Why We Need TOC in Medicine

I have a friend who had a recent health challenge. He's better now, but for a while he was uncomfortable and limited by this problem. He didn't get a lot of help from our healthcare system, and that's what I'd like to look at. 

This man is in his 60's, well regarded in his field, and well educated. He's certainly well able to understand whatever his doctor told him. He's also well motivated to do whatever his doctor told him to do to resolve the problem. I mention these things because the lack of them are commonly cited by those of us in Medicine when our patients don't get better. We usually blame the patient, but this guy was not to blame.

What happened to my friend is this. One day, without acute injury, his leg started to swell. Not just a part of his leg, but the whole thing began to swell. When limb swelling isn't limited to a particular joint or site of injury, it's a pretty clear sign that the lymphatic system isn't working, so the sign is called lymphedema. That's latin for swelling from lymph. Lymph is a sort of tissue fluid that comes from protein and water leaking out of the blood system. Like blood, it too has to be returned to the heart for recirculation, and so, when the system of lymphducts doesn't work well, this fluid can accumulate in a limb causing lymphedema. 

My friend was diagnosed with Lymphedema Tarda (LT), which is Latin for Late Life Onset Swelling From Lymph. Very descriptive for any ancient Roman, but it hardly tells us what was wrong with my friend. In this case, "late life" starts at age 35, but I guess if we're going to use Latin, we ought to use Roman lifespan expectations as well. 

So here's the real issue. LT is considered one of the hereditary lymphedemas. That means it's primary, otherwise known as has no known cause. Now you'd think that would mean that given the huge increase in our genetic knowledge since primary lymphedema was first described, that we'd have found THE genetic cause. Well, indeed, it seems we have, at least to a certain degree. Two different forms of lymphedema, one that presents at birth and one that presents around puberty, are associated with known mutations of two different genes. These mutations don't explain all the cases of these two types of primary lymphedema, and, in fact, identify that these two forms of primary lymphedema have different causal mechanisms. In other words, primary lymphedema isn't primary. It's different forms are caused by different causes. In any case LT hasn't been associated with any genetic abnormality, and, therefore, may represent a third caused condition. 

But perhaps my friend's doctor didn't know all that. After all, it took me 10 min on Google (about the length of the average doctor office visit) to find all that out. Anyway, thinking it was primary, as everyone in Medicine does when they can't find an obvious cause, he chose to treat it symptomatically: compression stockings, trials of diuretics, leg elevation, etc. None of these worked. My friend suffered along, a little better, but only because he was limiting himself.

Then something really weird happened. For a completely different reason my friend chose to vastly lower the intake of carbohydrates. Very rapidly his leg swelling decreased to almost normal, and he's much better. One might think that he's only better because of the normal fluid loss that occurs when one stops eating carbs, but lymphedema isn't too much fluid in the body; it's the inability to correctly move the fluid that's there.

So here's where TOC comes in. In TOC, my friend's leg swelling would not be called a problem or sign as in Medicine, but rather an Undesired Effect (UDE - pronounced ooo-dee). That's because nothing is assumed to be primary. Unlike in Medicine, when the practitioner of TOC can't find a cause after a cursory examination of the problem, he assumes he's missing something, not that there's no cause. The TOC practitioner in this case would think about what the lymphatic system does, and what it would take to make it swell a leg, specifically what it would take to swell a leg but leave the arms alone as well as the other leg. Thinking about it logically, we have a couple of possibilities.

1. Lymphatic drainage of the leg is blocked to some degree to which it wasn't blocked before

2. Lymphatic production has increased suddenly so as to overcome the ability of the system in that leg to drain it completely

In short, something changed. If it changed, something changed it. We need to find what changed it, and, if possible, get it to change back. Well, in this case, and admittedly with 20/20 hindsight, knowing that increased intake of carbohydrates increases insulin production, and knowing that insulin is inflammatory, we might consider that what blocked the ducts was inflammation. But could we have gotten there before my friend stopped the carbs? 

I think we could if we changed how we think about things in Medicine, and that's what we need to do. In too many aspects of medical care, we abdicate our responsibility to think in favor of checking off a list of approved causes, and once we've checked them off, assume things are just the way they are. Oh, well. And why are things this way? Because we don't pay doctors to think anymore. We pay them to do quick office visits and put checks in boxes in electronic medical records. That's not how it always was.

Dr Osler, the father of modern American Medicine, said, "If a diagnosis doesn't change treatment, don't use it." I think he'd be very at home with TOC. We should give it a try.