Emulating Janus: Inculcating a sense of history
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.173631
Source of Support: None, Conflict of Interest: None
As a nation, we do not cherish history. Our archeological monuments are neglected with consequent thefts of historically invaluable sculptures and other relics. Our museums, barring a few exceptions, are dusty, unkempt, unattractive, and uninspiring. When queried, those in charge at the Archeological Survey of India trot out the usual response, “We are short staffed and cannot look after all the monuments under our charge.”
Museums in other countries are avidly sought and well attended. The government and the population at large consider them their treasures. Britain has more than its share of great museums and libraries on the history of medicine, the Wellcome Collection on Euston Road in London being an excellent example. America too has them in abundance, the National Library in Bethesda being its showpiece.
We are hard put to assemble a list of Indian historians who have contributed in depth and with universal success. We have been fortunate in having stalwarts such as R. C. Majumdar (1882–1980); S. Krishnaswamy Aiyangar (1871–1946); R. G. Bhandarkar (1837–1925); Gaurishankar Hirachand Ojha (1863–1947); K. M. Panikkar (1895–1963); K. A. Nilakanta Sastry (1892–1975); and more recently, Irfan Habib, Sarvepalli Gopal, Romila Thapar, S. Muthiah, and Ramachandra Guha… but how many of us can claim familiarity with their magnum opuses?
I wonder how many doctors, even in Mumbai, will be able to provide details on the historical works that made Dr. Gerson da Cunha and Dr. Bhau Daji—physicians who lived and practiced in this city—famous.
We have had distinguished medical historians. Dr. Pranjivandas Mehta translated the Charaka Samhita and presented the reader the Sanskrit text side-by-side with his English translation. His work won praise from such experts in the field as Dr. Henry Sigerist. Professor of Physiology, Dr. Parvathi Devi from Madurai, ably supported by her husband, Dr. Venkoba Rao, started 'the Indian Journal of the History of Medicine.' Dr. D. V. Reddy, working single-handed at the start, set up the imposing 'Institute of the History of Medicine' on the campus of Osmania Medical College and Hospital and published the Bulletin of the institute. Dr. N. H. Keswani and Dr. Asoke Bagchi also deserve our gratitude for their efforts in popularizing the subject. Dr. P. Kutumbiah's work on ancient Indian medicine remains a classic. It is a sad commentary that after each of these devotees to the history of medicine passed away, the edifices built by them crumbled.
Dr. O. P. Jaggi, the lung specialist in Delhi, has published books on several aspects of the history of medicine in India. More recently, Dr. M. S. Valiathan has published translations and commentaries on the Charaka and Sushruta Samhitas and written on our legacy from Vagbhata. Dr. K. Rajasekharan Nair continues to publish papers and books on the history of the neurosciences in India. I do hope their postgraduate students and protégés will keep their flags flying high in the future.
Ancient Romans had two-faced Janus as their God of beginnings and transitions. One of his faces looked to the future and the other to the past. There is sagacity in the vision of a God who not only looks to the future, but also continues to harken back. Such a God and his followers will retain lessons from the past based on experiences, embody the wisdom of the ages, and remain inspired by the great thinkers and pioneers who blazed trails, even as they plan for the future.
Henry Ford's statement “History is more or less bunk….” is oft-quoted.
Does this make intellectual sense? Are the pioneers and their efforts, beliefs, practices, and achievements of no significance?
Let me place some arguments in favor of the need to be cognizant of the past. I use two illustrative and oft-quoted examples drawn from the history of medicine.
Semmelweis and puerperal fever (puer child + parere to give birth to)
From time immemorial, women about to give birth were known to be at risk for contracting fever with fatal consequences. In the 1800s, in Europe, 40% of women died of this illness during childbirth, and the figures remain high in several countries, including India, even today. A fatalistic attitude prevailed in the absence of an understanding of the cause of this fever. When it was suggested that doctors attending to these women carried infection from one woman to another, the eminent obstetrician and teacher in Philadelphia, Charles Meigs (1792–1869), proclaimed, “Doctors are gentlemen, and gentlemen's hands are clean.”
Hence, it came to pass that women delivered by gentlemen doctors in their clinics and hospitals got sick and died, whereas those who gave birth in their homes, attended to by humble midwives, fared well.
