What the Doctor Ordered

Overview

Chapter covers period 1750-1900, during which technology evolved rapidly. As a result there are innumerable interconnections between disciplines, making for a very complex tale. However, four main threads can be identified:

• 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) or residence 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 and absorbed
• Problem: you can never see a direct connection between arteries and veins
• Galen (150 A.D.) believed blood passed from one side of the heart 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 1500 gallons of blood a day.
• If blood is created and absorbed, the body must secrete and absorb 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 to rule out hypothesis.
• Blood actually passes from arteries to veins through capillaries

Medicine about 1800 

Bore a striking resemblance to what we now 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 or observe: subjects limited to condemned criminals, paupers, or worse – cadavers supplied by grave robbers and body snatchers.
• No knowledge of  role of micro-organisms
• “Control by the patient of the doctor’s efforts …. prevented an already ignorant community of physicians from making any scientific headway.” Burke (195)
• Almost no interchange of knowledge
• Elitism: physicians were mostly upper class, treated upper class (where the money was). Rarely saw traumatic injuries or many diseases of the poor. Looked down on surgeons, who actually were obtaining working practical knowledge.
• There’s nothing wrong with a more holistic approach, but in 1800 the necessary technical knowledge simply did not exist.

Who’s a “Doctor?”

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

Hospitals

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

Philosophy meets medicine

Wolfgang Rau (1764) and Johann 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) are hard-wired into the human brain

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

• Knowledge can be reduced to a small number of general principles

Friedrich von Schelling 1805, Naturphilosophie

• Man lost his original oneness with nature through artificial thought constructs
• There must be a few basic laws that underlie life
• Perhaps we can find the fundamental life-force

Effect of philosophy on medicine

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

The French Revolution

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

Effects on Medicine

• Physicians (upper class, mostly) were suspect, purged, or fled
• Surgeons, being lower class and laborers, were “politically correct.”
• Huge volume of casualties
• Experiment or die
  • Supplies short, had to make do with field expedients
  • Many traditional remedies made things worse
    • Cauterization
    • Delaying amputation
    • Trepanning (drilling skull to relieve pressure)
• New observations
  • Foreign objects always led to infection (gruesome note for those who think modern warfare is worse than bygone days – one of the most common foreign objects in wounds was bone fragments of other soldiers)
  • Irrigation with water was an effective means of cleansing wounds
  • Importance of treating for shock first
  • Importance of internal injuries
• In postwar France, huge hospitals were opened for casualties.
  • Surgeons were in charge
  • Hospitals were specialized
  • Emphasis on observation and practice
  • France soon led the world in medicine
  • Hospitals (see above) for the first time became places to go to get well.
  • Doctors had automatic right to dissect cadavers

Separating the Patient from the Process

• Specialized hospitals meant patients came to be seen as categories
• Doctors were in charge
• Patients had no power to control process 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 never happen) to 1 (certain)
• Probability = (ways event can happen)/(possible outcomes)
• Flipping a coin heads = (Heads)/(heads or tails) = ½ = 0.5
• Rolling a 6 on a die = (rolling a 6)/(rolling 1,2,3,4,5 or 6) = 1/6
• Drawing the ace of hearts from a deck 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: multiply probabilities. 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 has to happen, regardless how low the probability. The chance of dealing cards from a 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, some sequence has to be dealt.
• Sometimes it’s easiest to consider the odds that something won’t happen.
  • How many people can you get together before there’s a 50-50 chance that two have the same birthday?
    • Well, if there’s only one, the odds are certain that nobody shares his birthday.
    • If there are two, there’s a chance of 364/365 that they don’t share the same birthday.
    • A third person has a 363/365 chance 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 ½ (0.5). It turns out, surprisingly, you only need 28 people.
  • I discovered, during a visit of the Moving Vietnam Wall, that not one of the members of my basic training company died in Vietnam. What are the chances of that happening?
    • There were 8.3 million Vietnam era veterans, of whom 58,000 died in Vietnam.
    •  So a Vietnam era vet had a chance of 58,000/8,300,000 or .007 of dying in Vietnam.
    • That means his chance of surviving was 1-.007 or .993.
    • The chance that a platoon of 55 trainees would all survive is .993 times itself 55 times, or .993⁵⁵.
    • The result is 0.68, a bit better than 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 1n 1024 of ten coin flips coming up HHHHHHHHHH. There’s an equal chance of the sequence TTHTHHHTTH coming up. To the coin, one is no more “random” than the other.

Long runs do not make an event less probable. If you flip 50 heads in a row, the odds of heads on the next flip are the same as always: 50 per 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. Just because a number hasn’t turned up in the lottery in a while doesn’t mean it’s “due.”

Spurious patterns: probably the basis of all other statistical 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 win back North America.

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

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

After-the-fact probabilities. Almost everything that happens in life is incredibly improbable, except that some sequence of events has to happen. Calculating the probability of a series of past events having happened makes sense only if you calculate the likelihood of all the other outcomes. A series of events may have only one chance in a billion of happening, but if there are a billion other equally likely (or unlikely) outcomes, it’s not remarkable at all.

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

Let’s not forget poor memory and fakery. There have not been 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 almost certainly 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 all life
• 1846, Karl von Beer observes cell division
• 1848, Rudolf Virchow discovers specialization of cells and claims 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 Auenbrugger discovers 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 blood pressure
• 1850, otoscope invented for ear examination
• 1851, Hermann von Helmholtz invents ophthalmoscope for eye studies
• 1857, Joseph Czermak invents laryngoscope for throat examination

Cholera and its Aftermath

• Cholera killed 22,000 in England 1831-33
• Riots and civil disorders sparked by poor living conditions, sparked reforms
• William Farr, a government clerk, compiled mortality tables that enabled doctors to identify unusual death rates.
• Farr noticed that cholera mortality decreased away from the Thames but suspected the stink from the river might be the cause.
• John Snow, 1853, began to suspect cholera was connected to contamination by fecal material.
• John Simon, Medical Officer for London, showed in 1855 that contaminated water was the cause.
• In 1858 Parliament voted on a massive rebuilding of the sewer system, with outlets downstream from London. Cholera stopped and never returned.
• 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 to control 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 prevent failures
• 1865: Joseph Lister (son of inventor of achromatic microscope) applies germ concept to surgery, begins using carbolic acid
• Identification of Disease Micro-organisms: Now We Know What to Look For
• 1876: Robert Koch isolates anthrax bacillus (you shudder to think of his primitive methods! Nowadays we would handle this organism in a high-tech isolation lab.)

Why Did These Developments Come So Late In History?

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

Stimuli for invention

• Belief that observations could be informative
• Belief that observations could lead to good use
• Once progress began in finding causes and cures of diseases, growth of medicine was explosive.

Poor optics were a real bottleneck

• Leeuwenhoek’s microscopes of the 1600’s were astonishingly good, but still magnified barely 100 times.
• Details of cell required the achromatic microscope

Antisepsis and anesthesia require some fairly advanced chemistry

• Alcohol is useful for both purposes but naturally fermented beverages not alcoholic enough
• Distillation discovered by Arabs of Middle Ages
• Nitrous oxide, ether, carbolic acid do not occur widely in nature and 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 14 November 2001

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