The Future of Medicine 2 The means at the doctor’s disposal

The Medicine Man obtains many of his results and maintains his power over primitive people by surrounding himself with as much ritual and mysterious mumbo-jumbo as possible, and by playing upon the ignorance of his tribe as to the functions of the human body. To primitive man the body must appear a very complicated and miraculous affair, and the Medicine Man who has acquired even a little knowledge of its behaviour under the influence of those diseases with which he is most familiar has gained a considerable power.

The doctor in a civilised community is often accused of utilising similar methods. His prescriptions, written in contractions of what was once Latin, are assumed to be so designed in order to delude the patient, and his mysterious references to the action of hidden organs and to disease processes are not always accepted as scientific facts. One difficulty is of course that the doctor has himself been taught those facts in a medico-scientific language which he has learned to understand but which he finds as difficult to translate into everyday terms as would be the case with an unfamiliar foreign language.

It cannot be denied that there are practitioners who do use this difficulty of translating their own knowledge into everyday language as a method of avoiding too much detailed discussion with patients and relatives. To a certain extent this is justified by the fact that Medicine is not entirely a true science but a profession into which a very large element of personal skill enters, and in which true diagnosis and skilful prognosis; still depend to a large extent on a combination of experience and intuitive assessment of the patient’s powers of resistance. These elements earn for this part of Medicine its oft-repeated description as an art rather than a science. This description has led to many discussions among doctors, for nothing is more difficult to define than an art.

To which branch does Medicine belong? To that of the painter who depicts, a familiar scene and by his use of colours creates an atmosphere and pictures a sky even more beautiful than the one we see with our own eyes? Or the sculptor who chisels at a ten-ton block of stone in order to tell us that we really do not know what our original forefather, Adam, looked like? Or the chef who made yesterday’s joint taste like some rare delicacy  or the lady who, discontented with Nature, changes overnight from brunette to blonde? Are we right in comparing the surgeon who completes a delicate operation to a modeller in clay or a physician who reads signs others cannot see to a soothsayer?

Those parts of a doctor’s ability that are called or likened to an art are, in fact, largely experience. It may be true that manual dexterity inherent in a person will tend to make him a surgeon, but all the manual dexterity will not give him that knowledge which enables a surgeon to recognise the moment for and the proper approach to a difficult operation. The power of keen reasoning may incline a young doctor to become a physician, but only experience and a retentive mind will enable him, faced with the same set of facts that have meant nothing to a less experienced colleague, to make a correct diagnosis or prescribe successful treatment.

Even in prognosis, so often extolled as the chief part of Medicine in which “art” must always predominate, it is experience that matters. No amount of artistic temperament will enable the inexperienced doctor to give that essential forecast as to the course and length of a serious illness. How many inexperienced practitioners have given a prognosis of early death, only to find their words quoted in the advertisements of a quack remedy which has “kept the patient alive for many years” or have been inexplicably hopeful, faced with a case that was soon to show the falsity of the prognosis given?

There is no longer, however, any need to surround either the art or the science of Medicine with ritualistic processes or prescriptions in symbolical language. While it is true that the knowledge that takes many years of studentship and experience to accumulate can be translated into simple language, nothing short of the same amount of training and experience would enable the lay person to understand all that the doctor gathers from his examination of a patient, or intends by the mixture of drugs which he puts into his pre­scription, so that the removal from medical practice of whatever elements of the mysterious still remain will not lessen the powers of the modem Medicine Man. It will, indeed, increase his power in so far as it enables the patient and his relatives to appreciate how well the doctor is carrying out his difficult task

Faced with a sick patient, that task is to discover which organs are functioning in an. abnormal fashion, to what extent they are abnormal, and to decide which particular disease process is likely to be causing these abnormal changes. This presupposes a correct picture in the doctor’s mind of how each organ functions both as a separate unit and in combination with other organs. There are a large number of mechanical, electrical, and other, devices which will assist in this procedure, but in the first instance the doctor is dependent on his own senses. To begin with, he always wants to know what the patient feels is wrong and how long this feeling of illness has lasted. Many are the amusing stories that doctors tell one another of the remarks made by patients faced with the simple question “What are you complaining of? ” The answer the doctor wants is an exact description of pains, aches; disorders of functions, and inability to  perform normal efforts; but nine times out of ten he gets an answer which tells him what someone else has said, or what the patient thinks is wrong, or an emphatic statement of the patient’s own ready-made diagnosis.

