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THE CLINICIAN AND THE COMPUTER
139
In
England Now
A
Running Commentary by Peripatetic Correspondents has been my lot to have to read through scores of proofs
IT each year and one strange fact stands out a mile (1.609341 km.) Most of those who wish to be seers clothe their thoughts in words which are so long and vague that they do not make Thus the torch passed on to us, which should burn sense. with a bright flame, is but dim and dull, and we are left to grope in the murk. The time spent to get script and proofs fit for press must cost a fair sum of hard cash and must raise a book’s price in the long run. The Book of Books, which has no peer, points out the true way of life in word and phrase so brief and clear that " men, though fools, shall not err ".1 Could we not in our small way do the same ? It is true that some terms, such as the names of drugs, can be long, but this does not mean that each word used must match them in length. It may be thought that fresh facts can not be put over in this terse way. If you have read this note so far and it has made some sort of sense, I would point out that this is not much of a feat: each word save the last is monosyllabic. *
*
*
During the refresher course a young consultant physician demonstrated the latest electrical teaching equipment and monitoring devices to reproduce all abnormal heart sounds and patterns. An oscilloscope showed an E.c.G. tracing, carotidpulse wave-pattern, and two recordings of the heart-sounds on a radar-like screen; a phonocardiosimulator reproduced variations in the amplitude, duration, volume of the heart-sounds and murmurs. Both were working at full pressure, and together they filled the hall with sound and vision. The patient was in a nearby room, but within hearing-distance. A G.P. asked " Can you suppress the breath sounds ? " The consultant " replied, Yes, quite easily ", and turning towards the patient’s room, he cupped his hands to form a megaphone and yelled, " Mr. Smith, please hold your breath for one minute ". *
*
#
peripatetic surgeon (Dec. 23, p. 1358) who was appalled by " the increasing narrowmindedness of modern hospital medicine " should take heart from the Chinese writer Sze-tsae-San-shoo who, according to The Lancet of April 22, 1826, wrote that the " Chinese rule given to physicians to ascertain a patient’s complaint is expressed in four words: Wang, look; Wan, listen; Wan, ask; Tsee, feel ... it is laid down as the only regular practice to proceed thus: to inquire of the patient the probable cause of his complaint; whether from affections of the mind; from irregular conduct, before proceeding to feel his pulse. The order, however, is that of the precept given above: first look at the patient’s countenance; next mark the tone of his voice; then ask him about his Pingyuen, the probable source or origin of his malady; and finally feel his pulse!" The
*
*
*
Nowadays I am up to date with modern medicine. The wrapper is stripped within 15 minutes of its arrival and The Lancet is studied at leisure during the next half hour. This is an advantage of the increasing traffic jams on the way to hospital. Never before have I known such peace, without telephone bell or interruption-except when the car ahead begins to move. It is better to read The Lancet than to invert one’s T waves from frustration. #
It
*
!?
two and a quarter hours in comreach item 7 on the agenda and pass a resolution that as from 1968 the annual report be produced annually. But it was depressing to find out that it would be annually three years in arrear. was
mittee,
reassuring, after
to
1.
Isaiah,
xxxv, 8.
