Section M

A Bit More of Medical History
Table of Contents
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William Stewart Halsted and the Origin of Surgical Gloves

William Stewart Halsted (1852-1922) was the first surgeon-in- chief of the new Johns Hopkins Hospital, established in 1889. He pioneered many surgical operations, including radical mastectomy and safer inguinal hernia surgery.

"He was a pioneer in cocaine anesthesia (1885); was the first to ligate the subclavian artery in the first portion with success (1901); devised the well known supraclavicular operation for cancer of the breast (1889). . . .In aid of a strictly aseptic technic he introduced gutta-percha tissue in drainage (1880-1881), rubber gloves (1890), silver foil dressing (1896), transfixion of bleeding tissues and vessels by fine needles and finest silk. Quietly and unobtrusively, Halsted has taught the delicate art of the perfect healing of wounds, which has been nowhere more beautifully demonstrated than at his clinic." [Quote from FH Garrison, An Introduction to the History of Medicine, 1922 (written while Halsted was still alive)].

Rubber gloves? As quoted by Sherwin Nuland in his superb Doctors: The Biography of Medicine, Halsted wrote the following description in a 1913 review article on surgical technique.

"In the winter of 1889 and 1890 - I cannot recall the month - the nurse in charge of my operating room complained that the solutions of mercuric chloride produced a dermatitis of her arms and hands. As she was an unusually efficient woman, I gave the matter my consideration and one day in New York requested the Goodyear Rubber Company to make as an experiment two pair of thin rubber gloves with gauntlets. On trial these proved to be so satisfactory that additional gloves were ordered. In the autumn, on my return to town, an assistant who passed the instruments and threaded the needles was also provided with rubber gloves to wear at the operations. At first the operator wore them only when exploratory incisions into joints were made. After a time the assistants became so accustomed to working in gloves that they also wore them as operators and would remark that they seemed to be less expert with bare hands than with the gloved hands."

According to Nuland, "this is very likely the most famous paragraph ever printed in the literature of surgery, not only for its description of the introduction of rubber operating gloves, but also because it is the only instance of the beginning of a researcher's love affair being recorded in a medical journal." On June 4, 1890 Halsted married the "unusually efficient woman," one Caroline Hampton.

RAPID SPREAD OF MEDICAL ADVANCES:

Most medical advances come about gradually, over years or decades. Examples are the gradual introduction of supplemental oxygen for hypoxemia, the gradual adoption of anti-hypertensive medications in medical practice, and the gradual (some would say glacial) appreciation of diet and cholesterol control in preventing heart disease.

On the other hand, a few medical advances are so striking that they sweep the world; from a defined moment of introduction, they spread like wildfire, so that within a year or two the advance is implemented in virtually all civilized countries. An excellent example is the introduction of insulin in 1922; its use spread quickly, and the Nobel Prize for the discovery was awarded in 1924 (see "The Story of the Medical Student Who Deserved (But Never Got) The Nobel Prize," Section F). Other examples are x-rays (discovered by Roentgen in 1895, Nobel Prize awarded to Roentgen in 1901); penicillin (first used during World War II, Nobel Prize awarded to Chain, Florey and Fleming in 1945); and polio vaccines (introduced in the mid 1950s).

There is one breakthrough, however, that ranks as number one both for its impact on the practice of medicine and for its rapid, worldwide acceptance: the introduction of inhalation anesthesia. I say "introduction" because the technique was actually used long before it was introduced to the world in 1846. In 1842 one Crawford W. Long, a Georgia physician and graduate of the University of Pennsylvania, successfully used ether in his medical practice. Unfortunately he didn't publish his discovery until several years after the technique had been introduced in Boston, and so did not receive credit for the introduction. (An analogy often quoted is the landing in North America by isolated European explorers long before Columbus in 1492; they might have been here first, but since they didn't tell anyone about it, credit for the discovery rests with Columbus.)

William T.G. Morton, a Boston dentist, was the solitary individual who introduced inhalation anesthesia to the world. Morton himself was neither a scientist nor a member of the medical establishment. He was simply an enterprising dentist who badly wanted some method to perform dental procedures without pain, in order to increase his practice. The idea of inhalation anesthesia had been suggested to him by a one-time dental colleague, Horace Wells, who had used nitrous oxide successfully in his own practice (but failed when he tried to demonstrate its use in 1845, due to improper technique). The idea of using ether as an anesthetic had been suggested to Morton by a respected Boston geologist of the time, Charles Jackson.

