The Differential Diagnosis of Weakness and Fatigue, 1944 Frank Allan

https://www.nejm.org/doi/full/10.1056/NEJM194409212311203

September 21, 1944
N Engl J Med 1944; 231:414-418
DOI: 10.1056/NEJM194409212311203
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YOu can see where the 'expect to diagnose FND in x out of 10 cases' idea came from then.

This is like an 80-20 rule chart. That then goes on to say and of that 20% (61 patients) 30 you could spot by eye without tests.

I'm curious given all that chart shows is what % they didn't diagnose with their tests that they tried as to what tests and diseases are now seen as attributable to vitamins vs back then - just as an example of that being the whinge of the day from this guy about the parasitic industry selling to those who were 'just tired and weak'.

Some stats are saying 5% of women and 2% of men have anemia in the USA and the best I can find is that the first blood test for iron was developed in the 1930s but I wonder when that became available and believed vs ideological stances in order that some doctor might then order it.


At least it was the USA in 1944 and not the UK in which case the 'our experience lends no support to the theory that vitamin deficiency seriously affects the health of a large % of the population' could only feel politically motivated.

But yes putting aside his prefered specific target this just reads like showing history repeating itself that we had to have a paper just a few years ago explaining that 'medically unexplained' means a failure in medicine to get to the bottom of and not 'doesn't exist'. With a feign to pretend this is considered by saying if it were a bigger clinic you might have seen the odd person with Addison's, but hey this is pretty complete and acknowledging that exception proves the rule type rhetoric.

I'm quite astounded at how rhetoric does seem to be the standard language of at least certain niches of the medical profession - fallacial thinking that it is based on is a no no in many academic essays and it is seen more as a nod to the political speech to base one's argument on them rather than critical evaluaion etc in other subjects.

 

I wonder what the causes of that anaemia are. The most likely is iron deficiency but it could also be B12 or folate deficiency. And there are other forms/causes of anaemia.

NICE has produced a Clinical Knowledge Summary on Iron Deficiency Anaemia.

And also a CKS on B12 And Folate Deficiency Anaemia

I wish doctors would automatically treat people with low iron and/or ferritin, and those with low B12 and/or folate, rather than telling patients they aren't anaemic so don't need treatment. But then of course there would be disagreement between patients and doctors on what constitutes a "low level". It would also be helpful if doctors would automatically re-test their patients three - six months after their prescription for iron, B12 or folate were finished just in case their levels dropped like a stone as they often do.

 

Agreed. It is common enough I don't fully understand why there aren't proper centres for it, they'd have gotten to the bottom of some mysteries and it seems a lynchpin measure that might help understanding of/flagging other conditions too. And we don't have more haemotologist or combined certs who can do this bit. But I suspect the historic gender differential says it all, plus insight from 'papers' like this and how they write-off debilitation and pay-that-forward as being appropriate for most who complain of it in the literature - heck I looked up a paper onthe history to find out the date testing came in for iron and it noted that they still haven't gotten to the bottom of why/how ferritin can be an issue: https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2141.2003.04529.x

Oh yeah, and there are plenty more they are cynical of - with the vitamin D one only very recently being something they will only cautiously say a 'tiny top-up for'. Whilst I am/was cynical of those who feel the need to do everyday x,y,z even though they've always been fine I am also intrigued by this instictive presumption/where it has come from and if it is kneejerk and says more about their attitude to vitamin sellers or the foolish publish who will believe anything or what.

I mean I'm sure these same people even back then must have got schooled in primary school history on how limes/citrus fruit started to be taken on ships like Columbus' because of vitamin C deficiency - that story in itself should basically by the right-thinking minds (that don't do it by rote) have been taken as a little lesson in science/history of observation, that if you get a big clump of people with certain symptoms maybe its worth a looky-see.

But then you can't have men getting off ships with bendy legs even back then vs these days people being pale, breathless and having pins and needles, exhaustion all somehow can be doubted apparently. I don't fully get what they think they are winning with it, given good management probably costs far less and certainly costs the patient and society far less - and then there is the long run.

But it is interesting to be reminded there was a gut instinct aversion to 'vitamins' even back then.

 

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OK so the first few paras here (which begin at the end of the previous post) are pretty key insight into how these things used to be seen.

The last para about 'benign nervousness' which is deemed caused by extrinsic rather than instrinsic (where it is neurotic) factors such as overwork is interesting too.

The lack of insight/self-awareness of the profession is really beginnning to show through when he basically describes a 'test' where these 'benign patients' can be identified from 'neurotic' because apparently when you tell the former there is nothing wrong with them they are relieved and satisfied and yet the latter reply by emphasising 'the seriousness of his complaints and how some abnormality must be found to account for them'.

Of course this is a poor test.

It is one which holds more power than it should - given this man is by no means qualified at all in scientific psychology or indeed in any kind of it, so it is his own bias/personal ideology he is confusing for expertise - particularly when combined with the second page that has been posted noting that an assessment of nervous factors should not only take place after exclusion because people can have both physical and nervous factors. I note hilariously with these squares of assessment/matrices, unlike with e.g. business where all 4 quadrants are described, this type of individual never wants to show it because they don't tend to acknowledge the quadrants they don't want to exist.

