THIS WEEK
EDITORIALS
1385 In praise of the physical examination 1386 Secret remedies: 100 years on 1387 World hunger: a reasonable proposal 1388 Where have all the hospital flowers gone?
YEARS LIKE THIS
1390 A journal of the plague year 1392 Sod’s law applied to medicine 1394 Patent medicines and secret remedies 1396 I should cocoa 1397 The Spanish flu through the BMJ’s eyes 1399 BMJ archive: the videos 1400 Ingested foreign bodies and societal wealth: study of swallowed coins
DIAGNOSIS
1402 Fatal alchemy 1404 Lead poisoning at the Swedish House 1406 Stigma and prejudice in Tintin 1408 Animated ophthalmology 1410 Lying obliquely—a sign of cognitive impairment 1413 Darwin’s illness revisited 1416 House calls 1417 George Clooney, the cauliflower, the cardiologist, and phi, the golden ratio
ANAESTHESIA
1418 Painless amputation 1420 Autoappendicectomy in the Antarctic 1422 Prescriber’s narcophobia syndrome
CHRISTMAS FAYRE
1423 Christmas quiz 1424 Santa Claus: a public health pariah? 1426 Ethical dilemma
MUSICAL INTERLUDE
1427 Django’s hand 1429 Listening to Nellie the Elephant during CPR training in lay people
YOUNG AND OLD
1432 Association of early IQ and education with mortality: 65 year longitudinal study 1433 Perceived age as clinically useful biomarker of ageing 1435 Attitudes to ageing in the Economist: apocalyptic demography for opinion formers?
AFTERLIFE
1438 Silent virtuous teachers 1440 From flower graves to breast clinics
PROFESSIONAL MATTERS
1441 Brain maps 1442 Wards of the roses 1444 Selling patients 1447 H-index pathology 1448 Christmas quiz: answers 1449 Evidence based merriment 1450 The Surgical Sieve
BMJ | 19-26 DECEMBER 2009 | VOLUME 339
editor’s choice
rob white
Thinking caps on for the archive issue
When I was a medical student a helpful anaesthetist explained that surgeons wore caps in theatre to stop the bright lights from transilluminating their skulls. Now an anaesthetist has lifted the lid and discovered that surgeons have brains very similar to those of higher primates, with surprisingly complex wiring. Apparently, anaesthetists’ brains differ markedly from surgeons’ (p 1441). Who would have thought? While this is brand new research, readers will discover many articles in this issue with a historical theme—intentionally chosen to mark the year that our complete archive (1840-
2009) was made available online. We’ve included a short description of the nine videos we commissioned to bring to life some of the important figures from the archive (p 1399). They’re viewable free at bmj. com/videos. And we publish the winners of our £1000 prize for the most interesting use of the archive. Tom Jefferson and Eliana Ferroni reviewed what the BMJ published on the Spanish flu 1918-1924, unearthing observations that may have lessons for today (p 1397). A quick glance at our editorials might suggest that this fixation on the past includes an unhealthy dollop of nostalgia—for a time when junior doctors could recognise whispering pectoriloquy (p 1385) and Nurse would gladly stick a bunch of flowers in a vase (p 1388). But David Colquhoun uses the centenary of the publication of Secret Remedies (p 1394) to urge us to look hard at the efficacy of medicines, now (p 1386). His editorial is timely, given that too many at the top of British medicine
seem frozen in the headlights of the complementary medicine bandwagon. He describes a recent session of the House of Commons Science and Technology Committee, devoted to homoeopathy, as “pure comedy gold.” We usually reject articles suggesting diagnoses for the illustrious dead because the hypotheses are untestable, and armchair diagnosticians usually come up with some equally plausible alternative within a year or two. But we’ve made an exception for Charles Darwin in his anniversary year (p 1413). John Hayman’s hypothesis that he had a mitochondrial disorder could be tested by checking descendants of his female relatives for the suspected genetic abnormality. We’ve included articles about possible causes of death of Diane de Poitiers (p 1402) and 17 Norwegian sealers (p 1404) but in these cases there was some tissue to analyse. Both have accompanying videos on bmj.com/videos.
For one year only, we’ve suspended our prohibition against publishing spoofs in the Christmas BMJ. I’m not revealing which article it is, but I can tell you that not all BMJ editors and outside reviewers spotted it. And for those of you who would like to stretch themselves mentally after a heavy Christmas meal, we have a short pathology quiz (p 1423). Tony Delamothe, deputy editor, BMJ
[email protected] Cite this as: BMJ 2009;339:b5471
GRAHAM BIGNELL & RICHARD ARDAGH NEW NORTH PRESS/02077293161
Articles appearing in this print journal have already been published on bmj.com, and the version in print may have been shortened.
Meet the experts. masterclasses.bmj.com
BMJ | 19-26 DECEMBER 2009 | Volume 339
Editorials represent the opinions of the authors and not necessarily those of the BMJ or BMA
EDITORIALS
For the full versions of these articles see bmj.com
In praise of the physical examination
SIMON FRASER/SPL
It provides reason and ritual
Abraham Verghese, professor and senior associate chair for the theory and practice of medicine
[email protected] Ralph I Horwitz, chair of the department of medicine and Arthur Bloomfield professor of medicine, Department of Medicine, S102, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305-5110, USA Competing interests: The authors have both served terms as directors of the American Board of Internal Medicine. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2009;339:b5448 doi: 10.1136/bmj.b5448
If an alien anthropologist were to visit a modern teaching hospital, “it” might conclude that, judging by where doctors spend most of their time, the business of an internal medicine service takes place around computer terminals. The alien might assume that the virtual construct of the patient, or the “iPatient”,1 is more important than the flesh and blood human being occupying the bed. But the alien would be wrong—patients are what medical care is all about. Yet the electronic medical record and advanced imaging technology have not only seduced doctors away from the bedside but also devalued the importance of their role there. Indeed, intensive care units exist where consultants conduct their “rounds” on the patients and adjust ventilator settings and drugs via telemetry.2 These trends have left educators and trainees in internal medicine in two camps when it comes to the merits of the bedside examination. In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time. We believe that the truth is somewhere in between. We argue that clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, The Stanford 25 1 Funduscopic examination for papilloedema, etc, using panoptic and regular ophthalmoscopes 2 Examination of the pupillary responses and relevant anatomy 3 Examination of the thyroid 4 Examination of neck veins/jugular venous distension for both level (volume) and common abnormal wave forms 5 Examination of the lung, including surface anatomy, percussion technique, identifying upper border of the liver, finding Traube’s space 6 Evaluation of point of maximal cardiac impulse, parasternal heave, and other precordial movements 7 Examination of the liver 8 Palpation and percussion of the spleen 9 Evaluation of common gait abnormalities 10 Eliciting ankle reflexes, including in a recumbent patient 11 Ability to list, identify, and demonstrate stigmata of liver disease, from head to foot
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such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test. In the United States, after a three year residency, trainees can become certified by the American Board of Internal Medicine on the basis of a multiple choice test—an examination that has been standardised and well studied. Because the oral clinical examinations of the past, in which external examiners assessed a doctor’s skills at the bedside, were viewed as subjective and not standardised, assessment of such skills was left in the hands of training programme directors, who themselves were ill prepared to conduct the test or be truly objective about their own trainees. Without a high stakes clinical examination looming over them, the bedside skills of trainees atrophy. In short, we now certify internists in the US without an external benchmark that ensures that they can find a spleen, elicit a tendon reflex, detect fluid in a joint, or detect a large pleural effusion by percussion. If the public fully understood this, they would be shocked. The good news is that in our experience, house staff and junior faculty members are eager to improve their skills at the bedside. They recognise that the clinical examination has value and that it is necessary, particularly because so many of our students and residents have some experience in practising abroad in resource poor settings, where the value of such skills is more obvious. Often they understand the theory of a physical diagnostic manoeuvre but their technique is lacking. To this end we have developed the “Stanford 25,” a list of 25 technique dependent physical diagnostic manoeuvres that we teach to our trainees.3 On the list are items such as the funduscopic examination, the thyroid examination, the study of jugular venous pressure and wave forms, and the performance of the Achilles tendon reflex in a bedridden patient—the last is a great example 12 Ability to list, identify, and demonstrate common physical findings in internal capsule stroke 13 Examination of the knee 14 Auscultation of second heart sounds, including splitting, wide splitting, and paradoxical splitting 15 Evaluation of involuntary movements such as tremors 16 The hand in diagnosis: recognise clubbing, cyanosis, and other common nail and hand findings 17 The tongue in diagnosis 18 Examination of the shoulder, specifically testing for rotator cuff tears, the acromioclavicular joint etc 19 Assessment of blood pressure; identifying pulsus paradoxus 20 Assessment of cervical lymph nodes 21 Detection of ascites and abdominal venous flow 22 Rectal examination 23 Evaluation of a scrotal mass 24 Cerebellar testing 25 Bedside ultrasonography
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EDITORIALS
of a technique dependent manoeuvre. It is a skill to get the patient to relax, to position the leg properly, and to strike the tendon correctly to elicit a reflex (and it also takes a tendon hammer, which, unlike the ubiquitous stethoscope, is often missing from the pocket of the trainee’s white coat). The Stanford 25 teaches trainees 25 useful manoeuvres, while helping them recognise how nuanced some of these tests are. It also gives junior faculty members a repertoire of skills to teach when they are at the bedside. A third view of the bedside examination, and one that we advocate, is that it is not just a means of data gathering and hypothesis generation and testing, but is a vital ritual, perhaps the ritual that defines the internist. Rituals are all about transformation. The elaborate rituals of weddings, funerals, or inaugurations of presidents are associated with visible transformation. When viewed in that fashion, the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic), wearing ritualised garments (patient gowns and white coats for the doctors)
and with ritualised instruments, and most importantly, the patient undresses and allows the doctor to touch them. Disrobing and touching in any other context would be assault, but not as part of this ritual, which dates back to antiquity. We propose that if the ritual is short changed, if it is done in a cursory fashion, if it not done with skill and consideration, if its sacredness seems to be violated, then the transformation (which in this case is the formation of the doctor-patient bond, the beginning of a therapeutic partnership and the healing process) does not take place. We believe that the failure to form that bond could account for a great deal of the dissatisfaction patients express and doctors feel about their encounter. 1 2
3
Verghese A. Culture shock—patient as icon, icon as patient. N Engl J Med 2008;359:2748-51. Breslow MJ, Rosenfeld BA, Doerfler M, Burke G, Yates G, Stone DJ, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med 2004;32:31-8. Stanford School of Medicine. Stanford initiative in bedside medicine. http://medicine.stanford.edu/education/stanford_25.html.
Secret remedies: 100 years on Time to look again at the efficacy of remedies
DIAGNOSIS, p 1394
David Colquhoun research professor, Department of Pharmacology, University College London, London WC1E 6BT
[email protected] Competing interests: DC held the AJ Clark chair of pharmacology at UCL from 1985 to 2004. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2009;339:b5432 doi: 10.1136/bmj.b5432
In the linked feature, Jeffrey Aronson describes how the BMA, BMJ, and politicians tried a century ago to end the marketing of secret remedies.1 They didn’t have much success. Forty years after their endeavours, A J Clark (professor of pharmacology at University College London and later at Edinburgh) could still write, “the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”2 Clark himself was sued by a peddler of a quack cure for tuberculosis for writing that: “‘Cures’ for consumption, cancer, and diabetes may fairly be classed as murderous.” Although he fought the libel case, impending destitution eventually forced him to apologise.3 Clark’s claim in 1927 that: “some travesty of physical science appears to be the most popular form of incantation”4 is even truer today. Homoeopaths regularly talk nonsense about quantum theory, and “nutritional therapists” claim to cure AIDS with vitamin pills. Some of their writing is plain delusional, but much is a parody of scientific writing, in a style that Ben Goldacre calls “sciencey.”5 It reads quite plausibly until you check the references. One hundred years on from the abortive efforts to crack down on patent remedies, we need to look again at the effiGlossary10 • Acupuncture: a rather theatrical placebo, with no real therapeutic benefit in most, if not all, cases • Herbal medicine: giving patients an unknown dose of an ill defined drug, of unknown effectiveness and unknown safety • Homoeopathy: giving patients medicines that contain no medicine whatsoever
1386
cacy of remedies. Indeed the effort is well under way, but this time it takes a different form. The initiative has come largely from an “intrepid, ragged band of bloggers” and several journalists, helped by scientific societies. It hasn’t been helped by the silence of the BMA, the royal colleges, the Department of Health, and a few vice chancellors.. Even the National Institute for Health and Clinical Excellence (NICE) and the Medicines and Healthcare Products Regulatory Agency (MRHA) could be helping more. The response of the royal colleges to the resurgence in magic medicine that started in the 1970s looks to me like embarrassment. They avoided the hard questions by setting up committees (often populated with known sympathisers) so as to avoid having to say “baloney.” The Department of Health, equally embarrassed, refers the hard questions to the Prince of Wales’ Foundation for Integrated Health. It was asked to draft “national occupational standards” for make believe subjects like “naturopathy”6). Two recent examples illustrate the problems. Take first the Pittilo recommendations for statutory regulation of acupuncture and herbal and traditional Chinese medicine.7 8 The Pittilo report recommended official recognition by statutory regulation and entry by honours degree. But you cannot start to think about a sensible form of regulation unless you first decide whether or not the thing you are trying to regulate is nonsense. This idea, however, is apparently lost on the Department of Health and the authors of the Pittilo report. Fortunately, consultation on statutory regulation has attracted many submissions that point out the danger to patients of appearing to give official endorsement to treatments that have no proper evidence base. The Royal College of Physicians seems to have experienced a major change of heart: its submission points out with admirable clarity that the statutory regulation of things that don’t work endangers BMJ | 19-26 december 2009 | Volume 339
EDITORIALS
patients (though they still have a blind spot about the evidence for acupuncture, partly as a result of the recent uncharacteristically bad assessment of the evidence by NICE). Such enlightenment doesn’t extend to the Prince of Wales, who made a well publicised intervention on behalf of herbalists after the public consultation closed.9 The other example concerns the recent “evidence check: homeopathy” conducted by the House of Commons Science and Technology Select Committee (SCITECH). Oliver Wendell Holmes said all that needs to be said about medicine-free medicines in his 1842 essay, Homeopathy and its Kindred Delusions11 So it is nothing short of surreal to find the UK parliament still discussing it in 2009. The committee’s proceedings are worth watching, if only to see the admirably honest admission by the professional standards director of Boots that they sell homoeopathic pills without knowing whether they work.12 But for pure comedy gold, there is nothing to beat the final session. The health minister Michael O’Brien was eventually cajoled into admitting that there was no good evidence that homoeopathy worked but defended the idea that the taxpayer should pay for it anyway. The chief scientific advisor in the Department of Health, David Harper, was not so straightforward. After some evasive answers the chairman, Phil Willis, said, “No, that is not what I am asking you. You are the department’s chief scientist. Can you give me one specific reference which supports the use of homoeopathy in terms of government policy on health?” One is tempted to quote Lewis Carroll “but answer came there none.” There were words, but they made no sense. Then at the end of the session Harper said, “homeopathic practitioners would argue that the way randomised clinical trials are set up, they do not lend themselves necessarily to the evaluation and demonstration of efficacy of homeopathic remedies.” Earlier, Kent Woods (chief execu-
tive officer of the MHRA) had said, “the underlying theory does not really give rise to many testable hypotheses.” Why not? The hypotheses are testable, and homeopathy— because it involves pills—is particularly well suited to testing by proper randomised controlled trials.13 It isn’t hard to do better than that. “Imagine going to an NHS hospital for treatment and being sent away with nothing but a bottle of water and some vague promises,” wrote the Sun’s health journalist Jane Symons recently.14 “And no, it’s not a fruitcake fantasy. This is homeopathy and the NHS currently spends around £10m on it.” It isn’t often that a Murdoch tabloid produces a better account of a medical problem than anything the Department of Health’s chief scientific advisor can muster. 1 2 3 4 5 6 7
8 9 10 11 12 13 14
Aronson JK. Patent medicines and secret remedies. BMJ 2009;339:b5415. Colquhoun D. Patent medicines in 1938 and now: AJ Clark’s book. 2008. www.dcscience.net/?p=257. Clark D. Alfred Joseph Clark. A memoir. C & J Clark, 1985. Clark AJ. The historical aspect of quackery. BMJ 1927 October 1. Goldacre B. Bad science. Harper Collins, 2008. Skills for Health. http://bit.ly/6wDdUL. Report to Ministers from the DH Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine Systems Practised in the UK. 2009. www.dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/documents/digitalasset/dh_086358.pdf. Colquhoun D. A very bad report: gamma minus for the vice-chancellor. 2008. www.dcscience.net/?p=235. BBC News. Prince Charles: “Herbal medicine must be regulated.” 2009 December 1. http://news.bbc.co.uk/1/hi/health/8388985.stm. Colquhoun D. Patients’ guide to magic medicine. www.dcscience. net/?page_id=733. Holmes OW. Homeopathy and its kindred delusions. 1842. www. homeoint.org/cazalet/holmes/index.htm. House of Commons Science and Technology Committee. Evidence check: homeopathy. 2009. www.viewista.com/s/fywlp2/ez/1 . Goldacre B. A kind of magic. Guardian 2007 November 16. www. guardian.co.uk/science/2007/nov/16/sciencenews.g2. Symons J. Homeopathy is draining resources. Sun 2009 December 3. www.thesun.co.uk/sol/homepage/woman/health/health/2755952/ Homeopathy-is-resources-drain-says-Jane-Symons.html.
World hunger: a reasonable proposal
BRUCE HANDS/GETTY IMAGES
Commodity markets explain why so many are going hungry in a world of plenty
Cite this as: BMJ 2009;339:b5209 doi: 10.1136/bmj.b5209
Last year saw 250 million people added to the ranks of the starving and malnourished, pushing the world total past one billion, or one in every six people on the planet.1 As I read reports of the dramatic upsurge I was reminded of a rainy afternoon in Cambridge two summers ago, when I interviewed Amartya Sen, the Harvard professor who had won the Nobel prize for economics in 1998 for his work on poverty and famine. According to Sen, hunger was not only entirely preventable but profoundly unreasonable. I had come to Amartya Sen’s house to discuss the recent efforts of the Bill and Melinda Gates Foundation and the World Food Programme to help eradicate world hunger by means of a new programme, called Purchase for Progress. And while our discussion began with the specifics of global food aid, it eventually ranged beyond the particulars of poverty. “I believe in reason,” Sen told me. “There are those who want to repress reason: Christian, Muslim, and Hindu fun-
BMJ | 19-26 december 2009 | Volume 339
damentalists, and those who pick a totem market economy, the liberal economic state. These are all anti-reason.” Ironically, at the time of my visit to Cambridge the world’s markets were in the throes of one of the greatest food commodity bubbles of all times, a deeply unreasonable surge of speculation that had already doubled the costs of wheat, rice, corn, cooking oil, and numerous other staples and sparked food riots in 39 countries across the globe. Such price spikes in world food markets had little basis in rationality—the wheat harvest of 2008 eventually proved larger than any wheat harvest in human history. But the damage had been done—a quarter of a billion more people had been relegated to a status the “hungercrats” euphemistically call “food insecurity.” As world hunger numbers rocketed, the Gates Foundation and the World Food Programme continued to back Purchase for Progress, which has made a totem market economy a panacea for starvation. It is common knowledge 1387
EDITORIALS
Frederick Kaufman professor, City University of New York Graduate School of Journalism is 219 West 40th Street, New York, NY 10018, USA
[email protected] Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed.
that markets do not always behave rationally, but that has not stopped one of the world’s premier capitalists and the world’s largest humanitarian organisation from pursuing various strategies to foster more robust grain markets in the world’s least developed countries. Indeed, one of their chief anti-hunger efforts centres around the creation of commodity markets.2 How can commodity markets resolve the tragedy of world hunger? In theory, the forward contracting methods developed by Purchase for Progress will give small farmers the opportunity to arbitrage—and thus stabilise—prices for their product. Instead of all farmers going to market at the same time of year, and thus driving post-harvest grain prices lower and lower, Purchase for Progress will provide the farmers of least developed countries a guaranteed sales price in advance of their harvest. Such price guarantees will provide a measure of financial security; collatoral for loans from local bankers; and thus the opportunity to purchase fertiliser, farm equipment, and perhaps even some day labour for the upcoming harvest. All this may sound like a pretty good idea, but programmes like Purchase for Progress take for granted the idea that free market dynamics can transform the indigent peasant into a bona fide agribusinessman, and that assured future sales of grain will increase output, help alleviate local conditions, and thus mitigate world hunger. But as the titans of global food aid seek solutions to mankind’s greatest health threat—a hunger related death every four seconds—they may do well to remember Amartya Sen’s warning and retain a healthy scepticism regarding the worship of a totem market economy. Free markets may have worked well for oligopolists like Bill Gates, but the World Food Programme cannot simply will them into existence. In fact, the imposition of commodity markets within the world’s least developed countries has a history of failure.3 It took hundreds of years for modern commodity markets to develop in London, Chicago, and New York, and these markets rode the back of heavy investments in infrastructure, transportation networks, and agricultural education. The Chicago Board of Trade may have facilitated American
farmers, grain storers, and millers in their efforts to produce and manage grain surpluses, but futures markets cannot resolve the intractable political, economic, and social ills of— for example, Uganda or Guatemala, and provide a short cut to food security. Such programmes will benefit bankers more than farmers, and perhaps further alienate the rulers from the ruled, an alienation that lies at the heart of hunger. Indeed, the dirty secret of world hunger is that the creation of a grain surplus is no solution. There is plenty of food on earth, more than double that needed to feed all 6.5 billion of us.4 The problem is not food availability, but price. People starve when the daily pay check doesn’t cover the daily bread. All of which is not to say that small farmers do not need our help. But instead of installing futures markets and teaching the nuances of arbitrage, Bill Gates and the World Food Programme might consider expending their manifold resources on emergency income creation and employment programmes. Perhaps even more important, small farmers and landless peasants need to be supported in their efforts to gain political voice and power. As Amartya Sen has often pointed out, there has never been a famine in a representative democracy.5 A political voice is often the shortest path to a full stomach. Finally—strange as it may seem—the best early warning system for a hunger crisis is not a futures market but a free press. Rulers do not like to see their starving subjects on the front page. Gates and the World Food Programme could spend their money to much better effect than on a programme like Purchase for Progress, because the totemic worship of liberal free market economics is not a reasonable solution to world hunger. And in this particular case, not being reasonable has fatal consequences. 1 2 3 4 5
Food and Agriculture Organization of the United Nations. The state of food insecurity in the world 2009. FAO, 2009. Kaufman F. let them eat cash. Harpers 2009;318:51-9. Adebusuyi BS. The stabilisation of commodity markets of interest to Africa. 2004. www.g24.org/Adebusuyi.pdf. McNeil DG. Malthus redux: is Doomsday upon us again? New York Times 2008 June 15. http://www.nytimes.com/2008/06/15/world/ americas/15iht-15mcneil.13714561.html. Sen A. Nobody need starve. Granta 1995;52:213-20.
Where have all the hospital flowers gone? They have fallen victim to new definitions of care PROFESSIONAL MATTERS, p 1442
Simon Cohn medical anthropologist, General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge University, Cambridge CB2 0SR
[email protected] Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2009;339:b5406 doi: 10.1136/bmj.b5406 1388
Christmas is a time for giving, so it is timely to consider the reasoning behind the extensive and growing ban on giving flowers to patients in hospital. The article by Giskin Day and Naiome Carter describes how both individual wards and entire hospitals are using their discretion to prohibit flowers on the ward, in the absence of any official ruling from the Department of Health.1 It is undoubtedly causing consternation for patients and visitors alike. The reasons for such prohibitions are varied, something that should immediately make us curious. As Day and Carter point out, some argue that it is about reducing the risk of injury from broken glass, or avoiding the depletion of oxygen in the air from decomposing
material, or even avoiding water spillage over modern electronic equipment. In addition, some staff cite the inconvenience of changing water regularly and the problems of disposing of dead flowers. Unsurprisingly, in the context of invigorated concern around hospital cleanliness, the most common explanation relates to hygiene—that either the flowers themselves, or the water in their vases, carry a risk of infection. However, none of these explanations has a secure evidence base. Although it is not surprising to learn that flower water can contain bacteria,2 3 rigorous studies have emphatically concluded that bedside flowers pose no particular threat to health.4 But what is of interest is just how widespread the bans are, despite the evidence. BMJ | 19-26 december 2009 | Volume 339
EDITORIALS
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Post hoc rationalisations of practices seem, by definition, logical and sensible—using partial bits of knowledge to mask, often from the protagonists themselves, the fact that an a priori decision was based not on facts but on values. For this reason, even compromises such as those Day and Carter present—for example, specifying the best kind of flowers or designating a shared common place—are no less perplexing, because they indirectly reinforce the idea that flowers are essentially inconvenient or pose some kind of hazard. Of course, this may not seem particularly important for hospital staff in the context of their extensive responsibilities, and we should be sympathetic to this. But the matter is important to patients and their visitors. The point about giving is that it reinforces meaningful relationships of love and friendship.5 And hospital gifts are perhaps even more nuanced than this. Firstly, the gifts are traditionally ephemeral in nature—whether flowers, fruit, or chocolate, there is something reassuring about them lasting a finite period, echoing the hope that soon the patient will recover and head home. Secondly, although giving flowers can be a sign of private intimacy, in a hospital setting the flowers also publically demonstrate social ties beyond visiting hours. A patient looking at a bouquet doesn’t just see the flowers but the person who gave them. And a nurse or doctor is often part of this—remarking on the gifts in small talk, and consequently becoming entangled in a comforting form of interaction. The apparent intransigence of hospital staff in the face of evidence suggests there might be more to this ban than merely the flowers themselves. In anthropological terms, hygiene is not defined by things being essentially “dirty,” but by things being perceived to be in the wrong place6—for example, soil is fine in the garden but dirty when on the carpet. So how is it that although flowers were once fine at a hospital bedside, they are suddenly in the wrong place and therefore unclean? Perhaps it is because flowers can mark out a small personalised space, domestic and non-clinical,
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where a different mode of relating can take place, and it is this that is really out of place on a modern ward. Underlying all the explicit arguments, the decision to ban flowers seems to reflect a much broader shift towards a model of care that has little time or place for more messy and nebulous elements.7 The development is not the articulation of rational science but increased rationalisation in the sociological sense, which equates with technical efficiency coupled with greater bureaucracy and accountability. The practice of healthcare delivery—with more prescriptive guidelines and targets, greater demands on time, and more explicit professional roles—means that there is simply not room for the more vague, apparently superfluous, practices on a well functioning ward. The flowers have been elbowed out. And so, in the context of health priorities, such an apparently inconsequential policy reflects a more general shift in current definitions of care. At this time of year, despite all the calls of commercialisation and trivialisation, in truth most of us still value ritualised contact with loved ones and the demonstration of relationships through giving and receiving. Perhaps, then, now is a good time to think about a broader version of care that increasingly needs to be protected on the ward and within the everyday practices of a hospital. Such a version of care would be thought of not as an outcome that can be delivered but as a relationship that can be exchanged. 1 2
3 4
5 6 7
Day G, Carter N. Wards of the roses. BMJ 2009;339:b5257. Kates S, McGinley K, Larson E, Leyden J. Indigenous multiresistant bacteria from flowers in hospital and nonhospital environments. Am J Infect Control 1991;19:3156-61. Taplin D, Mertz P. Flower vases in hospitals as reservoirs of pathogens. Lancet 1973;302:1279-81. Gould D, Chudleigh J, Gammon J, Ben Salem R. The evidence base and infection risks from flowers in the clinical setting. Br J Infect Control 2005;6:18-20. Mauss M. The gift: forms and functions of exchange in archaic societies. London: Routledge, 1990. Douglas M. Ritual uncleanliness. Purity and danger. London: Routledge, 1966. Mol A. The logic of care: health and the problem of patient choice. London: Routledge, 2008.
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ecent Years have seen a Catalogue of Plagues and sundry other Contagions. Hard on the scaly Heels of Avian Flu follows Global Warming, Swine Flu, Obesity, and now the Economic Plague. This Litany of Woes has affect’d me deeply, as these few Entries from my Diary this past Year shew.
5th April
Rose early to enjoy reading the latest Bill of Mortality of Estate Agents in the Parish of St. Giles’s, which show’d again a monthly Increase. The Bankers, too, have this past Year been struck low, and it transpires that their Understanding of the term “Bank” has left much to be desired; they have been sinking our Shillings in miscellaneous crackpot Schemes in the Colonies that few understand, and fewer profit from: to wit, Hedge-Funds, Subprime Mortgages, Ponzi schemes, Plans to build golden Stairways to the Moon, and God knows how many other feeble minded Schemes. Fearful of my own Savings, I visited my Bank in the Strand this Morning, only to find to my Dismay the Building lock’d up with a large “X” marked roughly upon the Door. I rapped loudly, and Mr Madoff put his Head out the Window. When I demanded to withdraw my Savings he tossed me a Florin, saying insolently, “This is what is left, Defoe, use it wisely. Remember, past Performance is no Guarantee of future Results—as I told you when you invested, the Value of your Savings can plummet, as well as fall briskly,” and with that he slamm’d the Window with a hollow Laugh. On close Examination I discovered the Coin to be but a poor Fake, bearing the Head not of our beloved Monarch but of one Fred the Shred, who some claim help’d land us up to our Necks in the financial Privy in the first Place.
12th May
Walked deep in Thought to the Tavern. Much Talk there of the Change in the Climate and the dire Consequences for the Publik Health. However the Country’s best Brains are at Work to identify Remedies, and I am heartened to read in a Broad-sheet that the Fashion World has come up with a Solution: viz, new “flood length trousers” which keep the wearer’s Hems out of the rising Waters.1 We need no longer live in fear of Flooding when the Fashion Industry is working so assiduously on our Behalf. (Mem: To Payment to Tailor for Reduction of Trousers to knee Length: 5 shillings) 1390
6th June
Up betimes and stroll’d down the Strand, only to be assail’d by the dismal Sight of formerly prosperous Bankers and Estate Agents begging for Alms. At Aldgate I was approach’d by one in Rags outside the Coffee House, who seiz’d me by the Elbow and hoarsely ask’d for the Price of a skinny venturi decaff soya latte with cream, an extra shot, and coffee on the side. Not to drink, mind, but simply and intransitively “To go.” It would be a harder Heart than mine that could turn down such a low Wretch and I toss’d him a Florin, which he bit to test its Soundness. Would that the Bankers had always been so careful.
7th June
Read in a Broad-sheet that a Banker has choked to Death on a counterfeit Florin in St. Giles’s. 2
3rd July
Remembering that a previous Plague—to wit, the Foot & Mouth—was combat’d by burning all our Cattle, and that we had to wipe our Feet when visiting our Country Estates, I am seiz’d with a Plan: viz, that all avian and porcine Visitors to the Country should wipe their Feet upon entering and that all those already here should be incinerated forthwith. In this latter Endeavour I intend to enlist the help of Britain’s many Fried Pullet and Braised Offal emporia. Three tallow Candles did I exhaust, as many Quills, and a night’s Sleep dismiss, in the fever’d Exposition of my proposal. I dispatched my Opus— extending to ten Quires of copperplate Manuscript—upon the Tea Clipper Sea Difficile bound for the English Colonies in America, for Consideration by their most highly esteem’d New England Medical Intelligencer. My Fortunes assured, I retired in high Spirits to my local Tavern, the Winter Swallow, to partake of a majestic Supper, before which I was entreated by the Victualler, “Goeth ye large? ‘Tis but a Ha’penny more.” The Inn’s recent Refurbishment with sturdy oak Furniture, reinforced against Obesity,3 will be viewed by future Generations as prescient and of much Comfort and Benefit to our expanding Populace. Doctors of Physik today are wont to say that Corpulence, like Plagues before it, is borne of an “obesogenic miasma.” Such an Observation is self evident, and any Man may test its Veracity. I, myself, found recently that after partaking of frequent long Walks in the Highgate Countryside I had need to entreat my Tailor to take in the Waistband of my Breeches. The only rational BMJ | 19-26 DECEMBER 2009 | VOLUME 339
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Explanation must be that the fresh and vital Air of Hampstead Heath is unpolluted by the “portly Odours” of the City.
1st September
Scarcely had the Difficile docked in New England than her sister Ship, C Shanty, return’d to London bearing Missives from the Referees of the Intelligencer. These discharged upon my Paper such Bile that I was sorely tempted to dispatch a quicke Response on the first Schooner at Dawn. The Referees’ Comments moreover were accompanied by an insolent Memorandum to the Effect that they receive many Epistles such as mine, and that unfortunately they can print only a sparse 10 per cent of them, etcetera. I replied by Return, saying that their Gross Inefficiency is not my Concern, and further drew their Attention to the Fact that I receive many such rejection Letters, but unfortunately I, too, can only accept 10 per cent of them.
2nd September, post meridian
With renewed Spirit, I consider’d the Views of my New World Critics and set down to draft again my Manuscript. Deftly, I filleted the Piece to one twelfth its original Length while introducing a fanciful Conclusion—to wit, that the Swine Flu might be attenuated through Variolation of the Sort that has been used to curb the Small Pox in Asia since the first Millennium. My Revision includes many clear Messages for Policymakers, Practitioners, Quacksalvers, Mountebanks, Poultry-keepers, Pill Merchants, and sundry other Busybodies, as required. To avoid any Delay by His Majesty’s Royal Mail—I admit, a most unlikely Eventuality—I dispatch my Footman, Lance, to Camden Lock, where a prestigious Journal— yet one of somewhat less Standing than the Intelligencer— has its Offices.
3rd September, ante meridian
I find this morning that my latest modest proposal too has been rejected by the onion-eyed Hedge Pigs4 who run this Penny Dreadful, and I repair to The Polar Bear & Wellingtons to mull over the sundry global Catastrophes which befall us and, more pressingly, to consider whether they afford me any Opportunity for Publication. I dash off a short Missive of Appeal for Consideration of my Paper.
20th December
Christmas draws nigh, and since my last Intervention, nothing but Silence from the Sots at the Journal, who no doubt are in their festive Cups instead of inking the Printing Presses. I repair to The Pig and Tamiflu for a small Cordial and to consider my few remaining Options.
21st December, ante meridian
A great Anxiousness afflicts me after a Night of diabolical Fever and I fear that I am finally succumbing to that most dreaded Distemper, the swine Pestilence, or, as it is now widely known, “The Pink Death.” From my Sick
Bed I draft my Obituary, in which, with sincerest Modesty, I detail my glorious Achievements, Laudations and major Contributions to the World. I enclose a small woodcut Likeness of my Visage, seal the whole with Wax, and dispatch it to a local but respectable Journal—though a modest one of considerable less Impackt, again—the Provincial Medical and Surgical Journal.
21st December, post meridian
Feeling much the better. Perchance the increasingly unseasonal meteorological Conditions, in which the Temperature of London has reached 80 degrees Fahrenheit in the Shade, accounted for my Feverishness; for it seems I am to be spared. While taking Afternoon Tea, a Messenger from the Provincial Medical and Surgical Journal is shewn into my Study, bearing a dainty folded vellum Notelet. Its Message can barely be deciphered having, it appears, been impressed by a very worn India rubber Stamp and not written out, proper. “Thank you for taking the Time to consider our Journal for your Obituary,” its single Sentence begins, “But we feel there would be insufficient Interest among our Readers for your Artickle.”
23rd December
I console myself by spending my last 12 shillings in The Sty in Quarantine; and thankfully after downing the first two Pints of Port, much of the Rest of the Evening, and indeed this sorry Year, remains a Blur. (I have a discomfiting Memory of a semi-naked Man lying in Russell Square Fountain holding a half empty Port Bottle, and singing “Deck the halls” or a Version thereof).
