The document provides an overview of the history of medicine from prehistoric times through the Middle Ages. It discusses early medical practices like trepanning and the role of shamans. It profiles important early physicians like Imhotep, Hippocrates, and Galen and how they advanced medical knowledge. It describes the decline of medicine during the Dark Ages and its later emergence at Salerno. Key developments included the influence of Arabic medicine and the rise of university medicine in Europe.

1. By George Sarka MD,MPH,FACP,FACR DrPH Candidate in Public Health at UCLA Assistant Clinical Professor in Medicine at UCLA Governor-Elect of the ACP Southern CA, Region 2 President of the LA Neurological Society President of LA County Medical Association-District 1 Staff Neurologist at SMMC Staff Rheumatologist at CSMC Staff Physician at the Klotz SHC at CSUN Medical Historian and Medical Lecturer Diplomate in Internal Medicine, Rheumatology, Neurology, Headache Medicine, Sports Medicine, Geriatrics and Emergency Medicine

2. Objectives for the Lecture At the end of this lecture, the physician should be able to do the following: 1. Discuss the evolution and significant events in the history of medicine. 2. Discuss the significant individuals responsible for the advances in medicine. 3. Discuss how this subject is germane to medical issues today.

3. Drug Company Affiliation None

4. William Osler said of Medicine and Art Medicine is a science of uncertainty and an art of probability. SirWilliam Osler

5. In the Beginning… In September 1940, four teenagers around the northern slopes of France’s Pyrenees mountains stumbled upon one of the most famous and astounding repositories of Paleolithic art in the world: the cave of Lascaux

7. Cave of Lascaux Hundreds of paintings and etchings of red cows, yellow horses, bulls and black stags fan out across the cave’s walls and ceilings in a literal stampede. It is the world’s oldest example of medicine in art, dating back 15,000 years.

8. Cave of Lascaux The lone human figure among all the animals is the man with a head of a bird, who appears to be in some kind of trance during a confrontation with a bull. Beside him is a staff. It is widely believed that the human figure is some sort of shaman. Shaman were in charge of the knowledge of health, and of life & death.

11. Trepanning Primitive man believed that head pain was the work of evil spirits who invaded the body of unfortunate individuals. If headache was caused by the invasion of evil spirits, then letting the spirits out of the skull should bring relief. Thus was born the surgical procedure known as trepanning which dates back ten thousand years or more. Such procedures were found in the South Pacific, Europe, North America and South America.

12. Themes in Medicine Superstition, Evil Spirits, Humours Blind Loyalty and Downright Stupidity The Emergence of Iconoclasts Ingenuity Common Sense Serendipity Kindling Phenomenon The Art and Science of Medicine Hard Work and Dedication Techology Imagination

14. Imhotep- “the One Who Walked in Peace” Vizier of a Pharaoh, lived about 2900 BC; He is credited with many accomplishments in many fields and one of his activities seems to have been that of a successful physician. He is one of the first medical men whose name is on record and rose from the role of medical hero to become God of Medicine. He began using simple surgery instead of just magic.

16. Sir William Osler tells us that Imhotep was the: "..first figure of a physician to stand out clearly from the mists of antiquity." Imhotep diagnosed and treated over 200 diseases, 15 diseases of the abdomen, 11 of the bladder, 10 of the rectum, 29 of the eyes, and 18 of the skin, hair, nails and tongue. Imhotep treated tuberculosis, gallstones, appendicitis, gout and arthritis. He also performed surgery and practiced some dentistry. Imhotep extracted medicine from plants. He also knew the position and function of the vital organs and circulation of the blood system. The Encyclopedia Britannica says, "The evidence afforded by Egyptian and Greek texts support the view that Imhotep's reputation was very respected in early times. His prestige increased with the lapse of centuries and his temples in Greek times were the centers of medical teachings."