Thus Morton was the prepared individual in the right place at the right time. With perhaps profit uppermost in his mind, Morton experimented until he developed a safe technique by which to deliver the ether. He then sought and received permission to demonstrate on a patient of renowned surgeon John Collins Warren, at the Massachusetts General Hospital. The date was October 16, 1846. Before that date all surgery was cut and slash, quick, brutal and painful. The best surgeons were the quickest surgeons, period. Surgical mortality rates were astronomical, both because of infection and the fact that the surgeon simply didn't have enough time to carefully dissect anything.

The patient was a young man with a jaw tumor. After he was put to sleep by Morton, Dr. Warren quickly removed the tumor; the operation took twenty-five minutes. Mirabile dictu! The patient didn't scream, didn't squirm, didn't have to be held down by strong men. He awoke and claimed he had felt no pain, at which point Dr. Warren uttered those five immortal word to the assembled audience:

"Gentleman, this is no humbug."

In the next few weeks other patients underwent surgery with ether inhalation. The astonishing results (pain-free surgery) were presented at two medical meetings in November, and published in the Boston Medical and Surgical Journal on November 18, 1846. The news spread quickly, and within a year ether was used throughout North America and Europe. The term anesthesia was suggested in America by Dr. Oliver Wendell Holmes and it caught on.

Unfortunately for Morton, his credit was sullied by several events, some of his own doing. Initially he tried to hide the nature of the anesthetic, then a commonly available chemical, so he could market it; to this end he obtained a patent and called his secret chemical "Letheon." However the fact of Letheon's wide availability became quickly obvious and Morton made no profit. Moreover, others laid claim to being the rightful discoverer/ inventor of anesthesia, specifically Wells and Jackson (years later Crawford Long also made a claim). The claims and counter-claims effectively prevented a very grateful medical profession and the U.S. Congress from bestowing any monetary award on Morton or the others. All died without the recognition they so craved (although Long never actively pursued any monetary award).

Had the Nobel Prize been available at the time, it would have been awarded, I believe, to Morton, Wells and Jackson, probably in 1847 or 1848. (Since Crawford Long did not publish reports of his early use of ether until December 1849, he would have been left out.)

A Case of "Munchausen"

A young man, Joe McShane, was admitted to our Cleveland hospital with hemoptysis. Unknown to anyone caring for him at the time, he was a classic Munchausen patient, someone who fakes an illness and then willingly subjects himself (or herself) to all sorts of investigations. He brought with him a letter from an Atlanta hospital, addressed:

To Whom It May Concern:

Mr. Joseph McShane was in Mercy Hospital August 1989 with acute pulmonary embolism. His lung scan is abnormal and diagnostic of pulmonary embolism. For acute attacks he receives heparin and coumadin. He can have severe pain with this problem. This letter is being given to him in case he travels out of Atlanta. [Signed, Dr. Howard Lee].

Yet our tests did not show pulmonary embolus nor did they discern any cause for the hemoptysis. I was still in the dark when, after several negative investigations, I proposed an invasive one pulmonary angiogram on the outside chance he might have recurrent emboli missed by a lung scan. I began to explain the procedure to him but before I could state the potential complications he interrupted me. What follows is an account of that conversation, my thoughts at the time, and what happened afterwards.

* * *

"I understand everything you say, Dr. Martin. Let's do the angiogram. I want to know why I'm coughing up blood."

"Are you sure?"

"Yes."

"Don't you want to know the potential complications?"

"I trust you, Dr. Martin. If you recommend it, that's good enough for me."

I wanted informed consent, not 'Yessir, anything you say, sir!' This guy was too eager. Too eager. No one has ever agreed so readily to have a pulmonary angiogram. Always, there are some questions, a quick consultation with the family, or some other hesitancy over having a catheter inserted into one's heart. I began to wonder (probably for the first time) about his psyche. He had a serious medical symptom but didn't seem to be handling it like a patient. What was the problem? In retrospect, he was too smooth. I find this difficult to explain, but it seemed as if he was both the patient and apart from the patient. He had the proper symptoms, but not the proper affect. Except when he complained of chest pain, I had the unsettling feeling he could put on a white coat and play my role, that of the detached professional. I needed to get out of his room and think things over.

"OK," I said, "Let me see if I can set up the angiogram this morning. I'll be back to let you know soon."

I went to the nurse's station and for the next few minutes pondered the situation with his chart open in front of me. I wasn't exactly sure what to do next about making a diagnosis. There was a 99% chance that a pulmonary angiogram would be normal. Should I subject him to this invasive procedure now, or do some other test (what?), or just wait for results of the blood tests (which, at best, would be inconclusive)? For a few minutes my mind just wandered. Then it hit me, the obvious next step.

I placed a call to the Atlanta hospital where he had been a patient the year before. Certainly a little more detail about his medical history couldn't hurt, and might even help decide what to do next. It was early and I figured the physician might be making hospital rounds.

