The ellipsis of prognosis in modern medical thought

Social Science and Medicine

Volumn 44, Issue 3, 1997, Pages 301-315

  Christakis, Nicholas A ^a  

^a UNIVERSITY OF CHICAGO MEDICAL CENTER   (United States)

Author keywords

Complications; Prognosis; Sociology of knowledge; Symptoms; Therapy

Indexed keywords

ARTICLE; CAUSE OF DEATH; HUMAN; INTERNAL MEDICINE; LOBAR PNEUMONIA; PROGNOSIS; THERAPY;

CURRICULUM; HUMANS; INTERNAL MEDICINE; PHILOSOPHY, MEDICAL; PNEUMONIA, PNEUMOCOCCAL; PROGNOSIS; TEXTBOOKS; TREATMENT OUTCOME; UNITED STATES;

EID: 0031018132     PISSN: 02779536     EISSN: None     Source Type: Journal    
DOI: 10.1016/S0277-9536(96)00100-1     Document Type: Article

References (27)

1. Christakis, N. A. (1995) Prognostication and Death in Medical Thought and Practice. University Microfilms, Ann Arbor, MI.
2. Osler, W. (1892) The Principles and Practice of Medicine, 1st edn. D. Appleton Company, New York.
3. Osler, W. and McCrae, T. (1924) The Principles and Practice of Medicine, 9th edn. D. Appleton Company, New York.
4. Christian, H. (1947) The Principles and Practice of Medicine, 16th edn. D. Appleton-Century, New York.
5. I must stress that when I use the terms "effective" and "ineffective" therapy here, I am using the actors' categories. Physicians practicing medicine between 1892 and the late 1930s (when antibiotics were introduced), knew that their therapy was ineffective and called it as such. Similarly, antibiotics were recognized as "effective" virtually from the moment they were introduced to clinical practice.
6. Lerner, M. and Anderson, O. W. (1963) Health Progress in the United States: 1900-1960. University of Chicago Press, Chicago.
7. U.S. Bureau of the Census. (1976) Statistical Abstract of the United States. Government Printing Office, Washington, D.C.
8. Ludmerer, K. M. (1985) Learning to Heal: The Development of American Medical Education. Basic Books, New York.
9. Rosenberg, C. E. (1987) The Care of Strangers. Basic Books, New York.
10. Rosenberg, C. E. (1985) The therapeutic revolution: Medicine, meaning, and social change in 19th-century America. In Leavitt, J. W. and Numbers, R. L. (eds) Sickness and Health in America, 2nd edn. pp. 39-52. University of Wisconsin Press, Madison.
11. Atwater, E. C. (1985) Touching the patient: The teaching of internal medicine in America. In Leavitt, J. W. and Numbers, R. L. (eds) Sickness and Health in America, 2nd edn, pp. 129-147. University of Wisconsin Press, Madison.
12. Peabody, F. W. (1927) The care of the patient. J. Amer. Med. Assoc. 88, 877-882.
13. Harvey, A. M. and McKusick, V. A. (1967) Osler's Textbook Revisited, p. 1. Appleton-Century-Crofts, New York.
14. See, for example, Fleming, D. (1954) William H. Welch and the Rise of Modern Medicine, p. 153. Johns Hopkins University Press, Baltimore.
15. Edelson, P. (1994) Adopting Osler's Principles: Medical textbooks in American medical schools, 1891-1906. Bull. Hist. Med. 68, 67-84.
16. Early texts often do not draw the current distinction between signs and symptoms, the former of which are currently configured as objective and the latter subjective.
17. Note that in ranking symptoms in terms of their "gravity," one might rely on how bothersome they were to the patient, how difficult they were to control, or how adversely they affected the patient's prognosis. It is noteworthy that the last option does not play a significant role.
18. Osler, W. (1897) On certain features in the prognosis of pneumonia. Am. J. Med. Sci. 1-9.
19. The 16 entities (with the description of their frequency, if any) are as follows: pleurisy, empyema ("most common"), pericarditis, endocarditis, peripheral vein thrombosis ("uncommon"), ante-mortem intracardiac coagulation ("very rare"), arterial embolism ("rare"), meningitis, peripheral neuritis ("rare"), gastric complications ("rare"), peritonitis ("rare"), meteorism ("not infrequent"), jaundice, parotitis, nephritis ("not often seen"), and arthritis. Empyema occurred in fewer than 2.2% of cases, according to the text; the rest of these complications thus necessarily had even lower incidences.
20. Many of these words have animistic overtones and carry connotations of the game-like relationship between the physician and the signs of disease as he or she goes about the work of diagnosis, treatment, and prognosis - a "game" in which the disease itself may not "play" according to the "rules" at all times. In a sense, the disease is "cheating" by becoming occult (or, indeed, non-local). An atypical presentation, in a part of the body other than the lung, is "unfair" and represents a form of concealment. In the era of effective therapy, as we shall see, the expectation that the disease will "play by the rules" is all the more palpable. Disease is expected reliably to yield to therapy: when it does not, it is violating expectations.
21. It is noteworthy that arthritis typically does not involve death. This is a singular example of a complication not linked to mortality. However, this exception appears to "prove the rule" since arthritis is deemed so serious that is treated as if it were as serious as death. In 1924, of course, "arthritis" from a bacterial infection often resulted in a fused and useless joint, and may have threatened the livelihood, if not the life, of the patient.
22. Although the text discusses sulfa drugs, in point of fact, by 1947, penicillin had largely, if not completely, supplanted them; this discrepancy can be attributed to the lag in publication of textbooks mentioned above.
23. Bigelow, J. (1858) Brief Expositions of Rational Medicine, to Which is Prefixed the Paradise of Doctors, p. iv. Phillips, Sampson and Co, Boston.
24. The approximate absolute lengths of three of the chapters are as follows: 1892, 12,670 words; 1947, 22,260 words; 1988, 11,780 words.
25. The relative salience of prognosis in the "pre-modern" textbooks is illustrated not only by the amount of text devoted to the topic, but also by the fact that the section on prognosis actually precedes the sections on diagnosis and therapy.
26. The 21-year gap between the 1947 and 1968 entries is explained by the absence of any new editions of the textbook in this period.
27. Foucault, M. (1975) The Birth of the Clinic: An Archaeology of Medical Perception, p. 97. Vintage Books, New York.