Journal of Humanitarian Medicine - vol. VI - n. 2 - April/June 2006

MEDICAL CONTRIBUTORS TO SOCIAL PROGRESS: A SIGNIFICANT ASPECT OF HUMANITARIAN MEDICINE

William C. Gibson, O.C., M.D., D. Phil., F.R.C.P.

Chancellor Emeritus, University of Victoria, Canada
Regent, International Association for Humanitarian Medicine Brock Chisholm

Scientific discoveries in the field of medicine over the last four centuries have undoubtedly had social repercussions. Edward Jenner (1749-1823) saw cowpox protecting milkmaids from smallpox and launched an inspired generalization upon the world, bringing us vaccination (from “vacca” meaning cow). While there were, temporarily, wild political happenings following the enforcement of vaccination laws—such as the burning down of the city hall by a mob in Montreal—there followed massive, improvements of health society and its instruments such as hospitals, libraries, and universities. Seven examples of social, humanitarian progress following medical discoveries are described below.
One of the most interesting physicians in this remarkable field was the little general practitioner in London’s east-end dockland—Dr James Parkinson. Today his name is on the lips of laymen and physicians alike, and the result of his description, in 1817, of six cases of paralysis agitans seen in his practice, or taken from the sparse literature of the time.
While Parkinson is remembered for his classic medical description, and to some extent for his early volumes on fossils, as well as the first description in English of perforation of the appendix, his contribution to social change is considerable. He began at age twenty-three with an attack on quacks! Moreover he struck a blow for freedom by piloting through the press the two-volume work of Tom Paine on The Rights of Man, after Paine had had to flee to France to escape arrest in London.
It was now Parkinson’s turn to be arrested, along with all who sold Paine’s works. Some were jailed for alleged “libel”, others “transported” to Australia. But Parkinson, on being hailed before Pitt, the Prime Minister, and the Privy Council, stood his ground and successfully challenged their right to apprehend him. Pitt spat on democracy and what he called “that monstrous doctrine” of “the rights of man”.
James Parkinson had been a pupil of the great surgeon John Hunter, whose lectures he took down in shorthand. His colleagues in the fight for a democratically elected Parliament numbered, among others, the writer Richard Brinsley Sheridan and Samuel Whitbread of the brewery family. The “underground” consisted of what were called “Corresponding Societies” that met in pubs—where information was exchanged and campaigns against a most corrupt British government were hatched. The problem was that while the great cities of Liverpool, Birmingham, and Manchester were denied even a single seat in the House of Commons, the unpopulated county, Cornwall, boasted forty-four seats.
Parkinson lived a busy life as a general practitioner while, at the same time, discharging broadsides against the government. His pamphlet which the government found most disturbing was entitled Revolution Without Bloodshed; or Reformation Preferable to Revolt, though it put forward social legislation that is today on the books of all advanced countries. His targets were well chosen: e.g., he said, “The present system of Excising (taxing) almost all the necessities of life, as soup, candles, starch, beer, etc. might be abolished”, and “The unfortunate tradesmen, ruined perhaps by some swindler of rank, might not be consigned to the horrors of a dungeon, because oppressed by the heavy load of misfortune.”
His books on gout and on dangerous sports must have been fitted into a demanding life, along with works on chemistry and paediatrics. He served as a church trustee and went about establishing Sunday schools. The apostate Edmund Burke, once a supporter of parliamentary reform, went over to the Tory government and became its defender of corruption. He now shouted against reform: “Learning will be cast into the mire and trodden down under the hoofs of a swinish multitude.”
Parkinson, using a pen rather than a sword replied by one of his sixpenny pamphlets entitled: “An address to the Hon. Edmund Burke from the swinish multitude”. He signed it “Old Hubert”. This pseudonym he applied to other pamphlets and posters put up at great risk by “billstickers”—many of whom were thrown in prison. Nevertheless Parkinson kept after Burke, the silver-tongued orator, in a further blast: “Pearls Cast Before Swine by Edmund Blake—Scraped Together by Old Hubert”. In this masterpiece Parkinson said it all in one phrase: “When bad men combine, the good must associate; else they will fall, one by one, an unpitied sacrifice in a contemptible struggle.”
We leave Parkinson, the physician, as we read the final words in his epoch-making Essay on the Shaking Palsy:

“Before concluding these pages, it may be proper to observe once more, that an important object proposed to be obtained by them is, the leading of the attention of those who humanely employ anatomical examination in detecting the causes and nature of diseases, particularly to this malady. By their benevolent labours its real nature may be ascertained, and appropriate modes of relief, or even cure, pointed out. To such researches the healing art is already much indebted for the enlargement of its powers of lessening the evils of suffering humanity. Little is the public aware of the obligations it owes to those who, led by professional ardour, and the dictates of duty, have devoted themselves to these pursuits…”.

