HEROES OF MEDICINE

By SHERWIN B. NULAND

Thomas Carlyle, more than 1 1/2 centuries ago, wrote that "history is the essence of innumerable biographies." Indeed, the literature of medicine introduces us to a cavalcade of colorful and intriguing characters, an assortment of personalities that prompted historian Fielding Garrison to remark that "all human life is there." And yet, as distinctive as each of its many outstanding innovators has been, through the many ages and places in which their discoveries were made, there is a sturdy thread of tangible traits that unites them all. Even during the past four decades, which have witnessed medical innovation on an unprecedented scale, that sturdy thread has not frayed. Nor has the rapidity of achievement--with the linear progress of yesterday succumbing to exponential acceleration--stretched it to the breaking point. If anything, the new science and its bedside applications have provided more evidence than ever before that certain tangible human characteristics inevitably accompany innovation.

A year ago, a special issue of TIME highlighted some of the biomedical advances of the late 20th century. This 1997 issue celebrates men and women who have contributed to those advances. Not all of the assemblage of healers presented here are doctors. Nurses, technical personnel and seekers of botanical remedies have also found the limelight. So has one committed American woman who donated her bone marrow to a desperately sick person whom she had never met. When she was asked what moved her to come forward, and how she could tolerate the weeks of soreness and fatigue that follow the marrow harvesting, her reply was unassuming. She did it, she says, because "there's no choice. You're talking about saving somebody's life."

Though she is not a healer by profession, the altruistic donor is imbued with the same stimulus, the same motivation, that has driven medical pioneers throughout history. The force that leads men and women to devote their lives to those who need help is their simple realization that, for them personally, there is no choice. More than a career, this has been their calling.

No matter what other goals it may achieve, the medical profession has always maintained as its ultimate mission the relief of human suffering. Though the greatest of medical innovators have made their most important contributions for any combination of personal and professional reasons, the background against which their motivations play has never changed. It remains what it has been since earliest s: the constant mindfulness that individual people are enduring the effects of disease and that only through the intervention of others can their problems be addressed.

Modern medicine has grown by means of a tradition that is almost 2,400 years old. Its practices are said to have begun on the Greek island of Cos, near the western coast of Asia Minor, where a school arose around the teachings of the legendary Hippocrates. Today the name of Hippocrates is mentioned most frequently in discussions of the oath attributed to him. But the Hippocratic physicians did far more than introduce the principles from which the codes of today's medical ethics have developed.

Perhaps the single most striking difference between the doctors of the Hippocratic school and all others was their injunction that the causes of disease should no longer be attributed to the influence of supernatural forces. Henceforth, the origins of illness were to be sought in observable natural factors that influence the functions of the body. Attempts were made to relate specific symptoms to actual internal or environmental causes, rather than to the intervention of displeased and vengeful gods. This was a departure for physicians accustomed to seeking cures by appealing to the divinities with prayer and sacrifice.

Casting off the shroud of mysticism, the Greek physicians replaced it with the thesis that the causes and cures of every disease are not only quite natural but also discoverable through the careful study of each patient. Thus curiosity, keenness of observation and the value of scrupulous record keeping became paramount priorities in the new philosophy of care. And as knowledge grew and was shared within the guild, the experience of a single physician became the experience of all.

Over the course of several hundred years, a literature, later known as the Hippocratic Corpus, was created, forming the basis of all medical practice. Since that , the accumulated and recorded knowledge of one generation has been passed on to the next through literature and via those who teach their successors. Docere, the Latin word from which the word doctor is derived, means "to teach."

The influence of a teacher can be profound, somes far more than intended. So it was with the heritage of Hippocrates. Although a great many writings would be added to the literature of medicine over the next 1,800 years, they were largely restatements of, or small emendations to, the vast store of original findings in the Corpus.

One exception was the work of Galen, an immensely productive, Greek-speaking physician who lived much of his life in Rome. By the of his death around A.D. 201, the indefatigable Galen had written some 350 treatises detailing his own experimental work in anatomy and physiology. Although he added much to medical knowledge, his studies were based largely on monkeys and farm animals and thus were frequently unreliable in their conclusions about human anatomy. But the sheer prodigiousness of Galen's output and the aura of infallibility that surrounded him served to perpetuate his errors and stifle further research. His work would remain unchallenged until the 16th century, as though the Hippocratic teaching of detailed, objective studies had been forgotten.

