Some days ago, reading “Awakenings” of Oliver Sachs, I stumbled into the following line: “The old rationality was become inapplicable and useless“

We, doctors, have been using – and yet we use –  with triumphant “rationality” some procedures, without questioning their validity and clinical efficacy.

Bloodletting – the pillar of medicine for two thousand years till a a few years ago – was based on the belief that the body has four major fluids that keep the body balanced: phlegm, black bile, yellow bile and blood; it was thought that if there was an excess or deficiency of any of the four humors, that letting out blood could help bring balance.

Trepanning was the process of drilling a hole through the head; like bloodletting, trepanning also was used to give evil spirits an exit strategy from the body, as it was believed that demons were the cause of psychiatric conditions such as psychosis and hysteria.

Radioactive water in the 1900s was used a treatment for mental illness and age prevention: radium also was eventually added to chocolates, toothpastes, contraceptives and suppositories; at the height of its popularity, the U.S. surgeon general believed radium to be a genuine and effective treatment for malaria and diarrhea. Radium was also used as a spa treatment in hot springs.

Morphine is used to treat strong pain in hospital settings,  but it was commonly used as an at-home remedy in the early parts of the 20th century; indeed, morphine, laudanum, heroin, opium and even cocaine could be bought over the counter to treat common colds, menstrual cramps and insomnia. Injection kits were even sold in the former Sears, Roebuck and Co. catalog. Not only that, but in the 1890s, Bayer sold heroin as a panacea for children’s coughs.

Vibrators were believed to often suffer from the psychiatric disorder of hysteria.  Physicians performed a type of pelvic therapy to induce a “hysterical paroxysm,” or in other words, an orgasm. At the end of the 19th century, roughly 75 percent of American women were seen to be victims of hysteria. With such an influx of women in need of the therapeutic pelvic practice, doctors decided they needed a way to perform the practice more quickly. That’s where electric vibrators came in. By the 1800s, the use of electric vibrators reduced the treatment time to 10 minutes as opposed to a laborious hour.

The history of psychiatry is more the history of mad doctors rather than mad patients. Fantastic therapies have been proposed and performed on patients, from insulin shock to lobotomy. At the point to grant a Nobel Prize to Dr. Egas Muniz for the advancement in the procedure of lobotomy (called leucotomy).

I listed a brief number of dogmatic dental procedures, wich have featured our clinical practice for centuries or decades. Notwithstanding today they are considered fanciful procedures lacking of any scientific support and evidence.

What and how many are the actual diagnostic principles and therapeutical aids wich in future shall be labelled as fanciful and scienceless?

This is the task of clinicians and scientists: examine the data daily available in oder to validate or to invalidate the actual models of interpretation and build new models more explicatives of the reality. We must never forget we cannot know the reality in its essence (the Kantian  “noumenon”), but we may only perceive it through our senses and the further brain elaboration (the kantian “phenomenon”). Noumenon comes from the ancient greek and it means “something that is thought”, id est the essence, the very nature of the things. Phenomenon come from the greek verb “faino” meaning “to appear” and phenomenon means “something that appears”, therefore how the things appear to us.

Thus, our knowledge of the reality is a subjective representation of it, featured by our senses  and our brain (who filters our sensations through memory, evolution history, etc.)

I wish to share the following passages written by some clinicians, ranging from 1600 till our days. Time changes, but the brains of doctor works the same,

The day 5 february 1747 doctor Symcotts from England wrote in his medical diary the following clinical case:

” Miss Baldwin from Great Staughton, who had been suffering from a long time of intense stomachache in the morning, started to feel during the night a lasting and intense pain in the right flank radiating towards the spine (back)….then an intense jaundice appeared, which ever and anon diminished and grew every time the patient got a colic. In order to placate the colic, causing intolerable pain at the stomach, I prescribed oil obtained from sweet almond and pepper’s water. Such remedies produced much relief to the patient. So, I prescribed also two large pills which, as soon as they arrived into the stomach, produced further relief and allowed the patient to sleep all night long. But, the night after, pain reappeared more violently. I tried many remedies with unsuccessfull results, only tobacco enema produced some sort of relief. The jaundice reappared and I treated it administering a rhubarb purging, but unsuccessfully. Therefore I decided to open a vein of her on the arm, and after 3 days I applied a leech. She got a temporary relief…..At that point I aministered her an emetic substance, from whom she got pain relief for 4 days. Since the pain represented, I prescribed again a rhubarb purging wich caused 31 bouts of diarrhea.The day after I open her arm’s vein again. Nonetheless colics and jaundice came back. Then I prescribed 3 spoons of emetic. In the interim every morning I administered her a dose of absinthe enriched with an infusion of ship excrements, white wine and powdered eggs. Because she did not heal, I gave ger a new purging, which this time provoked only 11 bouts of diarrhea…then I suggested her to drink frequently little sips of coagulated milk and beer. Besides, I prescribed her the following preparation: powdered eggshell, millipedes drowned in with wine or in brandy, desiccated millipedes and Gascoyne powder….”