From this questioning the doctor at last feels that he has got a clue to the condition, and proceeds to his examination. He may already have discovered much from the appearance of the patient. This was, in fact, one of the earliest methods of diagnosis propounded and used by the ancient Greek physicians! The texture of the skin, appearance of the eyes, softness or firmness of the: facial muscles, even a drooping moustache  tell some part of the story to the duly observant doctor. The general condition of the body, how much superfluous fat there is, or the occurrence of rapid loss of weight, and the state of the bodily muscles, all continue the story. In the examination of the body the doctor depends on what he can feel with his fingers and what he can hear to give him the first indications of  the condition of the internal organs. Everyone who has been ill is familiar with the doctor rapidly tapping at various parts of  the chest, and many have been sceptical of what could be learned by this procedure. Yet the information given is very accurate, and the method used— that of percussion— has been, in vogue for about 200 years

The story is told of how the first doctor to develop. this method, Leopold Auenbrugger, was the son of an  innkeeper who often tapped on the side of his wine barrels to see how much wine was still in them. The innkeeper knew that as  the cask emptied so the level at which a knock would produce a musical note would become lower.   Applied to the chest wall, Auenbrugger found that while the normal lung produced a clear note on tapping it with the finger the presence in the chest of fluid— a common indication of disorder— would cause a dull, solid sound.   Percussion will, however, tell more than the presence of fluid inside the chest, for changes in the lung itself cause alterations in the note produced by the tapping finger.

Patients sometimes have a condition in which they become aware of sounds inside their own body.   In the lungs there is a constant movement of air with every breath, and there cannot be such air currents through the narrow tubes that make up the windpipe and the lungs without noises being, set up, nor can the heart pump blood through its valves without producing sounds.   For over two thousand years doctors put their ear to the chest wall and listened to these sounds without gaining much exact knowledge. To most ears the noises were too weak to mean very much.. To the French physician Laennec (born at the time of the French Revolution) is attributed the discovery of a more accurate means of hearing them. One day he had to examine a woman, patient who had, he thought, heart disease,  But, so the story goes, it was very unlikely that she would permit him the liberty of placing his ear against her chest, and it was while pondering over the problem of surmounting her modesty that he was reminded, by seeing some children playing in the hospital garden, that wood might be a very good conductor of sounds. In a few moments he realised ;that a hollow tube of wood would probably not only enable him to hear the heart sounds of his modest patient but might even clarify them.   So was born the stethoscope.   For many years: it remained the simple tube of wood devised by Laennec, but today we are all more familiar with the twin rubber tubes and metal mouth- piece of  the modern instrument.   We have seen the development of electrical devices which enable the sounds of the heart  to be heard on loudspeakers!

A great variety of sounds both in the lungs and in the heart can be heard when disease is present, but the correct interpretation of these is essential if an accurate diagnosis is to be made. With no other aid than the stethoscope the general practitioner may arrive at a fairly accurate diagnosis of many conditions, but he is fortunate to have at the present day many ways of confirming his opinion  He has for example, instruments which enable him to look into the eye, to measure any departure from normal, and to see changes which not only indicate disease of the eye itself but may reflect deterioration of other organs. Thus a patient who goes to the doctor to complain of a defect of the vision may be surprised to be told that he has kidney disease or is suffering from diabetes. Other tests will soon confirm these deductions. The ear and the throat can also be looked at closely, and defects of the nervous system can be analysed by a series of tests based on our feelings of pain, and touch. Lastly there is the apparatus for assessment of blood-pressure, the raising of which is a common cause of a wide variety of symptoms which bring people to the doctor’s surgery. The blood circulates from the heart throughout the body in a series of narrow tubes, the arteries and veins. To maintain this circulation the heart pumps the blood at a considerable pressure which is fairly uniform for healthy individuals. The usual method of measurement is by means of an apparatus which shows how much pressure (estimated as with the barometer and other pressure instruments in terms of a column of mercury) is needed to obliterate the ordinary pulse felt at the wrist.