I made the call myself and had no trouble reaching the Atlanta hospital's switchboard operator. I introduced myself and asked if Dr. Lee [the name on a letter provided by McShane] was in the hospital, and if not could she please give me his office number. After the customary 'One moment please' there was a long pause, perhaps half a minute.

"I'm sorry, Sir," she came back, "but we have no one here by that name. You did say Dr. Howard Lee?"

"Yes. Are you sure? Has he left the hospital staff?"

"I don't know, sir. I only have a list of active staff physicians. Are you sure you have the right hospital?"

A copy of the 'To Whom It May Concern Letter' was in McShane's chart. I checked it again.

"Yes, I'm sure of that."

"Would you like me to connect you to the Office of Medical Staff? They would know if this doctor recently left the hospital."

"Yes, please."

I was connected to a secretary in Mercy's Medical Staff Office. She listened dutifully to my query, then put me on hold while she checked some records. About two minutes later she returned.

"I'm sorry to keep you waiting, Dr. Martin. We have no record of any such physician on our staff in the past five years. You say you have his letter on our hospital stationery?"

"Yes, right in front of me." I read her the heading, address and all. This bit of hard evidence intrigued her, as well it should.

"Would you mind faxing that letter to me? If you do that, I can show it to a few people and maybe help you that way."

Strangely, my first thought was that this letter pertained to a patient of mine and that I could not send any part of the medical record without his permission. But this thought quickly dissipated as I contemplated the specific circumstances and how I came to have the letter in the first place.

"Yes, I'll fax it right now. Just do me a favor, please."

"What is that?"

"I need to make some decision about this patient fairly soon. Could you work on this now and get back to me by noon? Either way, even if you come up empty handed?"

"Yes, Dr. Martin. I'll do my best to find out more about this matter. And I'll get back to you either way."

"Thanks," I said, and gave her my office and beeper numbers. It was now shortly after 9 a.m. I saw no reason to go back to Mr. McShane's room right away. I would wait until I had more information.

About 11 a.m. I was paged to the phone. It was the Atlanta hospital's switchboard operator. She had a call for me from Dr. Howard Lucas, an Atlanta internist. I knew it was about McShane but my mind was a blank. What was the real story?

"Dr. Martin?"

"Yes."

"Hello. I'm Dr. Howard Lucas. Beverly [the medical affairs secretary] fax'd me your letter a few minutes ago, and asked me to call you. Hope I'm not interrupting something important." His voice was pleasantly southern, with long I's and soft consonants.

"No, Dr. Lucas, not at all. Thank you for calling. Maybe you can clear up a few things. Do you know about my patient or his letter? We admitted him to our hospital yesterday morning. He gave us that letter and said he was in your hospital for hemoptysis, and that Dr. Howard Lee took care of him. I gather there is no Howard Lee on your staff?"

Dr. Lucas let out a soft chuckle. "Yes, I'm afraid we know your patient. Beverly called the legal office when she got your fax. It seems that a patient checked out of here last year AMA, and before leaving he had somehow managed to lift a bunch of hospital stationery and other supplies. And his name was Shane, John Shane. Well, I was his doctor, so Beverly called me next. Is your patient about five feet ten, slim, brown hair? Sort of looks athletic?"

"Yes, that's him. Then you had him in the hospital?"

"John Shane was our patient. Came in with hemoptysis, pretty convincing story. We did all sorts of tests but found nothing wrong. Yet he kept coughing up blood. He really had us puzzled. He had a lot of chest wall pain, too. Got Demerol about every six hours until we wised up.

"About his third or fourth day here he coughed up blood while watching television in his room. He called a nurse over and without taking his eyes off the tube said, 'Here, here's some more blood' like he was giving her a urine sample or something. She thought his affect was strange, especially since she had been giving him injections for pain, and called me. By then we were mighty suspicious. I sent the "blood" for examination. Guess what? There was no blood in the sample! It was ketchup or something. The guy's a con artist. A real sicko. We're convinced he faked his hemoptysis the entire time. Sorry you got caught with him."

"Did you call in a psychiatrist?"

"Well, we were going to, but as soon as we exposed him he signed himself out AMA. Haven't heard from or about him since. Until just now."

"Well, it certainly sounds like the same guy," I said. "He also told us he was in your hospital twice, about six months apart, and that the first time doctors just diagnosed bronchitis."

"Is that so? I'm sure we only had him once, the time I just told you about. I guess he makes up his story as he goes along."

"He also told us he's visiting his sister here, that he's a computer salesman and lives in Atlanta with his family, a wife and two kids."

"Now that you mention it, I remember he told us he was from Texas or some place out west, and was in Atlanta for an accountant's convention. I never heard about any family. I'm telling you, the guy's a looney tune. He sounds like a classic Munchausen. Didn't pay his bill, either. In fact, his insurance card was phony and all his bills were returned with No Forwarding Address stamped on them. He stiffed the doctors and the hospital."

