Pathophysiology: Concepts of Altered Health States

1478 Pages·2004·49.42 MB·English

by  Carol Mattson Porth

U N I T
I
CCoonncceeppttss ooff HHeeaalltthh
aanndd DDiisseeaassee
E
arly peoples were considered long-lived if they reached 30 years
of age—that is, if they survived infancy. For many centuries, infant
mortality was so great that large families became the tradition; many
children in a family ensured that at least some would survive. Life ex-
pectancy has increased over the centuries, and today an individual in
a developed country can expect to live about 71 to 79 years. Al-
though life expectancy has increased radically since ancient times,
human longevity has remained fundamentally unchanged.
The quest to solve the mystery of human longevity, which
appears to be genetically programmed, began with Gregor Mendel
(1822–1884), an Augustinian monk. Mendel laid the foundation of
modern genetics with the pea experiments he performed in a
monastery garden. Today, geneticists search for the determinant, or
determinants, of the human life span. Up to this time, scientists have
failed to identify an aging gene that would account for a limited life
span. However, they have found that cells have a finite reproductive
capacity. As they age, genes are increasingly unable to perform their
functions. The cells become poorer and poorer at making the sub-
stances they need for their own special tasks or even for their own
maintenance. Free radicals, mutation in a cell’s DNA, and the process
of programmed cell death are some of the factors that work together
to affect a cell’s functioning.

C H A P T E R
1
Concepts of Health
and Disease
Georgianne H. Heymann
Carol M. Porth
ogy. There has been an increased knowledge of immune
HEALTH AND SOCIETY mechanisms; the discovery of antibiotics to cure infec-
HEALTH AND DISEASE: A HISTORICAL PERSPECTIVE tions; and the development of vaccines to prevent disease,
The Influence of Early Scholars chemotherapy to attack cancers, and drugs to control the
The Nineteenth Century manifestations of mental illness.
The Twentieth Century The introduction of the birth control pill and im-
The Twenty-First Century proved prenatal care have led to decreased birth rates and
declines in infant and child mortality. The benefits of sci-
PERSPECTIVES ON HEALTH AND DISEASE
ence and technology also have increased the survival of in-
IN INDIVIDUALS
fants born prematurely and of children with previously
Health
untreatable illnesses, such as immunodeficiency states and
Health and Disease as States of Adaptation
leukemia. There also has been an increase in the survival
Disease
of very seriously ill and critically injured persons of all age
Etiology
groups. Consequently, there has been an increase in lon-
Pathogenesis
gevity, a shift in the age distribution of the population, and
Morphology
an increase in age-related diseases. Coronary heart disease,
Clinical Manifestations
stroke, and cancer have now replaced pneumonia, tuber-
Diagnosis
culosis, and diarrhea and enteritis—the leading causes of
Clinical Course
death in the 1900s.
PERSPECTIVES ON HEALTH AND DISEASE
This chapter, which is intended to serve as an intro-
IN POPULATIONS
duction to the book, is organized into four sections: health
Epidemiology and Patterns of Disease
and society, historical perspectives on health and disease,
Prevalence and Incidence
perspectives on health and disease in individuals, and per-
Morbidity and Mortality
spectives on health and disease in populations. The chap-
Determination of Risk Factors
ter is intended to provide the reader with the ability to
The Framingham Study
view within a larger framework the historical aspects of
The Nurses’ Health Study
health and disease and the relationship of health and dis-
Natural History
ease to individuals and populations, and to introduce the
Levels of Prevention
reader to terms, such as etiologyandpathogenesis,that are
Evidence-Based Practice and Practice Guidelines
used throughout this text.
