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THE ETHICS OF SURGERY
1170
of canicola fever in
man has lately been established Puerto Cuba,15 Rico,16 Brazil,17 Scotland,18 Indonesia,19 and Malaya.2O Even now, however, a certain number of cases are discovered almost by chance,1 so no useful estimate of the true incidence can be made ; but it seems unlikely to be as high as 3 per 100,000 of population per annum, which is the figure suggested by STEIGNER and MESSERSCHMIDT.13 It is of course well known that L. canicola is primarily a parasite of dogs, and that after clinical recovery from the illness the animals continue for a time to excrete leptospires in the urine. The carrier state is generally believed to persist for rather less than a year, but BROOM1 refers to unpublished work by G. L. MONTGOMERY and W. 1. M. McINTYRE who demonstrated leptospires in the kidneys of dogs 41/2 years after apparent cure of the disease. This observation is of special importance in view of the efficacy of penicillin in the acute stages of canicola fever in dogs,21 because it was later found 22 that penicillin does not prevent the colonisation of the renal tubules and the development of the carrier state. Complete eradication can, however, be achieved even in chronic infections by administering streptomycin.22 It seems probable, though no records have yet been published, that the same treatment would be effective in healthy carriers. It is impossible even to conjecture what proportion of dogs may be healthy carriers, since the condition is not likely to be suspected unless the animal transmits the infection to In all likelihood, however, the rate is high, man. because serological surveys have proved that 25-40% of dogs become infected at some time in their life. In man the disease is most often contracted by direct contact with infective dog’s urine. Infection can also be acquired by bathing in contaminated fresh-water pools ; PRIMAVESI 14 has described 8 cases in children who had bathed in a muddy pond along with two dogs ; the serum of both animals contained agglutinins for L. canicola, but no further proof that they were carriers is adduced. Such evidence is not always easily obtained ; for example, BROOM1 states that L. canicolct was isolated from a suspect dog by injecting a suspension of its kidneys into hamsters, , after repeated microscopical examination and inoculation of its urine had failed to reveal the organism. Because of the mode of transmission sporadic cases are the rule ; and multiple cases, even in one household, are rare except when the nursing of a sick dog has been shared by two or more members of a family.’ 12 13 23 Epidemics of 39 and 28 cases have, however, been investigated in Germany. In one of these epidemics 13 contact with dogs was proved in every case, and the serum of all the surviving animals contained agglutinins for L. canicola. In the other epidemic 10 the first, explosive outbreak occurred among pea-harvesters, who were not accompanied by their dogs to the fields. GLATTKOWSKI10 therefore
in
15. Curbelo. A., Marquez, V. Rev. cubana pediat. 1949, 21, 290. 16. Boyer, C. I., Dammin, J. J., Reyes, F. M. Puerto Rico J. publ. Hlth, 1948, 24, 177. 17. Correa, M. O. A., Meira, J. A. Rev. med. cir. S. Paulo, 1949, 9, 185. 18. Joe, A., Sangster, G. Edinb. med. J. 1951, 58, 140. 19. Wolff, J. W., Loman, S., Wielenga-Bergman, A. B. Docum. neerl. indones. Morb. trop. 1951, 3, 187. 20. Broom, J. C. Unpublished correspondence. 21. Joshua, J. O., Freak, M. J. Vet. Rec. 1947, 59, 595. 22. Brunner, K. T., Meyer, K. F. Proc. Soc. exp. Biol., N.Y. 1949, 70, 450. 23. Campbell, A. M. G., Macrae, J., Manderson, W. G., Sumner, K. C., Broom, J. C. Brit. med. J. 1949, i, 336.
suggests that some unidentified rodent may have been the carrier host. Certainly the epidemiology of canicola fever is not fully known, because cases undoubtedly occur in which the most searching inquiries fail to reveal any obvious source of infection from dogs. At present it is advisable to include canicola fever, and of course the non-icteric form of true Weil’s disease, in the differential diagnosis of all cases of pyrexia of unknown origin " especially if the symptoms include meningitis, nephritis, muscle tenderness, or injection of the conjunctivae, and the history suggests any possible contact with the dejecta of dogs "
or
rats.
