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Milestones in Modern Medicine I

The history of medical milestones is not always as shine as expected but it is accompanied by failure and coincidence. Other disciplines, especially physics, chemistry and biology contributed enormously to medical milestones and even enabled many of them.

This article is not a list of milestones, but I tried to show you the big picture with some examples. For those of you who love lists there will be a follow-up article soon.

What is a milestone?

Milestones are great they can be put in a hierarchical or chronological order and satisfy our “need” for lists. I myself love lists about the “top 3”, “top 5”, “top 10” etc. on certain issues because they are informative and comfortable. But it needs to be said that the concept of milestones oversimplifies historic events:

Milestones do not happen out of a sudden but are built on other inventions,which might not seem related at the first glance: Imagine the invention of vaccine without syringe. Well, that is not really working.

In the retro-perspective they seem planned, error-free, leading to a steady progress and to be invented by one genius. Actually many milestones happened by chance and failure. Often their potential was not recognized at their time but much later. Milestones are not forever but can be overthrown or updated by new findings.

Another hard thing with milestones is how to measure them:

  • Is it about the impact they had at the time they were invented? Well, then the blood circulation by William Harvey is not really a milestone.
  • Is it about the impact on society or science?
  • Is it about winning awards and then about which awards? Maybe the Nobel Prize in Physiology or Medicine? Well, then no medical milestones happened before the 20th century, which is for sure wrong.

Milestones in medicine: 18th-21st century

Here is a very basic overview on medical milestones: I decided to differentiate between technological, medical and social/political aspects, which all interact with one another.

 technologicalmedicalsocial/political
1700-1799 Invention of vaccinationModern hospitals
1800-1899 Professionalization of medicine

Germ theory
Statistics

Foundation of the Red Cross
1900-1999Insights into the human body: EEG, MR, CT, ultrasound etc.

Life-saving and prolonging machines
Chemotherapy

Transplantation of human organs

Prenatal testing  
Awarding medical milestones (e.g. Nobel Prize)

Ethical codices

Herd immunity due to vaccination

Sexual liberation (1905s onwards)
2000 onwards DNA 
Medical Milestones from the 18th-21st century

Medical milestones of the 18th century till today are build upon those from Antiquity, the Middle Ages and the Renaissance: During the Renaissance the “classic-theories” of Greek-Roman antiquity and Arabic medicine were recapped and questioned. Experimental investigations, especially in dissection and body examination increased and so advanced the knowledge on human anatomy.
During the Age of Enlightenment medicine became more scientific and finally professionalized, as many other disciplines, in the 19th century.

The 18th century

The invention of vaccination was a very essential milestone, as for the first-time prevention was used in medical therapy.
Another milestone was the invention of modern hospitals: Hospitals as place where sick were treated goes back to antiquity but in the early 18th century they turned into centres for medical innovation, research and education. Examples of these new types of hospital are the Charité (1710), Westminster Hospital (1719) and the Vienna General Hospital (1784). In dispensaries the poor were treated for free, like in the Public Dispensary of Edinburgh (1776).

The 19th century

The 19th century lead to the professionalization of medicine, the foundation of the Red Cross, the germ theory and the use of statistics for medical purposes.

The upcoming of the germ theory was an essential medical milestone in the middle till late 19th century and overthrow the miasmatic theory. The miasmatic theory was based on the ancient Greek “miasma”, which stands for “pollution” and “bad air”, and held miasma responsible for diseases and epidemics. The new germ theory pointed out that not miasma but germs cause specific diseases.

Pioneers in these field were John Snow (1813-1858), Louis Pasteur (1822–1895), Robert Koch (1843–1910) and Pasteur´s and Koch´s students and colleagues:

  • In 1849 Snow recommended during the cholera epidemic in London to filter and boil water before drinking.
  • In the late 1850s and in 1860 Pasteur proofed that fermentation is a biochemical process, where microorganisms are involved.
  • In 1876 Koch was the first who outlined the connection between the microscopic pathogen and the disease anthrax. In the 1880s he discovered the “tubercle bacillus” and the pathogen of cholera.

With the use of statistics in medicine diseases and their spread became measurable and allowed politics to take actions: E.g. The British nurse Florence Nightingale (1820 –1910) provided a large data set including graphs and maps on the Crimean War.

The 20th century

The technological advances allowed doctors to see into the human body without doing an operation, and to use life-saving and prolonging machines, like respirators and defibrillators. Cancer can be treated with chemotherapy, organs can be transplanted and potential illnesses of babies can be predicted.

