Transcript By George Sarka MD,MPH,FACP,FACR DrPH Candidate in Public Health at UCLA

By George Sarka MD,MPH,FACP,FACR
DrPH Candidate in Public Health at UCLA
Assistant Clinical Professor in Medicine at UCLA
Governor-Elect of the ACP Southern CA, Region 2
President of the LA Neurological Society
President of LA County Medical Association-District 1
Staff Neurologist at SMMC
Staff Rheumatologist at CSMC
Staff Physician at the Klotz SHC at CSUN
Medical Historian and Medical Lecturer
Diplomate in Internal Medicine, Rheumatology,
Neurology, Headache Medicine, Sports Medicine, Geriatrics and
Emergency Medicine
Objectives for the Lecture
 At the end of this lecture, the physician should be
able to do the following:
 1. Discuss the evolution and significant events in
the history of medicine.
 2. Discuss the significant individuals responsible
for the advances in medicine.
 3. Discuss how this subject is germane to medical
issues today.
Drug Company Affiliation
None
William Osler said of Medicine
and Art
 Medicine is a science of uncertainty
and an art of probability.
SirWilliam Osler
In the Beginning…
In September 1940, four
teenagers around the northern
slopes of France’s Pyrenees
mountains stumbled upon one
of the most famous and
astounding repositories of
Paleolithic art in the world: the
cave of Lascaux
Cave of Lascaux
Hundreds of paintings and etchings
of red cows, yellow horses, bulls and
black stags fan out across the cave’s
walls and ceilings in a literal
stampede.
It is the world’s oldest example of
medicine in art, dating back 15,000
Cave of Lascaux
 The lone human figure among all the
animals is the man with a head of a bird,
who appears to be in some kind of
trance during a confrontation with a
bull. Beside him is a staff.
 It is widely believed that the human
figure is some sort of shaman.
 Shaman were in charge of the
knowledge of health, and of life &
death.
Trepanning
 Primitive man believed that head pain was
the work of evil spirits who invaded the body
of unfortunate individuals.
 If headache was caused by the invasion of
evil spirits, then letting the spirits out of the
skull should bring relief.
 Thus was born the surgical procedure known
as trepanning which dates back ten thousand
years or more.
 Such procedures were found in the South
Pacific, Europe, North America and South
Themes in Medicine
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Superstition, Evil Spirits, Humours
Blind Loyalty and Downright Stupidity
The Emergence of Iconoclasts
Ingenuity
Common Sense
Serendipity
Kindling Phenomenon
The Art and Science of Medicine
Hard Work and Dedication
Techology
Imagination
Imhotep- “the One Who Walked in
Peace”
 Vizier
of a Pharaoh, lived about 2900 BC;
 He is credited with many accomplishments in
many fields and one of his activities seems to
have been that of a successful physician.
 He is one of the first medical men whose
name is on record and rose from the role of
medical hero to become God of Medicine.
 He began using simple surgery instead of
just magic.
Sir William Osler tells us that Imhotep was
the:
 "..first figure of a physician to stand out clearly from the
mists of antiquity." Imhotep diagnosed and treated over 200
diseases, 15 diseases of the abdomen, 11 of the bladder, 10 of
the rectum, 29 of the eyes, and 18 of the skin, hair, nails and
tongue. Imhotep treated tuberculosis, gallstones,
appendicitis, gout and arthritis. He also performed surgery
and practiced some dentistry. Imhotep extracted medicine
from plants. He also knew the position and function of the
vital organs and circulation of the blood system. The
Encyclopedia Britannica says, "The evidence afforded by
Egyptian and Greek texts support the view that Imhotep's
reputation was very respected in early times. His prestige
increased with the lapse of centuries and his temples in
Greek times were the centers of medical teachings."
The Healing Art and Disease
 Physicians based their healing art upon
the belief that evil spirits, hateful
demons, and vengeful gods struck
people with diseases.
 Invisible arrows shot by the Greek god
Apollo caused pain.
 One treatment for disease was for the
victim to travel to one of the many
pagan temples in Greece.
The Healing Art and Disease
 The sick person made a sacrifice and
then spent the night in the temple. As
he slept, he was supposed to dream away
the sickness.
