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Since Beethoven’s death on this day 188 years ago, debate has raged as to the cause of his deafness, generating scores of diagnoses ranging from measles to Paget’s disease. If deafness had been his only problem, diagnosing the disorder might have been easier, although his ear problem was of a strange character no longer seen. It began ever so surreptitiously and took over two decades to complete its destruction of Beethoven’s hearing.
The field of anaesthesia is a subtle discipline, when properly applied the patient falls gently asleep, miraculously waking-up with one less kidney or even a whole new nose. Today, anaesthesiologists have perfected measuring the depth and risk of anaesthesia, but these breakthroughs were hard-won. The history of anaesthesia is resplendent with pus and cadavers, each new development moved one step closer to the art of the modern anaesthesiologist, who can send you to oblivion and float you safely back. This timeline marks some of the most macabre and downright bizarre events in its long history.
Heading image: Junker-type inhaler for anaesthesia, London, England, 1867-1 Wellcome L0058160. Wellcome Library, London. CC BY 4.0 via Wikimedia Commons.
Teachers at medical schools have struggled with a basic problem for decades: they want their students not just to be competent doctors, but to be excellent ones. If you understand a little history, you can see why this is such a challenge. Medical schools in the United States and Canada established a standard four-year curriculum over a century ago. Since that time, the volume of medical information has grown exponentially. How should medical schools cram the ever-growing body of knowledge into the same curricular space? This challenge has led to a constant process of curricular reform as faculty cut what was once cutting-edge science to make room for new cutting-edge science. Anatomy has long been a rite of passage of medical school. Bacteriology once exemplified modern life science. But deans of medical education now wonder how much their students really need to learn about these sciences. Can these older fields be displaced to make space for new fields such as genomics, immunology, and neuroscience? Time in the curriculum is increasingly contested.
Given this state of affairs, it might come as a bit of a surprise that faculty representing twenty medical schools met recently to make the case not for the new but for the old, specifically for the history of medicine. Even as medicine remains committed to pushing the frontier of knowledge, there is growing recognition that essential lessons for students and doctors derive from studying history.
Why are historical perspectives invaluable to physicians in training? For starters, it is critical that physicians today understand that the burden of disease and our approach to therapeutics have both changed over time. This is obvious to anyone who has spoken to their grandparents about their childhood, or to anyone who has looked at bills of mortality, old pharmaceutical advertisements, or any other accounts of medicine. The challenge is to have a theory of disease that can account for the rise and fall of various diseases, and an understanding of efficacy that can explain why therapeutic practice changes over time. A condition like obesity may well have a strong genetic component, but genetics alone cannot explain the dramatic rise in obesity prevalence over the past generation. New treatments come and go, only partially in response to evidence of their efficacy. Instead, answers to questions about changing diseases and treatments require careful attention to changing social, economic, and political forces—that is to say, they require careful attention to historical context.
In an underground surgery room, behind the front lines on Bougainville, an American Army doctor operates on a US soldier wounded by a Japanese sniper. Public domain from Wikimedia Commons.
Medical knowledge itself–firmly grounded in science as it may be — is nonetheless the result of specific cultural, economic, and political processes. What we discover in the future will depend on what research we fund now, what rules we set for the approval of new remedies, and what markets we envisage for future therapies. History provides perspective on the contingency of knowledge production and circulation, fostering clinicians’ ability to tolerate ambiguity and make decisions in the setting of incomplete knowledge.
Ethical dilemmas in medical research and practice also change over time. Abortion has been criminalized and decriminalized, and is now at risk of being criminalized once again. Physician-assisted dying, once anathema, has lately become increasingly acceptable. History reveals the specific forces that shape ethical judgments and their consequences.
History can teach many other lessons to students and doctors, lessons that offer invaluable insight into the nature and causes of disease, the meanings of therapeutic efficacy, the structure of medical institutions, and the moral dilemmas of clinical practice. We have not done, and likely cannot do, rigorous outcomes research to prove that better understanding of the history of medicine will produce better doctors. But such research has not been done for many topics in medical school curricula, such as anatomy or genomics, because the usefulness of these topics seems obvious. We argue that the usefulness of history in medical education should be just as obvious.
Making the case for the essential role of history in medical education has the unfortunate effect of making the basic problem — of trying to cram ever more material into the curricula — even worse. Perhaps not every school has yet recruited faculty suited to teach the full range of potential lessons that history offers. But many schools do, and in others much can be done with thoughtful curriculum design. Just as medical school faculty work constantly to find room for new scientific discoveries, they can make space for the lessons of history, today.
