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The paranasal sinuses and other enigmas: an aquatic evolutionary theory

Peter H. Rhys Evans

The Journal of Laryngology and Otology March 1992, Vol. 106, pp. 214-225

Abstract

The functional role of the paranasal sinuses in man has long been in dispute and as yet no satisfactory explanation has been offered for these “unwanted” spaces. An answer may be found by study of the comparative evolutionary development of the sinuses in man and other higher primates.

Several unique physical characteristics of man not seen elsewhere in the ape family, or indeed in other terrestrial mammals, including some relating to the upper aerodigestive tract, are not satisfactorily explained by the traditionally held theory of evolutionary development of early man directly from the arboreal ape.

It is argued that these developmental differences are much more logically explained by a period of aquatic adaptation at a crucial period in the evolution of pre-hominid man. A new theory is proposed which might explain the importance of the sinus air cavities as buoyancy aids for protection of the upper airway tract in such an aquatic environment.

Further evidence is offered relating to a pathological condition of the external ear canal which supports this theory that man at some stage in his early development acquired an affinity for an aquatic environment.

Explanation of these unique hominid characteristics in terms of an aquatic evolutionary theory may help to resolve some of the enigmatic inconsistencies between man and other higher primates, and may account for man’s eventual emergence as the dominant extant species, and perhaps an explanation for the “missing link”.

Introduction

“Remnants of the past that don’t make sense in present terms – the useless, the odd, the peculiar, the incongruous – are the signs of history”.

Stephen Jay Gould

The Greek physician Galen (130-201 AD) is credited with the original description of skull porosity, but it was Leonardo da Vinci who clearly demonstrated for the first time the existence of the paranasal sinuses in his publication “Two views of the skull” (circa 1489). Direct reference to the sinuses was made later by Vesalius in his treatise “De Humani Corporis Fabrica” published in 1543. However, the functional role of the paranasal sinuses in higher primates and in particular, man, has remained a mystery despite the formulation of many theories since the time of the Renaissance to explain their anatomical or physiological significance.

The eminent otolaryngologist, Sir Victor Negus, who devoted much of his life to the study of the comparative anatomy and development of the upper aerodigestive tract, discounted these theories but was unable to offer any possible alternative (1958). More recently in his essay on evolution of the sinuses, Blaney (1990) concludes that no plausible argument has yet been proposed which offers a satisfactory explanation for their existence. Takahashi (1983) also acknowledges the significance of these air spaces as one of the most difficult problems in human evolution.

Although many of these theories of paranasal sinus function may have seemed superficially plausible at the time of their conception in the context of the anatomical and physiological development of modern Homo sapiens, they do not fully address the reality of the evolutionary process in terms of time and functional necessity. Not unreasonably, they are also based on the traditionally accepted theory of evolution of early man (the savannah ape) from the arboreal ape, which only recently has been called into question (Hardy, 1960; Morgan, 1982).

The essential point is that evolutionary adaptations take place in response to things that have happened, not things which are predestined to happen (Morgan, 1990). Evolution does not aspire to the development of “unwanted spaces” any more than to the development of bipedalism or loss of body hair, unless these characteristics provide a definite evolutionary advantage to survival.

That man possesses a large volume of empty paranasal sinuses, including an extensive labyrinth of ethmoid cells not found in any other species, must have an important evolutionary significance. There must have been some logical explanation for the expansion of the sinuses in early anthropoid man and development of additional ethmoid cells which offered a definite survival advantage over other ape species.

It can certainly be argued that this legacy left to modern man has proved much more of a liability than an asset as no other species has the misfortune to suffer from sinusitis or other allied upper respiratory problems. This cannot simply be due to the presence of ethmoid sinuses, and two other contributory characteristics, both also unique to man, are of equal relevance as aetiological factors.

The first of these is man’s upright posture which has a distinct disadvantage in providing inadequate drainage of the sinuses, which previously had evolved quite satisfactorily in quadruped mammals over many millions of years. The second contributory factor is that man is the only terrestrial mammal not to be an obligatory nose breather. In all land mammals except man, the larynx is in contact with the soft palate, and the normal airway, from the nasal cavity to the trachea, is thus protected from possible aspiration of liquid and food, which pass around larynx directly into the pyriform fossae.

The descent of the human larynx allows the possibility of free mouth breathing and with this comes the unique ability to speak. Despite this obvious advantage, the cost of breathing through our mouths when we are speaking or exerting ourselves, or through necessity because of nasal obstruction from a deviated septum, for example, is significant. With it comes the loss of the important physiological advantages of nasal breathing such as olfaction, humidification, disinfection and temperature control of inspired air.

These factors, predisposing to the development of upper respiratory infections are unique consequences of the various modifications of the upper aerodigestive tract in man. The only animals to suffer similar problems are breeds like Pekinese dogs in which selective breeding has artificially reduced the length and efficiency of the nasal passages (Morgan, 1990).

Since these modifications to the upper aerodigestive tract in man seem to have occurred at more or less the same time in his evolution, it is perhaps more relevant to consider them together rather than in isolation. There are also other important features about the human nose, particularly relating to its shape and structure, which are quite different from those of all other species.

These changes could not have evolved for any trivial reason and must represent some significant developmental adaptation that occurred in the vital period of ape/man transition which did not happen to other members of the ape family who evolved over millions of years with very little change into modern apes and chimpanzees. In a broader context, we cannot ignore other unique human features such as bipedalism, loss of body hair, presence of subcutaneous fat and differences in sweat and tear production, which evolved over the same transition period.

There is certainly no doubt about the validity of Darwin’s theory of evolution of man and ape from a common ancestor, but the widely accepted concept that early man evolved directly from apes who came down from the trees and ventured on to the savannah offers no convincing argument to explain all the evolutionary adaptations that have occurred in man, and why there are gorillas, chimpanzees and humans and not simply three different species of African ape.

Before considering what appears to be a more logical explanation of these changes, it is pertinent to discuss what is known about the comparative evolutionary development of the sinuses and current theories of paranasal sinus function.

Evolution and comparative anatomy of the human paranasal sinuses

“Anatomy is to physiology as geography to history:

it describes the theatre of events”.

Jean Fernel (1497-1558)

Study of the evolutionary development of the paranasal sinuses is difficult to consider as a whole since their functions are widely different. The maxillary sinuses are distinct in origin, and while the frontal and sphenoidal air spaces can be grouped together, the ethmoid sinuses are only present in man, although they are found in rudimentary form in some other higher primates. However, certain facts are acknowledged about the functional role of the paranasal sinuses in the arboreal ape such as Ramapithecus and in other species during the immediate prehominid era (10-20 million years before present (mybp)).

Maxillary sinus

The maxillary sinus shows considerable variation in size and is particularly well developed in the higher primates, notably man, and some ungulates. In the chimpanzee it extends across the floor of the nasal cavity to communicate with its opposite sinus and also with the few ethmoid sinuses present.

To some extent, the size of the maxillary sinus depends on the length of the upper jaw which primarily was evolved for the purpose of seizing and devouring prey. As pointed out by Wood-Jones (1916), the length of the snout varies inversely according to the ability of prehension with the forelimbs. Animals which can grasp food, whether fruit or nuts, as in the case of monkeys or squirrels, or animal prey (e.g. the cat tribe), usually have a short snout. Others which have to crop herbage, such as ungulates, some rodents and marsupials (e.g. kangaroos) or predators that can seize prey with their jaws (e.g. dogs, bears and raccoons) in general have a long and protruding snout (Negus, 1958). In many of the carnivorous animals with long snouts the additional space in the upper jaw is occupied by important olfactory maxillo-turbinals.

Frontal and sphenoidal sinuses

The frontal and sphenoidal sinuses are present in many different species but are particularly well developed in keen scented animals such as the carnivores. Extension of the olfactory mucosa from the nasal cavity into adjacent cavities is seen in members of the cat and dog tribe where there is excavation of the sphenoid and frontal bones (Negus, 1958). Some herbivorous animals also have a large olfactory area in the nasal cavity with specialized mucosa covering five or more ethmoturbinal bodies.

In both groups of animals the ethmo-turbinals have a similar arrangement within the nasal cavity and the remaining space is occupied by the maxillo-turbinals which are the main source of moisture for humidifaction of the inspired air, essential for olfaction. The result is that in keen-scented animals, the nasal fossae are filled with ethmo- turbinals and maxillo-turbinals, with little or no free space.

In primates, however, there is a wide difference in the extent of these sinus cavities. The majority have no frontal or sphenoid sinuses, but in the gorilla and man these spaces are often well developed without any obvious reason, for their olfactory area is very restricted and they have a feeble sense of smell (Negus, 1958).

Ethmoid sinuses

The reduction of the olfactory area in higher primates has resulted in regression of the olfactory turbinals which instead are replaced by additional air spaces – the ethmoid sinuses. According to Cave and Haines (1940), the chimpanzee has a small anterior ethmoid cell opening into the frontal sinus, and a posterior cell, whereas the gorilla has an anterior and two posterior cells.

In man, however, there is unique development of large and numerous ethmoid sinuses, communication with the nasal fossae by narrow ostia, despite the absence of any olfactory or other apparent role. In addition, the sinus openings are well protected from the nasal airstream by single scroll-like turbinates which project downwards to cover the ostia, forming narrow valve-like communications.

The extensive system of empty ethmoid cavities found only in man form a honeycombed labyrinth situated between the upper part of the nasal cavity and the orbit, resulting in characteristic widening of the intercanthal distance. There may be as few as three or as many as 18 on each side, their number varying inversely to their individual size. The pyramidal shaped labyrinth has an average length of 4-5 cm, a height of 2.5-3 cm, a width anteriorly of 0.5 cm widening to 1.5 cm posteriorly, giving an overall volume of up to 30 cc (Mosher, 1929).

In the context of higher primate evolution, the emergence of early man with his short snout but extensive framework of large empty paranasal cavities, despite a rudimentary olfactory or prehensile requirement, poses an apparently unanswered question: “what was the purpose of these empty sinuses and why did man develop a profusion of additional ethmoid spaces not present in any other animal?”

Theories of paranasal sinus function

The hypothetical role of the paranasal sinuses have been the subject of much speculation but little empirical research or investigation over the last few centuries. Several well known theories have been proposed but later discounted for lack of substantial evidence or conclusive observations.

1. Resonance theory. Bartholinus (1660) originally proposed that the sinuses were important in phonation by aiding resonance of the voice. As Blaney (1990) points out, this theory has been discounted because the size of the sinuses bears little relation to the strength of the voice. Animals such as the giraffe and rabbit, despite having large sinuses, have a weak or shrill irresonant voice (Negus, 1958), whereas others, for example, the lion, although possessing small sinuses, can produce an unmistakable loud roar (Proetz, 1953).

2. Mucus secretion theory. In 1763, Haller suggested that the sinuses played an important role in moistening the olfactory mucosa but this theory has been discounted because of a comparative lack of mucus glands in the paranasal sinus lining (Skillern, 1920; Negus, 1958; Mygind and Winther, 1987).

3. Olfactory theory. This theory was first proposed in 1830 by Cloquet who assumed quite erroneously that the large sinus cavities in man were lined with olfactory epithelium. As with other animals which have a poor sense of smell, the olfactory mucosa in man is confined to a limited area in the roof of the nasal cavity and the sinuses are lined with respiratory epithelium (Rhys Evans, 1987).

4. Thermal insulation theory. First suggested in 1953 by Proetz who likened the paranasal sinuses to “an airjacket about the nasal fossae closely resembling the water jacket of a combustion engine”, this theory has been discredited for several reasons. In species which require the greatest degree of warming the air for increasing humidification, the heating apparatus takes the form of an elaborately branching maxillo-turbinal body inside the nasal cavity.

Heat exchange of the inspired air is much more efficiently carried out with this extensive system of superficial vascular spaces in contact with the nasal air stream than with large sinus cavities situated adjacent to, but separate from, the nasal fossae. Furthermore, the presence of only one small ostium, or occasionally two, precludes the possibility of adequate circulation of air into the sinuses (Negus, 1958).

In addition to the humidification theory, it has also been suggested that the paranasal sinuses help with insulation of the base of the brain, but the apparently anomalous presence of large frontal sinuses in the African Negro (Brothwell et al., 1968; Wolfowitz, 1974) and frequent absence in Eskimos (Koertvelyessy 1972; Tillier, 1975), would seem contradictory to this theory.

Neanderthal man also possessed large frontal sinuses which according to Coon (1962) were adapted to insulate and protect the brain from the cold but as Tillier (1975) points out, this theory cannot be extended to other hominids since the frontal sinus and supraorbital size relationship is unique (Blaney, 1990). Quite apart from this, Neanderthal man was mainly accustomed to a temperate climate with little need for partial cerebral insulation.

5. Lightening the skull. Another suggested role of the paranasal sinuses is to lighten the skull, particularly its anterior half, in order to reduce the work of the neck musculature (Skillern, 1920). Unlike other primates such as the gorilla, orang, chimpanzee and gibbon, man is unique in maintaining his upright posture. In these other species the skull is held in a forward inclined position requiring strong neck muscles capable of supporting the head under all conditions. Only in man is the head balanced on occipital condyles situated in the middle of the skull base rather than at its posterior extremity, as in most four footed animals (Wood-Jones, 1916).

“If sinuses served no other useful purpose than the supposed reduction in weight”, writes Negus (1958), “the obvious alternative would be the apposition of the two tables of bone which form their walls”. He goes on to say that “this would be a simple matter in the frontal and sphenoid regions” and elimination of the necessity for maxillary sinuses could be evolved, as in the baboon, by incurving of the cheeks.

6. Facial growth theory. Proetz (1922) originally considered the presence of nasal sinuses to be directly related to the development of the face and that “we are not called upon to attribute to these cavities any further functional activity”. He concludes that “the face parts develop because the individual has need of them: larger, stronger jaws, increased breathing space. The sinuses, which, after all, are nothing but unoccupied spaces, result incidentally”.

More recent authors have stressed the importance of craniofacial development and increase in the angle between the forehead and frontal cranial base in dictating sinus morphology (Takahashi, 1983; Shea, 1985; Blaney, 1990). But these arguments do not explain the evolutionary necessity for the presence of large empty spaces in the facial skeleton adjacent to the nasal cavity in man when compared to parallel development in other species.

Although this theory may be tenuously applied to the maxillary and ethmoid sinuses, there does not appear to be any reason to regard the presence of the sphenoidal sinus as connected with growth of the face, since it does not form part of the facial structure. Similarly the wide variation in the size of the frontal sinuses without obvious change in the shape of the facial contour seems to render this argument invalid.

Certain conclusions about functional importance of the paranasal sinuses may therefore be derived from a general survey of their comparative anatomy and evolutionary development. Expansion of the nasal fossae and adjacent sinuses was almost universally apparent only for purposes of extension of the olfactory mucosa in carnivora and other keen-scented animals, apart from the higher primates and perhaps one other exception – the excavated sinuses and hollow horns of some ungulates.

Other functions ascribed to the sinuses in man such as vocal resonance, humidification, heat exchange, thermal insulation and craniofacial development may be discounted for the various reasons described. Since these theories, based on traditional evolutionary ideas of ape/man transition, are not wholly convincing, we are still left with the same unanswered question about the functional role of the sinuses and why they developed to such an extent in man. If, however, we introduce the concept of aquatic adaptation as proposed by Hardy (1960) and Morgan (1982), many of the puzzling evolutionary changes seem to have a more logical explanation.

Paranasal sinus function – buoyancy theory

“We must, however, acknowledge, as it seems to me,

that man with all his noble qualities

still bears in his bodily frame, the indelible stamp of his lowly origin”.

Charles Darwin (1809-92)

As we shall see later, the theory proposed by Skillern (1920), that expansion of the sinuses in man was for the purpose of lightening the skull, may be nearer the truth. The counter-arguments to this theory pointed out by Negus (1958) and others are perfectly valid when taken in context of the accepted savannah theory of ape/man evolution. If simply lightening of the anterior part of the skull was needed for reducing work of the neck musculature, this could equally be achieved by reduction in sinus size and apposition of their walls.

If, however, we argue that the anterior part of the skull not only needed to be light, but also buoyant, the presence of air in the cavities would be essential, and development of larger and more numerous sinuses (e.g., ethmoid cells) would be even more advantageous. From purely a physical and anatomical point of view, this would seem to be the simplest and most logical explanation.

