50 Years of Fibre-optic Colonoscopy

Posted on 16th February 201916th February 2019 by Edward Wawrzynczak | Leave a comment

2019 marks 50 years since the advent of fibre-optic colonoscopy. This blog discusses the development of this widely used technique and associated technology, and its impact on modern medicine.

Colonoscopy is a technique that allows direct visualisation of part of the large intestine (the colon). A flexible tube (endoscope) with a light source is inserted into the anus and images from the inside of the colon are projected onto a monitor. As well as being used for diagnostic purposes, colonoscopy can also be therapeutic, for example allowing for the removal of pre-cancerous growths.

The technique of modern colonoscopy is largely thanks to the work of several doctors in the 1960s and 1970s. The fibre-optic colonoscope was developed by Dr Niwa and Dr Yamagata at Tokyo University. Two physicians based in America, Dr William Wolff and Dr Hiromi Shinya, then pioneered its use, performing the first modern colonoscopies in June 1969. They described ‘over 1000 successful and totally uncomplicated endoscopic examinations’. The colonoscope, unlike the flexible sigmoidoscope, allowed for visualisation of the complete colon. Wolff and Shinya later developed and started using an electrosurgical polypectomy ‘snare’ to remove polyps. They published a seminal paper in 1973 demonstrating the utility, safety and cost-effectiveness of colonoscopy. The practice of colonoscopy increased during the 1970s and 80s, facilitated by the associated public exposure when President Ronald Regan underwent several colonoscopies to remove polyps in the mid-1980s. The New York Times quoted the advice given by Ronald Reagan’s surgeon who stated that the president should ‘undergo an examination of his intestines, a colonoscopy, within six months and every year after that, as well as periodic blood tests to check for possible colon malignancy’.

So how has colonoscopy changed over the past few decades? Well, to be truthful, not much! The technique is very much the same. However, the instruments used today are more flexible, making them easier to manipulate. This allows for better visualisation of the colon and reduces the amount of time needed to perform a colonoscopy.

Colonoscopy is essential in the diagnosis of bowel cancer which is the fourth most common cause of cancer in the UK. It is used for both the surveillance of patients with previous bowel cancer or significant risk factors, and in screening for bowel cancer. Colonoscopy can also be therapeutic. It can facilitate the removal of lesions and the cessation of bleeding in the bowel, through electrocoagulation, injection therapy and the use of special clips secured over bleeding blood vessels.

Endoscopic examination of a patient’s gut by Dr A.I. Morris, Royal Liverpool University Hospital. Drawing by Julia Midgley, 1998. Wellcome Images.

Improvements in optical imaging have already increased the quality of the images seen on the monitor as a colonoscopy is being performed. Higher definition images mean more subtle lesions and even small polyps can be visualised. Less invasive imaging modalities, such as virtual colonoscopy (computed tomography colonography) and capsule endoscopy, have been developed as potential options for those who are unable to undergo a complete colonoscopy.

Many believe that colonoscopy will grow to play a bigger therapeutic role in the future. Watch this space…

Caricature, contestation and the making of ‘Typhoid Mary’

Posted on 12th January 201912th January 2019 by Edward Wawrzynczak | Leave a comment

The story of Mary Mallon (1869-1938), reprehensibly branded ‘Typhoid Mary’ by the American press, provides an excellent example of how caricature and animation played an intrinsic role in the dissemination of information in relation to epidemic disease. ‘Typhoid Mary’ was the first healthy carrier of typhoid to be identified in the United States. An immigrant from the shores of Ireland, Mary was a cook by trade and had efficiently been serving up typhoid bacteria along with her food since she first set foot in an American kitchen in 1900. In 1907, the New York health authorities discovered her infective potential: as a result, she was isolated and quarantined for a total of 26 years. Mary Mallon was formally held responsible for infecting 53 people with typhoid fever, three fatally so. However, historian Richard Gordon clarifies that her casualty list was probably far larger than this, there is even speculation that she caused the 1903 epidemic at Ithaca, New York, which had a devastating 1,400 victims.

Image 1: ‘Typhoid Mary’, Wikimedia Commons. The image first appeared in The New York American on June 20, 1909.

The negative media portrayal that Mallon was subject to encouraged her forceful treatment by the health authorities. The papers delighted in depicting Mary as a devious cook, out to poison her employers. Mary Mallon was, as Roy Porter so aptly describes, “rapidly demonised”: by 1909, macabre cartoons in the popular press depicted her cracking egg-like skulls into a frying pan. The juxtaposition of such images of habitual domestication with deadly disease generated fear and panic amongst the American public. Mary herself was very aware of the bad reputation she was accruing, stating to the New York Times that she was “treated like a leper”. Mary’s description was not an exaggeration: she was banished to an island, destined to live the rest of her days in enforced solitude.

