A History of
Medicine in Sonnets

As described by my friend, Dr. M. S. Valiathan, one of India’s most prominent surgeons and academic, Susruta was ‘a surgical colossus standing astride many centuries of India’s past, who nevertheless remains a historical puzzle (Valiathan, M.S. “The Legacy of Susruta”, Orient Longman, 2007). Some stories about him are undoubtedly true, but many have uncertain provenance. It appears that he was the son of Visvamitra, one of the most revered and respected sages of ancient India. The exact period in which he lived is a matter of some speculation, some believing it was around 1,000 BC but others putting the date nearer 250 BC.

So pervasive are elements of Chinese culture that most people are familiar with the concept of Traditional Chinese Medicine (TCM). However, the actual origins of TCM are unclear since Chinese history in general represents a merging of myth and reality. On the mythical side are the suggestions that TCM originated with the Emperor Huangdi, in around 2,600 BC. Known as the Yellow Emperor, believed to be one of the Three Sovereigns and Five Emperors of the Huaxia Chinese, it is claimed that he wrote a treatise on health and disease.

Hippocrates, who lived in Greece around 400BC, is often referred to as the “Father of Medicine”. How much of his ‘writings’ were actually composed by him, and how much other people have written about him is true, are a matter of conjecture. While it has been suggested that Hippocrates never actually existed, there is a sufficiently significant body of evidence that confirms certain details of his life and career as a physician, and provides testament to his ethos of renouncing the influence of superstitions, spirits and Gods on human health and furthering the need for close observation of patients and the combined effects of diet, sleep, work and exercise on an individual’s well-being.

Like many true Renaissance Men (including Michelangelo), Leonardo never quite finished his main masterpieces. Although he was a truly accomplished painter, sculptor, mathematician and inventor, it was his anatomical studies that were groundbreaking, way ahead of their time. At an early stage he started to compile his meticulous anatomical drawings, and always planned to write an illustrated De Humanis Corpore, but he never finished it, and the book was never published. The collection was assembled and acquired by the British Royal Family in the 17th Century.

Paracelsus, formally known as Philippus Aureolus Theophrastus Bombastus von Hohenheim, was born towards the end of 1493 in Switzerland. He moved with his father to Austria when very young and took up interests in minerology and medicine. This was during the later stages of the ‘Middle Ages’, when science and medicine had been grossly neglected for centuries. He travelled through much of central Europe, hoping to be enlightened by the masters at top universities, but was singularly unimpressed.

Nearly contemporaneous with Paracelsus was Ambroise Paré, a barber surgeon based in Paris, France. He gained much practical experience on the battlefields of the French army, especially in Italy, where he realized that the revered theories of Greek and Roman physicians, particularly Galen, were of little value when treating the injuries of soldiers, and he was able to revolutionize the practice of surgery through the use of empirical observation and the application of gentle care to major wounds and the treatment of pain.

William Harvey, an Englishman, lived more than a century after da Vinci. It is not clear just how much the former knew of the latter, and although they both derided the influence of Galen, and although Harvey gained much of his experience in Padua, Italy, working with Fabricius in the famed Teatro Anatomico, he rarely referred to, or acknowledged da Vinci. This was no doubt partly due to the lack of formal anatomical or medical training of da Vinci, Harvey himself being a graduate of the Kings School, Canterbury and Cambridge University as well as a Fellow of the Royal College of Physicians.

Although historians have speculated that smallpox infected human more than 10,000 years ago, and provided credible theories about such infections in Egyptian times, using markings on mummies as evidence, there is widespread agreement that it was a devastating disease in both Greece and Rome when in their heydays. There is reason to believe that the highly contagious disease spread across much of North Africa and Western Asia, and it was the Spanish and Portuguese conquistadors who took it to South America, devastating Aztecs and other groups.

This is a long-running epic, with a few momentous events and a still-evolving end-point. That this subject commands an important place in the history of medicine rests with the impact that anaesthesia has had on millions of patients who undergo major surgery each year, essentially pain-free, and often comatose during the procedure. For much of the medical time-line, surgery was accompanied by powerful pain, whether it was for amputation of a limb, a tooth extraction or attention to a fast-growing cancer. Thousands of years ago, the Chinese and Indian medical practitioners worked with natural products such wine, cannabis and opium and techniques such as acupuncture to dull surgical pain; early Europeans used plants such as mandrake and the Incas of South America used cocoa, chichi and tobacco.

