Posted on 06/27/2004 10:59:58 PM PDT by neverdem
CASES
In 1931, a third-year Harvard medical student saw a cluster of small red dots on his forearm and knew without a shadow of a doubt that he would be dead within six months.
In 1942, an obscure medical journal published the student's diary posthumously, for he did indeed die of the disease he had diagnosed in himself, subacute bacterial endocarditis, an infection of the heart valves that was uniformly fatal before the advent of antibiotics.
The Harvard professor who submitted the diary for publication said in a brief, sharp introduction that as far as he was concerned, doctors were reading too much about laboratory tests and too little about the subjective experience of illness. The diary would afford readers the unique, stereophonic experience of hearing what illness felt like from someone who also knew what it looked like.
In 1979, one of my medical school professors gave us copies of this article - gray, lopsided sheets run off a primitive copier from an original that my teacher had received from a teacher of his own.
We read the story. At age 13, rheumatic fever had damaged one of the student's heart valves. Ten years later, the damaged valve became infected, and was slowly destroyed. Microscopic clusters of tissue debris were flung off the valve's shaggy edges into the student's bloodstream and carried throughout his body. They caused the red dots he saw on his arm and the knots that developed on his hands. Big clumps blocked the blood flow to his spleen, causing excruciating pain in his left side. A clump blocked a major blood vessel in the brain, causing a stroke. His weakened heart beat erratically, then stopped beating. The entire process took six months.
For as long as he could write, the student described it all both as a doctor (his extrasystoles, splenomegaly and petechiae) and as a patient (his fear, pain and continuous hope that one or another useless treatment would save him). It was an unforgettable story.
It was also a story that, for a time, no medical student was likely ever to read again.
Over the last three decades, medicine has become firmly tethered to Medline, the National Library of Medicine's vast computerized database of journal articles that is accessible without charge from any computer in the world. For technical reasons, the system for years coded only articles published from 1966 onward. And 1966 effectively became Year 1 of medicine.
If you are a medical student trying to learn about tuberculosis, you will find thousands of up-to-date articles on Medline, but not the article describing the intoxicating triumph of the first effective anti-tuberculous drug; that article was written in 1948.
If you are looking for information on smallpox, you will find nothing at all of a vast literature from the 1920's through the 1940's. And if you are looking for information on subacute bacterial endocarditis, you will find several thousand articles on treating the infection, but certainly not the student's diary, published long before treatment was possible.
Many doctors do not miss the old stuff at all. "It has less and less practical importance," a journal editor told me recently.
But the people at the national library have a different opinion.
"Not everything that's worth knowing came out in the last 10 years," a spokesman there said last week.
And so slowly over the last decade, with no fanfare, the custodians of Medline have been pushing back the Year 1. Now their database includes articles written through the mid-1950's. The aim, given enough time and money, is to extend the starting date back to the beginning of the 20th century.
Is that money well spent? Perhaps the answer depends on one's definition of "practical importance."
Cutting-edge medicine has clear practical importance. One might say that everything else then fades away. Or one might make the case that those who study the past in medicine are not so much condemned to repeat it as, occasionally, privileged to do so.
In 2004, early this month, in fact, a man sat in my examining room cradling his left side in a peculiar way. He had already been to two emergency rooms in the city, where two "young doctors" assured him that everything was fine. Everything was indeed fine in the usual places - he did not have pneumonia, a broken rib, a kidney stone or colitis. But he could barely sit still for the pain.
The fact that I knew instantaneously what his problem was - and that two young emergency room doctors did not - I ascribe entirely to an article published in 1942 that described the feeling of a blockage in the blood supply to the spleen with such heartbreaking precision that no one could ever forget it.
PING
interesting post!
PING
bttt
Glad to see that "the old days" aren't so dismissable.
bttt
Ask any nurse and they'll probably express their frustration at drs that look at lab tests, not the patient, and miss what's actually going on.
A doc that doesn't look at patient and labs is a lawsuit waiting to happen.
This wealth of knowledge includes the vast repertoire of combined allopathic procedures made available i the last 175 yrs.
My daughter is an RN, and she has had that experience more than once.
Carolyn
Kass of the president's bioethics council uses literature to discuss bioethics...
http://www.bioethics.gov/bookshelf/
Bump to share this article with the doctors at work.
When I learned to repair IBM mainframe computers in 1965, I had to learn the internal operations of the arithmetic-logic unit (ALU) on a bit by bit, control line by control line basis, because I would have to trace a failure to that level. And I had to learn other areas, such as communication with external devices, to the same level. Later on, when I moved over to software support, I had an understanding of how software controlled hardware that my colleagues trained only on software could not match.
Today, all ot that detail resides within a single chip that self diagnoses and signals its own failure, and is replaced as a single unit. Nobody needs that detail any more, but sometimes it helps to understand what is happening, particularly when something goes wrong.
Perhaps. There was a case in the last 2-3 years of a young person who had volunteered for medical trials. When problems developed, the doctors couldn't find the problem in the literature in the computer database although apparently it was well documented prior to when the literature went online. The person died.
When I worked in a law library, I always had to tell the young students that all the law was not in the online services; that they might actually have to go in the stacks and look at the reporters to find what they need sometimes.
I imagine this problem will only become worse as more young people think everything is online and stop becoming used to going to books for information. If they don't find it online they think it isn't there. We can't put everything online that we may want (such as very old medical articles or legal opinions)due to lack of funding.
In my own research for my PhD, I found that other graduate students couldn't be bothered to dig deep in the library. Again, if it isn't online and easy to find and retrieve, they don't have time for it. Based on my own limited findings, I've become increasingly skeptical of the quality of research that I see.
Online resources are great and allow access for people everywhere. I'm all for that. It's just that everything needed for quality research isn't online and we need to realize that and be willing to get off our rears and do the necessary work.
/rant
How did you happen to come across this thread?
. . ."just looking". .
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