Prevention Of Disease—the Ultimate Object Of Medical Science
( Originally Published 1936 )
The best fruits of medical science will be the prevention, not the cure, of disease.
To build a healthy race, to see that every person has sanitary living conditions, a clean and adequate food supply, and protection from crippling accidents or poisonous products of any kind—such an ideal is certainly the foundation of any modern and intelligent state.
No wonder the editor of The Forum, Henry Goddard Leach, in announcing his platform, took pains to declare that while he favored "drastic reduction of the expenses of government," this did not apply to public health services.
And yet the difficulties in the way of complete realization of such a program are almost insurmountable. Not the least of these is the indifference of the public. One of the unfortunate features of human nature is that we cannot conceive of anything disagreeable happening until it has happened. Many a mother and father with an epileptic or mentally defective child actually on their hands wish that they never had married. But try to persuade a boy and girl in love not to marry in order to avoid such unhappiness and how far do you get? ,
People will do anything to save a child dying of typhoid fever. But they would not hear of having it vaccinated against typhoid six months ago!
Even with all this indifference and ignorance and against all this stubbornness, however, progress goes on. It is encouraging to compare the program of the Royal Sanitary Commission in 1871 with the "Provisional Articles of a National Policy in Preventive Medicine," drawn up for England by Sir George Newman in 1926.
The 1871 ideal was a clean supply of drinking water, proper disposal of sewage, regulation of streets, highways and new buildings, inspection of food, regulation of epidemics, proper lighting of cities, disposal of the dead without injury to the living, and registration of births and deaths.
Nearly every item of that program now is in force. See how the plans have broadened:
NEWMAN'S "PROVISIONAL ARTICLES OF A NATIONAL POLICY IN PREVENTIVE MEDICINE," 1926
1. Heredity and race.
2. Maternity and the care, protection and encouragement of the function of motherhood.
3. Infant welfare and the reduction of infant mortality.
4. The health and physique of the school child and adolescent.
5. Sanitation of the environment, the control of the food supply, and an improved personal and domestic life in the home.
6. Industrial hygiene, the health of the worker in the workshop.
7. The prevention and treatment of infectious disease.
8. The prevention and treatment of non-infectious disease.
9. The education of the people in hygiene.
10. Research, inquiry and investigation, and the extension of the boundaries of knowledge.
UNBELIEVABLE HUMAN ACTIONS RECORDED IN MEDICAL SCIENCE
Respectfully submitted to Mr. Ripley's "Believe It or Not" column are the following medical records:
Eating.—A boy of twelve is reported to have eaten 384 pounds of food in six days. At the same time he vomited constantly, and when food was withheld he would bite off pieces of his own flesh. The only explanation medical science can offer is that it was an example of insanity.
Drinking.—A young man under ordinary circumstances drank from eight to twelve gallons of water a day. At night he had a tubful of water at the side of his bed. At times his thirst would become so excessive that he would drive hogs from their troughs or mudholes in order to quench it. The explanation would seem to be that it was an example of a disease known as "diabetes insipidus" (not the same as ordinary diabetes). In this condition there is a disturbance of water balance: Due to a lesion at the base of the brain the body is unable to "fix" the water consumed in the tissues. It can be treated by the use of pituitary extract.
Heat Endurance. —A Russian named Chamonni made his living by entering an oven carrying a raw leg of mutton, and would stand there until the meat was cooked. There is no adequate explanation except to say it was adaptation. However, his adaptation was not sufficiently complete, because one day he died at the end of the performance.
Injuries.—The amount of insult which the body can withstand successfully has been the subject of countless reports. Not long ago was reported the case of a youth who in an automobile accident was impaled on the point of a splintered two-by-four, as a beetle is impaled by a naturalist on a pin, and yet recovered.
At the meeting of the American Medical Association one year Dr. Gardner of Cleveland described a woman who had half her brain removed on account of tumor, and yet was able to see and hear and move.