In the 1860s the French scientist Louis Pasteur worked on the role of microorganisms in fermentation processes in beverages such as beer, wine and milk, and in the causation of some human diseases. In Glasgow, Scotland, the young Regius Professor of Surgery at the University of Glasgow read Pasteur’s “Recherches sur la Putrefaction” and proposed that the same processes involved in fermentation were also associated with wound sepsis.

In the nineteenth century, the main essential components of food necessary to sustain human life were pretty clear, involving proteins, fats, starches, sugars and some minerals containing, for example, calcium and phosphates. Experiences with crew on long-distance ocean travel, who were often denied fresh food for months, suggested that something was missing, especially as some sailors, near to death on reaching land because of the resulting scurvy, made rapid recoveries once provided with fruits and vegetables. Other diseases such as beriberi also resulted from such restricted diets.

For centuries, nerves were assumed to be under the control of animal spirits or mysterious fluids that dripped from them onto muscles for their stimulation. The profound work of Luigi Galvani in Bologna, Italy, in the eighteenth century established that electricity was the ‘substance that filled the nerves’. In 1791 he published his study ‘Commentary on the Effects of Electricity on Muscular Motion’. It does not seem that he followed up this work with observations on the heart, but others did over the next half century, particularly E-J Marey in Paris who studied ventricular contraction and other heart activity, producing the first crude electrocardiogram with a dog in 1875. It was a French-British physiologist, A. D. Waller, who recorded the first e.c.g. in a human in 1897.

Thomas Hunt Morgan was born in 1866 in Lexington, Kentucky, and became a professor in Bryn Mawr College – no wonder that I was confused about a putative, but erroneous, Welsh connection. He moved to Columbia University, as Professor of Experimental Zoology, and set up his famous “Fly Room”, where he and his students studied the genetics of Drosophila melanogaster, a fruit fly, for close to 20 years. They were able to demonstrate the chromosomal theory of inheritance, wherein genes are located on chromosomes, and where some genes are linked, being on the same chromosome and always inherited together.

Diabetes mellitus, ‘to pass through, sweet as honey’, has been known for thousands of years, water passing through the body by excessive thirst and urination, producing sweet tasting and smelling urine. Prognosis was poor, especially in children, and no therapy was remotely useful until the 1920s. Frederick Banting, the originator of the ideas about insulin, whatever later controversies suggested, was born in Ontario, Canada in 1891. His medical education was interrupted by the first world war, and he qualified at the end of the war and took up a post as lecturer in pharmacology at the University of Toronto. He started to become interested in the pancreas and studied previous work on the fate of pancreatectomized dogs.

Rarely in the history of medicine has a single observation had such a great impact, and rarely has that observation been entirely accidental. Alexander Fleming, later Sir Alexander Fleming, Nobel Laureate, a quiet, unassuming, research bacteriologist in London, UK, found, in 1922, that a chemical agent present in tears and saliva, which he named lysozyme, had weak antibacterial properties. This was potentially important to him since he had observed, when serving as a captain in the Army Medical Corps during World War One, that conventional antiseptics used on battlefield injuries usually caused more harm than good, and much better agents were needed.

There was only one solution for cancer up to the beginning of the twentieth century; cut the tumor out and hope for the best. Radiation therapy for cancer was introduced a few years into that century but the long-held belief that chemical or biological agents could affect the growth of tumors had not been realized in practice. Arsenicals were still being tried at that time, but without success.

During the First World War, new weapons such as heavy artillery, created battlefield injuries that had never been seen before. Shrapnel-filled shells caused immense damage in facial and head wounds. These injuries were not easily treated on the front line, and any emergency wound closure that was possible usually resulted in scarring and flesh tightening, which, along with massive tissue lost, pulled faces into a hideous configurations, leaving men unable to eat or drink, or even breathing normally. Into the horrendous hospital environment for the war- wounded back in England, came the New Zealander, surgeon Harold Gillies; he set up a special ward for facial wounds at the Military Hospital in Aldershot, and then at The Queen’s Hospital where he was able to reconstruct wounded men’s faces as fully as possible. This was the beginning of military plastic and reconstructive surgery.

