Eric Anderson, MD

, where I read about a British accountant who, faced with a 39-week wait for cataract surgery through the NHS, chose to have the surgery privately-in Norway. Despite consumer costs in that country that seem high even to visiting Brits (about $14 for a pint of beer), the prices for elective private surgery in Norway pale in comparison to Britain: Cataract surgery on two eyes that costs £4,000 ($5,719) privately in the U.K. costs £2,750 ($3,932) in Norway-and that includes air and travel insurance, and a hotel room for the patient and a companion. 

Evidently, there are patients out there who are vocal about what they see wrong with the NHS and are prepared to put their money where their mouth is. There was an article in the 

 about a 23-year-old accountant-what is it with accountants?-who decided to have private cosmetic surgery to shorten her toes so she would look better in today's fashionable "peep-toe" shoes. It will be months before she can walk, so she better hope that style of shoe is still in fashion when she finally is able to slip on her stiletto.  

The public showed its ire in a report that general practitioners were being given bonuses for 

 referring patients to hospitals. It seems, under the scheme, a primary care doctor's practice could earn up to an additional £20,000 ($28,594) above its usual compensation by treating patients who might have previously been sent to specialists.  

In the United States, the American Academy of Family Physicians has long maintained that a very high proportion of all problems can be treated by family physicians, but this U.K. concept is something quite different. It's being viewed by patient-support groups as an unethical attempt by bureaucrats to deny services. In County Oxfordshire, incidentally, 80 of 82 GP practices have signed up for this "non-referral" scheme that only began last October. 

It's quite a struggle to read the daily news and not feel it's a script for a Monty Python sketch. A woman was admitted to a hospital in Manchester after a fall at home. The 78-year-old fell out of bed in the hospital two months later "because of an insecure [bed]rail." Four days later, an X-ray revealed a neck fracture; she died the next day. The pathologist described the injury as the only recent fracture identified, but later said he'd made a mistake by using the word "recent." The death was then said to be the result of natural causes. The family protested, but the subsequent inquest, five years later, cleared the hospital.  

Maybe George Bernard Shaw was right. We really are two countries separated by a common language.  

, MD, is a retired family physician in San Diego, California. Send your feedback to 

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Articles

How is socialized medicine going? Just look to the U.K.'s newspapers.

Viewpoint: What's really happening with the U.K.'s health system

 Come to the Greek island of Kos, where the Western world's first medical school   thrived, and time still moves to ancient rhythms. 

Text and photos by Eric G. Anderson, MD
  Family Physician / San Diego

The sunset at Cape Sounion, on the journey to Kos, is spectacular.

 Greece has always been a mystical place for me. It's where arguably the greatest   civilization in history began, where democracy first flowered, and where the   greatest physician of all time was born, lived, and practiced his craft, on   the island of Kos. 

Kos, which lies so far east in the Dodecanese chain that its shores are only four miles from the mainland of Turkey, is the Greek island least visited by Americans. But it's such a summertime favorite of Scandinavian, German, and British tourists that a spring or fall visit is advisable if you want to savor the place for what it has to offer.

And what it offers, if you get beyond the new resorts that rise up around the waterfronts of the capital, also called Kos, is fishing villages where the rhythms and flavor are Greek.

We sat in a taverna in the little town of Kardamena, 18 miles southwest of the capital. Our lunch was the typical "peasant salad" of tomatoes, olives, cucumbers, and onions with huge chunks of feta cheese on top, and some honey and yogurt on the side. Even for spring, it was a hot, languid day and no one was in a hurryespecially the waiter. We mentioned that to a Greek companion, who responded with the remark heard all over Europe: "Americans hurry too much."

 He pointed out the owner of the taverna, a burly man sitting with friends   around a long table in a corner. They were all clutching their ouzo, telling   stories, and having a great time. 