This hypothesis would obviously have no relevance if one continued to accept the traditional savannah ape theory of evolution. It is, however, consistent with the aquatic theory (Hardy, 1960; Morgan, 1982), which proposes that certain early hominids, ancestral to Homo sapiens, spent a period of several million years in an aquatic environment before returning to their terrestrial existence. In this situation, additional buoyancy of the facial structure would certainly be advantageous to an aquatic ape living in a marine environment, in helping to keep the airway opening above water, relieving workload of the cervical muscles and assisting forward migration of the cervico-occipital articulation.

Other aquatic species evolved structural buoyancy to suit their individual needs. Those non-air breathing animals which live an entirely submarine existence, such as fish, require mainly negative buoyancy, which is controlled in many species by a swim bladder, but others which need to surface for breathing have additional buoyancy. Aquatic mammals such as cetacea (whales and porpoises) have developed a layer of subcutaneous fat which provides buoyancy as well as streamlining and insulation. This layer of subcutaneous fat is also a unique feature which distinguishes man from all other primates. If we regard Homo sapiens as a terrestrial mammal, this distribution of fat is highly uncharacteristic, but as an ex-marine mammal this feature would be conforming to type.

Maintenance of the airway is essential in air-breathing animals. In whales and other cetacea the nostril or blow-hole has migrated well on to the dorsum of the head which allows the snout to remain submerged on the surface while the animal is still breathing. In the reptile family the long characteristic boatshaped snout of the crocodile gives additional buoyancy for the airway is also vital for maintaining its acute sense of smell.

The presence of air sacs or cavities is one of the most efficient means of assisting buoyancy as seen in some surface insects. In frogs and toads the air sacs provide buoyancy for the head while the animal is partially submerged to help keep the nasal opening above water. It is therefore not unreasonable to suggest that in primates, who already have rudimentary sinuses, expansion of the cavities and development of additional ethmoid spaces could not have evolved in man for the same purpose.

The nasal valve

One other essential characteristic of air-breathing marine animals is the ability to close off their airway when submerged, which can be done either by a valvular mechanism to close the nostril (newt, crocodile, cetacea, salamanders, sea elephants, sea lions, seals and polar bears), or the laryngeal aperture (penguins). This provides protection for the airway and allows the animal to catch or eat prey whilst under water. Of tailless amphibia, the frog has a specialized pad on the anterior angle of the lower jaw which is thrust upwards when submerged to close the external nares (Young, 1950). The ability to close off the nostrils is not exclusively aquatic since the camel can also achieve this in order to keep sand out.

The mechanism of closure of the nostril is by two sets of opposing muscles, the dilator and constrictor naris situated on the dorsum of the nasal aperture. It is perhaps curious that although humans are not able to completely close off their nostrils, they are unlike any other higher primate in possessing similar muscles around the external nares which can be used for flaring the nostrils. The only difference between man and the seal in this respect is that when the muscles are relaxed, the seal’s nostril are completely closed, whereas ours are not (Morgan, 1982).

The external nose

The shape of the human nose has intrigued scientists and anatomists for centuries, but no logical explanation has been offered to account for its elongated form and the unique differences which distinguish it from those of other higher primates.

The prominent cartilaginous portion of the nose has made it vulnerable to trauma causing deviations and fractures, but functionally it may have evolved to allow closure of the external nasal valve. It has also been suggested by Morgan (1982) that its protective hooded shape may be important when diving and swimming in deflecting water from the nasal opening, preventing inundation of the airway. Certainly the caudally directed opening in man differs significantly from the wide ventral aperture seen in other higher primates. The only other primate to possess a prominent nose of any proportion is the semi-aquatic proboscis monkey.

Thomson and Dudley Buxton (1923) have studied the configuration of the nose in modern man in relation to race and climate and found that the wide platyrrhine nose i associated with a hot, moist climate and the narrow leptorrhine with cold, dry conditions. The breadth of the pyriform aperture, however, has no correlation with racial difference (Negus, 1958).

Other hominid evolutionary adaptations

In his opening introductory paragraph to “The Origin of Species”, Darwin states: “until recently the great majority of naturalists believed that species were immutable productions, and had been separately created. Some few naturalists, on the other hand, have believed that species undergo modification, and that the existing forms of life are the descendants by true generation of pre-existing forms”.

The process of natural selection applies equally to man, and the various unique modifications evolved in early hominids during the ape/man transition must have had some important evolutionary significance. These adaptative changes are questioned in the light of traditionally held beliefs of anthropoid evolution, and an alternative theory of aquatic adaptation is suggested which may provide a more logical explanation.

1. Bipedalism

The most striking feature that distinguishes man from all other primates and terrestrial mammals is his upright mode of locomotion. What may seem quite natural to us has only been made possible through adaptation over millions of years, but for the savannah ape the initial impetus which promoted this dramatic evolutionary change is difficult to explain.

The only other quadrupede which can move faster on two legs than on four, albeit by hopping, are those which have large heavy counterbalanicing tails such as kangaroos and wallabies. Apes and chimpanzees can travel for short distances on two legs, usually when holding something in their hand, but it is characteristically in a diagonal direction using their other hand for stabilization. One other primate which can walk on two legs for an appreciable distance is the proboscis monkey when in shallow waters.

Other land-dwelling primates (macaques) and rodents (beaver) which live near the shore, may adopt an upright posture when wading into the water in search of food, sometimes using their forelimbs to carry objects. According to Hardy’s original hypothesis (1960), the initial impulse towards bipedalism came when the ancestral primate waded into the sea. Additional buoyancy in the water would have reduced pressure on the spine and assisted rotation of the pelvis to bring the spine and hind limbs into alignment.

One other creature to have undergone similar adaptation is the penguin, which unlike any other bird, has a perpendicular stance, just as ours is dissimilar to any other mammal. This posture is maintained whether the animal is swimming, floating or on dry land, and after a few million years would have achieved a degree of stability which could be retained permanently, irrespective of environment.

2. Loss of body hair

Another unique characteristic which distinguishes man from other higher primates is his relative hairlessness. Why did he lose his furry coat, which for a terrestrial mammal made him less adaptable for regulation of body heat, since a hairy skin is much more efficient for keeping the body warm in the cold and keeping cool when it is hot?

Man in fact does have an equal distribution of hair follicles per unit surface area when compared to the chimpanzee, but the hairs are short, thin and largely vestigial – but for what reason? Perhaps, as Sokalov explains in his book “Mammal Skin” (1982), the answer is that “in water, fur provides poor insulation and becomes atrophied”. Such a naked ape is unique and the only other hairless mammals dwell either in the sea (whales and porpoises) or underground (the naked mole rat).

3. Subcutaneous fat

The presence of a layer of subcutaneous fat is another remarkable feature of human skin which is unique among primates. This is far more characteristic of aquatic mammalian species for which it provides buoyancy, streamlining and an effective form of insulation. Fat stores in terrestrial mammals are located mainly in the mesenteries and around the kidneys; subcutaneous deposits are minimal since these do have a distinct disadvantage in terms of optimum mobility and weight distribution.

4. Sweat and tear production

The proliferation of lipid secreting sebaceous glands in human skin is undeniably unique among terrestrial primates but common in aquatic species where it serves the useful purpose of waterproofing. Moreover, the presence of eccrine glands producing a hypotonic saline solution is important in thermoregulation in man, but in terrestrial animals they do not function in a similar fashion, since loss of vital salt and water would be potentially fatal. It is quite possible that at some stage in our evolution, ancestral man developed this capacity for excreting excessive salt through the skin as well as through the kidneys, particularly if he lived in a marine environment.

One other method of excretion of excessive salt, found in marine reptiles and in some marine mammals, is through the production of tears. Although nearly all land mammals possess lacrimal glands, man is the only weeping primate, a phenomenon which is difficult to explain purely on a quantitative basis.

Tears produced in response to emotional stimuli are quite different in their chemical composition to reflexive ones and Frey (1985) has suggested that the lacrimal glands in these situations possibly function to eliminate excess stress-related chemicals, thus bringing emotional relief. Morgan (1990) also postulates that the well known globus sensation associated with the emotional weeping response may well be a primitive protective cricopharyngeal contraction reflex preventing swallowing of undesired chemical excretions.

A theory of evolution

“They are 193 living species of monkeys and apes.

One hundred and ninety-two of them are covered with air.

The exception is a naked ape self named Homo sapiens”.

Desmond Morris (1928-)

The publication of “Origin of Species” by Charles Darwin in 1859 was followed in 1871 by his book “The Descent of Man” which expounded his theory of evolution of man and apes from a common ancestor. There is little dispute today about the validity of this theory, although there is much argument about the manner in which the remarkable differences between the higher apes and man were evolved.

“Considering the very close genetic relationship that has been established by comparison of biochemical properties of blood proteins, protein structure and DNA and immunological responses”, writes Elaine Morgan (1982), “the differences between a man and a chimpanzee are more astonishing than the resemblances. They include structural differences in the skeleton, the muscles, the skin and the brain, differences in posture associated with a unique method of locomotion, differences in social organization, and finally the acquisition of speech and tool-using, together with the dramatic increase in intellectual ability which has led scientists to name their own species, Homo sapiens sapiens – wise wise man”.

There is little doubt that the three main higher primate species: the gorilla, the chimpanzee and prehominid ape evolved from the common ancestral African ape. But what were the circumstances which dictated such a divergent evolutionary path for man during which he acquired unique adaptations such as bipedalism, loss of body hair, subcutaneous fat, an excess of sweat and sebaceous glands, changes in sexual and social habits, as well as modifications to the upper aerodigestive tract, which set him so much apart from the other apes?

A theatre of change

“When it is not necessary to change, it is necessary not to change”

Lucius Cary, Viscount Falkland (1610-43)

It is difficult many of these enigmatic human characteristics in terms of traditionally held beliefs of prehominid evolution. Some other vital factors or circumstances must have played a role in motivating these unique adaptations which are clearly more advantageous in setting man apart from his primate cousins on a path of evolution leading ultimately to the emergence of Homo sapiens.

The crucial period of time during which these remarkable divergent evolutionary changes were taking place in the higher primates was the late Miocene/early Pliocene epoch which commenced about 9 million years ago and lasted roughly 5 million years. Fossil remains of ape-like prehominid primates during the preceding Miocene period are abundant both in Africa and Asia, and one bearing early changes in jaw structure thought to be possible precedent to the hominid ape was Ramapithecus, discovered by G. E. Lewis in India in 1930 and later by Leakey in Africa.

During this time, large populations of ape-like creatures flourished in temperate forest expanses widely distributed throughout Asia, Africa, and Europe. A dramatic climatic change, however, was to alter the geological and ecological structure in many of these regions, and in one place in particular, in the Afar region of East Africa, these environmental changes may have been significant in altering the destiny of primate evolution.

The onset of what was known as the Pliocene drought resulted in decimation of the forest habitat of these apes and created a changing environment when adaptation was essential for survival. At the same time, continental shift of the East African plate caused inundation of a large low-lying area with formation of an extensive inland sea. This sea eventually died up after several million years leaving only deep deposits of salt as evidence of its former existence.

Fossil evidence has shown that the majority of ape-like species evolved with few changes during the Pliocene period, but remains discovered in the Olduvai gorge in East Africa from about three and a half million years ago indicated that a dramatic evolutionary step had occurred in one particular branch of the ape family. Australopithecus, as he was called (meaning southern ape), was different from all other apes in that he walked upright on two legs instead of four.

One of the most remarkable finds in this region was “Lucy” whose almost complete skeleton was discovered by Donald Johanson. “in 1973″, he writes “I found a humanlike knee joint that proved beyond doubt that our ancestors walked erect close to three and a half million years ago – long before they developed the big brains that had once been thought to be the hallmark of humanity” (Johanson and Shreeve, 1989).

Similar discoveries of hominid fossils in this area have proved beyond reasonable doubt that at some time between six or seven million years ago and three and one half million years ago, probably somewhere in North East Africa in the Afar region near the Red Sea, certain anthropoids stood up and began walking erect (Morgan, 1990). “Something must have happened”, she adds, “which meant that the near universal mammalian mode of locomotion (walking on four legs) rather suddenly ceased to be efficient for them. They switched to a mode that was not merely different, but unique among mammals”.

Other proof that divergence of evolution between man and apes from common ancestors took place about this time has come from molecular biological studies, and in particular DNA hybridization (Sarich and Wilson, 1967).

The Savannah Theory

The traditionally held Darwinian “Savannah” theory postulates that gradual evolution of ancestral man from the arboreal ape occurred because of climatic and behavioural changes. Loss of their forest habitat with corresponding extension of grassy plains or savannahs resulted in movement of prehominid apes from the tree habitat on to the plains.

Other ape species who remained in the forests ultimately developed into gorillas and chimpanzees with few morphological or physiological changes during this period. Parallel behaviour changes developed mainly as a result of dietary requirements. No longer able to depend on lush vegetation in the forest, the Savannah apes gradually evolved an omnivorous diet scavenging for small game to satisfy their needs, later evolving into hunters.

According to this theory, the one crucial development of bipedalism in the Savannah ape evolved because of the alleged advantage of standing upright on two legs and being able to see further over the plains and high grass in search of prey. Later, the advantage of having two hands free to carry weapons enabled his development as a hunter in pursuit of game (Morgan, 1982). One other complex and less tenable theory proposed by Lovejoy (1990) is that bipedalism actually evolved in these apes when still forest dwellers for various social and sexual reasons.

The Aquatic Theory

“Nothing of him that doth fade

But doth suffer a sea change

Into something rich and strange”

William Shakespeare (1564-1616)

In April, 1960, an article appeared in the New Scientist by Sir Alister Hardy suggesting an alternative theory of evolution which seemed to explain many of the dramatic changes that occurred during Man’s development from the arboreal ape.

He proposed that as a result of the changing environment at the onset of the Pliocene drought with reduction of the forest habitat and vegetation, certain anthropods were driven by competition from life in the trees to assume a new habitat on the shores of inland waters where they became adept at hunting for food, shell fish and sea urchins in the shallow coastal waters. The coincidental inundation of the Afar region in East Africa would have provided an ideal environment for these changes.

Initially wading on all fours, these aquatic apes gradually assumed a more upright posture enabling them to extend their territory into deeper water, also allowing them to escape more easily from predators, later developing the ability to swim and dive.

Because of the additional buoyancy, stability on two legs would have been much easier to acquire in the water environment than on the savannah, as exemplified by the only other primate to have ventured into the sea. The proboscis monkey lives in the mangrove swamps in the coastal waters of Borneo, and among other features, the male of the species is characterized by his enormous nose. Although retaining a mainly terrestrial quadruped gait similar to other apes living in the trees, he can adopt a bipedal mode when wading in the shallows in order to keep his head above water. In certain instances he has even been noted to use this mode of movement for walking on dry land.

The compelling argument proposed by Hardy that ancestral Man spent a period of aquatic adaptations is not unique in evolutionary history. On the contrary, this process is well recognized and several species of birds, reptiles and mammals are known to have abandoned their terrestrial existence to become adapted and modified to an aquatic life.

An early example is a member of the dinosaur family (ichthyosaur) which took to the water, evolving flippers instead of legs before becoming extinct. Among mammals, members of the cetacean family (the whales, dolphins and porpoises) successfully adapted to an aquatic existence, as did some of the hoofed mammals related to the elephant (the sea cows and manatee). Others include aquatic birds (penguins), aquatic carnivores (sea lion, seal, otter), aquatic rodents (beaver, water vole), aquatic reptiles (crocodile, sea snake) and aquatic insectivores (water shrew, desman).

There is, therefore, no reason to suppose that a similar transformation did not occur among the primate order. The aquatic theory postulates that one such species of ape did embark on this course and that adaptation to this new environment resulted in the emergence of a bipedal age, ancestral to Australopithecus and eventually Homo erectus.

It has been argued that such rapid evolution could not have been possible over a period of 3 to 4 million years, but evidence suggests that when the Afar was invaded by marine waters about 6.7 million years ago (Barberi et al., 1972a,b) in the late Miocene period, certain mountainous regions may have become isolated from the mainland. One such area known as Danakil Island may have been the site where a group of apes along with other animals was trapped, on a biological island where evolutionary adaptations are known to occur much more rapidly (Morgan, 1982). Increasing desiccation and loss of the forest habitat on the island may have provided an ideal environment where certain families of apes living near the coastal waters were forced to adapt to a more aquatic existence in search of food by wading into the shallow waters. Under these unusual conditions rapid evolution of the hairless, bipedal Australopithecus apes described by Hardy and Morgan may have taken place.

Episodic volcanic activity in the Afar triangle is known to have taken place since the early Miocene Period (Gass, 1974) and bridging of the Danakil Strait would certainly have allowed migration of apes and other animals from the island back to the mainland. Among them would have been hominid Australopithecus who ventured south along the Afar Gulf towards the Hadar settlement where fossils were eventually found (Johanson and White, 1979).

