ACO National Conference: The history of medicine

The space available here does not allow justice to be done to his ambitious project – to use his words, 4,000 years of medical history in one hour. Historically, early humans noted the appearance of the tongue, they were aware of the heart’s pulse and blood flow, but were averse to cutting the body meaning any ‘discoveries’ were dependent largely on observation of war wounds and trauma outcomes.Fast forward a millennia or two to arrive at 129 AD when Galen, physician to the gladiators started to formalise primitive medicine using observation and reason to ‘diagnose’. Galen noted arteries and veins, introduced couching for cataracts (in some rote, unserved parts of the earth, couching is still in use because it is better than the alternative – mature cataract blindness), had an understanding of motor nerves and the brain as the central nervous syst ‘co-ordinator’, voice and the role the larynx played, and the role the liver’s in blood.Fast forward another 1.5 millennia to arrive at 1628 and realize that William Harvey (physician, England) was discovering aspects of the heart, 72 beats per minute, the ventricle contained about 60 grams of blood, the heart was shifting 250 kg of blood per hour (about the weight of 3 men – it was 1628 after all), from which he deduced that the heart was a pump, a theory that was unacceptable at the time.The stethoscope had to wait until 1816 when René Laennec (physician, France) used a roll of paper to form a crude stethoscope to hear the heart. That endeavour morphed into a hollow wooden cylinder for better results. Blood pressure was donstrated in 1750, the mercury column as a means of measuring blood pressure (in a horse by direct arterial tapping) 1828, the inflatable cuff 1883, and Korotkoff sounds (physician, Russia) 1905.Dr Levitz noted that by the auspicious year of 1950, we still had no idea of what blood pressures were ‘normal’ and it was 1960 before blood pressure became a treatable entity. It was until the CATIS randomized clinical trial published in 2013 in the Journal of the American Medical Association that established the real benefits of immediate blood pressure reduction in hypertensive and stroke patients.Pseudoephedrine was known to the Chinese by 2,500 BC and atropine (from Atropa Belladonna or deadly nightshade a mber of the tomato family) was used by society ladies to enhance their appearance (mydriasis) and was also used to kill perors Augustus (14 AD) and Claudius (54 AD).The analgesic effects of Meadowsweet were known for a long time (its salicylic acid content was the active ingredient) but is was not until 1897 that Bayer (Germany) chist Felix Hoffmann (working under project leader Heinrich Dreser) discovered aspirin (acetylsalicylic acid) – the mechanism was not uncovered until 1971.Later Dreser developed heroin, later still codeine so his projects’ contribution to mankind are a mixed bag).Anaesthesia (ether initially although alcohol by mouth probably preceded that by 1,000 to 5,000 years) was first used by American dentist William Morton in 1846. Chloroform was used a year later. Topical ocular anaesthesia in the form of cocaine was first used by Austrian ophthalmologist Karl Koeller (on his own eye) in 1884.In the same year William Halsted (surgeon, USA) injected cocaine into nerves and proceeded to performed a blood transfusion (on his sister) and a gall bladder operation (on his mother). His success was not met with universal approval at high levels of the medical establishment when the august journal The Lancet condned anaesthesia on the basis that the patient must feel pain.The concept of germs spreading disease was first proposed by Girolamo Fracastoro (physician, poet, mathatician, and geographer, Italy) in 1550 when he postulated that disease was spread by ‘seeds’, either chical or living, and could be caught by, or communicated to, others.The refinent of the microscope circa 1660s by Dutch tradesman and scientist Antonie van Leeuwenhoek allowed him to confirm the existence of blood cells. Cell multiplication was observed in 1840.Rudolf Virchow (medical practitioner, scientist, and politician, from what was German Prussia, now Poland) discovered the connections between abnormal cells and tissues and disease. He also insisted on all medical advances being based on robust, well-researched science, a view that led him to fall foul of the medical publishing establishment of the time.His probls proved to be so great that he and a like-minded colleague (Benno Reinhardt) started their own rigorous medical journal (Archiv für pasthologische Anatomie und Physiologie, und für die klinische Medizin [translation: Archive for Pathological Anatomy and Physiology and Clinical Medicine]), a publication that continues to this day (now known simply as Virchows Archiv).Perhaps one of the greatest contributions to medical science that benefited the whole of the human race was the observations and developments surrounding vaccination by Edward Jenner (physician, England) in 1796. His work built on the risky but relatively common inoculation process in which a lesser disease was introduced deliberately with the intention of preventing the occurrence of a more serious and debilitating disease subsequently (e.g. cow pox to prevent smallpox [trialed in 1774 by Benjamin Jesty, farmer, England and others]). Initial work was the result of careful observation by several scientists but the basic technique was know in China and the Middle East well before any use in England or North America.Louis Pasteur’s work in France on fermentation and fermentation prevention by heat, added to scientific knowledge. However, Pasteur could never accept the concept of tiny organisms causing disease in such a large animal as the human.The first antiseptic, carbolic acid (phenol in modern parlance), entered use circa 1869 following research by Joseph Lister (surgeon, England) that built on that of Pasteur. Lister’s first antiseptic operation was performed in 1865. The alarmingly high hospital operation mortality rate of almost 65% was reduced to 15% by using Lister’s methods. Lister went on to confirm the germ theory of disease and identify the causes of TB and cholera. Those were milestones in the history of medicine.Other significant surgical advances are relatively recent, e.g. rubber gloves (1890), surgical masks (1897) but routine use of surgical gloves in the UK only entered the scene in 1960. While the details are now better understood, intuition still has a role in the practice of medicine regardless of the era of practice, e.g. in 3,000 BC people were advised to have clean hands, clean finger nails, and clean beards, Sushrata (India, era uncertain – range: 1,000 BC to 100 AD) wrote a medical text detailing treatment of 1,120 conditions including 51 eye conditions along with descriptions of surgical tools, herbal redies, tissue grafting, plastic surgery, and wound care before, during, and after surgery.The development of penicillin by Scot, Alexander Fling in 1928 (with the involvent of Florey and Chain much of which is shrouded in claim and counterclaim) rounded out the general major developments in medicine.An overview of cataract surgery rounded out the lecture. The name cataract can be traced to Greek or Arab words that translate to falling water (white water). Eye surgery is recorded in Egypt in 1,200 BC and cataract surgery some time later. Couching for cataract was described by Sushrata (see above).Greek surgeon (but Rome citizen) Antyllus (2nd century AD) describes a small incision and sucking-out as the treatment for cataract, a method improved upon in the 10th century AD by Muhammad ibn Zakariya al-Razi (a Persian polymath).Extracapsular cataract extraction (ECE) was first described by Jacques Daviel (ophthalmologist, France) in 1747.The modern era owes much to Friedrich Von Gräfe (ophthalmologist, German Prussian) circa 1850 but perhaps the greatest advance is that of (Nicholas) Harold Ridley (ophthalmologist, UK, 1906 – 2001) who performed the first IOL implantation in 1949 using an IOL manufactured by the Rayner company. His advance was met with significant resistance for many years but his contribution was recognised eventually with a knighthood in 2000. Further developments followed, e.g. David Choyce developed haptics and iris clip designs of IOL, foldable IOLs appeared circa 1984 as a result of the desire for small-incision (often sutureless) surgery. The evolution of IOLs and the Rxs offered followed.The most recent, and one of the more controversial advances of recent times, is that of ftosecond laser cataract surgery (FLCS). FLCS and the early days of Ridley’s IOLs would se to have much in common. Only time will tell if FLCS will become mainstream.