Medical Progress Past, Present, and Future
Medical Progress Past, Present, and Future
To appreciate the advances that have been made in the last century, I have reviewed the status of health and knowledge that existed in the late 19th and early 20th centuries.
In 1876, when the English surgeon Baron Joseph Lister visited the United States, American surgeons were still consulting the weather to fix the day of an operation and were operating in frock coats. Some believed that a wind from the northeast carried the germ of erysipelas. It was not until then that the surgeons and their assistants began to clip their fingernails and scrub their hands and arms thoroughly with soap and water. They would also dip them into a solution of bichloride of mercury before operating. Also, during this same period, sea sponges were replaced with linen sponges that were boiled. In Europe, Dr. Joseph Plenck had recommended the use of gloves for obstetricians to protect them from venereal infection in the early 1800s. However, it was not until 1890 that Dr. Horatio Storer of the Boston Lying-In Hospital recommended boiled rubber gloves as an occupational safety practice for physicians in the United States. Dr. William Stewart Halsted is credited with introducing the hygienic use of rubber gloves in 1905.
Life expectancy for people born in the United States has changed dramatically as shown in Table 1. In 1900, life expectancy was influenced by the fact that yellow fever, typhus, and bubonic plague remained formidable foes, and their mode of transmission had not been discovered. Insulin, antitoxin for diphtheria, vitamins, antibacterial drugs, and safe techniques for blood transfusion did not exist. Radiographs were just coming into use in hospital practice. The only form of preventive medical therapy other than the sucking of lemons and limes by sailors to prevent scurvy was the smallpox vaccination. Only 58 organizations were engaged in public health nursing, employing 130 nurses for the entire United States.
The 10 leading causes of death (as a percentage of deaths) are shown in Table 2. National statistics for maternal and infant mortality, based on live births were first available in 1915. Table 3 shows maternal and infant mortality.
The most common items in the billing records of a family physician for patient visits in the 1930s were:
Several important discoveries and significant occurrences in the 20th century brought about a healthier life for United States citizens:
Looking at these developments we can appreciate the statement, "Much of the health made in this past century has been the conquest of infectious diseases, often by environmental means of through the use of simple preventative or therapeutic measures such as vaccines and antibiotics."
The first description of a blood transfusion was recorded by an Italian physician in the 1600s. Later, blood transfusions were used in World War I. However, it was not until 1930 that Karl Landsteiner determined that there were four blood types.
Today, we accept education as essential and are constantly striving to improve on methodology and maintain quality. Undergraduate, graduate, postgraduate, and continuing medical education is foremost in our minds. This has not always been the case. In the early 1900s, three types of medical schools existed as described by Dr. Flexner. The "first rank" (about 10% of total schools) required 1 year of college work, the "second division" (about 33%) required a high school diploma for entrance, and the remainder of the schools settled for entrants with a grammar school education or some unenforced equivalent. Flexner's report of 1910 was the stimulus for the development of American excellence in scientific medicine and the implementation of the full-time system in clinical as well as preclinical medical education. According to one count, 76 medical schools disappeared from existence between 1906 and 1920, either by ceasing to function or by merging with stronger institutions. Another account recorded the closing of 92 medical schools between 1904 and 1915.
The first specialty group to establish a means for certifying its members was ophthalmologists when they established the American Board for Ophthalmic Examinations in 1916. The American Board of Otolaryngology was incorporated in 1924, and the American Board of Obstetrics and Gynecology was established in 1930. A proposal was made in 1927, a certificate of incorporation was granted by the state of Delaware in 1930, and the first written examination for obstetricians and gynecologists was held on March 13, 1931. In 1951, 11 physicians founded the American College of Obstetricians and Gynecologists (ACOG). As of June 30, 1999, ACOG reported a membership of 39,162.
The formal residency system was developed by Dr. John W. Williams of Johns Hopkins. In 1931, there were 83 residency programs in obstetrics and gynecology approved by the Council on Medical Education and Hospitals of the American Medical Association and the Committee of Graduate Education of the American Board of Obstetrics and Gynecology. Today, 125 medical schools are accredited by the Liaison Committee on Medical Education with 66,000 medical students. More than 7,000 residency programs with 100,000 residents are recognized by the Accreditation Council of Graduate Medical Education, making medical education in the United States the envy of the world.
