THE ELLIPSIS OF PROGNOSIS IN MODERN MEDICAL THOUGHT

Contemporary textbooks of internal medicine give scant attention to th e prognosis of diseases. Has this always been the case? If not, when a nd why did prognosis come to be de-emphasized? Using a highly regarded , standard medical textbook initially authored by William Osler, The P rinciples and Practice of Medicine, I performed qualitative and quanti tative content analysis of entries regarding lobar pneumonia in select ed editions published between 1892 and 1988, with special attention to the period between 1892 and 1947. I chose lobar pneumonia because it was a leading cause of death throughout this period and because it is recognizable across time, thus making it possible to follow the evolut ion in clinical thinking about prognosis while holding constant the di agnosis. I argue that two powerful forces converged to lead to the ell ipsis of prognosis: (1) the emergence of effective therapy, and (2) a fundamental change in the cognitive basis of medicine. With respect to the former, I show that there is a complementary, inverse relationshi p between the clinical acts of prognostication and therapy; as one inc reases in salience in the management of a :disease, the other decrease s. With respect to the latter, I argue that the particular clinical fa cts deemed to be important about a patient's case have shifted over ti me, and I explore changes in the clinical and cognitive foundations of physicians' estimation of patients' prognoses-in particular, ''sympto ms'' and ''complications.'' I conclude that, concurrent with a shift i n clinical thought from an individual-based to a diagnosis-based conce ptualization of disease, prognosis came to be seen as intrinsic to dia gnosis and therapy, and explicit attention to prognosis consequently d iminished. Copyright (C) 1997 Elsevier Science Ltd.