Vote on the most important medical advance since 1840
Medical milestones: summaries
Anaesthesia:
Symbol of humanitarianism
Stephanie J Snow
By the end of the 19th century
anaesthesia was proclaimed as one of the civilising factors of the Western
world, and it remains today the most vivid example of medicine’s capacity to
diminish human suffering. Anaesthesia continues to develop: muscle relaxants and
techniques such as spinal anaesthesia have brought new benefits; anaesthetists
have extended their practice to intensive care and management of chronic pain;
and new inhaled and intravenous anaesthetic agents have facilitated the
development of day case surgery. The detail of anaesthesia will surely continue
to evolve. But nothing is likely to be as significant as the demonstrations by
19th century pioneers such as John Snow and James Young Simpson of the potential
of anaesthesia to alleviate the pain of surgery.
Antibiotics:
The epitome of a wonder drug
Robert Bud
The discovery of antibiotics heralded a
dramatically new approach to infection control and health care, enabling nations
to prosper and overturning the concept of health as a moral duty. Penicillin is
the iconic antibiotic—its introduction into clinical practice was widely
celebrated, and its benefits (protection against wound infection and a potential
syphilis epidemic) were critical in
Chlorpromazine: Unlocking psychosis
Trevor Turner
From the 1950s, when chlorpromazine
came into use, the numbers of inmates in asylums began to fall dramatically, and
over the next few years antidepressants and antipsychotics arrived en masse. A
new world of a truly biological as well as psychosocial psychiatry had begun.
Without the discovery of drugs such as chlorpromazine, our modern, multiskilled
mental health workforce might never have emerged. The modern emphasis on users
of mental health services and their carers would have been impossible. The
progress initiated by the discovery of chlorpromazine means that we can replace
baggy terms such as paranoid schizophrenia with “temporal lobe hyperdopaminergia,”
and we may yet eradicate the monsters of stigma and neglect that still beset
mentally ill people.
Computers:
Transcending our limits
Alejandro R Jadad,
Discovery of
DNA structure: The best is yet to come
John Burn
Watson and Crick’s 1953 report of DNA
structure as a double helix and their recognition, at a stroke, of the digital
basis of genetic information opened the floodgates to further discoveries. The
most dramatic evidence of that flood is the human genome project, humanity’s
biggest research endeavour, permitting rapid progress in linking gene sequence
variants to thousands of genetic disorders. Identifying gene mutations in common
diseases such as eczema exposes relevant pathogenic pathways and enables new
interventions for these conditions. From human insulin to hepatitis B vaccine to
trastuzumab (Herceptin), an understanding of DNA permeates myriad developments
in treatment. The evidence already before us is dramatic but is nothing compared
with the tsunami to come.
Evidence
based medicine: Increasing, not dictating, choice
Kay Dickersin, Sharon E Straus, Lisa A Bero
In a world without evidence based
medicine, a boy with asthma might have his treatment changed every six weeks as
new drug samples are dropped off at his doctor’s surgery. Most women with early
breast cancer would still be undergoing mastectomy instead of lumpectomy and
radiation. Now they can choose. Evidence based medicine is about making
decisions that are based on the best available evidence, not dictating what
clinicians do. The systematic synthesis of evidence is the foundation of all
medical discoveries and of good clinical practice. The question has moved beyond
“Why is evidence based medicine important?” to “Why is it not already a
reality?” and “How can we all work together to make it a reality, quickly?”
Germ theory:
Invisible killers revealed
Harry Burns
Semmelweis’s work on hand washing and
Lister’s antisepsis techniques helped to turn the germ theory of disease into
clinical reality. The theory was eventually universally accepted after further
work by Koch and Pasteur. These insights into the prevention and treatment of
infectious disease moved us from a society at the end of the 19th century in
which infection typically caused 30% of all deaths to one at the end of the 20th
in which less than 4% of deaths were due to infection. The fall in childhood
mortality profoundly affected family size and fertility. Our understanding of
hygiene, sanitation, and pathology from the development of germ theory has done
more to extend life expectancy and change the nature of society than any other
medical innovation.
Imaging:
Revealing the world within
Adrian M K Thomas, John Pickstone
At the root of sophisticated 21st
century medical imaging we find the chance discovery of x rays by Wilhelm
Röntgen in a physics laboratory in the 19th century. The discovery led to an
array of visualisation and interventional techniques that permeate modern
practice. Imaging came into its own as an aid to surgery and evolved to modern
digital radiology, such as computed tomography, which has transformed
investigative medicine. X rays became a mainstay of cancer treatment, and modern
imaging is now used to guide interventions such as angioplasty and stent
insertion. Without x rays, doctors—like Röntgen—would be working in the dark.
