History of Medicine in Practice: An Interview with Dr. Adam Rodman of Bedside Rounds

By: Ariel Gershon

In my previous posts, I have been trying to share some interesting facts from medical history, and have been trying to describe why studying the history of medicine is meaningful for those of us entering this profession.

For this post, Dr. Adam Rodman, the creator of one of my favourite medical podcasts joins me for an interview.

Dr. Adam Rodman is an internal medicine physician at Hospitalist at Beth Israel Deaconess Medical Center, and an Instructor at Harvard Medical School. He runs the podcast Bedside Rounds, which is chock full of fascinating narratives from the history of medicine.

Could you tell us about yourself? What does a typical work day look 
like for you?

Thank you for having me! I’m a hospitalist now, though initially I was a global health physician through the amazing Beth Israel Deaconess Medical Center Global Health Fellowship program, where I worked at Scottish Livingstone Hospital in Molepolole, Botswana. I was the physician on the medical and tuberculosis wards; physician there means, as it still does in much of the world, an internal medicine-trained doctor. My life is a little less exciting now that I’m permanently in Boston, but I still have a great job. It’s actually not that different than Botswana, though the pathology is different, of course. I care for medically-complex patients in the hospital, with either myself as their sole doctor, or as part of a larger team of residents and students.

In a typical day, I get to the hospital around 8 and start to “bedside discovery round” with my team — that is, we go and see each of our patients together, and along with the patient we review their data and discuss their plan for the day. In the afternoon, I’ll either help my team by seeing patients, teach the students and residents, precept in a student-run clinic,  or even just work on my academic research, including my podcast Bedside Rounds, which I make in partnership with the American College of Physicians.

At what point in your medical career did you become interested in
the history of medicine?

Oh, that’s a great question! I’ve always been interested in history, unsurprisingly — I was a history major in college. But I don’t think my interest in the history of medicine came until well after medical school. As I’m sure you know, medicine is presented very ahistorically — you drink from a firehose of information, with very little context or background for why or how things developed. Like most students, I just accepted this. This is how medicine was:MONABASH* after MI, a fever is 38 centigrade, make sure you pre-round on all your patients or the attending will be mad. When I was a resident, though, I became more and more curious about WHY we do the things that we do. There are lots of ways to address the question “why”. A lot of basic science research seeks to answer these questions, as does the evidence-based medicine project at large. For me, medical history was my outlet for curiosity. So, to answer your question, I’d say the second year of residency was when I really started getting comfortable enough with my own medical practice to start questioning things.

Do you feel that studying the history of medicine changes how you
practice medicine? If so, can you share an example?

Yes, yes, and yes! Studying history has changed my entire approach to practicing medicine. So first, at a concrete level, it helps me question dogma. So, like I was mentioning before, the study of medical history will quickly reveal that so much of what we’re taught in medical school stands on shaky foundations.

One of the classic examples is the definition of a “fever”. We’re all taught that a fever is 100.4 or 38 degrees Celsius. It’s scientific simplicity. You’ll even see some of our colleagues confidently announce, “it’s either a fever or it’s not!” and make fun of patients who say, “I run low, so 99.7 is a fever for me.” But even a cursory examination of history will show that this was based on mid-19th century data from Wunderlich, using an esoteric thermometer, axillary temperatures, unclear data analysis, and a, let’s just say… an imprecise method of measuring data. Moreover, numerous studies have shown that body temperatures are not only lower, but vary throughout the day — and in fact, the most important thing appears to be variation from the patient’s own baseline. It turns out, in this case, that taking an historical approach is, in fact, taking the scientific approach, critically appraising data that has real clinical impact. And while we’re at that, taking an historical approach also shows that our patients’ own experiences are probably accurate — they probably do “run low” because 98.6 F is high! **

And once you start to realize this with one subject, you realize that a whole spate of medical knowledge is equally shaky or contingent. You’ll discover arbitrary drug dosing and durations, very real epistemological concerns about our ability to know what causes disease, and even reason to doubt some randomized controlled trials — I don’t want to turn this interview into a lecture about skepticism, but I’ll add that the more you read about the fragility index, the more you’ll see that the basis of our knowledge is often far shakier than we’d like to admit.