In 1846, Ignaz Philip Semmelweis, a Hungarian physician of German extraction, was appointed as an assistant in the First Obstetrical Clinic in Vienna General Hospital. He found the mortality rate in women giving birth to be around 10%. Women preferred getting admitted to the Second Obstetrical Clinic. On enquiry, the puzzled Semmelweis learnt that this was because of the public knowledge that the death rate in that clinic was around 4%. Some desperate women even preferred to give birth in the streets near the hospital to getting admitted to the First Clinic.
Semmelweis decided to learn why the mortality rates differed. He noted that the First Clinic was used to teach medical students whereas the Second Clinic was only for educating the student midwives. Medical students often came to the First Clinic immediately after having participated in autopsies.
In 1847, his friend, Jakob Kolletschka, Professor of Forensic Medicine, died. Here, in Semmelweis' words, is what followed: “Kolletschka, Professor of Forensic Medicine, often conducted autopsies […] in the company of students. During one such exercise, his finger was pricked by a student with the same knife that was being used in the autopsy […]. Professor Kolletschka contracted lymphangitis and phlebitis in the upper extremity. Then, [..] he died of bilateral pleurisy, pericarditis, peritonitis, and meningitis. A few days before he died, a metastasis also formed in one eye. […] I could see clearly that the disease from which Kolletschka died was identical to that from which so many hundred maternity patients had also died. The maternity patients also had lymphangitis, peritonitis, pericarditis, pleurisy, and meningitis and metastases also formed in many of them. Day and night, I was haunted by the image of Kolletschka's disease and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died.”
Semmelweis concluded that he and the medical students carried “cadaverous particles” on their hands from the autopsy room to the patients they examined in the First Obstetrical Clinic. This explained why the student midwives in the Second Clinic—who were not engaged in autopsies and had no contact with corpses—saw a much lower mortality rate.
He was aware that chlorinated lime was effective in taking away the putrid smell from infected tissues in the autopsy room and elsewhere. He decided to study whether this would help in the First Clinic as well. He started using a solution of chlorinated lime in the clinic and insisted that anyone approaching a woman in labor had to wash hands in this solution before examining the patient. As this became the accepted practice, the mortality rate progressively dropped to that prevalent in the Second Clinic and eventually almost to zero.
Elated by his findings, he proclaimed them to his colleagues and to the medical profession, in general, expecting an immediate change in practice. Instead, he was ridiculed. He was dismissed from the hospital and had to move to Budapest. No one, it appeared to him, was willing to use chlorinated lime solution to help his or her patients. His frustration worsened. He wrote letters to prominent European obstetricians, calling them murderers. He was committed to an asylum, as even his wife believed that he was losing his mind. There, ironically, he died of septicemia from injuries.
Years after his death, Louis Pasteur developed the germ theory, Joseph Lister demonstrated the efficacy of antisepsis, and Semmelweis was vindicated.
Semmelweis' findings, scientifically documented, were discarded in his day as they conflicted with the received wisdom. At a time when belief in miasmas was all pervading, talk of cadaverous particles was deemed to be ridiculous. The unwillingness to even look at an alternative hypothesis, examine its scientific basis and consider its usage is a human trait that unfortunately persists even in our times.
Werner Forssmann and the advent of cardiac catheterization
When—as at present—the atmosphere is vitiated by crass materialism, cynicism, corruption, and unethical practices, examples of medical pioneers exist, who advanced our science without any thought for their own safety and, at times, at risk of great harm to themselves. They remind us of our great heritage, and their noble actions serve as an inspirational beacon against the current trends.
Werner Forssmann is one such role model for us. His interest in cardiology, the recordings of intra-cardiac pressures in horses by inserting catheters directly into their hearts, and the publications of Helen Taussig, inspired him to seek ways of studying the structure and function of the living heart. To this end, he carried out experiments to study the chambers of the heart in living dogs and could demonstrate them successfully by injecting radio-opaque contrast into them. How could this be done in humans?
He suggested the use of a flexible tube that could be inserted into a vein in the arm and then advanced into the heart. Through this tube, radio-opaque chemicals could be used to study the chambers of the heart, and drugs could be injected into the heart for cardiac resuscitation.
He was then a 1st-year resident doctor and subjected to the supervision of his seniors and his professor. When he broached this topic before them, he was ridiculed and warned of the likely catastrophic consequences of such a practice.