The Two Great Names in the History
of Greek Medicine
 Hippocrates-dominated the beginning
of a period of remarkable scientific
creativity, which lasted more than 700
years
 Galen—near the end of the period, both
furthered scientific knowledge and
crystallized it in an amazing volume of
written works. His influence lasted for
1500 years/45 generations.
Hippocrates(460B.C.-377B.C.
 Hippocrates is know as the “Father of Medicine.” He
is considered one of the greatest physicians the
world has ever known.
 He was the first to attempt to separate the practice
of medicine from religion and superstition.
 Hippocrates developed his pledge of proper
conduct for doctors. “I will use treatment to help
the sick according to my ability and judgment, but
never with the view to injury and wrong doing…Into
whatsoever houses I enter, I will enter to help the
sick.”
“On Airs, Waters, and Places” around
400B.C.
 Hippocrates penned a tract called “On Airs, Waters, and
Places.”
 This was the earliest reference to epidemiologic
thinking.
 He emphasized familiarity not only with the patient’s
symptoms, but also with the season of the year and the
patient’s living conditions, diet fluid intake, and
exercise habits:
“On Airs, Waters and Places”
 “For if one knows all these things well, or at least the
greater part of them, he cannot miss knowing, when he
comes into a strange city, either the diseases peculiar to
the place, or the particular nature of common diseases,
so that he will not be in doubt as to the treatment of the
diseases, or commit mistakes, as is likely to be the case
provided one had not previously considered these
matters. And in particular, as the season and the year
advances, he can tell what epidemic diseases will attack
the city, either in summer or in winter, and what each
individual will be in danger of experiencing from the
change of regimen.
Hippocrates Refusing Gift from Alexander by
Anne-Louis Girodet(1816)
The Hippocratic Oath
 Hippocrates also made changes in how physicians
looked upon their profession.
 During his time, a doctor was sometimes bribed to see
that a patient died, or asked to prepare poison to kill an
enemy. If a ruler wanted to rid himself of a rival, he
could hire a court physician who would see that the rival
became sick and died.
 Hippocrates taught against such improper conduct. He
told his students to treat everyone the same.
 “Sometimes give your services for nothing…for where
there is love of man, there is also love of medicine.”
The Hippocratic Oath
 A statement describing proper conduct.
 It was a pledge and is a guideline for honorable
standards of action.
 “I will use treatment to help the sick according to my
ability and judgment, but never with the view to knjury
and wrong doing…Into whatsoever houses I enter, I will
enter to help the sick.”
Allegories of the Healing Arts
 An allegory, or a pictorial symbol, serves
to formulate into some tangible aspect
an idea or point of view that may exist
vaguely in the minds of many.
 The allegories of the Healing Arts—
visual images around which are
centered the faith and hope of
mankind.
Head of Asklepios(Greek Coin, II
Century B.C.)
 The earliest icon of medical significance
 Head of Asklepios was pictured on a silver
drachma, a Greek coin minted on the island
of Cos
 He was the son of Apollo
 The centers of his cult were temples where
the sick went, similar to our modern day
sanatoriums, with emphasis on diet,
massage, baths and the like.
Head of Asklepios(Greek Coin, II
Century B.C.)
 The god was supposed to reveal to the patient
in a dream the cure for his/her disease.
 The serpent, symbolic of regenerative power,
was sacred to Asklepios and to Apollo.
 The emblem, in the form of a rod with a
coiled serpent, is still used to represent the
art of medicine
Note the Hippocratic Oath
“I swear by Apollo the physician
and Asklepios and his
daughters, Hygeia and Panacea,
and all the Gods and
Goddesses…”
Hippocrates was also born on
the Island of Cos
Galen Described Wounds as
“Windows to the Body”
 Galen, the great 2nd century physician and anatomist, spent
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his early medical career as a surgeon to the gladiators.
He employed as many as 20 scribes to write down all that he
said in the work.
He dissected countless animals in his prolific medical
research.
Galen also studied philosophy and wrote that a motive of
profit was incompatible with a serious devotion to medicine,
stating that doctors must learn to despise money.
He was a proponent of the miasma theory of infection,
which essentially blamed infection on clouds of poisonous
gases.
