Thomas Linacre and the Royal College of Physicians

The Royal College of Physicians is a U.K. based, internationally recognised, professional body that is dedicated to the improvement of medical practice and patient care. It is also the oldest royal medical college in the world.

In 2006 I became a member of the Royal College of Physicians after navigating their tricky exams, and over a decade later this remains my proudest academic achievement. I try to visit the London College a couple of times a year, and thoroughly enjoy walking the medicinal garden and grounds, and visiting the museum. It has a rich and varied history that is truly fascinating and its story started with a humanist scholar and priest by the name of Thomas Linacre.

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The Story of the Tendon Hammer

The tendon hammer is one of the most historically resilient medical instruments still in use today. It is a simple yet invaluable device that can be used to diagnose a wide variety of nervous system and muscular disorders. Almost 130 years after the invention of the first tendon hammer they can be found on nearly every hospital ward, and can be seen in use on nearly every medical round and during most medical exams.

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Going round in circles: The discovery of the body’s circulatory system by William Harvey

Do you ever feel like you are going round in circles? Well, your blood is continuously going round in circles, in the pulmonary and systemic circulations. Less than 400 years ago, however, these life-giving, life-sustaining circles were not known about. The heart was undervalued, and the liver was thought to be key, just as it was once claimed that the earth was at the centre of the solar system (Harris, 1916).

It was the obsessive, relentless work of one Folkestone famer’s son, called William Harvey, which demolished centuries of understanding about the human circulation, revolutionising our understanding of the human heart. Today, the fact that the heart’s contraction is the cause of the arterial pulse is understood by primary school children. Yet without the work of Harvey and others, who dared to question traditional thinking, such fundamental truths would not be known about; building on his foundation, however, we are now able to stent, bypass, dialyse and medicate the circulatory system to human benefit.

Let us take a walk back in history, then, to the prevailing ideas pre-Harvey, before taking a look at the man himself: his influences, the threats to his work, and the great discovery itself.

 

Early ideas: Galen (AD 129-c210)

Galen, a Greek-Roman physician and master of animal dissection was the first to correctly define the differences between arterial and venous transport, noting the relative thickness of arterial walls and the redness of the blood (Gordon, 1991). He was, however, fixated on the importance of the liver in the movement of blood, describing how all blood was made here before being carried by the venous system to all the organs of the body, as they somehow ‘attracted’ the blood to themselves and ‘consumed it’. The heart, in particular fascinated Galen, as he saw it ‘swell during filling before collapsing in on itself and ‘spilling’ some blood into the aorta’. Diastole was, therefore, the important part of the cardiac cycle in Galen’s view, with the heart seen as a ‘set of bellows’ (Gordon, 1991).

Galen’s description of what happened to the blood in the heart is fascinating: the heart is seen as a furnace, ‘boiling the blood’ so that it changes from purple to red as it heats up. Blood is explained to pass across the septum into the left heart, through tiny pores (Harris, 1916). The importance of the pulmonary circulation in changing the colour of deoxygenated blood or in allowing blood to move from the right heart to the left heart was unknown: the lungs were judged simply to be consuming blood for their own need, as all other organs did (Wright, 2013).

Out of interest, blood made in the liver was only one of 4 ‘body humours’ that Galen was interested in: he also recognised phlegm from the lungs, yellow bile from the gallbladder and black bile from the spleen. All health and illness was attributed to a balance or imbalance of these humours, and so most medical therapy aimed to redress this balance, perhaps by bloodletting or leech therapy (Gordon, 1991).

Galen’s ideas were accepted as fact, and even in Harvey’s time, students at the College of Physicians in London had to swear never to speak disrespectfully of his work. It was going to take a lot to undo these incorrect ideas.

 

Early ideas: the Church

Despite prevailing academic ideas about the importance of the liver in the circulation, the church has always recognised the importance of the heart in spiritual and emotional matters. It has been thought of as the ‘residence of man’s soul’ and images of the ‘Sacred Heart of Jesus’ adorned church interiors throughout Europe. Saint’s hearts were often removed, embalmed and worshipped (Dobson, 2007).

In the Bible itself, the heart is frequently seen as a source of sin in the Psalms, whilst the unyielding Pharaoh in the book of Exodus is said to have a hardened heart. In John Bunyan’s Pilgrim’s Progress, the heart is pictured as a dusty room which cannot be cleaned by human effort, only by divine intervention (Bunyan, 2003).

Later ideas: Mondino, da Vinci, Vesalius and Colombo

Anatomists, meanwhile, clung to Galen’s ideas despite advances in dissection and the gifting of supreme artistic skills. Mondino, carrying out the first public human dissection in the University of Bologna in 1315 (Galen’s work had all been performed on animals), continued Galen’s theories. Da Vinci, despite his eye for detail and his ability to understand the human form, made Galen’s theories fit his intricate drawings of the human body (Wright, 2013).

One brave Belgian anatomist, however, described more than 200 errors in Galen’s work. Andreas Vesalius (1514-64) lectured students on surgery and dissection at the University of Padua, and produced his ground-breaking, beautifully illustrated ‘De humani corporis fabrica’ (‘On the structure of the human body’) in 1543, addressing such points as the lack of pores in the septum of the heart (McMullen, 1995). Despite being ignored and ridiculed at the time, a copy of his book is at the Oxford University Science Library today.