He brooded over his project and eventually mustered enough courage to enlist the help of a nurse, Gerda Ditzen. All that would be needed for his experiment was collected in bits and pieces over time in a manner that would occasion no suspicion of his intent.
With the help of his accomplice, he enlisted a radiology technician. He then took the vital step.
During the summer of 1929, 25-year-old Forssmann anesthetized his lower arm and opened the left antecubital vein. He inserted a well-lubricated four Charrieres-thick ureteral catheter into his bloodstream and watched on a fluoroscope screen as it progressed 65 cm up his arm and toward his heart. He then walked up the floors and got an X-ray film done showing the catheter in his right auricle. He could not advance it into the ventricle as the catheter was not long enough. This was the first time that heart had been catheterized in a living human being.
Forssmann was not unaware of the likelihood of his ureteral catheter tearing the wall of a major vein or the right atrium, but this knowledge did not deter him.
He published a paper on his experiment, suggesting that this technique would allow measurements of blood pressure inside the chambers of the heart. It could be used to inject radio-opaque chemicals to demonstrate these chambers and to study abnormalities in them.
Instead of being applauded for the risks he had taken and his unique success, Forssmann was dismissed from his post as a resident as he had acted without the consent of his superiors. He was perceived as a reckless—even suicidal—individual. As one senior put it, his actions were good for a circus but not for a hospital!
There is a happy ending to this account. In 1956, Forssmann was awarded the Nobel Prize for his courageous and path-breaking experiment on himself.
Semmelweis, Forssmann, and others like them serve to inspire us, especially when we face obstacles, are misunderstood or even debunked and victimized. The spirit of research and belief in the cause that inspires our work will provide strength to us.
Classics in the neurosciences
We stand on the shoulders of generations of far-sighted pioneers who uncovered the medical facts we take for granted today. They made us aware that the thick-walled pipes in our bodies, the ancients called arteries, carry blood and not air; that blood is in continuous circulation; that blood from the right ventricle does not pass into the left ventricle through imagined pores in the inter-ventricular septum but via the lungs; that the ventricles of the brain contain cerebrospinal fluid and not a nebulous entity termed animal spirit; and that the pineal gland is not the seat of the soul.
The paucity of libraries with collections on medical history and museums devoted to this subject in our country poses a formidable handicap. How then are we to seek lasting inspiration?
The magical medium of the internet has provided us unparalleled access to many accounts on the lives and achievements of those who have bestowed rich inheritances on us.
Those of us who were students in the 1950s and 1960s will recall the countless hours spent in dusty libraries and the calluses that developed on the thumb, index, and middle fingers from the reams of notes made in notebooks from old journals and biographies.
The student of today is spared all that. Many of these classics can be downloaded within minutes.
Here is one example relevant to all of us who believe that it is not possible to diagnose a spinal tumor or perform any neurosurgery without X-rays, computed tomography, and magnetic resonance scanning.
In 1888, Dr. William R. Gowers saw a patient with pain below the lower part of the left scapula. The patient went on to develop difficulty in walking, spasticity in the lower limb muscles, and progression of weakness to paraplegia. Based on the history and clinical findings, Dr. Gowers suspected a spinal tumor and sought the help of Dr. Victor Horsley.
A spinal tumor had never been removed successfully thus far. Clinical diagnoses were tested only at autopsy.
The operation took place on June 9, 1887. The initial laminectomy, based on the level of sensory loss, was from the third to seventh dorsal vertebrae. When no tumor was found, the laminectomy was extended up and down. Dr. Horsley noted: “At this juncture, it appeared as if sufficient had been done, but I was very unwilling to leave the matter undecided… I removed another lamina at the upper part of the incision. On opening the dura mater, I saw… a round, dark, bluish mass…” The tumor attached to the highest root of the fourth dorsal nerve was excised. Dr. Horsley noted that the tumor was actually 4 inches above the level of complete anesthesia. By November 17, the patient was walking in his garden, and by January 24, 1888, had walked three miles at a stretch. The book by Gowers and Horsley, published in 1888, contains details regarding this historic clinical diagnosis, confirmed—without any of the investigations we take for granted—for the 1st time ever at operation. You can download it from https://archive.org/details/acasetumourspin00gowegoog.