Galen(Galenos) meaning calm or
serene— “The Infallible Master”
 The profession of medicine gained a wealth of facts and
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ideas from Galen.
He gave to the world a synthesis of medical thought and
knowledge solid enough to last nearly 1500 years.
His mind was quick and well organized.
He was well informed on many subjects.
In the earlier period of his life, he continually insisted on
experiments and on demonstrable proofs.
But the open-minded young Galen later became one of the
great dogmatists of all times. The magnitude of his
dogmatism was increased by his followers and
commentators.
Galen
 Galen believed that disease resulted from an imbalance
of the vital fluids, or humors, of the body. This idea was
developed by Hippocrates, and consolidated by Galen.
 “The body has in itself blood, phlegm, yellow bile, and
black bile…We enjoy the most perfect health when
these elements are in the right proportion.”
 The medicine and pathology Galen practiced, and about
which he wrote, were based mainly on speculative
Hippocratic theories of the 4 humors, on critical days,
and on fallacious theories regarding pulse and urine.
The Four Humours
 Developed out of the humoral theory of
Empedocles(500 to 430B.C.), the Scilian philosopher.
 Developed by Hippocrates and consolidated by Galen.
 From the 4 elements: earth, air, fire and water derived
the idea of the 4 humours(or fluids) of black bile,
yellow bile, blood and phlegm with their associated
meancholic, choleric, sanguine and phlegmatic
temperments.
 It was believed that the balance of these humours in the
body determined physical states of health.
Galen
 Galen made the first attempts to master
anatomy. He studied the anatomy of animals
and applied it to humans.
 Medical schools used Galen’s books as
textbooks for more than a thousand years. He
became the undisputed authority. NO ONE
DARED TO EVER DIFFER WITH HIM!
 From physicians to emperors as well as
commoners in the Roman Empire, Galen was
considered a shrewd observer who gained
much experience through experimentation.
The Picture
 Galen, whose teachings were accepted as
dogma by medical men for 1500 years, is
pictured in a 2nd century Roman home
applying cupping, a form of treatment that
he advocated.
 Galen was a pillar of medicine and the last
important pillar in the millennium of Greek
domination of the medical world.
St. Cosmas and St. Damian
 Traditionally acclaimed the patron saints of
the physician and apothecary
 These 2 brothers were Syrian Christians who
were reputed to have effected many
miraculous cures before their matyrdom in
the reign of Emperor Diocletian(A.D.303)
 Seen frequently in paintings, miniatures, or
prints
Rome Falls in 476A.D.
The Dark Ages of Medicine begin.
Medicine in the Dark Ages (roughly 500-1050
AD)
 Massive decline in the number, and quality,
of medical writings available.
 2 important features stand out during this
decline:
 A) Preeminence of ‘do-it-yourself’
handbooks, primarily of dietetic medicine.
 B) The ecclesiastical takeover of medical
learning and learning in general. For few
could read outside the ecclesiastical
community.
Medicine in the Dark Ages (roughly 5001050 AD)
The relatively learned medicine was
supplemented by the healing
offered at shrines and by holy men.
Tales abound of miraculous cures
via shrines and icons.
Some saints were almost specialists:
Some Saints as Medical Specialists
St. Dymphna was favored for
mental diseases
St. Roch for plague
St. Hubert for rabies sufferers
St. Blaise for throat complaints
The King’s/Queen’s Evil
 Medieval people seemed to have suffered
much from TB but most probably had the
glandular form scrofula.
 In England and France, it was believed that
royalty had the power to cure the affliction by
touching the sufferers, and from the 12th to
the 18th century, ‘the king’s/queen’s touch”
was regularly used against this condition.
The King’s/Queen’s Evil
 Remember after the Reformation, the
Church of England rejected all forms of
recourse to Saints, relics, holy water,
and so on, which the Roman Catholic
Church had recommended.
 This practice involved the ruling
monarch curing victims of scrofula and
similar ailments.
The King’s/Queen’s Evil
The king touched the victim and
often also a gold coin - usually
an Angel, showing the
Archangel Michael killing the
dragon - that was then worn
around the victim's neck, and
the person promptly recovered.
