Galen,father of systematic medicine. An essay on the evolution of modern medicine and cardiology

Galen (129–217) was the ultimate authority on all medical subjects for 15 centuries. His anatomical/physiological concepts remained unchallenged until well into the 17th century. He wrote over 600 treatises, of which less than one-third exist today. The Galenic corpus is stupendous in magnitude; the index of word-entries in it contains 1300 pages. Galen's errors attracted later attention, but we should balance the merits and faults in his work because both exerted profound influences on the advancement of medicine and cardiology. Galen admonished us to embrace truth as identified by experiment, warning that everyone's writings must be corroborated by directly interrogating Nature. His experimental methods' mastery is demonstrated in his researches, spanning every specialty. In his life-sustaining schema, the venous, arterial, and nervous systems, with the liver, heart, and brain as their respective centers, were separate, each distributing through the body one of three pneumata: respectively, the natural, the vital, and the animal spirits. He saw blood carried both within the venous and arterial systems, which communicated by invisible “anastomoses,” but circulation eluded him. The “divine Galen's” writings, however, contributed to Harvey's singular ability to see mechanisms completely differently than other researchers, thinkers and experimentalists. Galen was the first physician to use the pulse as a sign of illness. Some representative study areas included embryology, neurology, myology, respiration, reproductive medicine, and urology. He improved the science and use of drugs in therapeutics. Besides his astounding reputation as scientist-author and philosopher, Galen was deemed a highly ethical clinician and brilliant diagnostician.     

John Keats: poet, patient, physician

John Keats, son of an ostler , was born in London in 1795. Despite an early interest in literature he was, surprisingly, apprenticed to an apothecary and continued his medical training at Guy's Hospital, obtaining the Licentiate of the Society of Apothecaries in 1816. He never practiced medicine. His early poems were not well received, and for the young poet with very slender means, life was difficult. Tragedy was added to difficulty when tuberculosis, which had already caused the death of his mother and uncle, became apparent in his brother Tom, whom Keats nursed through his illness when the brothers were living together in Hampstead . Subsequently Keats developed the disease, but despite its rapid progress, he managed in a single year - 1819 - to produce some of the finest lyrical poetry in the language. He went to Italy in the hope of obtaining a cure but died in Rome in 1821, aged 25. Medicine certainly contributed to the man, but also something to the poet, Keats; his training and his family and personal experience of tuberculosis speak for themselves. More subtly , his medical experience influenced in some degree his ideas and even his choice of words. The interrelations of poet-patient and trainee-physician are examined in this essay.     

Medical Treatment for Thoracic Aortic Aneurysm – Much More Work To Be Done

A 45 year old executive presents to your office for risk assessment after learning that his sister required an ascending aortic aneurysm repair. He is a well-informed man, concerned about his personal risk for aortic disease, and undergoes a cardiac screen which reveals a dilated ascending aortic aneurysm, measuring a maximal diameter of 4.4 cm. His aortic valve is tricuspid. He is non-Marfanoid and asymptomatic. He realizes that he does not yet meet guideline criteria for aortic surgery, but he is also cognizant of the fact that he is approaching the cut-off for surgical intervention. He wishes to minimize his future risk of aortic rupture, dissection and aortic expansion and seeks your input. Should ‘medical treatment’ should be employed at this stage? Is there sufficient basis to initiate any form of pharmacotherapy? Would you start a beta-adrenergic receptor blocker, an angiotensin receptor blocker, a matrix metalloproteinase inhibitor (doxycycline), or a statin to reduce his aortic risk for rupture, dissection or need for surgical repair? Does your clinical decision match evidence from existing data? Our paper will address these issues among other questions relevant to the role of medical therapy for thoracic aortic disease.     

