What the Doctor Ordered

Steven Dutch, Professor Emeritus, Natural and Applied Sciences, Universityof Wisconsin-Green Bay

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Overview

Chapter covers period 1750-1900, during which technologyevolved rapidly. As a result there are innumerable interconnections betweendisciplines, making for a very complex tale. However, four main threads can beidentified:

• Philosophy and social theory
• Advances in biological knowledge
• Advances in data collection and interpretation
• Advances in instrumentation and medical techniques

How Disease Survives

• Kill the host too quickly, the organism dies out
• Pathogen and host evolve to coexist (popular stereotype)
• Disease remains lethal but messy to facilitate spread(cholera, Ebola)
• Disease is lethal but has long mild phase (AIDS) orresidence in some other vector (Ebola)

Ancient and Medieval Medicine

• Gross human anatomy known in ancient times
• General functions of major organs known
• Detailed workings of organs unknown

Circulation of the blood

• Either blood circulates or it is continually created andabsorbed
• Problem: you can never see a direct connection betweenarteries and veins
• Galen (150 A.D.) believed blood passed from one side of theheart to the other through tiny pores
• Many later physicians dutifully reported “observing”the pores during dissections

William Harvey, 1628

• Volume of blood in heart is a few ounces, say two
• Heart beats 100,000 times a day
• That means the heart pumps 200,000 ounces or over 1500gallons of blood a day.
• If blood is created and absorbed, the body must secrete andabsorb about 100 times its own volume in blood every day.
• Clearly ridiculous – hence blood must circulate
• One of the earliest examples of “back of the envelope”or “order of magnitude” calculations in science. Use of rough calculation torule out hypothesis.
• Blood actually passes from arteries to veins throughcapillaries

Medicine about 1800 

Bore a striking resemblance to what wenow call “holistic”

• Patient dictated treatment
• Every case individual
• Bedside manner all-important for physician’s practice
• Disease viewed as imbalance of forces in body

Only problem: it didn’t work

• Poor understanding of bodily functions
• Dissection frowned upon and difficult to perform orobserve: subjects limited to condemned criminals, paupers, or worse – cadaverssupplied by grave robbers and body snatchers.
• No knowledge of  roleof micro-organisms
• “Control by the patient of the doctor’s efforts ….prevented an already ignorant community of physicians from making any scientificheadway.” Burke (195)
• Almost no interchange of knowledge
• Elitism: physicians were mostly upper class, treated upperclass (where the money was). Rarely saw traumatic injuries or many diseases ofthe poor. Looked down on surgeons, who actually were obtaining working practical knowledge.
• There’s nothing wrong with a more holistic approach, butin 1800 the necessary technical knowledge simply did not exist.

Who’s a “Doctor?”

• The word Doctorcomes from the Latin word for “teacher” (related to the word“doctrine”). In medieval universities, it meant any scholar who had learnedthe curriculum well enough to teach it.
• Medicine was not one of the original curriculum subjectsbut was added in the Middle Ages
• Hence physicians appropriated the title “doctor” fromprofessors, not the other way round.
• Surgeons were considered manual laborers on a par withbarbers until well into the 1700’s (In fact, they often were barbers. The red and white striped barber’s pole symbolizesblood and bandages. Modern barbers, however, strive to minimize bloodshed.)

Hospitals

• Hospital, hospitality,hostel and hotel allderive from the Latin hospes, host.Recall the Good Samaritan, who dropped off his charge at an inn and gave theinnkeeper money for his care.
• Medieval hospitals were basically places for sick people toget out of the weather and (maybe) get rudimentary care and feeding.
• Until about 1800, they were places to go if you weredesperate and had no alternative
• Basically the patient either recovered on his own or (moreoften) at least died under a roof.

Philosophy meets medicine

Wolfgang Rau (1764) andJohann Peter Frank (1790): national health as an economic resource.

John Locke

• Knowledge has no basis but experience
• There are simple irreducible ideas derived from nature

Immanuel Kant

• Certain concepts (time, space, causality) arehard-wired into the human brain

• No laws in nature itself butmerely mental constructs in human brain. Note that this goes far beyond Locke.Locke believed our ideas are derived from nature, Kant that the ideas arehard-wired in the brain and not derived from nature.

• Knowledge can be reduced to asmall number of general principles

Friedrich von Schelling 1805, Naturphilosophie

• Man lost his original oneness with nature throughartificial thought constructs
• There must be a few basic lawsthat underlie life
• Perhaps we can find thefundamental life-force

Effect of philosophy on medicine

• There is a national interest in public health
• Experience and observation should rule (as opposed totheories based on how we think thebody should work. Medicine was one of the last holdouts of the ancient idea thatthe world should be understood through pure knowledge rather than observationand experiment)
• There were principles underlying natural phenomena
• Instead of every disease being unique, there wereunderlying principles
• Search for the natural principles underlying health anddisease
• Search for the fundamental life-force: a stimulus toinvestigation, but also an imaginary theory that would waste efforts andobstruct progress.

