Archive for the ‘medical history’ Category

Genetics and Archeology

Monday, May 9th, 2016

Neanderthal

I recently read a book titled, The 10,000 Year Explosion.

Its premise is that evolution did not stop or “pause” with the development of modern man 40,000 years ago.

A few basic facts about genetics. Genes are sets of nucleotides that encode proteins by encoding RNA. This is all in my book, A Brief History of Disease, Science and Medicine. One key fact is that:

Genes can acquire mutations in their sequence, leading to different variants, known as alleles, in the population. These alleles encode slightly different versions of a protein, which cause different phenotype traits.

I discussed this at some length two years ago and then, because it stirred a hornets nest at Ricochet, I posted some of the nasty replies here.

Mutations occur at random or under the influence of outside influence like UV radiation. Some are harmful, like cancer, and are not continued in the “gene pool.” Some are beneficial and may persist as they provide an advantage to the individual who may live longer, have more children and have more of the children survive to reproduce.

Humans evolved in Africa and spread outside of Africa before 50,000 years ago. There have been successive waves of modern humans that were better adapted to life, especially in areas that were new and often inhospitable like Ice Age Europe. One such group was called the “Neanderthal, as they were found in the Valley of the Neander River in Germany.

Neanderthals came to Europe some 300,000 years ago. They hunted big game with stone tools. Their territory spanned Europe and Asia. They left distinctive “Mousterian” artefacts.

There were other groups and we are starting to find out who and what they were from their DNA.

We know that modern humans first arrived in Europe about 45,000 years ago when the continent was still a Neanderthal stronghold. Over the next 30,000 years – archaeological work has revealed – a procession of different cultures, each associated with different artefacts and lifestyles, rose in Europe.

Archaeologists tend to think these sort of cultural shifts reflect the spread of new ideas through an unchanging population. But a new analysis of nuclear DNA taken from 51 ancient Eurasians tells a different story. They actually reflected the spread of different peoples.

The Neanderthals were gone earlier than recently believed.

“Until recently, I and many with me had thought that Neanderthals survived until 30,000 years ago, or perhaps even slightly later,” says Svante Pääbo of the Max Planck Institute for Evolutionary Anthropology in Leipzig, Germany. “The new dates make it clear that they disappeared 10,000 years earlier.”

What happened ?

For Pat Shipman of Penn State University, this supports her theory that modern humans acted like an invasive species in Europe, beating the Neanderthals in a competition for resources. That’s a “distinct possibility”, Higham says.

But that does not mean we murdered our cousins. There is no evidence humans ever killed Neanderthals, and they probably didn’t meet often, says Higham.

So what role did we play? Many now suspect we were the last straw for an already fragile species. Genetics suggests Neanderthal numbers dropped sharply around 50,000 years ago. This coincides with a sudden cold snap, hinting climate struck the first blow.

The Ice Ages were a huge stress.

Over the next 30,000 years – archaeological work has revealed – a procession of different cultures, each associated with different artefacts and lifestyles, rose in Europe.

Archaeologists tend to think these sort of cultural shifts reflect the spread of new ideas through an unchanging population. But a new analysis of nuclear DNA taken from 51 ancient Eurasians tells a different story. They actually reflected the spread of different peoples.

Some of this change involved breeding with Neanderthals, and many of us (including me) have some Neanderthal DNA. Why ? The Neanderthals might have been better adapted to Ice Ages which waxed and waned.

During this period, there were several changes between glacier advance and retreat. The Last Glacial Maximum, the maximum extent of glaciation within the last glacial period, was approximately 22,000 years ago. While the general pattern of global cooling and glacier advance was similar, local differences in the development of glacier advance and retreat make it difficult to compare the details from continent to continent (see picture of ice core data below for differences).

From the point of view of human archaeology, it falls in the Paleolithic and Mesolithic periods. When the glaciation event started, Homo sapiens were confined to Africa and used tools comparable to those used by Neanderthals in Europe and the Levant and by Homo erectus in Asia. Near the end of the event, Homo sapiens spread into Europe, Asia, and Australia.

Maybe Neanderthals were better adapted to glacial epochs.

The Aurignacian culture was dominant between about 45,000 and 35,000 years ago. This culture produced fine bone and stone tools, and some of Europe’s oldest and most beautiful art – for instance at Chauvet cave in southern France.

By about 33,000 years ago a new culture that began in south-east Europe was beginning to spread across the continent: the Gravettian. This is famous for big-game hunting of mammoths and bison.

And later, at the height of the Ice Age about 19,000 years ago, yet another culture swept across west and central Europe. This Magdalenian culture is famous for its reindeer hunts and for its artwork, carved into bones and antlers.

One of the oldest individuals examined by David Reich at Harvard Medical School in Boston and his colleagues is represented by a thigh bone found at a site called Goyet cave in Belgium. Radiocarbon dating shows it is 35,000 years old, meaning the Goyet individual is associated with the Aurignacian industry.

Now, it appears that these people were quite different genetically.

the Aurignacians were pushed aside by an expanding wave of Gravettians.

“It is exciting and striking how a relatively homogeneous population sweeps across large parts of Europe between 33,000 and 26,000 years ago, displacing the populations that were there before,” says Reich.