The year of Parkinson’s death, 1824, saw a precocious and diminutive youth entering Harvard College. Oliver Wendell Holmes found it chilly and cheerless around the temples of the law and, fortunately for all women bearing children in bacterially polluted hospitals, he took up the study of medicine. As was the custom in Boston 150 years ago, Holmes with the sons of John Collins Warren, Nathanial Bowditch, and James Jackson went off to Paris to walk the wards of La Pitié with the great clinician Pierre Louis (also once a law student), and the father of statistics in clinical medicine Gabriel Andral. The young Americans, upon examination, became members of The Society for Medical Observation, where no holds were barred.
Holmes prospered in this highly charged intellectual climate and developed two convictions: (a) that most medicine being prescribed then were better thrown into the sea, though that would be hard on the fishes; and (b) that childbed or puerperal fever was demonstrably contagious. The rigorous discipline exercised by Louis over his foreign students was the making of Holmes as a penetrating analyst of medical causes of social distress.
On returning to graduate in medicine at Harvard in 1836, with a thesis on pericarditis, Holmes lost no time in joining The Boston Society for Medical Improvement. There he learned that a physician who had done an autopsy on a woman with childbed fever succumbed himself to the infection which he acquired at the post-mortem table—but not before he had infected a number of women he was still able to attend. This lit a fire under the receptive Holmes and he set out to collect the facts on this pestilence. He was already well known to the public for his widely admired poem “Old Ironsides”, which caused the Secretary of the Navy to think twice before sending the famed frigate Constitution to the shipbreakers. In addition, at age 33, he had rallied the medical profession against quackery, as Parkinson’s first paper had done. Holmes’ essay on “Homeopathy and its Kindred Delusions” convinced his readers that he had given up the levity of his days in the Hasty Pudding Club at Harvard, and was now waving a pen sharper than any bistouri.
A year later he launched the rocket which assured his place in both medical and social history. He collected and analysed reports on dozens of deaths from childbed fever. If ever a man had been well prepared for this demanding task it was Holmes, the student of Andral. As Pasteur used to say, “Fortune favours the prepared mind.”
Of these stirring days of conflict with the obstetricians Holmes wrote, years later, to William Osler:

“I have rarely been more pleased than by your allusions to an old paper of mine. There was a time, certainly, in which I would have said that the best page of my record was that in which I had fought my battle for the poor poisoned women (i.e., The Contagiousness of Puerperal Fever). I am reminded of that Essay from time to time, but it was published in a periodical which died after one year’s life…”.

General practitioners wrote sad letters to Holmes saying that they now realized how they had been transmitting infection to their maternity patients. However, the obstetricians tried to belittle the matter, while surreptitiously trying to have Holmes dismissed from his Chair of Anatomy at Harvard. To its everlasting credit Harvard replied by making Holmes the Dean of Medicine.
Before we leave Holmes’ contributions it should be noted that he gave us the terms “anaesthesia” and “anaesthetics”. He was also the founding president of the Boston Medical Library in 1875, which in its re-incarnation today remains a beacon of enlightenment.
Nine years junior to Holmes “the poet” was Ignaz Semmelweis “the peasant”. Boston and Budapest saw these two disparate young men studying law at first, but emerging as medical graduates. Semmelweis studied first in Pesth and then in Vienna, where he graduated in 1844, his thesis describing his experiments on pneumonic infection in animals. His degrees were Doctor of Medicine and Doctor of Midwifery.
Paralleling Holmes’ first awakening to the possible cause of puerperal sepsis, Semmelweis grieved for the loss of one of his obstetrical colleagues, who had died of a small dissecting wound following an autopsy, and began to connect the large number of similar deaths on his obstetrical service with the examinations made by professors and students proceeding directly from the anatomy and the pathology dissecting rooms. By instituting the scrubbing of hands with calcium chloride he was soon able to reduce the incidence of childbed fever to one-eighth of what it had been.
The conservative Vienna Medical Society, led by Scanzoni, heard this 29-year-old’s views with alarm. Though the veterans Skoda and-Hebra stood by Semmelweis he was relieved of his post, and wisely returned to Budapest. There he found that his teaching wards were situated between the morgue and the cemetery. He soon changed this and was able to show that in 514 confinements on his service there were only two deaths. With this experience as his springboard he began, at age 39, to write his immortal book, The cause, concept and prophylaxis of puerperal fever.
What a clarion call to action it was:

“My Doctrine is not firmly established in order that the book expounding it may moulder in the dust of a library; my Doctrine has a mission and that is to bring blessings into practical social life. My Doctrine is produced in order that it may be disseminated by teachers of midwifery, until all who practise medicine, down to the last village doctor and the last village midwife, may act according to its principles; my Doctrine is produced in order to banish error from the lying-in hospitals, to preserve the wife to the husband, the mother to the child.”

Alas, Semmelweis died at age 47, in a mental hospital, broken in spirit and in body after twenty years of suffering the ignorant abuse of his obstetrical colleagues. Society will remember him long after they are forgotten.
Three years younger than Semmelweis was Rudolph Virchow, the father of “cellular pathology”. His war-cry was “omnis cellula e cellula”—each cell arises from an antecedent cell. Virchow was an army medical student in Berlin, as was the forerunner of penicillin therapy, Ernest Duchesne in Lyons. As an undergradute Virchow conducted research on the inflammation of the cornea in rabbits, which were sent to him by his father in Pomerania. After a post-graduate year in pathology Virchow was sent by the German government to investigate the sudden appearance of typhus in Upper Silesia. His report was a “blockbuster—which included his typhus findings, but much more. He advocated “full and unrestricted democracy… with freedom and prosperity”.
He was already suspect for publishing at the age of 25, in the first volume of his Archiv, his credo:

“The role of pathological anatomy as a dogmatic science is at an end.”

He prophesied that pathological physiology would henceforth be “recognized as the stronghold of scientific medicine to which pathological anatomy and clinical observation form but the outworks.”
The Prussian government was already paranoid on the subject of social revolution. Karl Marx had been doing too much reading in the British Museum! (Another of our physician reformers, Sun Yat Sen the non-communist, was to do the same fifty years later.) The Communist Manifesto of 1848 had the crowned heads of Europe in an uproar. Virchow told his students that Prussia was being ruled by a family wherein the father had softening of the brain, the grandfather hardening of the brain, and the grandson no brain at all.
This brought about Virchow’s speedy dismissal from his post in Berlin, and luckily he found a most hospitable opening at the University of Wurzburg. Seven years later this talented teacher was invited, by a unanimous vote of the faculty, to return as Professor of Pathology in Berlin, where an institute was built for him.
This creative man was soon elected to the Reichstag, and he remained there for 50 years, the sworn enemy of the dictatorial Bismarck. Virchow’s greatest coup was, as chairman of the Reichstag’s finance committee, to prevent Bismarck building a large German navy early in the 20th century. On a more positive side Virchow was the supporter of his friend Schliemann in digging up another civilization at Troy in Asia Minor.
We leave Virchow, who was Osler’s and Sherrington’s teacher, with a glance at his far-sighted words written at age 30, so reminiscent of James Parkinson’s. Virchow said:

“There are also those who, if they do not create the current, still give it its direction and force. These men are not always the happiest. Many go down in the movement, or by it. Many grow weary after they have given it their best forces. Much power and great tenacity are necessary if the individual shall not only live to see his triumph but also to enjoy it.”

