Correspondence

Medicine in the Past Millennium

N Engl J Med 2000; 342:1365-1367May 4, 2000

Article

To the Editor:

I was delighted that you treated us to a broad view of what was really important in medicine during the past millennium (Jan. 6 issue).1 The editorial reminded me of Lester King's list of the “dozen who made a difference.”2 To avoid a bias toward the selection of more recent achievements, King stopped with the 19th century. His list, like yours, included Galen, Vesalius, Harvey, Virchow, and Koch. Readers may wish to consult King's article to see why he also included Paracelsus (whose middle name was Bombastus), Sydenham, Paré, Newton, Bacon, Boerhaave, and Bichat.

Eugene C. Ciccarelli, M.D.
116 Camp St., Hyannis, MA 02601

2 References

1. 1

   Looking back on the millennium in medicine. N Engl J Med 2000;342:42-49
   Full Text | Web of Science | Medline

2. 2

   Breo DL. MDs of the millennium -- the dozen who made a difference. JAMA 1990;263:108, 110-108, 113
   Web of Science

To the Editor:

One of the most important developments in medicine in the past millennium occurred near its beginning. It was at this time that medicine was included as an academic subject in European universities, and its subject matter became part of the academic canon.

The designation of medicine as a learned profession and an academic discipline had at least two important consequences. First, it permanently linked medical knowledge to that of the other disciplines represented in the canon of knowledge that was taught and explored in universities. Second, when the techniques of natural science — systematic observation, classification, measurement, and deduction — were ultimately applied to the study of the physical world, the link with the academic community put medicine in a position to apply these techniques to the study of the human body and its diseases. Health-related occupations that were established as crafts rather than as learned professions (e.g., surgery and dentistry) were unable to advance at a rapid rate until they joined the medical profession or found a parallel position in the academic world.

Allan J. Jacobs, M.D.
New York University School of Medicine, New York, NY 10016

To the Editor:

Laënnec's invention of the stethoscope in 1816 changed the way in which doctors look at the body. The physician began to learn “from the outside much about what was occurring on the inside.”1 The stethoscope also led to a “shift in the conceptualization of all disease from symptom groupings to organic alterations in the human organism.”2

Paul Berman, M.D.
184 Northampton St., Easthampton, MA 01027

2 References

1. 1

   Atwater EC. Touching the patient: the teaching of internal medicine in America. In: Leavitt JW, Numbers RL, eds. Sickness and health in America: readings in the history of medicine and public health. Madison: University of Wisconsin Press, 1985:129-47.
   

2. 2

   Duffin JM. The cardiology of R.T.H. Laennec. Med Hist 1989;33:42-71
   Web of Science | Medline

To the Editor:

Mindful of the selectivity involved in assembling the historical developments described in your memorable millennial editorial, I was nonetheless saddened by the omission of a venerable drug synthesized about 100 years ago in Germany: aspirin.

John C. Di John, M.D.
65 Van Siclen Ave., Brooklyn, NY 11207-2601

To the Editor:

The editorial on the millennium in medicine offers an eloquently summarized and informative account. Nonetheless, we believe we would be remiss not to call attention to the omission of the study and understanding of the mind, with its conscious and unconscious processes, and of emotion and relatedness.

Evelyne Albrecht Schwaber, M.D.
4 Welland Rd., Brookline, MA 02445

Mitchell J. Schwaber, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215

To the Editor:

Your editorial states that surgical anesthesia came about only as a result of the efforts of Horace Wells, who used nitrous oxide in 1844, and the public demonstration of ether anesthesia by William Morton in 1846. You ignore Crawford Long's article in the Southern Medical and Surgical Journal, in which he claimed he was the first to have used ether as a surgical anesthetic — in 1842.1 In the same issue, the editors reported that they had received notarized affidavits from persons attesting to this fact. For 16 years, beginning in 1847, Congress debated the question of credit for the discovery. Although Congress eventually denied credit to Wells and Morton, it could not decide between Long and Charles Jackson.2

The electors of members of the Hall of Fame at New York University debated the priority question in 1913. As a result of Sir William Osler's influence, they credited Morton with the discovery of surgical anesthesia.2 But in 1921, the American College of Surgeons, after examining all the available evidence, gave the credit to Long.2 We think the best evidence supports Long as the discoverer of surgical anesthesia.3

Meyer Friedman, M.D.
Meyer Friedman Institute, San Francisco, CA 94115-3511

Gerald W. Friedland, M.D.
Stanford University, Palo Alto, CA 94301-3009

3 References

1. 1

   Long CW. An account of the first use of sulphuric ether by inhalation as an anaesthetic in surgical operations. South Med Surg J 1849;5:705-713
   

2. 2

   Boland FK. The first anesthetic: the story of Crawford Long. Athens: University of Georgia Press, 1950.
   