Heading image: Anatomy of the heart; And she had a heart!; Autopsy. By Enrique Simonet (1866-1927). Public domain via Wikimedia Commons.
Today rheumatic and musculoskeletal diseases affect more than 120 million people across Europe, but evidence shows that people have been suffering for many thousands of years. In this whistle-stop tour of rheumatology through the ages we look at how understanding and beliefs about the diseases developed.
Rheumatology is the branch of medicine dealing with the causes, pathology, diagnosis, and treatment of rheumatic disorders. In general, rheumatic disorders are those characterized by inflammation, degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints, joint capsules, tendons, bones, and muscles. There are over 150 different forms of rheumatic or musculoskeletal diseases. These conditions may be acute or chronic, and affect people of all ages and races.
Rheumatic and musculoskeletal diseases in paleopathology
Palaeopathology is the study of the diseases of humans and other animals in prehistoric times, from examination of their bones or other remains.
Definition of 'rheum'
The term ‘rheuma’ dates back to the 1st century a.d., when it had a similar meaning to the Hippocratic term Catarrhos. Both terms refer to substances which flow, and are derived from the term phlegm, which was one of the four primary humors. The first known use in English is from the late 14th century.
Thomas Sydenham’s description of gout
Thomas Sydenham, 1624–89, was an English physician who has often been called ‘the English Hippocrates’. He established the value of clinical observation in the practice of medicine and based his treatment on practical experience rather than upon the theories of Galen. He suffered from gout, of which he left a classic description and wrote frequently about it.
Famous suffers of gout
Kings Henry VII and VIII; Queen Anne and King George IV; many of the Bourbons, Medicis, and Hapsburgs. Others said to have been affected include William Cecil, Francis Bacon, William Harvey, Oliver Cromwell, John Milton, Isaac Newton, William Pitt, Samuel Johnson, John Wesley, Horatio Nelson, Charles Darwin, Benjamin Franklin, and Martin Luther. Indeed, it is said that it was the incapacity from gout affecting William Pitt which kept him away from the English Parliament when it passed the heavy colonial duty on tea which resulted in the Boston Tea Party and the loss to England of the American colonies.
Augustin Jacob Landre-Beauvais
The first clinical description of rheumatoid arthritis is credited to Landre-Beauvais (1880). He described a series of women with a disease he considered to be a variant of gout. The patients were nine long-term residents of the Salpêtrière hospice in Paris. After reviewing the main features of ordinary or regular gout, Landré-Beauvais points out that the disease he calls “asthenic gout” exhibits several distinctive features, including predominance in women, a chronic course, involvement of many joints from the onset, and a decline in general health.
First use of the term 'rheumatoid arthritis'
Sir Archibald Garrod first used the term ‘rheumatoid arthritis’ in the late 1850s, and he is Oxford English Dictionary’s first quotation for the term.
Philip Hench, awarded a Nobel prize for his work in Rheumatology
Philip Showalter Hench 1896–1965, American physician won the Nobel prize in 1950 for his work developing the first steroid drug. For many years Hench had been seeking a method of treating the crippling and painful complaint of rheumatoid arthritis. He suspected that it was not a conventional microbial infection since, among other features, it was relieved by pregnancy and jaundice. Hench therefore felt it was more likely to result from a biochemical disturbance that is transiently corrected by some incidental biological change. The search, he argued, must concentrate on something patients with jaundice had in common with pregnant women. At length he was led to suppose that the antirheumatic substance might be an adrenal hormone, since temporary remissions are often induced by procedures that stimulate the adrenal cortex. Thus in 1948 he was ready to try the newly prepared ‘compound E’, later known as cortisone, of Edward Kendall on 14 patients.
