by the use of codeine to suppress coughs, by the use of pain medicines to suppress pain, and by the use of morphine derivatives to suppress diarrhea. As Experimental Medicine became more sophisticated, it extended this strategy to the correction of various abnormal laboratory tests back to the normal values of healthy 20 year olds. Blood pressure is maintained at the normal levels of young adults by the use of diuretics, beta blockers and calcium channel blockers. In Diabetics, blood sugar levels are adjusted toward normal levels with insulin. In hospitals, physicians try to suppress variations of the electrolyte concentrations of the blood by adding or withholding sodium, potassium, chloride, bicarbonate, magnesium and calcium. If an individual has a low blood level of iron attempts are made to correct this back to normal levels with iron supplements. In patients with infections, variations in the blood levels of amino acids are returned toward normal levels by the administration of intravenous amino acid solutions. Thus, the attention of modem physicians is directed towards the suppression of the symptoms of illness. This view that symptoms are the pathologic consequence of illness is of course the exact opposite view of Traditional Western medicine that symptoms were the physiological and appropriate response of the body to an illness.
The role of Modem Physicians in the care of their patients is radically different than that of Traditional Western Physicians. As we discussed above, the principle charge of a Traditional Western Physician was to prevent disease in his patient through the recommendation of a healthy diet, by the maintenance of a healthy envirorunent and through a regular exercise program. In contrast, Modem Physicians focus on the identification of symptoms and then the suppression of these symptoms in their patients. Thus, time distribution for Physicians has radically changed. Traditional Western Physicians devoted most of their time to maintaining the health of their patients while Modem Physicians spend their time attempting to regain the health of their patients.
The concept that Surgeons should attend medical school is a recent one. Indeed, when my medical school was founded in the 18th Century here in New York, this was such a novel idea that the school was called the College of Physicians and Surgeons to draw attention to the fact that both were educated together. Surgeons in Britain are still called Mister rather than Doctor and are rather insulted if you make the mistake of calling them Doctor. Consequently, the traditions of Surgery are quite separate from that of Modern Medicine. Whereas Modem Experimental Medicine choose to break its ties with Traditional Western Medicine, Surgery did not. This fact is quite discernible even in the contrasting style of Surgical and Medical publications. Surgical articles always start with a detailed history of the operation being considered. Surgeons from ancient Egypt, Greece and Rome are often cited. It is common to describe the approach taken to the problem by surgeons of the 17th, 18th, 19th and early 20th Century. Current Surgical technique rests on the shoulders of millennia of empirical experience. In contrast, Medical articles rarely cite papers more than a few years old and are typically reporting the results of a new drug or treatment modality. Thus, Modem Experimental Medicine moves rapidly from one novel therapy to another and consequently rests on very little accumulated experience.
The indications for surgical treatment of diseases have changed very little over the last several thousand years. Surgeons repair simple and discrete mechanical problems. When a bone is broken, a surgeon mends it. When a sinus becomes obstructed and no longer drains, a surgeon drains it. N"en a person is shot or stabbed, a surgeon closes the holes. When the bowel becomes obstructed by twists, scar tissue, strictures or tumors, a surgeon removes the obstruction. Vvhen a cancer develops in the breast, stomach or colon, a surgeon removes it. When a hole develops in the groin, abdominal wall or hiatus, a surgeon repairs the hernia. Thus, surgeons try to correct defects inflicted upon the body often by outside agents. Moreover, surgeons rely entirely upon the normal response to injury of the body to heal the wounds produced by surgery. As a result, much of surgical research has focused on means to promote the normal metabolic response to injury or to promote wound healing rather than to suppress the normal physiologic response to injury. One of the best ways to accomplish this is to avoid a large abdominal wall incision and to accomplish a laparoscopic operation.
The most recent major advance in the craft of surgery was the development of laparoscopic surgery. In this type of surgery, abdominal operations such as removal of the gallbladder, repair of hiatal hernias, removal of parts of the colon and repair of inguinal hernias are accomplished through several quarter inch incisions rather than one large incision that might be a foot long or even longer. The abdomen is blown up like a balloon with gas so that there is open space inside. A video camera is introduced into the abdomen through one of the quarter inch incisions. The video image is digitized, computer enhanced and projected on a high resolution monitor with 15 to 20 times magnification. This allows the surgeon to see the abdominal anatomy with greater clarity than could be obtained with even the largest possible incision. The same operation that has been used for decades for the various conditions is then accomplished inside of the abdomen using long and narrow scissors and clamps that are introduced through the other quarter inch incisions. Thus, laparoscopic surgery allows surgeons to perform safely standard, long established operations through quarter inch incisions.
