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The New England Journal of Medicine (NEJM) commented on the end of the
millennium by choosing the most important medical developments of the past
thousand years. Their choices were restricted to developments that "changed the
face of clinical medicine, not preventive medicine or public health or health care
delivery or medical ethics ." They arbitrarily chose 11 and presented them "not in
order of importance, but in rough chronologic order according to the first noteworthy
step taken in a given area."
There were few advances in clinical medicine until the Renaissance. "There are many
reasons little progress was made" until then "but one of them was surely that the only
fit pursuit for scholars in those centuries was considered to be knowledge of God, not
of man. Only with the flowering of humanism that characterized the Renaissance did
that change…." So, the major developments of the past millennium are really those of
the past 500 years. Here are the major developments as presented by NEJM in
outline form.
Founding gure: William Harvey established that the blood circulates within a
closed system with the heart serving as a pump; the pulse is due to the filling of
arteries with blood after the heart contracts; the right ventricle of the heart
pumps
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Milestones ; Past
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… left ventricle pumps blood to the rest
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of the body.
Other major gures: Stephen Hales (first measured blood pressure [in a horse]);
Werner Forssmann, Andre Cournand, and Dickinson Richards (the clinical use of
heart catheterization); and Robert Gross, Elliott Cutler, Charles Hufnagel, and
Alfred Blalock (open-heart surgery).
Founding gure: Antony van Leeuwenhoek, with an object held close to the lens
he had made (and with his nearsightedness ) was first able to see minute
"animalcules" (probably bacteria and protozoa) and discover that tissues had
complex inner structures.
Other major gures: Robert Hooke (described plant cells); Matthias Schleiden
and Theodor Schwann (described animal cells); and Rudolf Virchow, Ludwig
Aschoff, and Carl Rokitansky (their work in cell biology led to insights into
disease processes).
Founding gure: Ernst Ruska made the first electron microscope in the early
1930s. With this primitive apparatus and, later, more sophisticated machines,
the rich subcellular structure of the cell became visible.
Founding gures: Thomas Willis set forth the idea in 1659 that "every Disease
acts its tragedies by the strength of some Ferment." This notion was amplified
by scientists such as Antoine Lavoisier, Jons Jakob Berzelius, and Louis
Pasteur.
Medical Milestones - The Past …
Other major gures: Amadeo Avogadro (whose law permitted the calculation of
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Famous clinical trial: James Lind treated 12 ship passengers who had scurvy
with either an elixir containing citrus juice or a remedy recommended by the
ship's surgeon. The success of the citrus-containing treatment led the British
Admiralty to mandate the provision of lime juice to all sailors (who became
limeys), thereby eliminating scurvy from the Royal Navy.
Another major gure: Richard Doll (who did a pioneering study of smoking
Medical Milestones - The Past …
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5. Development of Anesthesia
Other major gures: The dentist Horace Wells (who in 1844 first used nitrous
oxide to anesthetize patients); his former partner, William Morton (who
demonstrated ether anesthesia in 1846 at the Massachusetts General
Hospital); James Young Simpson (who in 1847 administered chloroform to a
woman in childbirth): and Harold Griffith (who introduced the routine use of
muscle relaxants during surgery in 1942).
Other major gures: Robert Koch (first person to isolate bacteria in pure culture;
discovered the agents of cholera and the cause of tuberculosis, and used his
own criteria [Koch's postulates] to distinguish a bacterial culprit causing a
disease from an innocent microbe); and Joseph Lister (who used carbolic acid
spray to kill bacteria, insisted that antiseptics be used on hands, instruments,
and dressings and made it safe to do major surgery).
Founding gure: Gregor Mendel did experiments and reported his results on the
segregation of traits in peas in 1865. (Mendel's work was ignored until 1902,
when William Bateson and others rediscovered it.)
