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MITRAL VALVE PROLAPSE AS METAPHOR JOHN L. COULEHAN* One of the aphorisms Eric Cassell teaches his students in medical interviewing at Cornell Medical College is "Sticks and stones may break your bones, but a word can kill you." This statement refers to the patient 's interpretation of what the doctor says and the need to avoid inadvertently harming the patient, and the doctor-patient relationship, through vague or contradictory statements. The converse of this aphorism is also true. Sticks and stones may break your bones, but a word can cure you. As the medical historian Lain Entralgo wrote, the therapy of the word has had an important place in the Western medical tradition since ancient Greece, although often unacknowledged and overshadowed by the "therapy of the act" [I]. The resurgence of the doctorpatient relationship as a therapeutic force in itself is perhaps best symbolized by Michael Balint's notion that "the doctor is the drug" [2]. What the doctor says and how he or she says it can contribute greatly to healing or to harming the patient. The doctor can be a therapeutic drug, but he or she may also have toxic side effects. The doctor-patient interaction is both the seat of "iatroplacebogenesis" [3] and iatrogenic suffering. Part of the power of the word in medicine resides in labeling. Ill people suffer not only from their primary symptoms but from anxiety about the meaning of their symptoms and about their loss of control over the body. One of the most frightening aspects of symptoms can be their unpredictability, their apparent meaninglessness. The need to interpret , to find a meaning, is a fundamental human attribute. Patients who come to their doctors have already, consciously or unconsciously, attributed some meaning to their illness or at least tried to do so. One potential power of medical labeling is that it can remove this particular load of anxiety from the patient's shoulders. A fear of lung cancer can be translated into a benign "bronchitis," and this change in personal ?Department of Community Medicine, University of Pittsburgh School of Medicine, M-200 Scaife Hall, Pittsburgh, Pennsylvania 15261.© 1988 by The University of Chicago. AU rights reserved. 0031-5982/88/3102-0571$01.00 252 I John L. Coulehan ¦ Mitral Valve Prolapst meaning can contribute to the therapeutic process. However, labeling is a double-edged sword. The patient's father may have died of an illness called "bronchitis," and the symbolic connotation of bronchitis may cause that specific patient additional suffering, particularly if the doctor is unaware of the personal metaphor and does nothing to alter it. Some medical diagnoses gradually develop accepted cultural meanings that assume lives of their own, far removed from the diseases that spawned them. The illnesses themselves become metaphors. This was the case, for example, with leprosy as a metaphor of sin or evil throughout much of Western civilization. Tuberculosis was a prominent metaphor during the nineteenth century, and, in our society, cancer serves as a rich metaphor ofsuffering and decay [4]. Some illnesses, such as the Taiwanese "fright" [5] and the Hispano-American "susto" [6] are culture bound and not reducible to specific disease etiologies in a modern biomedical framework. In these cases, the culturally sanctioned metaphor provides a meaning for symptoms, a meaning that can then be manipulated through healing rituals to yield an altered meaning (e.g., recovering, wellness). This may or may not be associated with the actual resolution of symptoms [5]. Diagnoses, however, generally have nonmedical connotations that are neither so culturally pervasive nor so negative as leprosy or cancer. I would like to discuss mitral valve prolapse (MVP) and its associated "syndrome" as examples of diagnoses that pack some metaphorical wallop today and that may have implications for both physicians and patients beyond their importance as "real" explanations for illness. In doing this, I recognize that my opinions are based largely on clinical impressions plus, perhaps, a healthy skepticism about easy answers for complex problems. Today in the United States MVP has a fairly robust cultural credibility that exceeds its scientific credibility and can influence both doctor and patient. For the doctor, as an explanation for atypical chest pain and other symptoms, MVP...


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