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AN INTRODUCTION TO THE HISTORY OF
MEDICINE
BY
S N KOTHARE
and
SANJAY A PAI
1
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ACKNOWLEDGEMENTS
Our grateful thanks are due to Dr. Mary Eapen ( Prof, of Anaesthesiology), Dr.
Balakrishna Shetty (formerly Asst. Prof, of Radiolog}') and Mrs.Rajaram (Librarian) of
St. John’s Medical College and Hospital. Bangalore. Dr.Y.M.Bhende ( Retd. Prof, of
Pathology. B.J. Medical College. Pune). Dr.N.G.Talwalkar
(Consultant Physician,
Bombay), Dr. Sulabha Punekar (Prof, of Urology, K.E.M Hospital, Bombay ), Dr. C.V.
Patel (Retd. Prof, of Surgery, K.E.M. Hospital, Bombay), Dr. Ravi Narayan and his
colleagues from Community Health Cell, Bangalore, for their assistance in printing the
manuscript. Our special thanks are also due to the management of “Physicians Update”,
Bangalore and the Alumini Association of the St. John’s Medical College, the publisher
of St. John’s Medical College Journal of Medicine, for permitting Dr SN Kothare to
reproduce material from his articles published in their respective journals. Finally, we
are grateful to Mrs V V Joglekar for having cheerfully - as ever - typed out the
manuscript.
z
TABLE OF CONTENTS
Foreword................................................................................... 5
1. Introduction............................................................................ 6
2. Mythology and Medicine....................................................... 9
3. Pioneers in Medicine............................................................ 13
4. Hospitals and Nurses............................................................ 19
5. Physicists and Medicine........................................................ 23
6.The Fountain of Life.................................................................. 27
7. Nutrition and Disease............................................................ 31
8.Organ Systems........................................................................ 35
9.Some Common Diseases.......................................................... 45
10. Pathologists and Microbiologists........................................ 51
11. Drugs................................................................................... 60
12. Sweet Slumber.................................................................... 67
13. The Romance of Surgery.................................................... 71
14. Obstetrics and Gynaecology............................................... 79
15. Evolution of Psychology and Psychiatry............................ 86
16. Sexually Transmitted Diseases and Skin Diseases............. 90
17. Emergencies....................................................................... 96
18 Versatile Personalities in Medicine........................................ 99
4
FOREWORD
The evolution of medicine as a process of trial and error has marked man’s tireless
crusade against the ravages of pestilence and disease. This “history of medicine”
deserves rhe attention of medical students and practicing physicians alike, but
unfortunately has played a minor role in the medical curriculum todate. Fortunately, I had
the privilege of being associated with two colleagues who shared a great interest in the
history' of medicine: Major General S.L.Bhatia, an Emeritus Professor of the History' of
Medicine and Dr.Shripad N. Koihare, a pathologist at St.John’s Medical College in
Bangalore, India. Dr.Bhatia’s love and interest in the subject resulted in many
publications and in the founding of the Institute of History of Medicine in Hyderabad and
later, the Bhatia Museum of St.John’s Medical College. Through his generosity, the
Museum was well-endowed with his personal collection of books, medical illustrations,
and funds. The task of Curator of the Museum was then taken by Dr. Kothare who further
organised it and enriched it with his own 13 publications on different aspects of the
subject.
He has now authored this book with the help of Dr. Sanjay Pai, a young
enthusiastic pathologist who is also interested in the historical aspects of the medical
sciences. The book provides a comprehensive summary' of the vast topic of the practice
of medicine all over the world in the preceding six thousand years. This includes the
roots of medicine in the third century' BC to the Vedas, the arrival of the Aryans,
Mohenjo-daro and Harappa, and finally, to our modern medical practices influenced by
lhe arrival of the Portuguese and English. Perhaps the hardships incurred by our
predecessors, as is well illustrated in this book, will inspire us in our quest for excellence.
And now, if I may be permitted to end on a more personal note : Shree, as he is known
to his friends, has been a good friend and colleague of mine for over 60 years and is
noted for his sincerity', patience, diligence, and perseverance in the fields of pathology'
and now in the history of medicine. I am indeed grateful to him for enabling me and
future readers to enjoy Iris contribution to the education of medical students.
Dr L Monteiro, MD
Formerly Professor of Pathology and Microbiology' and The Dean,
Topiwala National Medical College, Bombay, India
and Dean [ Retd ], St. John’s Medical College, Bangalore, India
Current address : 12, Lees Lane. Westport, CT 06880 -2018, USA
5
CHAPTER 1 : INTRODUCTION
This book is compiled with the object of providing the medical strident and the
layperson an introduction io the evolution of medicine through the ages.
Postgraduate students, particularly those writing their dissertations may find useful
references to their topics of interest. This attempt to condense the vast information
covering a period of six thousand years or more is indeed a formidable task, and
carries with it the possibility of errors of omission. For such deficiencies we crave
for the indulgence of our readers.
History7 by definition is a record of events and I or of personalities of respective
periods usually in a chronological order. This definition cannot be applied strictly io
the history of medicine because of certain shortcomings such as the non-availability
of written scripts over a period of several centuries. This lacuna is more acutely felt
when it concerns ancient Indian (Hindu) medicine. It is believed that in India, the
first known writing was recorded in Bramhi script in the third century' B.C. For
centuries in India, knowledge was propagated by word of mouth from Guru [ teacher
] to Chela [ student ] and this situation persisted till the arrival of the Aryans.
Information on Egyptian, Babylonian and Greek civilizations has been derived by
deciphering hieratic, hieroglyphic and cuneiform writings available through
archaeological excavations.The excavations of Mohenjo-Daro and Harappa have
thrown light on community living and sanitary' conditions in ancient Indian
civilizations, which even by current standards were conunendable. In fact, our
present water carriage system of drainage is an improved version of the same. The
chief sources of information of ancient Hindu culture and medicine are the four
Vedas amongst which the Rig Veda was the earliest and the Atharva Veda, the last.
The Atharva Veda, believed to have been composed some time in 1200 B.C.is the
most important source of information on ancient Hindu medicine. All four Vedas are
in the form of shlokas (hymns), verses, incantations and rites, used on appropriate
occasions to propitiate the respective deity, depending upon the need of the afflicted.
It is a far cry from the primitive to present-day medicine. The days of myth,
mysticism and religion being related to illness are fast disappearing. The sorcerer,
the soothsayer, the witch doctor, the apothecary, the medicine peddlar and such
others are being replaced by practitioners of rational medicine, hi India, we are
fortunate in having different schools of medicine such as the Ayurvedic, Unani and
Western. The people of rural Lidia who constitute nearly 80 per cent of the country’s
population, often look upon Western medicine with suspicion and prefer medicines
from the indigenous system because of their easy availability' and low cost. Under
these circumstances, will it not be prudent to bring about an integration between the
existing systems for the greater good of humanity ?
6
The renowned seals of learning of ancient Indian medicine were Kashi ( Varanasi /
Banaras) in the East and Taxiia (Taksasila) in the West. Sushruta was the teacher of
surgery- at Kashi while Atreya taught medicine and surgery' at Taxiia. The Dayanand
Ayurvedic College was established in Jullundar in 1898. Takmil-Ut-Tib College in
Lucknow in 1902 and National Homeopathic Medical College in Lucknow in 1921.
With the Moghul invasion of India. Unani medicine was introduced and the first school
of Unani medicine was established in Delhi during the reign of Akbar. By 1990 , there
were 11 schools of Unani medicine, 131 colleges of Homeopathic medicine, and 83 of
Ayurvedic medicine. There are over 460,000 practitioners of traditional Indian medicine
in India today.
With the arrival of the Portuguese, Western medicine was introduced into India ( Vasco
da Gama arrived at Calicut in May 1498 ). There were European physicians in the courts
of Shah Alam, Haider Ali, Tipu Sultan and Maharaja Ranjit Singh. The first medical
schools of Western medicine were established by the English in Madras and Calcutta in
1835 and in Bombay in 1845 as well as by the Portuguese at Mandovi in Goa in 1842.
Earlier, in 1703, a rudimentary course in medicine was conducted at the Royal Hospital
in Goa. Since then, the number of such schools/colleges in India has been growing
steadily. By the end of 1989 there were 125 such institutions with over 14,000 new
graduates every year.
The first Indian woman to graduate in Western medicine is believed to be Anandibai
Joshi of Pune, in the year 1886. She was the first Brahmin student from Poona (Pune).
She took her training in the United States of America in “The Woman’s Medical
College”. Philadelphia and completed her M.D. in 1886. She was greatly encouraged by
her husband Gopalrao , a clerk in the postal department who stronly advocated women's
education. Soon after her return to India, she was appointed as a physician in charge of
the female ward of the Albert Edward Hospital at Kolhapur. ( The present Civil Hospital
in Kolhapur was formerly known as Albert Edward Hospital ). She however died of
tuberculosis at the age of 22 years in 1887. Her distant cousin Pandita Ramabai, the
poetess and a social worker was invited by the Dean of the college to attend the
graduation ceremony of Anandibai. Pandita Ramabai wrote about Anandibai in her book
“ High caste Hindu woman “. Sharayu Bhatia in her book “The Firsts- Life Sketches of
Medical Women in India ’ writes that Anandibai Joshi was the first Indian woman
graduate trained abroad.
The first four men to qualify in Western medicine from the Calcutta Medical College in
1838 were Uma Karan Set, Dwarka Nath Gupta. Raj Kristo Dey and Nobin Chander
Miner.The first batch of students admitted in the Grant Medical College, Bombay, in
1845. were awarded the diploma “Graduates of Grant Medical College,” (G.G.M.C.) in
1851. They were Bhau Daji Lad Parsekar, Sebastian A.D’Carvalho, Atmaram Pandurang
Tarkhad, Paul Frances Gomes. Merwanjee Sorabji, Burjorji Dorabji, Anant Chundroba
7
Dukle and J.C. Lisboa. Information about students of Madras Medical College was not
available in books referred to nor could it be obtained from the institution concerned.
REFERENCES
i) Alsop, G. F. : History of the Woman’s Medical College, Philadelphia, Pennsylvania,
1850-1950 A.D. : Philadelphia, London, Montreal, 1950
ii) Directory of medical colleges in India: Government of India Press, Nasik, 1978.
iii) Goyal, K. : Binnys Director}' of Medical College in India : Ed.8, Binnys Publishing
House, 86 U.B. Jawahar Nagar, Delhi - 110 007, 1990
iv) India-1976: Publication Division, Ministry of Information and Broadcasting,
Government of India, 1976
v) Jaggi, O P. Medical Education and Research. Vol 13, 1979. Publisher Atmaram and
sons, Delhi.
vi) Talwalkar, NG. Men and memorabilia of Grant Medical College and JJ Group of
Hospitals. The Research Society, JJ Group of Hospitals and Grant Medical College,
Bombay 400 008, 1995
8
CHAPTER 2 :
MYTHOLOGY AND MEDICINE
HINDU MYTHOLOGY
Ancient Indian medicine, in fact Hindu medicine, since Hinduism was the only religion
existing those days in India, goes back to 6000 years B.C. or more. According to Hindu
mythology', the creator of the Universe, Lord Brahma, was the first teacher to make a
compilation of Ayurvedic texts which he later abridged into eight parts , with medicine
(Kayachiktsaya) and surgery (Shalya tantra) as the main subjects. It is believed that
Brahma propagated this knowledge through Daksha Prajapati who in turn taught this
science to the Aswini Kumars (the twin sons of the Sun God ). The Aswinis imparted
the science to Indra. Upto this time, the knowledge of Ayurveda was known only to
celestial personalities. It is believed that it was Lord Indra who passed on this knowledge
of Ayurveda, the "science of life”, to sages and rishis ( mortals ) , the first pupil being
Bharadwaja. He, in turn, taught this subject to others including Atreya. He, it is believed,
lived in the period 700 - 600 B.C. and became a renowned teacher at Taxila. Due to the
profound depth of his teachings, Atreya has been reverentially been considered the
"Father of Indian medicine”. One of Aireya's disciples Charak, born in Varanasi some
lime in the year 320 B.C. subsequently migrated to Taxila, and became an illustrious
personality like his guru. “Charak Samhita” is essentially a compilation of Aireya’s
teachings, covering the theory' of drugs, diseases and their correlation Lord Vishnu is
also believed to have been associated with ancient medicine. It is said that several sages
approached the Lord and begged of Him to help them save humanity' from diseases and
suffering. In response to their plight and prayers, he ordered the churning of the ocean of
milk with the aid of “ vasukis ” and “ asuras “. Dhanvantari then came out of the ocean
with the pot of “ amrita ” in his hands. (There is a sculpture of Dhanvantari in the
Somanathpur temple in Karnataka). According to another version, Lord Indra favoured
and blessed him with knowledge in Ayurvedic medicine. Dhanvantari, in years to come,
became a renowned teacher in the art of surgery' and taught this subject to his disciples at
Varanasi (Kashi). Fie was considered the “Patron Saint of Surgery'” and later elevated to
divinity of classical medical wisdom. He lived some time in the Sixth Century' B.C.
Sushruta, one of his disciples attained great proficiency in surgery and came to be known
as the “Father of Indian Surgery”.
Ancient Indian medicine can conveniently be classified into three broad groups :
a) the Pre-Vedic period ( from 6000 B.C. upto the Arvan invasion of India , about 1500
B.C.,),
(b) the Vedic period ( 4000 B.C.- 700 B.C.), and
(c) the Post -Vedic period ( 800 B.C. - 200 A.D.).
9
It must be noted that these dates are not authentic but derived from archaeological
findings and other available data. Diseases during the Pre-vedic period were attributed to
supernatural powers, magic, etc; hence the treatment consisted of prayers, to appease the
supernatural powers, and religious riles, talismans, amulets etc. to counter evil magic.
The four Vedas were written during the Vedic period and of these, the Rig Veda, the
oldest, was written some time in 4000 B.C. This scripture contains, besides spiritual and
philosophical thoughts, some minor contributions to medicine. Atharva Veda which was
written some time around 700 B.C. covers essentially medicine - the origin of Ayurveda.
Diseases were, as in the earlier period, attributed to evil spirits, magic and the wrath of
God. The treatment consisted of prayers and religious rites for appeasement, with
addition of medicines of herbal and animal origin.
During the Post-Vedic period (800 B.C. - 200 A.D.) medicine assumed a more rational
approach under the great gurus Atreya, Dhanvantari, Sushruta and Charak.
EGYPTIAN MYTHOLOGY
Like ancient Indian medicine, ancient Egyptian medicine dates back to 3000 B.C. and
even earlier. During those days. Egyptians attributed diseases to the displeasure of
various Gods, the Sun, the Moon and their effects on the human body. Imhotep who lived
some time in 2980 B.C. was a renowned architect, astronomer and later a physician. He
is in fact, the first physician mentioned in history. He designed for King Zoser of the 3rd
dynasty, the free standing step pyramid of Sakkara. A century after his death, he was
considered a demigod of medicine by the Egyptians and, later by 525 B.C., he was
elevated to the status of God of Healing. Thoth (2000 B.C.) was a scribe and a sage.
With his wisdom, he prescribed therapautic measures which were successful and in turn
enhanced his reputation as a physician.
Isis (1500 B.C.) was considered the “Divinity of Medicine” and was a renowned teacher
of surgical skill. Horus was the son of Isis and had lost his sight in childhood. Isis
prayed to Thoth and her prayers were answered with the restoration of the eyesight of
Honts. Since then Homs has been worshipped as the “God of Medicine” and the eye of
Homs, has become a symbol of protection of health.
The significance of the symbol Rx dates back to 3000 B.C. It was also supposed to have
arisen from the eye of Homs. It was a symbol of durability, strength and beneficence of
the medical profession and (he Egyptian druggist, and is hence conventionally written at
the beginning of all medical prescript ions.
10
GREEK MYTHOLOGY
In Greek mythology. Zeus was considered the God of Gods, as also the weather God and
the protector of health. He was the son of Kronos and was married to his own sister Hera.
Such marriages between brother and sister were practised among ancient Egyptians and
Greeks to maintain the “purity” of the race and of the royal family in particular.
Apollo was considered the earliest Greek God of medicine. Apollo was born in Delos and
brought up in Delphi. Here, as the legend goes, the infant Apollo slew a python or a
monster that had plagued the site. Following this, Delphi became a sacred place in
Greece, where oracles occured ; (oracle : divine advice / solution to problems including
those of health and sickness). Apollo is similar to the Egyptian Horus. Apollo was
supposed to be the son of Vulcan. Amongst the Greek Gods, Zeus was considered even
higher titan Apollo. Apollo taught the healing art to Chiron, the gifted Centaur , who is
sometimes regarded as the God of Surgery'. He taught the art of healing to Achilles,
Asculapius (Asklepius) and Jason.
Asculapius may have lived around 130 - 40 B.C. ; he was a physician who cured many
patients. He was later diefied as athe son of Apollo. It is believed that Apollo killed his
wife and released Asculapius from her womb, because he suspected her of infidelity'.
Another version states that she was killed by a thunderbolt. Pluto, the ruler of the
underworld, fearing that the supply of souls might thereby be depleted appealed to the
supreme God Zeus, who promptly slew Asculapius with a thunder- boll. Asklepieia, the
places for cure named after Asklepius, were generally situated in healthy areas with fine
scenery', natural springs etc. The important Asklepieia were situated in Tricca, Epidaurus
and Cos. Even in its present ruined state, Epidaurus, a place in the Peloponnesian
province of ancient Greece where a good Asklepiea was situated, is a lovely place.
Asculapius is usually shown with a staff and a single entwined serpent. The serpent is a
symbol of health and healing power. The Greeks ate snakes to acquire immortality. The
serpent was also revered by Egyptians for its healing abilities. In Asklepieia , serpents
were induced to lick wounds as a therapeutic measure.
CHINESE MYTHOLOGY
The primitive Chinese attributed diseases to demons; each disease was due to a
particular demon. Hence the treatment was in the hands of priests and sorcerers, who
employed divination, incantation and magic including the use of special herbs.
Shen Nung (2838 - 2698 B.C.) was the legendary “ Father of Chinese Medicine” . The
Chinese medical classic, “Canon of Medicine”, is supposed to have been written by
Huang Ti, the Yellow Emperor (2698 - 2598 B.C.). It consisted of two parts: the second
part was a treatise on Acupuncture However, prohibition of dissection of the human
body due io religious beliefs, retarded the progress of medical science in China. The
11
dissection of the human body was later permitted by the presidential mandate of
November 1913. One of the most famous physicians of China was Pien Chiao (255 B.C.)
from the Chou Dynasty. He had a good knowledge of herbal medicine: it is said he made
two patients unconscious with a narcotic wine probably containing hemp. He was later
assassinated due to professional jealousy.
MESOPOTAMIAN AND PIEBREW MYTHOLOGY
Gilgamesh was the only known Mesopotamian God of Medicine and a mythological
hero. Not much is known of this personality'.
Flebrew medicine was essentially borrowed from the Egyptians and is hence of little
importance. Moses (1250 - 1230 B.C.) formulated the Mosaic code, a landmark in health
and sanitation with i ts emphasis on personal hygiene. An outstanding example of this is
the practice of circumcision amongst Jews since then.
REFERENCES:
i) Bhatia. Maj. Gen. S.L. Medical sciences in ancient India, 1972.
ii) Bhatia, Maj. Gen. S.L. History' of medicine with special reference to the orient:
published by management commitee, Dr B.C. Roy' Award Fund, Office of Medical
Council of India, New Delhi- 110 002, 1977.
iii) Ency'clopedia Britannica Inc, Publisher William Benton, Chicago, Illinois, London,
Manila, Vol. 2, 1969.
iv) Mettler, Cecilia. C. : A History' of Medicine, The Blackstone Company, Philadelphia,
Toronto. 1947
v) Vakil, R.J. Romance of Healing and other Essays - Our Medical Heritage, Asia
Publishing House, Bombay, Calcutta, New Delhi, Madras, London, New York, 1961.
vi) Wong, K. Chimin, and Lien-Teh, Wu: The History' of Chinese Medicine, Tientsin
Press, Tientsin, China, 1932.
12
CHAPTER 3 :
PIONEERS IN MEDICINE
During the period 500 - 100 B.C. great men of learning contributed to the advancement
of Indian (Hindu). Chinese and Greco-Arabic medicine ( which came to be known later
as Unani Medicine ) and Persian medicine too. Among these, Atreya, Dhanvantari,
Sushruta, Charak, Vagbhata, Nagatjuna , Rhazes, Avicenna, Hippocrates and Galen are
some of the most famous personalities.
INDIAN (HINDU)
Atreya (700 - 600 B.C.) was an eminent sage and a pupil of Bharadwaja at Taxilla
(Taksasila) situated on the banks of 1he river Sutlej now in Pakistan. He taught medicine
and ushered in the age of scientific medicine through his astute observations of
symptoms, disease and their correlation. He is rightly known as the “Hippocrates of
Ancient Indian Medicine” as well as the “Father of Indian Medicine”. Charak was one of
his students. Like Atreya, Dhanvantari (600 - 500 B.C.) at Banaras (Vamasi), became a
renowned teacher of surgery and later came to be known as the “Patron Saint of
Surgery'”. Sushruta was one of his pupils.
Sushruta . the greatest surgeon of ancient India lived some time in 400 B.C. He devoted
himself to surgery and taught the subject to his pupils. His famous writings known as
‘■Sushruta Samhita” are devoted essentially to surgery. But that was not all: he also wrote
on Medicine. Pathology', Anatomy, Midwifery', Ophthalmology, Biology and Hygiene.
From the available records, it is evident that major abdominal operations were also
carried out. Vesical calculi, even those days, were common and hence the operation for
the removal of vesical calculi was well described in Sushruta Samhita. Surgical
procedures for anal fistula, fractures, extraction of foetus in abnormal presentation,
amputation, excision of tumours, repair of hernia and couching of cataract were also
known. Rhinoplasty was commonly performed for restoration of severed or cut noses as
punishment for certain offences such as adultery. He carried out plastic surgery, giving
his patients a new nose or a new ear by the process of skin grafting. Dr.Hirschberg of
Berlin pays his tribute to Ancient Indian Surgery' by writing “The whole plastic surgery'
in Europe took a new flight when these cunning devices of Indian workmen became
known to us”. Sushruta described many sharp surgical instruments emphasizing the need
to get them made of “pure, strong and sharp iron”. Several types of knives and needles
have been described depending upon their use and tissues concerned. He taught his
pupils how to make incisions on the abdomen by using a pumpkin for demonstration
purposes. It is believed that the following ingenious method for suturing the severed
ends of intestine was employ'ed. The cut ends of the intestine were apposed to each other
and big black ants, collected specifically for this purpose were made to bite the apposed
ends and their heads severed when their pincers had closed. Thus the pincers remained
‘in situ’ due to rigor mortis retaining the cut ends of the intestine in apposition for some
time. The heads and the pincers of the ants being organic matter got digested in due
13
course of time, not unlike the catgut of the present day surgery. His works were translated
into Arabic by the 8th century A.D. and called“ Kitab-i- Susrud “.
Charak, the great Hindu physician lived some time around 320 B.C., There is a lot of
uncertainly regarding his parentage, his place of abode and whether Charak was his
personal name, the name of the school he belonged to, or a title he assumed for himself,
or which was conferred upon him. His teachings are complied into what is known as
“Charak Samhita” which forms along with the “ Sushruta Samhita “ some of the classics
of ancient Indian Medicine. Referring to ancient Indian Medicine, Castiglioni writes
“....we must admit that Indian Medicine, and especially its surgery, had a development in
ancient times that was most probably quite independent of Greek medicine “.
Vagbhata I was another important personality of the time. He probably lived around 200
B.C.. His chief work was “Astanga Samgraha” ,a comprehensive treatise on Medicine,
Therapeutics, Hygiene, Anatomy, Surgery and other allied subjects. Vaghabhata H wrote
extensively on medicine which is known as “ Astanga Hridaya Samhita”. A lot of matter
in this work appears to be , more or less, a reproduction of Charak’s and Sushruta’s
teachnings. Madhavacharya dealt with methods of diagnosis of diseases. His compilation
is known as “Rugvinischaya” and it also includes pathology - “Nidana”. Nagarjun was a
renowned alchemist and is very rightly known as the “Father of Indian chemistry”. He
lived some time during the period 100 B.C. -100 A.D.
CHINESE
In Chinese Medicine the “pulse” is given a lot of importance and is taken on both , the
right and the left hand, at sunrise or otherwise. There are 52 types of pulse classified in
Chinese Medicine. Chinese therapeutics consists of (a) acupuncture, (b) moxa or
moxibustion : Moxibustion is like cauterization but more painfill as a counter irritant, (c)
massage.
Besides these, a rich materia medica essentially of herbal origin exists. There is also a
mention of substances derived from sheep’s thyroid for treatment of Goitre and
Cretinism and the use of sheep liver for disorders of the blood.
Lin Tan (600 B.C) w'as also known as Lao Tzu: according to him, health depended upon
the interplay of two cosmic forces, - “Yin” and “Yang”, - the negative and the positive
force. “ Yin”, the female force was associated with evil and its dominance resulted in
disease. “Yang”, the male force had an opposite and favourable effect in man. The body
was composed of five elements (wood, fire, earth, metal and water), which wrere kept in
balance by “ Yin” and “Yang". Their disturbance resulted in ill-health.
14
Three famous Chinese physicians of antiquity are :
1) Ts’Kung ( circa 180 B.C.)
(2) Chang Chungchin ( c 168 A.D), also known as“Hippocrates of China” and
(3) Hua T?o ( c 190 A.D.). a surgeon. Hua T’o employed anaesthetics (probably Cannabis
indica), for his surgical treatment.
Hospitals or hospital-like institutions existed in China since 1000 B.C. With the spread of
Buddhism many more hospitals were established till 827 A.D. However, in 845 A.D.
under the order of Emperor We Chung, many Buddhist temples were demolished and
with these, the so called hospitals for the sick and the infirm.
PERSIAN
Learned men of Indian and Greek medicine were invited by Persian Kings, and were
retained in their courts with due recognition of their knowledge and contribution to
medicine. Jirjis lived some time in the Eighth Century and was a Persian physician of
repute from Jundi Shapur. He was invited by the Caliph-Al-Mansur to Baghbad in 765
A.D., to lake charge of the hospital. He came from a family of physicians of six
generations.Baghdad was then the medical centre and intellectual capital of Islam under
the patronage of a broad minded Caliph, Harun- al -Harun (763- 809 A.D.) and later his
son A! Mamun (786-833 A.D.). During this period, in Persia, organized examinations
were conducted and a diploma in Medicine was awarded.
The Arab invasion of Persia took place in 636 A.D., with the subsequent capture of
Jundi Shapur. Arabic Medicine emerged as an off shoot of alchemy and chemistry. The
use of senna, camphor, sandalwood etc. was borrowed from ancient Indian medicine substantive evidence of the Ayurvedic influence. The Greco- Arabic Medicine was and is
even today known as Unani Medicine. Among the well known personalities associated
with this system of medicine were Rhazes, Avicenna and Albucasis.
Rhazes (Abu Bakar Muhammed Ibn Zakariya Al Raz (841-926 A.D.) was born in
Teheran. He wrote books on medicine and surgery : liis original observations were on
small-pox, measles, stones in the bladder and kidney and what is, at present, known as
"hay-fever". He differentiated small-pox from measles and also described the recurrent
laryngeal nerve and the guinea worm. He had varied interests [ including philosophy J
apart from medicine. His fame as a physician spread far and wide. His encyclopaedia
“Kitab-al -hawi” was a source of reference for therapeutics for three centutries. The
ruler of Ravy conferred on him the position of the head of the hospital in Baghdad.
Avicenna (980 -1037 A.D.) also known as Ibn Sina ( Abn -Ali- Al - Hussain ) was
another important personality of Persian medicine. His observations on respiration and
15
pulse could well be considered as pointers to modern concepts on respiratory and
cardiovascular physiology respectively. He wrote several books, including his famous
compilation "Qanum” on various aspects of medicine.
h is believed that with the invasion of India by Alexander, the Great, in 327 B.C., Unani
medicine was introduced into this country, and it flourished under the tutelage of the
Moghul Kings. Hakim Ali Gilani was a protagonist of Unani medicine during the reign of
Emperor Akbar. The first Unani Medicine school was founded by Haziqul Mulk Hakeem
Abdul Majeed Khan in Delhi in the year 1893.