Similarly the case is reported by Dr. C. B. Schutz of Kansas City of a man who had half his brain cut away by a large hand saw. "The plant foreman poured iodine on the surface of the brain and trans-ported the man some twelve miles to a hospital, where he promptly recovered."
The "famous American crowbar case" concerned a workman who exploded a charge of dynamite with his crowbar, driving it up through his jaw and through the frontal lobes of his brain. These lobes are supposed to control intellectual processes only, and this case seems to confirm that idea because the only bad result was that the man had a change of disposition and became moody and irritable. All the functions of sight, hearing, movement of both hands and legs, etc., remained intact.
THE IMMEDIATE FUTURE OF MEDICAL SCIENCE
A glance at the work that the Nobel prize winners have done indicates several possibilities in the development of medical science I believe is not far off.
For instance, the work of Landsteiner on blood grouping showed that the blood serum of one person of a certain type may dissolve the blood cells of another person. It is for this reason that the blood of donor and recipient has to be tested before blood transfusions can be performed.
The report of only last year from London that Dr. Lumsden had succeeded in producing a serum which had the selective power of killing certain cells in a body, opens up the possibility of the thing that everyone has been looking for—cancer cure.
In another field, we seem to be on the very verge of making important progress. This is in our knowledge of the filtrable viruses, which are considered to be the cause of the common cold, chickenpox, infantile paralysis, measles, and possibly many other infectious diseases.
The future, at least the immediate future, seems to many to belong to the biochemist and to the physiochemist. They may be able to tell us something of the nature of tissue changes which will take us into the very heart of the mystery of life itself.
In three departments of knowledge changes are being made so rapidly that we can easily predict, before long, a widespread change in our ideas. These are the vitamins of food, the ductless glands and hypersensitivity or allergy. While work in these departments is very feverish, one feels a certain dissatisfaction with it.
The allergist is able to do much for his patients, but no one has yet thrown any light on the actual nature of the process of hypersensitiveness, or the intimate chemical changes which occur in the cells or the tissue juices. Until such a definition is made, we feel that any fundamental progress will be accidental rather than logical.
The work on the ductless glands is unsatisfactory, because while it provides a fascinating lot of laboratory results, the practical results are very few and far between.
What we want about the vitamins, is more of them. There must be dozens as yet unidentified.
Of course, it is possible that just ahead there is some startling discovery for which no preparation has been made, such as was the case with the x-ray. The application of the x-ray created a field of knowledge which simply did not exist before.
Accidents have determined many medical discoveries in the past. Galileo began to count the pulse because he saw a chandelier swinging. Galvani accidentally discovered the electrical nature of impulses while preparing frogs' legs for supper. Whether such things will occur in the future as often as they have in the past is debatable.
WHAT THEY SAY ABOUT THE DOCTORS
I enjoy books of quotations. Not for reference only, but for reading. They are like the stew you find in the restaurants on Monday—the concentrated essence of the delicacies of the past. So I have had a good time with Burton Stevenson's "Home Book of Quotations."
He has a novel section on doctors. Not entirely flattering to our ego. "A physician is a person who pours drugs of which he knows little into a body of which he knows less."—Voltaire. Pausanius said to a physician who remarked on his great age, "That happens because you are not my doctor."
The costs of medical care loom ever --
"The alienist is not a joke; He finds you cracked and leaves you broke. ! —Keith Preston.
And grave (usually unfounded) suspicions. "There are worse occupations in the world than feeling a woman's pulse"—Sterne.
"The physician is superfluous among the healthy"—Tacitus, who lived before the modern doctrine of the annual physical examination or health audit. Along the same line is Mrs. Piozzi's, "A physician can sometimes parry the scythe of death, but has no power over the sand in the hourglass"—a doctrine I have long expounded, but less pungently.
