A Short Historical Survey

Modern knowledge in medicine, methods of diagnosis of human diseases, and their treatment have been built on the experience ac­cumulated by man over his long history, a history measured by thousands of years. Our concept of disease and diagnosis developed together with biology and other sciences. The history of diagnosis is therefore part of the general history of medicine. The current state and development of the science of disease and diagnosis are closely connected with the level of philosophy in each epoch and a concrete knowledge of nature.

During the age of primitive medicine, simple symptoms, such as vomiting and diarrhoea, fever and pain, or obvious fractures and wounds were used for primitive diagnosis. Diagnosis was based on the simplest ex­amination techniques, such as palpation and inspection, which were not planned and were carried out without a detailed study of symptoms of the disease.

Physicians of ancient Egypt and India paid attention to the body temperature; they used auscultation and palpation. Chinese physicians developed the science of the pulse. The Cos and Cnidus medical schools in Greece(Hippocrates) greatly contributed to the development of the science of diagnosis; the Cos school is considered the precursor of modern clinical medicine.

The diagnostic studies of Hippocrates were based on thorough observa­tion of the patient at his bedside and by comparing his condition before and during the disease. Some tests were used to determine the response of the patient. " If the symptoms of the disease are not sufficiently obvious, man must help nature to show these symptoms". The patient was thus asked to move about or his chest was shaken (Hippocratic succussion). Some tools were also used for diagnostic purposes (a probe to examine the uterus, vaginal and rectal specula). Hippocrates auscultated the lungs, Palpated the liver and the spleen. He paid great attention to the general condition of the patient rather than to a search for an affected site or the naming of the disease, because he believed that the condition of a part depends on the condition of the whole. Diagnosis of the disease was based on understanding of the unity of the human body: " Everything is in-

General Part

Chapter 2. History of Diagnosis

terdependent in a living body". Disease is a suffering of the entire body. Diagnosis included the determination of the stage or a period of the disease, and also its origin: " The main object is to determine the cause of the disease, and the source of the original defect".

Hippocrates is the founder of diagnostics. Some of the general prin­ciples used at his time are still valuable for modern medicine. Hippocrates created a method of diagnostic examination and thinking which includes the study of all symptoms of the disease in their succession. He developed rich clinical casuistics and symptomatology. They were not an occasional combination of signs or certain diseases, but a connection of the symptoms with periods of the diseases, steps in the course of the diseases depending on the combination of various conditions. Hippocrates dismissed the ex­istence of " sacred" causes for diseases and considered them to be a natural phenomenon and the result of various external effects.

Hippocrates was aware of the difficulties that the physician meets, and believed that the cooperation of society in carrying out practical medical measures was necessary. " Nothing could be further from the aloof oracular physician-priest. Here, the doctor enlists the patient's help, and that of the 'externals'—the forces of Nature". Following Hippocrates, the science of diagnosis developed for centuries according to his postulates, mainly in special cases enriching medicine with new methods of examina­tion and the symptomatology of new diseases.

Important contributions to the development of medicine and diagnostics were made by Galen (" Corpus medicorum") and especially by Avicenna (" Canon"). The influence of Avicenna continued until the 16th century, both in the Arabian East and in Europe.

New diagnostic methods were developed during the Renaissance. Paracelsus' attempts to diagnose by chemical and physical methods were significant. He was followed by van Helmont and Sylvius, who discovered fermentation and importance of acid-base equilibrium. Santorio used a balance and a hygrometer in his attempts to determine the metabolic in­dices, while Borelly applied the laws of mechanics and mathematics to ex­plain the work of the heart and the skeletal muscles.

The revival of Hippocrates' methods of medical diagnosis (bedside observation) was an important event (Padua and Leiden Universities, and also England).

New valuable methods of examination were introduced into clinical practice in the 18- 19th centuries. Thermometry was suggested by de Haen in 1758. Percussion discovered by Auenbrugger in 1761 was another impor­tant event of that time. A still more important innovation was the stethoscope invented by Lae" nnec in 1819. The Russian physicians M. Mudrov, G. Zakharyin, and A. Ostroumov introduced systematic in-

quiry (anamnesis) into diagnostic methods. V. Obraztsov proposed a plan­ned palpation of the abdominal organs and L. Traube proposed a method of clinical assessment of thermometry.

Clinical observation of the patient and physical examination by auscultation, palpation, measuring temperature, weighing, etc., remained the main and most important diagnostic procedures until almost the 20th century. Practical medicine was then enriched with new additional diagnostic methods, such as laboratory and instrumental techniques. A sphygmograph (Marey, 1860), a sphygmomanometer, Riva-Rocci ap­paratus (1891) were invented.

