Science and Evolution of

Health Care
October 19th, 2017 Week 7
KA Hogan rn phd
From Butchery to Brilliance
Trephination: Drilling into the head
Seems to have been the 1st surgery

Releasing pressure, eliminating evil spirits!

One theory is that it might have been used for the
exit or entrance of spirits believed to cause illness or
as a cure of convulsions, headaches, infections and
fractures

Headaches, seizures, loss of consciousness

Used from Neolithic period (last stage of the Stone
Age) to today
Trephination
Was most often performed on adult males- but found in the skulls of children and
women
These operations were often high successful and many people must have
survived the treatment, as is evidenced by skulls that show bone regrowth
Used today (relief of epidural and subdural hematoma)
Surgery

Originally it was seen as a lesser prestige because the rational

thinking brain was valued whereas surgery was rough work
with your hands

Today however
Surgeons are at the top of pay and prestige bracket these days.
At the top of medical community
Barber Surgeons
Medical practitioners
Performed surgery on war victims
Learned trade as apprentices
Often illiterate
Teeth-pulling and bloodletting
 Blood Letting

Dates back to the four humors of Hippocrates

May have be cut, or use leeches
1st line treatment
Belief - all illnesses stemmed from an overabundance of
blood
Was performed by the church until late 1100s
Fixing Faces

Surgeons were trained as barbers (Barber Surgeons)

Early surgery was called optimistic butchery
Surgeon known as the harbinger of death
The patient could go into shock, there was no anesthetic,
they could bleed out
Syphilis turned victims into social pariah, excluded from
society because of lack of nose. Thought to have been
brought from South America
Surgical Prerequisites

1. Understanding anatomy (Vesalius)

a)Medical school profs would send out their students to gather
cadavers (i.e homeless, alcoholics)
b)Became acceptable cut open and study the body. Before this you
didnt know what connected to what
c)Bodies decomposed very quickly in the summer which is why they did
more autopsies in the winter
 2. Managing blood loss (Pare) invented the ligature
a)They did the leg amputations in 28 seconds. They might go into shock from
the pain or bleed out
b)Pare managed blood loss during surgery
 3. Discovery of pain relief (anesthesia) (James Younger Simpson)
-1840 conscious throughout your surgery
- For pain relief in olden days they tried hypnosis, alcohol;
later ether; chloroform
Simpson discovered the anesthetic properties of
chloroform; tested it on himself and colleagues.
Childbed fever

4. Battling infection
Women dying in childbed -of septicemia (blood poisoning)
More mothers dying in doctors care in hospitals than those of
midwives or births at home
Death on their hands (literally) dirty hands
Dr. Igaz Semmelweiss the father of infection control
IGNAZ SEMMELWEIS

(18181865)
the saviour of mothers
Died from septicemia
died in a public insane asylum
at the age of 47 (Best and Neuhauser, 2004)
Death on their hands`

Semmelweisss ideas conflicted with the

current concepts of medicine but also
with the doctors view of THEMSELVES!

THEY could not be the cause of deaths!

 The Doctors Plague
1600s to 1800s
Doctors are gentlemen, and gentlemens hands are clean. --
Dr. Charles Meigs, Obstetrician, teacher
Louis Pasteur studies of bacteria; germ theory of disease
Joseph Lister: introduced carbolic acid same as what was
used in cleaning sewers to sterilize instruments and wounds
Lister is known as the father of antiseptic surgery
Hospitals in 1830s
Often people who went into
hospital died They were Dirty

Badly run

Nurses didnt know what to do

Florence Nightingale
Parents did not want her to become a
nurse
She studied medicine books herself
for years
She was 30 when her parents let her
go to Germany and Paris to study
nursing
Florence Nightingale
The first infection prevention and control champion
Research into hospital sanitary problems made her a firm
believer in pure air, pure water, efficient drainage,
cleanliness, and light
Nightingales firm belief in preventive medicine led to an
established standard of formalized cleanliness and
sanitation in hospitals and the military
 Leonardo da Vinci (14521519)

Several people such as Plato and Aristotle had studied the topic
beforehand, yet Da Vinci was among the first to provide both
accurate drawings and explanations of the anatomy