Some of these will be more appreciated by the profession than the laity. For those who are always wanting consultations--so one doctor can "check" on the other, as if they were a pair of accountants—we recommend:
"A single doctor like a sculler flies,
Rabelais' proverb : "Happy the physician who is called in at the end of the illness," applies to the familiar fact that some diseases run their natural course, uninfluenced by treatment. The patient blames the succession of doctors who fruitlessly treat him during the course of the disease, and gives all credit to the last who arrives just at the time he is going to get well anyhow.
But we get some praise. "A country doctor needs more brains to do his work passably than the fifty greatest industrialists in the world require" Walter B. Pitkin. And I like the description of the surgeon: "In a good surgeon, a hawk's eye, a lion's heart, and a lady's hand"—Leonard Wright, in 1589, mind you.
The most familiar of the quotations is perhaps "A good bedside manner." It is ascribed to George du Maurier in Punch, 1884. The complete text—"What sort of a doctor is he?" "Well, I don't know much about his ability, but he has a good bedside manner." Next most familiar is "Physician, heal thyself," flung at every sick doctor by every egregious ass to the point of fury. And next, "Every man is a fool or a physician at forty." Some, I may add, are both.
But the most familiar of all doctor quotations is not here. "Elementary, my dear Watson." Watson is that Dr. Watson who was associated with the only fictional character of modern times whose name is universally a household word—Sherlock Holmes.
WHY PATIENT SHOULD KNOW SOMETHING OF DIAGNOSES
When people talk about the advance of modern medicine, they are usually thinking in terms of the treatment or cure of disease. But the doctor knows that the greatest advances have been in the field of diagnosis, in the development of methods for ascertaining exactly what is wrong with the patient. This situation has both a hopeful and a somewhat discouraging side.
It is paralleled in ordinary experience with the situation today as regards economics and social security. All our politicians are good diagnosticians but few have any remedy, except the nostrum vendors. Everyone knows that the principal cause of the depression is decreased consumption. Production is ahead, so is distribution—consumption lags.
All right, this is the diagnosis, but what is the treatment? We have tried a good many treatments, and you may judge of their effectiveness. It is so in medicine.
Our methods of diagnosis are so numerous and so varied that the physician and patient often feel that great progress is being made simply because of the pyrotechnics of the examination.
The high cost of medical care is partly due to the fact that many patients want a lot of examinations made, whether they are useful or not. I hear of patients who demand an x-ray of the abdomen in the case of, we will say, a fibroid tumor, when such an examination is not calculated to give any information whatever.
To overcome this unfortunate situation it is advisable that the patient should know something about the possibilities of diagnostic methods so that indiscriminate demands for all kinds of examinations, whether they are calculated to do any good or not, will not be made. We will, therefore, review this week the principal methods of diagnosis which are at hand for the modern physician.
They may be classed into six groups: (1) The patient's history; (2) the physical examination—what the doctor can find out with his unaided eyes, ears and fingers; (3) the laboratory examination—chemical, microscopical and bacteriological; (4) the x-ray examination; (5) physiological methods to test the capacity of an organ or of the whole body, and (6) special methods, consisting largely of instrumental examination of different cavities of the body.
The most important of these is still the patient's history. The patient's recital of his own symptoms gives to the astute diagnostician the best hint as to what the general situation is and where the trouble lies. This is so for two reasons—one is that the history affords a sort of sheet anchor to keep the diagnostician from going astray. If the patient's story states that he fell down and hurt his ankle, it is not logical that the physician is going to treat him for an ulcer of the stomach. Second, the patient himself is a very delicate physiological machine, and if he records his symptoms accurately—and the diagnostician must become a judge of whether he is doing so or not—he will record phenomena that are characteristic of different diseases, and which are very valuable in coming to a conclusion.
THE SECOND STEP IN DIAGNOSIS-PHYSICAL EXAMINATION
We said in the previous article that the patient's recital of the history of his illness is the most important item in diagnosis. In many cases the diagnosis can be made from that alone.