Unless we consider the meaning of single actions implemented by doctor Symcotts, and we focus our attention upon his reasoning, many fundamental aspects arise:

– the English clinician does not tell anything about the reason of his diagnostic and therapeutical conduct and how he chooses those therapies instead of other therapies. Nonetheless we have the impression that the decisional reasoning was considered implicitly superfluous. In effect, all clinicians of that age would have understood and shared more or less the reasons of his clinical choices, reasons which escapes to our actual comprehension. Similarly, an actual clinician, at the presence of a “pneumonia”, does not feel the need to justify the institution of antibiotic therapy because his choice is considered comprehensible to all the clinicians. It is inevitable that to our eyes the therapies of dr. Symcotts appear irrational and fanciful, but probably at that age it was different: in fact, at that age, many therapies such as leechs, enemas, were considered unanimously “efficacious” on the basis of precise theories of body function, as the humoral doctrine (well recognized by the medical community at that age). So we may not consider dott. Symcotts an eccentric clinician if we relate to that period.

Dr. Symcotss, after a brief anamnesis and description of main symptoms and signs, prescribes a first therapeutical aid and then observes the changes of symptoms and signs. A relief, though temporary, was bestowed to the efficacy of treatment. If the pain reappeared, he would propose the same therapy, eventually doubling the dose. If such strategy failed again, the clinician would adopt a new therapy, sush enemas and leechs.

The following passage is from “Clinical Pharmacology”, 1972….

“W.L. patient, black, 36 years old, married. He came to First Aid owing to an intense migraine. He tells that he started to have some headaches in the morning from almost 4 years ago. Those headaches used to disappear during the afternoon. We found a blood pressure of 180/120. We prescribed a therapy with reserpine and thiazidic duiretics. Though the answer to the therapy was initially positive, the patient developed resistance to those drugs and we added alfa-metil-dopa to the therapeutical regimen. But this new therapy failed to control the blood pressure. Therefore we changed the therapuetical regimen administering guanethidine 25 mg/die per os, and we increased the thiazidic diuretic 2 times per day. Initially the answer was good, but soon he developed resistance to guanethidine. The pressure now was 260/160”

The sequence and progression of events is very similar to that descrbed by Symcotts, at three centuries of distance.

The folllowing clinical story was described by Oliver Sachs in the middle of ’80. The similarity with the former two stories shall leap out at the reader.

“….though having started the therapy from 5 days, and assuming 0,5 g of L-Dopa daily, miss D. continued to present some general restlessness, and increased tremor in the right hand and in the mandible….she presented a complex mixture of desirable and unwanted effects…her breath was become rapid, superficial and irregular, and every 2-3 minutes sudden and violent inhaling. Therefore the dosage of L-Dopa was reduced…nevertheless the symptoms and signs grew worse…the attacks last 1-3 hours….the 16 july I noticed that the attacks was assuming a terrific intensity…. in spite of the low dosage of L-Dopa, miss D. continued to suffer of respiratory attacks….the further reduction of dosage was followed by an oculogyric crisis…increasing the L-Dopa dosage, these oculogyric crisis ceased, but the respiratory attack grew worse….at the dosage of 0,0375 gr (a little bit higher that the latter) miss D. got both crisis: oculogyric and respiratory. The 23 july a new symtom appeared: she was not able to raise her legs…in the next days some immobilizing acts appeared…in the absence of food in the mouth she used to bite her lips and brux (teeth grinding). The 29 july she presented some difficulties to speak, and for the first time she presented an uncontrollable tendency to repeat the same words and phrases many times (palilalia). At the end of 1970, Miss D. had faced every therapeutical aids: L-Dopa, amantadina, dopa-decarbossilasis, apomorphine, antiadrenergic, antihystaminic, and every other drug the medical ingenuity could suggest”

 

Bibliography