Lung cancer was a rarity until the first years of the twentieth century, as was tobacco smoking. The mass production of cigarettes pre-world war I, and the massive encouragement of smoking in the military, increased this use of tobacco enormously. Nobody seemed to notice the abrupt and coincidental increase in lung cancer. By the end of the Second World War, both the UK and the USA were recording a very high incidence of the disease.

James Watson and Francis Crick, at Cambridge University, are rightly credited with the discovery of the double helix structure of DNA, although it has always been known that this would have not been possible without the contributions of Rosalind Franklin and Maurice Wilkins at King’s College, London. Within the story of this discovery, and the fame of the resulting Nobel Prize for Physiology or Medicine in 1962, the work by many scientists on DNA in the previous 75 years, is often overlooked.

Cataracts are areas of protein deposition within the eye that lead to increasing cloudiness and blurring of vision. Although they may involve genetic factors, or be associated with certain diseases such as diabetes, or with life-style matters such as smoking, they are essentially a consequence of ageing. Until the late 1940’s, the end stage of cataract treatment was simple removal of the affected lens and ‘correction’ of vision by eye-glasses. Around 1946, Harold Ridley, an ophthalmologist in London, considered the possibility of replacing the lens with a pieced of transparent plastic.

Poliomyelitis, usually referred to simply as polio, has probably affected humans for thousands of years, but was relatively uncommon until the late nineteenth century. However, it reached epidemic status in the early twentieth century and was particularly prevalent in countries with a high standard of living and in people of generally good health. By the 1950s, prevalence in the USA was around 60,000 new cases per year. Most of these were children; although around 5% of these died from the disease, the majority were paralyzed to some extent, without any really effective therapy.

John Charnley, later Professor Sir John Charnley, was an orthopedic surgeon based in the north- west of England, spending much of his career at Wrightington Hospital, just outside Manchester. He initially specialized in the treatment of fractures but soon turned his attention to osteoarthritis, especially of the hip. Although in early days he favored treatment by arthrodesis, that is by producing fusion in the hip joint, he soon saw the potential of arthroplasty, that is the replacement of the diseased joint by a structure that would permit complete movement. There had been attempts to use hemi-arthroplasty, replacing just one side of the joint, but this had serious limitations.

Angina pectoris, the clinical manifestation of myocardial ischaemia, was described in some detail, and given its name, by William Heberden in 1772. It is a consequence of coronary artery disease (CAD), which is now prevalent on an almost global scale. For the first 50 years of the twentieth century, many physicians and surgeons offered theories and experimental techniques to treat CAD, including Alexis Carrel, Claude Beck and Arthur Vineberg, the latter using ligation of the right internal mammary artery to increase blood flow to the coronary circuit. A major advance was made with the direct coronary anastomosis of the left internal thoracic artery to the left anterior descending artery (LAD) to enhance this flow.

There are very many elements to this episode in history; and I do mean history and not just medical history. In the 1960’s the country of South Africa powerfully embodied and formalized racism, the white Afrikaans dominating poorer black and colored communities. Apartheid, as this policy was known, caused the country to be shunned by much of the world, and this continued into the 1990s. In Cape Town a young cardiac surgeon was staking his claim as a pioneer and he had his eye on that elusive first, the transplantation of a heart from a ‘dead’ donor to a living, critically ill patient. Barnard went to the USA, where some very famous surgeons were working on the same target, and learnt their techniques. They were very close to carrying out this procedure, and virtually all surgical challenges had been solved.

Ever since the work of Louis Pasteur, Paul Ehrlich, Elie Metchnikoff, Robert Koch and others in the second half of the nineteenth century, it was realized that there were both humoral and cellular-driven processes that were involved with the defense of the human body, effectively defining the essence of the immune system. An central feature of this system is the ability to distinguish self from non-self constituents. This makes a great deal of sense but it was clear in the middle of the following century that this posed a very serious problem in the era of allograft tissue and organ transplantation. The solution to the problem was obvious; tease the immune system, preventing, or suppressing those mechanisms that normally rejected foreign agents.