Health and Society
T
he concepts of what constituted health and disease at
the beginning of the last century were far different Everyone who is born holds dual citizenship in the kingdom of
from those of this century. In most of the industrial- the well and in the kingdom of the sick. Although we all prefer
ized nations of the world, people now are living longer to use only the good passport, sooner or later each of us is ob-
and enjoying a healthier lifestyle. Much of this has been ligated, at least for a spell, to identify ourselves as citizens of
made possible by recent advances in science and technol- that other place.1
3
4 UNIT I Concepts of Health and Disease
After completing this section of the chapter, you should be able to
meet the following objectives:
✦ Describe the concepts used to establish belief systems
within a community and the effects on its health care
practices
✦ Identify a disease believed to be generated by specific
emotions and the characteristics ascribed to it
✦ Explain how mythologizing disease can be detrimental to
individuals in a society
There is a long history that documents the concern of
humans for their own health and well-being and that of
their community. It is not always evident what particular
beliefs were held by early humans concerning health and
disease. Still, there is evidence that whenever humans
have formed social groups, some individuals have taken
the role of the healer, responsible for the health of the
community by preventing disease and curing the sick.
In prehistoric times, people believed that angry gods
or evil spirits caused ill health and disease. To cure the
sick, the gods had to be pacified or the evil spirits driven
from the body. In time, this task became the job of the
healers, or tribal priests. They tried to pacify the gods or
drive out the evil spirits using magic charms, spells, and
incantations. There also is evidence of surgical treatment.
Trephining involved the use of a stone instrument to cut
a hole in the skull of the sick person. It is believed that
this was done to release spirits responsible for illness. Pre-
historic healers probably also discovered that many plants
can be used as drugs.
The community as a whole also was involved in se-
curing the health of its members. It was the community
Influences of zodiac signs on the human body. (Courtesy of the
that often functioned to take care of those considered ill or
National Library of Medicine)
disabled. The earliest evidence of this comes from an Old
Stone Age cave site, Riparo del Romio, in southern Italy.
There the remains of an adolescent dwarf were found. De-
spite his severe condition, which must have greatly limited flourishing anatomic and physiologic programs of the Re-
his ability to contribute to either hunting or gathering, the naissance, the Western tradition was created based on the
young man survived to the age of 17 years. He must have belief that everything that needed to be known essentially
been supported throughout his life by the rest of the com- could be discovered by probing more deeply and ever
munity, which had incorporated compassion for its mem- more minutely into the flesh, its systems, tissues, cells, and
bers into its belief system.2 Communities such as this DNA.3Through Western political and economic domina-
probably existed throughout prehistory; separated from tion, these health beliefs now have powerful influence
each other and without any formal routes of communica- worldwide.
tion, they relied on herbal medicines and group activity to Every society has its own ideas and beliefs about life,
maintain health. death, and disease. It is these perceptions that shape the
Throughout history, peoples and cultures have devel- concept of health in a society. Although some customs
oped their health practices based on their belief systems. and beliefs tend to safeguard human communities from
Many traditions construed sickness and health primarily in disease, others invite and provoke disease outbreaks.
the context of an understanding of the relations of human The beliefs that people have concerning health and
beings to the planets, stars, mountains, rivers, spirits, and disease can change the destiny of nations. The conquering
ancestors, gods and demons, the heavens and underworld. of the Aztec empire may be one example. Historians have
Some traditions, such as those reflected in Chinese and In- speculated how Hernando Cortez, starting off with fewer
dian cultures, although concerned with a cosmic scope, do than 600 men, could conquer the Aztec empire, whose
not pay great attention to the supernatural. subjects numbered millions. Historian William H. McNeill
Over time, modern Western thinking has shed its ad- suggests a sequence of events that may explain how a tiny
herence to all such elements. Originating with the Greek handful of men could subjugate a nation of millions.
tradition—which dismissed supernatural powers, although Although the Aztecs first thought the mounted, gun-
not environmental influences—and further shaped by the powered Spaniards were gods, experience soon showed
CHAPTER 1 Concepts of Health and Disease 5
otherwise. Armed clashes revealed the limitations of horse- improving one’s own health, and for support of efforts to
flesh and of primitive guns, and the Aztecs were able to improve the health status of others.
