Indigestion in Harvey’s Time

THOMAS HUNT, C.B.E.. D.M., F.R.C.P.

London, England

Digestive troubles in Harvey’s time must rarely have been out of people’s thoughts; although today this may still be true, it was then more often troubles of alarming or fatal nature than those which commonly form topics of light conversation at cocktail parties now.

From St. Mary’s Hospital, London, England. Re- quests for reprints should be addressed To Dr. Thomas Hunt, 53 Townshend Road, NW8 6W, London, England. Manuscript accepted September 26, 1978.

Harvey himself was not a great clinician, and although men like Sydenham were beginning to practice bedside medicine as we know it in the 20th century, this did not come to any real maturity until Boerhaave began his teaching at Leyden a hundred years after Harvey. But it was the early decades of the 17th century that saw the begin- nings of new ideas when doctors became willing to question the old authority of Hippocrates and Galen with their long established tradi- tions. Harvey himself seems to have accepted the Galenical theory about digestion-food was concocted (cooked) in the stomach, with the diaphragm acting as a partition to protect the heart from “the noisome, sooty and crude vapours which arise from this concoction.” Further cooking went on in the liver, in which the thyme was freed of impurities, combined with “natural spirit” and converted into venous blood. Members of the Royal College of Physicians at this time were fined if they were known to support anything contrary to Galen’s in- fallible teaching. Diagnosis was almost entirely empirical, and there were, of course, no scientific means of investigating disease. Treat- ment was largely in the hands of the apothecaries or of “quacks” who rarely, if ever, carried out any physical examination. A consultant’s opinion was based upon a brief history of the case provided by the apothecary, and only rarely was the patient actually seen at all. Sometimes a specimen of urine was assumed to hold the secret of diagnosis, and medical pictures of the period show innumerable paintings, by great masters, of the doctor inspecting the urine in a fine glass beaker with a look of deep wisdom or surprise on his face. Dropsy and diabetes could be diagnosed in this way, as Harvey records, but most of the assumptions made by this ritual must have been pure guesswork and planned largely to impress. Harvey’s supreme gift to medical practice lay largely in his determination, as he says, “to accept nothing on verbal or written authority” in keeping with his emphatic view that “our first duty is to enquire whether a thing be or not, before asking wherefore it is.” This put an almost total reliance upon ob- servation and structure with little concern for the study of function. This was, in fact, the general attitude of physicians of the period; what we now call “clinical physiology” did not develop till many decades

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later-indeed as a practical science hardly before the time of Mackenzie, Sir Arthur Hurst and Sir Thomas Lewis! Although bodily structure was meticulously ob- served, theories about the causes of disease, and pathologic processes in general on which treatment was based, remained wildly improbable and, to our view, both bizarre and incomprehensible.

Medicine was closely linked with theology, and reli- gion played a vital part in almost all forms of treatment. Belief in mythology, sympathetic magic, evil spirits and acid fluxes governed most medical practice. For many

years after its introduction into general use by Syden- ham in 1663, Protestants would not allow the use of the wonderful new “Cinchona” (quinine) because of its association with the Jesuits (who first used it and called it Jesuits’ bark). Similarly, although tobacco was being much used for the “cure of all sorts of diseases,” in- cluding colic and “cold and weak stomachs.” King James I, in his “counterblast” (1604) to the dreadful effects of smoking, dubbed “this filthie noveltie” as antireligious and a Sin against God, whilst the Pope in 1624 excommunicated all those who took snuff in church!

Amongst these strange associations between illness and religious beliefs one clear voice spoke out-John Locke. His classic “Essay on Human Understanding” stands as a landmark in psychological thinking and makes the first clear exposition of what we now call “psychosomatic” medicine. At the same time, Harvey recognized the “sympathy between the stomach and the brain” and noted that “if the stomach be affected the brain suffers and debility and melancholia follow.” He certainly had a great interest in psychological dis- orders and the force of habit, but he seems to have relied in his practice on the almost ritual use of purges, clysters (enemas), emetics and blood-letting.

Indeed few physicians of his time doubted the value of elimination treatment in almost any illness, to rid the body of evil humors in every way they could. It was perhaps lucky that putting things into the body was less popular than letting things out when the curious mix- tures of unlikely preparations given for treatment are remembered. Elias Ashmore (1617-1692), the re- markable virtuoso who gave Oxford the Ashmolean Museum and was granted a doctorate of Medicine by the University, records how he cut out the livers of 40 frogs, dried them, swallowed them and then hung three spiders about his neck and “so drove his ague away.”

