The James Lind Library: explaining and illustrating the evolution of fair tests of medical treatments.

The James Lind Library (www.jameslindlibrary.org) has been established to improve public and professional general knowledge about fair tests of treatments in healthcare and their history. Its foundation was laid ten years ago at the Royal College of Physicians of Edinburgh, and its administrative centre is in the College's Sibbald Library, one of the most important collections of historic medical manuscripts, papers and books in the world. The James Lind Library is a website that introduces visitors to the principles of fair tests of treatments, with a series of short, illustrated essays, which are currently available in English, Arabic, Chinese, French, Portuguese, Russian and Spanish. A 100-page book-- Testing Treatments--is now available free through the website, both in English and in Arabic and Spanish translations. To illustrate the evolution of ideas related to fair tests of treatments from 2000 BC to the present, the James Lind Library contains key passages and images from manuscripts, books and journal articles, many of them accompanied by commentaries, biographies, portraits and other relevant documents and images, including audio and video files. New material is being added to the website continuously, as relevant new records are identified and as methods for testing treatments evolve. A multinational, multilingual editorial team oversees the development of the website, which currently receives tens of thousands of visitors every month.

Visible signs of illness from the 14th to the 20th century: systematic review of portraits.

OBJECTIVES: To see whether a collection of portraits depicting inhabitants of a defined geographical region and covering several centuries is a useful source for studying the sociocultural significance and epidemiology of particular visible diseases, such as goitre, which is known to have been common in this region. DESIGN: Systematic review of portraits and description of visible signs of illness. SETTING: The Burgerbibliothek (archives of the burghers' community) in Berne, Switzerland. DATA SOURCES: 3615 portraits; 2989 of individuals whose identity is known and 626 of individuals whose identity is unknown. MAIN OUTCOME MEASURES: Visible signs of illness evaluated by means of a standardised visual assessment. RESULTS: Visible signs of illness in portraits were common and appeared in up to 82% (451/553) of paintings from the 17th and 18th centuries. The most common findings were signs of goitre in women and overweight in men. In only the portraits where the neck region could be evaluated, 41% of women with known identities (139/343) had goitre compared with 24% of men with known identities (21/86). The prevalence of goitre was even higher in sitters whose identities were unknown: 63% in men (5/8) and 68% in women (82/121). Overweight in people with known identities was more common in men than in women (30%, 346/1145 v 44%, 811/1844). Overweight was most common in sitters aged >40 than in those aged 40 or younger. Other conditions, such as missing teeth, amputated limbs, or osteoarthritic deformations were surprisingly rare in the portraits under evaluation. CONCLUSIONS: Goitre and other diseases are under-represented in the people depicted in these portraits. Artistic idealisation is a likely explanation for this observation: what was reproduced depended on what was considered pathological or shameful at the time, and therefore depended on age and sex. Stigmatising details may have been omitted. Further, artistic skills and contemporary fashion may have influenced the way in which people were reproduced. People depicted are possibly not representative of the general Bernese population as they constituted a socioeconomically advantaged group.

[Women under the knife--another history of surgery]. / Frauen unter dem Messer - auch eine Geschichte der Chirurgie.

UNLABELLED: During the 19th century, surgery developed from management of lesions mainly on the surface of the body to operative treatment within the body as well as, at the same time, from a handicraft to a scientific discipline based on pathological anatomy. In the 1860s, ovariectomy became the 'key operation' in supervening traditional boundaries. The increasing safety of surgical intervention soon led to unspecifically indicated operations on normal organs within the female abdomen, aiming at curing 'typically female mental abnormalities', i.e. a kind of psychosurgery. This is still occasionally found today. The operative management of normal situations has even increased in gynaecology (hysterectomy) and obstetrics (caesarean section) in the 1970s and 1980s. Traditional medical ethos has therefore not been able to prevent it. Another new field, plastic and aesthetic surgery, had its specific ethical problems, which were well recognised as early as 1900. Because of the relative frequency of goitres and their operative treatment, after 1883 women came to the fore of the concepts of internal secretion, organ transplantation, and physiological surgery. IN CONCLUSION: In view of cultural and gender history, socio-cultural factors have been at least as decisive as medico-scientific 'facts' for the frequency of some of the operations performed on women. These operations have, in turn, accelerated the progress in surgery and medicine in general.

[Medical ethics: innovation due to deficiencies?]. / Medizinethik: Innovation aus Mangel?

A historical follow-up using three examples--euthanasia, choice of therapy for tuberculosis of bones and articulations and economic management of a medical office reveals that comprehensive timeless medical ethics independent from cultural and social influences ('hippocratic oath') do not exist. There are, however persistent as well as increasingly new fields of conflict in daily practise. The latter are partly related to increased medical efficiency. Deficiencies in explicit ethic reflexions and empiric research for coping with such problems led to interdisciplinary medico-ethical work groups and journals over the last years. In this context traditional subjective ethics of care founded on altruism still remain important: The present essay shows, why the new objective and the older subjective approach to moral dimensions of healing professions are mutually founded on each other and should converge in the course of a decision process.

[Theodor Kocher: surgery and ethics]. / Theodor Kocher: Chirurgie und Ethik.

Theodor Kocher's (1841-1917) creative participation in the rise of modern surgery and his internationally prominent standing therein at the turn of the century are briefly outlined. Kocher experienced, however, the last decade of his career as a period of transition. First new developments within medicine and surgery questioned some of the new "radical" operations by then seen as sole progressive therapeutic possibilities. Second, new emotional and ethical conflicts ensued for the solution of which the traditional ethos (viz. "to help and to do no harm") was felt to be insufficient: The choice between two therapeutic possibilities and the unjustice of socially stratified treatment. Kocher tried to cope with this transition scientifically by promoting basic research, emotionally and ethically by explicitly stressing his long familiar Christian faith.

[The way from medical to physiological chemistry at the University of Göttingen, 1840-1940]. / Der Göttinger Weg von der medizinischen zur physiologischen Chemie 1840-1940.

In the nineteenth century chemistry was separated from medicine and reorganized as a "pure" academic science. Those left-over parts of chemistry that were more oriented towards medical application formed the nucleus of modern physiological chemistry, but could usually only exist in connection with other subjects. Especially the combination with physiology proved to be stable. Discipline building was delayed by the fact that a lot of physiologists resented a separation from physiology. Also in Göttingen physiological chemistry was attributed to the Physiological Institute, but initially still had close connections with the General chemical Laboratory. At the end of the nineteenth century a first attempt to establish itself as a discipline together with hygiene failed. Physiological chemistry stayed a part of physiology until 1939 when the Institute of Physiological Chemistry was finally founded. The Göttingen way is characteristic for the general establishment of the discipline in Germany.