Due to the effective use of vaccinations, which lead to herd immunity in many countries, infectious diseases became less lethal and stopped to be the main course of death, which are now tumors and cardiovascular diseases in developed countries. In 1977 the world became smallpox free and in 2011 the rinderpest was eradicated too.

From the 1950s onwards sexual liberation happened around the world (with some delays): Sex became less taboo and the anti-baby pill has allowed women to prevent conception.

Ups… I guess we changed history

Many medical inventions are based on pure coincidence but that does not mean that their finding is less important or that their “inventor” is less skilled because the “inventor” still needed to draw the right conclusions from the coincident.

X-Rays, Penicillin and Viagra have one thing in common: They were all invented by chance.

… X-Rays

The physicist Wilhelm Conrad Röntgen (1845-1923) found by chance a new form of rays, which he called X-Rays, at the University of Würzburg on the 8th November in 1895. With his invention Röngten enabled to have a look insight the human body without opening it in an operation. The potential of the X-Rays were realized very soon and it was used commercially in early 1896 in Germany, Great Britain, France and the US.
For his finding Röntgen was awarded with the first Nobel Prize in Physics in 1901.

One of the first X-Ray pictures (1896)

Like with many other milestones a heated social debate started: Are X-Rays the new hope within medicine or do they lead to a loose in privacy?

At the beginning the potential danger of the new method was unknown: A trend to nearly x-ray everything started. The consequences were cancer or the loose of hands and arms and lead to the invention of safety cloths for medical personnel and patients against X-Rays.

Tip: If you are interested to learn more about X-Rays and Mr. Röngten , check out the Google Arts & Culture exhibition of the German Röngten Museum.

… Penicillin

One sometimes finds what one is not looking for. When I woke up just after dawn on September 28, 1928, I certainly didn´t plan to revolutionize all medicine by discovering the world´s first antibiotic, or bacteria killer. But I guess that was exactly what I did.

Sir Alexander Fleming (1881-1955), won the Nobel Prize for his finding in 1945

Have you ever been on holiday and when you returned to your workplace you changed history by chance? Well, I guess not, but it is exactly how Sir Alexander Fleming “invented” one of the most important medicine of the 20th century, penicillin:

Returning from his holiday in 1928, Fleming sorted petri dishes with Staphylococcus bacteria. One dish was different form the others: In one area was “mold juice”, how Fleming called it, and no bacteria left. Fleming tested the “mold juice” on other bacteria, like streptococcus, meningococcus and the diphtheria bacillus, and it killed them all. He assigned his assistants Stuart Craddock and Frederick Ridley, to isolate pure penicillin from the “mold juice”.

… in the Science Museum London

The breakthrough of penicillin came 11 years later: in 1939, when Howard Florey and Ernst Chain founds out that it can be used to heal infected wounds. In 1941 it was used at a patient for the first time. In 1945 Fleming, Florey and Chain were awarded with the Nobel Prize in Medicine.

During WWII and especially in preparation for the D-Day landing in the Normandy the “miracle drug” was primary for military use and civilians were just treated with penicillin, if no other treatment had worked. The enormous increase of production in early 1944 in the US (from 21 billion units in 1943 to 1,663 billion units in 1944 and 6.8 trillion units in 1945) made penicillin available to the public: By March 1945 penicillin could be bought at pharmacies throughout the US.

Penicillin ad by US firm Schenley Laboratories Inc. during WWII
Credits: Enquiries to Science Museum, London

Tip: More on Fleming and penicillin in the Google Arts & Culture exhibition of The Royal Society.

Hoffmann or Eichengrün – Who invented it?

Even for modern times milestones the inventor is not always clear, like for Aspirin: In 1897 Felix Hoffmann (1868-1946), a German chemist and pharmacist at Bayer, synthesize pure acetylsalicylic acid, better known as Aspirin.

In a letter from the concentration camp Theresienstadt to I.G. Farben (better known as Bayer) the German-Jewish chemist Arthur Eichengrün (1867-1949) claimed to be the real inventor of Aspirin and that Hoffmann just supported him in the process. Eichengrün´s claim is supported by Walter Sneader, professor at the Strathclyde University Glasgow, in 1999: Even though Bayer still names Hoffmann as inventor of Aspirin, the protocols of 1897 support Eichengrün´s involvement. As no eyewitnesses exist anymore, the role of Eichengrün in the invention of Aspirin can not be clarified for sure.