"I was in this restaurant one night," said our guide, "when an American tourist signaled he wanted his bill. He couldn't get the owner's attention. Finally he went over and said he wanted to pay. The owner replied that he'd come to the man's table in half an hourhe was with friends. The American got angry and said he'd leave without paying if he couldn't have his bill immediately. The owner said, 'That's okay. Go.'

"The American flung some money on the table and stormed out. He didn't understand."

 I thought of this the next day at the harbor, where an old fisherman had laid   out sponges harvested from the sea. Usually Greeks enjoy hagglingand, of   course, being originally Scottish, I like a bargain, too. 

He had two qualities of sponges, with brown cardboard signs showing the prices of $1 and $2, oddly enough in US dollars. I picked up a big $2 sponge from the table and said, hopefully, "One dollar?" He slapped my handI guess playfullyand said, "You bad boy!"

 I came back to the hotel to show my wife the $2 sponge I'd got for $2 and   some native-fired china I'd bought at Clarisse's Keramik factory on the outskirts   of town.

On the islands, life hasn't changed much since an unknown sculptor created   this statue of Hippocrates.

The next day, I drove two-and-a-half miles out of Kos, past chickens and pigs and goats, past honey-colored buildings laden with bougainvillea and gardens spilling with olive trees and oleanders, to the most famous architectural ruins in medical history.

When Hippocrates was born on Kos in 460 BC, the prosperous island was home to 160,000 people. Today, the population is one-sixth that number. Thanks to tourism, however, local residents are regaining some of their affluence.

Astypalaia, the capital in the fifth century BC, lay on the west side of the 28-mile-long island, distant from the eastern sea routesand the pirates who plied them. This gives some credibility to the theory that Hippocrates taught his students on the west coast of Kos, nowhere near the present capital. According to some historians, the father of medicine never entered the temple of healing, the Asklepieion.

But when the settlements in the western part of the island were destroyed by an earthquake and a subsequent Spartan invasion in 411 BC, the people moved the city to the present location of Kos, to be close to a friendly populace and the Asklepieion itself. Some writers, describing a fire there, relate that Hippocrates tried to save "manuscripts and tables of the temple" and was severely burned, nearly losing his life.

But was the Asklepieion, unearthed in 1902, the same one honored by Hippocrates?

Many archaeologists believe so. That's good enough for physicians who 

, as they wander in the Asklepieion, that they're walking in the footsteps of Hippocrates himself. This ancient center of healing spreads across wooded groves on the lower slopes of Mount Oromedon. That the grove was sacred in earlier times adds to the belief that Hippocrates practiced here, even though his teachings and writings were the antithesis of the "incubation" ceremonies, miracle cures, and other religious rituals of ancient Greece's temple priests.

Roman conquerors partook of the mythology surrounding Hippocrates.
  They built the temple of Apollo at Asklepios.

The area is laid out in three terraces. The view from the upper level carries   the eye over tall cypress trees to the green fields and cobbled streets of Kos,   to the harbor and the 14th-century battlements of the Knights of St. John andbeyond   the turquoise seato the coastline of Turkey itself. 

In contrast to many archaeological sites, this one is easy to understand. The lower terrace was the entrance and arena for special events. It contained health spas, bathhouses, and fountains spouting water from nearby springs.

The water of one fountain is rich in sulfur. Says a local guide, Christa Mee, "Whatever effect the water was intended to produce upon . . . invalids, it is perhaps no coincidence that . . . a sumptuous latrine was constructed in the vicinity."

The middle terrace, 30 steps up, contains the foundation of the altar of Asklepios; built between 350 and 330 BC, it's the earliest symbolic structure left on the hillside. On the right, to the west side of the altar, is the Temple of Asklepios, constructed in the third century BC to house gifts the sick brought their priest-physicians. To the east is another temple, constructed by the Romans and dedicated to Apollo.

 Sixty more marble steps bring visitors to the foundation of the huge temple   of the upper terrace, built in the second century BC with 104 Doric columns   around its 340-foot perimeter. 