17. The Healing Art and Disease Physicians based their healing art upon the belief that evil spirits, hateful demons, and vengeful gods struck people with diseases. Invisible arrows shot by the Greek god Apollo caused pain. One treatment for disease was for the victim to travel to one of the many pagan temples in Greece.

18. The Healing Art and Disease The sick person made a sacrifice and then spent the night in the temple. As he slept, he was supposed to dream away the sickness.

19. The Two Great Names in the History of Greek Medicine Hippocrates-dominated the beginning of a period of remarkable scientific creativity, which lasted more than 700 years Galen—near the end of the period, both furthered scientific knowledge and crystallized it in an amazing volume of written works. His influence lasted for 1500 years/45 generations .

21. Hippocrates(460B.C.-377B.C. Hippocrates is know as the “Father of Medicine.” He is considered one of the greatest physicians the world has ever known. He was the first to attempt to separate the practice of medicine from religion and superstition. Hippocrates developed his pledge of proper conduct for doctors. “I will use treatment to help the sick according to my ability and judgment, but never with the view to injury and wrong doing…Into whatsoever houses I enter, I will enter to help the sick.”

23. “ On Airs, Waters, and Places ” around 400B.C. Hippocrates penned a tract called “ On Airs, Waters, and Places.” This was the earliest reference to epidemiologic thinking. He emphasized familiarity not only with the patient’s symptoms, but also with the season of the year and the patient’s living conditions, diet fluid intake, and exercise habits:

24. “ On Airs, Waters and Places” “ For if one knows all these things well, or at least the greater part of them, he cannot miss knowing, when he comes into a strange city, either the diseases peculiar to the place, or the particular nature of common diseases, so that he will not be in doubt as to the treatment of the diseases, or commit mistakes, as is likely to be the case provided one had not previously considered these matters. And in particular, as the season and the year advances, he can tell what epidemic diseases will attack the city, either in summer or in winter, and what each individual will be in danger of experiencing from the change of regimen.

26. The Hippocratic Oath Hippocrates also made changes in how physicians looked upon their profession. During his time, a doctor was sometimes bribed to see that a patient died, or asked to prepare poison to kill an enemy. If a ruler wanted to rid himself of a rival, he could hire a court physician who would see that the rival became sick and died. Hippocrates taught against such improper conduct. He told his students to treat everyone the same. “ Sometimes give your services for nothing…for where there is love of man, there is also love of medicine.”

27. The Hippocratic Oath A statement describing proper conduct. It was a pledge and is a guideline for honorable standards of action. “ I will use treatment to help the sick according to my ability and judgment, but never with the view to knjury and wrong doing…Into whatsoever houses I enter, I will enter to help the sick.”

29. Allegories of the Healing Arts An allegory, or a pictorial symbol, serves to formulate into some tangible aspect an idea or point of view that may exist vaguely in the minds of many. The allegories of the Healing Arts—visual images around which are centered the faith and hope of mankind.

32. Head of Asklepios(Greek Coin, II Century B.C.) The earliest icon of medical significance Head of Asklepios was pictured on a silver drachma, a Greek coin minted on the island of Cos He was the son of Apollo The centers of his cult were temples where the sick went, similar to our modern day sanatoriums, with emphasis on diet, massage, baths and the like.

33. Head of Asklepios(Greek Coin, II Century B.C.) The god was supposed to reveal to the patient in a dream the cure for his/her disease. The serpent, symbolic of regenerative power, was sacred to Asklepios and to Apollo. The emblem, in the form of a rod with a coiled serpent, is still used to represent the art of medicine

34. Note the Hippocratic Oath “ I swear by Apollo the physician and Asklepios and his daughters, Hygeia and Panacea, and all the Gods and Goddesses…” Hippocrates was also born on the Island of Cos

36. Galen Described Wounds as “Windows to the Body” Galen, the great 2 nd century physician and anatomist, spent his early medical career as a surgeon to the gladiators. He employed as many as 20 scribes to write down all that he said in the work. He dissected countless animals in his prolific medical research. Galen also studied philosophy and wrote that a motive of profit was incompatible with a serious devotion to medicine, stating that doctors must learn to despise money. He was a proponent of the miasma theory of infection, which essentially blamed infection on clouds of poisonous gases.

