The doctors Symcotts.
Some days ago, reading "Awakenings" of Oliver Sachs, I stumbled into the following line: "The old rationality was become inapplicable and useless"
Daily, in our clinical routine, we apply diagnostic criteria and therapeutical aids with absolute certainty of their validity and effectiveness, without never wonder what has been the rational process which have led to their formulation. The necessity to bury the implant under the mucosa has been considered for many years a basis for osteointegration. The delayed loading of an implant has been considered for many years unanimously a necessary condition to osteoinegration. The application of a base under the filling has been for decades an inescapable practice for preserving the pulp health. The culture technique in endodontics has been a necessary step toward success. The insertion torque of an implant more than 25-40 newton a certain cause of bone necrosis and non-osteointegration. And so on.
I listed a brief number of dogmatic dental procedures, wich have featured our clinical practice for decades. Notwithstanding today they are considered fanciful procedures lacking of any scientific support and evidence.
What and how many are the actual diagnostic principles and therapeutical aids wich in future shall be labelled as fanciful and scienceless?
This is the task of clinicians and scientists: examine the data daily available in oder to validate or to invalidate the actual models of interpretation and build new models more explicatives of the reality. We must never forget we may not know the reality in its essence (the Kantian "noumenon"), but we may only preceive it through our senses and the further brain elaboration (the kantian "phenomenon"). Noumenon comes from the ancient greek and it means "something that is thoughed", id est the essence, the very nature of the things. Phenomenon come from the greek verb "faino" meaning "to appear" and phenomenon means "something that appears", therefore how the things appear to us.
Thus, our knowledge of the reality is a subjective representation of it, featured by our senses and our brain (who filters our sensations through memory, evolution history, etc.)
I wish to share the following passages written by some clinicians, ranging from 1600 till our days.
The day 5 february 1747 doctor Symcotts from England wrote in his medical diary the following clinical case:
" Miss Baldwin from Great Staugnton, who had been suffering from a long time of intense stomacache in the morning, started to feel during the night a lasting and intense pain in the right flank radiating towards the spine (back)….then an intense jaundice appeared, wich ever and anon diminished and grew everytime the patient got a colic. In order to placate the colic, causing intollerable pain at the stomach, I prescribed oil obtained from sweet almond and pepper's water. Such remedies produced much relief to the patient. So, I prescribed also two large pills wich, as soon as they arrived into the stomach, produced further relief and allowed the pattient to sleep all night long. But, the night after, pain reappered more violently. I tried many remedies with unsuccessfull results, only tobacco enema produced some sort of relief. The jaundice reappared and I treated it administering a rhubarb purging, but unsuccessfully. Therfore I decided to open a vein of her on the arm, and after 3 days I applied a leech. She got a temporary relief…..At that point I aministered her an emetic substance, from whom she got pain relief for 4 days. Since the pain represented, I prescribed again a rhubarb purging wich caused 31 bouts of diarrhea.The day after I open her arm's vein again. Nonetheless colics and jaundice came back. Then I prescribed 3 spoons of emetic. In the interim every morning I administered her a dose of absinthe enriched with an infusion of ship excrements, white wine and powdered eggs. Because she did not heal, I gave ger a new puging, wich this time provoked only 11 bouts of diarrhea…then I suggested her to drink frequently little sips of coagulated milk and beer. Besides, I prescribed her the following praparation: powdered eggshell, millipedes drowned in with wine or in brandy, desiccated millipedes and Gascoyne poweder…."
Unless we consider the meaning of single actions implemented by doctor Symcotts, and we focus our attention upon his reasoning, many fundamental aspects arise:
– the english clinician does not tell anything about the reason of his diagnostic and therapeutical conduct and how he choose those therapies instead of other therapies. Notwithstanding we have the impression that the decisional reasoning was considered implicitly superfluous. In effect, all clinicians of that age would have understood and shared more or less the reasons of his clinical choices, reasons which escapes to our actual comprehension. Similarlly, an actual clinician, at the presence of a "pneumonia", does not feel the need to justify the institution of antibiotic therapy because his choice is considered comprehensible to all the clinicians. It is inevitable that to our eyes the therapies of dr. Symcotts appear irrational and fancyful, but probably at that age it was different: in fact, at that age, many therapies such as leechs, enemas, were considered unanimously "efficacious" on the basis of precise theories of body function, as the humoral doctrine (well recognized by the medical community at that age). So we may not consider dott. Symcotts an eccentric clinician if we relate to that period.
– Symcotss, after a brief anamnesis and description of main symptoms and signs, prescribes a first therapeutical aid and then observes the changes of symptoms and signs. A relief, though temporary, was bestowed to the efficacy of treatment. If the pain reappared, he would propose the same therapy, eventually doubling the dose. If such strategy failed, the clinician would adopt a new therapy, sush enemas and leechs.
The following passage is from "Clinical Pharmacology", 1972….
"W.L. patient, black, 36 years old, married. He came to First Aid owing to an intense migraine. He tells that he started to have some headaches in the morning from almost 4 years ago. Those headaches used to desappear during the afternoon. We found a blood pressure of 180/120. We prescribed a therapy with reserpine and thiazidic duiretics. Though the answer to the therapy was initially positive, the patient developed resistance to those drugs and we added alfa-metil-dopa to the therapeutical regimen. But this new therapy failed to control the blood pressure. Therefore we changed the therapuetical regimen administering guanethidine 25 mg/die per os, and we increased the thiazidic diuretic 2 times per day. Initially the answer was good, but soon he developed resistance to guanethidine. The pressure now was 260/160"
The sequence and progression of events is very smilar to that descrbed by Symcotts, at three centuries of distance.
The folllowing clinical story was described by Oliver Sachs in the middle of '80. The similarity with the former two stories shall leap out at the reader.
"….though having started the therapy from 5 days, and assuming 0,5 g of L-Dopa daily, miss D. continued to present some general restlessness, and increased tremor in the right hand and in the mandible….she presented a complex mixture of desirable and unwanted effects…her breath was become rapid, superficial and irregular, and every 2-3 minutes sudden and violent inhalings. Therefore the dosage of L-Dopa was reduced…nevertheless the symptoms and signs grew worse…the attacks last 1-3 hours….the 16 july I noticed that the attacks was assuming a terrific intensity…. in spite of the low dosage of L-Dopa, miss D. continued to suffer of respirastory attacks….the further reduction of dosage was followed by an oculogyric crisis…increasing the L-Dopa dosage, these oculogyric crisis ceased, but the repiratory attack grew worse….at the dosage of 0,0375 gr (a little bit higher that the latter) miss D. got both crisis: oculogyric and repiratory. The 23 july a new symtom appeared: she was not able to raise her legs…in the next days some immobilizing acts appeared…in the absence of food in the mouth she used to bite her lips and brux (teeth grinding). The 29 july she presented some difficulties to speak, and for the first time she presented an uncontrollable tendency to repeat the same words and phrases many times (palilalia).
At the end of 1970, Miss D. had faced every therapeutical aids: L-Dopa, amantadina, Dopa-decarbossilasis, apomorphin, antiadrenergic, antihystaminic, and every other drug the medical ingenuity could suggest"