An old man, only a few hours before he died, told me that he had
lived for one hundred years without experiencing any physical failure
other than weakness; and sitting on the bed in the hospital of Santa
Maria Nova in Florence, he passed from this life, giving no sign of any
accident. And I dissected his body, in order to understand the cause of
so easy a death. I discovered that it came to him through a lack of
blood in the arteries that fed the heart and the lower parts, which
were used up and dried out.
Leonardo da Vinci
The Surgical Robot
Artificial Limbs and Synthetic Organs
Contact Lenses
Nazi Medical Experiments
1930s & 40s
Freezing / Hypothermia
Genetics
Infectious Diseases
Interrogation and Torture
Killing / Genocide
High Altitude
Pharmacological
Sterilization
Surgery
Traumatic Injuries
 Nazi Medicine

Doctoring the nation more important than doctoring individuals - Nazism as

applied biology
Focus on preventive medicine and public health: anti-tobacco and anti-alcohol
campaigns, environmental toxins, organic farming -to improve
Aryan stock
Nazi soldiers given anabolic steroids to increase aggressiveness
 Nazi Physician-Researchers

Dr. Sigmund Rascher - coagulation/amputation studies; hypothermia

experiments
Dr. Karl Gebhart: heteroplastic transplantation experiments
c.f. Stalins attempts to create interspecies (half-men/half-apes) super-warriors
Drs. Karl Clausberg and Viktor Brack: X-irradiation/sterilization
 Nazi Physician-Researchers

Drs. Joachim Mrugowsky, Erwin Ding-Schuler, and Waldemar Hoven: IV

phenol and gasoline executions
Dr. Friedrich Wegener (Wegeners Granulomatosis): German
pathologist, Nazi party member, autopsied a prisoner with oxygen
injected into his bloodstream in an embolism study; may have
participated in experiments on concentration camp inmates
Nazi Physician-Researchers

Dr Hans Conrad Reiter (formerly Reiters Syndrome, now

reactive arthritis): senior Nazi official
Dr. Joseph Mengele: Septicemia/twin vivisection studies
Dr. Hans Eppinger - father of modern hepatology
Indirect Participants
Prof. J Hallevorden:

Look here now, boys, if you are going to kill all these people at least
take the brains out so that the material could be utilized the more
(brains) the better.I accepted these brains of course. Where they
came from and how they came to me was really none of my business.
Doctors and Resistance
German invasion of Poland (1939)
Drs Eugene Lazowski and Stanislaw Matulewicz created a
fake typhus epidemic, using a harmless bacterium to
innoculate non-Jews, knowing that infected Jews would be
summarily executed
Germans fooled, quarantined area, many Jews escaped
death
Nuremberg Doctors Trial
23 German physicians tried
16 found guilty
7 hanged (incl. Gebhardt, Brack, Hoven, and Mrugowsky)
Rascher died before trial; Mengele fled for Argentina
(remains verified 1985); Hallevorden committed suicide
before trial
Nuremberg Code
1. The voluntary consent of the human subject is absolutely essential
2. The experiment should be such as to yield fruitful results for the good of
society
3. The anticipated results will justify the performance of the experiment.
4. Avoid all unnecessary physical and mental suffering and injury
5. Protect the experimental subject against even remote possibilities of
injury, disability, or death
6. Be conducted only by scientifically qualified persons.
7. Subject should be at liberty to bring the experiment to an end.
8. Scientist in charge must be prepared to terminate study.
 Declaration of Geneva
I will not permit considerations of religion, nationality,
race, party politics or social standing to intervene between
my duty and my patient
I will not use my medical knowledge contrary to the laws of
humanity.
It is unethical for physicians to employ scientific knowledge
to imperil health or destroy life.
Declaration of Helsinki
Patients rights to respect, self determination, informed
decision-making
Investigators duties: primacy of subjects welfare, ethical
considerations take precedence over laws and regulation
Allows for surrogate consent
Post-WW II Human Subject Experimentation
Tuskegee Syphilis Study
The mens status did not warrant ethical debate. They
were subjects, not patients; clinical material, not sick
people.
Dr John Heller, Director of Venereal Diseases at PHS
between 1943 and 1948 (interviewed in 1976)
 Post-WW II Human Subject Experimentation

Guatemala STD study (1946-8)