24th December
Mem: To purchase of Tincture of Willow Bark: 2 shillings; Laundry of sundry Items of wet and soil’d Clothing: 6 shillings; To postage of numerous Letters of Apology to Residents of Russell Sq: £0-12-6. Mark Petticrew chair in public health evaluation, London School of Hygiene and Tropical Medicine, London WC1E 7HT David Morrison director, West of Scotland Cancer Surveillance Unit, Section of Public Health and Health Policy, University of Glasgow, Glasgow G 8RZ References are in the version on bmj.com
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Modern medicine has failed to take account of one of history’s most fundamental rules and the lessons of a neglected 16th century philosopher, write Tony Hope and Dominic Wilkinson Iudico potere essere vero che la fortuna sia arbitra della metà delle azioni nostre, ma che etiam lei ne lasci governare l’altra metà, o presso, a noi. [I believe that it is probably the case that fortune controls half of what we do, but she allows the other half to be controlled by ourselves.] Niccolò Machiavelli, 1513 (published 1532) Modern medicine attempts to exert control over outcomes. It is the intellectual descendant of Machiavelli. But are such attempts to manipulate and minimise chance futile, do they risk making the worst outcome more likely? Such questions were anticipated and debated five centuries ago by a contemporary of Machiavelli, now largely forgotten, the Italian philosopher Girolamo Di Sod.
Girolamo Di Sod Di Sod was born in Florence to a poor aristocratic family, towards the end of the 15th century. He was almost certainly in correspondence with Machiavelli before the age of 20.2 With Machiavelli’s support, he was invited to take part in the literary gatherings at the Oricellari Gardens, where he engaged with some of the finest political thinkers of the age. Although none of Di Sod’s works has survived, descriptions by other members of Orti Oricellari suggest that he was both brilliant and eccentric. He studied with the Franciscan Luca Pacioli who 1392
NUNEZ DE VILLAVICENZO: BOYS PLAYING DICE/PC/CHRISTIE’S/BAL
Will it all go wrong? Sod’s law applied to medicine
DI Sod, not playing dice
had, a decade earlier, written the first printed work to discuss probability.3 However, Di Sod quickly transcended his teacher in his efforts to quantify and control the element of chance. One of Di Sod’s most distinctive views related to the conservation of personal fortune—episodes of fortune must be balanced by episodes of misfortune. He developed a pathological fear of gambling, convinced that good luck in such games might hasten his death. This fear, commented on by his contemporaries, gave rise to a common aphorism in the 16th century (later misquoted by Einstein), “Di Sod does not play dice.” Di Sod’s behaviour became progressively more extreme, including the imposition of severe dietary restrictions (he ate only plain bread) and insistence on wearing weatherproof clothing in the height of summer.4 In his last years he wore a metal helmet while riding his horse in case of falls. The circumstances of his early death in his late 20s are unclear, but one report suggests that he may have been the victim of a lightning strike.5 If so, his customary head covering may have contributed to his demise—a striking confirmation of his famous law.
What is Di Sod’s law? None of Di Sod’s writings survives. The sad irony is that Di Sod, determined that his writings should survive beyond his death, stored them in a fireproof box
in a locked safe at the centre of his house. However, it seems that the manuscripts were lost during the siege of Florence in 1529, two years after his death. The keys to Di Sod’s strong box (which he had stored in several hidden locations in the house) could not be found in time to save the work before the house was demolished.4 Di Sod’s major work “In un’istanza di sventura” (On the instantiation of misfortune) has been lost. What we know of his famous law comes from secondary sources. What we find are references to examples of its operation, and we must infer its content from these examples. Modern statements of the law do not do justice to the depth of Di Sod’s thinking. None deals with the important issues with which Di Sod and his contemporaries were struggling: the epistemological status of the law; the underlying causal mechanisms of the law; and, crucially, the limits of human agency in the events of history.
Di Sod and Machiavelli Any analysis of the law must start from an understanding of Di Sod as a critic and intellectual combatant of Niccolò Machiavelli. Machiavelli had seen his beloved Florence decline from a powerful and independent city state to become a second rate power under domination from Spain and later France. He sought to understand the role of human agency in such changes: specifically how BMJ | 19-26 december 2009 | Volume 339
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LORENZO LOTTO: PORTRAIT OF A GENTLEMAN, GALLERIA DELL ACCADEMIA, VENICE/BAL
makers (Fratellanza dei costruttori di ombrelli), who, in the 18th century, marketed their leather umbrellas to farmers citing Di Sod and claiming that the purchase and use of an umbrella would ensure long periods of sunshine.
Expecting the worst, and not disappointed
the behaviour of rulers can affect outcomes for good or for bad. Di Sod’s reading of history profoundly opposed that of Machiavelli. Where Machiavelli saw failure of proper leadership, Di Sod saw the unrolling of events outside human control. Where Machiavelli saw examples of successful leadership, Di Sod saw only temporary success followed by disaster. Di Sod came to two central conclusions: the powerlessness of human agency and a general pessimism about the effects of events on human aspirations. All historians since Di Sod, whether they agree with him or oppose him, have had to take a view on both these matters.
How should Di Sod’s law be understood? So where does this leave us with regard to an understanding of Di Sod’s law? There have been, broadly, four interpretations. Empirical prediction “Each individual misfortune, to be sure, seems an exceptional occurrence; but misfortune in general is the rule.”6 A common example of Sod’s law is that toast will usually fall butter side down. This is a testable empirical prediction.7 The generalised form of this interpretation is that if there are two or more possible outcomes the most likely is the one that is judged to be the worst.
What humans notice According to this interpretation, Sod’s law tells us more about ourselves than about the external world. We notice when the toast falls butter side down in a way that we do not notice when it falls butter side up: we are more aware of bad outcomes than of good ones.8 Human judgment According to this view we tend to judge whatever happens in a negative way.9 If toast usually falls butter side down then we judge this to be the worse side for it to fall. We could have considered it better for toast to fall butter side down because, if it does, we notice the accumulated detritus (dog hairs, grit, nail parings) and throw it away, thereby avoiding any risks to health. According to this interpretation, the toast falling butter side up would be the worse outcome because we would probably make some ineffectual attempt to brush the toast and then eat it, thereby exposing ourselves to the risk of disease. As an exhortation to prepare for the worst According to this interpretation, Di Sod’s law is an elliptical way of stating how we should think or behave. If we prepare for the worst, the worst will be less likely to happen, and if it does, we will be less psychologically affected by it. This is the interpretation of the Italian guild of umbrella
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Implications of Di Sod’s law for medicine As will be clear there are two profoundly opposed conclusions to be drawn from these interpretations—that bad outcomes can be reduced by appropriate preparation (the last interpretation above) or that we can do nothing to reduce bad outcomes (the other three interpretations). The first conclusion, favoured by Leibniz, implies that a systematic scientific approach to medicine may enable us to create the best possible world10: assiduous attention to the latest evidence averts misfortune for our patients. The second conclusion, favoured by Schopenhauer,11 is that misfortune is inevitable. This implies that seeking the best evidence to guide medical treatments is at best useless and at worst may increase the chances that we will get it wrong. For example, antihypertensives may produce clear benefits in trials, but in clinical practice they may lead to worse outcomes—for example, causing patients to fall and fracture their hips. Conclusion Attention to his pessimistic outlook gives credibility to the view that the correct interpretation of Di Sod’s law is that misfortune is inevitable. If this view is correct it has profound implications for epistemology. It implies that if we view knowledge as providing us with tools to change outcomes, then no true knowledge exists. Evidence based medicine is an illusion that has no valuable effect on the care of patients. In other words, in the end we know Di Sod all. As a footnote we would like to emphasise the irony that Di Sod has virtually been written out of history. It is only in Britain, Australasia, and a few other places that his famous law is known by his name. Even in his native Italy it is named after the American engineer, Murphy, who lived four hundred years later.12 Modern uses of Murphy’s law lack completely the profundity of Di Sod’s law and are little more than cocktail party banter. Tony Hope professor of medical ethics and honorary consultant psychiatrist, Ethox Centre, Department of Public Health, University of Oxford, Oxford OX3 7LF
[email protected] Dominic Wilkinson Oxford Nuffield medical research fellow, Oxford Uehiro Centre for Practical Ethics, Department of Philosophy, University of Oxford OX1 1PT Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. This paper arose from speculation over a theinated beverage about the origin and meaning of Sod’s law. Neither of the authors is a medieval scholar or Italian speaker, and it is possible that they may have misunderstood or just made up some of the details about Di Sod’s life. Contemporary references are more reliable. Tony Hope is the guarantor, and guarantees that it will rain if he forgets his umbrella. References are in the version on bmj.com Cite this as: BMJ 2009;339:b5299 1393
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Patent medicines and secret remedies As arguments between doctors and advocates of alternative medicine continue, Jeff aronson describes how the secret ingredients of patent medicines were uncovered a century ago
P
atent means open (box 1), but patent medicines have traditionally contained secret ingredients. The Oxford English Dictionary defines a patent medicine as “a proprietary medicine manufactured under patent and available without prescription.” However, the term and its current definition are historically misleading. From the start, the hallmarks of patent medicines were that they were advertised direct to the public and sold over the counter. They were rarely patented because it was advantageous to be secretive about ingredients that were often ineffective and even hazardous. If a product had a patent it was generally because the remedy was effective—Epsom salts, marketed by Nehemiah Grew in the late 17th century, contained magnesium sulphate as a purgative. Patent medicines could be purveyed by physicians and apothecaries or by unqualified quacks, mountebanks, and charlatans (boxes 1 and 2). Historian Roy Porter suggested that between 1600 and 1850 there were more similarities than differences between quacks (“less cheats than zealots”) and regular practitioners,2 an assertion that is borne out by the history of patent medicines. Sales of patent medicines burgeoned during the 18th century. They were often named after their inventor (Swaim’s Panacea, Turlington’s Balsam of Life); after a famous, but often conveniently dead, practitioner (Dr Boerhaave’s red pills, Dr Radcliffe’s drops), or after the place of origin (Epsom salts, California vinegar bitters). The name might include the source of the
medicine (Clark Stanley’s snake oil liniment) or its supposed indication (Dr D Jayne’s expectorant, Mayr’s wonderful stomach remedy). Exoticism could be an advantage (Indian panacea, Green Mountain magic pain remover). Advertisements for such products, promoting (?) their value in wide ranges of conditions, indeed often for all conditions, might be accompanied by recommendations from patrons—Dr Scott’s bilious pills had benefited “the Dukes of Devonshire, Northumberland and Wellington, the Marquesses of Salisbury, Angelsea, and Hastings, the Earls of Pembroke, Essex and Oxford and the Bishops of London, Exeter and Gloucester.”4 Testimonials from grateful patients were also cited— an advertisement for Lydia Pinkham’s vegetable compound for women stated, “Lydia Pinkham’s private letters from ladies in all parts of the world average one hundred per day.”5
Secret remedies yesterday Regular practitioners have always been critical of patent medicines. In 1790, for example, James Adair, a Scottish physician, published a scathing indictment.6 “Many persons have been destroyed by quack drugs,” he wrote, “but dead men tell no tales.” He and others pointed out that quack medicines contained conventional treatments (such as opium and ipecacuanha in Dover’s powder), poisons (such as hemlock), or nothing of value whatsoever. However, during the second half of the 19th century, with the rise of the chemicals industry and the consequent beginnings of drug com-
panies, such as Hoechst and Bayer in Germany and Burroughs–Wellcome in the UK,7 the criticism became more intense and evidence based. Pharmacology (the word dates from the start of the 18th century8) was becoming scientific. In America, concern about adulterated and misbranded foods and drugs culminated in the publication of 11 articles by Samuel Hopkins Adams in Collier’s Weekly in 1905, titled “The Great American Fraud,” in which he exposed many of the false claims made about patent medicines. This led directly to the 1906 Pure Food and Drugs Act. Doctors, supported by the American Medical Association, then published robust criticisms of the purveyors of patent medicines. They were met by a riposte in the form of a pamphlet, published by the Proprietary Association.9 The Proprietary Association collected newspaper reports of adverse events, including deaths that had been attributed to various medicines, and claimed that patent medicines were less dangerous than other medicines. Something of the flavour of this report emerges from the data on whiskey and alcohol (84 cases, 61 deaths) and Cannabis indica (one case, no deaths). In the UK, patent medicines had been specifically excluded from the Pharmacy Act of 1868 and the Sale of Food and Drugs Act of 1875, and their contents could therefore be kept secret.10 11 Many of them, such as Battley’s
Box 1 | Etymologies Patent comes from the hypothetical Indo-European root PET, to spread or open out. Petals spread out; patellas, spatulas, and spades look like open dishes; space is an open area; and paella is cooked in an open pan. According to the Oxford English Dictionary, letters patent (Latin litterae patentes) were originally open letters from a monarch or government, intended “to record a contract, authorize or command an action, or confer a privilege, right, office, title, or property”; the term then came to mean documents that grant “for a set period the sole right to make, use, or sell some process, invention, or commodity.” It was subsequently shortened to patent. Quacks, originally quacksalvers, supposedly quacked or boasted about their salves; a mountebank was a man who would mount a soapbox (Italian: montare in banco) to shout his wares at a fair; charlatans were wont to prattle (Italian: ciarlare) about their medicines1
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Box 2 | History of apothecaries Apothecaries were originally members of the grocers’ livery company. However, during the late 16th and early 17th centuries, under the leadership of Francis Bacon and the Huguenot refugees Gideon de Laune and Théodore Turquet de Mayerne, they sought to secede. Eventually, the Worshipful Society of Apothecaries of London was incorporated by royal charter of James I on 6 December 1617, although it continued to be allied to the Society of Grocers. The grocers stocked perishable goods, the apothecaries non-perishable ones, including spices, sweetmeats, preserves, and medicines. Apothecaries purveyed and compounded drugs, dispensed physicians’ prescriptions, and charged for medicines. Physicians employed apothecaries or used them as required and charged for consultation and advice. The decision of the House of Lords in 1704 in the case that the College of Physicians brought against an apothecary called William Rose, accusing him of administering medicines without licence from the college, without the direction of any physician, and without taking or demanding any fee for his advice, established that apothecaries could independently prescribe and dispense medicines. The college’s monopoly was broken.3 In 1711, the Worshipful Society of Apothecaries was established as a separate livery company.
the hallmarks of patent medicines were that they were advertised direct to the public and sold over the counter. they were rarely patented because it was advantageous to be secretive about ingredients that were often ineffective and even hazardous
WELLCOME IMAGES
sedative solution, Daffy’s elixir, and Godfrey’s cordial, contained opium, and their sales increased. In the 1880s, therefore, doctors, supported by Ernest Hart, editor of the British Medical Journal, started to campaign against this abuse. A Patent Medicine Bill in 1884, which would have controlled these products, failed because of pressure from the Society of Chemists and Druggists. Undaunted, the campaigners used as a test case Dr Collis Browne’s chlorodyne, which contained chloroform, morphia, tincture of Indian hemp, and prussic acid and was responsible for a large number of cases of poisoning. The chairman of the parliamentary bills committee of the British Medical Association sent a memorandum to the Pharmaceutical Society, the Society of Apothecaries, and the General Medical Council, attacking patent medicines in general and chlorodyne in particular. Questions were asked in the House of Commons in 1891, to no avail. However, the parliamentary bills committee then persuaded the Treasury’s solicitor to prosecute the manufacturers of chlorodyne. The magistrate defined a patent medicine as one that was issued with a government patent. Chlorodyne, having no such patent, therefore came under the 1868 Pharmacy Act. What had once been secret became open. The manufacturers were fined for marketing a scheduled poison. Other similar patent medicines were thus brought under the act
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Although the ingredients of UK patent medicines are now stated on packets, the information will mean little to most consumers, and important information may in any case not be available Although a select parliamentary committee was subsequently appointed to investigate patent medicines, it published its report on 4 August 1914, when public attention was focused not on Dr Boschee’s German Syrup, but on Germany itself; its recommendations were not pursued.18
Secret remedies today Two Latin tags summarise the success of patent medicines, even today. The first, omne ignotum pro magnifico (ignorance makes everything look superb), was quoted in the preface to the first volume of Secret Remedies. The second, populus vult decipi (the public wants to be deceived), appeared as the legend to an early 17th century engraving by the Dutch artist Jan van de Velde, showing eager customers clustering around a quack and his wares. In 2007, American adults spent $12bn consulting practitioners of
complementary and alternative medicine and $22bn buying their products.19 Although the ingredients of UK patent medicines are now stated on packets, the information will mean little to most consumers, and important information may in any case not be available. The two volumes of Secret Remedies constituted a landmark publication in the control of over the counter medicines. Their story has modern resonances. Nostrums are still available over the counter. Perhaps another edition of Secret Remedies is needed. Jeffrey K Aronson clinical pharmacologist, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF
[email protected] This article is based on JKA’s Gideon de Laune Lecture, given to the Society of Apothecaries in 2008. Competing interests: JKA is president of the British Pharmacological Society, a member of a NICE technology appraisal committee, and a member of the formulary committees of the British National Formulary and the British National Formulary for Children. The views expressed here are not necessarily shared by those organisations. Provenance and peer review: Commissioned; not externally peer reviewed. References are in the version on bmj.com Cite this as: BMJ 2009;339:b5415
See editorial, p 1386
Examples of secret remedies16 17 Product Blair’s gout and rheumatic pills
Claim “Immediate relief and cure of acute and chronic gout, rheumatism, suppressed gout, rheumatic gout, gouty skin diseases, bronchitis and asthma, sciatica, lumbago, and neuralgia” Damaroids “A safe and sure remedy for general weakness, spinal exhaustion, neurasthenia, physical decay, and loss of nerve power” Pink Pills for Pale “When the muscles and nerves are tortured by poisons in the blood, be People the result rheumatism, sciatica, or lumbago … anaemia, indigestion, palpitations, influenza’s after-effects, eczema, sciatica, St Vitus’ dance, spinal weakness, the many forms of nervous disorders dreaded by men; also the special ailments of women” “Professor” O Phelps “For the positive and speedy cure of epilepsy or fits, dyspepsia, Brown’s vervain indigestion, all derangements of the stomach and bowels, and for every restorative assimilant form of debility” Wood’s cure for “Tobacco habit conquered in 3 days” tobacco habit
Stated contents Powdered Colchicum corm, burnt alum
Price (cost of manufacture)* 1s 1½d(<1d)
Iron hypophosphite, quinine sulphate, sugar, talc Iron sulphate, potassium carbonate, magnesia, powdered liquorice, sugar
2s 9d(3d)
Vervain, port wine, rectified spirit
2s 9d(5d)
A series of formulations containing: phenolphthalein, quassia, aloin, and strychnine; asafoetida, iron, and strychnine; methylene blue; and methyl salicylate
£1 1s
2s 9d(<1d)
*In old pounds, shillings, and pence (£, s, d): 12d = 1s; 20s = £1; 1s = 5 new pence. Price index for 2009:1909 ≈ 75:1.
I should cocoa My great grandfather was William Tibbles, the originator of Dr Tibbles’ Vi-Cocoa, which became well known in the first part of the 20th century. I have no idea whether he was really medically qualified, although the BMJ carried obituaries of his sons and grandson. I have found several articles and letters by them in the BMJ’s online archive, but nothing about Dr Tibbles’ Vi-Cocoa, which James Joyce mentioned briefly in Ulysses. 1396
The Lancet was fulsome in its praise (according to an advertisement in Newfoundland’s Evening Telegraph), saying it “must be assigned to a place in the front rank of really valuable foods, since it is the embodiment of all the numerous principles contained in Malt, Hops, Kola and Cocoa. Of distinct value as a restorative and stimulant food.” Its effects were probably due to cocaine. It was certainly very
popular in the Commonwealth and was widely advertised, carrying endorsements from doctors, nurses, postmen, writers, blacksmiths, and many others. A “dainty” free sample was always on offer. Mike Hincliffe retired general practitioner, Llandrillo, Corwen, Denbighshire
[email protected] This is an abridged entry for our competition for the most interesting use of the BMJ online archive (1840-2009). Cite this as: BMJ 2009;339:b5392
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THE ROYAL PHARMACEUTICAL SOCIETY OF GREAT BRITAIN MUSEUM
and controlled. Some manufacturers removed opioids from their products. Sales fell. However, patent medicines continued to be sold, and the campaign continued. In the 1900s, the BMJ published a series of articles under the general title “The Composition of Certain Secret Remedies,” dealing with drugs used to treat epilepsy,12 headache,13 kidney diseases,14 and other conditions. In 1906 it started to reprint similar articles from the Deutsche Medizinische Wochenschrift.15 In 1909, the BMA gathered the articles into a single volume, Secret Remedies.16 Public interest was enormous, fuelled perhaps by H G Wells’s 1909 novel Tono-Bungay (“slightly injurious rubbish at one-and-three half-pence a bottle”). Secret Remedies sold 62 000 copies by June 1910.12 A second collection was published in 1912.17 The entries listed the ingredients in each product, details of the “claims and exuberant boasts” made by their manufacturers, and the prices charged. Comparisons with the actual costs showed how large the manufacturers’ profits were. The table summarises some of the entries, whimsically chosen from the two volumes.
years like this Winner of our competition for the most interesting use of the journal’s archive
The Spanish flu through the BMJ ’s eyes Can the “Spanish flu” of 1918-9 teach us anything about future pandemics? Tom Jefferson and Eliana Ferroni investigated contemporary accounts in the BMJ
TOPICAL PRESS AGENCY/HULTON ARCHIVE/GETTYIMAGES
T
he great Spanish influenza of 1918-9 is perhaps the best known of all pandemics. A vast number of books have been written on the topic, and “Spanish flu” still represents a rich topic of discussion and research.1 Although many scientific questions posed at the time have been answered by nearly a century of subsequent discoveries, some puzzles remain—such as the reason for the high case fatality rate (>2.5% according to some estimates),2 the high incidence in young adults,3 and the role played by the first world war and its aftermath.4 At the time, the aetiology was not known and the disease’s mode of transmission could only be hypothesised by careful observation. In addition the effects of preventive measures remained largely unevaluated. Most descriptions of the event seem to be based on secondary sources— that is, they are not direct eyewitness accounts— although recently efforts to go back to primary sources have been made.4 Reliance on secondary sources is a potential source of selection bias: the reader gets a selected view of events, and some of the contemporary observations and explanations are lost. Interpretation of events and actions of a bygone era from a modern perspective is another perilous activity. We exploited the opportunity to consult the newly digitised BMJ archives to carry out a review of what was published at the time. We tried to look at the pandemic through the eyes of contemporary BMJ contributors and readers and give them their voice back. We chose the Spanish influenza pandemic because we believed some of the observations and issues raised at the time may still be relevant to the events of today, although some have been forgotten.
Tin miners at Redruth mine, Cornwall
Methods We carried out a search of the BMJ archives using the keywords “influenza,” “flu,” “pandemic,” and “Spanish influenza” for the period 1918 to 1924. We read the content of each article, looking for unusual or forgotten observations and still unresolved questions. We excluded well known facts (such as clinical descriptions and presentation of the disease), and we did not carry out a detailed analysis of observations that are explicable with today’s knowledge (such as the contemporary conclusion of the presence of “filterable virus,” which was then invisible and unidentified). We grouped the findings by broad headings covering the capricious nature of the spread of disease and its relation to climatic conditions, the possible multifactorial nature of the high case fatality rate, the unusual effects of poison
Table 1 | BMJ reports of associations between exposure to poison gas and other gases and influenza and other acute respiratory illness Reference
Type of tgas
Population
Observation
Ball, 191912
SO2
Copper smelters
“Consumption was practically unknown”
Shufflebotham, 191913
Sulphurated hydrogen, chloro-picrin, and chlorine
Poison gas workers
“Poison gas workers were practically immune from influenza in this district”
Mustard gas
Gas workers
“The amount of absenteeism during the two epidemics was not increased beyond normal”
Phosgene
Gas workers
“Workers were more prone to influenza infection than other classes of the community”
NO2 and SO2
Workers
“Certain gases have a powerful inhibitory action on post-nasal flora, and such action is quite sufficient to render many workers in those gases immune to diseases which invades the body through the upper respiratory passages”
Gregor, 191914
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gas on munitions workers’ health, and possible causality and preventive measures. We did not carry out a systematic review but selected items that we consider still highly relevant today but largely forgotten. We make no claims as to the completeness or fairness of our selection, but we have listed our search yield and sources in the appendix on bmj.com to encourage readers to consult the original records.
Results We found 55 articles of varying nature—including studies, reports, and letters—published between July 1918 and October 1920. Spread of disease and its relation to climatic conditions One of the least studied aspects of the pandemic was the appearance of synchronous cases or clusters of cases either apparently unconnected or a great distance apart. This had also been a feature of the 1789 and 1889 pandemics (and would be again in 1957 and 1968).5 Dr Andrew Garvie, a general practitioner in Halifax describes the conundrum: “But why the first case in the household was, on the average, more serious than the sporadic, and why the ‘clumping’ should occur, is difficult to understand. Casual observation might lead one to suppose that the spread was due to actual contagion from one house to another. At first I regarded it simply as due to ‘neighbourliness,’ but later on became convinced that this could only be a partial explanation 1397
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Table 2 | Exposure to gas and incidence of influenza (adapted from Gregor, 191914). (Values are numbers of subjects unless stated otherwise) Population
Cases
Total
Case incidence (%)
Navy
446
1350
30.2
Army
210
1050
20.0
Not working in fumes
221
732
30.1
Working in fumes
15
318
4.7
Gas workers
10
148
6.7
Not working in fumes (one epidemic)
14
23
60.8
Working in fumes (one epidemic)
3
27
11.1
Cordite workers:
Tin mine workers:
Table 3 | Effects of influenza vaccines in British troops in 1918-9 (adapted from Leishman, 192017). (Values are numbers of subjects unless stated otherwise) Population
Pulmonary complications
No pulmonary complications
Inoculated (n=15 624)
26
15 598
1.66
Uninoculated (n=43 520)
583
42 937
13.40
of the spread. In many of the households affected in a ‘clump,’ a suggestion of being in any of the other affected houses was absolutely denied. It will further be noticed that within one particular ‘clump’ two or three houses commenced on the same date, and further, owing to the general fear of the epidemic, spread by newspaper reports and other methods, if the epidemic was known to be present in a house, the house was usually shunned by neighbours. In many cases the houses were not in direct contact but separated by the breadth of the street or by garden walls ... but why people within small radii of one another, of all ages, of different occupations, not coming in actual contact with one another, should develop synchronous attacks, still remains a mystery to me.”6 Dr Major Greenwood, later first professor of epidemiology and vital statistics at the London School of Hygiene and Tropical Medicine, writing arguably the most complete description of the UK pandemic in the autumn of 1919, had the following explanation for the observation: “A mass attack, indeed, forms an invariable link in the chain of events, but scattered individual cases are antecedent. This observation removes the most formidable objection to a belief that influenza is contagious, and it is easy to understand why we discover no confirmation in historical records. In such epidemic diseases as plague the preceding sporadic cases are recorded because their high fatality leads to illusion in bills of mortality; but in consequence of the very low fatality of primary epidemic influenza early mortality records are wanting. The mass phenomenon strikes the imagination of the recorder and an illusion of suddenness and simultaneity is produced.”7 In other words ascertainment bias was the most likely explanation for the observation. Greenwood and other BMJ contributors (such as Dr Mercer Watson writing in 19198) dedicated a lot of time to describing the prevailing atmospheric conditions in relation to the subsequent 1398
Incidence rate per 1000
waves of the pandemic. This may be a relic of the old miasma versus contagion debate of previous centuries.
High case fatality rate A hallmark of the Spanish influenza pandemic was its high case fatality rate. Greenwood described its causes in the spring and summer of 1918 period as “excessive mortality being mainly due to the accident of season, aided by the special circumstances of overcrowding and fuel shortage which are due to the war. In a word, this is not essentially a war epidemic.”7 The role of wartime shortages and troop concentrations and movements has always been a moot point with historians and epidemiologists. Those who refute these as factors cite the example of whole countries or isolated communities not involved in the war being virtually wiped out—that is, being fatal exceptions to the theory.9 However, a closer look at the description of conditions by BMJ contributors shows the importance of studying context in the devastation. Surgeon Lieutenant Francis Temple Grey in charge of the Samoa relief expedition is cited by the BMJ in 1918 explaining the high native mortality compared with the white population: “The incidence among the natives was 80 per cent. Out of a population of 36,405 the deaths numbered 7,264.” Grey attributes the high mortality partly to the fact that natives, although apparently of fine physique, have generally a poor chest expansion, and to their habits. “The native house has a raised floor of coral and lava pebbles, a thatched roof supported on poles, and no walls, but at the beginning of the epidemic, when a native fell ill he lay down in his hut, and his family, having pulled down the blinds, which are usually lowered only in wet weather, lay down with him in sympathy. When the fever was at its height, on the third day, the natives cast off their clothes, pulled the blinds up, and many of the men went into the sea to cool themselves. This was often followed by pneumonia,
although, except in children, few cases, even with precautions, escaped bronchopneumonia. At the height of the epidemic many lives were lost owing to want of food consequent on the cessation of its collection. On December 8th, 1918, food collecting was resumed, and the decline of the epidemic was popularly dated from that… Among the whites the incidence was put at 60 per cent, and the case mortality at 2 per cent.”10 Writing in 1920, Dr A H Macklin, formerly of the Imperial Trans-Antarctic Expedition, helps us to understand some of the reasons behind the often quoted devastation in Lapland: “The Laplanders had a very thorough if unsympathetic way of dealing with their cases. The settlements were composed of wooden huts, small, but generally well made and warm. A common type consisted of but one room used by the family for all purposes. Better class Lapps had better huts, with two or three rooms. In each settlement one of the single-room huts had been set apart, and into this each case of sickness as it arose was unceremoniously pushed; and none were permitted to return to their own huts until completely recovered. Whilst there they received practically no attention, and no healthy person ever entered to attend to their wants. Occasionally a bowl of water or reindeer milk was hastily passed in at the door, or a huge chunk of reindeer meat thrown in, uncooked and uncarved… Constipation was a constant factor, and many cases had not had their bowels opened since the onset of their illness—in some cases seven to ten days. Others had voided urine and faeces just as they lay. In some huts those of the patients who had passed the worst stages of their illness assisted and looked after those more acutely ill.”11
The effects of poison gas on munitions workers’ health By 1918 the use of poison gas, first introduced in 1915, was routine when bombarding enemy trenches. A great number of workers were BMJ | 19-26 december 2009 | Volume 339
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SSPL/GETTYIMAGES
Women working in the huge cordite explosives factory in Gretna, Scotland
assigned by the Ministry of Munitions to produce shells filled with the noxious substances. Numerous BMJ authors remark on the apparent protection afforded by all types of gas production except phosgene (table 1). Dr Gregor, writing in 1919, informs us that it was apparently “custom to take children suffering from whooping cough to the nearest gasworks and expose them to the fumes emanating from the oxide of the iron purifiers during the process of cleansing, and the parents of these children firmly believe that by doing so the attack is much mitigated.”14 He goes on to report a comparative cohort analysis of the incidence of influenza in populations with different exposure levels to gases (table 2). Assuming that uniformed personnel were the fittest population, the difference in incidence is striking.
Causality and prevention By 1919 Dr Benjafield of the British Expeditionary Force in Egypt thought that “In this case it is more than possible that the primary etiological agent is ultramicroscopic and is a filterable virus, which renders the individuals infected hypersensitive to organisms which formerly only possessed a low degree of pathogenicity.”15 This
was also the conclusion of Rose Bradford et al of the British armies in France.16 If this hypothesis were true, experimental vaccines against a collection of bacteria would be expected to achieve at least partial effectiveness. This is exactly what Sir William Leishman experimented with, using it on troops during the closing stages of the war.17 The vaccine contained a mixture of Bacillus influenzae (Haemophilus influenzae type b), streptococci, and pneumococci. Leishman’s BMJ paper does not report details of methods, but his observation of effectiveness against influenza, pulmonary complications, and deaths is upheld by our reanalyses. For example, the odds ratio for pulmonary complications was 0.12 (95% confidence interval 0.08 to 0.18) (table 3). The views on the effectiveness of other interventions such as masks and distancing were varied.
Discussion We found several articles reporting unusual observations. Even today many of these have no explanation. We feel that the observations should first be corroborated and perhaps explored further. The idea that exposure to gaseous fumes (even potentially toxic) prevented or ameliorated respiratory disease seemed established at the time. Today, however, that is flatly contradicted by unreferenced statements in publicly available documents.18 The causes of the high case fatality rate are still unclear, but modern research suggests that the pandemic was a lot more than just a “one germone disease” affair. 19 This view is supported by the apparent success of antibacterial vaccines against influenza and its complications (with all the probable methodological shortcomings of Leishman’s study). Agents other than the influenza virus probably played a part. Above all, the environmental explanations of the high Samoan and Lapp mortality rates indicate the peril of generalising across contexts and simplifying causation models. The
origin and spread of the pandemic are also far from clear, but the repeated reporting of multiple synchronous foci should be investigated in today’s pandemic. This may give us an indication of the means of seeding, trigger, and possible spread of respiratory viruses. Tom Jefferson researcher,
[email protected] Eliana Ferroni researcher, Acute Respiratory Infections Group, Cochrane Collaboration, Rome, Italy We acknowledge the keen interest and accurate reporting of our predecessors, who kept their nerve in the midst of an ugly pandemic and the carnage of war. Funding: None. Competing interests: None declared. 1
Alcabes P. Dread. How fears and fantasy have fuelled epidemics from the Black Death to avian flu. Public Affairs, 2009. 2 Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics. Emerg Infect Dis 2006;12:15-22. 3 Glezen WP. Emerging infections: pandemic influenza. Epidemiol Rev 1996;18:64-76. 4 Mark Honigsbaum. Living with enza: the forgotten story of Britain and the great influenza pandemic of 1918. Macmillan Science, 2008. 5 Shope RE. Influenza: history, epidemiology and speculation. Public Health Reports 1958;73:165-78. 6 Garvie A. The spread of influenza in an industrial area. BMJ 1919;2:519-23. 7 Greenwood M. The epidemiology of influenza. BMJ 1918;2:563-6. 8 Mercer Watson A. Influenza epidemic in Q.M.A.A.C. hostel, Edinburgh. BMJ 1919;1:40-1. 9 Horder T. Preventive treatment in influenza: a British Medical Association lecture given to the southern branch, at Southampton, November 13th, 1919. BMJ 1919;2:695-8. 10 Influenza in Samoa: value of vaccines. BMJ 1919;2:499500. 11 Macklin AH. Influenza amongst the Lapps. BMJ 1920;1:465-6. 12 Ball EJ. The epidemiology of influenza among workers. BMJ 1919;1:358. 13 Shufflebotham F. Influenza among poison gas workers. BMJ 1919;1:478-9. 14 Gregor A. A note on the epidemiology of influenza among workers: in gas works, in a cordite factory, and in a tin mine. BMJ 1919;1:242-3. 15 Benjafield JD. Notes on the influenza epidemic in the Egyptian Expeditionary Force. BMJ 1919;2:167-9. 16 Rose Bradford J, Bashford EF, Wilson JA. Preliminary report on the presence of a “filter passing” virus in certain diseases: with especial reference to trench fever, influenza, and nephritis. BMJ 1919;1:127-8. 17 Leishman WB. The results of protective inoculation against influenza in the army at home, 1918-1919. BMJ 1920;1:214-5. 18 IPCS INCHEM. Mustard gas. www.inchem.org/ documents/pims/chemical/mustardg.htm (accessed 12 Sep 2009). 19 Brundage JF. Interactions between influenza and bacterial respiratory pathogens: implications for pandemic preparedness. Lancet Infect Dis 2006;6:303-12. Cite this as: BMJ 2009;339:b5313
BMJ archive: the videos Late last year the journal’s full archive was uploaded on to bmj.com, enabling readers to trawl 169 years of articles, letters, and research papers direct from the website. Suddenly, luminaries such as John Snow, David Livingstone, Arthur Conan Doyle, and Florence Nightingale can be found through a simple search. But we wanted to do more to bring such figures and their contributions to life. Given the success of a
short video we commissioned last Christmas to accompany a paper on Oliver Twist’s workhouse diet, we approached the science producer Martin Freeth. He enlisted the neurobiologist Colin Blakemore, former head of the UK’s Medical Research Council, to present two films, The Evidence, and The Stories, which provide an overview of the archive and its historic significance. After these we
BMJ | 19-26 december 2009 | Volume 339
commissioned seven further films, each one devoted to a separate study or series of clinical studies. One of the films we commissioned gained poignancy last month with the death of the respiratory specialist John Crofton, at the age of 97. A few months earlier Professor Blakemore had interviewed Crofton about using streptomycin to treat tuberculosis. The two talked about the importance of randomisation
and blinding and how this has helped to make medicine more evidence based. You can watch all nine films at http://bmj.com/video. Did we choose the right lives to feature? Would you have included any others? Tell us by responding to this article at bmj.com. David Payne editor, bmj.com, BMJ
[email protected] Cite this as: BMJ 2009;339:b4745
1399
years like this
Ingested foreign bodies and societal wealth: three year observational study of swallowed coins P G Firth,1 H Zheng,2 J A Biller3 Anaesthetist, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA 2 Biostatistician, Biostatistics Center, Massachusetts General Hospital, 50 Staniford Street, 5th Floor, Suite 560, Boston 3 Gastroenterologist, Department of Gastroenterology, Mass General West, 40 Second Ave, Suite 340, Waltham, MA 02451, USA Correspondence: P G Firth
[email protected] 1
Cite this as: BMJ 2009;339:b5066 doi: 10.1136/bmj.b5066
Abstract Objective To examine the relation between coins ingested by children and the Dow Jones Industrial Average. Design Observational study. Main outcome measures Total value of coins ingested and number of incidents of coins versus other objects swallowed, measured before and after the stock market crash of October 2008. Results Eighteen objects, including 11 coins, were ingested (NASDAQ (numismatic and sundry detritus acquired) composite of 18). The total value of the 11 coins swallowed was $1.03 (FTSE 100 (fraction of the US$ or 100 cents) index of 103). The pecuniary extraction ratio (PE ratio) was 0.57 (9/16). Comparing values for a period before and after October 2008, the mean monthly NASDAQ composite (0.41 (SD 0.67) v 0.5 (0.85), P=0.75), FTSE 100 index in cents (2.3 (6.8) v 3.1 (7.8), P=0.77), and PE ratio (0.54 (0.52) v 0.66 (0.29), P=0.50) did not change. The mean end-of-month closing value of the Dow Jones, however, decreased significantly (12 537 (841.4) v 8388 (699.8), P<0.001) Conclusion There was no detectable difference in the total value of coins ingested, or ratio of coins to other objects swallowed, before or after a massive stock market crash. Introduction Aspiration and ingestion of foreign objects are well recog‑ nised problems in young children.1 One festive Australian toddler aspirated a plastic Christmas tree,2 while around Guy Fawkes Day British children prefer fireworks.3 The culinarily more sophisticated Italians reported an aspi‑ rated lobster antenna,4 while an adventurous American 2 year old staying at a roadside motel aspirated an unfor‑ tunate cockroach, which remained undetected for three days.5 Coins are a common foreign object swallowed by small children.6 Historically, the frank, mark, guilder, lira, drachma, and other currencies went down best in Europe, but the introduction of the euro saw a wave of new paedi‑ atric euroaspirants.7‑9 As the offending objects therefore reflect the environment, we hypothesised that the trickle down effect from the stock market, good or bad, would be reflected in what trickles down the paediatric oesophagus.