Immunology:
Making magic bullets
D Michael Kemeny, Paul A MacAry
Understanding how the immune system
distinguishes host cells from “foreign” cells has made organ transplantation
feasible, saving thousands of lives. Understanding the biological weapons in our
immune system has resulted in antisera and monoclonal antibody technology.
Monoclonal antibodies are used to diagnose and monitor disease, to ensure the
quality of food and other biological materials, and to test for trace amounts of
drugs and toxins. They have also been used to treat otherwise intractable
diseases such as rheumatoid arthritis and to target anticancer agents precisely
to the tumour—the “magic bullet” approach. More than a third of all drugs
currently being developed by drug companies are monoclonal antibodies, and this
technology will enable many more medical milestones to be reached.
Oral
rehydration therapy: The simple solution for saving lives
Olivier Fontaine, Paul Garner, M K Bhan
Oral rehydration solution to replace
the water and electrolytes lost through vomiting and diarrhoea was initially
used only by paediatric specialists in tertiary referral hospitals. When it was
tested in refugee camps in the 1970s, mortality fell dramatically. Since then
this simple and cheap oral solution, given at home or in healthcare centres, has
been integral to the World Health Organization’s diarrhoeal disease control
programme. In the 1980s nearly five million children under 5 years old died each
year from diarrhoea. In 2000 this figure had dropped to 1.8 million. Because
oral rehydration has saved more than 50 million children’s lives over the last
25 years, a large chunk of the adult population in developing countries is alive
today.
The pill:
Emblem of liberation
Carl Djerassi
The pill offers women the ability to
decide on their own whether or when to become pregnant, thus undermining the
historical dominance of men in sex and reproduction. The repercussions of this
have been cultural, economic, professional, and educational and have affected
millions of people. No drug has had such an enormous effect on religion. The
discipline of epidemiology has probably been improved more through the thousands
of studies on the pill than through those on virtually any other drug. Moreover,
the pill is the preferred method of reversible contraception in more than half
the countries in the world. It is one of the few drugs to have remained
essentially unchanged decades after its synthesis—testament to its enduring
value.
Risks of
smoking: All done and dusted
Simon Chapman
Two landmark studies in 1950 led to a
growing body of evidence for the harmful effects of tobacco. Since then, the
prevalence of smoking has fallen in countries where tobacco control is taken
seriously. For all the money poured into cancer research in recent decades, most
of the progress in reducing cancer mortality has been due to deaths avoided
through successful tobacco control. Despite the efforts of the tobacco industry
to fight back, smoking has been transformed from a pleasant, mannered pastime to
a badge of low education, social disadvantage, and ostracism. The end game for
smoking may well be just 20 years away in nations where smoking is currently in
free fall.
Sanitation:
Pragmatism works
Johan P Mackenbach
In the 1800s acute infectious diseases
that killed male breadwinners were a major cause of poverty. Believing that
diseases were caused by air contaminated by poor urban drainage, governments
built new sewage disposal and water supply systems. This revolutionised public
health in Europe, and mortality from infectious diseases fell dramatically.
Nowadays we know that better water supply and sanitation can cut diarrhoea among
children in developing countries by about a fifth. The 19th century “sanitary
revolution” shows that effective intervention does not always need accurate
knowledge, that environmental measures may be more effective than changing
individual behaviour, and that universal measures may be better than targeted
measures in reducing health inequalities.
Tissue
culture: Solving the mysteries of viruses and cancer
Yvonne Cossart
Tissue culture allows cells to be grown
on an industrial scale, yielding vaccines and other biological products such as
recombinant factor VIII for haemophilia. Tissue culture techniques have been
crucial in the work of more than a third of the Nobel prize winners for medicine
since 1953. Without cell culture we would lack vaccines against measles, mumps,
and rubella and would still depend on much more expensive and reactogenic
vaccines for polio, rabies, and yellow fever. We would be unable to karyotype
patients with suspected genetic disorders or perform in vitro fertilisation.
Monoclonal antibodies now used for diagnostic and therapeutic purposes would not
be available. Gene therapy and the use of stem cells to repopulate damaged
organs would be beyond imagination.
Vaccines:
Conquering untreatable diseases
Michael Worboys
Vaccines have saved millions of lives
and spared generations the suffering and long term consequences of infections.
The vaccines we have today are grounded in the knowledge and techniques that
Louis Pasteur introduced with his rabies vaccine. Pasteur’s breakthrough in 1885
represented the medical conquest of an untreatable disease. In the 21st century,
smallpox has been eradicated, and in countries such as the United Kingdom once
common childhood diseases such as diphtheria, whooping cough, measles, rubella,
polio, mumps, and rubella are rare memories. As new vaccines and vaccine
delivery systems continue to be introduced, there is no reason to suppose that
the future of vaccines will be any less remarkable than their past.