GRECO-ROMAN
Greco-Roman medicine borrowed a lot from the Egyptian medicine. Egyptian medical
men were invited by Greeks to practice medicine in their countries and were highly
respected.
Pythagoras (570-489 B.C.) was a mathematician and a physicist; Although known to all
as the discoverer of the theorem in geometry which goes by his name, he was also known
for his profound influence on medicine. According to him, diseases were due to
disturbances of four humours: (1) Black bile was cold and dry. (2) Yellow bile was hot
and dry, (3) Phlegm was cold and moist and (4) Blood was hot and moist. There is a
similarity between Pythagoras’ concept of diseases and the Ayurvedic concept
enunciated al least two centuries earlier.
Hippocrates (460 - 370 B.C.) was an astute Greek physician who was born on the island
of Cos, but probably practised on Rhodes. He was the first to maintain records of his
patients’ complaints and his own observations. With this began the study of symptoms
and signs and their correlation. With the use of several such records it was possible to
diagnose similar conditions in other patients. Among his contributions to medicine are
the descriptions of the face in the terminal stages of life [ Hippocratic facies ]. It was
Hippocrates who enunciated the Physician ‘s oath , now known as the “Hippocratic
Oath”. The following is an abstract from the famous Hippocratic oath.
“ I swear by Apollo, the healer, invoking all the Gods and Goddesses to be my witnesses,
that I will fulfil this Oath and this written convenant to the best of my ability and
judgment. I will look upon him who shall have taught me this art even as one of my own
parents. I will impart this art by precept, by lecture and by every mode of teaching. The
regime I adopt shall be for the benefit of the patient according to my ability and
judgement, and not for their hurt or for any wrong. In my attendance on the sick or even
part therefrom, whatsoever things I see or hear, concerning the life of men, which ought
not to be spoken abroad, I will keep silence thereon, counting such things to be as sacred
secrets”.
16
His aphorisms are also famous, some of which state :
"Life is short and the art long; opportunity is fleeting, experience fallacious, judgement is
difficult.”
“In every disease, it is a good sign when the patient’s intellect is sound and he enjoys his
food; the opposite is a bad sign.”
“ In winter occur pleurisy, pneumonia, colds, sore throat,
apoplexy'.”
headache, dizziness,
It was Hippocrates who gave a humane and philosophical face to medicine. He is rightly
considered the “ Father of medicine “.
Claudius Galen of Pergamon (130-200 A.D.) at the young age of twenty' one, went to
Smyrna in Asia Minor to study anatomy. Later he proceeded to Alexandria where he had
an opportunity to examine a human skeleton. He also undertook long journeys to Asia
Minor in search of new dmgs. He was an anatomist, a physiologist, a pharmacologist and
a physician. Since dissection of human beings was not allowed during his time, Galen
dissected pigs . dogs and Barbary' apes and extrapolated his findings onto man. In
retrospect, it appears that this dogmatic attitude coupled with the fact that his disciples
blindly followed him was responsible for stagnation in medical learning and progress, for
over a thousand years. Galen was also a good diagnostician and had a good knowledge
of the anatomy of the brain as well as of the bones, joints and muscles. He showed that
arteries contained blood and not air and studied the function of the spinal cord by
injuring it at various levels. In his writings- he wrote about 500 books ! - he often
acknowledged his indebtedness to Hippocrates. He was the physician to the great
philosopher-emperor, Marcus Aurelius.
Paracelsus, was the adopted name or nom de plume of Aureolus Theophrastus
Bombastus von Hohenheim. Born in Switzerland in 1493 of a physician - father and a
hospital superintendent- mother, Paracelsus was exposed to medicine right from
childhood. He spent his youth wandering from one university to another in France, Italy
and Germany learning bits and pieces of chemistry,
alchemy and astrology'. He
returned to Basel in 1527 and was appointed city physician. Here, Paracelsus discarded
the traditional clothes of the physician of the Sixteenth Century (a wig and a scarlet coat)
and wore conventional clothes. Further, he taught his students and wrote his
prescriptions in German and not in Latin as was the prevailing practice . This was
unacceptable to the so-called experts and they denounced Paracelsus. In disgust,
Paracelsus burned books of Galen and Avicenna - thereby making permanent enemies
and forcing him to leave the city for good. He was the first person to describe “Miner’s
Lung” or “Pneumoconiosis”, the relationship between Goitre and Cretinism, the
difference between Mental retardation and Insanity and to use sulphur and antimony as
drugs. Paracelsus died in 1541 A.D.
17
Among those who also contributed to the study of anatomy was Leonardo da Vinci
[ 1452-1515 A.D.], He is, of course known to the world as the painter of the famous
Mona Lisa which is in The Louvre, Paris. He dissected thirty corpses and made
remarkable pencil drawings of this findings. He was among the first people to contradict
Galen - he drew what he saw with his own eyes and not what Galenic theory stated. Since
he did not publish his works, there was little impact on medical science.
In the Sixteenth Century the name of Andreas Vesalius (1514-1564 A.D.) stands
supreme. He was a Belgian by birth and spent most of his time in Italy studying Anatomy
and contributing to the subject by his personal observations. It may not be an
exaggeration to state that the practice of modern medicine or Allopathy really began
with this man. Vesalius , after completing his studies at Louvain, and later at Paris went
to Padua which was then one of the leading medical schools in the world. By careful
observations and performing dissections himself, Vesalius realized that a lot of Galenic
anatomy was wrong, hi Basle, in 1543, he published his De Humani Corporis Fabrica
and changed the face of anatomy. It will interest readers to know that 1543 was also the
year that Nicolas Copernicus published his revolutionary work De Revolutionibus
Orbium Celestium in which he demolished the Ptolemic theory that the earth was the
centre of the Universe. Thus, two of the most important and influential works in science
were published in the same year'. In his book, Vesalius pointed out over 200 errors in the
Galenic teachings. He also stared that his book was merely a reference book for his
students - in order to learn anatomy, they would have to perform dissections themselves.
Vesalius later became the court physician to Charles V and later to Phillip II of Spain.
There is adequate evidence that in ancient India, anatomical study of the human body
was carried out. This is borne out by the writings in Sushruta Samhita. To quote the
appropriate translation, “Any one, who wishes to acquire a thorough knowledge of
anatomy, must prepare a dead body and carefully observe and examine all its parts”. The
method of study was to submerge the body in water and allow it to decompose: an
examination of the decomposing body was carried out at intervals to study strutcures,
layer by layer, as they got exposed following decomposition.
REFERENCES:
i)
Bettman, O.L.: Pictorial History' of Medicine, Charles C. Thomas, Springfield,
Illinois, U.S.A., 1956
ii)
Leonardo, R. A.: History of Gynaecology-, Richard A. Froben Press, New York, 1944
iii) The Charaka Samhita, Edited and published by Since Gulab Kunverba Ayurvedic
Society, Jamnagar, 1949.
iv) The Sushruta Samhita, Edited and published by Kaviraj Kunja Lal Bhishagranta,
No. 10. Kashi Ghose’s Lane, Calcutta, 1907
v)
Thapar, Romila : A history' of India , Penguin Books, 1966
18
CHAPTER 4 : HOSPITALS AND NURSING
In ancient India, hospitals for men and animals, were established during the reign of
Mauiya and Gupta Kings. Under the Emperor Asoka (260 B.C.), there were schools with
attached hospitals. A few religious and charitable endowments in South India established
schools with attached hospitals. Such hospitals were known as “Veera Solan”. In South
India an edict dated 1097 A.D. of Veera Chola Maharaj refers to a sixteen bedded
hospital for students of the school attached to the temple at Tirumakundal in Chingleput
District. There are also ruins of a hospital at Mahintale near Anuradhpura in Sri Lanka. It
is believed to have been constructed by Mahendra,the son of Asoka. Emperor Akbar, in
the Sixteenth Century, built a large hospital at Fatehpur Sikri.
Hospitals in China were built as early as the Tenth Century B.C.; subsequently with the
spread of Buddhism many hospitals were built by 845 A.D. In the Greco-Roman
civilization “Asklepieia,” - the helath resorts named after Asklepius - existed, where
patients were admitted and treated for their illnesses. Under the patronage of Caliph
Harun- Al -Rashid (763 - 809 A.D.) and later his son Al Mamun (786 - 833 A.D.), the
first hospital in Baghdad flourished.
In Europe in the Sixteenth Century, certain religious orders were exclusively connected
with nursing. Among these the Augustinian Sisters of Hotel Dieu of Paris stand supreme
in their service to the sick and the infirm. In Europe the first organised hospital was built
in Paris in the year 660 A.D. and named "Hotel Dieu of Paris”. The first schools of
medicine were started in Montpellier in 1220 A.D. and in Paris in 1270 A.D. In London,
St.Bartholomew’s Hospital was built in 1123 A.D. and St.Thomas Hospital in 1215 A.D.
It is believed that a medieval hospital was built on the Island of Rhodes, during the
Crusades by knights of St. John, in 1311 A.D.
In India, Western medicine was introduced by the Portuguese some time in the Sixteenth
Century. In 1510 A.D., Albuquerque built the Royal Hospital in Goa. Many years later,
in 1703 A.D., an elementary course in medicine was organised in this hospital. The East
India Company built a Military Hospital in Madras in 1664 A.D.; later on in 1750 A.D., it
was declared open to the civilian population, hi Bombay, the first hospital was opened in
1676 A.D. Later, the J.J. group of hospitals, founded in the year 1843 A.D., started
functioning in May 1845 A.D. Named after Sir Jamshetjee Jejeebhoy whose munificent
donation helped in the building of this hospital, the J.J.Hospital with its Grant Medical
College was responsible for introducing modem allopathy to western India. The idea of
starting such an institute had earlier been mooted by Sir Robert Grant, then Govemer of
Bombay in 1835 A.D. Earlier, medical schools had already been established in Calcutta
and Madras .
19
By the turn of the Twentieth Century', however on seeing that less qualified Britishers
were preferred over competent Indian physicians for jobs, nationalists decided to build a
hospital where Indian doctors could treat patients. This led to the formation of the King
Edward VH Memorial Hospital (KEM Hospital) in 1926 A.D. The famous personalities
associated with this hospital over the years include Jivraj N Mehta and R.J. Vakil
(physicians ), R.N. Cooper, A.V. Baliga, P.K.Sen (surgeons) and V.R. Khanolkar
(pathologist). The Tata Memorial Hospital (1941 A.D.) and the Cancer Research Institute
(1952 A.D.) are in the forefront of India’s fight against the dreaded disease, Cancer. The
motto of the Tata Memorial Centre , Bombay [ comprising the above two institutions ] is
; Service, Research. Education". This centre was built solely out of the personal tragedy.
Lady Meherbai Tata was sent to England in 1930 A.D. for treatment of leukaemia. Her
husband, Sir Dorabji realized that such a thing would not be possible for most Indians; he
decided, therefore, to build a hospital for cancer patients in India. Another institution of
repute is the AHMS (All India Institute of Medical Sciences), New' Delhi which was
started in 1956 A.D. for the development of excellence in all aspects of health care
including undergraduate and postgraduate teaching, training, research and
experimentation. The first successful heart transplant performed by P.Venugopal in 1994
was in this hospital.
Perhaps the Indian hospital best known all over the world is the Christian Medical
College, Vellore. It is a 1500-bed hospital, based at a town, 130 km from Madras in
South India. Ida Scudder, an American Schoolgirl was visiting her parents in India in the
late 19th century. Asked to assist in a childbirth, Ida refused since she was ignorant of
the procedure. To her horror, all 3 children died. This prompted Ida to study medicine in
the USA. On returning to India in 1900, Ms Scudder, started a Clinic in Vellore. Later,
she started a school for compounders (1903 A.D.), a school for Nurses (1909) and finally
a medical school for women in 1918. From 1947 onwards, males were also admitted.
NURSING
In the ancient Indian Medicine, there is a reference to the qualities a nurse should
possess. To quote from Charak Samhita. “Knowledge of the maimer in which drugs
should be prepared or compounded for administration, cleverness, devotedness to the
patient waited upon, and purity both of the mind and body, are the four qualifications of
the attending nurse”. Those days there were mainly male nurses, but it is probable that
women played the role of the midwife in China ; nurses were generally filthy and often
under the influence of alcohol . The result was that respectable girls did not enter the
nursing field. Florence Nightingale however deeply believed that it was God’s will that
she take up nursing (much against her parents’s wishes ) and did a course of training at
Kaiserworth in 1851 A.D. She later joined the Hospital for Invalid Gentlewomen at
London. Her success there led to her being asked to organise the nursing services in the
military' hospitals during the Crimean War, fought by the British, French and Turks
20
against the Russians in 1854 A.D. Miss Nightingale with her team of 38 nurses (24
Sisters and 14 lay-women) then went to Constantinople and later to Scutari. The
unhygienic conditions in the hospitals, the dirty linen, poor diet and other factors had led
to a mortality rate of 42 per cent. Within months of their starting work, mortality had
gone down to 2 per cent. Miss Nightingale not only dressed their wounds but also saw to
it that the clothes were washed well, hospitals cleaned and administered better, and diet
improved. It is said that eveiy night she covered several miles of the camp carrying a
small lamp. Thus she came to be known as the “Lady with the Lamp”. An idea of the
number of patients she had to attend to may be gauged when one realises that there were
four miles of beds , each barely 18 inches apart. Her devotion to duty earned for herself
the love and respect of many men whose lives she saved. Prior to this, women were not
included in the services of the English Army. This indeed was the beginning of a new
era in Nursing. She also authored a book “ Notes on Nursing”.
Other nurses who have made a contribution to modern medicine are Sister Mary Joseph
and Caroline Hampton. Sister Mary Joseph was a nurse at the St. Mary’s hospital, a part
of the Mayo Clinic from 1899 till her death in 1939 A.D. Once, during her general
examination of a patient , she noted a nodule at the umbilicus and pointed it out to Dr.
William Mayo. Clinical examination later revealed it to be a metastatic tumour. These
nodules, now called Sister Joseph Nodules in her memory' represent metastatic
carcinomas usually from the stomach, ovary' or breast.
The great American surgeon, William Halstead was in love with his chief surgical nurse,
Caroline Hampton. She however developed a dermatitis due to the aseptic precaution
followed in those days (1889-1890) viz. washing of the arms and hands by soap and
water, followed by potassium permanganate , then oxalic acid and finally bichlorite of
mercury. Halstead could not bear to see his lady love suffer. He immediately asked the
Good Year Rubber Company to manufacture gloves of thin rubber for her. The use of
gloves resulted in reduction of her dermatitis - and with the introduction of gloves, a
decrease in the incidence of post operative infections was noted. A new chapter in
surgery was thus opened. On June 4, 1890, Caroline Hampton married William Halstead.
The nursing profession was brought to India some time in February' 1888 A.D. when 10
nursing sisters arrived here from England. Earlier in 1872 A.D. training classes were held
in Delhi and later in Madras in the year 1897. The first Indian nurse Bai Kashibai Ganpat
of Thane was trained in J.J.Hospital, Bombay in the year 1891. The first Nursing school
in India was established at Cama Hospital, Bombay in 1886 A.D. By 1990, there were 23
Nursing Schools/ Colleges in India. The first Nursing School in China was established in
the Mission Hospital of Foochow.
Today the role of a nurse in a modern hospital is not limited to mere doling out of
medicines and dressing wounds. With the doctor concerned she actively participates in
21
restoring the patient to health and happiness. She also enjoys the key position between
the doctor and the patient, and at times, a very vigilant nurse may ward off an untimely
death. Just as medicine has entered a speciality age, so also there are specialities in
nursing i.e. oncology nursing, psychiatry nursing. Hence, they are rightly known as
“Angels of Mercy”.
REFERENCES:
i)
Charaka Samhita,: edited and published by Shree Gulab Kunverba Ayurvedic
Society, Jamnagar, 1949.
ii)
Degenshein G.A. : The Golden Age of Surgery7, The Surgical Clinics of North
America, Vol. 58, No.5, Oct. 1978.
iii) Dock, L.L. and Stewart, I.M. A short History of Nursing 4th edition, G.P.Putnam
and Sons, New York, London, 1938
iv) Goyal, K.: Binnys Directory of Medical Colleges in India, Ed. 8, Binnys Publishing
House, 86 U.B. Jawahar Nagar, New Delhi 1990
v)
Pacheco da Figueiredo J.M.: Escola Medico Cirurgica de Goa, 1968
vi) Ross,J.S. and Wilson, K J W. Foundations of Nursing and First Aid, 4th Ed, 1969,
E & S Livingstone Ltd., Edinburgh and London
vii) Wilkins, Frances. Six great nurses. Hamish Hamilton, London. 1962.
viii) Wilkinson A.: History of Nursing in Indian and Pakistan, published by the Trained
Nurses Association of India. 1958
22
CHAPTER 5 :
PHYSICISTS AND MEDICINE
Zacharias Jansen and his father Johannes Jansen of Holland in the year 1590, discovered
the principle of microscopy and telescopy by placing two lenses together in a tube.
Galileo Galeili (1564-1642 A.D.) was essentially an experimentalist. His doubts
regarding accepted facts led him to discoveries such as the rate of acceleration of falling
bodies. It is believed that he carried out these experiments by dropping weights from the
"Leaning Tower of Pisa”. Having heard of Jansen’s discovery of the microscope and the
telescope, it was he who for the first time in 1609 in Italy, used lenses for magnifying
objects. Armed with a telescope he embarked on the study of Astronomy and saw the
four moons of Jupiter - the discovery which was in keeping with Copernicus’ theory that
the sun was the centre of the solar system and not, as was believed then, the earth. It is
said that he also made a microscope which fact was not publicised. This was the
beginning of the impact of basic sciences on medicine and was also one of the early
examples of the experimental method in science.
Anthoni van Leeuwenhoek (1632-1723 A.D.) of Delft, Holland was a very keen
investigator. He had a small shop where he sold odds and ends and where he went about
grinding lenses. He assembled and used a simple microscope which was only 3 inches
(7.5 cm) high . He examined a drop of water from his garden pool under his microscope
and saw liny moving structures - what we now know as bacteria. He later named them
"animalcules” as he believed that they were tiny animals. This was the beginning of
Microscopy and Microbiology. With his microscope he succeeded in magnifying objects
to a magnification of at least 160 and perhaps upto 300 times. Today we have many types
of microscopes including the Electron Microscope. Leeuwenhoek showed that muscles
ar e made of alternating dark and light bands and described spermatozoa, red blood cells
of di fferent species and studied the flow of blood through capillaries in an eel’s tail. He
is thus considered to be the “ Father of Protozoology and Bacteriology
Today, the
Electron Microscope with its one hundred thousand times magnification can reveal the
contents of a cell at the subcellular level. The first Electron Microscope was invented by
Knoll and Ruska in 1931.
Wilhelm Conrad Roentgen (1845 -1923 A.D.) was another person whose discoverychanged the face of medicine . Roentgen’s childhood held no clues to the genius that he
ultimately turned out to be. He was expelled from school and even failed his
matriculation examination ! He however developed a love for physics and this ultimately
led to the discovery7 of x-rays, On 8th November, 1895, Roentgen (then the Professor of
Physics at the University of Wurzburg) was performing an experiment in his laboratory'
when he accidentally discovered a new phenomenon. He was studying the beam of
electrons emanating from the cathode in a low pressure discharge. The electron beam not
only emerged from the cathode ray tube but managed to light up some fluorescent
23
material at some distance. As he was unable to determine what the rays were, he called
them ’X-rays’. After working on this phenomenon for a few days, on 22 December,
Roentgen informed his wife about it and took an x-ray of her hand. On 28th December,
he delivered the manuscript to the Physiological and Medical Society of Wurzburg. It
was not long before x-rays and radiology' became an important part of the diagnostic
armamentarium of the physician. Dr Albert von Kolliker suggested that these remarkable
new rays be named ‘Roentgenrays’ in honour of their discoverer. Roentgen was awarded
the first Nobel prize in Physics in 1901. It is significant that he not only refused to patent
the discovery, but also donated bis prize money for scientific research at the University- of
Wurzburg.
In Paris, Marie Curie (1867-1934 A.D.) and her husband Pierre Curie (1859-1906 A.D.),
were engaged in their laboratory' experimenting with various elements and their
properties. She saw a luminous object on her desk wlrich she brought to the notice of her
husband. Radium was thus accidentally discovered by them in 1898. The use of radium
as a therapeutic agent was noted by the French physicist. Henri Becquerel. He suspected
that radium could also cause burns which was later confirmed by Pierre Curie in 1901.
Deep X-ray, Radium, the Cobalt bomb and the Laser Beam are useful weapons in the
hands of modem Oncologists in the treatment of Cancer.
The use of the LASER beam (Light Amplification by Stimulated Emission of Radiation)
was first demonstrated by Maiman in 1960, using a synthetic ruby' rod. Since then
several types of Laser Beams have been evolved. The Laser currently used in surgery' is
the CO2 Laser. With the use of the Laser, both superficial and deep seated tumours can be
extirpated with minimal damage to the surrounding healthy tissue.
Since the days of Roentgen, Radiology' has advanced considerbly. With the use of Closed
Circuit Television screen, a patient can see his own internal organs during the
examination.
Ultrasound: Firestone in 1940 demonstrated the power of penetration of the high
frequency sound beam. Fie used it for localizing defects in metal castings. Karl Kursik, an
Australian psychiatrist, in 1942, used the ultrasound technique to localize intracranial
tumours. D H Howry and Ian Donald in the 1960s produced various tissue and organ
images using ultrasound equipment. This technique is useful in detection of deep seated
tumours, pathological conditions of internal organs, lesions of the heart etc. In obstetric
practice it is widely used in following foetal growth and in detection of foetal anomalies.
Computerized Tomography (C.T.): Bracewell, in 1956. developed different techniques of
image reconstruction for use in Radio-astronomy. Based on the physical principle that
there is a difference in the radiation absorption of various tissues, Sir Godfrey Hounsfield
attempted to reconstruct an image of the human body. The first accurate reconstructed
24
image of the brain was produced in 1973. This was the most significant advance in the
field of Radiology since the discovery of X-rays. A whole body scan of a patient can also
be carried out by radiological technique known as CAT-scan (Computerized Axial
Tomography). For their invention, Allan Cormack and Hounsfield received the Nobel
Prize in Physiology in 1972. To our knowledge, they are the only physicists, apart from
Francis Crick [ 1962, structure of DNA ], who have received a Nobel Prize - for
medicine !
Magnetic Resonance Imaging (MR1): Bloch and Parcell, in the late 1940s, were the first
to postulate that certain nuclei with a magnetic moment precessing in a strong magnetic
field may emit a detectable radio-signal. In 1973, Lautebur succeeded in producing the
first nuclear magnetic resonance image. This technique is employed in visualizing axial,
sagittal and coronal sections of different parts of the body and also blood vessels, without
resorting to any invasive method, such as catheterization (MR Angiography).
Electro-Cardiogram (E.C.G.) : Electrical phenomenon associated with the contraction of
the heart was first noted by R. A. Kolliker and J Muller in 1856. They placed the sciatic
nerve of a frog across the contracting heart of the same frog and elicited contraction of
the enervated muscle at each systole. The same phenomenon could be elicited by placing
a sciatic nerve preparation of one frog across the contracting heart of another frog thus
proving conclusively, the origin of the electrical charges from the contracting heart
muscles.
Willem Einthoven (1860- 1927 A.D.), a Dutch physicist, devised a galvanometer
recording the voltage produced by the activity of the heart on the skin, in 1903. This
instrument was the Electrocardiogram and Einthoven was awarded the Nobel Prize in
1924. Thomas Lewis and his coworkers, W H Crab, F N Wilson and others through their
research established the foundation of Electrocardiography. Clinical and experimental
studies of Lewis, Wiggers, Wilson et al, contributed to the understanding and
interpretation of electrical variations during cardiac activity.
Renal Dialysis and Renal Transplant: Thomas Braham first reported “dialysis” through a
semi-permeable membrane sometime in the 1860s in experimental animals. Haas, in
1925, was the first to perform dialysis in a patient. In India, the first dialysis was
performed at Christian Medical College ,Vellore in 1961. In 1923, Ganter performed the
first peritoneal dialysis in a uraemic patient. Subsequently chronic intermittent peritoneal
dialysis was introduced by Boen et al in 1962. In 1976, Pepovich introduced the
“equilibrium peritoneal dialysis technique” where the dialysate after infusion into the
peritoneal cavity was allowed to equilibrate for 5 hours while the patient carried on with
his normal activity. Since 1978 the name of this method has been changed to “
Continuous Ambulating Peritoneal Dialysis (CAPD)”. Through this method, the concept
of home dialysis has been popularised.
25
Heart Lung Machine : For a surgical procedure, on a continuously moving vital organ
such as the heart or the lung, complete cessation of its movement and its functions
appeared an impossibility’ about 50 years ago. The concept of a mechanical device taking
over the functions of such an organ, albeit temporarily, was first put into practice by
John H Gibbon, Jr. of the Mayo Clinic in 1956, - the first heart - lung machine. Later D
G Melrose and others devised reusable metal pump oxygenerator. Subsequently such
cumbersome machines have been replaced by the present day disposable handy plastic
oxygenerator. Through the use of such a device, the heart and lungs are put out of action
and eventually cease to move. The so -called “still” heart can be opened and operated
upon with ease. After the surgical procedure, the process is reversed.
REFERENCES
i)
Hounsfield, G.N.: Computerized Transverse Axial Scanning (Tomography), British
Journal of Radiology, 46: 1016-1022, 1973
ii) Khattab ADS. Dances with microscopes: Antoni van Leewenhoeck [ 1632-1723],
Cytopathology, 6:215-218; 1995
iii) Melrose, D.G. Cardio-Pulmonary Bypass History, edited by K..M.Taylor, 1st edition,
Chapman and Hall, London, 1986
iv) Technological Review, New Scientist, 54: 207, 1972
26
CHAPTER 6
THE FOUNTAIN OF LIFE
“The arterial blood of rhe healthy one, warm and full of spirit, will leap into the sick one
and immediately will bring to him the fountain of life and will drive away the languor” Andreas Libavius.
For centuries, the custom of offering sacrificial gifts of animals and their blood to deities
has existed all over the world. Homer wrote that Odysseus revived himself by drinking
blood when he was in the realm of the dead . Egyptians, Hebrews and Syrians used blood
as a medicament. Roman noblemen drank fresh blood of gladiators and decapitated
criminals as a therapy for rejuvenation. In Bodhisatvapadana Kalpalata, there is a
reference to blood transfusion. It is stated that a benevolent king gave lais blood to one of
his subjects on the advice of a physician that only a blood transfusion would save the
patienrs life.
The modem history of blood transfusion begins in the 15th century'. In Rome, in 1492,
Pope Innocent VIII had an apoplectic stroke; he became weak and went into a coma. His
physician advised a blood transfusion as a therapeutic measure for the Pope’s illness. He,
however, did not benefit from it and eventually died at the end of the year. In 1615,
Andreas Libavius had described his technique of blood transfusion which was
unfortunately not adequately publicized.
In the early seventeenth century, William Harvey (1578-1657 A.D.) described the
functions of the heart and the circulation of blood which was indeed a landmark in the
history of blood transfusion. He showed that the heart was a pump and that the pulse
wave was caused by the contraction of the heart which expelled blood into the arteries.
The same blood then returned to the heart by travelling tlirough the veins. Flence, blood
moved in a circle in the body. Harvey was also able to deduce that the function of the
valves was to prevent backflow of the blood in the veins. Harvey used to teach this in his
lectures as the Lumlean lecturer in surgery' at The Royal College of Surgeons from 1615
onwards, but published it first only in 1628. His book, Exercitatio anatomica De Motu
Cordis et sanguinis in animalibus, which was published in Frankfurt is considered a
milestone in medical literature as it was one of the early examples of using experimental
observation and reasoning as the basis for scientific thought. Since most of the scientific
community' accepted his theory by the middle of the seventeenth century, it has been
written, with more than a grain of truth, that Harvey was perhaps the only man that ever
lived to see his doctrine established in his lifetime.
In 1665, Richard Lower (1631-1691 A.D.) transfused blood of one animal into another.
In 1667, he transfused sheep’s blood into a man with fatal consequences. In 1667, Jean
Baptiste Denis, a French physician, performed a successful blood transfusion and
27
prescribed it for many ailments. Several such transfusions were not as beneficial and a
few even caused the death of the patient and thus the remedy fell into disrepute. Hence,
blood transfusion was prohibited by law in France. Then followed a period of stagnation
for more than 150 years. James Blundell, an English physiologist and obstetrician was the
first to perform a successful blood transfusion in England in 1824.