The Emergence of Medicine from the
Dark Ages
 Occurred around 1050 in the region of
Salerno, southern Italy where this thriving
medical community was in touch with the
Greek and Arab worlds as well as the
wealthiest and intellectually most advanced
abbey of Europe, Monte Cassino.
 In 1080, the Salernitan masters reintroduced
theoretical speculation into medical
teaching.
The Emergence of Medicine from the
Dark Ages
 From 1200, Latin translations of some
Arabic texts by Constantine the African,
re-established Galenic academic
learning, combining commentary on a
few set texts with philosophical
discussion of wider issues.
 By 1250, practical demonstrations of
animal anatomy was introduced.
The Three Consequences of
Translation Movement
 1.The amount of learned medical
material suddenly burgeoned beyond
all recognition
 2.The language of medicine was heavily
arabized and its therapeutics depended
heavily on Arabic sources, especially in
pharmacology/surgery.
 3.Now, there was a heavy philosophical
component, based on Aristotle (natural
philosophy) in the new medicine.
The Arab Influence
 Arab medicine, so-called because of the language in
which it was written down, greatly influenced the
medical thinking of the West from the 12th to 15th
centuries.
 The Arabs played an import part in teaching the art of
prescribing and surgery.
 Avicenna(980-1037 A.D.), the “prince of physicians,” is
noted for his Canon of Medicine.
Avicenna(980-1037 A.D.) and the
Canon of Medicine
The Development of University Medicine
First occurred in northern Italy, in
the wealthy towns of Bologna and
Padua, then in France (Paris and
Montpellier), and in England
(Oxford).
Germany lagged behind, but by 1400
many areas of Western Europe had
their own institutions of higher
learning.
The Development of University Medicine
 Medicine came late into the universities.
 Professional associations of medical
teachers, as at Salerno, joined universities
only when they saw the advantages of the
new institutions’ ability to secure their own
rights and privileges in law and theology, and
many universities, especially in France, never
had a medical faculty.
Hotel Dieu, 1500 by Triptych
Triptych showing the Hôtel Dieu
in Paris, about ad 1500. The
comparatively well patients (on
the right) were separated from
the very ill (on the left). Note
there were always two patients
to a bed.
The Father of Modern Toxicology
 Phillipus Aureolus
Theophrastus
Bombastus von
Hohenheim
 “All substances are
poisons; there is
none which is not a
poison. The right
dose differentiates a
poison and a
remedy.”
Paracelsus(1493-1541) and Chemical
Remedies
 One of the most famous questioners of medical
authority.
 Paracelsus was an enigmatic character, flamboyant,
quarrelsome and reforming. His somewhat eccentric
behavior prevented his settling down in any one place
and gave his life a vagabond flavour.
 Not content with refuting the authority of Galen and
Avicenna, he publicly burned their books.
 He is credited with enlisting the help of chemicals in
therapeutics and vigorously opposing polypharmacy, or
the prescription of multiple ingredients in a single
medicine.
Andreas Versalius(1514-1564)
 Was the first master of human anatomy.
 His careful studies provided doctors with the accurate
information that they need to save lives.
 Versalius did not accept the teachings of Galen without
experimenting on his own.
 Versalius kept a copy of Galen’s books on hand and made
changes in them. He found over 200 mistakes in the ancient
books—mistakes that were still being taught by doctors of
his day!
Andreas Versalius(1514-1564)
 Versalius learned human anatomy by looking
at humans not just animals.
 He made detailed drawings of his findings so
others could also learn.
The Fabric of the Human Body
 Varesalius was just 28 when he published the
above.
 It was published in 1543, contained 663 pages
and 300 beautiful illustrations.
 Versalius spent his personal fortune and all
his enthusiasm on it.
 The publication of Fabric marked a turning
point in the history of medicine.
The Father of Modern Surgery
 Professors in medical schools seldom performed
surgery.
 They did not think that it was proper for a professional
man to do such work.
 Surgeon is from a French word meaning “one who works
with his hands.”
 In the Europe of the 1500s, barbers, not doctors,
performed minor operations, pulled teeth, and treated
cuts.
 Barbers who gained skill in closing wounds were called
barber-surgeons.
The Striped Barber Pole
 The barber pole is a symbol of the profession and is a legacy
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of bloodletting.