drive Cortez and his men from their city. Unbeknownst to
the Aztecs, the Spaniards had a more devastating weapon
In summary, what constitutes health and disease changes
than any firearm: smallpox. An epidemic of smallpox
over time. Prehistoric times were marked by beliefs that angry
broke out among the Aztecs after their skirmishes with the
gods or evil spirits caused ill health and disease. To cure the
Spaniards. Because the population lacked inherited or ac-
sick, the gods had to be pacified or the evil spirits driven from
quired immunity, the results were catastrophic. It is pre-
the body. Tribal healers, or priests, emerged to accomplish this
sumed that a quarter to a third of the population died from
task. Prehistoric healers used a myriad of treatments, includ-
the initial onslaught.
ing magic charms, spells, and incantations; surgical treatment;
Even more devastating were the psychological impli-
and plant medicines.
cations of the disease: it killed only American Indians and
Throughout history, the concept of health in a society has
left Spaniards unharmed. A way of life built around the old
been shaped by its beliefs about life, death, and disease. Some
Indian gods could not survive such a demonstration of the
beliefs and customs, such as exhibiting compassion for dis-
superior power of the God the Spaniards worshipped. It is
abled community members, tend to safeguard human com-
not hard to imagine then that the Indians accepted Chris-
munities and increase the quality of life for all community
tianity and submitted meekly to Spanish control.4Although
members. Others invite and provoke disease outbreaks, such
we live in an age of science, science has not eliminated
as myths about the causes of disease.
fantasies about health; the stigmas of sickness and the
Even though science and technology have advanced the
moral meanings that they carry continue. Whereas people
understanding and treatment of disease, misconceptions and
in previous centuries wove stories around leprosy, plague,
fantasies about disease still arise. In previous centuries, dis-
and tuberculosis to create fear and guilt, the modern age has
eases such as leprosy, plague, and tuberculosis were fodder
created similar taboos and mythologies about cancer and
for taboos and mythologies; today, it is cancer and AIDS. The
acquired immunodeficiency syndrome (AIDS).
psychological effects of disease mythologies can be positive or
The myth of tuberculosis (TB) was that a person who
negative. At their worst, they can stigmatize and isolate those
suffered from it was of a melancholy, superior character—
who are ill; at their best, they can educate the community and
sensitive, creative, a being apart. Melancholy, or sadness,
improve the health of its members.
made one “interesting” or romantic. The general percep-
tion of TB as “romantic” was not just a literary device. It
was a way of thinking that insinuated itself into the sensi-
bilities and made it possible to ignore the social conditions,
such as overcrowding and poor sanitation and nutrition,
that helped breed tuberculosis. Health and Disease:
The infusion of beliefs into public awareness often is A Historical Perspective
surreptitious. Just as tuberculosis often had been regarded
sentimentally, as an enhancement of identity, cancer was
After completing this section of the chapter, you should be able to
regarded with irrational revulsion, as a diminution of the
meet the following objectives:
self.1Current accounts of the psychological aspects of can-
cer often cite old authorities, starting with the Greek physi- ✦ Describe the contributions of the early Greek, Italian, and
cian Galen, who observed that “melancholy women” are English scholars to the understanding of anatomy,
more likely to get breast cancer than “sanguine women.” physiology, and pathology
Grief and anxiety were cited as causes of cancer, as well ✦ State two important advances of the nineteenth century
as personal losses. Public figures such as Napoleon, Ulysses that helped to pave the way for prevention of disease
S. Grant, Robert A. Taft, and Hubert Humphrey have all had ✦ State three significant advances of the twentieth century
their cancers diagnosed as the reaction to political defeat that have revolutionized diagnosis and treatment of
and the end to their political ambitions. Although distress disease
can affect immunologic responsiveness, there is no scien- ✦ Propose developments that will both hamper and
tific evidence to support the view that specific emotions, contribute to the promotion of health and the
or emotions in general, can produce specific diseases—or elimination of disease in the twenty-first century
that cancer is the result of a “cancer personality,” described
as emotionally withdrawn, lacking self-confidence, and It has been said that those who do not know history
depressive. are condemned to repeat it. There are many contributors
These disease mythologies contribute to the stigma- to the understanding of how the body is constructed and
tizing of certain illnesses and, by extension, of those who how it works, and what disease is and how it can be
are ill. The beliefs about health and disease have the power treated, which in turn leads to an understanding of what
to trap or empower people. They may inhibit people from health is and how can it be maintained.
