Oxford Medical School Gazette
Volume 60(2)
Below is the full text of OMSG 60(2), with references.
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Begins overleaf
Editorial
Welcome to the latest issue of the Oxford Medical School Gazette. The theme for this issue is
‘Stranger than Fiction’. This was chosen with the aim of inspiring our writers to explore the weird
and wonderful side of medicine, whilst still encouraging a wide variety of articles. They have not
disappointed us. Jonathon Best sets off to explore bizarre culture-bound syndromes from around
the globe (page 38), Benjamin Stewart delves into medical advances from the world of science
fiction (page 55), and Chris Deutsch discovers ‘penis captivus’: a condition direct from Oxford’s
greatest practical joker (page 51). On a rather different note, Annabel Christian investigates the
medicolegal angle of those who become murderers while they sleep (page 43), Charlotte Skinner
investigates the draw of the criminally insane (page 40).
Moving away from the theme, there are a variety of other articles to peruse and ponder. Roughly
a decade since they began, Benjamin Stewart takes stock of the various genome projects and
examines whether the vast amount of data harvested will deliver on the promises made (page 30).
Elizabeth Anscombe reports from the front line of cancer research, focussing on recent advances
and personalized therapy (page 34) and Matt Harris illustrates the power of non-verbal
communication in clinical practice (page 8). Looking to the past, Charis Demetriou takes a scenic
tour through 700 years of medicine in Oxford, visiting various landmarks around the city and
uncovering their secrets (page 52).
Staying with the focus close to home, Sophie James highlights the creation of the new Osler
House (page 72), while Jack Pottle reports on paediatric cardiac surgery at the John Radcliffe and
its implications for surgical training (page 6).
Regular readers of the Gazette will also notice the inclusion of a brand new peer review section in
this issue (page 62). This section showcases original research from medical schools across the
UK, giving students the opportunity to get their feet on the rungs of academic medical ladder.
From over forty submissions, we present two papers in this edition from the world of obstetrics
and gynaecology, focusing on endometrial cancer imaging and pre-eclampsia genetics
respectively. All papers published are reviewed by academics and senior clinicians in the relevant
area, and this is the standard we are looking to maintain. We hope the peer review section will
continue in future years, with a view to encouraging proactive research, both clinical and
laboratory-based, throughout UK medical schools. The Gazette is therefore not only the world’s
oldest medical school publication, but also the UK’s only peer reviewed medical student journal!
As the year draws to a close, our time as Gazette editors has come to an end, but we hope that our
successors will continue what we have begun. We have thoroughly enjoyed our time working on
the Gazette and would like to thank the medical school for providing us with the opportunity to
do so. Most importantly, we hope that you have enjoyed reading the last few editions of the
Gazette and trust you will continue to do so for many years to come.
The OMSG editors,
Jack Pottle
Matt Harris
Namrata Turaga
November 2010
Contents
Letters
3
Practice
Too good to be true? - Fraud in medical research
4
“Thrive or perish” - Mentoring and paediatric cardiac surgery at the John Radcliffe
6
Communication on the front line - Why GPs make the difference
8
An epitaph for eponyms - How to get an eponymous syndrome
10
“Push harder you silly woman!” - O&G in Karachi
12
Comment
What if everything you though you knew about AIDS was wrong?
15
For love or money - Prostitution and the law in the UK
18
Evidence-based resurrection - The truth behind religion
21
Review
Neuroethics and oxytocin - Professor J. Giordano discusses love and drugs
24
Maternal mortality - Have the Millennium Development Goals delivered for women?
27
Deciphering our genetic code - The history of the Human Genome Project
30
The enemy within - Current progress in cancer therapeutics
34
Frith Photography Prize
36
Spotlight
Culture-bound syndromes - Bizarre disorders from around the globe
38
Dangerous liaisons - Why women can’t resist the criminally insane
40
Sleep killing - Homicidal somnambulism and the parasomnias
43
Synaesthesia - The human cost of merging the senses
46
The colour blind doctor - I see trees of red, green roses too...
49
Timeline
Penis captivus - ...and other tales from Egerton Y. Davis
51
The creation of Oxford medicine - 700 years on the streets of Oxford
52
Science fiction medicine - The fate of inventions from the movies
55
Ondine’s curse - The story of congenital central hypoventilation syndrome
58
Peer Review
Placental gene expression, pre-eclampsia and growth restriction
62
3-D transvaginal ultrasound in endometrial cancer
66
Obituary
Dr Klaus Schiller
70
Back Pages
Osler Report 2010 - A year in Osler House
72
Tingewick Archives - An interview with outgoing Tingewick patron David Messer
74
Book reviews
76
Emergencies: Labour - How to deliver a baby. In an aeroplane.
77
Crossword
78
Medical records - Some of the strangest world records ever to have been broken
79
Letters to the editors
Re: Healthcare under siege, OMSG 60 (1)
Dear Editors,
It is a pity that such a politically biassed article as that by Messrs Abdel-Mannan and Mahmud
should appear under the imprimatur of an organ of the University of Oxford. To describe the
plight of the Gazans as a consequence of “collective punishment” by Israel is a travesty of the
facts.
Hamas are dedicated to the genocidal destruction of Israel and to this end have waged war from
within, and at great cost to, their own civilian population showering rockets and missiles on the
people of Israel. As an Islamist movement supported by Iran they are not at all interested in a
secular state of Palestine and killed 350 of their Fatah compatriots in their bloody takeover in
2007. The contrast of Gaza with the increasingly prosperous West Bank is something the authors
might perhaps have addressed. Thanks to the reduction in terrorism and violence due to Israel’s
security fence and coordination with better trained security forces of the Palestinian Authority,
there was in the West Bank in 2009, an increase of 8.5% in the GDP (it was only 1% up in Gaza)
and a 9% reduction in unemployment and this at a time of world economic recession.
The authors pay some lip service to the need for the Palestinians to get their house in order.
Unhappily for the Gazans, the Hamas agenda gives priority to the removal of Jews from “Muslim
lands” and to Islamic conquest. Their murder of four Israelis with the stated intention of derailing the face-to-face peace talks between the two sides says it all.
Yours sincerely,
Dr Barry Hoffbrand
Queen’s 1952
Right of reply from the authors
Dear Editors,
Dr Hoffbrand’s response is a typical example of the factual inadequacy of many of Israel’s
staunchest supporters. Despite what he might like to imply, the international community is
unanimous in its agreement that Israel’s flagrant and collective punishment of Gazans is illegal,
and nothing less.
We refer Dr Hoffbrand to institutions not in the business of fiction, namely the International
Committee of the Red Cross, Amnesty International and the United Nations. Their statements can
be found online [1-3]. If Dr Hoffbrand would like to take his complaint to these organisations, we
would be most eager to hear their responses.
Despite his enthusiasm, Dr Hoffbrand hasn’t engaged with any of the medical issues outlined in
our article, which has deliberately avoided partisanship and political leaning (for example, the
simple observation that Israel has had more than 220 UN resolutions condemning its abuse of its
neighbours). Rather than dealing with the ethical and legal implications of documented White
Phosphorous burns inflicted by the IDF on masses of civilians [4], Dr Hoffbrand has attempted to
undermine honest discussion of the human rights violations of Palestinians by portraying their
struggle as a religious crusade; a great disservice to 60 years of Palestine’s struggle for selfdetermination.
We, as medical students and future doctors, must be guided by intellectual honesty, and
compassion in the face of human suffering. In this vein, we commend the work of Physicians for
Human Rights – Israel, and refer our readership to their detailed reports on Gazan health
(www.phr.org.il) and Israel’s ongoing siege.We trust our readers will appreciate the facts for
what they are.
Sincerely,
Imran Mahmud and Omar Abdel-Mannan
References
1. International Committee of the Red Cross:
http://www.icrc.org/web/eng/siteeng0.nsf/htmlall/palestine-update-140610
2. United Nations:
http://www.unhchr.ch/huricane/huricane.nsf/0/9B63490FFCBE44E5C1257632004EA67B?opend
ocument
3. Amnesty International: Amnesty International:
http://www.amnesty.org/en/news-and-updates/suffocating-gaza-israeli-blockades-effectspalestinians-2010-06-01
4. The Lancet, White Phosphorous burns:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)608124/fulltext?version=printerFriendly
The editors will not be publishing any further correspondence on this topic.
Too good to be true?
Mary Denholm examines fraud in medical research
At the end of 2004 everything seemed to be working out perfectly for Korean stem cell researcher
Woo Suk Hwang. Named one of Time magazine’s ‘People Who Mattered 2004’, the magazine
described how he had proved that “human cloning is no longer science fiction, but a fact of life.”
[1] Earlier that year he had published a landmark paper in Science describing the successful
creation of human embryonic stem cells using somatic cells and eggs from a single female donor.
Another apparently incredible piece of research appeared in Science in June 2005, when he again
claimed to have created human embryonic stem cells, but this time using only human somatic
cells. Unfortunately for him, and for stem cell research, things began to unravel four months later
when he was accused of unethical conduct in sourcing his donor eggs. Buoyed for a while by his
enormous public support in Korea where he was a national hero, things ultimately came to a head
early in 2006 when Seoul University announced that all eleven of his stem cell lines, and both his
iconic papers, were completely fabricated. His papers were unconditionally retracted and the stem
cell world was left reeling, with the resulting paranoia about validity and reproducibility still felt
today, creating an air of pessimism and scepticism in an exciting field of research.
With stories such as Hwang’s and the saga surrounding MMR researcher Andrew Wakefield
receiving widespread media coverage, it could be tempting to think that these are isolated
incidents: freak happenings in unfortunately high-profile areas of research. Worryingly however,
this seems not to be the case [2]. A meta-analysis by Fanelli [3] reviewed the results of 18
surveys of scientists and medical professionals involved in research and, of 12,000 subjects,
found that approximately 15% knew of someone who had falsified, fabricated or altered data,
with 2% admitting they had done so themselves. Unfortunately, similar findings have been
reproduced several times in other surveys [4]. It seems those cases exposed are just the tip of the
iceberg; an uncomfortable idea for the scientific community [5] which relies heavily on trust.
But how do we know what is fraudulent or unethical, and what if you accuse the wrong person?
There are also notable instances of the latter, shattering research programmes and careers. At the
end of the 1990s, a clinical trial in Stoke-on–Trent was examining the role of continuous negative
extrathoracic pressure (CNEP) in paediatric respiratory support. The parents of one child in the
trial accused the researchers of misconduct and there followed a prolonged set of investigations
by several NHS bodies, the GMC and an official government report. Over ten years later, it was
concluded that the defendants in fact had no case to answer, the trial was in no way unethical and
the government report itself was flawed. However, this was too little, too late for the defendants
as the case against them had been spread throughout the media, accusing the trial of “killing
premature babies” and the researchers of offences including forging consent forms [6].
Even several years before the case of Hwang and the eventual resolution of the CNEP incident, it
was plain that better regulation of research was needed, not only to identify cases of fraud but to
make the process of flagging up concerns fair and structured. In 1997 the Committee on
Publication Ethics (COPE) was created by editors of several British journals with the intention of
providing advice to editors on dealing with suspected fraud and producing guidance on proper
and ethical practice. Its formation was particularly timely due to a scandal the previous year,
whereby two eminent London consultants, Malcolm Pearce and Geoffrey Chamberlain, produced
a case report detailing the successful reimplantation of an ectopic pregnancy with a resulting live
birth. Later exposed as totally fabricated, the subject of the case report being fictional, their
careers were ruined despite Chamberlain’s insistence that he hadn’t known what was in the report
despite his name being on it, so-called ‘gift authorship’.
COPE aims to target all forms of fraud, whether the more overt cases such as fabrications and
falsification or slightly ‘greyer’ issues such as gift authorship and authorship disputes. Whilst
COPE’s work is clearly thorough and their website full of clear and constructive algorithms for
spotting and dealing with possible fraud, it is largely aimed at journal editors. The first person to
ring the alarm bells in the case of Pearce and Chamberlain was a junior doctor, but as we all
know, standing up and pointing out flaws is often easier said than done. However, many of us
have been or will be involved in research either as medical students or in our future careers, so
what should we do if we suspect something is amiss? The National Academy of Sciences has
published a guide entitled On Being a Scientist, which contains helpful advice on many potential
hurdles, including choosing research groups, research on students, and ideas for how to deal with
any suspicions you may have. It also succinctly describes the principles of staying on the right
road, reminding us of the obligations of any researcher “....toward other researchers, toward
oneself, and toward the public…” [7].
For any potential project, check the background to the research and any work done before your
involvement. Is ethical approval needed and has it been obtained from the appropriate university
or regional committee? If you are unsure at any point, try to raise any doubts you have and don’t
be afraid to ask for help or advice from external sources, even if it’s simply for your own peace of
mind in the end. It might not be all bad news for those above either, with some observers
suggesting that tackling internal fraud can actually boost an institution’s reputation, despite the
initial headaches and embarrassment [8].
By bearing these principles in mind we can hope to maintain our share of the trust on which the
scientific research community relies.
Mary Denholm is a final year medical student at Jesus College
The author would like to thank Professor Margaret Rees, Linda Gough and COPE for their
encouragement in writing this article.
References
1. TIME magazine: People Who Mattered 2004 - Dr Hwang Woo Suk. 2004 [cited 2010];
Available from:
http://www.time.com/time/asia/2004/personoftheyear/people/hwang_woo_suk.html.
2. Moore R, Derry S, McQuay H. Fraud or flawed: adverse impact of fabricated or poor quality
research. Anaesthesia. 2010 Apr;65(4):327-30.
3. Fanelli D. How many scientists fabricate and falsify research? A systematic review and metaanalysis of survey data. PLoS One. 2009;4(5):e5738.
4. Titus S, Wells J, Rhoades L. Repairing research integrity. Nature. 2008 Jun;453(7198):980-2.
5. Solutions, not scapegoats. Nature. 2008 Jun;453(7198):957.
6. Hey E, Chalmers I. Mis-investigating alleged research misconduct can cause widespread,
unpredictable damage. J R Soc Med. 2010 Apr;103(4):133-8.
7. Committee on Science Engineering and Public Policy. On Being a Scientist - A guide to
responsible conduct in research. 3rd edition ed. USA: National Academy of Sciences; 2009.
8. Misconduct? It's all academic... Nature. 2007 Jan;445(7125):240-1.
“Thrive or perish”
What’s wrong with surgical training?
The concept of the surgical learning curve is not a new one. As a surgeon enters their trade, their
skills are minimal - they may know the theory but the practice is quite different. Because of this,
their surgical outcomes will (all things being equal) be worse than those of a more experienced
surgeon. As the surgeon progresses, he learns from his mistakes, becomes more proficient, and
the curve levels off. This curve is often taken as a necessary evil; every surgeon has to perform a
procedure for the first time. However, in the current era of transparency and patient choice, the
public tolerance of this learning curve has understandably diminished. I for one would rather have
my child’s surgery performed by a consultant than a registrar.
It has therefore become imperative to minimise the surgical learning curve. Indeed, there should
be “no learning curve as far as patient safety is concerned” [1]. The two key angles from which to
tackle this problem are training and mentoring. Training implies active teaching on surgical
techniques, both on-the-job and in theory, and covers the use of laparoscopic training, cadaveric
dissection and many other widely practiced methods [2]. Mentoring, however, goes much deeper.
It carries the implication of a relationship; the mentor and the mentee must work together to help
develop the mentee’s potential. It also involves trust between the two parties – the trust that
support will be provided where it is needed but that independence will still be encouraged.
Mentoring is repeatedly identified as the key to improving surgical learning. However, it is a
scarce commodity in surgical fields [3]. Why is this? Perhaps, as can be seen from the above
description, it is because mentoring is a rather fluffy concept. Surgeons generally don’t like fluffy
concepts. This is never truer than in paediatric cardiac surgery, where the technical challenges
and high-stakes outcomes tend to attract individuals who have intense self-belief and will not
stand for anything less than perfection. This selection bias is, in a way, ideal, as it creates
technically excellent surgeons. It is not, however, necessarily the person who would want to put
in “time, patience, dedication and selflessness” to “foster and encourage independence” in a
mentee [4, 5]. The selection bias of the infinitely capable and self-confident surgeon also creates
problems from the other end: surgical trainees might not feel they need a mentor, let alone want
to be a mentor themselves. However, it is exactly this mismatch between confidence and
competence which is truly dangerous; as surgeons work outside their capabilities and without
appropriate support, mistakes increase.
Therefore there remains an “absolute apathy” towards mentoring in surgical circles, particularly
higher up the surgical ladder [3]. On asking one senior consultant about the role of mentoring, I
was told that there was no place for “hand-holding” in surgery, that all a surgeon needs is
experience, and that surgical training is simple: “you thrive or perish”. This viewpoint, which I
imagine is not an isolated one among consultants, reflects a gross misunderstanding of
mentorship. It also jeopardises the whole of surgical training and is, in a large part, responsible
for the fact that surgical trainees often feel let-down and isolated in their posts [3].
Perhaps it could be argued that the higher one rises up the surgical hierarchy – or medical
hierarchy for that matter – the less one needs support and mentorship. Perhaps that is what the
senior consultant quoted above meant. However, in the current era of lifelong learning and the
fact that surgeons in particular need to adapt to new techniques, those at all levels should feel they
have a mentor. As Professor Edward Baker, ORH Medical Director, notes: “Mentorship is a very
important method for professional development at many different stages in many different
careers.” In addition, although the concept of formal mentorship is a relatively new one,
“Insightful doctors have always sought informal mentorship in the past and experienced doctors
have been willing to offer it” [7]. While invaluable, the trouble with this informal mentorship is
that some people will inevitably slip through the gaps. Without a formalised mentorship
programme in training, there will always be occasions where surgeons find themselves alone and
unsupported.
The lack of support for surgeons – even those at consultant level – was illustrated by a report
earlier this year into the John Radcliffe’s paediatric cardiac surgery unit (see box 1, below). The
report levelled particular criticism at support and mentoring in the department and recommended
that the unit remain closed until practice is changed substantially [8]. The impact of a lack of
mentorship on clinical practice is therefore clear.
It is true, however, that experience is the key to learning. If we see surgery as a trade then surgical
training is essentially an apprenticeship - a word synonymous with experience. Unfortunately,
surgical training is not as simple as this. The European Working Time Directive limits hours in
theatre, the demand for higher theatre throughput limits time on each case, and the lack of
tolerance of mistakes discourages consultants from allowing their junior colleagues to operate on
their patients. As such, junior surgeons no longer have the freedom to gain experience where and
how they want it.
And it is this point, that surgery is not like it used to be, that seems to have been missed by some
surgeons and that fosters the misunderstanding about mentoring. When the current senior
consultants were on the way up the ladder, training was very different. Surgeons learned as they
went along, often teaching themselves in an environment where the training and support
structures of today were non-existent. What needs to be understood, however, is that that era is
over. Mentoring, be it structured or simply the knowledge that there is a colleague you can
discuss a case with outside the hospital, is vital to developing trainees. As Mr Ashok Handa,
Oxford’s director of surgical training, points out: “We’re here for patients, to deliver the best
possible care as safely and efficiently as possible. If that means we’ve got to work and be trained
in a slightly different way to continue our lifelong learning then so be it. Mentoring is a key part
of that.” [6]
If this message fails to get through, and consultants stick to the “thrive or perish” philosophy, the
development of surgical trainees is in trouble and ultimately it is our patients who will suffer.
Jack Pottle is a final year graduate-entry medical student at Magdalen College
Box 1: The demise of paediatric cardiac surgery at the John Radcliffe









In July 2010 an independent review, commissioned by the South Central Strategic Health
Authority, recommended that: “Paediatric cardiac surgery remain suspended in Oxford
until or unless the service can safely be expanded”.
This review followed four postoperative paediatric deaths between 22 December 2009
and 18 February 2010, a mortality rate 4.8 times higher than the national average
(p=0.012). The story was widely covered in the national media.
One newly appointed consultant surgeon was operating, without senior assistance, in all
of the cases. He ceased operating of his own accord following the fourth death. Oxford
then suspended its paediatric cardiac surgery service and a serious untoward incident was
declared.
The surgeon in question noted that he had experienced difficulties which “had surprised
him and the cause of which he could not explain”, though the review concluded that there
were “no errors in judgement directly leading to any of the deaths”.
The review identified various root problems, including that the new surgeon “would have
benefited from help or mentoring from a more experienced surgeon”.
The review panel’s report made 16 recommendations. Regarding mentoring, they
recommended that “all newly appointed consultant staff have access to an appropriate
mentoring arrangement”. In the case of paediatric cardiac surgery, they stated that this
“must include arrangements that facilitate joint operating”.
In October 2010 the NHS Safe and Sustainable review team recommended that Oxford
should not be considered as a possible centre for children’s heart surgery when a
consultation takes place in January.
The Oxford paediatric cardiac surgery unit is therefore likely to remain closed for the
foreseeable future.
The full report can be accessed at:
www.southcentral.nhs.uk/document_store/12804012741_orh_paediatric_review.pdf
References
1. Senate of Surgery: Response to the General Medical Council determination on the Bristol case,
1998, Senate of Surgery: London.
2. Hasan, A., M. Pozzi, and J.R. Hamilton, New surgical procedures: can we minimise the
learning curve? BMJ, 2000. 320(7228): p. 171-3.
3. Memon, B. and M.A. Memon, Mentoring and surgical training: a time for reflection! Adv
Health Sci Educ Theory Pract, 2009.
4. Cohen, M.S., et al., Mentorship, learning curves, and balance. Cardiol Young, 2007. 17 Suppl
2: p. 164-74.
5. Macafee, D.G., B. Mentoring and coaching: what's the difference? BMJ Careers 2010
07/10/2010 [cited 2010 07/10].
6. Handa, A., Personal communication: interview regarding surgical mentorship, J. Pottle,
Editor. 2010.
7. Baker, E., Personal communication: e-mail to Oxford Medical School Gazette, J. Pottle,
Editor. 2010.
8. Kirkup, B., Review of paediatric cardiac surgery services at Oxford Radcliffe Hospitals NHS
Trust, as commissioned by the South Central Strategic Health Authority. 2010.
Communication on the front line
It’s not just what you say or how you say it
As medical students, it’s not uncommon to be approached by friends and family for advice about
medical problems. Often it’s something completely benign, such as low back pain without the red
flags, and we can feel confident enough to reassure. Occasionally however, it may be something
potentially sinister, with cancer on the differential. This is a situation I found myself in recently
when a relative told me that she had recently experienced some post-menopausal bleeding
(PMB). Those who have done Obstetrics and Gynaecology will know that PMB is endometrial
carcinoma until proven otherwise and must be referred urgently for an ultrasound scan within two
weeks.
I suddenly found myself in very unpleasant and unfamiliar territory. As a relative, I was gripped
with numerous fears. What if this was cancer? What would happen to them? What if they died?
What would I do without them? But equally, I was very aware that as a medical student, this
relative was looking to me for reassurance and that any trace of worry or concern on my face
would be very obvious and unsettling to them. Despite my concern, I found myself slipping into
medical student mode: putting on a brave face, saying reassuring things and racking my brains for
the PMB differential so I could say something like “It’s probably just polyps”. I began to cobble
together something that resembled a gynae history, which, given the patient, was a rather
awkward task, and it became apparent that there had been two episodes of light PMB, or
‘spotting’. In addition, and more worryingly, there was continual pain on the right hand side
where the perineum meets the top of the lower thigh.
I asked my relative if she had been to see her GP and it turned out that she had been three times.
On the first occasion, she was examined, reassured and sent home with the usual safety-netting of
“Come back if it doesn’t get better or if it gets worse”. I found this somewhat unsettling given the
guidelines on PMB mentioned above, but put this down to the light nature of the bleeding. On the
second occasion, two months later, she mentioned that the pain had become worse. The GP froze
with a look of dread across her face. “Well I’m not even going to examine you this time, I’ll just
refer you urgently” she said. My relative knew immediately exactly what she was thinking: “It’s
cancer”.
The first problem here is that, having been reassured on the previous occasion, to be given an
urgent referral suddenly is rather alarming. The second problem here is the lack of examination. I
agree that examining the patient is not going to change the management: she will still be referred.
But assuming that there would be no abnormalities detected, this would be a great comfort to the
patient during her two week wait, especially after being given the impression that she has cancer.
In failing to examine the patient, the GP missed a valuable opportunity to reassure her. The third
problem here is how transparent the GP’s look of horror was. I imagine she was thinking “PMB
plus pain: it must be a gynaecological malignancy”. I agree that it should be on the differential
and that it must be referred in order to rule it out, but there are many things that could present in
this way. They may even be two independent problems. Assuming that it is cancer is jumping to
conclusions. Giving your patient that impression is disgraceful.
On the third occasion, the following week, my relative returned because she had questions that
she was in too much shock to ask about on the previous occasion; questions she had been
worrying about for the preceding week. “I’m quite worried”, she said nervously, hoping for
reassurance. The GP replied: “You’ve got every reason to be worried”.
Surely she didn’t mean that? Perhaps she meant “You’ve got every right to be worried”, still quite
an unsettling response. Personally I would have gone for “It’s natural to be concerned”. But to
say “You’ve got every reason to be worried” implies that the patient’s concerns are justified and
the diagnosis is in no doubt.