Letters
to
the Editor
HOSPITAL ADMISSIONS AND INVESTIGATIONS SIR The correspondence columns of the medical journals and lay Press have shown a welcome concern for the need to eliminate patients’ waiting-times in hospital outpatient The same attention has not been paid to the departments. " " waiting-time for inpatient investigations. Delays in X-ray and laboratory investigations of inpatients adversely affect the economics of the National Health Service; whilst the delays have been tackled by automatic analysers in the laboratory and automatic processing in the X-ray department, these aids have been used without regard to the basic fault-namely, " ondemand " investigation. No laboratory or X-ray department can ever be large enough to meet all requests for " instant " X-ray or laboratory investigation without a great imbalance in the manpower and financial resources of the National Health Service. If on-demand investigation in X-ray department or laboratory is restricted to emergency cases it should allow much smaller departments to cope with larger volumes of work. A central administration, possibly through the medicalrecords office, should surely be the correct body to plan admissions and investigations so that beds are not wastefully occupied. The central records office can arrange that bookings are made in the appropriate investigative departments when the patient is recorded for admission, so that those which cannot be carried out before, can at least be done immediately after, admission. There are few hospitals in the United Kingdom where admission of patients is correlated to the capacity of the X-ray departments or biochemical laboratories. More liaison in this area would surelv eliminate manv of the delavs. Radiodiagnostic Department, The Royal Infirmary, ERIC SAMUEL. Edinburgh 3. THE CLINICIAN AND THE COMPUTER SIR,—I should like to comment on the correspondence that followed publication of my article.1 Evidently, I did not express my argument about the nature of clinical diagnosis as clearly as I had hoped, since Dr. Soothillseems to have missed my point that the general " a disease ", is logically complex. Its complexity concept, must be openly acknowledged by defining it in such a way that deficiency, and the defining characteristics of an individual disease can be chosen from any convenient area of study. Thus, so far from merely tentatively distinguishing syndromal and structural diagnoses, I insist that definitions of diseases can properly be formulated in terms of clinical description (syndrome), morbid anatomy (structure), aetiology, disturbance of function, specific deficiency, and indeed any other sort of criterion that can be stated clearly and that characterises a group of patients in whom for one reason or another we are interested. When we do this, we must recognise the logical precedence of the defining characteristic. In saying that a patient has a certain disease, we are committing ourselves, of necessity, only to the proposition that he has the defining characteristic of that disease. But study of patients known to have this defining characteristic will have provided a description of the disease, including information about the proportions of such patients showing important and relevant findings in all areas of study. This knowledge will justify us in making deductions about the probability of the presence of each of these findings in a patient in whom we have satisfactory evidence that the defining characteristic is present. The names of diseases, defined in this way, can be used as convenient logical devices by which we can express briefly our knowledge or belief about a patient’s illness; and of course as Dr. Hall3 suggests our knowledge may become more precise, 1. 2. 3.
Scaddmg, J. G. Lancet, 1967, ii, 877. Soothill, J. F. ibid. p. 1084. Hall, G. H. ibid. p. 984.
140 or our
illness,
opinion change, during the evolution of a protracted so that we may add to, or modify, our original brief
statement.
Dr. Soothill’s suggestion that programming should be " geared to defined decision situations rather than to’‘ disease ’ is less radical that it looks at first sight. As he points out, the informed clinician does often proceed in this way; in some situations he acknowledges openly that he cannot make a diagnosis, but he knows what to do next. Though pragmatically we accept the inevitability of such situations, most of us regard them as representing failure in ourselves or in the present state of medical science, preferring to make as precise a diagnosis (to approach as nearly to thorough knowledge) of the patient’s illness as possible before embarking on treatment. The suggestion that medical thought should be expressed in terms of decision-making reminded me of a general practitioner for "
whom I did
a
locum
some
38 years ago. As he told
me
about
patients currently under treatment, I became aware that he often went straight from physical signs to treatment: There’s old Mr. Smith with a bad chest; I heard some rales at his bases last week, so I put some digitalis in his mixture ". The wheel "
full circle: Dr. Soothill now wants computers to elaborate this procedure by suggesting courses of action based upon " automated routine investigation ". Dr. Payne4 also has missed one of the principal points of my article. This was that, while computers can evidently be applied usefully to assist differential diagnosis in certain situations in which the range of possibilities has been limited to diseases whose basis of definition is in a single field of study, some published studies of the use of computers where the range of possibilities has not been so limited have been based upon an inaccurate and indeed naive analysis of the meaning of diagnostic terms and of the diagnostic process. So far from " discussion about the nature of disease and diagnosis " being academic " (presumably meaning, for Dr. Payne, of little practical importance), and likely " to cloud the issue about the value of computer-assisted diagnosis ", a generally agreed clarification of these basic concepts is an essential first step towards the useful application of computers in this area. To apply precise methods to vague and ill-defined concepts is likely to perpetuate confusion, by lending it an air of respectability, and to provide an example of what I call, borrowing and adapting a phrase from A. N. Whitehead, the fallacy of turns
UNUSUAL REACTION TO B.C.G.