Mary Mallon’s story sparks social, moral and legal debate that has extensive contemporary societal relevance when considered within the context of epidemic disease. It is a mark of the infamous nature of this case that the phrase ‘Typhoid Mary’ still carries strong connotations, defined figuratively in the Oxford English Dictionary as “A person who… is the source of undesirable opinions, emotions, etc.; an unpopular or subversive person”. The power of caricature was instrumental in rendering ‘Typhoid Mary’ an inextricable part of American popular culture.

The Gripe Water

Posted on 21st November 201821st November 2018 by Edward Wawrzynczak | Leave a comment

Early modern receipt books may be defined as collections of food recipes, medicinal remedies and household tips. These handwritten manuscripts were generally compiled by the housewife; she would use the receipt book as a means to record her own recipes as well as those borrowed from friends, neighbours, family, and even doctors and surgeons. Receipt books were highly valued and were often passed down through the generations; they were even formally bequeathed in wills. These manuscripts provide intriguing evidence of the homemade medicinal remedies in use in the early modern period. This blog is focused on a recipe for ‘Gripe Water’ from a receipt book attributed to Mary Chantrell, dated 1690. The manuscript can be found at the Wellcome Library in London and it is also available in a digitised format online via their website.

Wellcome Library MS.1548, 53.r-v

The layout of this recipe is interesting: it is written in prose, and there are no separate lists of ingredients or utensils as is often the case in modern-day recipes. It must have been rather difficult for early moderns to make sure they had all the ingredients required before starting to make the recipe!

One of the most striking things about this particular recipe is the number of individual ingredients used: ‘gilley flowers’, ‘rosemary flowers’, ‘borage flowers’, ‘blacke cheryes’, ‘strawberyes’, ‘rasberyes’, ‘mint’, ‘balme’, ‘angellicoe’, ‘rue’, ‘morella cheryes’ ‘coriander seeds’, ‘caraway seeds’, aneseeds’, ‘nutmeg’, ‘cloves’, ‘mace’, ‘cinamon’, ‘ginger’, ‘pennyroyall’, ‘brandy’, ‘sherye’ and ‘white wine’. Some of these herbs and spices were difficult to cultivate in seventeenth-century English gardens necessitating their purchase from specialist suppliers. Exotic spices, such as ginger, mace, cinnamon and nutmeg often had to be imported. The housewife would need to know where to obtain these individual items as well as how to judge their quality in the making of this remedy.

The quantities of ingredients is notable: a gallon each of strawberries and raspberries, 12 pounds of cherries, three gallons of brandy, a gallon of white wine and a gallon of sherry! Such quantities would have made the recipe expensive. Perhaps the large amounts used were due to the recipe being made for a large household, or maybe the intention was to share or exchange the final product amongst others in the local community. Perhaps the ‘Gripe water’ would be made once and then kept and stored for future use over the coming months or even years.

Finally, the equipment used is interesting. The recipe mentions the use of a ‘Limbeck such as the Apothecaryes use’. This ‘Limbeck’ (more commonly termed an ‘alembic’), was an apparatus used for the purposes of distillation. Using this kind of equipment supports the notion that activities commonly associated with the history of science might be performed in the home, and encourages us to consider the domestic environment as an ‘experimntal space’.

Early modern receipt books, like this one, raise many questions. But they also provide us with a tantalising window through which to view early modern domestic medicine.

The First Bone Atlas—A Success or Failure?

Posted on 24th August 201828th August 2018 by Edward Wawrzynczak | Leave a comment

William Cheselden completed a surgical apprenticeship in 1709. Remaining in London, he was unable to immediately develop a practice and instead taught anatomy. He eventually turned his class notes into a book, The Anatomy of the Humane Body. It was wildly successful, partially because it was in English rather than Latin. The book proceeded through 13 editions and was the go-to source for surgical anatomy for a hundred years.

Based on his deep understanding of anatomy, Cheselden became an adept surgeon—setting fractures, removing cataracts, and extracting bladder stones. His surgical reputation rapidly spread far and wide.

Cheselden is best remembered, however, for what might be considered a failure. Understanding that skill in surgery requires a thorough understanding of anatomy, in 1733 he published Osteographia, or the Anatomy of the Bones. The book took several years and £17,000 to complete. It was the first book devoted solely to bone anatomy. It sold only 97 copies, yet Osteographia is a treasure of anatomy and artistry.

Cheselden recognized that techniques of perspective and shading were critical to rendering three-dimensional objects accurately onto paper. Just a slight shift of the artist’s head or an urge to highlight a shadowed surface distorted the results. These were outcomes that Cheselden wanted to avoid. Surgeons needed absolutely accurate representations of the skeleton. The subtleties of each contour had to be perfect.

Under Cheselden’s guidance, two artists accomplished his aim. Unique at the time for medical illustration, they suspended the bones from a tripod placed in front of a large box. A tiny hole in one end allowed light and an image of the bones to enter. One of the artists sat at the open end and traced every detail onto a glass plate, which Cheselden then converted to an engraving. At the time, the technique of using a camera obscura was unique for medical illustration. Today we recognize the device as a pinhole camera.