Other Australopithecus may have remained on the island to continue their evolution, crossing to the mainland about 1.75 mybp, to the Koobi Fora and Olduvai Gorge where the remains of Homo habilis were found (Leakey, 1979; Morgan, 1982). According to Morgan (1982), further development continued on Danakil Island with emergence of Homo erectus (about 1 mybp), until the final desiccation of the Danakil Depression about 30.000 years ago (Bonatti et al., 1971; Tazieff, 1972).

The aquatic theory postulates that when these upright, hairless Australopithecus re-emerged back on to the savannah, they brought with them various adaptations acquired during this aquatic period which were retained and which provided distinct advantages over other ape species. Their stable bipedal gait permitted more freedom of the forelimbs once they were back on land to enable them to hold and carry objects and weapons which was distinctly favourable in their emergence as dominant hunters in this new terrestrial environment.

What is the evidence?

Whatever is the truth about evolutionary development of early man from the arboreal ape, suppositions must be based on established scientific facts, although the final explanation of the sequence of events may not be readily apparent. The aquatic theory does seem to provide a more logical and consistent answer to many of the enigmatic inconsistencies between higher primates and man, and is frequently supported by parallel development in other species.

Fossils provide the only “hard evidence” of evolutionary changes and have proved beyond doubt that bipedalism was the first crucial adaptation in early hominid evolution (Johanson and Edey, 1981). Recent detailed studies of early skulls and post-cranial remains of Homo erectus by Rightmire (1990) have also provided useful information about comparative changes in bone structure. Although much of the evidence for Elaine Morgan’s aquatic theory relates to soft tissue adaptations such as changes in skin structure, where specific dating is hard to establish, it is based on sound scientific deductions (Charlton, 1991).

Preservation of skeletal remains in a marine environment is extremely unpredictable because of continuous wave erosion, and if the aquatic theory is to be believed, it is not surprising that no early hominid fossils dating from this period have been found. However, those remains of primitive Australopithecus which have been identified, have all been in the vicinity of costal areas or inland waters in the region of the Afar peninsula and Olduvai Gorge, a fact which protagonists of the savannah theory claim is coincidental.

There may nevertheless be some tangile evidence of the aquatic theory, which so far has been overlooked by anthropologists and scientists, which might provide important evidence that early man did venture into the sea in search of prey, and that unlike his ape predecessors, he did spend a large proportion of his time swimming in the water. This evidence is crucial to the argument supporting the aquatic theory and may be relatively easy to prove or disprove, given fossil remains of early anthropoid man. It relates to the presence of ear canal exostoses.

External auditory canal exostoses

Bony swellings of the external ear canal occur with varying frequency and are of two distinct types. Osteomata usually arise in the outer part of the canal and have a pedunculated or lobular appearance. They are composed of dense ivory bone are considered true pathological benign tumours of bone. There may be a hereditary factor in their aetiology, since Roche (1964) has found an incidence of 27.9 per cent in Australian aborigines. Hrdlicka (1935) has also described a particularly high incidence in Peruvian and American Indian populations.

True exostoses of the ear canal arise in the deep part of the meatus, close to, but not evolving the annulus of the tympanic membrane. There is usually one situated on the lower anterior wall and one in a similar position posteriorly, and sometimes a third arising from the roof. Progressive growth may gradually reduce the size of the deep meatus to a pinhole, causing deafness and often secondary otitis externa. Smaller exostoses of similar aetiology may also be found arising near the annulus. The relevance of this condition is in its pathogenesis, for it occurs exclusively as a direct result of exposure to relatively cold water in swimmers.

An experimental study in Guinea pigs reported by Fowler and Osmun (1942) demonstrated fibrous proliferation of the subcutaneous tissue in the deep meatus with new bone formation. Repeated exposure to cold water in the canal stimulates the periosteum to produce a layered formation of periosteal bone, suggesting a periodic growth pattern. With further growth, it undergoes remodelling to produce lamellar bone.

No adequate explanation has been given for this condition, but I believe that this process may represent an adaptive response to an aquatic environment. Land based animals which depend on air mediated sound transmission at the tympanic membrane usually have a widely patent external ear canal for maximum reception of auditory stimuli. Marine mammals, on the other hand, have adapted to sound transmission in an aquatic medium and have narrow or vestigial canals. A wide meatus is no longer needed and may also be a dangerous liability predisposing to rupture of the tympanic membrane because of rapid increase in external pressure when diving.

The relationship between swimming and exostoses is a phenomenon well known to otolaryngologists, but the relevance of their pathogenesis has been largely overlooked by physical anthropologists and archeologists who have considered both types of ear swellings as one of a range of discrete cranial traits helpful in determining ethnic affinities and population movements (Mann, 1986). Korner (1904) was the first to note the difference in incidence of exostoses between coastal and inland populations in Germany, and suggested salt water as a cause.

In 1935, Belgraver found an overall incidence in his clinic patients of 2.02 per cent but in members of swimming clubs the incidence was as high as 42.8 per cent and virtually all structures were found to possess exostoses. Other studies by van Gilse (1938), Harrison (1962) and Mann (1986) have produced similar results, the last study by Mann showing an incidence of 64 per cent in people swimming at least three times a week. In all of these papers, the most important and consistent finding was that no person was found with exostoses who was not a frequent swimmer.

Other factors such as age, sex, racial variations and water temperature are also important in determining the incidence of exostoses. In warmer climates they are found less frequently, comparative population studies are few, but one by Kellock and Parsons (1970) in Polynesian and Melanesians, where the average temperature of the sea differed by 4 C, showed an incidence of 5.3 per cent and 1.3 per cent respectively.

Hrdlicka (1935) observed that exostoses were far more common in males, and this has been confirmed in other series, presumably reflecting a greater affinity for swimming in this sex, certainly in the earlier studies this century. The incidence also increases with age due to longer duration of exposure to water. Racial variations suggest a genetic component, but this most probably is explained by environmental, temperature or cultural differences, which determine swimming habits in different communities.

The presence of exostoses in skulls of four different archeological population groups ranging from 300 – 5000 BC has also been studied by Mann (1986), who found a variable incidence of 0 – 7.5 per cent (Table 1). There appeared to be an increasing incidence over the centuries and the groups from Gizeh (300 – 600 BC) and Qau (1500 BC) seemed to have a similar incidence to series from this century, indicating similar swimming habits. Other authors, including Adis-Castro and Neumann (1948) and Gregg and McGrew (1970), have also described cases in archeological populations; but have not associated these with swimming habits. Ortner and Putschar (1981) describe “numerous examples of ear exostoses in the collections of the National Museum of Natural History, USA”, but the two examples illustrated in their publication are clearly osteomata, arising in the outer part of the canal, rather than true exostoses.

Studies of prehistoric skulls are clearly more difficult to interpret because of increased fragmentation and erosion, but Rightmire’s recent publication (1990) on the evolution of Homo erectus includes comparative examinations of fossil skulls from the early Pleistocene period (1-2 mybp). He describes several variations or abnormalities of the temporal bone and external auditory canal, including one from Lake Ndutu in the Olduvai Gorge, where “the plate surrounding the auditory porus is clearly thickened”. Whether or not this thickening does represent the formation of exostoses clearly requires further detailed examination to determine its true pathological significance.

It is obviously important do differentiate between the social aspects of swimming and the necessity for swimming and diving for hunting purposes. The presence of exostoses in modern and more recent archeological populations reflects the former social aspect, but if their occurrence is verified in primitive hominids such as Homo erectus or Australopithecus, this surely must provide substantial evidence that early man spent considerable periods of time in the water, for hunting rather than social reason.

It is well known that apes and other higher primates, with the exception of the Proboscis monkey, have an abhorrence for water, and not surprisingly, exostoses have not been described in these species. If we do accept the aquatic theory for hominid evolution, vital supporting evidence may possibly be found by careful search for the presence of exostoses in primitive hominid skulls. Although no fossils from the crucial late Miocene/early Pliocene epoch have yet been identified, the finding of hominid skulls with exostoses from this period would certainly justify the existence and belief in the reality of “The aquatic ape”. Could this also provide an explanation and proof of “The missing link”?

P. H. Rhys Evans, F.R.C.S.,

The Head and Neck Unit,

The Royal Marsden Hospital,

Fulham Road, London SW3 6JJ.

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New Guidelines for HIV Treatment

NEW YORK (Reuters Health) – HIV therapy needs to start earlier and guidelines are being changed to reflect that, officials said this weekend at the International AIDS Conference in Vienna. The 2008 guidelines from the International AIDS Society-USA advised that antiretroviral therapy (ART) begin before the CD4 cell count dropped below 350 cells/uL. Now, said Dr. Melanie A. Thompson, from the AIDS Research Consortium of Atlanta and chair of the IAS-USA Panel, the group has moved the treatment threshold up to 500 cells/uL. The new guidelines appear in the July 21st issue of the Journal of the American Medical Association, released early to coincide with the conference. “This change is based upon several findings,” Dr. Thompson told Reuters Health in e-mail. First, she said, “Uncontrolled HIV viremia is associated with immune activation and inflammation.” Second, “Immune activation and chronic inflammation are associated with morbidity and mortality from serious ‘non-AIDS’ diseases even at high CD4 cell counts.” Third, new data have shown that morbidity and mortality are much lower when ART starts before the CD4 cell count falls below 500/uL. And finally, patients now have more options “for highly potent and durable viral suppression with improved tolerability and toxicity,” and in most cases it’s possible to suppress multidrug resistant virus. Regardless of the CD4 cell count, certain conditions are absolute indications for ART, the panel says: –Symptomatic patients with established disease –Rapid decline in CD4 count (> 100/uL per year) –Plasma HIV-1 RNA > 100,000 copies/mL –Age over 60 years –Pregnancy –Chronic hepatitis B or C infection –HIV-associated kidney disease –High cardiovascular risk –Opportunistic infections –Symptomatic primary HIV infection –High risk of HIV transmission, such as HIV-serodiscordant couples Still, the authors of the guidelines urge physicians to make sure the patient is ready and willing to adhere to lifelong therapy before starting. “Patients must be willing to embrace therapy as a lifelong endeavor,” Dr. Thompson said. “It is important to learn about the patient, including his/her knowledge and beliefs about HIV and ART, and what support is available. Education is necessary regarding the benefits of therapy, as well as the importance of adherence, and potential side drug effects and their management.” “Beginning ART should be seen as a process, not a single visit,” she added. The authors also emphasize the need for individualized regimens. Factors to consider include resistance testing results, drug-drug interactions, toxicity and tolerability, and comorbidities, along with pill burden, dosing frequency and cost. The guidelines panel recommends that the initial regimen include two nucleoside or nucleotide analogue reverse transcriptase inhibitors (nRTIs) plus “a potent third agent from another class.” Their first choice for nRTIs is tenofovir/emtricitabine; an alternative is abacavir/lamivudine, so long as the patient is screened for HLA-B*5701 to reduce the risk of abacavir hypersensitivity. Recommended third agents are efavirenz (a nonnucleoside reverse transcriptase inhibitor), atazanavir or darunavir (protease inhibitors) boosted with ritonavir, and raltegravir (an integrase strand transfer inhibitor). Alternatives are lopinavir or fosamprenavir (boosted with ritonavir) or the CCR5 antagonist maraviroc. The panelists suggest specific regimens for patients with high atherosclerotic cardiovascular risk, chronic kidney disease, chronic hepatitis B or C infection, pregnancy, or opportunistic infections. (JAMA has made these regimens – and the entire text of the updated recommendations – available in their entirety, at no charge. The link appears below.) Plasma HIV-1 RNA should be measured 2-8 weeks after starting ART, then every 4-8 weeks until no longer detectable (which should occur within 24 weeks). Patients can then be monitored every 3 to 4 months for 1 year, then every 6 months as long as viral load is suppressed and CD4 counts remain above 350/uL. The panel also advises genotypic testing for resistance at baseline and in cases of virologic failure. In the event of virologic failure, the replacement regimen should include at least two fully active drugs, and ideally three. For nonnucleoside reverse transcriptase inhibitor failure, replacements should include a ritonavir-boosted protease inhibitor or an agent from a new class. “Advances in ART have shown that AIDS, as traditionally defined, can be prevented,” the writing group comments. However, Dr. Thompson said, “We face an enormous challenge to implement these new guidelines and we must address significant social and structural barriers to testing and care in order to fully realize their benefit. Stigma and discrimination continue to be obstacles to testing, linkage to care, and treatment. These guidelines challenge us to muster the creativity and political will needed to provide adequate funding and infrastructure to bring these high standards of care to every person with HIV infection.”

The River

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Tracing the source of AIDS through detective work

‘The River’

By Edward Hooper

(CNN) – Based on over a decade of research, involving more than 600 interviews and analysis of more than 4,000 scientific texts, “The River” examines the myriad theories about the origin of the AIDS epidemic – and reaches a stunning and startling conclusion.

Chapter One

Frozen in Time: 1959

Let us take a moment in time. Let us freeze it. Let us watch as the crystals form, as it becomes translucent. Let us mount it on a slide and lift it to the microscope stand. Using strong light and mirrors, adjusting the focus, let us see what can be seen.

Truth, like beauty, resides in the eye in the beholder. Whatever the material on that glass slide – be it a moment in history or a cluster of cells – it is inevitable that what you see and what I see will be different. I may see colors, a myriad of dots, a divine impressionistic sweep of light and shade. You, the historian, may see a pattern, a grand design, the beginning of a chain of cause and effect. Now let us change the eyepiece, increase the magnification. This time I may see a meaningless smudge with specks of darkness within, while you, the biologist, may see a nucleus and mitochondria, the beauty of simplicity, the pulsating potential of a cell ready to divide. How will we describe our truths, you and I, for the blind man, for the child without a microscope? And whose description will be more accurate?

While I pack away the lenses, and you put the glass rectangle into its slot in the velvet-upholstered case, remember this. Empirically, the image that you see and that which I see are the same. What differs is our relative clarity of vision, level of understanding, power of analysis – and the language we choose to describe what lies beneath the lens.

It is the February of 1959. It is a particular moment in the history of the world. The old order is breaking up; the barriers of time and space are tumbling. The first jet planes are taking off, heading for destinations – Hong Kong, Nairobi, Sydney – that once were days away, but are now just hours. There is a new type of global language too, as people talk of atom bombs, the cold war, of international power blocs, and the arms race.

It is also a particular time in the history of Africa. The wind of change is blowing hard: in the last two years Ghana and Guinea have attained independence, and across the continent the clamor is rising. The old colonial powers – the British, the French, the Belgians – are, each in their own time, recognizing the inevitability of the process, acknowledging that these are the final days of the Raj; only the Portuguese are still defiantly opposed. Here, in the Belgian Congo, amidst the wide, gracious, tree-lined avenues of the capital, Leopoldville, the first round of riots has just ended, with more than fifteen hundred Africans arrested. The Belgians are bewildered. People returning to Brussels tell the man from the London Times that “something untoward is brewing at Stanleyville,” the town a thousand miles upstream at the great bend in the river.

Meanwhile two doctors, one American and one Belgian, are traveling around the capital immersed in their own world, which is one of scientific inquiry. The American, funded by grants from the U.S. Public Health Service and the Rockefeller Foundation, arrived in Leopoldville just after the end of the unrest, and neither saw evidence of its impact nor, one suspects, would have had much appreciation of its significance had he done so. The Belgian, for his part, has just been appointed chair of microbiology at the newly built university of Lovanium, eight miles from the city center on the banks of the Congo River – but for all that, he is happy for the chance to collaborate with such a rising star in the firmament of human genetics. These are impassioned men operating in an era that reveres their activities, in an era when science is the new religion, and the men in white coats its prophets and priests.

Over the next few weeks the American, Arno Motulsky, and the Belgian, Jean Vandepitte, with the help of other local doctors, start collecting blood samples from medical staff, hospital patients, and police recruits in Leopoldville, and from a large group of villagers living to the south, near the Angolan border. Motulsky is keen to investigate the relative incidence of two genetic traits in different ethnic groups in sub-Saharan Africa, and their possible relationship to malaria. Later, he visits several other regions of the Belgian Congo and the neighboring territory of Ruanda-Urundi, administered by the Belgians as a trusteeship since Germany was dispossessed of its African colonies after the First World War. At the end of three months, he and his Belgian colleagues have collected nearly eighteen hundred blood samples from eight different population groups, including pygmies from the Ituri Forest, hospital patients from Stanleyville, and schoolchildren from the two principal ethnic groups in Ruanda-Urundi, the Tutsi and the Hutu. Most of these samples are finger-prick specimens mounted on glass slides and examined in local laboratories the same day, but more than seven hundred are samples of whole blood, which are then refrigerated and flown back to Motulsky’s department at the University of Washington in Seattle.