SIR The usual reaction to vaccination with B.c.G. is the appearance of a local granuloma. In some patients there may be lymphadenopathy, even with suppuration. In rare instances the clinical picture of tuberculosis may be seen and fatal cases have been recorded. The patient described here showed a generalised hypersensitivity reaction involving the skin and probably the muscles and
joints, which responded poorly to steroids but with tuberculostatic drugs. We were unable to find a similar case in the available published reports. The patient was a 13-year-old boy. The past history was non-contributory. 2 months before admission to this departdisappeared
on
treatment
he had a routine B.C.G. vaccination on his left shoulder. 3 weeks later a rash had appeared which initially involved the legs and the gluteal region and eventually spread to the upper extremities and other parts of the body. Some parts of the skin had been closely covered by the rash, with older efflorescences disappearing and new ones showing up. Concomitantly, he had complained of muscle pain, especially in the calves, which became worse on walking, and of abdominal and joint pain (mainly knees and ankles). On admission there was a diffuse, red, maculopapular rash, mainly on the lower extremities (fig. 1), but also on other parts ment
"
misplaced precision. Institute of Diseases of the London S.W.3.
Fig. 1—Macutopapular rash 2
Chest,
J. G. SCADDING.
months after B.C.G. vaccination.
Fig. 2-Microscopy of papular skin lesion. (Reduced to about two-thirds from
x
10.)
of the
BEDSORES
SIR,—Your leading article5 is incorrect. Bedsores are not always preventable and to say that they are, without qualification, will arouse considerable guilt in the minds of many nurses.
We are thinking particularly of a group of patients with extensive metastases which make constant turning and handling intolerable, and often mean that only one position is comfortable for the patient. Frequent care, sheepskins, use of large-cell ripple beds, and imaginative nursing can postpone the incidence of bedsores, but once a patient really reaches the terminal stage and cannot eat they may be an insoluble problem and may not be of major importance. To accept that bedsores may sometimes be inevitable is not merely a counsel of despair. Fresh approaches are being made to the problem of prevention but this certainly has not been solved, and in some cases would seem to be insoluble. To make the emphatic statements of your leading article is unfair to home and hospital nursing, which may be of the highest quality and yet unable sometimes to prevent bedsores. V. WEIST St. Christopher’s Hospice, CICELY SAUNDERS 51 Lawrie Park Road, ALBERTINE WINNER. London S.E.26. 4. Payne, L. C. ibid. 5. ibid. p. 1289.
p. 1304.
body. The left ankle was painful when moved. Erythrocyte-sedimentation rate was 28 mm. in the lst hour (Westergren) ; leucocytes 13,000 per c.mm. Microscopy of the papular skin lesion (fig. 2) showed subepidermal cedema, perivascular infiltration in the dermis consisting mostly of lymphocytes and histiocytes, and some thickening of the arteriolar wall. Initially the treatment consisted of tripelennamine (’Pyribenzamine ’). When this failed to influence the rash, triamcinolone was given. After a few days most of the rash disappeared, as did the muscle, joint, and abdominal pain, but despite the maintenance of steroid therapy for about 2 weeks, new, though less numerous, lesions continued to appear. At this point the possible connection of the entire clinical picture with the B.C.G. antigen was entertained. Steroids were stopped, and the patient was given sodium aminosalicylate (P.A.S.) and isoniazid. Within a week of starting these drugs the skin lesions diminished strikingly, and they finally disappeared after 3 weeks of the treatment. The tuberculostatic drugs were continued for Neither the rash
about 2 months.
other symptoms
nor
re-
appeared, and the B.c.G.-vaccination granuloma became much smaller than in the pre-treatment period. The patient was followed up for about health.
a
year afterwards.
He remained in
good
The beneficial influence of steroids on the mucles and joints and in part on the skin lesions can be explained by their effect 1.
Anderson, A. S., 1965, 65, 311.
et
al. Br.
med. J. 1959, i,
1423.
