News #13 | April, 2010
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100 Years of Medicine: a Historical Perspective - Part I
Manuel Valente Alves
Director of the FMUL Museum of Medicine

Just like the cyclist in whom movement is a condition of his stability, the human being’s condition of survival seems to be evolution. Over a hundred years went by from the discovery of the neuron, by Ramón and Cajal in 1904, until the complete sequencing of the human genome in 2007. During this period medicine evolved much more than in millennia of history. 

Reforms in Medical Teaching
In 1910 the American scholar Abraham Flexner produced his famous report Medical Education in the United States and Canada, the conclusions and proposals of which would be at the origin of important changes in medical teaching, not only in the USA, but also in the whole of the western world, which profoundly altered medical praxis and consequently the doctor-patient relationship. Flexner, combining the English university model with the German one, proposed the definition of the entrance standards; increasing of the length of medical courses to four years; introduction of laboratory teaching; stimulation for full-time teaching; creation of the Basic cycle and the expansion of clinical teaching, particularly in hospital; linking of medical schools to universities; emphasis of biological research as a form of overcoming the empirical era of medical teaching; linking of research to teaching and control of professional activity by the organized profession.

The following year saw the beginning of the most important university reform in Portugal over these last hundred years, which created the Universities of Lisbon and Oporto, and from which emerged an elite of doctors, the “Medical Generation of 1911”, which revolutionized medical teaching in Portugal. The Lisbon Medical-Surgical School became the Faculty of Medicine, and the Basic research institutes were founded, articulating medical aid to teaching, according to the Humboldtian model of the University of Berlin. Among the protagonists of this movement one should highlight: Augusto Celestino da Costa, founder of the Institute of Histology and Embryology; Henrique de Vilhena, founder of the Institute of Anatomy; Azevedo Neves, founder of the Institute of Legal Medicine; Aníbal Bettencourt, Director of the Bacteriological Institute after the death of Câmara Pestana; Sílvio Rebello, founder of the Institute of Pharmacology; Marck Athias, founder of the Institute of Physiology (with Joaquim Fontes and Ferreira de Mira); Francisco Gentil, pioneer of Oncology in Portugal. In clinical practice one should also mention from this generation the psychiatrists Júlio de Matos and Sobral Cid, and the internal doctor António Pulido Valente, who introduced the anatomical-clinical model into Portugal with the support of the German anatomo-pathologist Friedrich Wohlwill.

On the 12th of August 1988 the Edinburgh Declaration is published within the scope of the World Conference for Medical Education, which draws up some guidelines for a reform in medical teaching. What stands out among them is the importance of investment, not only in scientific research, but also in humanist culture: “Scientific research continues to bring rich rewards; but man needs more than science alone, and it is the health needs of the human race as a whole, and of the whole person, that medical educators must affirm.”

On the 3rd of November of the same year there is the publishing of the report of the Lisbon Initiative of the “Ministerial Consultation for Medical Education in Europe”, which concludes the following: “The Ministerial Consultation was most encouraged by the firm decision taken by the Ministers of Education and Health of Portugal to take immediate steps to start the process for ensuring change in line with the Edinburgh Declaration and the European health for all strategy. The Ministerial Consultation proposes that all other countries should consider following this example.”

In the report by the World Federation for Medical Education, on the 14th of February 1992, the effort made in Portugal in this sense is mentioned: “Contemporary medical education demands coordination between medical schools, teaching hospitals, hospitals in the government health services, health centres and primary care provision including general practitioner services. At an international meeting in Paris, called by the Organization for Economic Co-operation and Development to clarify problems relating to academic teaching hospitals, the national arrangements of the medical school/teaching hospital interface in Portugal were revised, the Portuguese case study presented by Rector Esperança Pina. […] The law 246 of 5 August 1989 established new arrangements for organizing teaching teams in all hospitals and other health services institutions with responsibilities in medical education.”

In 1999 the Bologna Declaration is presented. Its main aim is to create a common educational space in Europe, giving higher education a more cosmopolitan dimension, in line with the original values of the University of Bologna in the XII century, in which free circulation was established in a charter, the Constitutio Habita.

