Chapter 30 History Lessons of Medicine

Conventionally, the beginning of modern medicine is set in the mid-1930s, marked by the entry of sulfonamides and penicillin into the Pharmacopoeia.Revolutionary forces in medical practice are also commonly attributed to these events.At the time, that was how it looked.Medicine has been turned upside down, literally revolutionized.Many incurable diseases in the past have found cures at that time.There is already a cure.It seemed like a whole new world to us at the time.It was astonishing that doctors were able to cure diseases this time, and no one was more surprised than the doctors themselves.

There is no doubt that it was indeed a great event in medicine, a huge victory for the application of biological science to medicine.But today, viewed from such a distance, it may not be a revolution.For the real revolution in medicine, the one that opened the way for antibiotics and other means of effective therapy today, occurred a hundred years before penicillin was invented.That revolution did not start with the introduction of science into medicine.It was many years before science was introduced into medicine.Like so many revolutions, this one began with the destruction of dogma.Around 1830, it was discovered that most of medicine was idle nonsense.

One of the reasons that this section of medical history has never been a prominent subject in medical education is that the story is tragic, irremediably tragic.Century after century, all the way back to the origins of medicine thousands of years ago, the profession has been based on pure guesswork and crude experimentation.It is hard to imagine, of all human endeavors, any enterprise less scientific than this.Virtually anything conceivable for healing is tried at one time or another, and once it is tried, it drags on for decades, if not centuries, before it is finally abandoned.In contrast, that kind of human experimentation is the most boring and irresponsible of all, based on mere trial-and-error, and usually ends up following that logic.Bloodletting, catharsis, cupping, infusions of every known plant, solutions of every metal, every dietary formula imaginable, including total fasting, all are based on The wildest imaginings of etiology are nothing more than fanciful fictions—this is the medical legacy of a little more than a century ago.It is astonishing that this business has survived for so long, with so many unsatisfactory things, that it has been let go without much protest.Almost everyone has been tricked into medicine.Obviously, one must be a natural skeptic, like Montaigne, in order to see through that ancient nonsense.He has written poignantly about medically-induced ailments hundreds of years before Ivan Illich.But even Montaigne couldn't help.Most people firmly believe in the magical power of medicine and accept it.

Then, in the middle of the 19th century, a few medical titans realized that almost all the sophisticated treatments available at the time didn't really work.In the United States and elsewhere, quite a few savvy physicians have suggested that most of these treatments are actually doing more harm than good.At the same time, a startling discovery has been made: certain diseases are self-limiting, incurable, with a "natural progression," so to speak.Today, it is difficult to imagine the weight of this discovery and its impact on medical practice.There is a long-standing medical tradition that no matter what kind of disease there is, there is a certain way to treat it.It is taken for granted that every disease requires treatment and, if left untreated, will kill. In 1876, Harvard professor Edward H. Clarke wrote a serious essay reviewing what he considered to be the major medical achievements of the previous fifty years.These achievements included studies that demonstrated that typhoid and typhoid fever patients healed themselves without medical intervention and recovered better than those treated with the then-fashionable herbal remedies, heavy metals, and heat.Delirium tremor is a disorder long thought to be fatal without sustained medical intervention, from which no one is spared.As a result, it has been observed that in untreated cases, the disease is more likely to remit and the survival rate is significantly improved.

Over the next few decades, traditional healing rituals were gradually abandoned and what came to be known as "medical art" emerged.Now it seems that this kind of medical skill is really the origin of medical science.It is based on careful, objective, even grim observation of the patient.Through this effort, we understand the details of the natural course of disease.As a result, people understood, for example, that typhoid fever and typhoid fever were two unrelated diseases with very different causes.Accurate diagnosis has become the central tenet and reason of medical ethics, and with the improvement of diagnostic methods, exact prognosis has become possible.Thus, patients and their families are not only informed of the name of the disease they are suffering from, but are also informed, with some confidence, of the most likely outcomes of the disease.By the turn of the century, it was widely accepted that these were the primary responsibilities of the physician.In addition, a new kind of therapy gradually emerged, much less ambitious and less ostentatious than its predecessors, called "supportive therapy," based in large part on some simple common sense: good care, appropriate Bed rest, a reasonable diet, avoiding those secret recipes and patented medicines, plus a measured trust in nature, believing that it will often lead things to a happy ending in its own process.