37. Galen(Galenos) meaning calm or serene— “The Infallible Master” The profession of medicine gained a wealth of facts and ideas from Galen. He gave to the world a synthesis of medical thought and knowledge solid enough to last nearly 1500 years. His mind was quick and well organized. He was well informed on many subjects. In the earlier period of his life, he continually insisted on experiments and on demonstrable proofs. But the open-minded young Galen later became one of the great dogmatists of all times. The magnitude of his dogmatism was increased by his followers and commentators.

38. Galen Galen believed that disease resulted from an imbalance of the vital fluids, or humors, of the body. This idea was developed by Hippocrates, and consolidated by Galen. “ The body has in itself blood, phlegm, yellow bile, and black bile…We enjoy the most perfect health when these elements are in the right proportion.” The medicine and pathology Galen practiced, and about which he wrote, were based mainly on speculative Hippocratic theories of the 4 humors, on critical days, and on fallacious theories regarding pulse and urine.

40. The Four Humours Developed out of the humoral theory of Empedocles(500 to 430B.C.), the Scilian philosopher. Developed by Hippocrates and consolidated by Galen. From the 4 elements: earth, air, fire and water derived the idea of the 4 humours(or fluids) of black bile, yellow bile, blood and phlegm with their associated meancholic, choleric, sanguine and phlegmatic temperments. It was believed that the balance of these humours in the body determined physical states of health.

42. Galen Galen made the first attempts to master anatomy. He studied the anatomy of animals and applied it to humans. Medical schools used Galen’s books as textbooks for more than a thousand years. He became the undisputed authority. NO ONE DARED TO EVER DIFFER WITH HIM! From physicians to emperors as well as commoners in the Roman Empire, Galen was considered a shrewd observer who gained much experience through experimentation.

44. The Picture Galen, whose teachings were accepted as dogma by medical men for 1500 years, is pictured in a 2 nd century Roman home applying cupping, a form of treatment that he advocated. Galen was a pillar of medicine and the last important pillar in the millennium of Greek domination of the medical world.

46. St. Cosmas and St. Damian Traditionally acclaimed the patron saints of the physician and apothecary These 2 brothers were Syrian Christians who were reputed to have effected many miraculous cures before their matyrdom in the reign of Emperor Diocletian(A.D.303) Seen frequently in paintings, miniatures, or prints

47. Rome Falls in 476A.D. The Dark Ages of Medicine begin.

48. Medicine in the Dark Ages (roughly 500-1050 AD) Massive decline in the number, and quality, of medical writings available. 2 important features stand out during this decline: A) Preeminence of ‘do-it-yourself’ handbooks, primarily of dietetic medicine. B) The ecclesiastical takeover of medical learning and learning in general. For few could read outside the ecclesiastical community.

49. Medicine in the Dark Ages (roughly 500-1050 AD) The relatively learned medicine was supplemented by the healing offered at shrines and by holy men. Tales abound of miraculous cures via shrines and icons. Some saints were almost specialists:

52. Some Saints as Medical Specialists St. Dymphna was favored for mental diseases St. Roch for plague St. Hubert for rabies sufferers St. Blaise for throat complaints

54. The King’s/Queen’s Evil Medieval people seemed to have suffered much from TB but most probably had the glandular form scrofula. In England and France, it was believed that royalty had the power to cure the affliction by touching the sufferers, and from the 12 th to the 18 th century, ‘the king’s/queen’s touch” was regularly used against this condition.

55. The King’s/Queen’s Evil Remember after the Reformation, the Church of England rejected all forms of recourse to Saints, relics, holy water, and so on, which the Roman Catholic Church had recommended. This practice involved the ruling monarch curing victims of scrofula and similar ailments.