As Jean Vandepitte bids farewell to Arno Motulsky at the airport, neither man has any inkling of the additional significance which one of these 5-milliliter blood samples will assume just over a quarter of a century later.

Independence arrives, and the countries where Motulsky obtained his specimens subsequently become known as the Republic of the Congo, Rwanda, and Burundi. Over the next few years, all three experience tragic events, as ethnic tensions and the meddling of foreign powers combine to promote upheavals, violence, and bloodshed. Meanwhile, back at the University of Washington, various tests are conducted on the blood samples, and a series of papers published in journals of genetics.

Several years later, Moses Schanfield, a professor from Emory University, contacts Motulsky to ask if he can undertake further genetic studies on the Congo cohort, and the remaining 672 frozen plasmas are flown to Atlanta.

Finally, in 1985, they change hands once more, and are given to another Emory professor, Andre Nahmias, who has an entirely different interest. He wants to test them for the presence of antibodies to a virus that has suddenly entered the medical limelight – the virus that causes AIDS. He examines not only the Motulsky samples, but a further 500 plasmas originating from South Africa, Mozambique, and Congo-Brazzaville, and collected at various times between 1959 and 1982.

Over the next few months, the specimens are examined exhaustively, first at Emory and then at Harvard; the results are then confirmed at two other laboratories, by a total of four different testing procedures. Of all the plasma samples, just one comes out strongly positive on all the tests. Its code number is L70, and it comes from a group of ninety-nine specimens taken in 1959, somewhere in or around Leopoldville.

In the mid-eighties, scientists are just awakening to the possibility that HIV (as it will soon become known) may have been present in sub-Saharan Africa for some years before the recognized start of the AIDS epidemic in North America and Europe in 1981, and the Nahmias investigation provides the first really dramatic evidence in support of this hypothesis. No further details appear to be available, however, about the source of the L70 sample. In the 1986 letter to The Lancet in which he reports the results of his investigations, Nahmias comments simply: “The identity of the donor is no longer known.”

Nearly four decades have passed since his trip to Africa, but Arno Motulsky, now professor emeritus, still lives in Seattle and is still a man of spiky brilliance. And his papers do reveal a little more about the identity of the L70 donor. They record that the blood was taken from a Bantu male, one of seventy-eight men in the group of ninety-nine designated as “Leo.”

Unfortunately, of all the twelve groups tested by Motulsky, there is less documentation about the “Leo” series than any of the others. Motulsky says that most of them were normal members of the population, and that around 20 percent were hospital patients. The identity of the hospital is not recorded, although Jean Vandepitte, now professor emeritus at the University of Leuven and the Institute of Tropical Medicine in Antwerp, believes that it was probably that at Lovanium, the great campus the Belgians constructed on the outskirts of Leopoldville, and which many consider to have been their parting gift to the country they ruled for seventy-five years.

Whatever, it appears that this tiny amount of blood, taken in 1959 from an unknown man living in the city now known as Kinshasa, the bustling capital of the Congo, represents the oldest specimen of the human immunodeficiency virus in existence. We shall return to it later in the story.

As with the early course of a river, where water may seep unnoticed through sphagnum bogs, or plunge underground through limestone, so with the early course of a new disease. It is, of course, entirely possible that the first traces of an unusual and hitherto unseen condition (especially a disease syndrome with a diverse range of presentations and a long latency period, like AIDS) will pass by unremarked. There again, perhaps because of serendipity, or an especially conscientious team of doctors, it can also happen that the crucial clues are noticed and recorded for posterity.

On January 31, 1959, just as Arno Motulsky was leaving for Africa, a twenty-five-year-old man from Reddish, a working-class suburb adjoining Manchester, was getting engaged. At the same time (though he could not have known it) he was becoming involved in a chain of events that would end up with his becoming public property, part of global folklore. For this man, David Carr, was about to become inextricably entwined with the early history of the AIDS epidemic.

By that year, Reddish was a place in decline. Cotton manufacturing was moving overseas to new nations where wages were lower, and the town’s huge mill finally closed its doors at the end of 1958. Many were reemployed at the breweries and railway repair yards, but the soul of Reddish seemed to have departed, together with much of its disposable income. There was only a light scattering of TV aerials on the long terraced roofs around the mill. For the fortunate few in the black-and-white flicker below, Harold Macmillan was meeting with General Eisenhower, issuing joint communiques from Chequers, reminding Britons that – with a nuclear deterrent of their own – they were one of “The Big Three,” telling them they had never had it so good. Not all believed him.

The country that had, until recently, viewed itself as lying at the fulcrum of global activity was now in reality a leviathan, grown loose-eyed and sleepy, still touched by memories of wartime sacrifice and ration books. Its grandiose dreams were fading, as one by one the countries of Africa and Asia were granted freedom; the sun was setting on an empire over which, it was once boasted, the sun never set.

Dave Carr was a former seaman, a local Reddish lad with crinkly eyes and wavy brown hair. “Elsie,” his fianc‚, was from northern Manchester; she had a strikingly trim figure and bright red hair, worn in a perm. They worked within yards of each other in the city center – he as a printer on the Manchester Evening Chronicle; she as a mantle machinist, making ladies’ gowns and raincoats. Each had a good sense of humor, but whereas Dave was easygoing, Elsie was strong-willed and known for speaking her mind. Their friends thought them a perfect match. To save money, they had bought the engagement ring from a pawnbrokers’ shop – a pledge made but broken, never redeemed.

Whether or not Dave and Elsie were planning an early wedding is a moot point, for since the end of the previous year, Dave’s health had suddenly collapsed. Throughout 1958 he had suffered from small but persistent ailments – chronic gingivitis, and a funny measles-like rash on his back and shoulders, for which he attended a local skin clinic on a monthly basis, receiving steroid creams and two courses of radiotherapy. In November, he had to have part of his lower gum removed in a gingivectomy, but for some reason, the wounds never healed properly. Then, toward Christmas, he developed a nagging cough and began having serious problems with his breathing. He had only to walk a few hundred yards or climb a flight of steps to end up gasping, panting, propped up against wall or lamppost. He was losing weight as well – a lot of it.

In the weeks that followed the engagement, Dave Carr got substantially worse. In February the hemorrhoids and pruritis ani from which he had suffered intermittently for years suddenly became more inflamed, and he developed a painful sore around the anus. The weight loss, night sweats, and fevers also became more pronounced, and now his chronic cough began bringing up mucus which was flecked with blood. He began to take more and more time off work at the Chronicle, and after work, over a pint, his mates would talk in undertones about leukemia, or about his picking up some strange bug while swimming in the local canal or during his National Service in the navy.

In March, Dave began seeing a private consultant, Dr. Charles Don. On the morning of his second appointment, in early April, a telegram was delivered, requesting a postponement, but Dave’s parents told him to turn up anyway. It was as well that he did. Dr. Don took one look at his patient’s anal fissure, now three inches long, and arranged for him to be admitted to the Manchester Royal Infirmary. Ward M4 (male) at the MRI was to become Dave’s home for the next five months.

The physicians in charge of the ward, notably the senior registrar, John Leonard, and the senior house officer, Trevor Stretton, were baffled by David Carr’s various maladies – the weight loss, persistent cough, breathing difficulties, the sore on his bottom, and the small “blind boil” that had appeared at the tip of his left nostril. All they knew was that here was a man just a few years younger than themselves, who until recently had appeared quite healthy, and who was now wasting away before their eyes, strafed by a series of apparently untreatable infections.

Their first response was to suspect miliary TB, an unusual form of tuberculosis, but when Dave failed to respond to the appropriate drugs, they wondered about sarcoidosis, and the collagen diseases (nowadays known as autoimmune disorders). They had already checked all the known cancers and lymphomas, but now they began to wonder about the possibility of an unknown malignancy.

Of course, they asked him questions about his past, about his time in the navy – and noted that he did not recall having any tropical diseases.

They tested for syphilis and found him negative, but they did not question him about his sexuality, for such matters were less frequently and openly discussed in 1959 and, in any case, did not seem relevant to the case.

They tried further radiotherapy, together with chemotherapy, steroids, and an even wider range of drugs. Once or twice he picked up briefly, for a week or two, but the remission never lasted.

By June, Dave’s fevers were becoming more frequent, and his breathing steadily worse. The spot in his nostril became an ulcer, which started eating away at his nasal cartilage and upper lip; shaving became impossible, so he grew a mustache, but it did little to hide the spreading open wound from view. The anal lesion also grew, until it became an excavated sore the size of a small football, covering most of his buttocks. A cradle was placed over him to keep the weight of the blankets from his body. But most dramatic of all was the emaciation. One year before, David Carr had been a strapping lad of 185 pounds, broad-shouldered and somewhat overweight for his five foot seven inch frame. Now, however, his face was drawn and his bones clearly visible through the skin. Elsie and his parents called at the hospital every day, but Dave began to discourage visits from friends.

Just a few days before Dave and Elsie’s engagement, an unusual death occurred in Canada, at Toronto General Hospital. The deceased was a thirty-six-year-old Japanese-Canadian man, who had been admitted six weeks earlier with severe breathing difficulties. Eventually he suffocated to death. At autopsy, Dr. John Barrie, a British ‚migr‚ pathologist, found a honeycomb of cyst-like cavities throughout the man’s lungs, which he ascribed to Pneumocystis carinii, a rare pathogen that takes advantage of a state of lowered resistance in the human host.

However, in the case of this patient, George Y., there were no clear indications as to what might have caused his resistance to be diminished, and for this reason Dr. Barrie wrote a paper about the case, which was published the following year. “We are not aware of any reports of deaths in adults which have been caused primarily by infection with Pneumocystis,” wrote Barrie, in the introduction. He reported that the patient had been well until March 1958, when he had experienced a five-day fever with chills, headache, and nonproductive cough, an episode that was repeated several times in the following months. In late October, he began to experience sharp pains in his chest, drenching night sweats, and pronounced weight loss. By December 1958, when he was admitted to hospital, he was losing weight dramatically, had chest pains, and would become breathless after the slightest exertion. The physicians administered a range of drugs in a bid to save his life – culminating in 100 milligrams (a very heavy dose) of a steroid, prednisone, every day for the final fortnight. At the autopsy, the only contributory factor noted was a mild cirrhosis of the liver, presumably from drinking.

In 1991, I located Dr. Barrie, by then in his late eighties, and he managed to procure a copy of his original autopsy report. This revealed that George had worked as a sawmill operator during the forties and then, for ten years from 1948, as a carpenter in Edmonton, Alberta. In 1958, however, he abandoned his steady job and migrated north to work in the Northwest Territories. It was when he arrived there in March that he suffered his first illness, followed by another in May, when “he developed … a virus infection common in the camp in which he was working at that time.” Something, it seems, had caused George Y. to become immunocompromised at some point during the final year or so of his life, leading to his demise from PCP in January 1959.

A few months later, in June of that year, Pneumocystis carinii pneumonia was responsible for another most unusual adult death at the Kings County Hospital in Brooklyn, New York. The patient, Ardouin A., had been born in Jamaica of Jamaican parents, but the family had moved to Haiti when he was seven, and he emigrated from there to the United States ten years later, marrying a Haitian ‚migr‚ soon afterward. Ardouin was an attractive man, with slicked-back hair, a thin mustache, and sharp dress sense – and he apparently had several girlfriends on the side. He also had several jobs, but after the Second World War began working as a shipping clerk for a dress manufacturer on Seventh Avenue in Manhattan – a post he was to keep for the rest of his life.

Ardouin had never been seriously ill in his forty-nine years, but in March 1959 his smoker’s cough became more severe and productive of large amounts of sputum, and he began losing weight. By June, his chest pains and wheezing had gotten so serious that he was admitted to hospital, where he was quickly placed on a respirator and treated with steroids. His doctors asked many questions and wanted to know whether he had ever been to Nevada, which suggests they thought he might have been present at an atom bomb test; he had not. They also tested his blood, bone marrow, and urine (including a check for beryllium content, since he had apparently broken a fluorescent lamp some while earlier), but found nothing untoward. Ardouin, meanwhile, became weaker, and told his family that he wanted to be buried in his blue suit. His prognosis was correct, for on June 28 he had to have a hole cut in his windpipe to assist his breathing, and he died later the same day.

His widow was terrified, fearing that voodoo was involved – while the pathologist, Gordon Hennigar, was mystified as to why he could find no underlying disease that might explain why the Pneumocystis infection had taken hold and proved so remorseless. The case was sufficiently unusual to be written up in two medical journals, and although one of the papers pointed out that the white blood cell count had sometimes been high (which might suggest a leukemoid reaction), its conclusion was that Ardouin represented “the first reported instance of unassociated [Pneumocystis carinii] disease in an adult.” Dr. Hennigar, meanwhile, decided to pickle Ardouin’s lungs for posterity.

While Gordon Hennigar filled his bell jar with formalin, back in the Manchester Royal Infirmary, David Carr’s symptoms were progressing inexorably. By July, the latest theory of his doctors was that he was suffering from Wegener’s granulomatosis, a fatal disorder of the connective tissue that often involves the respiratory tract. Altogether, just fifty-six cases of Wegener’s had been recorded in the medical literature.

Dave kept cheerful to the end, but by August he and Elsie and his parents all knew that he was dying. At this stage, pustular ulcers were appearing on his stomach, inner thighs, and fingers, over both his lips, and inside his mouth. He developed spiking fevers and found it more and more difficult to breathe. He had what appeared to be an untreatable pneumonia, and sometimes he became cyanotic, with his extremities turning blue from lack of oxygen and his fingers swelling at the tips. In the final week of his life, he was put in a separate room and treated with Euphoricus, a sedative cocktail of morphine, cocaine, and gin. At three o’clock on the afternoon of August 31, as he was being lifted on to the commode, he died.

It was only when the tissues taken at autopsy were examined microscopically by pathologist George Williams that two unexpected conditions were identified. One was disseminated “cytomegalic inclusion disease,” a condition caused by a virus that, the following year, would be renamed cytomegalovirus, or CMV. The other was Pneumocystis carinii pneumonia, PCP.

Thus, in the first eight months of 1959, three apparently healthy men from different parts of the world died primarily as a result of PCP, a disease previously unrecognized in healthy adults. During the next twenty-five years, the doctors who had been involved with these three patients, either alive or dead, continued to be intrigued by their illnesses, and by the continuing mystery of underlying cause. At times they would review their papers, and wonder about this possibility or that – exposure to some toxic agent, an undiagnosed cancer or leukemia, a congenital immunodeficiency that they had failed to spot. But none of these tentative explanations was entirely convincing. It was only in the eighties, after the recognition of the AIDS epidemic, that a solution to the mystery seemed to have emerged – for between 1983 and 1987, several researchers proposed that these three deaths might represent pre-epidemic cases of AIDS.

Were they right? Was David Carr in Reddish an antecedent of the coming epidemic? Were George in Toronto and Ardouin in New York? Were these men the harbingers of a new disease beginning its global spread, the earliest, unfortunate infectees with some new pathogen that was already – in 1959 – becoming widely dispersed, albeit extremely thinly? This is one of the hypotheses that we will be investigating in some detail in the course of this book. As the condition of David in Manchester deteriorated ever faster, and as Ardouin in Brooklyn entered the final week of his life, a very different event was taking place in Washington, D.C. Whereas the savage disease processes affecting these two men were graphic reminders of how, even in the best-equipped medical systems in the world, nature could still get the better of doctors, this latter event was essentially a celebration of the triumph of modern medicine over disease.

Poliomyelitis, until then the most dreaded of illnesses, the one that caused authorities to close down schools and swimming pools, and that persuaded people across America to donate their small change to the March of Dimes, was about to be vanquished, and the world’s pre-eminent virologists and physicians had gathered in the national capital to witness the coup de grace.

The event was called the First International Conference on Live Poliovirus Vaccines, and among the seventy attendees from the ranks of the great and the good were two doctors – Albert Sabin and Hilary Koprowski – who had probably done more than any others to bring about this hugely popular scientific achievement, this metaphorical lunar landing of the fifties.

Both of them had developed their own sets of oral polio vaccines (OPVs), and all the indications were that the United States was about to adopt either Sabin’s or Koprowski’s strains. In fact the stakes were even higher, for it was apparent that whichever vaccine set was approved in America would – in all probability – be adopted by the rest of the world also.

