“Everything we call real is made of things that cannot be regarded as real”
Erwin Schrödinger
During medical training I felt (western) medicine was more ‘real’ than traditional forms of medicine. I’ll try to clarify this idea by comparing ‘western medicine’ to more traditional forms of medicine. It is, without having substantial knowledge about the subject, however. Traditional medicine: the mind is real, the symptoms are real and undoubted. At least, that is how it appears to me. Also, in traditional medicine disease seems more a conceptual idea than it is tangible. By times more mystique than it is real maybe? Less importance seems to be attributed to the extent of reality of the cause of disease. Also, when compared to ‘western’ standards, traditional treatments seem less rigorously tested, less ‘proved’, less ‘scrutinized for reality’. This also seems to apply to the practitioner patient relationship. In non-western medicine, neither side, patient nor practitioner, seems to criticize or doubt the other. All parties seem to agree many aspects of medicine go beyond questioning. So, in traditional medicine there is faith as well as mysticism. But above all there is no questioning about reality. At least, that is how it appears to me.
Now, let us take a look at western medicine. In Europe medicine evolved along strong scientific ideas. In an earlier episode we have seen the influence on medicine of ‘British empiricism’, embodied by John Locke and ‘French Rationalism’ as proposed by René Descartes. To me, what unites them is that for both views the first priority in science is to establish reality. Locke by repeated observation, Descartes by wondering what could be considered to be really real. In medicine both views seem to be present in the concept of disease. Bacon’s repeated observation is represented by the individual cases within ‘one’ disease. Following Descartes we will see that in medicine reality is questioned in quite some, but oddly not all, respects. Also, Cartesian doubt seems to have snuggled itself into doctor-patient relations.
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In prior posts was depicted what the arising of medicine might have looked like. I emphasized the view that before being a science medicine is a tool designed to decide what is best to be done in the face of unhealthiness. For unhealthiness to be adequately addressed predictions need to be made. These predictions are based upon models we call diseases. Besides being a model we also conceive diseases as entities. This means that diseases are more than just states one can be in. It is more like a ‘thing’ different individuals can have ‘the same’ of. Per definition entities are ‘one’. In ‘western’ medicine however, diseases seem to be more than ‘one’, diseases almost substantiate and receive an identity. This (id)entity than is added to the individual affected by this disease. This entity is definitely not conceived as part of ourselves. It is a foreign entity. It is herein that western medicine really sets itself apart from other forms of medicine. The western perception is that when having contracted a disease we are able to fight it off like it was an invader.
Depicting ‘disease’ as a foreign entity adds to ‘disease’ being conceived as very much ‘real’. I’m not telling diseases are not real. But they are entities in between the concrete and the abstract. Hence, the true nature of their reality might never be concisely captured. Like in Plato’s shadow cave in a way, as pointed out by my friend Gerrit: “What is actually the true nature of reality?” Even when there is no apparent reason to doubt reality as we see it, we can never be sure we see reality as it is. I realise this view clashes with British empiricism (whether by Locke, Bacon, Newton, … ) where the reality of things was ascertained by precise and repeated measurements. Partially abstract things however are measured and weighted in our mind. Therefore there is a difference in how Empiricism could ‘see’ the reality of physical things right away (for instance by observing falling objects over and over again) whereas the reality of abstract things can never be ‘seen’ but only ‘conceived’.
Since the mind is involved in seeing the reality of abstract things, psychological mechanisms might significantly contribute to the extent with which disease is perceived as having a ‘real’ existence. The fact a disease is being perceived as an entity, as ‘one’, might be a major factor herein, since in general, both simplicity and repetition of a statement add to the perceived extent of reality of that statement. Therefore, every instance of presenting a disease as ‘one single’ entity, such as in ‘One cause, one disease’, will support the conception of ‘a disease’ being ‘real’.
So, being ‘real’ and being ‘one’ seem closely related as far as disease is concerned. But what about that other central concept in medicine: the symptom.