3. 3

   Friedman M, Friedland GW. Medicine's 10 greatest discoveries. New Haven, Conn.: Yale University Press, 1998:55.
   

To the Editor:

Some comments on the development of modern surgery by great innovators and teachers such as Theodor Billroth (1829–1894) and William Halsted (1852– 1922) should have been included in the editorial on the millennium in medicine.

Gilbert J. Wise, M.D.
Maimonides Medical Center, Brooklyn, NY 11219

To the Editor:

The inclusion of surgery is essential to any overview of the millennium in medicine. After the slow evolution of this ancient craft over centuries, there was a tremendous expansion of its scope in the last 150 years of the millennium. The control of pain by Morton in 18461 and the prevention of infection by Lister in 18672 widened the extent and increased the safety of surgical operations.

The management of injury, particularly during war, has been a historic mission of surgery. Until the time of the Civil War, compound limb fractures required amputation because of the inevitability and lethality of post-traumatic osteomyelitis. By the time of World War I, amputation after injury had become unusual.

In the early decades of the 20th century, elective clean surgery became widely available for the treatment of disorders of all the organ systems of the body.3-5 With World War II came the use of massive blood transfusion, antibiotics, and anticoagulants. After World War II, there were several major developments in surgery.

Extensive surgical research has brought a better understanding of the disordered physiology often associated with massive hemorrhage, thromboembolism, peritonitis, traumatic shock, wounds, burns, and starvation. An understanding of the accompanying metabolic changes has, in turn, led to a better understanding of the requirements for intravenous feeding and to increased survival rates.6

Surgery of the heart and major vessels has been revolutionized. The repair of heart defects was made possible by the development in surgical laboratories of devices for extracorporeal circulation and the pump oxygenator (in 1954), with safe, prolonged anticoagulation.

Minimally invasive procedures have been developed for several operations by using a surgical telescope with a video presentation. In addition, the treatment of deafness and blindness has become much more effective through microsurgery of the ossicles of the middle ear and reattachment of the retina.

Finally, a triumph of surgical and immunologic research has been the successful transplantation of organs and tissues from living or deceased human donors,7 with the use of immunosuppressive drugs to control rejection.

Education in surgery, both undergraduate and postgraduate, has been severely challenged to keep pace with this widening scope. An extensive system of advanced residency programs and national examinations to certify the qualifications of specialists (the American Boards), first developed in the field of surgery (in 1916), has been adapted to all medical specialties, including family practice.

An effective medical establishment will always depend on a healthy balance between generalists and specialists, each joining with the other to provide full service to their communities.8 In this very surgical millennium, we have learned that the specialist, as well as the generalist, can and must appreciate the emotional needs and general health status of the patient, as well as the occupation, family, and social setting to which the patient will return.

Francis Daniels Moore, M.D.
Harvard Medical School, Boston, MA 02115

8 References

1. 1

   Bigelow HJ. Insensibility during surgical operations produced by inhalation. Boston Med Surg J 1846;35:309-317
   Full Text

2. 2

   Lister J. On a new method of treating compound fracture, abscess, etc. Lancet 1867;1:326-329
   CrossRef

3. 3

   Warren JC. To work in the vineyard of surgery: the reminiscences of J. Collins Warren, 1842-1927. Churchill ED, ed. Cambridge, Mass.: Harvard University Press, 1958.
   

4. 4

   Holman E. William Stewart Halsted. Johns Hopkins Med J 1974;135:418-426
   Medline

5. 5

   Fulton JF. Harvey Cushing: a biography. Springfield, Ill.: Charles C Thomas, 1946.
   

6. 6

   Dudrick SJ, Wilmore DW, Vars HM, Rhoads JE. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 1968;64:134-142
   Web of Science | Medline

7. 7

   Murray JE. The first successful organ transplants in man. Les Prix Nobel, Stockholm, Sweden: Nobel Foundation, 1991.
   

8. 8

   Moore FD, Priebe C. Board-certified physicians in the United States, 1971-1980. N Engl J Med 1991;324:536-543
   Full Text | Web of Science | Medline

To the Editor:

Your editorial was fascinating to read, and considering the vastness of the subject, I think your choices were on target. However, I would like to add one comment and one name.