Colombo, an Italian anatomist (1515-1559) extended Vesalius’ work, further confirming the non-porous nature of the septum, and also realising that blood changed colour in the lungs, not in the heart. A supremely important revelation was that systole, rather than diastole, was the ‘active’ part of the cardiac cycle: blood didn’t just ‘spill’ out of the heart after diastole, but there was a forced ejection of blood from the heart during systole, and this drove the whole circulation (Ruoff, 2012). With such fundamental findings, why are the names of these men not better known today? And what of William Harvey?

 

William Harvey: the circles

“I will demonstrate to you today, how blood is sent from the heart throughout the body via the aorta by means of the heartbeat. Having nourished the remotest parts of the body, the blood then flows back to the veins from the arteries, then returns to its original source, the heart. The blood moves in such a quantity around the body and with so vigorous a flow that it can only move in a circle, continuously. This is an entirely new theory but, as you will learn, numerous arguments and our senses confirm that it is true”. (Wright, 2013, p xvii)

This was how Harvey’s famous circles of blood circulation would be introduced to packed lecture theatres as he would skilfully dissect dogs and humans (often the bodies of executed criminals or even those stolen from hospitals and graveyards). The presentations would usually be in Latin and accompanied by lutes. The supporting text was his weighty ‘Exercitatio anatomica de motu cordis et sanguinis in animalibus’ (‘Anatomical exercises concerning the motion of the heart and blood in living creatures’) published in 1628 (Leake, 1929).

His demonstrations would involve cutting the pulmonary artery in a dog whose heart had been exposed, showering the audience with blood as the right ventricle contracted; ligating the pulmonary artery and filling the right ventricle with water until it might burst – yet the absence of any water in the left ventricle proved the non-porous nature of the septum; and watching the subsequent passage of water from the right heart once the pulmonary artery was opened, through the lungs and into the left ventricle to prove the pulmonary circulation (Wright, 2013).

Further demonstrations involved ligating the vena cava of a dog, and seeing the subsequent emptying of the pulmonary circulation and the aorta; meanwhile, ligating the aorta and then releasing it (or even piercing it) showed blood forced out of the heart into the systemic circulation. That systole was an active contraction of the heart muscle, rather than it simply ‘collapsing’ after diastole was proven by watching the beating heart in situ: first on transparent cold blooded fish, whose heart naturally beat more slowly, aiding observation, and then on a young man with a chest injury, exposing his beating heart (Silverman, 2007).

To complete the circuit back to the heart, blood must enter the venous system and Harvey studied this with delight, affectionately calling the valves in veins the ‘little doors’ that prevent backflow. He would ligate human forearms, and show that blood would not pool in the hand despite the added pressure, owing to these strong little membranes (McMullen, 1995).

The two circles of man’s circulation had thus been demonstrated beyond question. That the blood moved in a continuous circuit, not being ‘consumed’ but ‘recycled’ was a revolutionary idea.

 

William Harvey: the odds stacked against him

It is nothing short of a miracle that Harvey discovered what he did, and that his work received acceptance even in his lifetime, since many factors seemed to work against him. There was the shipwreck in 1600 when, as a young Cambridge graduate, he headed to Padua University, Italy, to continue his studies. All on-board the ship died, yet Harvey had been the only man prevented from boarding – he saw it as God’s providence (Wright, 2013).

He had also been steeped in the teachings of Galen: his copy of Galen’s work is highlighted, annotated and marked throughout. Galen’s work was held as truth, and Harvey had absorbed it all – yet this did not prevent him from thinking independently, and allowing himself to challenge general opinion (Silverman, 2007).

Gaining acceptance for his work amongst Galen supporters was probably aided by his esteemed role as physician to King James I and King Charles I. Such a position commanded respect, though, as with all healthcare workers, he occasionally gave the wrong diagnosis and treatment, losing respect and therefore acceptance from his peers (see the famous case of Sir William Smith’s bladder stone (Wright, 2013)).

A final threat to the dissemination and acceptance of Harvey’s work came when many of his works were destroyed in the Great Fire of London in 1666, and by wilful vandalism during the English Civil War (Silverman, 2007).

 

William Harvey: all things working together for good

Despite the setbacks and threats to his work, Harvey’s ideas succeeded in demolishing theories that had stood for nearly a millennium and a half. This must have been, in part, to Harvey’s tireless, unquenchable drive to pursue his experiments. At school and university he would regularly work an 18 hour day, in his spare time he would explore and investigate nature, in his later life he would often dissect in his study at home, reconfirming his theories. He even performed the autopsy on his own father in 1623 (Wright, 2013).

Being the firstborn son of nine children and marrying the daughter of the Queen’s physician ensured that he received the best education and mixed in wealthy circles – his father-in-law helped him to become a member of the College of Physicians.