The Knights of St. John chose to use parts of the Asklepieion for fortification against the Ottoman Turks. Little of value remains.

There are more than 300 centers in the ancient world named for Asklepios, but none as famous as this. You sit on the upper terrace, imagining what Hippocrates' students must have felt sitting at his feet, here and under a great plane tree in the center of town.

A functioning windmill on Kos blends ancient and modern forms.

 A similar conviction is necessary at the other end of the ruined agora. But   when you walk into the Greek Archaeological Museum on the island of Kos, you   nearly step on one of its treasures, a mosaic floor transferred from a Roman   villa in the ancient part of town. The mosaic shows Asklepios, the god of healing,   arriving on the shores of Kos and being welcomed by an islander and by Hippocrates,   the father of medicine. Created in the third century AD, about 600 years after   the death of Hippocrates, it remains one of the few illustrations of medicine's   founder. 

Beyond the Roman courtyard is another significant image for an American doctor: a statue from the fourth century BCidentified by Italian architects when a 1933 earthquake exposed what had been an arena, the Odeon. The statue stands in an apse at the end of a hallway. Bathed in deep green light, it seems to stare into the distance. The sun streaming in through the overhead window highlights this link to medicine's heritagethe image of Hippocrates himself.

A recent best-seller in Greece talks about health and alternative medicine, popular subjects even for defenders of the present medical establishment. According to a spokesman in the Office of Public and Trade Relations of the Greek National Tourist Organization in New York, "the book is as current and significant today as it was more than 2400 years ago."

 The book, rewritten in a contemporary voice, is called 

.   Its author is a Greek physician named Hippocrates. 

Eric Anderson. In search of Hippocrates. 

Come to the Greek island of Kos, where the Western world's first medical school thrived, and time still moves to ancient rhythms.

In search of Hippocrates

The profession's past is rich in heroes. Among the mostnotable are the scientists profiled here.

Text and photos by Eric G. Anderson, MD
 Family Physician / San Diego

The turn of the millennium is a time to look both forward and back. Forwardcan be fun, but as doctors we have plenty to look back uponand appreciate.

A mere 500 years ago, mankind wasn't at all clear on how the body worked,wasn't even certain of all the parts. Today we engineer genes. Many brilliantscientists brought us to this point, andbecause medical history is oneof my hobbiesI have visited a number of their shrines. With considerablehumility, I've held Lister's carbolic spray device, Pasteur's lab bottles,and Osler's copy of Vesalius' 

. I've stood in Fleming's labat St. Mary's Hospital and looked through Sabin's microscope in Cincinnati.

This is a tribute to a handful of the medical giants.

For more than 1,300 years after his death in AD 200, the Greek physicianGalen stood as the world's undisputed authority on human anatomy. The virtualfounder of experimental physiology, he was also the personal physician tothe Roman emperor Marcus Aurelius. So lionized was Galen that he dominatedmedical thought through all those centuries; no voice dared dispute him.

Andreas Vesalius (1514-1564) was descended from four generations of Brusselsphysicians and apothecaries. He studied in Paris and Padua, the center ofmedical learning at the time. Based on his own dissections of human cadavers,Vesalius taught himself anatomy. In the process, he discovered that Galen'sscience was bogus: The revered anatomist had dissected animalsdogs, monkeys,pigsand applied his conclusions to humans. Indeed, historians later learnedthat in Galen's day the Roman religion strictly forbade dissection of thehuman body.

Before Vesalius, researchers who found discrepancies between Galen'swork and their own declared that the human body must have changed sinceGalen's time. Vesalius was the first with enough courage and confidenceto challenge Galen.

In 1543, Vesalius sparked outrage throughout Europe by publishing thewatershed anatomy book, 

De Humani Corporis Fabrica Libri Septem (TheSeven Books on the Structure of the Human Body)

. With it, human dissectionwas introduced into the medical curriculum. After Vesalius, anatomy becamea scientific discipline with implications reaching all areas of biology.

