From New York State Journal of Medicine.
Medical literature is enormous and the vast majority of medical books and articles are unreadable and possess no intrinsic value; they are scarcely glanced at by the initiated and are soon forgotten.
However, we find throughout history medical writings few in number of the utmost value, writings which show great originality of thought, keen observation and broadness of view, which will live for all time. Hippocrates wrote 2,300 years ago and most of his writings are as valuable now as they were at the dawn of history. Every valuable now as they were at the dawn of history.
Every experienced physician and surgeon will read with delight and with practical advantage the Hippocratic books, and he will find that his horizon will be widened and he will learn much of sterling value from the Father of Medicine. I have frequently quoted Hippocrates at length in my writings and so have many other medical authors.
Some time ago I read an amazing lecture delivered in New York by Lord Horder. It was an epoch-making paper, and it will live for time. It ought to be compulsory for every medical student to read it, and every medical student should be examined on it before being given his degree. To my great pleasure I am able to reprint his most valuable paper, and I imagine that all my readers, both professional and lay, will read it with pleasure, and will derive from it the greatest possible practical benefit.
Lord Horder, thought very eminent on the scientific side of medicine and thoroughly familiar with the achievements of the laboratories, recognizes rightly that “Nature is the curer of disease”, as Hippocrates proclaimed 2,300 years ago.
His lecture is intended to bring back modern medicine out of the morass in which it has become entangled, and to lead it back to the safe and sound paths which were marked out for future generations by the Father of Medicine. EDITOR, “HEAL THYSELF.”.
OF late years the clinicians function has fallen a good deal into disrepute. I want to analyse, as briefly as may be possible, some of the reasons for this.
The first reason that calls for comment, because it is undoubtedly a potent one, is the development, during the past thirty years, of laboratory methods of diagnosis. The study of the patient, qua patient, has been supplemented by the study of materials derived from the patient. Some of us saw the birth of clinical pathology, and many of us have watched this lusty babe grow up to a vigorous manhood.
As is wont with the virile adolescent, there have been times when he thought himself more important than he really was, when he sought to bestride the whole world of medical knowledge, when he firmly believed he was medicine rather than merely making his contribution to medicine. His incursion into the sick room was apt to be somewhat brusque, not to say at times truculent. Cuckoo-like, he jostled and pushed and oft-times succeeded in ousting his more timid and gentle colleague from the latters legitimate sphere.
He took to describing himself in the telephone directory as “physician”, and he invited the credulous sick to consult him. The public, with its child-like confidence in apparatus, loved him, welcoming his advent as signalling the millennium of exact medicine, and unaware that the human brain is the best machine of all. A catalogue of the flora of the fauces and / or if the faeces, a complete blood count, a chemical analysis of the urine to the third place of decimals: “What further may be sought for or declared?” Not only was the new gospel about to dispel the darkness that shrouded diagnosis, it was about to illumine the therapeutic field also.
The “opsonic index” for an exact diagnosis, the hypodermic syringe, charged with the appropriate antigen, for effective treatment, and medicine was “taped” at last. The clinician came to be regarded by some with amused tolerance; by others, even less generously minded, as obstructive to real progress. Nosology disappeared and pathology contracted down to the name of the infecting agent; patient no longer suffered from diseases but from micro-organisms. To the question: “what is the matter with the man in bed 4?” the answer came: “T.B.”.
But fortunately for the patient, for whom, like the soul of Faustus, the powers of good and evil were fighting, some clinicians kept their heads. But the result of the new development was that the older and cruder notions of infection had to be entirely revised; and gaps in the knowledge of metabolism had to be filled. Not only was it necessary that the clinician should think vitally and morbid-anatomically, it was necessary that he should think bacteriologically and biochemically also.
During the recent period of intensive laboratory investigation on the clinico-pathological side of diagnosis, the notion has arisen that the clinician;s observations are not really scientific, that they are of the nature of guess work, whereas everything that happens in the laboratory is controlled by the infallible rules of logic. The argument went rather like this. The test-tube and the microscope cannot lie.
But God alone knows if what the physician thinks is an enlarged spleen is the spleen; or if rose spots are not “any old spots”; or the association of a soft and infrequent pulse with a continued high fever is not some infrequent pulse with a continued high fever is not some odd trick of Nature designed to intrigue the curious minded; and why should not a week of intense headache pass away somewhat suddenly and be replaced by a muttering delirium; and an unexplained deafness appear?
Funny things like these do happen to people who suffer from the disease of microbic origin. But the one certain thing is that the disease isnt typhoid fever, or any infection on the R.A.B. group, because there is no agglutination of the laboratory stains of those organisms by the patients serum.
Strange, this idea that facts have a different value according as they are observed at the bedside or in the laboratory. Stranger still, the idea that one negative observation in the laboratory should, even by responsible clinicians, be regarded as more important than the co-existence of six positive observations at the bedside. In the words of the logician, “we can never, by a single experiment, prove the non-existence of a supposed effect”. If “science arise from the discovery of identity amidst diversity”, then it matters not if the identity be discovered by careful observation of the patient clinically or pathologically.
The whole question is, is it a true identity? But this, in the last resort, depends upon the critical judgment of the observer. Granted that the exercise of judgment at the bedside is more difficult than it is in the laboratory, mistakes in judgment are not confined to the bedside. We have only to send a specimen of the same stool to two, or even to six, bacteriologists, equally expert, to find that failure to “discover identity” is by no means only a beside difficulty. Here the question of criteria is involved, as we known, and criteria are not always uniform even amongst laboratory workers. Their results are, therefore, of necessity, not always comparable.
Now the clinician criteria are, in general, less exact than the pathologists, or can they be made so exact very easily; but if they are made severe, as they should be-if nothing is termed positive which is only doubtfully positive; if the clinicians judgment concerning his observation is controlled by reliable technic; if discovered identities are unequivocal-then the clinicians facts” are as scientific and as logical as are those of the pathologist. The truth is that clear- thinking, with forbearance, is essential to the satisfactory solution of a diagnostic problem whether the contribution comes from the laboratory or from the bedside.
There is a technic of the mind as well as of the eye and of the hand, and the former is quite as essential as the latter. It is not only what you find at the bedside, it is also what you bring to the bedside that matters. The eye sees what it takes with it the power seeing; in other words, it is the mind that sees. And surely it is the same words, it is the mind that sees. And surely it is the same in the laboratory?
In both spheres there comes to some-slowly, painfully, towards the end (alas!) facility born by patient practice out of time. clinician and pathologist are more akin than they sometimes realize. Each of them takes a pride (which the other regards as excessive) in his small discoveries, and each of them lacks humility (or so the other thinks) in face of the of the ward or in the laboratory, momentous things are happening under their very eyes, yet they see them not, for they are both under the same ban-they cannot live in advanced of their generation.
But clinical medicine is just now coming back into its own. The prince has taken notice of the neglected charms of our modest Cinderella. A marriage has been arranged. Professors are leading the bride to the altar, and the name of her bridegroom is Research. There is just time for me, as an interested and loving uncle, to give the pair my blessing:.