Finally, his faith in God helped him to view man as the summit of creation and worthy of scholarly investigation. The following is a quote from his work, “We acknowledge God, the supreme and omnipotent creator, to be present in the production of all animals, and to point, as it were, with a finger to his existence in his works” (Leake, 1929). Few have investigated human anatomy as thoroughly as Harvey did.

 

Concluding remarks

William Harvey changed the face of cardiology when he proved the existence of the double circuit, comprising the pulmonary and systemic circulations, that delivers blood to the whole body.

Remarkably, another English physician, Thomas Willis, was proving the existence of the Circle of Willis at the base of the brain in the same century as Harvey (Martini, 1998). These three circulatory circles really do give new meaning to the phrase ‘circle of life’, being life-sustaining in their design.

 

References:

Bunyan J (2003) The Pilgrim’s Progress. Oxford World’s Classics. Oxford.

Dobson M (2007) Disease: The Extraordinary Stories Behind History’s Deadliest Killers. Quercus History.

Gordon EJ (1991) William Harvey and the Circulation of the Blood. Southern Medical Journal 84(12): 1493-8

Harris DF (1916) The Influence of Greece on Science and Medicine. The Scientific Monthly 3(1): 51-65

Leake CD (1929) Exercitatio Anatomica De Motu Cordis Et Sanguinis In Animalibus (Anatomical Studies on the Motion of the Heart and Blood) by William Harvey: An English Translation with Annotations. Springfield, Illinois: Charles C Thomas

Martini FH (1998) Fundamentals of Anatomy and Physiology: Fourth Edition. Prentice Hall, Inc.

McMullen ET (1995) Anatomy of a physiological discovery: William Harvey and the circulation of the blood. J R Soc Med 88: 491-8

Ruoff HW (2012) William Harvey: A brief guide to his life and work. A.J.Cornell Publications

Silverman ME (2007) De Motu Cordis: the Lumleian Lecture of 1916. An imagined playlet concerning the discovery of the circulation of the blood by William Harvey. J R Soc Med 100(4): 199-204

Wright T (2013) Circulation: William Harvey’s Revolutionary Idea. Vintage, London.

 

 


Thank you to Helen C. Cowan for this guest post. This article was first published in the British Journal of Cardiac Nursing as part of the History in Cardiology series. Read the rest of the series at http://www.magonlinelibrary.com/toc/bjca/current

 

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Willem Einthoven and the Electrocardiogram

ECG interpretation has long been a guilty pleasure of mine. One of the first books I purchased as a medical student was the ‘ECG Made Easy’. After reading that book for the first time ECG interpretation seemed far from easy and I didn’t develop a strong grasp of the subject until many years later.

Whilst working as an A&E SHO many years ago I missed a fairly simple ECG diagnosis, which was fortunately picked up by another doctor that I worked with. This incident highlighted an educational need and my obsession with the ECG has remained ever since. I still look at ECGs on an almost daily basis and it never ceases to amaze me that such a ‘simple’ tool can provide such a wealth of information about a patient. We would not have this remarkable diagnostic tool without a remarkable man, Willem Einthoven.

 

Who was Willem Einthoven?

Willem Einthoven was born on May 21st 1860, in Semarang, a coastal city on the island of Java, which was then part of the Dutch East Indies (now Indonesia). He was the son of a doctor and army medical officer, Jacob Einthoven, who had been posted to the Indies. His mother was Louise de Vigel, the daughter of the then Director of Finance in the Indies.

When Einthoven was six-years-old his father died and a few years later his mother decided to move back home to Holland with Einthoven and his two brothers and three sisters. The family settled in Utrecht and Einthoven would attend the University of Utrecht to study medicine a few years later. Einthoven qualified with a degree in medicine in 1885. The following year he was appointed to the position of Professor of Physiology at the University of Leiden. He was a talented researcher and it was during his time at Leiden that he would develop the string galvanometer, an invention that would change the face of medicine and cardiology to this very day.

 

Willem Einthoven pictured in 1906

 

Animal Electricity

Long before Einthoven’s time, it was known that the beating of the heart produced electrical currents, but there was no instrument available to measure these currents in an acceptable and non-invasive way.

The long road to the development of the electrocardiogram began with the work of William Gilbert, who was Queen Elizabeth I’s personal physician and President of the College of Physicians (before its Royal Charter). Gilbert published the famous paper ‘De Magnete’ in 1600, his findings suggested that ‘magnetism’ and ‘static electricity’ were separate entities. It was in this paper that he introduced the term ‘electrica’ for insulators that hold static electricity. 46 years later the famous polymath Sir Thomas Browne would refine this term and define ‘electricity’ as “the power to attract straws or light bodies, and convert the needle freely placed”.

The first person to make the observation that electricity existed and played a role inside the bodies of animals was the British scientist John Walsh. He managed to obtain a visible spark from an electric eel. He used thin strips of tin foil and demonstrated this technique to many colleagues and visitors in 1773.

