Archive | The Osler Files

The Osler Society’s First Meeting & My History Project for the Year

Posted on 15 October 2015 by Rob Bobotsis

The Osler Society (Schulich’s History of Medicine Interest group) had our first meeting of the year recently. This is my second year as a member and the meeting was conducted in a very similar manner to last year’s gathering. As was done last year, we discussed the first chapter of Dr. Jacalyn Duffin’s History of Medicine: A Scandalously Short Introduction. However, with a sizeably larger group full of new faces, I found that the discussion took a much different path. One idea in particular stayed with me after I left the meeting, namely whether it is the medical invention or the inventor(s) that is more significant. I think one can find the inventor more interesting than their invention (and vice versa), but both are necessary for medical progress and therefore equally as important in my view.

Dr. Paul Potter and Dr. Shelley McKellar are faculty who we are very fortunate to have join us for Osler Society meetings. They asked if one can we really attribute an invention to one “great mind?” There was a resounding “no” to that question; rightly so in my opinion because no idea is created in a vacuum. There are so many external influences affecting how people think, behave and create. All this talk about innovation also had me thinking about how medical innovations, due to their inherent direct impact on human health, can be so controversial. Whether or not something is an innovation is hugely defined by the acceptance of the general public who will be subjected to a new drug, surgery or treatment modality. As I thought more about this idea, perhaps one of the most polarizing branches of medicine came to my mind, namely homeopathy.

I am no stranger to complementary and alternative medicines primarily through the influence of my father. He depends on insulin to live, yet strangely condemns modern medicine (I was there for his proclamations of the nescessity of iodine, then there was the salt craze and of course the importance of “earthing”).

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I know of homeopathy more so through friends and neighbours who are patients of homeopaths, but I also do quite a bit of independent researching on my own. I believe it is important to know about other treatment modalities as physicians because we have to be informed in discussions with our patients. Otherwise, our lack of knowledge as perceived by patients will negatively impact the relationship.
Homeopathy was created by Dr. Samuel Hahnemann (born in Germany in the mid-18th Century). He graduated from medical school and within 3 years of practicing he decided that he had a problem with the way medicine was being conducted. In particular he could not accept the practice of bloodletting because he thought it was too extreme. So, he decided to switch careers and became a translator. While translating Materia Medica, a treatise written by 18th century Scottish physician Dr. William Cullen (1710-1790, Professor of Medicine at Edinburgh), Dr. Hahnemann disagreed with Dr. Cullen’s explanation of how Peruvian bark (the source of quinine use to treat malaria) functioned. Hahnemann decided to experiment on himself by ingesting the bark, after which he experienced malaria-like symptoms (fever, diaphoresis, nausea etc). Hahnemann concluded therefore that a substance that causes a symptom in a healthy person will cure that same symptom in an ill person because the Peruvian bark, used to treat malaria, caused the same symptoms in a healthy person (himself). Hahnemann went on to test this principle by ingesting other substances, and whatever symptoms they caused he proclaimed they were also a cure for and from these tests Hahnemann devised the first rule of homeopathy, which is that “like cures like”.

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For the longest time I have wondered how this branch of medicine survived and more importantly has thrived for over 200 years to the present day. I have decided to dedicate my history of medicine project for the year to this end and that is what I am finally going to find out. Am I biased? Of course, but I am definitely open-minded enough and have a genuine curiosity to learn more. That is my history of medicine project this year, what are you curious about?

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How Mohs Surgery Transformed From Surgical Quackery Into a First-Line Treatment of Skin Cancer

Posted on 05 July 2015 by Rob Bobotsis (Meds 2018)

Mohs surgery is currently considered ideal treatment for many types of skin cancers, the most common form of cancer affecting North Americans today.[1] Cancer patients who undergo Mohs surgery can expect excellent survival rates, extremely small recurrence rates and pleasant cosmetic results. However, time and place matter with regards to how and why medicine is practiced and the transition from established medical dogma to novel discovery is not always smooth. This was certainly the case for Mohs surgery, which contradicted many standards of practice when the technique was first performed during the mid-20th century. Developed by American surgeon Dr. Frederic Edward Mohs (1910-2002), the desire to have a significant impact on skin cancer treatment may have been shaped during Mohs’ formative years as he recalls even as a young boy he knew skin cancers were not always being cured.[2]