The 17th century was indeed a peak period for making elaborate pharmaceutical preparations from which of course the name “Galenicals” is derived. There was a remarkable ingenuity in the concoction of mixtures with many strange components, vegetable and animal, but it was also the time when Glauber’s

Salts-much used by Oliver Cromwell-were popular, and England’s Epsom Spa gave rise to the general use of Epsom Salts. Rhubarb and Senna were in great de- mand as purgatives, and Galen’s old recommendation of the therapeutic value of wine (which must be at least seven years old) was widely accepted. Coffee, too, which was first introduced into England about 1630, was much vaunted for its power to “cleanse the stomach,” Harvey himself being one of the first to use it and, in- deed, to become strongly addicted to it.

Accurate records of the kind of digestive disorders which Harvey and his fellow physicians had to diagnose and treat are difficult to find. Acute enteritis and colitis made up the greatest proportion of gastroenterologic cases, and many of these must have been severe. The general lack of hygiene and the heavily contaminated water supplies made typhoidand the Salmonella group a constant hazard; this may well have been the main cause of “the raging disease of the army” which at- tacked Cromwell’s troops as well as those of King Charles I.

7~phu.s was also a continuing danger-a disease for which Harvey treated Prince Maurice in 1642. Tuber- culous enteritis, secondary to the very widespread pulmonary tuberculosis, caused many deaths, and amongst the large number of cases of malaria (ague) many of those affected must have presented with di- gestive symptoms. Colic has many undiagnosed causes, but most men’s diet contained so much non- digestible residue that this probably was a major factor in causing this common symptom.

Harvey writes that “not all colic derives from flatus,” but concludes that “men are made joyful by purgatives,” an opinion supported much later by the poet Byron, who praised the euphoric effects of a good dose of salts: in a letter to a friend he writes “There is nothing which cheers your spirits up like a dose of Epsom Salts.” Lead poisoning may account for some of the severe cases of colic, although it was not recognized until Sir George Baker in 1767 described the “Devonshire Colic” due to contamination of cider standing in lead pipes before being drawn off. Plumbism with its intense abdominal pain was, of course, a frequent cause of illness and death in Roman times when wine was often stored for long periods in large lead vessels.

Dietary deficiencies-especially in the winter months-were frequent causes of ill health. Scurvy in particular was a major cause of digestive symptoms in addition to its other manifestations, whilst lack of good protein and green vegetables played a part in causing that large group of anemic-“chlorotic’‘-young women, and the feeble and debilitated condition of many of the elderly. It was then relatively rare for people to live to really old age, the expectation of life at birth in the mid-l 7th century being about 38 years. Most of the

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deaths occurred in infancy or early childhood, but there was a heavy mortality in 50 and 60 year olds.

Various nonbacterial impurities in food and drink accounted for much more illness than was realized. “Black” bread contained a mixture of cereals, including barley and rye, and there are many accounts in medical history of serious or fatal diseases due to “tares among the wheat,” including ergotism. The detection in this century of the hepatotoxic Aflatoxins from mouldy grain and ground-nuts is a sharp present-day reminder.

Harvey himself had planned to write a “Tract on Nutrition”: it is sad that he seems never to have done this, although it is possible that his notes for it were destroyed when his house in London was ransacked during the Rebellion.

Although he has much to say about diet and the bowel, Harvey makes no mention of disease of the appendix and understandably has little to say about the cecum, which he says is so called because “it is ob- scure in its function: in man it is merely a token like the nipple.” He does observe that worms are supposed to breed in it and adds “worms are in all the guts-nothing

so common as worms!” Little comment is made about the duodenum, but earlier physicians seem fully to have recognized the symptoms of hiatus hernia. Andrew Boorde (1490-l 549), author of the famous “Dietary,” as early as 1547 refers to remaining upright after a meal-“if need compel a man to sleep after his meat let him make a pause, and then let him stand and lean and sleep against a cupboard or else let him sit upright in a chair . in your bed lie with your head somewhat high lest that the meal which is in your stomach, through eructations or some other cause, ascend to the orifice of the stomach.”

Startling though many of the changes in medicine have been during the three centuries since Harvey’s death, and dramatic though the advances in treatment, there are still some things which remain the same. Not the least of these is that aspect of practice which de- pends upon the physician’s humanitarian outlook and his breadth of general knowledge, for upon this depends in great part the powerful effect of the placebo and that vital trust in the doctor which can easily be lost in a more sceptical and technological age.

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