What is already known on this topic Small children often swallow coins The stock market valuations have been extremely volatile in recent years
What this study adds This article is an abridged version of a paper that was published on bmj.com. Cite this article as: BMJ 2009;339:b5066 1400
Children decrease the supply of coins in circulation It is difficult to detect the plausible association between the value of the stock market and the value of coins children ingest
We therefore examined the relation of coins ingested to the Dow Jones Industrial Average.
Methods After ensuring that our institutional review board had a well developed sense of humour, we compiled data on all numismatic and sundry detritus acquired (NASDAQ com‑ posite index) from children’s gastrointestinal tracts by the paediatric gastroenterology service at our hospital between August 2006 and July 2009. We identified these from the computerised records of the endoscopy suite. No patients were excluded. We calculated the financial total swallowed and extracted as a fraction of the US$ or 100 cents (FTSE 100 index), and the ratio of patients with coins versus all those with foreign objects removed (pecuniary extraction ratio, PE ratio). We calculated the mean end-of-month clos‑ ing value of the Dow Jones Industrial Average.10 We exam‑ ined whether there was a change in the monthly mean NASDAQ, FTSE, and PE ratio before and after the collapse of the Dow Jones Industrial Average of October 2008. We used a two sample t test, assuming unequal variances. Results The patients were aged 1 to 15 years. The NASDAQ composite index was 18. Eleven coins were retrieved from nine patients: three pennies (or cents), five nickels (1 nickel=5 cents), no dimes (1 dime=10 cents), and three quarters (1 quarter=25 cents), giving a total return on ingestment for the period, or FTSE 100 index, of $1.03. Seven other objects in seven chil‑ dren included an unsafe safety pin (open), a battery, a mar‑ ble, a ballbearing, a magnet, a dentist’s guard, and a rubber doorstopper. The PE ratio was therefore 0.57 (9/16). The table shows data before and after the stock market collapse. Discussion We examined the value of coins ingested by children dur‑ ing a time of profound changes in the stock market valu‑ ation. We found no change in the FTSE 100 index (2.3 v 3.1, P=0.77) or PE ratio (0.54 v 0.66, P=0.5) during a period of dramatic alterations in Dow Jones (12 537 v 8388, P<0.0001), despite the NASDAQ composite index remain‑ ing stable (0.4 v 0.5, P=0.75). In other words, despite a massive swing in the stock market there was no concomi‑ tant absolute or relative change in paediatric wealth intake against an unaltered background rate of foreign body ingestion. Strengths and limitations We used a sensitive and well recognised marker of environ‑ mental conditions: the objects ingested by children.1‑5 7‑ 9 Indeed, the validity of this model is illustrated by the fact that our 27% penny aspiration rate (n=3/11) was lower than the 36% penny pinching rate reported in 1982.6 BMJ | 19-26 december 2009 | Volume 339
years like this
Fig 1 | X ray pictures can easily detect an ingested coin. Position of coin on lateral view (left), relative to anterior (right) or posterior picture affects size of image on film (Madoff effect)
Fig 2 | Coin denominations extracted
This is exactly as one would predict, given inflation rates over time. Our inability to detect a change in coin inges‑ tion might, however, be credited to a unique confounder expected to influence both the risk factor (changes in stock market value) and the societal wealth marker (paediatric coin ingestion): the supply of credit. A reduction in credit supply will mean that, to meet household obligations, the use of relatively difficult to ingest credit cards will be swapped for more palatable hard cash denomination. This credit denomination swap obligation could result in a paradoxical increase in the rate of paediatric wealth consumption, while lack of credit simultaneously restricts economic growth and depresses the stock market. This potential confounder might influence the risk factor and the societal wealth marker in opposite directions, hence masking a relation between them.
other studies Despite the thousands of articles about aerodigestive for‑ eign bodies, there is surprising little gastropecuniary lit‑ erature. This might be because of non‑standardisation of numisluminal terminology and measurement. East of the Atlantic, the diphthong is widely used (oesophagus, aetiol‑ ogy, paediatric, for example), while on the western fringes (edema, anesthesia, humor, by illustration), its employ‑ ment is typically limited to Miami Beach. The introduction Objects ingested before and after collapse of stock market. Values are means (SD) unless stated otherwise Value Dow Jones Industrial Average NASDAQ composite index Monthly mean FTSE 100 index (US$) Monthly mean (cents) PE ratio
Before October After October 2008 2008 12 537 (841.4) 8388 (699.8)
P value <0.001
13
5
—
0.41 (0.67) 0.72
0.5 (0.85) 0.31
0.75 —
2.3 (6.8)
3.1 (7.8)
0.77
0.54 (0.52)
0.66 (0.29)
0.50
NASDAQ=numismatic and sundry detritus acquired from gastrointestinal tract; FTSE 100=full total swallowed and extracted, as fraction of US$ or 100 cents.
BMJ | 19-26 deceMBer 2009 | VoluMe 339
of the euro brought a welcome standardisation of units of ingestion, at least in the eurozone.7‑9
clinical practice The fate of an aspirated coin can be followed on x ray film to see what develops. The asymptomatic child can be re‑examined later to see if there is any change, but symp‑ tomatic coins or those lodged in the oesophagus need to be removed. The positioning of the x ray plate affects the image,11 such that, for example, an anterior‑posterior view can produce an apparent increase in the size, and hence value, of deposits in the anterior abdomen (the Madoff effect) (fig 1). A small overestimation of the diameter of a penny can lead to the misassumption that it is a nickel (5c), or similarly that a nickel is a quarter (25c), a Mad‑ off effect of 400% (fig 2). While this insider information might be marginally more reliable than a parliamentarian’s expense account, this insight can be turned to good use when wagering on the value of the coin to be extracted. Parenthetically, before placing one’s retirement funds on gastroesophaegal futures or derivatives, attention should be directed to the more proximal gastrointestinal tract to ensure the tongue is firmly in the cheek. Further details on how our findings could affect an economy’s money supply can be found on bmj.com. We thank Eric Brynjoffsen, MIT Sloan School of Management, for economic advice on monetary theory and why it is important to pay off your credit card; Elizabeth Hohmann of the Massachusetts General Hospital for humour in ethics; Scott Tolle of the Massachusetts General Hospital for clarity in imaging as usual; Allan Low, Gerry McCartney, and the BMJ editors for economic and epidemiological advice. contributors: PGF conceived the study and wrote the manuscript with input from HZ and JAB; HZ performed the statistical analysis; JAB provided details of the foreign bodies. PGF is guarantor. Funding: Funding was obtained from the gastrointestinal tracts of our patients. Absolutely no taxpayer money was used for this research. competing interests: The desires of the authors to earn Wall Street salaries conflict with their jobs in academic medicine. ethical approval: A member of the institutional review board of the Massachusetts General Hospital thoroughly approved of this study. data sharing: No additional data available. Accepted: 16 November 2009 References are in the version on bmj.com 1401
diagnosis
Fatal alchemy
G
old’s supposed powers of regeneration go back to antiquity. Pliny the Elder (AD 23-79)1 describes the preparation of two remedies using gold and their therapeutic properties. In the 13th century, alchemists like Michael Scot, Roger Bacon, and Arnaud de Villeneuve wrote about “Aurum potabile”—drinkable gold—and how to obtain it.
Drinkable gold Aurum potabile included many gold preparations, from almost pure water to real gold solutions prepared using nitrohydrochloric acid. Some types of drinkable gold were made by distilling alcohol solutions with sulphuric acid. During the process diethyl ether was made and this dissolved gold chloride, which formed a yellow coloured supernatant phase above a colourless aqueous phase.2 This was considered by some to be true drinkable gold.3 Drinkable gold was well known in the 16th century French Court, and Alexandre de la Tourette dedicated his book on the subject to King Henri III.4 In the 17th century, many doctors and chemists like Jean Beguin and Christophe Glaser published gold recipes, including drinkable gold, in their chemistry manuals.5 6 Chronic poisoning in the 16th century In 2008, during an archaeological dig in the cemetery of Anet in France, skeletons were excavated near a monument to Diane de Poitiers. She was a favourite of King Henri II despite being 20 years his senior.7 Diane was a particularly athletic woman, who swam, hunted, and rode horses every day. She died in 1566 when she was 66 years old, but the exact circumstances of her death are unknown. It is thought that the mass grave that was found during the excavations was where Diane’s mummified remains were thrown after revolutionists opened her tomb in 1795.8 1402
J POUPON AND P CHARLIER
Did gold kill a 16th century French courtesan and favourite of Henri II, ask Philippe charlier and colleagues
above: The last portrait of diane de Poitiers, showing how closely the mandible excavated from the dig fitted her image. Left : diane de Poitiers’ hairs (× 40) showing hair thinning and no surface deposits
Identifying the remains of Diane de Poitiers Diane de Poitiers’ remains were identified from the other desecrated skeletons by some physical particularities: the preserved fragments of the pelvis were those of a woman; severe arthritic lesions and important ante mortem tooth loss7 showed that she was old; and consolidated tibia and fibula fractures corresponded to those Diane sustained in a riding accident in 1565, and for which Ambroise Paré treated her. The skull showed a perfectly concordant superposition of the mandible and left jawbone when compared with the last portrait of Diane by François Clouet.9 When fragments of bone still covered by deposits of putrefaction fluid10 were carbon dated,11 they gave aberrant results (two sigma calibrated results: AD 900 to 920 and AD 950 to 1040). These results indicated that the remains had been aged by the bitumen during embalming. This was confirmed by a molecular analysis of putrefaction fluid deposits by gas chromatography mass spectrometry after an extraction with cyclohexane. The analysis showed the presence of linear alkanes and alkenes that were directly related to the fragmentation of the bitumen. Analysing the hair When the graves had been desecrated during the French revolution, some of Diane’s hair had been preserved at the castle in Anet.8 Analysis of this hair from the castle and the hair from the remains using inductively coupled plasma
mass spectrometry showed a great concentration of gold in the putrefaction fluid deposits (111 ng/g), and demonstrated the homogeneity of the two sets of samples. Elemental analyses of this hair showed a gold concentration (about 10 000 ng/g) about 500 times the actual reference values (median 20 ng/g; range: 1 to 50 ng/g 12 ). Hair thinning is a symptom of chronic gold intoxification and Diane’s hair diameter was around 65µm (normal diameter 80-90µm) (see figure).13 14 Diane is known to have undergone a long course of gold treatment hoping it was an elixir of youth. Brantôme in Vies des Dames illustres, francaises et etrangers wrote of her, “I saw her at seventy years of age beautiful of face, also fresh and also pleasant as she had been at thirty years of age...and especially she had a very large whiteness without any make-up. But it is said well that, every morning, she used some drinks made up of drinkable gold and other drugs which I do not know given by good doctors and subtle apothecaries.”15
Evidence from chrysotherapy When used to treat rheumatoid arthritis the half life of gold is 20 days,16 which may lead to gold accumulating in tissues, including hair. Gottlieb and colleagues17 found a concentration of 5000 ng/g in the hair of one patient treated with aurothioglucose.17 In some patients receiving gold sodium thiomalate, levels in hair were more than 1500 ng/g.18 Recently, we reported a case BMJ | 19-26 deceMBer 2009 | VoluMe 339
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Watch a reconstruction of Diane de Poitiers’s life and the investigation of her death at bmj.com/video of an acute intoxication after less than a month of treatment with sodium aurothiopropanolsulphonate.19 When the treatment was stopped, gold levels were 34 278 ng/g dry tissue in liver and 158 ng/g in the hair. We might expect chronic intoxication in Diane’s case, which would explain the high levels of gold in the hair compared with gold residues in other tissues.
Other explanations Two other hypotheses may explain the relatively low levels of gold measured in the tissue residues. Firstly, she may have stopped taking gold in the few days or weeks before death, and secondly her skeleton had been buried for two centuries. Mercury was used by alchemists to purify gold and prepare some gold remedies, and analysis of Diane’s remains showed concentrations of mercury in the hair at twice the upper limits of normal. External contamination of the remains of the body by gold jewellery does not seem plausible. Not being a queen, Diane de Poitiers would not have worn a crown, and it is hard to see how other jewellery could have contaminated the hair and tissues. Indeed, after her death, Diane was embalmed so her body dried without putrefying. When the coffin was opened in 1795 the body appeared intact.8 20 Gold is not included in the list of substances used during the embalming process.21 Under microscopic examination, the hairs were clean and no superficial deposits were seen. Any
deposits, especially containing lead, may have occurred as a result of the reaction between the body fluids and the lead of the sarcophagus. Such lead deposits are well documented in the case of Agnès Sorel.22 After the desecration of her grave, only her body, without any clothes or jewellery, was buried in the cemetery8 so no contamination could have occurred since then. Moreover, hair we analysed was taken just before the burial and would have not been in contact with soil or pollutant.
Forever young? We have identified the remains of Diane de Poitiers to a high degree of confidence. We believe that she drank gold, which is compatible with Brantôme’s report.15 The high concentrations of gold in her hair indicate that she could have died of chronic intoxication with gold. Philippe Charlier forensic medical examiner and archaeologist, Raymond Poincaré Hospital, Garches, France
[email protected] Joël Poupon biological toxicologist, Lariboisière Hospital, Paris, France Isabelle Huynh-Charlier radiologist, Salpêtrière Hospital, Paris, Fance
Right: The lock of Diane’s hair preserved at Anet Castle. Below: A still from the video accompanying this article
BMJ | 19-26 december 2009 | Volume 339
Jean-François Saliège professor of environmental sciences and climatology (retired), Institute of Geophysics, Paris, France Dominique Favier chemist specialising in fragrances and flavours, IFF France International Flavors and Fragrances, Asnières, France Christine Keyser specialist in forensic genetics, Institute of Legal Medicine, Strasbourg, France Bertrand Ludes professor of legal medicine, Institute of Legal Medicine, Strasbourg, France Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2
Pliny the Elder. Naturalis Historia, XXXIII, 25. Glauber JR. La teinture de l’or ou le véritable or potable (trad Du Teil). Thomas Jolly, 1659. 3 Buffon. Œuvres complètes. Tome III. Lejeune, 1829, p 262. 4 De la Tourette A. Bref discours des admirables vertus de l’or potable. P Roussin, 1575. 5 Béguin J. Les éléments de chymie. C Chancey, 1645, p 273-82. 6 Glaser C. Traité de la chymie. 2nd ed. Jean d’Houry, 1668, p 87-94. 7 Dreux du Radier. Mémoires historiques et anecdotes sur les reines et régentes de France. Tome 4, 1776, p 468-71. 8 Roussel PD. Histoire et description du château d’Anet depuis le dixième siècle jusqu’à nos jours, précédée d’une notice sur la ville d’Anet, terminée par un sommaire chronologique sur tous les seigneurs qui ont habité le château et sur ses propriétaires et contenant une étude sur Diane de Poitiers. 1875. 9 Benazzi S, Stansfield E, Milani C, Gruppioni G. Geometric morphometric methods for three-dimensional virtual reconstruction of a fragmented cranium: the case of Angelo Poliziano. Int J Legal Med 2009;123:333-44. 10 Charlier P, Georges P, Bouchet F, Huynh-Charlier I, Carlier R, Mazel V, Richardin P, Brun L, Blondiaux J, Lorin de la Grandmaison G. The microscopic (optical and SEM) examination of putrefaction fluid deposits (PFD). Potential interest in forensic anthropology. Virchows Arch 2008;453:377-86. 11 Beta-analytics (London and Miami) performed the carbon dating. 12 Ferguson JE. The noble metals in hair. In: Brooks R R (ed) Noble metals and biological systems: their role in medicine, mineral exploration, and the environment. CRC Press, 1992, p 91-128. 13 Charlier P (ed). Ostéo-archéologie et techniques médicolégales : tendances et perspectives. Pour un Manuel pratique de paléopathologie. Paris: De Boccard, 2008, p 215. 14 Tett SE. Clinical pharmacokinetics of slow-acting antirheumatic drugs. Clin Pharmacokinet 1993;25:392-407. 15 Brantôme. Vies des Dames illustres, françaises et étrangères (ed Moland L). Garnier Frères, 1868. 16 Messori L, Marcon G. Gold complexes in the treatment of rheumatoid arthritis. In: Sigel A, Sigel H, eds. Metal ions and their complexes in medication. CRC Press, 2004, p 280-301. 17 Gottlieb NL, Smith PM, Smith EM. Tissue gold concentration in a rheumatoid arthritic receiving chrysotherapy. Arthritis Rheum 1972;15:16-22. 18 Gottlieb NL, Smith PM, Penneys NS, Smith EM. Gold concentrations in hair, nail, and skin during chrysotherapy. Arthritis Rheum 1974;17:56-62. 19 Basset C, Vadrot J, Denis J, Poupon J, Zafrani ES. Prolonged cholestasis and ductopenia following gold salt therapy. Liver Int 2003,23:89-93. 20 Chevard V. Histoire de Chartres et de l’ancien pays Chartrain avec une description statistique du département d’Eure et Loir. Chartres: Durand-le-Tellier, 1801, p 389. 21 Charlier P. Evolution of embalming methodology in medieval and modern France (Agnès Sorel, the Duc de Berry, Louis the XIth, Charlotte de Savoie). Med Secoli 2006;18:777-97. 22 Charlier P. Who was the “Dame de Beauté?” Scientific study of the remains of Agnès Sorel. Hist Sci Med 2006;40:255-63. Cite this as: BMJ 2009;339:b5311 1403
diagnosis
Lead poisoning at the Swedish House Was scurvy really the cause of death of 17 stranded sealers in winter 1872? Ulf Aasebø and Kjell G Kjær consider a different diagnosis
I
n September 1872 six sealing vessels from Tromsø were north of Spitsbergen at the Grey Hook (Grahuken). A northern gale closed the bay with ice, trapping the six ships and 59 sealers with the prospect of “overwintering” with few provisions. At the same time, Adolf Nordenskiöld, the Swedish explorer,1 was setting up his winter quarters, “Polhem,” at Mossell Bay (Mosselbukta) (figure). His ships were also trapped, leaving him with a critically low food reserve. Seven of the stranded sealers crossed the ice, some 50 km, to ask Nordenskiöld for help. He was able to help some but advised the othVelkomstpynten Mo sselb
ukta
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Grahuken 9/10
10/10 Kin gs fjo rde n
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s Ka
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Map of the north western part of Spitsbergen, showing the rowing route 1404
ers to spend the winter in the Swedish house at Kapp Thordsen in Isfjorden. The house had been set up in the previous summer by a mining company that aborted their project because of poor harbour conditions and was well stocked with tinned food.2 3 Axel Envall, Nordenskiöld’s physician, advised the sealers on how to avoid scurvy.4 The 17 men then rowed some 350 km and reached the house in seven days, on 14 October. Meanwhile, the ice broke up, and the remaining trapped sealers escaped in two ships. Two chose to stay with the remaining ships and died from scurvy in April 1873.4 The men at Kapp Thordsen hunted polar bear and reindeer until the arctic night descended and then relied on the stored food. Through a diary they recorded all food consumed, weather conditions, sickness, and death but gave no details regarding symptoms of disease.5 On 2 December, two men were reported as sick; by Christmas, they were all sick. On 19 January, two men died after “hard sickness.” Two more died in February, five more in March,5 and the last one probably just before they were found on 16 June by members of a hunting expedition from the mainland who wanted to visit them.6 7 The first two men who died were buried. The next five men to die were left outside under a tarpaulin,6 7 six were found in an adjoining room, and the remaining in the living quarters. The rescue team buried them in a common grave.6 7 Their deaths were attributed to scurvy due to laziness and bad leadership in allowing scurvy to occur despite an ample food supply and the means to prevent it, and the men were left little honour.7 In 1845, Admiral John Franklin set out with 129 men and two ships to find the northwest passage.8 They took large amounts of tinned
food. The expedition was equipped for four years but was never heard from again. Final evidence of the disaster came in 1859, when a written account of their ordeal was found in a crumble of stones.9 The ships had been wrecked by ice, and the men eventually started to walk south, dying as they walked. In the 1980s a team from Alberta University exhumed three sailors buried in permafrost at the expedition’s winter quarters and found high concentrations of lead in hair samples.8 Bones from crew members, found scattered along the track, showed high concentrations of lead, while Inuit bones did not.10 The conclusion was that the sailors had lead poisoning, possibly leading to their death.10
Open graves Having pieced together the events in the Swedish house in 1872-3, in light of the Franklin disaster, we saw the similarities. In 2007 we discovered a previously unregistered two man grave, 540 metres from the house. Through a damaged corner, cervical vertebrae were visible and accessible for lead analysis. Several hundred empty tin cans were scattered behind the house. The inside solder was evident, and many cans had “icicles” of solder on the sides. The discovery of the tin cans with lead/tin solder supported our hypothesis that lead poisoning might have contributed to the deaths. We applied for permission to open the two graves to take specimens for lead analysis and inspection of bones for signs of scurvy. In August 2008, we revisited the site and sampled a 1×1 cm piece of solder. We dug a shaft 50×50 cm in the upper part of the common grave and encountered wooden planks 60 cm down. Underneath we met an ice block. The bodies were in permafrost, and further exploration was abandoned. BMJ | 19-26 december 2009 | Volume 339
diagnosis
Let us bring the story of the death of the sealers at the Swedish House to life. Listen at bmj.com/audio Through the opening in the two man grave, we extracted one humerus, one clavicle, two cervical vertebrae, and a scapula; all from one skeleton. All bones had smooth surfaces with no signs of subperiosteal bleeding (scaling). We took bone and soil samples, which were analysed in Oslo. We found no macroscopic evidence of scurvy. All bone surfaces were smooth with no scaling or enhanced ridges. The samples contained 65 μg/g of lead in dry bone, equivalent to a concentration of 102.05 μg/g.11 The lead content of the solder was 40%. Culture for Clostridium botulinum was unsuccessful because of overgrowth of other bacteria.
Lead poisoning Though the deaths of the sealers in Kapp Thordsen have been attributed to scurvy, our research indicates that lead poisoning was a more likely cause. Scurvy, caused by lack of vitamin C, was a plague of seafarers until its prevention was discovered in 1753, and intake of lime juice was implemented in the British navy in 1795.12 The disease causes disintegration of connective tissue and can be visualised macroscopically in skeletons of people who have died from scurvy. The subperiosteal bleeding leads to diagnostic scaling of the bone surfaces and enhanced ridges of the muscle attachments.13 The prevention of scurvy had been documented as early as 1816 in arctic Norway, where sealers and fishermen used “scurvy grass” (Cochlearia officinalis).14 The sealers at Kapp Thordsen had received instructions on how to avoid scurvy, so we think it an unlikely cause of their deaths, particularly we found no signs of previous subperiosteal bleeding. As it has been postulated that botu-
lism might have caused the deaths of those in the Franklin expedition15 we tested for this but did not succeed in culturing the bacteria. Lead is a poisonous heavy metal that has acute and chronic effects on the body. According to the inventory list, the men at Kapp Thordsen consumed large amounts of tinned food. They probably reheated the tins on the stove, exposing the lead alloy to acid and dissolving the lead in the food.16 Lead poisoning typically leads to stomach pains and cramps, anorexia, weight loss, a blue line of the gingival margin, neuropathy particularly affecting the extensor muscles, joint pain, and a curious condition called “debility”—inertia and complete loss of incentive and interest.17 The content of lead in our samples was 102.05 μg/g. Samples of soil from outside the burial grounds showed 16 μg/g of lead. The lead content in the bones from the Franklin expedition ranged from 97.6 to 188.6 μg/g, accumulated over about three years.10 In our case, the lead accumulated over a few weeks. The first men were sick by 2 December. As the accumulation of lead in bone occurs slowly, at a rate of 1 mg a year if the blood concentration is 1.8 μmol/l in cases of chronic lead poisoning,18 our victim must have had high blood concentrations of lead. To our knowledge, there are no cases in the literature examining simultaneous blood and bone concentrations of lead. The blood concentrations must therefore be extrapolated. In the Franklin expedition, if half the bone lead content had been accumulated during the expedition, the cumulative blood lead concentration over this time must have been 29.0-75.5 μmol/l, giving a mean concentration of 29.024.2 μmol/l.10 This is three to 10 times higher
Rusting tin cans behind the house
Smooth surfaced bones argue against scurvy
BMJ | 19-26 december 2009 | Volume 339
Watch Ulf Aasebø and his team as they travel through the frozen tundra of Svalbard at bmj.com/video the recommended upper concentrations of lead in the blood to prevent neurological damage.18 When our “patient” had accumulated 102.6 μg/g in 13-14 weeks, he must have been suffering from acute as well as subacute lead poisoning. The evidence gives strong indications that our “patient” died of lead poisoning. The other man in the grave also probably suffered the same fate. Possibly, lead poisoning, because of its “debilitating” effect and anorexia, worked with other factors, contributing to their death. Ulf Aasebø professor of lung medicine,
[email protected] Kjell G Kjær retired historian, 9136 Vannareid, Norway We thank Tora Hultgreen of Svalbard Museum, Einar Johansen of the Polar Institute, Yngvar Thomassen of the National Institute of Environmental Health, and the National Veterinary Institute for their contributions towards this expedition. A more extensive version of this paper is in press with Polar Record. Contributors: See bmj.com. Competing interests: None declared. Ethical approval: The study was approved by the National Ethics Committee for Medical Research and the Governor of Cultural Heritage. Data sharing: No additional data available. 1
Kjellman FR. Svenska polar-expeditionen I året 1872-1873 under ledning af A.E. Nordenskiöld. Norstedt, 1875. 2 Tieberg J. His diary. Tromsø Stiftstidende 4 May 1873, Tromsø University library. 3 Tieberg J. A list of the food and provisions stored in Svenskhuset when the Norwegians arrived. Tromsø Stiftstidende 1873, Tromsø University Library. 4 Envall A. Rapport till Kungl. Sundhetskollegium öfver hygienen och sjukvården under den svenske polarexpeditionen 1872-1873. Svenska läkaresälskapets nya handlingar. 1874;series II: 87-122. 5 Albrigtsen K. Dagbog over de i Isfjord 1872. A diary from October 14th 1872 till February 1873; a handwritten account of food and provisions taken out of the store at Kapp Thordsen. Tromsø University Library, 1873. 6 Tellefsen OB. His diary from 1873; unpublished document. Tromsø: Norsk Polarinstitutt, 1873. 7 Mack F. His report dated June 18th 1873 to Professor Henrik Mohn, Metrologisk Institutt. Oslo National Library, 1873. 8 Beattie O, Geiger J. Frozen in Time. The fate of the Franklin expedition. Bloomsbury, 2004 9 Houston CS. Continuing interest in the Franklin expeditions. Can Med Assoc J 1986;135:109-10. 10 Keeleyside A, Song X, Chettle DR, Webber. The lead content of human bones from the 1845 Franklin expedition. J Archaeological Science 1996;23:461-5. 11 Woodard HQ. The elementary composition of the human cortical bone. Health Physics 1962;8:513-7. 12 Lind J. A treatice of the scurvy. 1753. In: CP Steward, D Guthrie, eds. Facsimile edition. Edinburgh University Press, 1953 13 Lamb J. Captain Cook and the scourge of scurvy. www. bbc.co.uk/history/2007. 14 Konow T. Sekondløytnant Thomas Konows dagbok. Norsk Tidsskrift for Sjøvesen, 4085 Hundvåg, 1816. 15 Horowitz BZ. Polar poisons: Did botulism doom the Franklin expedition? J Toxicology Clin Toxicol. 2003;41:841-7. 16 Magruder WE. Lead-poisoning from canned food. Medical News 1883;Sept 8:261-3. 17 McCord CP. Lead and lead poisoning in early America. Indust Med Surg 1954;23:120-5. 18 Nearing JN. Health effects of inorganic lead with an emphasis on the occupational setting. An update. Technical Report. Ontario Ministry of Labour, 1987. Cite this as: BMJ 2009;339:b5038 1405
Diagnosis
Juan Medrano, Pablo Malo, José J Uriarte, and Ana-Pía López look for evidence of prejudice against mental illness
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n 2007, a New York library found Tintin in the Congo racially offensive and moved it to a secure back room. The UK Commission for Racial Equality asked for it to be removed from sale because of “hideous racial prejudice,” and a Congolese student in Belgium started a complaint against the book. For Tintin’s creator Hergé, the pen name for Belgian Georges Prosper Rémi (1907-83), Congo was a naive work, influenced by stereotypes and misconceptions common in Europe when it was first published (1930).1 Despite the older Hergé’s efforts to offer a progressive view of himself,1 2 the Tintin books have been accused of several forms of prejudice. The depiction of Africans in Congo and in The Red Sea Sharks suggested racism. The Shooting Star, published while the holocaust was taking place, was accused of anti-Semitism because a first version featured greedy Jews and a villain has an unintended Jewish surname. Misogyny was suspected because rotund Bianca Castafiore is the only remarkable feminine character. And animal rights activists deplore wildlife carnage in Congo. In this article, we analyse appearances of, or allusions to, mental disease in the Tintin series to see how mentally ill people are portrayed.