56. The King’s/Queen’s Evil The king touched the victim and often also a gold coin - usually an Angel, showing the Archangel Michael killing the dragon - that was then worn around the victim's neck, and the person promptly recovered.

57. The Emergence of Medicine from the Dark Ages Occurred around 1050 in the region of Salerno, southern Italy where this thriving medical community was in touch with the Greek and Arab worlds as well as the wealthiest and intellectually most advanced abbey of Europe, Monte Cassino. In 1080, the Salernitan masters reintroduced theoretical speculation into medical teaching.

58. The Emergence of Medicine from the Dark Ages From 1200, Latin translations of some Arabic texts by Constantine the African, re-established Galenic academic learning, combining commentary on a few set texts with philosophical discussion of wider issues. By 1250, practical demonstrations of animal anatomy was introduced.

59. The Three Consequences of Translation Movement 1.The amount of learned medical material suddenly burgeoned beyond all recognition 2.The language of medicine was heavily arabized and its therapeutics depended heavily on Arabic sources, especially in pharmacology/surgery. 3.Now, there was a heavy philosophical component, based on Aristotle ( natural philosophy ) in the new medicine.

60. The Arab Influence Arab medicine, so-called because of the language in which it was written down, greatly influenced the medical thinking of the West from the 12 th to 15 th centuries. The Arabs played an import part in teaching the art of prescribing and surgery. Avicenna(980-1037 A.D.), the “prince of physicians,” is noted for his Canon of Medicine.

61. Avicenna(980-1037 A.D.) and the Canon of Medicine

62. The Development of University Medicine First occurred in northern Italy, in the wealthy towns of Bologna and Padua, then in France (Paris and Montpellier), and in England (Oxford). Germany lagged behind, but by 1400 many areas of Western Europe had their own institutions of higher learning.

63. The Development of University Medicine Medicine came late into the universities. Professional associations of medical teachers, as at Salerno, joined universities only when they saw the advantages of the new institutions’ ability to secure their own rights and privileges in law and theology, and many universities, especially in France, never had a medical faculty.

65. Hotel Dieu, 1500 by Triptych Triptych showing the Hôtel Dieu in Paris, about ad 1500. The comparatively well patients (on the right) were separated from the very ill (on the left). Note there were always two patients to a bed.

66. The Father of Modern Toxicology Phillipus Aureolus Theophrastus Bombastus von Hohenheim “ All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy.”

67. Paracelsus(1493-1541) and Chemical Remedies One of the most famous questioners of medical authority. Paracelsus was an enigmatic character, flamboyant, quarrelsome and reforming. His somewhat eccentric behavior prevented his settling down in any one place and gave his life a vagabond flavour. Not content with refuting the authority of Galen and Avicenna, he publicly burned their books. He is credited with enlisting the help of chemicals in therapeutics and vigorously opposing polypharmacy, or the prescription of multiple ingredients in a single medicine .

69. Andreas Versalius(1514-1564) Was the first master of human anatomy. His careful studies provided doctors with the accurate information that they need to save lives. Versalius did not accept the teachings of Galen without experimenting on his own. Versalius kept a copy of Galen’s books on hand and made changes in them. He found over 200 mistakes in the ancient books—mistakes that were still being taught by doctors of his day!

70. Andreas Versalius(1514-1564) Versalius learned human anatomy by looking at humans not just animals. He made detailed drawings of his findings so others could also learn.

72. The Fabric of the Human Body Varesalius was just 28 when he published the above. It was published in 1543, contained 663 pages and 300 beautiful illustrations. Versalius spent his personal fortune and all his enthusiasm on it. The publication of Fabric marked a turning point in the history of medicine.

76. The Father of Modern Surgery Professors in medical schools seldom performed surgery. They did not think that it was proper for a professional man to do such work. Surgeon is from a French word meaning “one who works with his hands.” In the Europe of the 1500s, barbers, not doctors, performed minor operations, pulled teeth, and treated cuts. Barbers who gained skill in closing wounds were called barber-surgeons.