Physicians are thus more useful and respected specialists than they were before.For all its limitations, although he can't do much to prevent or end the disease, you can rely on him to explain things, to ease anxiety, and to be present.He is relied upon as an advisor and guide in times of difficulty, including death. At the same time, from the last decade of the 19th century onwards, the basic science needed for future medicine was already on the way.The role of germs and viruses in disease is recognized.The main pathogenic microorganisms, most notably Mycobacterium tuberculosis and Treponema pallidum, have been recognized for their appearance and role.By the end of the 1930s, this research had paid off.The techniques of active and passive immunization have been invented for diphtheria, tetanus, lobar pneumonia, and several other bacterial infections; the taxonomy of infectious diseases has become a disciplined discipline; , streptomycin, and everything else.But it needs to be emphasized that it took about 50 years of persistent efforts in basic scientific research to reach this level; without this kind of research, it is impossible for people to think that streptococcus and pneumonia still exist diplococcus stuff, that would make no sense in trying to find antibiotics.Without long and painstaking research on the bacillus tuberculosis, we would still think that tuberculosis is caused by night air, and would still try to cure it by basking in the sun.

By this time, milder skepticism about healing had lasted for about a hundred years, and at last almost reached the point of nihilism.At this moment, we suddenly entered a new period, almost overnight, some of the most common and deadly human diseases-lobar pneumonia, meningitis, typhoid, typhus, tuberculosis, various types of sepsis, It can be cured immediately with antibiotics.Only those viral diseases were out of reach, and even some, such as polio, were soon to be brought under control, thanks to new techniques for making vaccines. When these events happened, people were just dumbfounded.I was a medical student when sulfa drugs and penicillin came along, and I remember the reaction being absolute disbelief.We were willing to fail in therapy a hundred years ago.There are only a few exceptions, which we regard as anomalies, such as vitamins for zeal rash, liver extracts for refractory anemia, insulin for diabetes, and so on.Cases of miliary tuberculosis and subacute bacterial endocarditis have a 100% mortality rate.So we are convinced that we can't change the course of a disease like this, we won't be able to do it in this life, and I'm afraid we won't be able to do it in another life.

Overnight, we become ardent optimists, realizing that if we know enough about how a disease works, we can treat it to make it better.This realization was a new concept only 40 years ago. Most people have forgotten those years, or are too young to remember them, so they take these things for granted.Either they were born with antibiotics, or, they got lucky, they fell from the sky into their arms.We need to be reminded, now more than ever, that medicine's ability to deal with infectious disease is not a blind cat and a dead mouse, or something that simply happens naturally over time.It was the direct result of many years of hard work.So many imaginative and skilled men had done it, but no one could have foreseen that there would be penicillin and streptomycin somewhere in the first few decades of their lives.It is a basic subject with a high level. It has accumulated a large amount of interesting knowledge for its own sake, generated a huge amount of information, and is ready. Once the time to use the knowledge comes, it will be ready to go.

For example, it took people a long time and a lot of work to understand that there is such a thing as hemolytic streptococcal vaccine, that there are more than forty major strep species serologically associated with human disease, that Some of them cause rheumatic fever and valvular heart disease.The first thing to be done was bacteriological and immunological research, which took decades, and by the early 1930s the work had progressed enough that streptococcal infection was recognized as being linked to rheumatic fever. It was not until this information became available that it was confirmed that rheumatic fever was preventable, and with it, the major heart disease that afflicts youth in large numbers, once a way to prevent strep infection was found.Likewise, identifying the role of pneumococci in lobar pneumonia, Brucella in Mediterranean fever, typhoid bacillus in typhoid fever, and meningococcus in epidemic meningitis requires an understanding of the Large amounts of information of seemingly infinite complexity are identified and analyzed.Most of the hard work in laboratories working on infectious diseases reached this level during the first third of this century.At the end of this study, the stage is set for antibiotics.