Many of the book's anatomical plates were drawn by Jan Stephan van Calcar,a fellow Belgian and a pupil of Titian. Its frontispiece, shown here, isan illustration of the famous anatomist demonstrating his dissections toa group of students in Padua. A special, hand-colored edition of 

, presented to Charles V, the Holy Roman Emperor, sold in 1998for $1,652,500the highest price ever paid for a rare medical book at auction.

The roots of modern cardiology go back more than 370 years, to the publicationof William Harvey's 

Exercitatio Anatomica de Motu Cordis et San- guinisin Animalibus (Anatomical Exercises Concerning the Motion of the Heart andBlood in Animals)

. Before Harvey, it was thought that the blood drawnin by the expansion of the heart simply ebbed away during contraction. Theliver was the "central blood organ." And, as with many medicaltheories of the early 17th century, to believe otherwise was consideredheretical.

Harvey demonstrated that the heart expands passively and contracts actively.When he measured the volume of blood flowing from the heart, he realizedthat the body could not continuously produce that amount. Eventually, hewas able to show that blood returns to the heart through the veins. (Harvey'ssuspicion that there was a connection between the arteries and veinsthecapillarieswouldn't be confirmed for another century.)

Harvey (1578-1657), the oldest of the seven sons of the mayor of Folkestone,England, was educated at Canterbury and Cambridge, then studied under asuccessor to Vesalius at Padua. In 1616, a week before the death of Shakespeare,he delivered his first lecture to medical students in London. Notes fromthat lecture are preserved in the British Museum, and illustrate that eventhen Harvey believed "the movement of the blood is constantly in acircle, and is brought about by the beat of the heart." Further researchled to the publication of 

Even though Harvey was King Charles I's private physician (and Charleshad contributed to his research), his private practice fell off in angryresponse to his book. Unlike many great scientists, though, Harvey livedto see his views enthusiastically embraced. He left his entire researchlibrary to the Royal College of Physicians.

 survive. In 1998, one sold at auctionfor $530,500. The one shown here is in the medical library at Yale University.

Medicine is serious business, of course, but the development of anesthesiahas a Keystone Kops flavor to it. First, a rural Georgia physician namedCrawford Williamson Long (1815-1878) noticed that people injured during"ether frolics" (social events at which participants got intoplayful states of ether-induced intoxication) felt no pain. In 1842, heremoved a tumor from a patient after administering ether. He continued touse the gas, but didn't publish a paper on his finding until 1849.

Meanwhile, in 1846, Boston dentist William T.G. Morton (1819-1868) wasthe first to use ether in the extraction of a tooth, after seeking advicefrom a local physician, Charles T. Jackson. Jackson (1805-1880) then claimedcredit for the discovery and denounced Morton as a swindler and a forger.Years earlier, Jackson had had a similar dispute: He claimed to have explainedthe principles of the telegraph to Samuel Morse. Morton spent the remainderof his life in costly litigation with Jackson; Jackson died in an asylumfor the mentally ill.

Around this time, a young professor of obstetrics in Edinburgh was lookingfor an effective anesthetic to use in midwifery. James Young Simpson (1811-1870)had learned of ether, but he and several assistants wanted to experimentwith chloroform. It was more toxic than ether, but less irritating to therespiratory passages. So they tried it on themselvesand knocked themselvesout. (The photo below shows a wax effigy of the unconscious Simpson, takenat a Simpson exhibit in the now-defunct Edinburgh Wax Museum.)

When Simpson began to use chloroform in birthing, the clergy objected:"You are robbing God of the deep earnest cries of women" in labor.But the practice gained wid espread acceptance after it was used by QueenVictoria herself. Simpson was knighted, and the world entered the era ofsurgery without pain.