The French Revolution

• When the French executed their King, they effectivelydeclared war on all the related crowned heads of Europe (who wanted to keeptheirs)
• France soon found itself at war with most of the rest ofEurope
• Resorted to huge citizen conscript armies to meet thethreat

Effects on Medicine

• Physicians (upper class, mostly) were suspect, purged, orfled
• Surgeons, being lower class and laborers, were“politically correct.”
• Huge volume of casualties
• Experiment or die
  • Supplies short, had to make dowith field expedients
  • Many traditional remedies madethings worse
    • Cauterization
    • Delaying amputation
    • Trepanning (drilling skull torelieve pressure)
• New observations
  • Foreign objects always led toinfection (gruesome note for those who think modern warfare is worse than bygonedays – one of the most common foreign objects in wounds was bone fragments ofother soldiers)
  • Irrigation with water was aneffective means of cleansing wounds
  • Importance of treating for shockfirst
  • Importance of internal injuries
• In postwar France, huge hospitals were opened forcasualties.
  • Surgeons were in charge
  • Hospitals were specialized
  • Emphasis on observation andpractice
  • France soon led the world inmedicine
  • Hospitals (see above) for thefirst time became places to go to get well.
  • Doctors had automatic right todissect cadavers

Separating the Patient from the Process

• Specialized hospitals meant patients came to be seen ascategories
• Doctors were in charge
• Patients had no power to controlprocess or object to treatment
  • Poor
  • Soldiers used to taking orders
  • “My way or the highway” –patients who objected could be discharged

Statistics

Some simple concepts in statistics

• Probability is expressed as a number from 0 (can neverhappen) to 1 (certain)
• Probability = (ways event can happen)/(possible outcomes)
• Flipping a coin heads =(Heads)/(heads or tails) = = 0.5
• Rolling a 6 on a die = (rolling a6)/(rolling 1,2,3,4,5 or 6) = 1/6
• Drawing the ace of hearts from adeck of cards = (Ace of hearts)/(52 possible cards) = 1/52

Multiple events

• One event or another (but not both): add probabilities. Probability of rolling a 6 or a 3 = 1/6 + 1/6 = 1/3
• Independent events: multiplyprobabilities. Probability of rolling 6 three times in a row = 1/6 x 1/6 x 1/6 =1/216. All three events have to happen to satisfy the probability.
• Some outcome hasto happen, regardless how low the probability. The chance of dealing cards froma deck in a certain order is 1 in 52 x 51 x 50 x 49 x…. x 2 x 1 = 1 in 8 x 10⁶⁷. But when you deal a deck of cards, somesequence has to be dealt.
• Sometimes it’s easiest to consider the odds thatsomething won’t happen.
  • How many people can you gettogether before there’s a 50-50 chance that two have the same birthday?
    • Well, if there’s only one, theodds are certain that nobody shares his birthday.
    • If there are two, there’s achance of 364/365 that they don’t share the same birthday.
    • A third person has a 363/365chance of not sharing a birthday with the other two.
    • So multiply (365/365) x (364/365)x (363/365) x (362/365) and so on until the result drops below (0.5). Itturns out, surprisingly, you only need 28 people.
  • I discovered, during a visit ofthe Moving Vietnam Wall, that not one of the members of my basic trainingcompany died in Vietnam. What are the chances of that happening?
    • There were 8.3 million Vietnamera veterans, of whom 58,000 died in Vietnam.
    •  So a Vietnam era vet had a chance of 58,000/8,300,000 or .007of dying in Vietnam.
    • That means his chance ofsurviving was 1-.007 or .993.
    • The chance that a platoon of 55trainees would all survive is .993 times itself 55 times, or .993⁵⁵.
    • The result is 0.68, a bit betterthan 2/3. So it wasn’t all that remarkable, but I was still glad to find out.

A Few Common Statistical Fallacies

Confusing order and probability. There’s one chance 1n1024 of ten coin flips coming up HHHHHHHHHH. There’s an equal chance of thesequence TTHTHHHTTH coming up. To the coin, one is no more “random” than theother.

Long runs do not make an event less probable. If you flip50 heads in a row, the odds of heads on the next flip are the same as always: 50per cent. The coin has no memory (but I’d check it for bias if I were you!)

Long negative runs do not make an event more probable. Justbecause a number hasn’t turned up in the lottery in a while doesn’t meanit’s “due.”

Spurious patterns: probably the basis of all otherstatistical fallacies. We look for order even when it’s not there. Gambling“systems” are mostly based on this fallacy. The Indians are using it to winback North America.

Clustering: a special type of spurious pattern. Planecrashes and celebrity deaths come in threes … and ones, twos, fours, etc.Princess Diana, fashion designer Gianni Versace and Mother Teresa all diedwithin a short time of each other: a classic cluster. Then John Denver had thebad manners to crash his plane. Oh well.

Clusters don’t make events more or less probable. It isno riskier and no safer to fly after a rash of plane crashes.