The principle of vaccination is that a tiny amount of a virus (either a weakened live virus, or else a virus that has been killed by chemicals like formalin) is introduced to the vaccinee, whose immune system responds by producing the appropriate antibodies. The subject will then be protected against exposure to the “wild” form of the virus found in nature, which might otherwise cause serious disease. In the case of poliomyelitis, the first vaccine to be adopted for general use in America – in 1955 – was the killed vaccine developed by Jonas Salk. Referred to by scientists as an inactivated polio vaccine, or IPV, this preparation had already, by 1959, been given to millions of children around the world. It was, however, gradually falling out of favor by the end of the decade and not just because sugar lumps are more popular with kids than shots in the arm. More crucially, there were demonstrable problems with its safety and effectiveness. In one infamous episode, the “Cutter incident,” hundreds of vaccinees and their close contacts contracted polio because a batch of vaccine had been improperly inactivated.

Furthermore, by the end of the decade, an increasing number of vaccinees were becoming paralyzed even after receiving the full course of three shots, showing that not all batches of the vaccine were protective.

By 1959, many virologists were persuaded that the more easily administered oral vaccines of Sabin and Koprowski were also capable of giving longer-lasting protection. On the question of safety, opinions were more divided. The live poliovirus in OPVs has first been weakened, or attenuated, by a series of passages through animals (such as rodents and monkeys) or through tissue cultures (layers of cells – typically from chicken embryos or the kidneys of monkeys – that are kept alive under laboratory conditions). However, the theoretical side of attenuation (relating to what causes the poliovirus to become innocuous for humans, and what keeps it that way) was still shrouded in mystery. For this reason there was considerable interest when, in a discussion session on the fourth day of the conference, Professor Albert Sabin made a dramatic accusation.

He repeated a claim that he had first made three months earlier, in an article in the British Medical Journal, that at least one batch of his rival Koprowski’s CHAT vaccine, which had been fed to hundreds of thousands of vaccinees in the Belgian Congo, had been contaminated with an unidentified simian virus, one that had nothing to do with polio – but which, like polio, was cytopathic (it killed cells when introduced into monkey kidney tissue culture). The unspoken inference was clear – that such a virus might also do damage when introduced into human beings.

A renowned Swedish virologist, Dr. Sven Gard, who had been on several months’ sabbatical at Koprowski’s research center, the Wistar Institute, spoke up in his defense. Gard said that he had tested the same lot of vaccine for the presence of extraneous virus, both in Sweden and the United States, and had found nothing.

And there, apparently, the matter rested. Certainly there is no further reference to the affair in the published record of the conference. But by voicing his concern, Albert Sabin had invoked a specter that was hovering over the proceedings the fear that OPVs, even while they were bringing the most feared viral disease of the era under control, might also be introducing new and perhaps more sinister viral agents into mankind, ones that proliferated during the process of vaccine manufacture.

This was a fear that was to become very much more substantial over the years that followed, as virologists began to learn a lot more about tissue cultures, especially monkey kidney tissue cultures, and the many ways in which they could become contaminated. Naturally, new procedures were introduced to ensure the safety of vaccines. But many of these men, when they looked back years later with the benefit of hindsight, would shiver at the risks which they had inadvertently taken in those days of blissful ignorance, those days of hope and courage, in the fifties.

Put the slide back in the case. Pick another. Here, try this one, from the nineties. Let us see whether it provides a different perspective – one that benefits from the accumulation of scientific wisdom. Perhaps try another lens, too. Some, of course, may have the corrective properties of hindsight.

It is March of 1993. The intervening years have seen further great victories for vaccination programs and the public health system, with the conquest of smallpox, and the suppression of malaria, measles, and cholera. But they have also witnessed significant reverses, such as the emergence of AIDS and the re-emergence of tuberculosis. And now, almost thirty-four years after that first international conference on live poliovirus vaccines, Albert Bruce Sabin has died peacefully at his home in Washington, D.C., at the age of eighty-six.

Despite his many achievements during more than six decades of scientific toil, he was always best known for his development of the OPVs, which would later be adopted in almost every country in the world. Now, in 1993, the World Health Organization is promoting a campaign of global poliomyelitis eradication by the year 2000. Even if this may be optimistic, polio is likely to become only the second viral disease to be conquered by human intervention, a state of affairs that owes much to the success of Albert Sabin’s slightly dirty-looking sugar lumps.

One of Sabin’s many other achievements was to identify a herpes virus of monkeys (B virus, or herpes B), which is harmless to its natural host but almost invariably fatal when transferred into humans, as evidenced by the deaths of some two-dozen monkey handlers and laboratory workers since the thirties. Sabin’s discovery of herpes B virus identified what then seemed the most formidable danger inherent in handling monkeys and their organs, and facilitated the adoption of minced monkey kidneys as a tissue culture for in vitro research and for the cultivation of viruses. This in turn paved the way for the golden age of virology in the fifties, and the production of polio vaccines on a commercial scale.

During his final years, Albert Sabin became increasingly concerned by the problem of AIDS, and wrote articles and letters about the problems inherent in developing an effective vaccine against the syndrome. The last of these was published in Nature a fortnight after his death. Like its predecessors, it predicted that attempts to vaccinate against HIV would prove unsuccessful, and ended with the words “In my judgment, it would be disastrous to continue the current inadequate methods of study of HIV and SIV vaccines, and to carry out large scale tests in humans of vaccines without adequate evidence that such vaccines can protect against natural infection.” From such an eminence grise, these were powerful final words of warning.

Five weeks after Sabin’s death, an obituary was published in Nature. It opened with a reference to “the heroic age of poliomyelitis research” and an acknowledgment that Sabin had been “one of the heroes,” before moving on to review Sabin’s life and works. By this stage of the obituary, the observant reader might have begun to suspect that writer and subject had not always been in agreement.

This was frankly admitted in the final paragraph, which read: At one time, Sabin and I became adversaries over the selection of polio virus strains to be used as oral vaccines. This did not affect our long-lasting friendship and mutual respect. In a letter to me written just a year ago, reviewing a paper speculating that AIDS started with polio vaccination in the Belgian Congo, Sabin expressed his opinion that this was “a most irresponsible and uncritical communication.” Courageous and wise. This is how I see him. I will miss him sorely.

The obituary was signed Hilary Koprowski, from the Wistar Institute in  Philadelphia.

Several of the scientists who knew the two men from the time of their great rivalry in the fifties and early sixties were intrigued by the obituary. They too had vivid recollections of the period, though their memories were rather different from Koprowski’s. They spoke of two Jewish emigrees from Eastern Europe, both possessed of keen intellects and quick tempers coupled, however, with great powers of persuasion (and, in Koprowski’s case, of charm). They spoke of two men cast from the same mold, men who shared many of the same tendencies and personality traits but who had somehow evolved into polar opposites.

Few of them recalled any tangible friendship (let alone one that was long-lasting) between Sabin and Koprowski, or remembered demonstrations of mutual respect. Instead, they spoke of a bitter enmity that had been barely – if at all – concealed in their respective articles in the medical literature and papers delivered at the great virology conferences of the day. They remembered the occasions when the great men had posed together, smiling, for the photographers, and then each had swiftly turned on his heel the moment the cameras were packed away. This rivalry, some of them hinted, had perhaps stemmed from the fact that Koprowski had been the first to feed an oral polio vaccine to humans in 1950, fully three years before Sabin had entered the field – and yet it was Sabin’s vaccines that had been licensed, Sabin who had won the lasting acclaim. “Koprowski and Sabin hated each other,” one contemporary told me. “Salk, Sabin, Koprowski, Cox – I would have loved to see them tag-team wrestling,” said another, referring to the four great polio vaccine-makers. “They were fighting like dogs over a bone – about who would make the vaccine of choice,” said a third.

Given this history, many scientists were dubious about Koprowski’s motivation for praising Sabin’s wisdom – particularly as, in the same breath, he noted Sabin’s rejection of a theory that suggested that one of his (Koprowski’s) vaccines had given birth to AIDS. Perhaps in 1993 few scientists would have recalled that, back in 1959, it was Sabin who had introduced the first slither of doubt about the safety of this very vaccine.

All in all, there was much that the obituary left unsaid, some of which has great relevance for the story that follows. We shall return to the tale of the obituary writer, and his uneasy relationship with his subject – a relationship that helped define the characters of both men – later in this book.

1999 by Edward Hooper

Oxford American Handbook of Clinical Medicine, 1st Edition

John Flynn

Thinking About Medicine

Mark T. Hughes

Ideals

Decision and intervention are the essence of action. Reflection and conjecture are the essence of thought. The essence of medicine is combining these realms of action and thought in the service of others. We offer these ideals to stimulate both thought and action. Like the stars, these ideals are hard to reach – but they serve for navigation during the night.

  • Remember the goal of healing is to make the person whole: This applies whether the aim is cure, relief of symptoms in an acute or chronic illness, prevention of complications in a chronic disease, or comfort in an incurable disease.
  • Do not blame the sick for being sick: They come to you for help. You are there for them, not the other way around.
  • If the patient’s wishes are known, comply with them.
  • Work for your patients, not your attending.
  • Use ward rounds to boost the patient’s morale, not your own.
  • Treat the whole patient, not the disease.
  • Admit people – not ‘strokes’, ‘infarcts’, or ‘gomers’.
  • Spend time with the bereaved; you can help them shed their tears.
  • Question your conscience – however strongly it tells you to act.
  • The nurses know the patient and are usually right; respect their opinions.
  • Be kind to yourself - you are not an inexhaustible resource.
  • Give the patient (and yourself) time: Time to ask questions, time to reflect, time to allow healing to take place, and time to gain autonomy.
  • Give the patient the benefit of the doubt. If you can, be optimistic: Patients want physicians to be realistic but also to instill hope.

Ideal and less than ideal methods of care

The story of Ivan Ilyich illustrates the options: ‘Special foods were prepared for him on the doctor’s orders, but these became more and more unpalatable, more and more revolting… Special arrangements, too, were made for his bowel movements. And this was a regular torture – a torture because of the filth, the unseemliness, the stench, and the knowledge that another person had to assist him… Yet it was precisely through this unseemly business that Ivan Ilyich derived some comfort. The pantry boy, Gerasim, always came to carry out the chamber pot. Gerasim was a clean, ruddy-faced young peasant who was thriving on town food. He was always bright and cheerful… “Gerasim,” said Ivan Ilyich in a feeble voice… “This must be very unpleasant for you. You must forgive me. I can’t help it.”… “Oh no, sir!” said Gerasim as he broke into a smile, his eyes and strong white teeth gleaming. “Why shouldn’t I help you? You’re a sick man.”… Ivan Ilyich had Gerasim sit down and hold his legs up, and he began talking to him. And, strangely enough, he thought he felt better while Gerasim was holding his legs… After that, Ivan Ilyich would send for Gerasim from time to time and have him hold his feet on his shoulders. And he loved to talk to him. Gerasim did everything easily, willingly, simply, and with a goodness of heart that moved Ivan Ilyich. Health, strength, and vitality in other people offended Ivan Ilyich, whereas Gerasim’s strength and vitality had a soothing effect on him.’

It was the pantry boy who was his true healthcare provider and caregiver, who took him on his own terms, cared for him, and gave him time and dignity. While Ivan Ilyich’s physicians and others cooperated in the “lie” that he was ill but not dying, “Gerasim was the only one who understood and pitied him.” Gerasim did not find his work burdensome, because he understood he was doing it for a dying man. As TS Eliot said, ‘there is, at best, only a limited value in the knowledge derived from experience’ – eg the knowledge encompassed in this book. The pantry boy had the innate understanding and the natural compassion that we all too easily lose amid the science, the knowledge, and our stainless steel universe of organized healthcare.

The bedside manner and communication skills

Our bedside manner matters because it indicates to patients whether they can trust us. Where there is no trust, there can be little healing. A good bedside manner is not static: It develops in coordination with the patients’ needs, but it is grounded in the timeless clinical virtues of honesty, humor, and humility in the presence of human weakness and human suffering.

The following are examples from an endless variety of phenomena which arise whenever doctors meet patients. One of the great skills (and pleasures) in medicine is to learn how our actions and attitudes influence patients, and how to take this knowledge into account when assessing the validity and significance of the signs and symptoms we elicit. The information we receive from our patients is not ‘hard evidence’, but a much more plastic commodity, molded as much by the doctor’s attitude and the hospital or consulting room environment as by the patient’s own hopes and fears. It is our job to adjust our attitudes and environment, so that these hidden hopes and fears become manifest and the channels of communication are always open.

Anxiety reduction or intensification. Simple explanation of what you are going to do often defuses what can be a highly charged affair. With children, try more subtle techniques, such as examining the abdomen using the child’s own hands, or examining their teddy bear first.

Pain reduction or intensification. Compare: ‘I’m going to press your stomach. If it hurts, cry out’ with ‘I’m going to touch your stomach. Let me know what you feel’. The examination can be made to sound frightening, neutral, or joyful, and the patient will relax or tense up accordingly.

The tactful or clumsy invasion of personal space. The physical examination can involve close contact with the patient that is normally not acceptable as part of usual social interaction. Acknowledging this to the patient can set both parties at ease. For example, during ophthalmoscopy, simply explain ‘I need to get very close to your eyes for this’.

The use of distraction to gather information. The skilful practitioner palpating the painful abdomen will start away from the part that hurts. They will watch the patient’s face while talking about a hobby or the patient’s family while they presses as hard as they need to. If the patient stops talking and frowns only when the doctor’s hand is over the right lower quadrant, the doctor will already have found out something useful.

Communication. Your skills are useless unless you communicate well. Be simple, and direct. Avoid jargon: ‘Remission’ and ‘growth’ are frequently misunderstood. Give the most important details first. Be specific. ‘Drink 6 cups of water per day’ is better than ‘Drink more fluids’. Provide written information with easy readability. Aim for a sixth grade reading level – more like the Reader’s Digest than the Wall Street Journal. If possible, show videos for patient education. Do not assume your patient can read. Naming the pictures but not the words on our visual test chart helps find this out tactfully.

Inquire about your patient’s views of what should be done. Patient-centered care improves provider-patient interactions and patient satisfaction. Find goals of care that can be mutually agreed upon. Learn more about the patient’s values. We often talk of compliance with our regimens, when what we should talk of is concordance, for concordance recognizes the central role of patient participation in all good plans of care.

What is the mechanism? Finding narrative answers

Like toddlers, we should always be asking ‘Why?’ – not just to find ultimate causes, but to enable us to choose the simplest level for intervention. Some simple change early on in a chain of events may be sufficient to bring about a cure, whereas later on in the chain such opportunities may not arise.

For example, it is not enough for you to diagnose heart failure in your breathless patient. Ask: ‘Why is there heart failure?’ If you do not, you will be satisfied with giving the patient an anti-failure drug, and any side-effects from these, such as uremia or incontinence induced by diuretic-associated polyuria, will be attributed to an unavoidable consequence of necessary therapy. If only you had asked ‘What is the mechanism of the heart failure?’ you might have found an underlying cause, eg anemia coupled with ischemic heart disease. You cannot cure the latter, but treating the anemia may be all that is required to cure the patient’s breathlessness. But do not stop there. Ask: ‘What is the mechanism of the anemia?’ You find a low serum ferritin and you might be tempted to say to yourself, I have the root cause.

Wrong! Put aside the idea of prime causes, and go on asking ‘What is the mechanism?’ Return to the patient (never think that the process of history-taking is over). Retaking the history reveals that the patient has a very poor diet. ‘Why is the patient eating a poor diet?’ Is he ignorant or too poor to eat properly? You may find the patient’s wife died a year ago, he is sinking into a depression, and cannot be bothered to eat. He would not care if he died tomorrow.

You now begin to realize that simply treating the patient’s anemia may not be of much help to him – so go on asking ‘Why?’: ‘Why did you bother to go to the doctor at all if you are not interested in getting better?’ It turns out that he only went to see the doctor to please his daughter. He is unlikely to take your treatment unless you really get to the bottom of what he cares about. His daughter is what matters and, unless you can enlist her help, all your therapeutic initiatives will fail. Talk with his daughter, offer help for the depression, teach her about iron-rich foods and, with luck, your patient’s breathlessness may gradually begin to disappear. Even if it does not start to disappear, you may perhaps have forged a friendship with your patient which can be used to enable him to accept help in other ways – and this dialogue may help you to be a more humane and a kinder doctor, particularly if you are feeling worn out and assaulted by long lists of technical tasks which you must somehow fit into impossibly overcrowded days and nights.