Surgeons for a long time believed that the magnitude of the operation inside the abdomen determined the magnitude of the injury to the patient. Consequently, it was expected that after large operations such as the removal of the gallbladder, the repair of a hiatal hernia or the removal of part of the colon, that patients would require months to require. Indeed, after these operations when performed through large incisions, patients were disabled on average six to eight weeks or even longer. When we began to remove gallbladders laparoscopically using four quarter inch incisions, we were surprised to find that the difficulty of removing the gallbladder did not influence the period of recovery. Recovery was determined by the size of the incisions. Patients that underwent laparoscopic surgery could usually leave the hospital is less than 24 hours after the operation and return to normal activity within one to two weeks. When we gained more experience and were able to perform other abdominal operations such as removing the spleen, repairing hiatal hernias and removing sections of the colon, we found the same thing. The patients recovered much more rapidly than after operations with large incisions. Patients typically stayed in the hospital about three days and returned to normal activity within two to three weeks.
The answer to this question is still not known for sure. My impression is that the major advantage of laparoscopic surgery stems from the decreased amount of pain that patients experience. Because they feel less pain, they are able to get out of bed sooner, eat sooner and take care of themselves sooner. Also, they require less narcotics than after operations with large incisions and this avoids the various side effects of the narcotics such as lethargy and paralysis of the gut. The total of these effects combine to give the patient an improved sense of well being. The result is more rapid recovery. In retrospect, of course, this finding should not have been surprising. The patients return to a normal diet, a normal environment and a normal pattern of exercise sooner and consequently regain their health sooner.
Most of the concepts and practices presented at this meeting under the label of "Alternative Medicine" fall well within the main stream of Traditional Western Medicine as taught by Hippocrates, Celsus, Galen, Aretaeus and Avicenna. These physicians taught that a healthy body was maintained through careful attention to diet, environment and exercise. Modem Experimental Medicine diverged from this ancient tradition in the early 20th Century to explore new and unproved concepts of therapy. As a result, Modem Medicine focuses its attention on the suppression of symptoms of disease rather than the maintenance of health. Moreover, Modem Medicine assumes that the responses of the body to illness are the pathologic consequences of the illness rather than the body's normal physiologic response. Consequently, Modern Experimental Medicine might better be called "Alternative" since it was Modem Physicians who separated from ancient Western traditions. Women played a central role in the delivery of Traditional Western Medicine but this role was suppressed first by the Inquisition and then by witch trials. Women need to recapture and to redevelop their pivotal role so that the deterioration in the health of our population that has been experienced this Century can be reversed in the next Millennium. Modem Surgery unlike Modern Medicine retained its link with ancient traditions and thousands of years of empirical experience. Consequently, Surgeons have attempted to promote natural healing processes rather than to suppress them. The most recent advance in this direction has been the introduction of laparoscopic surgery. The avoidance of a large wound and the accomplishment of long established surgical procedures through quarter inch incisions speeds recovery. This most likely happens because the patients return to a normal diet, normal environment and normal exercise program and regain a sense of well being sooner than when large incisions are used. This observation once again supports the basic precepts upon which Traditional Western Medicine have been firmly founded for thousands of years.
1 . Hippocrates. Hippocratic Writings. J. Chadwick & W. N. Mann (Trans.). Penguin Books.
London, United Kingdom. 1983.
2. Celsus. De Medicina. W. G. Spencer (Trans.). Harvard University Press. Cambridge, Massachusetts. 1977.
3. Galen. On the Natural Faculties. Arthur John Brock (Trans.) Harvard University Press. Cambridge, Massachusetts. 1979.
4. Galen. Galen's Hygiene (De Sanitate Tuenda). Robert M. Greene (Trans.). Charles C. Thomas. Springfield, Illinois. 195 1.