After-the-fact probabilities. Almost everything thathappens in life is incredibly improbable, except that some sequence of events has to happen. Calculating the probabilityof a series of past events having happened makes sense only if you calculate thelikelihood of all the other outcomes.A series of events may have only one chance in a billion of happening, but ifthere are a billion other equally likely (or unlikely) outcomes, it’s notremarkable at all.

Treating non-random events as chance events. The odds offinding 50 given people in a room by chance is close to zero, but if they’reall enrolled in a class and there’s an exam that day, the probability is closeto 1.  Some people argue againstevolution by saying the creation of complex organic molecules by chance is nearzero, except chemical reactions aren't random.

Let’s not forget poor memory and fakery. There have notbeen enough bridge hands dealt in history to have come up with a perfect deal(each player gets 13 cards of one suit). Claims to the contrary are almostcertainly due to faulty recall or failure to shuffle the deck properly.

Discoveries in Biology

• 1831, Mathias Schleiden observes cell nucleus
• 1839, Theodor Schwann describes cells as the basis of alllife
• 1846, Karl von Beer observes cell division
• 1848, Rudolf Virchow discovers specialization of cells andclaims disease attacks cells.

Instrumentation and Medical Techniques

The microscope

• 1600's: Anton Leeuwenhoek invents microscope, discovers micro-organisms
• Why did it take 200 years to discover the cell nucleus?
• Answer: microscopes were crude, barely magnified 100 times, optically poor
• 1829, Joseph Lister invents achromatic microscope

Seeing Within the Body

• 1761, Joseph Auenbruggerdiscovers that tapping the chest reveals clues to internal organs
• 1816, Theophile Laennec, invents stethoscope
• 1830's: not a recommended method for routine investigations. Dr. William Beaumont treated a patient, Alexis St. Martin, for a gunshot wound to the stomach. Amazingly, St. Martin survived. Even more amazingly, the hole did not heal, and Beaumont was able to make observations of the internal processes of digestion. Beaumont, often referred to as the "Father of American Physiology", practiced medicine as an Army physician at the Fort Crawford in the 1830s. Fort Crawford is located at Prairie du Chien, Wisconsin. 
• 1848, Karl Ludwig’s kymograph records heartbeat
• 1855, Karl Vierordt devises means of measuring bloodpressure
• 1850, otoscope invented for ear examination
• 1851, Hermann von Helmholtz invents ophthalmoscope for eyestudies
• 1857, Joseph Czermak invents laryngoscope for throatexamination

Cholera and its Aftermath

• Cholera killed 22,000 in England 1831-33
• Riots and civil disorders sparked by poor livingconditions, sparked reforms
• William Farr, a government clerk, compiled mortality tablesthat enabled doctors to identify unusual death rates.
• Farr noticed that cholera mortality decreased away from theThames but suspected the stink from the river might be the cause.
• John Snow, 1853, began to suspect cholera was connected tocontamination by fecal material.
• John Simon, Medical Officer for London, showed in 1855 thatcontaminated water was the cause.
• In 1858 Parliament voted on a massive rebuilding of thesewer system, with outlets downstream from London. Cholera stopped and neverreturned.
• Nobody knew, even then, what specifically caused cholera

What causes disease?

• Rising mortality in hospitals as operations increase
• Cholera epidemic of 1830’s
• Approaches to contagion
  • Bad air as cause (malaria from Latin for “bad air”)
  • Quarantine
  • Some understanding of cleanliness but insufficient tocontrol disease
• 1857: Louis Pasteur and fermentation
  • Agent is alive and reproduces
  • Agent can travel through air
  • Food does not spoil if agent excluded
  • 1864: pasteurization
  • We finally know why food canning works and how to preventfailures
• 1865: Joseph Lister (son of inventor of achromaticmicroscope) applies germ concept to surgery, begins using carbolic acid
• Identification of Disease Micro-organisms: Now We Know Whatto Look For
• 1876: Robert Koch isolates anthrax bacillus (you shudder tothink of his primitive methods! Nowadays we would handle this organism in ahigh-tech isolation lab.)

Why Did These Developments Come So Late In History?

The Babylonians could have measured blood pressure orinvented the stethoscope, so why did it take so long?

Stimuli for invention

• Belief that observations could beinformative
• Belief that observations couldlead to good use
• Once progress began in finding causes and cures ofdiseases, growth of medicine was explosive.

Poor optics were a real bottleneck

• Leeuwenhoek’s microscopes of the1600’s were astonishingly good, but still magnified barely 100 times.
• Details of cell required theachromatic microscope

Antisepsis and anesthesia require some fairly advancedchemistry

• Alcohol is useful for bothpurposes but naturally fermented beverages not alcoholic enough
• Distillation discovered by Arabsof Middle Ages
• Nitrous oxide, ether, carbolicacid do not occur widely in natureand all require sophisticated chemistry to produce (by 1800 standards - these are all simple compounds in modern terms)

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Created 24 October 2001, Last Update 11 January 2020