Foreward to the first edition of the journal Annals of Physical Medicine
Lord TJ Horder, in his foreword to the first edition of the Journal of the Annals of Physical Medicine, now called Rheumatology
Image credits: Brown rust paper background by cesstrelle; Public Domain via Pixabay. Texture background by Zeana; Public Domain via Pixabay. “English Caricaturists, ‘The Gout'” by James Gillray, 1893; Public Domain via Wikimedia Commons. Background abstract texture green; Public Domain via Pixabay. Hans Holbein the Younger; Public Domain via Wikimedia Commons. Portrait of Anne of Great Britain by Michael Dahl; Public Domain via Wikimedia Commons. Giovanni di Medici by Bronzino; Public domain via Wikimedia Commons. Francis Bacon, Viscount St Alban; Public domain via Wikimedia Commons. Oliver Cromwell Gaspard de Crayer by Caspar de Crayer; Public domain via Wikimedia Commons. Samuel Johnson by Joshua Reynolds; Public domain via Wikimedia Commons. Jwesleysitting by Frank O. Salisbury, Public domain via Wikimedia Commons. Horatio Nelson by Lemuel Francis Abbott; Public domain via Wikimedia Commons. Charles Darwin; Public domain via Wikimedia Commons. Benjamin Franklin 1767 by David Martin. Public domain Wikimedia Commons. Martin Luther, 1528 by Lucas Cranach the Elder. Public domain via Wikimedia Commons. Renoir by Pierre-Auguste Renoir. Public domain via Wikimedia Commons. J.B. Arrieu Albertini, Public domain via Wikimedia Commons. James Coburn in Charade, Public domain via Wikimedia Commons. Lucy YankArmy cropped, Public domain via Wikimedia Commons. George IV of the United Kingdom by Thomas Lawrence. Public domain via Wikimedia Commons. Abstract ink painting on grunge paper texture dreamy texture via Shutterstock. An anatomical illustration from the 1909 American edition of Sobotta’s Atlas and Text-book of Human Anatomy. Public Domain via Wikimedia Commons. An anatomical illustration from the 1909 American edition of Sobotta’s Atlas and Text-book of Human Anatomy. Public Domain via Wikimedia Commons. Backdrop watercolour painting Public Domain via Pixabay. Colorful circles of light abstract background via Shutterstock.
Contagious disease is as much a part of our lives as the air we breathe and the earth we walk on. Throughout history, humankind’s understanding of disease has shifted dramatically as different cultures developed unique philosophic, religious, and scientific beliefs. From Galen in Ancient Rome to Walter Reed in the United States, the collective experiences of those before us have come to inform our present understanding of contagious disease. See how much you know about the history of contagious disease.
Headline image credit: Copper engraving of Doctor Schnabel [i.e Dr. Beak], a plague doctor in seventeenth-century Rome, with a satirical macaronic poem (‘Vos Creditis, als eine Fabel, / quod scribitur vom Doctor Schnabel’) in octosyllabic rhyming couplets. Public domain Wikimedia Commons
In May this year, the American Osler Society held a joint meeting with the London Osler Society and the Japanese Osler Society in Oxford at the Randolph Hotel. The Societies exist to perpetuate the memory of arguably one the most influential physicians of the early twentieth century, and to discuss topics related to Sir William Osler’s interests. It is fitting that this meeting was held in Oxford, where Osler spent his time as the Regius Professor of Medicine having transferred from another great seat of medical learning at Johns Hopkins Medical School in the United States.
Osler was interested in medical education (he produced his classic textbook, which ran to several editions) and set about trying to improve the education of future doctors. Osler’s other great legacy was his combination of superb clinical skills honed by experience not only on the wards but also in the laboratories, and his great interest in the humanities. Osler always tried to combine these two approaches in his work, and much of his writings and aphorisms are as relevant today as when they were first written. Medical students could read Aequanimitas today more than a century after it was written, and would profit from much of the advice to students within this volume of essays and addresses.
Osler had a great interest in the History of Medicine and helped found the history section of the Royal Society of Medicine in London. This scientific section has continued to flourish for over a century. He believed physicians should be well rounded and well read, and that medicine was a calling of both art and science. Although Osler was not against the idea of specialisation in medicine, he was a superb generalist and could manage both adult and child patients. He believed that doctors owed it to themselves to be well versed in the range of disease and illness afflicting mankind. His early interest in comparative pathology during his time at the Montreal Veterinary College prepared him well when dealing with infectious diseases which in the pre-antibiotic area were the scourge of the day, as compared with today in the West where degenerative diseases, cancers and diseases of longevity have overtaken infections as a major killer in the Western world.
The centenary of the Great War is 2014; it was Osler who started a campaign for the compulsory vaccination of soldiers for typhoid, publishing letters in the Times and The British Medical Journal on this topic. That year his literary output also included his Incunabula Medica, a study of 214 of the earliest printed medical books from 1467-1480. Although finished, it was not published until 1923, four years after his death.
Throughout the late twentieth century medicine has continued to super-specialize at an alarming pace throughout the world, driven by the rapid advances in medical diagnosis and treatment. X-rays were only invented in 1895, and the early part of the twentieth century began to see the introduction of chest x-rays into clinical practice. This was still a world away from CT scans, ultrasounds, and MRI scans, which are now de rigueur in the management of patients. Yet in spite of all this progress, disaffection with the medical profession seems rife. Could it be that the general physicians are going to make a comeback? Perhaps a more humanitarian approach to the patient is what is required again, maybe combined with the inexorable technical progress which will undoubtedly continue in the future. Osler would have been amused to see how the wheel of medical fashion has turned full circle.
