Sir William Macewen (1848-1924) with Adolph Barkan (1845-1935), Stanley Stillman (1861-1935). Levi Cooper Lane (1828-1902), Joseph Oakland Hirschfelfer (1854-1920) demonstrating Macewen’s triangle by Stanford Medical History Center CC BY-NC-SA
I was recently given an early birthday present from my sister. It was quite unexpected, especially since our family has always considered it bad luck to open gifts early (knocks on wood). I was even more thrown-off by the gift itself – several volumes of medical journals from 1919. Super cool! The pages are browned with age, and it even comes with old pictures. As I compared it to my notes from almost 100 years later, I was astounded at how much medicine has changed over the past century. Except for the anatomy sections, which other than being translated back from English to Latin for some reason, are bang-on what we understand today.
I occasionally hear jokes about how everything I am learning will become obsolete in 5 years time, but it is not a far cry from the truth. Consider a patient that presents with symptoms of heart attack, or myocardial infarction (MI). This is something that is very well understood. The most common cause of MI is having plaques in the coronary arteries, which are the small vessels that perfuse the heart with oxygen and nutrients. We have three major diagnostic criteria for MI: 1) does the clinical picture make sense (e.g. chest pain, nausea and vomiting, sweating); 2) does this look like a heart attack on our trusty neighborhood EKG (ST segment elevations); and 3) are cardiac enzymes elevated (e.g. high troponins)? If we can say yes to any of the above, we will give the patient a slew of medications (aspirin, heparin, Plavix, etc.) and send them for either stenting or thrombolytics (depending on the center and other factors).
Now lets to back in time a few years to… oh… how about 1919. According to volume I of Health Knowledge, the leading theory behind the etiology of heart attacks was a “neurosis of unknown etiology.” It was diagnosed entirely on a clinical picture (which is based largely on how it normally presents in white males only), and there are no fancy tests that can be ordered. The crux for me was the treatment recommendations: inhaled opiates, ether vapors, and avoidance of movement. Really?!?
There has been such a growth in technology and knowledge in what seems to be a relatively short period of time. Moore’s law transferred to healthcare. Although from a patient’s perspective, I would no doubt prefer to be treated today than when these tomes were written, I have to wonder about the differences in practicing medicine. Unlike in 1919, the dream of being that super doc who knows and treats everything is over. Nowadays we have so many specialties within specialties that we are down to one of two career options: 1) knowing about only a very small fraction of medicine, but being an expert in it; or 2) knowing about many fields, but being an expert in none. There was a single page dedicated to pneumonia in this book, yet there are entire textbooks on my Ipad.
I feel both nostalgic about a time I never knew, and excited about all the things that remain to be learned. But I can appreciate why we still do some of the physical exams we do, even though we can just as easily order a lab test that has better sensitivity and specificity. Medicine is an ancient art. As necessary as it is to continue moving forward, there may always be a place for old, outdated traditions. As long as we still do the new and fancy tests after to confirm our suspicions!
Pro Re Nata | PRN 