In all likelihood there of course even if in his dream-world all these things did always contribute (and does it matter because if treatments for the 'nervous' are useless but physical ones that do work and fix it are then sort those first and see if the former still exists?) then you'd have just by basic logic:
1.physical and nervous both 'on'
2.physical 'on' and nervous 'off'
3. physical 'off' and nervous 'on'
4. physical 'off and nervous 'off'

But they seem to want to still capture 'box 4' as the mystery that will be assumed as 'nervous'? as well as 1 and 3? based merely on how they respond to being fobbed off and told there is nothing wrong, rather than the more accurate 'we haven't found anything in the tests we have'

and I'm not quite sure also how you exclude properly and contextually (ie noting that the situation or the condition someone actually has could mean that what the physicain might deem as seeming nervous is caused by them or the condition ie not abnormal but to be expected - a big issue with psychiatry is an unwillingness to cateogirse 'normal reaction to abnormal situation' because they don't like defining situation, looking at it or using empathy so anything is 'high anxiety' rather than 'being terrorised' or 'nervous exhaustion' rather than 'constantly overworked with deliberately interrupted sleep by a neighbour') the nervous from his description - which kind of writes off his seemingly feasible and logical but ultimately fallacial suggestion of it not being only looked at after exclusion of physical. Because erm that physical and that partt of the history should be in any reasonable assessment as context for assessment of the nervous. e.g. having cancer potentially with a big lump would make someone nervous as well as be the cause of weakness. Treating the cancer has to be the first step, being aware of doing so with empathy and understanding what someone must be going through is the requirement for the nervousness not 'thinking differently' because the nerves are logical.

It's fascinating to read how people delude themselves that their screwed up not there yet thinking is logic, instead of seeking to learn. The more I look at this the more I think deficiency in the skill of empathy and the sales pitch that it isn't a skill to learn (when it is perhaps the most important one for a profession based on history and observation and claiming it is a science that works on things it needs to therefore get good at seeing and understanding - which you can't do by 'standing off' and thinking only from your naive experience of your own life in your own body) is behind all of this. And having the people who are the least capable at reading behaviour inflating themselves that 'their reading of others' behaviour' is a good proxy - it just feels like 'pass-me-down-science' ie myth, being written down as process

 

OK that is interesting that anemia is mentioned and was tested in some form as it was found in 5 cases (1.7%), but I don't know enough detail to know whether back then the reference ranges and tests would cover all the anemia and individuals who might come under that term today. If it is 5% of all women and 2% of all men, and he was looking at those who presented at a clinic for fatigue and weakness then it does seem strange to have such a low % of his cases coming out with it where the testing was of equivalent standard, rather than a higher %.

 

He gets a few things right in his last para.

"The study of weakness and fatigue leads to a consideration of medical problems covering nearly every area of medicine"

and

"IN any case these symptoms warrant thorough and complete investigation"

But these sandwich the worrying part.

"Although a high percentage with these complaints have no physical disorder, there is a group in which unusual physical conditions of interest may be discovered."

I'm guessing the statistics pass themselves down through time and become self-fulfilling prophecies then.

In a way I have no problem, language aside with the big picture stuff - barring what is written above with the 'nervous' title for assessment just like a sensible model that noted overworking someone will first result in symptoms of overwork and then lead to pathology even after not overworking can't shake off would be logical where the biopsychosocial model is the complete opposite.

It's the silly no-win tests where someone they don't find anything on the tests they do do for physical things such as 'tell them nothing is wrong and if they are OK and don't ask for anything more and never come back it isn't neurotic and if they do it is"

Where on earth is the science or qualifications behind that. It points towards weaponising (maybe subconsciously) the label - to which they shouldn't be entitled to give - of neuroses when the failure of medicine to find something is met with 'not satisfaction' by the patient.

Sadly this back-covering delusion and habit that seems to have persisted and hand-me-downed through time has the potential to stymie science and epidemiology in particular as a subject. If you insist on instead of having a box with a question-mark having one that you assign to something you are neither qualified to nor intend to develop a science to tackle as you prefer your own presumptions and think of it as 'valid enough' you stymie the future of your subject to being a pseudoscience going forwards where the problems don't slot underneath knowledge already known. Because you red-herring every other path into somewhere that is intent on trickery that can't be falsified and noone takes away your toys.

I have a horrible feeling the list on page 4 (which begins at the very end of the page above it) of the particular 'types' of exhaustion that are most likely to be nervous are insightful here and sounds very much like what you see in ME/CFS. That it is worst in the morning, rather than later in the day (which to me just means 'it isn't normal people's tiredness') and good days followed by bad and so on. This is mixed in with stuff that infers the placebo/trickery effect 'when vigour immediately returns following medication e.g. for iron, y, z, digitalis etc' or 'when it immediately disappears following one missed dose'

With no evidence at all I assume these assertions are based only on bigotry, implicit stuff handed down through generations not of medics because they are qualified but of people - which might include the medics just because they are flawed people too. Except if they were scientists their job would be to see these are symptoms and clues where they've hit on them as failings and indicators of neuroses, with probably the most unrooted and unevidenced paragraph in the whole piece. It is just trotted off as a truism without him even realising it.

Not that we didn't all already know this that we suffer because the symptoms of our illness are as unacceptable socially as anything can be - for strange reasons. There is nothing so frowned on as sleep-reversal that can't be controlled, or full-on exhaustion that doesn't follow the pattern of normal people and you can do some things at some points but not others.

Or is it that these are basically taught as malingering detection symptoms all together, when they are completely flawed by assumptions that all exhaustion or weakness must only operate like an exagerrated version of well people's?