Journal of the Royal Society of Medicine Volume 85 May 1992
Another look at holistic medicine It seems that Dr Patersoh (January 1992 JRSM, p 60) and I agree that every clinician deals with 'patients rather than bits of them', and that differential diagnosis is a sine qua non in every case. The problem is to steer an optimum course between the Scylla of failing to diagnose organic disease and the Charybdis of concentrating overmuch on circumstances affecting the patients peace of mind. Admittedly some are better than others in the art of comprehending the whole circumstances of any given patient especially if time is no object. Lord Horder was a master of diagnosis. He taught that one should not judge a doctor by his answers to a patient's questions, but by the questions he asks the patient. In holistic medicine the important skill is to know which questions to ask' and which aystems to examine, while leaving the patient; in no doubt as to the empathy which motivates the doctor. Of course, some practitioners are better at holistic medicine than others. As one might expect the list ofmembers ofthe British Holistic Medical Association includes many illustrious representativessof most specialties1. Nonmembership does not signify opposition to holism. General Smuts may have coined the word 'holism' but he did not invent the philosophy which underlies this approach to healing the sick2. I take issue with Dr Paterson's assertion that 'It is rare indeed to predict therapeutic outcome'. If he means the ability to give any patient a guarantee of 100% cure for active treatment of every patient for any disease by any method he is on safe'ground, for there are few such treatments. In practice the forecast of the therapeutic outcome in any given case must be based on probability, as indicated by the results of controlled clinical trials3. I do not think I wa's very wide of the mark when I suggested that most of the 30 therapies in Dr Paterson's trial gave resiilts that were not much better than the'33% expected from placebos. He agrees 'that local injections may be of benefit'. The results of my clinical trials are grounds for prediction of outcome in any given case, viz. 50%
Book reviews Colour Doppler Flow Imaging W Dennis Foley 176 pp £95.00 ISBN 0-926521-2-1 Oxford: Butterworth Heinemann, 1991 This subject is very timely as, increasingly, patients can be investigated without contrast studies of venography or arteriography ard as an outpatientmost of the vascular tree can be assessed. This book is written by a Professor of Radiology and both this discipline and vascular laboratories -associated with vascular surgeons are gaining experience in this field. The opening chapter explains the method of achieving the image and it is well illustted and-explained. The chapters give illustrations- of how colour Doppler flow imaging is currently applied to different parts of the body. In the neck orbit and neonatal brain-section; it is perhaps regrettable that transcranial Doppler imaging is not included in any depth as it is now realized that information from the middle cerebral
cure of pain or 25% alleviation of pain for at least 6 months, and availability of further treatments at intervals indefinitely4'5. I suggest that prediction of outcome of any treatment should be expressed as percentage probability based on experience. I H J BOURNE Richmond, Thorndon Approach, Brentwood CM1 3PA
References 1 Holistic Medicine 1990;6:1 2 Smuts JC. Holism and evolution. London: Macmillan, 1927:2 3 Young JC. Individual psychology, psychiatry, and holistic medicine. London: Daniel 1934:33 4 Bourne IHJ. Treatment of chroniic back pain comparing corticosteroid/lignocaine injections with lignocaine alone. The Practitioner 1984128&833-8 5 Bourne IHJ. The general practitioner and management of chronic pain. In: Burrows DG, ed. Handbook ofchronic pain management. Amsterdam: Elsevier, 1987:197-203
The wart lady of Kansas My colleagues and I enjoyed Burns' erudite excursion exploring 'Warts and all' - the history and folklore of warts (January 1992 JRSM, p 37). We are aware of another effective and potentially lucrative treatment for warts. In the 'Bible Belt' of Kansas, an itinerate healer is widely known as the 'Wart Lady of Kansas'. The wart lady travels from town to town. In the local church on Sunday morning all the children with warts line up, with some anxious anticipation. The wart lady ceremoniously touches the tip of her tongue to each verrucous. The 'cure' is reported as 'always effective'. In the absence of a controlled trial and meta-analysis, the wart lady of Kansas' approach appears to be even more effective than Huckleberry Finn's Missouri 'spunl water'. J A MCGREGOR
Department of Obstetrics & Gynecology, University of Colorado Health Sciences Center, 4200- East Ninth Avenue, Denver, Colorado 80262, USA
artery can greatly improve the evaluation of the carotid and the vertebral system, not least during an operation such as carotid endarterectomy. Blind transcranial Doppler work has been superseded by colour coded imaging currently. Clearly, the editor and authors have catalogued the occasions where patients have been sent to them for imaging in their radiological- facility. Vascular laboratories associated with vascular surtgeons clearly approach the subject in a different way and are more concemed about what the technique can do in terms of managing a patient and following disease progression. Another example of current activity in vascular laboratories is for surveillance of vein bypasses after implantation and to study and note changes within a vein graft which might lead to sudden occlusion. These are areas where colour coded imaging is being performed but probably not by radiologists. I would imagine that this book would be welcomed by radiologists in training who have an interest in vascular investigation. R M GREENHALGH Professr of Surgery Charing Cross & Westminster Medical School, London
