Persistent Problems of Medicine

I

In 1928, when I entered medical school, our class was fully aware of the great ferment taking place in medicine. Insulin had only recently been discovered, and so had the curative value of liver in pernicious anemia. Endocrinology was emerging as an active discipline. The important role that electrolytes played in health and disease was receiving abundant study. Protein chemistry was making great progress, as was immunology. Surgical interventions were becoming more and more dramatic. By the time we graduated we were fully convinced that the medicine of our day was a truly scientific discipline and that it contrasted markedly with the empirical approach that had prevailed in the previous generation.

In the medical records that we wrote as students we would note the diagnoses and treatment that the patient might have received earlier from his family physician. We referred to this family doctor as the LMD — the local physician of the community, in contrast to the hospital-based physician — and we implied, condescendingly, that before the patient came into our hands he had been subjected not to scientific study but only to blundering guesswork. In the exuberance of youth we had little appreciation of the real problems of medicine.

The years passed swiftly. During World War II we were the young well-trained physicians, ten years out of school, rapidly becoming leaders in the profession. The book learning we had acquired seemed to remain essentially valid, and our theories had been tempered by considerable practical experience. During the war, and for a brief period thereafter, we enjoyed a sense of mastery that we would never feel again.

Our own training had taken place during economic depression, when research was receiving only limited support, and during war years, when research was more practical than theoretical. Then, after the war, medicine acquired a new momentum that increased at a frightening rate. For a long time the physicians of my generation could keep up in our own specialties and even contribute to their advancement. But as the years passed the over-all changes in both theory and practice forced each of us deeper into his own niche of specialization. And from our limited positions we could see a tidal wave of progress — new technology, new theory, new practice — engulfing the medical world. Younger men were taking over leadership. The years passed more and more rapidly until at length the members of my own generation could, if lucky, assume the status of elder statesmen in medicine. If not so lucky they acquired the status of old fuddy-duddy, regarded by the new bright young men just as we had regarded the LMD who had graduated in 1905 or 1910.

The great rush of progress produced the viewpoint that modern medicine differed markedly from that of the past, and that only now, in what we may call the electronic age, was medicine at last really scientific. And the questions arose: When did this transformation take placer When did medicine become truly modern, truly scientific? In 1932 my own generation thought that it had all the answers, but now the new generations of physicians, together with the students they taught and the lay public they indoctrinated, all had a different set of answers. The very brash would say that only for the past ten years was medicine truly scientific, the more conservative would say twenty or twenty-five years. But there was general agreement that what took place more than twenty-five years ago was no longer part of current medicine but belonged rather to medical history. And what took place before World War II held only archeological interest for the medical student or resident. The general public tended to follow this belief.

This attitude was being continually reinforced by well-meaning deans and medical educators who would emphasize the transitory nature of medical education. In effect, these prophets said, of all the information learned today, approximately half would be obsolete within five years. Hence the catchy phrase, that the "half-life" of medical knowledge is a scant five years. Some optimists (or were they pessimists?) might extend the limit to as much as eight years.

Such concepts gave a vivid sense of tumultuous progress and appealed to the popular imagination. But for medical students this was a rather discouraging thought and for many of the older physicians twenty-five years out of school it was a shattering prospect indeed. But what does such facile generalization about medicine really mean? How much change have we actually had? Before we accept at face value all the publicity that medicine receives, we should study the presuppositions that inhere in the concept of medical progress.

The lay public shows a great curiosity about medical progress. Many newspapers and popular journals have special editors who ferret out the new discoveries and present the gist in suitable lay language. A constant stream of books and articles tells the public about the latest advances in medicine. To such lengths has popularization gone that physicians in practice occasionally complain that their patients, after reading popular magazines, may know more about new remedies than they themselves do.

This lay interest in health matters can distort our perspective. A succession of "breakthroughs," enthusiastically reported in the press, can lead the public to expect continued breakthroughs; and journalists looking for copy and not wanting to disappoint their public may magnify the importance of new medical reports. As a result, progress may seem to be greater than it actually is. Publicity may inflate significance.

Other factors may contribute to this inflation. Fund raising for medical research is big business, and fund raising thrives better when new advances seem imminent-hence the temptation to exaggerate the significance of new findings. Then, as a correlative, institutions that seek research support may sometimes encourage publication before conclusions are fully established. And, among individual researchers, the race for priority may induce premature publication or exaggerated claims. Without laboring the point I suggest that important advances may not be as numerous as we may at first think.

Yet, even after allowing for exaggeration and inflated importance, we must stand in awe at the changes that have taken place in medicine in the past twenty-five years. They affect all modalities. We have new modes of treatment, ranging from a succession of "wonder drugs" to fabulous operations such as microsurgery and organ transplants, while new diagnostic tools such as computerized x-ray studies allow extraordinary discriminations. More important, however, are the conceptual advances in fields as widely diverse as immunochemistry, neurophysiology, and genetics.

Yet those who concentrate on advances in medicine lose sight of an important truth: the very fact of change implies something constant that does not change. Aristotle expounded this principle when he distinguished form and matter. Forms do indeed change, but the constant feature that does not change he called "matter." In medicine today the Aristotelian doctrine of form and matter does not have the significance it had 350 years ago, 1 but the principle involved does have relevance. In the explosion of medical knowledge we readily appreciate the facts of change — they are vast and indisputable — but we must not ignore the aspects of constancy, those features of medicine which have not changed. In our present-day preoccupation with what is new, we can profitably keep in mind the factors that remain the same.