 

Mohs Surgery: The Beauty Behind the Method

Mohs technique was much like traditional cancer excision, but with additional modifications. Mohs first treated a skin tumour with a zinc chloride paste he developed, which killed cancer tissue while making the sample firm and easier to handle. However, Mohs believed the most important effect was its preservation of microscopic features (much like formalin fixes tissue in vitro) allowing tissue to be accurately viewed microscopically.[3] Mohs sectioned tissue horizontally, which allowed 100% of the surgical margins to be viewed under the microscope. Contrast this with traditional pathologic processing of tissue where representative vertical sections are taken every 2-4 mm. This is fine for well-defined tumours, but recurrent tumours have bizarre conformations with thin outgrows extending beyond the tumour bulk that would be missed unless all the margins are analyzed. Additionally, Mohs maintained the orientation of the excised tissue so he could return to a very specific area of the wound to remove additional tissue areas that were cancer-laden.[4] Therefore, the least amount of tissue was removed from the patient while ensuring no cancer cells were left behind.

 

Influences That Prevented the Acceptance of Mohs Surgery

The early-to mid-20th century was a time rife with cancer quackery as a variety of pills, potions and ointments were being touted as cancer cures and promoted widely. Born in rural Illinois in 1901, Harry Hoxsey was an ex-coal miner who defined himself as a healer in the 1920’s and was one such individual promoting these controversial cancer cures.[5] What was ill-fated for Dr. Mohs was one of Hoxsey’s treatments and Mohs’ paste both contained zinc chloride.[6] As a result, zinc chloride had largely been rejected by the medical community because of the horror stories associated with its use, particularly in Hoxsey’s clinics.[7] While there was certainly this larger dogmatic barrier due to the quackery association, there were also factors related to the technique itself that made it difficult for colleagues to accept. Surgeons at this time believed cutting into the tumour would to cause it to spread, so Mohs’ approach of removing the tumour piece by piece was thought to be dangerous for the patient.[8] The procedure itself also took days to complete and was painful for patients as Mohs would apply the zinc chloride paste (an escharotic agent) the day before surgery.[9] Mohs’ approach was so unlike the accepted procedures of surgical tumour removal that when other physicians saw the extensive erythema, edema, and purulence of the open slowly healing wounds, they thought their suspicions were confirmed.[10]

 

Circumstances that Lead to the Acceptance of Mohs Surgery

Today Mohs surgery is certainly not considered surgical quackery, nor is it considered a deviation from standards of surgical practice, but the eventual acceptance of Mohs surgery was a long process. The zinc chloride paste eventually disappeared as a barrier to the acceptance of Mohs surgery because there was a transition from the so called “fixed-tissue technique” (Mohs surgery with the zinc chloride paste) to a “fresh-tissue technique” (Mohs surgery without the use of the zinc chloride paste). This helped eliminate the association of Mohs surgery with the charlatan applying caustics to tumours. Mohs was originally targeting his research towards the attention of his surgical colleagues, but through various talks he gave during the 1940’s Mohs realized it was the dermatologists who were interested in his work. Theodore Tromovitch was a dermatologist and one of the first physicians to train with Mohs.[11] Tromovitch was instrumental in transitioning Mohs surgery from a fixed-tissue to fresh-tissue technique and reported great success in the early 1970’s performing Mohs surgery without the zinc chloride paste.[12] Not only were outcomes just as promising, but patients were even more grateful because of the decreased morbidity associated with the procedure. Tromovitch reported that his patients experienced significantly less pain as the zinc chloride paste was no longer applied to their skin the night before the surgery.[13]

 

Conclusions

Mohs considered himself an inventor, and based on the historical trajectory of Mohs surgery thus far I would argue that the real innovation here was the microscopic control, not the zinc chloride paste that caused so much resistance from Mohs’ colleagues.[14] Microscopic control referred to this idea of removing tissue in pieces, examining it under the microscope for the presence of cancer cells and then only returning to areas where cancer was present to remove additional tissue from the patient. This would ensure no cancer cells were left behind as this process was repeated until a cancer free plane was observed microscopically. It also ensured the least amount of tissue was removed from the patient as only areas with cancers cells present were excised further. Once the zinc chloride paste was removed from the procedure it became much easier for others to see the beauty of Mohs’ methodology, a transition which would not have occurred without the help of dermatologic colleagues.