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From the beginning of medicine till about the 1950’s a diagnosis was almost exclusively made upon symptoms alone. To put things into perspective, the ancient theory of humorism relating health and personality to bodily fluids (phlegm, blood, black bile, yellow bile) was only abandoned around 1850. Further more, around 1950 a pregnancy test still consisted of injecting urine under the skin of a female frog and wait for her to produce eggs. Another example. Although radiology was available from the beginning of the 1900’s the diagnosis and localisation of an eventual brain tumour in the 1950’s still relied upon systematically questioning the patient. The technical investigation mostly came down to electroencephalography (EEG) where a great number of electrodes objectify altered electric activity of the surface of the brain due to superficial brain tumours, stroke, scar tissue, epilepsy etc. Radiology could provide some information after replacing the patient’s cerebrospinal fluid the brain is bathing in by air or some other gas. A more final diagnosis could only be made upon opening the skull during surgery, or post mortem. Thus, based on sheer symptoms medical practice had to select the correct diagnosis, make predictions and initiate proper treatment. In the decades following the 1950’s there has been a strong belief ongoing technological developments would enable diagnoses to be made on more objective information. Despite tremendous technological progress, in many instances symptoms remained all there was to base the practice of medicine upon. Thus, up to the 1950’s one simply got the diagnosis that fitted best with the symptoms. No further questions asked. Or was it?
Well, not entirely. There seemed to be something odd about the symptoms. Many symptoms did not provide any information about the diagnosis at all, they merely did just co-exist with diseases without seeming to be really part of them. Moreover, those symptoms that were failing to contribute to the correct diagnosis seemed a major factor in seeking medical attention. Estimations vary widely but let us say that in half of the consultations the presented symptoms cannot be explained. Ultimately, patients might present these symptoms void of medical information in such a way or quantity that the presentation itself becomes the diagnosis. The diagnosis I am referring to here is somatization disorder. It has gone by many names and exists under many forms. Hysteria, psychosomatic symptoms, hypochondria, medically unexplained symptoms and stress-related symptoms. What unites them is that medicine seems to consider either the condition as being entirely real or the symptoms. Not both at the same time. My current understanding is that somatization disorder as a diagnosis is considered real but the symptoms seem adrift in between real and not real. The explanation medicine provides for this is:
‘the mind’
The symptoms are in the mind or labelled as ‘non-medical’. medically unexplained symptoms …. or, the mind pays too much attention to stimuli ‘normal people’ would not even notice.
Medicine has a long history of not being open about the way it regards these symptoms. Nor is Medicine assuming its explanatory obligation regarding these symptoms. Medicine implicitly transfers this obligation towards Psychology and the medical halfling Psychiatry, reproached by many, mostly doctors, for being unable to establish any tangible (real) cause to any of the conditions in its field.
Anyway, back to medical practice and its ways towards the correct diagnosis. To find the correct diagnosis the medical practitioner should identify the ‘correct symptoms’ or at least eliminate all symptoms that are void of information. To do so, a sharp definition of what a symptom is might bring some clarity. I found the following text dating from the late 1960’s. It clearly explains the difference between symptoms and signs:
“A symptom is a manifestation of disease apparent to the patient himself, while a sign is a manifestation of disease that the physician perceives. The sign is objective evidence of disease; a symptom, subjective. Symptoms represent the complaints of the patient, and if severe, they drive him to the doctor’s office. If not severe, they may come to light only after suitable questions.“
I took this definition from: Signs and symptoms. King LS.JAMA. 1968 Oct 28;206(5):1063-5. Virtually everything I refer too is open access on the internet, in this instance the definition is in the abstract. The double definition seems pretty straight forward. One can speak of symptoms only in relation to the disease provoking them. You probably have noticed I spoke several times so far of ‘symptoms’ where, according to this definition, I should have used ‘complaints’. As clear as this definition might seem though, it brings in some circular reasoning. Symptoms are supposed to lead to the diagnosis and definitions are supposed to enable the recognition of whatever is defined. In the definition of symptoms however the diagnosis is telling which complaints are actually to be considered as symptoms in the first place. Clearly, this definition cannot be used to find out which complaints are in fact symptoms. The idea that before 1950 diagnoses were being made exclusively on symptoms is therefore somewhat contradictory itself. More worrisome, medicine makes improper use of the word ‘symptom’ itself since symptoms that in the practice of medicine are sometimes said to be ‘in the mind’ or ‘medically unexplained’ are in fact complaints. With the definition being of no help, medicine can only reject those complaints that should not acquire the status of ‘symptom’. The medical practitioner uses a tool that allows him to decide which complaints cannot acquire the status of ‘symptom’. This ‘tool’, more an idea actually, is known as ‘Leonard’s law of physical examination’ and it is formulated as follow:
“It’s obvious or it’s not there.”
The tool is generally explained as follows:
“If during physical examination a symptom, as faint as it is, is not present every single time it is provoked than it is not a ‘real’ symptom.”
I can only speculate why this is called a law. What I do know is that this saying is often abbreviated to ‘Leonard’s law’ and that its application might not always be restricted to physical examination alone.