Normally the disease is self-limiting-only 2 fatalities have been recorded 24 25-and treatment is mainly symptomatic ; but in view of the predilection of leptospires for the kidneys particular attention should be paid to the renal condition. It is difficult to assess the value of antibiotics in the treatment of the benign forms of leptospirosis ; penicillin does not produce a dramatic improvement in man, as it does in dogs, and reports ownthe use of the newer antibiotics are too few to allow of any conclusions. To prevent transmission of infection from sick dogs man the
to
should be warned of the risk and instructed how to disinfect the animals’ dejecta. Fresh-water bathing-pools should be protected against both rats and dogs ; chlorination is effective against leptospires as against other micro-organisms. When a case arises in man every effort should be made to trace the source of infection so that further spread can be averted. owners
Annotations THE ETHICS OF SURGERY
THE responsibility of the surgeon to modern society was discussed at this year’s annual session of the American Medical Association by Dr. 1. S. Ravdin, chairman of the surgical section.26 The problems he propounded are, as he said, not new ; they are as old as the healing art itself. In, any professional group there will be some who do not maintain the ethical standard observed by the majority ; but whereas in most occupations the results are usually felt in the end by the defaulters, in surgery the greatest sufferer may be the patient. Overcharging and fee-splitting are faults with which Ravdin is much concerned. But what of operations that are unnecessary or have been advised on slender grounds ? Apart altogether from avarice or the desire to earn a living, the temptation to resort to surgery is great. The technique of surgery was, for the most part, worked out by our forbears, but the high degree of safety with which it can now be practised is. due, on the one hand, to the development of .antibiotics, and, on the other, to the great advances in anaesthesia and restorative methods, such as blood.transfusion. Every corner of the body has become accessible, and the mechanical part of surgery has been very largely standardised. Shock can be eliminated, and restoration is easy. Hence a young surgeon, provided he is not ham-handed, can reasonably quickly gain the skill necessary to operate with certainty, accuracy, and expedition. The risks the older surgeon (or rather his patient) had to face have largely vanished. It is so easy to " look and see." Judgment, however, remains as necessary as ever : indeed it grows more necessary with each advance enabling u,s to alter the 24. Weetch, R. S., Colquhoun, J., Broom, J. C.
Lancet, 1949,
i, 906. 25. Wolff, J.W., van Dam, R., Minkenhof, J. E. Ibid, 26. Ravdin, I. S. J. Amer. med. Ass. 1951, 147, 535.
1951, i, 1100.
1171 structure of the body without immediate danger. At providing such care, the medical school can relate itself present, for example, we do not know much about the to its own community. In the U.S.A. the formal part of medical education is remote effects of extensive sympathectomy or of leucotomy, or of the huge operations now carried out for likely to cover a dozen years-four at college, four at the medical school, and four in hospital. Thus there are two cancer ; yet all these operations can be done by men who may not be qualified to judge their advisability sharp breaks ; and " the student may lose his way at in particular circumstances. The risk is always that the either of them." No matter how assiduously a boy " comparative ease with which technical surgical skill devotes himself to premedical’’ requirements he may can be acquired and safely applied may lead to the fail to get into the medical school of his choice or indeed training of men who are not of high enough calibre to any medical school at all. Again, after four successful take the vital decisions so often necessary in surgery. years at the medical school he may fail to get an This risk increases as the specialties narrow in scope ; internship that advances his professional growth. for the more restricted the skill, the more readily it is Perhaps the medical school should clarify for the colleges learnt. If the men working in the specialties cease to and for their students (as well as for itself) its conception of the qualities which justify an undergraduate in considering possess and use a critical intelligence and wide knowledge, himself a candidate for medical training, or even commit to the are bound be with enthusiasts, swayed by they itself earlier than it does now to eventually admitting a result that unnecessary and unsuitable operations will particular student. Almost certainly it should take more of more numerous. In this the become way narrowing for the graduate training of the doctors who and their men with practice by merely responsibility specialties, under present circumstances must be turned over to technical skill, could bring surgery into disrepute. good, bad, and indifferent internships at a wide variety of The moral is clear-namely, that only men of good hospitals." general education and sound principles are really suitable Furthermore, if the college could provide a setting for training as surgeons. If we have the right students, in the