seeking early treatment, diminish personal responsibility Much of what we take for granted in terms of treating
for practicing healthful behaviors, or encourage fear and the diseases that afflict humankind has had its origin in
social isolation. Conversely, they also can be the impetus the past. Although they are seemingly small contributions
for compassion to those who are ill, for commitment to in terms of today’s scientific advances, it is the knowledge
6 UNIT I Concepts of Health and Disease
produced by the great thinkers of the past that has made anatomy, laid the foundations for the later scrutiny of the
possible the many things we now take for granted. human body. For Aristotle, the heart was the most im-
portant organ. He believed it to be the center of the blood
system as well as the center of the emotions. However,
THE INFLUENCE OF EARLY SCHOLARS
Aristotle’s main contributions were made to science in
general.
Knowledge of anatomy, physiology, and pathology as we
The person who took the next major step was Galen
now know it began to emerge with the ancient Greeks.
They were the first to recognize the distinction between (AD129–199), a physician to the emperors and gladiators
of ancient Rome. Galen expanded on the Hippocratic doc-
internal and external causes of illness.
trines and introduced experimentation into the study of
To Hippocrates and his followers, we owe the founda-
healing. His work came to be regarded as the encyclopedia
tions of the clinical principles and the ethics that grew into
of anatomy and physiology. He demoted the heart—in his
modern medical science. Hippocrates (460–377 BC) was a
view, the liver was primary for venous blood, whereas the
blend of scientist and artist. He believed that disease oc-
seat of all thought was the brain. He described the arteries
curred when the four humors—blood from the heart, yellow
and veins and even revealed the working of the nervous sys-
bile from the liver, black bile from the spleen, and phlegm
tem by severing a pig’s spinal cord at different points and
from the brain—became out of balance. These humors were
demonstrating that corresponding parts of the body be-
said to govern character as well as health, producing phleg-
came paralyzed. According to Galen, the body carried three
matic, sanguine, choleric, and melancholic personalities.
kinds of blood that contained spirits charged by various
This belief paralleled the even older Chinese tradition,
organs: the veins carried “natural spirit” from the liver;
which was founded on the complementary principles of yin
the arteries, “vital spirit” from the lungs; the nerves, “an-
(female principle) and yang (male), whose correct propor-
imal spirit” from the brain. The heart merely warmed the
tions were essential for health. Hippocrates is identified with
blood. After Galen’s death, however, anatomic research
an approach to health that dictated plenty of healthy exer-
ceased, and his work was considered infallible for almost
cise, rest in illness, and a moderate, sober diet.
1400 years.
It was Aristotle (384–322 BC) who, through his dissec-
As the great medical schools of universities reformed
tion of small animals and description of their internal
the teaching of anatomy in the early 1500s and integrated
it into medical studies, it became apparent to anatomists
that Galen’s data—taken from dogs, pigs, and apes—often
were riddled with error. It was only with the work of
Andreas Vesalius (1514–1564) that Galen’s ideas truly were
challenged.
Vesalius, professor of anatomy and surgery at Padua,
Italy, dedicated a lifetime to the study of the human body.