So, it is maybe not entirely true that before 1950 one simply got the diagnosis that fitted best with the symptoms. But otherwise, by applying the idea of ‘Leonard’s law’, separating symptoms from complaints seems pretty straight forward. In between the ‘symptoms that are only in the mind’ and real symptoms things are simply called complaints.
“Right? Or aren’t they?”
“Well,…,maybe not.” It seems medical practice might be trying to simplify things with some more reductionism. See the previous episode on how enlightenment ideas like reductionism shaped medicine. I’ll try to show here how medical practice in some implicitly recognizes the existence of ‘not really real symptoms’ as some category in between ‘the real and therefore correct symptoms’ and complaints. One might be surprised and ask:
“aren’t all symptoms real?”
“Yes indeed, there are symptoms that are not really real symptoms.”
Now one might think:
”Why is this guy making such a fuss about these ‘not really real symptoms’? I have never heard of those. How common are those ‘not really real symptoms’ exactly? What are we talking about anyway, please give us an example!”
This might be my most pivotal point: despite Leonard’s law seemingly is some ‘reality check’ the reality level of symptoms can still vary widely. In my opinion medicine fails it scietific and other responsibilities by silently allowing symptoms to be rated. From ‘real’ down to totally ‘unreal’. For being well known let us take irritable bowel syndrome as an example of condition consisting of ‘not really real symptoms’. For those who are not familiar with irritable bowel syndrome itself, a syndrome is nothing more than a complex of concurrent symptoms, some of which evolve into diseases over time. The irritable bowel refers to the episodic complaints of abdominal discomfort such as cramping or bloating, accompanied by pain, diarrhoea and or constipation.
For those familiar with irritable bowel syndrome and feeling there is no problem in irritable bowel syndrome is being taken seriously, please do know we will travel back in time to a period where these symptoms still were truly ‘not really real’ for real. For the medical field having the “justified true belief” it was as such. Even though Edmund Gettier in his 1963 paper already had demonstrated that “justified true belief” is not necessarily equal to knowledge. According to Gettier ‘justified true belief‘ symptoms must originate in mind does not enough to make it equal to ‘knowledge’. (In the same way we argued “One cause, one disease” also is not equal to knowledge.) The only problem is that there is no trace of a clue to a ‘real’ explanation of how these functional symptoms could result from some real ‘bodily’ signals. “Well, not really the only problem.” Irritable bowel syndrome is definitely intimately related to stress(Konturek 2011, Qin 2014). This probably is the main reason for Irritable bowel symptoms to be conceived as ‘not really real’. To prove irritable bowel syndrome is a ‘real’ condition now requires to find some physical (real?) aspect of stress that strongly relates to the mind. Radical thinkers like Wilhelm Griesinger’s already conceived mental illnesses as diseases of the brain. In my conception the reality is even more radical. Over the next episodes we will find out that what we call stress and its effects on ‘the mind’ might actually not be confined to the brain alone.
So, my aim is to provide support for the idea of ‘not really real symptoms’ are being a reality within medicine. For this we picked the year 1990 and irritable bowel syndrome. Around 1990, irritable bowel disease was still a diagnosis in the making. There simply was no consensus on it being a disease or even a condition at all.
But, “When to speak of disease?” This question is still unsettled in the whole of natural sciences. Around the 1970’s it was heavily debated though. I just drop this in the middle of things. Just to get rid of it.
There are several dominant views to the nature of disease(Toon 1981). I will briefly go over some of them just to show medicine is not having like ‘one’ official view on what is meant by ‘disease’. Naturalists only consider objective criteria to separate healthy from diseased individuals. Realists conceive disease as having one single specific cause(Campbell 1979, Gillon 1986). In normativism disease is a judgement on value, not sheer objective parameters. Nominalists believe disease is an entity existing only as a label since each individual will have its own set of biochemical characteristics accounting for its disease. Nominalists might think of disease as “the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm of their species in such a way as to place them at a biological disadvantage.”(Campbell 1979).
I hope I gave an accurate description of the four more dominant views. But, medicine would not be medicine if its view on disease would not be ‘medical’. And there is nothing more ‘medical’ than medical practice itself. For real.
Independent from this philosophical debate most would agree only objectivity would warrant all doctors would come to the same diagnosis when confronted to the same case. So Medicine would remain ‘one’.