It has always seemed to me that there was at least one case of a “prepared mind”—to use Pasteur’s phrase again—having the satisfaction of seeing his diagnosis and treatment of a social ill compressed into one week. Dr John Snow (1813-1858) at the age of 36 won a prize of 30,000 francs from the Institut de France for an essay on the spread of cholera. Suddenly, on the first day of September in 1854, people in the immediate neighbourhood of the Broad Street pump in London began dying. By September 7th more than 500 were dead. On September 8th Snow, with the informed permission of the Guardians of the Parish of St James, removed the pumphandle and the epidemic stopped. He was then able to go back to his practice as an anaesthetist. In that role he twice attended Queen Victoria during confinement. He developed a pulmotor for infants on the point of asphyxia, and still had time to invent a trocar for draining the chest.
While these things were happening in the middle of the last century, war broke out between a French-British coalition on one side and the defending Russians on the other. The Crimean peninsular struggle on the Black Sea became one of the bloodiest shambles in history. You will ask: “How is that campaign related to doctors and social progress?” The answer is, of course, that despite the worst bureaucratic military medical martinets in history, Florence Nightingale (1823-1910) began the uphill battle to establish the profession of nursing. Without the congenital irrascibility of Sir George Hall, the Inspector General of Hospitals during that war, which produced in the perceptive Miss Nightingale just the reverse, it is possible that military nursing, in fact all nursing, might have taken much longer to emerge as a respected and humane service.
The story is too well known to require repetition here, but I want to mention the hospital at Scutari, just south of Constantinople (Istanbul today). The area is called locally, Uskudar. Her hospital had to be laboriously developed out of a rat-infested military barracks—a quadrangle, with each side the length of three city blocks.
So much for a triumph over doctors who tried to impede social progress. Even as Florence Nightingale was leaving Scutari to return to England, Dr Hall was spitefully writing in his diary: “Can any nonsense go beyond this?”, referring to her distribution of remaining and unneeded rations to military stations, rather than to his medical establishment. Other gifts by her were, in his caustic words, “A matter of absurdity on the part of the kindhearted well-intentioned contributors, and a piece of silly ambitious vanity on her part to have the European reputation for being the guardian angel of the sick and wounded, but if she and her supporters could hear the commentary of our neighbours it would cool, if not cure, her officious intermeddling with other people’s affairs.” He certainly wore his liver on his sleeve.
A happier chapter in the history of social progress inspired by doctors is one which began in the spring of 1897 when a medical student, E.O. Huntington, at Columbia University took a long walk in New York with the Rev. Frederick Gates, who had been his pastor years before in a struggling Baptist church in Minneapolis. Gates asked the student if there was a textbook of medicine which would help a layman to understand the current position of medical science in the United States. The youth replied at once that William Osler’s recent volume, The Principles and Practice of Medicine, was just what he wanted. Thus Gates, the adviser to John D. Rockefeller, purchased Osler’s well-written and truthful volume, along with a medical dictionary, and went off to the Catskills for his summer vacation.
Gates returned from his vacation an inspired man. He had, as the saying goes, “got religion”—this time in the form of medical research. He would have passed for an Old Testament prophet, thundering away against disease, sloth, malfeasance, and other crimes. Disease was his enemy and nothing less than a holy war would suffice. His retirement speech in 1923, according to one of his successors, Dr Alan Gregg of the Rockefeller Medical Sciences Division, as related in his biography by Wilder Penfield, is a masterpiece. Before the assembled and terrified Board of the Foundation, Gates roared:

“And when you die and come to approach the Judgment of Almighty God, what do you think he will demand of you—yes, each one of you? Do you for an instant presume to think he will inquire into your petty failures, your trivial sins, your paltry virtues? NO! He will ask you just one question: ‘WHAT did you do as a Trustee of The Rockefeller Foundation?’”