If, after reading this, you study the life of Sir Victor Horsley, you will understand what Sir Geoffrey Jefferson meant when he stated: “Horsley's researches gradually came to show that the anatomy on which a surgeon's training is traditionally based must have life breathed into it by physiology.” Stephen Paget's biography of Horsley can be downloaded from https://archive.org/details/sirvictorhorsley00page.
Sir Victor Horsley visited Bombay and lectured at the Grant Medical College shortly before he returned to Amarah, Iraq, where he died of a febrile illness complicated by a heatstroke.
Is there scope for historical research in medicine in India? What can we do?
The choices are limitless.
Legends have their basis in historical facts though these facts may have been distorted over time and in the repeated narratives. Attempts at understanding the origins of such legends will provide clarification and may also stimulate innovative thought.
How did the legend on what we proudly proclaim as the first human transplant originate? What was behind the substitution of an elephant's head onto Ganesha's body?
Jivaka (544 B.C. - 491 B.C.), physician to Gautama Buddha, performed neurosurgery. Can we obtain details on the variety of operations he performed and on his patients and their progress after surgery?
Raja Bhoja, the 11th-century philosopher king of central India, was operated on for a brain tumor by surgeons from Ujjain, who were twins. Anesthesia was induced using Sammohini and he was revived using Sanjeevini. Who were these surgeons? What was the nature of the two drugs, one inducing coma and the other resuscitating the patient? One report suggests that the tumor resembled mother-of-pearl. Was it an epidermoid tumor?
What were the contributions of officers in the Indian Medical Service in our understanding of neurological diseases in India? Did Indian officers equal the contributions made by their British counterparts?
Even in modern times, there is so much to be learned and documented. The lives and contributions of our pioneers in the neurosciences in the 20th century deserve study. While some, such as Dr. Jacob Chandy, Dr. B. Ramamurthi, and Dr. Dayananda Rao, have published their autobiographies, future generations will have little information on such individuals as Dr. S. T. Narasimhan, Dr. Baldev Singh, Dr. V. R. Khanolkar, Dr. B. K. Bacchawat, Dr. R. G. Ginde, Dr. T. K. Ghosh, Dr. R. N. Chatterji, Dr. Asoke Bagchi, Dr. T. Desi Raju, Dr. R. M. Varma, Dr. K. S. Mani, Dr. C. G. S. Iyer, unless a concerted attempt is made to record their biographies.
We do not have a tradition of analyzing the pathology of diseases suffered by persons in positions of leadership. The illnesses of our eminent citizens—politicians, philosophers, scientists, medical doctors— and the consequences on their public and private activities are not documented. Few reports are available on their fatal illnesses. This is a fertile field for exploration, especially when their illnesses involved the brain and mind.
Neurology India has a long tradition of publication of obituary notes on its members. It is also inspiring some senior neuroscientists in India to write on topics dear to their hearts in this column. Perhaps, it can also develop a section on Indian Neurological Classics where papers by Dr. Chandy, Dr. Ramamurthi, Dr. Baldev Singh, Dr. B. K. Anand, Dr. R. G. Ginde, and others can be reproduced alongside with a review of the progress of knowledge since those papers first saw the light of day.
This journal can also take a lead by publishing a supplementary issue containing all the orations and lectures delivered during the year.
The Neurological Society of India and the Indian Academy of Neurology could set up a joint project with aims similar to those of the Harvey Cushing Society (). Books on the development of neurosciences in India, video recordings of interviews with our eminent neuroscientists, and the creation of a cybermuseum could form some of their activities.
Museums on the history of the development of neurosciences in each institute can form a fertile source of information and inspiration for its undergraduate and postgraduate students. They can also serve as repositories of books, papers, diaries, and letters of our respected teachers, researchers, and practitioners. If such a collection featuring memorabilia of such individuals as Dr. R. N. Chopra, Dr. U. N. Brahmachari, Dr. B. C. Roy, Dr. P. Kutumbiah, and Dr. Minocher Mody been available, it would have inspired so many of our younger colleagues.
We need our heroes for our own well-being and progress. Let us cherish and preserve their memories so that we remain inspired. Their contributions will help us set targets for ourselves. As we strive toward achieving our goals, we shall prove ourselves worthy of them.