At the beginning of the twentieth century, with the discovery of blood groups, interest in
blood transfusion was revived.The person responsible for this was an Austrian named
Karl Landsteiner. Bom in 1868, Landsteiner did his medical studies before joining the
University of Vienna to do research on blood. In 1901, he discovered that human blood
could be divided ( based on substances present on the red blood cells ) into groups A, B
and O. Later his pupil Sturli [ in collaboration with de Casteo ] added one more group AB - and thus the four main blood groups were established. In 1903, with Richter, he
showed that the knowledge of blood groups could be used in forensic medicine. In
addition to lais research and teaching, he also found time to perform over 3500 autopsies.
In 1908, Landsteiner went to the Wilhelminen Hospital in Vienna where his research
showed that polio was a viral disease. This finding led four decades later to the eventual
development of the polio vaccine. After World War I, Landsteiner worked for a few
years in a hospital in Holland before moving in 1922, to the Rockefeller Institute in New
York. Here, in collaboration with Phillip Levine, he discovered 3 more blood groups- M,
N and P. Landsteiner published 390 scientific papers and has been called the Einstein of
the biomedical sciences. Lansteiner’s other work included the elucidation of Paroxysmal
Haemoglobinuria [ with Donath ], the introduction of darkfield microscopy and
complement fixation tests for the diagnosis of Syphilis. For his services to mankind, he
was awarded the Nobel prize in 1930. Landsteiner passed away in 1943 while working in
his laboratory.
In 1939, Levine and Stetson detected an unusual agglutinin in the blood of a woman who
had recently delivered a baby. They postulated that the mother was immunized during the
pregnancy with the corpuscles of the foetus or its father’s corpuscles by the
transplacental route. Landsteiner and Weiner, in 1940, while experimenting with monkey
corpuscles found that the anti-Rhesus serum agglutinated not only monkey red blood
cells but also the red blood cells of 85 percent of the white population of New York.
These individuals were labelled as !Rh positive' and others as ‘Rh negative’. It has been
subsequently found that 85 percent of individuals in Western countries, as well as in
India, are ‘Rh positive ‘. Thus, since 1940, the ‘Rh factor in human cells was established.
Weiner and Peter described four recipients of blood transfusion with agglutinins against
their ‘Rh positive donors. Y.M. Bhende and his associates, at Seth G.S.Medical college
and K.E.M. Hospital, Bombay, discovered a rare subgroup in 1952 which is now known
as “Bombay Subgroup”.
With the outbreak of World War I, the need for blood as a life-saving measure was
appreciated. It was soon realized that blood had to be stored in a suitable condition for
28
use at a later date. Oswald H. Robertson of the American army had observed, in 1918,
that blood collected in sterile Sodium Citrate solution could be preserved in an “ice box”
for a month without deterioration. The concept of the “Blood Bank” was thus formulated.
In Russia, attempts at large scale blood storage began in 1936 at the Sklytavosky
Emergency Hospital in Moscow. During the Spanish Civil War (1936-1939 A.D.) a
regular blood bank was established in Barcelona. In India, first attempt at blood banking
was made in 1939-1940 in Calcutta and later in 1942 in Bombay, when the Japanese
army occupied Burma during World War II. Now there are several blood banks all over
the world. Blood can be stored as whole blood, plasma or serum in liquid or in dried
form. However whole blood cannot be stored indefinitely. Modem blood banks also
provide separate cellular constituents and plasma fractions. Some of the fractions can be
stored in a lyophilised (dehydrated) form for use, at a later date, in a reconstituted form.
Cellular components can also be used in specific blood disorders.
ANAEMIA
Sushruta described anaemia as a form of Panduroga or Jaundice. It was believed to be
due to the derangement of kapha or phlegm and was manifested by whiteness of the eyes,
skin and finger nails. Charaka described another form of Panduroga associated with the
habit of eating clay. In 280 A.D., Wang Shu-Ho, using the doctrine of “the pulse”,
diagnosed the deficiency of blood by a superficial and weak pulse .
hr the 16th century .all anaemias, irrespective of whether they were due to iron deficiency
or other causes, were grouped under one category, ‘Chlorosis’ by Jean Varandal. In
1554, Johann Lange for the first time singled out a case of what may have been
hypochromic anaemia, giving a concise and clear clinical picture. He described the
symptomatology in a letter to a friend whose daughter Anna had extreme pallor ( “as
though exsanguinated” ), palpitations, dyspnoea, and swelling of the ankles. He used the
classical term “morbus virgineus” and attributed the condition to a block in the menstrual
blood flow from the liver to the uterus, a pathway which was not fully established at
puberty. He drew attention to the fact that although Hippocrates in his book “ Diseases
of Young Women” advocated venesection, he himself (Lange) advised an early marriage
as a therapeutic measure.
Iron was utilized in therapy by European physicians through the Middle Ages and the
Renaissance, but the rationale behind the treatment was not understood. In ancient Indian
medicine, it is reported that Charaka treated anaemia with iron rust pills prepared by
soaking iron powder for seven days in cow’s urine along with milk.
In the 17th century, the causative role of iron deficiency in the then prevalent “Green
Sickness” or “Chlorosis” of adolescent women began to be recognized. Thomas
Sydenham is credited with being the first to identify iron as a specific remedy. In 1681 he
29
wrote: " To the worn out or languid, blood gives a spur or fillip whereby the animal
spirits which lay prostrate and sunken under their own weight are raised and excited”.
In 1832 the French physician Pierre Blaud reasoned that Chlorosis arose from a defect in
the formation of blood whereby the colouring matter was affected, making it unsuitable
for stimulation and maintenance of the organism and its functions. He prescribed ferrous
sulphate as a therapy for anaemia - “the veritable pills of Blaud” which his nephew
distributed all over the world.
In 1849, Addison described a fatal anaemia, later known as Pernicious Anaemia, and its
characteristic blood picture. Whipple, in 1925, demonstrated the curative effect of raw
liver in dogs in which simple anaemia had been experimentally produced. In 1926. Minot
and Murphy at Harvard showed that liver also cured patients with Pernicious Anaemia.
Whipple, Minot and Murphy shared the Nobel Prize in 1934. In 1929, Castle of Harvard
found that meat predigested with an artificial gastric juice had no beneficial effect on
patients suffering from Pernicious Anaemia; however results were favourable when
normal gastric juice was used. The discovery of an ’’Intrinsic factor” in gastric juice was
thus made. Nearly 20 years were to pass before Riekes, Smith and Parker isolated an
‘Extrinsic’ factor subsequently identified as Vitamin B12. Wills and her associates in
1937 described macrocytic anaemia in women in India that responded to crude liver
extracts but not to the purified extract known to be effective in Pernicious Anaemia.
Tliis factor was first called “Wills” factor and later, Vitamin M; and still later identified
as folic acid, which was recognised and isolated by the Indian scientist Yellapragada
Subbarow and his group. Subbarow, working with Paul Gyorgy in 1939, also isolated
‘Adermin’, later known as Vitamin B6 or Pyridoxine.
Thus, over the years our concepts of the etiology of anaemias have undergone many
changes, changes reflecting the advances in laboratory medicine and the discoveries of
haematopoietic factors.
REFERENCES:
i)
Kothare S.N.: Blood Transfusion, Indian Journal of Dental Association, 1954
ii)
Huchins, P.: History' ofBlood Transfusion , Surgery, 64: 685, 1968
iii) Raphael, S.S.: Lynch’s Medical Laboratory' Technology, 3rd Edition, 1976
iv) Sri Kantha S. The blood revolution initiated by the famous footnote of Karl
Landsteiner’s 1900 paper. Ceylon Med J.1995, 40:123-125.
v)
Sri Kantha S. Is Landsteiner the Einstein of the biomedical sciences ? Med
Hypothesis 1995, 44: 254-256.
vi) Greenwait, T.J.: Blood Banking. The Surgical Clinics of North America, 58:1095,
1978
30
CHAPTER 7 : NUTRITION AND DISEASE
INTRODUCTION
Man has always known that adequate nutrition is a prequisite of good health. Primitive
man satisfied his nutritive needs from the vegetation and animal life abounding in his
environment. Over the years, with the depletion of vegetation in the immediate
neighbourhood, man resorted to cultivation of vegetables and edible crops, domesticating
and breeding animals and hunting others for his sustenance. Fish was generally consumed
by those living in the vicinity of rivers, lakes and the sea. The availability of human meat,
after tribal conflicts, perhaps led to the practice of cannibalism among certain primitive
races. Scarcely less revolting, to modern minds, was the gruesome belief of ancient
Egyptians, Greeks and Romans in the medicinal value of blood. Blood baths were given
to rejuvenate debilitated and aged Egyptian princes. Roman nobles used to rush into the
arena to drink the fresh blood of gladiators and decapitated criminals.
Man was evidently aware of the advantages of good nutrition, and had designed balanced
diets long before the advent of biochemistry. The South African tribe of the Bantus
existed on a diet of mealy meal [ food cooked and preserved in a special manner in order
to last for a few days ], milk and herbs, which was quite adequately balanced; in fact the
advent of the white man into their world disrupted their lifestyles, as well as their diets.
On long expeditions, American Indians (Red Indians) were known to carry pemmican, a
dried meat preparation, supplementing their diet with fresh cherries along the way, to
satisfy the vitamin requirement.
It can be concluded that man evolved his eating habits with the sole purpose of attaining
physical fitness for survival; early man ate to live, and did not live to eat.
NUTRITION
Both Charaka and Sushnita have dealt with extensively on the subject of nutrition,
emphasizing the virtues of a balanced diet, the methods of preparing various kinds of
food, rhe nutritive value of foods as diverse as an alligator and lotus stalk and foods to be
avoided in specific conditions.
During the Chou Dynasty of 1121 B.C., Chinese medicine also stressed the importance of
moderation in eating; although the diet need not necessarily be exclusively vegetarian.
Confucius recommended that the amount of meat should never exceed the quantity of
rice in a meal.
31
In the time of Hippocrates, the art of nutrition was given due importance. Physicians
trained in the Hippocratic tradition stressed the role of good nutrition in maintenance of
good health. Many Hippocratic writings were devoted to details of particular foodstuffs
and their effects on the healthy or the sick individual. In the first century Galen, in his
treatise “De alimentorum facultatibus librities” wrote on the characteristics effects of
different types of food. Thirteen hundred years later, Galen’s ideas of regulating diet and
thereby keeping the humours of the body clean and temperate, were still the dominant
theories of medicine. Venetian Luigi Cornaro, an important personality of the
Renaissance period, at the age of S3 years, wrote four treatises on moderation in eating
and drinking. He also attributed his continued good health and longevity to his eating
habits. He died at the ripe old age of 98.
Early in the Nineteenth Century, interest began to be focussed on three classes of
foodstuffs which later came to be known as the proximate principles: the proteins, fats
and carbohydrates. Although vitamins were identified much later, their deficiency states
had been described by earlier physicians.
The first description of Beri-beri, a disease prevalent in the Far East at that time, was that
of Jacob de Bondi in his book on Indian medicine (De Medicina Indorum) written in
1642. The first modern account, which included description of the cardiac form and the
‘wet’ form, was published in 1835 by John Grant Malcolmson of Madras, who was in the
service of the East India Company. Between 1882 and 1885 Baron Kanchiro Takaki
practically eradicated the disease from the Japanese Naval Fleet by supplementing their
diet of rice with fish, meat and vegetables. Between 1893 and 1897 Christian Eijkman
produced Beri-beri in fowls by feeding them exclusively on polished rice. Fie, however,
interpreted these findings in a manner now known to be erroneous. His successor Gerrit
Grijns suggested, in 1901. that Beri-beri was due to the absence in the diet of a factor
which was present in the rice polishings. This was further substantiated in 1907, when
William Fletcher, working in a lunatic asylum at Kuala Lumpur, showed clearly that
about a quarter of those patients who were on polished rice alone developed Beri-beri,
while only 2 of 123 patients who received unpolished rice developed the disease. In
1906, Fredrick G. Hopkins emphasized that besides this disease, others such as Scurvy
and Rickets, were also deficiency diseases.In 1912, Casimir Funk, at the Lister Institute
in London, endeavored to isolate these “accessory food factors’ which he called
“Vitamines”. They were named so because they were believed to be “vital amines “ It
was later shown that they were amines in chemical composition, and the final ‘e’ was
then dropped, as Funk’s assumption was unjustified.
In 1915, a chemist named Elmer McCollum working at an American agricultural
experiment station, found that rats fed on artificial diet did not thrive, and developed
Keratomalacia, However, when butter was added they were cured. He proposed the term
"fat soluble A” for the vitamin present in butter. Later he found a similar accessory factor
32
which prevented the development of Polyneuritis and, as it was soluble in water, he gave
it the name •‘Water soluble B”.
Joseph Goldberger, a United States public health surgeon, began studies on Pellagra in
1914. in orphanages, asylums and prisons, and proved that dietary deficiency was the
cause. In 1926, he identified the constituent of the vitamin B complex, later known as
Nicotinic acid, which caused the dreaded disease.
The story of James Lind, who in 1753 revolutionized Naval medical practice by keeping
large amounts of lime on board his ships is well known . Earlier, when the four ships that
came from England to India as the East India Company, it was noted that the sailors on
only one of them - the one that carried stocks of lime juice- did not get Scurvy. Although
the reason for this was not clear, the Company adopted the idea of supplying lemon juice
to all their sailors. James Lind however evaluated this scientifically and wrote about it in
his “Treatise of the Scurvy”. The practice of the British of carrying lime in their ships
led to their being termed as “ limeys a term which is still used ! “Vitamin C”, the
preventive factor for Scurvy, was eventually isolated by Waugh and King in 1932 from
the lemon fruit.
The first clinical description of “Rickets” was made by Daniel Whistler in 1645. It was
based on a study of English children prompting him to name the disease
“Paedosplanchnosteocaces” By the middle of the Nineteenth Century, the presence of
Rickets was noted in many other countries. Evidence indicated that the disease responded
to the administration of the codliver oil as well as exposure to the sunlight and
conflicting claims were made for both as the best therapeutic measures. In 1919 , (Dame)
Harriette Chick led a team of investigators who studied the population in Viemta, which
had suffered considerably from the ill-effects of undernourishment during the World War
I. In their final report submitted in 1922, they supported the deficiency theory7 and
emphasized the beneficial role of sunlight.
In 1936. Evans and co-workers at the University7 of California isolated Vitamin E from
wheal germ. The vitamin was named Tocopherol as it was a type of alcohol. It was found
to have some relation to sterility as well as to diseases of the muscle in man.
In 1929, Car! Dam of Copenhagen found that chicks fed on a diet poor in fat developed
subcutaneous haemorrhage and that their coagulation time was increased. Dam and
Edward Doisy in the United States isolated Vitamin K in the pure form in 1939, for
which they shared the Nobel Prize in 1943.
The effect of nutrition on health has been extensively studied. One such study, conducted
at the Nutrition Research Laboratory, Hyderabad by C. Gopalan et al (1968) investigated
33
the effect of Kwashiorkor on mental development. The study revealed a significant
difference in the performance of intelligence and sensory development tests between
subjects treated for Kwashiorkor and the control. The retardation in the experimental
group was essentially in the area of perceptual and abstract abilities.
REFERENCES
i) Stephen, Chitra and Kothare, SN. Nutrition and Anaemia. Physician’s Update. 1989,
2(4): 169-172.
34
CHAPTER 8 : ORGAN SYSTEMS
This chapter discusses some of the organ systems in the human body and the scientists
who are associated with them.
The heart
Since time immemorial, the heart has been known to be the most important organ in the
human body. It has been considered as the seat of the soul, the abode of love and
affection. The heart has been mentioned several times as a “lotus with nine gales”, in the
Atharvaveda as early as 700 B.C. Sushruta and Charaka (500 -400 B.C.) thought that the
heart was the central organ and the seat of consciousness. It is but natural that an organ
like the heart, which offers unflinching service from the fourth week of our intra-uterine
life till the ven.' last moment, should receive our careful and considered attention when
dealing with human ailments.
It is interesting to note that the Egyptians, during the process of embalming, eviscerated
all organs except the heart, which was left ‘in situ’ within the thoracic cage, probably due
to the belief that it was essential to the individual even after death. In the Papyrus of
Ebers, an Egyptian document on medicine, dating back to 3000 - 2500 B.C., there is a
reference to the heart’s movements and its importance in diseases; there is also a
description of an ailment in man’s “cardia”, with symptoms of pain in the breast and one
side of the heart and arm, - probably of Angina pectoris. Charaka and Sushruta
considered the heart to be a receptacle and not a pump.
Heart diseases are considered in one of the chapters of Sushruta Samhita (400 B.C.). In
one of the types of heart disease, “a pain is felt in the region of the heart in which the
bean seems as if being drawn and crushed, pierced and cracked, pricked and split”. The
descriptions fits in fairly well with the symptoms of Angina pectoris.
Aristotle, the Greek philosopher and writer (384-322 B.C.), speculated on the role of the
heart, and concluded that it was the body’s nerve centre and the organ of thinking.
Erasistratus of Keos (310-250 B.C.), an illustrious contemporary of Herophihts and the
pupil of Chrysippus of Cnidus was, according to Finlaysons, the first man to describe the
heart as “pump’. According to him, wltile the heart contracts and dilates “like the bellows
of a blacksmith”, the pulse moves forward as a wave, a discovery proved correct almost
two thousand years later by modern research.
35
The pulse
In Ayurveda, over 600 different types of pulse readings have been recognized and dealth
with. The pulse is regarded as a “meter”, which indicates the state of the “soul”,
embedded within the body - whether happy or sad, whether troubled by heat, cold or air.
Although Chinese pulse-lore is usually credited to Pien Ch’iao (600-500 B.C.), it was
Wang Shee-ho (280 A.D.) who popularized the art, by writing a monumental treatise on
the pulse, in ten volumes. Diagnosis of any disease in those days depended mainly on a
study of the pulse and to a lesser extent on the state of the tongue and the facial
appearance of the patient.
In Greek medicine, Hippocrates and his contemporary, Demokritos of Abdern (500- 400
B.C.) have been considered the earliest authors to make a mention of the pulse.
Herophilus (400 B.C.), bom of Asiatic-Greek parentage at Chalcedon, and tutored by the
great Pythagoras, is often regarded as the “Father of Anatomy”. He was the Hi st to study
the rhythmical wave of the pulse, and described in elaborate terms, the pulse under
normal and abnormal conditions. He was also the first to time the bears of the pulse with
a “water-clock”. It was Erasistratus, who by detecting a sudden leaping of the pulse - the
so called “lover's pulse”, - while examining Antiochus, son of Seleucus, put down his
melancholy to an uncontrollable desire for his step-mother Stratonice. Galen described
27 varieties of pulse readings, according to then- length, breadth and depth.
HYPERTENSION
Until the 1920’s Hypertension (HT) was considered beneficial to man, as it facilitated the
perfusion of adequate amounts of blood through tlrickened arteries, especially those of
the kidney. Lowering the blood pressure (BP) was thought to lead io ischaemia of the
kidney and uraemia. At that time HT was classified as reversible and irreversible. There
was no known treatment for either of these conditions.
The concept of renal clearance as a rough measurement of renal blood flow demonstrated
that temporarily decreasing BP did not reduce kidney perfusion. Reports on
Phaeochromocyioma did much to show that HT was not harmless. Harvey Goldblatt’s
experiment in which HT was produced by clamping the renal artery , demonstrated that
Renin from kidney extract was not by' itself a direct pressor substance, but converted
Angiotensin-I to Angiotensin- II. Observations that persons with high blood pressure
were more susceptible to cardio-vascular accidents and “ Heart attacks” identified
hypertension as a potent risk factor, and helped to initiate the search for anti-hypertensive
drugs.
36
THE EVOLUTION OF THE SPHYGMOMANOMETER
Among the distinguished men who contributed to our present day knowledge of blood
pressure and its measurement, was an English clergyman named Stephen Hales. He
perhaps was the first to demonstrate, that the blood in arteries is under a great deal of
pressure. Stephen Hales, (1677-1761 A.D.) known as the “Physiological Parish Priest”
was instrumental in initiating the process of measuring the BP. In recognition of his
genius the Royal Society published, in 1733, his two volume work entitled, “ Statistickal
Essays”. His “Volume-I, Vegetable Staticks” dealt with the movement of sap in plants,
while “Volume-11, Haemastaticks”, described his Haemodynamometer.
Rev. Hales inserted one end of a brass pipe into the ligated left Crural artery of a horse,
and to the other end he attached a vertically positioned glass tube, nine feet in length. On
untying the ligature on the artery, blood rose in the tube to a height of eight feet three
inches above the left ventricle of the heart. This was the first recorded estimation of BP.
With this, he determined the quantity' of circulating blood in the horse and observed that
the Jugular venous pressures was twelve inches when the horse was at rest, and fifty-two
inches when excited.
He also demonstrated that the pulse rate was more rapid in small animals than large
animals and that BP was proportionate to the size of the animal. One of his more exotic
experiments was Leonardo da Vinci’s method of injecting wax into the heart chambers of
cadavers to determine the capacity' of these chambers by measuring the volume of the
casts.
John Leonard Marie Poisseuille (1799-1869 A.D.) improved upon the original BP
measuring apparatus by substituting the short tube of a mercury manometer for the
inconveniently long tube used by Hales. Connection with the artery' was established by
means of a hollow lead tube filled with potassium carbonate, to prevent coagulation. This
was Posseuille’s haemodynamometer of 1828, with which he showed that BP rises and
falls with expiration and inspiration.
Karl Ludwig (1816-1895 A.D.) improved upon the instrument by adding a float, thus
devising a method to measure BP on a recording cylinder. Thus, in one stroke he gave us
the kymograph and the application of the graphic method to Physiology.
Karl Vierodt (1818-1884 A.D.) constructed a Sphygmograph - the first instrument with
which a tracing of the human pulse wave could be made. By adding weights to little pans
attached to a lever, he attempted to estimate the BP. His instrument was cumbersome and
his measurements inexact, but he established the principle that the estimation of BP can
be accomplished by measuring the outside pressure necessary to obliterate the pulse, - a
method we employ even today.
37
All the above methods required the placing of a tube into an artery and so were
unsuitable for routine clinical use. The first instalment which did not necessitate
puncturing tire skin was developed by Samuel Von Basch in 1880. This was very similar
to the apparatus used today, as was the one developed later by Scipione Riva Rocci in
1896. Von Basch's instrument was greeted by the British Medical Journal with the
remark : “ By such methods we pauperize our senses and weaken clinical acuity”.
bi 1905. the Russian. Korotkoff, introduced the auscultatory method of estimating blood
pressure. Within a few years the Sphygmomanometer took its place with the Stethoscope
and the Thermometer as essential to every physician’s armamentarium.
RESPIRATORY DISEASE
Atreya’s discourse on hiccup and dyspnoea is described in detail in Charaka Samhita. He
described five types of cough, each attributed to the disorder of Vata, Pitta, Kapha ,
pectoral lesions and loss of body elements. The description of one of the disease
associated with cough and blood stained, purulent sputum, etc fits in with that of
Pulmonary Tuberculosis. Symptoms of each type of cough were described with their
respective treatment. In Charaka Samhita it is stated that the word ‘cough’ (Kasa) is
derived from the root “ kas” meaning “to move”. ‘ Kasa’ causes the movement of phlegm
upwards through the respirator}' passages.
In Sushnita Samhita, cough is considered to be due to deranged Vayu or Pitta or Kapha,
the presence of Kashta (an ulcer) or a wasting process (Kshayaja). Different kinds of
pain, such as burning, pricking, tearing in the chest, have been described as being
associated with the five types of cough. Kshayaja Kasa was characterized by cough,
gradual emaciation of the body, generalized weakness and spitting of blood, streaked
with pus.
Other civilisations have also contributed. In Hebrew medicine, from the “Talmud”, the
authoritative document on Hebrew medicine, it appears that tumours of the lung were
identified.
In Greek medicine, Galen is credited with a fairly accurate description of Phthisis
[tuberculosis]. He also stressed the need for a healthy climate and good diet including
milk in the treatment of this disease. Caelius Aurelianus who is believed to have lived
during the 4th or 5th century A.D. has described symptoms of Phthisis in detail, including
haemoptysis, hoarseness of voice, fever, rapid laboured breathing, pain in the chest,
cough with expectoration and a rapid pulse rate.
38
Avicenna, also known as Ibn -Sina (Abn-Ali- Al Husain) an important personality of
Persian medicine lived during the period 980-1037 A.D. His asmte observations on
respiration were useful pointers to modern concepts on respiratory physiology'.
Marcello Malpighi studied lungs of animals and demonstrated the vesicular structure of
the lung and the presence of capillaries, in his article “De pulmonibus” published in
1661. In 1667, Swammerdam pronounced that the lungs of an infant who has breathed
even once, will float in water. This indeed turned out to be an important contribution to
Forensic medicine in differentiating between stillbirth and infanticide. Giovanni Battisa
Morgagni (1682-1771) described Pneumonia with consolidation of the lung. He realized
that in Pneumonia, consistency of the lung was like that of the liver, and later the term
hepatization was introduced. Corvisart, Napolean’s physician, re-emphasized the value of
the technique of chest thumping developed earlier by Leopold Auenbrugger of Austria.
Auenbruggcr, in 1753, discovered how to differentiate the unhealthy lung from the
healthy lung, by different sounds produced on percussing the chest. It is believed that as
an inn-keeper’s son , he used this technique to determine the amount of wine in the
barrels and was smart enough to realize its application in medicine. It is admirable that
Corvisart refused to accept credit for the discovery of this method.
Rene Theophile Hyacinthe Laennec (1781-1826 A.D.) has given an excellent account of
Phthisis, Bronchiectasis, Pneumothorax, Cancer of the lung, Emphysema, and Pneumonia
in particular. Years later, Osler, the great physician, used to recommend Laennec’s
description of Pneumonia to his students. In 1816, Laennec invented the stethoscope, first
made of rolled paper and later of a wooden hollow tube. In 1819, he published an
account of his work using the stethoscope. By an irony of fate, he died young in 1826, of
Pulmonary Tuberculosis, a disease he described in such great detail. Carl Rokitanksy was
the first to differentiate between Lobar and Bronchopneumonia while Hurting and Hesse,
in 1879, described cancer of the lung in miners.
In France, Jean Fernel described for the first time, an epidemic of influenza in 1544.
Influenza appeared again iit Europe in 1557 and subsequently in repeated epidemics. The
great pandemic of influenza of 1767 in Europe found its echo also in America. A similar
pandemic broke out in 1918-19, and spread all over the world with high mortality. Fifty'
million people were afflicted, with 20 million dead; in India 6 million died. The next
pandemic - the 'Asian flu - occurred in 1957 followed by the so-called ‘Hong Kong flu’
in 1968. The viral etiology of this disease was established by Smith, Andrews and
Laidlaw in 1933. Different outbreaks have been attributed to antigenic changes.
During World War I (1914-1918 A.D.) the incidence of sputum borne infections,
particularly Pneunomia, increased both in the civilian population and in the army
personnel. Until this time, the treatment for Pneumonia was essentially supportive, with
high mortality'. All over the world a search for more specific treatment was a natural
39
William of Salceto (1210-1280 A.D.), a surgeon, in his book ‘In Scientia Medicinalis’,
described dropsy with contracted kidneys, perhaps an early description of chronic
nephritis. William Charles Wells (1757-1817 A.D.), an American, who studied in
Edinburgh described ‘albuminous’ urine associated with dropsy. John Blackall (17711860 A.D.) stated that dropsy was associated with albuminuria and diseased kidneys.
Richard Bright (1789-1858 A.D.), in his masterly study of 23 cases of dropsy published
in 1827 documented his observations on the association between diseased kidneys,
albuminous urine and dropsy. He also differentiated between dropsy of renal origin and
that of cardiac origin. Bright, an accomplished artist., produced accurate reproductions of
his observations on pathologic anatomy in general and the kidneys in particular.
Sir William Bowman (1816 -1892 A.D.), a great Briish ophthalmologist, contributed to
the understanding of the structure and the function of the kidney, In 1842, he described
the continuity of the glomerular capsular space with the adjoining tubules. At
approximately the same time, Ludwig independently concluded that the glomerulus was a
filtering mechanism. Heidenheim, in 1874, established the relationship between blood
pressure and urine secretion. Cushing, in 1917, also contributed to the knowledge of
kidney functions. Marshall and Vickers described the role of tubules in the transport of
some substances directly from the blood into the urine.
