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 K. said to Esquirol ‘a very interesting patient, who is but slightly excited, and whom I have withdrawn from scenes calculated to augment his excitement, which you will speedily cure.’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.

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