Fortunately I was on leave at the time of her outpatient appointment. I was able to go with my
relative and reassure her. When the radiographer announced that the endometrial lining was of
normal thickness I breathed a massive sigh of relief. In fact, I think my relative was slightly
surprised by the extent of my relief; my brave face must be very convincing! At this point,
standard procedure is to discharge the patient back to their GP for debriefing. I suspected that this
would be inviting yet more trouble so I piped up and asked if she could go on to the outpatient
appointment anyway, just to talk things through. The radiographer, looking slightly taken aback,
and, probably wondering what the hell I was doing in the examination room anyway, replied
“Erm, yes, I should think that’ll be alright”. After speaking to a specialist nurse, my relative left
feeling relieved and reassured.
I’d like to make it clear that this article is not in any way about GP-bashing, although I can
appreciate that it may come across in that way. I have no interest in GP-bashing – I myself would
like to become a GP one day. The healthcare professional in this article could have come from
any specialty. What I want to get across is the importance of good communication skills. We are
all taught about it at medical school. We attend classes where we cover various issues through
role-play with actors whilst our colleagues watch. But these scenarios will always be rather
artificial. It is only in the real world, where bad communication has real consequences, that the
importance of good communication becomes apparent. Communication takes place both verbally
and visually, and can be incredibly subtle. The GP in this tale made errors in both of these
departments. So when a patient presents with worrying symptoms, don’t jump to any conclusions,
think about what you’re going to say, give them the facts, and don’t let your inner concern show
on your face.
Matt Harris is a final year graduate-entry medical student at Magdalen College
An epitaph for eponyms?
Or, how to have your disease and name it too
Wouldn’t it be great to have a disease named after you? To go down in the literature as one of the
great doctors of all time, to be remembered alongside such greats as Alzheimer, Bell, Osler (and
Lou Gehrig)? Apart from the forgotten issue that it tends to mean your name will be forever
associated with pain (I don’t particularly envy Huntington – can my disease be mild, interesting
and completely curable, please?) there are no drawbacks. But how to get a disease named after
oneself?
Turns out, people are pretty flexible on naming diseases. It ends up just being whatever catches
on. Every few years the debate seems to flare up again – should we only have more descriptive
terms? Is it wrong to remember Nazis through disease names? The opponents of eponyms would
say yes; syndromes such as Reiter’s, Wegener’s and perhaps most famously Hallervorden-Spatz
(which you’ll all know, of course) are tainted with the blood of thousands. Hallervorden and
Spatz actively encouraged preservation of specimens from the gas chambers on the basis that they
were going to die anyway and it seemed a shame to waste such a valuable resource. When you
tell someone they have a disease, some would argue having it named after a war criminal makes it
worse, but is this actually what they think about when they are diagnosed? It is surely more to do
with the standing of the person honoured with a disease name; they become a medical great as
soon as they appear on whonamedit.com. And we want to keep the riff-raff, and the Nazis, out of
this club.
So, to be on the safe side, in our quest for an eponym, perhaps avoid war crimes. How else might
we increase our chances? It seems the next step is to find yourself a good teacher. It is never too
early to be eponymised. Our friend Huntington achieved international recognition with his
description of the disease at the tender age of 22 (although it had been described in Norwegian
twelve years earlier – but Lund’s disease doesn’t have the same ring to it), and studying under a
great will help you out no end. Consider the mega-celebrity Charcot; eponyms coming out of his
ears, including an island, which few doctors can boast. But he was as generous as he was utterly
egotistical, hence our knowledge of his students: a young Babinski, Freud, Gilles de la Tourette,
who after years and thousands of pages written on hysteria had a tic disease named after him that
he had written one article on. Still, fame is fame. Also, our favourite German, von
Recklinghausen, was a student of the great Virchow (he of the node) and consequently, despite
contributing next to nothing (two case reports, not the first, not all the clinical features), managed
to bag himself rather a tidy eponym. So snuggle up to Lancaster and Handa, the modern greats –
who knows what tasty little vascular abnormality might be tossed your way?
The other option, of course, is to be famous yourself. Big dogs such as Charcot could afford to
chuck the odd inconsequential disease down the ladder because they were just so stupidly wellknown anyway. Our own great physician, Thomas Sydenham, gave an incomplete description of
childhood chorea, as well as describing rheumatic fever, but failed to link the two and kept the
name anyway.
Of course, there is the proper way – years of hard graft, slowly collecting cases until finally
putting the pieces together in the manner of the Hollywood film. Arvid Lindau spent many a year
patiently collecting cases of cerebellar and retinal haemangioblastomas associated with cysts and
tumours of the pancreas, adrenals and kidney, and now, of course, he is more famous than God
(who incidentally is yet to have a disease named after him). But it is so much quicker to nick
someone else’s work, and we are after the quick fix (there is Huntington to compete with, after
all), and so maybe we can take a leaf out of the book of Johann Friedrich Horner, who dropped in,
had a quick look through his blurry eye and pulled together everyone else’s work on the
syndrome which then became his own.
Perhaps the quickest way, though, is to get the thing yourself. Admittedly this requires quite some
degree of luck, but there is always the satisfaction of guilt-tripping your excited neurologist into
letting you have the name. Julius Thomsen’s family, including himself, were affected by an
autosomal dominant disease causing myotonia and muscular hypertrophy and he described this in
1876; we now call this Thomsen’s disease. Every cloud.
Finally, if none of the above appeal, build yourself a great rivalry; I’m thinking Holmes-Moriarty,
Tom-Jerry, Lancaster-Handa. The greatest of these was, of course, between Josef Brudzinski and
Vladimir Kernig, both of whom claimed they had the most sensitive indicator for meningitis. To
this day, doctors all over the world pick a side. The battle outlived them both.
So you have your eponym. But what now? The naysayers want their more descriptive terms.
They want long, floridly scientific terms. Granted, they might be fairer, more easily classifiable
and more clinically useful (did you know that only 11% of orthopaedic surgeons could describe
Finkelstein’s test for tendovaginitis? Disgraceful!). But what of the history? What of the romance
of the men and – no, wait, just men, apparently – who toiled over their microscopes and
dissection tables? Are they to be swiftly forgotten? The glamour of medicine is fading fast, and
we cling to our last chance of fame. That is, before we switch to eponymous TV shows.
Tom Campion is a final year medical student at Wadham College
Push harder you silly woman!
State-run obstetrics and gynaecology in Karachi
In our fifth year, some of us are lucky enough to be able to do part of our Obstetrics and
Gynaecology (O&G) rotation abroad. Karachi, in Pakistan, doesn’t sound like an obvious
location for this. It’s a developing country lacking the ‘glamour’ of somewhere like South Africa,
the political situation is such that many people are afraid to leave their homes due to the very real
risk of bombings and, as an Islamic country, it’s not the ideal place for a male medical student to
learn about O&G! However, I had relatives to stay with and managed, very tenuously, to find a
gynaecology professor contact who reassured me that I would be able to fulfil most of my
objectives (mainly, delivering some babies!). She arranged for me to spend two weeks in Civil
Hospital in the centre of Karachi. Here is an abridged version of the blog I wrote while I was
there about a fascinating fortnight.
Tuesday 15 March 2010
Civil Hospital is government-funded, so treatment is free but resources are limited. The patients
are mainly from the rural suburbs and are very poor, badly educated and often illiterate. Many
women present for only the first or second time during pregnancy when they are in labour itself,
which impacts heavily on the pathology. For example, on my first ward round, I saw a lady who
was diagnosed with type 2 diabetes when she came in mid-labour and her baby (who weighed 5
kg) had severe shoulder dystocia and died before delivery.
The hospital itself is huge. In the main ‘courtyard’, there are loads of people wandering around,
some on stretchers or limping with dirty bandages towards A&E, plus the ubiquitous beggars and
vendors. There is a muggy smell as you enter the O&G Department, not helped by the forty
degree heat (there’s no air conditioning, just ceiling fans). I had extremely low expectations of its
general condition, having heard stories, for instance, about cats wandering around eating
placentas (which, apparently, doesn’t happen anymore!) but it isn’t too bad. The wards are basic,
containing simply lots of beds (ie an old mattress and sheet and a rusty bed frame), some of
which are shared between patients. Other than that, they are quite non-descript: dirty, cracked
white walls, no curtains and no electronic equipment.
Friday 18 March 2010
The labour ward floors are a grubby white with smashed tops of glass ampoules and dirt scattered
aroun. The twelve beds are arranged open-plan. They consist of two detachable parts, between
which is a metal bucket. The dirty black plastic ‘mattresses’ on the top half are covered by a grey
plastic sheet (I am unsure if these get changed) and the curtains are too small to serve any
purpose. When I saw a 22 year-old girl give birth yesterday, nurses were just walking past and the
other patients looked-on nervously, knowing that they would be going through the same ordeal
shortly. There are not enough anaesthetists to give epidurals either, so the ward is an unnerving
place to be when women are in labour! When everything had calmed down, the strategically
placed metal bucket was washed and put back. And the new mum finally showed some sort of
happiness at seeing her new baby boy!
Tuesday 22 March 2010
The operating theatres here are clearly different to the pristine ones we’re used to in the UK but
they weren’t terrible. There was an anaesthetics machine, the patient was draped and the surgeons
were gowned and gloved. It was only after the first operation that I realised the cloth drapes and
gowns are re-useable, as is the surgical equipment. However, instead of being irradiated, the
instruments are washed in the sink, while the green, blood-drenched cloth is rinsed and then
washed more rigorously outside and dried. All of this is finally sterilised in a rusty autoclave.
Similarly, ‘scrubbing in’ involves washing to the elbows with a bar of soap and tap water, before
putting on a gown and sterile gloves. Post-operative infection rates are apparently quite high. It’s
very easy to be really snobbish about all this, but I keep reminding myself of the money pumped
into the NHS that funds disposable equipment and that this sort of practice is completely
unfeasible here, where little money comes from a corrupt government and the patients can barely
afford the pennies to get the bus, let alone contribute to financing their care.
Saturday 26 March 2010
I actually felt quite sad during my last day yesterday, but there was a point on Thursday
afternoon, whilst standing at the foot of a Labour Room bed watching a doctor screaming at a
patient and preparing for another episiotomy, that I realised I’d had enough! The bursts of
positive emotion you might expect are also distinctly lacking, due to the very business-like,
unempathetic doctor-patient relationship and the mothers being simply relieved post-birth that the
pain is over.
Also, for many, this may be their fourth or fifth child born into poverty and clearly, especially in
the long-term, will represent a burden rather than a beacon of joy. This was exemplified by the
birth of quadruplets I saw on Thursday. Herds of journalists quickly descended upon the
delighted Labour Ward, as it was the hospital’s first quads that had all survived perinatally. But
during one of the interviews, the Head of Department walked past and pleaded that the patient’s
financial plight be highlighted during the news broadcast so she might get help from somewher;
she already had three young children and was clearly poor. It was quite disturbing seeing her
answer the reporter’s question: “Are you worried about having to care for four more children?” It
suddenly struck her that the coming years would be even more tough than the unimaginably
difficult conditions she was already experiencing.
Monday 28th March 2010
Finally, I just went to the private Aga Khan University Hospital (AKU), which is the country’s
top medical school. It is a huge complex of extremely well-maintained pink buildings, boasting
award-winning Islamic art and architecture, with beautiful lakes and flowers in the impressive
grounds. It’s pretty much the direct antithesis of Civil, which is only a few miles away. In
Pakistan, you can either afford to go private (£1000 gets you a private, en-suite delivery room), or
you end up in state care. The difference is inconceivably vast and patients who would be treated
using world-class techniques in AKU would simply be left to die in government hospitals.
The contrast between these two hospitals was a stark reminder of the chasm in Pakistan between
the very rich, with their Ferraris, and the extremely poor, where five year-old children beg at car
windows. Just yesterday, as I was giving gifts to the staff, one of the operating theatre technicians
pretty much begged me for 100 rupees (about a pound). After initially saying no, I gave him the
money I had, realising that even a few pounds might really help him out.
Reflections
So, it was an extremely interesting two weeks, both in terms of seeing Karachi itself and seeing
how a developing world state hospital, in a city with 19 million people, operates. Other than
performing one delivery and assisting in some Caesarian sections, I didn’t get to do much (no
gynaecology), but that was expected. I was the only male in the department, which made doing
anything very difficult – I was only allowed to do the delivery because the doctors felt sorry for
me! Nevertheless, the whole experience that was so incredibly intriguing that I have no regrets
whatsoever. It’s easy to criticise the lack of Labour Room privacy, infection control issues and
basic wards, but you soon recognise that limited funds mean the main aim is to safely manage
patients and that any ‘perks’ are a waste. The doctors – who, incidentally, work 36-hour shifts –
also describe how their medical acumen improves by having to diagnose most conditions
clinically, as investigations cost valuable money. In light of these obstacles, it’s incredibly
impressive that such a department can cope with thirty births each day, several Caesareans, and
the odd ruptured ectopic, neonatal resuscitation and eclamptic patient, plus elective surgery and
outpatients. It really opens your eyes to the challenges, and relative successes, of developing
world healthcare.
Aamir Saifuddin is a final year medical student at Exeter College
The author would like to thank Professor Ayesha Khan for her help in organising the placement.
What if everything you thought you knew
about AIDS was wrong?
Jack Carruthers examines the sinister ramifications of AIDS denialism
HIV does not cause AIDS. AIDS (acquired immune deficiency syndrome) is a dustbin acronym
for any disease that can result from detrimental lifestyle choices, particularly the use of
intravenous drugs, poppers and AIDS medication, azodothymidine (AZT). These drugs assault
the immune system leading to an AIDS-related disease. But HIV (human immunodeficiency
virus) cannot do this. Brainwashed as we are by the HIV=AIDS=death paradigm, can we take a
step back and question this insidious implication?
Christine Maggiore did so. I read her polemic, What if everything you thought you knew about
AIDS was wrong? on the train from Oxford to London one January afternoon. Fellow passengers
regarded me with wary sympathy: “Poor boy. He has AIDS and he doesn’t even understand...” I
don’t have AIDS, actually. Nor do I have HIV. If I did, however, I can’t help but think I would be
seduced by Maggiore’s message that rips apart the causative link between HIV and AIDS [1].
And I’m a medical student with a reasonable grasp of the scientific process, and an education in
HIV/AIDS that indisputably links the two. For someone without this background, I can imagine
that some of the arguments put forward by AIDS denialists – as Maggiore and others who think
like her have been branded by the scientific community – would be more than compelling.
Maggiore’s position is concisely outlined in layman’s language without being patronising. She
notes that since Gallo’s discovery of HIV in 1984 “more than 100,000 papers have been
published on HIV” and that not one of them has “demonstrated that HIV can kill T cells” [1] [2].
According to Maggiore, twenty years of research into cancer retroviruses have conclusively
proven that retroviruses like HIV are not cytotoxic, and so cannot possibly deplete T cells to the
levels seen in AIDS patients. Tellingly, the paper published by Gallo after he announced to the
media during an international press conference that he had discovered the “probable cause of
AIDS”, failed to document the presence of “HIV (actual virus) in more than half of the AIDS
patients in his study” [1,3].
I was tempted to dismiss Maggiore as a delusional sensationalist until I found that the works of a
significant number of pre-eminent scientists were the rationale behind AIDS denialist philosophy.
Surely the most notorious is Peter Duesberg, a man (perhaps unfairly) rubbished by the scientific
community due to his controversial refutation of the HIV=AIDS=death paradigm. He is a
retrovirologist at Berkeley, University of California, and in 1987 published a paper demonstrating
that HIV is in fact harmless and that AIDS is caused by things like illicit drug use and, more
controversially, by AIDS medication such as AZT, a point to which I will return. The Nobel
prize-winning chemist, Kary Mullis, who developed the polymerase chain reaction, agrees with
Duesberg, claiming that there is “no scientific evidence” to show that HIV causes AIDS. Mullis
even writes the foreword to Maggiore’s book writing that she gives “the simple truth about
AIDS” [1]. Duesberg is no quack either. He rose to fame in the 1970s as the first man to
demonstrate the existence of retroviral oncogenes that could cause cancer in mammalian cells. He
later became a member of the prestigious National Academy of Sciences [4].
Since his espousal of AIDS denialism, Duesberg has become something of a pariah in scientific
circles. His laboratory is a barren shell of its former self, consisting of just Duesberg and a
graduate student, compared to its 1980s heyday of numerous graduate students and post-doctorate
researchers. He has had funding applications for even non-AIDS related research denied twenty
times [5]. Despite this, I felt that given Duesberg’s uncommon achievements in cancer research,
his views on AIDS cannot be summarily dismissed. Perhaps there is merit in claiming that drugs
and other lifestyle choices cause AIDS?
AZT is the bête noire of AIDS denialists, who claim that it is a sinister cause of AIDS foisted
upon us by greedy pharmaceutical companies. AZT carries a label dominated by a picture of a
skull and dire warnings in the case of accidental ingestion [6]. AZT was originally developed as a
cancer chemotherapy agent in the 1950s but was, according to Duesberg, withdrawn after mice
died in clinical trials from severe toxicity [7]. A nucleoside analogue, AZT works by terminating
DNA chains made by reverse transcriptase and is now almost always prescribed as part of highly
active anti-retroviral treatment (HAART) [8]. Duesberg attacked AZT, alleging that it is nonspecific to viral DNA. It kills human DNA as well and results in severe depletion of bone marrow
leading to immune deficiency or AIDS [9]. According to denialists, it causes the cytotoxicity
attributed to HIV infection. In addition to AZT, poppers (nitrite inhalants), heroin, and cocaine
are all cited by AIDS denialists, including Duesberg, as AIDS-causing. A Dutch study into
heroin-use and AIDS found just that. The group measured T-cell reactivity as a result of heroin
injections in both HIV-negative and HIV-positive individuals and found that T-cell reactivity was
negatively correlated with drug use. In other words, immunity was compromised by the use of
heroin. AIDS denialists claim that such conclusions are borne out in real life. It is no secret that
the gay community has suffered from the scourge of high AIDS-rates more than the straight one,
and this can be attributed, say denialists, to its use of recreational drugs, especially poppers [9].
I was disquieted by these denialist revelations among others. Had I unwittingly bought into a
medical conspiracy? Delve a little deeper, though, and you will find, as I did, that denialist
claims, while compelling in print, mask a multitude of sinister implications for real life. Therein
lies the danger. Indeed, AIDS denialism has been described by Warren Winkelstein Jr., a
Berkeley AIDS epidemiologist, as “irresponsible, with terribly serious consequences” [4]. I
would go one step further and say that denying the link between HIV and AIDS has such severe
ramifications for society that it is almost criminal.
Duesberg appears to have misunderstood the results of the Dutch study that he claims shows
heroin can cause AIDS. Whilst it is true that T-cell reactivity decreased in both HIV-negative and
HIV-positive patients, it is not true that the HIV-positive individuals developed AIDS as a result
of their drug use. Indeed, the HIV-positive patients had average T-cell counts well below the
clinically normal range of 600–1200, unlike the HIV-negative patients, suggesting that there was
already a decline in T-cell count due to HIV infection prior to the study [9].
The belief that drugs such as AZT can cause AIDS is dealt a further blow by evidence which
suggests that AZT helps to prolong life and reduce the number of AIDS-related diseases in the
first year after diagnosis with AIDS (not HIV). This was conclusively demonstrated in the
British-French Concorde study which involved 1,759 HIV-positive people [9]. Despite this, few
would argue that AZT is a wonder drug. As a result, it is now only prescribed as part of HAART
and is just one treatment weapon in a multi-pronged attack on HIV.
While it is true that scientific consensus has been unable to conclusively demonstrate how HIV
kills its target T cells, it is untrue (as Maggiore falsely alleges) that we have not come close. A
casual search of PubMed reveals many scientific papers that posit possible mechanisms whereby
HIV kills its target. These include over-accumulation of viral transcripts in the cells, in addition
to indirect autoimmune mechanisms and apoptosis in a kind of self-preserving attempt [10]. And
many of these papers were written before the 2000 edition of Maggiore’s book.
AIDS denialism is not confined to leprous pseudo-scientific back-rooms. It pervades society
today. Former president of South Africa Thabo Mbeki’s administration refused to implement an
overall national treatment programme for anti-retroviral medication in a country stricken by the
AIDS epidemic because it doubted the link between HIV and AIDS. Public health researchers
assert that the implementation of such AIDS denialism has contributed to 340,000 deaths from
AIDS in South Africa [11].
But what of Christine Maggiore? Her book is emblazoned with endorsements from various
notables. She writes clearly and intelligently – a message of hope. There are photos of her looking
pretty and healthy with her son. They seem to belie the fact that she was diagnosed with HIV in
1992 after a series of inconclusive tests for HIV – a factor which contributed to her growing
scepticism [1]. Maggiore held steadfastly to her beliefs despite constant criticism from the media,
the scientific establishment and AIDS activist groups. Indeed, her conviction was so strong that
she did not take antiretroviral medication during her second pregnancy. When her child, Eliza
Jane was born, she refused to test the baby for HIV and recognise the real risk that her daughter
had contracted the virus. On 16 May 2005, Eliza Jane collapsed and later died in hospital. Eliza
Jane was revealed by autopsy to be chronically under-weight and under-height. Her lungs were
infected with Pneumocystis jirovecii, an opportunistic pathogen and the leading cause of
paediatric AIDS-related deaths [12]. Maggiore herself died in 2008 from disseminated herpes
infection and oral candidiasis at the age of 52 [13]. I need not mention that these diseases are all
too common in HIV-positive AIDS patients.
It seems to me that Eliza Jane died because of her mother’s trenchant unwillingness to believe
that HIV causes AIDS. Even if this was not the case, and she did in fact die of a tragic case of
childhood pneumonia, Maggiore’s views are difficult to justify. Perhaps those who would agree
with AIDS denialists deserve our sympathy. They are liable to die earlier than they otherwise
would should they contract HIV and refuse to take medication. However, these people become
dangerous apologists for ignorance when their beliefs prevent others from receiving the education
and treatment for AIDS that they need. AIDS denialism has a human face and a human cost. For
that, AIDS denialists deserve not our sympathy but our strongest contempt.
Jack Carruthers is a third year medical student at St. Hilda’s College
References
[1]
Maggiore, C. What if everything you thought you knew about Aids was wrong? (4th ed.)
The American Foundation for AIDS Alternatives: Studio City, California, USA.
[2]
Altman, L. New York Times: April 1984.
[3]
Gallo, R. 4th May 1984. Science; 224: 502.
[4]
Cohen, Jon. The Duesberg Phenomenon. Science 9th December 1994; 266.
[5]
Lenzer, J. AIDS dissident seeks redemption...and a cure for cancer. Discover Magazine
15th May 2008. Available at: <http://discovermagazine.com/> [7th August 2010].
[6]
<http://www.google.co.uk/> Image result. Search: AZT.
[7]
Duesberg, P. Inventing the AIDS virus. Regenery Press: Washington DC, 309 – 359.
[8]
Mitsuya, H., Yarchoan, R., Broder, S. Molecular targets for AIDS therapy. Science; 249
(4976): 1533–44.
[9]
Cohen, Jon. Could drugs, rather than virus be the cause of AIDS? Science 9th December
1994; 266.
[10]
Finkel, T.H., Banda, N.K. Indirect mechanisms of HIV pathogenesis: how does HIV kill
T cells? Current Opinion in Immunology August 1994; 6(4): 605 – 15.
[11]
Chigwedere, P. et al. Estimating the Lost Benefits of Antiretroviral Drug Use in South
Africa. Journal of acquired immune deficiency syndromes October 2008; 49: 410
[12]
HIV infection in infants and children. (July 2004) [Online]. Available at:
<http://www.thebody.com/> [8th August 2010].
[13]
[Online]. Available at: <http://www.Aidstruth.org/> [1st July – 31st August 2010].
For love or money
“You’ll never, ever make sex work disappear”, says Justin Gaffney, a consultant nurse in sexual
health who has specialised in providing healthcare for sex workers for over 16 years. However,
the Home Office continues to attempt the eradication of this so-called “informal economy”[1] the unregulated, untaxed industry which strives to remain invisible to the state.
New UK legislation to “tackle the demand for prostitution” came into force on 1 April 2010, as
part of the government’s Coordinated Prostitution Strategy. New ruling prohibits collaborative
prostitution, making brothels illegal, and criminalises the purchase of sex from those forced into
prostitution, using the chilling flagship slogan “Walk in a punter. Walk out a criminal.” [2] But
will the government’s new rules help the vulnerable people they wish to protect?
Between April and September 2009, Gaffney and his colleagues carried out a survey of male sex
workers. This not only challenged ingrained views of sex work as an exploitative, coercive
underworld of crime, drug addiction and social exclusion, but also highlighted the serious unmet
health needs of sex workers. For example, although the majority of the survey’s respondents were
engaged in sex work by choice, over two thirds of those working in the porn industry had
engaged in ‘bare-back porn’. They mistakenly believed that the production companies employing
them, despite being both independent and unregulated, were responsible for ensuring they were
protected against contracting HIV on-set. Although 85% of the men had undergone an HIV test,
the vast majority had little or no understanding of post-exposure prophylaxis (PEP) or how to
access it, correlating with a lack of contact with outreach health services [3].
Gaffney’s concerns are shared by colleagues working in parallel with female sex workers.
