Physicians

Back In the Day *

flying cadeuciiMany people believe that neurologists are particularly attracted to detail.  I prefer to think of the issue as one of precision rather than pointless obsessiveness.  Some years ago, I was asked to discuss a case for the New England Journal of Medicine’s series of CPCs called the Cabot Cases.

In preparing the case for publication, I found myself in an argument with the editor about the placement of an apostrophe. There were two diagnoses in this case: aphasia from a cardiac source embolism to the left cerebral hemisphere and hypercoagulability as a paraneoplastic syndrome. In my view, aphasia is a Trousseau syndrome (i.e., the word “aphasia” was suggested by Trousseau), whereas hypercoagulability as a paraneoplastic syndrome was Trousseau’s syndrome, because Trousseau both described and suffered from the disease. I am very much opposed to the trend to remove eponyms from the names of diseases and syndromes as to do so strips medicine of some of its most illustrious history.  But, only a handful of eponymic disorders deserve the apostrophe. Antonie van Leeuwenhoek’s disease (diaphragmatic myoclonus) is another example.

History in medicine is not a mere avocation. In addition to the old saw of helping to prevent the same errors from being repeatedly made, it provides us with the perspective needed to approach diagnostic and scientific challenges in our own era. It also combats hubris. In carefully researching my eleven New England Journal CPCs I have never encountered an idea that had not evolved from those before it.

In grand rounds, in medical journals, and particularly in the lay press, we are regaled with “revolutionary” ideas, but that they are completely new is an illusion. Throughout history, people have always been on the “cutting edge” and have repeatedly believed that they had some sort of huge advantage over prior generations.

Technological advances have often provided the impetus for this belief, whether it be the light microscope (Antonie van Leeuwenhoek’s other discovery, that of microorganisms, falls into this category), the electron microscope, genetics, or imaging. I am particularly amused by the students or residents who are shocked to learn what was known “back in the day,” as they derisively call it.

In 1865, Armand Trousseau described phlegmasia alba dolens, painful white edema, caused by venous thrombosis related to an underlying occult cancer. He suspected that this was caused by a factor in the blood that enhanced coagulation. His hematologists could not find that factor. A century and a half later, we have very little to add. It is obvious from the tone of Trousseau’s lecture that he considered himself superior to those around him. He believed that he had “discovered” a new phenomenon. It is very unlikely that this was the case. Like all of us in medicine, before and after Trousseau, our ideas are a manifestation of the times in which we live. Now we talk about chronic disseminiated intravascular coagulation instead of the quaint-sounding phlegmasia alba dolens of Trousseau, but knowledge of the phenomenon remains and always will remain incomplete. It is likely that fewer than 1 percent of all physicians in the 21st century know what Trousseau knew about this phenomenon, despite the Internet.

Less than a year after Trousseau’s lecture on the subject, he diagnosed the syndrome in himself, earning him the apostrophe. The touching story of his effort, as he lay mortally ill, to make contact with his estranged son, a doctor who was living in Hawaii, provides a poignant punctuation to this remarkable story. Did Trousseau sacrifice too much of his personal life for the profession of medicine? Looking back, it seems easy for us to believe that we will do better, but that’s the way they did it “back in the day.”

 Martin A. Samuels, MD is  chairman of the neurology department at Brigham and Women’s Hospital. 

*  Adapted from Perspective and Updates, In Samuels & Ropper’s Neurological CPCs from The New England Journal of Medicine, pps 265-266. Oxford 2013

 

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William Palmer MD

I wonder about tissur factor because of circulating tumor cells.