Herman Senator (1834-1911 A.D.) , a Polish Prussian by birth, published his monograph
on kidney diseases in 1896, while Franz Volhard and Fahr wrote a treatise on Bright’s
disease after a study of several such cases. A.N. Richards and his associates introduced
the needle biopsy of the kidney, which contributed to the understanding of renal lesions
“in vivo’’. Kimmelstiel and Wilson, in 1936, described a series of cases of Diabetes with
generalized oedema and proteinuria , a syndrome which subsequently came to be
known by their names [ Kimmelstiel - Wilson kidney ].
Carl Rokitansky was the first to describe Amyloid disease of the kidney. Rudolph
Virchow more than a century ago identified this substance in organs by the mahogany
brown colour it gave when smeared with Iodine solution. Because of this chemical
reaction, he presumed it had a cellulose component and starch. A large series published
by Bellin in 1946 focussed the attention of physicians on Amyloid Kidney. In India, the
first report of this rare renal lesion was an autopsy study of a male aged 27 years with
Generalized Amyloidosis, published by Louis Monteiro of the K.E.M. Hospital, Bombay
in 1942.
Renal Hypertension: Goldblatt of Chicago, in 1928, demonstrated that experimentally
produced renal ischaemia in animals, resulted in hypertension. These experiments
41
conclusively established the association between ischaemic kidneys and hypertension in
man. N. Goormaghtigh, in 1932 and in 1940. described in detail the juxtaglomerular
apparatus as a source of pressor substance and its role in experimentally produced
hypertension in dogs and rabbits with ischaemic kidneys.
In 1919. Goodpasture described autopsy findings of blood in the alveoli of lungs,
associated with a kidney lesion. The patient was an 18 year old man who died after an
attack of influenza, during which he had symptoms of blood stained expectoration and
chest pain. The condition came to be known as the Goodpasture Syndrome.
Analgesic Abuse and the Kidney: The association between prolonged and heavy
consumption of analgesics containing phenacetin and kidney disease, was first pointed
out by Spuhler and Zollinger in 1953. The kidney lesions were described as Chronic
Interstitial Nephritis and Papillary Necrosis
Pyelonephritis: Staemmler (1932) appears to have been the first to report on upper
urinary tract infection, then known as pyelitis and later rightly recognized as
pyelonephritis. Weiss and Parker (1939) pointed out the association between Chronic
Pyelonephritis and Hypertension.
Nephrosis: At one time Nephrosis was considered to be a variant of nephritis with heavy
albuminuria. Friedrich Muller coined the word “ nephrosis” in 1905. Munn, in 1913,
preferred the term “Lipoid Nephrosis’” his choice being based on the morbid anatomy
and histology of the kidney in this condition. In 1914. Volhard and Fahr described
Nephrosis in detail and established the correlation of the kidney lesion with clinical
features. They were the first to recognise the disease as an entity quite distinct from
Bright’s Glomerulonephritis.
OTHER ORGAN SYSTEMS AND SCIENTISTS
In a small book of this size, it is not possible to address all the organ systems and
physicians associated with them. It would however be inappropriate to close this chapter
without mentioning, in brief, some of the other noteworthy achievements in the field of
medicine.
Most of our concepts of digestion, particularly the role of the stomach were because of
the fortuitous association between Dr William Beaumont and Alexis St. Martin in the
early part of the Nineteenth Century. St Martin, a Canadian trapper of French origin
accidentally shot himself in his abdomen. Beaumont, a physician at an army camp nearby
was called to treat him. Beaumont cleaned the wound and expected the patient to die. To
his surprise, St Martin improved. The growth of granulation tissue partially closed the
42
wound forming a gastric fistula and St Martin was able to lead a reasonably normal life.
However, this gave Beaumont the opportunity to see the inside of the stomach in a living
person. Suffice it to say that he was the first person in the world to do this and in Sir
William Osier's words “ The man and the opportunity had met “. Beaumont introduced
pieces of food into the stomach by tying them with a piece of string, and on drawing the
siring put after some time, he found , to his amazement, that the food had disappeared [
digested ]. He was also able to study the response . ... The relationship between the two
was strange - and strained. Wltile St Martin needed Beaumont for financial sustenance,
Beaumont himself could not do his research without St Martin. The rude behaviour of
Beaumont antagonised St Martin who disappeared without warning one day. Inspite of
returning because of financial constraints, he again disappeared, - never to return.
Sir William Osler ( 1849-1919 A.D.) has been aptly described as “the world’s greatest
doctor". This was in 1949. 30 years after his death. Almost 50 years later, this statement
remains true. Osler gave to modem medicine, what Hippocrates did thousands of years
ago. He gave it a soul. Osier’s contribution to the medical world can fill up textbooks and indeed, it has. No physician or scientist has ever had so much written on him over the
years. Significantly, not even one of these many works has ever criticised him. Osler was
responsible for starting the system of bedside teaching in the wards, a practice taken for
granted today. It was he who wrote the first comprehensive textbook of medicine “ The
principles and practice of medicine “ in 1892. He also wrote prodigiously and taught
students - at University of Pennsylvania, Jolins Hopkins Hospital and at Oxford - amidst
his busy practice. He found the lime to describeTrichinella spiralis [ as a young physician
in Canada ] and the Osler- Weber- Rendu syndrome [ Hereditary Haemorrhagic
Telangiectasia ], Vaquez- Osler Syndrome [ Polycythemia vera ] and Osier’s nodes of
Infective Endocarditis. The “ Quarterly Journal of Medicine “ was founded by him.
Genetics and immunology are probably the fields in which great advances are being
made. This is only natural because they deal with subcellular organelles and their
functions. The future of medicine probably lies in understanding the genetic and
biochemical basis of life. Genetics however, is not a new field. Its founder was an
Austrian monk, Johann Gregor Mendel (1822-1884 A.D.) who lived in his monastery in
Brno and who carried out his experiments on the pea plant. He used smooth and wrinked
peas, as well as green and pink ones and used over 28.000 plants in his experiments. His
work was not known to the outside world until 1900.
One of the most important discoveries in biomedical resear ch was made about 40 years
ago. In a celebrated letter to the editor to the journal Nature, James Watson and Francis
Crick described the double helix structure of the DNA molecule, the molecule of life.
They [ along with Wilkins ] were awarded the Nobel Prize in 1962 for this discover}'.
Today, gene therapy has been successfully attempted in select diseases in the USA and
may become more important in years to come. From the structure of DNA in the 1950s to
43
genetic engineering later; and now gene therapy in the 1990s, medicine has indeed come
a long way. in the latter half of this century.
Immunology’, too, is not a new subject since its principles were introduced to clinical
medicine by Edward Jenner. The greatest impact of this field in recent years has been in
the manufacture of monoclonal antibodies in diagnosis and therapeutics. These were
discovered by Georges Kohler and Cesar Milstein in 1975, for which they were awarded
the Nobel Prize in 1984.
REFERENCES
i)
Kothare, SN. Heart and pulse. Physician’s Update. 1988, 1(1); 28-29.
ii) Kothare, SN. Respiratory diseases. Physician’s Update. 1989, 2 (1): 26-28
iii) Kothare, SN. Renal diseases. Physician’s Update. 1989, 2 (3): 124-125.
iv) Strauss M B and Well L G. Diseases of the Kidney. Little Brown and Co, 1963.
v)
Harrison. C V. Recent advances in Pathology. I960. J A Churchill Ltd
vi) Monteiro L. Medical Bulletin, Bombay. 1942.
44
CHAPTER 9 : SOME COMMON DISEASES
This chapter traces the history of two relatively common diseases - Diabetes Mellitus,
which is very common and Cancer; the latter winch is possibly the most feared disease.
For the sake of completion, it may be stated that the other common diseasesHypertension, Tuberculosis, Anaemia, ADDS, Nutrition disorders, etc, have been
addressed to in other chapters.
DIABETES MELLITUS
Centuries ago Diabetes Mellitus was known to our ancestors and references to this are
found in Indian, Egyptian and Greek medicine.The Papyrus of Ebers, written probably in
the first half of the 16th century B.C. in Egypt, mentions, amongst other ailments, the
passing of excessive urine. This perhaps refers to Diabetes or Cystitis. Surprisingly, there
is no reference to Diabetes in Chinese, Persian and Greco-Arabic (Unani) medicine as
could be ascertained from available reference books. In Charaka Samhita, 20 varieties of
“Prameha" or polyuria are .mentioned. One such variety of "Prameha” caused by
“disturbance of air", is described with symptoms of flabbiness of flesh, dryness of the
mouth and throat, sweet taste of the saliva, burning of palms and soles and passing of
sweet urine. The sweetness of the urine was attributed by the ancient Hindu physicians to
the presence of honey and hence the disease was known as “ Madhu Meha”. This was
corroborated further by their observation that insects and ants were attracted towards
such urine. This description is highly suggestive that the ancient Hindus were familiar
with Diabetes Mellitus.
In the writings of Aretaios (Arctacus) of Cappadocia, a Greek physicianswho lived during
the period 120-200 A.D., there is a reference, probably to Diabetes. Amongst the disease
described, he mentioned a condition associated with unquenchable thirst, excessive
drinicing of water and excessive passing of urine. The word “Diabetes" is perhaps derived
from a Greek word signifying a siphon, appropriately describing how in the disease the
fluid cannot be retained in the body. Greek physicians, like ancient Hindu physicians,
used to taste the patient’s urine to detect abnormal constituents. The practice, though
unpleasant, perhaps enabled them to detect diabetic patients.
Then followed a long period of several centuries between the 3rd and the early 17th
Century A.D during which the disease did not evoke any special interest amongst
medical men. till after the “Renaissance”. During and after the 17th century, several
researchers contributed towards the better understanding of this malady. In the present
century the emphasis has been essentially on the evolution of the treatment of Diabetes
mellitus.Thomas Willis, in 1764, observed that the urine of a diabetic patient was sweet
and he surmised that it contained cither sugar or honey. Francis Home (1719-1813 A.D.)
of Scottish origin, was the first observer to report fermentation of sugar in diabetic urine
45
by yeast, some time around 176c. In 1776. in Liverpool, an Englishman named Mathew
Dobson was the first doctor to experimentally detect the presence of sugar in the urine of
a diabetic patient , by evaporating the urine. He also observed the sweet taste of the
serum from a known diabetic, thus establishing beyond doubt, the state of
hyperglycaemia. That the sugar in the diabetic urine is glucose, was established by
Michael Eugene Chevreul of France in 1815.
In 1846. Claude Bernard, a Frenchman, found that a wound in the floor of the brain near
the cerebellum produced transient diabetes in animals. This perhaps marked the
beginning of experimentally induced diabetes in laboratory' animals. Adolf Kussmaul
(1822-1902 A.D.), a German, described a peculiar type of breathing associated with
diabetic acidosis now named after him “Kussmaul's Air Hunger”. This observation
turned attention of researchers to the biochemical changes in Diabetes. Karl Petreu
(1868-1927 A.D.) a Swede, studied various metabolic disorders including Diabetes
mellitus and recommended a special diet (Petreu diet) for diabetics which consisted of
low protein and liigh fat content because of the belief that protein was the chief
ketogenic factor in these patients. This, however, was eventually proved to be an
incorrect concept following the work of Knoop in 1904 regarding the origin of ketogenic
bodies.
Joseph von Mering (1849-1908 A.D.) and Oscar Minkowsky (1858-1931 A.D.), both
students of Bernard Naunyn, in 1889, at the suggestion of their teacher, produced
Diabetes in a dog by complete extirpation of the pancreas. Minkowsky also, in 1906,
noted the formation of acid in diabetic coma and coined the term “acidosis”. Animal
experiments by Naunyn, von Mering and Minkowsky' pinpointed the role of the pancreas
in Diabetes. Earlier in 1893, E.Lagnesse had drawn attention to the role of the islets of
Langerhans, described earlier by Langerhans, in the production of an internal secretion
responsible for the well-being of an individual. George Zucler, a German, in 1900
obtained the pancreatic extract which he named “Acomatol”. It contained insulin but its
use was discontinued due to serious side reactions. However, with this observation a new
era dawned in the treatment of Diabetes.
In 1912 Frank demonstrated the presence of an anti-diuretic hormone in the posterior
lobe of the pituitary gland which controlled Diabetes insipidus. Evans on the other hand
produced Diabetes mellitus in experimental animals by injecting anterior pituitary'
extract. Young, in 1937, confirmed the role of anterior pituitary extract in induced
diabetes. B.A. Houssay (1887-1953 A.D.), a South American, described the role of
Hypophysis in Diabetes mellitus in experimental dogs - known later as the famous
“Houssay Dogs”. For this and other related researches Houssay shared the Nobel Prize in
1947. Earlier, in 1916, the term “ insulin” was coined by Edward Sharpey-Schafer for
the internal secretion of the pancreas. Opie described lesions of the islets of Langerhans
in fatal Diabetes. The problem of the relationship between insulin , the pancreas and
46
diabetes was finally solved by Banting , John Janies Richard MacLeod, Best and Collip [
refer to the chapter on drags j.
Janbon and co-workers, in 1942, accidentally discovered sulfonamide induced
hypoglycaemia. Following this discovery, several other orally effective organic
compounds were made available. Human insulin was prepared by cloning of DNA in E.
coli by Frank and Chance in 1983. This has now been put to practical use in the treatment
of Diabetes Mellitus.
CANCER
The term ’'Cancer’' is used in this article in a general sense meaning a malignant growth,
irrespective of tissue of origin. The word “Cancer” is derived from the Greek word
“Karkinos” meaning crab. - the body of the crab representing the main tumour mass, and
the legs, by its extensions, resulting in the spread of the tumour. This, indeed was an
astute observation in the absence of any magnifying device. Paleo-pathology has
contributed considerably to our liistorical knowledge of cancer, through the discovery'
and study of bones and fossils that show evidence of tumours. References to cancer are
found in the Hippocratic writings and so also in Galenic writing ; the latter, an ardent
admirer of Hippocrates, refers to a cancerous growth as a hard mass of malignant tissue
with or without ulceration.
During the last hundred years, numerous workers have published their findings on
benign and malignant tumours, experimental cancer, transplantable tumours, and the role
of viruses and immunity. As William Boyd writes “Everything under the sun, including
the sun itself causes cancer “. In this brief account, it is possible to cover only a few of
the historical aspects of Cancer.
In Indian medicine, there are detailed descriptions of tumours by both Charaka and
Sushruta, who refer to them as "Arvuda”, - all types of these having their origin in
’deranged’ flesh and blood. The preponderant action of the deranged blood would lead to
“Rakta-arvuda’, while a dominant action of deranged flesh would cause the
‘Manasarvuda’ type - both types being incurable.
Treatment at that time consisted of application of poultices and plasters, some of them
containing curd-cream, so as to encourage worms and parasites to consume the tumour.
Any part being left would then be cauterized with fire. Superficial tumours were excised
or cauterized, care being taken to ensure that no part was left behind, as these pans
would, they warned, lead to fresh growths and “bring on death, just as the least particle of
an unextinguished fire will lead to a renewed conflagration ”.
47
Paul of Aegina (625 - 690 A.D.), a Byzantine physician, some lime in the first half of the
7th cenntry wrote seven books “On Medicine”, in which he referred to Cancer in general.
and to that of the uterus and breast in particular. For cases of uterine cancer, he did not
recommend removal because of the rapid progress of the disease and early recurrence.
Rudolf Virchow recognized Cancer as a disease entity, but his concept of its origin from
the pluripotential connective tissue cell needed rectification, and this was carried out by
Remak and Waldeyer. Remak (1815-1865 A.D.) differentiated tumours into two broad
classes, those of epithelial and those of mesodermal origin. Later Waldeyer and lais
associates established the fact that the mode of spread of malignant tumours involved
lympatic and vascular channels. Lisfranc (1833) is believed to be the first surgeon to
successfully treat Rectal Cancer using the perineal approach.
EXPERIMENTAL CANCER
It is now well known that tumours, both benign and malignant, can be experimentally
produced in animals through the medium of physical, chemical and infective agents, and
that heredity is an important predisposing factor. In 1915, Yamagiwa and Ichikawa
produced epithelioma by repeated application of tar to the skin of animals. With this
discovery', attention was drawn to the causative role of hydrocarbons in certain cancers.
SMOKING AND POLLUTION
In 1949, Richard Doll and Austin Bradford Hill first reported the association between
cigarette smoking and lung cancer. At the time, this disease affected more than 278 per
million persons in Britain; they also found that most victims of the disease had been
chain smokers for over twenty years. There is also evidence that atmospheric pollution
contributes to a higher incidence of lung cancer in industrialized cities. In 1955,
D.D.Banker reported an increase in the incidence of lung cancer among city' dwellers of
Bombay. Amongst Indians, the role of chewing tobacco and slaked lime in the causation
of cancer of the Oral cavity, has been demonstrated by' L D Sanghvi, Kasturi Rao and
V.R. Khanolkar in 1955.
PHYSICAL AGENTS
Skin cancer, in exposed parts of the body' is a well-known example for the carcinogenic
effect of Sunlight, particularly among the Australians. Rusch and Baumann
experimentally confirmed in mice that these lesions are caused by the ultraviolet
component of the Sunlight. In India, “Kangri cancer “ of the skin and “Chutta cancer” of
the oral cavity are examples of chronic irritation due to heat, reported by E.F.Neve in
1900 and Kini and Subba Rao in 1937 respectively. Khanolkar also documented the
Dhoti Cancer [ squamous carcinoma of the skin caused by the wearing of tight dhotis]
and Khaini Cancer of the lip in 1945.
48
Radium and radioactive substances used as therapeutic measures in the treatment of
malignant neoplasia can also prove to be neoplasm-producing agents, if used indiscreetly.
The use of Radium (discovered by Marie Curie in 1898), as a therapeutic agent was
noted by the French physicist Henri Becquerel. He also suspected that Radium could
cause bums, a fact that was confirmed by Pierre Curie in 1901. The first series of cases
with malignant disease were reported by Manland and Humphrey in 1929. Girls
employed in an American walch factory to paint dials with luminous paint containing
Radium and Mesothorium were in the habit of reshaping their brushes with their lips,
thus swallowing small amounts of these substances. Over the years, this led to the
formation of osteogenic sarcoma in these workers.
HORMONES
The relationship between excess of Oestrogen and breast cancer was conclusively
established by Lacassagne in 1935. Several years earlier, Lathrip and Loeb had
demonstrated, in experimental animals, the association between breast cancer and
ovarian hormones.
VIRUSES AND PARASITES
In 1911, Peyton Rous established that a cell free filtrate from a malignant tumour in a
fowl, when injected into another fowl, could produce tumours in several succeeding
generations. This tumour subsequently came to be known as Rous Sarcoma. Andrews, in
the course of his research from 1931-33, succeeded in demonstrating antibodies in the
serum of tumour -bearing fowls: this observation supported the infective theory of
tumourigenesis, further justifying the search for the infective agent. In 1957, the first
report of Herpes simplex as a premalignant condition was made by R. Wyburn Mason.
Malignant tumours in association with parasitic infestation, have been known to occur in
lower animals, though rarely. Cysticercus fasciolans, the cystic stage of T.crassicollis, is
known to promote sarcoma in the liver of rats.
IMMUNITY
In recent years, numerous studies have focussed attention on the immune system as a
means for sustaining a non-neoplastic state, or for developing a specific mode of anhcancer therapy. This focus on the inunune system centres around the belief that given an
intact, competent immune system, surveillance mechanisms would destroy cells bearing
new surface antigens.
49
REFERENCES:
i)
Hadfields G. And Garrod. L.P., Recent Advances in pathology, published by J. A.
Churchill Ltd, London, 1943
ii)
Reddy, D.J., Cancer-Customs, Habits, Usages and Environment, Published by
Current Technical l iterature Co.Pvt., Ltd., India House,Bombay, 1968
iii) Wybum-Mason,R., Malignant Change following Herpes Simpex,
615-616
1957, pp
iv) Burnet, F.M., The Concept of Immunological Surveillance, Prog. Exp. Tumour Res.,
1970
v)
Castiglioni A: history of Medicine, edited by B. Krumbhar, 1941, p.834
vi) Koihare, S N. Diabetes mellitus. Physician’s update 1988, 1(2) :71-72.
vii) Marble A. and others: “Joslin’s Diabetes Mellitus”, 12th Ed. Philadelphia, Lea &
Febiger 1985
Opie
viii)
E.L.: On the Relation of Chronic Interstitial Pancreatitis to the Islands of
Langerhans and to Diabetes Mellitus, J.Expt. Med. 5: 397, 1901
ix) “Goodman and Gilman’s The Pharmacological basis of Therapeutics”, 6th ed.
Macmillian Publishing Co., Inc, New York, 1980.
x)
Frank B.H. and Chance R.E.: Two Routes for Producing Human Insulin
xi) Utilizing recombinant DNA Technology, M.M.W. 1983, 125, 14-20.
50
CHAPTER 10 : PATHOLOGISTS AND MICROBIOLOGISTS
Information on pathological lesions in ancient times, part icularly of the early stone age, is
available through paleopathology and paleoodontology, the study of bones and teeth of
the early stone age. Evidence of tuberculosis of the spine and other bone lesions is
derived through the study of Egyptian mummies. Archaeological findings of sculptures,
dating back to the Mohenjo-daro and Harappa Civilizations, ancient Greek pottery with
paintings of deformed bodies and votives on Asclepieia, are indeed precious
contributions.
In 1987, William Turnbull and his associate Bruce Rothschild detected chemical traces
of the “Syphilitic Organism” in the 11.000 year old vertebra of a bear in the collection of
Chicago's Museum of Natural History. The well known adage says “ Dead men tell no
tales”. But the anthropologist Geroge Armelagos of University of Massachusetts has a
different version. To quote him, “ Well, dead men and women tell us a great deal about
the problems we are facing now.”
Hammurabi (1948- 1905 B.C.) is believed to have contributed to Pathology as surmised
from materials available fron the library of Ashurbanipal who lived during the period
669-626 B.C. Hippocrates recorded good clinical descriptions of many diseases
including Cancer but did not contribute to Pathology'.
Avicenna in 1000 A.D. differentiated Haemolytic jaundice from the Obstructive type. He
also believed that wound infection with ptis formation (laudable pus ) was a favourable
sign. Albucasis (25 B.C.-50 A.D.) described dental deformities. Celsus (25 B.C. - 50
A.D.) described the signs of inflammation viz. tumor | swelling ], calor [ warmth ], dolor
[pain ], rubor [ redness ] as well as the symptoms of Rabies and Appendicitis in man. He
described Carcinoma as a fixed tumour having two states, the earlier being the "non
ulcerating “ and the later being the “ ulcerating” ; the latter being the most malignant.
During the medieval period (500 A.D. - 1500 A.D.) there was generally no progress in
learning and hence this period is known as the “Dark Ages”. There were of course a few
exceptions to this. Fracastorius (1483- 1553 A.D.) from his observations in diseased
persons postulated that certain diseases were transmitted from the diseased to a healthy
individual - the contagious nature of diseases. The acceptance of the practice of
dissection of dead bodies opened a new vista. It was then possible to correlate a disease,
its symptoms and its appearances. Leonardo da Vinci , Vesalius and a few' others w'ere
important contributors through their dissections and their faithful drawings. Ambroise
Pare described carbon monoxide poisoning in the year 1575.
51
Paracelsus considered himself superior to Celsus; his revolt against Galenism and its
dogmas gave direction to the search for new concepts of disease. His account of
“Miners’ Phthisis”, though published posthumously, has been considered as a great
contribution to the understanding of the disease.
Marcello Malpighi ( 1624 -1694 A.D.), the Professor at Bologna and later at Pisa, was
the first anatomist to make use of the microscope. He saw red blood cells flowing
through the capillaries of a frog’s web, thus confirming William Harvey’s concept of
blood circulation. The Malpighian corpuscles in the kidney and the Malpighian layer of
the skin are named after him.
Giovanni Morgagni ( 1682-1771 A.D.) was an Italian pathologist who was one of the
founders of morbid or anatomic pathology. He wrote a book called De sedibus et causis
inorborium per anatomen mdagatis in 1761, in which the clinicopathologic corelation
between clinical symptoms and gross anatomy were demonstrated. Morgagni described
Cerebral Gumma, Syphilitic Aneurysms and Tuberculosis of the kidney.
John Hunter (1728-1793 A.D.) and his elder brother William (1718-1768 A.D.), through
their meticulous study of medicine in general and pathology' in particular, collected a
large number of specimens over 13,000, - and established the first museum of Anatomy
and Pathological Anatomy in London. The best known specimen was that of Charles
Bryne, the Irish giant. Bryne tried his best to prevent Hunter from getting his body after
his death but Hunter ultimately bribed people and suceeded in retrieving the body. John
Hunter was a great surgical pathologist and did research on inflammation and on gunshot
wounds and was also the first to establish the presence of collateral circulation.
Marie Francois Xavier Bichat (1771 - 1802 A.D.) was another French pathologist who
contributed handsomely to his favourite subject. He established that the tissue, rather
than the organ, was the important biological unit; this was the beginning of “Cellular
Pathology”. He also differentiated twenty one types of [ non-microscopic ] tissues in the
human body and was the first to recommend division of Morbid Anatomy into two parts
which we now understand as ‘General Pathology'’ and ‘Systemic Pathology’.
Rene Theophile Hyacinthe Laennec (1781- 1826 A.D.) the discoverer of the art of
auscultation and the inventor of the stethoscope, described lung sounds and the clinical
manifestations and pathology of Pulmonary' Tuberculosis. It is indeed an irony of fate
that he, at a young age, died of the same disease. His name is associated with several
pathological conditions of the lung. He also described a condition of the throat for which
he coined the term Diphtherite’ - now known as Diphtheria.
Carl Rokitansky' (1804 - 1878 A.D.) like Morgagni, was a gross descriptive pathologist
of eminence. He described “ Periarteritis nodosa” , differentiated between Lobar and
52
Bronchopneumonia as well as between Bright’s disease of the kidney and Amyloid
kidney. He described several anomalies of the human body particularly congenital heart
defects. His learned discourses attracted students from far and wide and the Viennese
School of Medicine soon became a well known seat of learning, particularly of
Pathology. It also came to be known as the ‘Mecca of medical students’. Rokitansky
personally performed 30,000 autopsies, supervised over 70,000 autopsies and collected
a wealth of pathological specimens over a span of 50 years, - no mean an achievement
considering the period he lived in.
Rudolf Virchow (1821 -1902 A.D.) was a multifaceted scholar. His contribution to
Pathology can provide material for an entire chapter. Some of his more important
contributions were the separation of Pyaemia from ‘Leukaemia’, [which terms he
coined], and the discovery of the phenomenon of embolism as well as of myelin. He was
the first to stain amyloid with iodine and sulphuric acid as well as describe
onychomycosis and describe pigments of the body. His publication Die cellular
pathologic, in 1858 is one of the classics of medical literature. In it, he postulated “The
cells are the loci of life and also the disease “ and “ Ominis cellula a cellula” or ‘ a new
cell can only arise from an old one”. He also believed that pathology was altered
physiology and that the latter had a direct bearing on pathological anatomy. Thus was
bom the concept of “Cellular Pathology'” and subsequent studies in the following
centuries, were based on furtherance of the above concept. Over 50 medical terms
including ‘Hyperplasia’ ,‘ Ischaemia’,1 Psammoma’ , “ Amyloid” , Pyaemia,
“Leukaemia” and “Giant cell” were first used by Virchow. He was also responsible for
starting the journal “Archiv fur pathologische anatomic and fur Klinische mediziri*
(Virchow’s Archives, a journal that is still published). How good a teacher he was may
be judged by the brilliance of his students. Suffice it io say that his students included Paul
Langerhans Jr. , von Recklinghausen, Conheim, Klebs, His and Hoppe-Seyle. Medicine
apart, Virchow found time to be a politician and a social reformer. He played a major
role in the construction of hospitals, canals and sanitation in Berlin. He also did research
in Anthropology and Archaelogy. In fact, a study of his had shown that only a minority of
German were blond and blue-eyed ; contrary to the popular belief that most Germans
were blonde and blue -eyed. This finding of course was contradictory to what Adolf
Hitler wanted to propogate about 70 years later about Aryan phenotype and superiority ;
as a result, Hitler tried to suppress Virchow’s findings.