The development of anesthesia has played an important role in medical progress this century. In their book Control of Pain in Childbirth, Lull and Hingson described historical anesthetic practices. These ranged from relatively modern agents such as barbiturates, opiates, ether, and nitrous oxide, as well as techniques of conductive and general anesthesia, to more archaic agents and techniques, such as cocaine, chloroform, ethyl alcohol, heroin, Jamestown weed, Kane's cocktail, mesmerism (ie, hypnotism), morphine, opium, and rectal ether. The introduction of analgesics and anesthetics occurred as follows:
Five essential parts of medical progress were developed this century:
Antibiotics and chemotherapeutics, together with the increasingly available immunizations, have benefitted untold millions. Today, we have sophisticated blood and blood volume replacement with fairly accurate scientific control of specific type and volume of blood products and electrolytes. Anesthesia has become a specialty we accept as a given, and we may not express our appreciation for the help we receive.
How was this accomplished? By dedication on the part of the practicing physician who thought and still thinks the practice of medicine is the greatest privilege in the world. It was also accomplished by research, which requires at least seven "Ds":
Our present circumstance is the result of education and research. We now have the potential of genetic engineering, better diagnostic modalities, improved medical and surgical means of therapy, and more specific and localized treatment -- as well as a strong emphasis on preventive medicine.
Is there any concern or apprehension that education and research will not continue as it has in the past? From my perspective there is. I would like to pose some questions for consideration. How many of your professors have had to decrease the amount of their teaching time and devote more time practicing medicine to keep their department financially viable? How many institutions and departments have had to decrease the number of persons providing direct patient care? How many institutions and departments have had to decrease the number of people doing basic research, and what percentage of research has been diminished? How many newspaper articles have you read regarding decreased funding for medical care? In our present atmosphere of managed care, government control, and the litigious attitude in our nation, what is the net exposure and experience of our students and residents in terms of patient contact?
After the publication of the Flexner Report of 1910, Dr. John W. Williams made this statement:
As far as I know there is only one medical school in the country which is properly equipped for teaching obstetrics and gynecology along the lines of a well conducted German woman's clinic. And I regret to say that it is not at Johns Hopkins Hospital, whose lying-in department is very inferior, and far below the standard maintained by the other departments of that institution. . . . After eighteen years of experience in teaching what is probably the best body of medical students ever collected in this country. . . . I would unhesitatingly state that my own students are unfit on graduation to practice obstetrics in its broad sense, and are scarcely prepared to handle normal cases.
His reason for making this statement was the lack of clinical experience students had with patients.
Today, a professional golfer may hit 1,000 practice balls daily. Yet, physicians in training may not have adequate exposure in obstetric and gynecologic or other medical or surgical procedures, even under controlled circumstances, that will enable them to provide what may well be lifesaving care when they go into practice.
Today, in the United States we have 650,000 doctors delivering health care. Our estimatedpopulation is 260 million. This equals 0.25% of the population. We may talk loudly and complain. However, until the patients, the "populace," are made aware that they, their children, and their grandchildren may not receive the best care because of decreased funding for education, research, and medical care, it is my opinion we will see a decline in the quality of medicine.
What can we do about this? In obstetrics and gynecology we have always tried to be patients' advocates for health. In my opinion, the health of our country now depends on you and especially the patients (the populace) becoming advocates for good health. This will not be successful through media blitzes, radio spots, or television, magazine, or newspaper advertisements. It must be done on a personal basis, just as we have delivered health care. Politicians listen to the "masses," the populace. It is our responsibility to educate our patients and the general population that their future health may well be in danger.
To appreciate the advances that have been made in the last century, I have reviewed the status of health and knowledge that existed in the late 19th and early 20th centuries.
In 1876, when the English surgeon Baron Joseph Lister visited the United States, American surgeons were still consulting the weather to fix the day of an operation and were operating in frock coats. Some believed that a wind from the northeast carried the germ of erysipelas. It was not until then that the surgeons and their assistants began to clip their fingernails and scrub their hands and arms thoroughly with soap and water. They would also dip them into a solution of bichloride of mercury before operating. Also, during this same period, sea sponges were replaced with linen sponges that were boiled. In Europe, Dr. Joseph Plenck had recommended the use of gloves for obstetricians to protect them from venereal infection in the early 1800s. However, it was not until 1890 that Dr. Horatio Storer of the Boston Lying-In Hospital recommended boiled rubber gloves as an occupational safety practice for physicians in the United States. Dr. William Stewart Halsted is credited with introducing the hygienic use of rubber gloves in 1905.