As discussed elsewhere in this collection, coronary artery disease (CAD) has been the leading cause of morbidity and mortality in developed regions for many years. Since coronary artery replacement techniques are thoroughly invasive, there has been a sequence of innovations aimed at minimally invasive therapies. Dr. Andreas Gruentzig, a German cardiologist, whose work was based on that of the American Charles Dotter, performed the world’s first coronary angioplasty on an awake human in 1977; in this he expanded a short section of the left anterior descending artery, that had 80% stenosis. Whilst this was a revolutionary step, the elastic recoil of the arteries and the formation of a neointima caused re-stenosis within six months in 30% of cases.

Dr. Catherine Hamlin, Australian born and educated obstetrician died, at the age of 96, in her adopted home Addis Ababa, Ethiopia, a few weeks before I write this. In her early thirties, with husband Reg and six-year old son, she moved to Ethiopia to work as a hospital doctor and gynecologist. She stayed there for 60 years, still operating when she was 92, saving the futures and indeed lives of tens of thousands of Ethiopian girls who had been injured in, and then rejected by, their communities through the tragedy of the obstetric fistula. This is a life-long story, not the single major event that marks most historical moments in medicine, and I would not be aware of it were it not for a very thought-provoking obituary in the Economist and the record of the philanthropy shown to her cause by Oprah Winfrey.

The history of the cochlear implant is confusing and, in contrast to many other items in this series, it is difficult to pinpoint any one event or inventor that unequivocally marks the birth of this particular medical technology. The cochlear implant is intended to apply electrical stimulation to the ear in order to produce the sensation of sound. The implant bypasses damaged parts of the ear to deliver sound signals to the auditory nerve. They have a sound processor behind the external ear which captures the signals and sends them to a receiver implanted under the skin. This receiver sends the signals to electrodes implanted in the cochlea within the inner ear. These signals stimulate the auditory nerve, directing them to the brain.

The biblical expression ‘An eye for an eye, tooth for a tooth’ has been frequently misquoted and abused, but taken literally, the last part of the phrase has been the ultimate objective of the dental profession for many years. For a long time, attempt were made to transplant teeth, from willing or unwilling donors, and some were successful for a short while, but the lack of a reliable, long- lasting, independent, tooth replacement has meant that dentists have had to use a tool-bag of metals, ceramics, plastics and composite to patch up diseased teeth or structures such as bridges and dentures that try to mimic the functionality of teeth.

Dr. Mark Cowley Lidwell, a physician and anesthetist at the University of Sydney, Australia, started work on a machine that could apply an electric current to resuscitate neonates who presented with asystole. His first patient was treated in 1926 using a transcutaneous needle and mains electricity. This achievement received much attention but did not gain acceptance clinically; nor did the efforts of Albert Hyman in New York and Wilfred Bigelow in Toronto over the next two decades. It was not until the 1950s that the technique, which became known as cardiac pacing, came into prominence.

There are several definitions of infertility, one common epidemiological version indicating that it is ‘women of reproductive age at risk of becoming pregnant who report unsuccessfully trying for a pregnancy for more than two years’. By this definition, it is estimated that there are some 50 million couples world-wide in this situation. Until quite recently, very little, at least from a medical perspective, could be done to help them.

Peptic ulcers, those sores that occur on the lining of the stomach or the small intestine, have a marked impact on the quality of life, with burning stomach aches, nausea and vomiting, bloody stools and so on. It was commonly associated with lifestyle issues, especially stress, smoking and diet; all these risk factors tended to increase acidity and decrease the resistance of the mucous lining. Some fifty years ago, millions of individuals around the world suffered, to some degree, from these ulcers. Conventional wisdom determined that ulcers were not caused by pathogenic microorganisms since these (especially bacteria) could not survive in the intestinal environment.

For many years there was only one treatment for cancer; cut out the tumor and hope for the best. Along came radiation therapy, usually used in random with surgery. As explained elsewhere in this collection, chemotherapy was added to this list in the middle of the twentieth century. These three pillars of cancer treatment worked together quite well, but the serious and unpleasant side effects of most chemotherapy agents constituted a significant disadvantage.