Andrea, a nurse who specialises in the sexual health of prostitutes, is worried about the risky sex
her clients are engaging in. “The sex industry is saturated at the moment”, she tells me, “The
market’s flooded by girls immigrating from overseas and the recession has also caused a drop in
custom. We find the girls offering increasingly risky sexual services, such as unprotected oral
sex, because it allows them to charge more money. We have to do a lot of work educating the
girls about contraception”. Aren’t drugs a problem in this population? “Drugs aren’t particularly
common amongst our patients” Andrea tells me, “you find the odd pocket of girls using crystal
meth to help them cope with long hours, but they usually avoid substances that affect their
judgement. One of our biggest problems is that a lot of our girls don’t have a valid immigration
status, so they’re afraid to access NHS healthcare services. A private abortion costs £500 with an
insecure income, and when supporting children and families back home, these girls haven’t got
that sort of money”.
The review used to back the UK’s new legislation boasts the use of research, audits and
ministerial visits to Europe to inform its recommendations. Of the 21 “stakeholders” listed as
participating in this research, none are actually sex workers, however, two thirds are members of
the UK Network of Sex Projects (UKNWSP), a non-profit, voluntary association of agencies and
individuals working with sex workers [4].
Unfortunately, the UKNWSP feel their views and experience have been disregarded and have
published a 26 page document detailing their dissatisfaction with the new legislation [5]. “Most
of the suggestions put forward by these projects were completely ignored, the Home Office
instead taking on board only recommendations from prohibition and abolitionist organisations
that see all sex work as violence against women and children.” Gaffney tells me. The UKNSWP
have observed that attempts to criminalise individuals involved in the sex industry erode the
probability that sex workers will be able to access social support and healthcare by driving sex
work further underground [5].
“It takes a lot of effort to reach the girls”, says Paz, an outreach worker at a sexual health and
social support practice in central London. “We have to work hard to gain their trust - even just to
make that first contact and give them some free condoms. It’s now illegal to advertise using
calling cards, and most girls use the internet to advertise so it becomes very difficult for us to
keep track of them. They move a lot and they’ll often put the phone down on you if they don’t
know who you are.”
The UKNSWP fear that the government has failed to address violence against sex workers and
improve their safety. The three Bradford murders reported in May this year exemplify the most
brutal examples of violence against prostitutes, but such tragedies are not the only danger a
prostitute faces. “Robberies are common” says Venetia, who runs a drop in health and social
clinic for female sex workers in central London, “Men will pose as clients but have a gang who
force entry to the flats when the girls open the door to them. The girls don’t understand that they
have the same rights to police protection as anybody else”.
Behaviour in the police force does not always serve to improve the relationship of sex workers
with the law. “Police will raid the working flats and take all the girls cash in the name of ‘seizing
the evidence’”, says Jane, who has coordinated a sex work project in London since the 1980s.
“The girls don’t stand up for themselves because they don’t know their rights. The
money can theoretically be reclaimed, but in reality ends up with the Inland Revenue.”
Venetia and others like her are also worried that new laws criminalising those who buy or profit
from sex compromise the girls’ safety: “Men buying sex obviously want to avoid prosecution, so
they’ll encourage women to go to more remote locations to provide services. Criminalising
brothels forces girls to work alone. This is very dangerous”. Venetia, like so many similar
organisations, runs an ‘ugly mugs’ scheme which allows women to anonymously report assaults
against them by so-called ‘dodgy punters’ which are then circulated to try and avoid similar
attacks on other sex workers.
But not all clients are violent, so who else is buying sex? Even the government can only provide
“suggested motivations” including “dissatisfaction with existing relationships”, “loneliness”,
“having no sexual outlet” and “curiosity” [6]. It seems there is no typical client. Consider Nick
Wallis, a young man born with the severely life limiting and disabling muscular dystrophy, who
lost his virginity to a prostitute at the age of 22. Previously feeling that he was living “an
existence, not a life”, Nick wanted to ensure he experienced “physical intimacy” before he died
[7]. His needs would be understood by Tender Loving Care (TLC), a trust that seeks to enable
professional sex workers to fulfil those who are “sexually dispossessed”. The TLC trust claim
that sex workers “rescue disabled people from personal anguish, sexual purgatory, and touch
deprivation” and that “two stigmatized groups provide each other with triumph: sexuallydeprived disabled people get laid, and sex workers gain a renewed pride in their work” [8].
The government’s own researchers have warned that the new legislation has already been shown
to be imperfect. In Sweden, following criminalisation of demand, the working conditions for
street workers appeared to deteriorate, and there was evidence of the market simply shifting
indoors [6]. Researchers also speculate that the low risk of arrest to an individual purchaser of
sexual services cannot act as an effective deterrent in reducing the demand for sexual services [6].
Of all the evidence they had analysed, the researchers stated that “methodological difficulties
plague research... There are many gaps in the research and much of the evidence is weak or
inconclusive” [6].
The UKNSWP has declared that concentrating on criminalisation rather than further investment
in support services for sex workers represents “extremely poor social care planning” [5]. They
believe that the government is failing to tackle the reasons people enter street work, and to
provide adequate specialist health services such as counselling and drug treatment services,
housing, and employment advice and training. “Women can become very institutionalised in sex
work and find it very difficult to leave” says Venetia, “They may ask us for guidance on finding
and training for another career. Interestingly they often seem to choose careers that share that
element of ‘love without consequence’: beauticians, hairdressers, pet-groomers, and that sort of
thing”.
Perhaps it is time the government listened to the prostitutes themselves. Sex worker Thierry
Schaffauser no longer wishes to be branded a public nuisance or spreader of disease. He writes
“The first step in the fight against “whorephobia” is to name the oppression… A further step
would be to fight the hate crimes sex workers suffer instead of criminalizing us” [9]. Perhaps the
hope for the future can be summed up by the tag line of the International Prostitute Collective:
“No bad women - just bad laws” [10].
Mary Keniger is a foundation doctor who graduated from Green-Templeton College in July 2010
References
1.
Day S. On the Game; Women and Sex work.
2.
Home
Office
Campaign
Poster.
Available
from:
http://toomuchtosayformyself.files.wordpress.com/2010/04/untitled.jpg?w=375&h=531
[Accessed 12th August 2010]
3.
Justin Gaffney, personal communication, June 2010.
4.
Home Office. Tackling the demand for prostitution: A review. November 2008.
Available: http://uknswp.org/resources/demandReport.pdf [accessed 24th June 2010]
5.
UKNSWP. Response to the Home Office “Tackling the demand for prostitution: A
review”. January 2009.
Available: http://uknswp.org/resources/demandResponse.pdf. UK Network of Sex Work Projects.
[accessed 24th June 2010]
6.
Wilcox A, Christmann K, Rogerson M, Birch P. Tackling the demand for prostitution: a
rapid evidence assessment of the published research literature. December 2009. Available:
http://rds.homeoffice.gov.uk/rds/pdfs09/horr27c.pdf [accessed 24th June 2010]
7.
Wallis N. My Lifelong Desire. The Guardian 15th Jan 2007. Available:
http://www.guardian.co.uk/society/2007/jan/15/health.socialcare [accessed 24th June 2010]
8.
TLC Trust [online]. Available from:
http://www.tlc-trust.org.uk/
9.
Schaffauser T. IN Whorephobia affects all women. (2010). Available:
http://www.guardian.co.uk/commentisfree/2010/jun/23/sex-workers-whorephobia
10.
International
Prostitutes
Collective.
[Online].
Available
from:
http://www.allwomencount.net/EWC%20Sex%20Workers/SexWorkIndex.htm
Evidence-based faith: The Resurrection
In the era of evidence-based medicine, Hugh Gifford wonders if the
same approach will work for religion
The underlying principle of evidence-based practice is that we base our actions on what is true.
Scientific enquiry is powerful. The medical profession boasts confidence in drug therapy for this
reason. However, as evidenced in the recent case of rosiglitazone, our faith can be misplaced.
What we believe about whether or not drugs work must be based on evidence.
Similarly, proper investigation can shed light on religious matters too. The resurrection is a
suitable example. It is a concrete historical event: it either happened or it did not. It is also the
cornerstone of Christian faith: without it, “our preaching is useless and so is your faith” (St Paul).
As medical students, we are often living by faith as we trust in the literature. Here’s a question
regarding your personal faith in warfarin. I assume that you believe it is an anticoagulant that can
reduce the incidence of stroke in a population with atrial fibrillation (AF). Is your belief based on
what you have heard or read and not on what you have seen? We are “sure of what we hope for
and certain of what we do not see,” (St Paul’s definition of faith) – unless we see it with our own
eyes.
As a profession, we even exercise blind faith. A good example is the case of the diabetes drug
rosiglitazone, a product of GlaxoSmithKline. This expensive medication has already been taken
by millions of people but now appears to increase the risk of heart failure and myocardial
infarction. “Hailed as a much needed new approach for patients with type 2 diabetes, the drug
was licensed 10 years ago with only limited evidence of its effectiveness and concerns over its
safety” writes BMJ editor, Fiona Godlee. She suggests that “rosiglitazone should never have been
licensed and should now be withdrawn” [1].
There was once a junior doctor. He had learned about the use of warfarin in AF while he was at
medical school. But on his first night shift, alone at the Churchill, he struggled to prescribe it.
“Unless I see the original randomized controlled trials (RCTs), I won’t write it up!” On handing
over the undone job to his senior house officer (SHO), he blushed a little. The SHO had just been
writing their dissertation of the subject, and was able to show him five RCTs that demonstrated a
reduced incidence of stroke with warfarin. “Touch them!” said the SHO, “There’s even a
Cochrane Review.” He peered down at BAATAF, SPAF I and SPINAF, conducted in the US,
CAFA in Canada, and AFASAK I in Denmark, all during the late 1980s. Two thousand three
hundred and thirteen patients with AF, mean age 69 years, mean follow-up 1.5 years, were given
a vitamin K antagonist to various degrees compared to placebo and saw “about 25
strokes…prevented yearly per 1,000 participants” [2].
Some require real evidence to believe, while others are happy to assume there is evidence. A
member of the former party, like our skeptical doctor, was ‘doubting’ Thomas. He would not
believe his friends’ reports that Christ had risen from the dead. “Unless I see the nail marks in his
hands and put my finger where the nails were – and put my hand into his side – I won’t believe
it.” It was only a week later, when he actually saw Christ, that he believed it. Before I knew the
evidence for warfarin, my faith was blind, resting on the assumption that modern medical
consensus is established on evidence. Thankfully, it does have an evidence base, but does the
resurrection?
The Evidence
The hypothesis is that, long before the phrase ‘gospel truth’ entered our vocabulary, Christ died
on a cross on a Friday c. 34 AD and was alive by the Sunday. This is an event, not a repeatable
experience, so the normal testing via experiment won’t help. As the philosopher Gary Habermas
says: “We don’t see dinosaurs, we study the fossils. We may not know how a disease originates,
but we study its symptoms. Maybe no-one witnesses a crime, but police piece together the
evidence after the fact” [3]. James Cameron, director of Terminator, Titanic and Avatar, asks,
“How did these ideas take root? How did they ultimately transform western civilization?” [4].
Evidence in favour of a resurrection can be neatly organized into the following arguments:





The case reports are several, accordant, high in copy number and concordant with local
history
Their style and detail are consistent with their being eyewitness accounts
The narrative confirms Christ died physically
A dead body was never found or produced by ruling authorities
Witnesses of the risen Christ were unanimously convinced to the point of evangelism
even in the face of death
We have several case reports, which are multiple, agree with each other and agree with local
history. There are five accounts of multiple appearances of Christ after his death to over 500
individuals. The earliest actual fragment from one of these accounts is dated c. 130 AD. They are
likely to have been written prior to AD 95, four between AD 50 and 70, all within living memory
of events. An actual abridged version of four of these accounts is dated c. 150, more fragments
between 200 and 300 AD and two complete copies of all five accounts c. 350 AD. The number of
early copies and fragments of was high (5,366), making it almost impossible to change them over
time. An international collaboration has made one entire 350 AD set available online [5].
Contemporary writings quote these accounts in over 19,000 instances. From Clement to Polycarp,
Ignatius to Barnabas, and Aristides to Justin Martyr, Christian authors in the years 96-167 AD
taught that Christ rose from the dead [6].
The accounts not only claim to be those of eyewitnesses, but the style is consistent with this. Two
(Mark and John) are quoted in contemporary writing as eyewitnesses. This is consistent with
textual criticism: the level of personal detail, the language of an eyewitness, the language of
accuracy, habitual accuracy and the lack of habitual flair [7]. One account includes an exhaustive
level of local detail; as W.M. Ramsay, New Testament historian, says: “Luke is a historian of the
first rank; not merely are his statements of fact trustworthy... this author should be placed along
with the very greatest of historians” [8]. Another account draws on Mark and Luke with added
detail. The fifth account, Paul’s letter to a church in Corinth, now in Turkey, gives a full list of
witnesses. The details do not engender heroes. Instead, they portray a pathetic following that
abandons Christ in his hour of need, even to the point of denying him. Further, the first witnesses
of Christ in the accounts are women; in the ancient world, a woman’s testimony was held in
lower regard than a man’s. The several accounts show events in a different light while the central
events remain the same. These apparent weaknesses in the testimony are more coherent with a
realistic experience by human beings as opposed to an engineered hoax.
A third point is that the narrative confirms Christ died physically. “Modern medical interpretation
of the historical evidence indicates that Jesus was dead when taken down from the cross,”
concludes a review in the Journal of the American Medical Association [9]. He underwent
flogging that produced deep lacerations and haemorrhage. He collapsed while carrying the cross
and exclaimed that he was thirsty when he was hung, suggesting hypovolaemia. Crucifixion
normally causes death by exhaustion asphyxia, as well as further blood loss from the nail wounds.
He was pierced with a spear to ensure he was dead: this was certified by Roman professional
military. “They knew a dead man when they saw one” [10]. Blood and water came out – Jesus
may have had either a pleural or pericardial effusion from cardiac rupture. Some say Jesus only
swooned – but this hypothesis requires Christ to survive 36 hours buried in grave clothes in a
tomb after the crucifixion before going for long walks and lying to his friends.
Another argument is that no dead body was ever found or produced by ruling authorities. The
author did not find any contemporary record of the body being found and no resting ‘tomb of
Christ’ to which pilgrimage could be made. A hoax would have been unsustainable in the
presence of the Roman military power. Jerusalem was a melting pot for riot and rebellion. The
impending explosion of Christianity could have been easily stopped if the body could be found.
This would be the case if the early witnesses had been to the wrong tomb. It appears that the
Romans “sent chosen and ordained men throughout all the world to proclaim that…his disciples
stole him by night from the tomb,” writes Justin Martyr c. 150 [11]. The alternative hypothesis is
that a dispersed set of grieving disciples overpowered the four-man Roman guard in order to
spend their remaining years lying.
Finally, the witnesses then died for their testimony. Peter was crucified 32 years later. The other
disciples appear to have been stoned, beaten and also crucified. Persecution of early Christians
included torture and being “thrown to the lions.” It is psychologically improbable that the
disciples would go from being dispersed and dejected to being missionary preachers of a factual
report unless they experienced it. It is improbable that the whole host of witnesses would have
hallucinated in such numbers and on several discrete, recorded occasions. Many were convinced
by their testimony at the outset – the early expansion of Christianity included the addition of
3,000 members in one day alone in Jerusalem. A new ritual symbolizing resurrection was
instituted (baptism) and the day of worship changed from Saturday (the Sabbath) to Sunday (the
day of resurrection). Historians of Jewish and Roman origin acknowledge the growing belief
system: Josephus (37-100) paid tribute while Tacitus (56-117) and Suetonius (71-135) labelled it
a “mischevious superstition.”
The importance of investigation
Richard Dawkins previously defined faith as “a belief that isn’t based on evidence” [12]. As I
have shown, that doesn’t fit with a belief in the Resurrection, but may have done with
rosiglitazone. It might even fit in with Stephen Hawkins’ recently published ideas on M-theory,
which “allows for 10,500 different universes, each with its own laws” [13], but which “we can
never actually validate” [14]. It is easy to exercise blind faith amidst the peer pressure of drug
reps and classmates. But it is also easy to exercise cavalier disregard in an issue in which a little
investigation will go a long way.
Hugh Gifford is a foundation doctor at the Horton General Hospital
References
1.
Godlee F. Rosiglitazone: a cautionary tale. BMJ 2010; 341: c4896
2.
Aguilar MI, Hart R. Oral anticoagulants for preventing stroke in patients with nonvalvular atrial fibrillation and no previous history of stroke or transient ischemic attacks.
Cochrane Database of Systematic Reviews 2009; 1
3.
Gary Habermas p63. In: Strobel L. The Case For Easter.
4.
James Cameron on Jesus, TODAY Entertainment. (2007). [Online]. Available from
http://today.msnbc.msn.com/id/17349123 [accessed 14th September 2010]
5.
British Library, National Library of Russia, St Catherines Monastery, Leipzig University
Library. Codex Sinaiticus [Online]. Available from http://www.codexsinaiticus.org [accessed 14th
September 2010]
6.
McDowell J. Evidence That Demands A Verdict (2nd Ed.) 1999.
7.
Bruce FF. The New Testament Documents; Are They Reliable? 1943
8.
Ramsay, W. M. The Bearing of Recent Discovery on the Trustworthiness of the New
Testament. 1953.
9.
Edwards WD, Gabel WJ, Hosmer FE. On the physical Death of Jesus Christ. JAMA 1986
255:11: 1455-63.
10.
Michael Green. Man Alive. 1968.
11.
Justin Martyr. Dialogue with Trypho. AD 108
12.
Dawkins R. Is Science a Religion? The Humanist. 1997
13.
Hawking SW, Mlodinow L. The Grand Design. (published 9th September 2010)
14.
Sacks J, The Times Online. Even great science tells us nothing about God (2nd September
2010).
[Online].
Available
from
http://www.thetimes.co.uk/tto/opinion/columnists/article2711505.ece [accessed 14th September
2010].
Neuroethics: Sharp ideas about
neurohormones, love and drugs
Professor James Giordano responds to Tanya Deb’s ‘Love is the drug’
in Volume 60(1)
Oxy- prefix [from the Greek: oxos] Sharp, pointed, precise.
Tokos [Greek] - to birth or give rise.
Touches, squirts and smooth muscle squeezes
Certainly most tongue in cheek, such etymology would suggest that the word oxytocin would
infer “giving rise to sharp and pointed ideas”. Indeed, Tanya Deb delivers several sharp concepts
about the putative function and roles of the neurohormone oxytocin [1]. But as with any new
discovery, sharp ideas can be a double-sided blade, and it’s crucial to measure twice before the
first cut is made, lest we further wound what we’re trying to heal. As Ms. Deb astutely notes,
several recent neuroscientific studies have shown the neurohormone to be involved in – if not
subserving – cognitive and behavioral mechanisms of emotional attachment [2-4]. The majority
of oxytocin is produced by a cluster of small nerve cells in a region at the base of the brain,
known as the hypothalamus. These cells extend into the posterior portion of the pituitary gland,
where oxytocin is released into the general circulation following sufficient activation of sensory
neurological pathways by tactile stimulation. Initially, it was believed that oxytocin was only
present in females, functioning to induce smooth muscle contractions in the uterus (during
stimulation of the cervix and pelvic floor during childbirth and/or sexual activity) and in ductal
tissue of the breast (upon nursing or during sex) [5]. Oxytocin-induced contraction of these
tissues can be rather strong and usually elicits equally strong sensory feedback that most women
have reported as ‘feeling good’.
“See one brain…”
More recent studies, including those mentioned by Ms. Deb have shown oxytocin to exert a more
extensive function in the brain that is due, at least in part, to the actions of this potent peptide
within other brain networks that are involved in cognitive, emotional, and behavioral aspects of
reinforcement, reward, attachment and affection [6, 7]. Moreover, it has been found that oxytocin
is present and active in both males and females, and while its effects may be somewhat greater in
females (because of more sensitive, or greater numbers of oxytocin receptors in the female brain),
such gender-specific effects do not appear to be uniform or universal. A number of factors
account for this.
First, is that like any nerve chemical, oxytocin’s activity is critically dependent upon myriad
interactions with other nerve chemicals, hormones and the overall biological environment of the
organism at a particular point in time. Second, it’s important to heed the increasingly popular
catch phrase of neuroscience: “see one brain, see one brain”. In other words, it is very likely that
no two brains are structurally or functionally identical, given the environmental dependency of
neurological development and plasticity. This reflects Nobel laureate Gerald Edelman’s concept
that “neurons that fire together, wire together” [8]. This brings us to the third point, which is that
the pattern of neuronal firing reflects both a genetic predisposition, and the ongoing effects of
internal and external environments. So, while the gross structure and overall functions of our
brains may be similar, significant differences lie in the details of our neural networks, and these
are a result of, and response to, the unique environments and circumstances of our individual
lives and experiences. Last, but certainly not least, is that each of these factors when taken
together contributes to how we individually experience, characterize, and react to our bodily
responses to various forms of environmental stimulation. Thus, our emotions appear to be a
cognitive interpretation of both an environmental situation and the physiological changes it
prompts or evokes. Neuroscientist Antonio Damasio refers to emotions as “the feelings of what
happens” bodily and environmentally [9]. So, while oxytocin can induce some fairly powerful
physiological responses and affect the activity of brain networks involved in attachment and
attraction, any interpretation of these effects or, more simply, their individual subjective
‘meaning’, is likely due to the interplay of biological, psychological, and social factors, and these
are all individually variant and susceptible to change (and some rather quickly).
Of neuroscientists, philosophers and poets
It’s becoming apparent that the more we learn about the brain, the more inadequate, if not wholly
incorrect, is a simplistic, “one size fits all” approach to relating brain structure and chemistry to
complex emotions, cognitions, and behaviors. Brain mechanisms function in concert rather than
as a series of well-defined solos, and while oxytocin clearly is important, instrumental, and
perhaps even strongly operative in attraction, attachment, and the more expansive constructs of
love, generosity, and altruism, these cognitions and emotions are the result of a dynamic, multicomponential symphony involving numerous nerve chemicals at several brain sites, which, may
actually differ, at least to some extent, in each individual. So, the “feeling of love” may be very
different for each person, even though its general characteristics can be codified under a single
rubric. To be sure, the phenomenologists appear to have gotten this right, and legions of poets
and songwriters throughout the ages have offered testimony to the uniquity of experience.
Complicating matters is that the mind somehow originates from a brain existing in a particular
body, and moreover, this complex unity of body-brain/mind is nested in the time, place, and
circumstances of environment. There is an inextricability of creature and culture, particularly if
we view ‘culture’ in the most literal sense, as both a medium that gives rise to the biological
organism, and a forum for its (physical and cognitive) experiences, and psychosocial and
behavioral expressions. The picture is one of a complex relationship of systems within systems,
and this makes it very difficult to ascribe or predict the activity of a single variable, such as the
role and effect of the neurohormone oxytocin, on the intricacies of human emotions, thoughts and
actions.
From bench to bedroom?
Still, it’s hard to buck your biology, and it’s important to recognize that the brain exists in a
delicate balance of chemicals and ions. Under normal physiological conditions, miniscule levels
of these substances, including oxytocin, are required to induce subtle changes in
neuropsychological function. Even so, we recognize that circumstances, events, and environments
that induce such changes can serve to potently reinforce and condition behaviors, and can lead to
profound biological, psychological, and social effects [10]. Ordinarily, we are attracted to, and
seek to engage and repeat those things that make us feel good. As Tanya Deb notes, for many of
us, the touch of a hand, an embrace or gentle caress, is a positive feeling, rewarding, and often
sought after. But this is in no means universal; not all touch feels good to all people, hugs are not
always welcomed, and some people frankly shun physical contact. Moreover, patterns of
attachment, attraction, affection, and altruism vary considerably. In the main, such variation can
be considered as ‘normal’. However, there are personal, social, and even clinically relevant
thresholds beyond which the indulgence or refutation of physical contact and feelings of
attraction, affection, and altruism are considered aberrant. Might research into the functional role
of oxytocin provide both insights into the underlying mechanisms of such abnormalities, as well
as afford possible means to effect treatment? It appears so. There is a slow, but steady impetus to
develop and employ oxytocin-like compounds to treat individuals with ‘attachment disorders’,
inhibited sexual desire, and even relational discord.
This approach is not new, in fact it is similar, if not identical, to the initially proposed clinical use
of methylenedioxymethamphetamine (MDMA), a drug better known as ecstasy. Originally,
MDMA was highly-touted and embraced by the psychiatric community for its ability to foster
feelings of empathy, bonding, and intimacy (as well as heightening sexual experience) within a
structured program of marital/relational therapy. It worked well. Perhaps too well, and as so
often, the golden goose flew the coop, and a treatment used in the clinical context became an
often mis-used enhancement in an unsupervised social setting. So, while ecstasy was used to
foster feelings of love, it wasn’t long before “the drug” was “the love”.
Balancing treatment and enhancement
So it may be with the potent peptide oxytocin and its pharmaceutical analogs. Clearly, we may
be poised to discover and develop an important treatment for a number of attachment and
affection disorders, either as components of psychiatric syndromes or as primary biopsychosocial conditions. Moreover, oxytocin and oxytocin-like drugs may have great utility in
treating individuals with schizoid or avoidant personality characteristics, and/or anti-social and
psychopathic tendencies. Pushing the envelope a bit, it’s not hard to imagine such compounds
being used more broadly, to increase affectionate and altruistic feelings and behaviors, and one
might imagine their (advocated or prescribed) use by those in the helping and caring professions,
and even ‘off-label’ use in social situations (ranging from enhancement of intimacy and/or
revivifying relational fortitude).