which student could actually test his facility in and the right teachers, there will be no need to appeal, and himself to them, admission people observing relating for Ravdin adherence to a ethical code. as stricter does, committees at medical schools would have more to work on, and the future doctor would have begun to get the MEDICAL EDUCATION IN THE U.S.A. kind of experience which is basic to medicine and which THE directors of the Commonwealth Fund, convinced he needs to motivate all his technical studies. At one that " medical education is approaching a new turning medical school young instructors who went out of their point," is allotting large resources to light the way. way to discover how first-year students were getting The fund’s annual report for 19511tells of present on were disturbed to find them so drugged by anxiety deficiencies in words which-allowing for our different over rote-memory tasks that they had no curiosity left : methods-might have come from the heart of a medical the transition from college to medical school had been teacher in Britain. It also tells, more cheerfully, of one of baffled disillusionment. tentative steps to bring medical education into line with "... other teachers at other schools have noted the present-day needs. effect of some conventional medical instruction, damaging No-one, says the report, would claim that medicine which may amount to a sort of atrophy of common sense, a alone determines the health of the people, or that the loss of normal everyday reactions by reasonably physician alone can carry the responsibility for it. Yet temporary and girls who are trying to assimilate too intelligent boys the doctor remains the key figure in man’s effort to many poorly organised facts. The tougher minds among If conserve vigour, escape illness, and postpone death. the students recover from this regressive experience more the social engineer whom some social scientists hope for quickly than the others ; some are permanently warped." should come into being, he may supersede the physician The student must not only learn and digest what he as the strategist of society’s campaign for health ; but can of the medical sciences ; he must also learn to deal the doctor is likely to remain for a long time its tactician with the individual patient. " It is easy for the student and field commander. Tactics rest on technology, and to see the ward as an album of diseases which the faculty doctors must have the best possible technological trainhas thoughtfully collected for him ; to find in the outing ; but a good technologist is not necessarily a good patient service a kaleidoscope of diagnostic designs tactician, and if the medical schools are to teach their so frequently that they never quite seem real. changing students how to deploy all the resources of medicine they He misses the rhythm and flow of the patient’s life, and must teach something more than technology. It is the so he may never fully understand the background, the effort to see clearly what this something more should be, consequences, or the full significance of the diseases to and then how to provide it, that gives rise to the anxious which his attention is directed." In the U.S.A. medical questions that now beset medical educators. One schools are trying to give the student the new dimension question is whether the right people are reaching the in experience which he has been missing-either by medical schools, how students should be chosen, and what the period during which he follows particular previous educational experience they should have had. extendingor families in or out of organised clinics, or by patients Another is how medical teaching can build on what the him to patients’ homes. At Duke University, sending student brings with him, how the medical sciences can be North Carolina, for example, senior students spend a woven together and related to the patient, and how the fortnight or more working with a country doctor.2 break between the " scientific " and " clinical " courses In the experiment being made by New York Hospital can be closed. Still another is how a sense of the relation and Cornell Medical College senior clerkships in medicine, between one person and another that lies at the heart of psediatrics, and psychiatry, instead of following each medicine can be carried through all this process ; and other in series, are to run concurrently ; so " instead of " how the student can see patients not as cases " isolated being successively a cub internist, a cub paediatrician, in space and time but as individuals interacting conand a cub psychiatrist, the student may learn to think tinuously, as they grow up and grow old, with their own of himself as a cub doctor." A clinic for particular environments. A very pressing problem is care is to be formed within the framework comprehensive of the pres3nt how the medical school can demonstrate in practice the service. As far as possible specialists will outpatient kind of medical care that students are exhorted to givecome to the patient and the student, so that the patient medical care that meets the patient’s needs without will be cared for as long as possible in the general clinic sacrificing the values of specialised skills-and how, in instead of being geographically and administratively "