Blattner, R. J. J. Pediat.
In
England Now
A
Running Commentary by Peripatetic Correspondents has been my lot to have to read through scores of proofs
IT each year and one strange fact stands out a mile (1.609341 km.) Most of those who wish to be seers clothe their thoughts in words which are so long and vague that they do not make Thus the torch passed on to us, which should burn sense. with a bright flame, is but dim and dull, and we are left to grope in the murk. The time spent to get script and proofs fit for press must cost a fair sum of hard cash and must raise a book’s price in the long run. The Book of Books, which has no peer, points out the true way of life in word and phrase so brief and clear that " men, though fools, shall not err ".1 Could we not in our small way do the same ? It is true that some terms, such as the names of drugs, can be long, but this does not mean that each word used must match them in length. It may be thought that fresh facts can not be put over in this terse way. If you have read this note so far and it has made some sort of sense, I would point out that this is not much of a feat: each word save the last is monosyllabic. *
*
*
During the refresher course a young consultant physician demonstrated the latest electrical teaching equipment and monitoring devices to reproduce all abnormal heart sounds and patterns. An oscilloscope showed an E.c.G. tracing, carotidpulse wave-pattern, and two recordings of the heart-sounds on a radar-like screen; a phonocardiosimulator reproduced variations in the amplitude, duration, volume of the heart-sounds and murmurs. Both were working at full pressure, and together they filled the hall with sound and vision. The patient was in a nearby room, but within hearing-distance. A G.P. asked " Can you suppress the breath sounds ? " The consultant " replied, Yes, quite easily ", and turning towards the patient’s room, he cupped his hands to form a megaphone and yelled, " Mr. Smith, please hold your breath for one minute ". *
*
#
peripatetic surgeon (Dec. 23, p. 1358) who was appalled by " the increasing narrowmindedness of modern hospital medicine " should take heart from the Chinese writer Sze-tsae-San-shoo who, according to The Lancet of April 22, 1826, wrote that the " Chinese rule given to physicians to ascertain a patient’s complaint is expressed in four words: Wang, look; Wan, listen; Wan, ask; Tsee, feel ... it is laid down as the only regular practice to proceed thus: to inquire of the patient the probable cause of his complaint; whether from affections of the mind; from irregular conduct, before proceeding to feel his pulse. The order, however, is that of the precept given above: first look at the patient’s countenance; next mark the tone of his voice; then ask him about his Pingyuen, the probable source or origin of his malady; and finally feel his pulse!" The
*
*
*
Nowadays I am up to date with modern medicine. The wrapper is stripped within 15 minutes of its arrival and The Lancet is studied at leisure during the next half hour. This is an advantage of the increasing traffic jams on the way to hospital. Never before have I known such peace, without telephone bell or interruption-except when the car ahead begins to move. It is better to read The Lancet than to invert one’s T waves from frustration. #
It
*
!?
two and a quarter hours in comreach item 7 on the agenda and pass a resolution that as from 1968 the annual report be produced annually. But it was depressing to find out that it would be annually three years in arrear. was
mittee,
reassuring, after
to
1.
Isaiah,
xxxv, 8.