Arpan K Banerjee qualified in medicine from St Thomas’s Hospital Medical School in London, UK and trained in Radiology at Westminster Hospital and Guys and St Thomas’s Hospital. In 2012 he was appointed Chairman of the British Society for the History of Radiology of which he is a founder member and council member. In 2011 he was appointed to the scientific programme committee of the Royal College Of Radiologists, London. He is the author/co-author of six books including the recent The History of Radiology.
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For five hours, the thirty-person surgical team worked in an operating room in Cape Town, South Africa. The head surgeon, Dr. Christiaan Barnard, was leading the team into uncharted territory, transplanting the heart of a young woman killed in a car accident into the chest of 55-year-old Louis Washkansky. As the operation neared to a close, Barnard used electrodes to stimulate the heart. It began pumping, and the team knew they had succeeded. The operation was not the first organ transplant—kidney transplants had been performed for more than ten years. In transplanting the heart, though, Barnard pushed medicine into a new phase.
“On Saturday,” Barnard remembered later, “I was a surgeon in South Africa, very little known. On Monday I was world-renowned.” The recipient, 55-year-old Louis Washkansky, lived only eighteen days after the surgery before dying of pneumonia. Nevertheless, Barnard had revolutionized cardiac care. The surgeon improved his heart transplant techniques over the years such that some patients lived for several years after surgery. He also experimented with new techniques, including using artificial heart valves and using hearts from monkeys as a stopgap measure for some patients.
Along with his medical breakthroughs, Barnard challenged social conventions. His second heart transplant roused controversy in his native land because the recipient was white and the donor was “coloured”—the term under South Africa’s apartheid system for a person of mixed white and black ancestry. Over the years, Barnard became more outspoken about the rights of black South Africans, putting his reputation behind the end of apartheid. He also became somewhat controversial for his obvious enjoyment of his celebrity status and for, late in life, trying to find ways to reverse aging.
Barnard will be most remembered, though, as a bold surgeon looking to expand the boundaries of medicine.
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As a historian who writes about the controversial topic of ‘alternative medicine’, I get a lot of questions about whether this or that therapy ‘works’. Sometimes, these questions are a test of my objectivity as a researcher. My questioners want to know whether I am ‘believer’, or a fan of alternative medicine, or have any stake in promoting or disdaining a given medical system. Other people are asking simply for advice: is it worth trying acupuncture, say, or homeopathy for a particular condition? From either angle, such questions ask me to take a stand on whether homeopathy is quackery, or whether I believe in acupuncture channels, or chiropractic manipulation.
My instinctive – if perhaps unhelpful – response to such questions is, more or less, to shrug my shoulders and reply that I don’t really care: the issue of therapeutic efficacy isn’t at the heart of my research on this fascinating subject. Instead, I want to know what lies behind the enduring popularity of alternative medicine, what is (or is not) really ‘alternative’ about it, and why so many of biomedicine’s current crop of ‘alternatives’ have been imported from very different global medical cultures. These are questions that a historian can answer. They are also questions that shed more light on the persistence of alternative medicine than would a yes or no answer about the efficacy of any given technique. After all, we know that once-respected mainstream therapies like bloodletting and purging enjoyed centuries of popularity despite being uncomfortable, potentially dangerous and (in light of today’s medical knowledge) ineffective. Even today, patients prescribed antibiotics for a nasty cold often report feeling better after taking them – despite knowing that most colds are actually caused by viruses, and thus immune to antibiotic therapy.
My position has not always been popular with my fellow authors writing on the topic. They are often passionately committed supporters or opponents of alternative therapies, and demand that I become one or the other as well. But history studies the interplay of light and shadow, not the boundaries between black and white. So I am happy to let the healers fight it out in the battle to prove or disprove the efficacy of their chosen treatments. My job as a historian is to remind them — and to remind us all as consumers — that even the most objective evidence remains historically contingent: no medical experiment can escape from its social milieu, since both its designers and its subjects are shaped by their own historical and cultural context and beliefs.
For example, in contemporary biomedicine, it is conventional to separate the mind and the body when designing a medical experiment: hence the rise of the double-blinded random controlled trial as medicine’s ‘gold-standard’ of proof. Yet physicians and researchers simultaneously acknowledge the impact of the mind on bodily processes. They call it the ‘placebo effect’. As understandings of the mind-body relationship become more sophisticated, it is possible that the blinded RCT will fall from favour, as a limited test of therapeutic activity which obscures an important variable. Such changes have happened in the past, as evidenced by the shifting balance between deductive and inductive reasoning in scientific experimentation since the Scientific Revolution, or the changing status of ‘empiricism’ in western medicine since the 18th century. Then again, it may not: history is not a predictive science! My point is that today’s objective truths are neither value-free nor future-proof.