Cases from the Osler Medical Service at Johns Hopkins University. Pseudoachalasia due to esophageal adenocarcinoma

Presenting features

A 69-year-old man presented with nausea and vomiting. He was in good health until 2 years before presentation, when he first noted occasional difficulty eating solid foods. He could chew food without difficulty, but sometimes he had the sensation that the food was lodged in his chest. This sensation would persist for several hours; occasionally, he would need to induce emesis for relief.These episodes of chest discomfort became more frequent over time. Two weeks before presentation, he had to induce emesis after every meal and began having difficulty ingesting both liquids and solids. On the day of his presentation, he awoke at 3:00 am feeling hungry. He drank some juice, after which he had emesis and chest pain, which led him to believe that he was having a myocardial infarction.His past medical history included hypercholesterolemia and gastroesophageal reflux disease attributed to a hiatal hernia. His only medication was simvastatin, which he stopped taking 1 month before presentation because he thought that it was con-tributing to his difficulty in swallowing. He had not smoked for more than 30 years. He previously drank one beer a day but recently stopped drinking as well. A review of systems was notable for an unintentional weight loss of 20 lbs during the past 6 months.On admission, his vital signs were normal. His chest, cardiac, and abdominal examinations were unremarkable. His electrocardiogram and laboratory tests were normal. A barium swallow (Figure 1 and Figure 2) demonstrated tapering of the distal esophagus.What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A healthy 44-year-old man presented to the Johns Hopkins Hospital after two episodes of nonpurulent hemoptysis, each consisting of approximately one-half cup of blood. The episodes were painless and were preceded by minimal coughing. The blood was bright red and without clots. He denied a recent history of upper respiratory tract infection, chest trauma, chest pain, or nasal/sinus disease. He had a chronic nonproductive “smoker’s cough.” He denied a recent history of fevers, chills, night sweats, hematuria, joint pains, epistaxis, or weight loss, and had no allergies. His past medical history was notable for neurogenic diabetes insipidus and diet-controlled diabetes mellitus. His only medication was intranasal desmopressin acetate. He smoked two packs of cigarettes daily for more than 20 years and rarely drank alcohol.On physical examination, he was afebrile, with normal heart rate and blood pressure. His oxygen saturation was 94% on room air, and his respiratory rate was 16 beats per minute. His lungs were clear to auscultation bilaterally, without evidence of crackles or wheezes. He had bilateral digital clubbing. His white blood cell count was 10,770/mm³, with a normal differential. His hematocrit was 46%, and his platelet count was normal. Blood chemistries and urinanalysis were normal. A posteroanterior and lateral chest radiograph obtained on admission demonstrated moderate diffuse interstitial fibrosis involving the upper and lower lung (Figure 1A and 1B ). What is the diagnosis?     

Sir Austin Bradford Hill: medical statistics and the quantitative approach to prevention of disease

Abstract Sir Austin Bradford Hill (1897-1991), son of a prominent medical physiologist, was destined for the study of medicine when World War I intervened. He chose to enlist as a pilot in the Royal Navy Air Service. Having contracted tuberculosis on his way to the Dardanelles, Hill was 'sent home to die'. In spite of the odds he recovered; but with no chance of working in physically taxing fields such as medicine or science. Advised and encouraged by Major Greenwood, he carved out for himself a career in medical statistics, first at the Medical Research Council and subsequently at the London School of Hygiene and Tropical Medicine, where his inspired teaching helped to shape the development of medical research in the second half of the twentieth century. He is particularly remembered for the way he made medical statistics an essential part of modern epidemiology, a new phase in an epidemiology concerned with chronic as well as with infectious diseases. At the same time, he introduced randomization where therapies-beginning with streptomycin in tuberculosiscould be evaluated in large-scale clinical trials. Perhaps his best known achievement is his design of the smoking and lung cancer trials, carried out with Richard Doll who later extended-and still extends-the trials which so convincingly have linked addiction to tobacco to patients' later problems with cancers and with coronary heart disease.     

Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: An 18-year-old white man was admitted to the Osler Medical Service with the chief complaint of back pain. Two weeks prior to admission, the patient developed diffuse and aching upper back pain. Over the next couple of days, he also developed severe anterior chest pain that was somewhat pleuritic in nature but diffuse and extending bilaterally into the shoulders. One week prior to admission, he developed intermittent fevers and night sweats. The patient denied any lymphadenopathy, pharyngitis, sick contacts, shortness of breath, rash, or bleeding. He was seen by a physician and told that he had thrombocytopenia. There was no history of recent or remote unusual bleeding episodes. His medical history was unremarkable except for a childhood diagnosis of attention deficit/hyperactivity disorder. He was not taking any medications and had no history of tobacco, alcohol, or illicit drug use. He had no risk factors for human immunodeficiency virus infection. Physical examination showed that he was afebrile and had normal vital signs. He was a well-appearing man who was lying still because of pain. HEENT examination was unremarkable. There was no pharyngeal erythema or exudates. His lungs were clear. His neck was supple and without lymphadenopathy. Examination of his back and chest revealed no focal tenderness. There was no hepatosplenomegaly, and his skin was without petechiae or rashes. Examination of the patient's joints showed pain on passive and active movement of his shoulders bilaterally, but no frank arthritis. There was no rash, petechiae, or echymoses. Chest radiograph and electrocardiogram were unremarkable. On admission, the laboratory examination was notable for a hematocrit level of 32.5%, with a mean corpuscular volume of 79 fL, and white blood cell count of 2.8 x 10(3)/microL. Platelet count was 75 x 10(3)/microL. A white blood cell differential revealed 7% bands, 53% polys, 34% lymphs, 5% atypical lymphocytes, 2% nucleated red cells, and a few young unidentified cells. His chemistry studies were unremarkable. What is the diagnosis?     

Enteroviral meningoencephalitis in a patient with non‐Hodgkin's lymphoma treated previously with rituximab

A 75‐year‐old man, with a long history of recurrent lymphoplasmacytoid lymphoma, presented with diffuse large‐cell lymphoma affecting adrenal glands and causing severe hypoadrenalism. The lymphoma responded to rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R‐CHOP) chemotherapy. Seven months postcompletion of chemotherapy, he developed signs of gastroenteritis and septicaemia. He deteriorated 24 h postadmission with a significant fall in Glasgow Coma Scale Score. Polymerase chain reaction testing of cerebrospinal fluid suggested enteroviral encephalitis. He responded symptomatically to intravenous immunogobulins. His immunoglobulin levels were monitored weekly and supplemented to maintain immunoglobulin G level at 10 g/l, but in spite of this, his neurological condition deteriorated and he died after 14 weeks. Rituximab can cause prolonged B‐cell deficiency. We speculate that profound immunosuppression induced by rituximab, together with previous chemotherapy, predisposed this patient to fatal enteroviral meningoencephalitis.     

Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: A 70-year-old African American man was admitted with a history of fever, chills, and malaise of several days' duration. His past medical history was notable for end-stage renal disease requiring hemodialysis, coronary artery disease, and aortic stenosis requiring a bioprosthetic aortic valve replacement. On the day of admission, the patient was noted to have a shaking chill while undergoing dialysis through his catheter and was admitted to the hospital. He complained of pain at the catheter insertion site, shortness of breath, and dyspnea on exertion, but denied chest pain. On physical examination, the patient had a temperature of 100.4 degrees F, with a heart rate of 64 beats per minute, blood pressure of 127/72 mm Hg, and an oxygen saturation of 97% on room air. He was a mildly obese man in no apparent distress. He had shotty cervical lymphadenopathy and a right subclavian dialysis catheter in place, with erythema and pus at the entry site. His jugular venous pressure was 10 cm H(2)O. Lung examination showed bibasilar rales. Heart sounds were normal, with no rub or gallop. He had a 2/6 systolic ejection murmur best heart at the left sternal border as well as a 3/6 holosystolic murmur at the apex that radiated to his left axilla. Examination of the abdomen and extremities was unremarkable. The patient's neurological examination was unremarkable, and he was alert and oriented to person, place, and time. Laboratory studies showed an elevated white blood cell count of 16,700 cells/microL. His blood urea nitrogen level was 43 mg/dL and his serum creatinine level was 4.9 mg/dL. Multiple blood cultures grew methicillin-resistant Staphylococcus aureus. An admission, chest radiograph showed no infiltrate. An admission electrocardiogram showed normal sinus rhythm with first degree atrioventricular block, left anterior fascicular block, and left ventricular hypertrophy. shows rhythm strips from lead II electrocardiograms 5 months before admission (top), on admission (middle) and 5 days after admission (bottom). What is the diagnosis?     