But, why stop there; how about oxytocin as the new ‘X’? Oxytocin parties? Slipping someone an
oxytocin ‘mickey’, by spiking their drink to induce emotional Velcro? And, of course, let’s not
forget how important such compounds might be in military and defense applications (putting a
new twist on the adage to “love thy enemy”). Without doubt, there are both natural and practical
kinds of thresholds for use that will need to be considered [11], and such consideration is both
scientifically right and morally sound.
Practical neuroethics
The issue at hand is one of interacting unknowns. Our knowledge of oxytocin is nascent, and in
reality our understanding of the brain-mind is incipient, and iterative. It’s far too easy to slip into
what philosopher, Hans Lenk, referred to as “the technological imperative” that compels us to use
a new technique, technology, or substance simply because we’ve discovered it, developed it, or
have it at hand [12]. But we must also recognize the important potential benefits that such
compounds might provide.
How do we balance a primary maxim of achieving the good, with the pulling forces of the market
and consumer desires, given what we know and don’t know about the brain, and the effects of
any new discovery or treatment? The answers are not easy, because the more we learn about the
brain, and the more advanced our technological capabilities to modify its function, the greater the
mantle of responsibility [13]. In short, it will be important to consider both proximate and
potentially distal benefits, burdens, risks, and harms that could be incurred. Understanding how
oxytocin affects the profundity of human emotions is important. It is likely that there will soon be
oxytocin-like compounds that can be used to affect these brain systems, to induce particular
cognitions, emotions, and behaviors. The question is not whether we can engage these
mechanisms, but rather whether, and how we should, because the pace of scientific discovery and
technological development is rapid, and such practical and ethical questions must be considered
before we loose – or slay – the golden goose.
Professor James Giordano holds positions as:
Research Associate at the Oxford Centre for
Neuroethics, University of Oxford.
Director of the Center for Neurotechnology Studies of the Potomac Institute for Policy Studies,
Arlington, Virginia, USA .
University Affiliate Professor of Neurosciences and Ethics at the Krasnow Institute for Advanced
Studies, George Mason University, Fairfax, Virginia, USA.
References
1. Deb T. ‘Love is the drug’ Oxford Medical School Gazette 2010, 60(1).
2. Uvnas-Moberg K. ‘Oxytocin may mediate the benefits of positive social interaction and
emotions’ Psychoneuroendocrinology 1998, 23(8): 819-835.
3. Carmichael M.S., Humbert R., Dixen J., Palmisano G., Greenleaf W., Davidson J. ‘Plasma
oxytocin increases in the human sexual response’ Journal of Clinical Endocrinology and
Metabolism 1987 64 (1): 27-31.
4. Zak J.P., Stanton A.A., Ahmadi S. ‘Oxytocin increases generosity in humans’ PLoS ONE
2007, 2(11): e1128.
5. Guillemin R. ‘Hypothalamic hormones: releasing and inhibiting factors’ In: Krieger D.T.,
Hughes J.C. (eds.) Neuroendocrinology. Sunderland, MA: Sinauer Publishers, 1980, p.23-32.
6. Neumann I.D. ‘Oxytocin: The neuropeptide of love reveals some of its secrets’ Cell
Metabolism 2007, 5(4): 231-233.
7. Gordon I., Zagoory-Sharon O., Leckman J.F., Feldman R. ‘Oxytocin and the development of
parenting in humans’ Biological Psychiatry 2010, 68 (4):377-382.
8. Edelman G. Wider Than the Sky. New Haven: Yale University Press, 2004.
9. Damasio A. The Feeling of What Happens: Body and Emotion in the Making of Consciousness.
New York: Harcourt. 1999.
10. Bures J., Buresova O., Krivanek J. Brain and Behavior: Paradigms for Research in Neural
Mechanisms. New York: John Wiley & Sons, 1988.
11 Gini A., Rossi J., Giordano J. Considering enhancement and treatment: On the need to regard
contingency and develop dialectic evaluation. American Journal of Bioethics-Neuroscience 2010;
1(1): 25-27
12. Lenk H. Technokratie als Ideologie. Sozialphilosophische Beiträge zu einem Politischen
Dilemma. Stuttgart: Kohlhammer, 1973.
13. Giordano J. ‘Neuroethics: Coming of age and facing the future’. In: In: Giordano J., Gordijn
B. (eds.) Scientific and Philosophical Perspectives in Neuroethics. Cambridge: Cambridge
University Press, 2010, p.xxv-xxix.
Maternal mortality
Have the Millennium Development Goals delivered for women?
Over the past two decades the medical community has saved millions of lives thanks to the
painstaking development of drugs and ever more complex procedures. Yet during the same
period, there has been little apparent progress in preventing the needless deaths of half a million
women each year in pregnancy and childbirth [1], despite these deaths being largely avoidable by
comparatively simple methods. It is even more worrying that more than 50% of these maternal
deaths occur in only six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the
Democratic Republic of the Congo [2]. Mothers have forever been a cornerstone of families and
communities, so why, after more than 20 years of interventions, are we still failing the world’s
women?
Two decades of initiatives
In February 1987, at the end of the United Nations (UN) Decade for Women, a campaign to
reduce maternal mortality was jointly launched by the UN Population Fund (UNFPA), the World
Bank, the World Health Organisation (WHO), the UN Children’s Fund (UNICEF), and the UN
Development Programme (UNDP). This was known as the Safe Motherhood Initiative, and by
1994, every region of the world had a safe motherhood conference. In 2000, the importance of
maternal survival was reinforced as a Millennium Development Goal (MDG), which boldly
aimed to “reduce by three quarters, between 1990 and 2015, the maternal mortality ratio” and
“achieve, by 2015, universal access to reproductive health”. This year, a decade after the
Millennium Declaration, world leaders have gathered again at the UN in New York to “review
progress, assess obstacles and gaps, and agree on concrete strategies and actions to meet the eight
Millennium Development Goals by 2015” [3]. So, what progress has been made so far to save
mothers’ lives?
T minus five years
With five years to go until the target deadline, the Millennium Development Goals Report 2010
shows that although some progress has been made to reduce maternal mortality (that is, maternal
death during pregnancy or within 42 days of termination of pregnancy from any cause), the rate
of progress has been slower than that of other MDGs and is still well short of the 5.5% annual
reduction required to meet the target by 2015 [3]. The shocking truth remains that most maternal
deaths could be avoided, with over half caused by haemorrhage or hypertension and 18% due to
indirect causes such as malaria and HIV/AIDS.
The report also highlights the terrible inequalities across regions. Women from Southern Asia and
Sub-Saharan Africa are most at risk of maternal death, due in part to the fact that more than half
of women in these areas deliver without the skilled care of a midwife, nurse or doctor. Although
rural-urban and rich-poor gaps in skilled care have narrowed in Southern Asia, urban women are
still twice as likely as rural women to receive skilled attendance during birth. Similarly, the
inequalities in care during pregnancy are striking. WHO and UNICEF recommend that women
are seen at least four times by a trained healthcare practitioner during pregnancy [4], yet still only
one in three rural women in developing regions are receiving this standard of care. It should be
noted, however, that there have been remarkable improvements in some regions; for example,
North Africa has seen a phenomenal 70% increase in antenatal care coverage since 1990.
The global campaign to reduce maternal mortality has also been working to reduce the adolescent
birth rate ie the number of births per 1,000 women aged 15 to 19. Teenage mothers generally face
greater obstacles in accessing reproductive health services and are at greater risk of
complications. Decreases in teenage pregnancies were seen between 1990 and 2000, but the
statistics can be misleading, and since then progress has stalled and some increases have even
been recorded in Sub-Saharan Africa and South East Asia. In this vein, an overall reduction in
adolescent birth rates has masked the growing disparity between rich and poor. The greatest
declines have been highest amongst urban, educated girls in the richest 20% of society, leaving
poorer girls with no education four times more likely to become pregnant.
Finally, the report examines progress made towards achieving universal access to contraception.
The 1990s saw significant increases in contraceptive use, and by 2007, 60% of women aged 1549 in marriage or union were using contraception. However, since 2000 this trend has plateaued,
and a widening gap has emerged between regions and across societal and educational divides. It
is predicted that meeting the family planning need would cause a fall in the annual number of
unplanned pregnancies from 75 million to 22 million, which in itself would reduce maternal death
rates by a staggering 27%. Furthermore, preventing closely spaced and adolescent pregnancies
would lead to an overall improvement in women’s health, increasing the chance of child survival.
The main obstacle in this area is adequate funding: aid for family planning as a proportion of the
total aid for health declined sharply between 2000 and 2008, from 8.2% to 3.2%.
Maternal health isn’t merely a ‘health disadvantage’
It is clear which medical procedures save maternal lives, but the international strategy needed to
improve global maternal health is far less obvious. For example, within a decade of launching the
Safe Motherhood Initiative, several policy U-turns were issued. In 1997, it was deemed that
antenatal care which focuses on screening women to identify those at risk of complications
(originally advocated in 1987) had failed, and it was acknowledged that every pregnancy requires
access to quality maternal health services. Similarly, in 1987 it was recommended that traditional
birth attendants should be trained to improve delivery at the community level. However, in 1997
the guidance was changed to promote the attendance at delivery of a skilled midwife, nurse or
doctor [5].
A fundamental impediment to reducing maternal mortality has been the difficulty in taking
account of its multi-faceted nature. In 1999, a joint statement was issued by WHO, UNICEF,
UNFPA and the World Bank, which read that an “important lesson learned from the past decade
has been that interventions to reduce maternal deaths cannot be implemented as vertical, standalone programmes. Maternal health is not merely a ‘health disadvantage’; it is a ‘social
disadvantage’” [6].
Although safe motherhood is, of course, critically dependent on access to good quality
reproductive healthcare, it must also involve strategies to empower women so that they have
access to education and information, to employment and to other resources. As such, achieving
safe motherhood is interpreted as fulfilling the human rights of women [7].
The counting problem
Research in the field is scarce and often speculative, as maternal mortality is often under- and
misreported in countries where systems are not in place to monitor clinical outcomes. This year
however, a systematic analysis of progress towards Millennium Development Goal 5 was
published in the Lancet, with some hopeful conclusions [1, 8]. The study estimates that there
were 342,900 maternal deaths worldwide in 2008, down from 526,300 in 1980, representing a
1.8% annual rate of decline. This indicates much better progress than previous UN estimates.
Overall, this new evidence suggests that “there is a much greater reason for optimism than has
generally been perceived and that substantial decreases in the maternal mortality ratio are
achievable in a short space of time.”
The report points to the fact that the four most powerful drivers of maternal mortality are
improving in most countries. First, despite an increase in the number of women of reproductive
age, the global total fertility rate has dropped from 3.7 in 1980 to 2.56 in 2008, which has kept the
global birth cohort (or the number of births) stable. The maternal mortality rate (MMR) and total
fertility rate are very closely correlated, although it is unclear whether the relationship is causal or
mediated through social change. Second, income per head has been rising, particularly in Asia
and Latin America: this can affect the MMR by improving nutritional status and providing
physical and financial access to healthcare. Third, maternal educational attainment has been
increasing; another strong correlate of a reduced MMR. In fact, the average years of schooling for
women aged 25-44 years has improved from 1.5 years in 1980 to 4.4 years in 2008. Finally and
crucially, there has been a rise, albeit slow, in attendance at birth of skilled healthcare
professionals.
Will we ever beat it?
This very significant study leads to two other vital conclusions. First, the importance of rigorous
data collection and research has again been highlighted by the fact that the study’s estimates of
maternal mortality are so vastly different from the most recent UN statistics. Like any good study,
a reliable measurable outcome is needed to determine the effectiveness of any intervention.
Second, it is fruitless to tackle maternal mortality in isolation. Given the incredibly strong
correlation between MMR and other indicators of poverty, it only makes sense to manage and
fund projects in an integrated manner. A shocking example of this is the authors’ estimate that in
the absence of HIV, there would have been 18% fewer maternal deaths worldwide in 2008 (see
figure 2). Without international political support and renewed vigour behind all of the Millennium
Goals, there is little hope of success in improving maternal health.
Finally, the current literature does not adequately address the impact of maternal death on both
the individual and society. The human cost is obviously tremendous. But it should also be
considered that the impact is equally devastating on a societal level: children left motherless have
a diminished chance of survival, let alone any hope of education, healthcare and stability. It is
surely true that investment in the health and survival of mothers guarantees incredible returns.
There have been tremendous advances in maternal health in some regions over the last two
decades: now is the time to step up the pressure to deliver on behalf of all of the world’s women.
Caroline Pendleton is a third year medical student at St John’s College
References
[1] Goal 5: Improve maternal Health Fact Sheet. The United Nations. 2008.
[2] Murray CJL et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of
progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23.
[3] The Millennium Development Goals Report 2010. The United Nations. Pages 32-40.
[4] Standards for Maternal and Neonatal Care. Department of Making Pregnancy Safer, World
Health Organisation. 2007.
[5] Safe motherhood initiative: 20 years and counting. Lancet 2006; 368: 1130-2.
[6] Reduction of maternal mortality: a joint WHO/UNFPA/UNICEF/World Bank statement.
World Health Organisation. 1999.
[7] Advancing safe motherhood through human rights. Department of Reproductive Health and
Research, World Health Organisation. 2001.
[8] Horton, R. Maternal mortality: surprise, hope, and urgent action. Lancet 2010; 375: 1581-2.
Image source:
Global maternal deaths, 1980–2008
Lancet 2010; 375: 1613
Deciphering our genetic code
Benjamin Stewart maps the history and consequences of the Human
Genome Project
On the 26 June 2000, the scientists of an extensive, collaborative effort to sequence the human
genome assembled in the East Room of the White House with political leaders from the USA and
UK to announce their success. Their path to that announcement was far from easy. Now, ten
years into the post-genomic era, there are arguably more unanswered questions about our genome
than before it was sequenced. Whilst the Human Genome Project (HGP) has given us great
insight into the fundamental nature of the genome, few of its findings have filtered through to
benefit patients. Nevertheless, the developments fuelled by the HGP to date provide a tantalising
glimpse of what is to come, most importantly the possibility of individualised medical treatment.
In the beginning
Genome sequencing began in 1977 when Fred Sanger determined the genetic sequence of phage
ϕX174 [1]. However, it was not until 1985 that the concept of genome sequencing accelerated as
Sydney Brenner, Renato Dulbecco, Robert Sinsheimer, and other eminent molecular biologists
proposed sequencing the human genome [2,3], and in 1986 the first automated sequencing
machine was produced by scientists at the California Institute of Technology [4]. Subsequently,
in 1990, the US National Institutes of Health (NIH) and Department of Energy published a plan
to map the genome using genetic markers, and to sequence 20 Mb of DNA in model organisms,
including the yeast Saccharomyces cerevisiae, by 2005. At this stage the technology was not
ready for an all-out assault on the genome, and both scientists and politicians favoured the
mapping approach over the slow and costly task of genome sequencing.
Competition and collaboration
In 1991, J. Craig Venter was working at the NIH as a molecular biologist. He proposed a project
that would find genes using expressed sequence tags (ESTs), short sequence reads from
complementary DNA (cDNA) libraries [5-7]. This technique provided a means to quickly
discover genes and analyse their structure. Venter created a storm of controversy by attempting to
patent thousands of ESTs and left the NIH shortly after to establish a non-profit institute - the
Institute for Genomic Research (TIGR).
This institute planned to advance molecular biology through genome sequencing, and established
Venter’s path towards the private effort to sequence the human genome. Around this time, the
Sanger Institute in Cambridge entered the HGP bringing with them funds from the Wellcome
Trust, and Francis Collins was named director of the NIH-based effort to decode the genome.
Thus the players were set for ten years of ambitious research culminating in a race to sequence
the human genome.
The race is on!
In 1995, Venter’s team at TIGR struck their first success when the genome sequence of
Mycoplasma genitalium was completed. As well as being important for defining the smallest
genome required for a free-living organism, this achievement also provided proof of principle for
Venter’s whole-genome shotgun sequencing approach in which the entire genome is broken into
short fragments which can be sequenced individually, and then stitched together using
overlapping regions [8].
Whilst the HGP had concentrated on mapping the human genome, Venter opened up the
possibilities of sequencing it. Nonetheless, the HGP model organism work had progressed
significantly since 1990, and the yeast genome project was completed in 1996 [9]. Provoked by
Venter’s success, and invigorated by the success of their own yeast project, the NIH enhanced the
HGP by funding six groups tasked with sequencing the human genome. The international
collaborators of the HGP agreed to release sequence data into a public database, GenBank, within
24 hours of sequencing, allowing researchers to perform accurate preliminary analyses. The HGP
was progressing, albeit very slowly.
The stakes get higher
In 1998, Venter boldly established Celera Genomics, a private genomics enterprise which aimed
to sequence the human genome within three years. This was a huge challenge to the HGP
consortium, which responded by pouring $460 million of Wellcome Trust and NIH money into
the HGP. With this additional funding they hoped to complete both the mouse and human
genome by 2003.
The HGP consortium and Celera were not only competing in a race to complete the human
genome, they were also testing different techniques. While Venter used the faster whole genome
shotgun sequencing technique, the HGP split the genome into bacterial artificial chromosomes,
which were sequenced individually and then pasted together using data from the genome map.
Although Venter’s whole genome shotgun approach had been successful on small bacterial
genomes, it required a trial-run on a large genome such as that of the fruit fly, Drosophila
melanogaster. In 2000 Venter published the 180 Mb genome of the fly, paving the way for his
team to sequence the human genome [10].
Compromise and collaboration
As the two groups raced to complete the genome, arguments began to rage concerning the quality
of data, patents, and depositing data into GenBank. The HGP consortium criticised Venter for
releasing data to subscribers on the Celera website rather than Genbank, whilst using Genbank
data to beat them to the finish line. Celera suffered disappointment when their plan to patent
thousands of sequences was condemned in an announcement by President Clinton, and as a result,
their stock crashed [5]. After an ugly feud, a truce was brokered: Celera and the HGP consortium
would announce their successes together, Celera would not be required to deposit to GenBank,
and the two groups planned to publish together [10]. Following the joint announcement at the
White House in June 2000, the HGP consortium published their work in Nature on 15 Febuary
2001, and Celera published a day later in Science [11, 12].
The post-genomic era
In addition to presenting 2.91 billion base pairs, the initial publications also began the long task
of analysing the sequence. There were some surprising results. For example, prior to the HGP, the
number of protein coding genes in the genome was estimated at between 28,000 and 142,000. By
examining the entire genome sequence with complex computational methods, taking into account
the identities of known proteins and gene sequences, Venter and his team has shown convincingly
that the number is actually around 26,000 - only 1.5% of the genome [12]. Furthermore, the
Nature paper characterised several important features of the genome; it gave insight into
processes as diverse as recombination, mutation rate, and evolution [11, 13]. The analysis of the
genome has continued since then: work on the protein coding regions was only the beginning, and
the complete sequence has allowed scientists to demystify the complex roles of non-coding
sequences, once erroneously thought of as ‘junk DNA’. Indeed, in 2005 the Encyclopaedia of
DNA Elements (ENCODE) project was launched, aiming to annotate the entire genome. This has
given an insight into the huge variety of the vast non-coding region of our DNA, from tandem
repeat patterns which hold a structural role, to regions transcribed as functional non-coding RNAs
which fulfil a regulatory role [14].
Technological advances
Unsurprisingly, many believe the greatest achievement of the HGP was advances in sequencing
technologies [15]. In order to accurately sequence large genomes with great speed, sequencing
technology and the computer power to stitch the genome back together again, had to keep up. It is
now possible to sequence a genome 50,000 times faster than in the year 2000, and more cheaply,
presenting the opportunity of the $1,000 dollar genome, a facility which would allow individuals
to discover their own genetic risks for particular diseases, and doctors the capacity to personalise
treatment. There are currently a number of biotechnology companies producing machines capable
of sequencing an entire human genome in a day for less than $6,000 [16]. However, the utility of
the $1,000 personal genome is quite limited at present, as an understanding of what most of the
variation between genomes means has not been established. The next great challenge in genomics
is matching up genotype data with phenotypes, and this requires sequencing of thousands, if not
millions, of genomes and linking that information with the phenotypes of the subjects to allow
accurate prediction of disease. Even if this were currently feasible, the computational power
required to compare this number of genomes is non-existent [16].
Future goals
Whilst the sequencing of the human genome has facilitated a wide range of advances in basic
biology, very few of these advances seem to have filtered through to clinical practice. The ability
to look at patient’s genome and personalise their treatment remains a lofty ambition for genomic
medicine, and it is just out of grasp due to cost and a lack of information [17]. One project hopes
to use individualised sequencing to benefit cancer patients: the NIH’s appropriately named The
Cancer Genome Atlas (TCGA) is sequencing thousands of individual cancers to identify the key
mutations in different forms of cancer. This should lead to more rational, targeted therapies [18].
As a result, oncology is probably where personalised genomic medicine will make its first mark,
and it may act as a model for effective implementation of genomic medicine.
Since their seminal Science paper, Venter and his team at Celera and the newly formed J. Craig
Venter Institute have continued to push the boundaries of genomics. In 2007 they produced the
first diploid genome from an individual human (Dr. Venter himself), demonstrating the
possibility of personal genomes [19].
This development led to a redefinition of the extent of variation between individuals to 3%, and
the identification of differences between the two sets of chromosomes [16]. Venter and his team
have made huge strides in the field of metagenomics – isolating and shotgun sequencing DNA
from environmental samples has allowed them to characterise vast microbiological genetic
diversity. This has been put to use to assess diverse populations including the flora of whole
oceans. After shotgun sequencing the Sargasso Sea, over 1.2 million previously unknown
sequences were identified, two thirds of which bore no resemblance to known sequences [20, 21].
The hope is that these new sequences underpin novel biological processes that we may be able to
harness in fields ranging from climate change, to the development of new, more effective
antibiotics and vaccines. This year, Venter announced he had created artificial life for the first
time. A bacterial cell controlled by a completely synthetic genome demonstrated that new
sequences discovered through the metagenomics route might be put to use in synthetic cells [22].
As with almost everything Venter does, this sparked much controversy [23]. Get ready for more
where that came from; the last ten years were only the beginning. ❍
Benjamin Stewart is a third year medical student at St. Hilda’s College
References
1.
Sanger et al. Nucleotide sequence of bacteriophage phi X174 DNA. Nature 1977; 265:
687-95
2.
Dulbecco. A turning point in cancer research: sequencing the human genome. Science
(Washington) 1986; 23: 1055-1055
3.
Smith and Hood. Mapping and sequencing the human genome: how to proceed. Nature
Biotechnology 1987; 5 (9); 933-939
4.
Smith et al. Fluorescence detection in automated DNA sequence analysis. Nature 1986;
321: 674-678
5.
J Craig Venter. A Life Decoded - My Genome: My Life. 2007 Penguin (1st edition)
6.
Adams et al. Complementary DNA sequencing: expressed sequence tags and human
genome project. Science (New York, NY) 1991: 252; 1651
7.
Nagaraj et al. A hitchhiker's guide to expressed sequence tag (EST) analysis. Briefings in
bioinformatics 2007: 8 (1); 6-21
8.
Fraser et al. The minimal gene complement of Mycoplasma genitalium. Science (New
York, NY) 1995: 270 (5235); 397
9.
Goffeau et al. Life with 6000 genes. Science (New York, NY) 1996: 274 (5287); 546
10.
Roberts L. Controversial from the Start. Science 2001: 291 (5507); 1182 - 1188
11.
International Human Genome Sequencing Consortium. Initial sequencing and analysis of
the human genome. Nature 2001: 409; 860-921
12.
Venter et al. The sequence of the human genome. Science (New York, NY) 2001: 291
(5507); 1304-51
13.
Li et al. Evolutionary analyses of the human genome. Nature 2001: 409 (6822); 847-849
14.
Alexander et al. Annotating non-coding regions of the genome. Nature Reviews Genetics
2010: 11; 559-571
15.
Butler. Human genome at ten: Science after the sequence. Nature 2010: 465 (7301);
1000-1
16.
Venter. Multiple personal genomes await. Nature 2010: 464 (7289); 676-7
17.
Varmus. Ten years on--the human genome and medicine. The New England Journal of
Medicine 2010: 362 (21); 2028-9
18.
Cancer Genome Atlas Research Network. Comprehensive genomic characterization
defines human glioblastoma genes and core pathways. Nature 2008: 455 (7216); 1061-8
19.
Levy et al. The diploid genome sequence of an individual human. PLoS biology 2007: 5
(10); 254
20.
Venter et al. Environmental genome shotgun sequencing of the Sargasso Sea. Science
(New York, NY) 2004: 304 (5667); 66-74
21.
Hutchison III. DNA sequencing: bench to bedside and beyond. Nucleic Acids Research
2007: 35 (18); 6227-6237
22.
Genome. Creation of a Bacterial Cell Controlled by a Chemically Synthesized Genome.
Science (New York, NY) 2010: 329; 52-56
23.
Henderson M. IN Scientists create artificial life in laboratory. (2010). [Online]. Available
from
http://www.timesonline.co.uk/tol/news/science/biology_evolution/article7132299.ece
[accessed: 12th August 2010]
The enemy within
Elizabeth Anscombe explores recent advances and future prospects for
cancer therapy
For many types of cancer, substantial improvements in survival rates have been achieved over the
last decade [1]. Some of these improvements are due to better screening programs, prevention
strategies, or general population-wide changes in lifestyle, such as reduced rates of smoking.
