|Year : 2018 | Volume
| Issue : 6 | Page : 459-460
The way forward: Reinventing the wheel: Aligning and re-aligning
Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||15-Nov-2018|
Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Banerjee A. The way forward: Reinventing the wheel: Aligning and re-aligning. Med J DY Patil Vidyapeeth 2018;11:459-60
A way of deriding any research is to use the phrase “reinventing the wheel.” However, even the full potential of the wheel lay dormant for centuries for the want of imagination. Ancient Mesoamericans designed wheels. However, they were on toys as decoration. Practical application of wheels took thousands of years. All the while, human labor manually moved heavy slabs of stone over flat surfaces building massive monuments. Wheeled carts would have made this labor less rigorous.
Late into the 20th century, scientists and researchers traveled all over the world to attend conferences. They carried their heavy suitcases themselves, used porters, or put them on top of a cart with wheels. None of these erudite scientists thought of putting small wheels directly under these suitcases. This brilliant application was perhaps an imaginative improvisation by some obscure luggage maker. And, it occurred more than three decades after human's landing on the moon.
These examples elegantly illustrate the gap between invention and application–known as “translation gap.” In the history of medicine, such translational gaps abound. A few landmark examples will illustrate this.
Hippocrates, who elegantly conceptualized the concepts of epidemiology in his treatise “on airs, waters and places,” had such an intimidating influence on subsequent practitioners that the discipline of epidemiology lay dormant for more than 2000 years after Hippocrates. Why this gap occurred is explained below.
Hippocrates in his treatise stated “…Whoever wishes to investigate medicine properly should proceed thus…to consider the season of the year…Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. In the same manner, when one comes into a city to which he is a stranger, he should consider its situation, how it lies as to the winds and the rising of the sun…One should consider most attentively the waters which the inhabitants use … and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor.”
The concepts of modern epidemiology starting from seasonal and environmental factors to lifestyle diseases were captured by the Father of Medicine. But, these lay dormant for more than two millenniums. In the interim, primitive myths and drastic practices such as humors, miasmas, and bloodletting thrived. Why this translational gap from theory to practice? Greenwood speculates that this is because Hippocrates used the word “consider” instead of “count.” And, no one questioned further.
The Hippocratic concepts of epidemiology were somewhat revived after they were infused with a dose of “counting and measurement.” One of the first counters was John Graunt, a London businessman (better at counting than doctors!). He was also a founder member of the Royal Society of London. Graunt started counting vital events such as births and deaths in 1662, publishing weekly reports which contributed more to demography than epidemiology. After Graunt, there was a gap of 200 years before the realization of further potential of counting health events. William Farr, a physician responsible for medical statistics of England, started compiling the annual reports of vital events related to health from 1839 and continued the practice for the next 40 years. He discerned patterns in these statistics, addressing some of the major concerns of modern-day epidemiology.
With the impetus provided by Farr, the static wheel of epidemiology gained motion. The landmark in communicable disease epidemiology using “counting and measurement” was Snow's classic investigation of the London cholera outbreak of 1854 which for the first time established polluted water as a cause of cholera by counting and measuring cholera in neighborhoods supplied by different water sources; one from polluted part of Thames river and the other from cleaner part. He put Hippocrates' advice of “…consider most attentively the waters…” on a firmer footing by “counting and measurement.”
The pioneers in lifestyle diseases were Doll and Hill, with their study of association of smoking and lung cancer among British doctors, and Morris who studied the outcome of sedentary lifestyle among London busmen and postal workers. The methodology of these studies involved counting and measuring lifestyle factors and health outcomes. The alignment from “consider” to “count” led to a large number of epidemiological studies of disease etiology. These methods were later adapted for the evaluation of therapeutic interventions culminating in the present-day practice of “evidence-based medicine.”
The field of surgery developed rapidly after the era of antiseptic surgery brought about by Lord Lister. He achieved this with divergent–convergent mode of thinking essential for creativity. His friend Thomas Anderson, an expert in agricultural chemistry, advised him to read Louis Pasteur's paper on how microbes spoiled wine and milk. From this divergent view, Lister converged that the same microbes may be leading to surgical wound infection. Anderson also discussed how he treated sewage with carbolic acid to render it suitable for agricultural manure safe for both animals and humans. Lister connected the stench of sewage and gangrene. Again from this divergent perspective, Lister converged to using carbolic acid to prevent gangrene in surgical wound infection. Surgeons started using carbolic acid sprays over the operative field with remarkable results. The re-alignment of the carbolic acid “wheel” from sewage to surgical wounds heralded the era of antiseptic surgery.
The lesson from the history of medicine is that there is a case for aligning and re-aligning the wheel. Counting and measurement took Hippocrates' concepts of epidemiology forward-aligning the wheel. The use of carbolic acid in one field, treating sewage, led to the adaptation in another diverse field, treating surgical wounds – realigning the wheel.
These strategies are needed in our country with its rich tradition of alternative systems of medicine. These disciplines have a rich armamentarium of herbal remedies since thousands of years. Besides, vivid description of symptoms mimicking modern-day mainstream conditions could be traced in ancient Indian texts. The “wheels” got buried over time. We need to dig out these buried wheels of traditional medicine and subject them to the rigors of evidence-based medicine aligning and re-aligning them along the way. There is a case for “reinventing the wheel.”
Two reviews in the present issue have dug out descriptions of diseases described in ancient Ayurvedic texts. One resembles catatonia and the other Graves' disease. There are striking similarities of these conditions as described in the modern textbooks of mainstream medicine and ancient Ayurvedic texts. The issue also includes a trial in mice of two variants of Ashtangavaleha, a well-known polyherbal remedy for asthma, for their antitussive properties. Though the authors conclude from their study that both formulations showed efficacy and recommend it as remedy for cough, studies in humans need to be done to meet the standards of evidence-based medicine. The wheel has to turn a full circle.
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