The Portuguese School of Angiography 

The Portuguese School of Angiography, in the context of which some of the most important research activities in the world in the field of imagiology have been carried out, placing Portugal on the pages of world history of science, was founded in 1927 by Egas Moniz and Reynaldo dos Santos. Egas Moniz, doctor, politician and writer, was the one who took the first step in inventing cerebral angiography that year, which for the first time made it possible to make a topographical diagnosis of intracranial lesions. In 1929 Reynaldo dos Santos, doctor and art historian, invented aortography and limb arteriography, and in 1939 introduced the “concept of the arterial tract in semiology and in therapy”, which opened the way to everything that is done today through the arteries (introduction of drugs, instruments, etc.). In 1930 the doctor Hernâni Monteiro developed a technique for visualising the lymphatic vessels called lymphoangiography, starting from the original method of cerebral angiography. In 1931 Fausto Lopo de Carvalho, a pneumologist, communicated to the Lisbon Academy of Sciences the results of the work that led him, along with Egas Moniz and Almeida Lima, to the invention of angiopneumography, a technique which allowed visualization of pulmonary circulation. In 1949 the doctor António de Sousa Pereira (1904-1986) introduced portography, which would open the way to the research by the Italians S. Abeatici and L. Campi, who, two years later, would invent splenoportography, a new method of exploration that facilitate pre-operational study of portal hypertension. The first flebography on a human being with visualisation of the femoral vein was carried out in 1938 by the surgeon João Cid dos Santos. In 1952 Eduardo Coelho, a Portuguese doctor and humanist, presented the first coronariographies on a living man to the 1st European Congress of Cardiology, in London, thus closing that which is considered by many to be the “Golden Age” of medicine in Portugal.

Egas Moniz, Nobel Prize 

In 1935 Egas Moniz invented pre-frontal leucotomy, a surgical technique used in the treatment of certain psychoses. The treatment rapidly became popular all over the world, opening up the vast field of research of contemporary neurosciences and neuroculture. Walter Freeman and James Watts dedicated their book Psychosurgery to him: “To Egas Moniz, the first one to conceive and carry out a valid operation for mental illness”. In 1949 he was awarded the Nobel Prize (shared with Walter Rudolf Hess).

New Therapies for Old Illnesses

In 1921 the Canadian scientists Frederick Grant Banting, Charles Best and James Collip isolated insulin for the first time in the world. The following year they administered it to a diabetic patient. The discovery saw Banting receive the Nobel Prize for Physiology and Medicine in 1923.

At the beginning of the nineteen-forties two major discoveries revolutionised the concept of risk associated to infectious diseases, then responsible for extremely high rates of mortality throughout the world: antimicrobial antibiotherapy, and the vaccines (against tetanus, diphtheria, initially, and then against tuberculosis, a polio and convulsive coughing).

Penicillin, the first antibiotic to be used successfully, was discovered in 1928 by Alexander Fleming, a British microbiologist, but it would only be commercialized later, in 1941.

In 1943 Selman Abraham Waksman, a Ukrainian biochemist, discovers streptomycin, the first antibiotic efficient against tuberculosis, one of the most devastating illnesses for humanity. The discovery earned him the Nobel for Physiology and Medicine in 1952.

As for vaccines, these ended up becoming the object of regulation and legislation, principally since the nineteen sixties. The prophylaxis then became a responsibility that was not only individual but collective. The mass vaccination of large populations, promoted by the World Health Organisation (WHO) from the sixties on, allowed the significant reduction of the incidence (or even the idea of eradication) of some devastating diseases, such as tuberculosis, which, however, is now emerging all over the place in the form of multi-resistant strains, for which traditional tuberculostatics are no longer efficient.

Smallpox, which killed a large number of people throughout the world, seems to have been eradicated today, thanks to the WHO programme of vaccination. The last recorded case of smallpox was in Somalia in 1977.

But there are diseases that have been neglected, as is the case of malaria or leprosy (Hansen’s disease), which because they affect populations in poor areas of the world are of little interest to the companies that support research. Fortunately the situation is beginning to improve with the development of some countries in South America, like Brazil, and in Africa, like Angola, or on the Asian continent, like China and India. Over the last years in Portugal there has been increasing interest by researchers for this type of diseases in the Institute of Hygiene and Tropical Medicine.

During the sixties and seventies the Swiss researchers Werner Arber and the Americans Daniel Nathans and Hamilton O. Smith discover that the enzymes of restriction, or endonucleases, possess the property of dividing the chain of DNA nucleotides into fragments, with each one of them containing determined genes. The preferred bacteria for the obtaining of recombining DNA is Escherichia coli, with which it was possible to obtain insulin that today is used in the production of vaccines, like those for hepatitis B. The discovery, which led to the creation of genetic engineering, won then the Nobel Prize in 1978.
In 2008 the Nobel Prize for Physiology and Medicine was awarded to the German virulogist Harald zur Hausen for the discovery of the role of the papilloma virus in cervical cancer in 1983. It is the rebirth of the germinal concept of oncological disease, which had been abandoned for a long time.

Photo 1. Infusion pump (used by Reynaldo dos Santos in aortography); torsion scale; timer. Exhibition "Passages - 100 works for the Museum of Medicine" at the National Museum of Early Art (MNAA), Lisbon (2005). Photo: Nina Szielasko

Photo 2. High vacuum unit (designed by A. R. Gilson in 1945). Exhibition "Passages - 100 works for the Museum of Medicine" at the National Museum of Early Art (MNAA), Lisbon (2005). Photo: Nina Szielasko

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Prof. Doutor J. Fernandes e Fernandes
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