"I think I'm getting the picture. Thanks, Dr. Lucas. You've been very helpful."

"No problem. Glad to help. Good luck with this guy. See if you can get psychiatry to see him. He certainly needs their help."

I felt like someone had punched me in the stomach, deflated my tires, stolen my bicycle. What kind of person fakes a serious illness? And why? I went back to the room to confront Mr. McShane aka Shane. Although I now felt betrayed by this imposter, I had to remind myself that he was still a patient, and would remain so until I could confirm this bizarre story and transfer his care to a psychiatrist. So, in a quiet, non-confrontational manner, I walked back to his bedside. He spoke first.

"Did you arrange for the angiogram, Dr. Martin?"

"No, I called the Atlanta hospital instead."

He showed no concern, no surprise. After all, he had given me the hospital's name, so I guess he figured there was nothing to hide.

"I spoke with a Dr. Lucas. There is apparently no Dr. Howard Lee on their staff."

"Oh? Well, he must have left. But it was his letter, alright."

"Dr. Lucas says he took care of you last year, but that he knows you under a different name, as Mr. Shane, not McShane."

"Sorry doc, I changed it recently. Having some alimony problems. I should have told you."

Lucas not Lee. Shane not McShane. And sorry doc? What's this doc? For almost 24 hours it had been Doctor Martin, formal, distancing. Now with his lies unraveling I was being addressed doc, and said with a touch of disdain. Oh, oh.

"He also said you claimed to be coughing up blood last year, but all they found under the microscope was ketchup, or something like ketchup."

I said these things calmly, matter-of-factly, careful not to sound like a prosecutor out to destroy the made-up alibi of some wretched defendant. My patient was sicker than anyone had realized and an accusatory posture would not help the situation. He had to know that we knew the truth and that we knew his needs were psychiatric, not medical. It would do no good to play his game, whatever that game was.

The truth was too much. At the mention of "ketchup" his head snapped into position and he stared straight at me. The intensity of his stare was frightening; if his eyes were lasers I am certain they would have burned two holes in my skull. After about ten seconds he spoke. There was anger in his voice.

"That is a bald . . . faced . . . LIE!"

The last word was yelled. I stepped back a pace, half expecting him to jump out of the bed and pummel me. He started to snarl, then contorted his face to express disgust: raised upper lip, flared nostrils, gritted teeth. Would he spit next? I decided to keep silent. The ball was in his court.

He relaxed his features. Then, with contempt in his voice: "Look, doc, you're a nice guy, but if YOU can't find the cause of my hemoptysis I'll go someplace else, to somebody COMPETENT. I don't need this phony accusation stuff thrown at me!"

A passing nurse entered the room, attracted by his loud voice. I motioned her to stay behind me, that everything was OK, and then tried to calm him down. I sensed my effort would be futile.

"I'm sorry, I'm just reporting what Dr. Lucas..."

"Lucas Schmucas," he interrupted. "He's a phony, too. Cut the crap, doc. Hey, whatever happened to your HIPPOCRATIC oath? Did you lose it somewhere? Maybe I can help you find it!"

Now he was visibly agitated. He jumped out of bed on the side opposite us and fidgeted with the nightstand drawers. He opened a drawer and took out his clothes: pants, shirt (red-stained), shoes and socks, and a folder full of papers (more letters?). In another two minutes he was out of his hospital gown and dressed in street clothes.

"Where are you going?"

"Sorry doc, you guys had your chance. Hey, what kind of doctor are you, anyway?"

"Mr. McShane, you need some help. Please stay and let us call a psychiatrist. You can't keep going from hospital to hospital with this complaint of hemoptysis. There's nothing wrong with your lungs. Somebody could do an unnecessary procedure and you could be harmed. Let us try to help you."

"Help me? Hah! You're the one who needs help. I've NEVER seen such UNPROFESSIONAL behavior. NEVER. And I've seen a lot, believe me!"

I kept my distance and did not reply. The nurse asked if she should call Security. No, I said, reminding myself that we can't keep patients against their will. Security would be no use in this case.

In less than a minute our patient walked off the ward, grabbed an elevator and was gone.