James Young Simpson 1811–1870

James Simpson was born on June 7, 1811, at Bathgate, Scotland, the youngest of seven sons of the village baker. His mother died when he was quite young but, because of James' obvious scholastic aptitude, his entire family agreed to do without in order to give him further education. He endered Edinburgh University at the age of 14 and began his medical studies two years later, graduating with his M.D. in 1832. His extraordinary abilities were soon recognized, and he was made president of the Royal Medical Society of Edinburgh in 1835 and appointed to the chair in midwifery in 1893 at the age of 28. He was the first in Britain to employ ether as an anesthetic and, with his associates, was the first to use chloroform as an anesthetic (1849). In addition to his achievements in the field of anesthesia, Dr. Simpson was responsible for laying a considerable part of the foundation of gynecology and obstetrics. He invented the uterine sound and the obstetrical forceps. His interests were many and varied. In addition to his considerable medical writings, he published three volumes on antiquarian subjects. But the subjett for thisclassic presentation is one which has generated little press and enthusiasm—that of coccygodynia. Simpson is the original describer of the condition to which he adds a discussion of various sarcococcygeal lesions. In 1866 Simpson achieved baronetcy, the first given to a doctor practicing in Scotland. He became a member or honorary member of nearly every medical society in Europe and America. Dr. Simpson died on May 6, 1870, at the age of 59. His family declined the offer of a grave in Westminster Abbey, but a bust was placed there on which is inscribed that to Simpson's “genius and benevolence the world owes the blessings derived from the use of chloroform for the relief of suffering”.     

Cases from the medical grand rounds of the Osler Medical Service at Johns Hopkins University

A 77-year-old man was in good health until he complained of fatigue 3 weeks before presentation. Two weeks before admission, he developed gradually worsening shortness of breath. One week before admission, he developed a cough that initially was nonproductive but later was associated with hemoptysis.His past medical history was remarkable for a history of colon cancer (Dukes' stage III), for which he underwent a hemicolectomy and treatment with adjuvant chemotherapy in 1993. He had a myocardial infarction in 1986 and underwent coronary artery bypass surgery in 1999. He also had a history of hypertension, type 2 diabetes, and gout. He smoked in the past but had stopped more than 30 years ago.He was initially evaluated by his primary care physician, who noted that he complained of diaphoresis but denied fevers, chills, or contact with others who were ill. His physical examination was remarkable for bilateral crackles that were more pronounced on the right. A chest radiograph demonstrated bilateral pulmonary infiltrates (Figure 1). He was treated with amoxicillin. The next day, however, his physician noted that his dyspnea had worsened and that his oxygen saturation on room air was poor. He was therefore admitted for further evaluation.The amoxicillin was discontinued, and he was treated with levofloxacin, followed by ceftriaxone and azithromycin as his pulmonary status continued to deteriorate. He received intravenous diuretic agents, which failed to improve his respiratory status.During the initial phase of hospitalization, he was anemic, with a hematocrit of 21.3%. His serum creatinine level, which had been 1.0 mg/dL in 1999, was now 2.5 mg/dL. Urinalysis was remarkable for the presence of numerous red blood cells. His oxygen requirement increased, and he eventually required a 100% nonrebreather mask. A computed tomographic scan of the chest demonstrated prominent alveolar opacities throughout the right upper, middle, and lower lobes, with similar opacities in the left upper and left lower lobes (Figure 2). An echocardiogram showed an ejection fraction of 50%, as well as mild mitral regurgitation. Serologies were remarkable for an antinuclear antibody titer of 1:320 and a P-antineutrophil cytoplasmic antibody (P-ANCA) titer of greater than 1:320. C-ANCA was negative. Anti-glomerular basement membrane and anti-human immunodeficiency virus antibodies were undetectable.     