Dr. John Cutler (research coordinator): Unless the law
winks occasionally, you have no progress in medicine
In 1943, Cutler infected volunteer federal prisoners in
Indiana with gonorrhea in exchange for cash
Post-WW II Human Subject Experimentation
Guatemala STD study (1946-8)
After Guatemala, Cutler oversaw the Tuskegee Syphilis Study
Was acting dean at University of Pittsburgh in 1960s
Post-WW II Human Subject Experimentation

University of Minnesota malaria study (1940s)

Drs. Thomas Francis, Jr. and Jonas Salk infect
psychiatric hospital residents with influenza (?if
consent adequate?)
Self-Experimentation

Albert Hoffman (LSD)

Werner Forssmann (right heart catheterization)
Barry Marshall (Helicobacter pylori)
What to do with data acquired via unethical means AMA
Policy E-2.30 Adopted 1998
All proposed experiments using human subjects should undergo
proper ethical evaluation by a human studies review board before
being undertaken.
Responsibility for revealing that the data are from unethical
experiments lies in the hands of authors, peer reviewers, and editors
of medical texts that publish results of experimental studies.
What to do with data acquired via unethical means AMA
Policy E-2.30 Adopted 1998

Each publication should adopt a standard regarding

publication of data from unethical experiments.
If data from unethical experiments can be replaced by
existing ethically sound data and achieve the same ends,
then such must be done.
 What to do with data acquired via unethical means AMA
Policy E-2.30 Adopted 1998

If ethically tainted data that have been validated by rigorous

scientific analysis are the only data of that nature available, and such
data are necessary in order to save lives, then the utilization of such
data by physicians and editors may be appropriate.
Should editors and/or authors decide to publish an experiment or
data from an experiment that does not reach standards of
contemporary ethical conduct, a disclaimer should be included. Such
disclosure would by no means rectify unethical conduct or legitimize
the methods of collection of data gathered from unethical
experimentation.
What to do with data acquired via unethical means AMA
Policy E-2.30 Adopted 1998
This disclaimer should:
(1) clearly describe the unethical nature of the origin of any material being
published
(2) clearly state that publication of the data is needed in order to save human
lives
(3) pay respect to the victims
(4) avoid trivializing trauma suffered by the participants
(5) acknowledge the unacceptable nature of the experiments
(6) endorse higher ethical standards.
What to do with data acquired via unethical means AMA
Policy E-2.30 Adopted 1998
Based on both scientific and moral grounds, data obtained from cruel and
inhumane experiments, such as data collected from the Nazi experiments and
data collected from the Tuskegee Study, should virtually never be published or
cited.
In the extremely rare case when no other data exist and human lives would
certainly be lost without the knowledge obtained from use of such data,
publication or citation is permissible.
In such a case, the disclosure should cite the specific reasons and clearly justify
the necessity for citation.
What to do with data acquired via unethical means AMA
Policy E-2.30 Adopted 1998

Certain generally accepted historical data may be

cited without a disclaimer, though a disclosure of the
ethical issues would be valuable and desirable.
Ethical Perspectives on Scientific Research
and War
Denial of moral responsibility for consequences
Recognition of moral responsibility but competing obligations
Recognition of moral responsibility and refusal to participate
Responsibility to inform or lead public opinion
Publication of research on dangerous/novel pathogens
 The role of the doctor in society
Public health versus individual health
Roles, responsibilities, and obligations
patients
society
institutions
families
government
world
 The role of the doctor in society
Theodore Billroth:
If the whole of Social Medicine needs to be part of
the curriculum of the medical student, it must not
take more than two hours per semester during the
last two semesters; otherwise, it will surely be
detrimental to his other studies
Social Medicine

The field of social medicine seeks to: understand

how social and economic conditions impact health,
disease and the practice of medicine;
And, foster conditions in which this understanding
can lead to a healthier society.
The role of the doctor in society
Rudolph Virchow:
Doctors are natural attorneys for the poor If
medicine is to really accomplish its great task, it
must intervene in political and social life
Rudolph Virchow
13 October 1821 5 September 1902

Advanced public health

Known as father of modern pathology discredited humourism
through a focus on cells

"Medicine is a social science, and politics is nothing else but medicine

on a large scale".