ORIGIN OF THE TERM "MUNCHAUSEN"

Con man? Not quite. A mentally ill man is more like it. Actually, Mr. Shane/McShane is a classic example of a condition long described in medical and psychiatric circles, the Munchausen Syndrome. The syndrome is named after an 18th century German, popularly known as Baron von Munchausen, real name Karl Friedrich Hieronymus, Freiherr von Munchausen (1720-1797). Munchausen, a soldier who served with the Russians against the Turks, was notorious for telling entertaining stories of outlandish proportion, entirely made up. Munchausen's reputation was enlarged upon by a contemporary, one Rudolph Erich Raspe, who anonymously published (in German) Baron Munchausen's Narrative of His Marvellous Travels and Campaigns in Russia (1785). This work, soon after translated into English as The Adventures of Baron Munchausen, became a popular book of the late 18th century and has gone through many editions. A copy of The Adventures, as well as several other books about the infamous Baron and his tall tales, may be found in some libraries.

The term "Munchausen's Syndrome" was first used in a 1951 article in The Lancet. A group of patients repeatedly sought hospitalization by simulating symptoms of illness. Dr. Richard Asher wrote:

Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly the syndrome is respectfully dedicated to the baron, and named after him.

The patient showing the syndrome is admitted to hospital with apparent acute illness supported by a plausible and dramatic history. Usually his story is largely made up of falsehoods; he is found to have attended, and deceived, an astounding number of other hospitals; and he nearly always discharges himself against advice, after quarreling violently with both doctors and nurses. . .

Since 1951 there have been medical reports of patients faking abdominal pain, seizures, kidney stones, back pain, asthma, mental confusion, fever, blood in the urine, hemoptysis and a variety of other illnesses. Although Asher called the syndrome common, it may only appear common because one Munchausen patient may be seen by so many different physicians and at a variety of institutions. A review published in 1967 found only 59 cases reported in the literature to that time. Munchausen remains a rare syndrome. In the 1967 review Munchausen men outnumbered women three to one; the age range was 19-62 years, with a mean age of 39.

Typical features of the Munchausen patient include:

faking an acute illness that requires hospitalization

familiarity with medical terms and diseases

lack of any obvious external reason for seeking hospitalization

aggressive behavior toward health professionals when the truth of the symptoms is challenged

leaving the hospital against medical advice

Munchausen patients frequently travel from city to city, or even to several hospitals within one large metropolitan area. It is not unusual to uncover a string of hospital admissions within a one or two year period, and spanning several states. There is one report of a patient who had, over a 16-year period: 40 hospitalizations in three states for abdominal pain, chest pain, loss of consciousness, blood in the urine and fever all apparently factitious; 32 emergency room visits for the same problems; four abdominal operations; and one brain operation. Whenever he presented to a hospital that had cared for him many times before he always told the doctors it was his first time there.

Another patient, a 33-year-old man, was discussed in two separate articles that appeared in a single issue of the New England Journal of Medicine (August 6, 1992). The first article covered his evaluation for a puzzling disorder at Brooklyn's University Hospital in 1991; the second article discussed evaluation for the same disorder after he was admitted to Yale New Haven Hospital in early 1992. The problem? Sudden onset of coughing up and urinating blood. Doctors at Yale knew nothing about the previous evaluation in Brooklyn. At each hospital, after an extensive workup, his physicians diagnosed the Munchausen syndrome and on both occasions he left AMA after he was exposed.

Why do people fake a serious illness? No one knows for sure, but the problem is widely accepted as psychiatric in nature, a form of character disorder manifesting as antisocial behavior. Munchausen is not a psychosis like schizophrenia, and paradoxically is much harder to treat. These patients don't respond to tranquilizers or other mind-altering drugs.

Munchausen patients who have been studied by psychiatrists seem to have one thing in common: an unhappy, unloving childhood. Their early home life is often described as abusive and neglectful. As adults they become attention seeking and in this way `act out' their rage over past deprivations. They seek nurturing for what they lacked in childhood.

Why does their nurture-seeking take place in hospitals? Because of some early experience they have learned to manipulate the medical care system. A modicum of medical training is common. Tricking doctors and nurses seems to satisfy their need to get back at society, even if this behavior puts them at risk for harm (by having unnecessary tests and procedures).

The only effective treatment, if it can be called that, is to replace their episodic (and chaotic) hospitalizations with intensive psychologic counseling in a chronic care facility, i.e., long term care in a psychiatric institution. Suffice to say, it is the rare Munchausen who ends up in such an arrangement.

William Bean, an eminent physician of internal medicine, described one Munchausen patient in verse; his poem ended thus:

I'm sorry I cannot fasten my claws on

What causes the syndrome named Munchausen

This off again, on again, gone again Finnegan

Comes in, goes out, and at length comes in again.

Munchausen's victims must be expected

To plague our lives unless deflected.

So be alert for this great nonesuchman

Munchausen syndrome's flying Dutchman.*

___________________

* William B. Bean, M.D. The Munchausen Syndrome. Perspectives in Biology and Medicine. Spring 1959.

