The separation of medicine into two major branches namely curative medicine, and public health/preventive medicine was evident at the close of the 19th century. At the end of the 19th century, medicine moved faster towards specialization, and a rational scientific approach to disease. The pattern of diseases began to change.
With the control of acute infectious diseases, the so-called modern diseases such as cancer, diabetes, cardiovascular diseases, mental illness and accidents came into prominence and have become the leading causes of death in industrialized countries. These diseases could not be explained on the basis of the germ theory of disease, nor treated with “magic bullets”.
Despite curative medicine being thousands of years old, modern medicine is just 100 years old. Its primary focus is on removing disease from the patient (rather than from the mass). It employs various modalities to accomplish this objective, e.g diagnostic techniques, treatment etc. Over the years, the tools of diagnosis have become refined, sophisticated and are numerous: the armamentarium for treatment is more specific and potent.
Towards the middle of the 20th century, “allopathic medicine” was defined as “treatment of disease by the use of a drug which produces a reaction that itself neutralizes the disease by the introduction of antibacterial and antibiotic agents.”
While treating the history of medicine during the past 100 years, we cannot but take note of the tremendous growth of specialization that has taken place in response to advances in medical technology due to changes in the nature and distribution of health and disease-pattern in the community. Some specialties have emerged based on clearly defined skills such as surgery, radiology, and anesthesia: some based on parts of the body such as ENT, ophthalmology, cardiology, and gynecology.
Preventive medicine is applied to “healthy” people, customarily by actions affecting large numbers of populations. Its primary objective is prevention of disease and promotion of health. The early triumphs of preventive medicine were in the field of bacterial vaccine and antisera at the turn of the century which led to the conquest of a wide spectrum of specific diseases.
Declines took place in the morbidity and mortality from diphtheria, tetanus, typhoid fever and others. Later, the introduction of tissue culture of viruses led to the development of anti-viral vaccines, e.g. polio vaccines (1955-1960). The eradication of smallpox (the last case of smallpox occurred in Somalia in 1977) is one of the great triumphs of preventive medicine in recent times. The search of better and newer vaccine (e.g against malaria, leprosy, syphilis and other parasitic diseases and even cancer) continues.
The discovery of sulpha drugs, anti-malarial, antibiotics, anti tubercular and anti leprosy drugs have all enriched preventive medicine. Chemoprophylaxis and mass-drug treatment have become important tools of preventive medicine.
The pattern of disease in the community began to change with improved control of infectious diseases through both prevention and treatment, and people are now living for longer years, especially those in developing countries.
A new concept – concept of disease eradication – began to take shape. This concept found ready application in the eradication of smallpox. Eradication of certain other diseases (e.g. measles, tetanus, guinea worm and endemic goiter) are on the anvil.
Another notable development in the 20th century is the development of “screening” for the diagnosis of diseases in its pre symptomatic stage (21). In the 1930s, the two most commonly used tests were the serologic blood test for syphilis and the chest X-ray for tuberculosis. Preventive medicine has become a growing point in medicine.
Advances in the field of treatment in no way has diminished the need for preventive care nor its usefulness.
Social medicine has been primarily a European specialty. The seeds that medicine is a social science were sown late in the 19th century by pioneers such as Neumann (1847) and Virchow (1848).
But their ideas were far too ahead of their time. The germ theory of disease and discoveries in microbiology checked the development of these ideas. In 1911, the concept of social medicine was revived by Alfred Grotjahn (1869-1931) of Berlin who stressed the importance of social factors in the etiology of disease, which he called “social pathology”.
Others called it geographical pathology and population pathology. In 1912 Rene Sand had founded the Belgian Social Medicine Association Developments in the field of social sciences (e.g. sociology, psychology, anthropology) rediscovered that man is not only a biological animal, but also a social being, and disease has social causes, social consequences and social therapy.
Social medicine has varying meaning attached to its label. By derivation, social medicine is the study of man as a social being in his total environment. Its focus is on the health of the community as a whole.
The great gains made in the field of medicine in the nineteenth century were being consolidated and perfected as the twentieth century began. Anesthesia and asepsis were becoming better understood as were the medical potentials of X-ray. Together they combined to make possible tremendous advances in surgery.
The field of biological medicines – vaccines to prevent diseases and antitoxins to combat them – started expanding. Chemotherapy, which had already developed basic analgesics such as aspirin and phenacetin, was on the verge of growing to full potential.
Dependence on drugs of vegetable origin – largest source of medicines then available to practicing physicians – began to wane as scientific advances improved the whole field of drug therapy.
