Sunday, March 18, 2007

Facing Life With a Lethal Gene - New York Times

Facing Life With a Lethal Gene is a very moving story about a woman who chose to learn that she had the gene for Huntington's Chorea. While this kind of knowledge is, of course, a relatively new development, it reminded me that doctors have long had some degree of prognostic ability that they could share with patients. I always recall the story of the poet John Keats, who was a physician, coughing red blood into his handkerchief and proclaiming something like, "I see here my death warrant." It also brought to mind the following story from the history of general paresis of the insane:
J.E.D. Esquirol, one of the architects of psychiatry's early nineteenth century therapeutic optimism, as well as one of the first do describe paresis among the insane boasted that his specialized expertise allowed him to detect signs of paresis that had eluded a provincial colleague. The patient was a 'strong, robust' thirty year old man who had persuaded himself that he possessed immense fortune and had yielded 'to all the excesses of the most fashionable life.' He was brought to Paris by the ‘skillful and estimable' Dr. K., who deferentially presented the patient to Esquirol. 'I commit to your care,' Dr. K. said to Esquirol ‘a very interesting patient, who is but slightly excited, and whom I have withdrawn from scenes calculated to augment his excitement, which you will speedily cure.’ Esquirol conducted a half an hour ‘conversation’ with the patient,during which he observed ‘some hesitation in the pronunciation of certain words’ and an ‘undue readiness’ to remain in a hospital. On the basis of these findings Esquirol disdainfully told his hopeful colleague, 'I think that your patient is incurable; that he will not recover, nor survive a year. Remain in Paris, and you will see, as the malady is making rapid progress.'5 Displays of diagnostic and prognostic abilities such as Esquirol's would be repeated by others during the nineteenth century but such displays could never fully conceal psychiatry's impotence in the face of this completely devastating and extremely common disorder.

Morgagni & Mid-18th Century Treatment of the Mad

I recently ran into the English translation of Giovanni Battista Morgagni's [1682-1771] treatise The Seats and Causes of Diseases Investigated by Anatomy. It consists of a series of Letters, the eighth of which is on madness. This letter is a rambling affair, where Morgagni sometimes sticks to his stated task of describing dissections of brains, but often describes clinical cases in some length. I found it an intriguing window into mid 18th century clinical psychiatric practice. Here is one of the shorter cases:

A strong man, by trade a blacksmith, having been liable, from a boy, to the incubus and vertigo, which had been brought on him by a fright, fell down suddenly in the winter-time, and complain'd, in confus'd words, of an internal pain in his breast. Being immediately brought into the hospital, he answer'd scarcely any thing to those who ask'd him questions; but shut his eyes, and cover'd his face with the sheet, like a man out of his senses. He was hot at the same time, and trembl'd' nor had drunkenness, or any other cause of that kind preceded; and a fever likewise attended. On the following day, he began to leap out of bed, to cry out, to threaten, and even to strike, all about him; so that being evidently a maniac, it was necessary that he should be confin'd with bands. He cried out violently and continually; and, at the same time, his whole body was agitated with convulsive motions. Then the physician, having order'd a vein in the foot to be open'd, and a pound of blood to be taken away, also ordered the cataplasm I have told you of [fresh cheese, of the coarser sort, mix'd with oil of violets] to be laid upon his head after being shaved. Do you ask me what was the event? Why by this means, within twelve hours, he was restored to perfect sanity; but whether the cure was accidental, or the effect of blood-letting only, or in some measure owing to the assistance of the external remedy [the cataplasm], I will leave you to determine. Those who foment the heads of insane patients with milk, will readily believe, that the cataplasm contributed thereto.

Giovanni Battista Morgagni, The Seats and Causes of Diseases Investigated by Anatomy, [English edition, 1769, reprinted 1960, original 1761] v1. pp. 149-150.

Saturday, March 10, 2007

On the madness of neuroscientists

Pierre-Jean-Georges Cabanis [1757-1808], an advocate of a monist or neuroscientific view of mind, writing about Democritus, an ancient Greek materialist relates the following story:
Hippocrates, called by the Abderans* to heal Democritus of his supposed madness, found him dissecting animal brains, from which he was trying to unravel the mysteries of … physical sensibility and to recognize the organs and the causes that produce thought. The two wise men spoke together on the general order of the universe, and on that of THE SMALL WORLD, or of man, with which both were almost equally occupied, …. In this conversation, Democritus appears to have felt even more the close connections between … physical and … moral states. And the doctor, as he retired, judged that it was to the Abderans, and not to the supposed patient, the the hellebore* should be administered [P-J-G Cabanis, On the Relations of the Physical and moral Aspects of man, Johns Hopkins U.P., 1981, v1,p 41].
*Abderans, residents of Abdera, Democritus' home. The air of Abdera was proverbial in Athens as causing stupidity
*Hellebore, a powerful laxitive and emetic thought to cure difficult diseases such as mania, by removing black bile.

Friday, March 09, 2007

Jay D. Haley, 83, Early Advocate of Involving Family in Therapy, Dies - New York Times

Learning of Haley's death brought to mind how much things have changed over the last thirty years.
I can remember when Haley's ideas about the double-bind and schizophrenia were the hottest around. Reading about paradoxical intentions in psychotherapy was both exhilarating and frightening. Having spent many years working with people suffering with schizophrenia, however, I can see clearly how wrong headed, and in the wrong hands, dangerous Haley's ideas were. Nonetheless, I can't help but admire his efforts to unravel the mysteries of this terrible affliction.
Jay D. Haley, 83, Early Advocate of Involving Family in Therapy, Dies - New York Times