Like Hippocrates, Galen had become a medical icon, and it would take a bold idol smasher to undo him. History found the perfect candidate in Andreas Vesalius, a contentious young Flemish physician who, in his single-minded pursuit of the correct human anatomy, cared not a whit about Galen's untouchable authority. Gifted with intelligence, drive and the courage to stick with his convictions, he went his solitary way, dissecting cadaver after cadaver until he had made enough unbiased observations to write a book that would forever transform medicine's image of the human structure. Vesalius was 29 when it was published in 1543. The anger first directed against him for daring to defy Galen's teachings was matched by his own contempt for those who took so long to accept the validity of his work.

The feisty spirit of Vesalius has pervaded the history of medical discovery--not the contentiousness, perhaps, but certainly the refusal to accept what is not verifiable by one's own observations and the willingness to stand alone when principle is involved. And always the capacity for hard work has been the glue that holds everything else together, the underlying characteristic that enables all of the other qualities to produce a successful conclusion.

Though their contributions were made in eras far apart, the Hippocratics, Galen and Vesalius all shared the same messianism that still characterizes today's outstanding medical achiever. Their discoveries were only the beginning of their contributions. Public demonstrations, the writing of treatises and books and the teaching of both colleagues and students became the vehicles for their individual crusades to better the state of medical care. Among them, like a constantly humanistic refrain playing softly in the background, the credo of the ancient Greek physicians prevailed. Nowhere is that principle more eloquently expressed than in the memorable words found in Precepts, one of the books of the Hippocratic Corpus: "Where there is love of humankind, there is also love of the art of medicine."

If medical theory and practice are based on an ever expanding body of knowledge handed down from one generation to the next, it follows that progress will occur only when additions are made to that knowledge. Although this is true for the most part, every era sees a few marked departures from the acquired wisdom--departures somes so radical as to create entirely new ways of looking at the evidence gleaned from the study of nature and disease.

The notion that disease originates in cells rather than tissues or organs, introduced in the mid-19th century by the German pathologist Rudolf Virchow, brought on just such a radical change in perspective. So too did the germ theory, based on British surgeon Joseph Lister's application of Louis Pasteur's work to prevent wound infections. Each was the result of thousands of meticulous observations made over many years. Virchow's studies were done in a university setting; Lister's in a laboratory that he and his wife set up in the kitchen of their home, where they worked tirelessly until they were ready to test their conclusions on a series of patients.

Both Virchow and Lister faced not only opposition but scorn until the medical mandarins of the day were finally brought around to admitting the truths on which the scientists' work was based. Lister, in particular, was ridiculed or ignored by his fellow surgeons, who refused to acknowledge the marvels he was accomplishing. But he forced himself to overcome his own gentle nature, persisting with the zeal of an evangelist. In the end, honored by Queen Victoria as Baron Lister, he lived to see his name ranked with those of the greatest medical thinkers of all time. As for Virchow, so revered did his theories make him that he came to be admiringly called "the pope of German medicine."

There are no new Listers or Virchows in the pages that follow, but the stories told are of healers who share those same qualities that have always been at the heart of medical innovation. Their contributions may not occupy entire chapters in future textbooks, but they have nonetheless helped many patients who might otherwise never have been relieved of their suffering. The men and women portrayed here are not so much icons as they are representatives of the kind of people who change medical care. The contributions of some are not, in fact, unique. Others are engaged in similar endeavors for similar reasons, and their work might just as appropriately have been chosen to illustrate the story of medical accomplishment in our time. And this, of course, is the real lesson of this special issue of TIME: The future of medical discovery is in good hands, and plenty of them.

The vision to see that things can be done better, a belief in principle, the conviction that comes with confidence in the correctness and value of what one is doing, and a strength of spirit that overcomes the inertia of long-established custom--these are ingredients without which the work cannot be accomplished. While genius is somes a factor, the tales in this issue tell of doggedness, common sense and the simple wish to help the sick or injured.

Though some of the contributions described here were the result of a few bursts of inspiration, there is not one that would have reached fulfillment were it not for the sense of personal responsibility that fueled its originator's persistence during the day-by-day grind necessary for success. In this, medicine is no different than any other form of endeavor. For when all is said and done, it is the perspiration that makes the difference. Henry Wadsworth Longfellow made the point much more elegantly:

The heights by great men reached and kept Were not attained by sudden flight, But they, while their companions slept, Were toiling upward in the night.

Sherwin B. Nuland, clinical professor of surgery at Yale University, wrote the 1994 National Book Award winner How We Die and The Wisdom of the Body, recently published by Knopf.