Tuesday, May 6, 2008

L'Envoi by George E. Ehrlich

The following essay was first published in Prognosis: Contemporary Outcomes of Disease, published by Charles Press, 1981. Permission granted from Dr. Ehrlich to reprint on Pallimed.

Prognosis is the essence of Medicine. It gives purpose to diagnosis and helps the physician ascertain what might happen and decide what ought to be done about it. It lends rationale to treatment. All therapeutic decisions, the popular cost-benefit ratio, and various equations that determine choices are based on what we understand about prognosis. It is bewildering, then, that prognosis receives only passing mention in the disease descriptions found in most textbooks and that its study has not yet been dignified by designation as a major scientific discipline.

And yet this should come as no surprise. The forbidden kernel in the gift of Prometheus was foreknowledge. Adam and Eve were expelled from Eden because they wanted to know what would happen next. Primitive instinct, which causes animals to respond with fear and flight, detects the danger without understanding it; only Man seeks to scan the future. Prognosis is the forbidden fruit and its pursuit is cloaked in magic. Laocoön perished with his sons in its service, and the gods assured Cassandra's warnings would not be heeded. Logic could infer that it was not too much to expect that the victorious general, Macbeth, would be awarded the traitor's earldom and an elective kingship upon death of the elderly Duncan; voicing the obvious could not come from Banquo or Macduff, however, but had to be pronounced by the three mysterious witches. Three sisters - the magic number: an exclamation point lest one not realize the terror implicit in knowing the future.

To learn what would be, Wotan was willing to sacrifice an eye. The malign, one-eyed Hagen was able to capitalize on this distinctive physical similarity to dominate the Nibelungenleid and to become the instrument that determined future events. The pallid Siegfrieds haven't a chance - the present is ephemeral, the future vast. Mephistopheles, Iago, Edmund, and Goneril and Regan - the villains move the piece and fascinate us - their actions become their prognosis. Alfred North Whitehead proclaimed that "It's the business of the future to be dangerous." The more one understands what the future will bring and the more one sees what might be, the more rationally one can behave. Early caveman developed society to aid in withstanding the rigors of existence and he developed agriculture because inclement weather was to be expected. Survival depended on the understanding that putting in stores during the good years and the good days would anticipate the bad. The dream of Joseph saved the peoples of the Mediterranean litttoral. Long before, hunters learned to follow spoor that would lead them to their prey, and the development of this ratiocination determined the optimal place to settle in order to survive. Like Brigham Young, they could say with certainty, "This is the place."

The pursuit of knowledge of the future comes dear and the knowledge itself dearer. The man that once did sell the lion's skin/while the beast liv'd was kill'd with hunting him," says Henry V. Croesus sought to know whether he ought to oppose the might of Persia or offer tribute. The Oracle informed him that, if he went to war, he would destroy a mighty empire. Thus emboldened, he fought the Persians, only to see his own empire destroyed. In reading the future, one must be certain not to be misled. Santayana warns that not to know the past is to be condemned to repeat it. I prefer Aubrey Menen's studious locust, as he became enlightened in the irreverent retelling of the Ramayana: "After titanic study he was satisfied that a thorough knowledge of the past could lead a profound scholar to predict the future course of history with great accuracy provided that it does not turn out quite differently."

The annals of prognosis are cloaked in mystery and feature a faintly disreputable cast. From the Witch of Endor to Nostradamus, from Heraclitus to Spengler, from Confucius to Malthus, being able to see more clearly assures immortality and hostility in equal measure. Yet the capacity to understand the future helped to create Man. The sibship of the correct prognosticator survived to become our ancestors. It is the knowledge of the future that is powerful medicine and thus it is of the Medicine Man that the tribe stood in awe. Empirical observation produced the skill. But how many pharaohs had to undergo trephining of their skulls because it once relieved the intracranial pressure in one?

The responsibility the physician assumes is great. The Ius Talionis saw to it that risks attended the rewards. The physician who cost the patient an eye suffered the loss of his hands. Codified by Hammurabi, the balance implies a sureness, a guarantee, that we have not achieved to this day. Scribonius made the doctor a productive servant of God from whom all healing comes and who imparts to medicines their power. Immortality was longed for, but mortality assumed. Maimonides set the span of life at one hundred and twenty years and argued that it was man who shortened it. How prescient, as Hayflick's cell division gives a figure only slightly lower! Can we determine the factors that shorten life in order to conquer them? Empiricism and the combination of simplistic holisms have given us a start in that direction. But the mischief of irresponsible prognostics is still with us and the task of sorting out only just begun.

The modern science of prognosis is based on analysis of groups of people. In most instances, it is not yet possible to extrapolate from the general to the specific in order to arrive at a correct prognosis in a single instance. Obviously it is more important to the patient to know what is going to happen to him than to know that eighty or ninety percent of people like him fare a certain way and the remainder another. Right now prognostication is based on probabilities, but perhaps this book will serve as a start toward a more active search for prognosticators that better characterize the individual. Γνϖδι σαντον, said the Greeks; "Know then thyself and seek not God to scan, the proper study of mankind is Man," echoed Pope. It is the certain knowledge of the future that separates the godhead from Man, and it is the pursuit of that knowledge that ennobles Science. And yet there is just the element of chance that must remain: . . . . "We doctors know a hopeless case if - listen: there's a hell of a good universe next door; let's go!"

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