VIII.

20th-Century Medicine

Medicine's most revolutionary advances have occurred since 1900. By the end of the 20th century, medical advances helped to increase the average person's life expectancy by almost 30 years. As people lived longer, new medical challenges emerged. Heart disease, cancer, stroke, and other conditions often associated with aging replaced infectious diseases as the leading causes of death. Physicians began to devote greater attention to preventing disease and keeping patients healthy into advanced age. Biomedical research also shifted focus to the most basic causes of diseases, including defects in individual genes.

A.

Infectious Diseases

Infectious diseases that historically have killed millions of people each year were conquered early in the 20th century by improved sanitation, antibiotics, and vaccines.

German physician Paul Ehrlich showed around 1910 that a chemical compound, arsphenamine, could treat syphilis. He opened the era of chemotherapy, in which physicians use chemical compounds that act selectively to target specific diseases.

In the early 1930s, German and French scientists showed that sulfonamide was effective in treating streptococcal bacteria infections. This discovery led to the first family of so-called wonder drugs, the sulfonamide antibiotics. In 1938 British biochemists Howard Florey and Ernst Chain purified penicillin, the bacteria-destroying compound that Alexander Fleming observed in mold ten years earlier. Streptomycin, the first antibiotic for tuberculosis, was discovered in 1944 by American microbiologist Selman Waksman. Dozens of other antibiotics were subsequently discovered, each stronger and more effective against a broader range of bacteria.

Scientists learned more about how the body's immune system protects itself from infections, resulting in new tests for diagnosing infectious diseases and new vaccines to prevent them. The Wasserman blood test for syphilis was developed in 1906 and the tuberculin skin test for tuberculosis appeared in 1908. By the 1930s new techniques for growing viruses in the laboratory led to vaccines against viral diseases. These included a yellow fever vaccine in the late 1930s and the first effective influenza vaccine in the 1940s. The American physician Jonas E. Salk developed a polio vaccine in 1954. Later virologist Albert B. Sabin developed a safer oral polio vaccine, which was in wide use by the 1960s. Later came vaccines for other childhood diseases, including measles, German measles, mumps, and chicken pox.

Infectious diseases, once thought conquered by antibiotics, became a major concern again in the 1990s. New forms of tuberculosis and other diseases resistant to antibiotics spread. Concerns also arose over new or newly recognized microbes, such as human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), which became epidemic in 1981. As human populations grow and expand into wilderness areas, humans and animals come in closer contact. A number of diseases transmitted from animals have become problematic in recent years, including the hemorrhagic fevers caused by the Ebola and Marburg viruses, hantavirus pulmonary syndrome, and Lyme disease. In other areas, physicians recognized that an easily curable bacterial infection caused most peptic ulcers, a disease once blamed on stress and diet.

B.

Nutrition

Polish-born American biochemist Casimir Funk introduced the term vitamine in 1912. Researchers later identified vitamins needed by the body to prevent deficiency diseases such as beriberi, rickets, scurvy, and pellagra. As better nutrition was developed and the quality of life improved, these diseases almost disappeared from industrialized countries (see Human Nutrition). But by the end of the 20th century, other nutritional disorders emerged. Studies conducted in the United States in the 1990s showed that more than 97 million Americans were overweight and risked health problems, such as heart disease and diabetes mellitus, commonly associated with obesity.

C.

Surgery

Operations that people once regarded as impossible became routine in the 20th century. Many of these surgical advances resulted from improved drugs or medical technology. Better drugs to prevent rejection of transplanted organs made transplantation of hearts, kidneys, livers, lungs, and other organs removed from donors possible. Patients were kept alive with artificial kidneys and temporary artificial hearts while awaiting a transplant (see Medical Transplantation). The heart-lung machine made it possible to stop and restart the heart during coronary bypass surgery. Small fiber-optic instruments called endoscopes led to the new field of minimally invasive surgery. These new tools made it possible to remove a diseased gallbladder or appendix, for example, through small slits rather than large incisions, greatly reducing the amount of anesthesia required during the surgery and lessening recovery time. Transfusions of blood, plasma, and other saline solutions, which went into use in the 1930s, helped prevent deaths from shock in surgery patients. In the 1990s, physicians even began performing surgery to repair defects in unborn infants.

D.

Radiology

New methods for viewing diseased structures inside the body improved diagnosis of disease beginning in the 1970s (see Radiology). A gamma camera detects radioactive medication that attaches to certain forms of cancer cells. Computed tomography (CT) scanners use X rays to produce lifelike three-dimensional images of body structures. Magnetic resonance imaging (MRI) scanners produce highly detailed images without X rays. Positron emission tomography (PET) detects very early warning signs of disease. Sonograms, or ultrasound, taken with high-frequency sound waves diagnose disease and monitor the progress of pregnancies. X rays and high-energy particles emitted by linear accelerators also are used to treat cancer. Lithotripsy uses high-frequency sound waves to destroy some kidney stones and gallstones, conditions that once required surgery.