The second most important is the old-fashioned method of physical examination—of seeing, feeling, percussing, and listening to various parts of the body. In fact, these two procedures alone will serve to make a complete diagnosis in almost 80 per cent of the cases that the physician handles. People often forget this and say, in effect, "Why, the doctor didn't do anything for me. He listened to my story and then felt of my arm. He didn't take an x-ray or make a blood examination, or anything, and yet he charged me a good amount."
This is an unfair attitude to take, because the physician who is able to make his diagnosis with his fingers and eyes and ears is practicing the greatest refinement of his art, and the older he gets, the more he learns to depend upon these rather than upon chemical or instrumental methods of examination.
There is a story of the great physician Corvisart, who was Napoleon's attendant, that he walked into a drawing room and saw a picture hanging on the wall and exclaimed suddenly, "That man has heart disease!" and so it turned out. The skill of Sherlock Holmes was due to his uncanny powers of observation. Diagnosis is a kind of detective work by these methods of using the eyes, the fingers, the ears and the wits.
Inspection has been practiced since the earliest times. In the books of the Father of Medicine, Hippocrates, he gives many descriptions of the appearance of patients and what disease was signified by this or that appearance.
Palpation was also used in very early days, especially to determine whether or not a bone was broken from the grating or "crepitus" as it is called, of the two broken ends rubbing over each other.
The other methods which depend upon hearing are relatively late developments. It was a young Austrian who learned that when the chest is struck with the finger a certain sort of a musical note is produced, and when consolidation of the lungs occurs, as in pneumonia, the note changes; also if there is an accumulation of fluid in the chest, there is a changed note. The physician who described these things was named Auenbrugger, who published them in a book in the middle of the eighteenth century-1761.
Another great advance was made in the early part of the nineteenth century, a little over 100 years ago, when a Frenchman, Laënnec, introduced the stethoscope, which is now so familiar a part of every physician's equipment. He discovered by using it that the heart makes certain signs in health, and that these sounds are changed when diseases occur; that the sounds produced by breathing, by the air passing over the bronchial tubes and into the lung cells, have a certain quality in health, which is also changed when disease conditions supervene.
The accomplished physician is distinguished from the second-rater, not by his use of instruments, but by fact that he has developed his touch and his sense of sight and his sense of hearing to the point that he can distinguish all the many changes that occur both in health and in disease.
How DIAGNOSIS IS MADE BY LABORATORY METHOD
We have described in this series of articles on diagnosis the two indispensable methods of approach to any diagnosis—the patient's story of the illness, and the physician's examination of the body with his own senses—especially sight.
These two sets of data will be used in every case. In a good pro-portion of all instances, nothing else will be necessary. The physician knows what a case of measles looks like. He will not require any chemical or instrumental tests to help him. And cases of measles make up a good share of the individual patients the general practitioner sees.
In most chronic conditions, however, some laboratory or mechanical method of examination will be of value in clearing the diagnosis or making the measurement exact. It will seldom be necessary to invoke every resource of modern diagnosis—it would take a week for a patient to submit to every method known: although I understand in some clinics that is what is done as a preliminary measure. It is a false show of thoroughness. The patient should learn to appreciate the physician who is wise enough and considerate enough (both to the patient's person and to his pocketbook) to select only the test which is calculated to be of value in his particular case.
The tests most frequently useful are those made in the laboratory. "The laboratory of clinical pathology" it usually is called.
A great variety of tests are made here—chemical, microscopical, bacteriological. The chemical tests include the examination of the urine, the stomach contents, and, of recent years, the blood.
Blood chemistry is coming to have an increasingly important role in diagnosis. It is amusing nowadays for a biologic chemist to hear people prate about what such and such a thing does to the blood—how it makes acid, for instance. Because the degree of acidity of the blood—and it is almost always nearly neutral, ever so slightly alkaline —can be measured down to the finest decimal point, and the things that "they" say make it acid, seldom do.