© by hergÉ/moulinsart s.a/casterman
Stigma and prejudice in Tintin The Adventures of Tintin Cigars of the Pharaoh
Review method We reviewed 22 books in the Spanish Tintin collection, published by Editorial Juventud (17th ed, 2005). The Lake of the Sharks, which was based on an animated film by Michel Regnier, was excluded. The early Spanish versions from Congo through to The Crab with the Golden Claws, published by Casterman, were also reviewed. Spanish translations were compared with those in French, English, or Basque where available. We classified our findings into four categories (table): • Alcohol intoxication or behavioral disorders related to alcohol • Mental disorders not caused by alcohol or head trauma • Psychiatric disorders secondary to head trauma • Psychiatrists and treatment. What we found Eighteen books had verbal references to behaviours, intentions, or ways of thinking related to mental illness. In all cases, behaviours were unwise or overtly impulsive, reflecting loss of control. In The Red Sea Sharks Haddock,
Synopsis of psychiatric findings in Tintin Category
Characters or feature
Depiction or intention
(1) Alcohol related disorders
Haddock, Tintin, Snowy, Pícaros, sheriff, San Theodorian militia, Bordurian policemen, drowned sailor
Childish, irrational, aggressive, funny
(2) Disorder not caused by alcohol or head trauma: Functional psychosis
Patients in asylum, Philippulus, Sophocles Sarcophagus, Zloty, Didi (Mr Wang’s son)
Childish, irrational, aggressive, funny
Malingered psychosis
Tintin
Childish, irrational, funny
Depression, suicide
Haddock, Wolff
Dramatic
Paranoid reaction
Calculus
Funny
(3) Head trauma
Calculus, Haddock, Syldavian spy, O’Connors
Funny, childish, irrational, dramatic
(4) Psychiatrists and treatment
Nameless asylum director, Dr Müller, Dr Krollspell
Lacking empathy, repressive, evil, greedy
Asylum, straitjacket, psychiatric assistants
Repressive, paternalistic
1406
whose rich, idiosyncratic repertoire of insults (ectoplasm, bashi-bazouk among others) was compiled in a dictionary,3 yells “paranoid” and “schizophrenic” to a slave dealer. The English edition published by Mammoth substituted “psychopath” for schizophrenic. Ten of the 22 books featured intoxication or behavioural disturbances related to alcohol (category one). A dangerous alcoholic in The Crab with the Golden Claws, Haddock later becomes a self controlled drinker, except in Explorers on the Moon. In Tintin and the Picaros alcohol is ubiquitous, with Alcazar’s troops dangerously intoxicated on whisky airdropped by General Tapioca, and Haddock surreptitiously treated by Calculus with an alcohol aversive that will eventually turn the Picaros into teetotallers. In The Cigars of the Pharaoh, the villains inject their enemies with rajaijah juice, which—especially in large doses—induces a psychotic disorder with childish, irrational, and dangerous features (category two). In The Blue Lotus, Didi, who has been injected with rajaijah juice, displays catatonic symptoms before attempting to behead Tintin. After being given fake venom, Tintin childishly pretends to be mad to fool Mitsuhirato. In The Shooting Star, Philippulus tries to plant a bomb before being taken to the hospital he had absconded from. In The Seven Crystal Balls, deaf and somewhat paranoid Calculus is kidnapped, and Haddock develops a reactive depression. Engineer Wolff’s death in Explorers of the Moon is a paradigm of Durkheim’s altruistic suicide. With regard to category three, Calculus’s amnesia in Destination Moon was described in a 1983 congress as, “one of the most beautiful observations of transient post-traumatic amnesia.”4 Other cases of mental disorder induced by head trauma include irrational behaviour and derailed, clinically incoherent, thought content. As for category four, The Cigars of the Pharaoh BMJ | 19-26 december 2009 | Volume 339
The Adventures of Tintin Destination Moon
depicts an asylum with odd “non-dangerous” excessively,8 and his mother was treated with patients and a nameless psychiatrist who, miselectroconvulsive therapy for involutional led by the villains, puts Tintin in seclusion and depression.4 says goodbye to the true patients as they leave the Psychiatrists are the only doctors with promiplace. Interestingly, for this 1934 psychiatrist the nent roles in Tintin, so their unfavourable porhero’s complaints at his detention mean a lack trayal is important. Instead of sharing common of insight and, therefore, a proof of illness. Some stereotypes such as oddity with their patients— frames later, the psychiatrist, wielding a trunwhich could point to stigma by association—the cheon while leading a pack of angry looking psypsychiatrists lack empathy and are repressive, chiatric assistants, chases after an escaping Tintin, greedy, or plainly evil. Interestingly, such a negwho will finally be detained and put in a straitative view did not arise from Hergé’s bitter disjacket. In The Black Isle, Dr Müller runs an asyappointment at his mother’s treatment, because lum where his enemies are detained and literally all psychiatrists except for greedy Krollspell driven mad. In Flight 714, truth serum inventor were created years before she became ill. Dr Krollspell will only dessert the villain RastaGiven the worldwide appeal of Tintin, and popoulos after learning the influence of chilthat he plans to kill him. Calculus’s amnesia in Destination dren’s media on negaWe could not agree on Moon was described in a 1983 tive views of mental whether Professor Fan congress as, “one of the most illness,9‑11 these books Shi-Ying in The Blue beautiful observations of transient may have passed on Lotus is a psychiatrist post-traumatic amnesia.” negative stereotypes or a researcher. Were he to young readers. Howa mental healthcare provider, this old silent Chiever, artistic work must be analysed as a whole. nese man would be the only psychiatrist in the Stereotyping is commonplace in Tintin—the ranks of the goodies in Tintin. baddies are extremely evil, the goodies (except for Pablo in The Broken Ear and Pícaros) are Commentary almost perfect, and Scottish policemen in Although Tintin books have been analysed to look The Black Isle are prototypically British. Furfor a deep, dynamic, and implicit psychological thermore, the depiction of mental illness and significance,5‑7 to our knowledge this is the first mentally ill people in Tintin reflect the shared attempt to explore psychiatric stigma. Although prototypical social views of the time. In the five we reviewed Spanish translations only, a random decades between Soviets and Pícaros, mental review of books in three other languages found illness was viewed negatively, with no awarejust one minor difference. ness of the stigma faced by affected people. In Even though the Tintin books depict mental the 1970s (in the last years of Hergé’s career), disorders unfavourably, with stereotypes such Spain’s criminal law still equated mentally ill as irrationality and dangerous behaviour compeople with dangerous animals—relatives of monly found, we cannot assume that Georges patients and owners of beasts were subject to Rémi was unsympathetic towards mental the same penalties in case of abandonment. illness. He had several depressive episodes Twentieth century literature and cinema offer himself and even consulted with Jung’s pupil a plethora of examples of good artistic work Dr Rickling during a period of personal turthat stigmatises mentally ill people. Hergé was moil. Some biographers suggest that he drank no more disrespectful than other creators who BMJ | 19-26 december 2009 | Volume 339
© by hergÉ/moulinsart s.a/casterman
© by hergÉ/moulinsart s.a/casterman
Diagnosis
The Adventures of Tintin The Black Isle
made fun of mentally ill people. Modern comic series such as the Spaniard Francisco Ibáñez’s Mort and Phil are far more stigmatising than Tintin. Finally, the psychiatric insult is still common in the political arena. Although Hergé has been sternly criticised for racism, anti-Semitism, male chauvinism, and cruelty towards animals, nobody seems to have noticed his unfavourable depiction of mentally ill people. But instead of accusing Hergé of psychiatric prejudice, we would like to stress that the series merely reflects the stigma faced for decades by mentally ill people. The media, politicians, and society should carefully scrutinise words used in everyday language and recognise that some shared images or ideas are simply negative stereotypes. Juan Medrano consultant psychiatrist,
[email protected] Pablo Malo consultant psychiatrist, José J Uriarte consultant psychiatrist, Ana-Pía López community mental health nurse , Centro de Salud Mental Gasteiz-Centro, 01002 Vitoria, Spain. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Thompson H. Tintin. Hergé and his creation. London: Sceptre, 1992. 2. Sadoul N. Tintin et moi. Entretiens avec Hergé. Paris: Casterman, 2000. 3. Algoud A. L’intégrale des jurons du Capitaine Haddock. Paris: Casterman, 2004. 4. Assouline P. Hergé. Paris: Folio Gallimard, 1996. 5. Tisseron S. Tintin et le secret d’Hergé. Hors Collection/ Presses de la Cité, 1993. 6. Tisseron S. Tintin et les secrets de familla. Paris: Aubier, 1993. 7. Apostolidès JM. Les métamorphoses de Tintin. Paris: Champs-Flammarion, 2006. 8. Peeters B. Hergé fils de Tintin. Paris: ChampsFlammarion, 2006. 9. Wilson C, Nairn R, Coverdale J, Panapa A. How mental illness is portrayed in children’s television. A prospective study. Br J Psychiatry 2000;176:440-3. 10. Coverdale JH, Nairn R. A research agenda concerning depictions of mental illness in children’s media. Acad Psychiatry 2006;30:83-7. 11. Rose D, Thornicroft G, Pinfold V, Kassam A. 250 labels used to stigmatise people with mental illness. BMC Health Serv Res 2007;7:97.
1.
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Diagnosis
Animated ophthalmology Daniel Ezra and colleagues warn that eye problems in cartoon characters often go undiagnosed
O
phthalmology has had a long tradition of studying the differences in presentation and natural course of disease in national and ethnic groups. The globe and orbit vary considerably in different groups, and this can predispose to different diseases.1 Large population based studies have been carried out in diverse groups such as Mongolian,2 Latino,3 and Inuit4 patients as well as patients from different geographical locations from Scandinavia to Ouagadougou.5 6 However, one group that remains overlooked is cartoon characters, whose health problems have been marginalised for decades. Moorfields Eye Hospital is the largest specialised eye hospital in the world with over 250 000 patient episodes a year. The unique volume and mix of clinical material seen at our institution, coupled with the academic resources provided by partnership with the Institute of Ophthalmology at University College London, has allowed us present the first case series of eye disorders in cartoon characters. The aim of this case series is to highlight the varied and serious ophthalmic diseases that afflict cartoon characters and to show that many of these blinding conditions are treatable. Informed consent was taken from each patient, and the study was conducted in accordance with the declarations of Helsinki and Narnia.
Case 2 Homer Simpson — Orbital varices
THE SIMPSONS © created by matt groening with jim brooks & sam simon/fox broadcasting
Mr Simpson, a white man in his mid-40s, presented to the emergency department with a painful and sudden anterior luxation of his left globe after having been strangled by a Scottish school caretaker. He reported
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Case 1 Sleepy — Levator disinsertion An achondroplasic white man in his late 50s presented to a primary care ophthalmology clinic. His presenting complaint was drooping eyelids, which had begun to interfere with his work. The ptosis was also affecting his confidence, and he was now being called Sleepy at work. He had a complex social history; he was of central European origin and had been doing heavy manual work and mining for many years. On direct questioning, he admitted snoring heavily at night with notable daytime hypersomnolence and was found to have an Epworth somnolence score of 20.7 He had no symptoms related to bulbar palsy, and indeed sings in a miners’ close harmony male choir. On examination he had bilateral symmetrical ptosis and high upper lid skin crease measurements but normal levator function. Marked frontalis overaction was observed. The results of cranial nerve examination were normal, and no diplopia was detected. There was no limb weakness or muscle wasting, although syndactyly of second and third digits was noted on both hands.
Diagnoses of myasthenia gravis, dystrophia myotonica, chronic progressive external ophthalmoplegia, and senile levator disinsertion were considered. Myasthenia gravis was thought unlikely as he had symmetric ptosis and was orthophoric (no strabismus) in the primary position. He had no limb weakness or myotonia, which makes dystrophia myotonica unlikely (although there is some frontal balding). The powerful frontalis overaction excludes a serious facial myopathy, which is common in chronic progressive external ophthalmoplegia and universal in dystrophia myotonica. Levator disinsertion was diagnosed on clinical grounds. The patient had bilateral anterior approach levator repairs. He was referred on for sleep studies and was found to have obstructive sleep apnoea. He now uses continuous positive airway pressure support and reports being much more alert during the day. He is being investigated for pulmonary silicosis, and an occupational injury claim to his mining company is ongoing.
no other preceding ophthalmic symptoms. He works as a nuclear safety inspector and is a father of three. On examination he was grossly overweight and systemically jaundiced. A full neurological examination showed no abnormality, but syndactyly of the second and third fingers was again noted. An ophthalmic examination found no signs of optic neuropathy with no errors on reading Ishihara plates and no relative afferent pupillary defect. Funduscopy showed no abnormal retinal vessels or retinal haemorrhage. He was treated with gentle manipulation to reduce the globe behind the orbital septum. The eye settled well with no corneal exposure or optic nerve compromise. Mr Simpson was later to perform a Valsalva manoeuvre while lowering his head below his knees. This
elicited a proptosis of the globe. No bruit was noted on auscultation of the orbit. A differential diagnosis of floppy eyelid syndrome8 (common in obese men of this age) and thyroid eye disease was considered, but the history of proptosis while being garrotted and during a Valsalva manoeuvre was highly suggestive of orbital varices. The cause of the jaundice was unknown but had been present since birth with a strong family history. Mr Simpson’s occupational exposure to radiation was such that computed tomography was considered unwise. Magnetic resonance imaging of the orbits and brain confirmed the diagnosis of orbital varices. Haematological investigations confirmed an unconjugated hyperbilirubinaemia with no macrocytosis and no evidence of haemolysis or hepatitis.
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Diagnosis
Mr Magoo, a man in his 70s, was referred from the geriatricians for ophthalmic review. He had been admitted to hospital after a fall. His family said that he had been constantly bumping into things for many years with unexpected and sometimes amusing consequences. He refused to admit that he had any problem with his vision but was noted to be unable to read the top letter of the Snellen chart, even at a distance of 1 metre. On assessment, he denied any subjective visual problems, but his visual acuity was recorded as hand movements only. He was noted to be peering through closed lids, a common technique used to increase acuity by people with large refractive error. An assessment by the local optometrist indicated
Discussion These cases show the wide spectrum of ophthalmic and orbital disease in cartoon characters, and the life changing effects of appropriate management. Equality and access to health care have been made a central plank of the NHS next stage review,9 but cartoon characters clearly are at the thin end of the wedge. Tragically, many of the conditions we have encountered are treatable causes of blindness that are often missed. We hope that this case series will alert the medical profession to be more aware of this vulnerable and overlooked group. Daniel G Ezra clinical lecturer in translational ophthalmic research,
[email protected] Geoff Rose consultant ophthalmologist Andrew Coombes consultant ophthalmologist, St Bartholomew’s and the Royal London NHS Trust, London E1 1BB Gordon Plant consultant ophthalmologist, Moorfields Eye Hospital NHS Trust, London EC1V 2PD Contributorship: DGE and GP conceived this study. The article was drafted by DGE and all authors appraised and reviewed the final manuscript. GP told DGE that he watches too much television, but AC and GR were too busy operating to comment. GP is the guarantor.
a refractive error of about −20.0 dioptres in both eyes. He had no evidence of cataract, and glaucoma and age related macular degeneration (for which high myopia is a risk factor) were excluded by visual field testing, scanning laser ophthalmoscopy, optical coherence tomography, and fluorescein retinal angiography. High myopia was diagnosed and several treatment options were considered. Mr Magoo discounted wearing spectacles because of the spherical aberration at high levels of refractive error. Rigid gas permeable contact lenses were not practical as his dexterity was limited by syndactyly of the second and third digits, making cleaning the lenses impossible. He preferred a permanent solution, but laser treatment was not appropriate for such high myopia. Finally, he was encouraged to have his lenses replaced with prosthetic intraocular lenses. One month after intraocular surgery his visual acuities were measured at 6/6 unaided in both eyes. He reported that his life had become much more uneventful since his vision had improved, and he was discharged from the clinic.
Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3
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Whitnall SE. Anatomy of the human orbit and accessory organs of vision. Henry Frowde, Hodder and Stoughton, 1921. Yip JL, Foster PJ, Gilbert CE, Uranchimeg D, Bassanhuu J, Lee PS. Incidence of occludable angles in a high-risk Mongolian population. Br J Ophthalmol 2008;92:30-3. Francis BA, Varma R, Chopra V, Lai MY, Shtir C, Azen SP, et al. Intraocular pressure, central corneal thickness, and prevalence of open-angle glaucoma: the Los Angeles Latino Eye Study. Am J Ophthalmol 2008;146:741-6. Haymes SA, Leston JD, Ferucci ED, Etzel RA, Lanier AP. Visual impairment and eye care among Alaska Native people. Ophthalmic Epidemiol 2009;16:163-74. Ertan A, Kamburoglu G, Bahadir M. Intacs insertion with the femtosecond laser for the management of keratoconus: one-year results. J Cataract Refract Surg 2006;32:2039-42. Meda N, Ouedraogo A, Daboue A, Ouédraogo M, Ramdé B, Somé D. [Etiologies of ocular and eyelid trauma in Burkina Faso] J Fr Ophtalmol 2001;24:463-6. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14:540-5. Ezra DG, Derriman L, Mellingtion FE, Jayaram H, Badia L. Spontaneous globe luxation associated with shallow orbits and floppy eyelid syndrome. Orbit 2008;27:55-8. Darzi A. High quality care for all: NHS next stage review review final report. Stationery Office, 2008.
Case 4 Kenny — Pauciarticular juvenile chronic arthritis Kenny McCormick, a 9 year old boy, was referred by his general practitioner. The doctor was concerned that he may have conjunctivitis but was unable to examine him as he refused to remove his hood). A full history was limited as his speech was incomprehensible and muffled by his hood. He had a difficult social background, coming from a poor household presided over by his violent, alcoholic, and unemployed parents. An examination under anaesthesia was required. Under aseptic technique, the hood was carefully removed by releasing the medial and lateral check ligaments. A flap was then raised and reflected by carefully dissecting in the appropriate plane. Once the face was exposed, a refraction and funduscopy were performed. The ocular media were found to be hazy bilaterally and a portable slit-lamp examination found severe bilateral anterior uveitis. Photophobia caused by uveitis was thought to be the reason for wearing the hood. Investigations included chest radiography, serum calcium, HLA-B27, syphillis serology, full blood count, erythrocyte sedimentation rate, and C reactive protein. A high erythrocyte sedimentation rate, high antinuclear antibody titre, and low serum albumin concentration were noted. Tuberculosis, sarcoidosis, and HLA-B27 related uveitis were excluded and pauciarticular juvenile chronic arthritis was diagnosed. The joint manifestations were mild, with significant uveitis and photophobia being the predominant symptoms. He was started on a course of intensive topical steroids and regular mydriatics as well as oral non-steroidal anti-inflammatory drugs. He improved dramatically, and after several weeks he remained asymptomatic and controlled with methotrexate with no further photophobia. Sadly, in his first venture out of the house without his hood up he was killed after being dragged on to train tracks by his go-cart and trampled by a herd of cattle. His body was eaten by rats.
Cite this as: BMJ 2009;339:b4948
BMJ | 19-26 december 2009 | Volume 339
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SOUTH PARK © created by TREY PARKER & MATT STONE/COMEDY CENTRAL/MTV
Case 3 Mr Magoo — High myopia
Diagnosis
Lying obliquely—a clinical sign of cognitive impairment: cross sectional observational study Peter Kraft,1 Ottar Gadeholt,1 Matthias J Wieser,2 Jenifer Jennings,1 Joseph Classen1 3 Department of Neurology, University of Wuerzburg, Germany 2 Department of Psychology I, University of Wuerzburg, Germany 3 Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany Correspondence to: J Classen
[email protected] 1
Cite this as: BMJ 2009;339:b5273 doi: 10.1136/bmj.b5273
Abstract Objective To determine if failure to spontaneously orient the body along the longitudinal axis of a hospital bed when asked to lie down is associated with cognitive impairment in older patients. Design Cross sectional observational study. Setting Neurology department of a university hospital in Germany. Participants Convenience sample of 110 older (≥ 60 years) inpatients with neurological conditions and 23 staff neurologists. Main outcome measures The main outcome measure was the association between the angle of the body axis and the results of three cognitive screening tests (mini-mental state examination, DemTect, and clock drawing test). Staff doctors were shown photographs of a model taken at a natural viewing angle to determine their subjective perspective of what constitutes “oblique.” Results 110 neurological inpatients (mean age 70.9 (SD 6.8) years) were included after exclusions. Evidence of cognitive impairment was found in 34, with scores indicating dementia in eight, according to the mini-mental state examination, and in 11 according to the DemTect. Across all patients, the mean angular deviation of the body axis from the longitudinal axis of the bed (range 0-23°) correlated linearly with the minimental state examination (r=−0.480), DemTect (r=−0.527), and the clock drawing test (r=−0.552) scores (P<0.001 for all), even after removing age as a covariate. Overall, 90% of staff doctors considered a minimal body angle of 7° to be oblique. Angular deviation of at least 7° predicted cognitive impairment according to the three different tests, with specificities between 89% and 96% and sensitivities between 27% and 50%. Conclusion Clinicians might suspect cognitive impairment in mobile older inpatients with neurological disorders who spontaneously position themselves obliquely when asked to lie on a bed.
What is already known on this topic Clinical signs detected during physical examination may provide important clues to cognitive abilities that are not confounded by the patient’s reaction to an explicit testing situation The ability to predict cognitive impairment from positioning behaviour has not been studied in clinical settings
What this study adds
This article is an abridged version of a paper that was published on bmj.com. Cite this article as: BMJ 2009;339:b5273 1410
Failure to orient the body axis in bed is an easily recognisable clinical sign This sign in older mobile neurological inpatients was associated with poor performance on several cognitive screening tests This sign may be useful to alert clinicians to the possibility of cognitive impairment and to prompt further investigations
Introduction More than 30% of older (≥60 years) inpatients in general medical units have major cognitive impairment1‑3 but this often remains unrecognised.1 2 We determined whether failure to spontaneously orient the body axis to the longi‑ tudinal axis of the bed when lying down is associated with cognitive impairment. Methods From March 2007 to April 2008 and from June to July 2009 we obtained convenience samples of inpatients aged 60 or more and being treated for neurological disorders at the University of Wuerzburg. To determine the orientation of the body axis we asked the patients to lie down from a sitting position on the side of a bed and took a digital photograph using a camera mounted above the patient (fig 1). The procedure was repeated from the other side of the bed for 88 patients. The patients were not specifically asked to remove their footwear. We defined the body axis angle as the angle between the patient’s body axis and the longitudinal axis of the bed (see bmj.com). The angle was assessed by an examiner blinded to the results of the cognitive tests. Cognitive testing Cognitive testing was carried out on the same day as the assessment of body axis using the mini-mental state examination,4 the DemTect,5 and the clock drawing test.6 7 Among them, the mini-mental state examination is the best evaluated test for cognitive screening.8 The DemTect has high sensitivity for detecting and grading mild cogni‑ tive impairment,5 9 independent of age and education.5 The clock drawing test is a simple tool, can be applied quickly, and is sensitive for visuospatial deficits and exec‑ utive functions.10‑12 The tests were presented in random sequence during one session. We operationally defined dementia as a mini-mental state examination score of less than 244 or a DemTect score of less than 9.5 Mild cognitive impairment13 was operationally defined by a mini-mental state examination score of between 24 and 265 14 and a DemTect score of between 9 and 12.5 Results of the clock drawing test15 were considered abnormal when the score was less than 5 (scale 1-6).11 Subjective estimate of obliqueness To obtain an estimate of which body axis angles would be perceived as oblique, we showed 23 staff neurologists photographs of a man lying at different body axis angles. They were asked to classify the orientation of the body axis as “reasonably straight” or “oblique” (see bmj.com). The photographs were taken from the foot of the bed. The actual body axis angle was determined from overhead photographs, which were not shown to the neurologists. BMJ | 19-26 december 2009 | Volume 339
Diagnosis
Results Overall, all but one of 110 included patients (see bmj.com) completed the tests and complied with instruc‑ tions. All patients whose body axis orientation was found to be skewed by the examiner were able to achieve a straight orientation on verbal directions. For patients who laid down from both sides of the bed, body axis angles measured on the one side were linearly correlated with those on the other side (Pearson’s correlation coefficient r=0.631; P<0.001). The angles were not statistically differ‑ ent (P=0.317; paired two tailed t test). For these patients the mean angle of both sides was considered in the analy‑ sis. The absolute value of the angle of the body axis orien‑ tation ranged from 0o to 23° with a median of 3°. Scores for the mini-mental state examination suggested cognitive impairment in 24 patients, with scores below the dementia cut-off value in eight. For DemTect, cognitive BMJ | 19-26 december 2009 | Volume 339
Mini-mental state examination (points)
Statistical analysis We carried out a correlational analysis (Pearson prod‑ uct moment correlation) on angular deviation using the mini-mental state examination, the DemTect, and the clock drawing test, respectively. Partial correlations were computed to control for age as a confounding factor. To compare the correlations between the tests and angular deviation, we computed t statistics for the differences between correlation coefficients.16 Receiver operating characteristics17 were generated by calculating the sensitivity and specificity for each value of body axis angle and plotting 1 minus specificity against sensitivity for each of the three cognitive screening tests. Data are presented as means with standard deviations. We considered results to be significant at P<0.05.
30
18
Normal
25
“Mild cognitive impairment”
20
“Dementia”
15 10 5 0
Normal
15 12
“Mild cognitive impairment”
9
“Dementia”
6 3 0
Clock drawing test (points)
Fig 1 | Measurement of body axis angle. Left: intact. Right: Failed
The smallest angle, which was perceived as oblique by at least 90% of the neurologists, was considered the angle for obliqueness.
DemTect (points)
impairment was suggested in 34 patients, with 11 of them having scores for dementia. For the clock drawing test, cognitive impairment was suggested in 33 patients. Larger angles were associated with greater severity on cognitive test scores. Fig 2 shows the relation between body axis angles and cognitive tests scores in the patients. Linear regression analysis using Pearson product moment correlation showed that angular deviation cor‑ related significantly (P<0.001 for all tests) with the minimental state examination (r=–0.480), DemTect (r=–0.527), and clock drawing test (r=–0.552). Correlations remained significant (P<0.001 for all) even when age was removed as a covariate: mini-mental state examination, r=–0.407; DemTect, r=–0.444; clock drawing test, r=–0.467. The correlations between each cognitive screening test and body axis angle were similar (all t<1, all P>0.05). Patients were stratified into three categories of cogni‑ tive status (“normal,” “mild cognitive impairment,” and “dementia”) as determined by the results of the mini-men‑ tal state examination and DemTect. Analysis of variants showed significant effects of “cognitive status” on body
6
Normal
5 “Cognitively impaired”
4 3 2 1 0 0
5
10
15
20
25
Body axis angle˚
Fig 2 | Relation between body axis angle and scores for cognitive screening tests 1411
Diagnosis
axis angle (see bmj.com). The body axis angles of patients reaching dementia scores were significantly larger than those with normal scores (see bmj.com). For the clock drawing test, angles of patients with normal test scores differed from those of patients with less than normal test scores. The association of oblique body axis and poor results in cognitive screening tests remained if the data were reanalysed after exclusion of four patients wear‑ ing shoes when lying down from a subgroup of patients (n=78) with footwear status that could be determined from the photographs. The obliqueness angle determined by 23 neurologists was 7° (see web extra on bmj.com). Using different out‑ come measures, the test characteristics of this oblique‑ ness angle were determined by the receiver operating characteristics analysis. Angles equal to or greater than the obliqueness angle detected cognitive impairment, with sensitivities between 27% and 50% and specifici‑ ties between 89% and 96% (see bmj.com).
Discussion Deviation of the spontaneous body axis angle from the longitudinal axis of a bed was highly predictive of impaired performance in three cognitive screening tests. As each of the tests has been validated for cognitive impairment,18 lying obliquely probably indicates cognitive impairment. A body axis angle of 7° was classified as oblique by 90% of neurologists. At this angle, specificity of more than 80% predicting impaired cognition was obtained in all tests, with sensitivities between 27% and 50%. Therefore lying down obliquely may be regarded as a simple clinical sign for cognitive impairment. Conclusions were derived from a population of older (≥60 years) inpatients with neurological disorders that was skewed against vascular dementia and dementia associ‑ ated with hypokinetic movement disorders. Those patients who kept their shoes on may have felt awkward about get‑ ting on to the bed, which could have affected the way they lay down. However, the association between oblique body axis and cognitive impairment remained after exclusion of patients who wore their shoes. Performance in the clock drawing test alone explained some 29% of variance in the data. As clock drawing has been shown to mainly tap into visuospatial and execu‑ tive abilities,10 12 disturbance in either of these cognitive domains may be an important component of the mecha‑ nism underlying failure to orient the body axis. Disorders of orientation discrimination—the inability to detect the orientation of an object in relation to others19—have been associated with Alzheimer’s disease20 and postural disor‑ ders.21‑24 For example, pusher syndrome, a behaviour in which patients with stroke in an upright position actively push away from the non-hemiparetic side and tilt the body towards the hemiparetic side, has been linked with the inability of patients to determine when their own body is oriented in a vertical position in the frontal plane.21 22 Similarly, it has been proposed that disrupted perception of verticality in the sagittal plane leads to backward tilt in the upright position in older people,23 and may be related to falls.24 1412
Obliqueness was clearly present in patients with cognitive impairment but who had not reached dementia scores in either the mini-mental state examination or the DemTect. This finding is consistent with the notion that impairment below the level of dementia may involve defi‑ cits in cognitive domains other than memory.13 We thank Klaus V Toyka (Department of Neurology, University of Wuerzburg) and Reinhard Gentner (Human Cortical Physiology Laboratory, Department of Neurology, University of Wuerzburg) for helpful comments, and staff doctors for participating. Contributors: See bmj.com. Funding: This study was part of OG’s MD thesis. The study was supported by research funds from the State of Bavaria. The sponsor did not have any active role in the study. The researchers were independent of the funders. Competing interests: None declared. Ethical approval: This study was approved by the ethics committee of the University of Wuerzburg. 1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
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Hickey A, Clinch D, Groarke EP. Prevalence of cognitive impairment in the hospitalized elderly. Int J Geriatr Psychiatry 1997;12:27-33. Raymont V, Bingley W, Buchanan A, David AS, Hayward P, Wessely S, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet 2004;364:1421-7. Bickel H, Mosch E, Seigerschmidt E, Siemen M, Forstl H. Prevalence and persistence of mild cognitive impairment among elderly patients in general hospitals. Dement Geriatr Cogn Disord 2006;21:242-50. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. Kalbe E, Kessler J, Calabrese P, Smith R, Passmore AP, Brand M, et al. DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia. Int J Geriatr Psychiatry 2004;19:136-43. Critchley M. The parietal lobes. Hafner, 1953. Sunderland T, Hill JL, Mellow AM, Lawlor BA, Gundersheimer J, Newhouse PA, et al. Clock drawing in Alzheimer’s disease. A novel measure of dementia severity. J Am Geriatr Soc 1989;37:725-9. Holsinger T, Deveau J, Boustani M, Williams JW Jr. Does this patient have dementia? JAMA 2007;297:2391-404. Troyer AK. DemTect effective in screening for mild cognitive impairment and mild dementia. Evid Based Ment Health 2004;7:70. Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry 1998;64:588-94. Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000;15:548-61. Freedman M, Leach L, Kaplan E. Clock drawing: a neuropsychological analysis. Oxford University Press, 1994. Petersen RC, Negash S. Mild cognitive impairment: an overview. CNS Spectr 2008;13:45-53. Kukull WA, Larson EB, Teri L, Bowen J, McCormick W, Pfanschmidt ML. The mini-mental state examination score and the clinical diagnosis of dementia. J Clin Epidemiol 1994;47:1061-7. Shulman KI, Gold D, Cohen CA, Zuccherio CA. Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry 1993;8:487-96. Cohen J, Cohen P. Applied multiple regression/correlation analysis for the behavioral sciences. 2nd edn. Lawrence Erlbaum, 1983. Fawcett T. An introduction to ROC analysis. Pattern Recognit Lett 2006;27:861-74. Cullen B, O’Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry 2007;78:790-9. Turnbull OH, Beschin N, Della Sala S. Agnosia for object orientation: implications for theories of object recognition. Neuropsychologia 1997;35:153-63. Caterini F, Della Sala S, Spinnler H, Stangalino C, Tumbull OH. Object recognition and object orientation in Alzheimer’s disease. Neuropsychology 2002;16:146-55. Karnath HO. Pusher syndrome—a frequent but little-known disturbance of body orientation perception. J Neurol 2007;254:415-24. Perennou DA, Mazibrada G, Chauvineau V, Greenwood R, R othwell J, Gresty MA, et al. Lateropulsion, pushing and verticality perception in hemisphere stroke: a causal relationship? Brain 2008;131:2401-13. Manckoundia P, Mourey F, Pfitzenmeyer P, Van Hoecke J, Perennou D. Is backward disequilibrium in the elderly caused by an abnormal perception of verticality? A pilot study. Clin Neurophysiol 2007;118: 786-93. Tobis JS, Nayak L, Hoehler F. Visual perception of verticality and horizontality among elderly fallers. Arch Phys Med Rehabil 1981;62:619-22.
Accepted: 17 November 2009 BMJ | 19-26 december 2009 | Volume 339
diagnosis
I
t is 200 years since the naturalist Charles Darwin was born. It is therefore an appropriate time to establish the nature of the illness that he endured throughout adulthood and to refute the many fanciful proffered diagnoses, both physical and psychological, or psychoanalytical.
Darwin on board HMS Beagle Throughout his adult life Darwin endured a chronic, relapsing illness. This was present even before he sailed on HMS Beagle in 1831: I was also troubled with palpitations and pain about the heart, and like many a young ignorant man, especially one with a smattering of medical knowledge, was convinced that I had heart-disease. I did not consult any doctor, as I fully expected to hear the verdict that I was not fit for the voyage, and I was resolved to go at all hazards1
darwin’s illness revisited
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JOhN COllier: POrTrAiT OF DArWiN/rePrODUCeD WiTh kiND PerMiSSiON OF The liNNeAN SOCieTY
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We discuss Darwin’s illness in a BMJ podcast, and find out what prompted John Hayman to investigate, at bmj.com/audio Sea sickness was a major problem for Darwin, to the extent that he was incapacitated for days at a time. On 30 December 1831 and again in January, he recorded his feelings in a diary (box). Darwin’s seasickness was clearly more severe than that normally experienced and lasted throughout the voyage. He was sick for days, even under relatively mild conditions. To his sister Susan he wrote:
“
Darwin also had eczema and had several attacks of boils. Interestingly, when his eczema erupted his main illness remitted, and remission also occurred during attacks of “rheumatism.” Emma Darwin, his wife, wrote:
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He has had a better week with much less
”
For the last four months I have not slept
more than one night in the Beagle; today took all my things on board meaning to stay–But I am writing this on shore; and what do you think is the reason? . . . Sea sickness3
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Darwin’s continuing illness Darwin’s sickness continued after the voyage. His illness was characterised by episodes of nausea, vomiting, intermittent abdominal pain, weakness, and lethargy and often associated with headache, dizziness (“swimming of the head”), visual disturbances, and palpitations. At times he complained of “inordinate flatulence” and diarrhoea:
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I am weak enough today, but think I am improving. My attack was very sudden: it came on with fiery spokes and & dark clouds before my eyes; then sharpish shivery & rather bad not very bad sickness. I got up yesterday about 2 & about 7. I felt rather faint & had a slight shaking fit & little vomiting then slept too heavily; so today I am languid and stomach bad, but do not think I shall have any more shivering & I care for nothing else4
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Extract on seasickness from Darwin’s diary • Dec 30th At noon Lat. 43, South of Cape Finisterre & across the famous Bay of Biscay: wretchedly out of spirits & very sick. I often said before starting, that I had no doubt I should frequently repent of the whole undertaking, little did I think with what fervour I should do so. I can scarcely conceive any more miserable state, than when such dark & gloomy thoughts are haunting the mind as have to day pursued me • January 1 (1832) The new year to my jaundiced senses bore a most gloomy appearance. In the morning almost a calm, but a long swell on the sea. In the evening it blew a stiff breeze against us. This & three following days were ones of great & unceasing suffering. • Monday 2nd Heavy weather. I very nearly fainted from exhaustion2
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sickness owing to a tightness of the chest & excema. The excema alas is gone & was hardly enough to affect him much but I am glad it is still lurking about him5
The episodes of sickness were at times completely disabling and Darwin was confined to his sofa in a constant nauseated state for days—even weeks—at a time. He was aware that the episodes could be initiated by excitement or stress, even by pleasurable events. In a letter to his old shipmate Philip King he wrote:
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I grieve to say that my health is so indifferent, I cannot stand seeing at present anyone here. Twice lately I could not resist seeing old friends . . . & the excitement made me so ill afterwards that I have been advised not to do so again. I am well enough in the mornings and when I keep quiet
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Again, a month later, writing to Thomas Rivers, a nurseryman specialising in the cultivation of fruit trees, he stated:
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I suffer severely from ill-health of a very
peculiar kind, which prevents me from all mental excitement, which is always followed by spasmotic sickness, and I do not think I could stand conversation with you, which to me would be so full of enjoyment6
”
Darwin went through many different treatments, without lasting improvement from any. The most famous of these was Dr James Gully’s cold water treatment, at his clinic in Malvern, Worcestershire. Darwin may well have gained some relief from this treatment, which would explain why he persisted with it for six months. Such relief may, however, have been due as much to the boredom of the place as to the prescribed therapy.
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I am rather weary of my present
inactive life & the Water Cure has the most extraordinary effect in producing indolence & stagnation of mind; I cd not have believed it possible7
”
Proffered diagnoses The nature of Darwin’s illness has been the subject of much and very varied speculation. Psychological diagnoses offered include hypochondria, neurasthenia, panic disorders, and agoraphobia.
Psychoanalysts have put Darwin’s illness down to “repressed anger towards his father,” nervousness about his relationship with his wife, and guilt over conflict with his earlier religious beliefs.8 Darwin was no hypochondriac or neurasthenic; he fought against his illness and struggled to work even when he was severely unwell. He did have anxiety but this may well have been engendered by his illness rather than being the cause of it. In later years he became almost a recluse for the good reason that travel, social contact, and meetings could trigger an attack. Suggested physical diagnoses include maladies such as Meniere’s disease (due to middle ear damage from game shooting), arsenic poisoning (from prescribed drugs),9 and Chagas’ disease resulting from an insect bite during his sojourn in South America.8 These diagnoses have all been disallowed for good reasons. Darwin never had deafness; nausea and vomiting rather than tinnitus were his main symptoms. Arsenic (Fowler’s solution) was prescribed for a variety of complaints and Darwin may have taken it as a young man for eczema. There is, however, no evidence that he received large amounts of arsenic. Darwin’s symptoms were episodic, and between episodes he could feel entirely well. Chagas’ disease is rejected for several reasons; exposure was too brief and Darwin had symptoms before he sailed. His tolerance of exercise was good and despite being examined by several eminent doctors he showed no evidence of organic disease.10 Speculation aside, we do know much about Darwin’s illness. It was chronic but intermittent (initially he had periods of sickness alternating with periods of being well). Episodes of sickness could be initiated by stress or overwork, even by pleasurable events, and they could last for days or weeks and were at times completely disabling. The illness was not fatal; it was present probably for at least 50 years and became less severe in old age BMJ | 19-26 december 2009 | Volume 339
john chancellor: HMS BEAGLE in the galapagos/© Gordon chancellor/www.johnchancellor.co.uk
diagnosis
(he died at 73 with symptoms of cardiac ischaemia and heart failure). He had no internal physical abnormalities.10 The illness did not impair his fertility; as well as being the father of modern biology he fathered 10 children, all conceived during his long period of ill health.
The diagnosis Darwin’s symptoms are those of cyclical vomiting syndrome.11 Although this is primarily a disease of children it may persist into adulthood or may appear for the first time in adulthood.12 The disease is related to classic migraine and abdominal migraine but is also linked to abnormalities of mitochondrial DNA,13 14 with mutations in the MTTL1 gene.15 This disease is neither well known nor well recognised, particularly in adults, although it was first described in the English literature in 1882.16 People with cyclical vomiting syndrome experience abdominal, circulatory, and cerebral symptoms, including headaches and anxiety. Symptoms overlap with those of classic and abdominal migraine, except for a lack of aura. Affected people may experience some or all of these symptoms, with each individual having similar symptoms with each episode. Over time, however, progression or change may occur in the most prominent feature, and episodes may coalesce. Many people report severe motion sickness, and this may be associated with a full episode. Episodes of illness may be divided into three phases—prodromal, emetic, and recovery—often with definite triggering events. Symptoms in the prodromal phase include fatigue, palpitations, and sweating. The emetic phase may consist of continuous nausea, with vomiting two to 20 times an hour. In most people this is associated with severe abdominal pain. Episodes may last one or two days or up to a week.