However, much of the improvements come from exciting new advances in treatment. In general,
cancer research is a well-funded area and this research has helped provide insights into basic cell
biology as well as new treatments, some of which have already reached the clinic. However, it is
worth asking whether these results really justify the massive amount of money which has been
spent.
Personalised therapies
One area of cancer therapy that shows great promise is the potential for personalised treatments
[2]. Moving from a ‘one-size-fits-all’ approach to more personalised treatments improves the
prognosis by maximising the effect on the tumour, whilst minimising side effects. The tumour is
screened for biomarkers, including particular proteins that are up- or down-regulated. This then
allows appropriate therapies to be started early without wasting time, money and causing
unnecessary side effects by giving treatments which will not work in that patient. Whilst the vast
promise of personalised medicine has yet to completely unfold, patients can currently be screened
for certain genes which increase disease risk, especially in cancers that appear to be inherited (for
example the BRCA1/2 mutation in breast cancer). Chronic myeloid leukaemia patients can also
be screened for the BCR-ABL translocation to decide whether to give imatinib (a tyrosine kinase
inhibitor) which specifically targets this protein [3].
Therapeutic monoclonal antibodies
Monoclonal antibodies are one class of drugs that have already proven their worth in the clinic
[4]. The main advantage of using antibody therapy is that it is highly specific, targeted only to the
antigen present in the tumour, so should present fewer side effects. Many very successful
therapeutic monoclonal antibodies are available, for example rituximab, (which targets CD20),
trastuzumab (also known as Herceptin, which targets HER2) and bevacizumab (which targets
VEGF-R). Antibodies may also be conjugated to a radioactive isotope or chemotherapeutic agent
to provide a very specific delivery vector; or they may be targeted to secreted tumorigenic
antigens, and neutralising these can drastically slow tumour growth. Many further possible
therapeutic antibodies are in development to target other antigens, and these drugs may prove
even more important over the next few years.
Targeting tumour metabolism
Many of the recent advances in chemotherapy have arisen from our increased understanding of
what causes a cell to become cancerous. Targeting cancer cells will always prove more of a
challenge than targeting external pathogens; bacteria and viruses have many types of surface
molecule and metabolic functions not present in a human cell, whereas cancerous cells are
fundamentally the same as our ‘normal’ cells. Recently, however, it has become clear that whilst
cancer cells appear similar at first glance, there are many striking differences which provide an
entry point for therapy. For instance, many tumour cells change their metabolism, ‘switching off’
their mitochondria and relying on glycolysis, maybe to avoid the pro-apoptotic functions of the
mitochondria. A drug called dichloroacetate, normally used to treat rare mitochondrial diseases, is
able to reactivate the mitochondria and lead to cell cycle arrest and apoptosis [6]. It has been
shown to be effective at shrinking tumour cells and recent preliminary human trials show
improved survival for patients given the drug [7]. Other possible targets in this pathway could
produce a similar effect. It has been observed that metformin inhibits glycolysis and that patients
on this drug for type 2 diabetes tend to have a lower susceptibility to cancer and improved
survival if they do develop the disease [8].
Sulfatase inhibitors: multi-functional therapies
The sulfatase inhibitors are an example of the success possible for more targeted therapies, as
opposed to generally cytotoxic compounds. These compounds were developed as a therapy to
treat breast cancers that have become resistant to tamoxifen, but were later found to be active
against the oestrogen-producing enzyme aromatase as well [9].
When drug resistance occurs within a tumour, one way to overcome this is to give two or more
drugs in combination, but many are incompatible due to drug interactions or side effects. A
compound with multiple targets can therefore be useful both for increased effectiveness and to
combat resistance issues. In development of the sulfatase inhibitors, a new metabolic pathway
was discovered: as with all medicine, one of the side benefits of cancer research is often a better
understanding of the workings of a healthy cell.
Radiotherapy and surgery
Improvements in radiotherapy and surgery have progressed along the same lines, generally
focusing on using a more targeted approach to give a better outcome. Three-dimensional
conformal radiotherapy, intensity-modulated radiotherapy and other kinds of radiotherapy guided
by tumour imaging all allow the dose to the tumour cells to be increased whilst sparing the
surrounding normal tissue as much as possible [10]. Improvements in surgical technique involve
minimising the amount of tissue to be removed to allow for faster recovery and decreased
psychological impact for the patient, seen particularly for breast cancer, where a full mastectomy
is becoming less common and reconstructive or breast-conserving surgery becomes more widely
available [11].
Cancer therapies for the 21st century
The last decade has been very exciting for cancer research and there are many promising future
prospects. Some of the more speculative ideas include the possibility of using antibodyconjugated quantum dots for tumour imaging [12]; using ‘microbubble’ technology for targeted
drug delivery (antibody-conjugated drug in a tiny gas bubble, which is then burst with ultrasound
to deposit the drug) [13]; or even using nanobots to deliver siRNA to tumour cells to turn off
specific proteins [14]. There is good reason to be optimistic about the future of cancer therapy,
and to expect further improvements in the survival rates for many types of cancer, largely based
on our better understanding of cancer biology and an increasingly targeted and personalised
approach to cancer therapy.
Elizabeth Anscombe is a second year D. phil candidate in Biochemistry at Magdalen College
References
[1] Jemal et al., ‘Cancer Statistics 2010’ CA Cancer J Clin 2010 epub ahead of print
[2] Holmes et al., ‘Fulfilling the Promise of Personalised Medicine? Systematic Review and Field
Synopsis of Pharmacogenetic Studies’ PLoS ONE 2009 4(12) 1-14
[3] Alymani et al., ‘Predictive biomarkers for personalised anti-cancer drug use: Discovery to
clinical implementation’ Euro J Cancer 2010 46 869-879
[4] Weiner, Surana and Wang, ‘Monoclonal antibodies:versatile platforms for cancer
immunotherapy’ Nature Rev Immun 2010 10 317-327
[5] Arnold and Seufferlein, ‘Targeted treatments in colorectal cancer: state of the art and future
perspectives’ Gut 2010 59 838-858
[6] Coghlan, ‘Cancer’s sweet tooth becomes a target’ New Scientist 2010 2760 6-7
[7] Michelakis et al., ‘Metabolic Modulation of Glioblastoma with Dichloroacetate’ Sci Transl
Med 2010 2(31) 31-34
[8] Gagnon et al., ‘Protective effect of metformin in lung cancer patients’ J Clin Oncol 2009
27(15S)
[9] Day et al., ‘The development of steroid sulfatase inhibitors for hormone-dependent cancer
therapy’ Ann N Y Acad Sci 2009 1155 80-87
[10] Bhide and Nutting, ‘Recent advances in radiotherapy’ BMC Medicine 2010 8 25-29
[11] Reintgen et al., ‘Advances in Local-Regional Treatment for Patients With Early-Stage Breast
Cancer: A Review of the Field’ Clin Breast Cancer 2010 10(3) 180-187
[12] Smith et al., ‘Bioconjugated quantum dots for in vivo molecular and cellular imaging’ Adv
Drug Deli Rev 2008 60(11) 1226-1240
[13] Klibanov et al., ‘Ultrasound-triggered release of materials entrapped in microbubbleliposome constructs: A tool for targeted drug delivery’ J Control Release 2010 epub ahead of
print
[14] Jesus Diaz, in Gizmodo ‘This is the Future of the Fight Against Cancer’ 2010 [Online]
Available from: http://gizmodo.com/5501103/this-is-the-future-of-the-fight-against-cancer.html
[Accessed 1st August 2010]
Localised patterns of troubling behaviour
Jonathan Best considers some of the most bizarre medical conditions to
ever afflict the human race
Penis inversion, semen loss and sudden nocturnal death don’t have a great deal in common. They
are all, however, the subject of morbid preoccupation in an unusual group of culturally-specific
psychoses and neuroses listed in the Diagnostic and Statistical Manual of Mental Disorders-IV as
‘culture-bound syndromes’. These disorders fascinate both psychiatrists and anthropologists, as
they offer a unique chance to study the interaction between culture and psychopathology. Of
course, they also make for excellent dinner-party anecdotes. Mainly in that spirit, this article
provides a glossary of some of the best.
Bangungut
Cultural factors not only influence the expression of mental illness, but also the interpretation of
physical illness as well. Bangungut and Hmong Sudden Death Syndrome describe sudden death
during sleep in young Filipino and Laotian men, respectively. The death is traditionally blamed
on malign spirits, such as the batibat, which sits on its victims and suffocates them. The victim
may be visited several times before death, experiencing a series of vivid nightmares. Today,
cardiac arrhythmias are thought to underlie this: Brugada syndrome has a high prevalence in
Asian populations, and an increased incidence of QT abnormalities has been reported in the
Hmong refugees most at risk of sudden death [4]. Therefore, although described regularly as a
culture-bound syndrome, a psychiatrist probably isn’t the most helpful specialist to consult about
this condition.
Koro
While many men might be said to suffer from delusional ideas with respect to their private parts,
few reach the bizarre levels seen in koro, a neurotic disorder first reported in Malaysian
populations. The sufferer, typically a young man, becomes obsessed with the idea that his penis is
imminently going to retract into his body and invert, leading to impotence, sterility, and a
strikingly unpleasant death. The patient will go to great lengths to avoid this. During an outbreak
in Singapore in 1967, men were reported to have resorted to weights, pegs and clamps to ensure
that their member remained safely in place [1]. Allegedly, some concerned relatives even ‘lent a
hand’. One can only imagine how awkward this made future family gatherings. What might
underlie such a bizarre delusion? Although epidemics of koro have been attributed to causes
ranging from swine-flu vaccination to genital-stealing fox spirits, the underlying cause seems
most likely to be a culturally-modulated form of status anxiety. It has been suggested that the
regions in which koro-like disorders are seen – South East Asia, India and Africa – place special
worth on a young man’s reproductive ability. However, women are not immune: vanishing
breasts and receding labia have both been reported.
Zar
Observed in North-East African and Middle Eastern cultures, zar is unusual in that it occurs
exclusively in women. Following emotional trauma, the patient experiences dissociative episodes
in which they shout, laugh, cry and head-bang. Negative symptoms include apathy, withdrawal
and food refusal. Household tasks are ignored. The woman believes that she is possessed by a
spirit, with whom she develops a long-term relationship. In Somalia, such spirits are called sar,
and are viewed as men-hating – which makes a certain amount of sense, given that the man now
has to do the housework himself. Interestingly, zar is not viewed locally as pathological. It is
tempting to speculate, then, that ‘spirit possession’ provides a culturally-acceptable means by
which a woman can escape the restrictive role imposed on her by her traditional society.
Amok
Amok made a sufficient impression on British visitors to the Malay Peninsula to give rise to an
English phrase. However, similar disorders are seen world-wide, from New Guinea (ahade idze
be) to Puerto Rico (mal de pelea). Like zar, the precipitant is a traumatic episode, such as a loss
of status. However, the response is rather more direct: a period of brooding, then random and
unprovoked violence. Eventually, the patient becomes exhausted and collapses. He subsequently
has no memory of his crimes, but may commit suicide anyway. Alternatively, he may be killed by
bystanders or his intended victims. In many ways, this pattern of behaviour resembles the killing
sprees and murder-suicides seen in Western societies. In the United States, a series of murders by
disgruntled postmen – of all people - gave rise to the term ‘going postal’: another culture-bound
syndrome? Perhaps not. The validity of amok as a culturally-specific illness seems doubtful, and
underlying personality disorder, delusional disorder or psychosis is a likely characteristic of those
who run amok and go postal alike [3].
Dhat
Another disorder arising from concerns over virility is dhat, an Indian term referring to fatigue,
weakness and sexual dysfunction arising from an irrational fear that sperm are being passed in
one’s urine [2]. Sufferers may even claim that their urine has started to resemble semen. In
ayurvedic philosophy, semen is derived from the conversion of food to blood, then flesh, then
marrow, which eventually gives rise to dhatu (‘elixir’). One drop of a substance requires forty
drops of its precursor to make. Since, by this calculation, one drop of semen is distilled from a
remarkable 2,560,000 drops of food, it is easy to see why semen loss might be a concern in
cultures influenced by this philosophy. Before laughing too much at this apparently primitive
superstition, consider attitudes towards masturbation in Victorian England. Condemned as
leading to blindness, debility and unpleasantly hairy palms, extra-marital ejaculation has been a
focus for neurosis ever since Onan spilt his seed on the ground. Perhaps this ‘culture-bound
syndrome’ is just an unusually florid example. As an aside, when eating breakfast tomorrow, you
might reflect that J. H. Kellogg designed his cereals principally to combat the evils of
masturbation. Fortified with vitamins and iron, indeed.
Windigo Psychosis
Ever worried you might be turning into a monster? A famous creature from Algonquian Indian
mythology, the Windigo was a malevolent cannibalistic spirit, capable of possessing a man by
turning his heart to ice. Travellers in the northern United States and Canada heard tales of Native
Americans becoming convinced that they were becoming Windigos. Some would even beg to be
killed whilst they could still resist their longing for human flesh. Although a compelling story,
that this ‘Windigo Psychosis’ ever really existed is doubtful: no single case has been described in
mainstream scientific literature [5]. This demonstrates a property of all culture-bound syndromes
– in being so bizarre, they attract interest far out of proportion to their incidence, and can become
something of a self-sustaining phenomenon. Somehow, this seems quite appropriate.
Conclusion
These culture-bound syndromes vividly illustrate the influence of culture on the presentation of
mental illness. Since the default culture of psychiatry is that of the Western societies which gave
rise to it, it is not surprising that the possibility of equivalent ‘Western’ syndromes has been
largely overlooked. However, anorexia and bulimia nervosa, chronic fatigue syndrome and
Munchausen’s syndrome all bear the mark of our image-conscious and highly-medicalised
modern society. In another world, this article might be about them.
Jonathan Best is a final year medical student at Trinity College
References
1.
Chong T. Epidemic {italicise} koro in Singapore. Br Med J. 1968 Mar;1(5592):640-1.
2.
Sumathipala A, Siribaddana S, Bhugra D. Culture-bound syndromes: the story of
{italicise}dhat syndrome. Br J Psychiatry. 2004 Mar;184:200-9.
3.
Saint Martin M. Running {italicise} amok: A Modern Perspective on a Culture-Bound
Syndrome. Prim Care Companion J Clin Psychiatry. 1999 Jun;1(3):66-70.
4.
Munger R, Prineas R, Crow R, Changbumrung S, Keane V, Wangsuphachart V, et al.
Prolonged QT interval and risk of sudden death in South-East Asian men. Lancet. 1991
Aug;338(8762):280-1.
5.
Semple D, Smyth R. Oxford handbook of psychiatry. 2nd ed. ed. Oxford: Oxford
University Press; 2009.
Dangerous liaisons
Charlotte Skinner examines the allure of the criminally insane
Human fascination with crime is not a new or abnormal phenomenon. Both real and fictionalised
crime holds a widespread appeal. There are numerous murder mysteries and detective dramas on
television, as well as true-life documentaries. Bookstores have entire sections dedicated to
fictional crime and thrillers, as well as ‘true crime’ or serial killer biographies. There are always
crime stories in the news and the advent of round-the-clock reporting has added a new intimacy to
police proceedings, as seen recently with minute-by-minute blogging of the recent Raoul Moat
police hunt. As a society we seem to be fascinated by crime. However, some people take this
fascination a step further and befriend, or even form intimate relationships with, some of society’s
most dangerous criminals and psychiatric patients. It seems to be mostly women who seek out
relationships with these dangerous individuals. It is thought that women who have been victims
of abuse are particularly drawn to these men as a means of compensating for the past. Some of
these men, especially the forensic psychiatric patients, can also be superficially charming and are
especially adept at preying on vulnerable women.
Prison is not normally thought of as the ideal place to begin a relationship with someone.
However, around 200 serving prisoners in the UK get married every year [1]. A number of these
relationships begin before jail, but there are an increasing number of unions which begin after the
prisoner’s sentence has started. A growing number of religious, charity and community
organisations encourage letter-writing to inmates. These organisations usually encourage letterwriters to keep relationships with prisoners platonic or focus on ‘spiritual growth’, according to
the organiser of one such charity [2]. There are means for prisoners to make contact with the
outside world as well; commercial websites, such as ‘MeetanInmate.com’ in the US, allow
inmates to post online advertisements for penpals. Some of the adverts request legal advice,
others request friendship and contact with the outside world, and some are personal adverts.
Would-be pen-pals are able to browse convicts’ profiles and obtain their mailing address for a
small fee.
There are also a number of prisoners sentenced to death in the US who are in relationships with
civilians. Currently, it is estimated that around 100 women in Britain are involved with men on
death row [3]. Interestingly, it is often the most notorious and dangerous inmates who receive the
most attention from admirers. Charles Bronson, often referred to as Britain’s most violent
prisoner, met and married his second wife whilst in prison. She had seen his photo in a local
paper and began writing to him. Timothy McVeigh, the Oklahoma bomber, received numerous
letters of admiration as well as marriage proposals before his execution.
Inpatients of high-security psychiatric hospitals also hold a similar appeal to some people. Some
of the countries most notorious criminals are held in these institutions and receive letters of
admiration, including marriage proposals, from members of the public. There have also been a
number of liaisons between staff at these institutions and inpatients. In the past three years, there
have been three nurses at Broadmoor Hospital who have been sacked or suspended once details
of their sexual relationships with patients were made public [4]. The inpatients involved were all
convicted sex offenders. Research in this area is understandably hard to obtain as it relies on selfreporting from psychiatric professionals. However, there are several reports in the literature of
staff-patient liaisons in all fields of psychiatry, including forensics. The evidence seems to
suggest, although the numbers are relatively limited, that in forensic psychiatry it is usually
female staff that form inappropriate relationships with male patients and vice versa in general
psychiatry.
“It is thought that women who have been victims of abuse are particularly drawn to these men as
a means of compensating for the past.”
Indeed, there is an overwhelming imbalance in the number of women who begin intimate
relationships with prisoners or psychiatric inpatients compared to men. The far greater number of
men in these institutions only partly accounts for this. There are a number of theories as to why so
many women are drawn to such dangerous men. Sheila Isenberg carried out an in-depth
psychological analysis and found that many of these women had been victims of abuse or
violence [5]. She hypothesises that this type of relationship gives them the control that they seek.
They decide when to visit, when to call, they always know where their partner is, and they
become their main link to the outside world. It becomes a means of re-writing the past. Many of
the women were also actively involve in trying to have their partner’s sentence revoked or
shortened and thus derived a sense of purpose and power from the relationship that they had not
experienced before.
Convicted killers can be very alluring according to Dr Patrick Kennedy, a consultant forensic
psychologist, and can have a strong sexual presence which is very masculine, traditional, and
appeals to some women [3]. They are often intelligent individuals who use whatever they have at
their disposal to get what they need and are quite able to charm their way into the affections of
women. Dr Kennedy also suggests that, by associating with these men, some women are
vicariously fulfilling their own wishes; that there is a ‘vicarious desire to have that murderous
power’ achieved by being in the presence of these men. It has also been suggested that the
susceptibility of some female staff members in forensic psychiatric units is because of the unusual
power balance that occurs [6]. These institutions contain some very dangerous men who, in
normal circumstances, would be very intimidating. However, they are in a secure environment
with a lack of autonomy and thus may perhaps be rendered ‘safe’. It has been speculated that this
may be a liberating influence for some staff members, combined perhaps with a sexual
fascination in some of the male sex offenders. Some of these inpatients may also be accomplished
at charming and seducing vulnerable women to get what they want. This is the so-called
‘charming psychopath’ which can be a feature of antisocial personality disorder. It would perhaps
be wise, when recruiting for positions at such institutions, to consider which people might be
most susceptible to forming inappropriate attachments with inpatients and to take measures to
protect the most vulnerable individuals.
Relationships with felons are not unusual it would seem and the majority of these are not highprofile ‘celebrity’ criminal unions but ones which have developed gradually over a long period of
letter-writing and prison visits. One author attributes the success of such relationships to this long
formal courtship, which is comparable to Victorian courting [7]. The ever-increasing media
coverage of crime and the use of internet dating sites have allowed more and more people to be
able to make contact with prisoners. The impulse that drives some people, usually women, to seek
out and form intimate relationships with some of the most dangerous members of society is
complex and incompletely understood. Some may feel sympathy and want to offer legal advice to
those they feel are wrongly incarcerated; others may be seeking a relationship where they have
control and power in contrast to their previous experiences; and some are drawn to convicted
criminals and killers with a morbid sexual fascination.
Charlotte Skinner is a final year graduate-entry medical student at Worcester College
References
[1] HM Prison Service Statistics
[2] Fisher R. What Draws People to Marry Prison Inmates? ABC News. 10th August 2005
[3] Wilson S. Women Who Date Death Row Prisoners. The Daily Telegraph. 14th June 2010
[4] Pyatt J. Broadmoor Rapist has Flings with Two Nurses. The Sun. 1st February 2010
[5] Isenberg S. Women Who Love Men Who Kill. iUniverse.com Publishers; 2000
[6] Peter-Thomas B, Garrett T. Preventing Sexual Contact Between Professionals and Patients in
Forensic Environments. The Journal of Forensic Psychiatry. 2000. 11:135-150
[7] Goodchild S. Jailbirds Make Good Lovebirds. The Independent. 7th April 2002
Sleep-killing
Annabel Christian on the truth behind homicidal somnambulism
You can hear him behind you, his footsteps crunching along the gravel as he moves closer and
closer. Your heart is pounding and you try to silence the short, ragged breaths that rip through
your chest. The fear becomes overwhelming as you realise he is going to find you. Turning
slowly, you grip the knife, ready to use it to protect yourself. And then, you strike. Everything
goes black.
Regaining your senses you feel startled and confused. You are breathing quickly and don’t know
where you are. Relief pours through you as you realise it was just a dream. You open your eyes
and stare into the terror-stricken face of your dead wife. Blood covers your body and face, and in
your hand you hold a knife.
Homicidal somnambulism
Murdering whilst asleep, known as homicidal somnambulism, has been described by Lord Justice
Lawton as a “quagmire of the law, seldom entered save by those in desperate need of some kind
of a defence” [1]. There have been approximately 68 cases worldwide of murdering whilst
sleepwalking and all have fared differently within the judicial system.
The law states that a person who commits a criminal act whilst asleep is not conscious of his
actions, and hence the defendant is able to make a plea of automatism. Committing a violent
crime during sleep is known as ‘sane automatism’, ie the automatism was the result of some
external factor, in this case sleep. The defendant is only required to produce medical evidence to
support this plea, with the burden of proof resting on the prosecution who has to disprove
automatism beyond reasonable doubt. A plea of ‘insane automatism’ occurs when the defendant,
at the time of the offence, was suffering from a defect of reason and results in an acquittal on the
grounds of insanity, often resulting in being committed to psychiatric hospital.
Parasomnias
Sleepwalking is just one type of sleep disorder in a class known as non-rapid eye movement
(NREM) parasomnias. A night’s sleep consists of two alternating cycles known as NREM and
rapid eye movement sleep (REM), each lasting approximately 90 minutes. It is during the REM
cycle that we dream; if woken during this cycle, the person regains clear consciousness very
quickly and can usually recall the dream. REM sleep is characterized by rapid eye movement and
low muscle tone: the body is paralysed and so the dream cannot be acted out.
NREM sleep is divided into four different stages, with stage four (slow wave sleep) being the one
in which parasomnias most commonly occur. Although mental experiences do occur, in NREM
sleep they are very different from typical dreams, being poorly formed. If one is aroused during
slow wave sleep, they will not regain clear consciousness immediately and will have poor
memory recall. As the body is not paralysed during NREM sleep, this is the phase during which
sleepwalking can occur. The sleepwalker is unable to reason, compare ideas or direct thought,
although curiously is able to maneuver around furniture and undertake highly complex and
coordinated movements, giving the appearance of engaging in purposeful behavior. Although the
eyes are usually open in sleepwalking, the sleepwalker does not fully incorporate the
environment. In Shakespeare’s Macbeth, the Doctor comments on Lady Macbeths sleepwalking:
“Her eyes are open”, to which the lady-in-waiting replies: “Aye, but her senses are shut”.
There are a number of sleep disorders characterized by committing unusual actions whilst asleep,
ranging from compulsive eating to engaging in sexual intercourse. In a condition known as
nocturnal sleep-related eating disorder, a person will roam the house looking for food and binge
on high sugar, high fat foods. Often the sufferer will wake up in the morning surrounded by
chocolate wrappers without any recollection of how they got there.
Sleep sex (a term first used by David Saul Rosenfeld in 2003, a neurologist with a specail interest
in sleep disorders), or sexsomnia, causes people to commit sexual acts whilst they are asleep. As
with homicidal somnambulism, people charged with committing a sexual offense have used a
sleep disorder as part of their defence; for example, James Bilton, a 22 year-old accused of three
counts of rape. Mr Bilton, who had suffered from sleepwalking from the age of 13, was
monitored by a sleep expert who agreed he was one of the 1.0-2.5% of the adult population that
suffers from sexsomnia. He was cleared of all three charges [2]. The fact that a person can, in
theory, carry out a wide range of actions whilst asleep, as demonstrated above, implies that
homicidal somnambulism may well be a valid occurrence and not just a legal loophole to avoid
prosecution after committing a murder.