 

Footnotes

[1] Randall K. Roegnigk and Henry H. Roenigk Jr., ed. Dermatologic Surgery Principles and Practice (New York, NY: Marcel Dekker, 1996), p. 703.

[2] Frederic E. Mohs, “Frederic E. Mohs MD,” Journal of the American Academy of Dermatology 9 (1983): p. 807.

[3] Frederic E. Mohs and Rachel Caruso, “Chemosurgery and Skin Cancer,” AORN Journal 13 (1971), 90.

[4] Ibid.

[5] Morris Fishbein, “History of Cancer Quackery,” Perspectives in Biology and Medicine 8 (1965): 157

[6] Dirk M. Elston, “Escharotic Agents, Fred Mohs and Harry Hoxsey,” Journal of the American Academy of Dermatology 53 (2005): p. 523.

[7] David G. Brodland, Amonette Rex, Hanke William and Perry Robbins. “The History and Evolution of Mohs Micrographic Surgery,” 26 (2000): p. 303.

[8] Ibid., p. 303

[9] Frederic E. Mohs, “Frederic E. Mohs MD,” Journal of the American Academy of Dermatology 9 (1983): p. 811.

[10] John A. Zitelli, “Mohs Surgery: Concepts and Misconceptions,” International Journal of Dermatology 24 (1985): p. 546.

[11] Frederic E. Mohs, “Frederic E. Mohs MD,” Journal of the American Academy of Dermatology 9 (1983): p. 810.

[12] Ibid., p. 811.

[13] David G. Brodland, Amonette Rex, Hanke William and Perry Robbins, “The History and Evolution of Mohs Micrographic Surgery,” 26 (2000): p. 304.

[14] Ibid., p. 305

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Anatomical Fascination: The Wax Venuses

Posted on 07 February 2015 by Cindy Zhu (Meds 2018), The History of Medicine Club

Today wax figures are synonymous with Madame Tussaud’s life-sized sculptures of famous movie stars, athletes, and historical figures, as a tourist attraction. What many may not know is that Tussaud’s wax modelling skills were actually apprenticed from a physician, Dr. Philippe Curtius, and that Curtius used these skills not only as a medium for the fine arts but for creating realistic anatomical models for medical education. As dissections of human cadavers were still infrequent and religiously opposed, and illustrations were limited by their two-dimensional nature, the art of anatomical modelling began to blossom in 18th century Europe. Frequently, these models were not simply instructional diagrams but also communicated the relationship between the human body and the divinely created world as a whole, as understood at the time.

History of Medicine (1)

Of particular interest are several Italian wax models of women sometimes called the “Anatomical Venuses”, created by Clemente Susini in Florence after he joined the workshop of La Specola in 1773. These life-sized figures are reclined on a silk bed in a glass and rosewood case, adorned with glass eyes and human hair, and can be dismembered into dozens of parts to reveal its finely crafted anatomy. Not at all suggestive of a medical specimen, these attractive figures recall the beauty of classical sculpture and almost seem to be alive.

History of Medicine (2)

Their languid gaze has been described as recalling that seen in the sculpture Blessed Ludovica Albertoni by Bernini, completed in 1674, where Ludovica is portrayed in a moment of mystical communion with God as her death nears. These figures thus make a statement about the nature of life and death, connecting a medical understanding of the body with its greater purpose of serving as a vessel for the soul during its time on Earth. The medical students of the time would be reminded of the context of their practice each time they used these models.