II

Let us approach this problem indirectly, by considering the student who is just beginning the study of medicine. I suggest that such a person is taking part, even if unwittingly, in a sort of relay race. We can imagine an invisible runner, a shadowy representative of times gone by, who approaches the new student and presses into his hand a scarcely palpable baton and then vanishes back into the world of shades. The student at first is perhaps not even aware of the baton he is carrying, but as he gains experience and maturity this heritage from the past begins to take on a perceptible shape. In time, as the student acquires further insight, he will realize that the baton had undergone many changes from the many hands that had grasped it in the past. And before he himself can pass it on, his own hands will have moulded it into something different.

The metaphor of a baton will symbolize the heritage of medicine that passes from one generation to another. For easier discussion I suggest a threefold division of the total tradition. First is the heritage of knowledge, that is, the aggregate of information painfully accumulated, together with the theories derived therefrom. This knowledge gets embodied in textbooks. Since medical information and medical ideas undergo constant modification, doctrines are always in a state of flux. The many changes get recorded in texts and journals, whose contents show marked transformation from one generation to the next. A survey of successive doctrines would comprise a history of medical concepts through the ages. This part of our heritage has received a great deal of attention from historians, but for the moment we will pass it by.

The baton also includes a heritage of traditions, customs, and behavior. Here I include that broad area often called medical ethics, which indicates what conduct is right and what conduct is wrong, as physicians treat their patients and interact with their fellow physicians and with society. In a wider sense this aspect relates not only to professional behavior but to the entire social relationships of the physician, considered as a healer, as a citizen, and as a member of society. This tradition of medical behavior is in part parochial, in part bound to total morality.

The third division, and the one that concerns us the most, I would call the heritage of problems. Over the past twenty-five hundred years of medicine certain problems have persisted with remarkable constancy. The medical student can draw comfort from realizing that when he enters practice he will be facing essentially the same problems that his medical ancestors also faced. As they labored to find solutions, so he too will labor. We must distinguish, however, between the continuity of the problems and the variations in the answers. The answers change; the problems, the questions, remain the same.

What, then, are these questions which remain constant? There is no single canonical list, for any selection will depend to some extent on interest. However, in line with my own interests I offer several suggestions, each of which has its own ramifications and subordinate topics. What is the disease from which the patient suffers? How can we identify it? What can we do for it? How can we prevent it? What is its cause? How much confidence can we place in our assertions and our judgments? How do we know if we are right in what we say and what we do?

These questions sound deceptively simple, so much so that they may seem scarcely worth bothering about. Quite obviously they engage the attention of physicians today. And even the most anti-historical scientist will grudgingly admit that in times past physicians probably had similar concerns. But, he will say, the conditions are so different that no comparison is possible. He will stress not the problems but the answers and will want to attend to the changes that have taken place in medicine in the past thirty or one hundred or one hundred and fifty years. Indeed, so prevalent is this attitude that, when regarding the past, most physicians and most laymen concern themselves with the overthrow of past error, the exposure of absurdities, the succession of triumphant breakthroughs, the achievements of technology.

An enormous literature recounts the triumphs of modern medicine, and in so doing stresses the aspects of medicine that have changed over the years. Such an emphasis, however, completely distorts the nature of medical science and medical practice. This distortion manifests itself by creating sharp discontinuities and sudden breaks with the past. An example of this type of thinking we find in Lewis Thomas. His views, which I offer in some detail, represent the diametrical opposite of my own concepts of medical history.

In a chapter called "Medical Lessons from History," Thomas described the period of the 1930s when the sulfonamides and penicillin were discovered. This, although a "major occurrence" in medicine, he did not consider to be an actual revolution. "For the real revolution in medicine ... had already occurred one hundred years before penicillin. ... Like a good many revolutions, this one began with the destruction of dogma. It was discovered, sometime in the 1830s, that the greater part of medicine was nonsense"]italics added].

Pointing to the unpopularity of medical history, Thomas said, "And one reason for this is that it is so unrelievedly deplorable a story." For millennia, he claimed, "Medicine got along by sheer guesswork and the crudest sort of empiricism. It is hard to conceive of a less scientific enterprise among human endeavors." Earlier treatments he condemned as "the most frivolous and irresponsible kind of human experimentation, based on nothing but trial and error." He believed that the traditional remedies rested "on the weirdest imaginings about the cause of disease, concocted out of nothing but thin air-this was the heritage of medicine up until a little over a century ago. It is astounding that the profession survived so long and got away with so much with so little outcry. ... Evidently one had to be a born skeptic, like Montaigne, to see through the old nonsense." There was, apparently, no merit in medicine until the 1 830s. Then, for reasons that Thomas does not disclose, there occurred a sudden discontinuity and the real beginning of modern medicine.

These paragraphs indicate Thomas' attitude toward the medical past and toward medical history as a discipline. I quote him to show the views toward history of a prominent and influential member of the medical profession, with a wide popular following.

Interestingly enough, Thomas uses the same word "heritage" to which I attach so much importance. In his words the earlier heritage was "concocted out of nothing but thin air"; but apparently "a little over a century ago" the heritage started to take on substance and significance and led to modern medicine. This, in my view, is an absolute misreading of history, one that, among its other errors, pays attention only to the changes and ignores the continuities. In my view our medical heritage, for at least twenty-five hundred years, has shown a continuity, with a substrate that exhibits a remarkable constancy — namely, a constancy of problems. In this book, I will deal with some of the problems of the past as they continue to concern present-day medicine. The key to understanding the present lies with the past, and the study of the medical past comprises medical history.