What was not appreciated then, and is not fully appreciated until now, is how difficult it is to get to this point in other human diseases.We still have heart disease, cancer, stroke, schizophrenia, arthritis, kidney failure, sclerosis, and the degenerative diseases that come with old age.All in all, about twenty-five major human diseases can be listed in this country, and in the underdeveloped countries of the world, a longer and more dire list can be made, including parasitic diseases, toxic diseases and nutritional diseases.They constitute the unfinished agenda of contemporary biomedicine.

With such a list, how would one formulate research policy?The quick and easy way is to conclude that these untapped diseases are simply beyond our reach.The thing to do is to stop there, stay with today's version of science and technology, and make the assurance that, in such an imperfect world, our health care system is well equipped and working to its fullest.The trouble with this policy is that we cannot afford it.The cost is already prohibitive and keeps increasing every year.Plus, existing measures just aren't good enough.We can no longer treat heart disease with open heart surgery.This method is implemented after the disease has run through the destructive course, and its cost is prohibitively high.On the other hand, we cannot procrastinate on solving the problem by simplifying it.In my opinion, it is a simplification that we attribute so many of today's chronic, disabling diseases to environmental or lifestyle inadequacies.The plain truth is that we don't know enough about the truth of things, and we should be more open about our own ignorance. It sounds like a paradox: On the other hand, never in the history of medicine has the future looked so bright.In medicine, there is an undercurrent of pessimism and frustration at the disorganized health care system and its enormous cost, namely, an almost unreasonable optimism that, as long as we can persevere in learning, Our future is boundless in the treatment of human diseases.Scientists working on the heart valve system have complete confidence.They will soon get close to the heart of the matter, and they will no longer regard the mechanism of heart disease as an unreasonable mystery.Scientists working on cancer, despite their public disagreements about how to organize their work, are also gaining insights into the inner behavior of normal and proliferating cells unimaginable just a few years ago.The eukaryotic cell, the cell with a true nucleus, has become a laboratory tool in itself, almost as delicate and handy as the bacterial cell in the early 1950s.This tool can now be used to elucidate how gene signals are switched on or off during the process of differentiation of developing cells, or, in the case of cancer cells, the arrest of differentiation.How carcinogens, or viruses, or other factors not identified so far interfere with the regulation of a cell's behavior remains an unresolved question.But the questions themselves now appear to be open to entry.Research on these issues can continue to move forward with the help of what has been learned over the past 10 years. Neurobiologists can do all kinds of things in their research, so that the human brain is a very different organ than it was 25 years ago.It is far from a complex but ultimately reducible mass of electronic circuits governed by a few circuit diagrams.It now appears to be an essentially endocrine organization in which the basic chemical reactions, the internal transmission of nerve impulses, are determined by biochemical catalysts and their inhibitors.Existing techniques for the quantitative study of single neurons are powerful and precise.Today, this research has turned to the behavior of cell groups, the centers of visual and auditory perception, etc., because this level of research can now be carried out.It's hard to imagine a problem that can never be studied.True, the question of consciousness is being debated as one of the ever-distant candidates, but the debate sounds more like a philosophical discussion.We used to think that we would never discover how the brain worked.Now, no one feels that way anymore. Immunologists, molecular biochemists, and a new generation of researchers fascinated by the structure and function of cell membranes all discovered that they were really doing research together, along with geneticists, in the study of a common Topics: How cells and tissues label themselves, what are the dynamics that govern the orderly development and differentiation of tissues and organs, and how errors in this process are controlled. These are truly unprecedented times.I find it hard to imagine that this new and enormous deluge of information ends up simply in understanding how normal cells, tissues, and organs perform their functions.At the same time, I think, certain details about the mechanism of the disease must be discovered. In my opinion, the record of the past half century establishes two general principles about human disease.First, we must learn more about the underlying mechanism of the disease before we can really take effective action; we must know that it is Streptococcus pneumoniae that causes lobar pneumonia before we can think of using antibiotics.You don't need to know all the details, or even how pneumococcus damages the lungs, but you do need to know that it's there and makes the difference. Second, every disease has a single key mechanism that overrides all others.If you can find it and figure out how to