77. The Striped Barber Pole The barber pole is a symbol of the profession and is a legacy of bloodletting. After the operation, the bandages would be hung on the staff and sometimes placed outside as advertisement. Twirled by wind, they would form a red & white spiral pattern that was later adopted for painted poles. The earliest poles were surmounted by a leech basin, which in time was transformed into a ball. The stripes of a barber pole still show the red for blood and the white for bandages. Sometimes there were poles with blue representing the veins.

78. Ambroise Pare(1510-1590) Pare used ointments and silk thread to repair injuries in place of burning oil and hot pokers. Pare discovered new techniques that made surgery practical. He published his book in French with useful information that all doctors could use. Pare did not have a formal education. He never earned a medical degree. Yet he became France’s most skilled surgeon. In 1562, he was given the dignified title, “First Surgeon of the King.” “ I treated him. God healed him.”

79. Medicine Prior to the 17 th Century The old-style physician had almost no diagnostic technology nor did he conduct a full, hands-on physical exam. Rather, he worked on the basis of his senses: sight, touch (of the wrist for the pulse), hearing, smell and taste (sampling urine for the sweetness symptomatic for DM.

80. Uroscopy Elaborate diagnostic charts exist, correlating these indications with various maladies. Even in the written literature of William Shakespeare does the above exist: “ Sirrah, you giant, what says the doctor to my water?...He said, sir, the water itself was a good healthy water; but for the party that owned it he might have more diseases than he knew for.” from Henry IV. Uroscopy

82. Uroscopy Wheel This is taken from The Fasciculus Medicinae by Johannes De Kethan, 1491. This was a collection of medical treatises dealing with medicine and surgery dating back to the 13 th century and included the first “modern” anatomic illustration .

84. Galen’s View of Blood Circulation- Based on False Ideas Galen said that blood in the veins always carried blood away from the heart. The flow was slow and irregular. Blood ebbed and flowed like tides. Galen taught that the liver manufactured new blood to replace the old. Blood surging through the heart caused it to beat. He had no ideas that the heart itself pumped blood.

85. The Age of Enlightment

86. Medicine in the 17 th Century The greatest physiological advance of the 17 th century was the discovery of the circulation of blood. Credit goes to the Englishman William Harvey(1578-1657). In 1628, Harvey’s De Motu Cordis which concerned with the mechanical process of circulation.

89. The Four Humors and William Harvey The "humors" theory of the body was centered on "vital spirits" moving from the heart; they regulated the balance of the four humors and could be disturbed by the spiritual intervention of the devil. Once Harvey’s notion that the heart was just a muscular pump moving blood around the body became prevalent, explanations in terms of demonic spirits no longer convinced .

90. “ William Harvey” by Robert Hannah, 1848 Harvey is famous for his discovery that blood circulates around the human body. He proved that blood circulates through the body in one direction.

91. Antoni van Leeuwenhoek (1632-1723) Developed the most powerful microscopes of his day. He discovered one-celled protozoans and bacteria. His work eventually led to the discovery of the causes of diseases, such as the Black Death.

92. The Art of Medicine Becomes Scientific Although this movement was launched in the 17 th century during the Age of Enlightment, it was not until the 19 th century that the true age of science was born.

96. Edward Jenner(1749-1823) Jenner was ridiculed and resented by his fellow doctors. This cartoon makes fun of Jenner’s inoculations. In a crowded room, Jenner prepares to vaccinate a young woman sitting in a chair. The scene about them is mayhem as several former patients demonstrate the effects of the vaccine with cows sprouting from various parts of their bodies.