307
Another look at holistic medicine It seems that Dr Patersoh (January 1992 JRSM, p 60) and I agree that every clinician deals with 'patients rather than bits of them', and that differential diagnosis is a sine qua non in every case. The problem is to steer an optimum course between the Scylla of failing to diagnose organic disease and the Charybdis of concentrating overmuch on circumstances affecting the patients peace of mind. Admittedly some are better than others in the art of comprehending the whole circumstances of any given patient especially if time is no object. Lord Horder was a master of diagnosis. He taught that one should not judge a doctor by his answers to a patient's questions, but by the questions he asks the patient. In holistic medicine the important skill is to know which questions to ask' and which aystems to examine, while leaving the patient; in no doubt as to the empathy which motivates the doctor. Of course, some practitioners are better at holistic medicine than others. As one might expect the list ofmembers ofthe British Holistic Medical Association includes many illustrious representativessof most specialties1. Nonmembership does not signify opposition to holism. General Smuts may have coined the word 'holism' but he did not invent the philosophy which underlies this approach to healing the sick2. I take issue with Dr Paterson's assertion that 'It is rare indeed to predict therapeutic outcome'. If he means the ability to give any patient a guarantee of 100% cure for active treatment of every patient for any disease by any method he is on safe'ground, for there are few such treatments. In practice the forecast of the therapeutic outcome in any given case must be based on probability, as indicated by the results of controlled clinical trials3. I do not think I wa's very wide of the mark when I suggested that most of the 30 therapies in Dr Paterson's trial gave resiilts that were not much better than the'33% expected from placebos. He agrees 'that local injections may be of benefit'. The results of my clinical trials are grounds for prediction of outcome in any given case, viz. 50%
Book reviews Colour Doppler Flow Imaging W Dennis Foley 176 pp £95.00 ISBN 0-926521-2-1 Oxford: Butterworth Heinemann, 1991 This subject is very timely as, increasingly, patients can be investigated without contrast studies of venography or arteriography ard as an outpatientmost of the vascular tree can be assessed. This book is written by a Professor of Radiology and both this discipline and vascular laboratories -associated with vascular surgeons are gaining experience in this field. The opening chapter explains the method of achieving the image and it is well illustted and-explained. The chapters give illustrations- of how colour Doppler flow imaging is currently applied to different parts of the body. In the neck orbit and neonatal brain-section; it is perhaps regrettable that transcranial Doppler imaging is not included in any depth as it is now realized that information from the middle cerebral
cure of pain or 25% alleviation of pain for at least 6 months, and availability of further treatments at intervals indefinitely4'5. I suggest that prediction of outcome of any treatment should be expressed as percentage probability based on experience. I H J BOURNE Richmond, Thorndon Approach, Brentwood CM1 3PA
References 1 Holistic Medicine 1990;6:1 2 Smuts JC. Holism and evolution. London: Macmillan, 1927:2 3 Young JC. Individual psychology, psychiatry, and holistic medicine. London: Daniel 1934:33 4 Bourne IHJ. Treatment of chroniic back pain comparing corticosteroid/lignocaine injections with lignocaine alone. The Practitioner 1984128&833-8 5 Bourne IHJ. The general practitioner and management of chronic pain. In: Burrows DG, ed. Handbook ofchronic pain management. Amsterdam: Elsevier, 1987:197-203
The wart lady of Kansas My colleagues and I enjoyed Burns' erudite excursion exploring 'Warts and all' - the history and folklore of warts (January 1992 JRSM, p 37). We are aware of another effective and potentially lucrative treatment for warts. In the 'Bible Belt' of Kansas, an itinerate healer is widely known as the 'Wart Lady of Kansas'. The wart lady travels from town to town. In the local church on Sunday morning all the children with warts line up, with some anxious anticipation. The wart lady ceremoniously touches the tip of her tongue to each verrucous. The 'cure' is reported as 'always effective'. In the absence of a controlled trial and meta-analysis, the wart lady of Kansas' approach appears to be even more effective than Huckleberry Finn's Missouri 'spunl water'. J A MCGREGOR
Department of Obstetrics & Gynecology, University of Colorado Health Sciences Center, 4200- East Ninth Avenue, Denver, Colorado 80262, USA
artery can greatly improve the evaluation of the carotid and the vertebral system, not least during an operation such as carotid endarterectomy. Blind transcranial Doppler work has been superseded by colour coded imaging currently. Clearly, the editor and authors have catalogued the occasions where patients have been sent to them for imaging in their radiological- facility. Vascular laboratories associated with vascular surtgeons clearly approach the subject in a different way and are more concemed about what the technique can do in terms of managing a patient and following disease progression. Another example of current activity in vascular laboratories is for surveillance of vein bypasses after implantation and to study and note changes within a vein graft which might lead to sudden occlusion. These are areas where colour coded imaging is being performed but probably not by radiologists. I would imagine that this book would be welcomed by radiologists in training who have an interest in vascular investigation. R M GREENHALGH Professr of Surgery Charing Cross & Westminster Medical School, London
307