There are conditions in which the action of the heart being deficient, the blood-pressure falls below normal, but the change which is most common, and which produces the most dangerous symptoms, is an increase. This may be due to a number of causes, and the doctor well knows that it is not— as many patients suppose —a disease in itself but a sign that something is wrong elsewhere. In those of  a plethoric constitution, who often appear to be in perfect health the increase in blood-pressure may frequently be so high as to be a source of danger since some of the finer blood-vessels  —for example in the brain—may be unable to stand the strain and burst causing the familiar “stroke,” or apoplexy. This is indeed one of the conditions which by a periodic examination of all individuals would be detected in its earliest and most treatable stage.

The heart suffers not only from its own diseases but whenever there is any disease in some part of the body. It may be poisoned by the presence  of germs in another organ or it may be strained when additional work is thrown upon it because of changes elsewhere. Since the heart is the most vital organ in the body, doctors have not been content to rely on their ear alone for its precise examination. The heart, as everyone knows, icomposed, almost entirely of muscle and each beat produces changes in those muscles which give  rise to small electric currents. These can be detected by  an apparatus known as the electrocardiograph, and the method is to utilise these tiny electric impulses to produce a photograph on a prepared scale of measurement. The study of these electrocardiograms enables those who are expert in their interpretation to detect any departure from normal with greater accuracy than by any other means. The electro­cardiograph is, however rarely used by the general, practitioner but it falls into the category of those scientific means of diagnosis which should be at the disposal of every doctor although the correct working and accurate interpretation of their results must be in, the hands of experts.

Another electrical apparatus, and one which requires more specialised knowledge than that of the average doctor, is the X-ray machine. Radiography, as the taking of photographs by means of X-rays is called, has become a  highly technical subject. In its simplest form the X-ray apparatus shows up the bones and is of great value in detecting fractures and in seeing that broken bones under treatment are being brought into correct position and are uniting normally. The modern X-ray apparatus however is capable of taking photographs which will show up defects in such soft tissues as the lungs, and  many cases of tuberculosis are first verified by; this method. X-ray photographs, are actually the shadows cast on the sensitive plate or films by organs which cannot be as freely ‘penetrated  by the rays as the other tissues around. A photograph of the arm, for example, shows  a faint shadow, without detail of the soft muscle and skin because the rays pass through them, while  the bone shows up clearly because its chemical composition and density of structure hold back most of the X-rays. A good photograph ,of course depends on the use of a strength of ray which will penetrate the soft tissues only.

Some organs offer no obstruction to the passage of these wonderful penetrative rays, but by the introduction into the body of various substances which are opaque the  radiologist can not only take photographs of these organs but can, by the process known as screening watch them functioning. The most common of these methods is that of giving a barium meal, by which the size and shape of the stomach and all the intestines can be made visible. The salts of the metal barium offer great resistance to the X-rays, are not absorbed by the digestive organs, and are harmless to the body. If a drink of barium, suitably prepared, is taken it will pass through the digestive organs unchanged, and if enough is given to distend the organs, for example the stomach to the normal extent, a photograph will show if the stomach is normal in size, shape,and position, or if it has an ulcer or other defect.

When X-rays fall on certain other chemicals they cause “fluorescence” the substance glowing with a soft yellow-green light.   An X-ray screen made with a layer of such a chemical and placed in the path of the-rays glows according to the density of rays reaching it. When a screen is held in front of the hand, for instance, and the rays passed through, the bones can be seen as in a photograph.   This method is of great value in examining the digestive organs during a barium meal.   As the patient swallows, the opaque barium can be followed from the mouth downwards and defects noted.   Confirmation, or further detail, may he obtained by photographs taken at the same time.

In addition to the barium meal, there are other substances which can be injected into a blood-vessel and pass out of the blood-stream through the kidneys, which can then with their assistance be photographed. Even the brain yields information to the eyes of the radiologist.

