From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: QT3???
Date: 25 May 1999 05:43:41 GMT

In <3748C7A2.C6F117C5@cs.uoregon.edu> Bret Wood
<bretwood@cs.uoregon.edu> writes:

>> Patinets with difficult to discern problems are difficult patinets.
>> They desire a diagnosis.  A label.
>
>Hell YES they do.  And you should realize that diagnosis is the most
>difficult and important part of medicine.  How can you treat something
>if you can't diagnose it.  THAT is why many of those difficult
>patients are desperate for a diagnosis, so that they can get
>treatment.


Comment:

    If that's their reason, it's a bad one.  Most treatment is given to
people without firm diagnoses, or with provisional diagnosese, or what
are, in effect, functional diagnoses (which means you're just giving a
name to a complex of symptoms or organ dysfunction pathophysiologies,
without knowing the proximate cause for them).

    Diagnosis is a method of organizing one's thinking, but I throw up
my hands at the idea that it's more "difficult" or more "important"
than some other area.  What important is that your patient's pathology,
by whatever you can use to mark it, is helped.  Even if you don't know
exactly what's doing the twisting.  In 50 years, I very much doubt
we'll have many of our present diagnostic names, but that doesn't mean
we don't *now* have to deal with just about all the same patients with
all the same problems as a doctor of 50 years from now.  And they can't
wait.  We're in somewhat the same situation of a doctor of centuries
past who could recognize "Blackwater fever" sometimes called "malaria"
(disease thought to be due to bad air, and producing black urine, hence
the terms), or "Bright's disease" (generic term for all
glomerulonephropathies) or "dropsy" (particularly virulent body edema/
anasarca from right sided congestive heart failure, from any cause) or
"bilious fever" (cholangitis or a number of types of infectious
hepatitis).

   But are these really "diagnoses"?  They're just handy tags.  They
don't tell you what is going on, and they help you treat or
prognosticate (to be sure) but only probabilistically.  You might as
well call them "symptom complex A, B, C, and D," and realize that many
people with the same symptom complex have it for different reasons.
That may *or may not* be important to treatment.  If your patient with
"blackwater fever" has what we today recognize as hereditary
spherocytosis, or even has variegate porphyria, quinine won't help.
Your patient with anemia on the other hand, might be helped by drinking
wine in which a sword hath been giv' to rust, if loss of sanguinary
humor be due to martial principle lost.  Or it may holpen be by ye
eating of ye liver ripp'd from ye belly of ye ox, and not gi'en to ye
cook, but yet eaten rawe.  Yet there is one anemia of ye most
pernicious typpe which is holdpen by means of ye rawe liver, but not
application of ye sword.  Where as ye most common anemia seen oftene in
younge mothers, is holpen by means of the martial principle, *or* by ye
liver, and seems no respecter of cures.

   And again, thou knowest that Dropsy may yield up Her watery humor to
ye Foxglove leaf, whether or not ye difficulty stem from childhood ill
and St. Vitus dance, or mayhap from a seizure of the "angina pectoris"
which abidest overlong in the Body and hath giv'n grave weakness.  May
thy Wisdome as a Physik ever guideth thee in such Matters, for in all,
thou knowest not at any time whether thou see'st True Illness, or
rather only divers manifestations of Forms unseen, as shadows thou
seest on a wall in a cave cast by figures before a fire, accordingly as
wise Plato hath instructed. Therefore, let thy treatment vary
accordingly to Every Signe, knowing always thou seest as through a
glass darkly, and True Causes be known but to God.  And sometimes not
even to Him, If He hath being having a Bad Day.

    Beholde, now, atht it be the same for many of the illes of ye
moderne age, and especially is it so for ye tyypes of Maddness, which
of olde were lain to Unclean Spirits entering to the body.  What's in a
Name?  A Madness by any other Name would Bed'lehem be.  But attend, for
thy medicine worketh in secret, and dependeth not that though know'st
the name of every Unclean Sprit which cometh into the Mouth unbidden,
and Speaketh to Men, nor that thou knowst all the Fires of the Heart
which giveth the Eye her color.  For specially When the Black Spirit of
Malancholia comtheth to Her House, then only to be turn'd from Her
Bedde by ye Greene and antic Spririt of Pan, only that again the Goat
be yet banished from ye house, whenst Melancholy abideth again-- then
let ye Physik pay call to ye Alchemist, and there obtain pharmacy
against the Falling Sickness, for in treating well the Fit thou doest
also treat Ungovernable Spirits.  Mark This Well.  And let him also
prepare Carbonate of Lithos, that on this Rock shalt stability prevail,
and Pan and Menancholia be losed as spirits, and he that is Possessed
shall Give up His Unclean Spirits, and be whole, rejoicing in the Name
of the Lord, Who hath mercy which droppeth like the dew, and is not
strained, and doth not screw up CPT codes, forever and forever, amen.