Homicidal somnambulism has been documented since medieval times, although the first recorded
case of sleepwalking being used as a defence for murder was in 1846. It is thought that many
more cases may have occurred but the willingness of nineteenth century jurors to accept this
defence means that few cases actually made it to court and hence there is limited documentation
of trials relating to homicidal somnambulism. In recent times, when cases of violence during
sleep occur, the courts have begun to rely heavily on the evidence provided by healthcare
professionals to explain whether or not this phenomenon is a valid defence. This is demonstrated
by the following case report of Kenneth Parks, a 22 year-old from Toronto, who in May 1987 was
charged with the first degree murder of his mother-in-law and the attempted murder of his fatherin-law [3].
Case report
On the evening of the murder, Kenneth Parks fell asleep on his sofa at approximately 1:30 am.
The next thing that he claims to remember is seeing the terrified face of his mother in law,
followed by some isolated memories (with amnesia in between), such as attempting to reassure
the young children present in the house by yelling “Kids, kids!” (although the hiding children
report only hearing ‘animal noises’ from Parks). Parks remembers arriving at the police station
for help and, on being questioned, answering: “I think I have killed some people…..my hands”.
It was only at this point that Parks felt any pain in his hands which had several severed flexor
tendons. Under police escort he was taken to the hospital for treatment where a physician noted
him to be “a sad, remorseful and perplexed male”. Parks was charged and subjected to both police
questioning and psychiatric assessment. There are some aspects of the night that Parks could
never remember, such as getting himself dressed, the 15 minute drive to his in-laws house (a
route that contains three traffic lights), and strangling his father-in-law unconscious before
stabbing his mother-in-law several times.
A number of different diagnostic possibilities were considered ranging from amnesic drug related
state to complex partial epileptic seizures with automatic behavior. After an intense psychiatric
assessment lasting four months, it was concluded that although he had characteristics of
depression and anxiety, none of the dissociative features of psychosis (such as hallucinations,
delusions and paranoia) were present. It was at this point that the possibility of Parks having a
sleep disorder was investigated. Parks’ family history contained a high frequency of parasomnias
including sleepwalking, sleep talking and night terrors (relevant since somnambulism has a strong
genetic component). Parks’ sleep was investigated using polysomnography, a multi-parametric
test used to monitor many body functions during sleep including eye and skeletal movement and
brain activity. Two polysomnographs confirmed that Parks did have abnormal sleep patterns, with
high levels of slow wave sleep consistent with sleepwalking. The legal defence claimed homicide
due to sane automatism as part of a presumed episode of somnambulism. Medical information,
teamed with the lack of motive, resulted in a verdict of not guilty and Kenneth Parks walked free.
Assessment criteria
Mahowald et al. devised a list of seven criteria for legal evaluation of sleep-related violence [4]
(see box 1). This is not a comprehensive list of criteria that must be met, but it is useful as
guidelines for both healthcare professionals and lawyers when assessing a case of homicidal
somnambulism. It is important to remember that these crimes occur only very rarely, and hence
often attract a lot of media attention. The most recent case in the UK was that of Jules Lowe who,
in 2003, battered to death his 82 year-old father during a sleepwalking episode. He was acquitted
on the grounds of insane automatism and committed indefinitely to a psychiatric hospital [5].
Homicidal somnambulism is an interesting and terrifying example of sleep related violence which
will always be a slightly grey area within the judicial system, relying heavily on medical evidence
to try and evaluate whether there was intent behind the actions of the defendant. If a person is
truly asleep when they commit a murder, and have no recollection of the event until they regain
consciousness, then surely the guilt that they have to live with for the rest of their lives is
punishment enough.
Annabel Christian is a fifth year medical student at Hertford College
Box 1: Assessment criteria for a sleep disorder






The duration of the action is usually brief (minutes).
The behavior is usually abrupt, immediate, impulsive, and senseless, without apparent
motivation.
The victim is someone who merely happened to be present, and who may have been the
stimulus for the arousal.
Immediately following the return of consciousness, there is perplexity or horror, with no
attempt to conceal, or cover-up the action.
There is usually some degree of amnesia for the event.
The sleepwalking would occur usually at least one hour after the onset of sleep and could
be due to sleep deprivation.
Text Boxes [6]
Esther Griggs
London housewife and mother of three, Esther Griggs, dreamt her house was on fire and threw
her baby out of a glass window. Witnesses on the street heard her screaming “Oh my children!
Save my children!” The grand jury ruled that Griggs need not be tried in court and hence she
walked free.
Albert Tirrell
In Boston, 1846, Albert Tirrell slit a young woman’s throat so savagely that her head was almost
severed before burning the body to cover up the murder. When the case came to trial, Tirrell's
famous lawyer Rufus Choate argued that Tirrell was not responsible for his actions as he was
asleep when he started the fires. The jury took less than two hours to agree and Tirrell was
acquitted.
Jo Ann Kiger
Teenager Jo Ann Kiger dreamt that her family was being attacked by a 'monster' and so in
defence took a revolver in each hand and fired, killing her brother and her father. She was found
not guilty.
Simon Fraser
Simon Fraser often dreamt that a beast invaded his home at night. On one occasion he fought
back and killed the beast. On waking, he had murdered his infant son. He was acquitted but
ordered by the court to sleep henceforth by himself in a locked room.
References
1.Regina v Quick. Queen's Bench 910. 1973
2.BBC news. Sleepwalking man cleared of rape. (2005) . [Online] Available from:
http://news.bbc.co.uk/2/hi/uk_news/england/north_yorkshire/4543340.stm [Accessed 31 August
2010]
3. Broughton R, Billinga R Homicidal somnambulism: a case report. Sleep 1994 17(3) 253-264
4. Mahowald M, Bundlie SR, Hurwitz TD, Schenck CH. Sleep violence: forensic science
implications: polygraphic and video documentation. J. Forensic sci 1990 ;35 413-32
5. BBC news. How sleepwalking can lead to killing. (2005) [Online] Available from:
http://news.bbc.co.uk/2/hi/uk_news/4362081.stm [Accessed 31st August]
6. Wallechinsky D, Wallace I, Wallace A. Book of lists 3 (1983)
“He had the colours all wrong”
Synaesthesia and its implications
We have all had dreams where we are not quite sure whether we are awake or asleep. Senses
blur and everything seems surreal. What would happen if you lived your entire life like this?
What if you could not separate sight from sound or taste from texture? To us, this may seem
stranger than fiction but for one group of people this seemingly inconceivable phenomenon is
reality.
The key to understanding our brain
Synaesthesia is a cross-modal sense phenomenon in which stimulation of one sensory pathway
results in the automatic activation of another. The word itself is derived from the Greek σύν (syn),
together, and αἴσθησις (aisthesis), sensation.
The epidemiology of synaesthesia is atypical. It is believed to be present until the age of six
months and persists in up to 5% of adults. Females are more affected than males and, according
to a survey of synaesthetes by the Cambridge Evening News, the ratio is as high as 6:1. One
quarter of synaesthetes also reported to have a first degree relative with the condition, suggesting
a strong genetic basis. Despite a large body of research, the causes of synaesthesia remain a
mystery.
There are two main theories explaining synaesthesia: cross-activation and disinhibitied feedback.
In the former it is believed that there are compromised or additional connections between the
sensory cortices [1]. In this way, visual information can cross over to the auditory cortex and vice
versa. These connections may be due to abnormal developmental processes or events which occur
later in life. Disinhibited feedback refers to the flow of sensory information. It is believed that
high order, complex cortical structures feedback to lower order, comparatively simple cortices
and even sensory organs to influence their activity. It is suggested that when this antidromic or
reverse feedback is compromised, sub-threshold sensation can enter consciousness, eliciting an
enhanced sensual experience, that is, synaesthesia [2].
Interest in synaesthesia peaked over a century ago with the highest publication rate between 1880
and 1910. Interestingly, this coincides with the most productive period of Vassily Kandinsky, the
famous synaesthetic artist. However, the subject lost appeal due to the inability to find a causal
mechanism. Recently researchers have returned to the subject realising its potential as the key to
elucidating the mysteries of normal cognitive function.
Personal accounts
Primary and secondary accounts of synaesthesia offer us an extremely important insight into the
phenomenon. Drawing together personal experiences will one day allow us to piece together the
jigsaw of the synaesthetic brain. I met up with a synaesthete to tell me more.
One of the most striking things you learn upon speaking to synaesthetes is that they consider the
condition to be a character-trait as much a part of the person as empathy or ambition. ZV said that
she has had it for as long as she remembers. She only became aware when she read Voyelles by
Rimbaud in a literature lesson: “A black, E white, I red, U green, O blue.” To ZV this was
strange: “I said I liked the poem, but he had the colours all wrong!” Synaesthesia is as personal
and varied as the human fingerprint. Another synaesthete, AH, finds sounds evoke powerful
visual perceptions. He says:
“These can be quite banal, a mouse click is a glossy light grey cone shape; or more elaborate, a
squeaking door is a very thin trench that decays to a point running through a yellow block. I find
it really difficult to try and describe a shape or colour without actually hearing it though - almost
like trying to remember a dream you can’t quite recall.”
The perceptions of ZV have remained almost completely unchanged throughout life except that
she mentioned “Saturday changed from light blue to grey.” Clearly synaesthesia is something so
intrinsic, so fundamental, and so concrete in the mind that it is protected within the brain, left
unmarred by time and experience. Synaesthetes often report that experiencing the world in this
way has an important impact on their lives. Needless to say when offered a hypothetical cure she
was quick to turn it down, if anything she seemed somewhat jealous of peers whose synaesthesia
was more profound.
The extent of the benefit of synaesthesia can be seen across the creative spectrum. Artists such as
Kandinsky, writers such as Baudleaire and musicians such as Billy Joel were all diagnosed with
synaesthesia [3]. Synaesthesia has been shown in these people to enhance their creativity. It is
unlikely that Kandinsky would have been the artist he was without synaesthesia. In this way
synaesthetes may find ways to benefit from their increased associations and insight.
Do children hold the key?
Synaesthesia may not be as black or white as was first assumed. In fact, it has been suggested that
we all have the power to unlock our own synaesthesia. Recent research has shown that
synaesthesia is present in all neonates. As such, a lack of synaesthesia in the adult is caused by a
failure to preserve these connections. If this were true then the phenomenon of synaesthesia holds
the key for various insights into the development of the brain.
Much of the evidence for this theory comes from histological evidence in animals. It has been
seen that the neonatal hamster has transient connections between the retina and the main sensory
and auditory nuclei of the thalamus. In the kitten there are connections between the visual,
auditory, sensory, and motor cortices. Maurer suggests that the same may be true in human
neonates. “During early infancy...evoked responses to spoken language [are recorded] not just
over the temporal cortex, where one would expect to find them, but over the occipital cortex as
well.”
Baron-Cohen suggests that a positron emission tomography (PET) imaging study on human
neonates would definitively answer the questions posed [4]. It is likely that we are a few years
off concluding on this subject. However, a breakthrough has come in the form of one person who
developed synaesthesia during their adult life, and could therefore give a verbal account of the
development of their synaesthesia.
In a blind town, the one-eyed man is synaesthetic
PH developed retinitis pigmentosa in childhood and progressively lost his vision until he became
completely blind at 40 years old [5]. At the age of 42 years he started experiencing vivid
synaesthesia; tactile stimuli on the hand evoked a vivid visual sensation of movement, expansion
or jumping. A facet of the disinhibition theory is that a poverty of sense will increase the
sensitivity of the others, giving rise to abnormally powerful senses. One possible mechanism for
this may be re-wiring of the brain due to neuronal plasticity. Famous examples include Ludwig
van Beethoven, Ray Charles and Stevie Wonder to name a few.
Before synaesthesia, he experienced vivid hallucinations, the primary feature of Charles Bonnet
Syndrome, a condition characterised by the experience of visual hallucinations in patients with
visual impairment. In PH the hallucinations started as a cluster of small red dots in his central
vision. He described them as “continuous.”
“Eventually as time went on the dots coalesced to form a reddish cartoon face that looked kind of
demonic. The colour would change from time to time, especially the eyes. This moved with my
eye movements. The face was originally in two dimensions but later acquired depth.”
However, his condition developed into total tactile synaesthesia. He said: “whenever I touch an
edge, it flashes in my head and when I see an angle, it is exaggerated [compared] to what I knew
it was.” Tapping his finger would cause “jiggling” or “flashing”, the frequency of which was
directly proportional.
This case provides good evidence that loss of sight could lead to synaesthesia. The experimenters,
Armel and Ramachandran go on to suggest that all blind people have the potential to develop
synaesthesia if they have certain characteristics. For instance it is believed that a period of clear
vision early in life is important. This case remains isolated and for that reason lacks any
predictive power. However, a substantial body of evidence is growing from an unlikely source.
Hallucagens: The gateway drugs?
A somewhat ethically questionable study showed that volunteers who took mescaline, LSD and
psilocybin gained synaesthetic perception [6]. The issue of drug-induced synaesthesia is one of
the most controversial, despite an unsurprising high number of test subjects willing to get paid for
their contributions.
This study is based on the idea that the inhibitory action of drugs may depress areas of the cortex,
thus creating the aforementioned poverty of sense. The study was conducted in 1962 and lacks
many of the definitive tests for synaesthetic visions we use today, such as PET and functional
magnetic resonance imaging. The results obtained from the volunteers
are subjective and open to considerable bias. Drugs are known to at least modify existing
synaesthesia. In one gustatory synaesthete, depressants such as alcohol accentuated their
synaesthesia whilst depressants such as nicotine and caffeine reduced them. Definitive evidence
could be achieved using PET to measure activation of sense cortices [7]. Unfortunately, ethics
committees continue to be adverse to supplying test-subjects with hallucinogenic drugs and
putting them in a PET machine!
Conclusion
Evidence, as well as the diagnosis of synaesthesia, remains controversial and undoubtedly fraught
with inaccuracies. Excitingly, several behavioural and imaging tests are beginning to elucidate the
truths behind many of the claims made about this condition [8, 9]. The aforementioned findings
are some of the more interesting examples but they are the tip of the synaesthetic iceberg. Others
include synaesthesia induced by hypnosis, blindfolds, meditation or even mirrors [10-13]
Synaesthesia remains popular and many people make unsubstantiated claims to have
‘synaesthetic visions’ This is partly due to differing opinions in what constitutes synaesthesia.
The idea of synaesthesia is intrinsically linked to metaphor and as such, synaesthetic descriptions
in non-scientific literature are surprisingly far-reaching. Not only is synaesthesia stranger than
fiction, but it remains a powerful inspiration in writing it.
Joshua Harvey is a third year medical student at Balliol College
The author would like to thank ZV and AH for agreeing to talk to him about their experiences as
synaesthetes. He would also like to thank Charles Spence for contributing to the author’s
understanding of the condition.
References
[1]. Ramachandran VS and Hubbard EM (2001). Synaesthesia: A window into perception,
thought and language, Journal of Consciousness Studies 8 (12): 3–34.
[2]. Grossenbacher PG and Lovelace CT, Mechanisms of synesthesia: cognitive and
physiological constraints, Trends in Cogn Sci. 2001, Jan 1;5(1):36-41
[3]. http://en.wikipedia.org/wiki/List_of_people_with_synesthesia
[4]. Baron Cohen. Is There a Normal Phase of Synaesthesia in Development? PSYCHE, 2(27),
June 1996
[5] Armel KC and Ramachandran VS, Acquired Synesthesia in Retinitis Pigmentosa, Neurocase
(1999) Vol. 5, pp. 293-296
[6] Hartman AM and Hollister LE, Effect of Mescaline, Lysergic Acid Diethylamide and
Psilocybin on Color Perception, Psychopharmacologia 4, 441--451 (1963)
[7] Paulesu, E.; Harrison, J.E.; Baron-Cohen, S.; Watson, J. D. G.; Goldstein, L.; Heather, J.
(1995), "The physiology of coloured hearing: A PET activation study of colour-word
synaesthesia", Brain 118: 661–676
[8] Baron-Cohen S, Burt L, Smith-Laittan F, Harrison J, Bolton P (1996). Synaesthesia:
prevalence and familiality, Perception 25 (9): 1073–9.
[9] Ward J, Tsakanikos E, Bray A (February 2006). Synaesthesia for reading and playing musical
notes. Neurocase 12 (1): 27–34.
[10] Kadosh, R.C., Henik, A., Catena, A., Walsh, V. & Fuentes, L.J. (2008), Induced cross-modal
synesthetic experience without abnormal neuronal connections. Psychological Science.
[11] Merabet et al Visual Hallucinations During Prolonged Blindfolding in Sighted Subjects, J
Neuro-Ophthalmol 2004;24: 109–113
[12] Roger Walsh, Can Synaesthesia Be Cultivated? Indications from Surveys of Meditators,
Journal of Consciousness Studies, 12, No. 4–5, 2005, pp. 5–17
[13] V. S. Ramachandran and D. Rogers-Ramachandran, Synaesthesia in Phantom Limbs
Induced with Mirrors, Proc. R. Soc. Lond. B 1996 263, 377-386
I see trees of red, green roses too...
Daniel Johnson on colour blindness in medicine
Staring down a microscope during the pathology course in my second year of pre-clinical was the
first time that being colour blind had an actual effect on my medical career. Now as I’m sure
you’re all aware, we normally have three types of cone cells in the eye, sensitive to different
ranges of the spectrum (approximately blue, red and green). The most common form of “colour
blindness” is anomalous trichromacy: a shift in the range of sensitivity of cones, usually the green
set. I, however, am lucky enough to have the superb title of protanopia (located just a few miles
from Utopia). In protanopia, there is a complete loss of the red cones. As our evolution to
trichromacy is thought to stem from the need to distinguish ripe from unripe fruits, my lack of red
cones not only means that I am a step backwards in evolution, but also means I am forever buying
green bananas and wondering why they’re so crunchy.
I have often wondered why I hadn’t considered my colour blindness potentially giving me
problems in medicine any sooner. There have been countless occasions throughout my life where
I’ve fallen foul of my absent cones. The first suspicion that something was wrong came from my
primary school teacher, Mrs Pearce. She picked up on my drawings of my family (green skin) and
of my colouring of Roger Red Hat and Billy Blue Hat (aka Garry Green Hat and Percy Purple
Hat). For a long time, the working diagnosis was that I was a bit thick. Fair enough. However,
one afternoon, while everyone else was colouring in (the basis of geography degrees the world
over) I was - not for the last time - separated from the other children and given a large pile of
Smarties. My task, should I choose to accept it, was to match all my Smarties into little piles of
red, green, blue, purple, and so on. If I got the Smarties in the right pile I could eat them. If I
didn’t, I couldn’t. I managed to eat the yellow Smarties and that’s it. And so Mrs. Pearce spoke to
my parents, they spoke to a doctor, and they all spoke to me and got me to trace out pictures in a
book with lots of coloured dots (being too young to count up to 42 as required for a normal
Ishihara test). And lo, I was diagnosed as colour blind.
At secondary school (and also at Scouts - what a candid look into my life you’re getting) I
discovered that no, I couldn’t read maps. Or titrate solutions in chemistry. Or colour anything
properly in art. Or cook in home economics (never trust me to cook your food properly, I’ll just
hope it’s been in the oven long enough and that it hadn’t gone off before I started cooking it).
And so to sitting in the MSTC, looking down a microscope, trying to distinguish Gram positive
and negative bacteria (purple and pink). This is not easy, but I do have some workarounds for
telling colours apart. One of these is to distinguish the intensity of certain shades. Hard to explain
really... my usual way of telling purple apart from blue is finding purple a more intense colour,
but I will still confuse it with a dark blue.
As such, I frequently misidentify bacteria due to how long they have been left to stain. The same
is true for a dark red and a brown, something which has reared its head when I was asked to
distinguish between new and old blood from a patient in A & E earlier this year. Thankfully, for
my pathology exam, I had written confirmation from the hospital of my protanopia, meaning I
would have someone in the exam to tell me what colour certain features in slides were. I cannot
put into words the relief of having the safety net of an examiner describe the colour of a tissue as
“salmony”, in the middle of an exam. “And what colour is a salmon?” I asked.
My inability to interpret slides occurred again in the pathology course at the start of clinical
school. This time I had reassurance that there would definitely be NO slides in the exam. As I
looked though my options for question two: “Identify the abnormality shown in the following
slides”, I began to fear for my chances. Fortunately, while I thought this would put me at a
disadvantage to everyone else, I am reliably informed that no one else had a clue what was shown
in the slides either. While I have no intention of going into pathology, I occasionally wonder
whether not being able to fully appreciate the educational value of those histology sessions has
hindered my learning of the features of certain diseases... then I get out the Oxford Handbook and
look up the answer.
Away from the laboratories, there have only been two scenarios where I’ve needed help during
my time in clinical school. One of these is something I am certain will follow me around for my
whole career, and that is not being able to distinguish the colours of the test tubes when taking
bloods. I either ask a nurse, doctor or medical student to get them out for me and then put them in
the correct order on my tray (thus meaning I never have to learn what order to take bloods in). On
a similar note, I have only ever once inserted a cannula, only to be told that I’ve put in the wrong
size (colour coding strikes again).
The second scenario is probably the one I find slightly more worrying. That is looking at a patient
and saying what colour they are. Given my hobby of colouring people in green, I do worry about
my ability to pick up if a patient is pale (pale green?) cyanosed or jaundiced. However, my fallback is, as always, if in doubt ask for help. I’m more than used to the embarrassment of asking
the staff in clothes shops what colour a shirt is before I buy it, so asking a nurse or fellow doctor
for the colour of a patient is like (purple) water off a duck’s back. ❍
Daniel Johnson is a final year medical student at New College
Penis Captivus
From the casebook of Egerton Y. Davis
In a sleepy rural town in 19th Century England, a distressed gentleman summoned his family
physician. It was late in the evening so the conscientious doctor, Egerton Y. Davis, must surely
have expected a good reason for the home visit. He was not to be disappointed, as the situation
that unfolded was both unusual and dramatic.
The gentleman who called on Davis did so on behalf of his coachman, whom he had found in bed
with one of the maids. Both coachman and maid were screaming loudly, locked together in
embrace. The screams were those of agony, fixed as the couple were in a state that may best be
described as de cohesione in coitu. The author of this remarkable case report comments that, as an
illustration of Iago’s beast with two backs, “the picture was perfect”.
Although he had never seen such a case before - popularly known as penis captivus - Davis
bravely attempted a number of interventions. Water and ice had little effect, and it was eventually
chloroform that relieved the maid’s spasm and released the couple.
Fortunately there were no long-term effects of this unfortunate condition. The maid was back to
herself as soon as the chloroform wore off; predictably however, the coachman was extremely
sore for a number of days. As to how this problem arose, Davis was unsure - he was ashamed to
report that his rushed approach meant he did not examine whether the sphincter ani was
contracted, which may have indicated whether this problem was limited to the vagina, or if it
represented tonicity of the entire pelvic floor.
This case report was published in the Philadelphia Medical News in 1884 as a reply to an article
Forms of vaginismus, written by Theophilus Parvin, an overbearing gynaecologist. Parvin’s
article was about the varying severity in presentation of vaginismus, and included the theoretical
proposition that a severe case may result in penis captivus. The editor of the journal
was therefore delighted to later receive a letter that appeared to uphold the work of his colleague
Parvin, but he had never heard of the author, Dr Davis. He consulted one of his fellow board
members, a certain William Osler, who was horrified: “For God’s sake, don’t print anything from
that man Davis. He is not a reputable character”. These words came too late - the journal had
already been distributed.
William Osler is known throughout Oxford both as Regius Professor of Medicine and for his
prominent contribution to cardiology with his eponymous nodes. Yet despite these austere
accolades, he appeared to have a lighter side. Ever since he was expelled from school for locking
geese in the building and, after a brief spell in jail for locking the unpopular school matron in her
office and filling it with burning mustard and molasses, it has long been known that he enjoyed
practical jokes under his favourite pseudonym, Egerton Yorrick Davis. As a good Oxford man,
Osler was a fierce proponent of evidence-based medicine. He considered Parvin’s article to be
weak on fact, and clearly decided to dress him down with this elaborate hoax of a case report. Dr
Davis crops up in print a number of times following the “unusual case of vaginismus”, but never
quite so famously.
As for the existence of penis captivus, the debate continues. There are a small number of
supposedly genuine descriptions, but thanks to the long-lasting legacy of Dr Davis’ beautifullycrafted work of fiction, they are hardly taken seriously. So whilst he may have described the
intestinal features of hereditary haemorrhagic telangiectasia earning his place in the eponym
Osler-Weber-Rendu syndrome, Egerton Y. Davis is yet another achievement of which Osler can
be truly proud.
Chris Deutsch is a final year medical student at St Edmund’s Hall
The creation of Oxford medicine
Charis Demetriou time-travels through seven hundred years of
medicine in Oxford to discover where and when it all happened
All great things start from somewhere. As 2010 sees us celebrating 700 years of medicine in
Oxford, it is only natural to look back through the creation of a tradition that goes back to the
time of King Edward II - best remembered as the first royal to establish Oxford colleges. It is
unfortunate, yet unsurprising, that the detailed beginnings of what was then known as ‘Schola
Medicinae’ have been, in the words of Prof. Derek Jewel, “largely lost in the mist of time”, but
still, there is no doubt that it has all happened right beside us [1].