1. Commonwealth Fund : 33rd Annual Report, 1951. Published by the Fund, 41, East Fifty-seventh Street, New York, N.Y
2. New York Times, Nov. 25.
of canicola fever in
man has lately been established Puerto Cuba,15 Rico,16 Brazil,17 Scotland,18 Indonesia,19 and Malaya.2O Even now, however, a certain number of cases are discovered almost by chance,1 so no useful estimate of the true incidence can be made ; but it seems unlikely to be as high as 3 per 100,000 of population per annum, which is the figure suggested by STEIGNER and MESSERSCHMIDT.13 It is of course well known that L. canicola is primarily a parasite of dogs, and that after clinical recovery from the illness the animals continue for a time to excrete leptospires in the urine. The carrier state is generally believed to persist for rather less than a year, but BROOM1 refers to unpublished work by G. L. MONTGOMERY and W. 1. M. McINTYRE who demonstrated leptospires in the kidneys of dogs 41/2 years after apparent cure of the disease. This observation is of special importance in view of the efficacy of penicillin in the acute stages of canicola fever in dogs,21 because it was later found 22 that penicillin does not prevent the colonisation of the renal tubules and the development of the carrier state. Complete eradication can, however, be achieved even in chronic infections by administering streptomycin.22 It seems probable, though no records have yet been published, that the same treatment would be effective in healthy carriers. It is impossible even to conjecture what proportion of dogs may be healthy carriers, since the condition is not likely to be suspected unless the animal transmits the infection to In all likelihood, however, the rate is high, man. because serological surveys have proved that 25-40% of dogs become infected at some time in their life. In man the disease is most often contracted by direct contact with infective dog’s urine. Infection can also be acquired by bathing in contaminated fresh-water pools ; PRIMAVESI 14 has described 8 cases in children who had bathed in a muddy pond along with two dogs ; the serum of both animals contained agglutinins for L. canicola, but no further proof that they were carriers is adduced. Such evidence is not always easily obtained ; for example, BROOM1 states that L. canicolct was isolated from a suspect dog by injecting a suspension of its kidneys into hamsters, , after repeated microscopical examination and inoculation of its urine had failed to reveal the organism. Because of the mode of transmission sporadic cases are the rule ; and multiple cases, even in one household, are rare except when the nursing of a sick dog has been shared by two or more members of a family.’ 12 13 23 Epidemics of 39 and 28 cases have, however, been investigated in Germany. In one of these epidemics 13 contact with dogs was proved in every case, and the serum of all the surviving animals contained agglutinins for L. canicola. In the other epidemic 10 the first, explosive outbreak occurred among pea-harvesters, who were not accompanied by their dogs to the fields. GLATTKOWSKI10 therefore
in
15. Curbelo. A., Marquez, V. Rev. cubana pediat. 1949, 21, 290. 16. Boyer, C. I., Dammin, J. J., Reyes, F. M. Puerto Rico J. publ. Hlth, 1948, 24, 177. 17. Correa, M. O. A., Meira, J. A. Rev. med. cir. S. Paulo, 1949, 9, 185. 18. Joe, A., Sangster, G. Edinb. med. J. 1951, 58, 140. 19. Wolff, J. W., Loman, S., Wielenga-Bergman, A. B. Docum. neerl. indones. Morb. trop. 1951, 3, 187. 20. Broom, J. C. Unpublished correspondence. 21. Joshua, J. O., Freak, M. J. Vet. Rec. 1947, 59, 595. 22. Brunner, K. T., Meyer, K. F. Proc. Soc. exp. Biol., N.Y. 1949, 70, 450. 23. Campbell, A. M. G., Macrae, J., Manderson, W. G., Sumner, K. C., Broom, J. C. Brit. med. J. 1949, i, 336.
suggests that some unidentified rodent may have been the carrier host. Certainly the epidemiology of canicola fever is not fully known, because cases undoubtedly occur in which the most searching inquiries fail to reveal any obvious source of infection from dogs. At present it is advisable to include canicola fever, and of course the non-icteric form of true Weil’s disease, in the differential diagnosis of all cases of pyrexia of unknown origin " especially if the symptoms include meningitis, nephritis, muscle tenderness, or injection of the conjunctivae, and the history suggests any possible contact with the dejecta of dogs "
or
rats.