deal with it, you can control that disease.This generalization is difficult to prove and is subject to controversy. It is not so much a scientific statement as it is a strong hunch.I believe, however, that the record to date tends to support this hunch.The most complex diseases that I know of involving multiple cells, multiple tissues, and multiple organs are tertiary syphilis, chronic tuberculosis, and refractory anemia.In each case, at least five major organs and tissues were involved, and each organ and tissue appeared to be affected by many environmental factors.Before their scientific evaluation, each was considered to be what we now call "multifactorial" diseases; they were too complex to allow consideration of any single pathogenesis.However, when all the necessary facts are in hand, it is clear that if one thing is switched off—H. It can be turned off all at once. A promising thing like this, I believe, is the hope of medicine.I have no doubt that dozens of independent factors will be found to cause cancer, including various carcinogens and probably various viruses.But I think it will prove in the future that there must be a single mechanism at the heart of the matter, waiting to be discovered.Schizophrenia, I think, will turn out to be a neurochemical disorder, with some central, single chemical event going awry.I think that a single pathogenic factor causes rheumatoid arthritis, and this factor has not been found so far.I think there are some key vascular abnormalities that trigger coronary blockages and strokes that are not identified yet, but they are there and need to be turned off or turned on. In short, I believe that major human diseases have become biological mysteries that can be explored and eventually solved.Thus it follows that it is now possible to imagine a human society relatively free from disease.Half a century ago, the idea was of course unthinkable.And oddly enough, the idea sounds a bit doomsday: What would we do with death if it happened?What do we do with such a large population?If we don't die from disease, what else can we die from? My answer is, it won't make a difference.We still age and decay, on a timetable similar to today's.The final event will be more like Oliver Wendell Holmes' famous one-horse carriage, which suddenly disintegrates and collapses in one fell swoop.The main effect, almost purely beneficial in my view, would be that we would not suffer from, and be characterized by, disease in the last few decades of our lives, as most of us do today.We may become a healthy species, not unlike the healthy and healthy variety of domesticated plants and animals we have taken for granted.Stroke, Alzheimer's, cancer, and arthritis are not a natural part of the human condition.We should get rid of such obstacles as soon as possible. There is another controversy to comment on such prospects.It is said that, as living beings, we are inherently fallible, prone to bad things.If we succeed in getting rid of one set of diseases, there will always be new ones waiting in the woods, ready to take their place.I don't know if such a thing ever happened.Today, of course, the incidence of chronic disease among older adults is higher than it was in the early 2000s.But that's because more people live into old age.As far as I know, no disease has replaced diphtheria, or cowpox, or whooping cough, or polio.Yes, nature is good at creating, so there will always be incredible new diseases, but the emergence of new diseases is not to make up for the doomed disease quota of human beings. Indeed, the official health care system's tables of morbidity and mortality seem to be telling us just such things.Yet, despite our anxiety, we seem reluctant to accept the news that Western societies are, on record, the healthiest societies in human history.A century ago, every family had to lose a young family member.Compared with that time, we are living in a brand new world.The death of a young man in the family is no longer regarded as an ordinary event, but as a rare and terrible misfortune.Our collective life expectancy is higher this year than any year in history.This general and slow improvement in health and survival is due in part to sanitation engineering, improved housing, and perhaps more affluent living, but in recent years, in large part, to biomedicine.We're not doing too badly.As good as it gets off to a start, I see no reason why it couldn't be better in the future. about how to do better.My argument will not be surprising.I would say that we must continue to conduct biomedical research on the same scale and breadth as it has been for the past 20 years, and make the expansion and development of this whole enterprise dependent on new frontiers.The undertaking is costly.Even so, it accounts for less than 3 percent of the total annual cost of health care today, a figure that adds up to $140 billion.And it's not at all expensive compared to trying to get by with the half-baked technologies we have to rely on at today's level of medicine; if we stayed with those half-baked technologies for the rest of the century This cost will skyrocket, and it will break through the ionosphere. But I would also like to insert a correction into this argument.It seems even more surprising that this revision came from a doctor.I believe that the mainstream of research work, the greatest investment in the future since ancient times, should be in the broad fields of basic biological sciences.Naturally, everywhere there are opportunities for immediate applied