We can measure also the amount of calcium, fat, protein, and the retention substances that accumulate when the kidney function is impaired.
For the examination of the blood as a tissue—the cellular elements —to see whether anemia is present, or whether the white cells are increasing in the face of infection, the laboratory consultant uses the microscope and a set of delicate little measuring instruments. Such methods were introduced about 1851 and made a great change in the study of diseases of the blood.
When expectoration is copious and the sputum must be examined, bacteriologic methods are used. As they are when in sore throat a membrane forms, because diphtheria must be excluded or determined at once.
A most useful field which the pathologist has opened up is that of tissue examination. Here is a spot on the skin that may or may not be cancer. Well, a small piece of it can be cut out and sectioned and put under the microscope : the conclusion reached then is much more reliable. The procedure takes about five minutes.
Yes, the clinical pathologist is a busy, a versatile and a very useful citizen.
DIAGNOSIS BY THE X-RAY HAS BROADENED WITH TIME
In the little city of Wurzburg in South Germany there stands a building which I would recommend to public works administrators, and all other planners who are trying to help out humanity, because it is the best example I know of the result of getting the most for your money by taking the long view. It is the Institute of Physics which was erected a good many years ago to develop experimental physics at the university. Something cataclysmic occurred there, because a genius happened to be made the head of the department of physics, and the result was that in 1895 W. C. Röntgen discovered the proper-ties of the X-ray.
The X-ray has been found useful in so many fields of diagnosis that I think, undoubtedly, it may be said to have been the greatest single discovery so far as the field of medical diagnosis is concerned.
When the first practice steps were taken with it, it was thought that its use would be confined entirely to diagnosis of injuries, fractures and dislocation of bones. While it has been continuously helpful in this, with the advance in technique and increase in the refinement of X-ray photography, its usefulness has broadened out so that there is hardly any part of the body to which it cannot be applied.
About ten years after its discovery, Dr. W. B. Cannon of Harvard found that by feeding food impregnated with bismuth, the bismuth would throw a shadow on the X-ray plate, and it was possible to take an outline of the stomach and intestines and also to show their movements. Thus the diagnosis of digestive diseases was extended. The idea that soft parts such as the stomach could be shown on the X-ray led to an extension of its application to diseases of the chest. At first this was called "soft tissue work," but now the differentiation is so fine that practically all diseases of the lung will show changes on the X-ray plate, and the size of the heart and its movements can be seen.
A whole field of discovery was opened up when the use of dyes which throw shadows on the X-ray plate was used. Among the most valuable was that of the dye excreted by the liver and held in the gall-bladder. This has allowed us to make positive identification of gall-stones, which usually threw no shadow on the X-ray plate under ordinary circumstances. Stones in the kidney, of course, were, early in the history of the X-ray, found to be identifiable.
In connection with dyes, one of the most interesting of the new developments is the possibility that a dye can be given which will remain in the blood vessels of the spleen, the kidney and the liver, and show the outline of these organs. Even the nervous system has yielded secrets to the X-ray. By the method of letting air into the cerebro-spinal canal the location of brain tumors has been greatly facilitated.
How INSTRUMENTS THAT SEE INTO BODY MAKE DIAGNOSIS
In reviewing the many methods of diagnosis used by the modern physician, as we have done so briefly, we have been able to do barely more than mention a great many of the most useful ones. But it must be evident that the most useful of all methods are those which depend upon the sense of sight.
There have not been many blind doctors in the world who have been active. I can recall only one—the late Dr. Babcock of Chicago, who had so trained his sense of hearing to compensate for his blindness that he was able to make uncanny diagnoses in the department in which hearing is important—that of the heart and lungs. For most of us sight is the most active and accurate sense, and it is here that the skin specialists have the great advantage over everyone else, because they can see exactly the diseased condition.