97. Edward Jenner(1749-1823) Jenner discovered that having cowpox protected a person against smallpox. Jenner’s cowpox serum saved many lives, and almost eliminated the disease of smallpox. His discovery of vaccination is considered one of the most important discoveries in medicine. Jenner nor any other doctor knew the cause of infectious diseases or why vaccination worked.

98. The Birth of Anesthesia A nineteenth-century physician administering chloroform prior to surgery. Ether was one of the earliest anesthetics to be used but it was difficult to administer as it usually made the patient choke.

99. Sir Humphry Davy (1778-1829) Humphry Davy discovered laughing gas(nitrous oxide) which has made dentistry much less painful.

100. Sir James Young Simpson (1811-1870) James Young Simpson discovered chloroform could be used as an anesthetic. Simpson fought to make anesthesia an established part of surgery.

101. William Thomas Green Morton(1819-1868) Invented a special glass inhaler and added perfume to ether. Successfully used either to pull a tooth and to then perform painless surgery. His tutor Dr. Charles Jackson gave Morton some advise on using ether and then later claimed it was all his idea.

102. The Recognition of Nutrition and Disease

103. James Lind(1716-1794) In James Lind’s experiment, those that ate citrus fruit stayed healthier. Captain Cook took Lind’s advice and his crew stayed health for a four-year journey. The British Navy finally ordered sailors to drink lime juice. Lind had found the cure for scurvy—vitamin C.

104. Christian Eijkman(1858-1930) Found that bacteria did not cause beriberi. He found that brown rice was a cure for beriberi because of a vitamin (now know to be thiamine) in the husks.

105. Jean Boussingault (1802-1887) Jean Boussingault found that a mineral called iodine could cure a goiter of the thyroid gland.

108. Rene-Theophile-Hyacinthe Laennec and the stethoscope “ In 1816 I was consulted by a young woman presenting general symptoms of disease of the heart. Owing to her stoutness little information could be gathered by application of the hand and percussion…I recalled a well-known acoutic phenomenon:namely, if you place your ear against one end of a wooden beam the scratch of a pin at the other extremity is distinctly audible. It occurred to me that this physical property might serve a useful…

109. Rene-Theophile-Hyacinthe Laennec and the stethoscope This physical property might serve a useful purpose in the case with which I was then dealing. Taking a sheet of paper I rolled it into a very tight roll, one end of which I place on the precordial region, whilst I put my ear to the other. I was both surprised and gratified at being able to hear the beating of the heart with much greater clearness and distinctness that I hever before by direct application of my ear.”

110. The Stethoscope Rene Laennec, who invented the first stethoscope, commented that "no patient report could suffice to characterize disease, and that for a certain diagnosis, mediate auscultation is required."

111. “ Miasmata” Originated from Galen Poisons in the atmosphere emanating from cesspits and rotting material caused illness. In 1840, the German pathologist Jakob Henle(1809-1885) published his essay: “On miasmata and contaia,” in which he tried to show that tiny living creatures in the human body caused infectious diseases. The idea of “germs” began to challenge the prevailing theory were caused by “miasmata.” The above was supported by the work of Frechman Louis Pasteur and the British surgeon Joseph Lister.

112. Public Health The concept had it origins in Biblical rules on health and hygiene as well as in great architectural works such as the building of the aqueducts to supply fresh water to Rome and the removal of waste by means of the great drain, the cloaca maxima . Principles regarding safe diets and person hygiene were taught by the great religions. These were reinforced by later miasmatic notions. Evil smells do indicate poor sanitation and their removal reduces sources of infection.

113. John Snow(1813-1858), the Father of Public Health Effectively brought an end to the 1854 epidemic in Soho, London by demonstrating only those who drank from the infected Broad Street pump contracted the disease.

115. Ignaz Phillipp Semmelweiss 1. Childbed fever was taking thousands of lives of young mothers 2. More women were dying under the care of doctors than midwives. 3. Some doctors were more interested in their reputations than in saving lives.