Around the 1990’s medicine fully embraced ‘Evidence based medicine’. This brought statistics into the field of medical practice in particular. Statistics is a mathematical way to evaluate which treatment or test is performing better over another in a specific group of patients. Evidence based medicine’s rigorously scientific assessment methodology was highly successful in improving the outcome of medical care.
In that same period the aforementioned quest for a definition of ‘disease’ came to a stand still. Medicine regaining momentum through ‘Evidence base medicine’ definitely sealed the mere philosophical debate on ‘disease’ from the point of view ‘when to speak of disease’. Along with more successful treatments as identified by ‘Evidence based medicine’ came the necessity for more explicit criteria defining each specific group of patients most suitable to receive each specific treatment. Sadly and almost imperceptibly it turned out to be just another vantage point on the same debate. With the aim set on results ‘Evidence based medicine’ did slip a new definition for ‘disease’ into the whole of medicine. Each disease became defined by its diagnostic criteria. From this resulted:
“Disease is when criteria for a diagnosis apply”
Here medicine simply defines disease extensively, it is, by listing all possible diagnoses. It is just a grim and cynical interpretation of the World Health Organization’s definition for ‘health’:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
So, just to recapitulate, symptoms alone are not a very solid base in support of a diagnosis. Besides, there where the ‘void’ symptoms not leading to the diagnosis of any ‘real’ disease. The technological elan of the 1950’s was expected to deliver the required objective information for diagnoses to be made upon. Meanwhile, from about the 1950’s onwards, medicine tried to get a sharper view on ‘when to speak of disease’. Again with high hopes for more objectivity. Diagnostic criteria, some of which were objective, made the respective disease look more ‘real’. The subjectivity problem of the symptoms remained largely unchanged. To me it seems that to some extent disease did gain some reality. But the amount of reality gained by diseases was in fact lost by their symptoms.
Nowadays symptoms are said to be stress related, in the mind, medically unexplained, being paid too much attention to, psychosomatic…..etc. It must be awfully important to know how real the presented symptoms are. Meanwhile the ‘not really real symptoms’ are not discussed openly and do not seem to require any real explanation. A new name for those complaints is sought to ease the public opinion as required. Within the medical field yet another name for them is being used:
“Functional symptoms”
Notably in neurology and psychiatry, ‘functional’ is understood as in opposition to ‘organic’. With ‘organic’ meaning there is something objectively wrong (with an organ)(Bell 2020). Defined as such the qualification of ‘functional’ comes down to a real dysfunction of let’s say, an organ. This seems like a fair approach on the phenomenon of the ‘not really real symptoms’. But since ‘functional’ is the opposite of ‘objectively wrong’ it might as well mean:
“objectively there is nothing wrong.”
Suppose a doctor uses the word ‘functional’. There is no way to know in which way it should be interpreted. Even not for another doctor. As such ‘functional’ has the same pejorative connotation as ‘psychosomatic symptoms’, ‘medically unexplained symptoms’, ‘stress related symptoms’ or ‘exaggerated symptoms’: It is in the mind or either way not real. Well, maybe not completely unreal, but in any case ‘not really real’.
My final point is that medicine’s definitions of reality do not take into account they might be premature. Medicine is putting a great deal of effort in defining reality. Judging on it. Medicine determines which symptoms are or are not ‘real’. Medicine defines which conditions are ‘real’: those that objectively affect an organ. All of this without explaining any disease nor the symptoms themselves. In this I see a parallel in how Physics defined the reality of the universe before relativity and quantum mechanics. In Newtonian physics, also called classical physics, masses pulling each other were a reality. But Newtonian physics failed to predict Mercury’s precession, which is the evolution over time of each of Mercury’s elliptical revolutions around the sun as compared to the preceding one. It is here that classical physics lost its claim on beholding reality.
Relativity and quantum mechanics were far more accurate in predicting reality but meanwhile completely failed to define the nature of this reality but left no doubt reality was more complex than previously foreseen. Let me illustrate medicine’s deep rooted desire to immediately judge on reality (immediate judgement on reality is probably something the human mind does but that does not sound nearly controversial enough). With our focus on ‘reality judgment’ we look into the history of Migraine.
Unlike ‘irritable bowel syndrome’, ‘Migraine’ was solidly established, both as medical condition and as diagnostic entity, well before the 1950’s. In fact ‘Migraine’ is probably the oldest medical diagnosis existing today. Migraine is a type of headache, most often half sided, classically starting hours or days prior to the attack with symptoms called a prodrome: constipation, irritability, sensitivity to smells or noise, depression, euphoria, food cravings, muscle stiffness typically in the neck, increased urination, frequent yawning. Half of the patients experiences an aura just prior to, or during, the attack lasting up to an hour, typically with experience flickering, blurring, pins and needles sensation. Some report temporally loss of a visual field or impaired speech.