Constructing imaginative narratives yielding new meanings. Doctors are often thought of as being reductionist and over-mechanistic. The above shows that always asking ‘why’ can sometimes enlarge the scope of our inquiries rather than narrowing the focus. Another way to do this is to ask What does this symptom mean? – for this person, their family, and our world. For example, a limp might mean a neuropathy, or inability to meet mortgage repayments (if you are a dancer) – or it may represent a medically unexplained symptom which subtly alters family hierarchies both literally (during family walks through the country) and metaphorically. Science is about clarity, objectivity, and theory in modeling our external world. But there is another way of modeling the external world which involves subjectivity, emotion, ambiguity, and the seeking of arcane relationships between apparently unrelated phenomena. The medical humanities explore the latter – and have been burgeoning during the last decade – leading to the existence of two camps – humanities and science. If, while reading this you are getting impatient to get to the real nuts and bolts of technological medicine, you are in the latter camp. We are not suggesting that you leave it – only that you learn to operate out of both. If you do not, your professional life will be full of failures (of which you may deny or remain ignorant). If you do straddle both camps, there will also be failures – but you will realize what these failures mean, and you will know how to transform them.

Always remember that medicine is both an art and a science. The physician must have the technical skill and knowledge to ply their craft, but they need the artistry to practice it with compassion in the context of a patient’s life.

Asking questions

No class of questions is ‘correct’. Sometimes you need to ask one type of question; sometimes another. The good clinician can shift from one kind to another, in order to use the most effective questions for each individual patient. The aim of asking questions is to describe, to find a shared world between the doctor and patient. Questions provide the means to offer practical help: Once the illness is described, a diagnosis can be made and a possible cure offered. If not curable, the experience can at least be shared, mitigated, and so partially overcome. Different kinds of questions either throw light on the experience, or obscure it, as in the examples below.

Leading questions. On seeing a bloodstained handkerchief you ask: ‘How long have you been coughing up blood?’ ‘6wks, doctor’ so you assume hemoptysis for 6wks. In fact, the stain could be due to an infected finger, or to epistaxis. On finding this out later (and perhaps after expensive and unpleasant investigations), you will be upset, but the patient was politely trying to give the sort of answer you were obviously expecting. With such leading questions as these, the patient is not given an opportunity to deny your assumptions.

Questions suggesting the answer ‘Was the vomit red, yellow, or black – like coffee grounds?’ – the classic description of vomited blood. ‘Yes, like coffee grounds, doctor.’ The doctor’s expectations and hurry to get the evidence into a pre-determined format have so tarnished the story as to make it useless.

Open-ended questions. The most open is ‘How are you?’ This suggests no particular answer, so the direction a patient chooses offers valuable information. Other examples are gentle imperatives such as ‘Tell me about the vomit’ ‘It was dark’ ‘How dark?’ ‘Dark with little chunks in it’ ‘Like…?’ ‘Like bits of soil in it.’ This information is pure gold, although it is not cast in the form of ‘coffee grounds’.

Patient-centered questions. ‘What do you think is wrong?’ ‘Are there any other aspects of this we might explore?’ ‘Are there any questions you want to ask?’ (a closed question). Better still, try ‘What are the other things on your mind?’ How is this affecting you? What is the worst thing? It makes you feel…’ (The doctor is silent.) Becoming patient-centered gives you a better chance of healing the whole person, and the patient may be more satisfied as a result.

Framing questions in the context of the family. This is particularly useful in revealing if symptoms are caused or perpetuated by psychosocial factors. Family-oriented questions probe the network of causes and enabling conditions which allow nebulous symptoms to flourish in a person’s life. Who else is important in your life? Are they worried about you? Who really understands you? Until this sort of question is asked, illness may be refractory to treatment. Eg: ‘Who is present when your headache starts? Who notices it first – you or your wife? Who worries about it most (or least)? What does your wife do when (or before) you get it?’ The spouse’s view of the symptoms may be the best predictor of outcome for the patient.

Framing questions in the context of culture. In medicine, we may encounter patients from diverse backgrounds, sometimes quite different from our own. The skillful clinician will be self-aware enough to recognize any biases they may have based on their own cultural identity. To be culturally competent, the clinician should be open to exploring the patient’s health beliefs from the patient’s cultural perspective. Admitting ignorance of the patient’s culture in an inquiring, respectful manner may provide clues as to how best help the patient within their worldview.

Echoing. Try repeating the last words said as a route to new intimacies, otherwise inaccessible, as you fade into the distance, and the patient soliloquizes ‘…I’ve always been suspicious of my wife.’ ‘Wife…’ ‘My wife… and her boss working late at night together.’ ‘Together…’ ‘I’ve never trusted them together.’ ‘Trusted them together…’ ‘No, well, I’ve always felt I’ve known who my son’s real father was… I can never trust those two together.’ Without any questions you may unearth the unexpected, important clue which throws a new light on the history.

Empathic opportunities. Remember that the purpose of the medical interview is not just to gain information, but to develop a relationship. Are you asking questions in a respectful way that validates the patient’s emotional experience? After getting facts about the illness experience, ask the follow-up question, ‘How did you feel about that?’ and acknowledge the emotions reported. Be attentive to nonverbal communication, which may shed light on the patient’s underlying feelings and ↑ the yield of the information. Match body language to build rapport and make it more likely that the patient will be open to answering questions.

The value of silence. Sometimes not asking a question will give the patient the opportunity to share important information. There is value in the pregnant pause…

If you only ask questions, you will only receive answers in reply. If you interrogate a robin, he will fly away: Treelike silence may bring him to your hand.

Health and medical ethics

Medicine has its own internal morality. This derives from a patient’s illness and their subsequent vulnerability, coupled with the physician’s intent to help the patient improve. Each time a physician asks of the patient, “How can I help you?” there is an implicit understanding that the physician will use their expertise to serve the best interests of the patient.

As members of a profession, physicians declare publicly that they will put aside their self-interest in the service of others. While society grants physicians certain privileges, it also expects certain duties of the profession, namely to be the stewards of valuable societal resources.

In the sphere of ethics, physicians are called upon to lead as often as to follow. To do this, we need to return to basic principles, and put society’s expectations temporarily on one side.

Our analysis starts with our aim: To do good by promoting people’s health. Health entails being sound in body and mind, and having powers of growth, development, healing, and regeneration. How many people have you made healthy (or at least healthier) today? Good is the most general term of commendation, and entails four chief duties:

Not doing harm (non-maleficence). We owe this duty to all people, not just our patients.

Doing good by positive actions (beneficence). We particularly owe this to our patients. There are four ways by which the patient’s good can be defined: (1) the ultimate good, that which has the highest meaning for the patient; (2) the biomedical good, obtained by treatment of the disease; (3) the patient’s perception of the good based on their life plan; and (4) the good of the patient as a person, deserving respect and the freedom to make reasoned choices.

Respecting autonomy or respecting the person. Autonomy (selfdetermination) is not universally recognized; in some cultures facing starvation, it may be irrelevant, or even be considered subversive. But respecting persons and their inherent dignity is to be found across cultures. This is manifested in medicine by upholding patients’ rights to be informed, to be offered all the options, to be told the truth, and to have their confidentiality protected.

Promoting justice – distributing scarce resources fairly and treating people fairly, such as when we respect their legal rights.

The point of having these guiding principles is to provide a context for our negotiations with patients. If we want to be better doctors, a good starting point is trying to put these principles into action. Inevitably, when we try to, there are times when the principles seem to conflict with each other. What should guide us when these principles conflict? It is not just a case of deciding off the top of one’s head. It requires further inquiry, deliberation, and aspiring to a synthesis – if you have the time (time will so often be what you do not have; but, in retrospect, when things have gone wrong, you realize that they would not have done so if you had made time).

Synthesis. When we must act in the face of 2 conflicting duties, one of the duties will take precedence. How do we tell which one? Trying to find out involves getting to know our patients, and asking some questions:

  • Are the patient’s wishes being complied with?
  • What do the patient’s loved ones (family and/or friends) think? First ask the patient’s permission to speak to the loved ones. Do the patient’s loved ones have his or her best interests at heart?
  • What do colleagues think? Often having the input of other clinicians can help sort out the complexities of a difficult case.
  • Is it desirable that the reason for an action be universalizable? (That is, if I say this person is too old for such-and-such an operation, am I happy to make this a general rule for everyone? – Kant’s ‘law’.)
  • What would the man on the street say? These opinions are valuable as they are readily available and they can stop decision-making from becoming dangerously medicalized.
  • If an investigative journalist were to sit on a sulcus of mine, having full knowledge of my thoughts and actions, would she be bored or would she be composing vitriol for tomorrow’s newspapers? If so, can I answer her, point for point? Am I happy with my answers? Or are they tactical cerebrations designed to outwit her?
  • What would I do if nobody were watching? Would I act the same way if there were no consequences in terms of public scrutiny? Will I be able to face myself in the mirror the next morning?
  • Do I need the input of the hospital ethics committee? In some cases, ethics consultants can help to facilitate discussion among interested parties, sort out the ethical issues at stake, and provide an opinion about ethically permissible options for resolution of the problem.

Medicine, art, and the humanities

Let us start with an elementary observation: The most famous doctors are those immortalized in literature – eg Dr Watson, Dr Zhivago, Dr Frankenstein, and Dr Faustus.1 Hereby we demonstrate the power of the written word. And it is an extraordinary power. When we curl up in an armchair and read for pleasure, we open the portals of our minds because we are alone. While we are reading, there is no point in dissembling. We confront our subject matter with a steady eye because we believe that, while reading to ourselves, we cannot be judged. Then, suddenly, when we are at our most open and defenseless, literature takes us by the throat – and that eye which was so steady and confident a few minutes ago is now perhaps misting over, or our heart is missing a beat, or our skin is covered in a goose-flesh more papular than ever a Siberian winter produced. Once we have been on earth for a few decades, not much in our mundane world sends shivers down our spines, but the power of worlds of literature and art to do this ever grows.

There are, of course, doctors who are quite well known as literary artists: Arthur Conan Doyle, William Carlos Williams, Somerset Maugham, and Anton Chekhov. What about Sigmund Freud? Here is the exception which proves the rule – proves in the sense of testing, for he is not really an exception. We can accept him among the great only in so far as we view his collection of writings as an artistic oeuvre, rather than as a scientific one. Science has progressed for years without Freud, but, as art, his work and insights will survive: And survival, as Bernard Shaw pointed out, is the only test of greatness.

The reason for the ascendancy of art over science is simple. We scientists, in our humble way, are only interested in explaining reality. Artists are good at explaining reality too: But they also create it. Our most powerful impressions are produced in our minds not by simple sensations but by the association of ideas. It is a pre-eminent feature of the human mind that it revels in seeing something as, or through, something else: Life refracted through experience, light refracted through jewels, or a walk through the woods transmuted into a pastoral symphony. Ours is a world of metaphor, fantasy, and deceit.

What has all this to do with the day-to-day practice of medicine? The answer lies in the word ‘defenseless’ above. When we read alone and for pleasure, our defenses are down – and we hide nothing from the great characters of fiction. This openness to the story of another helps to keep us connected with our patients. So often, a professional detachment is all that is left after all those years inured to the foibles, fallacies, and frictions of our patients’ tragic lives. It is at the point where art and medicine collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients. Art and literature can cultivate our empathy, so that, at some level, there can be truth to the statement, ‘I understand what you’re going through,’ even though we ourselves may not have had to endure the illness experience of the patient.

We all have an Achilles heel: That part of our inner self which was not rendered forever invulnerable to mortal cares when we were dipped in the waters of the river Styx as it flowed down the wards of our first disillusion. Art and literature, among other things, may enable this Achilles heel to be the means of our survival as thinking, sentient beings, capable of maintaining a sympathetic sensibility to our patients.

Narrative medicine allows us to see the patient as text, and thereby foster ethical reasoning and speculation about the patient’s worldview of illness. No matter his or her specialty, each physician should recognize that in the practice of medicine, every contact with a patient has an ethical and artistic dimension, as well as a technical one.

Prescribing drugs

Consult the Physicians’ Desk Reference (PDR) or your local equivalent before prescribing any drug with which you are not thoroughly familiar.

Before prescribing, ask if the patient is allergic to anything. The answer is often ‘Yes’ – but do not stop here. Find out what the reaction was, or else you run the risk of denying your patient a possibly life-saving and very safe drug, such as penicillin, because of a mild reaction like nausea. Is the reaction a true allergy (anaphylaxis, or a rash?), a toxic effect (eg ataxia is inevitable if given large quantities of phenytoin), a predictable adverse reaction (eg GI bleeding from aspirin), or an idiosyncratic reaction?

Remember primum non nocere: First do no harm. The more minor the complaint, the more weight this dictum carries. The more serious the complaint, the more its antithesis comes into play: Nothing ventured, nothing gained.

Ten commandments. These should be written on every tablet.

  • Explore any alternatives to a prescription. Prescriptions lead to doctordependency, which in turn frequently leads to bad medicine and drives up the expense of healthcare. There are 3 places to find alternatives:

The kitchen: Lemon and honey for sore throats, rather than penicillin.

The blackboard: – eg education about the self-inflicted causes of esophagitis. Rather than giving expensive drugs, advise against too many big meals, eating close to bedtime, smoking and alcohol excess, or wearing overtight garments.

Lastly, look to yourself. Giving a piece of yourself, some real empathy, is worth more than all the drugs in your pharmacopoeia to patients who are frightened, bereaved, or weary of life.

  • Find out if the patient wants to take a drug. Are you prescribing for some minor ailment because you want to solve every problem? Patients may be happy just to know the ailment is minor. If they know what it is, they may be happy to live with it. Some people do not believe in drugs, and you must find this out.
  • Decide if the patient is responsible. If they now swallow all the acetaminophen with codeine pills that you have prescribed for their acute pain at one time, death will be swift.
  • Know of other ways your prescription may be misused. Perhaps the patient, whose ‘insomnia’ you so kindly treated is actually grinding up your prescription for injection in order to get a fix. Will you be suspicious when they return to say they have lost your prescription?
  • Address these questions when prescribing:
    • How many daily doses are there? 1-2 is much better than 4.
    • How many other drugs are to be taken? Can they be reduced?
    • Can the patient read the instructions on the bottle – and can they open it?
    • Is the patient agreeable to enlisting the help of a loved one or caretaker to ensure that they remember to take the pills?
    • Is the patient taking the medication properly? Check by counting the remaining pills at the next visit.
    • How will the patient refill their prescription?
    • How will you know and what will you do if the patient does not come for a follow-up visit?
  • List the potential benefits of the drug for this patient.
  • List the risks (side-effects, contraindications, interactions, risk of allergy). Of any new problems, always ask yourself: Is this a side-effect?
  • Try to ensure there is true concordance between you and your patient on the risk:benefit ratio’s favorability. Document your discussion.
  • Record how you will review the patient’s need for each drug and quantify progress (or lack thereof) towards specified, agreed goals, eg pulse rate to mark degree of beta-blockade; or peak flow reading to guide steroid use in asthma.
  • Make a record of all drugs taken. Offer the patient a copy.

The art and science of diagnosing

The central processes of medicine are: Relieving symptoms, providing reassurance and prognostic information, and lending a sympathetic ear. But it is very difficult to do this well, and to ↑ your rapport with your patient, unless you have a working diagnosis. How is this achieved?

We diagnose, it is held, by a 3-stage process: We take a history, we examine, and we do tests. We then collate this information, by a process which is never explained, and compare it with features of diseases we know. We then find the best match, and call this the diagnosis. Other nearly matching diseases then form the differential diagnosis. This model ignores two factors: (1) Often no match can be found. (2) Doctors, in practice, hardly ever work like this. So how are diagnoses made?

Diagnosing by recognition. For students, this is the most irritating method. You spend an hour asking all the wrong questions, and in waltzes a doctor who names the disease, and sorts it out before you have even finished taking the pulse. This doctor has simply recognized the illness like they recognize an old friend (or enemy). But don’t worry: You too will soon reach this position, if you spend enough time at bedsides with other doctors – and you too will just as effortlessly make all the errors that this approach is prone to.

Diagnosing by probability theory. Over our clinical lives we unconsciously build up a personal database of diagnoses and outcomes, and associated pitfalls. We unconsciously run each new ‘case’ through this personal and continuously developing fine-grained probabilistic algorithm – eventually with amazing speed and effortlessness.

Diagnosing by hypothesizing. We formulate a hypothesis and then try to disprove or prove it. The generation of a hypothesis can start with the chief complaint. Our subsequent questions in history-taking, the focus of our physical exam, and/or our selection of tests provide the data to prove or disprove our original hypothesis, or to formulate a new one.