Postscript: When I was a medical student at the University of Edinburghin the early 1950s, this story was part of the Simpson lore: On a Sundaymorning in Edinburgh, one of Simpson's sons developed a toothache. Aftersearching the city, Simpson found a drugstore that was open, put down hiscoin, and asked for a bottle of chloroform. "No," he was told."We dinna sell such-like medicine to folk who know nothing aboot it."

The apothecary shop at the Shelburne Museum in Vermont features a pillpress and other paraphernalia to create the appearance of a late 19th-centurydruggist's quarters.

Miscellanea Astrologica Astronomica etMathematica

 is at Harvard University's Francis A. Countway Library ofMedicine. The right-hand page shows the best phases of the moon for bloodletting.

On the one hand, Louis Pasteur was a modest man, referring to himselfas "a mere chemist." On the other, his single-minded devotionto his work and his refusal to consider opposing opinions made him appeararrogant. At one point, a dissenting surgeon even challenged him to a duel.But he also agonized over his mortality, lamenting that he had but one lifeto devote to his experiments. We can only imagine what he'd have accomplishedhad he had two.

Pasteur (1822-1895) gave the world its understanding of the relationshipbetween bacteria and infectious diseases. By a brilliant series of experimentshe proved that the fermentation of wine and the souring of milk are causedby living organisms. That led toamong many other thingsa rabies vaccineand the "pasteurization" of milk.

Pasteur's contributions to medicine also include his influence on JosephLister (1827-1912), who introduced the antiseptic principle to surgery.When Lister accepted the surgery chair at the University of Glasgow in 1860,he found that the city's new hospital had been built over a cemetery filledwith cholera victims. Surgical patients there were in greater danger fromiatrogenic infection than from the surgery itself. Lister deduced that organismsin the air caused the surgical infections.

The obvious great need was for a barrier between the surgical woundsand the germ-filled atmosphere. Lister found it in carbolic acid, and operatingroom infections and deaths dropped dramatically. Others soon refined thetechniques of sterilizing the surgical environment. It was the beginningof modern surgery.

The Lister carbolic spray device from 1872, shown above, is from theDittrick Museum of Medical History in Cleveland.

A striking irony regarding the discovery of the X-ray, which exposesthe most secret places of the body to inquisitive minds, is that it wasmade by a shy, private man. He was Wilhelm Conrad Roentgen (1845-1923),a German physicist. Trained as a mechanical engineer, Roentgen worked onthings as diverse as elasticity, the capillary action of fluids, the absorptionof heat by gases, conduction of heat in crystals, and piezoelectricity.But history remembers him for work completely outside his field.

In 1895, while experimenting with electric current flow in a partiallyevacuated Crookes tube, Roentgen noticed fluorescence in nearby crystalsof barium platinocyanide. He theorized that when the cathode rays struckthe glass wall of the tube, an unknown radiation was formed that traveledacross the room, struck the chemical, and caused the fluorescence. Paper,wood, aluminum, and other materials, Roentgen found, were transparent tothis new form of radiation. Roentgen also noticed that it affected photographicplates, but he mistakenly thought it had no relation to light. Uncertainof its nature, he called this new phenomenon X-radiation. Others calledit Roentgen radiation.

Roentgen took the first X-ray photos of the insides of metal objects.Later, he made an X-ray of the bones in his wife's hand. The world was awestruck;within a year, a reported 1,000 scientific papers were published on theX-ray. Roentgen had revolutionized diagnostic medicine.

In 1901, he was awarded the first Nobel Prize for physics. Ever modestand unassuming, he declined to give the expected lecture. Roentgen's originalX-ray tubes, of which one is shown here, are in the Smithsonian Institutionin Washington, DC.

Roentgen might have been too quick to chalk his achievements up to thevagaries of fate. But fate played an undeniable role in the discovery ofpenicillin. Alexander Fleming, of course, added the intense curiosity andgreat perspicacity needed to follow up on fate's kindness.