Just over a decade later the Italian Anatomist Luigi Galvani made one of the most important observations in understanding the physiological role of electricity when he noticed the twitching of the muscles of a dissected frog’s leg when touched with a metal scalpel. On 20th September 1786 he wrote:

 

“I had dissected and prepared a frog in the usual way and while I was attending to something else I laid it on a table on which stood an electrical machine at some distance from its conductor and separated from it by a considerable space. Now when one of the persons present touched accidentally and lightly the inner crural nerves of the frog with the point of a scalpel, all the muscles of the legs seemed to contract again and again as if they were affected by powerful cramps.”

 

Galvani coined the term ‘animal electricity’ to describe the force that activated the muscles of his specimens. The phenomenon was later called ‘galvanism’ after Galvani but today the study of galvanic effects in biology is better known as electrophysiology. Galvani’s name is also given to the ‘galvanometer’ an instrument for measuring and recording electricity, which is integral to the modern electrocardiogram.

The galvanometer was used by the Italian Physics Professor Leopoldo Nobili to detect the flow of an electric current in the body of a frog from the muscles to the spinal cord in 1826. A student of Nobili, Carlo Matteucci, would later observe in 1838 that an electric current accompanies each heartbeat in a frog.

This work of Matteuci would in turn influence the German physiologist Emil du Bois-Raymond, who attempted to duplicate his work and ended up discovering the nerve’s ‘action potential’ in 1843. He detected a small voltage potential present in resting muscle and noted that this diminished with contraction of the muscle. To perform this experiment he created an incredibly sensitive galvanometer that need over 5 km of wire. This galvanometer would later be improved upon by William Thompson (Lord Kelvin), when he created the ‘Thompson Siphon Recorder’ in 1867.

 

The Road to the Electrocardiogram

It is thought that the first human electrocardiogram was recorded by the Scottish electrical engineer Alexander Muirhead in 1870. He is said to have used a Thompson Siphon Recorder to do so at St. Bartholomew’s Hospital, but this is somewhat disputed as the work was never published.

The British physiologists John Burden Sanderson and Frederick Page would make great strides in the advancement of the understanding of the electrical activity of the heart in the late 1800’s. In 1878 they used an invention called the capillary electrometer to directly record the electrical current within the heart and were the first to note that it consisted of two phases, which would later be recognised as the QRS complex and the T wave.

The first published human electrocardiogram was recorded by the British physiologist Augustus Waller of St. Mary’s Medical School in London. This was also recorded using a capillary electrometer and was performed on a laboratory technician called Thomas Goswell.

 

Enter Willem Einthoven

Up until this point the recordings of the heart’s electrical activity were crude and the measuring devices cumbersome. Einthoven witnessed a demonstration by Waller at the First International Congress of Physiology in Basle, Switzerland, in 1889. Waller demonstrated using his pet dog, Jimmy, who apparently sat patiently with his paws in glass jars of saline.

 

Augustus Waller in his lab and his dog “Jimmy” with his paws in glass jars of saline, image sourced from Wikipedia
Courtesy of Wellcome images CC BY-SA 4.0

 

Inspired by this demonstration Einthoven made considerable improvements to the recording of cardiac electrical activity with the capillary electrometer and he introduced the term ‘electrocardiogram’ at a meeting of the Dutch Medical association in 1893. Two years later in 1895 Einthoven managed to distinguish five deflections using an improved electrometer and a correction formula. He named these deflections P, Q, R, S, and T using a mathematical convention dating from Descartes. N has other meanings in mathematics and O is used for the origin of the Cartesian coordinates. P was simply the next available letter and the nomenclature has stood to this day.

Einthoven’s big breakthrough, however, came with his invention of a new galvanometer in 1901. This version of the galvanometer, which he named the ‘string galvanometer’ used fine quartz string coated in silver and weighed approximately 600 lbs. A year later Einthoven published the first electrocardiogram recorded on his string galvanometer and within a year the production of the worlds first commercial ‘ECG machine’ was underway.

 

An early ECG machine (circa. 1911)

 

Einthoven’s Legacy

Following Einthoven’s work the use of commercial ECG machines became increasingly commonplace. Numerous advances in both recording and interpretation of ECGs would occur over the years that followed. Einthoven received the Nobel Prize in Medicine for inventing the first practical system of electrocardiography used in medical diagnosis in 1924.

The work of Einthoven and the many pioneers of science that went before him have left a remarkable legacy to medicine. The ECG remains one of the most useful investigations available to us in medicine and each and every hospital produces literally hundreds of recordings now on a daily basis. These ECG recordings have resulted in the saving of countless lives due to cardiac problems and will no doubt continue to do so long into the future.

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Dr Joseph Bell: The Real Life Sherlock Holmes

I have been fascinated with the detective Sherlock Holmes since childhood. His almost supernatural powers of observation and deduction in stories such as ‘The Sign of the Four’, ‘The Speckled Band’, and ‘A Study in Scarlet’ captivated me and I have re-read them many times. More recently I have greatly enjoyed watching the TV series ‘Sherlock’ in which Benedict Cumberbatch plays a modern day Holmes and Martin Freeman plays his sidekick Dr. Watson. I have even experimented with the mind palace technique that Sherlock used in “The Hound of the Baskerville” episode to help memorise large chunks of information for exams.