Many people with cyclical vomiting syndrome have eczema that may be related to various food allergies. The eczema is a form of atopic dermatitis—Darwin was diagnosed posthumously as having atopic dermatitis.17 Affected people harbour staphylococci in their skin and often have recurrent skin infections.18 Many of the people in the reported series had transient alleviation of symptoms by taking baths or showers, although these, unlike Dr Gully’s hydrotherapy, were mostly with warm water. Many patients report a link between episodes and excitement, even pleasurable excitement, as did Darwin. Being in an institution where there was dull routine may have helped Darwin recover from months of sickness as much as the cold water therapy. Darwin’s mother Susannah died with abdominal pain when he was 8. As a child she had vomiting and boils, experienced motion sickness, had excessive sickness during pregnancies, and “was never quite well.”19 Her younger brother Tom had similar symptoms, with headaches, abdominal pains, and motion sickness. A sister, Sarah, considered that Charles and his uncle Tom had the same illness.20 Evidence of a matrilineal inheritance pattern is good, consistent with an abnormality of mitochondrial DNA.
Conclusion Darwin’s symptoms may be explained by the diagnosis of cyclical vomiting syndrome, with secondary complications such as atopic dermatitis with staphylococcal infections, dental decay, oesophageal tears, and skin pigmentation. He had a severe form of this illness with periods of coalescence of episodes. His was a well defined but not well known inborn illness; he did not primarily have hypochondriasis, neurasthenia, agoraphobia, or any of the strange psychoanalytically derived maladies that have been proposed.
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Darwin suffered symptoms before, during, and after his voyage on HMS Beagle
Darwin was not aware of mitochondria or of genes and genetic mutations but he was very aware of random variations within species. This was the keystone for his theory of the “survival of the fittest,” the driving mechanism of evolution. His personal inherited genetic variation made him substantially “less fit,” but his survival prospects were greatly increased by his driving intellect; loyal colleagues; devoted wife, family, and household servants; and personal wealth. John A Hayman associate professor, Department of Anatomy and Developmental Biology, Monash University, Clayton, Melbourne, Victoria 3800, Australia
[email protected] The Complete Work of Charles Darwin Online (John van Wyhe ed), (http://darwin-online.org.uk) and the Darwin Correspondence Project, containing 5000 of Darwin’s letters online (www. darwinproject.ac.uk) are the source of abundant original material. John Bertram and Dave Souza read the original draft and made suggestions. Funding: None. Competing interests: None declared. 1
Barlow N. The autobiography of Charles Darwin 18091882, with original omissions restored. Collins, 1958. 2 Darwin C. Darwin’s Beagle diary (1831-1836). 1839: Darwin Online. 2009. http://darwin-online.org.uk. 3 Darwin C. Letter 119 to S E Darwin. Darwin Correspondence Project, 1831;1(143). 4 Darwin C. Letter 1180 to E Darwin. Darwin Correspondence Project, 1848;4(147). 5 Darwin E. Letter 4429 to J D Hooker. Darwin Correspondence Project, 1864;12(77). 6 Darwin CR. Letter 3879 to Thomas Rivers. Darwin Correspondence Project, 1862;10(635). 7 Darwin C. Letter1240 to W D Fox. Darwin Correspondence Project, 1849;4(234). 8 Colp R. Darwin’s illness. University Press of Florida, 2008. 9 Winslow JH. Darwin’s Victorian malady. American Philosophical Society, 1971. 10 Woodruff AW. Darwin’s health in relation to his voyage to South America. BMJ 1965;1745-50. 11 Fleisher DR, Matar M. The cyclic vomiting syndrome: a report of 71 cases and literature review. J Pediatr Gastroenterol Nutr 1993;17:361-9. 12 Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ. Cyclic vomiting syndrome in 41 adults: the illness, the patients, and problems of management. BMC Med 2005;3:20. 13 Boles RG, Adams K, Li BU. Maternal inheritance in cyclic vomiting syndrome. Am J Med Genet A 2005;133A:71-7. 14 Wang Q, Ito M, Adams K, Li BU, Klopstock T, Maslim A, et al. Mitochondrial DNA control region sequence variation in migraine headache and cyclic vomiting syndrome. Am J Med Genet A 2004;131:50-8. 15 Salpietro CD, Briuglia S, Merlino MV, Di Bella C, Rigoli L. A mitochondrial DNA mutation (A3243G mtDNA) in a family with cyclic vomiting. Eur J Pediatr 2003;162:727-8. 16 Gee S. On fitful or recurrent vomiting. St Bartholomew’s Hospital Reports, 1882;18:1-6. 17 Sauer GC. Charles Darwin consults a dermatologist. Int J Dermatol 2000;39:474-8. 18 Leyden JJ, Marples RR, Kligman AM. Staphylococcus aureus in the lesions of atopic dermatitis. Br J Dermatol 1974:90:525-30. 19 Healey E. Emma Darwin: the inspirational wife of a genius. Headline, 2001. 20 Wedgwood B, Wedgwood H. The Wedgwood circle 17301897. Macmillan, 1980. Cite this as: BMJ 2009;339:b4968 1415
Diagnosis
N
europhobia—the fear of neurology1— is well described in medical students and is postulated as the reason for an apparent bias favouring neurology in case studies. Neurological cases represent more than a quarter of all Lancet case reports: 29% of 523 cases during 1996-20022 and 26% of 360 cases during 2003-8.3 Coles et al attributed this to “the trepidation and interest that neurological syndromes generate among physicians.”2 They considered this stigmatisation of a core medical specialty to represent our continued inability to demystify the subject. However, the literature does not tell us whether neurological cases are genuinely over-represented or merely appropriately common. We set out to determine this by comparing the pattern of cases from a UK publisher (BMJ Case Reports) with the UK burden of disability. We also hypothesise that a more eloquent explanation for neurological case dominance is not neurophobia, but rather that the cases are simply more entertaining. Perhaps clinical neurology is not a dark mystery but a popular thriller. To test this assertion, we needed to examine cases where the motivation is to entertain rather than educate: the television medical drama House MD. For those doctors who are allergic to medical drama, House MD stars Hugh Laurie as the maverick Gregory House. He is a diagnostician with an acerbic charm who solves mysteries loosely based on real medicine. The character resembles Sherlock Holmes—a drug using misanthrope and music loving genius. The series was reported to be the most watched television programme in 2008, with 82 million viewers worldwide.4
Results Many episodes from House had more than one diagnosis, some had none. The two most common categories were neurological (27.5% of cases) and infectious conditions (16%) (see table): occasionally cases represented both (such as Lyme disease). Seizures were commonly seen, both as the presenting symptom and as a result of (often inappropriate) treatment. 1416
Intrigued by a common assumption that neurological cases are over-represented in published case reports, Rhys Thomas and Naomi Thomas investigate whether this is true and explore possible reasons FOX
Methods The World Health Organization publishes “the global burden of disease” as disability adjusted life years (DALY), calculated using standard categories and methods to ensure cross-national comparability. We extracted the age standardised data for the UK in 2004 from their survey5 and then examined the final diagnoses from House MD (series one to five).6 We grouped the WHO data and the House diagnoses into similar categories as Coles et al,2 but included extra categories for aetiology (such as infectious, genetic, or oncological). Using the same method, we then scrutinised the BMJ Case Reports archive.7
House calls Proportion of case reports by system and aetiology. Values are numbers (percentages) System and aetiology Neurology Gastroenterology Rheumatolåogy Respiratory Dermatology Cardiology Haematology Endocrinology Obstetrics and gynaecology Renal Ear, nose, and throat Psychiatry Ophthalmology Poisoning Infectious Allergy Genetic Oncology
House MD*
BMJ Case Reports†
UK burden of disease‡
55 (27.5) 11 (5.5) 3 (1.5) 5 (2.5) 3 (1.5) 10 (5) 13 (6.5) 8 (4) 7 (3.5) 3 (1.5) 0 8 (4) 0 14 (7) 32 (16) 4 (2) 13 (6.5) 11 (5.5)
172 (17.3) 83 (8.3) 40 (4) 48 (4.8) 34 (3.4) 166 (16.7) 31 (3.1) 65 (6.5) 20 (2) 24 (2.4) 21 (2.1) 25 (2.5) 34 (3.4) 19 (1.9) 84 (8.4) 14 (1.4) 29 (2.9) 87 (8.7)
600 (5.1) 347 (3) 526 (4.5) 1017 (8.7) 85 (0.7) 1694 (14.5) 164 (1.4) 723 (6.2) 154 (1.3) 70 (0.6) 320 (2.7) 2601 (22.3) 702 (6) 14 (0.1) 1007 (8.6) — — 1664 (14.2)
*Series 1 to 5.6 †2007 to Aug 2009.7 ‡Values from WHO,5 as age standardised disability adjusted life years (DALYs) per 100 000 of population.
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Diagnosis
Discussion The burden of UK disease cannot be appreciated from case reports alone: the dominance of neurology in BMJ Case Reports is disproportionate but is similar to that found in the Lancet.2 3 This bias is mirrored in the House episodes, suggesting neurological cases do make a gripping yarn. Why is neurology so well suited to both case reports and the television? Neurology is poorly understood by many, and mystery can be compelling. We suggest that neurology’s myriad symptoms make it suitable for an entertaining case report. The symptoms are fascinatingly diverse: presentations include isolated loss of colour vision, an inability to name familiar objects, or fatigable drooping eyelids. With sufficient knowledge, you can have the satisfaction of predicting correctly where the lesion must be to cause these symptoms. It is no surprise therefore that the public has such an appetite for cases as in Oliver Sacks’ The Man who Mistook his Wife for a Hat,8 but there has never been much demand for “the man who passed frequent bloody stools.” In addition, the fear of neurodisability is deeply entrenched, and neurological symptoms can be devastating: watching House “cure” someone who was thought to have motor neurone disease (this is an example, not a plot spoiler) does have more emotional resonance than treating glue ear or piles. Furthermore, neurological disease is seen as permanent or progressive, and, therefore, any case that ends with “a twist in the tail” (that is, a remedy) is deemed worthy of report. Finally, the blurred line between organic and functional disease can lead us to question our very sense of self, and conflict is the essence of good drama. The general enthusiasm for neurological stories should be harnessed to ensure that we lose the stereotype of neurology as the impenetrable preserve of eggheads in bowties. We can engage students in the entertaining detective work of clinical neurology—without perpetuating unnecessary neurophobia. Rhys H Thomas specialty registrar and clinical research fellow, Wales Epilepsy Research Network, Institute of Life Sciences, Swansea University Swansea SA2 8PP
[email protected] Naomi J P Thomas specialty registrar, Prince Charles Hospital, Merthyr Tydfil We thank Adam Handel and Leone Risdale, who provided ideas for our discussion, and Phil Smith for his support. Competing interests: None declared. References are In the version on bmj.com Cite this as: BMJ 2009;339:b5256
George Clooney, the cauliflower, the cardiologist, and phi, the golden ratio The challenge for scientists of all disciplines is to discern basic patterns and laws of nature that can be described mathematically— all this in a universe generated apparently from chaos and influenced by random events. The “golden ratio” is one such phenomenon and has been known to mathematicians since ancient times. Two quantities are in the golden ratio when the ratio between their sum and the larger one is the same as the ratio between the larger one and the smaller. The Italian mathematician Leonardo Pisano, often known as Fibonacci, discovered the sequence (which was named after him) from which phi (Φ), the golden ratio, can be calculated. Stakhov et al show in a review that Φ (1.6180339887...) can be found in many aspects of nature and art.1 Leaf branches and the florets in a cauliflower head exhibit Φ proportions. The proportions can also be found in architecture of the past (such as the Notre Dame cathedral in Paris and even as far back as the Parthenon in Athens) and were consciously adopted by more modern architects, such as Le Corbusier. Even in the structure of DNA, Φ has its place. The DNA molecule is 3.4 nm (34 angstrom) long and 2.1 nm (21 angstrom) wide, resulting in a length:width ratio of 1.61905.1 Similarly, evidence exists that Φ is also present in the design of the human body. For example, in the “perfect” body, Φ can be found by splitting certain distances (such as head to pelvis, or fingertip to wrist) into numerous segments— for example, mouth and nose are found at Φ proportions of the distance
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between the eyes and the chin. The American actor George Clooney exhibits the golden ratio in his face proportions). Anecdotal reports have been published on the importance of Φ in cardiovascular physiology. A heart beat that produces a Φ relation between the T waves in an electrocardiogram has been reported to represent a state of health, peace, and harmony.1 However, surprisingly little exploration of Φ relations has been undertaken in medical research. One problem is that very large datasets are needed to reduce the effects of random error. We hypothesised that Φ can be found in important biological variables, such as arterial blood pressure. The Vorarlberg Health Monitoring and Promotion programme, covering a primary care based cohort of 166 377 people (mean age 42 years) in the far west of Austria, has offered routine screening periodically over two decades.2 We evaluated the ratio between systolic and diastolic arterial blood pressure at first visit in the cohort database. Although the systolic:diastolic blood pressure ratio in the whole
population was 1.6235, the mean ratio was 1.6180 in the participants who did not die during the 20 year observation period and 1.7459 in those who did. This finding suggests that blood pressure values in “well” individuals, but not in those who are at risk of dying, exhibit the golden ratio. Although this finding is not likely to be of practical relevance for individual clinicians, at a population level this may be an important phenomenon and should be investigated in other cohorts. Hanno Ulmer medical statistician,
[email protected] Cecily C Kelleher public health physician, School of Public Health and Population Sciences, University College Dublin, Dublin, Ireland Martin W Dünser intensivist, Department of Intensive Care Medicine, Inselspital Bern, Bern, Switzerland Competing interests: None declared. 1
2
Stakhov O. Museum of Harmony and the Golden Section. Mathematical connections in nature, science, and art. http:// www.goldenmuseum.com/ Ulmer H, Kelleher C, Diem G, Concin H. Long-term tracking of cardiovascular risk factors among men and women in a large population-based health system: the Vorarlberg Health Monitoring & Promotion Programme. Eur Heart J 2003;24:1004-13.
Cite this as: BMJ 2009;339:b4745
claudia bentley
Neurological conditions were also the commonest category in BMJ Case Reports (17.3%), with cardiovascular second (16.7%), and oncology, infectious disease, and gastroenterology also well represented (8-9%). However, the greatest burden of disability in the UK is provided by psychiatric disease (22.3%), cardiovascular disease (14.5%), and oncological causes (14.2%).
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Anaesthesia
Many fainted during amputation, more remained agonisingly conscious
Painless amputation: history of a discovery that wasn’t made Sam Shuster ponders on why his retrospective discovery of tourniquet anaesthesia wasn’t made earlier, when it would have mattered
M
y realisation that using tourniquet ischaemia in the pre-anaesthetic era could have made amputation painless led to the idle thought of why it hadn’t been discovered, and then, to the even more idle thought of whether looking at why discoveries aren’t made would help us understand how they can be made. Because this could be answered only by a study of the history of amputation that looked for the ambience of ideas and practices rather than their chronology, that is where my idleness ended—with a new reading of the original documents on amputation procedures from the 16th century onwards, written by surgeons who had used or developed them, in addition to historical reviews.
The pain of pre-anaesthetic amputation The horror of amputation without anaesthetic is revealed by contemporary accounts, of which this by James Cooke in 1685 is typical1: “Dismembering is a dreadful Operation; yet necessary, that the dead part may not injure the living, nor procure death . . . let one man be at the Patients back holding him, and another before him, holding the upper part of the limb; and a Third holding that Part that must be taken off . . . you are to make strong Ligature with broad Tape . . . about three inches above the Place you intend to incise . . . and let him that has the Gripe haul up the Muscels tort . . . This done (and the Man having had a Spoonful of Cordial to cherish him), you must with your dis-membring Knife, take two large Slashes round the part in the form of half rounds, and let one meet the other as evenly as possible, and let them be deep enough. Then with your Catling divide the Flesh and Vessels about and 1418
between the Bones, and with the back of your Catling, remove the Periostium that it may not hinder the Saw, nor cause greater Torment in the Operation. So Saw off the Bone at as few stokes as possible, and let him that holds the lower Part have a Care to hold steady least he break the Bone before the Saw is quite through . . . see that your Instrument maker hath set the Teeth of your Saw wide enough, so it may not stick [have] . . . two saws, lest one should break” and several knives, because “after an operation or two [they] lose their keenness.”2 We should stop there, before the pain of cautery and sutures. Many fainted during amputation, more remained agonisingly conscious, and a few suffered in silence (despite the more often quoted than referenced story of a sailor who sang Rule Britannia as his arm was removed3).The brutality of amputation left a profound scar even on men as brave as Nelson: “The sufferings of the operation . . . strongly impressed on his mind . . . so painfully and deeply was the recollection engrafted on his feelings.”4 He controlled his fear of further amputation by insisting that the pain had been from “coldness of the knife,”4 5 not its cut, and this allowed the comforting belief that the pain of the “next time” would be overcome by the warmed knives he demanded were always ready.4 Fortunately, Nelson’s concealment of his deep fear was never exposed. The agony and sequelae of amputation were accepted because it was thought to be life saving and without alternative, “when part of a Limb is carried away, or the Bones so shattered . . . if that be left on, it will Gangreen, and Death will issue”6; few people who refused surgery survived. The perceived necessity of amputation explains why so lit-
tle was thought about its pain—some texts ignore it,7 others offer sympathy,8 but all early writings proposed speed as the only way to minimise pain.9 Yet, however fast the amputation, the devastating intensity of the agony remained.1 2 6‑ 9 So what else could have been offered? Volatile anaesthetics were not available before 1846, but alcohol and opium were; yet, amazingly, they were used postoperatively, if at all. In face of the “violent and inexpressible Pain . . . the Operator is to encourage the Patient, and having given him half a Glass of Wine to enable him the better to endure his Pain;”10 the preoperative gulp of alcohol was given for fortitude not anaesthesia.1 6 11 But was this what was commonly practised? One way of assessing best practice is to examine what was given to the best, as in Eshelby’s bald summary of his treatment of Lord Nelson: “The arm was immediately amputated and opium afterwards given.”12 The reason that alcohol and opium “anaesthesia” was rarely used is not clear. Kirkup lists variable efficacy, dose, and nausea,13 but my reading of the original texts suggests another reason— surgeons believed patients had to be conscious and alert to withstand amputation: “proceed as soon as possible . . . otherwise the patient may . . . be so exhausted to make it very hazardous, and his recovery doubtful.”14 This belief probably explains the extraordinary sitting posture used. The notion that its purpose was to achieve pain relief by inducing syncope is unlikely,13 because fainting was considered an undesirable response.1 Although the association of “alertness” with response was correct, cause and effect were confused, and this led to the unfortunate exclusion of alcohol and opium preoperatively. BMJ | 19-26 december 2009 | Volume 339
images from charles bell: illustrations of the great operations of surgery
Had the tourniquet been applied earlier it would have allowed painless amputation
Finally, physicians were licensed to use drugs but surgeons just operated—this may have contributed to the poor appreciation of the use of drugs and non-surgical methods, and may partly explain why use of the tourniquet wasn’t extended beyond haemostasis.
Tourniquet anaesthesia and painless amputation The tourniquet evolved from the bandage, thread, and screw device15; it allowed vessel ligation and banished painful cautery. It was applied immediately before surgery; had it been applied earlier, anaesthesia would have allowed pain-free amputation. Impaired neural function from ischaemia— as when a leg “goes to sleep”—is so familiar that it tends not to be noticed. I was reminded of it when using a sphygmomanometer just above arterial pressure to stop the circulation and fix vasoactive agents in the forearm,16 as with histamine.17 Limb ischaemia induced a proximally spreading anaesthesia with motor paralysis, complete in 30 minutes, that recovered rapidly on release. But a narrow cuff and higher pressures cause local pain and nerve damage from compression.18‑21 Thus, application of a broad low pressure tourniquet 30 minutes before surgery would have allowed painless amputation in the pre-anaesthetic past. Tourniquet anaesthesia could still be used in extreme circumstances; it probably has been used unknowingly in the self amputation of trapped limbs, with the entrapment acting as a tourniquet. Why wasn’t tourniquet anaesthesia discovered earlier? I made my anachronistic discovery when studies of naval health22 revived my earlier tourniquet
observations,16 and its ease of discovery made me question why it had not been made before anaesthesia made it irrelevant. Absence of the idea of improving pain control and, therefore, methods for its achievement, and the isolation of surgeons as technical practitioners are obvious, but re-examination of the historical accounts revealed a more interesting explanation. When any procedure is used, all possible variants will occur, most of which inevitably follow the law of Murphy’s cynical partner; thus although the tourniquet was applied immediately before amputation, there will have been exceptions; indeed the gangrenous consequence of leaving a tourniquet too long were well known,23 as with tight splinting.24 Although the opportunity to see the progressive course of tourniquet anaesthesia must have occurred, I found no records of such observations in the original texts or recent reviews.13 25‑ 29 In addition to this tantalising closeness of the observational opportunity, I also found ideas that could have led to tourniquet anaesthesia. In 1637, William Clowes notes, “the pain of the [haemostatic] binding doth greatly obscure the knife and feeling of the incision.”11 James Yonge’s 1679 account says, “nor shall the pain of that operation be comparable to what it would be, were not the member nummed by the Compress.”23 Of course, this was distraction by tourniquet pain—the onset was too rapid for tourniquet anaesthesia. Nevertheless, the idea of “numbing” wasn’t that far off, and it got closer when the anaesthetic effect of screw pressure on a nerve was found.30 So the ideas and techniques were there, waiting for the link; why didn’t it happen?
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Although accidental tourniquet anaesthesia must have occurred, either it wasn’t noticed or its application wasn’t realised. Failure to notice is a consequence of the need for reflex action rather than thought, when quick responses are essential. If it had been noticed, even in part as some accounts suggest, surgeons of the time were essentially operative technicians, working at great speed and stress at times of battle, with no time to consider, analyse, and classify the “interesting” neural consequences of tourniquet ischaemia, let alone develop its possible uses, as would a clinical researcher whose main life stress is finding a grant. Thus, the failure of busy surgeons to extend their use of the tourniquet to anaesthesia is an almost inevitable consequence of the constraints of practice at the time. Having reached the limits of speed for reducing pain, further improvement needed awareness of the problem and a search for its solution; and that could only come with independence from clinical constraints. Time for reflection and experiment is essential to clinical advance and underlines the differences in the methods and traditions of clinical practice and clinical research.31 The gap between the two has closed, but, sadly, it is still obvious—otherwise, the retrospective discovery of tourniquet anaesthesia would have been made sooner, when it mattered. Sam Shuster emeritus professor of dermatology, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH
[email protected] Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. References are in the version on bmj.com Cite this as: BMJ 2009;339:b5202 1419
Anaesthesia
Autoappendicectomy in the Antarctic The Russian surgeon Leonid Rogozov’s self operation, undertaken without any other medical professional around, was a testament to determination and the will to life, explain Vladislav Rogozov and Neil Bermel
T
he ship Ob, with the which shifted to the right lower sixth Soviet Antarctic quadrant. His body temperature expedition on board, rose to 37.5°C.1 2 Rogozov wrote in sailed from Leningrad his diary: on 5 November 1960. “It seems that I have appendiAfter 36 days at sea she decanted citis. I am keeping quiet about it, part of the expedition onto the even smiling. Why frighten my ice shelf on the Princess Astrid friends? Who could be of help? A Coast. Their task was to build a polar explorer’s only encounter “A job like any other, with medicine is likely to have been new Antarctic polar base inland at Schirmacher Oasis and over- a life like any other”— in a dentist’s chair.” winter there. After nine weeks, on Leonid Rogozov As a surgeon Rogozov had no dif18 February 1961, the new base, ficulty diagnosing acute appendicicalled Novolazarevskaya, was opened. tis. In this situation, however, it was a cruel trick They finished just in time. The polar winter of fate. He knew that if he was to survive he had to was already descending, bringing months of undergo an operation. But he was in the frontier darkness, snowstorms, and extreme frosts. The conditions of a newly founded Antarctic colony sea had frozen over. The ship had sailed and on the brink of the polar night. Transportation would not be back for a year. Contact with the was impossible. Flying was out of the question, outside world was no longer possible. Through because of the snowstorms. And there was one the long winter the 12 residents of Novolazafurther problem: he was the only physician on revskaya would have only themselves to rely the base. on. One of the expedition’s members was the 27 30 April year old Leningrad surgeon Leonid Ivanovich All the available conservative treatment was Rogozov. He had interrupted a promising scholapplied (antibiotics, local cooling), but the arly career and left on the expedition shortly patient’s general condition was getting worse: before he was due to defend his dissertation his body temperature rose, vomiting became on new methods of operating on cancer of the more frequent.1 2 oesophagus. In the Antarctic he was first and “I did not sleep at all last night. It hurts like the foremost the team’s doctor, although he also devil! A snowstorm whipping through my soul, served as the meteorologist and the driver of wailing like a hundred jackals. Still no obvious their terrain vehicle. symptoms that perforation is imminent, but an oppressive feeling of foreboding hangs over me 29 April 1961 . . . This is it . . . I have to think through the only After several weeks Rogozov fell ill. He noticed possible way out: to operate on myself . . . It’s symptoms of weakness, malaise, nausea, and, almost impossible . . . but I can’t just fold my later, pain in the upper part of his abdomen, arms and give up.
1420
“18.30. I’ve never felt so awful in my entire life. The building is shaking like a small toy in the storm. The guys have found out. They keep coming by to calm me down. And I’m upset with myself—I’ve spoiled everyone’s holiday. Tomorrow is May Day. And now everyone’s running around, preparing the autoclave. We have to sterilise the bedding, because we’re going to operate. “20.30. I’m getting worse. I’ve told the guys. Now they’ll start taking everything we don’t need out of the room.”
Preparation for the operation Following Rogozov’s instructions, the team members assembled an improvised operating theatre. They moved everything out of Rogozov’s room, leaving only his bed, two tables, and a table lamp. The aerologists Fedor Kabot and Robert Pyzhov flooded the room thoroughly with ultraviolet lighting and sterilised the bed linen and instruments. As well as Rogozov, the meteorologist Alexandr Artemev, the mechanic Zinovy Teplinsky, and the station director, Vladislav Gerbovich, were selected to undergo a sterile wash. Rogozov explained how the operation would proceed BMJ | 19-26 december 2009 | Volume 339
Anaesthesia
Rogozov worked mostly by feel. Anticipating this he had decided to work without gloves
and assigned them tasks: Artemev would hand him instruments; Teplinsky would hold the mirror and adjust the lighting with the table lamp; Gerbovich was there in reserve, in case nausea overcame either of the assistants. In the event that Rogozov lost consciousness, he instructed his team how to inject him with drugs using the syringes he had prepared and how to provide artificial ventilation. Then he gave Artemev and Teplinsky a surgical wash himself, disinfected their hands, and put on their rubber gloves for them. When the preparations were complete Rogozov scrubbed and positioned himself. He chose a semi-reclining position, with his right hip slightly elevated and the lower half of the body elevated at an angle of 30°. Then he disinfected and dressed the operating area. He anticipated needing to use his sense of touch to guide him and thus decided to work without gloves.
The operation The operation began at 2 am local time. Rogozov first infiltrated the layers of abdominal wall with 20 ml of 0.5% procaine, using several injections. After 15 minutes he made a 10-12 cm incision. The visibility in the depth of the wound was
not ideal; sometimes he had to raise his head to obtain a better view or to use the mirror, but for the most part he worked by feel. After 30-40 minutes Rogozov started to take short breaks because of general weakness and vertigo. Finally he removed the severely affected appendix. He applied antibiotics in the peritoneal cavity and closed the wound. The operation itself lasted an hour and 45 minutes.1 2 Partway through, Gerbovich called in Yuri Vereshchagin to take photographs of the operation. Gerbovich wrote in his diary that night3: “When Rogozov had made the incision and was manipulating his own innards as he removed the appendix, his intestine gurgled, which was highly unpleasant for us; it made one want to turn away, flee, not look—but I kept my head and stayed. Artemev and Teplinsky also held their places, although it later turned out they had both gone quite dizzy and were close to fainting . . . Rogozov himself was calm and focused on his work, but sweat was running down his face and he frequently asked Teplinsky to wipe his forehead . . . The operation ended at 4 am local time. By the end, Rogozov was very pale and obviously tired, but he finished everything off.”
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After the operation Afterwards Rogozov showed his assistants how to wash and put away the instruments and other materials. Once everything was complete, he took sleeping tablets and lay down for a rest. The next day his temperature was 38.1°C; he described his condition as “moderately poor” but overall he felt better. He continued taking antibiotics. After four days his excretory function came back to normal and signs of localised peritonitis disappeared. After five days his temperature was normal; after a week he removed the stitches.1 2 Within two weeks he was able to return to his normal duties and to his diary. 8 May 1961 “I didn’t permit myself to think about anything other than the task at hand. It was necessary to steel myself, steel myself firmly and grit my teeth. In the event that I lost consciousness, I’d given Sasha Artemev a syringe and shown him how to give me an injection. I chose a position half sitting. I explained to Zinovy Teplinsky how to hold the mirror. My poor assistants! At the last minute I looked over at them: they stood there in their surgical whites, whiter than white themselves. I was scared too. But when I picked up the needle with the novocaine and gave myself the first injection, somehow I automatically switched into operating mode, and from that point on I didn’t notice anything else. “I worked without gloves. It was hard to see. The mirror helps, but it also hinders—after all, it’s showing things backwards. I work mainly by touch. The bleeding is quite heavy, but I take my time—I try to work surely. Opening the peritoneum, I injured the blind gut and had to sew it up. Suddenly it flashed through my mind: there are more injuries here and I didn’t notice 1421
Anaesthesia
them . . . I grow weaker and weaker, my head starts to spin. Every 4-5 minutes I rest for 20-25 seconds. Finally, here it is, the cursed appendage! With horror I notice the dark stain at its base. That means just a day longer and it would have burst and . . . “At the worst moment of removing the appendix I flagged: my heart seized up and noticeably slowed; my hands felt like rubber. Well, I thought, it’s going to end badly. And all that was left was removing the appendix . . . “And then I realised that, basically, I was already saved.”
Leaving Antarctica More than a year later the Novolazarevskaya team left Antarctica, and on 29 May 1962 their ship docked at Leningrad harbour. The next day Rogozov returned to his work at the clinic. Shortly thereafter he successfully defended his dissertation. He worked and taught in the Department of General Surgery of the First Leningrad Medical Institute. He never returned to the Antarctic and died in St Petersburg, as
Leningrad had by then become, on 21 September 2000.
The boundary of the humanly possible There are some references to autoappendicectomies in the literature. The earliest one was possibly that performed by Dr Kane in 1921 (although the operation was completed by his assistants).4 5 We know that Rogozov had not heard about it before he performed his operation. Rogozov’s self operation was probably the first such successful act undertaken in the wilderness, out of hospital settings, with no possibility of outside help, and without any other medical professional around. It remains an example of determination and the human will for life. In later years Rogozov himself rejected all glorification of his deed. When thoughts like these were put to him, he usually answered with a smile and the words: “A job
like any other, a life like any other.”6
Vladislav Rogozov consultant anaesthetist, Department of Anaesthetics, Sheffield Teaching Hospitals, Sheffield S10 2JF; Department of Anaesthesiology and Resuscitation, Cardiac Centre, Institute of Clinical and Experimental Medicine, Prague, 140 21, Czech Republic
[email protected] Neil Bermel professor of Russian and Slavonic studies, Department of Russian and Slavonic Studies, University of Sheffield, Sheffield S3 7RA Competing interest: VR is a son of Leonid Rogozov. 1
Rogozov LI. Self operation. Soviet Antarctic Expedition Information Bulletin. Washington, DC: American Geophysical Union 1964;4:223-4. 2 Rogozov LI. Operacija na sebe. Bjulleten sovietskoj antarkticheskoj ekspeditzii 1962;37:42-4. 3 Gerbovich VI. Fragment from diaries in V proshlom u nego moglo byt bolshoe budushchee. Omsk Humanitarian Institute, 2007;63-185. 4 Rennie D. Do it to yourself section: the Kane surgery. JAMA 1987;257:825-6. 5 Frost JG, Guy CC. Self-performed operations: with report of a unique case. JAMA 1936;106:1708-10. 6 Rogozov V. Operace vlastniho appendixu v Antarktide. Vesmir 2004;1(83):25-8. Cite this as: BMJ 2009;339:b4965
Prescriber’s narcophobia syndrome: physicians’ disease and patients’ misfortune Prescriber’s narcophobia syndrome (PNS) is a professionally disabling neuropsychiatric malady. It strikes physicians who, as medical students, wished to alleviate suffering and improve patients’ wellbeing. Once afflicted, physicians become frustrated by patients in pain and treat them without compassion. Physicians succumb to PNS early in practice and often for decades. However, brief remissions occur when treating a malpractice attorney, hospital administrator, or someone who reminds the physician of himself or herself. PNS is highly infectious, passed at the bedside from teachers to students. Usually the victim of a physician with PNS projects obvious verbal and behavioural cues of severe pain. Hence PNS may reveal sadistic sociopathy of a physician wishing for the patient to suffer. This explains forced discharge of patients with persistent pain and prescribing ineffective non-narcotic agents with poor side effect profiles. Alternatively, PNS may uncover a variant of autism in a doctor who is unable to perceive the patient’s emotions or read behavioural cues. Such doctors avoid eye contact with patients in pain and are hyperfocused on their diseases instead of how they feel. Alternatively, paranoid schizophrenia may explain physicians’ bizarre thinking that every patient requesting effective pain relief is a
1422
“drug seeker trying to get high.” Supporting evidence includes physicians’ delusional belief that not treating pain will cure the “addiction” caused by desire for pain relief.
The “modified” CAGE questionnaire1 • Do you ask a colleague to Cut down on
their narcotic prescribing?
• Do you become Angry when patients
claim that narcotics work for their pain?
• Do you feel Guilt after writing a narcotic
prescription?
• Do you avoid Eye contact with your
patients in pain?
Answering Yes to ≥2 makes PNS more likely
Initiating prompt therapy for PNS stops the vicious cycle of oligoanalgesia and professional frustration. Educational literature shows the inadequacy of non-narcotic agents for treating severe pain and highlights the safety and efficacy of judicious narcotic use. Behavioural counsellors literally “hold your hand” while you write a prescription for oxycodone and point out increased patient satisfaction. However, the traumatic approach works best. Begin by kicking the narcophobic physician in the shins to create a nondisabling, continuously painful disruption to daily function and enjoyment of life (the doctor’s recent patients will gladly do this
part). Then, the physician is given his or her choice of non-narcotic analgesia to show its relative impotence. Finally, narcotics are administered, offering rapid relief. Consequent is a life altering realisation of how much good the physician may do for patients by a change of behaviour. Remember the ethic of reciprocity, or “golden rule.” One day, every physician will find himself or herself in enough pain to seek out another physician. How would you like that physician to approach your pain? Boris D Veysman assistant professor, Robert Wood Johnson Medical School, New Brunswick, USA
[email protected] 1
Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252:1905-7.
Cite this as: BMJ 2009;339:b4987
BMJ | 19-26 december 2009 | Volume 339
Christmas fayre
Eating, drinking, and being merry. But is Santa a good role model for children? See p 1424
Christmas quiz: what are these?
Fig 1
Fig 2
See page 1448 for answers >> Fig 3
Fig 4
Write your answers on the notepad
Fig 1
Fig 2
Fig 3
Fig 4 Fig 5
Fig 5
Clare Verrill consultant histopathologist, Royal Bournemouth Hospital, Bournemouth BH7 7DW
[email protected] Cite this as: BMJ 2009;339:b4889 BMJ | 19-26 december 2009 | Volume 339
1423
Christmas fayre
Santa Claus A public health pariah?
duncan smith
Santa Claus is a well known and loved character, but Nathan Grills and Brendan Halyday question whether he is a healthy role model
S
anta Claus long ago displaced the Virgin Mary and baby as the most unmistakable Christmas iconography. A recent study among hospital inpatients concluded that awareness of Santa was near universal.1 Given Santa’s fame, he has considerable potential to influence
1424
individual and societal behaviour—and not necessarily for good. Santa is a late adopter of evidence based behaviour change and continues to sport a rotund sedentary image. But this is not the only example where Santa’s behaviour and public image are at odds with contemporary accepted public health messages.