Fleming (1881-1955) was working with staphylococcus bacteria in a smallPetri dish in his lab at the University of London when a unique combinationof factors occurred there: Rare mold spores drifted through an open door;Fleming's Petri dish was perfectly positioned to catch them; the weatherwas first warm enough to incubate the staphylococci, then cool enough forthe mold to grow.

Fleming noticed a bacteria-free circle around the mold growth in hisculture dish. Upon closer examination, he found a substance in the moldthat contaminated the bacteriathat is, prevented its growtheven whenit was diluted 800 times. Fleming isolated the mold, grew it in a fluidmedium, and saw that it produced a substance that kills many of the commonbacteria that infect humans. He called it penicillin.

Scientists of the dayFleming among themdreaded contaminated bacteria."As soon as you uncover a culture dish, you're asking for trouble,"he said, "and something tiresome is sure to happen. Things fall outof the air." This time, he inexplicably didn't discard the plate. Later,when asked the meaning of his life, he said, "I can only suppose thatGod wanted penicillin, so He created Alexander Fleming."

Fleming shared the Nobel Prize for Physiology in 1945 with two OxfordcolleaguesErnst Boris Chain and Howard Walter Floreywho had purifiedFleming's "mold gold," allowing for its large-scale productionand use in injections.

As far back as 1889, it was known that the pancreas had something todo with diabetes mellitus. The mystery was narrowed, first in 1901 whendegenerative changes in the beta cells of the islets of Langerhans werelinked to the disease, and later when researchers found that those cellscontrolled the metabolism of carbohydrates. But endocrinology was stillin its infancy. The term hormone wasn't even introduced until 1905. In subsequentyears, scientists made steady progress isolating, identifying, and studyingthe endocrine glands.

The outstanding event in the early history of endocrinology occurredin 1921 when Frederick G. Banting (1891-1941) and his lab assistant at theUniversity of Toronto, Charles H. Best (1899-1978), discovered the elusivehormone insulin. Almost overnight, diabetes became a manageable diseaserather than a death sentence.

Oddly, the 1923 Nobel Prize for Physiology or Medicine was given to Bantingand J.J.R. MacLeod, a physiologist who had given lab space to Banting andBest. Best was excluded because he hadn't received his MD degree yet. Bantingprotested, and shared his half of the award with Best. Decorated for conspicuousbravery during World War I, Banting died in a plane crash at the age of49. Best later introduced anticoagulants to the treatment of thrombosis.

Albert B. Sabin and Jonas E. Salk both graduated from the medical schoolat New York University (1931 and 1939, respectively). They both then becameresearchers, and followed separate paths in the conquest of poliomyelitis,the disease that had crippled Franklin D. Roosevelt. In 1952, this age-oldscourge, known since the days of the pharaohs in Egypt, claimed 58,000 victims,mostly children, in the United States alone.

Sabin (1906-1993), who began his research in 1935, first disproved theprevailing theory that the polio virus entered the body through the nose,then identified the illness as an infection of the alimentary tract. Hegrew the virus in live nerve tissue and postulated that a live, attenuatedvirus, administered orally, would provide better immunity than a dead, injectedone. By 1957, he had isolated three strains of the live virus that couldstimulate antibodies but not the disease. Once the effectiveness of hisoral vaccine was conclusively demonstrated, it was approved for use in theUS in 1960.

Salk (1914-1995), who had begun similar work in 1947, concluded thata killed virus was a shortcut to immunization. He tested it on monkeys,then on his own children. Field trials were held in 1954, and Salk's injectionvaccine was approved for use in 1955. In 1963, he became a fellow and directorat the Institute for Biological Studies in San Diego, later called the SalkInstitute. The photos here are of Sabin's microscope and the Salk Institute.



Eric Anderson. Here's to the giants of medicine. 

The profession's past is rich in heroes. Among the most notable are the scientists profiled here.

Author | Eric Anderson, MD

Articles

Viewpoint: What's really happening with the U.K.'s health system

In search of Hippocrates

Here's to the giants of medicine