By Charles C. Rogers, MD, FACR, Emeritus Professor, GWUMC
Enormous amounts of energy and efforts are spent quarreling over the logistics of the delivery of modern medical knowledge. In my opinion, what has been lost, in the heat of the discussion, is what should be a celebration for the explosion of scientific knowledge (and mostly), the implementation of radical improvements in the quality of science-based medical care. This essay will catalog some of these. However, our nation has delivery problems, including, (but not limited to) an indefensibly high infant mortality rate, for example, in spite of these advances. (1) Infant mortality rate is an important index of a nation’s health.
Allow me to set the time-frame I wish to review.
Consider the last 50,000 years: Allow me to define one generation of humans to be 25 years. The history of mankind would have occurred in 2000 Homo Sapiens generations. (2) In 150 years, 1865-2015, this last 0.3% and 1965-2015, the last 0.1% of human history. Let me cite some relatively recent medical failures and scientific discoveries that have radically improved our medical care in an amazingly short segment of history.
Only 134 years ago: September 19, 1881: The sitting President of the United States, James Garfield, died, after a modest wound, because of inept, archaic treatment which was used because of the lack of science-based knowledge, of wounds and infections. (3) Four months after President Garfield’s inauguration, a deranged assassin left the wounded president in a bitter behind-the-scenes struggle for power. A team of selected, prominent physicians administered shockingly inept treatments, to disastrous effect.
You may think this is an exception. I will cite other recent medical outcomes of Presidents and their families, in spite of immediate access to the best known medical care.
Only 236 years ago: December 14, 1779: George Washington, father of the country, died from being purposefully bled by his physicians. Washington, suffering from a throat infection, received the nations “best” medical care. (4) Today it is well established that bloodletting is not effective for most diseases. Indeed, it is mostly harmful, indeed lethal, since it can weaken the patient and facilitate infections.
Only 153 years ago: February 20, 1862: William Lincoln, age 11 years, son of The sitting President – living in the White House – died of Typhoid Fever, for lack of any effective treatment. (5) Typhoid fever is now treated with antibiotics that kill the Salmonella bacteria. Prior to the use of antibiotics, the fatality rate was 20%. With antibiotics and supportive care, mortality has been reduced by 1%-2%. Chloramphenicol became clinically available in 1949.
Only 91 years ago: July 4, 1924: Calvin Coolidge’s son, Calvin, Jr. – son of a sitting President – died of a streptococcus skin infection which led to septicemia, under the care of the best infectious disease physicians. (6) Penicillin almost certainly would have saved Calvin, Jr.’s life. It was put into clinical use in 1941.
Only 70 years ago: April 12, 1945 Franklin D, Roosevelt, Sitting four term, President, leader of the “Free World” died of a cerebral hemorrhage as a complication of uncontrolled hypertension. (7) This left a poorly informed Vice-President Harry S. Truman in charge of a country still fighting the Second World War and in possession of a weapon of unprecedented and terrifying power. Roosevelt’s blood pressure would have been controlled, and his life extended with common diuretics. In the US Veterans Study, whereas 27 out of 70 untreated hypertensive patients sustained strokes, only 2 out of 70 in the treated group continued such strokes during the one-year study period. The race was on to develop an effective medication relatively free of adverse effects.(8) This has largely been achieved.
I am unusually aware of this progress. I will be citing relatively recent discoveries and developments that have occurred in the span of my own family’s immediate history. My early life took place with the face-to-face presence of my grand parents and three of my great-grandparents. I have a four-generations photograph. I shared 15 years of life time with my mother’s father’s mother. My great-grand parents were born about 1865. In this span of this short period, most of the scientific basis of modern medicine has been discovered and implemented.
1846 -On October 16, William T. G. Morton -First in the world to publicly and successfully demonstrate the use of ether anesthesia for surgery. This occurred at what came to be called “The Ether Dome,” at Massachusetts General Hospital. (9) Surgeon John Collins Warren. Dr. Oliver Wendell Holmes, Sr.-suggested the terms “Anesthetic” and “anaesthesia”. 1847 Robinson authored one of the first textbooks on anesthesia: A Treatise on the Inhalation of the Vapour of Ether for the Prevention of Pain in Surgical Operations.
1847- Ignaz Semmelweis: “The concept of infection was unknown until relatively modern times. The first progress in combating disease was made in 1847 by the Hungarian doctor Ignaz Semmelweis, who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths.” (10)
1867- Joseph Lister and Louis Pasteur. “pioneers of antiseptic surgery. Until the pioneering work of British surgeon Joseph Lister in the 1860s, most medical men believed that chemical damage from exposures to bad air was responsible for infections in wounds, and facilities for washing hands or a patient’s wounds were not available. Lister became aware of the work of French chemist Louis Pasteur, who showed that rotting and fermentation could occur under anaerobic conditions if micro-organisms were present. Pasteur suggested three methods to eliminate the micro-organisms responsible for gangrene: filtration, exposure to heat, or exposure to chemical solutions. Lister confirmed Pasteur’s conclusions with his experiments and decided to use his findings to develop antiseptic techniques for wounds. As the first two methods suggested by Pasteur were inappropriate for the treatment of human tissue, Lister experimented with the third, spraying carbolic acid on his instruments. He found that this remarkably reduced the incidence of gangrene and he published his results in The Lancet. Later, on 9 August 1867, he read a paper before the British Medical Association in Dublin, on the Antiseptic Principle of the Practice of Surgery, which was reprinted in The British Medical Journal. His work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern antiseptic operating theaters widely used within 50 years.”(11)
1895 – Wilhelm Conrad Röntgen discovers X-rays
1896 – Henri Becquerel discovers radioactivity
1897 – J.J. Thomson discovers the electron in cathode rays.