It is no secret that one of the attractions of studying medicine at Oxford is that both the course
and the city are layered with history and tradition, all the way from ‘dissection drinks’ in medical
students’ first week in Oxford, to graduation in the Sheldonian Theatre. One college medical
tutor, who shall remain anonymous, has even found it a good icebreaker for his new tutorial
groups to send them on a treasure hunt around the city to discover exactly why Oxford is such an
exciting place to be reading medicine. But for those of you perhaps not fortunate enough to have
been to Brasenose or Pembroke, here is a short guide to the places where, over the last 700 years,
it has all happened. ❍
The Rose Gardens in the Botanical Gardens
Even though the phenomenon of ‘antibiosis’ was known from the start of the 20th century, and
Alexander Fleming discovered penicillin in 1928, it wasn’t until 1939, when Chain and Florey
started working together in the Dunn School that this was systematically studied. After showing
that penicillin was not toxic to rats (though they later admitted those early experiments might
have been flawed), the group proceeded to their first conservative human trials in the Royal
Infirmary, though at the time the substance was still so badly purified that several bathtubs of the
liquid were needed for each of the initial patients. [8]
In remembrance of the people who first used antibiotics on human subjects, the following
inscription can be found in one of the most beautiful corners of the celebrated Botanical Gardens:
This rose garden was given in honour of the research workers in this university who discovered
the clinical importance of penicillin for saving of life, relief of suffering and inspiration to further
research. All mankind is in their debt. Those who did this work were:
E.P. Abraham E. Chain C.M. Fletcher H.W. Florey M.E. Florey A.D. Gardner N.G.
Heatley M.A. Jennings J. Orr-Ewing A.G. Sanders
Logic Lane
Another cobbled lane that runs off the High Street, through University College and onto Merton
Street, it is rumoured that this was where human brain neurons were first visualized under the
microscope.
So named because it was once the residence of many philosophy and logic readers and tutors, the
lane ends at Merton College, where the legendary 13th Century medical textbook ‘Rosa
Medicina’ is kept [2]. This manuscript copy is widely considered to be the first modern medical
textbook, providing not only evidence that medicine has been taught in Oxford for 700 years, but
also giving Oxford a claim to the title of the birthplace of medical textbooks.
This forerunner of our beloved ‘Cheese and Onion’, which contains mostly Galenic anatomy, was
written by John of Gaddensdon, who it is believed plagiarised over 43 other sources whilst
authoring it! [2]
University College
University College asserts it is the University’s oldest college, but its claim to fame does not end
there. The college site currently occupied by the memorial to the poet Percy Bysshe Shelley.
It is widely believed to be the location where Robert Boyle and Robert Hooke were first able to
construct a microscope and visualize the living cell. Hooke, who was originally the assistant of
Thomas Willis, of ‘circle of Willis’ fame, was the first to coin the term ‘cell’, while on the same
site he also came close to the discovery of oxygen and assisted Boyle in formulating his law of
gases.
Chang Mai Kitchen restaurant on the High Street
That William Harvey is considered the father of human circulation is a well-known fact. That he
was briefly Warden of Merton College in 1645-8 is perhaps less well-known. But it is a well-kept
secret that even though Harvey knew of the main circulatory principles since the 1600s, it wasn’t
until he arrived in Oxford almost 50 years later that his knowledge was used to save the life of a
youth in a humble room opposite Brasenose College on the High Street, now occupied by the
Thai restaurant, Chang Mai Kitchen.
The story goes that Harvey was able to save his patient from hypovolaemic shock, and although
anecdotal, it is often recounted by enthusiastic physiology lecturers to undergraduates.
Norham Gardens
Upon William Osler’s arrival in Oxford in 1905, he and Lady Osler purchased this North Oxford
property as their residence [6]. The house was often referred to by Osler as ‘the hotel’, a
nickname it earned by hosting over 6,000 visitors from North America alone [6].
It is difficult to grasp just how much Osler’s bedside teaching methods were to revolutionize
medical education, not only in Oxford, but also the rest of the world. It is telling of how
groundbreaking his methods were considered at the time that Osler said after his appointment: “I
desire no epitaph other than that I taught medical students on the wards” [3]. After Osler’s death,
it took over 10 years to catalogue his vast collection of medical textbooks, which was viewed as
perhaps the largest of its kind at the time [6]. A further two Regius Professors of Medicine lived
in that property before it was purchased by Oxford University. It is currently preserved as
archives, with Osler’s study having been kept as he left it on his death [6].
The Peter Medawar Building for Pathogen Research
Squashed between the massive buildings of Zoology, Experimental Psychology and
Pharmacology lies the little-known building of Peter Medawar. Peter Medawar, one of Oxford’s
most famous medical alumni, was a student, then fellow, at Magdalen College, and was awarded
the Nobel Prize in 1960 for his work on the immunology of grafting and transplant. Today, the
building is a buzzing home to a dozen research groups studying immunology and infectious
diseases, including malaria, HIV and HCV, and is the origin of many of Oxford’s current vaccine
trials.
The Sir William Dunn School of Pathology
The teaching of pathology at Oxford University goes back to the 19th century, but the building
which provides dedicated premises to this discipline was not completed until 1927, using a
benefaction by the trustees of the will of Sir William, who had passed away 15 years earlier.
In addition to the purification and delineation of the chemical structure of penicillin, this was also
the place of discovery of cephalosporins and the lifecycle of lymphocytes, and was one of the
pioneering centres for therapeutic antibody research [8]. The site has now expanded to include the
Medical Sciences Teaching Centre, an area extremely well-known to those elusive undergraduate
medics that actually attend lectures.
The John Radcliffe Hospital
Virtually the home of current medical students, it might have been named after Dr Radcliffe, but
it was actually Osler himself who envisaged establishing medical services at this Headington site.
Inspired by local philanthropist Miss Price, Osler encouraged the Radcliffe Infirmary treasury to
purchase the land now occupied by the JR site in order to build a tuberculosis sanatorium [3].
Unfortunately he didn’t live to see the completion of the ‘Osler Pavilion’ in 1926, six years after
his death. In 1969, the first generation of the modern day buildings (or JR1, now the Women’s
Centre) replaced the old sanatorium. The site was later expanded to include JR2 (present-day
home of the Medical Sciences Offices), and more recently, the Weatherall Institute of Molecular
Medicine and the highly contemporary West Wing.
Radcliffe Infirmary
Established in 1770, this hub of medicine in Oxford for over three centuries was finally closed
down in 2007 [4]. It was built with the generous bequest of Dr John Radcliffe, the most famous
physician of his time, who had amassed wealth practicing for many years as a private doctor to
the rich and famous (including Queen Anne) in London.
It was Radcliffe’s request that his bequest should first be used to complete a library (the worldfamous Radcliffe Camera), but upon completion of that project, the trustees of his legacy saw it
fitting to proceed with the funding of a hospital [5]. The site was home to the first clinical
students who arrived at the University 70 years ago, and who first started putting on the
Tingewick pantomime (then known as the ‘Raspberries’) so as to entertain the nurses after the
staff’s annual Christmas dinner [7]. At the time of the first pantomime performance, the only
rooms to have electricity generators were the theatres, it was still common practice for gloves to
be patched up with glue and re-used, and the dustbins lining the walls of near-by Somerville
College were discreetly used for the disposal of body parts [7]. Current plans are for the 1770
original buildings to be renovated and passed over to the mathematics and humanities
departments, while the newer buildings will be demolished in order to bring the area back to its
former glory, including making the Radcliffe Observatory more prominent in the local landscape
[7].
The Churchill
Founded in 1942 by the American military for the anticipated casualties of the war in the
continent, until recently, the Churchill site bore all the signs of war-time architecture: badly
designed, unpractical, unsightly, and named after an inspiring figure [4]. However, visit the site
today and you will be surprised to discover a true jewel of both clinical practice and
contemporary research. Sandwiched between the Nuffield Orthopaedic Centre and the
Warneford, the site now includes the brand new state-of-the-art Cancer Centre, the Oxford
Transplant Centre, the centre for Vaccinology and Tropical Medicine, and the Oxford Centre for
Diabetes, Endocrinology and Metabolism. On the research side of things, the University’s Old
Road Campus includes the Wellcome Trust Centre for Human Genetics, the Rosemary Rue
building, and the clinical trials service unit in the Richard Doll building, named after the late
Regius Professor of Medicine who was the first to produce evidence for the link between
smoking, asbestos and cancer.
References
1.
Jewell D. Letter from the President. Oxford Medicine December 2009.
2.
Sidebottom E. Oxford’s first Textbook of Medicine: John of gaddesdon’s 1314 Rosa
Medicinae. Oxford Medicine February 2007
3.
Little R. The man who had the prescription for doctors. OMA newsletter, November
2005
4.
Holt J.M. Letter from the president. Oxford Medicine July 2006.
5.
Ryan T. University of Oxford Masterplan for the RI site. Oxford Medicine July 2006.
6.
Ryan T. An Archive of Public health and a history of Oxford Medicine at 13 Norham
Gardens. Oxford Medicine November 2008
7.
Ryan T. The Radcliffe Infirmary 1770-2007 February 2007
8.
A brief history of the departments and its pioneering work in penicillin. Available online
at http://www.path.ox.ac.uk/contact/history. Accessed 20th March 2010.
Medicine for the future
Benjamin Stewart examines the viability of medical devices from the
world of science fiction
Science fiction is a fertile breeding ground for technical ideas. Since its inception as a genre by H
G Wells and Jules Verne, some of the more plausible ideas it has generated have inspired real
technological developments. The Star Trek communicator provided inspiration for the mobile
phone, and motion controlled computers first seen in the 1951 film The Day The Earth Stood
Still, and more recently in Minority Report, are now a reality.
Advances in medicine are ubiquitous in science fiction, particularly in utopian accounts of the
future where both realistic and unrealistic advances deliver health and longevity.
Nanotechnology, diagnostic scanners, and machines capable of supporting pre-natal life are all
imaginatively discussed throughout science fiction, but are these ideas mere fantasy, or could we
soon see these technologies become a reality?
Nanotechnology
Nanotechnology makes a prominent appearance in the books of the great science fiction authors
Arthur C Clarke, Ben Bova, and Michael Crichton. They envisage the development of
nanomachines within the next 100 years which would be able to deliver drugs and other
molecules effectively to a target within the body, attack pathogens or cancers, and aid in the
regeneration of damaged tissues. The idea of miniaturization was first popularized in the 1965
Isaac Asimov film, The Fantastic Voyage, in which a submarine crew is miniaturized and tasked
with destroying a dangerous blood clot.
Could we create machines that function similarly? One of the main challenges is creating a device
that is entirely degradable, or that can be expelled from the body without causing harm, and that
is biologically inert. Furthermore, the therapeutic or diagnostic facility on the machine would
need to only be active when necessary. Another challenge to the development of machines on a
nanoscale is powering the nanodevice. Such a device would experience considerably more
viscosity in blood than water or air and would thus have a substantial energy requirement [1]. It
would also need a highly efficient means of propulsion; current designs are based either on
bacterial flagella, which use a corkscrew like motion, or sperm which swim with a beating
motion. Recently, a number of groups have created nano-propellers controlled by weak applied
magnetic fields, based on both of these approaches [2-4].
The first successful usage of nanotechnology is likely to be innovative drug delivery systems, for
example, the development of dendrimers, highly branched tree-like molecules that can be used as
building blocks for nanomachine-like structures able to target cancer cells, deliver gene therapy
agents, or act as magnetic resonance imaging contrast reagents [5-7].
In Bova’s novels nanomachines continually repair damaged tissues, and augment physiological
processes. Thus far, the only foray nanotechnology has made into regenerative medicine is the
development of biomimetic nanomaterials which have found use in tissue engineering,
particularly of bone and cartilage. These nanomaterials mimic bone, which is itself a nanoscale
composite of protein and inorganic components overlaid with cells. By mimicking closely the
physical characteristics of tissues, nanomaterials are a useful tool in tissue regeneration [8]. The
original concept of nanorobots for tissue regeneration is, however, fanciful. Although computer
chips continue to shrink, they are not yet small enough to allow nanoscale robots to be built. Even
if they could be built, it is unclear how they would go about repairing tissue damage more
effectively than our own cells.
Hand-held diagnostic scanners
Other than the communicator, the signature hand-held device used by Star Trek physicians is the
medical tricorder. It acts as a handy plot device, doing away with the tedium of a physical
examination and history taking. A swoosh of the tricorder across the patient results in an instant
diagnosis, often at molecular resolution [9].
The medical tricorder is postulated to work in part by detection and interpretation of the
electromagnetic spectrum and so takes a similar approach to many analytical devices already in
use [10]. Every day millions of diabetes patients use hand-held blood glucose biosensors. These
take advantage of the enzyme glucose oxidase and use small electrodes to measure the magnitude
of the reaction it catalyses. Whilst current models are relatively invasive, future versions might
extract glucose through the skin, or use measurements of glucose in saliva or sweat [11].
Many of the functions of the tricorder remain in the development stages, for example, scientists at
Stanford University have developed a hand-held device capable of identifying a wide range of
toxic chemicals using an electrophoresis-based technique [12]. Furthermore, scientists at the
University of California, Berkeley, have succeeded in shrinking conventional
DNA sequencers to the size of microchips capable of sequencing an entire complex genome [13].
Another group in California has extended the ‘lab on a chip’ concept to microchip scale lens-free
imaging of cells, paving the way for instant blood counts, and immediate diagnosis of cellular
pathology [14]. This concept is key to the creation of a multifunctional hand-held diagnostic
scanner.
In addition to performing an array of analyses at a molecular and cellular level, the fictional
tricorder is a powerful anatomical imaging device. Hand-held ultrasound machines are already
with us [15], however powerful imaging modalities such as magnetic resonance imaging (MRI)
still take up whole rooms. Although smaller models are being investigated, for example
magnetomers able to measure magnetic fields produced by the heart or the brain, MRI is a long
way from becoming truly portable [16].
Beginning of life
The novel Brave New World, by Aldous Huxley, introduced the idea of ectogenesis, or artificial
wombs, into mainstream science fiction [17]. In this dystopian work, foetuses are grown in
hatcheries where their social stratum is classified before birth. Clearly, this would be a
development fraught with ethical concerns. However, the technology that would underpin an
artificial womb is of interest to both neonatal and reproductive medicine [18]. Developments in
neonatal medicine now help babies born as early as 20 weeks gestation to survive. Furthermore,
IVF allows the culture of embryos outside the womb for several days. Thus the development of
technologies to maintain the life of a foetus seems to be a likely byproduct of research in these
areas [18, 19].
The crucial invention for reproductive medicine would be an artificial placenta. Oxygenating the
blood of the foetus could be accomplished in one of two ways: directly threading catheters into
the umbilical arteries and veins of the foetus, or filling the lungs with oxygen-infused
perfluoronated hydrocarbon [18, 20].
The latter therapy has received some investigation in human neonates; two important studies took
small numbers of neonates in extremis and demonstrated the therapy to be superior to mechanical
ventilation; some of these individuals are now in their teens [21, 22]. In light of the advances in
neonatal medicine, the second half of gestation seems relatively straightforward. Whilst Huxley’s
novel depicts the artificial womb as a harmful component of a dystopian future, such a device
might have enormous potential for reproductive medicine.
Tomorrow’s World?
Science fiction authors depict future medicine as a brilliant, although occasionally dark result of
technological progress. Central themes in this progress are miniaturization and convergence of
technology. Nanotechnology would allow physicians to better manipulate human biology at the
molecular and cellular level, and multi-functional scanners would cram a room full of lab
equipment into a single hand-held device. There has already been significant progress towards
miniaturization, most convincingly embodied in the ‘lab on a chip’. However, some
developments continue to elude us; computer chips are not yet small enough to create semiautonomous nanorobots, and imaging technology remains cumbersome.
Whilst many of the concepts examined here bring us a step closer to the science fiction world,
few are direct replicas of the authors’ original ideas. Much of the time necessity remains the
mother of invention. The importance of science fiction lies in showing us how the small steps we
take now bring us closer to a better future, and in helping us understand the impact of progress
already underway.
Benjamin Stewart is a third year medical student at St. Hilda’s College
References
1.
Kostarelos K. Nanorobots for medicine: how close are we? Nanomedicine 2010; 5(3):
341-342
2.
Dreyfus R et al. Microscopic artificial swimmers. Nature 2005; 437(7060): 62-865
3.
Ghosh A, Fischer P. Controlled propulsion of artificial magnetic nanostructured
propellers. Nano Lett 2009; 9(6): 2243-2245
4.
Zhang L et al. Artificial bacterial flagella: fabrication and magnetic control. Applied
Physics Letters 2009; 94: 64107
5.
Roco MC. Nanotechnology: convergence with modern biology and medicine. Current
Opinion in Biotechnology 2003; 14(3): 337-346
6.
Silva GA. Introduction to nanotechnology and its applications to medicine. Surgical
Nurology 2004; 61(3): 216-220
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Zhang L and Webster TJ. Nanotechnology and nanomaterials: Promises for improved
tissue regeneration. Nano Today 2009; 4(1): 66-80
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Ondine’s curse
The patient is male, aged 32 and suffering from severe sleep apnoea; he refuses to switch off the
television for fear the silence would cause him to stop breathing. With a progressive and
unresectable left brainstem growth impinging on medullary respiratory centres, he is found dead
in bed, only days after being seen by doctors. The television is switched off [1].
This, then, is Ondine’s Curse. A fatal-if-untreated case of hypoventilation caused by a loss of
autonomic and spontaneous control of ventilation – sufferers must consciously force themselves
to breathe. Few eponymous diseases have as captivating a history. The name, Ondine’s Curse,
refers to a mythological story which has been alive in the European literary tradition since the
16th Century (and was adapted and popularised by Hans Christian Anderson in his classical story,
The Little Mermaid).
So begins the tale: Ondine, a beautiful and immortal water nymph, falls in love with a mortal
man, Count Hans, acquiring a soul in the process and becoming fully human. Her lover swears to
her his undying love, promising her the dedication of every waking breath of his life. And yet,
after years pass, the Count breaks his covenant, falling in love with another woman. And so, the
King of the nymphs curses the Count for reneging on his promise; and the man, destined for
death, cries out in agony: “Everything my body should do I have to command it to do… One
moment of inattention and I shall forget to hear, to breathe. He died, they will say, because
breathing bored him [2].” This version, an adaptation of the original legend described by
Paracelsus in the 1500s, was created by Jean Giraudoux, the French playwright, in his play
“Ondine: A Dream Play in Three Acts” (1939). It was Giraudoux who first associated the name,
Ondine’s Curse, with a loss of involuntary control in autonomic bodily functions. Despite this
however, it would be several years before Ondine’s Curse would make it into medical literature
[2].
The year was 1962; John Severinghaus, MD, in San Francisco, California, had just recently seen
Girardoux’s play. When three patients with unique symptoms presented to him and his colleague,
Robert Mitchell, the use of the term Ondine’s Curse as an understood medical condition began to
take shape. Severinghaus and Mitchell observed that each of the patients reported lengthy periods
of apnoea but were able to breathe normally when told to do so. All three had undergone recent
pain-control cordotomies on spinothalamic tracts within the brainstem. Presumably, some damage
was caused to brainstem respiratory centres but this remains unknown. The two researchers used
a popularised (and quite historically inaccurate!) version of the Germanic legend (“… Ondine,
having been jilted by her mortal husband, took from him all automatic functions, requiring him to
remember to breathe. When he finally fell asleep, he died…”), and used the term Ondine’s Curse
to describe the disease [1-4].
The use of the term ‘Ondine’s Curse’ by Severinghaus and Mitchell, as well as subsequent
authors [5-6] to describe the symptoms they observed in their patients has met with scathing
criticism. Weese-Mayer et al. claims that Ondine’s Curse is a misnomer and should be avoided
[7], in part because modern adaptations incorrectly assume that the mortal lover ‘forgets’ to
breathe, when this is certainly not the case in the disease. There does seem to be a need to use
only the correct scientific nomenclature; take the following interpretation by Fielding et al. [8],
for example: “Ondine, a shepherd in Greek mythology, was cursed for his misdeeds by being put
into a sleep from which there was no awakening.” Such varied, and seemingly subjective,
retellings of the original tale can lead to an incorrect understanding of the aetiology of Ondine’s
Curse, or indeed allow for numerous, distinct conditions to all be labelled as one [2]. It seems
poignant, then, that Dr Oscar Sugar at the University of Illinois declares: “An Ondine’s curse (in
its entirety) on writers who fail to read the original sources!” [9].
Regardless of the consternation that many hold, as well as the fact that many researchers actively
discourage the use of the phrase [7, 10], the term has still remained in the colloquial medical
vocabulary, and although in the modern vernacular it has come to encompass and be superseded
by others – primarily Congenital Central Hypoventilation Syndrome (CCHS), but also to a lesser
degree, primary alveolar hypoventilation and sleep apnoea – ‘Ondine’s Curse’ is certainly not in
any danger of becoming extinct. It must be noted however, that modern literature almost
exclusively uses the term CCHS to describe Ondine’s Curse.
CCHS is a disease primarily affecting neonates; the condition is rare (1 in 10,000 – 1 in 200,000
live births [11]), and is defined by “alveolar hypoventilation in the absence of primary lung,
cardiac or neuromuscular disease or an identifiable brain lesion” [12]. There have been instances
of adults presenting with CCHS [11]; however, such cases have been strongly linked with
childhood presence of the disease suggesting chronicity. For example, some presenting adults
have been shown to have prolonged breath-holding abilities as children and the ability to stay
under water longer than their contemporaries [13].
The typical CCHS phenotype is commonly characterised by a decreased (or in some cases,
completely absent) response to hypercapnia [14] manifesting in near-normal to normal ventilation
during periods of wakefulness, with apnoea and hypoventilation during sleep. Rarer, severer
types of CCHS may cause hypoventilation during wakefulness also [7]. Diagnosis is confirmed
by a combination of genetic testing via PCR-based analysis and clinical indicators; as many as
90%, if not all, children suffering from CCHS have been shown to suffer from a repeat expansion
mutation in the PHOX2B gene – involved, amongst other things, in regulating noradrenergic
neuron development in the locus coeruleus and other centres in the autonomic nervous system [7,
12, 14-15]. Mutations in PHOX2B have also been tentatively linked with Hirschsprung disease, a
failure of enteric nervous system development, and various other conditions associated with
neural crest derivatives such as neuroblastomas, ganglioneuroblastomas etc [7, 12]. This raises
interesting questions with regards to commonality in origins of brain stem respiratory centres and
peripheral neural-crest cell lines. Indeed, CCHS was once classified as a disease of the neural
crest [16], but it is generally understood today that neurones regulating autonomic respiration are
neural tube in origin and not neural crest, although, curiously, PHOXB2 still seems to be the
common link between CCHS and various neural crest-linked conditions.
Many of the patients originally diagnosed with CCHS have lived into adulthood with a near
normal quality of life [11], showing that the condition can be managed effectively. Very young
infants require tracheostomy and perennial ventilatory support [7]. Older children (and some
young adults) with the disease who have greater motility may have diaphragm pacers inserted
into the chest [17]. This is particularly useful for more severe cases of CCHS where
hypoventilation occurs during periods of wakefulness also. The procedures described above,
particularly the insertion of a diaphragm pacer, can interfere with vocalisation, and as a partial
solution, patients can wear a Passy-Muir one-way speaking valve during the day to aid speech.
The valve prevents air from exiting the tracheostomy tube upon exhalation; instead forcing it
through the vocal cords, producing sounds [18]. Another option used is to cap the tracheostomy
tube whilst awake, allowing for easier vocalisation; upon resumption of mechanical ventilation
the cap is removed [7].
The scope of this article illustrates the rich tapestry woven by Ondine’s Curse through the last
five centuries. Indeed, the study of the disease with all the eccentricities and enigmas connected
with the mythology surrounding it, as well as the often spirited criticism relating to the
inaccuracies in its nomenclature, throws one back to a more romantic time. A time where
medicine was not bound so vigorously by the rigors of the scientific method; where curses and
spells were very much a part of the everyday consciousness, and where for good or bad, diseases
were attributed to causes not based so much on rational and verifiable phenomena, but more on
the supernatural experiences humanity has faced throughout its existence. From the awful
premise of the disease (the inability to automatically breathe!) to modern interventions enabling
an almost normal life, rarely does medicine have such happy endings.
Mohammad Ali is a third year medical student at Oriel College
References
[1] Kuhna M, Lütolfb M, Reinharta WH. Ondine’s Curse. Respiration 1999; 66(3); 265-265
[2] Nannapaneni R, Behari S, Todd NV, Mendelow AD. Retracing “Ondine’s Curse.”
Neurosurgery 2005; 57(2); 354-363
[3] Severinghaus JW, Mitchell RA. Ondine’s curse: Failure of respiratory center
automaticity while awake. J Clin Res 1962; 10; 122
[4] Severinghaus JW. Hans Loeschcke, Robert Mitchell and the medullary CO2 chemoreceptors:
a brief historical review. Respiration Physiology 1998; 114(1); 17-24
[5] Mullan S, Hosobuchi Y. Respiratory hazards of high cervical percutaneous
cordotomy. J Neurosurg 1968; 28; 291–297
[6] Swift PG. Ondine’s curse. Lancet 1976; 2; 588–589
[7] Comroe JH Jr. Frankenstein, Pickwick, and Ondine. Am Rev Respir Dis 1975; 111; 689–692
[8] Weese-Mayer DE, Marazita ML, Berry-Kravis EM. Congenital Central Hypoventilation
Syndrome.