Andrew Taylor Still and the Origin of Osteopathy

In addition to the 126 medical schools there are 17 schools of osteopathy in the U.S. Today, of course, osteopathic-trained physicians (DO's) practice side by side with MD's (called allopathic medicine). Both groups share the same privileges, but it was not always that way. How did osteopathy begin?

Andrew Taylor Still (1828-1917) was a self-trained physician (not unusual in the mid-19th century) who found the traditional practice of medicine wanting. His disillusionment in part arose after he witnessed the demise of three of his children from spinal meningitis. Like other zealots of the period with a medical mission (e.g., Reverend Sylvester Graham who preached on diet, Mary Baker Eddy who founded Christian Science, Daniel David Palmer who founded chiropractic), Andrew Still focused on one very narrow idea for healing all ills. His epiphany was that the spinal column holds the key to good health. Still surmised that out-of-place vertebrae caused disease. By simply re-aligning the vertebrae, using nothing more than the human hands, diseases could be conquered. He called his method "osteopathy" from the Greek words for "bone" and "suffering."

Still's development of osteopathy took place in the 1870s and 1880s, severing ties with traditional medicine along the way. The main difference in practice was that traditionalists used medicines to effect cures. Still's osteopathy did not. The main difference in theory was that, in the late 19th century, traditional medicine increasingly embraced scientific advances: the germ theory of disease, basic physiology, and surgical technique. In its origins osteopathy was anti-science. Still was quoted as saying things like "All the drugs man needed were put in him by Nature's Quartermaster" and "I believe but very little of the germ theory and care much less."

By the 1880s Still had amassed a large following, and claimed cures for drug addiction, asthma, heart disease, arthritis, head-ache, diarrhea, appendicitis just about whatever the patient had, osteopathy claimed a cure. In the tradition of most faith healers and quacks of the period, Still advertised and made numerous claims without a shred of scientific backing. However, unlike most of his non-traditional contemporaries, Still took the next great step. He founded a school for his disciples.

In the late 1880s Still helped the invalid daughter of a minister in Kirksville, MO, to walk again. His reception in town after this feat convinced him to settle there in 1887; Still's sons, osteopathic doctors, followed him soon afterwards.

The first osteopathic school of medicine was established in Kirksville in 1892. In answer to the traditional M.D. degree, the school granted the D.O. degree (as do all osteopathic schools today). A turn-of-the-century photo of the school building shows the following advertisement in large letters, visible from the street.

OSTEOPATHY

GIVEN TO THE WORLD BY

* A. T. STILL *

A.D. 1874

From the beginning the Kirksville school admitted blacks and women, and in this regard was something of an educational pioneer. During the school's first decade one in five students was female.

In 1894 Andrew Still established the Journal of Osteopathy. Nonetheless, organized medicine and allopathic physicians looked down their noses at osteopathy and considered it pure quackery. In 1897 the Journal of the American Medical Association denounced Still's followers as "degenerates who constitute most of the devotees of and the practice of quackery." Physicians argued that students entered osteopathic schools only because they couldn't get into real medical schools.

Despite the challenge from organized medicine, Still won a major legal victory in 1897 when Missouri legalized osteopathy. Certainly traditional medicine as practice by MDs was itself inadequate at the turn of the century, so it is no surprise that patients migrated to osteopaths, who always practiced "hands-on" therapy. Soon other osteopathic schools were created; about a dozen were in operation by 1910.

Another competing school soon opened in Kirksville, one that was to have a major effect on Still's operation. The new school was founded by Marcus Ward (1849-1929), a former assistant of Still's. Ward eschewed his mentor's rigid ways, and emphasized pharmacology and surgery in addition to traditional osteopathic manipulations. The two schools later merged and Ward's influence on the curriculum remained.

Perhaps the biggest shift in osteopathy came about because of the 1910 report by Abraham Flexner on medical education in the United States. This report was commissioned by the Carnegie Foundation for the Advancement of Teaching. Flexner criticized virtually all U.S. medical and osteopathic schools for their sloppy instruction, lack of science education, and generally poor standards. As a result of this report a landmark in the history of medical education many professional schools shut down.

The surviving schools became much more rigorous, adding science courses and tightening pre-admission requirements. By 1940 all DO and MD schools required at least two years of college for admission, and by 1954 at least 3 years.

Osteopathy really took off after Still's death in 1917. Before, there was a power struggle between Still's close followers ("10-fingered" osteopaths) and those who accepted modern medical techniques ("3-fingered osteopaths"). After 1917 the latter won over. In 1929 the American Osteopathic Association okayed "supplementary therapeutics" to go with osteopathy, giving official recognition to what, by then, was standard practice by most osteopaths.

Today, osteopathic schools teach the same courses as MD schools, plus traditional osteopathic manipulations. Osteopaths are licensed as physicians in all 50 states, the last being California, which re-instated its licensure in 1974 (the state had ceased licensing them in 1962).