The brain is one of the organs which in a diseased condition often defies the diagnostic skill of the general practitioner.   The whole, nervous system is exceedingly complicated and the brain centralises the control of all our functions in a way that defies description in simple language.   But within the brain many functions come under the control of small, clearly defined areas of its substances and by a careful study of any change the nerve specialist, the neurologist, may be able to locate disease processes with great accuracy.   Thus a brain tumour of small size may be defined with such precision by the examination of the rest of the body that the surgeon can open the skull with absolute certainty that he is at the right spot to find and remove the offending growth; Assistance in this and in the diagnosis of other brain diseases is given by the pathological laboratory by the examination of the cerebrospinal fluid with which the whole of the brain and spinal cord are surrounded.   The com­position of this remains remarkably constant in normal people.   If, however, any disease occurs in any part of the central nervous system, changes will at once take place in the fluid.

We have for example  infections which attack the delicate membrane, the meninges which covers the brain.   One form is due to a small germ called the meningococcus because of its preference for this part of the brain more than any other part of the body.   It sets up the disease with which we have become somewhat familiar since the outbreak of war— cerebro-spinal  fever,   or   meningococcal  meningitis.   The general practitioner will usually diagnose inflammation of the brain, and from a number of signs, particularly the occurrence of a rash which has given rise to the other name for this disease – spotted fever, will be fairly certain which germ is the cause.   Treatment, however, depends on identifying the germ, for if it is the tubercle bacillus nothing can be done, whereas meningococcal cases usually recover when given M&B 693.

This identification of the causative germ is a job for the clinical pathologist.   A sample of the cerebro-spinal fluid is drawn off from the spinal canal through a hollow needle and most of the germs which cause meningitis can be identified in it.   Other changes can also be detected, and the examination  of the cerebro-spinal fluid has become one of the most used of all laboratory procedures which assist the doctor.

Another example will show how the most skilled general practitioner must have at his disposal the services of a laboratory. There are many conditions in which the patient has a persistent rise in temperature, and among these is a number of diseases in which the diagnosis may not be clear for some days and will ultimately depend not on any observation which the doctor can make but on the discovery in the laboratory of the actual cause.   A febrile illness may have presented no serious features, but when it has persisted for a week the doctor must think of the possibility of typhoid fever or a closely-related disease, or of the more unusual undulant fever which occurs in this country by infection from non-pasteurised milk.   All these diseases result in the production in the blood-stream of substances which by their action on the germs may lead to recovery.   Fortunately these substances, or antibodies as they are called, can be detected, and proof of their presence in large amounts is one way in which the laboratory can sort .out these diseases for the general practitioner.   The other way isof course, to isolate  the germ itself from some part of the body.

The diagnostic methods of which we have been speaking involve the use of apparatus which is too expensive or too technical in use for the ordinary doctor, or employ procedures which can only be done in a satisfactory way by those who have long experience in them.   There are many cases of illness, too, in which the general practitioner requires additional help in the form of the opinion of those of his colleagues who have had greater opportunity of studying the rarer diseases than can fall to the lot of the average doctor. It must be remembered that disease is the result of two factors, attack by the disease-producing agent and the degree of resistance which the body is able to offer.   While the picture of a typical case of a particular disease in the average individual is one which every doctor would recognise, there, are many cases in which the attack is either milder or more severe than average, or in which the incidence of more than one morbid condition leads to an unusual state of affairs. It is in such cases that the consulting physician or surgeon plays his part in reaching a decision as to the nature of the illness, the treatment to be followed, and the possible outcome. It is evident therefore that the doctor of today cannot be efficient and remain an isolated individual however skilled he may be.   He has not the time to do his job exactly as he would wish, carrying out all the procedures involved in modern medical technique, nor can he be expected to have experience in every one of those hundreds of diseases which might attack his patients.   That he remains an isolated individual— or at the most combines with two or three of his fellow practitioners— is probably the greatest weakness of general practice at the present day.   It has long been accepted among doctors that in the case of the specialised procedures discussed in this chapter the best results are produced by teams of workers (either of doctors or of doctors and technical assistants); but in fact all the important methods now being used in medical science depend for their greatest success on the work of medical men co-operating in teams.