Sherlock Holmes may be one of the most famous fictional characters in literature but many people do not realize that he was actually modeled on a real-life surgeon called Joseph Bell.

 

Who Was Dr. Joseph Bell?

Joseph Bell was born in Edinburgh on the 2nd December 1837, the son of Dr. Benjamin Bell and his wife, Cecilia Barbara Craigie. He studied medicine at the University of Edinburgh Medical School and qualified in 1859. He was a talented and highly thought of medical student and delivered a dissertation to the Royal Medical Society as a student, which is still in their possession to this day.

Bell had an accomplished medical career and served as a personal surgeon to Queen Victoria whenever she visited Scotland, published several medical textbooks and became president of the Royal College of Surgeons of Edinburgh in 1887.

He was the great-grandchild of the forensic surgeon Dr. Benjamin Bell, a pioneer of forensics that is widely regarded as being the first surgeon to ‘practice scientifically’ and has been described as the father of the Edinburgh school of surgery. Benjamin Bell is quoted as having stated that “In medical practice it is inevitable to observe the details” and Joseph Bell certainly inherited his grandfather’s eye for detail.

Joseph Bell himself became a popular lecturer, renowned for his extraordinary observational abilities. He was able to tell from the tattoos of sailors where they had sailed, could discern a man’s origin from their accent and could tell the profession of a patient from glancing at their hands. He famously concluded that one man was an alcoholic by observing that he habitually carried a flask in the inside breast pocket of his coat. He is reported to have noted that another man was a cobbler by seeing that the inside of the knee of the man’s trousers was worn in a particular way. He could also apparently tell with great reliability that someone had lied to him by observing their behaviour and mannerisms.

 

Joseph_Bell
Dr. Joseph Bell circa. 1910

 

Sir Arthur Conan Doyle and Joseph Bell

Sir Arthur Conan Doyle first met Dr. Joseph Bell in 1877 whilst he was a medical student and he served as a clerk for him for a time. Bell became Doyle’s mentor and he spent a great deal of time observing Bell’s celebrated deductive abilities. In many ways he was Dr. Watson to Bell’s Sherlock Holmes.

The following is an account of Doyle’s recollection of one particular example of Bell’s observational abilities that occurred when Bell observed a patient that he had never spoken to or met before:

“Well, my man,” Bell said, after a quick glance at the patient, “you’ve served in the army.”

“Aye, sir,” the patient replied.

“Not long discharged?”

“No, sir.”

“A Highland regiment?”

“Aye, sir.”

“A non-com officer?”

“Aye, sir.”

“Stationed at Barbados?”

“Aye, sir.”

 

Bell turned to his bewildered students. “You see, gentlemen,” he explained, “the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned civilian’s ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British, and the Scottish regiments are at present in that particular island.”

 

Very Holmes-like observational skills indeed! It is not just Holmes’ observational and deductive skills that can be attributed to Bell, but also his fashion sense. Joseph Bell is reported to have often worn a long coat and a deerstalker hat and a few famous photos of him in this attire exist.

Doyle once wrote a letter to Bell thanking him and acknowledging him for his influence in the creation of his most famous character:

“It is most certainly to you that I owe Sherlock Holmes … round the centre of deduction and inference and observation which I have heard you inculcate I have tried to build up a man.”

 

Book Illustration Depicting Sherlock Holmes and Dr. Watson in a Train Cabin
Holmes (wearing a long coat and deerstalker) and Watson together in an illustration by Sidney Paget.

 

A Long Lasting Legacy

Bell died on the 4th October 1911 and his grave can be found at the Dean Cemetery in Edinburgh alongside that of his wife, Edith Katherine Erskine Murray, and their son Benjamin, and next to his father and brother’s plots.

His legacy lives on though, and Sherlock Holmes and the many other characters based upon him continue to inspire and new generations of readers to this day.

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The Russian Plague of 1770-1772

In the summer of 2016 a 10-year-old Russian boy cut himself skinning a marmot whilst hunting with his grandfather in the remote Kosh-Agach region in the Atlai Mountains. A few days later he developed a fever and a flu-like illness and was taken to a local hospital. He had contracted bubonic plague.

His case caused panic and hit the international news. Everyone he came into contact with was quarantined and thousands of emergency vaccines were administered. Fortunately his case was isolated and fears of an outbreak proved to be unfounded.

The last major outbreak of bubonic plague in Russia occurred almost 250 years earlier in 1770 and the outcome was very different indeed. It was a devastating epidemic that claimed the lives of as many as 100,000 people.

 

The Russo-Turkish war

In 1770 the Russo-Turkish war was well underway. The conflict had started in 1768 and was contested between the Ottoman Empire and the Eastern Orthodox coalition, that was led by the Russian Empire. The majority of the war was fought in the Balkans and Caucasus, where the plague was endemic in some areas.

In January 1770 some Russian troops stationed in Maldova started to develop feverish illness and swollen lymph nodes. Gustav Orreus, A Russian-Finnish surgeon stationed with the troops, recognized the symptoms and signs immediately and identified the illness as being bubonic plague, an infectious disease caused by the bacterium Yersinia Pestis. An outbreak developed and 1,500 troops subsequently contracted the plague by August of 1770, of these only 300 survived.