116. Ignaz Phillipp Semmelweiss 1. Discovered that the doctors were spreading childbed fever. 2. He proved that doctors were carrying the disease from corpses to their patients. 3. He proved that cleanliness could prevent childbed fever.

117. Problem in Surgery Infection was a major problem during surgery. People often died after surgery from the infection alone. Compound bone fractures almost always ended in death because of infections.

119. Joseph Lister(1827-1912) and Infection Discovered that carbolic acid prevented infection on compound infections. By insisting that everything be kept clean and disinfected, he lowered the death rate in his surgeries. He discovered it was not the presence of acid bit the absence of germs that mattered in surgery.

122. The Search for the Etiology of Disease Robert Koch discovered that anthrax was caused by bacteria. He discovered how to grow bacteria in cultures for study, and how to add stain in order to see them. Robert Koch proved that most diseases are caused by a particular bacteria. Microbiologist, Robert Koch discovered the tubercle bacillus in 1882 where one in seven deaths in Europe was due to TB.

123. Koch’s Postulates to Advance the Germ Theory The causative agent must be present in every case of the disease and must not be present in healthy animals. The pathogen must be isolated from the diseased host animal and must be grown in pure culture. The same disease must be produced when microbes from the pure culture are inoculated into healthy, susceptible animals. The same pathogen must be recoverable once again from this artificially infected animal and must be able to be grown in pure culture.

124. Louis Pasteur(1822-1895) Louis Pasteur dismissed t he “miasmatic” theory of disease. He argued that diseases were caused by germs and so effectively established bacteriology as a science.

125. Louis Pasteur Returns to the Scene Louis Pasteur discovered that chickens could survive cholera when given a weakened form of the disease. He found that an anthrax vaccine could be made by heating the bacteria. He discovered rabies was caused by a virus instead of bacteria and then developed a vaccine for humans .

126. Medical Schools in the United States High-quality medical schools and clinical investigations developed more slowly. In its laissez-faire, business-dominated atmosphere, many schools were blatantly commercial, inadequately staffed and offering cut-price degrees.

127. What Was It Like to be a Medical Student 140 years ago? No one worried about admissions, for entrance requirements were lower than they are for a good high school student. Instruction was superficial and brief. The terms lasted only 16 weeks, and after the second term the M.D. was automatically given, regardless of a student’s academic performance

128. What Was It Like to be a Medical Student 140 years ago? Teaching was by lecture alone. Thus, students were spared the onerous chores of attending labs, clinics and hospital wards. It was not uncommon for students to graduate without ever having touched a patient.

129. Medical Schools in the 1860s and 1870s Many were privately owned, operated for profit and without university affiliation. Physicians often had little to offer their patients other than sympathy and tender care for ailments they lacked the means to cure. The medical profession was held in low regard by the general public.

130. The Birth of Johns Hopkins University and Medical School At Hopkins, a new era of American medicine was born, with rigorous admission requirements and a quality of training that set new standards in the United States and compared favorably with the venerable European institutions.

131. At Johns Hopkins University and Medical School Candidates for admission to Hopkins were required to have a four-year college degree, including two years of premedical training in biology, chemistry and physics, and a reading knowledge of French and German.

133. The “Big Four” of Hopkins William H. Welch in pathology and the future Dean Osler in medicine William S. Halsted in surgery Howard A Kelly in gynecology All younger than 40 years old, organized the hospital departments.

136. Evolution of Disease In the 19 th century, diarrheal diseases were the biggest killer of children, and tuberculosis was the leading cause of adult mortality. In the 20 th and 21 st centuries, chronic diseases are now the leading cause of disease and death in adults.

137. Technology Reigns Supreme William Crookes invented the Crookes’ tube which developed into TV’s and monitors. Wilhelm Roentgen invented the x-ray machine by using the Crookes’ tube. Because of its ability to see inside the body, x-ray photography is one of the most important medical discoveries.