More practically, it is also my task to point out that the arguments used on either side — for instance, ‘homeopathy is bunk; no trace of the medicinal substance remains in a homeopathic dilution’, or ‘biomedicine reduces h
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The American-born pharmaceutical entrepreneur Sir Henry Wellcome dreamed of creating the world’s greatest museum of medicine. His enormous wealth and ambition led him to acquire a collection so vast that, at his death, it still lay in warehouses, unseen and incomplete - allegedly with more items than held by the Louvre. Today, after decades of work by his successors, parts of the collection can been seen around the world. In the original post below, Frances Larson, author of An Infinity of Things: How Sir Henry Wellcome Collected the World, tells us about one of those pieces: the smallest medicine case in the world.
It was not much bigger than a sugar cube. ‘The smallest medicine chest in the world’ was less than two centimeters wide but it was fitted with twelve tiny bottles. Together, they held fifteen pints of fluid medicine in condensed form: there were 300 doses of medicine in this miniature magic box. It was a technological marvel, a work of art.
The idea for the tiny medicine case came from Henry Wellcome, proprietor of the international pharmaceuticals firm Burroughs Wellcome and Company. He had walked into a meeting one day, taken a tiny golden box out of his waistcoat pocket and, to the astonishment of his audience, announced that he wanted it made into a medicine chest.
Henry Wellcome regularly expected the extraordinary. If any of his employees protested against his plans, he would put his hand on their shoulder, look them straight in the eye, say, ‘You know, I think it could be done if we could find the right man’, and walk away. He was rarely disappointed.
‘The smallest medicine chest in the world’ was an advertising masterpiece. It was photographed balancing on the tip of a man’s finger. The upward pointing finger directed attention to the miniature box while acting as the perfect measure of scale. Burroughs Wellcome were presented as magicians, conjuring a generous supply of medical cures from a few drops of liquid.
The image was apt, because the Burroughs Wellcome were famous for their compressed medicines. In 1884, Henry Wellcome had coined the word Tabloid, now more commonly associated with ‘downscale’ newspapers, to describe his firm’s compact products. Hundreds of gelatin-coated pills and compressed tablets were manufactured every minute in their factories. They were so beautiful, according to the British Medical Journal, that they ‘might almost be mistaken for sweets’.
Few people knew how these beautiful preparations worked. They were developed in research laboratories of the highest caliber, but the firm’s procedures were a closely guarded secret. Orders were made through special channels to disguise their interests, identifying marks were chiseled off new equipment, and every member of staff signed a detailed confidentiality agreement. Medicine had never been so simple, so efficient, or so mysterious.
Compressed medicines were perfect for travel, and Burroughs Wellcome medicine cases became market leaders. They were designed to fit every means of transportation, whether it was the handlebars of a bicycle, the cockpit of an aeroplane, or the runners of a sledge. Burroughs Wellcome medicines had been ‘First at the North Pole and First at the South Pole’: Amundsen, Scott, Shackleton and Peary had all embarked on their polar expeditions with Burroughs Wellcome equipment.
The medicine cases were available in a range of finishes: crocodile leather, bronzed aluminium, silver, doeskin. Such stylish coverings hinted at the desirability of the objects within. These products blurred the boundaries between looking good and feeling good: clasps clicked smoothly, corners were polished smooth, hinged racks swung out and revolved automatically, offering up neat rows of syringes and tiny tubes of tablets. Burroughs Wellcome manufactured a sense of control in material form, and Henry Wellcome knew that small things could make a big difference.
Henry Wellcome was a perfectionist. One of his employees remembered that ‘under his direction one learned to pay special attention to minute detail’. He constantly pushed his staff to raise their standards. No job was too small, whether it was improving the stopper on a tube of insect repellent or testing the effects of water on soap wrappings.
‘The smallest medicine chest in the world’ encapsulated all these qualities: precision, convenience and hidden power. It sent a message that people no longer had to worry about their health, because Burroughs Wellcome had done all the worrying for them. In the early 1920s a replica chest in fifteen carat gold was made for Queen Mary’s dolls’ house, a fact that Burroughs Wellcome were quick to publicize. The implication was clear: thanks to their hard work, good health had become child’s play.
Based on documents kept at the Wellcome Library (file references: WF/M/H/07/04, WA/HSW/PE/C.23 and WF/M/H/07/01). British Medical Journal, 25 July 1885, 155.
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