Yersinia Pestis is a particularly nasty bacterium that can infect both animals and humans. It uses rats and other rodents as a reservoir species. Fleas then act as a vector species, acquiring Yersinia Pestis whilst feeding on the infected rodent and the bacteria is then passed to humans via a fleabite. The classic sign of bubonic plague are buboes, horribly swollen lymph nodes. These most commonly appear in the inguinal nodes, situated in the groin region because most fleabites occur on the legs. Those infected will first experience fevers, chills and muscle pains before developing septicaemia or pneumonic plague. Death can occur in less than 2 weeks.

 

Plague_-buboes
The classic ‘buboes’ of bubonic plague.

 

The plague reaches Moscow

Medical quarantine checkpoints had been set up years earlier by Peter the Great, and these had proved to be very efficient at preventing plague from entering Russia during peacetime. The effectiveness of these checkpoints fell apart during wartime though, and in the Christmas of 1770 it finally spread all the way to Moscow.

Dr. Shafonskiy, the chief physician at Moscow General Hospital, identified a case of the bubonic plague and promptly reported it to a German physician Dr. Rinder, who was in charge of the public health of the city. Unfortunately Dr. Rinder didn’t trust Shafonskiy’s judgement and ignored his report.

Government officials chose to listen to Rinder and also ignored Shaifonskiy. Unfortunately by the time that it became obvious to everyone that this was an outbreak of bubonic plague it was too late to stop the spread with the traditionally employed measures and it had started to take hold. In February 1771 the plague broke out at a textile mill in the city and workers from the mill started to spread the plague around the city. By the spring of 1771 a major epidemic was in full effect. In June 1771 Dr. Rinder himself contracted the plague from a patient and died a few days later.

 

The Plague Riot

The government responded to the epidemic by setting up hospitals and quarantines around the city. The rich started to flee to the neighbouring countryside, but the city was shut down to the poor, who were not allowed to leave.

Some of the measures instituted by the government were interpreted as being heavy handed by the city’s populace. Contaminated property was destroyed without compensation, public baths were closed and many felt that the government had trapped them inside the city on purpose.

 

Plague Riot
1930s Watercolour of the Plague Riot by E. Lissner

 

The plague peaked in September 1771, killing over 1000 people every day. Fear and anger were widespread, and protests against the measures taken started to occur. In mid September, Archbishop Ambrosius attempted to prevent citizens from gathering at the Icon of the Virgin Mary in central Moscow as a quarantine measure. This lit the torch paper of the Plague Riot and on September 15th 1771 huge crowds of angry citizens descended upon the Red square, invaded the Kremlin and destroyed the Archbishop’s residence. The following day the situation worsened and the Archbishop was murdered by the rioters. The riot was eventually suppressed by the military, but not until 3 days and a huge amount of destruction had occurred.

 

Murder_of_Archbishop_Ambrosius_(Geoffroy,_1845)
The murder of Archbishop Ambrosius by Charles Michel Geoffrey (1845)

 

Grigory Orlov takes control

Following the riot, Empress Catherine dispatched Count Grigory Orlov to take control of Moscow. Orlov was an interesting figure and was a trusted favourite of Empress Catherine. He had led the coup that overthrew her husband Peter III and installed Catherine as Empress a decade earlier, and was also rumoured to have been her lover.

Orlov arrived in Moscow on September 26th 1771 with four regiments of troops and immediately called an emergency council with the local doctors.

He went on to do a good job, gaining the trust of the people and changing public opinion about the government’s emergency measures. With Moscow’s medical commission fully engaged and the support of the people, the quarantine methods employed started to take effect. Through October and November the number of new cases started to slow down and on November 15th Empress Catherine declared that the epidemic was officially over.

There would be further deaths in the early part of the following year, but with effective quarantine measures in place only 330 deaths were reported in January 1772.

 

The consequences of the Russian plague

The plague would have long-lasting effects upon Moscow. The epidemic would ultimately reshape the map of Moscow as new cemeteries were established outside the city in an attempt to both combat the epidemic and deal with the astonishing death toll. Taxes and military conscription quotas would be markedly reduced in many provinces and it the effects would alter the course of the Russo-Turkish war.

The estimated total death toll from the epidemic lies somewhere in the region of 100 thousand people, which was an astonishing one-third of the population of the city of that time.

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Claudius Galen

The Greek physician, Claudius Galen, is considered to be one of the most important figures in the history of Medicine. Galen was the greatest physician of his era and was also a skilled surgeon and renowned philosopher. He was responsible for numerous advances in the fields of anatomy, physiology and therapeutics and led a truly remarkable life.

 

His father’s dream

 

Galen was fortunate to be born into an affluent home, in the city of Pergamon on the Aegean coast in AD 129. His father, Aelius Nicon, was a wealthy and well-respected architect and builder. Nicon was an educated man with interests in literature, astronomy, mathematics and logic. Galen described him as a “highly amiable, just, good and benevolent man”.