While many valuable drugs still in use were originally derived from vegetable sources (ephedrine, reserpine), disappearance of many medicines of doubtful value was hastened by the contributions of chemotherapy. Given impetus by Ehrlich’s creation of the arsphenamines as specifics for syphilis, chemists brought forth a number of new classes of medicines – anesthetics, barbiturates, and anti malarial.
The use of hormones in medicine, first by employing thyroid extract, in 1891, for treatment of myxedema, followed by the discovery of epinephrine, led to the examination of other glandular functions.
Discovery of insulin in 1921 by Banding and Best helped to prolong and save lives of millions of diabetics across the world. From hormone research, there also developed the study of the complex chemistry of steroids, opening another new source of compounds useful to medicine.
The study of vitamin deficiencies got under way with the work of many men in many countries, encouraged by the findings of Eijkman and his associates in the Far East, of Casimir Funk, in 1911, and of Joseph Goldberger in 1914, in the United States. These scientific studies led not only to a better understanding of causes and treatment of vitamin deficiencies, but to improved nutritional practices.
The need for improved sulfa drugs prompted chemists to experiment with synthetic compounds, many of which led them to previously unexplored tracks. Promin (sodium glucosulfone), the first synthetic drug to prove truly effective in arresting leprosy, resulted from the new intense interest in synthetic compounds. Out of research studies of sulfa derivatives have come a group of oral diuretic compounds; and of oral ant diabetic drugs that supplement and sometimes replace injections of insulin.
Great strides were made in the field of anesthetics — inject able and inhalant types. An understanding of important of electrolyte balance in body fluids made possible advances in surgery and it improved patients’ likelihood of rapid recovery. Physico medical developments, such as the artificial lung, the kidney, and the artificial heart, greatly extended the surgeon’s field of operation.
Tissue banks, making possible such procedures as corneal transplants, replacement of arteries, of bones, and other parts of the body, enabled medical people to save many lives. Recognition of importance of fractions of the blood, and of how to utilize these substances, gave new life to scores of patients.
Intense research in brain surgery, mental diseases, advances in psychiatry, and application of tranquilizers and psychic energizers, contributed greatly to restoring afflicted persons to normalcy. Advance in heart surgery led to the correction of many lesions, congenital or chronic, and gave a second life to persons otherwise doomed to death or crippling.
Mechanical developments such as artificial heart valves, and electronic equipment that will stimulate or regulate performance of abnormal hearts, also have contributed tremendously to welfare and comfort of many people. Application of new knowledge of radiation, and especially adaptation to medical use of products of the atomic age, have further extended lives of persons suffering from lesions beyond reach of surgery.
Thanks to the work done on vaccines and biological medicines just before the turn of the century, diphtheria and small-pox have nearly disappeared; typhoid and tetanus are seldom encountered in settled communities; and the threat of polio has been largely diminished.
There have been many changes in the practice of medicine, too. Specialization has increased, with disciplines and boards to govern each group. While the traditional “family doctor” has largely disappeared, general practitioners (GP) have come into existence who organize courses assuring continuation of high standards of family care.
As improved methods of medical care and better medicines started becoming available and the average life-expectancy of people got lengthened, new problems arose for patients as well as health professionals. Lowering of death rates from infectious diseases resulted in more persons reaching the older age brackets, and consequent medical focus on groups of diseases that were not so frequently seen in the past.
Degenerative diseases, particularly those affecting the circulatory system, mental processes, and various forms of cancer, now rank among the foremost afflictions demanding the skills of physicians, surgeons, and researchers.
Enhanced research in medicine may bring more breakthroughs helping to improve the health delivery systems benefitting more and more people worldwide. In the winter of 1988, a San Francisco cardiologist, Dean Ornish, shocked the medical community when he proved that forty patients with advanced heart disease could in fact shrink the fatty plaque deposits that were progressively blocking their coronary arteries.
As the deposits were reduced, the patients’ arteries began to open and oxygen was able to reach their hearts. Most of the patients no longer suffered from the chest pain or were no longer at risk of having a heart attack.
What was amazing about Ornish’s clinical experiment was the therapy he used to make the plaque disappear. Ordinarily, a heart specialist uses surgery to open the clogged artery or bypass the artery altogether. Instead, Ornish used nature — the innate healing power of the body itself. Some of the patients “reversed” their disease with yoga, meditation, a low-cholesterol diet, exercise and group therapy. After approximately one year of lifestyle changes, their clogged arteries had repaired themselves.
The medical therapies Ornish incorporated into his treatment form the nucleus of what is considered today as ‘parallel/alternative/complementary medicine’ and this is the integration paradigm we need to develop.