I don’t want to say that a study of history has made me cynical — it hasn’t; if anything, I’m far more aware of how much good we can do now compared to past eras. But it’s made me very humble about the limits of our knowledge. And it’s made me focus on many of the older qualities of being a physician — compassion, good communication skills, and being at the bedside.

In your episode “The Cursed” you describe the outlandish      
autopsy findings of King Charles II of Spain as an example of how a
different system of medical knowledge can produce a difference
medical gaze. Can you talk about how being aware of your own gaze
changes how you approach medicine, if at all?

I was hoping you’d ask this question! So as a brief explanation to your readers, the clinical gaze refers to the postmodern concept first stated by Michel Foucault in the Birth of the Clinic that our scientific and epistemologic structures fundamentally shape how we approach the patient. Listen to the episode if you want more! Or even better, read the Birth of the Clinic!

As medical students, you are all becoming acculturated in a very specific gaze. It’s not necessarily a bad thing, I should add — my clinical gaze allows me to suspect, say, pericardial tamponade within minutes of talking to a sick patient (as happened in the past few weeks). But being aware of my own gaze has made me realize that many of the things I do are for my gaze, rather than for my patient. Examples abound, but generally we want data at the expense of our patient’s experiences; we have elderly patients who are woken up every 4 hours overnight for vitals checks. We draw “daily” labs at 4 AM on patients who have long since showed clinical stability; if a patient is getting better, you do not need to “trend” their leukocytosis resolving; if they are stably anemic you do not need to “continue to monitor” their hemogram. That only satisfies our gaze. We forget that the patient is in front of us, and not in the computer (another postmodern concept — the EHR as simulation).

It’s also made me re-prioritize how I spend my limited time during my day. Often one of the least useful things to a modern clinical gaze is the thing that patients most appreciate — sitting at their bedside and chatting with them about their lives. I think we all know we need to spend more time with our patients — but being aware of my gaze has really made me understand why.

Is there anything else you would like to add or talk about?

Yeah, one final thing — a plug for students. You do not need to be really into medical history to be a good doctor. But the impulse that is behind it — curiosity — is essential, and often squelched in medical education. We have an amazing field that privileges such an important position in our patients’ lives. What differentiates the great doctors from the merely good is a deep, abiding curiosity — about science, about our patients, about why we do the things the way we do. Make sure to cultivate your curiosity and creativity throughout medical school, and not just in medicine. Keep playing your instruments, keep producing art, keep reading for fun. The curious mind makes a wonderful physician!

If you are looking for a podcast to listen to in between your 
studying sessions, I highly recommend Bedside rounds
(http://bedside-rounds.org). Dr. Rodman is starting  a medical
podcasting clinical elective in Boston later this year. Follow him
@adamrodmanMD (https://twitter.com/adamrodmanmd )

* Editor’s note: MONABASH is a mnemonic for remembering the management of acute coronary syndrome. It stands for Morphine, Oxygen, Nitro, Aspirin… (review this here: https://www.timeofcare.com/monabash-management-of-acs/ )

** Editor’s note: There is a discussion of the origin of fever measurements in episode 33, found here: http://bedside-rounds.org/episode-33-alexis-and-william/

About Author: Ariel Gershon

Ariel Gershon (Meds 2019) completed a BSc at the University of Toronto in pathobiology before starting at Schulich. He was a president of Schulich’s Osler Society from 2016-2017, a group of medical students who meet to talk about the history of medicine over lunch. He‘s interested broadly in the medical sciences, medical humanities, and indoor gardening. Tweet at me @GershonMD2019

Photo Credits: American College of Physicians (ACP)

Part 2: The Philosopher Emperor

By: Eric Di Gravio

Marcus Aurelius: In the Capitoline Museum

In my previous blog post, I started to describe how Marcus Aurelius thought that we should face all our struggles without complaint. But where does the strength to do this come from? Let’s continue with what Marcus thought the answer to that question was:

You have power over your mind-not outside events. Realize this, and you will find strength.