Today, these figures are open for public viewing in the museums of medical institutions as objects of art and spectacle, perhaps not unlike Madame Tussaud’s exhibitions. As I learned about them during my research on the use of modelling in medical education, I could not help but become fascinated by this combination of the medical, the artistic, the religious and the social context which exemplifies the appeal of studying the history of medicine for many.

 

References

  1. Ballestriero, Roberta. Anatomical models and wax Venuses: art masterpieces or scientific craft works? Journal of Anatomy. 216(2):223-234.
  2. Ebenstein, Joanna. “An Ode to an Anatomical Venus.” Atlas Obscura. 14 Feb 2013. Web. <http://www.atlasobscura.com/articles/an-ode-to-an-anatomical-venus-morbid-anatomy>
  3. Kemp, Martin and Wallace, Marina. Spectacular Bodies: The Art and Science of the Human Body from Leonardo to Now. Hayward Gallery, University of California Press. 2000.
  4. Riva, Alessandro. Flesh & Wax: Clemente Susini’s Anatomical Models in the University of Cagliari. Illiso Publishing House. 2007.

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A discussion based on “History of medicine: A scandalously short introduction”

Posted on 29 November 2014 by Annie Li (Meds 2018), The History of Medicine Club

How do social practices fair in the face of epidemic disease?

Looking into the past, we arrive at The Plague of Athens, where a contagious and fatal disease was rampant. Determining disease etiology was highly important as it provided insight to possible remedies. The clergy believed that the plague was due to divine punishment. Others believed that the attacking Spartans had poisoned their wells. Still others said that the plague was due to the long war and starvation. When the etiology could not be identified, and no remedy effective, social structure broke down – fear, self-preservation and perhaps opportunistic gains took over.

Moving forwards, we arrive at the Black Death – a disease that produced in its victims symptoms of fever, swollen and oozing nodes, dehydration and death. At the time, Black Death was known to be spread by travellers. This caused a heightened sense of them and us. The outcome was such that not only travellers suffered cruelties, but minorities, and village idiots were also targeted. Social construct within the dominant population also broke down; the living wandered the countryside, the sick were shunned, and the dead left unburied. Furthermore, the certain fatality of this disease and the inability of any authority to remedy it shook the foundations of the feudal social system.

Further still, we arrive on North American shores where waves of European immigrants brought with them typhus and cholera. Treatment towards the immigrants was incredibly biased and unjust. Boarders lined with angry and fearful residents. Unfortunately, sick and healthy immigrants were regarded alike and were forcefully isolated and quarantined together. Inevitably, the healthy became sick and the majority of immigrants succumbed to the disease. With imported diseases, social structures dealing with the other are under strenuous stress and courtesy is unlikely to be observed.

Presently during the Ebola epidemic in West Africa, how have we faired? Fear, there is definitely plenty of that – both in Western Africa and in the Americas. In West Africa fear may be gathered from the unburied bodies, street riots and vigilant adherence to rituals. In the Americas fear is seen in futile and exaggerated precautions to this virus. Futility is seen in the implementation of thermal scans at airports, which neither accounts for the incubation period of the disease nor the other more common diseases associated with fevers abroad (e.g. malaria). Exaggerated response is seen in the suspension of basic human rights to a nurse who had returned from West Africa. Ms. Hickox and was forced to live in a tent, in a hospital, without shower and directed to wear paper scrubs. Despite this fear (which spans back to antiquity), I would argue however, that we are learning. Fear is limited by limiting the epidemic. Given our current understanding of science, epidemics are best limited by targeted and vigorous screening, isolation or quarantine and if need be, proper disposition of the body. (These elements may be seen in Nigeria’s successful response to Ebola.)

It is perhaps instinctive that during epidemics (historical or present), fear transcends established social structures. Although it seems circular, one feasible solution preventing the collapse of social constructions during epidemics is to prevent epidemics altogether. Currently, with our investment and knowledge in science, we are in a much better position to prevent epidemics than our historical counter parts.

 

Reference

Duffin, Jacalyn. “Chapter 7: Plagues and Peoples: Epidemic Diseases in History.” History of Medicine, Second Edition: A Scandalously Short Introduction. 2nd ed. Toronto: U of Toronto, 2010. 163-194. Print.

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