Quotes of the Month

July 2002
     This month's Webletter will be a departure from its usual format, which consisted of paraphrasing in laypersons terms Preventive Medicine articles from the medical literature.

     I read an interesting editorial by Ronald C, Hamdy, M.D., FRCP, FACP. Unfortunately I had torn this editorial out of a journal and there was no indication, on the typed sheets, what the name of the journal was. The editorial used the disease hypertension to illustrate how Preventive Medicine achieved it's importance and how the evaluation and treatment of this disease altered and improved the overall health of our human global population.

     Dr. Hamdy emphasized that the discovery and availability of safe and effective anti-hypertensive medication has changed the impact of that disease and in doing so has dramatically revamped the roles of physicians in society and has enhanced the influence of medicine on that same population. Before safe anti-hypertensive medication became available, patients went to see their doctors only if they were feeling bad or had an obvious medical problem. If the physician noted an elevated blood pressure, then he/she generally placed the patient on a rigid diet such as the Kempner diet, told them to lose weight, if appropriate, and to start or increase an exercise program. The diet consisted of boiled or steamed unsalted rice and certain fruits and vegetables. Water and fluids were also restricted. As you can imagine, patient compliance was low or nonexistent. Physicians have known for many years how to measure blood pressure, and they also knew the consequences of sustained hypertension, but their ability to manage or control the disease was limited.

     In the 1960's,two studies clearly demonstrated that lowering blood pressure significantly reduced the incidence of strokes. Those studies were both in England and in a U.S. Veterans Health System. The pharmaceutical industry quickly realized that there should be a valuable market for safe and effective anti-hypertensive medications. The first group of drugs produced so many egregious symptoms (dizziness, sedation, impotence, blurred vision, dry mouth, and constipation) that patients who felt well, yet were just trying to lower their blood pressure upon their doctor's recommendation, refused to take them.

     Diuretics were the first group of drugs that significantly lowered blood pressure without unpleasant side effects. The effectiveness of this class of medications was serendipitously discovered when it was noted that patients taking sulphonamides had a marked diuresis that lowered elevated blood pressures. A research chemist, Karl Beyer, modified, by trial and error, the anti-microbial's formula to come up with chlorthiazide.

     Next came Beta-blockers and propanolol, which was the group's prototype, and was designed intentionally by James Black who was a research chemist. This discovery was quite important in physician's quest to control hypertension, but it was also a monumental event for the pharmaceutical industry-they could now design specific medications. Later this process has been further enhanced by the use of sophisticated computer software.

     Physicians were so inundated with medications with similar actions and different side effects that it became imperative for them to know which ones were best and safest for particular patients. Randomized controlled clinical trials became the yardstick for determining the effectiveness of those medications and also their safety. The evaluation of minor differences seen in various trials rocketed the profession of statistical analysis into the forefront of medicine. Physicians had to learn how to interpret those statistics and the art of medicine that had relied on clinical experience and anecdotal impressions was changed to the science of medicine that could be measured and ascertained by statistical analysis and significance.

     Physician's attention to routine physical examinations, on supposedly healthy patients, in order to determine whether they had asymptomatic hypertension which was amenable to correction by appropriate medication, led to the evaluation of other abnormal laboratory markers which might herald future problems. Examples of those laboratory evaluations of a person's physiological functions were tests for cholesterol and triglyceride levels, occult blood in the stool, electrocardiograms, routine chest x-rays, mammograms, and pap smears.

     Preventive medicine had been practiced for years but in the late 19th and early 20th century it was mostly associated with public health centers and not in physician's individual practices. I had never thought about it before, but I had to agree with Dr.Hamdy; the evaluation and control of hypertension has changed the scope of preventive medicine and significantly improved the health and sense of well being of the world's human population. The human life expectancy of industrialized nations has, accordingly, been vastly lengthened. The next step is introducing the concept and worth of preventive medicine into the primitive areas of the earth and into the minority population of our own country.

"It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well and circumstances must be favorable."

"The life so short, the craft so long to learn."
     - Hippocrates c.460-357 B.C.
Take care until next time,
Richard J.Turner, III, M.D., F.A.C.S.

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