Some of the most remarkable developments in diagnosis have been the methods which have extended the sense of sight so that portions of the body ordinarily hidden have been brought to view. In a sense, the X-ray is nothing more than an uncanny magical extension of the sense of sight, dealing with opacities and comparative densities, rather than with color.
One of the earliest of these extensions of sight for purposes of diagnosis was made in 1851 when Helmholtz invented the ophthalmoscope, by which he was able to look into the back of the living eye. It is simply the reflection of a ray of light into the back of the eye with a simultaneous observation of the objects thus illuminated. But it is a wonderful help in every field of medicine, to every form of specialty, because nowhere else can we see the minute and middle-sized blood vessels so plainly shown. Helmholtz has recorded his emotions when he knew he was the first to view the inside of the living human eye, and it must have been an exciting moment, as indeed it was a very fruitful discovery.
Not long afterward, a singing master, Manuel Garcia, conceived the idea of looking into the vocal cords by reflected light on a dental mirror in the back of the throat.
These two discoveries practically founded the specialties of the eye and the throat. It is astonishing that they were not thought of before. We remember that so comparatively short a time ago as the period of the death of George Washington, that great man died of a throat complaint, and yet none of his attending physicians had the initiative to attempt to look inside his open mouth to see if they could see the trouble.
Similar to the ophthalmoscope and the laryngoscope is the otoscope, with which we can look into the ear drum and deduce conditions of the middle ear.
A whole series of instruments have been invented for looking into cavities of the body ordinarily hidden. These work on the principle of the periscope, with an electric light on the end and a series of reflecting mirrors through a narrow tube. With them we can view the lining of the bronchi, of the stomach, of the lower bowel, and of the bladder.
Along the same lines as the extension of sight, we have methods of diagnosis which depend upon transillumination—the illumination of body cavities in a dark room. This gives valuable information in diseases of the nose, and it has lately been extended to the abdomen. The light being placed in the bladder and in a dark room, the entire contents of the abdomen are vividly outlined.
The final step in summing up the diagnosis of a particular individual is to try to decide what his functional capacity is. Most diagnosis is anatomical. We say that the heart is enlarged; the valves are dam-aged, or that the thyroid gland is diseased, or that there is a stone in the kidney, etc., but the greatest refinement comes in deciding how much work this damaged organ can do. We know that a badly dam-aged heart may serve its owner for many years. Everyone knows of such cases. We find hearts at an autopsy so diseased that it is a matter of marvel that the man could have lived at all, and yet he did, doing a fair amount of work.
The decision as to this functional capacity or, in other words, this physiological diagnosis, has depended in the past largely upon the clinical judgment and experience of the physician, but we are finding methods of exact measurement which bid fair to be increasingly important. Measurement is the final test of science, and no science made much growth until it began to have standards of measurement.
Thus, I received the other day, the report of the young army surgeon who took care of Napoleon at St. Helena during his last illness. He records that the Emperor's body heat was high or low, but he gave no exact measurements because the clinical thermometer had not yet been perfected.
Clinical medicine has been borrowing instruments from the physiological laboratory for the purpose of making these more exact measurements of functional capacity. One of the first that we borrowed was the blood pressure apparatus. Another recent one was the apparatus for measuring basal metabolism. Basal metabolism is the total energy exchange of the body, and is measured by the amount of oxygen which it consumes per square area of body surface. We have found, especially in activity of the thyroid gland, that the basal metabolism is high, and that when it degenerates the basal metabolism is low. This is true because the thyroid is the regulator of energy exchange.
Another method of physiologic examination is that of the irregularities of the pulse and the integrity of the conduction system of the heart muscle. This is done by a very delicate indicator of galvanic electricity called the "electrocardiograph." A tracing of the heart's action can be made upon a roll of photographic film so that an extremely good idea of what is taking place inside the heart can be obtained.
By still other methods, more or less chemical in nature, we are able to judge the functional capacity of the kidneys, and of the liver.