With the enuciation of Virchows’s concept, the collaboration with physiologists became
imminent. Several physiologists through their experimental research contributed in
unraveling pathological processes. Amongst these, Claude Bernard’s concept of the
‘milieu interior’ (internal environment) was an outstanding contribution based purely on
the physiology' of a cell, its surrounding, intercellular fluid and its dynamic role in
maintaining the health of the cell. Bernard (1813 - 1878 A.D.) for the first time,
introduced experimental study of disease in the living . He is also known for his
experimental production of glycosuria which he did by puncturing the fotuth ventricle.
Bernard also described the functions of the liver, the digestive ac tion of the the pancreas,
53
the nature of curare poisoning on muscle , oxygen carrying capability' of the RBC; it is
said that if Nobel prizes had existed in his time, he would have bagged at least four I
Between 1840 and 1932 Mohr, Frolich, Simmonds and Cushing were associated in the
understanding of the pathology' of lesions of the Central Nervous System.
A reference to Indian contributors will not be out of place. Vasant Ramji Khanolkar
(1895-1978 A.D.) was bom and brought up in Quetta. He took his M.D. in Pathology'
from the London University in 1923. On his return to India, in 1924, he was appointed
Professor of Pathology and Bacteriology at the Grant Medical College, Bombay, which
post he relinquished in 1926 to join the staff of Seth G.S . Medical College and K.E.M.
Hospital, Bombay as the Professor and Head of the Department of Pathology' and
Bacteriology. Later, he was the Director of Laboratories of Tala Memorial Hospital,
Bombay [ 1941 - 1952 ] before becoming the Director of Indian Cancer Research Centre
(ICRC) from its inception in 1952, till his retirement in 1963. At Tata Memorial Hospital
and I.C.R.C., he carried out a number of research projects on experimental cancer and
related topics. He established the role of tobacco as a carcinogen in the causation of
Cancers of the mouth region. He could rightly be called the “ Kennaway of India” for his
contributions to the subject of carcinogenesis in general. He was also interested in
Leprosy and through his studies the mode of spread of M. leprae in neural leprosy was
established. Under his guidance attempts were made to cultivate M. leprae “ in vitro” ; a
strain has been isolated. He was also a linguist. Besides English, German and French he
knew Marathi - his mother tongue, Pushtu and Urdu. He was the recipient of national and
international honours, including the Padma Vibhushan in 1955 and the first National
Research Professorship of the Government of India in 1963.
P N Wahi (1908-1991 A.D.) was bom at Moradabad in Uttar Pradesh. He graduated
from King George’s Medical College, Lucknow in 1932, took liis M.D. from the same
college in 1934 and M.R.C.P. (London) in 1938. He joined the Department of Pathology
of the S.N.Medical college, Agra in 1935 and became the Professor and the Head of the
Department in 1941. He was appointed the Director of I.C.M.R. in 1969 and retired in
1974. His well known observations on the precancerous and cancerous lesions of the
uterine cervix, oral cavity and others, contributed in no small measure in planning of the
National Cancer Control Programme. He was the recipient of several national awards for
his outstanding contributions to medical education and research.
Y.M .Bhende (1911-^) graduated from the Grant Medical College, Bombay in the year
1935. He took his M.D. in General Medicine in 1940 and later , M.D. in Pathology' and
Bacteriology in 1945 from the Seth G.S. Medical College, Bombay. That same year he
was appointed the Professor and Head of the Department of Pathology' and Bacteriology.
In 1952 he resigned and joined the B.J. Medical College, Ahmedabad. Since his early'
days, at P.G. Singhanee Hindu Hospital, Bombay, when working under Raghvendra Row,
he had an interest in Haematology and he continued io pursue his interest in this subject.
Subsequently he published several studies on Anaemias in Indians and threw new light
on their aetiology and pathogenesis. He and his associates discovered in 1952 , a new
blood sub-group which is now known as the “Bombay blood group”. During his tenure at
B.J. Medical College, Ahmedabad, he contributed several papers on Amyloidosis in India
and published his experimental work on the role of Argemon oil and its relation to
Epidemic Dropsy. He was subsequently transferred to the B.J. Medical College, Poona
(Pune) and retired due to superannuation in the year 1967.
In eulogizing anatomic pathologists, one cannot forget the important role played by
workers in allied subjects. Studies of Louis Pasteur (1822 - 1895 A.D.) and Robert Koch
(1843 - 1910 A.D.) conclusively established that many diseases were caused by invading
bacteria. This observation had an important bearing on subsequent researchers in
Pathology and Microbiology. Subsequently, research has been directed towards the
understanding of various kinds of tumours and their origin. The introduction of the tissue
culture technique has unravelled several mysteries in Oncogenesis.
MICROBIOLOGY
The concept that diseases are caused by tiny organisms, goes back to Marcus Terentius
Varro (127- 116 B.C.). Girolamo Fracastorius, in 1546, hypothesized the existence of
invisible living “Semina” through which diseases spread. Augustino Bassi (1771- 1856
A.D.), an Italian law graduate had varied interests including Anatomy and Physiology'. In
1835, he described a disease of silk worms due to a parasitic fungus- known later as
“ Borirytis bassiana” and its treatment.
Olive Wendell Holmes (1809-1894 A.D.) an American, though a graduate in medicine,
was keenly interested in literature and poetry'. In 1843, he had observed that puerperal
sepsis was transmitted through contaminated hands. This observation, though made three
years earlier was not known to Semmelweiss, when he published his observations on the
same subject in 1846. Holmes is also well known for Iris statement , “if all the drugs in
the world were sunk to the bottom of the sea, it would be all the better for mankind and
all the worse for the fishes
a statement which indicates rhe state of therapeutic
medicine then.
Edward Jenner (1749- 1823 A.D.) was the favourite student of John Hunter. Jenner used
to write to Hunter for advice. In one of his replies [ regarding hibernating hedgehogs ],
Hunter wrote : “Your suggestion is just ; but why think, why not try the experiment ?”;
advice often quoted even today to young researchers. Jenner had been told by a
milkmaid that she would not ever suffer from Small-pox as she had already had Cow
pox , having handled animals with Cow-pox infection . Jenner through his ingenuity,
introduced Cow-pox vaccination in 1796 with the pious hope that, it would serve as a
prophylaxis against Small- pox; it did work. With this observation began the era of
vaccination as a prophylaxis against infectious diseases and the role of immunization in
combaring disease. During ancient times, in India and China there existed a practice of
55
“variolation” in which protection against Small-pox was produced by inoculating live
organisms front pustules.
Louis Pasteur (1822 -1915 A.D.), a Frenchman, was born in Dole. He obtained his
doctorate in Sciences in 1848. His first research was highly acclaimed by “Academic des
Sciences”. As a renowned chemist, he was called upon by the French Government to
resolve problems in the manufacture of wine. He continued Iris studies in the
fermentation of alcohol and lactic acid. Later he announced that fermentation of sugar
into alcohol and carbon dioxide was due to round globules, later identified as yeast cells.
His proof of the existence of germs in the air led Lister to apply the same principles in
Surgery. He also described a method of sterilization at 60° C, known as “Pasteurisation”.
He coined the term “vaccine” and prepared vaccines against Antlirax, Chicken Cholera
and Rabies. His experimental approach to confirm the efficacy of Iris Anti-rabies vaccine,
is indeed commendable considering the circumstances and facilities prevailing then. He
was fortunate io get an opportunity to try out his vaccine on a nine year old boy - Joseph
Meister - who was bitten by a rabid dog on 6th July 1885. The treatment was a success
and soon patients bitten by rabid dogs came to Pasteur for lais miraculous treatment. In
recognition of his achievements, the “Academic des Sciences” of France recommended
the establishment of an institution for research named “Institute Pasteur” after the
illustrious chemist turned microbiologist.
/mother outstanding personality in the latter half of the 19th century was Robert Koch
(1843-1910 A.D.) who was bom in Klansthal in Germany. He developed, by painstaking
effort, a procedure to cultivate Bacillus anthracis on laborator}' media. Earlier, in 1850
Davaine and Pollender had demonstrated Anthrax bacillus in the blood of animals dying
of this disease. Koch, in 1881, published his new method of solidifying a meat infusion
of culture medium for the growth of bacteria by the addition of gelatin. This has been
considered by some as the greatest contribution to Microbiology. Employing his staining
technique, which he had devised earlier, he confirmed in 1882, the presence of tubercle
bacilli in the sputum of patients suffering from Pulmonary Tuberculosis and in 1883.
Vibrio cholerae in the excreta of patients suffering from severe diarrhoea, now known as
Cholera. He designed the hanging drop procedure for the study of micro-organisms. He
prepared Tuberculin as a treatment for Tuberculosis but failed. Tuberculin, however, has
an application in the diagnosis of tuberculosis. Finally he has given us the Koch’s
Postulates according to which proof that an organism can cause disease exists only when
certain criteria are met, viz., the organism must be present only in the diseased animal
and not in normal animals, the causative organism must be isolated from the diseased
animal and grown in pure culture, must reproduce the disease when the organism is
introduced into a susceptible animal and the organism must be re-isolated from this
animal. Koch received the Nobel Prize in 1905 and with Pasteur, can truly be called the
“Founder of Bacteriology”.
Waldemar Mordecai Haffkine (1860-1930 A.D.) was born in Odessa, Russia, of Jewish
parents. He took his degree of Doctorate of Science from the University of Odessa. His
56
interest in Cholera was aroused during the years 1888 and 1889 when there was an
epidemic of this disease in Russia. Earlier in 1883. Robert Koch had established the
causal relation between Vibrio cholerae and the disease. Taking the cue from this
observation. Haffkine prepared an Anti-cholera vaccine and after testing the efficacy in
laboratory animals, he persuaded his colleague to inject the same into his arm to prove
not only its harmlessness but also its beneficial effects as an immunizing agent. This was
reported to the Biological Society of Paris in the year 1892. In 1893, the then Governor
General of India, requested the services of Haffkine to combat the Cholera epidemic
which was raging in Calcutta and its surrounding regions. In March of the same year he
arrived in Calcutta and with the assistance of local doctors embarked on a programme of
mass inoculation as a Prophylactic measure and succeeded in bringing down the
mortality by 70 percent. He, in his modesty, admitted his inability to evaluate the degree
of immunity and its duration. In 1896, an epidemic of Bubonic Plague broke out in
Bombay and once again the British Government reassigned Haffkine to Bombay. He
arrived at Bombay in October 1896 and set up a one room laboratory, in the corridor of
Framji Dinshaw Petit Laboratory of the Grant Medical College, Bombay. By December
of the same year . he started experimenting on laboratory animals with his Anti-plague
vaccine and was soon convinced of its efficacy in preventing the disease and its spread.
In January 1897, he persuaded Dr. F.N. Surveyor, to inoculate him (Haffkine) with the
vaccine in the presence of the Principal of the Grant Medical College. This is an example
of self-experimentation in medicine, a feature which was not uncommon in those days.
The next day he was at work inspite of the local and general reaction following the
inoculation. He urged the Government to introduce mass inoculation programme in
epidemic diseases, as a preventive measure. Following this there was a great demand for
his plague vaccine from countries all over the world. He founded the Plague Research
Laboratory' which was subsequently moved to the “Old Government House”, Parel,
Bombay. In 1925, this laboratory' was renamed “The Haffkine Institute” in his honour. In
recognition of his devoted work and research, several Indian and International awards
were bestowed upon him. Tn 1915, he retired from Haffkine Institute due to
superannuation.
Ronald Ross ( 1857- 1932 A.D.) was born in India during the days of the British Raj.
After his medical education in England, he was commisioned in the Indian Medical
Service in 1881. A chance meeting with Sir Patrick Manson in London influenced him
greatly and he decided to do research on Malaria. In 1880, Alphonse Laveran, a French
army physician discovered the Malarial parasite as the causative agent of Malaria by
demonstrating it in the red blood cells of man. After much painstaking reseach, Ross
discovered pigmented cells in the stomach of the Anopheles mosquito in 1897. This was
published in The Indian Medical Gazette in 1898. In 1899, Sir Ronald Ross went back to
London where he was a Lecturer in Tropical Medicine and later Professor of Tropical
Medicine at Liverpool School. Ross received the Nobel Prize in 1902.
Walter Reed [1851-1902 A.D.] was a doctor in the American army. He went to Cuba in
1898 to study Yellow Fever, a disease which caused high morbidity and mortality. His
57
experimental work there proved Carlos Finlay’s theory that the mosquito bite of the
Aedes led to the development of this disease.
Raghvendra Row (1873-1953 A.D.), was bom in Honavar in North Kanara. He graduated
from the Grant Medical College. Bombay. He proceeded to London for further studies
and returned to India in 1911. He was the first Indian to take the degree of Doctor of
Medicine from London. On his return to Bombay, he was appointed as honarory
Physician at the J.J.Group of Hospitals, Bombay. In 1926, the Government of Bombay
Presidency, (as it was known then) persuaded him to accept the post of the Professor of
Pathology and Bacteriology at the Grant Medical college, Bombay, which had fallen
vacant due to the resignation of Dr. V.R. Khanolkar. Besides General Medicine, he was
also intensely interested in Parasitology. In order to pursue research in Malaria, Kala
Azar and Leprosy, he established a Research laboratory' at the above Institute at his own
expense. The aim of his research was to cultivate parasites of the above mentioned
diseases and also Lepra bacilli (M. leprae) in the laboratory and eventually prepare a
vaccines. In a suspected case of Rat Bite Fever, he injected the patient’s blood,
intraperitoneally into a mouse and succeeded in demonstrating the Spirillum minus in the
peripheral blood of the mouse. This was reported in the Indian Medical Gazette in 1941.
Fie published seventy' two scientific papers and in recognition of his work, he was
awarded the Degree of “D.Sc.” (London). After his retirement from the Grant Medical
College in 1931, he joined P.G. Singhanee Hindu Hospital, Bombay as a Physician and
Pathologist. One of his valued patients was H.H. the Maharaja of Mysore. He donated all
bis eamngs from the private practice to this hospital. He was both, an astute scientist and
a philanthropist. Row died in 1953.
C G Pandit (1895-1991 A.D.) joined the Elphinstone College in 1910. He proceeded to
London and was the first recipient of the Ph.D. in Bacteriology from the London
University. On his return, he joined the Medical Research Deparrment and was posted
at the Kang Institute, Guindy, Madras in 1924 and later as the First Indian Dir ector of the
same Institute. He is known for his contributions on Rabies, Cholera and other Tropical
Diseases. His interest in Filariasis, in and around Madras, culminated in the discovery' of
the "adhesive phenomenon “ in 1929 in individuals suffering from Filariasis. This test
was confirmed by Japanese and American scientist nearly 35 years later. His peliminary
studies on “Endemic Fluorosis” and its association with high fluoride content in the
drinking water published in 1940 initiated further studies in this field. He was the
recipient of National and International awards. He published his autobiography “ My
World of Preventive Medicine”. In recognition of his contributions to microbiology he
could justifiably be called "The Indian Microbe-hunter”.
Shambu Nath De (1915-1985 A.D.) completed his MBBS from Calcutta Medical College
and later his Ph. D. In London. He began research on Cholera in 1949 and discovered the
cholera exotoxin with an animal model in the ligated loop of a rabbit’s small intestine.
58
Dharmendra (1900 - 1991A.D.) was one of the most eminent leprologists in the world.
He was bom in Lahore and graduated in Medicine in 1928. He later took his Diploma in
Bacteriology from the London University and joined the Calcutta School of Tropical
Medicine in 1933. For the next 22 years, he was involved in various research projects on
Leprosy. In 1957, he was appointed as the Director of Central Leprosy Teaching and
Research Institute (CLTRI) at Chingleput, Madras, which post he held till his retirement
in 1966. His contributions to leprosy research eventually culminated in his well known
skin test with an antigen prepared by him, which was later known as "Dharmendra
Lepromin" test. He published books on various aspects of Leprosy. For his outstanding
contribution to Leprosy, National and International awards were bestowed upon him.
Several viruses are now implicated as etiological agents in Oncogenesis: but the first to
draw attention to the association of viruses and malignancy were Ellerman and Bang in
1908. tlrrough their tissue culture technique. Peyton Rous in 1911, discovered filterable
Sarcoma in fowls which was a prelude to the discovery of viruses. It is of interest to note
that he received the Nobel Prize as late as 55 years later [ 1966 J - a world record for the
longest period taken by a scientist to achieve 'recognition’. With the discovery of
electron microscope by Knoll and Ruska, viruses could be visualized, resulting in rapid
advances in viral diseases and their pathology. Twort, in 1915 and D’Herelle, in 1917,
independently discovered a lytic agent of bacteria which was subsequently known as “
Bacteriophage”.
REFERENCES:
i)
Krumbhaar, E.B.: Pathology, Hafner Publishing Co., New York, 1962
ii) Turnbull, W. And Rothchild B.: “Tell Tale Bones”, SPAN. January, 1990
iii) Bhende. Y.M., Deodhare, S.G., Kelkar, S.S. General Pathology; Scientific Study of
Diseases,Popular Prakashan Publishers, 1969.
iv) Ananthanarayan, R and Paniker, J.C.K. Text Book of Microbiology “ Historical
introduction”, published by Orient Longman Ltd., 160 Anna Salai, Madras - 600002.
Edition. 4, 1990.
v)
Roitt. I.M., Essential Immunology, Blackwell Scientific Publication, edition 5, 1984
vi) Lutzeker, Edythe: Haffkine Institute, 1890-1974, Platinum Jubliee Commeration
Volume, published by Haffkine Institute, Parel, Bombay- 400 012
vii) Bhende, Y'.M.: Personal Communication, 1993.
viii) Desikan, K.V., “ Obituary' - Dr. Dharmendra”, Indian J Med Res (A) 93, May 1991.
59
CHAPTER 11: DRUGS
A drug is defined as any substance or product that is used or intended to be used to
modify or explore physiological systems or pathological states for the benefit of the
recipient. Drugs in the distant past were generally of herbal or animal origin. Heavy
metals and their salts, though sparingly used, were also included in the ancient
physicians's armamentarium. With advances in chemistry, specially during the last two
centuries, various chemicals were introduced as drugs, and in this century many drugs
have been also synthesized in the laboratory. The spurt of progress in the search of
antibiotics and newer drugs began with the discovery of Penicillin. The antibacterial
activity of the fungus Penicillium notatum was accidentally discovered by Alexander
Fleming in 1928 . However, the use of mouldy bread as a home remedy for certain
ailments, was known to our ancestors many centuries ago, and was practiced by the
Mayans and others.
References to medications dating back to the Pre-Vedic period, 6000 years B.C. and even
earlier, are found in Hindu Mythology. It is believed that Lord Vishnu when approached
by the sages to provide relief for mankind's ailments, ordered the churning of the ocean
of milk with rhe aid of “Vasukis” and “Asuras”. Out came Dhanvantari with the
“Amrita” pot in his hand, a potion which could not only alleviate human suffering but
also bestow immortality upon the consumer.
In the Siddha System of Medicine which dates back to almost 5000 B.C., there are
references to medicinal preparations of plant, animal and mineral origin. Fruits such as
the lemon and leaves of certain plants, were frequently prescribed becuse of their
medicinal properties, such as Margosa leaves for Small-pox. Similarly, in Ayurvedic
Medicine, drugs, of vegetable origin (fruits, leaves, bark and roots), of animal origin, and
minerals such as gold, copper, iron, are available. In the Charaka Samhita 2000 such
drugs are included. A few such ancient drugs are still in use in modern medicine in their
refined form; the well known examples being Quinine from Cinchona bark, Reserpine
from Rauwolfia and Bromhexine from Adathoda vascica.
Nagaijuna lived some time during the period 100 B.C.- 100 A.D.: he was a great
alchemist and was later known as the “Father of Indian Chemistry”. He was the first to
use metal oxides, black sulphide of Mercury (Kajjali) and other Mercury preparations in
medicine.
Bhava Mishra ( 1600 A.D.), the author of “Bhava Prakasha” makes a mention of drugs
brought from outside India after his contact with the Portuguese, who came here as
traders.
60
Sumerian and Babylonian Medicine is nearly 5000 years old. Mesopotamian physicians
used drugs of herbal origin, such as Hyoscyainus, Hemp, Mandrake, Opium, Belladonna,
etc., besides those of mineral and animal origin. “Assyrian herbal", a document written
on clay tablets in cuneiform script, from King Ashurbanipal’s library, was deciphered by
Thompson. In this document he has reported 250 drugs of vegetable, and 120 of animal
origin.
Ancient Egyptian Medicine was equally advanced, and dates back to nearly 3000 B.C.
Their custom of mummification of bodies, a few of which are fairly well preserved,
offers ample proof of their thorough knowledge of preservatives. The Egyptian “Papyrus
of Ebers”, probably written in the 16th centuiy B.C. in hieroglyphs and cuneiforms,
deciphered later by Prof. Ebers in 1873 is a medical compilation now considered a
classic. Many prescriptions mentioned in this document date back to 3000-2500 B.C.
Ancient Chinese Medicine is perhaps as old as Indian and Egyptian medicine. It,
however, remained unknown to the rest of the world for a long time due to the physical
isolation of the country. According to ancient Chinese medical theory, diseases are due
to the imbalance between the “Fang” (male) and the “Yin” (female) principle. Drugs are
classified on this basis; stimulants, resolvents, expectorants, etc, belong to the Yang
group and astringents, purgatives, bitter substances, etc. to the Yin group. Chinese
pharmacology is essentially of herbal origin. The great herbal “Pentsao Kang Mu”
written by Shen Nung probably in the 16th century B.C., contains 1,892 remedies and
1000 prescriptions. Out of the 365 drugs mentioned in this document, 240 are of
vegetable origin. From this Chinese classic, it is evident that they had a thorough
knowledge of the medicinal properties of plants and vegetables.
Ancient Egyptian and Mesopotamian Medicine obviously had a certain amount of
influence of early Greek Medicine. Greek Medicine and its influence extended over a
period of a millennium, from the time of Hippocrates to 500 A.D. This was followed by
the Medieval period from 500-1500 A.D. which was generally a period of stagnation and
decline.
Chemistry was well advanced in Arabia, - in fact, some of the words used in chemistry
eg. alchemy, alcohol, alkali and aldehyde are of Arabic origin. Jabir who lived some time
in 900 A.D. tried to convert lesser metals into gold and silver by alchemy and hence was
known as the “Father of Arabian Alchemy”. Arabs introduced new drugs such as senna,
camphor, sandalwood, cassia, tamarind, nutmeg, cloves, aconite and mercury. Solvents
such as rose water, orange water and tragacanth were also known those days. Arabs were
aware of the anaesthetic effect of Cannabis indica and Hyocymus.
61
Ths period of the Renaissance (1500-1700 A.D.) saw a resurgence of scientific curiosity
leading to renewed research in various fields including chemistry, which, in turn,
contributed to advances in medicine. Perhaps the greatest medical personality of the
period was Paracelsus. He introduced powdered tin as an antihelminthic and used
mercury, antimony, zinc and their salts as medicines. He also advocated the use of pure
chemicals for specific diseases. Tills practice led to the birth of rational medicine.
Louis Pasteur (1822-1895 A.D.), the chemist-nimed-microbiologist, applied his
knowledge of microbes to the process of fermentation and brought about a great
improvement in wine production. His subsequent work on Anthrax in animals, and
Chicken Cholera, led to the development of vaccines and antitoxins. With this discover}'
new biological products were introduced as remedies. The outstanding example is the
Rabies vaccine that Pasteur gave to the world, which has saved thousands of lives. By the
end of the 19th century the “Germ theory” of many diseases became an established fact,
and the search for more specific medicines was intensified.
At the dawn of the Twentieth Century, the science of chemistry was making rapid
advances, specially on the European continent. During this period the name of Paul
Ehrlich (1854-1915 A.D.) looms large on the horizon of the medical world for his
outstanding contributions in Chemotherapy. He and his Japanese assistant Sahachiro
Hata, in 1910, discovered “Salvarsan” ( Agent 606), an anti-syphilitic arsenical
compound. Later, he and lais associate synthesized “Neosalvarsan” which was extensively
used in the treatment of Syphilis until the advent of Penicillin. Ehrlich may thus be
regarded as the “Father of Modern Chemotherapy “.
In the first three decades of the present century, many chemotherapeutic substances were
in use as drugs. One such drug was Quinine, which was then the only drug effective
against malarial parasites. In 1677 Cinchona bark was found effective in fever associated
with a feeling of “cold” and “shivering”. However, the quinine alkaloid was isolated
from Cinchona in 1820 by Polletier and Couventou and its use as a specific therapeutic
agent in Malaria was appreciated thereafter.
Gerhard Domagk (1895-1964 A.D.) in 1935, synthesized Prontosil with anti-bacterial
properties. Following this discoveiy several other drugs with the sulfa radical were
synthesized, tested for their anti-bacterial activity and toxicity, and made available to the
medical profession.
The history of antibiotics is comparatively of recent origin. In 1899 Emmerich and his
colleagues isolated a pigment, Pyocyanin, a bactericidal substance from Pseudomonas
aeroeinosa. The next outstanding contribution was the dramatic discovery of Penicillin
by Alexander Fleming (1881-1955 A.D.) in the laboratory of StMary’s Hospital in
London in 1928. He noticed that a mould which had accidentally contaminated a culture
62
of Staphylococci, inhibited the growth of this micro organism. To Iris surprise, he found
that the same mould had similar effect on other pyogenic organisms. The significance of
this discovery’, however, was not understood till 1939, when scientists at the Sir William
Dunn School of Pathology, Oxford, applied their minds to the study of this substance.
With the outbreak of World War II, the need for antibiotics to treat wounded soldiers
increased and hence research was directed towards manufacturing large amounts of
Penicillin. Howard Florey and Ernst Boris Chain were already experimenting with
Penicillin at Oxford. Their observations were released to the scientific world through The
Lancet, dated August 24, 1940 . They then went to Peoria in the USA to produce large
amounts of Penicillin for clinical trials. By 1944, large amounts of the drug were being
manufactured. Thus, the development of this drug was largely due to a war; like many of
the surgical skills developed in the middle ages. Florey, Chain and Fleming shared the
Nobel Prize for medicine in 1945.
In 1943, Selman A. Waksman [1888-1973 A.D.] isolated a strain of Streptomyces griseus
which produced an antibiotic which he named “Streptomycin” . This antibiotic had a
bacteriostatic effect on Mycobacterium tuberculosis and proved to be a great boon to
patients suffering from Tuberculosis. For this, he was awarded the Nobel Prize in 1952.
After 1947 many broad spectrum antibiotics have been synthesized in laboratories for
human use including Chloramphenicol and the Tetracyclines. Amongst the latest
additions to the ever lengthening list is Moxalactan.
Equally fascinating is the story’ of insulin. Frederick Banting was a young Canadian
Orthopaedic Surgeon who , having failed in liis practice at the age of 30. decided to carry
out research in Diabetes at the University of Toronto. He worked along with a graduate
medical student, Charles FI. Best and later Collip. Based on a grant of a hundred dollars
and ten dogs, these three men - who were most unqualified for the job - managed to
solve a problem which even the experts could not solve. They were given eight weeks to
discover the cause of the disease. Since John J R McLeod [ 1876 - 1935 A.D. ] the
Professor of Physiology was on leave in Europe, they' decided to work on, - and were
successful. The Nobel Prize in Medicine was awarded to Banting [ who shared it with
Best] and McLeod [ who in turn shared it with Collip] in 1923.
ANTIHYPERTENSIVES - A STRANGE CASE OF NEGLECT
The initial step in the elaboration of antihypertensive agents was the work by Sir Henry'
Dale (1906) and Burn and Dale (1914), who showed that Ergot contained vaso-active
substances, and that tetra-ethyl ammonium chloride compounds blocked autonomic
ganglia and decreased the blood pressure. Dale showed the action of Acetylcholine and
was awarded the Nobel Prize in Medicine in 1936. Quarternary ammonium compounds
were nor greeted very' enthusiastically as the blockade of both Parasympathetic and
Sympathetic Systems led to what was humourously called “ The Hexamethonium Man”,
who was deprived of Iris important and enjoyable functions.
63
In the early 1930s attempts were made to decrease blood pressure with Thiocyanate.
Alfred Adson performed anterior nerve root section known as ‘Surgical Mayhem”. The
operation did not decrease the BP but miraculously reversed the malignant syndrome in a
few. The other treatment then available was a salt restricted diet, rest, abstinence from
smoking, and strangely, tonsillectomy ! Headache was treated with nitrites, catharsis and
hot mustard foot baths: if the headache persisted, lumbar puncture was resorted to.