Other major gures: Archibald Garrod (who showed that inborn errors of
metabolism are inherited); Thomas Hunt Morgan (who drew maps of genes
along chromosomes); George Beadle, Edward Tatum, and Boris Ephrussi (who
showed that genes specify enzymes); Thomas Avery, Colin MacLeod, and
Maclyn McCarty (who found that DNA is the genetic material); Erwin Chargaff
(who described the bases of DNA and the rules of base pairing); Rosalind
Franklin (whose x-ray diffraction pictures of DNA permitted the discovery of the
double helix); James Watson, Francis Crick, and Maurice Wilkins (the double
helix); Jacques Monod and Francois Jacob (DNA to protein via messenger
RNA); Frederick Sanger and Walter Gilbert (who created methods for decoding
the sequence of bases in DNA); and David Baltimore and Harold Temin (who
discovered reverse transcriptase, which converts RNA into DNA).
Famous train ride: On a train from Denver to Chicago in 1949, William Castle told
Linus Pauling about sickle cell anemia. Pauling and coworkers then
demonstrated the molecular consequence of a mutation (sickle hemoglobin)
that causes a genetic disorder (sickle cell anemia) and termed it "a molecular
disease." (The sickle mutation was later shown by Vernon Ingram to be due to a
single amino acid substitution in the molecule).
Other major gures: John Enders (measles vaccine) ; Thomas Weller, Frederick
Robbins and Enders (the polio vaccine); Albert Sabin (the live weakened polio
virus); Jonas Salk (the killed-virus vaccine); and Michael Heidelberger (laid the
foundation for the pneumococcal vaccines).
Medical
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DNA technology (for hepatitis B) was approved by
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the Food and Drug Administration in 1986. The new millennium "promises a
potentially revolutionary form of vaccination based on sequences of DNA that
encode microbial antigens."
First stage: Imaging science has evolved in three stages. In the first stage, the
aim was to develop imaging techniques to define the anatomic features and
functions of the internal organs. Additional "rays" for this purpose were
discovered, including ultrasound and radioactive tracers, and contrast agents
were developed to reveal previously indiscernible structures.
Second stage: The interior of the heart and blood vessels were delineated by
angiography . Other new tools included computed tomography (CT or CAT
scan ) and magnetic resonance imaging (MRI), which permitted resolution of
very small structures throughout the body.
Third stage: Imaging methods are now being used to guide therapy directly --
from long-term guidance of cancer therapy to immediate, on-line guidance of
minimally invasive surgery.
First noteworthy step in the discovery of antimicrobial agents: Turn of the 20th
century.
Founding gure: Paul Ehrlich discovered salvarsan (also known as "606," the
606th compound he had tried) as a treatment for syphilis and showed that
certain dyes also had antimicrobial activity.
Other major gures: Gerhard Domagk (who found that the red dye Prontosil
cured strep infections, which led to the development of the sulfa drugs);
Alexander Fleming (who stumbled onto the inhibition of Staph bacteria by a
mold, Penicillium)
Medical ; Howard
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… Ernst Chain (who purified penicillin for
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Other major gures Thomas Beatson (who used ovariectomy [removal of the
ovaries] for breast cancer); Charles Huggins (showed value of orchiectomy
[removal of the testes] for prostate cancer). Alfred Gilman and Frederick Philips
(found that nitrogen mustard -- the mustard gas of World War I - helped treat
lymphomas); Sidney Farber (introduced methotrexate for treating childhood
leukemia); Barnett Rosenberg (discovered the anticancer drug cis- platinum);
and James Black (whose work led to the development of beta- blockers).
Conclusions
The effective treatment and prevention of disease has "extended life expectancy and
reduced disability beyond the most optimistic hopes of physicians even a few
decades ago -- and far beyond the dreams of their predecessors a thousand years
ago. We are no more able than they were to predict what this new millennium will
bring."
SourceThe Editors. Looking back on the millennium in medicine. New Engl J Med
342: 42-49, 2000.
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