A strong person, according to Marcus, recognizes that strength comes from within. It’s in our thoughts and in how we choose to perceive the world around us. The Stoic philosophy that Marcus learned as a young adult taught him that no events which happen are in themselves evil, it’s only our perception of them that is evil. If we have the inner fortitude and belief that we will overcome whatever hardship we are facing, then that is the source of true strength. Marcus explains this well and takes it a step further when he says:

Apply this principle: not that this is a misfortune, but that to bear it nobly is good fortune.

Again, it all comes down to perception. Question yourself: Is this difficult task or unfortunate event really a bad thing, or is it simply an opportunity to make myself better? If we begin to face our problems with this in mind (which I understand is no easy feat), then we will be facing it with all the strength we can muster, and we can’t ask for much more than that.

One last passage on this topic that I found particularly powerful is the following:    

Thou sufferest this justly: for thou choosest rather to become good tomorrow than to be good today.

Medical school and being a doctor isn’t going to be easy, it was never going to be. But all the exams we write, the facts we memorize, the patients we will see and inevitably, the mistakes we will make along the way, are simply necessary steps to make us better people, and doctors of tomorrow. 

What Motivates Us

In his Meditations, Marcus spends much time discussing the purpose of his life. As he mentions over and over again, he finds the praise of others (remember that he was considered a god), the pursuit of fame, glory and wealth all as hollow things. His line of thinking is, if everything including yourself is transient, then what is the point of achieving fame and glory when people are bound to forget you eventually? As Marcus says:

What is even an eternal remembrance? A mere nothing.  What then is that about which we ought to employ our serious pains? This one thing, thoughts just, and acts social, and words which never lie, and a disposition which gladly accepts all that happens

This was not meant to be some doom and gloom statement about how we are all going to die and nothing matters. Instead, by constantly repeating statements like the ones above, Marcus was attempting to keep himself well-grounded and not to get caught up in all the extravagances that many prior, and certainly many later emperors did. He was reminding himself then, and us now, what the truly important things in life are: acting justly and for the common good, and being thankful for what life has given you. Marcus then goes a step further and says:

Have I done something for the general interest? Well then I have had my reward. Let this always be present to thy mind, and never stop doing such good.

Here again, Marcus is reiterating the fact that acting for the common good is the highest reward one can receive, even if its not appreciated at the time. Indeed, it is the very act of working for the common good that should serve as our motivation for everything we do. In other words, the most important thing is being able to go to bed each night with the satisfaction of knowing that we helped someone that day, and that that act in and of itself should be all we need to keep us satisfied and motivated.

Final Thoughts

I couldn’t help but wonder what Marcus would say if now, almost 2000 years later, I were to ask him for one piece of advice about how to be a good person and leader. But then I came across this passage in Meditations that I think answers that question pretty clearly.

Waste no more time arguing what a good man should be. Be one.

Alright then Marcus, point taken. I guess he would say that we all already have it in our hearts what it takes to be a good person and doctor, we just have to have the strength and dedication to do it.

A note on translations:

Since the Meditations are essentially Marcus’s reflections on the philosophical school of thought called Stoicism, and the vast majority of philosophical teachings at the time were written in Greek, Meditations too was written in Greek (even though Latin is the language most commonly associated with Ancient Rome). As in any work of literature originally written in ancient Greek, there are various different translations which all have the same essence, but with slightly different wording. Therefore, if you look up these quotes online or have heard/read a slightly different quote than one I have used here, note that it is simply a different translation of the same piece of work, and hopefully you can see that it captures the same meaning.