Osteographia ranks as one of the all-time great anatomy atlases in scope and elegance. The camera obscura, depicted on the book’s title page, signals the work’s accuracy. Osteographia’s sensitivity and elegance become quickly evident when noting the exquisite detail of the drawings, their arrangement on each page, and the lack of overlying labels or lines. The text is sparse. Cheselden knew that the images could tell their own story. They continue to do so.

Roy A. Meals, MD blogs regularly at www.aboutbone.com

Jenner, Fewster and Jesty

Posted on 30th May 201830th May 2018 by Edward Wawrzynczak | Leave a comment

Jenner vaccinating (Gillray) – Courtesy Wellcome Images

On the 14^th May 1796 Edward Jenner carried out the first stage of his now famous vaccination experiment and inoculated a young boy named James Phipps with cowpox. To this day Jenner’s name is associated with the discovery of vaccination as a concept, and the worldwide eradication of smallpox. However, there were others who helped light the path to Jenner’s discovery, and even carried out that same experiment decades before Jenner.

Vaccination could not have happened without the development of variolation; the process of inoculating healthy individuals with smallpox matter in order to confer immunity against the disease. It was based on the observations that a primary attack of smallpox often provided a degree of immunity against contracting the disease again in the future. It was introduced to Britain in the early eighteenth century by Lady Mary Wortley-Montagu, who had come across the concept of ‘smallpox parties’ whilst living in Turkey. Following the successful variolation of her own son, she also had her daughter inoculated with smallpox matter in 1721 by the surgeon Charles Maitland. Others soon followed suit, including a royal variolation when George II had his two daughters inoculated with smallpox, at the request of his wife Caroline, Princess of Wales.

The concept gradually spread across the country, but it was not until it reached the county of Suffolk and the ears of a young surgeon named Robert Sutton, that it truly took off. Sutton advertised variolation as a service, including bed and board with the added incentive of ‘tea, wine, fish and fowl’ all for a monthly fee. Gradually inoculation houses started to appear across the country, inspired by the likes of Sutton and his business enterprise.

It was at one of these inoculation houses that in 1768 John Fewster, a Gloucestershire surgeon and apothecary, recognised that a great number of patients could not be infected with smallpox. On enquiry he discovered that they had all previously been infected with cowpox. He made note of this and communicated it to a small medical society of which he as a member at the time. It just so happened that Edward Jenner was also present at this society meeting, as a young apprentice to another local surgeon named Daniel Ludlow. Fewster was a strong supporter of the Suttonian method of variolation and he did not recognise the importance or see the need at the time for the development of inoculation with cowpox.

It would be wrong to talk about the history of vaccination without mentioning Benjamin Jesty (1736-1816), a dairy farmer from Yetminster, in Dorset. Not only did he recognise the protective effect that cowpox had over smallpox, but he also went so far as to vaccinate his wife and children with cowpox in 1774, at least twenty years prior to Jenner’s famous experiment. Furthermore he tested his vaccination trial in 1789 when his two sons were variolated by their local doctor and they did not go on to exhibit any signs of a reaction. Jesty unfortunately did not go on to publish his results, and perhaps due to the public outrage that ensued when the locals discovered that he had inoculated his family with animal matter, did not go out of his way to publicise them either. However, his experiment did not go unrecognised, and he was invited to attend George Pearson’s Original Vaccine Pock Institute in 1805. The physicians at that institute decided that Jesty’s experiment had pre-empted Jenner’s, and they awarded him with a testimonial scroll stating just this.

It is evident that the history of vaccination is more complex than the well-known story of Jenner, the milkmaid and the cow. The concept of cowpox being protective against smallpox was reportedly widely known throughout the dairy country in England and across the continent in Germany. However, it cannot be disputed that Jenner was the only one to make this fact publicly known and to recognise the importance that this discovery could have in the fight against smallpox. It was his determination and dedication to the subject which subsequently led to the World Health Organisation declaring the eradication of smallpox on 8^th May 1980.

More can be discovered about this fascinating subject by paying a visit to Dr Jenner’s House, Museum and Garden in Berkeley, Gloucestershire. https://jennermuseum.com/

Roy Porter, ‘The Prevention of Smallpox’, in The Greatest Benefit to Mankind. A Medical History from Antiquity to the Present.(London: HarperCollins, 1999) 275-6

S.L. Kotar and J.E. Gessler, Smallpox: A History (North Carolina: McFarland & Company, 2013),18

Robert Jesty and Gareth Williams, ‘Who invented vaccination’, Malta Medical Journal, 23, 2 (2011) 29-32

Lydia Thurston and Gareth Williams, ‘An examination of John Fewster’s role in the discovery of smallpox vaccination’, J R Coll Physicians Edinb,45 (2015) 173-179

Lydia Thurston