Cases from the Osler Medical Service at Johns Hopkins University. Bartonella henselae infection of the liver and spleen

Presenting features

A 26-year-old man with human immunodeficiency virus infection (CD4 count, 3/μL) was admitted for evaluation of a 2-month history of fevers and fatigue and a 1-week history of nausea and abdominal pain. He had no previous history of opportunistic infections. His physical examination was notable for a temperature of 39°C and mild hepatomegaly without significant tenderness. There were no heart murmurs, and he did not have splenomegaly, lymphadenopathy, skin rash, or neurological changes. His white blood cell count was 2.9/μL, his platelet count was 132,000/μL, and his hematocrit was 22.4%. His alkaline phosphatase level was slightly elevated at 152 U/L, but his aminotransferase and bilirubin levels were normal. Evaluation included negative hepatitis serologies, negative blood and mycobacterial cultures, negative toxoplasmosis immunoglobulin (Ig) M and IgG, a nonreactive rapid plasma reagin, a negative purified protein derivative skin test, and negative serum cryptococcal and urine histoplasmosis antigens. A computed tomographic scan of the abdomen (Figure 1) revealed hepatomegaly with a patchy enhancing pattern, periportal edema, and multiple small lesions in the spleen.Upon further questioning, the patient reported that he had traveled extensively in Italy, France, and Spain while in the military, during which had he consumed unpasteurized milk products. He was currently working as a drill sergeant at a prison. He also had a pet cat and had recent contact with a friend’s kitten.What is the diagnosis?     

Burnet and Medicine

Sir Macfarlane Burnet had a progressive rise in the world of Medical Science, from a shy ward medical officer at the Melbourne Hospital to a scientist of world renown as Director of the Walter and Eliza Hall Institute. He won fame in the field of virology, making a special study of the influenza virus, which he began in London under Sir Henry Dale. In 1957 he switched his researches from virology to immunology and again achieved fame by his study of autoimmune disease. His contributions to clinical medicine were many and varied, including the isolation of C. burneti, the discovery of two strains of poliomyelitis virus, and the applications of his clonal selection theory to the autoimmune diseases in Man. Amongst his many honours and awards were the Order of Merit, and the Nobel Prize which he shared with Sir Peter Medawar of London. Congratulations on his achievements are extended to him on the occasion of his seventieth birthday.     

Wilhelm His Jr. (1863-1934)--the man behind the bundle.

Wilhelm His Jr. (1863-1934) was a Swiss-born cardiologist and anatomist. In 1893, he discovered the bundle of His-the specialized tissue in the heart that transmits the electrical impulses and helps synchronize contraction. He pioneered studies in cardiac conduction and coined the term "heart block," which he identified as the cause of Adams-Stokes disease. He was a professor of medicine at the University of Berlin, became the dean of medicine in 1918 and in 1928 was elected rector of the University of Berlin. Through his long clinical and teaching career he became better known for his work on gout and diseases of the joints. "Trench fever," or Werner-His disease, was also named after him. This report presents the life and work of Wilhelm His Jr., who was described by his colleagues as "a master of his profession, a great physician, investigator, and a well cultured gentleman."     