Normally the disease is self-limiting-only 2 fatalities have been recorded 24 25-and treatment is mainly symptomatic ; but in view of the predilection of leptospires for the kidneys particular attention should be paid to the renal condition. It is difficult to assess the value of antibiotics in the treatment of the benign forms of leptospirosis ; penicillin does not produce a dramatic improvement in man, as it does in dogs, and reports ownthe use of the newer antibiotics are too few to allow of any conclusions. To prevent transmission of infection from sick dogs man the
to
should be warned of the risk and instructed how to disinfect the animals’ dejecta. Fresh-water bathing-pools should be protected against both rats and dogs ; chlorination is effective against leptospires as against other micro-organisms. When a case arises in man every effort should be made to trace the source of infection so that further spread can be averted. owners
Annotations THE ETHICS OF SURGERY
THE responsibility of the surgeon to modern society was discussed at this year’s annual session of the American Medical Association by Dr. 1. S. Ravdin, chairman of the surgical section.26 The problems he propounded are, as he said, not new ; they are as old as the healing art itself. In, any professional group there will be some who do not maintain the ethical standard observed by the majority ; but whereas in most occupations the results are usually felt in the end by the defaulters, in surgery the greatest sufferer may be the patient. Overcharging and fee-splitting are faults with which Ravdin is much concerned. But what of operations that are unnecessary or have been advised on slender grounds ? Apart altogether from avarice or the desire to earn a living, the temptation to resort to surgery is great. The technique of surgery was, for the most part, worked out by our forbears, but the high degree of safety with which it can now be practised is. due, on the one hand, to the development of .antibiotics, and, on the other, to the great advances in anaesthesia and restorative methods, such as blood.transfusion. Every corner of the body has become accessible, and the mechanical part of surgery has been very largely standardised. Shock can be eliminated, and restoration is easy. Hence a young surgeon, provided he is not ham-handed, can reasonably quickly gain the skill necessary to operate with certainty, accuracy, and expedition. The risks the older surgeon (or rather his patient) had to face have largely vanished. It is so easy to " look and see." Judgment, however, remains as necessary as ever : indeed it grows more necessary with each advance enabling u,s to alter the 24. Weetch, R. S., Colquhoun, J., Broom, J. C.
Lancet, 1949,
i, 906. 25. Wolff, J.W., van Dam, R., Minkenhof, J. E. Ibid, 26. Ravdin, I. S. J. Amer. med. Ass. 1951, 147, 535.
1951, i, 1100.
1171 structure of the body without immediate danger. At providing such care, the medical school can relate itself present, for example, we do not know much about the to its own community. In the U.S.A. the formal part of medical education is remote effects of extensive sympathectomy or of leucotomy, or of the huge operations now carried out for likely to cover a dozen years-four at college, four at the medical school, and four in hospital. Thus there are two cancer ; yet all these operations can be done by men who may not be qualified to judge their advisability sharp breaks ; and " the student may lose his way at in particular circumstances. The risk is always that the either of them." No matter how assiduously a boy " comparative ease with which technical surgical skill devotes himself to premedical’’ requirements he may can be acquired and safely applied may lead to the fail to get into the medical school of his choice or indeed training of men who are not of high enough calibre to any medical school at all. Again, after four successful take the vital decisions so often necessary in surgery. years at the medical school he may fail to get an This risk increases as the specialties narrow in scope ; internship that advances his professional growth. for the more restricted the skill, the more readily it is Perhaps the medical school should clarify for the colleges learnt. If the men working in the specialties cease to and for their students (as well as for itself) its conception of the qualities which justify an undergraduate in considering possess and use a critical intelligence and wide knowledge, himself a candidate for medical training, or even commit to the are bound be with enthusiasts, swayed by they itself earlier than it does now to eventually admitting a result that unnecessary and unsuitable operations will particular student. Almost certainly it should take more of more numerous. In this the become way narrowing for the graduate training of the doctors who and their men with practice by merely responsibility specialties, under present circumstances must be turned over to technical skill, could bring surgery into disrepute. good, bad, and indifferent internships at a wide variety of The moral is clear-namely, that only men of good hospitals." general education and sound principles are really suitable Furthermore, if the college could provide a setting for training as surgeons. If we have the right students, in the which student could actually test his facility in and the right