After the operation, the bandages would be hung on the staff
and sometimes placed outside as advertisement.
Twirled by wind, they would form a red & white spiral
pattern that was later adopted for painted poles.
The earliest poles were surmounted by a leech basin, which
in time was transformed into a ball.
The stripes of a barber pole still show the red for blood and
the white for bandages. Sometimes there were poles with
blue representing the veins.
Ambroise Pare(1510-1590)
 Pare used ointments and silk thread to repair
injuries in place of burning oil and hot pokers.
 Pare discovered new techniques that made surgery
practical.
 He published his book in French with useful
information that all doctors could use.
 Pare did not have a formal education. He never
earned a medical degree. Yet he became France’s
most skilled surgeon. In 1562, he was given the
dignified title, “First Surgeon of the King.”
 “I treated him. God healed him.”
Medicine Prior to the 17th Century
The old-style physician had almost
no diagnostic technology nor did he
conduct a full, hands-on physical
exam. Rather, he worked on the
basis of his senses: sight, touch (of
the wrist for the pulse), hearing,
smell and taste (sampling urine for
the sweetness symptomatic for DM.
Uroscopy
 Elaborate diagnostic charts exist, correlating
these indications with various maladies.
 Even in the written literature of William
Shakespeare does the above exist: “Sirrah,
you giant, what says the doctor to my
water?...He said, sir, the water itself was a
good healthy water; but for the party that
owned it he might have more diseases than
he knew for.” from Henry IV. Uroscopy
The Village Doctor by David Teniers the
Younger(17th Century)
Uroscopy Wheel
 This is taken from The Fasciculus
Medicinae by Johannes De Kethan,
1491.
 This was a collection of medical
treatises dealing with medicine
and surgery dating back to the 13th
century and included the first
“modern” anatomic illustration.
Galen’s View of Blood Circulation-Based on
False Ideas
 Galen said that blood in the veins always carried blood
away from the heart.
 The flow was slow and irregular. Blood ebbed and
flowed like tides.
 Galen taught that the liver manufactured new blood to
replace the old.
 Blood surging through the heart caused it to beat. He
had no ideas that the heart itself pumped blood.
The Age of Enlightment
Medicine in the
th
17
Century
 The greatest physiological advance of
the 17th century was the discovery of the
circulation of blood.
 Credit goes to the Englishman William
Harvey(1578-1657).
 In 1628, Harvey’s De Motu Cordis which
concerned with the mechanical process
of circulation.
The Four Humors and William
Harvey
 The "humors" theory of the body was
centered on "vital spirits" moving from the
heart; they regulated the balance of the four
humors and could be disturbed by the
spiritual intervention of the devil. Once
Harvey’s notion that the heart was just a
muscular pump moving blood around the
body became prevalent, explanations in
terms of demonic spirits no longer
convinced.
“William Harvey” by Robert Hannah,
1848
 Harvey is famous for his
discovery that blood
circulates around the
human body.
 He proved that blood
circulates through the
body in one direction.
Antoni van Leeuwenhoek (16321723)
 Developed the most
powerful microscopes of
his day.
 He discovered onecelled protozoans and
bacteria.
 His work eventually led
to the discovery of the
causes of diseases, such
as the Black Death.
The Art of Medicine Becomes
Scientific
Although this movement was
launched in the 17th century during
the Age of Enlightment, it was not
until the 19th century that the true
age of science was born.
Edward Jenner(1749-1823)
 Jenner was ridiculed and resented by his
fellow doctors.
 This cartoon makes fun of Jenner’s
inoculations. In a crowded room, Jenner
prepares to vaccinate a young woman sitting
in a chair. The scene about them is mayhem
as several former patients demonstrate the
effects of the vaccine with cows sprouting
from various parts of their bodies.
Edward Jenner(1749-1823)
 Jenner discovered that having cowpox
protected a person against smallpox.
 Jenner’s cowpox serum saved many lives,
and almost eliminated the disease of
smallpox.
 His discovery of vaccination is considered
one of the most important discoveries in
medicine.
 Jenner nor any other doctor knew the cause
of infectious diseases or why vaccination
worked.