THE GOLDEN AGE - 1950s AND EARLY 1960s
The ami-hypertensive effect of Rauwolfia serpentina has been recognized in Indian as
early 1918, and was conclusively demonstrated by Rustom J. Vakil in 1949. But
Reserpine was isolated only in 1954 by Muller Schlittler and Bein (CIBA). The discover}'
of Alpha-methyl dopa (1955-Merck) and Sodium nitroprusside (1956-Roche) soon
followed.
A major breakthrough in the chemotherapy of Hypertension came with the Thiazide
diuretics, Chlorothiazide (1957-Novella and Sprague-Merck), and Dihydrochlorothiazide
(1958-CIBA). The 1960s and 70s brought Spironolactone, Clonidine, Pronetholol and
Captopril in quick succession.
Another significant advance was the demonstration by Powell and Slater of Eli Lilly and
Company, that a dichloro analogue of isoproterenol blocked the inhibitor}' but not the
excitatory effects of sympathomimetic amines. Studies by Moran and Perkins showed
selective blocking of the positive inotropic and chronotropic effects of adrenergic
stimuli, and it was left to Black and Stephenson of Imperial Chemical Laboratories to
introduce the beta-receptor blocking compound, the Pronetholol. This drug was the first
of a large and important group of anti-hypertensive agents that were synthesized and
continue to be synthesized by the dynamic pharmaceutical industry. The role of
pharmaceutical companies in promoting research on antihypertensive drugs was, and
continues to be impressive. Most of the drugs came into being, as a result of the
industry’s early recognition of the importance of drug therapy for hypertension.
Cancer Chemotherapy is another field where medicine has made great advances.
Although cancer is far from being conquered, there are today, cancers which are
potentially curable - a statement that could not be made about 30 years ago. In fact, even
the first edition of Goodman and Gilman’s textbook of pharmacology made no mention
of Cancer Chemotherapy. Ironically, these same authors later described drugs for the
treatment of Cancer. - Mustard gas for Leukaemia, in the 1950s.
The team formed by George Hitchings and Gertrude Elion made great advances as they
isolated 6-mercaptopurine and thioguanine for the treatment of Leukaemia. They also
64
isolated pyrimethamine as an antimalarial and azathioprine for organ transplants and
allopurinol for Gout. Hitchings and Elion shared the Nobel Prize for medicine in 1988 for
their discoveries in Chemotherapy. Sir James Black was the third person who shared the
prize with them. Black had isolated Propranalol in 1964. In 1972. his research led to the
discovery of Cimetidine or the H2 antagonist drugs. He was the Director of Therapeutic
Research at the Wellcome Research Laboratory from 1978 to 1984. Thus, it can be
stated, without exaggeration, that two of the most commonly used dmgs at present came
from the laboratory and scientific genius, of one man.
Cancers that can now be controlled include the non-Hodgkin’s Lymphomas, Hodgkin’s
Disease, Germ Cell Tumours and Choriocarcinoma. Antifolate drags, used for
Choriocarcinoma were based on the work done by Subba Row.
Indians have also contributed in a small way to the therapeutic measures that a modem
physician now possesses. Rauwolfia serpentina was known to the ancient Indians and
used in Unani medicine by Hakims Ajmal Hussain and Jamal as a cure for insanity [
hence called ' puglee ka davaa ‘ ]. Another example of a herbal remedy which has found
its way into modem allopathic medicine (the other being Digitalis) is Reserpine which
was introduced by Rustom Jal Vakil after a careful study which was published in the
British Heart Journal in 1949. Suffice it to say that as recently as 1988, Krikler wrote
“no other paper has had such a great impact on the management of hypertension” . Vakil
was a popular professor and Cardiologist at the K.E.M. Hospital, Bombay and in 1957
was awarded the Albert Lasker Award for Medical Research. He was the first Asian to
receive this award. He was also the recipient of the Magsaysay and other Indian awards
for his contributions to Medicine.
Sir Upendranath Bannerjee (1875-1948 A.D.) who taught medicine at different medical
colleges in Calcutta is known for his discovery of the use of Ureastibamine for the
treatment of Kala Azar. He also performed research on Infantile Biliary Cirrhosis.
Another well known name in pharmaceutical research is that of Yellapragada Subba Row
(1895-1948 A.D.). Row isolated an antibiotic Aureomycin as well as folic acid and his
work led to the discovery of antifolates. He also isolated Vitamin B12 from the liver but
did not specifically identify it. He devised the colorimetric method for determining the
amount of phosphorous in body fluids and co-discovered phosphocreatine and ATP .
Even a brief History of Pharmacology will be incomplete without the mention of the
“Thalidomide Tragedy”. Thalidomide was introduced in Germany in 1958 as a sedative
and hypnotic and was widely used until 1961 when it was realized that Thalidomide
caused congenital anomalies in children born of women who had taken the drug during
pregnancy. The abnormalities included Cardiovascular Anomalies. Neuropathies and the
one which was most striking and crippling - Phocomelia, - failure of development of
arms and legs. It must be stated that Frances Kelsey who was in the Food and Drugs
55
Administration Office of the USA was never convinced of the safety of this drug and
hence did not grant the drug a license in the USA. President Kennedy awarded her the
Congressional medal for Bravery in 1962 for her act.
REFERENCES:
i)
Krikler D M. Natl Med J India 1989,1:210-216.
ii) Mellin G W, Katzenstein M. The Saga of Thalidomide. New Engl J Med 1962, 267:
1184-1193.
iii) Mellin G W, Katzenstein M. The Saga of Thalidomide. New Engl J Med 1962, 267:
1238-1244
iv) Page, I FI: Hypertension - A Strange Case of Neglect, J.A.M.A. 1976, 235: 809-10.
v)
Page, I.H.: Antihypertensive Drugs: Our Debt to Industrial Chemists - New England
Journal of Medicine 1981, 304: 615-618.
vi) Weatherall, M. In Search of a Cure. Oxford, 1990
vii) Kothare, S N. Drugs and Antibiotics. Physician’s Update 1988, 1(3): 127-129.
Rego,
viii)
179.
Anne and Kothare, S N. Hypertension. Physician’s Update 1988, 1(4) :177-
66
CHAPTER 12 : SWEET SLUMBER
The importance of developing painless surgery is obvious. For centuries, people were
terrified of surgery because of the immense and torturous pain that they had to undergo.
The quest for an agent that blocked pain is centuries old. Pundit Ballala has mentioned in
"Bhoj Prabhandd' (980 A.D.) that Raja Bhoja’s skull was trephined under the influence
of some plant “ Sammohini”, as an anaesthetic. The same was also applied as a healing
balm to surgical wounds. A drug called “Sanjivani “ was administered to revive him and
help him regain consciousness. The ancient Chinese used opium as a means of stopping
pain. The Egyptians beleived that Mandragora [ Mandrake ] was a gift of Ra, the Sun
God. Both Mandragora, as well as opium have been mentioned by William Shakespeare
in his plays as substances which can induce painlessness. Hashish also was a popular
agent for the purpose of relieving pain in ancient times.
Pedanios Dioskorides who lived during the first century, having noted the soporific effect
of Opium and Mandragora, was possibly the first Greek to use the word Anaesthesia.
Through his travels with Roman armies he collected information on the medicinal
properties of herbs, plants, fruits, metals and animal substances. He wrote his famous
book on this subject in 77A.D. Hua T’o (190 A.D.) employed anesthesia during surgical
procedures. It was probably Cannabis indica mixed with wine.
Theodoric De Lucea (1205 - 1298 A.D.), an Italian practitioner, used a sponge soaked in
hot water and a mixture of Mandrake with Opium in difficult surgery. Valerius Cordus
and Paracelsus synthesized Ether in 1544 but its properties were not known then. In 1776
Joseph Priestley prepared Nitrous Oxide. However it was Humphrey Davy, in 1800 who
had noted that his headache had disappear ed with the use of this gas . He then suggested
the use of Nitrous Oxide as an anaesthetic and also coined the term ''laughing gas”. The
suggestion, was however not taken up seriously.
Michael Faraday (1791-1867 A.D.) some time in 1816, noted the anaesthetic effect of
Ether. William E. Clerk, a chemistry student in Rochester, United States of America, in
January 1842, used Ether as an anaesthetic. Earlier he and his friends indulged in “Ether
Frolica” by inhaling Ether and getting “high”.
Il can be stated without fear of contradiction that few events in medicine have been
shrouded in as much controversy as the discovery of anaesthesia. The individuals
concerned in this sad story are the following; Crawford William Long, Horace Wells,
William Thomas Green Morton, Charles Jackson.
67
Crawford Williamson Long was the first to use Ether as an anaesthetic in Jefferson,
Georgia, in the year 1842. He first used it to excise two tumours from the neck of a
patient named James Venable. Following this, he used it successfully for thousands of
operations including amputations of the fingers and toes over the next few years.
Unfortunately, he did not choose to either publish or publicise the matter until almost
1849, when other people had also discovered the process of painless surgery. In fact, he
was practically forced by his friends to stake his claim as the true discoverer of
anaesthesia when William Morton applied to the American Congress for a reward for
having discovered anaesthesia. Long was never given the credit for the development of
anaesthesia. He died a disappointed man in 1878. The maimer in which he died was
appropriate for a pioneer of anaesthesia. Moments after having delivered a baby from a
woman who had just been given Ether to relieve the pain of labour, Long had a stroke
and became unconscious. He died a few hours later, unaware that his last conscious act
was obstetric analgesia.
Gardner Quincy Colton had a travelling show in which he showed audiences the pleasure
of using Nitrous Oxide as a laughing gas. Horace Wells, a dentist in the audience in
Hartford, Connecticut, on 10th December 1844 noticed that one of the volunteers
appeared to feel no pain inspite of having injured himself. He then introduced Nitrous
Oxide as an anaesthetic in his Dental practice. In the true spirit of the pioneers, he
experimented on himself and found that it succeeded in making tooth extraction painless.
He discussed this with his student William Green Morton, who in turn mentioned it to his
colleague, Charles T Jackson. Unfortunately Wells’ first public demonstration in the
lecture room of Dr John Collins Warren at Cambridge College, Massachussets, was
deemed a failure, with the result that it went into obscurity for a long time. The
unfortunate truth is that the man rendering the anaesthetic agent had probably given less
than was required, with the result that the patient felt a little pain - though not as much as
was usually felt. The damage was, however, done and Wells was denounced and the
entire process was called “humbug”. William Thomas Green Morton experimented with
Ether as an anaesthetic in his surgical practice and discovered its anaesthetic effects. On
16th October 1846, he used it sucessfnlly during an operation on Gilbert Abbot, a young
man with a tumour at the angle of the jaw. The surgery was performed by Dr Warren who
later remarked “ Gentlemen, this is no humbug. “ hi the meanwhile, a frustrated Wells
continued to use anaesthesia for surgery. In 1847, in Paris, he met C Starr Brewster who
sympathized with him and tried to help him. The Paris Medical Institute had already
given financial aid and recognition to Jackson and Morton for their alleged discovery of
anaesthesia. The newspapers too treated Wells kindly and considered him a pioneer. But
in America, the rivalry between Jackson and Morton , compounded by the challenge of
Chloroform anaesthesia, discovered by Simpson, led him to despair. In 1848, Wells
anaesthesised himself with Chloroform and slashed his Femoral artery with a razor. A
few days later, a letter from Brewster reached lais house intimating that the Paris Medical
Institute had, on deliberation, decided that it was Wells who deserved the credit for the
discovery of anaesthesia.
68
Charles Thomas Jackson was an eccentric charlatan. He claimed to have discovered the
telegraph before Samuel Morse, gun cotton before Schonbein and probably tried to steal
material [ gastric juice ] from William Beaumont if he had had the opportunity. His claim
that he had discovered anaesthesia is not very strong. Jackson, a chemist, had actually
been consulted by Morton because his own [ Morton’s ] concepts of chemistry' were not
very clear. After the Paris Medical Instutute initially gave him credit for the discovery, it
was withdrawn. Jackson spent the rest of his life trying to get recognition and died insane
in an asylum in 1880.
Sir James Young Simpson of Edinburgh used Ether in Obstetric practice in 1847 and also
tried Chloroform as an anaesthetic and found it was a better agent. The first professional
anaesthetist was John Snow of London who had tire privilege of administering
Chloroform to Queen Victoria on two occasions. John Snow is also well known for
having proved that the spread of Cholera in Broad Street in London was due to
contamination of the water supply. He removed the handle of the pump , thereby
preventing people from using it - and thus limited the further spread of the epidemic.
This again, is one of the earliest known examples of preventive medicine.
Joseph Thomas Clover (1825 - 1882 A.D.), in England, invented a device, the
Chloroform Inhaler, for the administration of anaesthesia. Albert Niehann of Germany, in
1860, isolated the alkaloid of Cocaine from the Peruvian Coca leaves; its anaesthetic
property' was demonstrated by Alexander Bennet in 1873. Karl Koller, in 1884
recommended the use of Cocaine as a local anaesthetic and used it in his Ophthalmic
practice with success. Sigmund Freud also was an enthusiastic user of Cocaine for
anaesthetic purposes.
Between 1884 and 1899 the names of Corning Quinicke and Bier were associated with
the discovery of spinal anaesthesia and its advance. It was Dogliotic who popularized
lumbar, epidural and caudal anaesthesia.
For the first time intra-tracheal intubation was carried out by Macewan, O'Dwyer and
Kulm. Ivan Magill (1888- 1986 A.D.), the most distinguished pioneer of endotracheal
intubation, had many innovations to his credit such as Magill’s Endotracheal tube,
Laryngoscope, Endobronchial tube, etc. Ralph Water (1883-1979 A.D.) has been
considered as the “Founder Father of Academic Anaesthesiology”
The first to employ mesmerism to relieve pain in surgical procedures was Jules Cloquet,
a French surgeon, some time between 1776-1780. James Esdaile, a medical officer with
East Indian Company, tried mesmerism as an anaesthetic and it is reported he carried out
261 painless operations under mesmerism.
69
With the turn of the Twentieth Century, mechanical devices were introduced to
administer anaesthesia in America and Germany. Later several modifications were
introduced; some of the more sophisticated ones were introduced by Druegar and Sons.
The most widely used machine has been designed by Robert Boyle, which is currently
used widely.
REFERENCES:
i)
Bhatia. Maj. Gen. S.L.: Surgery in Ancient India - A lecture. Personal
communication. 1980.
ii) Barash. P.G. Cullen, B.F. and Stoelting, R.K.: Clinical Anaesthesia : Publisher
Lippincott. 1989.
iii) Ylie and Churchill-David : A Practice of Anaesthesia, published by P.GI. publishing
Pvt Ltd., Asian Economy Edition, Singapore, Hong Kong, New Delhi, 1986
70
CHAPTER 13: THE ROMANCE OF SURGERY
“Surgery is the first and the highest division of the healing art, pure in itself, perpetual in
its applicability, a working product of heaven and sure of fame on earth” - Sushruta (400
B.C.)
Through the study of paleopathology and recover}' of bones of prehistoric man. it is
evident that diseases similar to those of the present time, were also prevalent. There is
ample proof from recovered skulls that different methods were employed in trephining as
treatment for headaches, epilepsy, etc. The purpose was to permit the “devil” causing the
disease to escape. Surgical instruments were made of sharpened stones and flint. Further
knowledge on the subject of surgery is derived from scripts written during respective
periods. Surgery', however, was practised in a very limited maimer. During the Roman
period, frequent wars gave an impetus to war surgery, particularly to Trauma Surgery'.
ANCIENT TIMES
Tire Egyptian practice of embalming or mummifying the body contributed to a certain
extent, to the knowledge of anatomy, surgery and bandaging. Among the ancient
Egyptians , circumcision of males was practiced as early as 5000 B.C. Tills was the
archaeological finding of Eliot Smith, in excavations of the preliistorical cemetery of
Naga-adder. Circumcision of the prepuce of the clitoris in females was also practised.
The Edwin Smith Papyrus is a surgical treatise probably written some time between
3000-2500 B.C., It is, surprisingly, the most important and complete treatise on Surgery'
in ancient Egypt. It dealt essentially with traumatic surgery'. The most important surgical
instrument of that time was the knife made of stone. By 1600 B.C., it was made of bronze
and iron.
Tire Ebers Papyrus of Egyptian Medicine dates back to 1500 B.C. Its surgical section
dealt with treatment of Carbuncles, Cutaneous tumours, Hernia, Hydrocele etc. Cautery
was also used for checking excessive bleeding during operations.
In ancient India , advances in surgery' took place through wars and battle wounds. Aryans
used their knowledge of herbal, mineral and other drugs effectively besides their surgical
skill. It is believed that Visapala, a woman related to Raja Chola, accompanied him into
the banle field and lost a leg. The Vedic surgeons Aswinis fitted her with an artificial leg.
Also described in Rig Veda as the legend has it, that Raja Bhoja’s (980 A.D.) skull was
trephined to relieve him of his severe headache and to remove the malignant portion of
the brain. After the surgical procedure, the Raja was cured of the pain. The contribution
of Sushruta has been discussed in the chapter on Pioneers.
In Ancient China, surgery' was practised in a very' limited manner. Hua T’o (190 A.D.)
has been quoted in ancient Chinese medical scripts as the leading surgeon. In order to
produce eunuchs for tire Imperial Court, castration with amputation of the penis was
71
performed prior to 1000 B.C. Chinese surgery apparently made no progress after the
advent of the Tang dynasty (619-907 A.D.) due to strong prejudices.
hi ancient Greek Medicine, reference is made to surgeons in one of the Homeric poems
written some time 1000 B.C. Therein, it is stated “One surgeon was worth an army of
men" recognizing the value of a surgeon during frequent wars that raged those days. It
was also believed that Hippocrates found in surgery, rational methods of treating certain
diseases.
MEDIEVAL TIMES
Albucasis. an Arab, was bom in Spain in the Tenth Century. In ancient Arabic medicine
he has been hailed as an outstanding physician and an able surgeon. With special
instruments devised by him, he removed polyps and tonsils; he frequently used branding
iron and cautery in his surgical practice. He also described obstetric instruments.
Roger Frugardi of Salerno wrote the first Western book on Surgery' in the year 1170; later
it was re-edited by his student Ronald of Parma. Roger recommended oral administration
of seaweed ashes for Goitre, not unlike the present day iodine therapy. His surgical skill
was exhibited in his technique in suturing severed intestines together over an elderwood
tube or an animal trachea.
Theodoric de Lucea (1205-1248 A.D.) postulated scrupulous cleanliness in surgical
procedures as the basis of success. Lanfrane, an Italian by birth, was educated in Milan:
he subsequently moved to Paris and settled down in practice as a surgeon. He spread the
Italian gospel of “healing wounds by first intention” some time in 1295.
In England, Jolm of Arderne (1307-1390 A.D.) established himself as a reputed surgeon
and later by 1376 became the pioneer proctologist. He wrote a treatise on Fistula-in-ano
and the use of rectal injections. He described his famous operation for Haemorrhoids the excision of the thrombosed vein. He also advised rectal examination to differentiate
between fistula-in-ano and anal cancer; the latter having a stony hard feel to the
examining finger.
Guy de Chauliac (1300- 1367 A.D.), a renowned French surgeon, in his book “Chirurgia
magna” stipulated the qualities of a good surgeon. To quote : “ A good surgeon should be
acquainted with liberal studies, with medicine and above all with anatomy; he should be
courteous; bold in security, pious and merciful, not greedy of gain, but looking for his fee
in moderation, according to the extent of his services”. These lines hold as true today as
they did 600 years ago.
72
SURGERY OF THE RENAISSANCE AND POST-RENAISSANCE PERIOD
With The discovery of the gun powder in the Fifteenth Centun' and the use of the
explosives in war weapons, extensive soft tissue injuries and fractures of bones became
quite common. The nature and severity' of wounds called for dexterity on the part of the
medical personnel and ingenuity for improvisation. In fact war-time was a boon for
surgeons with skill and intelligence. Amongst these surgeons, Ambroise Pare (1510-1590
A.D.), a field surgeon became an outstanding surgeon of the Sixteenth Century and
indeed, one of the greatest of all time. He wrote extensively on gun shot wounds and
published a treatise in 1545. He advocated the use of ligatures to control bleeding and a
limited use of cautery in amputation. He is well known for showing that a mixture of
eggs, oil of roses and turpentine gave better results than boiling oil in gun-powder
wounds - a serendipitous discovery' made due to the lack of oil. It is said that on the battle
field Pare was considered equivalent to 10,000 men because soldiers believed that with
Pare around, their chance of survival was the greatest. Fie w'as a “Barber Surgeon” but his
skill and achievements were better than the so-called surgeons of those days. He was
grudgingly admitted to the College de St Come despite the fact that he did not know
Latin. Pare abolished the common procedure of castration during herniotomy and also
invented the artery' forceps. He is thus considered the ‘Father of Surgery’’. Pare is best
known for his statement “ I dressed him, God cured him “ , a statement that shows the
humility of the man and serves as a lesson to surgeons of all ages.
SURGERY DURING THE SEVENTEENTH, EIGHTEENTH AND NINETEENTH
CENTURY
In the Seventeenth Century in England, Surgery was in the hands of “Barber Surgeons”.
They carried out both simple procedures like pulling out a painful tooth as well as a
complicated operation such as amputation of the leg. For anaesthesia, they made the
patient unconscious by giving him a knock on the head with a wooden hammer. During
the Eighteenth Century several British men of Medicine contributed to the advancement
of Surgery. Only a few of these are mentioned here due to limitations of space.
Percival Pott (1713 -1788 A.D.) was famous for his treatise on wounds, fracmres and
dislocations and less known for his work on Hydrocele and Cataract. Sir Percival
himself had a fall on London Bridge and fractured his tibia [ Note that this is not Pott’s
fracture ]. The story' goes that Pott refused to be treated at his own hospital,
St.Bartholomew’s , saying that the only good surgeon there had injured himself and was
not in a position to heal others. He used the door of the nearest house as a splint and w'ent
to Guy’s Hospital for treatment. Pott however, is remembered for olherobservations such
as his description of Tuberculosis of the Spine (Pott’s Spine) and more importantly his
observation of Carcinoma of the Scrotum in chimney' sweeps. Poti realised that this
devastating disease was caused by the soot remaining in contact with the skin, (the young
boys had to climb naked into the chimneys) and described a simple cure - a daily bath.
This not only marks the beginning of concept of occupational disease, but also of
73
preventive medicine. Two hundred years later, the age of specialisation has termed this
field Preventive Oncology.
John Hunter (1728-1793 A.D.), the brother of the Anatomist and Obstetrician William
Hunter, was a great surgeon and an experimentalist. It is said that it is he who found
surgery a mechanical art and introduced it as an experimental science. He proved the
existence of collateral circulation by his experiments on antlers of deer and made studies
in Comparative Anatomy, Botany and Zoology. Hunter, in 1767, inoculated himself on
his forearm with what he believed to be gonococcal pus to prove that Syphilis and
Gonorrhea were the same disease. His deductions were fallacious as the man from whom
he exrracted ihe pus had both the diseases. His experiment, however showed the
contagious nature of the disease. Hunter, as a result, is reported to have suffered from a
syphilitic affliction of the blood vessels for the rest of his life. In fact, he suffered from
Angina pectoris in his later years and always said “ My life is in the hands of any rascal
who chooses to annoy and rease me “ . Nevertheless this experiment led to the use of the
term “Hunterian Chancre”. Hunter died precisely as he had predicted, - he collapsed after
a heated discussion with someone, in a pub.
Astley Paston Cooper (1768-1841 A.D.) was a student of John Hunter. He had a passion
for Anatomy which brought him in touch with body snatchers through whom he obtained
bodies for dissections. Pie made London the surgical centre of the world in the early
Nineteenth Century. He was the first to ligate the abdominal aorta. He successfully
excised a lesion in 1820, probably a sebaceous cyst from the head of King George IV, for
which he was awarded a Baronetcy. The anatomy student would have heard of his name
in the ligaments of Cooper in the breast.
More or less at this point of time the use of Ether and Chloroform as anaesthetics turned
out to be a milestone in the development of complicated surgery'. With the improvement
of the technique of prolonged anaesthesis, surgeons resorted to more complicated
techniques, as the duration of the surgical operation was not any more an important
factor. However, deaths due to post-operative infections continued to be a major
obstacle.
James Syme (1799-1870 A.D.) was born in Edinburgh. He made several contributions to
the surgical literature including the Symes Amputation for the ankle joint. In 1823, in
Great Britain he was the first to perform a hip disarticulation. He was also probably the
first European surgeon to adopt ether anaesthesia and later, Lister’s antiseptic technique.
Joseph Lister , lais house-surgeon- and later, bis son- in- law , derived a lot of inspiration
from his illustrious teacher.
James Paget (1814-1899 A.D.) is associated with two conditions, Pagel’s disease of the
nipple and Paget’s disease of bones.
74
Il is said that the history of surgery may be divided into 2 parts - before and after Lister.
Lord Joseph Lister (1827-1912 A.D.) was a multifaceted individual. In the early part of
his career he described two distinct muscles in the iris of the eye, the dilator and the
sphincter, and also muscles attached to hair follicles. Contraction of these elevated the
hair, resulting in goose skin appearance. In Glasgow, as a Professor of Surgery, Lister
pondered over the fact that while simple fracures usually healed without problems, most
compound fractures got infected and led to the patient’s death. A professor of chemistry
named Thomas Anderson put him on the right track by introducing him to the papers of
Louis Pasteur. Pasteur had just shown that grape juice when exposed to air fermented,
due to the presence of some agent that fell from the air, leading to the formation of wine.
Extrapolating from this concept, Lister thought of the possibility of a similar agent falling
into the open wounds of a compound fracture and leading to the infection.
During his dialogues with others on this topic, Lister learned that the use of carbolic acid
(phenol) had destroyed the stench of the sewers in Carlisle. He then decided to
experiment with carbolic acid on a patient with a compound fracture. The first patient
died. However, his second patient survived, - practically a miracle in those days, - and
antiseptic surgery was born. Lister in a letter to his father in June 1866 wrote that he had
discovered “ one of the 10 most important things that have ever happened to the human
race”. He published his paper in the Lancet in March 1867 and later read it a British
Medical Association meeting - and was scoffed at. He also used the ‘donkey spray’ with
which carbolic acid was sprayed over the field of the operation in order to destroy the
microbes from the air during surgery. Lister stuck to his beliefs, and propogated them
strongly. Two events took place that aided him greatly. First, he successly drained an
abscess for Queen Victoria - using his antiseptic technique. Later, In the Franco Prussian war, surgeons made use of Lister’s antiseptic surgery - and saw a decrease in
the incidence of hospital gangrene. Lister also invented the sinus forceps, aortic
tourniquet, wire-needle and catgut ligature. In 1897, he was elevated to the Peerage as
Lord Lister for his surgical achievements.
A mention must be made of Lord Lister’s wife, Agnes. She typified the saying “ Behind
even' successful man. there is a woman”. Agnes not only supported her husband
throughout in his beliefs [ which were then controversial ], but directly played an
important role in his work. It was she who translated Pasteur’s work from French into
English for the benefit of her husband.
In Germany, Christian Albert Theodor Billroth (1829-1894 A.D.) was making a name for
liimsclf through his surgical skill, particularly of the gastro-intestinal tract. He, for the
first time, resected the oesophagus and also performed the first laryngectomy. In 1881,
he performed the first resection of the Pylorus for cancer. Besides his professional
achievements, he was also an excellent painist and a great friend and admirer of
Johannes Brahms.
75
Theodore Kocher (1841-1917 A.D.), a Swiss surgeon, was the first to surgically excise
the Thyroid gland as a means of treating Goitre, which was cosmetically disfiguring.
Kocher was the first surgeon to be awarded the Nobel Prize in Surgery' [ in 1909 ], an
award he richly deserved.
Paul Broca (1824-1880 A.D.) was a multifaceted individual who was a Neurosurgeon,
Orthopaedic surgeon, Neurologist and Anthropologist. He described the area 44a, also
called Broca’s area, which is the centre for articulate speech and was the first to use a
trephine to drain a brain abscess. He established scientific societies and built up a
medical museum and even became a senator in his later life. Ironically, this pioneer of
neurological sciences died of a burst aneurysm in the brain.
American surgeons have contributed in no small way to our knowledge of surgery.
