Sunday, July 07, 2013

1849: The dawn of modern medicine (the height of the scientific revolution)

Oliver Wendell Holmes was among the first to realize that
fevers can be spread by unclean hands. (4, page 457)
William Henry Osler was born in Canada on July 12, 1849.  This was an era where age old habits, methods and ideals used by physicians were being reconsidered.This was an era where physicians were just starting to adapt the use of the stethoscope, laryngoscope, thermometer and microscope into their daily practice.  It was from these devices that physicians were leaning that what went on inside the body effected what went on outside the body.  Through scientific method, many ancient ideas about medicine were being reviewed, and some were even cast away in favor of better wisdom.

Consider the following wisdom that was plastered throughout the medical community:

1843:  Oliver Wendell Holmes (1809-1894) announced to the medical community that women in child bed should not be attended by physicians who had studying the victims of perpetual fever.  He was concerned the causative agent might be spread to the mothers and their babies.  He recommended that physicians and medical caregivers wash their hands and change their clothing after leaving patients infected with perpetual fever. He received harsh criticism from his fellow physicians who were in harsh opposition to change. (4, page 457)

Ignaz Semmelweis proved washing hands and changing
dirty attire between patients reduces the spread of sickness.
Despite his evidence, he was mocked and ignored. (4, page 458)
1846:    Ignaz Philipp Semmelweis (1818-1865) became an assistant in an obstetric ward in Vienna where there was such a high death rate from child bed fever that women feared to go there.  Semmelweis observed the death rate was higher in the 1st ward where he and his fellow male physicians worked compared to the 2nd ward where female mid wives worked.  Upon investigation he learned the women were much cleaner in appearance than the physicians, who often walked proudly around with blood stained hands and aprons.  The physicians also were more likely to perform postmortem investigations just prior to checking the vagina.  The women, on the other hand, did not have blood stained clothes and washed their hands in calcium chloride solution between patients.  When he insisted his physicians likewise wash their hands and put on clean clothes prior to checking women in child bed, the death rate fell from 9.92% to 3.8%.  The following year it was down to 1.27%.  The proud physicians were unhappy, and eventually rejected Semmelweis.   After they went back to their old poor habits, the death rare once again duly rose.  (4, pages 457-8)

1859:  Charles Darwin  (1809-1882) published his "Origin of Species" in which he published his theory of evolution.  This may have been one of the key publications that helped to spark the scientific revolution. The medical profession was one of the main beneficiaries of this revolution.  However, many proud and stubborn medical professors and physicians refused to let go of old theories.  Continued investigations, and scientific evidence, would ultimately force change.  
Louis Pasteur forever changed medicine with his
Germ Theory of Medicine. 

1865:  Louis Pasteur (1822-1895) discovered that microbes were the cause of diseases, and he saved the silk worm industry by his discovery that "microbes were  went on" to extend his germ theory to develop causes and vaccinations for diseases such as anthrax, cholera, TB and smallpox." (3)

1870s:  Joseph Lister (1827-1912) discovered that antiseptic use reduced post surgical infections.  He was a British scientist and physician who observed that about 50 percent of amputation patients survived the surgery but died later of septic fevers, or what was known as "ward fevers."   With knowledge of the works of men like Pasteur and Semmelweiz, Lister surmised microbes in the air were infecting wounds, and so he used phenol as an antimicrobial to reduce the death rate by 15 percent. (4)  He recommended the antimicrobial carbolic acid to be placed on bandages to keep the wounds clean, and he invented a machine to pump carbolic acid into the air in the rooms where surgeries were being performed, and mortality rates from infections after surgeries plummeted. (5)

1879:  While working with Jordan Wheat Lambert (1851-1889), Lister invented an antiseptic to use during surgeries.  In honor of Lister's discovery, Lambert insisted the product be named "Listerine," introducing it to surgeons in 1879.  The product was so successful that it was ultimately marketed to dentists as an oral rinse in 1895, and to the public as a mouthwash in 1914.  The product is still available on the market to this day (although the taste has been improved).