The Birth of Anesthesia
A nineteenth-century physician administering
chloroform prior to surgery. Ether was one of the
earliest anesthetics to be used but it was difficult to
administer as it usually made the patient choke.
Sir Humphry Davy (1778-1829)
 Humphry Davy
discovered
laughing
gas(nitrous oxide)
which has made
dentistry much
less painful.
Sir James Young Simpson (18111870)
 James Young
Simpson discovered
chloroform could be
used as an
anesthetic.
 Simpson fought to
make anesthesia an
established part of
surgery.
William Thomas Green
Morton(1819-1868)
 Invented a special glass
inhaler and added
perfume to ether.
 Successfully used either
to pull a tooth and to
then perform painless
surgery.
 His tutor Dr. Charles
Jackson gave Morton
some advise on using
ether and then later
claimed it was all his
idea.
The Recognition of Nutrition and
Disease
James Lind(1716-1794)
 In James Lind’s
experiment, those that
ate citrus fruit stayed
healthier.
 Captain Cook took
Lind’s advice and his
crew stayed health for a
four-year journey.
 The British Navy finally
ordered sailors to drink
lime juice.
 Lind had found the cure
for scurvy—vitamin C.
Christian Eijkman(1858-1930)
 Found that bacteria
did not cause
beriberi.
 He found that brown
rice was a cure for
beriberi because of a
vitamin (now know
to be thiamine) in
the husks.
Jean Boussingault (1802-1887)
 Jean Boussingault
found that a
mineral called
iodine could cure
a goiter of the
thyroid gland.
Rene-Theophile-Hyacinthe Laennec and
the stethoscope
 “In 1816 I was consulted by a young woman
presenting general symptoms of disease of
the heart. Owing to her stoutness little
information could be gathered by application
of the hand and percussion…I recalled a wellknown acoutic phenomenon:namely, if you
place your ear against one end of a wooden
beam the scratch of a pin at the other
extremity is distinctly audible. It occurred to
me that this physical property might serve a
useful…
Rene-Theophile-Hyacinthe Laennec and
the stethoscope
 This physical property might serve a useful
purpose in the case with which I was then
dealing. Taking a sheet of paper I rolled it
into a very tight roll, one end of which I place
on the precordial region, whilst I put my ear
to the other. I was both surprised and
gratified at being able to hear the beating of
the heart with much greater clearness and
distinctness that I hever before by direct
application of my ear.”
The Stethoscope
Rene Laennec, who invented the
first stethoscope, commented
that "no patient report could
suffice to characterize disease,
and that for a certain diagnosis,
mediate auscultation is
required."
“Miasmata”
 Originated from Galen
 Poisons in the atmosphere emanating from cesspits and
rotting material caused illness.
 In 1840, the German pathologist Jakob Henle(1809-1885)
published his essay: “On miasmata and contaia,” in
which he tried to show that tiny living creatures in the
human body caused infectious diseases.
 The idea of “germs” began to challenge the prevailing
theory were caused by “miasmata.”
 The above was supported by the work of Frechman
Louis Pasteur and the British surgeon Joseph Lister.
Public Health
 The concept had it origins in Biblical rules on health
and hygiene as well as in great architectural works such
as the building of the aqueducts to supply fresh water to
Rome and the removal of waste by means of the great
drain, the cloaca maxima.
 Principles regarding safe diets and person hygiene were
taught by the great religions. These were reinforced by
later miasmatic notions. Evil smells do indicate poor
sanitation and their removal reduces sources of
infection.
John Snow(1813-1858), the
Father of Public Health
 Effectively brought an end
to the 1854 epidemic in
Soho, London by
demonstrating only those
who drank from the
infected Broad Street
pump contracted the
disease.
Ignaz Phillipp Semmelweiss
 1. Childbed fever was taking thousands
of lives of young mothers
 2. More women were dying under the
care of doctors than midwives.
 3. Some doctors were more interested in
their reputations than in saving lives.
Ignaz Phillipp Semmelweiss
 1. Discovered that the doctors were
spreading childbed fever.
 2. He proved that doctors were carrying
the disease from corpses to their
patients.
 3. He proved that cleanliness could
prevent childbed fever.
Problem in Surgery
Infection was a major problem
during surgery.
People often died after surgery
from the infection alone.