War as driver for medical innovations

A war benefits medicine more than it benefits anybody else. It’s terrible, of course, but it does.

Mary Merrit Crawford (1884-1972), surgeon in France during WWI

Medicine and war are linked since antiquity: Homer´s The Illiad (9th century BC) offers an insight on how wounds caused by war were treated and Hippocrates (5th century BC) is quoted on saying that “war is the only proper school for a surgeon.”

War is always a tragedy as it leads to distress, displacement and death but also a driver for medical innovations, which have benefited not just soldiers during war but also civil society during and afterwards: The challenges let medical personnel from doctors to nurses and paramedics become creative and innovative or refocus research:

  • shortage in medical personnel and supply but serious wounds/illnesses
  • the advances in warfare itself: new weapons made new treatments necessary
  • poor hygiene in military camps with soldiers living close to each other, which fosters the spread of diseases
  • are typical conditions of wartime medicine, especially on the battlefield.

This highly mediocre situation explains why until the 1900s more soldiers died of disease than their wounds caused in battle.

Here are some war related medical milestones:

  • In 1537 Ambroise Pare used ligatures to tie them onto the soldiers close to their wounds to stop their bleeding. The method was not new as it was used by the Romans and Arabs but in the 16th century doctors did not use this method anymore but preferred to treat wounds with boiling oil. For the patients Pare´s treatment was far more comfortable, but one disadvantage stayed: Veins and arteries were crushed and so amputations were mostly following.
  • His experience in the Crimean War (1853-1856) made Nikolai Iwanowitsch Pirogow (1810–1881) invent the triage: Hereby the patients are divided into five groups, which are treated based on the severity of the illness/wound: The worst wounded (“the hopeless”) are not treated or accompanied during dying to save personnel and medical treatment for those who have a chance to survive. In a modified form Pirogow´s scheme is used till today in all situation were many patients have to be treated, such as in wars, natural disasters and epidemics like the current COVID crisis.
  • During the US Civil War (1861-1865) the New York surgeon Gurdon Buck invented plastic/reconstructive surgery, especially facial reconstruction. More information here.
  • In World War I (1914-1918) transportation of wounded by airplanes started, vaccines against infectious diseases were developed and used, e.g. against typhoid to decreases sepsis, and female nurses, who worked close to the battlefields, increased in number. The improvements in ambulance, antiseptic and anesthesia decreased the number of amputations, which before were (nearly) the only treatment of wounds.
  • World War II (1939-1945) lead to mass production and a widespread use of antibiotics, especially sulphanilamide and penicillin, X-rays and the electrocardiograph to monitor the interior body functions. As learning from the Spanish Civil War (1936-1939) blood transfusion and storage became common.
  • During the Korean War (1950-1953) Pare´s treatment was advanced: The US Army vascular surgeon Carl Hughes and his colleagues managed to repair insured arteries or veins and so reduced amputations dramatically.
  • The Korean and Vietnamese War (1959-1975) improved the trauma care
  • Trauma care for the civilian population was influenced by medical advances during the Korean War (1950-53) and Vietnam War (1959-75).

The Foundation of the Red Cross: Safe and Fair Treatment for the Wounded on the Battlefield

Would it not be possible, in time of peace and quiet, to form relief societies for the purpose of having care given to the wounded in wartime by zealous, devoted and thoroughly qualified volunteers?

Henry Dunant in “A Memory of Solferino”

A very essential milestone is the foundation of the Red Cross: In 1859 Jean-Henri Dunant (1828-1910) was on a business trip when he witnessed the aftermath of the Battle in Solferino, today in Italy. He recorded the horror in “A Memory of Solferino”: What he saw there changed human history in war but also in peace times as it lead to the foundation of the International Committee of the Red Cross (ICRC) in 1863 and influenced the Geneva Convention in 1864. In the following years national societies of the Red Cross were founded throughout Europe due to the rise of nationalism in the late 19th century.

For his engagement Dunant was awarded (along with Frédéric Passy, a leading international pacifist) with the first Nobel Peace Prize in history in 1901.

… in the Museo Nazionale del Risorgimento, Torino

Tip: If you are interested what Dunant saw in Solferino and inspired him to found the Red Cross download Henry Dunant´s “A Memory of Solferino” here.

To sum up the relation between war and medical innovations, it can be said that some wars were more influential in leading to medical innovations than others but the tragedy of war by far outweighs the gained benefits for medicine.