A method for determining arterial pressure was proposed by a Russian physician Korotkov (1905), oesophagoscopy and a gastric tube (sound) were proposed by Kussmaul (1867- 1868), gastroscopy by Mikulicz (1881), cystoscopy and rectoscopy by Nitze (1879), bronchoscopy by Killian (1897-1898), spirometry by Hutchinson (1894), ophthalmoscopy by Helmholtz (1851), laryngoscopy by Garcia (1855); a method for determin­ing basal metabolism was proposed by Pettenkofer (1861-1862), a method for estimating protein in urine was proposed by Esbach (1874). Biochemical studies were also introduced into clinical practice. The discovery of X-ray by Roentgen was a valuable contribution to diagnostics (1895). Einthoven invented a string galvanometer and was a pioneer in electro- and phonocardiography. Pirquet (1907) proposed an allergic skin test for the diagnosis of tuberculosis. Rieder (1904) worked out a method for X-ray examination of the gastrointestinal tract. Widal proposed the ag­glutination test for diagnosis of typhoid fever (1896) and a method of cytological diagnosis (1900). Schilling used differentiated counts of leucocytes (1912), Bernatsky substantiated a diagnostic value of the erythrocyte sedimentation rate (1894), Arinkin proposed sternal puncture (1927) for intravital study of the bone marrow. Zimnitsky (1923) proposed a method for functional diagnosis of renal diseases; Sahli (1907) introduc­ed sphygmometry and Pachon (1909) oscillometry. Frank (1914) recorded the heart sounds and Castelianos (1937) introduced angiocardiography. Next were introduced ballistocardiography, laparoscopy, and other methods. Methods of biopsy, puncture of the lymph nodes, liver, spleen and other organs have become popular now.

Our concepts of the essence of pathological processes occurring in the body have changed with the development and introduction into clinical practice of new diagnostic methods and with the description of earlier unknown symptoms of diseases and the study of their pathogenesis. In an­cient times, the physician would establish diagnosis by the outward symp­toms of the disease, and would interpret the disease quite subjectively and speculatively. A more accurate diagnosis of diseases have become possible

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Chapter 2. History of Diagnosis

with development of biology and other related sciences. In the 18th- 19th centuries the physicians did not limit themselves by mere speculations but observed their patients from scientific standpoints and discovered many new diseases that had been unknown before. Sydenham, for example, described scarlet fever (1675), Vieussens mitral stenosis (1715), and Boerhaave mediastinal tumours (1718). Heberden described the clinic of angina pectoris (1768), etc. Each decade enriched the list of known diseases. Botkin (1883) gave an account of acute infectious hepatitis, Obraztsov and Strazhesko (1909) described the clinic of thrombosis of cor­onary arteries. The number of discovered nosological entities continues in­creasing, especially during the past decades. The list of known diseases pro­bably doubles each next decade. Diseases that are known to medicine now count to 10000. The number of nosological terms is 8000, and the number of syndromes is about 1600.

The rapid growth of the list of symptoms, syndromes, and diseases can be explained by the development of more accurate diagnostic techniques. Biochemical studies of the blood, urine, and other bodily fluids and excre­tions, methods of functional diagnosis of the respiratory organs, the cir­culatory system, alimentary tract, urinary tract, metabolic system, etc., have become very important for diagnosis during the past decades. X-rays are also widely used for diagnostic purposes (angiocardiography, encephaloroentgenography, etc.). Electrophysiology is also used to diagnose diseases of the heart and brain (electroencephalography, vector-cardiography, etc.). Traced elements help the diagnosis of many diseases. Immunological methods (radio-immunological determination of gastrin of the blood serum included), echographic studies of the heart, gall bladder and pancreas, pH metering (pH-metry) of the gastric contents are now widely used for diagnostic purposes. A thermographic method was developed in 1970 in the Soviet Union (IvanoVa and other scientists) and it is now employed for clinical diagnosis. Endoscopic instruments are being continually improved: flexible endoscopes are now quite safe and the diagnostic procedure is easily tolerated by the patient. Biopsy of various organs becomes more important from the diagnostic standpoint. The methods by which the bioptic specimens are studied are improved as well. In.addition to histological examination of the specimen, modern diagnosis is now facilitated by histochemical, electron-microscopic, immunomor-phological and other studies. Samsonov (1970) proposed a morphometric method. (The ratio of the cell elements of the gastric glands is, for exam­ple, determined by this method.) Various functional " load" tests are now widely used in clinical practice. They provide an accurate information on the functional state of various internal organs (bicycle ergometry, glucose load test, histamine, pentagastrin, and other tests).

The choice of diagnostic means continues increasing. New techniques are developed and old improved. Special tests are proposed. The identifica­tion of diseases becomes more accurate and early, while the diagnostic pro­cedures require many new laboratory and instrumental methods and tools. New diagnostic methods help discover new properties of the human body and enrich our knowledge of the patient and the disease to provide grounds for successful treatment.