 

His father had planned for Galen to study philosophy and politics, which were the most respected of the academic pursuits in Greece at that time. This all changed, however, following a dream that he had in AD 144, when his son was aged 15. In this dream Asclepius, the God of medicine and healing, appeared to Nicon and informed him that he should allow his son to study medicine. After this dream it was arranged for Galen to begin his medical studies at the healing temple, or Asclepieum, in Pergamon following his 16th birthday.

 

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Asclepius, the God of medicine and healing

 

Galen’s early medical career

 

Over the next four years Galen studied medicine at the Asclepieum with several illustrious physicians including Aeschrion of Pergamon, Stratonicus and Satyrus.

 

In AD 148 his father Nicon died, leaving Galen with a substantial inheritance and little in the way of ties to Pergamon. With this newfound freedom he decided to dedicate the next period of his life to travelling and gaining new medical knowledge. His travels took him to Smyrna, Crete, Corinth, Cyprus and finally to the great medical school in Alexandria. Over the next 9 years he would gain an unusually wide and varied medical education that would prove to be invaluable to him. In AD 157, he finally returned to Pergamon and was appointed physician and surgeon to the gladiators of the High Priest of Asia.

 

 

Unique insights into anatomy and trauma

 

It was during his time working with the gladiators that Galen would develop unique insights in the fields of anatomy and trauma. It is claimed that he was chosen for this job over other physicians when the High Priest eviscerated an ape and challenged the physicians to repair the damage. When they refused, Galen performed the surgery himself and was successful in his attempts, greatly impressing the High Priest and securing the position for himself.

 

He became very seasoned in the art of treating combat wounds and was also able to gain knowledge of practical human anatomy in a time when human dissection was strictly forbidden. He is said to have described the gladiator’s wounds as “windows into the body”. He would later further improve his knowledge of anatomy by performing dissections on apes and monkeys and became uniquely skilled in this field.

 

Only five gladiators died during his time as their appointed physician, a remarkable number when compared to the 60 deaths his that occurred during the time his predecessor cared for them. This was attributed to the meticulously painstaking wound care that he applied.

 

 

Marcus Aurelius and the Antonine Plague

 

In AD 161, aged 32, Galen travelled to Rome, and this is where he would spend the majority of the rest of his life. Whilst in Rome he gave numerous public lectures and anatomical demonstrations, which eventually brought him to the attention of the Emperor Marcus Aurelius. Galen would go on to become the personal physician of Marcus Aurelius and served him during his wars against the barbarian invaders that threatened the Daubian frontier.

 

In 166 AD the Antonine Plague struck Rome and Galen was present at the start of the outbreak. Galen helped to treat those afflicted with the illness and his descriptions of the outbreak have led many historians to believe that it was an outbreak of smallpox.

 

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Galen, pictured in an engraving by Georg Paul Busch.

 

The latter years of Galen

 

Galen spent the remainder of his life in Rome and, following the death of Marcus Aurelius, he would serve as the physician to two of his successors, Commodus and Septimus Severus. He became a prolific writer and medical investigator and was responsible for over 80 separate works of great importance in the fields of medicine, anatomy, physiology and philosophy.

 

In the field of pharmacology he created the system of Galenic degrees, which is the first recognized attempt to precisely gauge the effects of medicines. As such he should be considered one of the earliest known clinical researchers. He is credited with the discovery that the arteries carried blood, was one of the first clinicians to recognize the importance of the pulse, and was the first person to discover that urine is formed by the kidneys.

 

Arabic sources state that he died aged 87 in 216 AD in Sicily. Galen left an indelible mark of the medical world during his lifetime and changed the practice of medicine for hundreds of years after his death. It was not until the Renaissance that many of his theories would be disproven or improved upon and without him the medical world as we know it today might be a very different one.

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The Dancing Plague of 1518

In the summer of 1518 in the city of Strasbourg, Alsace, a woman by the name of Frau Troffea took to the streets and started to dance. She continued to dance day and night without stopping. No one knows why she started but within a few days others started to join in. Within a week Frau Troffea had died, presumably from exhaustion and 34 others are reported to have joined her dancing in the streets.

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The Story of Rene Laennec and the First Stethoscope

No single piece of equipment is more synonymous with the medical profession than the stethoscope. I can vividly remember wearing my brand new Littmann stethoscope with pride on ward rounds as a medical student, desperately trying to discern diastolic murmurs and extra heart sounds with little success. Few people realise that if it wasn’t for the shyness of a young French doctor called Rene Laennec that this amazing piece of equipment may never have been invented.

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The Mysterious Sweating Sickness

The Middle Ages are renowned for being a turbulent and difficult period of history. War, famine and disease occurred throughout the period and one of the most devastating pandemics in history, the Black Death, occurred in the mid 14th century.

The Black Death was not the only disease to wreak havoc in this period though, and another disease, now known as ‘Sweating Sickness’, or ‘The English Sweate’ claimed thousands of lives in the 15th and 16th centuries.

 

The first outbreak

 

In the summer of 1485, at the start of the reign of Henry VII, a previously unseen disease started to spread across England. Some have suggested that it was brought to England by French mercenaries in Henry Tudor’s army but this is by no means certain and there are no reports of it affecting the Tudor army.