1898 – Marie Curie discovers polonium, radium and coins the term “radioactivity”n 1901 Roentgen received the first Nobel Prize awarded in physics.
1901 – Radiation therapy began with radium and with relatively low-voltage diagnostic machines. In France, a breakthrough took place when it was discovered that daily doses of radiation over several weeks significantly improved the patient’s chance for a cure. The methods and the machines that deliver radiation therapy have steadily improved since then.
1901 Discovery of human blood groups / Landsteiner
1906 Existence of vitamins proposed / Hopkins
1909 Idea of genetic disease introduced / Garrod
1910 First mapping of a gene to a chromosome / Morgan and others
1910 The Flexner Report of 1910 transformed the nature and process of medical education in America with a resulting elimination of proprietary schools and the establishment of the biomedical model as the gold standard of medical training. This transformation occurred in the aftermath of the report, which embraced scientific knowledge and its advancement as the defining ethos of a modern physician. Such an orientation had its origins in the enchantment with German medical education that was spurred by the exposure of American educators and doctors at the turn of the century to the university medical schools of Europe. American medicine profited immeasurably from the scientific advances that this system allowed, but the hyper-rational system of German science created an imbalance in the art and science of medicine. A catching-up is underway to realign the professional commitment of the physician with a revision of medical education to achieve that purpose. (12)
1911 Discovery of the atomic nucleus / Rutherford
1921 Isolation of insulin / Banting & Best
1928 Discovery of penicillin / Fleming
1930s Theory of chemical bonds developed / Pauling
1931 First electron microscope / Ruska
1932 Discovery of the neutron / Chadwick
1939 Discovery of nuclear fission / Meitner & Frisch
1943 Mutations in bacteria identified / Luria & Delbrück
1944 Evidence in bacteria that DNA is the genetic material / Avery, MacLeod, and McCarty
1945 Formulation of the one-gene, one-enzyme hypothesis / Beadle & Tatum
1946 Radiocarbon dating / Libby
1946 Initial elucidation of the reactions involved in photosynthesis / Calvin
1947 Invention of the transistor / Shockley, Bardeen, and Brattain
1949 Immunological tolerance hypothesis proposed / Burnet
1951 Presentation of the idea of gene transposition: “jumping genes” / McClintock
1952 First polio vaccine / Salk
1953 Production of amino acids in “early Earth” conditions / Miller & Urey
1953 First determination of the amino-acid sequence of a protein / Sanger et al.
1953 Structure of DNA: the double helix / Watson & Crick
1953 – First Medical use of a linear accelerator and “supervoltage” radiation therapy.
1958 First three-dimensional protein structure published / Kendrew et al.
1960 First laser / Maiman
1973 Advent of genetic engineering techniques / Cohen, Boyer, and Berg
1973 Invention of magnetic resonance imaging / Lauterbur
1974 Principles of cell-mediated immunity unveiled / Zinkernagel & Doherty
1975 Monoclonal antibodies created / Köhler & Milstein
1977 First complete DNA sequence of an organism / Sanger et al.
1980 First human oncogene / “cancer gene” identified / Weinberg
1983 AIDS virus identified / Barré-Sinoussi et al.
1985 Genetic fingerprinting invented / Jeffreys
2001 Publication of near-complete sequences of the human genome / International Human Genome Sequencing Consortium; Venter et al.
2001 Telesurgery – Jacques Marescaux
2003 – Carlo Urbani, of Doctors without Borders alerted the World Health Organization to the threat of the SARS virus, triggering the most effective response to an epidemic in history. Urbani succumbs to the disease himself in less than a month.
2005 – Jean-Michel Dubernard performs the first partial face transplant
2006 – First HPV vaccine approved
2006 – Second rotavirus vaccine approved (first was withdrawn)
2007 – Visual prosthetic (bionic eye) Argus II
2008 – Laurent Lantieri performs the first full face transplant
2013 – First kidney grew in vitro in the U.S.
2013 – First human liver grown from stem cells in Japan
There are two medical concerns for our national community: Transferring and implementing our best care to those who need it and the proper accounting for the ethical use of the nearly twenty percent of our GDP which we spend on health care. What is the correct role of profit in the health of our nation?
(1) Despite healthcare spending levels that are significantly higher than any other country, the US infant mortality ranking among 20 industrialized nations declined from 6th in the 1950-1955 period to a tie for last place in 1980-1985. The United States has a higher infant mortality rate than any of the other 27 wealthy countries, according to a new report from the Centers for Disease Control. A baby born in the U.S. is nearly three times as likely to die during her first year of life as one born in Finland or Japan. That same American baby is about twice as likely to die in her first year as a Spanish or Korean one. A child born in the U.S. is less likely to see his first birthday than one born in Hungary, Poland or Slovakia. Or in Belarus. Or in Cuba, for that matter. Infant mortality rates is an important index of a nations health. Christopher Ingraham, Washington Post, September 29, 2014, and http://www.popline.org/node/347626#sthash.z331rMtk.dpuf
(2) Yuval Harari, Sapiens,: A Brief History of Humankind,
(3) Candice Millard, Destiny of the Republic, A Tale of Madness, Medicine and the Murder of a President, Unabridged Audiobook
(4) Blanton, Wyndham B. “Washington’s Medical Knowledge and Its Sources,” Annals of Medical History, 4 (1932), 52-61.
(5) Brad Denis, Washington Post special section, Civil War: 150: Ripples of War.
The Death of President. Franklin Roosevelt, 1945
(8) A Cooperative Study Group: Effects of treatment on morbidity of hypertension. JAMA 1967; 202:1028-1033 20th century
(9) Proceedings of Massachusetts General Hospital. 1846
(9) Wikipedia: History of Surgery
(10) History of Surgery, Wikipedia
(11) Joseph Lister, The Lancet,1867