Vesalius carried out some unprecedentedly scrupulous dis-
sections and used the latest in artistic techniques and print-
ing for the more than 200 woodcuts in his De Humani
Corporis Fabrica(“On the Fabric [Structure] of the Human
Body”). He showed not only what bodily parts looked like
but also how they worked. The book, published in 1543, set
a new standard for the understanding of human anatomy.
With this work, Vesalius became a leading figure in the re-
volt against Galen’s teachings.
One of the most historically significant discoveries
was made by William Harvey (1578–1657), an English
physician and physiologist. He established that the blood
circulates in a closed system impelled mechanically by a
“pumplike” heart. He also measured the amount of blood
in the circulatory system in any given unit of time—one
of the first applications of quantitative methods in biol-
ogy. Harvey’s work, published in On the Motion of the Heart
and Blood in Animals(1628), provided a foundation of phys-
iologic principles that led to an understanding of blood
pressure and set the stage for innovative techniques such
as cardiac catheterization.
With the refinement of the microscope by the Dutch
lens maker Anton van Leeuwenhoek (1632–1723), the
stage was set for the era of cellular biology. Another early
Hippocrates: A blend of scientist and scholar. (Courtesy of the user of the microscope, English scientist Robert Hooke
National Library of Medicine) (1635–1703), published his Micrographiain 1665 in which
CHAPTER 1 Concepts of Health and Disease 7
William Harvey’s most eminent patient, King Charles I, and the
future King Charles II look on as Harvey displays a dissected deer
heart. (Courtesy of the National Library of Medicine)
he formally described the plant cells in cork and presented
his theories of light and combustion and his studies of in-
sect anatomy. His book presented the great potential of the
Painting by Georges-Gaston Mélingue (1894). The first vaccination.
microscope for biologic investigation. In it, he inaugurated
Here Dr. Jenner introduces cowpox taken from dairymaid Sarah
the modern biologic usage of the word cell.A century later,
Nelmes (right) and introduces it into two incisions on the arm of
German-born botanist Mathias Schleiden (1804–1881) and
James Phipps, a healthy 8-year-old boy. The boy developed cow-
physiologist Theodor Schwann (1810–1882) observed that pox, but not smallpox, when Jenner introduced the organism into
animal tissues also were composed of cells. his arm 48 days later. (Courtesy of the National Library of Medicine)
Although Harvey contributed greatly to the under-
standing of anatomy and physiology, he was not interested
in the chemistry of life. It was not until French chemist
Antoine Lavoisier (1743–1794), who was schooled as a
given off from dung heaps and decaying matter (poisons
lawyer but devoted to scientific pursuits, overturned 100-
in the air, exuded from rotting animal and vegetable ma-
year-old theories of chemistry and established the basis of
terial, the soil, and standing water) or with contagion
modern chemistry that new paths to examine body pro-
(person-to-person contact).
cesses, such as metabolism, opened up. His restructured
In 1865, English surgeon Joseph Lister (1827–1912)
chemistry also gave scientists, including Louis Pasteur, the
concluded that microbes caused wound infections. He be-
tools to develop organic chemistry.
gan to use carbolic acid on wounds to kill microbes and re-
In 1796, Edward Jenner (1749–1823) conducted the
duce infection after surgery. However, Lister was not alone
first vaccination by injecting the fluid from a dairymaid’s
in identifying hazards in the immediate environment as
cowpox lesion into a young boy’s arm. The vaccination
detrimental to health. English nurse Florence Nightingale
by this English country doctor successfully protected the
(1820–1910) was a leading proponent of sanitation and
child from smallpox. Jenner’s discovery led to the devel-
hygiene as weapons against disease. It was at the English
opment of vaccines to prevent many other diseases as well.
base at Scutari during the Crimean War (1854–1856) that
Jenner’s classic experiment was the first officially recorded
Nightingale waged her battle. Arriving at the army hospi-
vaccination.
tal with a party of 38 nurses, Nightingale found nearly
2000 wounded and sick inhabiting foul, rat-infested wards.
