Archive for the 'Medical History' Category



Albert Schweitzer, Action Hero

Last week marked the anniversary of Albert Schweitzer’s death, at age 90, in 1965. He went to Africa to begin his missionary work one hundred years ago, in 1913.

As the son of a Protestant minister, in a German speaking province that sometimes belonged to Germany and sometimes to France, Schweitzer had a solid religious upbringing. As a young child he began to include wild and domestic animals in his evening prayers. His lifetime motto, “Reverence for Life”, was germinating in his mind already then.

While still in school, he formulated a life plan to first study religion and music, and after the age of 30, find a concrete, hands-on way to practice his faith. He had no idea then what that would be.

His study of music, particularly Bach and his organ music, including theories of organ building and restoration, was earning him international standing by the time he was 24. In 1905, at age 30, he published the first of several works on Bach with insights from his own religious upbringing and study of theology.

Albert Schweitzer became a widely respected theologian. In 1901, at age 26, one year after earning his degree, he became Principal of his alma mater, the Theological College of St Thomas. In 1906 he published “The Quest of the Historical Jesus”, his perhaps most famous book on theology.

True to his earlier commitment, he realized at age 30, that he wanted to be a missionary doctor in Africa. By 1911, now 36 years old, he had earned his medical degree, and by the spring of 1913 he was headed for Africa. Because he was Protestant, the organization he wanted to work for would not accept him. Instead, he largely financed his mission himself with earnings from lectures and concerts. Other medical personnel joined him on his voyage into the jungle, 200 miles upstream from the nearest port.

He built and ran his hospital in Lambarene, and made it a haven for patients, their families and scores of animals. He saved the life of an orphaned kitten, who came to spend much of her time for the next twenty years sitting on Schweitzer’s desk as he wrote by a kerosene lamp every night.

Patients stayed at the hospital, which was laid out like a small village, until their treatment was completed. For patients with leprosy, the treatment could last over two years. Able-bodied patients and family members were required to work, and Schweitzer taught them basic carpentry, concrete making and other skills needed to expand the hospital. He planted gardens and made the hospital less dependent on food from outside Lambarene, but funds were still needed and he sometimes went back to Europe to lecture, give concerts and record music. Some of his travels away from Africa were involuntary, resulting from French-German animosity during and after World War I and from illness.

His work at Lambarene gained him world-wide recognition, as did his writings promoting peace and denouncing nuclear war. He was awarded the Nobel Peace Prize in 1952, and used the money to improve his hospital.

Albert Schweitzer is said to have met Albert Einstein some time around 1930, and the two corresponded about their work for peace. Einstein compared Schweitzer to Ghandi in his leading by example.

Last night we watched Jerome Hill’s 1957 documentary on Schweitzer (available on Amazon and iTunes), filmed with the restriction that it was not to be released until after his death. We watched him move among patients, their families, dogs, cats, goats and pelicans in Africa and we watched him play the organ in his home church in Alsace. We watched him, at age 81, lead construction of the new leper wards in Lambarene. We watched footage from the hospital that only had electricity in the operating room. We heard Schweitzer quoted as saying that having thermometers would only have you pay more attention to the heat that you couldn’t do anything about anyway.

He went on, tirelessly, for nine more years. He died peacefully at the hospital he had built.

This remarkable man had three strong callings, three unique talents, three fulfilling careers, all interrelated. He was a true man of action.

A Samurai Physician’s Teachings

Every now and then the title of a book influences your thinking even before you read the first page.

That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.

This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700’s, but in Japanese translation. One of his favorite quotes was:

“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference to archetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.

People these days are not like his. They drink wine as though it were berry juice, make arbitrary what should be constant, get drunk and indulge in sex, deplete their pure essence because of desire, and thus suffer a loss of their fundamental health….Thus they fizzle out after fifty years or so.”

During the Ming dynasty, a prominent physician wrote:

“Premature death due to the hundred diseases is mostly connected to eating and drinking.” 

That quote still carries relevance today.

Interestingly, Ekiken sees medications, herbs, acupuncture and all the available treatments of his time as a last resort because they are unbalanced interventions to counter the imbalance of the body. Almost a hundred years later, Samuel Hahnemann coined the word allopathy for this type of treatment.