teachers, there will be no need to appeal, and himself to them, admission people observing relating for Ravdin adherence to a ethical code. as stricter does, committees at medical schools would have more to work on, and the future doctor would have begun to get the MEDICAL EDUCATION IN THE U.S.A. kind of experience which is basic to medicine and which THE directors of the Commonwealth Fund, convinced he needs to motivate all his technical studies. At one that " medical education is approaching a new turning medical school young instructors who went out of their point," is allotting large resources to light the way. way to discover how first-year students were getting The fund’s annual report for 19511tells of present on were disturbed to find them so drugged by anxiety deficiencies in words which-allowing for our different over rote-memory tasks that they had no curiosity left : methods-might have come from the heart of a medical the transition from college to medical school had been teacher in Britain. It also tells, more cheerfully, of one of baffled disillusionment. tentative steps to bring medical education into line with "... other teachers at other schools have noted the present-day needs. effect of some conventional medical instruction, damaging No-one, says the report, would claim that medicine which may amount to a sort of atrophy of common sense, a alone determines the health of the people, or that the loss of normal everyday reactions by reasonably physician alone can carry the responsibility for it. Yet temporary and girls who are trying to assimilate too intelligent boys the doctor remains the key figure in man’s effort to many poorly organised facts. The tougher minds among If conserve vigour, escape illness, and postpone death. the students recover from this regressive experience more the social engineer whom some social scientists hope for quickly than the others ; some are permanently warped." should come into being, he may supersede the physician The student must not only learn and digest what he as the strategist of society’s campaign for health ; but can of the medical sciences ; he must also learn to deal the doctor is likely to remain for a long time its tactician with the individual patient. " It is easy for the student and field commander. Tactics rest on technology, and to see the ward as an album of diseases which the faculty doctors must have the best possible technological trainhas thoughtfully collected for him ; to find in the outing ; but a good technologist is not necessarily a good patient service a kaleidoscope of diagnostic designs tactician, and if the medical schools are to teach their so frequently that they never quite seem real. changing students how to deploy all the resources of medicine they He misses the rhythm and flow of the patient’s life, and must teach something more than technology. It is the so he may never fully understand the background, the effort to see clearly what this something more should be, consequences, or the full significance of the diseases to and then how to provide it, that gives rise to the anxious which his attention is directed." In the U.S.A. medical questions that now beset medical educators. One schools are trying to give the student the new dimension question is whether the right people are reaching the in experience which he has been missing-either by medical schools, how students should be chosen, and what the period during which he follows particular previous educational experience they should have had. extendingor families in or out of organised clinics, or by patients Another is how medical teaching can build on what the him to patients’ homes. At Duke University, sending student brings with him, how the medical sciences can be North Carolina, for example, senior students spend a woven together and related to the patient, and how the fortnight or more working with a country doctor.2 break between the " scientific " and " clinical " courses In the experiment being made by New York Hospital can be closed. Still another is how a sense of the relation and Cornell Medical College senior clerkships in medicine, between one person and another that lies at the heart of psediatrics, and psychiatry, instead of following each medicine can be carried through all this process ; and other in series, are to run concurrently ; so " instead of " how the student can see patients not as cases " isolated being successively a cub internist, a cub paediatrician, in space and time but as individuals interacting conand a cub psychiatrist, the student may learn to think tinuously, as they grow up and grow old, with their own of himself as a cub doctor." A clinic for particular environments. A very pressing problem is care is to be formed within the framework comprehensive of the pres3nt how the medical school can demonstrate in practice the service. As far as possible specialists will outpatient kind of medical care that students are exhorted to givecome to the patient and the student, so that the patient medical care that meets the patient’s needs without will be cared for as long as possible in the general clinic sacrificing the values of specialised skills-and how, in instead of being geographically and administratively "
1. Commonwealth Fund : 33rd Annual Report, 1951. Published by the Fund, 41, East Fifty-seventh Street, New York, N.Y
2. New York Times, Nov. 25.