Advertising to children Eric Schlosser and Morgan Spurlock have both described how McDonald’s used Ronald McDonald to target their products at children by creating an association between McDonald’s food and happy times.2 3 Spurlock showed how Ronald McDonald was more highly recognised than the American president or the Pope.2 Interestingly, Schlosser documents that among American schoolchildren Santa Claus was the only fictional character more highly recognised than Ronald McDonald.3 If Ronald McDonald can be so effective at selling burgers to children, we might expect Santa to be equally effective at selling other goods. After all, it was Santa’s advertising potential that reincarnated simple Saint Nicholas into the glory of a universally recognised icon. Santa’s contemporary image was cemented by the Coca-Cola advertisements that began in the 1930s.4 By the mid-1950s Santa had become the leading sales consultant for numerous other companies and products. Today, he is one of the biggest sellers at Christmas and appears in adverts on television, the internet, billboards, and shop fronts. Public health needs to be aware of what giant multinational capitalists realised long ago: that Santa sells, and sometimes he sells harmful products. Several countries, like the UK, limit what can be advertised to children. Since Santa is a childhood icon should we prevent him from selling products such as alcohol and unhealthy foods? Furthermore, Santa has a growing impact on international public health. Like Coca-Cola, Santa has become a major export item to the developing world. Countries such as India are increasing celebrating the Christmas festival. The potential for Santa’s growing acclaim to be misused may even be greater in countries where there is less regulation of advertising. Obesity Epidemiologically there is a correlation between countries that venerate Santa Claus and those that have high levels of childhood obesity.5 6 Although given the various confounders it BMJ | 19-26 december 2009 | Volume 339
Christmas fayre
“Oh Mum, how bad can smoking be? Santa smokes, and he must be at least 99 and hasn’t died of lung cancer yet.”
Poor role model
is premature to conclude causality, there is a temporal pathway whereby Santa promotes a message that obesity is synonymous with cheerfulness and joviality. Rear Admiral Galson, acting US surgeon general in 2007, commented, “It is really important that the people who kids look up to as role models are in good shape, eating well and getting exercise. It is absolutely critical.”7 He went on to explain that Santa should slim down. To create a supportive environment for Santa’s dieting we should cease the tradition of leaving Santa cookies, mince pies, and milk, brandy, or sherry. This is bad not only for Santa’s waistline but for parental obesity. When Santa is full, Dad is a willing helper. Maybe we should encourage Santa (and his helpers) to share the carrots and celery sticks commonly left for Rudolf. Santa might also be encouraged to adopt a more active method to deliver toys—swapping his reindeer for a bike or simply walking or jogging.
Endorsing smoking Santa was a former lead salesman for cigarettes; however, thankfully, Santa has been banned from overtly advertising cigarettes in many countries. Referring to a letter in which Santa claims he quit, John Banzhaf, an antismoking advocate, said: “Christmas is about children, and it is wonderful that Santa Claus is setting such a powerful example in protecting them from tobacco smoke pollution. Perhaps the most important and lasting gift any smoker can give a child is to give up smoking, or at least to stop smoking around the child.”8 Although Santa is banned from smoking in public, the image of the jolly, pipe smoking, bringer of good tidings remains firmly engrained in many people’s imagination. Furthermore, images of Santa enjoying a cigar are still available on Christmas cards and drawings.9 One blogger recounts how a 4 year old child spotted one such picture and said, “Look, Mommy, Santa Claus is smoking.”10 You can just imagine a cheeky 12 year old arguing, BMJ | 19-26 deceMBer 2009 | VoluMe 339
Reckless role model Injuries are the leading cause of death in childhood.11 Santa’s public health image in relation to injury prevention has been questioned. The tradition of leaving Santa a cup of brandy led one mother to worry “that my kids are going to think I am encouraging drink driving.”12 With a few billion houses to visit, Santa would quickly be over the limit. Reassuringly however, another blogger responded to the concerned mother, arguing that “technically it is not Santa driving as Rudolph and the Reindeers are trained to pull Santa.” Other dangerous activities that Santa could be accused of promoting include speeding, disregard for road rules, and extreme sports such as roof surfing and chimney jumping. Despite the risks of high speed air travel Santa is never depicted wearing a seatbelt or a helmet. Infectious disease vector A quick perusal through the Victorian infectious diseases surveillance records shows no notifications of infectious disease outbreaks associated with kissing Santa. Although there were no cases of infectious mononucleosis (“kissing disease”) associated with Santa, there have been numerous foodborne viral and salmonella outbreaks associated with Christmas parties. Santa was not named as a suspected point source. Surveillance programmes do not routinely collect data on Santa exposure but, temporally at least, Santa is potentially a point source for infectious diseases outbreaks. The grey literature documents clear basic hygiene issues arising from interactions with Santa. One survey found that “Santa is sneezed or coughed on up to 10 times a day.”13 The potential for
Given santa’s fame, he has considerable potential to influence individual and societal behaviour— and not necessarily for good. santa is a late adopter of evidence based behaviour change and continues to sport a rotund sedentary image Santa in his asymptomatic phase to propagate an infectious disease is clear. Unsuspecting little Johnny gets to sit on Santa’s lap, but as well as his present he gets H1N1 influenza. Santa continues on his merry way and gives the present to a few more 100 kids before coming down with influenza himself. This then becomes a contact tracer’s nightmare. Additionally, in Australia there is no health check required for most Santas. I have played Santa for two school concerts and one staff function. I was not required to have a health check. It basically relies on the impersonator’s judgment. Indeed, in my first appearance I was filling in for my father who had a viral respiratory illness. He had the insight, or at least a good excuse, to delegate the Santa responsibility and so avoided infecting children. There were no tests for meticillin resistant Staphylococcus aureus, no screening for current viral illnesses, and no immunisation checks. I was kissed and hugged by snotty nosed kids at each performance and was never offered alcohol swabs to wipe my rosy cheeks between clients. The reality is that Santa impersonators are in short supply in December,
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Christmas fayre
Public healthy santa: a better role model
and organisers of such events are so desperate for Santa impersonators that they skimp on public health safeguards. In America, some Santas are subject to criminal background checks and pre-employment drug screens.3 However, there is no standardised requirement for Santa to have a medical check-up or even prove his immunisation status. Regulations to mitigate this public health risk should be considered. Clearly, basic Santa education and Santa screening are warranted. Even more concerning is how Santa’s travels might contravene the international health regulations in the context of an outbreak of new infectious diseases such as avian influenza.14 In the case of a public health emergency, WHO may
institute measures to prevent the international spread of disease. However, Santa flouts the requirements for surveillance at “designated airports, ports and certain ground crossings,” and the international regulations do not mention how to control this transnational unconventional public health threat.
Conclusion Santa studies is a developing field in public health, and currently there is a disappointing lack of rigorous research on the effect of Santa on public health. More targeted research is required before authorities might take action to regulate Santa’s activities. This research should particularly focus on the ability of Santa to encourage unhealthy behaviour; the use of Santa in advertising to kids; and the infectious disease risk of Santa impersonators. We need to be aware that Santa has an ability to influence people, and especially children, towards unhealthy behaviour. Given Santa’s universal appeal, and reasoning from a population health perspective, Santa needs to affect health by only 0.1% to damage millions of lives. We propose a new image for Santa to ensure that his influence on public health is a positive one. nathan J Grills public health fellow, monash university, department of Epidemiology and Preventative medicine, Commercial Road, melbourne, Vic 3000, australia Brendan Halyday illustrator, Level 1/95 Johnston St, Collingwood, Vic 3066, australia correspondence to: n J Grills
[email protected] this work was completed during nJG’s participation in Victoria’s public health training scheme, funded by the State of Victoria through the department of Human Services/ department of Health. the views are those of the authors
and not necessarily those of these departments. contributors and sources: the article was developed after discussions with senior public health professors on role models and norms in tackling obesity and inactivity. nJG completed an mSc and dPhil in public health under a Rhodes scholarship at Oxford university and will complete his public health physicians training in January, after which he is considering a job as a public healthy Santa. Bh provided advice on the visual impact of different representations of Santa and helped develop a Santa caricature that might better reflect a public healthy Santa. competing interests: none declared. Provenance and peer review: not commissioned; externally peer reviewed. 1 2 3 4 5
6 7 8 9 10 11 12 13 14
Cyr C. Do reindeer and children know something that we don’t? Pediatric inpatients’ belief in Santa Claus. CMAJ 2002;167:1325-7. Spurlock M. Don’t eat this book: fast food and the supersizing of America. Penguin, 2005. Schlosser E. Fast food nation: the dark side of the allAmerican meal. Houghton Mifflin Harcourt, 2001. St Nicholas Center. Saint Nicholas and the origin of Santa Claus. 2008 www.stnicholascenter.org/Brix?pageID=35. Organisation for Economic Cooperation and Development. OECD health data 2008: statistics and indicators for 30 countries. www.oecd.org/document/30/0,3343,en_2649 _34631_12968734_1_1_1_37407,00.html. Nelms B. Santa Claus: good or bad for children? J Pediatr Health Care 1996;10:243-4. Underwood M. Hey, St Nick: put down the cookie. Boston Herald 2007 Nov 30. www.bostonherald.com/news/ regional/general/view.bg?articleid=1047979. Action on Smoking and Health. Santa quits smoking for Christmas. 2005. http://no-smoking.org/dec05/12-2405-1.html. Santa smoking a pipe. www.cardcow.com/53309/santasmoking-a-pipe-christmas-santa-santa-claus. Window ad—Santa Claus smoking. MyFolsom.com. www.tomatopages.com/folsomforum/index.php? showtopic=6514. WHO. World report on child injury prevention. Geneva: WHO, 2008. Emma-Kate. What do you leave for Santa? Yahoo Answers http://uk.answers.yahoo.com/question/index?qid=20060 828135144AAQTqdh. Naughty not nice: instances of Santa abuse reported. Insurance Journal 2006 Dec 20. www.insurancejournal. com/news/national/2006/12/20/75188.htm. WHO. International health regulations (2005). 2005www. who.int/csr/ihr/en/.
Cite this as: BMJ 2009;339:b5261
Ethical dilemma For 11 years the registered charity the Children’s Heart Federation has taken a group of children with congenital heart disease to Lapland at Christmas. We drafted a proposal to study these children, which we submitted to the local ethics committee for approval. The methods included a plan to escort a group of children to Lapland to visit an obese, hirsute, elderly white male dressed in a red costume. We sought permission to collude with this man in deceiving young children that he would visit them on Christmas Eve, arriving in a flying sleigh drawn by reindeer, one with a red nose. At first glance this proposal seems to contravene the ethics of truth and honesty, but one study has reported that 87% of parents are happy about such a deception.1 The ethics committee readily gave its consent to the plan. But was the committee right? 1426
the photograph was supplied by the Children’s heart federation, which has parental permission for publication
competing interests: the Santa Claus imposter received payment from nn to finance a troop of elves, a supply of carrots, and a bottle of rum.
1
Trinkaus J. Visiting Santa: an additional look. Psychol Rep 2007;101(3, part 1):779-83.
nitha naqvi paediatric cardiology specialist registrar, Royal Brompton hospital, London
[email protected] Piers e F daubeney paediatric cardiology consultant, Royal Brompton hospital, London; reader in paediatric cardiology, imperial College London Cite this as: BMJ 2009;339:b5074
BMJ | 19-26 deceMBer 2009 | VoluMe 339
MUSICal interlude
Nellie knows what to sing to keep rhythm while carrying out CPR, see p 1429 and vote on bmj.com
Michel Descamps, 1950. INSET: WILLIAM GOTTLIEB/REDFERNS/GETTYIMAGES
J
ean-Baptiste Reinhardt, better known by his gypsy name “Django” meaning “I awake,” was a Manouche Gypsy born in a “roulotte,” a wooden caravan, near Liberchies, Belgium, on 23 January 1910. He was the son of a travelling musician and learnt to play the violin aged 9 before teaching himself to play a banjo guitar, with which he soon supplemented the family income by playing the popular accordion “musette” waltzes. He had exceptional natural talent and a promising future as a professional musician. Although almost illiterate and unable to read music, he had an incredible ability to play a tune perfectly after hearing it once, and could improvise tirelessly for hours at a time. However, on 26 October 1928 disaster struck. A carelessly dropped cigarette ignited a bunch of highly flammable celluloid flowers, turning Django’s roulotte into an inferno. He grabbed a blanket to shield himself from the flames and managed to escape, but sustained burns to the left side of his body as well as to his left hand, which had been holding the blanket. He was admitted to the Hôpital Lariboisière in Northern Paris, but fearing that the doctors would amputate his leg, on 22 November he fled back to the gypsy encampments where he was treated with traditional remedies. His wounds became infected and he was admitted to the Hôpital Saint-Louis on 23 January 1929 for debridement and cautery with silver nitrate under chloroform anaesthesia.1‑6 The burns slowly healed, but resulted in severe contractures of the left ring and little fingers which made conventional guitar technique impossible. Despite these devastating injuries Django painstakingly re-learnt the guitar during an 18 month convalescence. His novel technique, combined with influences from musette, flamenco, bebop and swing jazz, as well as classical influences from the composers Bach, Debussy, and Ravel, defined a new genre of music known as “Gypsy Jazz” that has influenced many generations of classical and popular musicians since then.7‑9 Django returned to public performance in 1930 and from this point he enjoyed worldwide acclaim as a musical pioneer and performer until his untimely death from a cerebral haemorrhage in the picturesque village of Samois-sur-Seine on 16 May 1953. He was aged only 43. Only a few minutes of film footage of Django’s playing exist,5 10‑ 17 but analysis of this gives us
Django’s hand David Williams and Tom Potokar analyse the burn injured fingers of the innovative jazz guitarist Django Reinhardt Django’s left hand showing dorsal scarring and contractures
some insight into the innovative techniques that he developed to overcome the limitations imposed by his injuries.
Musical technique Django devised a highly efficient system of three note chord shapes, each of which encompassed inversions of several different chords. He developed unorthodox techniques to play these, including the use of his left thumb to fret the lower one or two strings, one fingered “double stops”—where two strings are fretted simultaneously by placing the tip of one finger midway between both strings—and employed his contracted ring and little fingers on the upper strings, where they acted like a single
BMJ | 19-26 december 2009 | Volume 339
finger. The last technique particularly suited ninth or minor sixth chords rather than the more conventional major or minor chords of the time, and introduced his audience to a new range of tonal colours. It is difficult to play standard scales with just index and middle fingers, so Django adopted an arpeggio-based rather than modal approach to soloing. He adapted arpeggios so that they could be played with two notes per string patterns which ran horizontally up and down the fret board instead of the usual vertical “box” patterns, enabling him to move around the fret board with great speed and fluidity. Influenced by his childhood violin lessons, he often oriented his left hand so that these fingers 1427
musical INTERLUDE
were almost parallel to the strings sue on the dorsum of his left hand instead of perpendicular to the fret measuring about 30 mm by 20 mm, board. His injuries also defined his overlying zone six of the tendons of phrasing and ornamentation—he the ring and little fingers, and fixed often incorporated open strings contractures of these fingers. Film into his solos, along with his tradearchives show no evidence of conmark chromatic glissando runs, for tracture or limitation of movement which he used his middle finger at the elbow, wrist, thigh, or knee, braced by the index finger—and the and so it is likely that these areas considerable strength that he had healed completely. to develop in these fingers enabled Delayed healing of a burn wound him to achieve wide string bending often results in chronic recurrent and vibrato effects. infection. Although the traditional As a result of the relative immo- Computer model of Django’s hand illustrating the deformity and effect of contractures remedies Django received would bility of his hand, Django often have included antiseptic herbal moved fixed shapes up and down the fret board Discussion poultices (“drab”),27 28 these would not have which produced intervallic cycling of melodic It is reported that Django had extensive full been sufficiently potent to treat this. The violinmotifs and chords, and played octave runs thickness burns “from knee to chest,” and ist Stephane Grappelli, who toured with Django with the index and middle or ring fingers—a that his hand was “grotesquely charred.”2‑4 for many years, observed that Django’s hand technique subsequently popularised by Wes However, from the mechanism and records never properly healed and “. . . would someMontgomery. of his injuries,1 the reality is that he probably times fester and weep and look very sore . . . sustained mixed thickness burns of 7% to 15% preventing him from playing.”29 Anthropometric analysis body surface area. Hand injuries can be devastating for musiDjango’s technique was only possible because The instinctive response when threatened cians, for whom music is their means of self of the remarkable length and span of his index by assault or fire is to protect the face by raisexpression and livelihood.30 31 Specialist treat18 and middle fingers. Photographs show that he ing the arms, which exposes the dorsum of the ment, intensive rehabilitation, and adaptation could play a “barre” across the full width of the hands to injury. The thin subcutaneous tissue are often necessary if they are to continue to perfret board using just the distal two phalanges of and superficial tendons in this region make it form. Adaptation may include the use of splints his index finger,19 and a half barre with the disvulnerable to subsequent deformity. or prostheses, modification of the instrument tal phalanx of his middle finger20; and analysis The fire occurred in an enclosed space and or technique, and adoption of a completely of film footage11 shows that he could effortlessly one account describes Django as initially being different musical style or instrument.30 32‑34 span a distance of at least 120 mm between the “barely conscious” as a result of being “robbed Where possible, management should be contips of his index and middle fingers. of oxygen and inhaling noxious fumes.”2 Howservative with early mobilisation and return to The authors used Luthiers’ blueprints of ever, no record of depressed conscious level playing. Surgical management should prioritise Django’s guitars to find the fret and fingeror airway burns on his arrival at the hospital reconstruction of the playing position over the board widths at each point on the necks of his shortly afterwards exists,1 so we conclude that anatomical “position of function” or cosmetic instruments.21‑23 By using these values for referDjango was able to escape without sustaining appearance.30 ence and comparing them with 14 rare archive major inhalation injury. photographs and images captured from video In the acute phase of severe hand burns, swellConclusions footage, it was possible to derive rough measing occurs which can result in compartment synDisaster can also be a positive catalyst for innourements of Django’s left hand. Corresponding drome and irreversible damage to the intrinsic vation. Modern reconstructive surgery would measurements from the right hand were also muscles of the hand. This was unlikely in Djanhave dramatically improved the function and taken to confirm the measurements where go’s case, as shown by the remarkable agility and cosmetic appearance of Django’s hand, but appropriate. Software (Adobe Photoshop CS2, span of his index and middle fingers. would have perhaps changed the course of Adobe Systems Incorporated, California) was Django initially stayed in hospital for 28 jazz music forever. The enduring popularity of used to correct for the effects of perspective days,1 11 by which time any areas of superficial Django’s music is testament to his innate genius and scale, but it was impossible to fully compartial thickness injury would have healed. and determination. We thank Roger Baxter for providing rare archive pensate for distortion because of parallax or Early excision and grafting of burn injuries photographs and film clips and the Romany community for the focal length of the original camera lenses. was not practised in this era, but debridement generously sharing their music and culture. These data were compared with anthropometwas often performed to remove necrotic tisDavid J Williams consultant anaesthetist and senior clinical ric reference data,24‑26 and used in combination sue and reduce the risk of infection. This was tutor, Department of Burns and Plastic Surgery, Morrison Hospital, Swansea SA6 6NL with 3D modelling software (Poser 6, Curious a very painful procedure, requiring general
[email protected] Labs, California) and texture map rendering of anaesthesia with chloroform or ether, and Tom S Potokar consultant plastic, reconstructive, and scar tissue (Photoshop CS2) to create a virtual the granulating tissue would bleed profusely, burns surgeon, and senior clinical tutor, Swansea University model for visualisation. requiring cautery. In Django’s case this proceMedical School, Singleton Park, Swansea SA2 8PP dure was performed nearly three months after Competing interests: David Williams and Tom Potokar are Listen to the music of Django Reinhardt and dedicated guitarists, and members of the gypsy jazz trio the original injury, which indicates that these other gypsy jazz musicians “Swing Bohème”.. areas had sustained deep, almost certainly full www.last.fm/music/Django+Reinhardt Provenance and peer review: Not commissioned; externally thickness, burns. peer reviewed. www.7digital.com/artists/django-reinhardt As a result of conservative management, References are in the version on bmj.com www.live365.com/stations/hotclubdepott Django was left with an ovoid mass of scar tisCite this as: BMJ 2009;339:b5348 1428
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musicAL INTERLUDE
Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial L Rawlins,1 M Woollard,2 J Williams,3 P Hallam4 Birmingham University School of Medicine, Edgbaston, Birmingham B15 2TT 2 Pre-hospital, Emergency and Cardiovascular Care Applied Research Group, Coventry University, Coventry CV1 5FB 3 School of Health and Emergency Professions, University of Hertfordshire, Hatfield AL10 9AB 4 West Midlands Ambulance Service NHS Trust, Waterfront Business Park, Brierley Hill, West Midlands DY5 1LX Correspondence to: M Woollard
[email protected] 1
Cite this as: BMJ 2009;339:b4707 doi: 10.1136/bmj.b4707
This article is an abridged version of a paper that was published on bmj.com. Cite this article as: BMJ 2009;339:b4707
Abstract Objectives To determine whether listening to music during cardiopulmonary resuscitation (CPR) training increases the proportion of lay people delivering chest compressions of 100 per minute. Design Prospective randomised crossover trial. Setting Large UK university. Participants 130 volunteers (81 men) recruited on an opportunistic basis. Exclusion criteria included age under 18, trained health professionals, and CPR training within the past three months. Interventions Volunteers performed three sequences of one minute of continuous chest compressions on a skill meter resuscitation manikin accompanied by no music, repeated choruses of Nellie the Elephant (Nellie), and That’s the Way (I like it) (TTW) according to a pre-randomised order. Main outcome measures Rate of chest compressions delivered (primary outcome), depth of compressions, proportion of incorrect compressions, and type of error. Results Median (interquartile range) compression rates were 110 (93-119) with no music, 105 (98-107) with Nellie, and 109 (103-110) with TTW. There were significant differences within groups between Nellie v no music and Nellie v TTW (P<0.001) but not no music v TTW (P=0.055). A compression rate of between 95 and 105 was achieved with no music, Nellie, and TTW for 15/130 (12%), 42/130 (32%), and 12/130 (9%) attempts, respectively. Differences in proportions were significant for Nellie v no music and Nellie v TTW (P<0.001) but not for no music v TTW (P=0.55). Relative risk for a compression rate between 95 and 105 was 2.8 (95% confidence interval 1.66 to 4.80) for Nellie v no music, 0.8 (0.40 to 1.62) for TTW v no music, and 3.5 (1.97 to 6.33) for Nellie v TTW. The number needed to treat for listening to Nellie v no music was 5 (4 to 10)—that is, the number of cardiac arrests required during which lay responders listen to Nellie to facilitate one patient receiving compressions at the correct rate (v no music) would be between four and
What is already known on this topic Mentally “singing” the song Nellie the Elephant is sometimes recommended during CPR training in the UK because of its appropriate tempo to help individuals keep a rate of 100 compressions per minute
What this study adds Listening to Nellie the Elephant significantly increased the proportion of lay people achieving compression rates of 95-105 a minute compared with no music Unfortunately it also increased the proportion of compressions delivered at an inadequate depth As current resuscitation guidelines give equal emphasis to correct compression rate and depth the use of Nellie the Elephant as a learning aid during CPR training cannot be recommended BMJ | 19-26 december 2009 | Volume 339
10. A greater proportion of compressions were too shallow when participants listened to Nellie v no music (56% v 47%, P=0.022). Conclusions Listening to Nellie the Elephant significantly increased the proportion of lay people delivering compression rates at close to 100 per minute. Unfortunately it also increased the proportion of compressions delivered at an inadequate depth. As current resuscitation guidelines give equal emphasis to correct rate and depth, listening to Nellie the Elephant as a learning aid during CPR training should be discontinued. Further research is required to identify music that, when played during CPR training, increases the proportion of lay responders providing chest compressions at both the correct rate and depth.
Introduction Cardiopulmonary resuscitation (CPR) is an important life saving technique that can be effectively taught to most people.1 It is important that skills are taught well so that bystanders feel confident enough to use them. Resuscitation Council (UK) guidelines for adult basic life support recommend a compression rate of 100 per minute, with a repeating sequence of 30 compressions followed by two rescue breaths.2 3 It is important to maintain chest compression rates and reduce interruptions to compressions as failure to do so is associated with a reduced chance of survival.4 Estimating a rate of 100 beats per minute (bpm) can be difficult. A pilot study involving listening to the song Stayin’ Alive by the Bee Gees while performing CPR has suggested this helps health professionals maintain a compression rate of around 100 bpm.5 Traditionally in the UK mentally “singing” the children’s nursery tune Nellie the Elephant has been suggested during CPR training to help learners maintain a rate of 100 compressions a minute because of its appropriate rhythm and tempo. We carried out a randomised crossover trial to test whether listening to Nellie the Elephant during training helps lay people to improve their performance of chest compressions during CPR compared with no music or a second tune with a similarly appropriate tempo. Methods Hypothesis and objectives—Our hypothesis was that listening to the songs Nellie the Elephant or That’s the Way (I like it) during CPR training would increase the likelihood of lay people performing chest compressions at the recommended rate, compared with the absence of music. Setting and participants—We invited staff or students aged over 18 at Coventry University to participate. We excluded healthcare students or professionals or those who had received CPR training within the previous three months. Participants were recruited on an opportunistic basis. 1429
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Table 1 | Comparison between interventions in performance of compression rate and depth No music
Nellie the Elephant
That’s the Way (I like it)
Median compression rate (IQR, range)
110 (93-119, 43-146)
105 (98-107, 48-162)
109 (103-110, 53-157)
Proportion of subjects delivering compression rate 95-105/min (%, 95% CI)
15/130 (12%, 7% to 18%)
42/130 (32%, 24% to 41%)
12/130 (9%, 5% to 16%)
Median for proportion of compressions delivered at correct depth (IQR, range)
24% (0-62, 0-99)
14% ( 0-59, 0-97)
11% (0-65, 0-98)
Design—This community based prospective randomised crossover trial assessed performance of manikin based chest compression. All participants were given a brief demonstration on the use of a resuscitation manikin and had one minute to practise while listening to a metronome. Participants were then asked to perform three sequences of one minute of continuous chest compressions carried out without musical accompaniment, with repeated choruses of Nellie the Elephant (Nellie) by Little Bear (105 bpm), or with That’s the Way (I like it) (TTW) by KC and the Sunshine Band (109 bpm) in a pre-randomised order. Outcome measures—Our primary outcome measure was the paired differences in average compression rates between interventions. Secondary outcome measures comprised paired differences between interventions in proportions of correct compressions, compressions too shallow, compressions too deep, compressions with incomplete hand release, compressions with incorrect hand position, compressions at the correct depth, participants delivering compression rates within the range 95-105 per minute, relative risk for compression rate of 95-105, and numbers needed to treat to achieve a compression rate of 95-100.
Results Of the 130 participants, 81 (62%) were men. The median age was 21 (interquartile range 20-25, range 18-72), and 94 (72%) had no previous CPR training. All analysis was by intention to treat. Table 1 compares the performance of compression rate and depth with each intervention. Differences between interventions in median compression rates were significant for Nellie v no music and Nellie v TTW (both P<0.001) but not for no music v TTW (P=0.055). Differences in the proportions of people delivering compressions at a rate of 95-105 were significant for Nellie v no music and Nellie v TTW (both P<0.001) but not for no music v TTW (P=0.55). Relative risk for a delivered compression rate of 95-105 was 2.8 (95% confidence interval 1.66 to 4.80) for Nellie v no music, 0.8 (0.40 to 1.62) for TTW v no music, and 3.5 (1.97 to 6.33) for Nellie v TTW. The number needed to treat for listening to Nellie v no music was 5 (4 to 10)—that is, the number of cardiac arrests
required during which lay responders listen to Nellie to facilitate one patient receiving compressions at the correct rate (v no music) might be as many as 10 or as few as four. There were no significant differences between interventions in the proportion of compressions given at the correct depth (no music v Nellie P=0.084; no music v TTW P=0.095; Nellie v TTW P=0.378). Table 2 shows that there were no significant differences between interventions for the proportion of chest compressions given correctly, the proportion given too deeply, or the proportion given with an incorrect hand position. There was a significantly greater proportion of compressions given to an inadequate depth when participants listened to Nellie compared with no music, but this difference was not significant for no music v TTW or Nellie v TTW. The proportion of compressions with incomplete hand release was significantly greater for both tunes compared with no music but not when both tunes were compared. Inadequate depth of compressions was the most common form of error. For all interventions the proportion of chest compressions given correctly was less than 25%.
Discussion Principal findings There was a significant increase in the proportion of participants providing an appropriate compression rate while listening to Nellie the Elephant compared with no music or That’s the Way (I like it) (TTW). Listening to TTW, however, showed no significant difference in the proportion achieving correct compression rates compared with no music. Disappointingly, for all three interventions the proportion of chest compressions given correctly was less than a quarter, with no significant difference between each. When participants listened to Nellie there was a significantly greater proportion of compressions delivered at an inadequate depth compared with no music or TTW. Strengths and weaknesses The randomised crossover design of the study ensured that any differences between interventions were not due to the effects of the sequence in which they were performed or differences in the skills, amount of practice, or fatigue of participants. Opportunistic sampling could have led to responder bias. Selection bias could have occurred as recruitment was solely from university premises. Strengths and weaknesses in relation to other studies A non-randomised observational pilot study previously investigated the effect of listening to Stayin’ Alive by the Bee Gees on compression rates performed by healthcare professionals but had only 15 participants.5 Our trial was on a larger scale, with 130 participants and a more robust randomised crossover
Table 2 | Comparison between interventions in proportion of compressions given correctly or incorrectly. Figures are median percentages (interquartile range, range) Compressions
No music (n=130)
P value for difference
Nellie the Elephant (n=129*)
That’s the Way (I like it) (n=130)
No music v Nellie
No music v TTW
Nellie v TTW
Correct
22 (0-61, 0-99)
14 (0-56, 0-97)
9 (0-53, 0-98)
0.07
0.07
0.41
Too shallow
47 (3-88, 0-100)
56 (6-97, 0-100)
57 (10-94, 0-100)
0.02
0.05
0.90
Too deep
0 (0-4, 0-98)
0 (0-3, 0-96)
0 (0-4, 0-98)
0.52
0.41
0.19
Incomplete hand release
0 (0-0, 0-60)
0 (0-0, 0-95)
0 (0-0, 0-87)
0.03
0.02
0.95
Incorrect hand position
0 (0-0, 0-76)
0 (0-1, 0-64)
0 (0-1, 0-89)
0.86
0.48
0.63
*Data missing for one participant.
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duncan smith
musicAL INTERLUDE
design. Both studies reported a positive impact on the delivery of compressions at the correct rate when listening to music. Previous research has reported poor performance of chest compressions. Before a basic life support course healthcare professionals delivered a median compression rate of 127 (interquartile range 93-133). After training, the median compression rate rose to 147 (135-161, P<0.001).6 This suggests that, in this population, traditional instructor led training decreased the likelihood of participants compressing at the correct rate, whereas in the current trial listening to Nellie had some positive effect. An observational study evaluating CPR performance after training in lay volunteers found that the proportion of participants giving compressions at a rate in the range 90-110 increased from a baseline of 10/118 (9%) before training to 24/112 (21%) after training (difference 13%, 3% to 23%, P=0.006).7 The proportion of participants in our study who listened to Nellie and compressed at the “correct” rate in the narrower range of 95-105 per minute was higher at 32%.
Meaning of study The significant increase in the proportion of participants achieving compression rates of 95-105 per minute when listening to Nellie might be because of the simplicity and familiarity of the song. Even though TTW has a similar tempo to Nellie, it resulted in no significant difference in the achievement of correct compression rates compared with no music. This might be because this song has a different style with more complex lyrics and percussion. The significantly greater proportion of compressions delivered at an inadequate depth when people listened to Nellie BMJ | 19-26 december 2009 | Volume 339
could be because of distraction from the task by the music, as several participants seemed amused by the song.
Implications for clinicians and policymakers As current resuscitation guidelines give equal emphasis to the importance of performing chest compressions at both the correct rate and depth, we regretfully recommend that playing or imagining hearing Nellie the Elephant during CPR training should be discontinued. Unanswered questions and future research Research is urgently required to identify other tunes that could be played during CPR training to improve the proportion of participants giving compressions at the correct rate and to determine if songs with a greater musical emphasis on each beat could provide motivation to deliver more compressions at a greater depth. Potential tunes include Another One Bites the Dust (Queen), Quit Playing Games (With my Heart) (Backstreet Boys), and Achy Breaky Heart (Billy Ray Cyrus). We gratefully acknowledge the contribution of the study participants and the cooperation of Coventry University. We also express our sincere thanks to all song writers and musicians with the insight to produce music at a tempo close to 100 bpm, and to the statistical peer reviewer whose poetical comments resulted in improvements to the first submitted draft of our paper. Contributors: See bmj.com. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests: None declared. Ethical approval: The study was approved by Coventry University. All participants gave informed written consent before taking part. Data sharing: See bmj.com. References are in the version on bmj.com Accepted: 4 November 2009 1431
young and old
Perceptions of older people in the media: how ageist is the Economist? See p 1433
The association of early IQ and education with mortality: 65 year longitudinal study in Malmö, Sweden A Lager,1 2 3 S Bremberg,2 3 D Vågerö1
Cite this as: BMJ 2009;339:b5282 doi: 10.1136/bmj.b5282
Summary answers Mortality differences among participants by own educational attainment were not explained by early IQ, and mortality differences by own early IQ were not explained by father’s education or one’s own educational attainment, but the effect of early IQ on mortality differed between men and women. What is known and what this paper adds Both intelligence and educational attainment are linked to disease, but the causal interplay between these associations is not yet understood. This analysis suggests that both factors are important. Furthermore, the clear difference in the effect of IQ between men and women suggests that IQ is linked with mortality in ways that involve the social and physical environment rather than simply being a marker of a healthy body to begin with. Cognitive skills should, therefore, be addressed in our efforts to create childhood environments that promote health.
Participants and setting This population based study assessed schoolchildren in Malmö, Sweden. Design, size, and duration A total of 1530 schoolchildren took IQ tests in 1938 at the age 10. These data were linked through personal identity numbers to the Swedish causes of death register up until 31 December 2003, when the participants were aged 75 years. Mortality risks were estimated with Cox proportional hazards regressions.
This is a summary of a paper published on bmj.com as BMJ 2009;339:b5282 1432
Main results and the role of chance For both sexes, own educational attainment was clearly associated with survival, even beyond the importance of early IQ. Each additional year in school was associated with a reduced risk of dying when early IQ and father’s education were adjusted for (hazard ratio (HR) for each additional year in school 0.91 (95% CI 0.85 to 0.97) for men and HR 0.88 (95% CI 0.78 to 0.98) for women). Higher early IQ was linked with a reduced mortality risk in men, even when own educational attainment and father’s education were adjusted for (HR for one standard deviation increase in IQ 0.85 (95% CI 0.75 to 0.96)). In contrast, there was no crude effect of early IQ on mortality for women, and women with above average IQ had an increased mortality risk when own educational attainment
SURVIVAL FROM AGE 60 YEARS BY SEX AND COGNITIVE ABILITY, ADJUSTED FOR OWN EDUCATIONAL ATTAINMENT Proportion alive
Study questions Can differences in early IQ explain why people with longer education live longer, or do differences in father’s or own educational attainment explain why people with higher early IQ live longer?
1.0
Men
0.9 0.8 0.7 Below average IQ
0.6
Proportion alive
Centre for Health Equity Studies (CHESS), Stockholm University/ Karolinska Institutet, Stockholm, Sweden 2 Department for Public Health Sciences, Karolinska Institutet, Stockholm, Sweden 3 Swedish National Institute of Public Health, Östersund, Sweden Correspondence to: A Lager
[email protected] 1
1.0
Above average IQ Women
0.9
0.8
60
65
70
75 Age (years)
was adjusted for, but only after the age of 60 (HR 1.60 (95% CI 1.06 to 2.42); figure ).