Ekiken wrote at length about what distinguishes a mediocre physician from a good one. For example, he describes the good physician as less in a hurry to prescribe medications. One of his many aphorisms seems uncannily relevant to today’s emphasis of guidelines over individualized treatment:

“A good doctor gives medicine in response to the condition of the situation…This is not a matter of adhering to one absolute method. It is rather like a good general who fights his battles well by observing his enemies closely and responding to their changes. His methods are not determined beforehand. He observes the moment and is in accord with what is right.”

Quoting Confucius, he ends his description of a good doctor:

“A good doctor warms up the old and understands the new”.

May all of us remember and respect the wisdom of the 2500 B.C. text, now almost 5000 years old, as it speaks of “avoiding overexposure to things that can damage your body”. It reminds me of all the lectures I have attended on diabetes and heart disease where the speaker devotes exactly one sentence to this topic, and then spends the rest of the time talking about all the interesting drugs we have to counteract the effects of our exposure to harmful or excessive foodstuffs.

A little samurai discipline and restraint could help most of us…

A Christmas Message to All Physicians from Sir William Osler

We can imagine a conversation in a library – A.D. 2009 – between two assistants wearily sorting a pile of second hand books just sent in. 

‘What are we to do with all this old rubbish by a man named Osler? He must have had very little to do to spoil so much paper. Where did he live anyway?’

‘Oh, I don’t know. Baltimore, I think. Any how they have a Hall there that bears his name.’

William Osler, 1909

Sir William Osler underestimated the influence he would have more than a hundred years after penning those words for the inauguration of Osler Hall. His oration was published in JAMA under the title “Old and New”.

His scientific discoveries and his method of teaching medicine at the bedside have lived on, and his words about being a physician still speak to doctors all over the world.

Thumbing through old books and reading online, I have found letters and speeches that could have been written specifically for doctors in my specialty, Primary Care, in 2011.

The other day my WordPress dashboard listed as one of the search terms that brought a visitor to A Country Doctor Writes “Holiday reflection by Sir William Osler”. That got me thinking: What would Sir William say to doctors like me today?

(Curiously, William Osler’s first published article, at age 20,  is said to have been one with a Christmas theme, “Christmas and the Microscope”, in Hardwicke’s Science-Gossip.)

Perhaps Sir William Osler would write something like this today (every phrase in black is quoted from his writings):

Christmas greetings to you all.

I hope everything is going well with you, the silent workers of the ranks, in villages and country districts, in the slums of our large cities, in the mining camps and factory towns, in the homes of the rich and in the hovels of the poor. To you is given the hard task of illustrating with your lives the Hippocratic standards of Learning, of Sagacity, of Humanity, and of Probity:

Of learning, that you may apply in your practice the best that is known in our art, and that with the increase in your knowledge there may be an increase in that priceless endowment of sagacity, so that to all, everywhere, skilled succour may come in the hour of need. Of a humanity, that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering, and broad charity to all. Of a probity, that will make you under all circumstances true to yourselves, true to your high calling, and true to your fellow man.

Each generation has its own problems to face, looks at truth from a special focus and does not see quite the same as any other.

In 1908 at Oxford William James made a remark that clung. ‘We live forward, we understand backwards. The philosophers tell us that there is no present, no now – the fleeting moment was as we try to catch it.’

The past is always with us, never to be escaped; it alone is enduring; but, amidst the changes and chances which succeed one another so rapidly in this life, we are apt to live too much for the present and too much in the future. It is good to hark back to the olden days and gratefully to recall the men whose labours in the past have made the present possible.

Hippocrates had a splendid paragraph in ‘Ancient Medicine’ on the attitude of mind towards men of the past: “We ought not to reject the ancient Art, as if it were not, and had not been properly founded, because it did not attain accuracy in all things, but rather, since it is capable of reaching to the greatest exactitude by reasoning, to receive it and admire its discoveries, made from a state of great ignorance, and as having been well made, and not from chance.’

Like a living organism, truth grows. Much of history is a record of the mishaps of truths which have struggled to the birth, only to die or else to wither in premature decay. Or the germ may be dormant for centuries, awaiting the fullness of time.

Read the classics of medicine, and also The Old and New Testament, Shakespeare, Don Quixote, Emerson, Oliver Wendell Holmes. The average, non-reading doctor might play a good game of golf or of bridge, but professionally he is a lost soul.

The love, hope, fear and faith that make humanity, and the elemental passions of the human heart, remain unchanged, and the secret of inspiration in any literature is the capacity to touch the cord that vibrates in a sympathy that knows nor time nor place.