In setting “a new standard for the understanding of human anatomy,” Vesalius incurred the wrath of the Inquisition, and he was sentenced to a pilgrimage to the Holy Land, which because of the uncertainties of travel at that time, practically amounted to the death penalty; indeed, he never came back from the trip.

Adolphe Quételet (1796–1874) introduced biometrics. Although his indice attracted little attention in the medical world 150 years ago, the body-mass index has become indispensable in the statistical evaluation of a number of medical conditions.

Roger Ghys, M.D.
Clinique du Sein Bourassa, Montreal, QC H2C 1E6, Canada

To the Editor:

I take issue with the assertion that “in the 1400 years between Galen and Vesalius, medicine was stagnant. . . . The only fit pursuit for scholars in those centuries was considered to be knowledge of God, not of man.” Perhaps in church-dominated medieval Europe that was the case. A notable exception, however, is the fact that the study of medicine was introduced as part of the regular curriculum in rabbinic academies throughout most Jewish communities around the year 1000. A long and distinguished line of rabbi-physicians were graduates of these academies and served caliphs and emperors, popes and kings, bishops and priests. The foremost of these rabbi-physicians was the universally acclaimed genius Moshe ben Maimon (1135–1204), better known as Maimonides.

Rabbi Aaron Parry, M.A.
1445 Glenville Dr., Los Angeles, CA 90035

To the Editor:

Muslim physicians made important contributions to medicine during the first five centuries of the past millennium.1 Avicenna (980–1037) was an influential contributor who wrote more than 100 books. He described the properties of alcohol and sulfuric acid and also described the guinea worm, he characterized anthrax as “Persian fire,” and he gave a good account of diabetes; his recommendation of wine as a dressing for wounds was very popular in medieval practice. Osler wrote, “The Canon by Avicenna was the medical bible for a longer period than any other work.”2

The books of Rhazes (circa 850–circa 923) were the principal textbooks of medicine throughout the medieval period as well as long after the Renaissance.1,2 Rhazes was also known for giving free care to the poor.

Ibn Nefis (1210–1288) first hypothesized that blood circulates through the lungs and the body3; his hypothesis was later confirmed by anatomical dissection. In the 12th century, Avenzoar described scabies caused by itch mites (Acarus scabiei ), serous pericarditis (from which he himself suffered), mediastinal abscess, pharyngeal paralysis, and inflammation of the middle ear.1 Alhazen (circa 965–1039) described ocular refraction and magnifying lenses.2,4 Later, Isa ben Ali performed a cataract operation with the use of suction through a hollow needle.

Albucasis's Altasrif (Collection) was the leading textbook of surgery until the time of Saliceto.1 It contains illustrations of surgical and dental instruments and describes amputations for gangrene; lithotomy; treatment of fractures and dislocations, wounds, and deformities of the mouth and dental arches; and the use of cautery.

In textbooks by European authors of the medieval period, such as Michael Servetus (Villanovanus), Henri de Mondeville, and Guy de Chauliac, the work of Arab physicians predominated, as evidenced by the mention of Avicenna, Albucasis, or Rhazes on virtually every page.2

The hospitals in Baghdad in the 12th century and Cairo in the 13th century provided free treatment, and on discharge, convalescing patients were given a suitable amount of money so that they would not have to return to work immediately.

Shakaib U. Rehman, M.D.
Medical University of South Carolina, Charleston, SC 29425

Ambreen Shakaib, M.B.
1850 Ashley Crossing Lane, Charleston, SC 29414

Shaukat Rashid, M.D.
Wayne State University, Detroit, MI 48201

4 References

1. 1

   The Mohammedan and Jewish periods. In: Garrison FH. An introduction to the history of medicine. 4th ed. Philadelphia: W.B. Saunders, 1961:126-39.
   

2. 2

   Medieval medicine. In: Osler WB. The evolution of modern medicine. New Haven, Conn.: Yale University Press, 1921:91-109.
   

3. 3

   Masic I. Ibn al-Nefis -- discoverer of pulmonary blood circulation. Med Arh 1993;47:101-105
   Medline

4. 4

   Puschmann T. A history of medical education. New York: Hafner Publishing, 1966:154-84.
   

To the Editor:

Thank you for the editorial on the millennium in medicine. It was beautifully written, concise, precise, and accurate; it was simply superb.

R. Lawrence Smith, M.D.
Virginia Beach General Hospital, Virginia Beach, VA 23454

Citing Articles (1)

Citing Articles

1. 1

   E. Mark Haacke. 2010. Haacke, E. Mark: Semper Incitare : In MRI Research, there is “Never a Dull Moment”. .
   CrossRef