Than follows the attack: headache, sensitivity, most often to light and sound, sometimes smell or touch, nausea and vomiting.
The last phase is called postdrome and last up to three days: more headache, hung over feeling, impaired thinking, gastrointestinal symptoms, mood changes.
The only objectively assessable symptom in ‘Migraine’ would be vomiting but doctors just take their patients word for it.
Based on the above description ‘migraine’ seems rather scraped together as a condition when comparing it with ‘irritable bowel syndrome’. Especially when considering there is also ‘Abdominal migraine’, Migraine without migraine’, Hemiplegic migraine’ with half-sided loss of motor function, ‘Vestibular migraine’ with spinning sensation, ‘Alice in Wonderland syndrome’ type migraine with delusions of altered body size, migraine with allodynia, which is pain being perceived upon non-harmful stimuli, migraine with speech disturbances ….. and more. Quite difficult to conceive ‘migraine’ as one.
There is some evidence for altered vascular flow in the brain and the presence of some peptide in the blood during an attack.
The different phases each having more or less specific symptoms should indeed give the idea of one condition, although the presentation of symptoms hugely varies among patients.
All together it is very hard to conceive migraine as ‘one’.
The pattern of a migraine attack however is very distinct. I agree this forms a powerful argument in favour of regarding migraine as ‘one’. On the other hand, many exceptions on the classical pattern are accepted within the diagnosis of migraine. This does not explain why migraine should be considered any more ‘real’ than ‘irritable bowel syndrome’ or psychosomatic complaints that, according to medical beliefs, emanate from the mind. What psychosomatic complaints, migraine and ‘irritable bowel syndrome’ all seem to have in common is that an attack typically is luxated by stress (physical, mental, alcohol, etc.) and slowly dissipates over up to three days. This pattern just does not seem to attract a great deal of attention. I could not find any published research.
My question here is:
“Why seemed ‘Migraine’ in the 1990’s a more real condition, a more justifiable reason to be sick than ‘Irritable bowel syndrome’?”
Was it that enough doctors experienced ‘Migraine’ themselves as compared to ‘Irritable bowel syndrome’? In the face of the unexplained the scientific truth sometimes comes down to beliefs and consensus. What is it ‘Migraine’ had but ‘Irritable bowel syndrome’ had not, back in the 1990’s? Was it that in 1990 not enough doctors suffered from ‘irritable bowel syndrome’ for the condition and it symptoms to be judged ‘real’?
In respect to symptoms, medicine is attributing an important role to ‘the mind’. But besides the mind medicine is not very motivated to explain how symptoms come about. As far as ‘real’ symptoms, as opposed to ‘only in the mind’ symptoms, are involved there must be an underlying biological mechanism medicine should feel compelled to explain. I did not so far find any publication on this topic. Medicine might as well believe symptoms pop mysteriously into existence, even the ‘real’ ones, just to tell the doctor what diagnosis needs to be made. In my opinion this is not much different from mysticism. Medicine could simply question the origination of symptoms but it does not. Maybe medicine evades this since asking what the ’cause’ of a symptom is might trigger the question:
“One cause, one symptom?”
The question whether a symptom is ‘one’ might sound silly. But seriously, imagine the collection of diseases that have one particular symptom in common. Now answer the question whether the cause of that symptom is entirely different for each of these diseases? How many different ways do exist for someone to experience that particular symptom?
This train of thoughts undermines how ‘real’ and ‘one’ a disease actually is. It would come down to a question medicine seems to fear:
“Are the symptom being treated or the disease?”
Maybe it is neither the disease nor the symptoms but the human body that is treated. At last, that is the most real entity among them three and the only one of them actually taking in the pills, the only entity accessible to anybody to appreciate.
In the end, medicine can evade as many debates it wants. To be itself rooted in reality however it has to address the following question:
“Does the explanation of a disease include an explanation for its symptoms or are symptoms allowed to be just magically there?”
“The conception of objective reality… has thus evaporated…”
Werner Heisenberg
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Blumenfield M, Strain JJ. Psychosomatic Medicine, Lippincott Williams and Wilkins, Philadelphia
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Gettier EL. Is Justified True Belief Knowledge? Analysis 1963 Jun 23:121-123.
Gillon R. On sickness and on health. Br Med J (Clin Res Ed). 1986 Feb 1;292(6516):318-20.
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