Today about 200 of the country's 5000+ hospitals are osteopathic, and about 30,000 of the 600,000+ physicians are osteopaths. Among the 17 osteopathic schools is the original one, now called the Kirksville College of Osteopathic Medicine, which has over 500 students.

Chiropractic

Different from both osteopathy and allopathic medicine is chiropractic, founded by one Daniel David ("D. D.") Palmer in 1895. The place: Davenport, Iowa. The first patient: Harvey Lillard, a janitor whom Palmer "cured" of sudden hearing loss by manipulating his vertebra.

The term chiropractic comes from the Greek "to work by hand." D.D. developed spinal manipulation as the way to cure ills, since most sickness, he believed, arises from vertebral mis-alignment that affects nerves. A mis-aligned vertebra, called "vertebral subluxation," puts pressure on the nerves and lowers the body's resistance to disease.

Originally chiropractic and osteopathy were considered similar, since both eschewed drugs and surgery. However osteopathy is now on parity with allopathic medicine, whereas chiropractic has remained decidedly outside mainstream medicine, and still uses neither drugs nor surgery.

So much has been written and argued about chiropractic that it is pointless to rehash the arguments. The AMA published its first anti-chiropractic article in JAMA in 1912, and relentlessly pursued the profession for decades. In 1947 the AMA asserted that "there is no pathological basis whatsoever for the theory of chiropractic and it is silly to allude to it as a science." The intent of such statements was to shut down chiropractic as a profession. In 1976 chiropractors filed a major anti-trust lawsuit against the AMA, which they won in 1987. Henceforth the AMA could not prevent or restrict its members from referring to or cooperating with chiropractors; the lawsuit also greatly weakened the AMA's publicity assault on chiropractic.

Today there are almost 50,000 chiropractors in the U.S. and they are licensed in all fifty states. Chiropractic is here to stay for one simple reason: millions of people suffer from back and neck pain, and many patients find relief from chiropractic manipulation. Nonetheless, the field is not based on any scientific methods or principles as physicians understand them.

Florence Nightingale -- Who Was She?

Born in Florence, Italy in 1820 (hence her first name), Florence Nightingale's family was upper middle class English, and she was raised in Derbyshire, England. When told she could not change the poverty and misery of early 19th century England, Florence reportedly told her father: "I will change it. I will make the world better." This was in 1836.

Spurning suitors for marriage, Florence trained as a nurse in France, Germany and Egypt (there were no nursing schools in England at the time). Back in England, she volunteered to care for English soldiers wounded in the Crimean war (1853-1856). The rest is history. Against incredible odds (including the stupidity of officers who couldn't fathom a woman as medical professional) Florence and her band of 38 volunteers became the de factor saviors of over 12,000 wounded men in Turkey and the Crimea (part of the Ukraine). As in many 19th century wars, far more men died of disease than of battlefield wounds.

She returned to London in 1856 and soon opened The Nightingale Home for Nurses in St. Thomas's Hospital. The opening of this school marked the beginning of professional education in nursing.

Her written works (including Notes on Hospitals, 1859; Notes on Nursing, 1860, the first textbook for nursing; and Notes on Nursing for the Labouring Classes, 1861) helped change nursing from untrained, menial labor to a full-fledged profession. Her 1858 Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army, in addition to improving the care of the English military, also is said to have influenced management of American hospitals during the Civil War.

In 1907 Florence Nightingale became the first woman to receive the British Order of Merit, for her army and hospital reforms. She died August 13, 1910.

FAME IS FLEETING OR, WHO WAS THAT DISEASE (SIGN, OR CONDITION) NAMED AFTER?

Addison, Thomas (1795-1860), English physician who is credited with discovery of both pernicious anemia (long known as Addison's anemia) and the more eponymically known adrenal insufficiency (in his era, usually due to tuberculosis).

Alzheimer, Alois (1864-1915), German neuropathologist who described the pathologic findings of presenile dementia: neurofibrillary degeneration and plaques in the cerebral cortex. His work was published in 1906-1907.

Babinski, Joseph Francois Felix (1857-1932), Parisian physician of Polish extraction. In 1896 he described upgoing toes in patients with certain diseases of the central nervous system. Babinski made many other contributions to the fields of neurology and neurosurgery.

Bell, Charles (1774-1842), Scottish surgeon and anatomist, who in 1821 published a Philosophical Transaction describing facial paralysis due to involvement of the seventh cranial nerve. Famous during his lifetime, Bell was knighted in 1831.

Bence Jones, Henry (1814-1873), British physician who in 1848 discovered the abnormal protein of multiple myeloma.