Bias, confounding, and other reasons for caution The figure should be interpreted with some caution because it pertains to subgroups. In addition, the analyses in this paper did not include the possible role of changes in IQ. Generalisability to other populations The participants in our study are from only one city; however, the study data come from a near total census of that city, namely almost all children in the third grade of school. Changes in children’s living conditions during the long followup period may affect whether our results can be generalised to today’s children. Sweden’s economic conditions in the 1930s were comparable to those in middle income countries today. Study funding/potential competing interests The Swedish Council for Working Life and Social Research financed the updating of the Malmö Longitudinal Study database. AL and SB were funded by the Swedish National Institute of Public Health. The authors declare no competing interests. BMJ | 19-26 December 2009 | Volume 339
young and old
Perceived age as clinically useful biomarker of ageing Kaare Christensen,1 Mikael Thinggaard,1 Matt McGue,1 2 Helle Rexbye,1 Jacob v B Hjelmborg,1 Abraham Aviv,3 David Gunn,4 Frans van der Ouderaa,4 6 James W Vaupel5 Danish Twin Registry and Danish Aging Research Center, Institute of Public Health, University of Southern Denmark, DK-5000 Odense C, Denmark 2 Department of Psychology, University of Minnesota, Minneapolis, MN, USA 3 Center of Human Development and Aging, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA 4 Unilever Discover, Colworth House, Sharnbrook, Bedfordshire 5 Max Planck Institute for Demographic Research, Rostock, Germany 6 Netherlands Consortium for Healthy Ageing, Leiden University Medical Centre Leiden, LUMC, 2300RC Leiden, Netherlands Correspondence to: K Christensen
[email protected] 1
Cite this as: BMJ 2009;339:b5262 doi: 10.1136/bmj.b5262
Abstract Objective To determine whether perceived age correlates with survival and important age related phenotypes. Design Follow-up study, with survival of twins determined up to January 2008, by which time 675 (37%) had died. Setting Population based twin cohort in Denmark. Participants 20 nurses, 10 young men, and 11 older women (assessors); 1826 twins aged ≥70. Main outcome measures Assessors: perceived age of twins from photographs. Twins: physical and cognitive tests and molecular biomarker of ageing (leucocyte telomere length). Results For all three groups of assessors, perceived age was significantly associated with survival, even after adjustment for chronological age, sex, and rearing environment. Perceived age was still significantly associated with survival after further adjustment for physical and cognitive functioning. The likelihood that the older looking twin of the pair died first increased with increasing discordance in perceived age within the twin pair—that is, the bigger the difference in perceived age within the pair, the more likely that the older looking twin died first. Twin analyses suggested that common genetic factors influence both perceived age and survival. Perceived age, controlled for chronological age and sex, also correlated significantly with physical and cognitive functioning as well as with leucocyte telomere length. Conclusion Perceived age—which is widely used by clinicians as a general indication of a patient’s health—is a robust biomarker of ageing that predicts survival among those aged ≥70 and correlates with important functional and molecular ageing phenotypes. Introduction Perceived age—usually the estimated age of a person—is an integral part of assessment of patients.1 2 It is influenced negatively by exposure to sun, smoking, and low body mass index (BMI) and positively by high social status, low depression score, and being married, though the strength of the associations varies by sex.3 We looked at age as perceived by geriatric nurses (who should be “experts” in evaluating the appearance of older people), older women (who could also be “experts”), and young male student teachers (who were expected to be the worst assessors). We also examined whether perceived age was correlated with physical and cognitive function and leucocyte telomere length in the older twins and whether the age, sex, and background of the assessors affected the results.
This article is an abridged version of a paper that was published on bmj.com. Cite this article as BMJ 2009;339:b5262
Methods Study population The Longitudinal Study of Aging Danish Twins (LSADT) follows a population based cohort of same sex twins aged ≥70.4 The study began in 1995, with assessments every two years up to 2005. In 2001 the study had a participation rate of 85%;
BMJ | 19-26 december 2009 | Volume 339
Fig 1 | Composite pictures each representing average appearance of groups of 10 twins aged 70 (range 69-71). Left hand image represents twins who looked younger for their age (average perceived age 64, range 57-69) than those represented by right hand image (average perceived age 74, range 70-78)
and 91% of the participants with normal cognition, aged 70-99, agreed to have their face photographed. A total of 1826 twins (840 men and 986 women) had a passport type photograph taken (fig 1). We used the Danish Civil Registration system, which registers date of death or emigration, to follow each participant from the date in 2001 when their photograph was taken to 31 January 2008. For further methods on assessing perceived age, physical functioning, telomere length, and analyses see bmj.com.
Results All three assessor groups rated 387 twin pairs (774 twins, 352 men and 422 women), corresponding to 175 monozygotic and 212 dizygotic twin pairs. Analysis of variance showed that the perceived age data from all three assessor groups had high reliability (0.82-0.94). Characteristics for age and sex specific thirds of perceived age for the full sample of 1826 pictures rated by the 10 nurses were consistent across all age and sex strata, with higher mortality and poorer functioning in the higher perceived age thirds. See bmj.com. The table on bmj.com shows comparisons of data generated by all assessor groups. The mean of the perceived ages was close to the mean of the chronological ages; within one year in all rater groups except the older assessors, who overestimated the ages by an average of 1.7 years. The mean chronological age was about two years higher in the total sample of 1826 twins than among the 387 twin pairs (774 individuals). The correlation between perceived age and chronological age was highest in the total sample (0.52), while it was lowest (0.22), but still significant, using data from the older female assessors. Ageing phenotypes Perceived age was significantly correlated with all functional phenotypes across all assessor groups and in both the twin 1433
1.0
Female nurses 0.001 <0.001
0.9 0.002
0.8 0.017
0.7 0.6 0.5
63/101
0.4 Proportion (95% CI)
Fig 2 | Comparison within pairs of dizygotic twins, showing proportions of pairs in which older looking twin died first. P values are two sided for standard binomial test. Numbers above x axis indicate absolute number of pairs in which older looking twin died first divided by total number of pairs
Proportion (95% CI)
young and old
1.0
51/74
38/48
21/25
Male students 0.001
0.9
0.004
0.8
0.005 0.017
0.7 0.6 0.5
63/101
Proportion (95% CI)
0.4 1.0
50/75
35/49
21/25
Older women 0.04
0.9 0.02
0.8 0.7
0.23
0.11
0.6 0.5 57/101
Proportion (95% CI)
0.4 1.0
45/75
All
18/25 <0.001
0.9 0.8
33/49
0.001 0.009
0.011
0.7 0.6 0.5 0.4
64/101
49/75
37/50
22/25
All
Top 75%
Top 50%
Top 25%
Difference in perceived age in twin pair
pair sample and the total sample. All tested indices of ageing were associated with increased perceived age in the expected direction.
Survival analysis At the end of follow-up, among the 387 twin pairs (352 men and 422 women), 225 (29%) had died, 116 (33%) men and 109 (26%) women. In the total sample of 1826 twins, 348 (41%) men and 327 (33%) women had died. For all the assessor groups, perceived age was highly and significantly correlated to mortality in the bivariate analyses and also highly and significantly correlated after adjustment for chronological age. The effect size for perceived age was the same as or larger than chronological age, both in the univariate and the bivariate analyses. See bmj.com. 1434
Perceived age was still significantly associated with survival after adjustment for other biomarkers of ageing. The effect size in the full sample, however, was attenuated from a hazard ratio of 1.08 (1.05 to 1.10) when we adjusted for chronological age and sex to 1.05 (1.03 to 1.07) when we added MMSE and grip strength and finally to 1.03 (1.01 to 1.06) when we also included strength score and cognitive score in the model together with all the previous covariates. As of 31 January 2008, there were 179 pairs (78 monozygotic and 101 dizygotic) in which at least one twin had died. Figure 2 shows that for the dizygotic twin pairs the likelihood that the older looking twin of the pair died first increased markedly with increasing difference in perceived age within the pair—that is, the bigger the difference in perceived age within the pair, the more likely it was that the older looking twin died first. There was a significant increasing linear trend for all assessor groups (P=0.001 for nurse assessors, P=0.021 for student assessors, P=0.03 for older assessors) and all assessors combined (P=0.02). There was no such association for monozygotic twins.
Discussion Perceived age predicts survival among people aged ≥70, even after adjustment for chronological age, sex, and other readily measurable biomarkers of ageing. Perceived age also correlates with age related phenotypes such as physical and cognitive functioning and leucocyte telomere length. We have shown that perceived age based on facial photographs is a robust biomarker of ageing that does not depend on the sex, age, and professional background of the assessors. We found common genetic factors influencing both perceived age and survival because controlling for genetic factors (the comparison within monozygotic pairs) removed the association between perceived age and survival. Genetic factors that, for example, influence the condition of cardiovascular tissue could affect the risk of myocardial infarction as well as the appearance of skin.9 For strengths and weaknesses of this study see bmj.com. When assessing health, physicians traditionally compare perceived and chronological age, and for adult patients the expression “looking old for your age” is an indicator of poor health. Our study indicates that this practice, which has existed for decades if not centuries,10 is actually a useful clinical approach especially given that in a clinical setting perceived age is based on an array of indicators in addition to facial appearance. A basic clinical tool such as perceived age is a useful biomarker of ageing, and facial photographs are, currently, likely to be more informative with regard to survival of older people than a DNA sample. We thank Unilever for supplying the composite images, which were generated by Sharon Catt with software from the Perception Laboratory, University of St Andrews. Contributors: See bmj.com. Funding: This study was funded by Unilever. The Longitudinal Study of Aging Danish Twins (LSADT) received grants from the US National Institutes of Health (grant No NIA P01 AG008761). The Danish Aging Research Center is supported by a grant from the VELUX foundation. No funders had any role in the study design, analysis, or writing of this paper. Competing interests: None declared. Ethical approval: The study was approved by the regional scientific ethical committee in Denmark (Case No VF20040241). Data sharing: No additional data available. References, table, and an additional figure are in the version on bmj.com. Accepted: 15 November 2009
BMJ | 19-26 december 2009 | Volume 339
young and old
Retrospective analysis of attitudes to ageing in the Economist: apocalyptic demography for opinion formers? Ruth Martin, Caroline Williams, Desmond O’Neill Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin, Ireland Correspondence to: D O’Neill
[email protected] Cite this as: BMJ 2009;339:b4914 doi: 10.1136/bmj.b4914
This article is an abridged version of a paper that was published on bmj.com. Cite this article as: BMJ 2009;339:b4914
Abstract Objective To investigate the description of older people and ageing in a major weekly newspaper, influential in political and financial circles, to see whether it reflected ageing in a balanced manner, and to what extent it indulged in apocalyptic demography—the portrayal of population ageing as a financial burden rather than a scientific advance. Design Electronic search of the digital archive of the Economist of articles published between January 1997 and April 2008. Main outcomes measures Categorisation of articles as portraying population ageing as a burden or a benefit or with a balanced view. Results Of 6306 identified articles, 262 were relevant. Most featured pensions, demography, and politics. Of these 262, 64% portrayed population ageing as a burden and 12% as a benefit; 24% had a balanced view. Most articles therefore showed a predominantly ageist view of older people as a burden on society, often portraying them as frail non-contributors. Recurrent themes included pension and demographic “time bombs” and future unsustainable costs of health care for older people. Conclusion This negative view of older people might be influential in shaping the attitudes of readers, who include opinion formers in political and economic circles. Gerontologists (including geriatricians) need to engage with influential media, as well as helping to promote a professional development of journalists that is informed and knowledgeable about the negative impact of ageism on the wellbeing of older people. Introduction Ageism is the discrimination against, contempt for, abuse, stereotyping, and avoidance of older people. Apocalyptic demography is a flawed concept that predicts dispropor‑ tionate burdens arising from population ageing,1‑3 This alarmist attitude fails to recognise the many benefits of age‑ ing and concentrates on the negative attributes of ageing. Official discourse on older people is often coloured by apocalyptic demography.1 Among the contributors to this
What is already known on this topic Ageism is common in both society and health care Service provision in health care is coloured by popular discourse and narrative Such prejudices need to be recognised to be addressed, and ageism has not yet been examined in the economics literature
What this study adds There is a significant trend to ageism in one of the most influential economic and political magazines in the world Geriatricians and gerontologists who want to influence policy makers to improve services for older people will need to engage in a dialogue with journalists in areas other than the biomedical literature
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Table 1 | Principal theme of articles on ageing in the Economist Categories
No of articles
Pensions
78
Demography
34
Ageing population
34
Politics
33
Health care
24
Retirement
20
Biology of ageing
12
Long term care of elderly
9
Centenarians
3
Euthanasia
2
Miscellaneous
13
misinterpretation are over-reliance on highly variable demo‑ graphic forecasts,3 misapplication of dependency concept, homogenisation of populations of older people, failure to count in reductions in child and education spending, and failure to incorporate scientific findings showing little extra impact from population ageing on health care.4 Tackling apocalyptic demography should concentrate on opinion formers, politicians, and in particular economists. We analysed articles in the Economist, a weekly magazine that has a uniquely powerful global readership, with 46% in senior management, 20% who have lobbied or advised government, and 28% who hold a position in a social or community organisation (http://theideaspeople.economist. com). This influence is even more marked in government circles, reaching 45% of opinion formers in US federal gov‑ ernment and rising to 56% of opinion leaders in the con‑ gressional branch of the executive. We hypothesised that the perspective on ageing of this influential newspaper might be unbalanced, thus perpetuating apocalyptic demography and ageism at the highest levels of society.
Methods Using the online digital archive of the Economist (from Jan‑ uary 1997 to the present day) in May 2008 we performed a search for the following five search terms: “older” or “eld‑ erly” or “pensions” or “retirement” or “long term care.” Two observers independently read and analysed arti‑ cles. Those considered relevant had at least one comment on older people. We assessed article content for stigma‑ tisation of older people on account of their age or ageing. We classified articles as to whether they portrayed popula‑ tion ageing as predominantly a burden or a benefit or took a bal‑ anced view with positive, nega‑ tive, and neutral comments in balanced proportions depending on the lan‑ guage they contained. We 1435
young and old
Table 2 | Content analysis of articles relating to ageing Positive
Balanced
Negative
Pensions
1
21
56
Ageing population
4
5
25
Demography
4
4
26
Politics
5
6
22
Health care
0
6
18
Retirement
5
8
7
Biology of ageing
3
6
3
Long term care
0
4
5
Centenarians
2
0
1
Euthanasia
0
1
1
Marketing
1
1
0
Wealthy Germans
0
1
0
Age discrimination
1
0
0
Suicide in Korea
0
0
1
Productivity
0
0
1
Technology and older people
1
0
0
Exercise and older people
1
0
0
Gadgets for elderly
1
0
0
Grandparents raising grandchildren
1
0
0
Funeral homes
0
0
1
Old musicians
0
0
1
Art
1
0
0
have previously used this approach in media studies on attitudes to older people.5 Disagreements were resolved by a third reviewer and consensus.
Results The search yielded 6306 articles, of which 262 were consid‑ ered relevant. The articles included 78 on pensions, 34 on demography, 34 on the ageing population, 33 on politics, 24 on health care, 20 on retirement, 12 on the biology of ageing, nine on long term care facilities, and the remainder on a range of other issues. The raters agreed on 256 articles, with recourse to third party adjudication on six. We found 168 articles portrayed population ageing as a burden, 63 articles portrayed a bal‑ anced view, and 31 portrayed it as a benefit. The box shows some quotes from the articles. Content analysis showed that the topics that tend to depict population ageing in the most negative light include those on pensions and demography. Despite the fact that our study was based on a 10 year period, analysis did not show a shift in attitudes over time. The numbers of articles portraying older people in a negative or positive light were comparable between 1997 and 2008. Discussion We found that nearly two thirds of the relevant articles por‑ trayed older people in a negative light, effectively as a burden to society. The subject matter in three quarters of the articles involved pensions, demography, health care, and politics; and the theme of apocalyptic demography was widespread. Older people were often portrayed as frail non-contributors to soci‑ ety. The alarmist words “time bomb” were commonly used in relation to demography and pensions. That the Economist, a highly influential economic news‑ paper that prides itself on being “an enemy of privilege, 1436
pomposity and predictability,” should have such a predomi‑ nantly negative view of older people, mirroring that found in the popular media and advertisements, is surprising. Given the influence of the newspaper—Time magazine describes it as “exerting an influence far beyond its circulation . . . its calm authoritativeness has made it a favorite of political and business leaders in the US as well as Britain”—the message it portrays affects not just its readers but a wider population. It would seem unconscionable that the newspaper would be openly racist or sexist, and use such dismissive descriptors for these groups, yet older people do not seem to be accorded the same degree of courtesy and critical thought.
Journalists, economists, and gerontology Given the scale and speed of demographic change of the past 50 years, journalists and economists (and indeed all involved in the formulation and debate of public policy) need to be edu‑ cated in a more comprehensive overview of ageing. A similar process has been reasonably well studied for racism in jour‑ nalism,6 with positive experiences with media literacy training that reduce stereotype activation. For economists, the challenge is more daunting, with not only powerful vested interests in the pensions industry but also deeply held beliefs about the “dependency” of older people, despite convincing arguments to the contrary. The
Positive quotes Age cannot wither them (16 April 1998) Grandparents are now raising an awful lot of America’s poorest and most troubled children (Skipping a generation, 14 June 2007) The new demographics that are causing populations to age and to shrink are something to celebrate (Incredible shrinking countries, 5 January 2006) Politicians may fear the decline of their nations’ economic prowess, but people should celebrate the new demographics as heralding a golden age (Incredible shrinking countries, 5 January 2006) The old are wealthier and healthier than ever (Over 60 and overlooked, 8 August 2002)
Negative quotes The older they get, the more they cost (23 September 2004) Fewer and wrinklier Europeans (13 January 2000) They waddle slowly through the shopping malls; drive with exaggerated care on the freeways; fumble with their change at the check-out tills (Venerable elders, 22 July 1999) After years of warnings about the “demographic time bomb” due to detonate some time around 2020 (All-clear? 13 April 2000) Given that they all agree that a demographic “pension time-bomb” is ticking, Europe’s policymakers have done remarkably little to defuse it (Old hopes stirring, 12 October 2000) Wrinklies (Fewer and wrinklier Europeans, 13 January 2000) Weary crumblies (Who wants to live forever? 21 December 2000) Granny farming (27 November 1997) At what point does an ageing mind become a liability and not an asset? (Wisdom or senility, 16 February 2006)
BMJ | 19-26 december 2009 | Volume 339
young and old
however, to prepare this paper on the basis of the results, regardless of the outcome. There is also some chance of missed relevant articles because of the necessary constraints of our search terms. The broad range and high number and range of articles read, however, give us some reassurance in our results. This study is not an attack on the Economist, but rather a manifestation of how deeply ingrained negative stereotypes and prejudices about ageing are in an influential magazine. We hope to stimulate reflection and discussion among jour‑ nalists and economists on one of the most extraordinary social changes of the past century—our increased longevity. Contributors: See bmj.com. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests: None declared. Ethical approval: Not required. Data sharing: No additional data available. Sontag S. Illness as metaphor. Farrar, Straus and Giroux, 1978. Mullan P. The imaginary time bomb: why an ageing population is not a social problem. IB Tauris, 2000. 3 National Academy on an Aging Society. Demography is not destiny. National Academy on an Aging Society, 1999. 4 Barer ML, Evans RG, Hertzman C, Lomas J. Ageing and health care utilization: new evidence on old fallacies. Soc Sci Med 1997;24:85162. 5 Martin A, Balding L, O’Neill D. Are the media running elderly drivers off the road? BMJ 2005;330:368 6 Coleman R. Race and ethical reasoning: the importance of race to journalistic decision making. Journalism Mass Commun Q 2003;80:295-310. 7 Rosa A, Pueyo F. Endogenous longevity, health and economic growth: a slow growth for a longer life? Econ Bull 2004;9:1-10. 8 Reinhart VR. Death and taxes: their implications for endogenous growth. Econ Lett 1999;92:339-45. 9 Murphy KM, Topel RH. The value of health and longevity. J Political Econ 2006;114:871-904. 10 Richards T. An age old problem. BMJ 2007;335:698. 11 Palmore EB, Branch L, Harris DK, eds. Encyclopaedia of ageism. Haworth Press, 2005:194-7.
1 2
Accepted: 13 October 2009
john shelley
relation between longevity and economic growth, however, is complex,7 with some linking increased longevity with eco‑ nomic growth—the “demographic dividend.”8 One calcula‑ tion of this dividend is that cumulative gains in life expectancy after 1900 were worth over $1.2m to the representative Ameri‑ can in 2000, whereas gains after 1970 added about $3.2 tril‑ lion a year to national wealth, equal to about half of gross domestic product.9 Fortunately, some international forums have understood the need to bring economists, politicians, and gerontologists together (as well as journalists), and the World Demographic Association meetings have helped to bring about a focus on the positive as well as the negative aspects of ageing.10 Others point out that ageism can be turned around by the same sort of methods that have been successful in reducing racism and sexism—education, persuasion, protest, organisation, legisla‑ tion, civil suits—and by the personal examples of “successful ageing” that challenge negative stereotypes.11 In defence of the Economist, the letters page shows a small but increasing volume of dissent to its ageist positions. In 2008 it ran a webcast from Robert Butler on whether John McCain was too old to run for the presidency (which empha‑ sised that the presidential candidate’s age was not relevant). The strengths of our study include the large time span over which the articles were produced (11 years) and the wide search terms, leading to over 6000 articles being analysed. The use of Goffman’s stigmatisation concept led to a high level of reliability between observers; only six of 262 articles required a third independent review. The weaknesses include a possible expectation of bias against older people, given that the senior author had previously analysed and described negative attitudes in the popular press to older drivers and stroke.5 We had agreed,
BMJ | 19-26 december 2009 | Volume 339
1437
Afterlife
From flower graves to breast clinics David Robinson describes how classic Chinese literature helped raise awareness of breast cancer in China
A
wareness of certain types of cancer can be boosted by media coverage of the experiences of famous personalities. In the UK uptake of mammographic screening increased after the singer Kylie Minogue’s well documented breast cancer,1 2 and there was a similar surge in screening for cervical cancer associated with the illness and death of celebrity Jade Goody.3 An analogous example occurred in China in 2007 and provides an interesting link between the classic vernacular literature of that country and present day Chinese public health campaigns.
Ancient story The Dream of the Red Chamber is one of the great classics of Chinese literature.4 Also known as The Story of the Stone,5 it was written in the mid 18th century during the reign of the emperor Qianlong. The author, Cao Xueqin, was a little known poet and painter whose family had held high ranking positions in the Manchu government. He died in 1763 before the book was finished, and the completion of the work is generally ascribed to Gao E. The novel details the day to day lives of an extended aristocratic family in Jinling (now called Nanjing) during the Qing dynasty. Its appeal stems from the detailed development of the individual characters and the acutely observed relationships between them. The tale revolves around the scion of the family, Jia Baoyu, and his dealings with the young women of the household, principally his cousin, the delicate and ill fated Lin Daiyu. Daiyu joins the Jia household after the death of her mother, and she and Baoyu grow up together through adolescence. She is a sensitive but sickly child, subject to attacks of a consumptive disease and prone to frequent bouts of melancholy. They spend their time composing poetry and in other literary pursuits, mostly in the majestic surroundings of the classically landscaped garden of the family mansion. The book is permeated with Buddhist undertones and allusions to the transience of life. In one famous chapter Daiyu is seen weeping over fallen peach blossoms, which she is carefully bury1440
ing in a specially prepared flower grave. She and Baoyu become unspoken sweethearts, but later in the story a rival for Baoyu’s affections appears in the form of another cousin, Xue Baochai, an equally beautiful but altogether more robust and practically minded young woman much favoured by the matriarchal head of the household. Eventually, Baoyu is tricked by his family into marrying Baochai. On hearing of this, Lin Daiyu retires to her sick bed and dies brokenhearted.
Modern star In the late 1980s the story was televised by China Central Television and broadcast across China, with the part of Lin Daiyu played by the actress Chen Xiaoxu. The series was an immediate hit and was repeated more than 700 times over subsequent years. Chen rapidly became the nation’s sweetheart, known throughout China as Lin Meimei (sister Lin). After a second starring role in an adaptation of Ba Jin’s “Torrents” trilogy (the books Family, Spring, and Autumn) she quit the world of entertainment and forged a successful career as a businesswoman, running a multimillion pound advertising agency. As such, she remained very much in the public eye, and became the role model for many aspiring young women in modern China. In 2007, at the age of 41, she stunned fans and admirers by retiring to the Baiguoxinglong monastery in Changchun, Jilin province, to become a Buddhist nun. It subsequently transpired that she had advanced stage breast cancer, and she died less than three months after her ordination. Her sudden death resulted in an immediate increase in public awareness of the dangers of breast cancer in China. Within days, hospitals were witnessing a 10% increase in visits to general surgery departments, with women demanding breast checks. According to a Hangzhou based newspaper, one hospital in Zhejiang received about 200 visitors on 16 May, just three days after Chen’s death, of whom some 70% had come to check about breast diseases.6 As one woman from Shanghai said: “Her death is shocking. She was an
idol for a whole generation.” Thus, through the life and tragic death of Chen Xiaoxu, the spirit of Lin Daiyu has exerted its influence down the centuries, and one of China’s best loved literary heroines has made an important contribution to the awareness of health and wellbeing of modern day Chinese women. Lin Daiyu was acutely aware of her frailty and the seeming unreality of existence. Similarly, towards the end of her life Chen Xiaoxu came to recognise the futility of the pursuit of fame and riches. In her own words, “Failure and success became unimportant.” As one contributor on sina.com remarked after the actress’s death, “Who will bury the flowers now that the most gracious flower has left us?” • I know not why my heart’s so strangely sad, • Half grieving for the spring and yet half glad: • Glad that it came: grieved it so soon was spent. • So soft it came, so silently it went! • Can I, that these flowers’ obsequies attend • Divine how soon or late my life will end? • Let others laugh flower burial to see • Another year who will be burying me?5 David Robinson is honorary senior lecturer, King’s College London, London SE1 3QD
[email protected] Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure. pdf (available on request from the author) and declares: (1) no financial support for the submitted work from anyone other than their employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) no non-financial interests that may be relevant to the submitted work. Provenance and peer review: Not commissioned; externally peer reviewed. 1
De Bruxelles S. “Kylie effect” sends women to breastscreening clinics. Times 2005 Oct 27. 2 Twine C, Barthelmes L, Gately CA. Kylie Minogue’s breast cancer: effects on referrals to a rapid access breast clinic in the UK. Breast 2006;15:667-9. 3 Boseley S. Jade Goody: celebrity’s fatal illness changed cervical cancer attitudes. Guardian 2009 Mar 22. 4 Tsao Hsueh-Chin, Kao Ngo. A dream of red mansions [Translated by Yang Hsien-Yi, Gladys Yang]. Foreign Languages Press, 1978. 5 Cao Xueqin, Gao E. The story of the stone. A Chinese novel in five volumes. [Translated by Hawkes D, Minford J]. Penguin Books, 1986. 6 Actress’ death a cancer warning. Today Morning Express 2007 May 19. Cite this as: BMJ 2009;339:b4932
BMJ | 19-26 december 2009 | Volume 339
afterlife
Silent virtuous Taiwanese teachers Steven C Lin, Julia Hsu, and Victoria Y Fan describe how a dissection course in Taiwan has inspired people to donate their bodies to science, an otherwise culturally avoided gesture in the East
D
issection is a core component of gross anatomy in medical education worldwide. Human dissection provides an opportunity to learn about the human body in three dimensions and, more recently, a chance to introduce medical students to humanistic approaches to confronting death.1 2 At least two challenges exist in creating and offering a successful dissection course. The first is having sufficient numbers of people donate their bodies. In Taiwanese society, there is a belief that cadavers should not be disturbed after death.3 People have been unwilling, therefore, to donate their bodies for medical purposes that require that their bodies be handled after death, leading to cadaver shortages. The second challenge is ensuring that students treat cadavers with due respect and thereby develop humanistic values, which may prove useful in coping with stressful emotions.4 5 We describe how the dissection course at Tzu Chi College of Medicine has navigated around these cultural concerns surrounding death, to
Beginning the dissection class, students show their respect by bowing to the “great body teacher”
1438
the benefit of medical students, body donors, and their families. We analyse the humanistic effects of this course on students, as well as on donors and their families, by drawing on examples of participant observation and students’ reflections in Chinese language literature.6 We suggest that the design of this curriculum fosters accountability and offers inspiration that may have otherwise been omitted through cadaver anonymity. Tzu Chi Foundation Tzu Chi Foundation was created in 1966 in Taiwan by Dharma Master Cheng Yen. Tzu Chi means “compassion relief” in Chinese. Buddhist Tzu Chi General Hospital was established in 1986 to address the poor access to health care in the rural eastern coast of Taiwan. The foundation established Tzu Chi College of Medicine in 1994 to train and retain medical students for the local community. Since receiving its first donor in 1995, Tzu Chi College of Medicine has implemented a dissection curriculum where only cadavers of voluntary,
A donor’s family member and a student serve as coffin bearers, followed by Tzu Chi commissioners. Together, they accompany the donor to the cremation site
non-anonymous donors are used to teach anatomy. The course has inspired many individuals in the community to bequeath their bodies and become highly respected “great body teachers” or “silent virtuous teachers.” This educational approach and cadaver donation system has resulted in an excess of donations. Today, six of the 12 medical schools in Taiwan receive cadavers from Tzu Chi College of Medicine, provided that they also abide by Tzu Chi philosophies and the same anatomy curriculum. Dissection course and ceremonies The anatomy course is mandatory during the third year of study and has four key features. Firstly, it encourages reflection on issues related to confronting life and death. The main concept is that one’s body can be used meaningfully after death, in this case through donation to serve as a “great body teacher” and instruct medical students who, in turn, are expected to serve and benefit society. Secondly, the title of “great body teachers” motivates donors to take the role of highly revered teachers of future doctors. One enlisted donor spoke to a class of anatomy students one year before passing away, saying that he would allow students to make wrong incisions on his body so they can learn and prevent future errors on a live patient. Thirdly, through reverent Buddhist rituals and reflection in the presence of donor family members, students cultivate qualities of gratitude, respect, and love that help alleviate fear, stress, anxiety, and other emotions that may arise when confronting death. Fourthly, medical students gain experience in nurturing the doctor-patient relationship by meeting the donors’ family members and, sometimes, future donors. This non-anonymous donation BMJ | 19-26 december 2009 | Volume 339
Afterlife
process helps foster accountability and ensures that bodies are treated with dignity. Pre-course activities Learning begins before the course officially commences. Students start by learning about the donors’ lives through home visits to the donors’ families. In rare cases, students are able to meet terminally ill donors before their death and form relationships during interviews. Next, a memorial blessing led by Buddhist nuns is held for donor families and students. During this memorial ceremony, four medical students and the donor’s family members stand on the two sides of the anatomy table where the body is placed. Under peaceful Buddhist chanting, students open the cover with humility and respect for the donors, bowing both to the body and then to the donors’ family members. Dissection course Following the memorial ceremony, the dissection laboratory commences. The school collects pictures and stories about the donors and displays them next to the relevant anatomy table and in the hallway for students to read. It is common for students to refer to the body as the “teacher,” because each class begins with students respectfully and humbly greeting the cadaver. One student says, “Thinking back to the first class, the professor told us that we should treat every ‘teaching body’ on the anatomy table as our teacher. So, I have developed a habit of telling my great body teacher every day, ‘Good morning, I have to trouble you again today to learn’ and ‘Thank you, teacher’ at the beginning and end of each class.”7 Concluding ceremonies and reflection At the end of the semester, students carefully sew
the skin pieces back together to ensure that a whole body is available for final rites. Each student prepares a letter with their reflections, and these are presented to the donors along with a floral bouquet. At the cremation ceremony, students, respective family members, and volunteers from Tzu Chi Foundation participate as coffin bearers for the teachers . Following cremation, final ceremonies are held and ashes are placed in urns and kept in the Great Body Teacher Memorial Hall on Tzu Chi College of Medicine campus. It is customary in Taiwanese culture to keep ashes and urns in temples or monasteries, not in people’s homes. The hall is open to the public, many of whom become inspired to be “silent virtuous teachers” of medical students. Effects on students and donors Medical students develop a relationship with their cadaver (“teacher”) by meeting family members in person, which nurtures a sense of responsibility and compassion within students. One student reflected thus on the student-donorfamily relationship: “When family members came to see their deceased relatives, [I] realised that we were dealing with not just a teaching tool. A tool is lifeless and has no feelings; but teaching bodies are different . . . when we cut into the body of a donor, the cut also reaches the heart of his family member. It is the hope that we can benefit and learn from all this that comforts the donor’s family.”8 Moreover, after developing relationships with students and participating in the pre-dissection memorial ceremony, donors’ families are more assured that bodies are treated with dignity. The actual dissection course lets students connect their “teachers” to their biographical profile, which rests at the dissection table to serve as a constant reminder of the underlying human story. This custom also promotes mindfulness of the teacher’s life experiences that may manifest physically. Meeting donors and learning about their lives fosters humanistic values in students, such as gratitude and respect in light of the donors’ selfless giving. Death and confronting death may at times be emotionally and psychologically challenging for
BMJ | 19-26 december 2009 | Volume 339
medical students; however, fostering compassion toward donors and their families might help students cope more effectively. Letter writing allows students to direct private and reflective thoughts towards their teachers. In one letter for the concluding ceremony, a student wrote: “Learning about you reveals your personality, making us feel closer to you. We feel as if we have become a part of your past life, sharing the same sorrows and joys, as if we are family members and friends, too.”8 The concluding burial ceremony provides an additional opportunity for students to interact with donors’ families. This event enables donor families and students to support each other in the mourning process, but with mutual respect, gratitude, and humility. Conclusions Although quantitative assessment of this approach to human dissection has not been conducted, the overall impressions from student and donor family reflections are positive: many students develop a deeper sense of respect for themselves, other students, and the cadavers. Students cultivate and integrate humanistic values into their training through positive interactions with donors and their families, by learning the human story of their “teachers,” and by taking part in culturally appropriate ceremonies. These aspects could be incorporated into dissection courses at other medical schools in different countries, although the mechanisms and success of such changes will differ depending on cultural context. Furthermore, prospective donors are well acquainted with, if not inspired by, the educational approach and teaching process at Tzu Chi College of Medicine, which suggests that information about cadaver use could increase donations. This paper adds to existing literature on implementation of dissection laboratories in an Asian Buddhist context, the most prominent example being in Thailand.9 Future research may study the long term effects of humanism on quality of patient care and on the feasibility of cross cultural adoption of aspects of this anatomy curriculum. Links • Tzu Chi Foundation (www.tzuchi.org) • Tzu Chi University (http://eng.tcu.edu.tw) • Buddhist Tzu Chi General Hospital (www.tzuchi. com.tw/tzuchi_en/) Steven C Lin doctor of medicine, Boston University School of Medicine, Boston MA 02118, USA Julia Hsu chair of the department of medical humanities, Tzu Chi College of Medicine, Hualien, Taiwan, Republic of China; Buddhist Tzu Chi General Hospital, Hualien, Taiwan, Republic of China
[email protected] Victoria Y Fan doctor of science candidate, Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA Competing interests: None declared. References are in the version on bmj.com Cite this as: BMJ 2009;339:b5001 1439
professional matters
Brain maps
Management hatred centre Externalising blame and stress nucleus
S Stress-boredom balance region
Accepting blame cell
Accurate time keeping cell
B Bollocking juniors region
Patients
Ego
-ve
Nurses Ego feeding centre Society Ambition region
Inhibitory neurone
SN Getting people to do your reasearch, admin, jobs, Paranoia etc, centre centre
Professional jealousy region
Anaesthetists
Operating department assistant-scrub nurse preference centre
ODA
Appreciation of anaesthetic skills ribosome Self doubt cell
SURGICAL BRAIN
No surgical equivalent Coffee centre
Cancellation centre
Eccentricity tumour (slow but relentless growth) Ego
Waiting to finish early nucleus
Telling self-denigratory stories region
Operating department assistant-scrub nurse preference centre
Ambition cell
SN Clock watching region (very accurate)
ODA
B Stress-boredom balance region
Looking Sudoku nucleus down (previously nurses’ tops Crossword region centre) (mainly male)
S
Private practice jealousy centre (can be very large)
Interest in ‘patients as people’ molecule
ANAESTHETIC BRAIN
BMJ | 19-26 december 2009 | Volume 339
CLAUDIA BENTLEY
Lawrence Caldicott, consultant anaesthetist, St James’s Hospital, Leeds LS9 7TF
[email protected] Provenance and peer review: Not commissioned; externally peer reviewed.