Select Quotes from Meditations:

  • “And though wilt give thyself relief, if thou doest every act of thy life as if it were the last, laying aside…discontent with the portion which has been given to thee.”
  • “Short then is the time which every man lives, and small the nook of earth where he lives; and short too the longest posthumous fame”.
  • “Which of these things is beautiful because it is praised, or spoiled because it is blamed? Is such a thing as an emerald made worse than it was, if it is not praised?”
  • “The best way of avenging thyself is not to become like the wrongdoer.”
  • “Let not future things disturb thee, for thou wilt come to them, if it shall be necessary, having with thee the same reason which now thou usest for present things.”
  • “No man can escape his destiny, the next inquiry being how he may best live the time that he has to live.”
  • “Look within. Within is the fountain of good, and it will ever bubble up, if thou wilt ever dig.”
  • “Neither in thy actions be sluggish nor in thy conversation without method, nor wandering in thy thoughts…nor in life be so busy as to have no leisure.”
  •  “This too is a property of the rational soul, love of one’s neighbour, and truth and modesty.”
  • “If it is not right, do not do it: if it is not true, do not say it.”

Author: Eric  Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 
Photo Credit: Marcus Aurelius, Creative Commons

The Philosopher Emperor

By: Eric Di Gravio

Equestrian Statue of Marcus Aurelius, Rome

Part 1

I have always considered myself a history buff. I will admit, I still pride myself on my collection of books accumulated from childhood that fill my room. While history has always been a hobby of mine, as I got older, I found myself finding inspiration in the lives and exploits of men and women throughout history; from ancient Mesopotamia to the global conflicts that shook our world in the 20th century. Since starting medical school, I now find myself reflecting on what it means to be a ‘good doctor’ and have begun to see the stories of these same men and women in that new light. Recently, I have been on a bit of an ancient Rome/Greece binge and in doing so have come across (again) the writings of the Roman Emperor Marcus Aurelius (yes, the old emperor in Gladiator). For reasons I will endeavour to share with you, I think that we have much to learn from this once beloved emperor about how to be a good person and by extension, good doctors. But first, let us start with some background.

Importance of the Roman Empire

Ask someone to blurt out the first thing that they think of when you say “Roman Empire” and chances are it will be the Coliseum, gladiators, togas or Julius Caesar. But the Roman Empire has given us so much more than a trendy tourist hotspot, movies with Russel Crowe fighting sadistic emperors, toga parties or Caesar salad (spoiler alert, Caesar salad has nothing to do with Julius Caesar). Rome is everywhere, from the ruins left behind to the borders of our modern-day countries, even to the organization of our governments. But what can we learn from the people, places and history of 2000 years ago? While that is a question that countless classical historians have spent their lives trying to answer, what I add is this: the world of the ancient Romans that Marcus Aurelius knew was not so different from ours. Just like us today, the ancients worried about the economy, national security, religion, politics, healthcare and countless other existential crises.

Who was Marcus Aurelius?

Born in 121 AD in Spain, Marcus Aurelius was adopted by his uncle and future Roman Emperor Antoninus Pius as his son and heir to the throne. Upon becoming emperor after the death of Antoninus, Marcus devoted much time to reforming the law to be fairer for the poor and powerless, promoting free speech, stabilizing the armies and boosting the economy. For this and for his famously humble and simple personal life, Marcus is known as the last of the five “Good Emperors” and the last emperor of the “Pax Romana (Roman Peace),” stretching from the first emperor Augustus all the way to Marcus, a period of about 207 years. While there has certainly been some romanticising of this era in Roman history, there is no doubt that these years saw Rome at the height of its power in terms of economic wealth, territorial extent, military success and relative peace within its borders. After the death of Marcus, the Roman empire fell under increasingly more despotic emperors, witnessed decades of civil war and economic recession, and never truly regained the same power, influence and wealth that it had enjoyed previously. 