Life expectancy for people born in the United States has changed dramatically as shown in Table 1. In 1900, life expectancy was influenced by the fact that yellow fever, typhus, and bubonic plague remained formidable foes, and their mode of transmission had not been discovered. Insulin, antitoxin for diphtheria, vitamins, antibacterial drugs, and safe techniques for blood transfusion did not exist. Radiographs were just coming into use in hospital practice. The only form of preventive medical therapy other than the sucking of lemons and limes by sailors to prevent scurvy was the smallpox vaccination. Only 58 organizations were engaged in public health nursing, employing 130 nurses for the entire United States.
The 10 leading causes of death (as a percentage of deaths) are shown in Table 2. National statistics for maternal and infant mortality, based on live births were first available in 1915. Table 3 shows maternal and infant mortality.
The most common items in the billing records of a family physician for patient visits in the 1930s were:
Follow-up incision and drainage of abscess.
Diphtheria immunization.
Follow-up drainage for mastoiditis.
Scrotal tap for epididymitis.
Several important discoveries and significant occurrences in the 20th century brought about a healthier life for United States citizens:
The American Association for Cancer Research was founded in 1907.
Water was first chlorinated in 1908.
The American Society for the Control of Cancer was founded in 1914 (It was later renamed as the American Cancer Society.)
Dr. Jonas Salk introduced polio vaccine in 1953. He, his wife, and their three sons were in the first group to receive the injections. The last case of indigenously acquired poliovirus occurred in 1979.
The elimination of rickets, pellagra, and malaria, as well as a marked reduction of typhoid fever in the United States improved life expectancy.
Diphtheria toxoid was introduced in 1920.
Insulin was discovered by F. G. Banting and C. H. Best in 1922.
Penicillin was discovered by Alexander Fleming in 1928, though it was not studied as an antibacterial drug for 10 years.
Looking at these developments we can appreciate the statement, "Much of the health made in this past century has been the conquest of infectious diseases, often by environmental means of through the use of simple preventative or therapeutic measures such as vaccines and antibiotics."
The first description of a blood transfusion was recorded by an Italian physician in the 1600s. Later, blood transfusions were used in World War I. However, it was not until 1930 that Karl Landsteiner determined that there were four blood types.
Today, we accept education as essential and are constantly striving to improve on methodology and maintain quality. Undergraduate, graduate, postgraduate, and continuing medical education is foremost in our minds. This has not always been the case. In the early 1900s, three types of medical schools existed as described by Dr. Flexner. The "first rank" (about 10% of total schools) required 1 year of college work, the "second division" (about 33%) required a high school diploma for entrance, and the remainder of the schools settled for entrants with a grammar school education or some unenforced equivalent. Flexner's report of 1910 was the stimulus for the development of American excellence in scientific medicine and the implementation of the full-time system in clinical as well as preclinical medical education. According to one count, 76 medical schools disappeared from existence between 1906 and 1920, either by ceasing to function or by merging with stronger institutions. Another account recorded the closing of 92 medical schools between 1904 and 1915.
The first specialty group to establish a means for certifying its members was ophthalmologists when they established the American Board for Ophthalmic Examinations in 1916. The American Board of Otolaryngology was incorporated in 1924, and the American Board of Obstetrics and Gynecology was established in 1930. A proposal was made in 1927, a certificate of incorporation was granted by the state of Delaware in 1930, and the first written examination for obstetricians and gynecologists was held on March 13, 1931. In 1951, 11 physicians founded the American College of Obstetricians and Gynecologists (ACOG). As of June 30, 1999, ACOG reported a membership of 39,162.
The formal residency system was developed by Dr. John W. Williams of Johns Hopkins. In 1931, there were 83 residency programs in obstetrics and gynecology approved by the Council on Medical Education and Hospitals of the American Medical Association and the Committee of Graduate Education of the American Board of Obstetrics and Gynecology. Today, 125 medical schools are accredited by the Liaison Committee on Medical Education with 66,000 medical students. More than 7,000 residency programs with 100,000 residents are recognized by the Accreditation Council of Graduate Medical Education, making medical education in the United States the envy of the world.
The development of anesthesia has played an important role in medical progress this century. In their book Control of Pain in Childbirth, Lull and Hingson described historical anesthetic practices. These ranged from relatively modern agents such as barbiturates, opiates, ether, and nitrous oxide, as well as techniques of conductive and general anesthesia, to more archaic agents and techniques, such as cocaine, chloroform, ethyl alcohol, heroin, Jamestown weed, Kane's cocktail, mesmerism (ie, hypnotism), morphine, opium, and rectal ether. The introduction of analgesics and anesthetics occurred as follows:
Dr. Crawford Long of Jefferson, Ga, used ether in the 1840s and reported his experience in the Southern Medical and Surgical Journal in 1849.