Letters
to
the Editor
HOSPITAL ADMISSIONS AND INVESTIGATIONS SIR The correspondence columns of the medical journals and lay Press have shown a welcome concern for the need to eliminate patients’ waiting-times in hospital outpatient The same attention has not been paid to the departments. " " waiting-time for inpatient investigations. Delays in X-ray and laboratory investigations of inpatients adversely affect the economics of the National Health Service; whilst the delays have been tackled by automatic analysers in the laboratory and automatic processing in the X-ray department, these aids have been used without regard to the basic fault-namely, " ondemand " investigation. No laboratory or X-ray department can ever be large enough to meet all requests for " instant " X-ray or laboratory investigation without a great imbalance in the manpower and financial resources of the National Health Service. If on-demand investigation in X-ray department or laboratory is restricted to emergency cases it should allow much smaller departments to cope with larger volumes of work. A central administration, possibly through the medicalrecords office, should surely be the correct body to plan admissions and investigations so that beds are not wastefully occupied. The central records office can arrange that bookings are made in the appropriate investigative departments when the patient is recorded for admission, so that those which cannot be carried out before, can at least be done immediately after, admission. There are few hospitals in the United Kingdom where admission of patients is correlated to the capacity of the X-ray departments or biochemical laboratories. More liaison in this area would surelv eliminate manv of the delavs. Radiodiagnostic Department, The Royal Infirmary, ERIC SAMUEL. Edinburgh 3. THE CLINICIAN AND THE COMPUTER SIR,—I should like to comment on the correspondence that followed publication of my article.1 Evidently, I did not express my argument about the nature of clinical diagnosis as clearly as I had hoped, since Dr. Soothillseems to have missed my point that the general " a disease ", is logically complex. Its complexity concept, must be openly acknowledged by defining it in such a way that deficiency, and the defining characteristics of an individual disease can be chosen from any convenient area of study. Thus, so far from merely tentatively distinguishing syndromal and structural diagnoses, I insist that definitions of diseases can properly be formulated in terms of clinical description (syndrome), morbid anatomy (structure), aetiology, disturbance of function, specific deficiency, and indeed any other sort of criterion that can be stated clearly and that characterises a group of patients in whom for one reason or another we are interested. When we do this, we must recognise the logical precedence of the defining characteristic. In saying that a patient has a certain disease, we are committing ourselves, of necessity, only to the proposition that he has the defining characteristic of that disease. But study of patients known to have this defining characteristic will have provided a description of the disease, including information about the proportions of such patients showing important and relevant findings in all areas of study. This knowledge will justify us in making deductions about the probability of the presence of each of these findings in a patient in whom we have satisfactory evidence that the defining characteristic is present. The names of diseases, defined in this way, can be used as convenient logical devices by which we can express briefly our knowledge or belief about a patient’s illness; and of course as Dr. Hall3 suggests our knowledge may become more precise, 1. 2. 3.
Scaddmg, J. G. Lancet, 1967, ii, 877. Soothill, J. F. ibid. p. 1084. Hall, G. H. ibid. p. 984.
140 or our
illness,
opinion change, during the evolution of a protracted so that we may add to, or modify, our original brief
statement.
Dr. Soothill’s suggestion that programming should be " geared to defined decision situations rather than to’‘ disease ’ is less radical that it looks at first sight. As he points out, the informed clinician does often proceed in this way; in some situations he acknowledges openly that he cannot make a diagnosis, but he knows what to do next. Though pragmatically we accept the inevitability of such situations, most of us regard them as representing failure in ourselves or in the present state of medical science, preferring to make as precise a diagnosis (to approach as nearly to thorough knowledge) of the patient’s illness as possible before embarking on treatment. The suggestion that medical thought should be expressed in terms of decision-making reminded me of a general practitioner for "
whom I did
a
locum
some
38 years ago. As he told
me
about
patients currently under treatment, I became aware that he often went straight from physical signs to treatment: There’s old Mr. Smith with a bad chest; I heard some rales at his bases last week, so I put some digitalis in his mixture ". The wheel "
full circle: Dr. Soothill now wants computers to elaborate this procedure by suggesting courses of action based upon " automated routine investigation ". Dr. Payne4 also has missed one of the principal points of my article. This was that, while computers can evidently be applied usefully to assist differential diagnosis in certain situations in which the range of possibilities has been limited to diseases whose basis of definition is in a single field of study, some published studies of the use of computers where the range of possibilities has not been so limited have been based upon an inaccurate and indeed naive analysis of the meaning of diagnostic terms and of the diagnostic process. So far from " discussion about the nature of disease and diagnosis " being academic " (presumably meaning, for Dr. Payne, of little practical importance), and likely " to cloud the issue about the value of computer-assisted diagnosis ", a generally agreed clarification of these basic concepts is an essential first step towards the useful application of computers in this area. To apply precise methods to vague and ill-defined concepts is likely to perpetuate confusion, by lending it an air of respectability, and to provide an example of what I call, borrowing and adapting a phrase from A. N. Whitehead, the fallacy of turns
UNUSUAL REACTION TO B.C.G.