Marcus’ biggest claim to fame however remains his Meditations. While by day Marcus was fending off the invasion of the Germanic “barbarians” into the Roman empire, by night he was writing in a personal diary his daily thoughts and feelings. Never intended for the public eye, Meditations reflect the inner thoughts of Marcus at his most vulnerable and dark times while he reflects back on the teachings of the Stoic school of philosophy that he had learned as a young man. Preserved after the death of Marcus, this diary allows us a glimpse into the thoughts of one of the most humble and down-to-earth people to ever live, let alone be an emperor. Reading his work, you get no hint that this was written by one of the most powerful men, in one of the most powerful empires ever to set foot on the world (considering that Roman emperors were basically treated as gods on Earth). Just like many people before me, I too have found inspiration in the words of Marcus and think that there is something in them that can give us some insight into how to be good people, and by extension, good doctors.

Following then, is a collection of some of the lessons I believe we all can learn from Marcus.

On Handling the Tough Times

Even though he was an emperor, Marcus was no stranger to struggle. Death loomed heavy over his head as he witnessed both the death of many of his children, and also the eventual death of his wife. Even Marcus himself was a sickly man, (although we don’t know his exact ailment today) his seemingly impending death seemed often to be on his mind throughout Meditations. Apart from personal struggles, Marcus also had an entire empire to worry about. Early in his reign, he was fending off invasions from the Parthian Empire in his Eastern provinces. Even after a Roman victory, there was no time for rest, as very soon after there was a plague (likely smallpox) that ravaged the empire, closely followed by an invasion of Germanic “barbarians” along the northern border… and it keeps going. 

The biggest lesson I think we can learn from Marcus in this regard is best summarized by this passage in Meditations:

‘A cucumber is bitter.’ Throw it away. ‘There are briars in the road.’ Turn aside from them. This is enough. Do not add, ‘And why were such things made in the world?’

            The lesson that Marcus has captured in this passage is the fact that hardships will happen to everyone and there is no use thinking “why me?”. Marcus would say that instead of becoming upset that such things have happened, we should focus our energies on solving them and moving forward. Thoughts of “why me” or “this is such a waste of time, why do I have to do this” are in themselves “wastes of time” and don’t help solve the problem or complete the task at hand. 

But where does the strength to do this come from? Check out my next blog post to learn where Marcus thought the answer to this question laid. 

Author: Eric Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 

How can we understand disease? In search of “best evidence”. Triangles, Diseases, and Illness in the History of Medicine.

Is it real? In the busy family medicine clinic, I am talking to a middle aged woman with a new diagnosis of diabetes. Even though she is reasonable and intelligent, she doesn’t really buy into it. I’d rather not be on medication. I feel fine. She’s right, but I know what could happen to her if she’s untreated.

What is a disease? Who is a patient?

These are fundamental questions to medicine. Studying the history of medicine allows you a deeper understanding of diseases. This is important because it has implications on what we are actually doing as medical students / future health professionals.

Maybe surprisingly, we don’t ask the question “what is a disease” very often in the medical school curriculum. It’s obvious most of the time; a problem in anatomy or physiology is a disease. Tuberculosis, diabetes, and thyroid cancer are all obviously diseases.

The closest the pre-clerkship curriculum comes to asking “what is a disease” directly is through psychiatry course in pre-clerkship. According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (the “DSM”), the definition of a disease depends on symptoms, but requires also a “functional deficit”. This means the symptoms must interfere with your life. According to this model, if a person had persistent low mood, changes in appetite, and visual hallucinations, (all symptoms of major depression), but was still able to function (ie. go to work or school), he would not have the mental disease we call depression.