scientific research, comparable to, say, making a polio vaccine, or designing a drug-combination therapy for pediatric leukemia.But these opportunities do not come often, nor can they be forced to appear when immature.What is urgently needed for future medicine is more information about life processes at the most fundamental level.We are far from ready to undertake large-scale projects in applied medicine.Because we don't know enough. As in physics, successful applied medicine requires a high degree of certainty about the fundamental facts that are available, and especially about their implications.And in much of medicine, we haven't gotten to that point yet.At this stage, we cannot predict with confidence, which specific new information will come from which field, and which specific disease is most likely to be related.In this case, there must be a certain amount of guesswork and even gaming.My personal opinion is that the most fruitful for the future should come from the fields that generate the most interesting, exciting, and amazing information.Start by being amazing. It seems to me that the safest and most prudent thing to do in this gamble is to bet on surprise.In all likelihood, what surprises us in biology today will be available and useful tomorrow.This, I think, is the ironclad record of past science itself.We have more confidence in dealing with this law.This is how chemical science worked at its inception; this is how we got electricity; and using wonder as our guide, we progress from Newtonian physics to electromagnetism, to quantum mechanics, to contemporary geophysics and cosmology.In biology, evolution and genetics were the big early surprises.But what has been going on for the past quarter of a century is nothing short of astounding.In medicine, the greatest surprises are still ahead of us, but they are there, waiting to be discovered, or tripped up, sooner or later. The starting point of my comments is the most practical, most down-to-earth, and most pragmatic.In the real world, doing research like this would most likely lead to major improvements in human health and be less expensive.Incidentally, this point deserves further emphasis.Once medicine has really achieved brilliant technical successes, say, as in immunology, or antibiotics, or nutrition, or endocrine replacement therapy, so that therapeutic measures can be directed directly at the underlying mechanisms and be decisive Potency, cost can be really low.Health care becomes horribly expensive only when our technology has to strike halfway through the disease, or has to be introduced after the event to replace the loss of damaged tissue.The better we understand disease mechanisms, the more opportunity we have to devise immediate and decisive measures to prevent disease, or to redirect it before it's too late. So much for the practical side.The future of human health requires much more basic science, which I will not discuss in detail. But I have one last point to make about biology.Even if I should be wrong about these prophecies, and it turns out that we can cure or prevent a disease by messing around without understanding the process (unless that happens, I'm would not believe it), as long as we continue to invest in bioscience, we will not fail.A wise Congress cannot fail.The public does not fail. That's all I want to say. Logically, this should be the golden age of the human mind.But that's not the case.All sorts of things seem to be proving wrong; a century seems to be slipping through our fingers, with almost no promises kept.I don't want to speculate here on all the reasons for our cultural misery, or even on the most important of them.But I can imagine one of our faults that still eats away at us: how little we know about ourselves.We are ignorant about how we function, where we occupy, and above all about this vast, incredible living system in which we are rooted as working parts.We don't understand nature, not at all.We have come a long way, but just enough to realize our ignorance.Total ignorance is not so bad a thing; the worst thing is to be halfway to true knowledge, far enough away to know one's ignorance.It's embarrassing, it's frustrating, and it's one of our troubles today. This is a new experience for all of us.Whereas only two centuries ago we were able to explain everything, purely reasoning, most of the harmonious structures painstakingly concocted are falling apart before our eyes.We were left speechless. In a sense, this is a health issue after all.For as long as we are obsessed with our own mysteries, disturbed by our relation to the rest of our beings, strange, bewildered, and dumbfounded by the inscrutable heights of our own minds, in the world today we It cannot be called a healthy animal. We need to know more.Awareness of this seems to be the only meaning of this seemingly inconclusive century.We've discovered how to ask important questions.What is really needed now, for the sake of our civilization, is to get some answers.We now know that we can no longer learn by searching the brain.Because there isn't much to search for there.Nor can we know by guesswork, or make up stories about ourselves.We cannot stay where we are, glued to today's level of understanding, nor can we reverse course.I don't see any real choice we have here because I only see the road ahead.We need science, more and better science, not for its technology, not for fun, not even for health and longevity, but for the hope of wisdom.Our culture must acquire wisdom to survive.