Compound bone fractures
almost always ended in death
because of infections.
Joseph Lister(1827-1912) and
Infection
 Discovered that carbolic acid prevented
infection on compound infections.
 By insisting that everything be kept clean
and disinfected, he lowered the death rate
in his surgeries.
 He discovered it was not the presence of
acid bit
 the absence of germs that mattered in
surgery.
The Search for the Etiology of Disease
 Robert Koch discovered that anthrax was
caused by bacteria.
 He discovered how to grow bacteria in
cultures for study, and how to add stain in
order to see them.
 Robert Koch proved that most diseases are
caused by a particular bacteria.
 Microbiologist, Robert Koch discovered the
tubercle bacillus in 1882 where one in seven
deaths in Europe was due to TB.
Koch’s Postulates to Advance the
Germ Theory
 The causative agent must be present in every case of the
disease and must not be present in healthy animals.
 The pathogen must be isolated from the diseased host
animal and must be grown in pure culture.
 The same disease must be produced when microbes
from the pure culture are inoculated into healthy,
susceptible animals.
 The same pathogen must be recoverable once again
from this artificially infected animal and must be able
to be grown in pure culture.
Louis Pasteur(1822-1895)
 Louis Pasteur
dismissed t he
“miasmatic” theory
of disease. He argued
that diseases were
caused by germs and
so effectively
established
bacteriology as a
science.
Louis Pasteur Returns to the
Scene
 Louis Pasteur discovered that chickens could survive
cholera when given a weakened form of the disease.
 He found that an anthrax vaccine could be made by
heating the bacteria.
 He discovered rabies was caused by a virus instead of
bacteria and then developed a vaccine for humans.
Medical Schools in the United
States
High-quality medical schools and
clinical investigations developed
more slowly.
In its laissez-faire, businessdominated atmosphere, many
schools were blatantly commercial,
inadequately staffed and offering
cut-price degrees.
What Was It Like to be a Medical Student
140 years ago?
 No one worried about admissions, for
entrance requirements were lower than
they are for a good high school student.
 Instruction was superficial and brief.
 The terms lasted only 16 weeks, and
after the second term the M.D. was
automatically given, regardless of a
student’s academic performance
What Was It Like to be a Medical Student
140 years ago?
 Teaching was by lecture alone.
 Thus, students were spared the onerous
chores of attending labs, clinics and
hospital wards.
 It was not uncommon for students to
graduate without ever having touched a
patient.
Medical Schools in the 1860s and
1870s
 Many were privately owned, operated for
profit and without university affiliation.
 Physicians often had little to offer their
patients other than sympathy and tender care
for ailments they lacked the means to cure.
 The medical profession was held in low
regard by the general public.
The Birth of Johns Hopkins University and
Medical School
At Hopkins, a new era of American
medicine was born, with rigorous
admission requirements and a
quality of training that set new
standards in the United States and
compared favorably with the
venerable European institutions.
At Johns Hopkins University and
Medical School
Candidates for admission to
Hopkins were required to have a
four-year college degree, including
two years of premedical training in
biology, chemistry and physics, and
a reading knowledge of French and
German.
The Four Doctors by John Singer
Sargent(1905)
The “Big Four” of Hopkins
 William H. Welch in pathology and the future
Dean
 Osler in medicine
 William S. Halsted in surgery
 Howard A Kelly in gynecology
 All younger than 40 years old, organized the
hospital departments.
Evolution of Disease
 In the 19th century, diarrheal diseases were the
biggest killer of children, and tuberculosis was
the leading cause of adult mortality.
 In the 20th and 21st centuries, chronic diseases are
now the leading cause of disease and death in
adults.
Technology Reigns Supreme
 William Crookes invented the Crookes’
tube which developed into TV’s and
monitors.
 Wilhelm Roentgen invented the x-ray
machine by using the Crookes’ tube.
 Because of its ability to see inside the
body, x-ray photography is one of the
most important medical discoveries.
The Use of Radiation
 Henri Becquerel proved that radiation
from uranium is like x-rays but more
powerful and is credited in discovering
radioactivity in 1896.
 Pierre and Marie Curie discovered
radium and other radioactive elements.
 When controlled, these radioactive
elements can be used to enhance x-rays
and fight cancer.
