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The Humpty Dumpty Problem – Part One

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden S. Lundgren
February 16, 2024

Foolish is the doctor who despises the knowledge acquired by the ancients.” – Hippocrates

Recently, there have been a number of articles in the lay press recommending a limited number of things to do to stay healthy. The advice is not surprising. It usually includes not smoking, a healthy diet, exercise, stress relief and social connections. All reasonable, and all supported by extensive studies. So, why do we see it in the lay press and not in medical journals? And why do we hear so little about it from our physicians? 

Hippocrates (died circa 375 BCE) being our ancient, let us begin there. He is believed to be the founder of Western medicine, a systematic and non-religious way to approach health and illness. Health consisted of the proper balance of humors (bodily fluids). Galen, a Roman physician linked these humors to the patient’s personality type. Illness then was an imbalance within the body—a state to be both prevented and treated by what we would recognize as lifestyle medicine.  

Hippocrates actually addressed most of the lay press advice stating that the safest way to health is the right amount of nourishment and exercise, recommended walking, aromatic baths and massage for stress relief. He believed that the body is self-healing with the right habits. “The greatest medicine of all is teaching people how not to need it.” His job then was more teaching than prescribing medicines, and his approach linked with that of Galen exemplified a radical holism of mind, body and environment.

So deep was this belief that much of it lasted into the 20th century. But there were steps along the way undermining Hippocratic/Galenic theories. One notable development was the 16th century work of Vesalius, a physician anatomist who regularly performed human dissections that accurately identified organs and their placement—and sometimes their functions. Until that time, most human anatomical knowledge was based on the study of animals. According to Siddhartha Mukherjee in The Song of the Cell: An Exploration of Medicine and the New Human, however, improved anatomical knowledge did not lead to an organizing principle of disease. I would argue that it was the first discovery that led to the reductionism that characterizes modern medicine.

The second was a shattering discovery: cellular pathology—a theory attributed to Rudolf Virchow, a 19th century physician scientist. Cells had been microscopically visualized since the 17th century, possibly earlier. By the 19th century, it had been hypothesized that all living things were comprised of cells as their basic units of structure and organization. Virchow brought his medical training to the study of the cell and located the site of disease in the cell. 

This focus on the cell coincided with the acceptance of the germ theory of disease. To be sure, there had been speculation about minute creatures spreading disease through the air since Roman times, but technical advances in the late 19th century provided solid evidence of the relation of microorganisms and disease. The most spectacular example was the identification of the causative agent of tuberculosis by Robert Koch in 1882.

By the early 20th century, the body had been separated into organs, and disease had been separated from the patient and redefined as a battle between cells. And health had been redefined as simply the absence of disease. But how did these discoveries come to dominate medical practice?      

Essentially, the answer to this question comes down to the influence of three men: William H. Welch, Franklin Mall and Abraham Flexner. Welch (one of the founders of the Johns Hopkins School of Medicine) and Mall were both physicians who were given to the science of medicine as practiced in a laboratory rather than at the bedside. Together, they developed the medical school as a regularized, university-based institution based on research.

Flexner, an educator with family connections to the Johns Hopkins School of Medicine, was hired by the Carnegie Foundation to report on the condition of U.S. medical schools. The schools were truly awful: proprietary, short programs, no standard curricula, few laboratories, little patient contact. Many schools had started their own improvements before the 1910 publication of the Flexner Report, but the Report clearly accelerated the process. Its main recommendation was to make all medical schools over in the Johns Hopkins model…and that is what happened. Disease became a specific entity defined by specific laboratory findings, detached from the patient and his/her environment or personality and the sole target of treatment. Health became merely the absence of a proven diagnosis.

The sweeping practices mentioned in the first paragraph of this column do not fit this model well. They do align much better with the Hippocratic/Galenic framework are also more appropriate for today’s world. Today, even allowing for COVID deaths, most people die from chronic diseases mainly cancer, cardiovascular disease and diabetes—conditions that are well-addressed by the Hippocratic/Galenic paradigm—a paradigm completely at odds with the regulatory framework of Western health care. But how do we shift to policy-making that aligns with today’s epidemiology? That will be addressed in Part Two.

Author: Burden S. Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care.  After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA.  She has served as a consultant to a number of non-profit groups.  Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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