140. The Use of Radiation Henri Becquerel proved that radiation from uranium is like x-rays but more powerful and is credited in discovering radioactivity in 1896. Pierre and Marie Curie discovered radium and other radioactive elements. When controlled, these radioactive elements can be used to enhance x-rays and fight cancer.

144. The Birth of the EKG Sir Thomas Lewis mastered the technology of the electrocardiogram in 1912.

145. Andrew W. “Doc” Fleischer In 1921, the above developed the mercurial sphygmomanometer and spent his career refining medical instruments, including the modern stethoscope.

146. The Birth of Medical Organizations/Societies ACP-1915;Joining of the ACP and ASIM AAN AAFP ACR AGS Etc.

148. The Advent of Drugs Dr. Gerhard Domagk(1895-1964) discovered sulfa drugs. This drug became world famous when Dr. Perrin H. Long used sulfa drugs to treat Franklin Roosevelt Jr. Sulfa was called a “wonder drug” because it killed bacteria but did not hurt the cells of human tissue.

150. Mold Becomes A Medical Ally in the Battle Against Bacteria Alexander Fleming(1881-1955) discovered penicillin which killed staphylococcal bacteria. Florey and Chain isolated the chemical and found that it could be mass-produced, making it more affordable. Penicillin was stronger(bacteriocidal) that sulfa(bacteriostatic) and had fewer side effects.

151. Technology Transform the Medical Arena Dr. Richard Drew(1904-1950) established the use of transfusion and blood banks. Dr. Christian Barnard(1922-2001) performed the first heart transplant in 1967. Dr. William Kolff developed an artificial kidney machine. James Watson and Francis Crick discovered DNA.

155. Technology and the 20 th /21 st Century(Medicines) Antiseptics Antibiotics Antiepileptics Antipsychotics Chemotherapies Myoclonal Antibodies Vaccines Biologic Agents Continuing Story of Aspirin Blood Transfusions and Blood Banks

156. Technology and the 20 th /21 st Century(Evaluative Procedures) Electron Microscope CT Scans MRI Scans MRA Scans Pet Scans Functional MRI The Human Genome Genetic Testing Genetic Enzyme Replacements Therapy

157. Technology and the 20 th /21 st Century(Surgeries) Artificial Kidney Machine—Dialysis—Kidney Transplants Coronary Artery Bypass Angioplasty Total Hip and Knee Replacements Neurosurgery Lasik Surgery Organ Transplants—Heart, Kidney, Lung, Liver, Pancreas, etc.

158. The Transformation of Medical Education Medical Schools and the Gender Gap Medical Schools and Diversity The Soaring Cost of a Medical Education The Primary Care Physician v. the Specialist Board Certification The Integration of Complimentary Alternative Medicine The Introduction of the Medical Home--ACP

159. Transformation of Medical Care The Advent of Chronic Disease as a Major Cause of Morbidity/Mortality Home Care to the Office to Hospital Care The Private Practictioner to the Medical University The Advent of Medicare/Medicaid in the USA Universal Coverage in Many Countries Managed Care HMOs, IPOs, PPOs, POS Primary Care Physician v. the Subspecialist The Advent of Medical Home Model(ACP) Hospice Care Accreditation, Quality Assurance, Board Certification HIPPA Medical Malpractice/Lawyers

160. Ethics and Medicine Sexuality Abortion What is Death? Growing Old Euthanasia/Right to Life/Pro life Quality of Life Issues Limited Health Care Resources Rationing of Health Care The Uninsured, The Undocumented Worker Universal Health Care The Use of Physicians in State Executions—i.e.,California

161. Challenges for the Future

162. Challenges for the Future Obesity/Diabetes Mellitus Smoking The Geriatric Population Drugs/Medications Alzheimer’s Disease Depression Medicare/Medicaid Euthanasia Etc.

163. The Future of Medicine Balance between the art of medicine and the science/technology of medicine with imagination, ingenuity and a little luck.

164. “ The Giant”(1923) by N. C. Wyeth