1441
professional matters
Wards of the roses With increasing numbers of hospitals banning bedside flowers from wards, Giskin Day and Naiome Carter investigate the pros and cons of floral bouquets
C
ut flowers form an important part of rituals surrounding celebration and consolation in a variety of cultures. Blooms are brought to the bedsides of the sick as tokens of care, but concerns about infection control have caused many hospital wards in the UK to ban, or at least discourage, bedside bouquets. Is this anxiety justified? What do patients feel about flower policies? We talked to patients and staff at the Royal Brompton Hospital and the Chelsea and Westminster Hospital about their attitudes to flowers. Stemming infection? Most hospitals have longstanding and uncontroversial policies of not permitting flowers in high dependency units. Press reports of flowers also being banned from general wards started appearing in 1996, when an Aberdeen hospital introduced a “no flowers” policy on an orthopaedic ward.1 The impetus behind the trend was that hospitals needed to show they were taking hospital acquired infections seriously. Banning flowers was a visible sign that bedside protocols were being revised. Hospitals tended to justify their actions by claiming that flower water harboured potentially deadly bacteria. Indeed, a 1973 Good flower guide Check that a particular ward accepts flowers before you send them If you are a regular visitor, take responsibility for changing the water If a friend is in hospital for a short stay, have the flowers sent to his or her home, as carrying and transporting bouquets can be an added complication to leaving hospital Bouquets are more likely to be accepted if they are • Not too big and unwieldy • Arranged in florists’ foam rather than in a glass vase or in no vase at all • On a firm base that is unlikely to tip over • Composed of flowers that do not shed pollen • Not too heavily scented
1442
study had found that flower water contained high counts of bacteria.2 However, subsequent research found that there was no evidence that flower water has ever caused hospital acquired infection,3 and the authors of one study concluded, “Banning flowers is not popular with the public and is unnecessary according to the evidence available.”4 Yet hospitals continue to introduce “no flower” policies, in spite of the Department of Health acknowledging in 2007 that it was “not aware of any instance of health care associated infection being traced to cut flowers in the hospital ward setting.”5 Other negative effects have been ascribed to hospital flowers. In the late 1900s it was common to remove flowers from bedsides at night as there was a widespread belief that the blooms competed for patients’ oxygen. But this was dismissed as a myth when studies showed that the impact of flowers on air composition in wards was negligible and did not justify the labour involved in moving flowers to and fro.6 A blooming nuisance Hospitals introducing “no flower” policies have met with local resistance. Recently Southend University Hospital imposed a blanket ban on flowers, in spite of intense lobbying from the local press and a campaign by James Duddridge, the MP for Rochford and Southend West. The hospital claimed its own survey found that patients supported the policy, on the grounds that flowers posed a health and safety risk because of high tech medical equipment around bedsides.7 However, as Humphreys points out, “Accidents arising from spilled water or broken vases are just as likely to occur with crockery containing drinks or food as with vases or jugs containing fresh flowers.”8 A study by Gould et al found that 80% of 39 nurses interviewed from a wide range of clinical settings were not in favour of flowers. They found some evidence that this attitude was related to the amount of work generated, with infection and other risks used to justify it.9 Indeed, interviews we conducted with staff at the Royal Brompton Hospital and the Chelsea and Westminster Hospital confirmed that
staff were more concerned about the practical implications of managing flowers than risks of infection. At the Chelsea and Westminster, senior staff nurse May Wesley said, “I love flowers myself, but they can be a hazard at the bedside.” She told us that the biggest problem was curtains catching on vases, sending them crashing to the ground in a shower of water and glass. “We’re lucky to have wide windowsills though, where flowers can be appreciated by everyone on the ward rather than having them on bedside lockers where they get in the way.” At the Royal Brompton Hospital, charge nurse Dermot Richards-Scully is adamantly opposed to the floral offerings of visitors. “I hate them,” he says. “My staff don’t have time to change stagnant water; spillage is responsible for slips, trips, and falls; and they cause hay fever.” If visitors turn up with an armful of flowers, RichardsScully politely asks them to take their flowers home. “The trust guidance specifies that flowers should be avoided in critical care areas, but we have wounds on our wards as well.” Procedures for dealing with flowers tend to vary from ward to ward. Some wards we visited had a cupboard full of vases, usually donated by patients. Often healthcare assistants were responsible for flower maintenance. Occasionally wards were fortunate to have hospital volunteers who helped with changing water, although these arrangements were often ad hoc. Other wards made no provision for flowers, and some patients resorted to using their water jugs as vases. BMJ | 19-26 december 2009 | Volume 339
professional matters
john shelley
flowers on the wards foretold death—Theresa told us that lilies tend to be avoided for their funereal connotations, “and it is also not advisable to give bouquets that are too large or that include flowers that shed lots of pollen.” Patricia Law, a GP and keen gardener, feels that choosing flowers is a very personal process: “When I cut flowers from my garden to give to a friend, I try to match the flowers to the person. When someone is critically ill, it’s often hard to know what to say. By giving them flowers or a cutting from your garden, you are letting them know that you are thinking of them.” Dr Law points out significantly fewer postoperative analgesics; that flowers take us back to our elemental conhad reduced systolic blood pressure and heart nections with nature. This can be comforting in rate; lower ratings of pain, anxiety, and fatigue; a hospital environment in which we are ineviand had more positive feelings than patients in tably reminded of our own mortality. the control group.11 Flowers and herbs have been used as Men are usually the givers rather than the remedies in the earliest hospitals, and as a receivers of flowers, but sometimes a stay means of cheering up the hospital environment in hospital is a good excuse to reciprocate. for at least 200 years. It seems remarkable that Haviland-Jones et al found that flowers have flowers still tend to be treated in an ad hoc fashimmediate and long ion in hospitals. The term effects on emo- Flowers have immediate and long design and arrangetional reactions, mood, term effects on emotional reactions, ment of most wards social behaviours, and mood, social behaviours, and memory make little or no provimemory for men and for men and women alike sion for flowers. Surely women alike.10 Robbedside lockers could ert Orbach at the Chelsea and Westminster be better designed to hold vases in such a way Hospital, recovering from knee surgery, was as to prevent spillages? Hospital art programmes delighted to receive two bouquets of chrysanhave done a great deal to transform corridors themums. “I’m a romantic at heart,” he said, and waiting areas, but wards tend to remain “and I like to give flowers, so it is very nice to frenetic environments for staff, but passive receive them.” He felt they had enhanced his and monotonous ones for patients. Although experience of his hospital stay. flowers undoubtedly can be a time consuming nuisance, the giving and receiving of flowers is Making arrangements a culturally important transaction. Hospitals Florists need to be aware of the practical are humane places, and, as John Ruskin said, implications of providing flowers for patients. “Flowers seem intended for the solace of ordiTheresa Johansson, florist at the Flower Stand nary humanity.”12 in Chelsea, often provides bouquets for visitors Giskin Day course director, medical humanities, Imperial College London, London SW7 2AZ
[email protected] to the several hospitals that are within walking Naiome Carter medical student, Imperial College London, distance of her stall. “People tend to ask for London SW7 2AZ bright and cheerful arrangements,” she says. References can be found on bmj.com “Sunflowers, gerberas, and dahlias are always Competing interests: None declared. popular.” Although many of the Victorian Patient and staff consent obtained. superstitions are no longer widely observed— Cite this as: BMJ 2009;339:b5257 for example, that bouquets of red and white See EDITORIAL, p 1388
Brightening effect On private wards, staff tended to be more receptive to flowers. Sister Susan Bunce, in charge of the Sir Reginald Wilson ward at the Royal Brompton Hospital, said, “We welcome flowers in patients’ rooms, as long as there are not too many, and they are not too smelly.” Unlike the other wards we encountered, here it was part of the cleaners’ jobs to change the water. “Maintaining flowers doesn’t take up any nursing time, and they have a positive effect on the patients,” says Sister Bunce. “Patients here have the luxury of space so flowers rarely get in the way.” We visited Mandana Tew, who was recovering from open heart surgery. At her bedside were some African violets and bright begonias. She invited us to take a peek into her bathroom, and there, floating in the bath, were more than a dozen long stemmed, apricot coloured roses. “I keep them in a cool bath during the day, and they stay fresh,” she explained. A keen gardener, Mrs Tew is enthusiastic about the effects her flowers have had on maintaining a cheerful atmosphere: “My flowers smile at me and make me feel better.” Certainly, Mrs Tew and many other patients smile back at their flowers. Haviland-Jones et al found that flowers presented to women always elicited the Duchenne or true smile (which requires zygomatic muscle activity as well as orbicularis oris movement) and reports of positive moods three days later.10 Another study used a randomised clinical trial of 90 patients to measure therapeutic effects of plants. Patients in hospital rooms with plants and flowers needed
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Selling patients The way hospital departments “sell” patients to each other has been parodied but seldom studied. Peter Nugus, Jackie Bridges, and Jeffrey Braithwaite explore the rules of the game “Since…gomers [Get Out of My Emergency Room] don’t die…the tern [intern] had to find other ways to turf them…The problem with the turf was that the patient might bounce, i.e. get turfed back…The secret of the professional turf that did not bounce, said the Fatman [a supervising Resident], was the buff…‘Because you gotta always remember: you’re not the only one trying to turf. Every tern and resident in the House of God is lying awake at night thinking how to buff and turf these gomers somewhere else.” “‘[That doctor’s] so scared of missing something by sending the patient back home that he admits them all. He’s a sieve… he lets everyone through…Be a wall. Don’t let anyone in.’…A mind-boggling thought: the delivery of medical care consisted of buffing and turfing the seeker of care to somewhere else. The revolving door with that eternally revolving door always waiting in the end.”1
Introduction Everyone’s got something to sell. Retailers sell products. Workers sell their labour and skills. Everyone sells their status and knowledge; academics and clinicians are prone to this. Emergency clinicians sell patients. Why? Emergency departments the world over are under pressure to diagnose and treat patients efficiently, and move them on as quickly as possible.2 There are always new patients arriving in the queue. Who’s the buyer? The rest of the hospital. In the UK, in particular, GPs package patients for the hospital, too. The novel House of God by Samuel Shem1 satirises the games and strategies that characterise the transfer of patients. With similar irony, Innes3 wrote about “Successful hospitalisation of patients with no discernible pathology.” Innes prescribed 11 “admission techniques” variously appropriate depending on the particular type of “difficult consultant” 1444
encountered. So, the concept of selling patients has been parodied. Studies have examined case shaping for organisational relevance4‑6; patient disposals7; interdepartmental identity and communication8; mutual alignment of goals in referring patients9; and how consumers communicate emergencies.10 We wondered why the game of selling to, from, or within the hospital had not been seriously studied.
Methods The way to understand behaviours as they happen is to observe them and the people who enact them.11‑13 This study draws on observations and interviews in two tertiary referral hospitals in Sydney, Australia, from a larger study examining the organisational work of emergency clinicians. We examined interactions between and within departments, drawing on structured observations and staff experiences derived from 28 semi-structured interviews that were audio-recorded and transcribed. Nurses and doctors from the emergency departments and four inpatient departments across the two hospitals were interviewed. Observations included accompanying junior, mid ranked, and senior emergency doctors and emergency nurses for a full shift each in each emergency department, comprising 24 full shifts and about 110 hours of structured observation, generating approximately 800 pages of field notes (box). Data were categorised in an inductive, grounded process,14 in which themes were compared and contrasted in a series of cycles to produce interpretations.15 16 The core analytical codes of “selling” or “mutual persuasion” were distilled, and exemplified below. Findings Telling and selling Selling emergency patients involves sorting
them into categories appropriate for potential inpatient admission. Patients admitted to the hospital are ultimately transferred to a specialty ward in the hospital if they require more than 24 hours in hospital. To transfer the medical care of the patient out of the emergency department, emergency doctors need to persuade an inpatient medical or surgical team to admit the patient formally under the care of their department. In the following excerpt a registrar, an intern, and a nursing unit manager (team Coordinator, TC) discuss which inpatient team to approach for review, telling, and selling: Reg [registrar]: “What’s her age?” Intern: “72. How old does she have to be to go to gerries [geriatrics]?” (looking it up in a booklet). TC: “It’s a bit soft. You mightn’t sell them.” Reg: “Gastro’d [gastroenterology] be even better” (JDB: 18).1 This exchange demonstrates that one of the roles of emergency clinicians is to decide, from a range of specialty teams and departments, where and under whose care to transfer the patient. They have to figure out who is most likely to consummate the deal and purchase the product. The centrality of this activity was inadvertently demonstrated to the first author BMJ | 19-26 december 2009 | Volume 339
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rob white
Game playing and strategies to sell things to others are ubiquitous human phenomena. There are elaborate clinical and organisational pressures on clinicians to discharge or transfer patients
by an emergency registrar: Emergency registrar (to researcher): “Are you a med reg [medical registrar]?” Researcher: “No, I’m not.” Registrar: “Oh well, I won’t try and sell you a patient” (SDA2: 30). Another registrar noted to the observing researcher that “the GP patients were well packaged today” (MDB1: 37). This meant that the patients sent to the emergency department by GPs were presented using a clear and well crafted narrative of the symptoms and potential for inpatient admission. Packaging emergency department patients involves recognition of the need to advertise patients and market them to inpatient teams. A medical ward round in one of the emergency departments typically focused on inpatient admissions. A resident, referring to a particular inpatient service, said: “[They’re] a bit of a wall.” An emergency staff specialist responded: “Good luck.” Other doctors laughed. In a field interview after the shift the registrar, citing terms from House of God, explained that a “wall” asks a lot of questions and is reluctant to admit patients even when the relevance of the condition to their specialty is “obvious.” She believed that “sieves” were very rare (MDA2: 42). Similarly, an inpatient registrar was in the emergency department, asking other registrars from other inpatient
teams to review his patients: Inpatient registrar: “I’m selling a lot of patients.” Emergency staff specialist: “Number two’s getting a lot better.” Inpatient registrar: “That’s good. Hopefully by the time I get to him he’ll be ready to go home” … Emergency registrar (chuckles): “[You’re] turfing to [each other]!” (MDB1: 26).
Teaching the new sales force The need to progress patients’ journeys makes patient marketing an inherent part of emergency department work, and part of the craft of emergency medicine. Emergency interns often have difficulty persuading inpatient team doctors to become involved in the care of emergency department patients. They often fail to appeal to the organ-specific requirements of doctors representing particular inpatient teams. Frequently, interns described at length the history of the patient, which did not provoke a commitment from the inpatient registrar to become engaged in the sale. There are hard lessons to be learnt in fulfilling the needs of inpatient teams. Selling patients usually requires minimising and maximising various aspects of the case to target a particular medical or surgical specialty. The excerpt below involved a call made by an emergency intern to an after-hours medical registrar. The intern’s supervising consultant listened eagerly. The
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responses of the registrar and the consultant epitomised the technique of persuasion that emergency doctors are required to learn: Intern to researcher: “I’ll ring the med reg [medical registrar]”. Phoned: “Hi, it’s ‘Trudy’ here from emergency. I have a patient that needs admitting…He’s got a history of acute appendicitis [Consultant behind—looks exasperated]…OK. Bye.” [Consultant]: “What did he say?” Intern: “He said call the surg reg.” [Consultant]: “Of course he did. You don’t tell him he’s got a history of appendicitis. That’s an easy bounce straight to surgery” (FNA: 185). The emergency specialist was explicitly teaching the intern to package the patient into an acceptable category to suit the particular sub-specialty. The game was to use marketing techniques on those whom they wished to persuade.
Discerning customers The responses of receiving doctors combined resistance and on-selling. An after-hours medical registrar explained to the observing researcher his expectations as a receiving doctor: “Emergency doctors have one of two philosophies: the ‘us versus them’ philosophy and the ‘you need to help 1445
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us because you provide specialty care’ philosophy. The first one never works. That’s when emergency doctors say, basically, ‘You must take the patient.’ The second approach is to say: ‘Here’s the evidence.’ Selling is the proper way—not demanding. The burden of proof is on emergency. They have to prove that the patient is worthy of your care. They have to ‘buff’ the patient [another House of God metaphor] to make it look good. I’ve been told they lie in this [emergency department]. I’ve never experienced that, but I have had [the message] distorted inadvertently…It’s normal to expect intervention but please do it properly… Give good info and give the right info that adds up to my specialty…You can’t cry wolf” (TCB2: 24-7). A cardiology registrar, in a field interview, explained the apparent reluctance of receiving doctors to become involved: “We’re overloaded. I mean, I’m a human being…We’re just so…short of time what are you going to do? An older person with a heart problem?...You try not to come down unless you’re convinced there’s a good chance it’s one of ours…A young person with a heart problem—now that’s interesting! I’m just being honest” (Cardiology registrar, Interview 81). An aged care registrar acknowledged that they were sometimes in a similar position to emergency doctors. After criticising emergency doctors the registrar said: “But you know I do the same thing. When I ring [the consultant in charge] in the morning after a night shift, or when I ring the boss on an evening shift, if I said that they’ve got a primarily respiratory problem, I’ll tell them a primarily respiratory story and then if they’ve got other problems as well you sort of downplay the other problems and tell them the respiratory problems. Everyone does it” (Aged care registrar, Interview 21). That everyone does it suggests that marketing and packaging patients might be a dimension to clinical care that needs to be taken seriously. But it’s not in any undergraduate or postgraduate teaching programme of which we are aware.
Discussion and conclusion Selling patients—packaging and marketing them—is an under recognised component of clinical work. Is this life imitating art or art imitating life? Shem, a psychiatrist, parodied much about the lot of young doctors. As 1446
How excerpts are coded Interview and observational field note excerpts are coded according to the primary participant being observed or recorded, whether a senior doctor (staff specialist) (SD), junior doctor (intern) (JD), team coordinator (nursing unit manager) (TC) or senior nurse (SN). FN signifies general field notes observed in unstructured observations. References also indicate whether the data were derived from Hospital A or Hospital B, which of the first or second shifts contributed the data in the case of structured observations, and the page number of the original field notes in which those particular data were recorded. For instance, “SNB2: 21” indicates that the excerpt of evidence was taken from page 21 of the field notes recorded during the second shift of the senior nurse of Hospital B. Names of participants have been changed to protect their identities. satire, his book trades on exaggeration. Our study shows that selling does occur, and that concepts about marketing and knowing the rules of “the game” are integral to clinical work. Game playing and strategies to sell things to others are ubiquitous human phenomena. There are elaborate clinical and organisational pressures on clinicians to discharge or transfer patients, such as the “four hour rule” in the UK.17 Clearly, the policy and organisational environments influence clinical practice. Selling may be widespread, including GPs selling patients to hospitals. Undoubtedly, they are mediated by knowledge, skills, seniority, experience, and interpersonal relationships. Different hospital departments provide specialised services. It might not be a bad thing for clinicians to defend the boundaries of their department and put their interdepartmental colleagues to the test to see that patient transfers are appropriate. Selling strategies by well intentioned doctors might work well most of the time, because they are designed to ensure that patients receive the right care from the most relevant team at the right time. Some patients might be transferred on the basis of quality of selling rather than patient need. How will we know? Bringing the politics of patient journeys to the surface might engender clarity, as might fair bargaining practices.18 The rules should be out in the open.19 One troublesome thing is that such skills are learned on the job rather than explicitly taught, with the benefits of business school research. Might we be only half jesting when we ask if there is a place for teaching Selling, Marketing and Packaging 101 to future emergency department physicians and GPs, and Negotiating, Resisting, and Reselling 101 to everyone else?
Peter Nugus research fellow, Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
[email protected] Jackie Bridges senior research fellow, School of Community and Health Sciences, City University London, London EC1V 0HB Jeffrey Braithwaite professor and director, Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia Contributors: PN, a sociologist of health care, conducted his PhD research on the organisational work of emergency department clinicians from which this paper was produced. JB is a registered nurse and has considerable experience in researching emergency departments and the impact of organisational processes on patient care. JB is an international leader in health services research, and in researching and publishing on health institutional structures and processes. He also supervised PN’s PhD. All three authors were involved in the design, planning, and writing of the paper. PN is the guarantor. Funding: The project was funded by the Clinical Excellence Commission. The only vested interest of the study funder was for the conduct of independent research on matters relating to patient safety. The funder had no role in directing the specific clinical or health system research topic within or the direction of the findings. Competing interests: None declared. Ethical approval: Human research ethics committee approval was obtained from the University of New South Wales and the two hospitals in which the research was conducted. 1 2
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Shem S. The house of god. Bodley Head, 1978. Nugus P, Braithwaite J. The dynamic interaction of quality and efficiency in the Emergency department: squaring the circle? Soc Sci Med 2009; published online 24 November (doi:10.1016/j.socscimed.2009.11.001). Innes G. Successful hospitalization of patients with no discernible pathology. Canad J Emerg Med 2000;2:47-51. Emerson RM. Case processing and inter-organizational knowledge: detecting the ‘real reasons’ for referrals. Social Problems 1991;38:198-212. Jean YA. Inclusive intake screening: Shaping medical problems into specialist-appropriate referrals. Sociol Health Ill 2004;26:385-410. Eisenberg EM, Murphy AG, Sutcliffe K, Wears R, Schenkel S, Perry S, et al. Communication in emergency medicine: implications for patient safety. Commun Monogr 2005;72:390-413. Bloor M. Bishop Berkeley and the adenotonsillectomy enigma: an exploration of variation in the social construction of medical disposals. Sociology 1976;10:4361. Hewett DG, Watson BM, Gallois C, Ward M, Leggett BA. Intergroup communication between doctors: implications for quality of patient care. Soc Sci Med 2009;1732-40. Hartswood M, Proctor B, Rouncefield M, Slack R. Making the case in medical work: implications for the electronic medical record. Comp Support Coop Work 2003;12:24166. Whalen M, Zimmerman D. Describing trouble: practical epistemology in citizen calls to the police. Language in Society 1990;19:465-92. Strauss A, Fagerhaugh S, Suczek B, Wiener C. Social organization of medical work. University of Chicago Press, 1985. Sudnow D. Passing on: the social organization of dying. Prentice-Hall, 1967. Hammersley M. What’s wrong with ethnography? The myth of theoretical description. Sociology 1990;24;597615. Tesch R. Qualitative research: analysis types and software tools. Falmer Press, 1990. Hammersley M, Atkinson P. Ethnography: principles in practice. 2nd ed. Routledge, 1995. Ragin CC. Constructing social research: the unity and diversity of method. Pine Forge Press, 1994. Hughes G. Political issues in emergency medicine: the United Kingdom. Emerg Med Aust 2004;16:387-93. Salhani D, Coulter I. The politics of interprofessional working and the struggle for professional autonomy in nursing. Soc Sci Med 2009;68:1221-8. Merton RK. Some preliminaries to a sociology of medical education. In: Merton RK, Reader GG, Kendall PL, eds. The student-physician: introductory studies in the sociology of medical education. Harvard University Press, 1957:3-79.
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H-index pathology The h-index has quickly become the standard method by which medical schools judge the impact of medical researchers. Rob Horne, Keith Petrie, and Simon Wessely describe a cluster of potentially pathological behaviours associated with the index
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n 2005 Jorge Hirsch proposed such as seminars in cultural studies the h-index as a means of and general practice conferences. measuring the productivity and impact of a researcher.1 A h-indexism—Appointing people to More than h citations researcher’s h-index is deteracademic positions based on their mined by the highest number of h-index rather than the traditional papers they have published to factors of appearance, high school receive at least that many citations attended, or whether they are Chelsea Citations = papers = h-index (figure). So a scientist with an Football Club season ticket holders. h-index of 40 has written 40 papers that have received at least 40 citah-Cite—Self citation of a paper based tions. The h-index can be obtained solely on the fact that more citations through the subscription databases of this particular paper will raise the of Web of Science and Scopus, or author’s h-index.5‑7 This should not through using Publish or Perish be confused with general self citation3 Papers software, which is based on the where any one of an author’s papers is First h papers Google Scholar database, enabling shamelessly referred to in the author’s brave (or reckless) authors to check own article.8 9 Illustration of h-index calculation their own h-index. Although the h-index is not HAART (highly articulate angry without its drawbacks, it has quickly become catastrophic effect on career aspirations, proresponse to teaching)—Reaction exhibited the standard measure by which medical schools fessional standing, and sense of self. Often maniwhen, on the basis of a low h-index, the academic judge the value of academic staff.2 The process of fested in the short term by an explosive venting is “invited” by the head of department to make observing or assessing performance can influence of emotion, sometimes accompanied by fainting the provision of undergraduate teaching his or behaviour and the h-index is no exception. The (H-ysteria) followed by chronic psychosomatic her “core mission.” Not to be confused with highly increasing importance of citation rate as an index illness (post traumHatic stress disorder), and active antiretroviral therapy.10 of success has led to an increase in self citation occasionally by psycHosis (see below). (where the author’s earlier work is cited in their Dropping your h’s—Letting one’s h-index slip in new publication).3 We have also noted the emerPsycHosis—A delusional state in which the sufsocial company in order to boost social standing. gence of a range of socially undesirable behavferer perceives their h-index to be much higher Sometimes causing arguments with h-eretics who iours associated with the h-index. We outline than it really is and behaves accordingly (for question the validity of the index. For those with the behaviours and discuss their implications for example, with understated academic swagger). a low h-index, this can take the form of a h-istory medical researchers and practitioners. (story fabricated to explain a low h-score).
H-index behaviours Home-ophobia—Irrational hatred of people with similar names who may dilute or diminish your h-index. The name of this syndrome derives from the fact that having a less h-endowed namesake also reduces the likelihood of a Google search revealing the subject’s personal home page at the top of the search result. The fear of h-index dilution, coupled with home page obscurity within the Google search, creates the state of home-ophobia. Particularly prevalent among academics named Smith, Jones, Cohen, and Patel. H-bomb—Where disclosure or discovery of an individual’s h-index has an immediate,
Retaining a dignified aloofness to the h-index is difficult for those with scores of less than 30
Sometimes linked to a failure to appreciate the influence of having a common surname, it is, in this respect, the reverse of home-ophobia. Unlike home-ophobia, psycHosis can also affect people with uncommon surnames, who can succumb to the delusional belief that they have authored a Nature paper.4 One h-manship—Surrounding oneself with individuals with a lower h-index in order to boost self esteem. This may involve attending meetings which would ordinarily be avoided,
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Comment We believe that the cluster of behaviours described here has implications for medical researchers and practitioners. An awareness of the existence of these behaviours in others may help medical researchers to avoid any h-index linked professional embarrassment. However, retaining a dignified aloofness to the h-index is difficult for those with scores of less than 30. For this reason, researchers may also wish to increase their h-index as quickly as possible by publishing innovative work or through cunning self citation.11 There are also implications for medical practitioners. Beliefs12 and behaviour 13 can influence health and we anticipate that general 1447
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researchers may wish to increase their h-index as quickly as possible by publishing innovative work or through cunning self citation and specialist physicians will see a large increase in the incidence of h-index related presentations, perhaps taking on new psychosomatic forms like those discussed above.14 Some cases may be managed by education15 and cognitive behaviour therapy16 but many will require medication.17 Prescribing creates a further challenge because many h-index patients will not perceive themselves to be ill, and consequently doubt that they need medication, leading to nonadherence.18 Moreover, being academics, they are likely to be dissatisfied with standard information19 demanding more detailed explanations and discussion about the condition and treatment. There are also important considerations for medicine as an academic discipline. The h-index is typically calculated for an individual. However, it can also be applied to groups of researchers.20 21 It could, in future, be applied to compare the research contribution of medical specialties in a medical school or of medical schools in universities with implications for the wellbeing of deans and editors of medical journals. rob Horne professor of behavioural medicine, Centre for Behavioural Medicine, The School of Pharmacy, London WC1H 9JP
[email protected]
Keith J Petrie professor of health psychology Simon Wessely vice dean, institute of psychiatry, Department of Psychological Medicine, University of Auckland, New Zealand We thank Amy Whitehead (research administrator, Centre for Behavioural Medicine, School of Pharmacy, University of London) for help in preparing this manuscript and all the authors who have cited their papers. We also thank the reviewer for helpful comments and the suggestion that we should cite one of his papers in the article. competing interests: None declared. The h-indexes of the authors are 24 (RH), 26 (KJP), and 52 (SW). 1 2 3 4
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Hirsch JE. An index to quantify an individual’s scientific research output. Proc Natl Acad Sci USA 2005;102:16569-72. Ball P. Achievement index climbs the ranks. Nature 2007;448:737. Craddock N, O’Donovan M, Owen M. Words, words, words: introducing Selfcite 2.0—career enhancing software. BMJ 1996;313:1659-60. Giese B, Amaudrut J, Kohler AK, Spormann M, Wessely S. Direct observation of hole transfer through DNA by hopping between adenine bases and by tunnelling. Nature 2001;412:318-20. Wessely S, Hotopf M, Hull L, Ismail K, Nicolaou V, David A. Is recall of military hazards stable over time? Evidence from the Gulf War. Br J Psychiatry 2003;183:314-22. Petrie KJ, Broadbent EA, Kley N, Moss-Morris R, Horne R, Rief W. Worries about modernity predict symptom complaints after environmental pesticide spraying. Psychosom Med 2005;67:778-82. Cooper AF, Jackson G, Weinman J, Horne R. A qualitative study investigating patients’ beliefs about cardiac rehabilitation. J Clin Rehabil 2005;19:87-96. Petrie KJ, Wessely S. Getting well from water. BMJ 2004;329:1417-8. Horne R, Petrie K, Weinman J, Vincent R. Patients’ interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction 4310. Heart 2000;83:388-93. Horne R, Cooper V, Gellaitry G, Leake Date H, Fisher M. Patients’ perceptions of highly active antiretroviral
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therapy in relation to treatment uptake and adherence: the utility of the necessity—Concerns framework. J AIDS 2007;45:334-41. Page L, Petrie KJ, Wessely S. Psychosocial responses to environmental incidents: a review and proposed typology. J Psychosom Res 2006;60:413-22. Petrie KJ, Weinman J. Why illness perceptions matter. Clin Med 2006;6:536-9. Rubin GJ, Amlôt R, Page L, Wessely S. Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey. BMJ 2009 339:b2651. Petrie KJ, Wessely S. Modern worries, technological change, and medicine. BMJ 2002;324:690-1. Wessely S, Bryant RA, Greenberg N, Earnshaw M, Sharpley J, Hughes JH. Does psychoeducation help prevent post traumatic psychological distress? Psychiatry 2008;71:287-302. Kennedy T, Jones R, Darnley S, Seed P, Wessely S, Chalder T. Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial. BMJ 2005;331:435. Song F, Freemantle N, Sheldon TA, House A, Watson P, Long A, et al. Selective serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability. BMJ 1993;306:683-7. Horne R, Parham R, Driscoll R, Robinson A. Patients’ attitudes to medicines and adherence to maintenance treatment in inflammatory bowel disease [IBD]. Inflammatory Bowel Dis 2009;15:837-44. Horne R, Hankins M, Jenkins R. The satisfaction with information about medicines scale [SIMS]: a new measurement tool for audit and research. Quality Health Care 2001;10:135-40. Bornmann L, Daniel H-D. What do we know about the h index? J Am Soc Information Sci Technol 2007;58:1381-5. Bornmann L, Daniel H-D. Convergent validation of peer review decisions using the h index: Extent of and reasons for type I and type II errors. J Informetrics 2007;1:204-13.
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Christmas quiz: Answers The five figures combined show Christmas lunch.
1
Macroscopic: Two legs, two wings, weight 3 kg Microscopic: Abundant skeletal muscle fibres with their peripherally placed nuclei diagnosis: Christmas turkey comment: Ice crystal artefact reveals author as a user of frozen turkey Cite this as: BMJ 2009;339:b4983
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2
Macroscopic: A multilayered green, oval lump with a distinctive aroma Microscopic: A complex swirling arrangement of vegetable matter is seen diagnosis: Brussels sprout
3
Macroscopic: Cup shaped tan material 7×7×5 cm; crispy outer texture, soft inside; a liquid brown substance on the surface Microscopic: Amorphous material with alveolar-type spaces diagnosis: Yorkshire pudding
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Macroscopic: Multiple rounded balls of tan material with a varied texture Microscopic: A complex intermixture of vegetable matter, skeletal muscle, and fat diagnosis: Stuffing
Macroscopic: An elongated, tan coloured cylinder wrapped in dark red material. Microscopic: Two distinctive adjacent areas, with skeletal muscle surrounding amorphous material diagnosis: Sausage in bacon comment: Note the complete absence of muscle fibres from the sausage compared with the bacon.
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Evidence based merriment Medical humour has a long history, but is short on evidence, say David Isaacs and colleagues
T
Pilot study The Royal Flying Doctor Service funded a pilot study. Hospital staff completed a standardised questionnaire about the role of humour in their department. The department of surgery expressed an interest in side-splitting jokes. The ophthalmology department insisted that all patients should have a slit lamp examination for aqueous and vitreous humour. The gastroenterology department wanted to ban sick jokes and toilet humour. The allergy department warned of the hazards of severe joke allergy. At least one child has suffered a severe allergic reaction to a shaggy dog story, while cat allergy predisposes to cataplexy. However, the most feared condition is anaphylaxis to puns, which can only be treated with outrageously expensive adrenaline syringes, called Epipuns. The State Department of Allergy and Over-reaction has recommended that all children with pun anaphylaxis carry Epipuns and that jokes are banned from nursery schools. The child must also bring to school a letter from their parents guaranteeing that they have not been told any jokes at home in the last 24 hours. The hospital administration warned that black humour contravenes health department policy on racial discrimination and punchlines are forbidden under department guidelines on bullying in the workplace. Study design Doctors will be randomised to an intervention group who will tell random jokes to children on the paediatric wards or a self control group who will be asked to save their jokes for their own long suffering children at home. Here is a random joke. “Two cannibals ate a clown doctor. One cannibal asked the other, did that taste funny to you?” The responses of joke recipients will be screened. Their facial contours will be exam-
ROB WHITE
he ancient Greeks introduced the world to bodily fluids called the four humours. You would think that a philosophy based on blood, choler, phlegm, and melancholy was no laughing matter. What is the evidence that medical humour benefits staff or patients? We performed a systematic revue, but it was not funny. We propose a randomised controlled trial of medical humour.
ined for increases in creases. Mirth will be measured in grins per milli-titter, gigglebytes, or smiles per hour. Belly laughs are expressed in units called Hertz. Laughter delayed for greater than 30 seconds is not classified as humour. He who laughs last, thinks slowest.
Statistics The data will be massaged and tickled and subjected to a Student’s t-hee test with a funnel plot to see if the jokes come out funnelly. Ethics approval The proposed trial will be submitted to the Institutional Ethics and Deforestation Committee, which requires 47 double spaced, single sided copies of the trial protocol. The protocol must be on the ethics committee application form, which can be completed in less than a month by anyone with an IQ over 130 and
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advanced degrees in information technology and communication. The ethics form needs to be countersigned by the Head of Department, the Head of Department’s Head of Clinical Stream, the Clinical Superintendent, the Chief Executive Officer and the Minister for Health.
Conclusion We call for a randomised fairly controlled trial of humour. Humour is a serious matter and should not be taken lightly. David Isaacs clinical professor in paediatric infectious diseases, Children’s Hospital at Westmead and University of Sydney, Sydney, NSW 2145, Australia Stephen Isaacs consultant child psychiatrist, Waltham Forest Child and Family Consultation Service, London, UK Dominic Fitzgerald senior staff physician in respiratory medicine, Children’s Hospital at Westmead and University of Sydney, Sydney, NSW 2145, Australia Competing interests: None declared. Cite this as: BMJ 2009;339:b5098 1449
Professional matters
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