Blog series: "Orthodoxy on trial: the pathogenesis of a diagnosis" by David Black

"David J Black explores the dangers of orthodoxy in the first in a four-part medico-legal series.

“Orthodoxy” wrote Bertrand Russell “is the death of intelligence”. Before placing this in a medico-legal context with specific reference to the 2009 case Fraser and another v The National Institute of Clinical Health and Excellence, consider the quandary of three anxious doctors gathered around the bed of a dangerously ill 67-year-old man fighting what appeared to be a severe attack of croup.

Two of the doctors were roughly his age. The third doctor, who was in his mid-thirties, had an inspired, if unorthodox, idea. With a simple tracheotomy procedure, the inflammation blocking the windpipe could be bypassed, and the patient might be saved. The problem was that it was December 1799, and the patient was George Washington, the nearest thing the secular United States had to a deity. Cutting his throat may well have saved his life, but the outcome, had the operation gone wrong, would not have been such a good one for the three Scots-American physicians concerned.

In the event Surgeon-General William Craik, the President’s brother-in-arms who had known him all his adult life, and Doctor Gustavus Brown, his neighbour from the other side of the Chesapeake, over-ruled Dr Elisha Cullen Dick of Alexandria, whom they clearly regarded as their junior.

They chose instead the route of 18th century orthodoxy, bloodletting and purging, with a few extras such as molasses, vinegar and butter gargles, and throat swabs made from a preparation of dried beetles. George Washington, minus around 40 per cent of his blood, was dead within a few hours, the victim of that very same medical orthodoxy."

....

"These colourful tales have very little in common with the case to be addressed, you might think, but the common theme here is that they invite us to consider the nature of orthodoxy, and to test Bertrand Russell’s dictum about it being the death of intelligence in our present era.

The first question to ask of any orthodoxy is, of course, “says who?” In the following example, the answer is psychiatrists Colin McEvedy and Bill Beard, who in 1970 published “A Concept of Benign Myalgic Encephalomyelitis” in The British Medical Journal. This became the founding doctrine of what might be termed the ‘psychogenic model’ for the study and understanding of a debilitating illness widely known as Chronic Fatigue Syndrome. As an orthodoxy the psychogenic model would hold sway for half a century, until it was finally discredited in November 2020, as we shall see."

Part one, https://www.scottishlegal.com/article/orthodoxy-on-trial-the-pathogenesis-of-a-diagnosis
Part two, https://www.scottishlegal.com/article/orthodoxy-on-trial-ii-dominance-by-induction
Parts three and four to follow.

 

maybe the legal profession will now wake up to the facts politically motivated fraud could lead to successful class actions and serious money to be made by lawyers at least .

 

Only in the US, but this is one of the only redeeming features of the US health care system: tort. Elsewhere medicine is above the law.

 

I have sometimes wondered whether this is why a model, first more or less fully described in Toronto in 1985, at a conference mainly involving US participants, came to be operationalised in the UK.

 

@chrisb - Do you have a link or other information on that Toronto conference? I'm not sure I've heard about that before

 

It was The 2nd International Conference on Illness Behaviour. The proceedings were described in Illness Behaviour-a multidisciplinary model by McHugh and Vallis, published in 1986. The 1st conference had been in Adelaide, academic home of Pilowsky, in1984.

The model has to be unravelled from the various papers. McHugh and Vallis give a description of the BPS model, as does the Hamilton Academicals star player Arthur Cott.

Eisenberg mentions his idea about spurious disease constructs, which he mentioned again in his Oxford lecture in 1987, and which much influenced Goldberg In his paper with Wood in the British Medical Bulletin. (Eisenberg of course knew a thing or two about spurious disease constructs admitting shortly before his death that his own model for ADHD was one such, due to absence of a proper control group.)

Cott, Eisenberg and Kleinman discuss illness in the absence of disease.

Cott describes treatment by a multidisciplinary team to provide the patient with reassurance in respect of false cognitions and maladaptive behaviour using a cognitive behavioural model.

Blackwell and Gutman recommend gradual increase in exercise. There is talk of deconditioning. And much more.

You would think that amongst all the papers cited by Sharpe and Wessely there would be some mention of this. The 1988 David Wessely Pelosi paper does mention an earlier paper by Pilowsky but that does not lead to the paper trail. One of the two UK attendees was Mayou, with whom Sharpe coauthored a paper in 1992 ( Sharpe Peveler Mayou Psychological treatment of functional somatic symptoms: a practical guide J Psychosom Res 36:515-527). Papers on this subject were also published in Shepherd's journal Psychological Medicine, in which Eisenberg also had some role. Shepherd is acknowledged by SW in his paper on hysteria published in that journal. The chances of Sharpe and Wessely being unaware of this body of work are approximately zero.

It could be argued that this does not relate to ME, but it does clearly relate to the original concept of CFS within the broader framework of MUS. The timing is interesting. 1985 was almost certainly the year Straus adopted his psychosomatic explanation, denouncing ME and adopting Imboden

I did start a thread on the McHugh and Vallis book which had references to the google books and readable Amazon pages, but I think I am probably beyond finding it at the moment. Some other time.

It might be thought that the links are tenuous but the overlap of personnel has to be considered. Eisenberg was key to turning the UK psychiatrists to the Imboden Canter Cluff model of "conversion reaction"-though it was never called that in anything they expected to be read. Kleinman chaired the CIBA conference along with Straus. I never understood why, until I found this. Mechanic and Katon were also present at both conferences.

 

I think this is the thread @chrisb is referring to:

https://www.s4me.info/threads/illne...chugh-and-vallis-edit-1986.17996/#post-305704

 

Fascinating, @chrisb Thank you for all this as I had never run across this. Interesting connection to Kleinman and the Ciba conference. I had assumed that Straus shifted to a psychogenic model after his Acyclovir trial failed to show anything. That study was published in 1988 but ran from 1984-1986 so the timing may be about right.

And thank you @voner for the thread. Looking forward to reading it.

 

I think they just updated the McEvedy mass hysteria from 1970 to illness behaviour, so dropped hysteria which was going out of favour for a more "scientific" illness behaviour model.

 

I'm not sure they needed to update anything in the US. They already had the Imboden Canter Cluff model which Imboden called "conversion reaction".

Plus ca change...

 

Orthodoxy on trial III: Did flawed science beget flawed law?
https://www.scottishlegal.com/article/orthodoxy-on-trial-iii-did-flawed-science-beget-flawed-law

 

This is solid. The legal issues here will be something to unfold, especially as it happened the way it happened pretty much simply because who the people pushing this were, working with to officials and authorities, could simply do it because they had the power to do it, and essentially broke the social contract.

I noticed a mistake, though, the article says that NICE lost the appeal for PACE data, rather than QMUL. Still, an important discussion that will be a hot topic in legal circles for decades to come, it's very rare to have such a perfect storm of corruption, ideology and the intersection of official power with magical thinking and impossible promises.

Seriously this will be discussed for decades to come, maybe stand for centuries as a special example of power and medicine gone mad.

 

Orthodoxy on trial IV: So long, psychogenia – but not quite yet
https://www.scottishlegal.com/article/orthodoxy-on-trial-iv-so-long-psychogenia-but-not-quite-yet

 

Very solid, again.

Have you seen this, @dave30th? Probably but damn it's really good.

 

I liked all four of these articles. I wonder if they will have any impact on IAPT or MUS or CBT for everything.