William Steward Halsted ( 1852-1922 A.D.) has already been mentioned [ in the chapter
on Nurses ] as being responsible for the introduction of gloves. He also performed the
Radical Mastectomy as a treatment for Carcinoma of the Breast, an operation called “ the
Halsted” in his honour. Finally, it was he who first used Cocaine as a local anaesthetic.
Unfortunately, he also became a life-long addict to the same substance. The Mayo family
is known throughout the world for their surgical skill. The father, William Worell (18191911A.D.) founded the Mayo Clinic in Rochester, Minnesota while his sons Charles
Horace ( 1861- 1939 A.D.) and William James ( 1865-1939 A.D. ) founed the Mayo
Foundation for Medical Education and Research. Charles was renowned for his thyroid
surgery and William, for his gastric surgery.
At this time, Harvey Cushing (1869-1939 A.D.) was making news as a Neurosurgeon.
He published his observations on the role of the Pituitary' and Sexual Infantilism, which
was further supported by experimental work. His classic publication on “The Pituitary
body and its Disorders” in 1912 is a masterpiece of meticulous observations and their
correlations. He was a prolific writer and published interesting papers on History of
Medicine including a biography of his great teacher entitled “Life of Sir William Osler”.
Walter Dandy [ 1886-1946 A.D.] , also an American Neurosurgeon was responsible for
introducing Pneumoencephalography as well as surgery for prolapsed intervertebral
discs, aneriovertebral malformations and intracranial aneurysms. Sir Victor Horsley was
the first to operate on spinal cord tumours and for epilepsy.
Subsequently', surgery' made rapid strides in the latter half of the Nineteenth Century' and
the early pan of the Twentieth Century', consistent with rapid advances in basic sciences.
As a result, specialization in surgery was envisaged and introduced to improve the quality'
of surgical practice. The most outstanding surgical achievement in the latter half of the
Twentieth Century' is ’Transplant Surgery'’.
Attempts at transplant of the skin were made by Susliruta. In 303 A.D. the twin brothers,
Cosmos and Damian, physicians of Arab origin, amputated the leg of a Caucasian and
76
attempted to graft in its place the leg of a recently deceased Moor. John Hunter
successfully transplanted the spur on the cock’s comb. With this was reborn the concept
of transplants of tissues and organs. In 1905, organ transplant was attempted by Alexis
Carrel, a French surgeon, - an autotransplant of a dog kidney. Although the attempt was
unsuccessful, he was awarded the Nobel Prize in medicine in 1912 for this experiment.
The first heart transplant was performed by Christian Barnard of South Africa in the
Groot Shuur Hospital, Cape Town, on 3rd December, 1967. In India, the first heart
transplant was attempted at the King Edward Vn^ Memorial Hospital, Bombay on 16th
February7, 1968 by the late Prafulla Kumar Sen, who was then the Professor and Head of
the department of Cardio-thoracic Surgery. The first successful heart transplant in India
was performed by P Venugopal at the AHMS in 1994. Other organ transplants are being
undertaken such as that of kidney, lung, bone marrow etc. The first kidney transplant at
K.E.M. Hospital. Bombay was attempted in 1966. The first successfill renal transplant in
India was performed at Cliristian Medical college, Vellore in 1977 by Mohan Rau. Bone
marrow transplants are the only transplants that do not fall within the purveiw of the
surgeon. The first bone marrow transplant in India was done by a team of doctors at the
Tata Memorial Hospital in 1983. The patient, Vandana Kadam. who then had Acute
Myeloid Leukaemia is still alive and well. Subsequently, the Christian Medical College,
Vellore and the AHMS have started bone marrow transplants.
The Nobel Prize in Medicine is awarded to persons making a significant achievement or
advance in that field. It would be fitting to conclude this chapter by mentioning the
surgeons who have won this coveted prize. They are Theodore Kocher (1909 - for his
contributions ot Thyroid Surgery and Physiology), Allvar Gullstrand (1911- for his work
on Dioptrics, the science of refracted light of the eye), Alexis Carrel (1912- for Vascular
Surgery7 and Organ Transplantation), Robert Barany (1916 - for Physiology and Pathology7
of the Vestibular apparatus), Werner Forssmann (1956- for his contribution to Cardiac
Catheterization), Charles Huggins (1966 - for hormonal manipulation of Prostatic
Carcinoma as a means of palliating or curing patients) and Joseph Murray (1990 - for
Renal Transplantation). Other surgeons who have won the Prize for non-surgical work
are Sir Frederick Banting, Sir Alexander Fleming ( he had received his Primary FRCS in
1909) and Walter Hess (1949- for research on the interbrain).
77
REFERENCES:
i)
Bhatia. Maj. Gen.S.L.: Surgery in Ancient India - A Lecture: Personal
communication
ii)
Kothare, S.N.: Surgery in Ancient and Medieval Times St. John’s Medical College,
Jour. Med.: 4: 64, 1991
iii) Starzl, T.E.: personal reflections in Transplantation, The Surgical Clinics North
America, 58: 8/9, 1978,
iv) Sabiston, Jr. D.C.: text Book of Surgery, “ The Development of Surgery” By G.H.
Brieger, publisher, W.B. Saunders Cp., Philadephia, London, Toronto, Tokyo, 12th
edition, 1981.
v)
Sagan, Carl. Broca’s Brain. Coronet books, Hodder and Stoughton, Great Britain,
1980.
78
CHAPTER 14 : OBSTETRICS AND GYNAECOLOGY
Obstetrics deals with pregnancy and childbirth while Gynaecology is concerned with
diseases and treatment of the female reproductive and genital tract. The history of
Obstetrics and Gynaecology must, for obvious reasons be as old as man himself. In
ancient times, when all doctors were males, they were forbidden from witnessing
childbirth. 'Hie Kahun papyrus [ 2000 B.C. ] , the Papyrus of Ebers [ 1550 B.C ] as well
as Ayurvedic books [ 1200 - 500 B.C ] included gynaecologic diseases in their text.
Deliveries were, therefore performed by midwives and relatives.
The Lex Caesara, a law passed in the Seventh Century B.C. in Rome stated that all
pregnant dying women should have abdominal surgery done in order to deliver the baby,
hence the term “Caesarian” delivery. Much later, Ambroise Pare started a school for
midwives in Paris. Obstetrics, as we know it today, began some time in the Eighteenth
Century with the work done by William Smellie [ 1697-1763 A.D. ] . Smellie
established a school of midwifery’ in London in 1752 and wrote “ A treatise on the theory'
and practice of Midwifery “, which was one of the earliest books devoted to this subject.
One of his students was the elder brother of John Hunter, named William Hunter, who
also became a famous Obstetrician and Anatomist.
The most fascinating part of the history’ of obstetrics is the story of the forceps. The
forceps are a two- bladed instrument made of metal which acts as pincers and holds the
infants head during delivery. It was the invention of the Chamberlen family. The
Chamberlens were French Huguenots who fled France in 1569 to escape persecution.
Dr. William, the father settled down in Southampton and later, in London. His sons,
Peter, the elder and Peter, the younger were barber surgeons and obstetricians. One of
them, probably Peter the elder, invented the obstetric forceps, the instrument that helped
them perform many difficult deliveries and brought them fame. Both were, however,
prosecuted by the Royal College of Physicians for breaking its rules. The Chamberlens
kept their instrument a close secret. Indeed, they carried it in a huge box and used it only
when the woman was blindfolded. This enabled them from preventing others from seeing
what their ‘ magical' instrument looked like. Peter, the Younger, had a son, also named
Peter, who continued the family tradition and practised obstetrics. His son, Hugh,
decided to sell the family secret for a sum of money. He was asked to demonstrate the
efficacy of his instrument on a rachity dwarf. Naturally he failed to save the baby’ or the
mother, - and to sell his secret. He tried later to deceive the Dutch physician, Rogier Van
Roon Huyze into buying some secrets, which were in reality not those of the forceps. His
son, Hugh Jr. divulged the secret. In 1733, Edmund Chapman published the first detailed
account of the forceps and instructed physicians and midwives about its use. The
Chamberlen forceps was finally discovered in 1813 in the family home in Essex. The
Chamberlens have been criticised for having kept secret for centuries, an instrument
which would have saved many lives. It is however incorrect to pass judgement on
someone who lived 400 years ago, by applying today’s principles and ethics. The use of
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this instrument probably gave them the fame, the name and the money that they wanted.
In this context, it is worth remembering that Roentgen and Waksman refused to patent
their discoveries - X-rays and Streptomycin respectively - as they felt it should be
dedicated to mankind. Today, however, patenting a discovery is quite common and often
there seems to be a fine dividing line between pure science and business.
The greatest fear regarding childbirth was the development of Puerperal Fever, which
was often fatal. Ignaz Philipp Semmelweiss, (1818-1865 A.D.), was a Hungarian
physician. As a medical student he had noted that deaths of young mothers were due to
puerperal infection, then known as “childbed fever” .The death of his pathologist friend,
Jacob Kolletschka, from a wound infection acquired during the examination of a women
suffering from “childbed fever”, prompted him to surmise that infection to maternity
wards was spread by students and ward attendants through their contaminated hands. In
1846, he suggested simple measures such as the washing of hands with soap and water
and/or chlorinated water before attending to women in labour. With the introduction of
this simple practice, the morbidity and mortality rate fell dramatically. This simple
measure was subsequently quoted by Joseph Lister and was the basis of his concept of
prophylaxis of surgical wound infections with the use of antiseptics. Semmelweiss’ story'
, however, is one of the great tragedies of medicine. He was disbelieved by all and
sundry' and eventually fled the city. Much has been made of the ironic manner in winch
he is supposed to have died. Generations of medical students have been told that
Semmelweiss died of a septicaemia due to an accidental injury’ afflicted on himself
during an autopsy. In his splendid book “ Doctors” , Sherwin Nuland has re-examined
the evidence and questioned it. Based on the history' and notes of his last few’ days, it
now appears that Semmelweiss died of injuries inflicted on him by' the staff in the
asylum where he had been admitted.
The test tube baby is a recent development. Louise Brown was delivered in 1978 as the
w'orlds first test tube baby. The persons responsible for this w'ere Robert Edwards and
Patrick Steptoe. The word “test-tube” of course is colloquial for “ in vitro “ fertilisation,
wherin the sperm is allow'ed to fertilise the ovum in vitro, before it is placed into the
uterine cavity'.
The name of V N Shirodkar ( 1899- 1971 A.D.) stands supreme among internationally
known Indian obstetrician-gynaecologists. It was he who developed the Shirodkar suture.
a circumferential suture applied in the incompetent cervix of women who repeatedly
abort in the second trimester.
Diseases of the female genital tract have been known to exist right from the time of the
ancient Egyptians, the Old Testament and the early Greeks. The modern practice of
Gynaecology', however, started only in the early 19th century when it was separated from
general surgery' as a speciality. The first recorded case of gynaecologic surgery took place
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in 1S09 when Ephraim McDowell of Kentucky was called to deliver the 38 year old
Ms.Crawford of suspected twins. The “twins” however turned out to be a large ovarian
tumor. McDowell took the risk of performing the first ovariotomy without anaesthesia or
aseptic precautions. It would interest readers to know that people in the town had
gathered outside the house with a noose as they planned to hang him if he failed in his
“butchery” ' McDowell performed twelve more ovariotomies without failure, an
incredible feat in those days. Retrospectively, it has been realised that the reason for this
astounding sucess was that McDowell, unlike surgeons of his time, used clean sheets for
his stir ger.’. He would boil the sheets in water in order to wash away the blood - and
inadvertently, sterlise it as well. In subsequent years, Auguste Nelaton, Sir Spencer Wells
and the Atlee brothers - John and William- also performed ovariotomies with sucess.
In 1855, the world’s first hospital devoted to diseases of women was set up in New York
by James Marion Sims. Earlier, in 1849, he had devised an operation for the treatment of
vesico-vaginal fistula and had published it in 1852. In addition, he fashioned the Sims’s
speculum and was responsible for determining Sims’s position for pelvic examination.
Robert Lawson Tait [ 1845-1897 A.D.], another pioneer gynaecologic surgeon was
among the first to perform surgery- for a tubo-ovarian abscess [ 1872], Hysterectomy
[1874 ] and Ectopic Pregnancy [ 1883], in addition to thousands of ovariotomies.
Significant additions were made to this field by Sir James Young Simpson who
introduced iron wires for abdominal sutures during ovariotomies, sponge forceps for
dilatong the cervix and chloroform for general anaesthesia during labour.
FAMILY PLANNING AND CONTRACEPTIVES
In Ancient Times pregnancy, culminating in the successful delivery of a baby, was
believed to be one of God’s blessings; whereas infertility was attributed to the wrath of
the Almighty or the effect of Evil Spirits. Hence the treatment for the latter problem
revolved around propitiating God or the Evil Spirit by supplication, incantation and
various kinds of religious rites including the sacrificial offering of animals. In primitive
society, the growth of population was checked by several factors such as natural
calamities, wars, high death rate and short life span. The control of disease led to a higher
standard of health, a gradual decline in the death rate, and increased longevity. All these
factors resulted in a rapid growth of the population, consequently producing pressure on
available living space. Under these circumstances it was but natural for man to attempt to
limit the population growth, without sacrificing the biological instinct of mating. Thus
the concept of family planning to limit the population is not new, although the methods
suggested have varied from time to time, depending upon the materials available and the
level of understanding of the processes of procreation and conception.
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TRIBAL MEDICINE AND CONTRACEPTION
.Amongst the ancient tribals, in various parts of the world different types of contraceptive
methods were practised. It is reported that prolonged breast feeding was a well known
method of safeguarding against pregnancy amongst the African and South American
tribals. The commonest, the simplest and the most widely practiced method was
"ceremonial abstinence” more or less similar to the present day “rhythm method”. Coitus
Interruptus was also known. In South America another method was the use of a “Female
Condom”. This was made of a vegetable pod with one of its ends cut off to convert it into
a tube with a blind end. This was introduced into the vagina to accomodate the phallus a reversed concept of the present day condom. Another method involved the insertion of
foreign bodies into the vagina to obstruct the introduction of penis, a practice widely used
by Arabs to prevent pregnancy in caravan camels. Surgical procedures though crude,
were also resorted to, usually on the vagina or the male sex organs. Amongst the
Abyssinian tribals infibulation in females by sewing together the lips of the vagina was
practised. In males an artificial opening in the urethra was made by splitting it at its base;
the seminal fluid was thus voided outside the vagina.
ANCIENT MEDICINE AND CONTRACEPTION
The Kahun Papyrus, an Egyptian treatise on Gynaecology of that time, mentions such
contraceptive methods as the use of a vaginal suppository containing crocodile dung
mixed with honey and Sodium Carbonate. In the Papyrus of Ebers, another ancient
Egyptian document on medicine, the recommended method was to insert into the vagina.
Acacia tips containing gum arabic which, when dissolved in water, liberated lactic acid, not unlike some of the present day contraceptive jellies containing lactic acid. In the
available literature, references to contraceptives in Ancient Indian Medicine are
conspicuous by their absence, presumbaly because the population growth at that time was
not alarming, and the pressure on the land was not too great.
Roman women enjoyed equal rights with men; in particular, they enjoyed a sexual
freedom which permeated through the various strata of their society, resulting in a
demand for contraceptives and abortificients. Soranus (98-138 A.D.) the great Roman
Gynaecologist, who was trained in Alexandria and practised in Rome, suggested the
following procedures as contraceptive measures:
1. To insert into the mouth of the womb a plug of lint,
2. To smear the cervix with rancid oil or honey or a decoction of cedar oil.
3. To introduce into the vagina an astringent pessary'.
Aetius of Amida (500-550 A.D.) of Mesopotamia, who studied medicine in Alexandria
and eventually settled down in Constantinople, recommended the use of contraceptive
methods only in those cases where pregnancy jeopardized the life of the woman, fo
prevent contraception, he advised smearing of the cetvical os with honey, opabalsam, etc.
82
It is also mentioned that he prescribed pessaries to bring about sterility but the details of
these prescriptions are not known.
With the dominance of the Catholic Church and the spread of its teachings during the
Medieval period in Europe, the subject of contraception was neglected till about the
Sixteenth Century'. The beginning of the birth control movement can be traced to the
formation of the Malthusian League after the famous Bradlaugh-Besant trial of 1877 for
their advocacy of the use of articifical devices of control conception.
In America, after 1880, articles discussing the merits and demerits of various
contraceptive methods were freely' discussed and published. Needless to say, there was
some opposition to such publications. However, in 1888 the Medical and Surgical
Reporter published a Symposium on Contraception. This, though giving an impetus to
the birth control movement, did not contribute to the advancement of techniques.
THE CONDOM
Legend has it that the condom was the creation of one Dr. Condom, during the reign of
King Charles II (1660-1685 A.D.). It is believed that the King, alarmed at the number of
his illegitimate children, publicised his need for a device to prevent pregnancy. His court
physician, named Condom, then invented the condom. Earlier, in Europe, it was
recommended as a prophylactic measure against venereal diseases in the Sixteenth
Century'. An Italian physician Fallopia.in 1564,was the first to recommend the use of a
linen sheath moistened with a lotion,as a protection against venereal diseases. In 1597,
Hercule Saxonia published a description of a modified version, impregnated with
inorganic salts and allowed to dry. The word “Condom" was derived from the Latin word
“Condus” meaning a receptacle. Interestingly', while the French referred to it as “La
capote anglaise”, the English termed it the “French letter” (envelope), hi the Eighteenth
Century' it was known as “Preservative”, “Machine” or “Armour”. Condoms in those
days were made of caeca of sheep or other animals. Its use became very popular in
England and was mentioned in the erotic poetry' of the time. The famous English writer
Boswell wrote in his London Journal on 10th May 1763 that he “picked up a strong
young jolly damsel, led her to Westminister Bridge and there, in “Armour” complete, did
I enjoy her upon this noble edifice”. In the 1890s rubber was introduced for the
manufacture of condoms and from the 1930s latex condoms have been in use.
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THE SAFE PERIOD
That periodic abstinence from coitus, enables women to avoid pregnancy has been
known since ancient times in various parts of the world. In 1853, in Europe, there was a
strong belief that the menstrual period was the most fertile period and the middle of the
cycle was an infertile period. Naturally, this erroneous concept spelt disaster for several
couples. In 1929, Knaus in Austria and Ogino in Japan independently propounded that
ovulation occured 14 days before the onset of the next menstruation and hence
recommended avoidance of intercourse during the mid-cycle phase. This resulted in the
proper understanding of the term “Safe period” and the introduction of the Rhythm
Method.
Diaphragms and Cervical Caps
In all these devices the basic principle is that of occlusion of the cervical os. Since
Ancient time, a variety of gums, leaves and seed pods have been in use. The precursors of
the cervical cap of the Eighteenth Century was one half of a lemon squeezed of its juice
and placed over the cervix; the residual citric acid provided an additional safeguard
because of its spermicidal action. By 1823, these caps were made of rubber and
popularized by Dr. F.A. Wilde as a “comfortable and effective” method of birth control.
Due to the shortage of materials during World War II, Marie Stopes in 1943 advocated
the introduction of wool, soaked in rancid butter into the vagina.
Chemical Contraceptives
Chemical and physical properties are considered important constituents of a reliable
vaginal contraceptive, the former as a spermicide and the latter as a barrier to sperm
penetration. In England W.J. Rendell in 1885 introduced a suppository' containing Cocoabuner and Quinine. The majority of the suppositories, jellies, creams and foams
contained Quinine, Boric acid, Lactic acid, Chinosol, Hexyl-resorcinol, Ricinoleic acid,
Formaldehyde, etc. Foam contraceptives were first introduced in Germany in the early
1920s.
Intra-uterine Devices
It is believed that Arabian and Turkish camel owners used stones as an intra-uterine
device to prevent pregnancy in camels. Guttmacher’s anthropological research has
revealed the use of such devices since ancient time in various strata of the society. The
stem pessary was first described and illustrated in the Lancet in 1868. Casanova’s
preference for the use of gold ball as a pessary is well known. Gold or gold-plated
“Wishbone” or “Collar stud” pressaries were popular in England and Germany. In the
1920s Grafenberg in Germany and Norman Flaire in Britain popularized the intrauterine
device in their countries. In Japan Kondo and Ishihama produced rings made of nylon
and polythene. Subsequently, several devices of various shapes and designs made of
polythene and stainless steel were released in the market.
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Oral Contraceptives
The history of oral contraceptives is of recent origin, although claims have been made in
the distant past, of the efficacy of certain herbs and their products. The thrust in this
direction began with the discovery, by John Beard in 1897. of the role of the Corpus
luteum in inhibiting ovulation during pregnancy. The role of the Pituitary in controlling
the ovarian cycle, and the subsequent discover}' by Moore and Prince in 1932 of the
pituitary feedback mechanism, opened up possibilities of inhibiting ovulation with
hormonal therapy. Sturgis and Albright, in 1940, injected oestrogen to relieve
dysmenorrhoea and inhibit ovulation. The next logical step was to discover a product,
which when given by mouth, would be equally effective. Ethisterone, discovered in 1938,
was found to be weakly active when orally administered. By 1956, Syntex released
Norethisterone, a powerfill oral progestational agent which proved to be an effective
contraceptive. In 1963, Goldsieher et al, introduced a sequential regime of Oestrogen and
Progestogen. In due course it was found to be a reliable and easy contraceptive and was
labeled the “Pill”.
Immunological Methods
These methods, to prevent pregnancy, were first tried by Landsteiner in 1899 and Baskin
in 1932. Initially attempts were made to bring about aspermatogenesis in male animals
and subsequently apply the methods to man. In the recent past several immunological
approaches have been tried; one of these is the immunization of women with a vaccine
prepared from the Beta sub-unit of HCG (Human Chorionic Gonadotrophin) carried on
tetanus toxoid. The vaccine is under trial and its long term effects are awaited.
REFERENCES:
i)
Kothare, S N. Family Planning and Contraceptives. Physician’s update 1989, 1(6)
:275-278.
ii) Richard A. Leonardo : History of Gynaecology, Froben Press, New York, 1944,
iii) John Peel and Malcolm Potts: Textbook of Contraceptive Practice, Cambridge
University Press, 1970,
iv) Intra-uterine Contraception. (Proceedings of the Second International Conference,
October, 1964, New York City by S.J. Segal and A.L. Southam, p 3 & 4
v)
Textbook of Preventive and Social Medicine, edited by J.E. Park & K. Park, 10th
edition, Chapter 10. Publishers Banarasi Das Bhanot, Jabalpur, India, 1985
85
CHAPTER 15 : EVOLUTION OF PSYCHOLOGY AND PSYCHIATRY
In the past, mental disturbances were considered under neurological disorders, without
any distinction being made between the two. Psycliiatry, as a separate speciality of
medicine, is of recent origin. - some time in the early 19th century and in India, in the
early Twentieth century.
In the primitive society, a mad person was considered to be possessed by a spirit or
demon which had taken the place of the habitual and natural resident. Changes in
personality were thus attributed to displacement of the customary spirit by some new and
utterly foreign usurping spirit. The belief in demonical causation of mental diseases still
persists, not only in India, but all over the world.
ANCIENT TIMES
Ln Ayurveda, Psychology and Psychiatry are treated as a unit and designated as
Bhutavidya. Bhutavidya referes to diseases which originate from the influence of Bhutas
(Graha). Eight types of Grahas were mentioned in the Sushruta Samhita and were
attributed to superhuman powers, which varied from the most benevolent type (Devas) to
the most devilish types such as Rakshasas (monsters) and Pisachas (filthy goblins). The
manifestations of the last two grahas were similar to those of Scltizoplirenia, Paranoia
and Manic Depressive Psychosis. From the writings of Charaka and Sushruta, it appears
that they did not strongly subscribe to the view that mental disorders were caused by
demonic possession, but attributed mental disorders to indigenous factors, the result of
disturbances of the tliree humours, or exogenous factors, - possession by supernatural
powers.
The treatment consisted of worship, sacrifices, yagnas, etc., to satisfy and gratify
favourites like Gana and Rudra. Amongest the vegetable preparations, roots of certain
plants were recommended. Perhaps Rauwolfia serpentina was also included in this group.
Besides these, weird concoctions of animal origin were also prescribed. In the Siddha
System of Medicine, a preparation called Peranda Bhasman was prescribed for
psychiatric disorders., consisting of human and dog skull bones ground together into a
powder.
Descriptions of menially disturbed individuals are found in the writings of the Greek
philosophers and writers Sophocles (496-406 B.C.) and Cicero (143 - 106 B.C.) In the
Greco-Roman period ‘Hysteria’ in women was attributed to the wandering of the uterus
(the word ‘hysteria” is derived from the Greek word for uterus). Hippocrates offered the
theory of an anatomical, physiological and psychological basis for mental illness. He
emphasized, like Freud later, that dreams were the expression of one’s desires. Celsus
who lived some time during the first half of the first century showed concern in his
86
writings over the treatment of the mentally ill. He advocated sudden fright as a
therapeutic measure. - shock treatment. Galen ascribed mental disturbance to organic
lesions of the brain, and to a sympathetic response of the brain to an illness in another
part of the body, now referred to as Psychosomatic Illness.
THE MIDDLE AGES
The Codex Theodosianus of 438 A.D. recommended the prosecution of the so called
possessed, - witches and sorcerers, as such illnesses were believed to be the handiwork of
the Devil. Torture. Immolation, etc., were the recommended weapons against disorders
of the mind. In Europe, the early Christian and Medieval period is known as the Dark
Ages due to the stagnation in various intellectual activities. The dominance of the Church
and its teachings proved largely detrimental to the advancement of sciences in general,
and medicine in particular. Mental disease were attributed to the influence of Satan, and
torture, sometimes leading to death, was often resorted to. The belief also led to the
practice of burning witches and sorcerers, which continued untill the Eighteenth Century'.
In 1782, the last witch was executed in Europe (Switzerland). The Middle Ages,
however, were not completely devoid of men of a more rational and compassionate
temper. Caelius Aurelianus (5th or 6th Century) was against chaining, Hogging, etc., for
the mentally imbalanced. His course of treatment included well lighted rooms, a humane
approach and hydrotherapy. Johannes Aetuarius, a 13th century court physician at
Constantinople, ascribed certain mental symptoms to physical disabilities, and did not
believe that mental disorders were caused by the activity of evil spiritis.
RENAISSANCE AND POST-RENAISSANCE
During the Renaissance, notable advances were made in the study of mental illness.
Paracelsus7 monograph on ‘Diseases that deprive man of Iris reason ‘ is a classic on
mental disorders of the time. G.B.D’ Monte identified melancholics as a separate group
and advocated batlis and blood letting for them, while Girolamo Mercuriale hypothesized
that Melancholia was due to a disturbance of the imaginative faculties. Among the other
noteworthy names of this period in Europe were Felix Plater (1546-1614 A.D.), Prospero
Alpino (1553-1617 A.D.), and Jerome Cardan (1501-1596 A.D.), Valsalva (1666-1723
A.D.), Vincenzo Chiarugi (1759-1829 A.D.) and Philippe Pinel (1745-1826). All these
men shared a common conviction that a more humane approach to mentally disturbed
patients was called for. Pinel, physician to the Bicetre Hospital for the insane in Paris,
described his experiences in his “Traite medicophilosophique sur 1’alienation mentale on
la manie’; and strongly attacked the use of mechanical restrains such as chaining and
caging. It is noteworthy that in India, a mental hospital at Dhar near Mandu in Madhya
Pradesh was established by Mohammed Khilji (1436-1469 A.D.), with Maulana Fazulur
Lah Hakim as physician in-charge.
Benjamin Rush, an American, published in 1812 ‘Medical Inquiries and Observations
upon the Diseases of the Mind’, a landmark in medical history. Having been incharge of
87
the mentally ill patients in Pennsylvania Hospital for 30 years, he was in an excellent
position to study and explain the role of heredity, traumatic injuries, malformation of the
brain, the effect of drugs, etc., in the causation of mental diseases. He is regarded as the
first American Psychiatrist.
Julius Wagner von Jauregg, an Austrian, advocated febrile therapy for patients suffering
from Psychoses; he proved his point on June 14, 1917, by infecting three psychotic
patients with Malarial parasite as a treatment and thereby improving their mental
condition. Sigmund Freud, born in Freiberg, Moravia in 1856 and brought up later in
Vienna, was initially interested in Botany and Chemistry, and later in Neuropathology.