SIR The usual reaction to vaccination with B.c.G. is the appearance of a local granuloma. In some patients there may be lymphadenopathy, even with suppuration. In rare instances the clinical picture of tuberculosis may be seen and fatal cases have been recorded. The patient described here showed a generalised hypersensitivity reaction involving the skin and probably the muscles and
joints, which responded poorly to steroids but with tuberculostatic drugs. We were unable to find a similar case in the available published reports. The patient was a 13-year-old boy. The past history was non-contributory. 2 months before admission to this departdisappeared
on
treatment
he had a routine B.C.G. vaccination on his left shoulder. 3 weeks later a rash had appeared which initially involved the legs and the gluteal region and eventually spread to the upper extremities and other parts of the body. Some parts of the skin had been closely covered by the rash, with older efflorescences disappearing and new ones showing up. Concomitantly, he had complained of muscle pain, especially in the calves, which became worse on walking, and of abdominal and joint pain (mainly knees and ankles). On admission there was a diffuse, red, maculopapular rash, mainly on the lower extremities (fig. 1), but also on other parts ment
"
misplaced precision. Institute of Diseases of the London S.W.3.
Fig. 1—Macutopapular rash 2
Chest,
J. G. SCADDING.
months after B.C.G. vaccination.
Fig. 2-Microscopy of papular skin lesion. (Reduced to about two-thirds from
x
10.)
of the
BEDSORES
SIR,—Your leading article5 is incorrect. Bedsores are not always preventable and to say that they are, without qualification, will arouse considerable guilt in the minds of many nurses.
We are thinking particularly of a group of patients with extensive metastases which make constant turning and handling intolerable, and often mean that only one position is comfortable for the patient. Frequent care, sheepskins, use of large-cell ripple beds, and imaginative nursing can postpone the incidence of bedsores, but once a patient really reaches the terminal stage and cannot eat they may be an insoluble problem and may not be of major importance. To accept that bedsores may sometimes be inevitable is not merely a counsel of despair. Fresh approaches are being made to the problem of prevention but this certainly has not been solved, and in some cases would seem to be insoluble. To make the emphatic statements of your leading article is unfair to home and hospital nursing, which may be of the highest quality and yet unable sometimes to prevent bedsores. V. WEIST St. Christopher’s Hospice, CICELY SAUNDERS 51 Lawrie Park Road, ALBERTINE WINNER. London S.E.26. 4. Payne, L. C. ibid. 5. ibid. p. 1289.
p. 1304.
body. The left ankle was painful when moved. Erythrocyte-sedimentation rate was 28 mm. in the lst hour (Westergren) ; leucocytes 13,000 per c.mm. Microscopy of the papular skin lesion (fig. 2) showed subepidermal cedema, perivascular infiltration in the dermis consisting mostly of lymphocytes and histiocytes, and some thickening of the arteriolar wall. Initially the treatment consisted of tripelennamine (’Pyribenzamine ’). When this failed to influence the rash, triamcinolone was given. After a few days most of the rash disappeared, as did the muscle, joint, and abdominal pain, but despite the maintenance of steroid therapy for about 2 weeks, new, though less numerous, lesions continued to appear. At this point the possible connection of the entire clinical picture with the B.C.G. antigen was entertained. Steroids were stopped, and the patient was given sodium aminosalicylate (P.A.S.) and isoniazid. Within a week of starting these drugs the skin lesions diminished strikingly, and they finally disappeared after 3 weeks of the treatment. The tuberculostatic drugs were continued for Neither the rash
about 2 months.
other symptoms
nor
re-
appeared, and the B.c.G.-vaccination granuloma became much smaller than in the pre-treatment period. The patient was followed up for about health.
a
year afterwards.
He remained in
good
The beneficial influence of steroids on the mucles and joints and in part on the skin lesions can be explained by their effect 1.
Anderson, A. S., 1965, 65, 311.
et
al. Br.
med. J. 1959, i,
1423.
Blattner, R. J. J. Pediat.