E.

Mental Illness

Even in the early part of the 20th century, mental illness was almost a sentence of doom, and mentally ill persons were handled with cruel confinement and little medical aid. In the latter half of the century, successful therapy for some mental illnesses has greatly improved the prognosis for these diseases and has partly removed their stigma.

The theories advanced by Austrian physician Sigmund Freud were among the first attempts to understand malfunctioning of the mind, but the methods of psychoanalysis advocated by Freud and modified by his followers proved ineffective for treating certain serious mental illnesses. Two early attempts to treat psychotic illness were the destruction of parts of the brain in a procedure called lobotomy, introduced in 1935, and electroconvulsive therapy, devised in 1938. Lobotomy and less severe forms of psychosurgery are now used only rarely, and electroconvulsive therapy is primarily a treatment for depressive illness that has not responded to drug therapy.

A new era in treatment of schizophrenia, a severe form of mental illness, began in the early 1950s with the introduction of phenothiazine drugs. These drugs led to a new trend, deinstitutionalization, in which patients were released from mental hospitals and treated in the community. Valium (see Diazepam) and other benzodiazepine drugs went into wide use in the 1970s for treating anxiety and other emotional illness. Late in the century, there was growing awareness about the importance of diagnosing and treating clinical depression, a leading cause of suicide. Advanced imaging techniques that show the structural and functional differences in the brains of people with certain mental illnesses have opened the door for new treatment options.

F.

Genetics and Biotechnology

The discovery of genes and their role in heredity and disease was one of the most important medical advances in history (see Genetics). In 1953 British biophysicist Francis Crick and American biochemist James Watson identified the double-helix structure of deoxyribonucleic acid (DNA). This discovery helped to explain how DNA carried genetic information. In the 1960s American biochemist Marshall Nirenberg added key details about how DNA determines the structure of proteins.

Indian-born American biochemist Har Gobind Khorana was the first to synthesize a gene in the laboratory in 1970, forging the way for scientists to develop ways to isolate, alter, and clone, or copy, genes. They applied these genetic engineering techniques to the diagnosis and treatment of diseases. Researchers identified genes associated with cancer, heart disease, mental illness, and obesity. With the genes identified, they worked on ways of modifying the genes to treat the disease. Gene therapy emerged as an experimental medical field that used genetically modified genes to treat diseases. In 2003 scientists completed the sequence of the human genome, in which they identified all the genes needed to make a human being (see Human Genome Project).

Genetic engineering techniques enabled production of scarce human hormones and other materials for use as drugs. A new biotechnology industry started producing these materials for medical use. Scientists also began genetically modifying sheep and other animals to produce drugs in their milk.

G.

Endocrinology

In 1905, British scientist Ernest H. Starling introduced the word hormone to describe substances secreted by the endocrine glands that regulate body functions (see Endocrine System). The discovery of adrenaline, or epinephrine, in 1901 led to identification and isolation of other hormones. One of the most important advances was the discovery of insulin by Canadian scientists Frederick Banting and Charles H. Best and Scottish physiologist John J. Macleod in 1921. For years people with diabetes mellitus used insulin extracted from animal pancreases. In 1981, human insulin produced using biotechnology became available. American physicians made another major advance in endocrinology in 1949. They discovered that cortisone, an adrenal gland hormone, relieved inflammation. New discoveries about human sex hormones later led to the first birth control pills.

H.

Pregnancy and Childbirth

Great advances were made in birth control with the improvement of intrauterine devices in the 1950s and the development of the birth control pill in 1960 by the American biologist Gregory Pincus. By the 1990s long-lasting hormonal implants and contraceptive injections such as Depo-Provera were developed. These options gave women more control in deciding whether to become pregnant. Voluntary sterilization, involving vasectomies in men and tubal sterilization in women, emerged as a popular way of permanent birth control. Unwanted pregnancies, however, remained a serious problem in the late 1990s. Researchers still sought more convenient and safer methods of birth control, including a male birth control pill.

By 1975 physicians were able to diagnose some congenital or inherited diseases before childbirth (see Birth Defects). Doctors take samples of placental cells (see Chorionic Villus Sampling) or of the amniotic fluid around the fetus (see Amniocentesis) to determine whether hereditary blood diseases, Down syndrome, defects of the spine, or other congenital diseases are present. Even the sex of a fetus may be known in advance.

In addition to advances in early diagnosis, progress occurred in identifying the causes of some birth defects. Excess alcohol consumption during pregnancy was linked to fetal alcohol syndrome, and inadequate intake of the vitamin folic acid was linked to spina bifida and other neural tube defects.