THE NINETEENTH CENTURY The war raged on, deluging the hospital with wounded as
Nightingale not only organized the nursing care of the
The nineteenth century was a time of spectacular leaps wounded but also provided meals, supplied bedding, and
forward in the understanding of infectious diseases. For saw to the laundry. Within 6 months, she had brought
many centuries, rival epidemiologic theories associated about a transformation and slashed the death rate from
disease and epidemics like cholera with poisonous fumes approximately40% to 2%.3
8 UNIT I Concepts of Health and Disease
Florence Nightingale caring for
wounded at Scutari, Turkey, during
the Crimean War. (Courtesy of the
National Library of Medicine)
From the 1860s, the rise of bacteriology, associated es- THE TWENTIETH CENTURY
pecially with chemist and microbiologist Louis Pasteur in
The twentieth century was a period of revolutionary in-
France and bacteriologist Robert Koch in Germany, estab-
dustry in the science and politics of health. Concerns
lished the role of microorganismal pathogens. Almost for
about the care of infants and children and the spread of in-
the first time in medicine, bacteriology led directly to dra-
fectious disease became prevailing themes in public and
matic new cures.
political arenas alike. It was during this time that private
The technique of pasteurization is named after Louis
duty and public health nursing emerged as the means of
Pasteur (1822–1895). He introduced the method in 1865 to
delivering health care to people in their homes and in
prevent the souring of wine. Pasteur’s studies of fermenta-
their communities. Social service agencies like the Henry
tion convinced him that it depended on the presence of
Street Settlement in New York, founded by Lillian Wald,
microscopic forms of life, with each fermenting medium
sent nurses into tenements to care for the sick.5The place-
serving as a unique food for a specific microorganism. He
ment of nurses in schools began in New York City in 1902
developed techniques for culturing microbes in liquid
at the urging of Wald, who offered to supply a Henry Street
broths. Through his work, he was able to dispel the disease
nurse for 1 month without charge.5Efforts to broaden the
theory that predominated in the mid-nineteenth century,
delivery of health care from the city to rural areas also were
attributing fevers to “miasmas,” or fumes, and laid the
initiated during the early 1900s. The American Red Cross,
foundation for the germ theory of disease.
which was reorganized and granted a new charter by Con-
The anthrax bacillus, discovered by Robert Koch gress in 1905, established a nursing service for the rural
(1843–1910), was the first microorganism identified as a poor that eventually expanded to serve the small town
cause of illness. Koch’s trailblazing work also included poor as well.5
identifying the organism responsible for tuberculosis and Scientific discoveries and innovations abounded in the
the discovery of a tuberculosis skin-testing material. twentieth century. In the early 1900s, German bacteriologist
In 1895, German physicist Wilhelm Röntgen (1845– Paul Ehrlich (1854–1915) theorized that certain substances
1923) discovered X rays. For the first time without a cata- could act as “magic bullets,” attacking disease-causing
strophic event, the most hidden parts of a human body microbes but leaving the rest of the body undamaged. In
were revealed. Even though he understood that it was a 1910, he introduced his discovery: using the arsenic com-
significant discovery, Röntgen did not initially recognize pound Salvarsan, he had found an effective weapon against
the amazing diagnostic potential of the process he had syphilis. Through his work, Ehrlich launched the science of
discovered. chemotherapy.
CHAPTER 1 Concepts of Health and Disease 9
The operating room. With the advent
of anesthesia, knowledge of how mi-
crobes cause disease, and availability
of incandescent lighting in the operat-
ing room, surgery became an option
for treating disease. Rubber gloves had
not yet been invented and the surgical
team worked with bare hands to per-
form surgery. (Hahnemann Hospital,
Chicago, IL. Courtesy Bette Clemons,
Phoenix, AZ)
The first antibiotic was discovered in 1928 by English By the 1930s, innovative researchers had produced a
bacteriologist Sir Alexander Fleming (1881–1955). As he cornucopia of new drugs that could be used to treat many
studied the relationship between bacteria and the mold of the most common illnesses that left their victims either
Penicillium,he discovered its ability to kill staphylococci. severely disabled or dead. The medical community now
However, it was not until the 1940s that later researchers, had at its disposal medications such as digoxin to treat
who were searching for substances produced by one micro- heart failure; sulfa drugs, which produced near-miraculous
organism that might kill other microorganisms, produced cures for infections such as scarlet fever; and insulin to treat
penicillin as a clinically useful antibiotic. diabetes.