Joesph Lister proved that antiseptic use during surgery
greatly reduced the post surgery morbidity and mortality.
A young William Osler must have been inspired by all this wisdom.  He became so rapt in it that he cast aside his father;s wish that he go into the ministry to study medicine.  However, while a young, impressionable Osler was keen about the new ideas regarding medicine, other physicians were pent on grasping onto the old theories holding on for dear life.  

For example, there were many medical professors who learned about Robert Bree's theory that asthma was caused by some peccant matter in the lungs, and an ideal sign this peccant matter was present was increased sputum.  Sputum, in essence, was the bodies attempt to rid of this peccant matter from the body.  These seasoned physicians worshiped this theory so long it was hard for them to let go.

This does not mean these were bad physicians.  They did the best they could with the wisdom that they had, although instead of doing better when the evidence was presented to them, they rejected it.  This is not in any way abnormal to humans.  It's normal to reject new ideas prior to accepting them.  Stated another way: the truth hurts before it makes you better.

By the various experts performing autopsies and dissections, these types of theories were cast aside for better ones, such as the spasmotic and nervous theories of asthma, as so duly noted by Henry Osler in his review of asthma in his 1892 book "The Principles and Practice of Medicine." (2, page 497)

In his review of heart failure he must have been among the first to describe it as a separate disease entity, as opposed to looping it under the asthma umbrella as so many physicians before him.  Through his writings on heart failure we can see how new ideas were still commingled with old theories.

Listerine bottle from the 1920s
Consider the following regarding heart failure from "The Principles and Practice of Medicine":

Osler explailned that as the flow of blood through the heart and lungs becomes blocked, perhaps from a stenosis (narrowing) of blood vessels or emphysema in the lungs, the heart becomes overworked.  This causes the heart to become hypertrophied (enlarged).  The heart becomes weak, and may cause blood flow to become "embarrassed" (slowed down, backed up, congested).  This in turn will cause acute (it's happening now) symptoms of heart failure (cardiac asthma).  (2, page 624)

Treatment for this would be:
  1. Rest: Allows heart time to catch up and breath can be restored
  2. Relief of embarrassed (impaired) circulation:  Dyspnea from blood pooling in the lungs may be severe, even fatal.  The vessels of the body become engorged with blood, thus dilating (enlarged). When this can be seen upon assessment, and when there is orthopnea and cyanosis, the following are the recommended treatment options:
    1. Venesection (bleeding): The abstraction of 20-30 ounces of blood. He notes that "this is the This is the occasion in which timely venesection may save the patient's life. It is a condition in which I have had most satisfactory results from venesection. It is done much better early than late. I have on several occasions regretted its postponement., particularly in instances of acute dilatation and cyanosis in connection with emphysema.'' (2, page 624)
    2. Depletion through the bowels:  This is particularly valuable when dropsy is present. Of the various purges the salines are to be preferred,and may be given by Matthew Hay's method. Half an hour to an hour before breakfast from half an ounce to an ounce and a half of Epsom salts may be given in a concentrated form. This usually produces  (2, pages 624-625)
So you can see that science had impacted his description of heart failure, although old theories regarding its treatment were still held on to.  It must have been well known to him that he couldn't cure disease, yet he did have the ability to alleviate pain and dyspnea with medicines like opiates, morphine and strammonium (or, in some cases, bleeding).  .

Through it all, and regardless of scientific advancements, even Osler must have known the limits of medicine. He must have known that the gentle touch of his hand, or the soft ring of his assuring voice, was all that was needed to alleviate suffering. Providing hope may have been the main job men like Osler, even during this era of improved medical wisdom. (3, pages 50-60)



References:
  1. "Sir William Osler At Seventy -- A Retrospect," The Journal of the American medical Association," 1919, Saturday, July 12, pages 106-108
  2. Osler, William, "The Principles and Practice of Medicine," 1892, New York, pages 497-501
  3. Bliss, Micheal, "William Osler:  A Life in Medicine," 1999, New York
  4. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, London and Philadelphia, 
Further readings:
  1. Jackson, Mark, "Asthma: The Biography," 2009, New York, pages 211-12
  2. Brenner, Barry E, ed., "Emergency Asthma," 1998, New York, pages 212-14

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