Henry Tudor arrived in London shortly after the Battle of Bosworth Field on the 28th August 1485 and the disease was first reported there less than three weeks later on the 19th September 1485. The disease then proceeded to run rampant in London, killing thousands and striking panic in the population.

 

Sweating Sickness first appeared in England shortly after the Battle of Bosworth Field.

 

One of the most terrifying features of the disease was the speed with which it could kill. There were numerous reports of people dropping dead in the street suddenly. Thomas Forrestier, a French physician living in London at the time, wrote of the disease:

We saw two prestys standing togeder and speaking togeder, and we saw both of them dye sodenly. Also in die—proximi we se the wyf of a taylour taken and sodenly dyed. Another yonge man walking by the street fell down sodenly.“

 

‘A great sweating and stinking’

 

The disease spread quickly and began suddenly, the afflicted suffering violent cold shivers, dizziness, thirst, headaches, joint pains, and a sense of apprehension. Some also reported that sufferers had a malodorous smell and appeared red and flushed. There appeared to be an initial ‘cold stage’ that lasted a few hours, followed by a ‘hot sweating stage’. One attack did not appear to offer immunity and some people suffered several bouts before dying.

The following description by Thomas Forrestier paints a vivid picture of what the disease must have been like:

And this sickness cometh with a grete swetyng and stynkyng, with rednesse of the face and of all the body, and a contynual thurst, with a grete hete and hedache because of the fumes and venoms.

It seems that the most dangerous stage of the disease was the first few hours, and that those who survived the first 24 hours would go on to make a full recovery.

 

Subsequent outbreaks

 

The 1485 outbreak lasted until late October that year and then disappeared for several years. There were reports of smaller outbreaks at periodic intervals but it was not until 1507 that a large outbreak occurred again. In 1517, a third and much more severe epidemic occurred that also spread across the channel and struck Calais, where it remained mostly confined to the English population. In 1528, the disease reached epidemic proportions again, this time it spread into parts of Europe including Hamburg, Switzerland, Denmark, Sweden and Norway, although none of these were as severely affected as England. The last major outbreak of the disease occurred in England in 1551 and after this it disappeared completely and has never been seen again.

 

Scourge of the English upper classes

 

One of most perplexing aspects of the disease was its predilection for the English upper classes, especially rich young men. Unlike many other medieval diseases, it seemed to spare the very young and the very old. It became known as ‘The English Sweate’ because it did not spread to Scotland, Ireland and Wales. It also seemed to affect foreigners living in England less severely.

It was most commonly seen in rural areas but also severely affected the nobility living in London and the student populations of Oxford and Cambridge. In later outbreaks Cardinal Wolsey would contract the disease twice and recover on both occasions but it claimed the lives of a large number of his household on both occasions.

 

Cardinal Wolsey is thought to have contracted the disease twice, in 1517 and in 1528.

 

It would also affect the court of Henry VIII and Anne Boleyn is said to have contracted and survived the disease. Chronicler Edward Hall commented on how it affected the Kings court and nobility in London:

“Suddenly there came a plague of sickness called the sweating sickness that turned all his [the King’s] purpose. This malody was so cruel that it killed some within two houres, some merry at dinner and dedde at supper. Many died in the Kinges courte. The Lorde Clinton, the Lorde Gray of Wilton, and many knightes, gentleman and officiers.”

Many Englishmen unsuccessfully tried to escape the disease by fleeing to Ireland, Scotland, and France only to die there. John Caius wrote in his 1552 publication ‘A Boke or Counseill Against the Disease Commonly Called the Sweate or Sweating Sicknesse’ that “It followed Englishmen like a shadow”.

Several hundred years later in 1881, Dr Arthur Bordier submitted a paper to the Anthropology Society of Paris entitled ‘On the special susceptibility of the fair-haired races of Europe for contracting sweating Sickness’. In the paper he presented an interesting, but unproven theory that Sweating Sickness did not solely affect Englishmen but instead had a tendency to infect those descended from the Anglo-Saxon and spared those descended from the Celts.

 

What was the cause of the Sweating Sickness?

 

There have been several hypotheses over the years as to the exact cause of the Sweating Sickness. Some have suggested that it was actually influenza, whilst others have suggested it was caused by anthrax or relapsing Fever.

One of the most compelling cases is that it was caused by hantavirus pulmonary syndrome. In 1993, an outbreak of this disease struck the Navajo people in New Mexico. This outbreak, known as the Four Corners outbreak after the region in which it was located, bore many resemblances to the Sweating sickness, prompting investigators to suggest it as a potential cause.

Like Sweating Sickness, hantavirus is characterised by a sudden onset of a fever, joint pains, headache. This is followed by shortness of breath and rapidly evolving pulmonary oedema that usually requires mechanical ventilation and has a mortality rate of 35-40% despite modern medical intervention.

 

The mystery lives on…

 

Despite the various theories as to why it behaved in such a strange manner, mainly affecting English nobility, and to the exact cause of the Sweating Sickness, we are still none the wiser. It may be that we never unravel the mysteries of this disease and that it will never be seen again.

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