His interest in Psychology was aroused by his friend, Joseph Breuer. Breuer, while
treating a female patient with hysterical symptoms, used hypnosis to help her recollect
circumstances of the origin of the disorder. On being made conscious of the origin of
Hysteria, her symptoms disappeared. This marked the origin of the theory of the
“Unconscious mind”, described in detail in a book ‘Studien uber Hypnose’ jointly written
and published by Freud and Breuer in 1893. Subsequently, Freud investigated cases of
Psychoneurosis and established the role of the unconscious in these cases. Freud died in
1939, as a refugee in England. How he died is of some interest, - over the years, he was
operated 33 times for a carcinoma of the tongue, probably the result of his chain
smoking. He finally persuaded his friend Max Scheur to inject him with I.V. morphine
- an early example of euthanasia, a subject of much debate in recent times.
With the deeper understanding, over the centuries, of the processes involved in mental
disturbances and their manifestations, the treatment of the mentally disturbed has
undergone radical changes. In the modem climate of opinion, it is difficult to believe that
in the past lunatics were caged in isolated premises and exhibited, against the payment of
a small fee, as strange animals. A case in point, Phillippe Pinel not only recommended
humane treatment for the mentally ill, but even lived with them in order to understand
their habits and personalities; as such he should be credited for originating the concept of
investigating such individuals as a whole, talcing into consideration their environmental
and social influences. To quote - “ The modern trend is to combine biologic, psychologic
and social intervention in a tailored approach to a particular patient with a specific
disorder”.
In India, Psychiatry as a separate subject was introduced into the medical curriculum in
the 1930’s. Since then, despite considerable progress in the treatment of the mentally ill,
few significant contributions to psychiatry in general have been made. An exception is
the development of the concept of Family Therapy. The development of Yoga as a mode
of treatment is no doubt beneficial in some psychiatric conditions, but further study is
required.
Modem treatment is available in the metropolises and in a few of the larger cities, and
for various reasons, benefits only a few patients. The large rural population (nearly 80
percent) is obliged to seek treatment from local temple priests, astrologers, soothsayers
88
and traditional healers, all of whom provide inexpensive and easily available treatment.
which however has the disadvantages of being ineffective and occasionally harmful.
REFERENCES:
i)
De Souza A and De Souza. D. (Eds.). 1984: Psychiatry' in India, publishers, Shri
Rajesh C. Bhalani, Bhalani Book Depot, Bombay
ii) Goldman. Howard H. Review of General Psychiatry, 2nd ed., 1988, Appleton Lange,
Prentice Hall International Inc.,
iii) Kothare, S N. Evolution of Psychology and Psychiatry. Physician’s Update 1989,
2(2): 75-77.
89
CHAPTER 15 : SEXUALLY TRANSMUTED DISEASES AND SKIN DISEASES
In Ancient Indian Medicine, Charaka and Sushruta have dealt with the subject of disease
of the male and female genital tract in great detail. Sushruta described an inflammatory
condition called Upandansa, the Raktaja and Sannipatika types which have features very
similar to those of Syphilis. Both Charaka and Sushruta stressed modes of transmission
other than sexual contact, such as the use of bristles of a water parasite (Suka) which on
pricking the penis produce an abnormally elongated penis, apprently a common practice
at the time. The treatment available was also varied, consisting of medications which
included douches and tampons with interesting ingredients; one such being yeast mixed
with honey, which may have been the beginning of the antibiotics therapy as we know it
today.
Chancres have been described in Ancient Chinese literature as early as the Seventh
Century A.D. However, the original texts are too brief to ascertain if the sores described
in these writings were true chancres or not. Most Chinese scholars agree that Syphilis
came to China only in the Ming Dynasty (1368-1662 A.D.) . It is believed by some
Chinese authorities that it was brought to Canton by Portuguese travellers from India, and
was then carried to Japan; from whence it spread to the rest of the world. Mercury' also
seems to have played its role in China, the earliest record of its use being in the form of
calomel.
Hippocrates (460 B.C.), in Inis writings described a form of lumbar pain designated as
“Tabes dorsalis” with coexisting penile discharge. In accordance with his humoral
doctrine, Galen attributed this group of diseases to foul humours and explained the
formation of ulcers and bubos as an escape route for such humours, with a subsequent
cure - undoubtedly an erroneous concept.
SEXUALLY TRANSMITTED DISEASES
SYPHILIS
In 1987, the researchers William Turbull and Bruce Rothschild found “chemical traces
of Syphilis Bacteria in the 11,000 year old vertebrae of a bear,” in the collection of the
Museum of Natural History, Chicago. The controversy as to whether Syphilis existed in
Europe before the return of Columbus or whether it was brought by lais crew returning
from the first voyage to Haiti in 1493, rages to this day. The first to enunciate the
Columbian origin theory' was the Spanish physician Rodrigo Ruiz Diaz de Isla in his
writings. He reported that on the return voyage, one of the Pinzon brothers, who was the
pilot of Columbus, acquired a “dreadful skin condition”, de Isla also claims to have
treated some of the diseased sailors of Columbus sliips upon their return to Barcelona.
The absence of syphilitic bones of pre-Columbus origin in Europe further supports this
point of view. However, in 1946, E.Herndon Hudson in his book entitled
90
“Treponematosis” questioned the above theory. In Europe, prior to the return of
Columbus, Leprosy was considered to be highly contagious. It was believed to have
been transmitted through sexual contact, display hereditary features and respond to
mercury therapy. Hudson erroneously identified Leprosy of that period with Syphilis.
However, the characteristics mentioned are similar to those of the latter than those of the
former.
Whatever be its origin, there is no doubt that Syphilis wrought havoc in Sixteenth
Century Europe. It is believed to have crossed over to Italy with the French troops, was
named “Morbus gallicus” or the “French disease”. It continued to be referred to as such
till Fracastorius in 1530, published his famous poem about the shepherd, “Syphilus”, who
was afflicted with the disease because of the wrath of Apollo whom he had insulted. The
rapid spread of syphilis was aided by public baths, an old Roman custom which was
revived in lire Thirteenth Century. With ablution came debauchery and the baths
flourished as centres of public contagion, till they were closed down following the
ravages of Syphilis. Initially, Syphilis was treated with an abundant use of purgatives and
antitoxic drugs, prepared by complicated processes such as the theriacum (the origin of
the word “Treacle”) and the mithridaticum. This was followed by the infamous “Mercury
cure” which consisted of anointing the skin with a burning mercury' salve and
incarceration of the patient in a stove for 30 days on a starvation diet. Intelligent patients
chose to die from the disease rather than go through this ordeal. Soon cases of mercurial
poisoning were encountered and as the French satirist Francois Rabelais noted “With
their faces sharp as a butcher's knife, their teeth rattling like the key-board of a broken
down spinet”. A second form of treatment was then introduced in the form of the “Holy
Wood” or Guaiac. The remedy was particularly popular in Germany where the poet
humanist Ulrich von Hutten recommended it strongly in his book published in 1519,
recounting his own suffering due to the disease. With the advent of printing and the wide
diffusion of knowledge, Syphilis never assumed the pandemic dimensions of Leprosy and
Plague. Attempts to study Syphilis led to unusual experiments such as the self-inflicted
Syphilis of John Hunter. It was Philip Ricord who in 1831, after a series of experiments
involving 2,500 inoculations, proved that Gonorrhea was different from Syphilis and
went on to describe the three stages of Syphilis, including the bone and muscle lesions .
Jean Alfred Fournier described, between 1876 and 1894, other syphilitic conditions such
as Tabes dorsalis and Congenital Syphilis. The early Nineteenth Century brought the
identification by Fritz Richard Schaudinn and Paul Erich Hoffman of the protozoal
parasite which causes Syphilis, initially named Spirochaeta pallida, in 1905. In the
following year August von Wasserman, an assistant of Koch, developed the test named
after him. This was followed in 1910 by the breakthrough of Paul Ehrlich and Sahachiro
Hata, when they discovered the trivalent arsenical compound 606, “Salvarsan”, and
released it to the world as the “Magic bullet” against Syphilis. Two decades later,
Alexander Fleming with his discovery, made Penicillin the drug of choice.
91
GONORRHOEA: Gonorrhoea is reported to have existed from pre-historic times. Il was
familiar to the Chinese more than 5.000 years ago and was known to the ancient Arabs,
Greeks, Indians and Romans. Galen gave it the name in the mistaken belief that it was an
involuntary flow of semen (gono-seed, rhoia-flux). But it was not until the Nineteenth
Century that the so-called “cold of the spout” was studied as a separate entity in Great
Britain.
Albert Neisser discovered the gonococcus in 1879, and although no treatment was
available at the time,in 1884, C.S.F. Crede, introduced instillation of the silver nitrate in
the eyes of the newborn as a step to prevent blindness due to this disease, a practice
prevalent even today.
CHANCROID: It was not until after 1850 that a “soft chancre” was distinguished from
the initial lesion of Syphilis and designated Chancroid. A. Ducrey in 1889 identified the
micro-organism which was later accepted as the causative agent.
LYMPHOGRANULOMA VENEREUM: This was first described as a clinical entity in
1913. Detailed information became available only in 1922 following studies by Joseph
Nicolas, Maurice Favre and J. Durand.
GRANULONIA INGUINALE: The first description of this disease was recorded in 1882.
In 1905, C. Donovan noted a “body” found in the diseased tissues. In 1945 the “Donovan
body” was cultivated in the yolk sac of the chick embryo by Dunham and Rake.
AIDS:
Acquired Immune Deficiency Syndrome (AIDS) was first noted as a disease entity in the
year 1981. The etiological agent, a virus, was first isolated from a West African patient
suffering from generalized lymphadenopathy by Luc Montagnier et al in 1983 at the
Pasteur Institute, Paris, in France. They labelled it as “Lymphadenopathy Associated
Vims” (LAV). In 1984, Robert Gallo and his colleagues from the National Institutes of
Health, USA, reported the isolation of a vims from AIDS patients. Subsequently , the
International committee on Virus nomenclature in 1986, gave the generic name “Human
Immunodeficiency Virus (HIV)” for these viruses. Unfortunately, there has been much
controversy about the discovery ; however, it now appears that Montagnier and
colleagues deserve the credit.
Initially believed to be restricted to homosexuals, haemophiliacs, Haitians and heroin
addicts, it is now clear that AIDS can affect almost anyone. The virus spreads through
sexual contact. through blood transfusion and also through the placenta - hence people
of both sexes and all ages, including the unborn foetus are at risk. Doctors and laboratory'
92
workers exposed to the blood of patients with AIDS as well as drug addicts are also at
risk. Fortunately, kissing,casual contact with patients or the sharing of clothes and
utensils does not cam' even the slightest risk of disease transmission.
Researchers have attempted to determine exactly how long this disease has been in
existence. There is evidence suggesting the existence of human infection with an HTLV
IH , LAV-like virus in Central Africa as early as 1959. It has been suggested by Robert
Gallo et al that HIV originated in Africa from where it spread to the Caribbean and from
there to the United States in the late 1970s. However, reports now suggest the presence of
the AIDS virus in USA, prior to this. In 1969, doctors in a St.Louis Hospital were baffled
by the death of a 15 year old boy with widely disseminated Chlamydial Infection.
Autopsy revealed extensive Kaposi’s Sarcoma. Western Blot and Antigen capture assays
on serum and tissue, frozen since 1969, showed that the sexually active teenager was
infected with a virus identical or closely related to HIV type-1.
The billions of dollars that have been spent in research have cleared a lot of our concepts
about the disease. However, an AIDS vaccine is years away and the drugs used presently
[ Sulpha drags and Zidovudine (AZT) ] offer only short term relief. In fact, even the
diagnostic test [ the Western Blot test ] has its deficiencies as it cannot conclusively
detect every case of AIDS. Like Leprosy, in earlier times, AIDS provides an example of
man’s inhumanity to man. Education and counselling are the key w'ords to the
management of AIDS. The media are being used to disseminate knowledge on AIDS.
The emergence of this problem emphasizes the importance of social and cultural factors
in disease.
SKIN DISEASES
Primitive ways of life associated with poor hygiene and close personal contact, favoured
the development and rapid spread of numerous skin diseases that flourished at the time.
The scantiness of the clothing made these conditions apparent and patients were open to
suggestions for treatment such as the hot springs of Magna Graecia, the copper and
asphalt deposits of Asia Minor, the sulphur streams of Syria and even the brine of the sea.
In ancient India, Sushruta and Charaka give detailed accounts of skin lesions, comparing
their colour of texture to that of a particular fruit and flower. Thus Psoriasis is described
as the colour of bitter-gourd flowers.
Among the Greeks and Romans of later years, the attention paid to regimen and hygiene,
with the emphasis on social bathing, would lead us to assume that skin disease were less
common. But from the writings of Hippocrates it is obvious that he had come across
several dermatologic complaints. He described these in great detail, and it is to him that
we owe such terms as "Alopecia, Lichen, Lepra and Pityriasis.”
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The first author to write a specific work on Dermatology was Galen in his “De tumoribus
praeter naturum”. He organised diseases on a humoral basis and divided them into those
affecting the hairy part s of the head, and those affecting the rest of the body. The Arabic
writers improved upon this, making further differentiations; such as the distinction made
by Rhazes between Measles and Smallpox. Avenzoar (1092-1162 A.D.) too is known for
his original theories, including Iris observation that Scabies was due to the itch mite.
Till the Nineteenth Century', classifications were based on the symptomatic nature of
diseases. The first rational nomenclature, based on the appearance of lesions, was
proposed by the English physician Robert Willan ( 1757-1812 A.D.) in 1807. His pupil,
Thomas Bateman completed his work, and their treatise, with its beautiful illustrations
and accurate descriptions, remains to this day a classic work of modern Dermatology'. To
Baron Jean Louis Albert (1768-1837 A.D.) we owe the identification of such diseases as
Mycosis fungoides and Keloid. His clinic at the Hospital St.Louis was for many years the
world's centre for Dennatology.The pathologist, Ferdinand von Hebra (1816-1880 A.D.)
was the first to acquire a sound knowledge of skin diseases based on pathologic anatomy.
His pupils, including his son-in-law Moritz Kaposi, carried on the great tradition of the
Viennese School of Dermatology which he had founded. To this school, is attributed the
first account of diseases such as Kaposi’s Sarcoma, Rhinoscleroma and Lichen ruber.
Tire United States, which until this time reflected the ideas of Europe in this field, began
to make significant contributions, especially to advances in deimatological education.
James C. White (1833-1916 A.D.) was the first to lecture at Harvard on the subject.
LEPROSY
The Sushruta Samhita (600 B.C.) gives a clear description of “Kushta” or Leprosy as a
contagious disease, and adds that one type produces “loss of preception of touch”. A
tubarak oil, (believed to be hydnocarpus oil), is mentioned as its treatment. The disease is
said to have then reached China from India and was noted there first in the Sixth Century
B.C. and treated with diaphoretics, purgatives and arsenic. One of Confucius’s own
pupils, Pe Nieu died of the disease. Leprosy entered Greece following its conquest by
Darius, the Persian King, in 480 B.C. It was subsequently introduced into Europe by
Roman soldiers of Pompeii in 62 A.D. and spread rapidly during the Middle Ages due to
the Crusades. It reached its peak during the Thirteenth Century when there were more
than 2,000 leprosaria in France alone. In 1235 A.D. St. Elizabeth, patron saint of those
with Leprosy, was canonized four years after her death at the age of twenty four. She was
the daughter of the King of Hungary and died in the service of those afflicted with the
disease. By the Eighteenth Century', Leprosy had spread from Spain to South America
and on to the Southern United Slates. In 1823 we find the first reference to Leprosy in the
Hawaiian Islands. In 1854. Chaulmoogra (hydnocarpus) oil was introduced into Western
medicine. The pathology of the disease was extensively studied by the Norwegian school
and especially by Boeck and Danielssen. In 1858, the latter inoculated himself and nine
other volunteers with lleprosy material in an effort to study the transmission of the
disease. In 1859, Rudolf Virchow visited Danielssen and demonstrated the “Brown
bodies” which we now know to be “globi”. Virchow went on to describe the “lepra cell”
94
in 1864. Bui the identification of the causative bacillus came onlj' in 1873 when Gerhard
Annaquer Hansen discovered M. leprae. In the same year Father Damien took up
residence with patients on Molokao, Hawaii, and after a dedicated service died in 1889.
Chaulmoogra oil remained the only treatment available till 1941, when Guy Faget of
Carville initiated the use of Sulfones in therapy. This was followed by the introduction
of DDS by R.G. Cochrane in the same year. The first Lepromin reaction was described by
Mitsuda in 1919: subsequently, a standardized, refined lepromin was prepared by
Dharmendra in 1942. Much work has been done, particularly in India, with regard to
research and reconstructive surgery towards rehabilitation of patients, suffering from
Leprosy . Dr Paul Brand of the CMC, Vellore did pioneering work on plastic surgery for
these patients. V.R. Khanolkar’s leprosy research in the 1950s has been appreciated all
over the world and has subsequently led to work on a possible leprosy vaccine. A
sustained propaganda effort is called for to remove prejudices against the afflicted person
and to establish that the disease, if treated properly and adequately, is curable.
REFERENCES
i) Stephen, Chitra and Kothare, S N. Sexually Transmitted Diseases and Skin Diseases.
Physician’s Update 1989, 2(5): 218-222.
95
CHAPTER 17 : MEDICAL EMERGENCIES
INTRODUCTION
Before the advent of a written script, information on diseases was transmitted in the form
of hieroglyphic (pictorial) and hieratic characters, and was consequently, scanty and
disorganized. The emergence of a written script, the understanding of the use of the paper
and the printing press, and of course, the zeal of medical scientists through the ages, have
enabled medicine to evolve into an organized science. In this chapter, a few topics arising
as emergencies in medical practice are discussed from a historical perspective, though in
a limited manner.
ACUTE ABDOMEN
The catastrophic potential of abdominal problems that are currently recognized under the
category of "Acute Abdomen” were recognized even in the time of Hippocrates. Earlier,
in 1552 B.C., Ebers recommended dieting for Hernia. Intestinal obstruction was observed
and treated by Hippocrates and the earliest recorded operation was performed by
Praxagoras (350 B.C.) who created an entero-cutaneous fistula to relieve the obstruction.
However, non-operative treatment, such as opium for pain, orally administered mercury
and lead shots to open an occluded bowel, gastric lavage and electric stimulation, was
preferred to operative treatment. There are occasional references to operations for acute
abdomen, but it was not until 1709 that Jean Louis Petit reported successful surgical
intervention in a patient with a Strangulated Hernia.
In 1836, Johann Friedrich Dieffenbach reported the first successful resection of the small
intestine, in a patient with a gangrenous sgment of the bowel. In 1776, Pillore of Rouen
performed the first Caecostomy. In 1797, Fine of Montpellier performed the first
Transverse Colostomy.
Hartwell and Hongent in 1912, observed that parenteral administration of saline
prolonged the lives of experimental dogs with intestinal obstruction. In 1930, the use of
the naso-gastric tube to relieve distension of the stomach was employed. From the 1940s
antibiotics have played an increasingly important role in the treatment of intestinal
obstruction.
Appendicitis, under such names as Perityphlitis and Iliac Passion, has been known to
man for the last 500 years. In 1827, Melier ascribed the origin of purulent iliac tumour to
inflammation of the appendix. Nicholas Senn was among the first surgeons to diagnose
Acute Appendicitis and to perform a successful Appendicectomy. In America, Reginald
Fitz at Harvard Medical School, in 1886 published his classic paper on “Appendicitis”, -
96
a term he coined. Charles McBumey, in 1889, described the location of the point of
maximal tenderness, and proposed a new site of incision for Appendicectomy [
McBurney's point and incision, respectively ] Others to contribute to this field were John
Murph)' who recommended surgery in the early stages of the disease, and George
Thomas Morton [ son of William Green Morton, a pioneer of anaesthesia] who
performed the first appendicectomy in America. Appendicitis, or rather Perityphlitis, as
it was then called, became a household word in Britain in 1902 when the coronation of
Prince Edward VII was postponed because of his Appendicitis. Late diagnosis resulted in
the development of an appendicular abscess. He was subsequently operated by Sir
Federick Treves. Lord Lister and Sir Thomas Barlow.
HEAD INJURIES AND NEUROLOGICAL EMERGENCIES
Though neuro-surgical procedures for head injuries have been practised only during the
past century, trephination existed in the Neolithic period 7000-3000 B.C... A triangular
knife fixed in a wooden handle was used for trephination. The bony defect was filled
with gold, and the wound was closed by tying the hair on either side across the wound.
The Edwin Smith Papyrus (1600 B.C.) contains descriptions of brain injuries affecting
functions of other parts of the body and causing Hemiplegia and Quadriplegia. For
wounds which penetrated to the bone, treatment consisted of drawing the edges together
and stitching them; fresh meat was then bound to the wound. If the stitches were undone,
the edges were drawn together with two strips of plaster and treated with grease and
honey. Hippocrates realized that a blow on one side of the head is followed by
convulsions or paralysis of the contralateral limbs and recognized the poor prognosis of
the patient with a head injury' complicated by dural laceration. In 1614, Fabricius
Hildanus mentioned head injuries amongst the causes of psychosis. Wepfer, in 1658,
established the relationship between Cerebral haemorrhage and Apoplexy'.
The word “Epilepsy” comes from a Greek word meaning “to be seized by forces from
without”. Hippocrates recognized Epilepsy as an organic process of the brain. Ancient
writers, however, considered “Seizures” to be the work of supernatural forces.
Hippocrates emphasized that heredity played an important role in the etiology of
Epilepsy. Caleres Aureliam differentiated Epilepsy from Hysteria. In 1875, Jolm
Hughlings Jackson [ 1834-1911] postulated that “Seizures” were caused by “Occasional,
sudden, excessive, rapid, local discharges of grey matter”.
TRAUMA, SHOCK AND PARENTERAL THERAPY
Surgeons in the 18th century', were unaware of the causes and effects of infection
resulting from trauma. Whenever battle injuries involved fractures, amputation was
resorted to. The word “Shock” was first used as a medical term in 1743. At the end of
the Nineteenth Century' surgeons recognized Shock as a clinical entity. In 1899, George
Crile published an experimental study in animals in “Shock” and observed that they
responded to intravenous administation of warm saline. During World War I, Sir Walter
97
Cannon and William Bayliss advocated the use of intravenous replacements to combat
Shock caused by haemorrhage and fluid loss. Cannon noted that a fall in the alkali
reserve was due to accumulation of fixed acids and advised the administration of Sodium
bicarbonate. Maintenance of haemostasis is recorded in ancient Chinese literature.
However, Hippocrates and Celine advised a limited use of ligatures in maintaining
haemostasis. It was Archigenes who advocated preliminary ligation of vessels. In 1552,
Pare rediscovered the ligature and employed it to control haemmorhage while amputating
the leg of an officer. The origin of the resuscitation process which uses expired air for
ventilation, can be traced to the Hebrew midwives who resuscitated newborn infants
(1300 B.C.) with this technique. The manual technique of Sharpey-Schafer was
introduced in 1904, but Bahnson was the first to apply the technique of pressure on the
sternum for external support of the circulation.
REFERENCES
i)
Kumar. Nirmal and Kothare, S N. Medical Emergencies. Physician's Update 1988,
1(4) :228-230.
98
CHAPTER 18. VERSATILE PERSONALITIES IN MEDICINE
A complete History of Medicine would have to include many references to subject items
such as the Philosophy and Ethics of Medicine. Scientific literature and their impact on
medicine. This is not possible in a book of this nature. We wish to conclude by making a
mention of some multifaceted individuals who could not be mentioned in the previous
chapters, which have been largely system-based, rather than in a chronological order, as
is usually the case in books on the History' of Medicine.
There have been people who have graduated in medicine but have had a greater impact
on other fields. Some of them include Sun-Yat-Sen [1866-1925 A.D.], Chinese
revolutionary, W G Grace [ 1848-1915 A.D., English cricketer ], Sir Roger Bannister
[ the first Englishman to run a mile in less than four minutes, and a distinguished
Neurologist ], Socrates [ contemporary Brazilian football player and a Paediatrician | and
Joshua Pirn [1870-1945 A.D., winner of the men’s singles title at Wimbledon in 1893
and 1894], Literature, however, seems to be the field in which many doctors have shifted
their allegiance too. William Somerset Maugham [ 1874-1965 A.D., author of The Moon
and Sixpence, The Razor’s Edge etc ], A J Cronin [ 1896-1981 A.D., author of The
Citadel, Adventures in Two worlds ], Anton Chekov [1860-1904 A.D.. Russian
playwright and author of short stories ], John Keats [ 1795-1821 A.D., English poet ],
Arthur Conan Doyle [ 1859-1930 A.D., creator of the fictional detective Sherloch
Holmes and his colleague, Dr Watson ], Oliver Wendell Flolmes [ 1809-1894 A.D.,
American litterateur ] and William Carlos Williams [1883-1963 A.D., American poet and
posthumous winner of the Pulitzer Prize ].
There have also been medical missionaries. Not satisfied by the thought of helping their
fellowmen in their cities, they went to other countries to help the poor and the
downtrodden. Some of them are named below:
David Livingstone [ 1813-1873 A.D. ], a Scotsman, was an explorer in addition to being
a missionary'. He introduced Western Civilisation, and trade and commerce in Africa. He
discovered the Victoria Falls. During one of his expeditions, he travelled so far into the
heart of Africa and lost to the Western world, that it was feared that he was dead. An
American journalist, Henry' Stanley, then set off in search of him and on finally meeting
him in 1871 at Ujiji, greeted him with the exclamation “Dr Livingstone. I presume I” inspite of the fact that there could have been no other while man in the area.
Albert Schweitzer [ 1875-1965 A.D.], called the “White Gandhi” was a Frenchman who
settled down in Lambarene, Gabon in 1913. Schweitzer was a Theologian who decided to
study medicine when he was in his early thirties , so as to serve the ill and the poor in
Africa. He was awarded the Nobel Prize for Peace in 1952. Norman Bethune [ 1890-
99
1939 A.D.]. a Thoracic Surgeon and blood transfusion pioneer worked on the front
during the Spanish Civil War and later in China , when Japan invaded it. Dr Komis, a
doctor from Bombay did likewise and was immortalised in V. Shantaram’s movie “ Dr
Kotnis Ki Amar Kahani a [ The story of the immortal Dr Kotnis ].
The contribution of women to medicine in earlier centuries was negligible because of the
fact that they were not allowed to enter a medical school. Fortunately, that is a thing of
the past. The first woman to study medicine was James Barry (1797-1865 A.D.) who
dressed up as a man and impersonated and even served in the British Army. It was only
on her death that the truth was discovered. Elizabeth Blackwell (1821-1910 A.D.)
practised Obstetrics and Gynaecology in New York and later in London. Anandibai Joshi
has already been mentioned earlier. Other women who made important contributions in
the field at a time when medicine was largely dominated by men, include Augusta
Dejerine [ nee Klumpke, 1859-1927 A.D.] who described Klumpke’s paralysis which is
caused by damage to the lower part of the Brachial plexus, Rebecca Lancefield who
classified Streptococci, Mary F Walker who descibed Anticholinesterase in Myasthenia
Gravis, and Helen Taussig (1898-1986 A.D.) who devised (with Alfred Blalock) the
Blalock -Taussig Shunt for Fallot’s Tetralogy.
100
REFERENCES - GENERAL BIBLIOGRAPHY
i)
Atkinson Donald T. Magic, Myth and Medicine. Fawcett Publishers Inc, Greenwich,
Connecticut, USA, 1956.
ii)
Castiglioni A. History of Medicine, edited by B Krumbhaar, 1941
iii) Major R H. History of Medicine Charles C Thomas, Springfield, Illinois, USA,
1954.
iv) Nuland , Sherwin. Doctors- the biography of medicine. Vintage books, New York,
1989.
v)
Great Moments in Medicine- A history of medicine in pictures. Published by ParkeDavis and co. Detroit, Northwood Institute Press, 1966
vi) Greene, Dr Jay E [ Editor]. 100 Great Scientists. Pocket Books, New York, 1964.
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About the authors
Dr. S.N. Kothare
♦
Held different posts in teaching and non-teaching institutions and hospitals in Bombay
♦
Professor and Head - Department of Pathology and Microbiology, St. John’s Medical College,
Bangalore
♦
Short-term Consultant, World Health Organization
103
♦
Honorary Consultant in charge of the Department of/Medicirre and Maj. Gen. S.O. Bhatia
Museum of History of Medicine, St. John’s Medical College, Bangalore
♦
Several publications in his subject of speciality
DR. S.A. PAI
♦
Held the post of Resident Pathalogist in teaching institutions in Bombay
♦
Several scientific papers in Pathology
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