What the Doctor Ordered
Steven Dutch, Natural and Applied Sciences, University
of Wisconsin-Green Bay
First-time Visitors: Please visit Site Map and
. Use "Back" to return here.
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
- 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
- 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
- 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
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
- “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.)
- 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.
- Knowledge has no basis but experience
- There are simple irreducible ideas derived from nature
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
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
- There were principles underlying natural phenomena
- Instead of every disease being unique, there were
- Search for the natural principles underlying health and
- Search for the fundamental life-force: a stimulus to
investigation, but also an imaginary theory that would waste efforts and
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
- France soon found itself at war with most of the rest of
- Resorted to huge citizen conscript armies to meet the
Effects on Medicine
- Physicians (upper class, mostly) were suspect, purged, or
- Surgeons, being lower class and laborers, were
- Huge volume of casualties
- Experiment or die
- Supplies short, had to make do
with field expedients
- Many traditional remedies made
- Delaying amputation
- Trepanning (drilling skull to
- 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
- Irrigation with water was an
effective means of cleansing wounds
- Importance of treating for shock
- Importance of internal injuries
- In postwar France, huge hospitals were opened for
- Surgeons were in charge
- Hospitals were specialized
- Emphasis on observation and
- France soon led the world in
- Hospitals (see above) for the
first time became places to go to get well.
- Doctors had automatic right to
Separating the Patient from the Process
- Specialized hospitals meant patients came to be seen as
- Doctors were in charge
- Patients had no power to control
process or object to treatment
- Soldiers used to taking orders
- “My way or the highway” –
patients who objected could be discharged
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) = = 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
- 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 (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
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
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
- 1846, Karl von Beer observes cell division
- 1848, Rudolf Virchow discovers specialization of cells and
claims disease attacks cells.
Instrumentation and Medical Techniques
- 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
- 1850, otoscope invented for ear examination
- 1851, Hermann von Helmholtz invents ophthalmoscope for eye
- 1857, Joseph Czermak invents laryngoscope for throat
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
- 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”)
- Some understanding of cleanliness but insufficient to
- 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
- 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
- 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
Antisepsis and anesthesia require some fairly advanced
- 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)
Return to Outline Index
Return to Professor Dutch's Home Page
Created 24 October 2001, Last Update
10 December 2010
Not an official UW Green Bay site