Answering the question “what is a disease” is out of the scope of this blog post, and there is more nuance to the DSM in that functional deficit can include emotional distress, which I will also put aside. What about my patient who was unconcerned with her high blood sugar over the past year? If she is able to go to work, and is not bothered by it, does she avoid having the disease called diabetes? Before you say “no, obviously” In order to understand the diseases we treat today, it is helpful to know that disease is a changing entity.

The pyramid of evidence based medicine

At some point in every medical school, this triangle is studied.

The “triangle of evidence” describes modern biomedical science in a single figure.

The picture describes a hierarchy of scientific studies. There are many variations on it, but the essentials are as follows: individual patient experiences (case series), and expert opinions are nearest to the bottom, while randomized large sample trials are nearer to the top. Even higher are “reviews” which average out multiple RCTs. The point is to average out as many patients as possible to average out the noise and arrive to an answer.

Nearly every one of these graphs has an arrow pointing upwards, reminding us which way to move. Strictly, the higher we go on the chart the more strength there are for causal claims. Most graphs drop the nuance and just say “increasing strength” or “increasing quality”.

The triangle is powerful, and this process provides medicine with practical answers to questions about causality. It has been applied to every area of medicine.

I argue that, while a powerful approach, EBM has a great weakness.

III. Duffin’s Hippocratic Triangle

The triangle of evidence is so commonplace it’s difficult to imagine what medicine looks like without it.

There were many scientific advances which dramatically revolutionized medicine – around 1900 germ theory is developed and doctors began to think about pathology at the level of cells. New ways are developed to look into the body and these become .the gold standard.

Before all this, diseases were primarily defined by symptoms, and the model for disease was based upon a balance of four humors – theoretical fluids filled in the body. For example, jaundice was caused by an excess of yellow bile.

The core of medicine was not in cells, but instead the ability to care for patients (from Latin patientem meaning “one who suffers”).

Dr. Jacalyn Duffin, a hematologist and historian, develops a different triangle in order to teach what a disease is which is rooted in history. By Hippocratic teaching, a disease is made up on a combination of the observer (the physician), the patient, and the illness. Two patients, being different people, have different experiences even with the same illness being treated by the same doctor – this means they have different diseases! Crucially, the observer (doctor or medical student) also makes up a part of the disease.

This triangle also lacks a hierarchy. There is no clear way “up” – the doctor, the illness, and the patient are equally important in defining a disease. In contrast, the “case report”, is always on the bottom rung of the EBM.

How does this help?

It’s good to know that metformin works to reduce blood sugars in diabetes. Even though the evidence is backed by RCTs, some diabetic patients do not take their prescribed medications. The medical term for this behaviour is noncompliance or denial. Often medical trainees and doctors can find this frustrating.

Being aware of Duffin’s triangle (and the history of medicine) makes you understand that the patient’s experience with an illness will actually produce a different disease every time. The triangle also reminds us that the physician matters. Diabetes, then, is not simply just abnormal blood values. Validating the “noncompliant” patient’s experience changes the disease.

Further reading

  1. Duffin ‘s book Livers and Lovers uses explores changing disease concepts over time
  2. Podcast lecture on the history of the stethoscope. This is related to the transition in medicine,  https://player.fm/series/big-ideas-video/jacalyn-duffin-on-the-history-of-the-stethoscope

About the Author: Ariel Gershon

Ariel Gershon (Meds 2019) completed a BSc at the University of Toronto in pathobiology before starting at Schulich. He was a president of Schulich’s Osler Society from 2016-2017, a group of medical students who meet to talk about the history of medicine over lunch. He‘s interested broadly in the medical sciences, medical humanities, and indoor gardening. Tweet at me @GershonMD2019

 

Photo Credits: Featured Image; Internet Archive Book, Creative Commons
Header Image; Ryan Adams, Creative Commons

Rogue One: A Drug Wars Story. What Can History Tell Us About Pharmacy?

How should we regulate pharmaceutical innovation?

This blog will have a series of posts which seek to explain why a medical student ought to care about the history of medicine.