At the turn of the century, social
service agencies like Henry Street
Settlement in New York sent nurses
into tenements to care for the sick.
(Schorr T.M., Kennedy S.M. [1999].
100 years of American nursing[p. 12].
Philadelphia: Lippincott Williams &
Wilkins)
10 UNIT I Concepts of Health and Disease
With the discovery of insulin, a once-fatal disease fresh air, and bed rest were prescribed in the belief that if
known from antiquity no longer carried a death sentence. the body’s natural defenses were strengthened, they would
Working together, Canadian physician Sir Frederick Bant- be able to overcome the tuberculosis bacillus. For almost
ing (1891–1941) and physiologist Charles Best (1899–1978) half a century, this would be the prevailing treatment. It
isolated insulin from the pancreas of a dog in 1921. The was not until 1945, with the introduction of chemother-
extract, when given to diabetic dogs, restored their health. apy, that streptomycin was used to treat tuberculosis.
In January 1922, they successfully treated a young boy Outbreaks of poliomyelitis, which had increased in the
dying of diabetes with their pancreatic extracts. Although early decades of the 1900s, served as the impetus for the
still incurable, it became possible to live with diabetes. work of American microbiologist Jonas Salk (1914–1995).
One disease that remained not only incurable but un- At its peak, the virus was claiming 50,000 victims annually
treatable through much of the twentieth century was tu- in the United States.3Test trials of Salk’s vaccine with in-
berculosis. With no cure or preventive vaccine forthcoming, activated virus began in 1953, and it proved to prevent the
efforts at the turn of the century were dedicated to con- development of polio. By 1955, the massive testing was
trolling the spread of tuberculosis. It was then that an complete, and the vaccine was quickly put into wide use.
alliance between organized medicine and the public re- Surgical techniques also flourished during this time.
sulted in the formation of voluntary local organizations to A single technical innovation was responsible for open-
battle the disease. These organizations focused on educa- ing up the last surgical frontier—the heart. Up to this
tion to counteract the fear of tuberculosis; at the same time, the heart had been out of bounds; surgeons did not
time, they warned against the disease. In 1904, the local have the means to take over the function of the heart for
organizations joined together to form a national organi- long enough to get inside and operate.7 American sur-
zation,the National Association for the Study and Preven- geon John Gibbon (1903–1973) addressed this problem
tion of Tuberculosis. In 1918, the name was changed to the when he developed the heart-lung machine. Dramatic
National Tuberculosis Association, which was renamed the advances followed its successful use in 1953—probably
American Lung Association in 1973.6 none more so than the first successful heart transplantation
The national and local tuberculosis associations played performed in 1967 by South African surgeon Christiaan
a vital role in educating the public by running campaigns Barnard (1922–2001).
urging people to have skin tests and chest x-rays as a For centuries, the inheritance of traits had been ex-
means of diagnosing tuberculosis. Once tuberculosis was plained in religious or philosophical terms. Although Eng-
diagnosed, an individual was likely to be sent to a sanato- lish naturalist Charles Darwin’s (1809–1882) work dispelled
rium or tuberculosis hospital. There, good nourishment, long-held beliefs about inherited traits, it was Austrian bo-
A tuberculosis skin testing clinic.
(Schorr T.M., Kennedy S.M. [1999].
100 years of American nursing[p. 49].
Philadelphia: Lippincott Williams &
Wilkins)