Advances in treating infertility, which prevents couples from having children, began with the world's first so-called test-tube baby born in the 1980s through in vitro fertilization. Other forms of assisted reproduction soon became available. Researchers in 1997 cloned a lamb from cells taken from an adult ewe. It led to speculation that human cloning could become another option in human reproduction.

I.

Heart Disease

Heart disease emerged as one of the leading causes of death in Western countries by the end of the 20th century. Great advances occurred in diagnosis, treatment, and prevention of this widespread disease.

Diagnosis improved with the widespread use of cardiac catheterization in the 1950s. This procedure involves threading a slender tube into the heart to take measurements and identify blocked arteries. Less invasive diagnostic methods, such as thallium scans in which a special imaging camera detects the movement of thallium in heart muscle, provided additional diagnostic improvements.

These techniques led to a new era in surgical treatment of coronary heart disease, artery blockages that cause most heart attacks. Physicians began treating blocked coronary arteries with a variety of new techniques. The first bypass operation was performed in 1967 and involved the creation of a new route for blood supply to reach blood-starved heart muscles. In balloon angioplasty, developed in 1977, a deflated balloon is inserted into a narrowed artery. The balloon is then inflated at the site of the narrowing to widen it. Other surgical advances included replacement of diseased heart valves with artificial valves; implantation of pacemakers that maintain normal heart rhythm; use of temporary artificial hearts; and better methods for correcting hereditary defects in the heart.

New drugs were developed to treat angina pectoris, the chest pain of heart disease; high blood pressure; dangerous abnormalities in heart rhythm; and high blood cholesterol levels. Studies showed that drug treatment could reduce the risk of a heart attack or stroke. In the 1980s, aspirin went into wide use to prevent blood clots that cause many heart attacks. Emergency medical personnel also began using drugs that dissolve clots and stop a heart attack if given soon after symptoms develop.

Advances have been made in the prevention of heart disease. Studies have identified risk factors such as high blood pressure, high blood cholesterol, cigarette smoking, diabetes, obesity, and lack of exercise. Government health agencies and public health groups began public education programs to help people reduce heart disease risks. These preventive methods seem to be working—according to the American Heart Association, the death rate from coronary heart disease declined 26.3 percent between 1988 and 1998.

J.

Cancer

Early detection and better treatment have resulted in major improvements in survival of patients with cancer. By 2000, 59 percent of people diagnosed with cancer were alive five years later, compared with only 25 percent in 1940. New drugs, surgical procedures, and ways of treating cancer with X rays and radioactive isotope radiation contributed to the improvement. In the 1990s, physicians used new knowledge about the human immune system to develop immunotherapy for some kinds of cancer, in which the immune system is stimulated to produce antibodies against specific invaders. Another form of immunotherapy is the use of monoclonal antibodies, genetically engineered antibodies that target specific cancer cells.

Screening tests for early detection of cancers of the cervix, prostate, breast, and colon and rectum (see Colorectal Cancer) became widely available. Researchers also made progress in identifying cancer genes that are associated with an increased risk of the disease and developed screening tests for some cancer genes. Advances in gene therapy also offered promise for new cancer treatments.

Health groups placed great emphasis in the second half of the century on cancer prevention through avoiding smoking and eating a diet rich in fresh fruits and vegetables. Despite these advances, the percentage of deaths from cancer increased from about 2 percent in 1900 to about 20 percent in 2000. Much of the rise, however, resulted from an increased proportion of older people, who are more vulnerable to cancer, and from cigarette smoking.

K.

Telemedicine

Advances in computer and Internet technologies created new possibilities for doctors and their patients in the early 1990s. Using computers to send live video, sound, and high-resolution images between two distant locations, doctors can easily examine patients in offices thousands of miles away. Rural patients no longer had to make long trips into urban centers to consult specialists.

In telemedicine, a computer fitted with special software and a video camera turns a live video image of a patient into a digital signal. This signal is transmitted over high-speed telephone lines to similar equipment at the doctor’s office, where it is converted back into a format that can be viewed live on a television screen. Telemedicine also includes machines specially designed to measure and record a patient’s vital signs at home, then transmit the information directly to a hospital nursing station. This electronic remote home care enables health care professionals to monitor a patient’s heart rate, temperature, blood pressure, pulse, blood-oxygen levels, and weight several times a day, without the patient ever having to leave home.

In addition to providing a vehicle for doctors and patients in remote locations to interact, telemedicine also enabled doctors in distant locations to share information. Patient charts, X rays, and other diagnostic materials can be transmitted between doctors’ offices. Moreover, doctors in rural areas of the world can observe state-of-the-art medical procedures that they would otherwise have had to travel thousands of miles to witness. Still in its infancy in the late 1990s, telemedicine may one day alleviate some of the regional inequalities inherent in modern medicine, not just between regions of North America, but also between developing countries and urban medical centers in the industrialized world.