In the distant past, James Payne, MD candidate 2021, wrote a compelling article arguing that the current pipeline for producing new medications may be overregulated. Contemporary drug development is loaded with checks for safety, efficacy, even just plain bureaucracy. James raises the possibility that regulation results in worse medicines.

In particular, the FDA has legal authority to approve or deny new medications on the basis of safety and efficacy. If clinical trials are unavailable or unconvincing, the drug cannot make it to market. Presumably, this is to protect the public health– how could it possibly be to anybody else’s benefit?

The world of pharmaceuticals is a complex swirl of economics, policy, organic chemistry, and medicine. What could a historian add to our understanding?

I argue that there are unique insights that the study of the history of medicine can contribute to this medical problem.

HIV medications, ACT UP.

In the early 1980s there was an unprecedented health crisis brewing in the US. In 1981, it was noticed that a population of homosexual men were suffering from diseases previously only associated with severely immunocompromised patients: Pneumocystis jirovecii pneumonia, esophageal candidiasis, Kaposi sarcoma. By the end of 1981, 270 of such cases were documented by the Centre for Disease Control. In 1992 alone, 33,590 were estimated to die of HIV related illnesses.

Amongst the outbreak, organizations advocating for faster drug development materialized.

Anti-retroviral were being developed but had not yet found use in the clinic. ACT UP was an activist organization whose goal was to take down the FDA. The main argument was that medications were a health care commodity, and that patients then had a right to access to those medications, even if through a research study. The specific research methodology of double-blind placebo was called into question as unethical. The slogan was simply “drugs in people”.

It was effective. HIV is, of course, still with us today. It has been tamed from a devastating epidemic into a chronic condition. In large part, this was due to the activists which called for the dismantling of FDA bureaucracy in a time of crisis.

One part of history of medicine is a collection of facts. Remembering the fact that thousands of HIV positive people died of AIDS in the absence of treatment can be an important consideration when thinking about the troubles associated with studying the safety of medication. It’s not simply an academic concern, but a lesson people have had to suffer through.

Psychiatry and FDA from 1950-1970s

The FDA was first established to regulate the safety of medications. On the face of it, they act as an agency to prevent the powerful pharmaceutical companies from taking advantage of the general population by producing unsafe or ineffective medications.

As ACT UP has argued, the outcomes of FDA regulation did not serve the general public in the case of patients dying from HIV. As opposed to outcomes, exploring the intent of the FDA, however also reveals that the priority may not have been for public good.

Dr. Edward Shorter, historian of psychiatry, explored unpublished and archival internal communications of the FDA from 1950s-1970s. In this time, the FDA was gaining new legal authority (through the Kefauver-Harris amendment in 1962), and was exercising this political will not in service of the public, nor in service of pharmaceuticals, but for itself! A number of previously safe and efficacious medications for mood disorders were banned from the market, for example meprobamate. Dr. Shorter describes this as the agency going “rogue”. The FDA decided first that meprobamate was to be regulated, and actively suppressed expert testimony to the contrary, as per internal documents.

The second part of the history of medicine is the process by which new facts are discovered. These new insights into the pharmaceutical industry could only be discovered by interrogating the archive.

One of the reasons I love studying history of medicine is that it allows us to seriously reconsider our presumptions. If we start by assuming pharmaceutical regulation is a positive, history gives us examples of the contrary. It’s our duty as future physicians to learn lessons from the suffering in the past.

 

Author: Ariel Gershon

Ariel Gershon (Meds 2019) completed a BSc at the University of Toronto in pathobiology before starting at Schulich. He was a president of Schulich’s Osler Society from 2016-2017, a group of medical students who meet to talk about the history of medicine over lunch. He‘s interested broadly in the medical sciences, medical humanities, and indoor gardening. Tweet at me @GershonMD2019

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

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”).

1

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?

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

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

Anatomical Fascination: The Wax Venuses

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.

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

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.