GeneReviews
(2008).
[Online].
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from:
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2010)
[9] Fielding JW, Tuul A, Hawkins RJ. “Ondine’s curse”: A complication of
upper cervical spine surgery. J Bone Joint Surg Am 1975; 57A; 1000–1001
[10] Sugar O. In search of Ondine’s curse. JAMA 1978; 240; 236–237
[11] Chin TW, Gozal D. Congenital Central Hypoventilation Syndrome. emedicine (2010).
[Online]. Available from: http://emedicine.medscape.com/article/1002927-overview [Accessed
26 July 2010)
[12] Lovell BL, Bullock RE, Anderson KN. An unusual presentation of congenital central
hypoventilation syndrome (Ondine’s Curse). Emerg Med J 2010; 27; 237-238
[13] Goridis C, et al. Phox2b, congenital central hypoventilation syndrome and the control of
respiration. Semin Cell Dev Biol 2010, 4 Aug.
[14] Antic N, Malow B, Lange N, et al. PHOX2B mutation-confirmed congenital central
hypoventilation syndrome: presentation in adulthood. Am J Respir Crit Care Med 2006; 174;
923-927
[15] Fayyas J, Lessnau K. Hypoventilation Syndromes. emedicine (2009). [Online]. Available
from: http://emedicine.medscape.com/article/304381-overview [Accessed 26 July 2010]
[16] paired-like homeobox 2b [Online]. Available from: http://www.genecards.org/cgibin/carddisp.pl?gene=PHOX2B [Accessed: 27 Aug 2010]
[17] Kincaid PK, Dietrich RB, Pais MJ.Pediatric case of the day. Neurocristopathy (OndineHirschsprung syndrome). Radiographics 1994; 14(5): 1139-43
[18] Shaul DB, Danielson PD, McComb JG, Keens TG. J Pediatr Surg. 2002; 37(7); 974-978
[19] Passy-Muir One Way Speaking Valve [Online]. Available from: http://www.childrensmercy.org/Content/view.aspx?id=5104 [Accessed: 27 Aug 2010]
Dr K.F.R. Schiller DM FRCP
Consultant Gastroenterologist
7 March 1927 – 9 July 2010
Klaus Schiller’s outstanding professional achievement was to pioneer and champion the use of
endoscopy in gastrointestinal investigations. He was motivated by the highest standards of
medical excellence and a commitment to patient care. Though some conservatives opposed him
(“Nothing useful whatever can be achieved with this expensive piece of illuminated spaghetti”)
endoscopy was not invasive like surgery and was more effective diagnostically and
therapeutically. He was truly a man of the enlightenment, literally in the case of his medical
specialty, and metaphorically in his abhorrence of ignorance, poverty and inhumanity.
Klaus was born in Vienna in 1927, to Walter, a gynaecologist, and Berta, the daughter of a
successful industrialist. A comfortable early childhood was interrupted by the Anschluss in 1938
and enforced emigration. His parents’ families, like many others, were non-practicing assimilated
Viennese Jews – ironically, he had to ask what a Jew was, having been beaten up in the school
playground for being one. Walter was imprisoned; Berta sent Klaus and his younger sister,
Verena, to England to live with their uncle’s family near Bishop’s Stortford. Within a few days of
his arrival, Klaus, speaking not a word of English, was packed off to boarding school. A few
months later, his parents and grandparents also came to England and the whole family settled in
Cambridge.
Schiller was sent to Clifton College, at that time evacuated to Bude, North Cornwall. In 1945 he
went up to the Queen’s College, Oxford to read medicine having been awarded a Neale
exhibition. He was taught by such giants as GSW Clark and the Nobel prize-winning Howard
Florey – who reproved Schiller and his friends for swimming in the Cherwell with its hazard of
leptospirosis. He won the Price Entrance Scholarship to the London Hospital, completing his
training in December 1951, and was appointed to two house officer posts at the London. He was
particularly fortunate to work for Sir Russell (later Lord) Brain. After two years of National
Service, a clutch of junior posts, and obtaining his MRCP, Schiller became senior registrar at the
Radcliffe Infirmary, where he benefitted greatly from the support of Professor Leslie Witts, who
steered him towards gastroenterology. He duly received his DM (Oxon) in 1967.
After a year’s research work at the Massachusetts General Hospital, he returned to Oxford and
joined forces with his next mentor, and later life-long friend, Dr Sidney Truelove. With Truelove,
his interest in gastroenterology increased, particularly through their joint work on acute
gastrointestinal bleeding, resulting in a major contribution on this subject (BMJ, 1970). They
undertook an in-depth survey of haematemesis and melaena, and the risky abdominal surgical
interventions that were undertaken as a result. Truelove had acquired the first flexible fibre-optic
gastroscope capable of taking biopsies under direct vision, and together they pioneered its early
use. Some conservatives opposed them, but they soon demonstrated that it allowed for safe and
non-invasive investigations that frequently obviated the need for surgery.
In 1967 Schiller was appointed Consultant Physician to St Peter’s Hospital, Chertsey. Outside
the major teaching hospitals gastroenterology was in its infancy, but he established a thriving
endoscopy unit and set about raising the profile of this specialty. He made contact with many
other aspiring endoscopists, resulting in the formation of the British Society for Digestive
Endoscopy (BSDE), with Truelove as its first President and Schiller as Honorary Secretary. The
BSDE proved an influential organisation, pleading successfully for the NHS to give the
burgeoning sub-specialty of endoscopy support. Through Schiller’s tenacity, in association with
many of his enthusiastic younger colleagues, regular national meetings ensued and training
courses flourished. The British Society of Gastroenterology (BSG) was at the time something of
a gentlemen’s club with very limited membership; the BSDE opened its doors to technicians,
nurses and instrument makers, democratising and championing the practice of endoscopy.
Although this new society strived, it took a little time before the more conservative BSG extended
a sisterly hand. Eventually the BSDE was absorbed into the BSG, a little earlier perhaps than
Schiller thought wise, but many of the pioneering initiatives were carried forward. Some years
later, he was proud to be elected Vice-President (Endoscopy) of the BSG, and an Honorary
Member after retirement.
Schiller published a number of papers and chapters. His most significant work, with Roy Cockel
and Richard Hunt, was A Colour Atlas of Gastroenterological Appearances (1986) which became
the standard reference book on the subject. It was later expanded and retitled as the Atlas of
Gastroenterological Endoscopy and Related Pathology (2001), with Bryan Warren joining the
original editorial trio.
Following retirement from the NHS, he moved to Oxfordshire and continued in private practice.
He developed a successful medico-legal practice as well as serving on Medical Appeals
Tribunals. Re-establishing his links with the John Radcliffe Hospital, he attended many of Derek
Jewell’s teaching sessions and courses there. He also helped to found Oxford Medical Alunmi
(OMA) and was its first Honorary Treasurer.
Klaus Schiller fully embraced England and Englishness. He always agreed with his friend the late
Professor Peter Scheuer that “the best thing that ever happened to us was to come to England”.
He was a committed rationalist who also delighted in absurdity and human frailty. He was a
deeply passionate man who, in a very English way, was uncomfortable when talking about his
emotions.
Schiller was enviably fit and healthy: for his 80th birthday, shortly after a hip replacement, he led
most of his family up an Austrian alp. His decline when it came was relatively and mercifully
swift. He died peacefully at the Churchill Hospital from complications following treatment for
primary amyloidosis. He is survived by his wife of 49 years, Judy, their four children and seven
grandchildren. Although one cannot call the death of an 83 year old grandfather tragic, his large
family and many friends greatly miss his solicitude and loyalty, his pedantry and provocation, and
his wise, good spirit. He had no god to thank, but was nevertheless, as he said, grateful. So are
we.
Ginny Schiller
September 2010
Osler report
During the past year I have spent as Osler President, Osler House has seen some of its biggest
changes in recent history. At the core of these changes still lies the undeniably strong sense of
community shared by medical students and staff alike. Osler House is growing ever stronger and
becoming an increasingly recognised and respected student body within Oxford University.
The major change
In September 2009, builders, decorators, plumbers, and electricians downed tools and the longawaited Osler House refurbishment was finally completed. After the years of planning and hard
work it was absolutely wonderful to see the dream building become a reality! The new House
offers double the floor space, a state-of-the-art multifunction room, changing facilities, a number
of seating and meeting areas, up-to-date high-speed computers, wireless internet, a grand piano,
newly landscaped gardens... the list goes on! It is an amazing new facility which will form the
foundation of a whole host of opportunities for Osler House members. Despite some initial
teething problems, the building is now up and running and beginning to thrive, and it is sure to
become the much-loved hub of activity that underpins medical student life at the hospital. A party
to commemorate its official opening was held on 12 September on a glorious sunny day.
Members new and old were in attendance to celebrate the past, present and future of Osler House.
A tree was planted in honour of the occasion and the Ledingham Bar was opened with a toast by
Prof John Ledingham himself. It will undoubtedly be a memorable day for all. On behalf of all
the students, words cannot express how grateful I am for the generous donations which funded
the project and made it possible.
Osler life
As always, the annual Freshers’ Fortnight was a resounding success and a lot of fun was had by
all. There were a variety of events to suit all tastes, including a very well-received ‘Freshers’
Formal’ at New College, welfare tea, trip to St. Giles Fair, film night in the Ultimate Picture
Palace, open-mic night, the ever-popular parents’ night, rounded off by the Friday bop. The
Tingewick Society started and finished the fortnight with two of their main charity events – the
annual garden party held in the lovely Corpus ChristI College grounds, and the legendary
Tingeaid comedy night where snippets of what was to come were performed.
The ‘Entz’ team have been particularly busy this year organising events both within and outside
of Osler. A private party in one of Oxford’s venues before Christmas provided the perfect way to
celebrate the end of term with festive cheer. Halfway Hall, attended by over 100 fifth years, was
held in New College Hall and was a lovely opportunity for everyone to catch-up and reflect on
our time in Oxford over a delicious meal. Brompton’s Cocktails was a real hit and tickets sold out
fast. Osler House was the perfect venue to dance the night away to the Magdalen Swing Band (of
which five members are medics), have your fortune told, and sip on inventive cocktails, all with a
1920s twist! Bops and bar opening events have proved ever-popular and a hope for the future is
to watch major sports fixtures or have casual film nights in the relaxed atmosphere Osler House
provides.
Extra-curricular activities are thriving with more sports teams and societies than ever before,
many of which are represented in college leagues. This is an impressive feat given the recent split
of Osler from Green-Templeton College. Last autumn, many of our sports men and women made
the journey to Cambridge to participate in the Varsity Sports weekend. A multitude of different
sports were played and although I cannot claim we were victorious, it was an enjoyable weekend
and the result didn’t dampen spirits! The newly-formed circuits club has proved incredibly
popular, as has the new Osler Rock Climbing Club who recently arranged the ‘Three Peaks
Challenge’. This involved 22 medics climbing the highest peaks in England, Scotland, and Wales
against the clock – hard work but very rewarding! This enabled Osler to continue its commitment
to charity with over £500 raised in sponsorship, which was donated to KEEN, a local charity that
students are eager to support. The spectacular new grand piano has provided the impetus for
musicians to come out of the wood-work and form Osler Music Society, which includes a choir.
There have been a number of concerts which have provided the perfect informal atmosphere for
players of any ability to perform either individually or in small groups. The standard has amazed
the audiences and highlights the fact that there are a whole range of very talented (but often
hidden) individuals in the medical school.
The Wing Tat Lee multifunction room has provided an ideal facility for various speakers, the first
of which was the highly prominent Professor Rubin, current head of the GMC. There have been a
number of other talks and presentations, with more in the pipe-line. Welfare has always been an
important aspect of Osler House life. Our welfare team have taken good care of us by providing a
number of teas; a free slice of cake is a simple but very effective way of boosting one’s mood,
and is always appreciated! The finalists enjoyed receiving goodie bags before their exams, as
well as the treat of champagne and strawberries that greeted them afterwards. On a more serious
note, welfare has supplied free rape alarms to all those who request them, and offered discounts
for bicycle safety equipment – particularly important given so many cycle to the hospital.
Congratulations go to all our current final year medics who achieved fantastic results on the
recent Foundation application system. Oxford students had the highest mean MTAS score of all
UK medical schools, and 94% were placed in their first choice Foundation School, which again
ranks them as top in the country. We wish them all the best in their future careers!
Looking to the future
With the redevelopment complete, a key priority for Osler is to now increase links between
current students and alumni. The reopening party and Oxford Medical Alumni annual dinner
allowed past and present students to mingle. The hope is to set up mentoring schemes and use
them as a potential target for fundraising plans, which will be needed to fund future projects at
Osler. The alumni rep is a new position created last year to help facilitate these links and will
therefore have an increasingly important role in years to come.
The above is certainly not an exhaustive list of all that has gone on in Osler this year but writing
this report has highlighted a recurrent theme – what an active, keen and diverse group of people
the medics are, which is something that should never be overlooked or taken for granted. The
events over the last year have demonstrated this perfectly and I feel very proud of what has been
achieved. All of this would have been impossible without a supportive committee who have stood
beside me, worked well as team, and taken initiative.
Sophie James is a final year medical student at Green-Templeton College
The Tingewick Archives
Celebrating Tingewick’s 70th with its outgoing patron, David Messer
In 2009 the Tingewick Society annual Christmas pantomime celebrated its 70th anniversary. To
mark this occasion I caught up with David Messer, who along with his duties as Office Manager
in the medical school office between 1969 and 2002 was also Patron of the Tingewick Society
from 2002 to 2009 – a ceremonial role recognising David’s support of the society. I discover that
despite an ever-changing hospital backdrop, the highs, lows and madness of putting on a show as
all-embracing as Tingewick are as perennial as Rita the Elephant’s triumph over that year’s evil
villain.
Location, location, location
Tingewick, named after the medieval Oxonian physician ‘Nicholas Tingewick’ (and possibly the
pretty village just off the A43) was born in the wartime Radcliffe Infirmary where it was
performed by both staff and students in the Nurses Recreation Hall in contrast to the clinical
freshers’ bonding event and Pathology course light-relief it has become today. As clinical
medicine began to migrate up Headington Hill in the late 1970s Tingewick soon followed, but
Rita’s new home was not initially as homely as she may have liked. David remembers: “The
show took place in the hall in the Academic Centre which was originally called the ‘Assembly
Hall’ and although it soon became the [now familiar] ‘Nicholas Tingewick Hall’, the space inside
was still rather drab”. This was not the case for long as David recalls that a medical student and
particularly dynamic Tingewick Producer, William Wraight, who along with the Secretary of the
medical school, David Bryan, was able to convince hospital authorities to spend thousands of
pounds to make the hall fit for the theatrical extravagance to which we have become familiar.
David remembers vividly how Wraight: “would park his ‘rather nice’ car outside the Academic
Centre on Tingewick business”. David smiled when I informed him of the uncanny resemblance
to the tendency of Ms. Demetriou’s (Producer 2009) Mercedes C-Class ‘runaround’ to occupy a
similarly prominent space under similarly quasi-‘official’ business during her tenure!
Technical triumphs
AA fully refurbished hall was meaningless without an equally stunning stage set to kit it out. This
ethos is played out every November as the Tingewick firm descend upon the JR’s academic
centre with hastily acquired power tools (for which they have received all but cursory training)
ready to transform the Hall ready for the show in early December. David recalls: “The sets would
seem to get more dramatic each year meaning the team would try to get in more and more early.
The only problem was that the annual Silver Star Children’s Christmas Party [fundraising for its
namesake high-risk maternity unit] also took place in the hall at this time of year”. David
recollects how this prompted concern from obstetric physician , Professor Chris Redman, who
remarked: “the children might pick up a power drill”!
Stray power tools aside, with an audience in the hundreds and a year group of expensively trained
future Doctors in the wings, health and safety at the pantomime is of utmost importance. Whilst
today’s Tingewick Producers must court the hospital’s Works department David recalls how this
used to fall to the City Council’s Environmental Health office. The inspector in question was
infamous for not only his close attention to detail, but also his resemblance to one of Rowan
Atkinson’s most famous characters. David informs me that contrary to my understanding,
Tingewick pyrotechnics first made an appearance in the 1980s. David describes how “[the
inspector] wanted reassurance that all the scenery was covered in flame retardant”. The typically
Tingewick solution to emphasise that his had been done correctly was to place used cans of flame
retardant in strategic locations near the stage which gave the desired effect.
Sending up (whilst avoiding being Sent Down)
WWith the stage set and inspectors satisfied the delirious parody of Tingewick can begin. The
usual suspects ranging from Professors of Medicine to idiosyncratic administrators all figure
highly in David’s recollection of targets lovingly mocked by ever-creative generations of
Tingewick writers. One of the earliest shows he can remember was 1970’s ‘At your Cervix’ (or
‘Dilated to meet you’), inspired by a highly charming O&G Consultant’s favoured clinical
introduction: “Delighted to meet you”. The Obstetricians and Gynaecologists of today are able to
take a collective sigh of relief as along with Paediatrics and General Practice the 5th year rotation
order fortuitously allows them to avoid becoming the Tingewick firm’s muse. Whilst today’s
Consultants may think otherwise, David believes that if anything latter-day Tingewick scripts
have been rather ‘kinder’ compared to material of the past, which could be a ‘bit cutting’. Indeed
David recollects how Tingewickers of yore would stare down potential career catastrophe with
glee as “they invariably got the department in question to be there”. I reassured David that recent
firms had not softened too much – the 2008 firm’s rendering of Tingewick Senior member, ‘His
Casualty’, the enigmatic Professor Bulstrode as a Cave Man enthusiastically demonstrating
‘Look, Feel, Move’ on collapsed time travelers comes to mind.
Onwards and upwards
David fondly recalls former Directors who have gone on to great things. Dr. Catherine Hood,
notable for her work on Channel 4, was a prominent Director and Dr. Amanda Salisbury, now
Consultant Clinical Oncologist and Senior Treasurer of the society, played a particularly
memorable Professor Weatherall. Dr. Anthony Berendt stands out for chasing a ‘patient’ down
the writing tops of Lecture Theatre 1 and somersaulting onto the stage as part of the sketch
performed for unwitting new clinical students. And finally David remembers the Tingewick times
of the current ‘His Munificence’, Dr Derek Roskell, and insightfully predicts: “Derek has
probably been taken off many times” (yes, most recently as ‘The Giant’).
Charity
In addition to ‘top-rate’ ‘comedy’ Tingewick exists to raise money for charity. David remembers
how in the early days Tingewick would have to seek out worthy causes but as the word got out
about the show the organisations themselves would come knocking on the door. In recent years
Tingewick has supported charities as diverse as Helen and Douglas House, Respite Nursing for
Oxfordshire’s Sick Youngsters, Alzheimer’s Society, and the Children’s’ Hospital Trust in South
Africa. This has been enhanced by the foundation of the Tingewick Trust which allows tax from
all donations at the shows to be re-claimed from GiftAid helping the fund raised to rise to everimpressive figures, culminating in over £20,000 in 2009. We conclude that future is bright; the
future is Tingewick Pink!
Tingewick Treasure
I greatly enjoyed reminiscing with David and we thank him for all his support over the years.
Here’s to another 70 years of the fun, frolics and fundraising extravaganza that is Tingewick. And
for those of us who near graduation and fear footage of their immodestly dressed ‘musical
interlude’ turning up in the hands of a Tabloid Editor in 30 years time, I would suggest hastily
tracking down those Tingewick DVDs and a clinical waste bag…
The author would like to thank Mr David Messer and Mr Allan Lacey for their time.
Adam Al-Diwani is a final year medical student at Corpus Christi College, and Tingewick
Treasurer 2009
Book Reviews
Oxford Handbook of Clinical Medicine 8
M. Longmore, I. Wilkinson, E. Davidson,
A. Foulkes and A. Mafi
The wait is over; a new Cheese and Onion has arrived!
Content
This pocket-sized nugget of knowledge covers all the important conditions any medical student
should know (and many of the more obscure ones). Sections on all the major specialties are
included, with the other Oxford Handbooks covering postgraduate specialties. Within each
section, the pathogenesis, symptoms, signs, investigations and treatments for each condition are
outlined.
Style
OHCM-8 is the epitome of concise. The focus is on what medical students and junior doctors
need to know to survive grillings on the ward. Summaries of investigations and treatments are
particularly useful for the practicalities of clinical work, as are the emergency topics towards the
back. With such a vast quantity of information, there is a risk of reducing medicine to a series of
list. However, OHCM-8 never loses sight of the patient as the centre of a consultation, and nestled among the onslaught of facts - are very human reminders of why we become doctors in
the first place.
The Good
Since OHCM-7, the content has been updated while the style has lost none of the OHCM essence.
Sections on radiology and practical procedures have been expanded, as have sections on historytaking and examination skills (ideal for exam preparation). The layout has also been improved
with all sections now being colour-coded and reliably indexed.
The Bad
As with any book containing such a wealth of information, some mistakes have crept in.
However, all information is regularly updated online and a PDA version (also regularly updated)
is available.
Personal Recommendation
All medical students should own an OHCM. When times are hard, when you need an answer, and
when there’s no-one else to turn to, it will be there in your bulging pocket: the best tutor you’ll
ever have.
Rating: 10/10
100 Cases in Paediatrics
J. Raine, A. Cunnington and J. Walker
The increasing use of problem and case-based learning has been reflected in the popularity of
books such as the 100 Cases series. This particular batch has already covered medicine, surgery,
primary care and obstetrics and gynaecology. Next in line is paediatrics.
Content
All body systems are reviewed in turn with a good range in the ages of the patients. A
miscellaneous section covers some more obscure cases in addition to important topics such as
child protection and sudden infant death.
Style
Each case is clearly presented with clinical findings and investigations including radiographs,
growth charts and electrocardiograms. Questions posed at the end of a problem cover general
diagnosis and management but also specific issues related to the condition in question, ensuring
that particularly important points are considered.
The Good
In its aim for diversity the book is certainly successful, covering a wide range of acute and
chronic medical problems and important social topics and legal issues.
Solutions include wide differential diagnoses, discussion of aetiology and comprehensive
management plans. The latter is particularly wide-ranging in many of the cases and covers
important conservative measures as well as medical or surgical management.
The Bad
The information in the book is unlikely to be enough to gain a broad understanding of the
problems covered on its own, but as an adjunct to a wider-ranging textbook it is more than
adequate and would be particularly useful for revision. More colour pictures or diagrammatic
representations would be useful.
Personal Recommendation
I would recommend this book as a useful aid alongside a more detailed text to anyone on a
paediatrics placement. It provides a useful framework for working through clinical problems, now
an integral part of the Oxford paediatrics course, and is good for consolidating key facts.
Rating : 8/10
Mary Denholm is a final year medical student at Jesus College
1000 Tiny Plays about the JR (apologies to Craig Taylor): A fitting end
A student nurse approaches a senior in A&E.
Student nurse: Okay, I’ve got three patients ready for discharge, I think, do you want to just check
them overNurse: Yes, of course, who have we got?
Student: Well, there’s Mrs Miller, andNurse: Mrs Miller?
Student: Yes.
Nurse: You think she’s ready for discharge?
Student: WellNurse: She’s in resus.
Student: Ah.
Nurse: Did you see her?
Student: Well, not as such, butNurse: Why do you think she’s ready for discharge?
Student: I was looking at the board, and it said she was fit for discharge.
Nurse: The board?
Student: Yes, it said ‘fit’.
Pause
Nurse: That means she’s had a fit.
Student: Ohh.
Beat
Student: Okay I don’t think Mr Craig is ready to go either then.
Tom Campion is a sixth year medical student at Wadham College
1000 Tiny Plays about the JR: Big questions
Two porters and a consultant are in a lift
Porter 1: I mean, she was just hugePorter 2: Really?
Porter 1: Yeah, we had no idea how we were going to shift her, she was massive, but she had to
move. So I had this idea to reinforce a gurney, rightPorter 2: Yeah, good idea, I’d have done thatPorter 1: But she was still falling of the sides, it was ridiculous, I had to call Steve as well, and
between us we could just about hold her on but we were going nowhere.
Porter 2: So what did you do?
Porter 1: So we got another gurney, we lashed the two together, right, and then we sort of spread
her across both of them
Porter 2: Both of them?
Porter 1: Yeah, and that was still only just big enough!
Porter 2: Must’ve been massive
Porter 1: We had to put one of those beeping things, you know like when a truck reverses, so that
people wouldn’t get crushed…it almost took out a five year old girl
Porter 2: Why do they need to be that big?
Porter 1: I know, it’s completely unnecessary.
Lift stops, door open
Consultant: I couldn’t help overhearing that. It’s disgraceful, how dare you talk about patients
like that? What if someone overheard? How do you think they’d feel? You should be ashamed of
yourselves, I’ve half a mind to talk to your supervisor.
He leaves. Doors close.
Beat
Porter 1: That’s political correctness gone mad, that is.
Porter 2: I don’t think he knew you were talking about the sofa for the consultant’s lounge.
Porter 1: Sofas offend easy these days.
Porter 2: Tell me about it.
Tom Campion is a sixth year medical student at Wadham College
Many thanks for reading the Oxford Medical School Gazette, we hope you enjoyed it. Please visit
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The Gazette editors, 2010