Ethics

Ethics play an essential role within the history of medicine: Many historic therapies were highly unethical from today´s perspective: In psychiatry, for example, electroshocks, insulin and other drugs, along with brain surgeries (leucotomy or lobotomy), where parts of the brain were removed, were used to “cure” patient. These procedures lead to severe mental issues and the death of many.

Experiments on human and animals can be find in all episodes of history and accompanied the invention of many milestones: E. g. Edward Jenner (1749-1823) tested his smallpox vaccination on a healthy boy and Louis Pasteur (1822-1895) his rabies vaccination on dogs.
Vivisections, operations on living animals and humans, were performed in the 3rd century BC Alexandria: Herophilos of Alexandria is said to have vivisected at least 600 prisoners. But also in the 20th century vivisection were used, especially on prisoners of war and often without anesthesia, by the Japanese military biological and chemical warfare research and development unit “Unit 731”, Nazi doctors, like the war criminal Dr. Josef Mengele (1911-1979), or the Khmer Rouge.

To counter unethical behaviour and misuse in medicine ethical codices were used as early as in the 5th century BC.

The Hippocratic Oath

The Hippocratic Oath (5th century BC) is the earliest document of medical ethics in the Western world and remains valid till today. The Oath established the principles of medical confidentiality and non-maleficence. In a modified form it is sworn by medical graduates in many countries.

[…] I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. […] But I will keep pure and holy both my life and my art. […

Ethical behaviour according to the Hippocratic Oath

The Geneva Conventions

On certain special occasions, as, for example, when princes of the military art belonging to different nationalities meet at Cologne or Châlons, would it not be desirable that they should take advantage of this sort of congress to formulate some international principle, sanctioned by a Convention inviolate in character, which, once agreed upon and ratified, might constitute the basis for societies for the relief of the wounded in the different European countries ?

Henry Dunant in “A Memory of Solferino”

On 22 August 1864, the first Geneva Convention “for the Amelioration of the Condition of the Wounded in Armies in the Field” was signed by 12 European states and kingdoms. Its 10 articles became the first legally binding rules within warfare: it protects wounded soldiers and field medical personnel and humanitarian institutions, who provide aid to the wounded.

The Geneva Convention was updated in 1906, twice in 1929 and in 1949: They set the basics for wartime prisoners – civilians and soldiers -, and guaranteed the protection for civilians in and around a war-zone. Knowingly attacking medical personnel hereby becomes a war crime. The latest version from 1949 was ratified fully or at least partly by 196 countries.

Chemical and biological warfare was regulated by the Hague Declaration of 1899 and the Hague Convention of 1907, which forbade the use of “poison or poisoned weapons”. The use of mustard gas and similar substances in the WWI lead to the Geneva Protocol, which came into action in 1928, and banned all forms of chemical and biological warfare. It had been augmented by the Biological Weapons Convention (1972) and the Chemical Weapons Convention (1993).

The Nuremberg Code (1947)

The Nuremberg Code is a set of 10 ethical principles for any human experiment -medical or psychological. It was created as a result of the Nuremberg medical trials (1946-1947) and established the principle of voluntary consent -without any influence or coercion- for the first time on an international level, which is a major milestone – even though it is not legally binding.

Furthermore experiments need to be useful and necessary for society, 3. based on results of animal experimentation and knowledge of the disease or issue studied, 4. avoid unnecessary physical and mental suffering and injury. Experiments are not allowed 5. where it could be believed that they will lead to death or disabling injuries. 6. the risk of the experiment shall never exceed its potential benefits, 7. proper preparations and safety measures are needed to secure participants health and life, 8. can be only conducted by scientifically qualified people, 9. participant can end experiment when continuing seems impossible for them and 10. scientists need to end the experiment if its continuation threatens the participants health or life.

The impact of the Nuremberg Code needs to be questioned considering the Stanford-Prison (1971) and the Milgram Experiment (1961).

In 1964 The Declaration of Helsinki, currently in its 7th revision from 2013, offered further ethical principles on human experiments, which are still not legally binding under international law. So the next logical step seems to be to develop an on the international level binding legal code.

How medical milestones effect our everyday lives?

The above mentioned milestones lead to:

  1. increased life expectancy: together with better nutrition. More information and interactive maps here
  2. an increase in the quality of life (especially where public health system is well developed)
  3. question of whether we shall do everything that is possible, like cloning or designer babies etc., and if we do so what ethical measures we use.

I am very curious what medical milestones await us in the foreseeable future 😉

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