Diagnosing by reasoning. Like Sherlock Holmes, we exclude each differential diagnosis, and then, whatever is left, however unlikely, must be the culprit. This process presupposes that our differential does include the culprit, and that we have methods for absolutely excluding diseases. All tests are statistical, rather than absolute – which is why the Holmes technique is, at best, fictional.

Diagnosing by a ‘wait and see’ approach. Some doctors (and patients) need to know immediately and definitively what the diagnosis is, while others can tolerate more uncertainty. With practice, one can sense that the dangers and expense of exhaustive tests can be obviated by the skillful use of time. This cough might represent pneumonia, but I may choose not to get a chest x-ray or sputum culture. Rather, I may say ‘take this antibiotic if you get a fever – but you probably don’t need it, and you’ll get better on your own: Wait and see’.

Diagnosing by selective doubting. Traditionally, patients are ‘unreliable’, signs are objective, and lab tests virtually perfect. When diagnosis is difficult, try inverting this hierarchy. The more you do so, the more you realize that there are no hard signs or perfect labs. But the game of medicine is unplayable if you doubt everything, so doubt selectively.

Diagnosing by computer. Computing power is the only way of fully mapping the interrelatedness of diseases – eg hyponatremia with eosinophilia points to Addison’s disease, but if there is oliguria too, a doctor with no computer may have to posit an unrelated disease; but the computer ‘knows’ that oliguria is a feature of shock, and shock is a complication of Addison’s.

Diagnosis by iteration and reiteration

A brief history suggests looking for a few signs, whose assessment leads you to ask further questions, and do a few tests. These results lead to further questions and tests. The process of taking a history never ends on this view, and as this process reiterates, various diagnostic possibilities crop up, and receive more or less confirmation. ‘I feel my heart racing’ – and the doctor immediately puts his finger on the pulse, and feels it to be irregularly irregular, and infers atrial fibrillation. He wants to know why there is AF, so he asks about weight loss and heat into lerance. This suggests hyperthyroidism as the cause of the AF. While he takes the pulse he notices clubbing of the fingers, so he makes a mental note to do a chest x-ray to see if there are signs of cancer (could this cause the AF? – yes). This reminds him to ask about smoking: While inquiring about habits, he asks about alcohol, and elicits excessive drinking. ‘Why now?’ ‘Because I lost my job.’ ‘Who cares about this more? You or your husband?’ In the time it takes to assess the pulse, the doctor has many promising leads to follow, and is starting to formulate a diagnosis in 3 dimensions: Physical, psychological, and social. The patient’s palms are clammy, and the pulse is weak, so the doctor knows he must be prompt and decisive, and gently explains that admission for various tests is needed. Whereupon the patient, who has been holding back tears, now weeps. Now holding her hand, as well as continuing to take her pulse, the doctor becomes aware of a change in rhythm. Is this sinus rhythm, brought on by the Valsalva-like maneuver of weeping? So the doctor now says ‘Well… let’s see how you get on over the next hour – you’ll feel better for crying.’ ‘Yes, you’re right, I feel better already.’

This is a microcosm of the intuitive world of medicine which the systematic (or only systematic) doctor never knows. He would come on to the pulse only after a ‘full history’ – and would have missed everything. The doctor who is prepared to appear muddled, and who can work on many different levels simultaneously, will often be the first to know the diagnosis.

Prevention

Two mottos: ‘The only good medicine is preventive medicine’ and ‘If preventable… why not prevented?’ During life on the wards you will have many opportunities for preventive medicine, and unconsciously you will pass most of them over, in favor of more glamorous tasks such as diagnosis, and clever interventions, involving probes, scalpels, and imaging. But if we imagine a ward where scalpels remain sheathed and the only thing being probed is our commitment to health, then preventive medicine comes to the forefront, and it is our contention that such a ward might produce more health than some entire hospitals.

Ways of thinking about prevention. Preventing a disease (eg by vaccination) is primary prevention. Controlling disease in an early form (eg carcinoma-in-situ) is secondary prevention. Preventing complications in those already symptomatic is tertiary prevention.

The best way of thinking about prevention is “What can I do now with this patient in front of me?” On the wards this will often be secondary or tertiary prevention – eg blood pressure screening in diabetes, or colonoscopy in ulcerative colitis (looking for colon cancer), or endoscopic screening for esophageal cancer in Barrett’s esophagus.

The first step in prevention is to motivate your patient to take steps to benefit their own health by asking Socratic questions. ‘Do you want to smoke?’ ‘What does your family think about smoking’ ‘Do you want your children to smoke?’ ‘Would there be any advantages in giving up?’ ‘Why is your health important to you?’ ‘Is there anything more important we can help with?’ ‘How would you spend the money you might save?’ These types of questions along with specific strategies in prevention are more likely to produce change than withering looks and lectures on lung cancer. In summary: In any preventive activity, get the patient on your side – make them want to change. Once you have done this, preventive activities you might promote include:

and 2° disease prevention: General health: Cancer screening:
Vaccination (eg flu shot if >65yrs) Healthy eating Colon cancer screening
Aspirin if vascular disease Regular exercise Pap smears
Cardiovascular risk reduction Advice on smoking and alcohol Mammography and annual breast exam
Osteoporosis prevention if on steroids or post-menopausal (calcium, vitamin D, ± bisphosphonate) House and car dangers: Seatbelts, accidents, falls, gun safety Genetic counseling, eg if family history positive in two 1st degree relatives

Sometimes referral to other agencies is needed – eg for genetic counseling, contraception, and pre-conception advice.

Concentrate on those preventive activities which are simple, cheap, and have a complication rate approaching zero. When considering a more complicated or ‘high-tech’ preventive procedure, be on guard for unintended consequences, such as colon perforation in colonoscopy. When risk is involved with the preventive strategy, weigh the procedure in light of the patient’s history and other medical problems. Get the patient’s input about whether the preventive measure is right for them.

Individualized risk communication. When counseling a patient about screening tests, communication should be based on a person’s individual risk factors for a condition (eg age, family history, smoking status, cholesterol level). With some conditions, this can be achieved with decisional aids or using formulae. A Cochrane meta-analysis suggests this kind of individualized approach will ‘not necessarily’ change behavior, although uptake of screening tests is improved. At least this technique promotes dialogue, and dialogue opens doors, minds, and possibilities for choice. Informed participation is the aim, not passive acceptance of advice. Improved knowledge, beliefs, and risk perceptions can be achieved with this approach. How clinical evidence is presented can make a difference in certain patient populations. Participatory decision-making is facilitated when the physician:

  • Understands the patient’s experience and expectations.
  • Builds partnership.
  • Provides evidence, including a balanced discussion of uncertainties.
  • Checks for understanding and agreement.
  • Presents recommendations informed by clinical judgment and patient preferences.

Difficult patients

‘Unless both the doctor and the patient become a problem to each other, no solution is found.’

Jung’s aphorism is untrue for half our waking lives: For an anesthesiologist, there is no need for the patient to become a problem in order for the anesthetic to work. But, as with all the best aphorisms, being untrue is the least of their problems. Great aphorisms signify because they unsettle. Our settled and smug satisfaction at finishing a rotation without any problems is so often a sign of failure. We have kept the chaos at bay, whereas, if we were greater men or women, we would have embraced it. Half our waking professional lives we spend as if asleep, on automatic, following protocols or guidelines to some trite destination – or else we are dreaming of what we could do if we had more time, proper resources, and perhaps a different set of colleagues. But if we had Jung in our pockets, he would be shaking us awake, derailing our guidelines, and saluting our attempts to risk genuine interactions with our patients, however much of a mess we make of it, and however much pain we cause and receive. (Pain, after all, is the inevitable companion to lives led authentically.) To the unreflective doctor, and to all average minds, this interaction is anathema, to be avoided at all costs, because it leads us away from anesthesia, to the unpredictable, and to destinations which are unknown.

So, every so often, try being pleased to have difficult patients: Those who question us, those who do not respond to our treatments, or who complain when these treatments do work. Very often, it will seem that whatever you say, it is wrong: Misunderstood, misquoted, and mangled by the mind you are confronting – perhaps because of fear, loneliness, or past experiences which you can only guess at. If this is happening, shut up – but don’t give up. Stick with your patient. Listen to what he or she is saying and not saying. And when you have understood your patient a bit more, negotiate, cajole, and even argue – but don’t bully or blackmail (‘If you do not let your daughter have the operation she needs, I’ll tell her just what sort of a mother you are…’). When you find yourself turning to walk away from your patient, turn back and say, ‘This is not going very well, is it? Can we start again?’ And don’t hesitate to call in your colleagues’ help: Not to win by force of numbers, but to see if a different approach might bear fruit. By this process, you and your patient may grow in stature. You may even end up with a truly satisfied patient. And a satisfied patient is worth a thousand protocols.

Is this new treatment any good? (Analysis & meta-analysis)

This question frequently arises when reading journals. Not only authors, but all clinicians, have to decide what new treatments to recommend, and which to ignore. Evidence-based medicine recognizes two fundamental principles: (1) the physician must assess the strength and validity of the evidence for the new treatment based on a hierarchy; (2) Decision makers must consider the patient’s values and trade off the benefits, risks, inconvenience, and costs of alternatives.

Users’ Guides to the Medical Literature have been created to help the clinician decide whether the results of a research study will help in the care of their patients. In assessing the use of research, ask the following:

  • Are the results valid? Much must be taken on trust as many statistical analyses depend on sophisticated computing. Few papers, unfortunately, present ‘raw’ data. Look out for obvious faults by asking:
  • Were comparison groups (experimental and control groups) similar in terms of prognosis and clinical characteristics at the start of the study?
  • Were patients randomized to the comparison groups? Did randomization produce groups that were well matched? Were the treatments being compared carried out by practitioners equally skilled in each treatment?
  • Was the study placebo-controlled? Good research can go on outside the realm of double-blind, randomized trials, but you need to be more careful in drawing conclusions – eg for intermittent symptoms, a bad time (prompting a consultation) is followed by a good time, making any treatment given in the bad phase appear effective. Regression towards the mean occurs in many areas, eg repeated BP measurement: Because of transitory or random effects, most people having a high value today will have a less high value tomorrow – and most of those having a low value today will have a less extreme value tomorrow. This concept works at the bedside: If someone who is drowsy after a head injury has a high bp, and the next measurements are higher still, ie no regression to the mean, then this suggests a ‘real’ effect, such as ↑ ICP.
  • Was the study blinded? In a double blind study, both patients and doctors are unaware of which treatment the patient is having. Could patients, doctors, or those assessing outcome have told which treatment was given, eg by the metabolic effects of the drug?
  • Is the sample large enough to detect a clinically important difference, say a 20% drop in deaths from disease ×? If the sample is small, the chance of missing such a difference is high. In order to reduce this chance to less than 5%, and if disease × has a mortality of 10%, >10,000 patients would need to be randomized. If a small trial that lacks power (the ability to detect true differences) does give ‘positive’ results, the size of the difference between the groups is likely to be exaggerated. This is type I error; a type II error applies to results that indicate that there is no effect, when in fact there is. So beware of quite big trials that purport to show that a new drug is equally effective as an established treatment.
  • How large was the treatment effect and how precisely was it measured?
  • Does the study give a clear, clinically significant answer as well as a statistically significant answer in patients similar to those I treat? Are the likely treatment benefits worth the potential risks and costs if applied in the clinical setting?
  • Is the journal peer reviewed? Experts vet the paper before release (an imperfect process, as they have unknown axes to grind ± competing interests).
  • Has time been allowed for criticism of the research to appear in the correspondence columns of the journal in question?
  • If I were the patient, would I want the new treatment?
  • What have the Centers for Disease Control (CDC) or professional organizations said? Have clinical guidelines been developed as a result of the research findings?

Meta-analyses. Systematic merging of similar trials can help resolve contentious issues and explain data inconsistencies. It is quicker and cheaper than doing new studies, and can establish generalizability of research. Be cautious! In one study looking at recommendations of meta-analyses where there was a later ‘definitive’ big trial, it turned out that meta-analyses got it wrong 30% of the time, and 20% of even good meta-analyses fail to avoid bias. Bias can result from pharmaceutical funding or from the meta-analyst’s own assumptions about the topic under study.

A well-planned large trial may be worth centuries of uncritical medical practice; but a week’s experience on the wards may be more valuable than years reading journals. This is the central paradox in medical education. How can we trust our own experiences knowing they are all anecdotal; how can we be open to novel ideas but avoid being merely fashionable? A stance of wary open-mindedness may serve us best.

Resource allocation and QALYs

Resource allocation: How to decide who gets what. There is a perception in the United States that healthcare resources are scarce. When one looks at the availability of organ transplants, critical care beds, home care services, and other potentially beneficial treatments, this appears to be true. Resource allocation is about cutting the healthcare cake – the size of which is given based on how much society is willing to expend on healthcare as opposed to other societal priorities.

Making the cake. Focusing on how to cut the cake diverts attention from the central issue: How large should the cake be? The answer may be that more needs to be spent on our healthcare services, not at the expense of some other health gain, but at the expense of something else.

Slicing the cake. In their daily practices, the majority of physicians will not have to contemplate about the larger picture of how society spends its healthcare dollars. They will have to worry about whether the patient can afford the medication just prescribed, whether a proposed treatment will be covered by the insurance plan, where their patient is on the transplant waiting list, etc. How much the everyday clinician needs to factor allocation of resources into treatment recommendations (ie bedside rationing) is a controversial topic. The physician must resist the temptation to live by the dictum primum non expendere, and should stay focused on serving the best interests of the patient. However, it must be recognized that in deciding how to slice the healthcare cake, methods have been developed to find a rational basis for allocating resources. One method used by health economists is the QALY.

What is a QALY? The essence of a QALY (Quality Adjusted Life Year) is that it takes a year of healthy life expectancy to be worth 1, but a year of unhealthy life expectancy is regarded as <1. Its exact value is lower the worse the quality of life of the unhealthy person. If a patient is likely to live for 8 yrs in perfect health on an old drug, he gains 8 QALYs; if a new drug would give him 16 yrs but at a quality of life rated by him at only 25% of the maximum, he would gain only 4 QALYs. The dream of health economists is to buy the most QALYs for his budget. QALYs are helpful in guiding rationing, but problems include accurate pricing, the invidiousness of choosing between the welfare of different patients – and the problem of QALYs not adding up: If a vase of flowers is beautiful, are 10 vases (or QALYs) 10 times as beautiful – or might the scent be overpowering?

The inverse care law and distributive justice

Availability of good medical care tends to vary inversely with the need for it in the population served. This operates more completely where medical care is most exposed to market forces… The market distribution of medical care exaggerates maldistribution of medical resources.

There is much evidence in support of this thesis formulated by Tudor Hart, and there is no doubt that if one wants to make a positive contribution to health, it is no good just discovering pathways, blocking receptors, and inventing drugs. The more this is done, the more urgent the need for distributive justice – that unyielding and perpetually problematic benchmark against which all civilizations must, sometime or other, come to measure themselves.

Psychiatry on medical and surgical wards

Psychopathology is common in colleagues, patients, and relatives.

Current mental state. Gently probe a patient’s thoughts, as you might explore a new garden. What is in bloom now? Where do those paths lead? What is under that stone? Focus on: Appearance; speech (rate; content); affect (withdrawn? anxious? suspicious?); mood; beliefs; hallucinations; orientation; memory (recall of current events, president’s name); concentration. Note the patient’s insight and degree of your rapport. Observe non-verbal behavior.

Depression. This is common, and often ignored, at great cost to well-being. ‘I would be depressed in her situation…’, you say to yourself, and so you do not think of offering treatment. The usual biological guides (early morning awakening, change in appetite, loss of weight, fatigue, and loss of energy) are common on general wards. Screening questions for major depression are: ‘Are you depressed?’ If so, the follow up question, ‘Have you found that you aren’t enjoying activities that you normally enjoy doing, or that you have lost interest in doing much?’ If yes to both questions, there is a 95% chance the patient has depression. There may also be guilt and feelings of worthlessness. Do not neglect to ask the patient if they have thought about suicide or have passive death wishes. Don’t think it’s not your job to recognize and treat depression. It is as important as pain. Try to arrange activities to boost the patient’s morale and confidence, and encourage social interaction. Communicate your thoughts to other members of the team: Nurses, physical and occupational therapists – as well as the patient’s loved ones (if the patient wishes). Among these, your patient may find a kindred spirit who can give insight and support. Counseling, psychotherapy, and/or anti-depressants may be appropriate in some patients. If in doubt, try an antidepressant, and see if it helps.

Alcohol. This is a common cause of problems on the ward (both the results of abuse and the effects of withdrawal).

