From Aphorisms to Apache: Medicine's Brave New World

FROM APHORISMS TO APACHE: MEDICINE'S BRAVE NEW WORLD RICHARD B. DAVIS* Aldous Huxley published Brave New World in 1932. With clairvoyance he predicted one advance in medical technology, namely in-vitro fertilization . He did not, however, suspect that clinical decision making could be driven by computer-based technology, using Bayesian and multivariant analysis, because the mathematical concepts underlying information storage and management were not developed until a decade after Brave New World was published. For at least two millennia before the advent of computers, the aphorism often determined the prognosis of a patient. Without doubt the best-known of all medical aphorisms is Hippocrates 's first aphorism: "Life is short, the art is long; opportunity fleeting, experiment dangerous, and judgement difficult" [I]. With some degree of hyperbole, Adams has characterized Hippocrates's writings as having a "Conciseness of expression, great condensation of matter, and disposition to regard all professional subjects in a practical point of view, to eschew subtle hypotheses, and modes of treatment based on vague abstractions " [2]. Hippocrates perceived that by observation the natural history of disease could be defined, was to some extent predictable, and thus was susceptible to prognosis. He incorporated rigidity into certain aphorisms such as his first aphorism (the mechanistic paradigm) [3], and flexibility into others (the probabilistic paradigm): "In acute diseases it is not quite safe to prognosticate either death or recovery." Hippocrates's writings spawned numerous commentaries, the earliest of which were written by Herophilus in 300 a.d. Many other ancients relied on Hippocrates's teachings and used aphorisms in their writing, including Galen, Avicenna the Persian, and Maimonides. Among the impressive collections of aphorisms are those of Maimonides (1,575 aphorisms ) and the 1,495 aphorisms of Boerhaave [4]. Boerhaave's apho- *Department of Internal Medicine, University of Nebraska Medical Center, 600 South 42nd Street, Omaha, Nebraska 68198-3330.© 1994 by The University of Chicago. AU rights reserved. 0031-5982/94/3702-0863$01.00 Perspectives in Biology and Medicine, 37, 2 ¦ Winter ¡994 | 237 risms are related to a wide variety of medical topics, and although highly influential in his time, they have now passed almost entirely into oblivion . More recently, the aphorisms of distinguished clinicians have been collected and compiled, including those of Latham [5], and William Osier [6]. Collections of aphorisms also exist in the medical literature on a wide variety of topics, including geriatrics, malaria, amoebiasis, suicide, cancer, surgery, catastrophic disease, and even research in writing . Osier's aphorisms were collected by Robert Bennett Bean, M.D., and were published by his son, William Bennett Bean, M.D. (1909-1989), Chairman of Internal Medicine at the University of Iowa during my freshman year in medical school. Having read all 357 of Osier's aphorisms , I was inspired ten years later to record 127 of the bedside maxims of one of the outstanding clinician-teachers of the midtwentieth century, Cecil James Watson (1901-1983) [7]. Dr. Watson was Chairman of the Department of Internal Medicine at the University of Minnesota Medical School from 1943-1966. His numerous accomplishments and honors have been documented [8] and need not be repeated. His reputation as a teacher was unexcelled [8]. His maxims were recorded at the bedside during 1960-1961 when two challenging clinical problems were presented on weekly chief's rounds. At that time there were no designated subspecialties at the University of Minnesota, but Dr. Watson encouraged the development of expertise in "hobby areas" of special interest . His special interests were liver disease and porphyria. He had an interest early in his career in bilirubin metabolism and was the first to crystallize and characterize stercobilin in Hans Fischer's laboratory [9]. As expected, the emphasis of his aphorisms followed his subspecialty interests, thus giving early de facto recognition to subspecialization in internal medicine, before the widespread advent of training and board examinations in subspecialty medicine. The maxims related to liver disease predominated (see Table 1), followed by those concerned with hematology . Other subspecialty related maxims were more evenly distributed , with the exception of renal and pulmonary disease, which were TABLE 1 Clinical Subspecialty Emphasis of C. J. Watson's Maxims Liver Disease .................................24.5%Porphyria .......................................8.5...