The Birth of the EKG
 Sir Thomas Lewis mastered the
technology of the
electrocardiogram in 1912.
Andrew W. “Doc” Fleischer
 In 1921, the above
developed the
mercurial
sphygmomanome
ter and spent his
career refining
medical
instruments,
including the
modern
stethoscope.
The Birth of Medical
Organizations/Societies
 ACP-1915;Joining of the ACP and ASIM
 AAN
 AAFP
 ACR
 AGS
 Etc.
The Advent of Drugs
 Dr. Gerhard Domagk(1895-1964)
discovered sulfa drugs.
 This drug became world famous when
Dr. Perrin H. Long used sulfa drugs to
treat Franklin Roosevelt Jr.
 Sulfa was called a “wonder drug”
because it killed bacteria but did not
hurt the cells of human tissue.
Mold Becomes A Medical Ally in the
Battle Against Bacteria
 Alexander Fleming(1881-1955) discovered
penicillin which killed staphylococcal
bacteria.
 Florey and Chain isolated the chemical
and found that it could be massproduced, making it more affordable.
 Penicillin was stronger(bacteriocidal)
that sulfa(bacteriostatic) and had fewer
side effects.
Technology Transform the
Medical Arena
 Dr. Richard Drew(1904-1950) established
the use of transfusion and blood banks.
 Dr. Christian Barnard(1922-2001)
performed the first heart transplant in
1967.
 Dr. William Kolff developed an artificial
kidney machine.
 James Watson and Francis Crick
Technology and the 20th/21st
Century(Medicines)
 Antiseptics
 Antibiotics
 Antiepileptics
 Antipsychotics
 Chemotherapies
 Myoclonal Antibodies
 Vaccines
 Biologic Agents
 Continuing Story of Aspirin
 Blood Transfusions and Blood Banks
Technology and the 20th/21st
Century(Evaluative Procedures)
 Electron Microscope
 CT Scans
 MRI Scans
 MRA Scans
 Pet Scans
 Functional MRI
 The Human Genome
 Genetic Testing
 Genetic Enzyme Replacements Therapy
Technology and the 20th/21st
Century(Surgeries)
 Artificial Kidney Machine—Dialysis—Kidney
Transplants
 Coronary Artery Bypass
 Angioplasty
 Total Hip and Knee Replacements
 Neurosurgery
 Lasik Surgery
 Organ Transplants—Heart, Kidney, Lung, Liver,
Pancreas, etc.
The Transformation of Medical
Education
 Medical Schools and the Gender Gap
 Medical Schools and Diversity
 The Soaring Cost of a Medical Education
 The Primary Care Physician v. the Specialist
 Board Certification
 The Integration of
 Complimentary Alternative Medicine
 The Introduction of the Medical Home--ACP
Transformation of Medical Care
 The Advent of Chronic Disease as a Major Cause of
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Morbidity/Mortality
Home Care to the Office to Hospital Care
The Private Practictioner to the Medical University
The Advent of Medicare/Medicaid in the USA
Universal Coverage in Many Countries
Managed Care
HMOs, IPOs, PPOs, POS
Primary Care Physician v. the Subspecialist
The Advent of Medical Home Model(ACP)
Hospice Care
Accreditation, Quality Assurance, Board Certification
HIPPA
Medical Malpractice/Lawyers
Ethics and Medicine
 Sexuality
 Abortion
 What is Death?
 Growing Old
 Euthanasia/Right to Life/Pro life
 Quality of Life Issues
 Limited Health Care Resources
 Rationing of Health Care
 The Uninsured, The Undocumented Worker
 Universal Health Care
 The Use of Physicians in State Executions—
i.e.,California
Challenges for the Future
Challenges for the Future
 Obesity/Diabetes Mellitus
 Smoking
 The Geriatric Population
 Drugs/Medications
 Alzheimer’s Disease
 Depression
 Medicare/Medicaid
 Euthanasia
 Etc.
The Future of Medicine
Balance between the art of
medicine and the
science/technology of
medicine with imagination,
ingenuity and a little luck.
“The Giant”(1923) by N. C. Wyeth
Question and Answer Period
The End
Thank You!
See You Next Year!