Dr. Kreis first reported the use of spinal anesthesia in obstetrics in 1900.
Dr. Gauz of Freidburg first reported the use of scopolamine in 1906.
Dr. Webster of Chicago was the first to use nitrous oxide and oxygen in the US in 1909.
Dr. Erwin Zwiefel reported on 4,000 cases of caudal anesthesia collected from the literature in 1920.
Drs. Hamblen and Hamlin of Virginia first reported the use of barbiturates in the United States in 1921.
Dr. Pages of Spain first used peridural anesthesia in 1921. However, Drs. Graffagnino and Seyler of New Orleans were the first to successfully apply this procedure for the relief of pains of labor and delivery.
Drs. Meeker and Bonar were the first to use caudal anesthesia in the United States in 1923.
Dr. Gwathmey reported in 1931 the use of rectal ether in 20,000 cases.
Drs. Franken and O'Connor reported the first successful use of spinal anesthesia for a cesarean section in 1934.
Five essential parts of medical progress were developed this century:
An attempt to control infectious processes.
The ability to use blood and blood products safely.
Anesthesia.
Medical education.
Research.
Antibiotics and chemotherapeutics, together with the increasingly available immunizations, have benefitted untold millions. Today, we have sophisticated blood and blood volume replacement with fairly accurate scientific control of specific type and volume of blood products and electrolytes. Anesthesia has become a specialty we accept as a given, and we may not express our appreciation for the help we receive.
How was this accomplished? By dedication on the part of the practicing physician who thought and still thinks the practice of medicine is the greatest privilege in the world. It was also accomplished by research, which requires at least seven "Ds":
Doctors -- MDs and PhDs, who have
Determination to win,
Dedication to the concept of research,
Devotion to the task at hand with a strong
Desire to
Discover something to benefit humanity.
Dollars, without which none of this can be accomplished.
Our present circumstance is the result of education and research. We now have the potential of genetic engineering, better diagnostic modalities, improved medical and surgical means of therapy, and more specific and localized treatment -- as well as a strong emphasis on preventive medicine.
Is there any concern or apprehension that education and research will not continue as it has in the past? From my perspective there is. I would like to pose some questions for consideration. How many of your professors have had to decrease the amount of their teaching time and devote more time practicing medicine to keep their department financially viable? How many institutions and departments have had to decrease the number of persons providing direct patient care? How many institutions and departments have had to decrease the number of people doing basic research, and what percentage of research has been diminished? How many newspaper articles have you read regarding decreased funding for medical care? In our present atmosphere of managed care, government control, and the litigious attitude in our nation, what is the net exposure and experience of our students and residents in terms of patient contact?
After the publication of the Flexner Report of 1910, Dr. John W. Williams made this statement:
As far as I know there is only one medical school in the country which is properly equipped for teaching obstetrics and gynecology along the lines of a well conducted German woman's clinic. And I regret to say that it is not at Johns Hopkins Hospital, whose lying-in department is very inferior, and far below the standard maintained by the other departments of that institution. . . . After eighteen years of experience in teaching what is probably the best body of medical students ever collected in this country. . . . I would unhesitatingly state that my own students are unfit on graduation to practice obstetrics in its broad sense, and are scarcely prepared to handle normal cases.
His reason for making this statement was the lack of clinical experience students had with patients.
Today, a professional golfer may hit 1,000 practice balls daily. Yet, physicians in training may not have adequate exposure in obstetric and gynecologic or other medical or surgical procedures, even under controlled circumstances, that will enable them to provide what may well be lifesaving care when they go into practice.
Today, in the United States we have 650,000 doctors delivering health care. Our estimatedpopulation is 260 million. This equals 0.25% of the population. We may talk loudly and complain. However, until the patients, the "populace," are made aware that they, their children, and their grandchildren may not receive the best care because of decreased funding for education, research, and medical care, it is my opinion we will see a decline in the quality of medicine.
What can we do about this? In obstetrics and gynecology we have always tried to be patients' advocates for health. In my opinion, the health of our country now depends on you and especially the patients (the populace) becoming advocates for good health. This will not be successful through media blitzes, radio spots, or television, magazine, or newspaper advertisements. It must be done on a personal basis, just as we have delivered health care. Politicians listen to the "masses," the populace. It is our responsibility to educate our patients and the general population that their future health may well be in danger.
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