For the general practitioner a well-used library is one of the few correctives of the premature senility which is so apt to overtake him. It is astonishing with how little reading a doctor can practise medicine, but it is not astonishing how badly he may do it.

With half an hour’s reading in bed every night as a steady practice, the busiest man can get a fair education before the plasma sets in the periganglionic spaces of his grey cortex.

Be patient. It has been said that “in patience ye shall win your souls,” and what is this patience but an equanimity which enables you to rise superior to the trials of life?

Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaint.

Respect the Psychical methods of cure. After all, faith is the great lever of life. Without it, man can do nothing. Faith is the aurum potabile, the touchstone of success in medicine. As Galen says, confidence and hope do more good than physic – “he cures most in whom most are confident.” While we doctors often overlook or are ignorant of our own faith-cures, we are just a wee bit too sensitive about those performed outside our ranks. In all ages the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. We physicians use this every day; without faith, we should be very badly off.

The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of influence.

In the words of Sir Thomas Browne, whose Religio Medici was the second book I ever bought:

“There is surely a piece of divinity in us, something that was before the elements, and owes no homage unto the sun.”

*

I hope this will reach you in time for Christmas. I think especially of you country doctors, members of the class ‘Hippocraticus Rusticus’.

Never has the outlook for the profession been brighter. Everywhere the physician is better trained and better equipped than he was fifty years ago. Disease is understood more thoroughly, studied more carefully and treated more skillfully. Diseases familiar to your fathers and grandfathers have disappeared, the death rate of others is falling to the vanishing point, and public health measures have lessened the sorrows and brightened the lives of millions.

The vagaries and whims, lay and medical, may neither have diminished in number nor lessened in their capacity to distress the faint-hearted who do not appreciate that to the end of time people must imagine vain things, but they are dwarfed by comparison with the colossal advances of the past century.

So vast and composite has the profession become that the real dangers and evils that threaten harmony among you are internal, not external. Yet, no other profession can boast of the same unbroken continuity of methods and ideals. We may indeed be justly proud of our apostolic succession.

Your profession in truth is a sort of guild or brotherhood, any member of which in any part of the world can find brethren whose language and methods and whose aims and ways are identical to his own.

I wish all of you the best for this Holiday.

Affectionately yours,

W. O.

Sources:

1.) Aequanimitas, Sir William Osler, P. Blakiston’s Son & Co., 1904

2.) The Evolution of Modern Medicine, by Dr. William Osler, (Originally published 1913), Kaplan Classics of Medicine, 2009

3.) Sir William Osler By Harvey Cushing, Oxford University Press, 1925

“Cure Sometimes, Treat Often, Comfort Always”

In my forays into the history of medicine I came across these six little words by Hippocrates. They seem strangely modern, almost like something you might find on a Hallmark-card for today’s medical school graduates. I don’t know how old the translation is and I couldn’t understand the original text if I tried – but these simple words really touched me when I first read them.

In Family Medicine we don’t often cure our patients’ diseases. Many of the things we think of as medical cures are possibly only spontaneous recoveries from ear infections, pneumonias, strep infections, indigestion and acne.

Mostly we treat chronic conditions in hopes of mitigating their effects on our patients’ vital organs – eye, kidney and nerve damage in diabetes or strokes and heart attacks in patients with elevated blood pressure and cholesterol. Sometimes we only treat the symptoms – pain from degenerative arthritis or cough, congestion and shortness of breath from chronic lung disease.

The one thing physicians always can and should do is the thing we may be inclined to forget when the everyday frustrations of modern medicine make us watch the clock, the reimbursement schedule or any one of the distractions that get in the way of real doctoring:

Comfort and hope should be offered to every patient, every fellow human being, in every encounter. We must never lose sight of the power we have in changing our patients’ perceptions and expectations of their diseases.

In Hippocrates’ era, doctors believed that patients had a natural ability to overcome disease. Medical treatments were meant to support the natural healing processes. Hippocrates is said to have written:

“Natural forces within us are the true healers of disease”.

How ironic that twenty-five centuries later we are re-discovering and proving, through the modern science of neuroimmunology, that patients’ frame of mind and perception of their disease predict their treatment success and cure rate more than many of the technical details of their condition or its treatment.

When we comfort a patient, we may be doing more than consoling him or her. We may be stimulating the patient’s immune system to overcome disease and return the body to a healthful balance.

We used to call that the Placebo Effect.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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