The social progress fostered by the Rockefeller Foundation through medical research and education is well known to you here, but from China there is a story too rarely told. Planning for the Peking University Medical College project began in 1913, and this superior medical faculty operated until the Japanese invasion of China in 1937. For years thereafter the fine granite buildings were used for hospital purposes, but in 1979 the PUMC, as it had been called since its inception, resumed its historic role in training scientist-clinicians and medical researchers. The competition for the thirty places in each year of study is intense, and one of the present students made the highest score in the entire country of one billion people, in any field of study, on his university entrance examinations.
This is all by way of introducing a physician who literally changed the world of one billion people and their successors. He was Sun Yat Sen, who was born in southeast China in 1866 into a poor farming family that lived in a forgotten hamlet euphemistically called “Blue Thriving Village”, in an area known as “The Fragrant Hills”. Before he died in 1925 of cancer of the liver in the PUMC Rockefeller Hospital just described, he, with his comrades, had finally freed his country from centuries of domination of the ruling Manchu line.
His fascinating life—much of it spent in exile—has been wonderfully chronicled by Abbie Lyon Sharman, an American who lived for years at Yenching University in China. Stanford University has reprinted her frank appraisal of a hero we should know more about. His wife, Soong Ching Ling, died only recently of leukemia at age 92, but not before my home university in Victoria, British Columbia, could honour her with an honorary doctorate at a ceremony in Beijing. The other two Soong sisters have been chronicled recently by Sterling Seagrave, a British writer who lived for forty years in China.
Now, in briefest form, the one-time theological student turned medical doctor received his first formal education at the Bishop’s School in Hawaii, where his older brother was in the sugar trade, near Pearl Harbor. Sun Yat Sen mastered the English language and, in his third year, received a prize given by the King. However, the brother detected a preoccupation in the precocious young man: an interest in learning English, in the American Constitution, and in Christianity, so he shipped him back to the “Blue Thriving Village” not far from Canton. On being baptized by an American missionary in Canton he proceeded with the good Dr Hager to evangelize the country villages, including those in his Fragrant Hills. With his black skull cap, long black gown, and a long braid of hair down his back he must have caught the attention of his traditionally Confucian relatives. He never forgot his humble origins, and years later made this clear when he said, in truth:

“I am a coolie, and the son of a coolie. I was born with the poor and I am still poor. My sympathies have always been with the struggling mass”. (The Chinese words “koo lee” mean “bitter labour”.)

It is reminiscent of Rudolph Virchow’s credo, so much in keeping with humanitarian medicine:

“The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”

From the age of 18 until he was 20, this young Chinese was employed in the Anglo-American Mission Hospital in Canton, and there he developed an interest in medicine.
By the age of 20 Sun Yat Sen was convinced the recent history of dismemberment of his country by the Great Powers must cease and, axiomatically, the weak and pliant Manchu dynasty must be replaced by a republic.
Perhaps, because a doctor’s expertise was easily portable and always in demand, he chose the medical career as his vehicle with which to accomplish the vast social transformation of China. After a year of medical education at the Canton Hospital he transferred to the superior College of Medicine for Chinese in Hong Kong, and there came under the tutelage of Dr James Cantlie, of whom more later, and of Sir Patrick Manson, the man who showed the role of mosquitoes in the transmission of the tropical disease, filariasis.
On graduation in 1892, at the head of his class, Dr Sun Yat Sen practised in clinics in Macao, the Portuguese island not far from Hong Kong, and then in Canton. His contact with endless indigent patients further strengthened his resolve to rid China of the Manchus.
You will wonder if the stage in China was already set, waiting for Sun Yat Sen to “walk on” as The Great Deliverer. He had no such good fortune. From 1894 to 1911 he laboured to educate his people (a) as to the scandalous things happening to Mother China and (b) as to the type of genuine reconstruction needed. Each of the ten times that uprisings against the Manchus failed, with frightful repression to follow, the masses came to heed what he was teaching them. He truly had a sense of mission and an evangelical approach to his eager audiences around the world.
Over and above these factors, however, was the stark reality of the butchery exhibited by imperialist powers such as Britain, France, Germany, and Japan. In fact, in the year in which he gave up medical practice, Sun Yat Sen was scandalized by the first major incursion of Japan into China. The Manchus were required, in the unique post-war “settlement”, to cede Taiwan to the aggressor, and to pay to Japan an indemnity which was two-and-one-half times China’s annual budget. France stripped China of what became euphemistically known as French Indo-China. Britain took a firm grip on Kowloon bordering Hong Kong. Germany cut itself a large piece of territory on the China Sea, at Tsingtao. It was disgraceful.
When, eventually, a deranged Dowager Empress sent her bare-handed “Boxers” against the imperialist powers who were battening upon a pitifully weak China, those eight powers combined to force yet another alleged “settlement”, further bleeding the floundering country.
While this crude geographical surgery was going on, Sun Yat Sen was organizing expatriot Chinese wherever he could reach them. He stopped long enough in London to read voraciously in the library of the British Museum—where many revolutions had their beginning. When the Chinese Embassy in London found that the much hunted and hated Sun Yat Sen was in Britain they kidnapped him and locked him up in a cell. Luckily he found a British employee at the Embassy to carry, hidden in a coal scuttle, an urgent message to Dr (later Sir) James Cantlie, his former professor of Hong Kong days, by now Head of the School of Hygiene and Tropical Medicine in London.
Cantlie alerted Sir Patrick Manson, the distinguished anti-malarial scientist, and together they descended on the Foreign Office, to no effect. Next they applied under habeas corpus for the release of the prisoner from his cell in the Chinese Embassy. That manoeuvre failed, but piqued the curiosity of a minor newspaper reporter. The lordly Times of London refused to print their letter to the Editor. Finally the news broke that the Embassy had cabled Peking for the funds to charter a vessel specifically to transport Dr Sun Yat Sen back to China for execution. The public clamour in London brought about his release on a Saturday. On Monday—too late—the cable arrived from China authorizing the ship’s charter, so he was saved.
Sun Yat Sen’s early message to his listeners at home and abroad consisted of three constant themes resulting from his reading at the British Museum. In addition to the “abolition of unequal treaties”.
These aims were:

• to achieve equality among the varied races within China and national independence and freedom without;
• democracy—“to strive for the political liberty and equality of the people” through election, recall, initiative, and referendum;
• “the people’s livelihood—achieving economic equality of people by peaceful and evolutionary means”.

I must not weary you with a litany of the frightful things which happened to Dr Sun Yat Sen and his movement after he was installed as the Provisional President of the Republic on January 1st, 1912. As in many human activities, some join a good cause to see what they can do for it. Alas, there are others who join to see what the cause can do for them. Unbridled war lords went on the rampage, some with foreign backing it was felt, and, all told, the years between 1912 and 1925, in which year Sun Yat Sen died, were lost in turmoil.
Right up to the time of his death in 1925 he kept elaborating his writings on the reconstruction of China, on local and central government, foreign policy and national defence. He did all this despite the destruction of his valuable library in 1922 by fire, when a traitor to the cause turned his cannon on a hill outside Canton where Sun Yat Sen’s headquarters had been established. He died a poor man, with little beyond a reconstituted personal library on political economy and a house purchased for him by overseas Chinese.
However, these were the years in which the beleaguered statesman did his finest writing—The First Step to Democracy, and A Plan for the Industrial Development of China, as part of his major work, The Plan of National Reconstruction.
In January of 1925 he was operated upon for cancer of the liver at the Peking Union Medical College Hospital but died on March 12th. His body rests in a vast mausoleum on the slopes of the Purple Mountain near Nanjing. Few memorials in the world can compare with it in size or beauty.
I have a copy of the surgical report which showed the massive inroads of cancer of his liver. This condition is still rampant in China today, killing one million people annually. Those cases represent one-tenth of the known cases of chronic but still active infectious hepatitis caused by a virus. Those ten million residual cases come from the one hundred million cases estimated to be suffering from that disease.
If Dr. Sun Yat Sen were alive today I think we would find him in another campaign—trying to rid China of tobacco-related deaths. All Chinese presently under the age of 20 years, will, during their lifetime, see 50 million of their number die of cancer of the lung, or of tobacco-related heart disease. The world’s top epidemiologists report that by the year 2025 there will be two million such deaths annually—unless drastic action is taken to stop foreign companies advertising and manufacturing high-risk cigarettes in China.
So, Dr Sun Yat Sen’s determination to “fight the good fight” goes on, his followers trying gradually to bring liberal democracy and good health to the world’s most populous land.
This brings us to the end of a cursory review of the contributions of physicians to the world’s progress. There are many, many others who could well have been discussed, but I hope that this sampling may give an increased pride in not only the medical but also the social achievements of this great profession, neatly summed up in the concept of Humanitarian Medicine.

BIBLIOGRAPHY

1. Gibson, William C., Young Endeavour: Contributions to Science by Medical Students of the Past Four Centuries. Ch. Thomas, Springfield, USA, 1958
2. Gibson, William C., Medical Comets: Scholarly Contributions by Medical Undergraduates, University of British Columbia Press, Vancouver, Canada, 1997.
3. Gibson, William C., Old Endeavour: Contributions to Medical Science Over the Age of 65. (In press, 2006)