Colles, Abraham (1773-1843), Irish physician who in 1814 published, in the Edinburgh Medical and Surgical Journal, a short paper on Fracture of the Lower End of the Radius. In addition, he also described (in 1801) Colles' fascia in the scrotal sac.

Down, John L. H. (1828-1896), English physician who published an 1866 paper "Observations on the ethnic classification of idiots," noting physical features of what we now call Down's Syndrome.

Duchenne, Guillaume B. A. (1806-1875), French neurologist who in 1861 described the form of muscular dystrophy that now bears his name: a progressive myopathy with onset in early childhood that is inherited as an X-linked trait.

Dupuytren, Guillaume (1777-1835), French surgeon who in 1832 described diagnosis and surgical management of digital contractures.

Gram, Hans Christian (1853-1938), Dannish physician and teacher of general medicine. While studying bacteriology in Berlin in 1884, Gram discovered and described the most important stain used for categorizing bacteria.

Graves, Robert James (1796-1853), Irish Physician who in 1835 published a classic description of exophthalmic goiter. Although his was not the first description, it was so lucid and attracted so much attention that to this day the condition is known as Graves' disease.

Guillain, Georges (1876-1961), French neurologist who, with Jean A. Barré (1880-1967), was among first to describe inflammation of the peripheral nerves leading to paralysis. He and Barré recognized that the paralysis occurred most commonly after a respiratory infection.

Hirschsprung, Harald (1830-1916), Danish physician who in 1887 described congenital dilatation of the colon. Although there were earlier references to this condition, Hirschsprung gave the first complete description, hence the eponym by which it is now known.

Hodgkin, Thomas (1798-1866), English physician who was singularly unsuccessful in his practice, so that he gave up medicine altogether. But not before he presented his paper, in 1832, On Some Morbid Appearances of the Absorbent Glands and Spleen, based on specimens of morbid anatomy. The condition was not called Hodgkin's disease until 1865.

Kartagener, Manes (1897-1975), Swiss physician who in the 1930s described situs inversus with bronchiectasis, a genetic disorder (isolated situs inversus is incorrectly called Kartagener's syndrome).

Meniere, Prosper (1799-1862), Parisian physician considered founder of otology; in 1861 he presented a paper on deafness, tinnitus and vertigo resulting from an inner ear lesion.

Osler, William (1849-1919), Canadian physician and academic pioneer (see section I), whose fame rests least on his eponymic conditions: Osler-Weber-Rendu disease (multiple telangiectasias) and Osler's nodes (painful skin lesions seen in bacterial endocarditis).

Paget, James (1814-1899), successful English surgeon of the Victorian era, he described both osteitis deformans and disease of the nipple.

Pott, Percival (1714-1788), English physician who is eponymically known for spinal deformity due to tuberculosis. He was also first to describe chimney sweep's cancer (carcinoma of the scrotum).

Trendelenburg, Friedrich (1844-1924), German surgeon best known today for his surgical position: a 45 degree head-down angle he used for gynecological and pelvic operations.

Von Recklinghausen, Friedrich Daniel (1833-1910), German pathologist, assistant of Virchow, who in 1882 described neuro-fibromatosis multiple tumors occurring along the course of cutaneous nerves.

Von Willebrand, Erik A. (1870-1949), a Finnish hematologist who in 1931 described an inherited bleeding disorder that he called "pseudohemophilia."

Bibliography for section M -- A BIT MORE OF MEDICAL HISTORY

Armstrong, David and Armstrong Elizabeth M. The Great American Medicine Show. Prentice Hall, New York, 1991.

Baily H, Bishop WJ. Notable Names in Medicine and Surgery, 3rd ed., HK Lewis, London, 1959.

Beighton, Peter and Beighton, Greta. The Man Behind the Syndrome. Springer-Verlag, Berlin, 1986.

Bettmann, Otto L. A Pictorial History of Medicine. Charles C. Thomas, Springfield, IL 1956.

Cook, Sir Edward. The Life of Florence Nightingale, MacMillan & Co., London, 1914.

Garrison, Fielding H, An Introduction to the History of Medicine, W. B. Saunders Co., Philadelphia, 1922 (3rd ed.) and 1929 (4th ed.).

Hume, Ruth F. Great Women of Medicine. Random House, New York, 1964.

Magner, Lois N. A History of Medicine. Marcel Dekker, Inc., New York, 1992.

Nuland, Sherwin. The Origins of Anesthesia, Gryphon Editions, Ltd., Birmingham, AL, 1983.

Nuland, Sherwin. Doctors: The Biography of Medicine, Alfred A. Knopf, New York, 1988.

Sigerist, Henry E. The Great Doctors. A Biographical History of Medicine. Books for Libraries Press, 1933.

END OF SECTION M
Table of Contents