Paul Kraske 1851–1930

Paul Kraske was born June 2, 1851, in Berg, near Muskau. He obtained his surgical training in Halle under the tutelage of Richard von Volkmann, working as his assistant from 1876 through 1883. In 1878 he presented his doctoral dissertation on an “Experimental Investigation Concerning Regeneration of Striated Muscle.” For several years Kraske demonstrated a particular interest in colorectal cancer, producing a number of publications on this subject. This was the foundation of his fame, so that he was appointed director of the Surgical Clinic in Freiborg at the age of 32 years. In 1885 he presented a lecture at the Fourteenth Congress of the German Society of Surgery on the subject of the transsacral approach to the removal of rectal cancer. His experience was based on cadaver dissection and treatment of two patients. It is for this report that Kraske achieved eponymous immortality. Kraske remained faithful to the University of Freiborg until his death. He led the clinic for 36 years and retired in 1919 at the age of 68. Kraske is remembered as a man with a “soft and feeling heart,” yet with a clear mind. He was always very critical with respect to the proposition of various scientific ideas. He was not one who immediately accepted change. He was felt to be rather shy and preferred quiet work in the operating room and at the patient's bedside. He was also considered a great patriot, having volunteered as a soldier in the Franco-Prussian war of 1870–1871, and as a medical officer in the beginning of the first world war (1914). His particular interest in later years was in the value of early exploratory laparotomy for abdominal wounds. Kraske died June 15, 1930, a the age of 80 years. He is considered one of the great early masters responsible for the development of surgery.     

To die in one's prime: the story of Paul Wood

Paul Wood, the leader of European cardiology during the mid-20th century, was internationally admired for his bedside teaching, clinical investigations, and an important textbook on cardiology. His studies, based on a unique quantitative approach to the grading and recording of clinical data, introduced cardiac physiology to the bedside, brought accuracy to the preoperative assessment of cardiac disease, and became the foundation for much of our current understanding about congenital and rheumatic heart disease and pulmonary hypertension. At the bedside, in front of a crowd of postgraduate students, registrars, and visitors, he was renowned for his showmanship and dazzling ability. His commanding personality--caustic, sarcastic, and combative--impressed many and offended some as he openly argued with himself and others to sleuth out the correct diagnosis. His 1950 textbook, Diseases of the Heart and Circulation, characterized by his lucid and personal style of writing and a fresh physiologic approach to cardiology, brought Wood worldwide recognition as the European authority on heart disease. The incessant demands to see patients, teach, and lecture, the burden of writing his third edition of the book, and his heavy smoking eventually took their toll. On July 13, 1962, at the age of 54, Paul Wood, the gale force wind of British cardiology and the inspiration and role model for many students, died quietly following a myocardial infarction. He left a legacy of great accomplishments as the transition figure between the old and modern era of cardiology.     

A case of thyroid storm with multiple organ failure effectively treated with plasma exchange

We describe a 48-year-old man with thyroid storm presenting with heart failure. He presented severely impaired left ventricular wall motion and a marked increase in the liver enzymes. He developed disseminated intravascular coagulation on day 2. Due to elevated serum thyroid hormone level, anti-thyroid hormone receptor antibody positivity, and his clinical symptoms, he was diagnosed as thyroid storm due to untreated Graves' disease. His condition did not improve even after 6 days of conventional therapy including steroids. After therapeutic plasma exchange was carried out, his thyroid hormone level decreased markedly. Consequently, his condition recovered gradually, and he was discharged at day 43.     

Perforation of the gall bladder following blunt abdominal trauma

A 66-year-old man presented after having been involved in a motor vehicle accident. He was not wearing his seatbelt, and his vehicle had a deformed steering wheel after the incident. In the emergency department, his only complaint was mild right lower quadrant abdominal pain without signs of rebound or guarding. His laboratory and radiologic evaluations were unremarkable and he was observed in the intensive care unit. Nine hours after the accident, he developed an acute abdomen; exploratory laparotomy revealed a perforation of the gall bladder. Gall bladder injuries secondary to blunt trauma are infrequent events.     

Normolipidemic xanthomata of the hand extensor tendons

A 48-year-old man presented with soft tissue lumps over the metacarpophalangeal joints of the long and index fingers of his left hand due to tendon xanthomas. His personal history and laboratory investigations were negative for familial hyperlipidemia or other medical conditions. A simple debulking procedure produced a good cosmetic and functional result at 7 years' followup.