The violent patient. Ensure your own and others’ safety. Do not try to physically restrain violent patients until adequate help is available (eg hospital security guards). Prevent violence by being aware of its early signs, eg restlessness, earnest pacing, clenched fists, morose silences, chanting, or shouting. Try to keep your own intuitions alert to developing problems. Common causes: Alcohol intoxication, drugs (recreational or prescribed), hypoglycemia, acute confusional states. Once help arrives, try to talk with the patient to calm them – and to gain an understanding of their mental state. Find a nurse who knows the patient. Assess for causes of delirium by measuring oxygen saturation level and blood glucose, or give IV dextrose stat. If not hypoglycemic, before further investigation is possible, drugs may be needed, eg haloperidol ~2mg IM; monitor vital signs closely.

If a rational adult refuses vital treatment, it may be as well to respect this decision, provided they are ‘competent’, ie they are able to understand the consequences of their actions and what you are telling them, they are able to retain this information, and they can form the belief that it is true. Decision-making capacity is rarely all or nothing, so don’t hesitate to get the opinion of an attending physician or psychiatric consultant. Enlist the persuasive powers of someone the patient respects and trusts.

Physical restraints. Familiarize yourself with hospital policies, local procedures, and laws pertaining to the use of physical restraints. Consider sitters and chemical restraints before resorting to physical restraints. A confused, violent patient may need to be physically restrained to prevent harm to themselves or others. Reevaluate the need for restraints periodically.

Death: Diagnosis and management

Death is Nature’s master stroke, albeit a cruel one, because it allows genotypes space and opportunity to try on new phenotypes. Our bodies and minds are these perishable phenotypes – the froth, on the wave of our genes. These genes are not really our genes. It is us who belong to them for a few decades. As our neurofibrils begin to tangle, and a neonate walks to a wisdom that eludes us, we are forced to give Nature credit for her daring idea. Of course, Nature, in her haphazard way, can get it wrong: People often die in the wrong order (one of our chief roles is to prevent this misordering of deaths, not the phenomenon of death itself).

Causes of death. Homicide, suicide, accident, or natural causes.

Diagnosing death. The pronouncement of death is an important responsibility of the physician. The physical exam done to diagnose death is a key symbolic ritual that brings closure to the patient’s life and closure for the physician, members of the healthcare team, and most especially the patient’s family. Death is determined by the absence of pulse and respirations, no auscultated heart sounds, and fixed pupils.

If a patient is on a ventilator, brain death may be diagnosed even if the heart is still beating, via brain death criteria which entail the irreversible absence of brain function, particularly in the brainstem. Death of the brainstem is recognized by establishing the absence of cranial nerve and respiratory reflexes. The Uniform Determination of Death Act recognizes that death can be diagnosed by neurologic criteria. In addition to evidence of a catastrophic brain injury, the following prerequisite criteria must be met:

Deep coma with absent respirations (hence on a ventilator).

The absence of drug intoxication and hypothermia (<32°C).

The absence of hypoglycemia, acidosis, hepatic failure, and electrolyte imbalance.

Tests: For determination of brain death, the following tests should be performed by qualified personnel. Repeat the tests after a suitable interval – at least 6h, although sometimes 12-24h is required to confirm irreversibility of the coma. It is often recommended that a neurologist perform the confirmatory tests.

  • Tests to establish that brainstem reflexes are absent:
    • Unreactive pupils. Absent corneal response.
    • No oculocephalic reflex (Doll’s eye test).
    • No vestibulo-ocular reflexes, ie no eye movement occurs after or during slow injection of 60mL of ice-cold water into each ear canal in turn. Visualize the tympanic membrane first to eliminate false negative tests, eg due to wax.
    • No motor response within the cranial nerve distribution should be elicited by adequate stimulation, eg absent facial grimacing when pressing on supraorbital ridge.
    • No gag reflex or response to bronchial stimulation with a catheter to the level of the carina.
  • Additional tests:
    • No spontaneous or reflex motor responses to noxious stimuli. There should also be no autonomic response to noxious stimuli or vagal stimulation. Spinal reflexes are not relevant to the diagnosis of brain death.
    • Positive Apnea test: No respiratory effort in response to hypercarbia. A tube is inserted through the endotracheal tube to the level of the carina in order to deliver continuous oxygen at a rate of 2-4L/min. The ventilator is disconnected, allowing PaCO2 to rise to ≥60mmHg or more (for patients with COPD, a rise of 20mmHg above their baseline). PaCO2 typically rises at a rate of 3mmHg per minute. Patients should be monitored for any hemodynamic instability during the test, and the test should be stopped if SBP falls by ≥20%, cardiac arrhythmias emerge, or the patient becomes hypoxic.

Other considerations: Ancillary studies may be needed when the prerequisite criteria cannot be met, eg the patient is receiving sedative or anesthetic infusions. An EEG recording is not a standard requirement, unless brain death is to be diagnosed within 6 h of apparent cessation of brain activity. Cerebral blood flow studies, eg with isotope angiography, are helpful when the patient is receiving treatments that suppress cerebral metabolic activity.

Organ donation: The point of diagnosing brain death is partly that this allows organs (kidney, liver, cornea, heart, or lungs) to be donated and removed with as little damage from hypoxia as possible. Do not avoid the topic with loved ones. Many are glad to give consent and to think that some good can come after the death of their relative, that some part of the relative will go on living, giving a new life to another person.

After death. Inform the patient’s attending and consultants. Meet with the patient’s next of kin and offer emotional support. Ask if they want an autopsy. Autopsy permission may be granted (in order of priority) by: Spouse, adult child, parent, sibling. Sign death certificates promptly. If DOA or within 24h of admission, or the cause is violence, trauma, accident, neglect, surgery, anesthesia, therapeutic mishap, drug/alcohol overdose, suicide, poisoning, or is unknown or suspicious, inform the Coroner/Medical Examiner.

Facing death

People imagine that they are not afraid of death when they think of it while they are in good health (Marcel Proust). So, to get into the mood, as a thought experiment, place a finger in your left supraclavicular fossa, and feel there the craggy node of Virchow, telling of some distant gastric malignancy, as if it were your death warrant. Perhaps you have just 4 months left. Live with this ‘knowledge’ for the rest of the day, or rest of the week, and see how it changes your attitude to family and friends on the one hand, and the million irrelevances which clutter our minds on the other. As the week unfolds, you may experience thoughts and feelings that are new to you, but all too familiar to your patients. And as the months and years roll by, and you find yourself sitting opposite certain patients, put that finger once more on that metaphorical node and turn it over in your mind, and it will turn you, so you are sitting not opposite your patient but beside him. There is only so much comfort you can bring in this way, as, in the end, you cannot tame death.

Whenever you find yourself thinking it is better for them not to know, suspect that you mean: It is easier for me not to tell. We find it hard to tell for many reasons: It distresses patients; it may hold up a ward round; we do not like acknowledging our impotence to alter the course of diseases; telling reminds us of our own mortality and may unlock our previous griefs. We use many tricks to minimize the pain: Rationalization (‘They would not want to know’); intellectualization (‘Research shows that 37% of people at stage 3 survive 2 years…’); brusque honesty (‘You are unlikely to survive 1 month’ and, so saying, the doctor rushes off to more vital things); inappropriate delegation (‘The nurse will explain it all to you when you are calmer’).

Why it may help the patient to be told:

  • The patient already half knows but everyone shies away so they cannot discuss their fears (of pain, or that their family will not cope).
  • There may be many affairs for the patient to put in order.
  • To enable them to judge if unpleasant therapy is worthwhile.

Most patients are told less than they would like to know.

Breaking bad news. Being able to deliver bad news compassionately and effectively is one of the most important skills of the physician. While each discussion must be individualized to the particular patient, some general principles have been recommended. These have been encapsulated in the mnemonic SPIKES1:

  • Setting the stage: Sit down. Arrange for privacy. Avoid interruptions.
  • Patient’s perceptions: What does the patient know about the situation?
  • Invitation for information: How does the patient want to be given information? Patients may either desire or shun information.
  • Knowledge: Giving a warning shot before providing information, ‘I’m sorry to tell you that …’ Use language that the patient can understand.
  • Emotions: Acknowledge emotions and offer empathetic statement, ‘I can see that this is upsetting to you.’
  • Summary and strategy: Review discussion and set agenda based on goals of care. Address any lingering misunderstanding, uncertainty, or fears.

What are the patient’s worries likely to be? Put yourself in the patient’s place.

  • Give some information, and then the opportunity to ask for more.
  • Be sensitive to hints that they may be ready to learn more. ‘I’m worried about my son’. ‘What is worrying you most?’ ‘Well, it will be a difficult time for him, (pause) starting school next year.’ Silence, broken by the doctor ‘I get the impression there are other things worrying you.’ The patient now has the opportunity to proceed further, or to stop. Ensure that the patient’s personal physician and the nurses know what you have and have not said. Also make sure that this is written in the notes.

Stages of acceptance. Accepting death takes time, and may involve passing through ‘stages’ on a path. It helps to know where your patient is on this path (but progress is rarely orderly and need not always be forward: The same ground often needs to be covered many times). At first there may be shock and numbness, then denial (which reduces anxiety), then anger (which may lead you to dislike your patient, but anger can have positive attributes, eg in energizing people – and it can trump fear and pain; it is different from hostility), then grief, and then, perhaps, acceptance. Finally there may be intense longing for death as the patient moves beyond the reach of worldly cares.

Living wills/advance directives. If a patient has the capacity to make their own decisions, then they should be asked directly what their treatment preferences are. If a patient lacks capacity and their views are known, comply with them. Some patients spell out their views in a written document. But these views change, are ambiguous, or are hard to interpret, even if a living will exists. Living wills only take effect when the patient is terminally ill. In many cases, there can be uncertainty or disagreement about whether to invoke the living will because it is not clear that the patient is ‘absolutely, hopelessly ill’.

If a patient desires to complete an advance directive, it is often more preferable to have the patient designate a durable power of attorney for healthcare or healthcare agent – a person who will speak for the patient if the patient is too ill to speak for himself. Designation of a healthcare agent can also be fraught with difficulties, especially if the named surrogate has not had a prior discussion with the patient about their wishes.

Perhaps the best strategy is to focus less on completion of the advance directive form and more on the discussion involved in advance care planning. This will be an ongoing process with the patient, reviewing the goals of care in light of the changing clinical situation and the patient’s hopes, fears, prognosis, quality of life, loved ones’ wishes, and underlying values.

Surviving residency

If some fool or visionary were to say that our aim should be to produce the greatest health and happiness for the greatest number of our patients, we would not expect to hear cheering from the tattered ranks of midnight housestaff: Rather, our ears are detecting a decimated groan – because these men and women know that there is something at stake in a housestaff training program far more elemental than health or happiness: Namely survival. Here we are talking about our own survival, not that of our patients. It is hard to think of a greater peacetime challenge than these first months on the wards. Within the first weeks, however brightly your armor shone, it will now be smeared and splattered, if not with blood, then with the fallout from very many decisions that were taken without sufficient care and attention. Not that you were lazy, but force majeure on the part of Nature and the exigencies of ward life have, we are suddenly stunned to realize, taught us to be second-rate: For to insist on being first-rate in all areas is to sign a kind of death warrant for many of our patients, and, more pertinently for this page, for ourselves. Perfectionism cannot survive in our clinical world. To cope with this fact, or, to put it less depressingly, to flourish in this new world, don’t keep repolishing your armor (what are the 10 causes of atrial fibrillation – or are there 11?), rather furnish your mind – and nourish your body (regular food and drink make those midnight groans of yours less intrusive). Do not voluntarily deny yourself the restorative power of sleep.

We cannot prepare you for finding out that you do not much like the person you are becoming, and neither would we dream of imposing on our readers a recommended regimen of exercise, diet, and mental fitness. Finding out what can lead you through adversity is the art of living. What will you choose: Physical fitness, music, martial arts, poetry, the sermon on the mount, juggling, meditation, yoga, a love affair – or will you make an art form out of the ironic observation of your contemporaries?

Many nourish their inner person through a religious belief, and attend mosque, church, synagogue, or temple. A multicultural society provides diversity and room for all branches of expression. Bear in mind not to compare yourself with your contemporaries. Those who make the most noise are often not waving but drowning. Plan your recreation in advance. Start thinking about what you will do after your training and seek out an advisor and mentor in the specialty you select. Such inquiries supply energy to get you through the long, though now limited, hours of residency, and may motivate you if the going gets tough. Not that this is any guarantee that the plans will work, but if your yoga, your sermons, and your fitness regimens turn to ashes in your mouth, then at least you will know the direction in which to spit.

Residency is not just a phase to get through and to enjoy where possible (there are frequently many such possibilities); it is also the anvil on which we are beaten into a new and perhaps rather uncomfortable shape. Luckily not all of us are made of iron and steel so there is a fair chance that, in due course, we will spring back into something resembling our normal shape, and, in so doing, we may come to realize that it was our weaknesses, not our strengths, which served us best.

Residency can encompass tremendous up-and-down swings in energy, motivation, and mood, which can be precipitated by small incidents. If you are depressed for more than a day, speak to a sympathetic friend, partner, or counselor to help you put it in perspective. Seek help for your own problems. Find professional help if needed. You are not the best person to plan your assessment, treatment, and referral. When in doubt, communicate.

On being busy: Corrigan’s secret door

Unstoppable demands, ↑ expectations as to what medical care should bring, the rising number of elderly patients, coupled with the introduction of new and complex treatments all conspire, it might be thought, to make doctors ever busier. In fact, doctors have always been busy people. Sir Dominic Corrigan was so busy 150 yrs ago that he had to have a secret door made in his consulting room so that he could escape from the ever-growing waiting room of eager patients.

We are all familiar with the phenomenon of being hopelessly over-stretched – and of needing Corrigan’s secret door. Competing, urgent, and simultaneous demands make carrying out any task all but impossible: The resident is trying to put up an intravenous infusion on a hypotensive patient when his pager goes off. On his way to the phone a patient is falling out of bed, being held in, apparently, only by his visibly lengthening catheter (which had taken the house officer an hour to insert). He knows he should stop to help but, instead, as he picks up the phone, he starts to tell the nurse about ‘this man dangling from his Foley’ (knowing in his heart that the worst will have already happened). But he is interrupted by a thud coming from the bed of the lady who has just had her occluded left anterior descending artery attended to: However, it is not her, but her visiting husband who has collapsed and is now having a seizure. At this moment a Code Blue is called, summoning him to some other patient. In despair, he turns to the nurse and groans: ‘There must be some way out of here!’ At times like this we all need Corrigan to take us by the shadow of our hand, and walk with us through his metaphorical secret door, into a calm inner world. To enable this to happen, make things as easy as possible for yourself.

First, however lonely you feel, you are not alone. Do not pride yourself on not asking for help. If a decision is a hard one, share it with a colleague. Second, take any chance you get to sit down and rest. Have a cup of coffee with other members of the staff, or with a friendly patient (patients are sources of renewal, not just devourers of your energies). Third, do not miss meals. If there is no time to go to the cafeteria, ensure that food is put aside for you to eat when you can: Hard work and sleeplessness are twice as bad when you are hungry. Fourth, avoid making work for yourself. It is too easy for physicians in training, trapped in their image of excessive work and blackmailed by misplaced guilt, to remain on the wards following up on patients, rewriting notes, or rechecking lab results at an hour when the priority should be caring for themselves. Fifth, when a bad part of the rotation is looming, plan a good time for when you are off duty, to look forward to during the long nights.

Finally, remember that however busy the call day (and night), your period of duty will end. For you, as for Macbeth:

Come what come may, Time and the hour runs through the roughest day.

Bike

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My son Marko Maksimovich is a keen bicycle rider.

There he goes practicing on the Matopos Road, Bulawayo, Zimbabwe.

DPPC Shooting

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I made a comment about the peritonsillar abscess at the otohns list. Recently read that comment again and cannot resist the urge to re-publish on this blog here.

Here comes:

Regards all!

So up to now we saw a rich doctor’s approach to peritonsillar abscess, thereafter somebody from a not so developed country etc.

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Good Books?!?

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Best Books

Here are 64 books from the 1117 reviewed that have particularly impressed me, divided into fiction and nonfiction lists. They can also be found in the other indices, marked with a “**”.

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http://www.sino-platonic.org/abstracts/spp122_chinese_africans.html

Mensa Invitational – A Work Of Literary Genius

The Washington Post’s Mensa Invitational once again asked readers to take any word from the dictionary, alter it by adding, subtracting, or changing one letter, and supply a new definition.

Here are the winners:

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