But that’s not the full story. The genetic analysis also looked at six Magdalenians: they are descendants of the displaced Aurignacians.

This is a real surprise, says team member Cosimo Posth at the Max Planck Institute for the Science of Human History in Jena, Germany. It shows that the Aurignacian lineage didn’t disappear when the Gravettians swept across Europe.

“In fact from the end of the Last Glacial Maximum some 19,000 years ago, its genetic component reappeared in Spain. From then to around 14,000 years ago this nuclear signal spread in Europe again,” he says.

They may have been pushed into a cul de sac in Spain but returned as the glaciers retreated. Why ?

We know a few things, such as why white skin evolved. As humans moved from Africa to Europe and faced cold climates, they needed Vitamin D which is synthesized in the skin.

Dark skin is useful and provides and evolutionary advantage in tropical settings. It also has some protective effect on sun burning and skin cancer. One negative consequence of inadequate Vitamin D is Ricketts, a disease of bones.

Rickets is defective mineralization or calcification of bones before epiphyseal closure in immature mammals due to deficiency or impaired metabolism of vitamin D,[1] phosphorus or calcium,[2] potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries.

This provides a strong feedback for selecting beneficial mutations.

Some of this will lead to modern therapy and that is why I wrote that I would not recommend a student for medical school who did not believe in evolution. Here is some of the negative response I got. I quit Ricochet when my subscription expired.

The Muslim war on immunization.

Saturday, January 16th, 2016

If anyone wonders about the level of civilization in Muslim countries and especially those in “radical” or “takfiri” subsets, the war on polio immunization should be a clue.

Recently, a suicide bomber attacked a polio immunization center in Pakistan.

The World Health Organization’s anti-polio vaccination program inside Pakistan has been a prime target of the Taliban. Mullah Fazlullah, the emir of the Movement of the Taliban in Pakistan, was one of the first leaders to have opposed polio vaccinations. On his radio program, Falzullah, who is also known as Mullah Radio, denounced polio vaccinations as Western attempts to sterilize Muslim boys.

Other Taliban commanders, including Mullah Bahadar and Mullah Nazir, who was killed in a US drone strike, as well as Pakistani clerics and leaders in the tribal areas, suspended polio vaccinations in areas under their control until the US ceased drone strikes against Taliban, al Qaeda, and other jihadist commanders.

Taliban commanders have also accused vaccination programs as serving as cover for CIA and western operations to target jihadist leaders inside Pakistan.

The largely Muslim state of Uttar Pradesh in India has been the last outpost of remaining polio cases in the world.

India was declared free of the wild polio virus in January 2011 however cases of flaccid paralysis continue to be reported in thousands from across the country. “In spite of the WHO declaring India polio-free, there has been an increase in the cases of non-polio paralysis. It is a huge cause of concern,” said Dr SD Gupta, president, IIHMR University.
In 2004, 12,000 cases of non-polio paralysis were reported which increased to 53,563 cases by 2012. According to the data published by the union health ministry in July, 2015, the total number of non-polio acute flaccid paralysis (NPAFP) cases across the country were 18,141, of which 5918 were reported from UP, 668 from Rajasthan, 102 from Telangana, 385 from Karnataka and 865 from Maharashtra, among others.

What is going on ? It seems that new enteroviruses may be involved. India has been largely successful in eliminating wild Polio virus.

India’s success in eliminating wild polioviruses (WPVs) has been acclaimed globally. Since the last case on January 13, 2011 success has been sustained for two years. By early 2014 India could be certified free of WPV transmission, if no indigenous transmission occurs, the chances of which is considered zero.

Great efforts were made.

The VE against types 1 and 3 was the lowest in Uttar Pradesh and Bihar, where the force of transmission of WPVs was maximum on account of the highest infant-population density. Transmission was finally interrupted with sustained and extraordinary efforts. During the years since 2004 annual pulse polio vaccination campaigns were conducted 10 times each year,

Muslims are determined to stop this effort. More evidence that they are not ready for civilization.

2015 is gone, thank God.

Friday, January 1st, 2016

2015-a-maes-Marty_thumb

I am content to see the year 2015 gone. I can remember as a college student thinking that 1960 would never come. That was a good year. I didn’t graduate from USC as planned but I did get married and I did get accepted to medical school.

Some of the story is here in my short biography. More of it is here in my “stream of consciousness.” The next installment is here as I describe Basic Training.

When I got back from Basic Training in December 1959, I had my first date with Irene Lynch. A year later to the day, we were married and a week later, I got a letter from SC Medical School telling I had been accepted to the class beginning in September 1961. So, 1960 was a pretty good year.

In 2015 I spent what I think will be my last year teaching medical students at what is now named “Keck School of Medicine of USC” and is where I attended from 1962 to 1966. I went back to teaching there in 1998 in a program called Introduction to Clinical Medicine, which seems to be disappearing into the “Family Medicine” Department which is a shame.

I now have a book of memoirs called “War Stories: 50 years in Medicine” and which is a Kindle book only so far. Much of my medical school experience is included along with stories from my years as a surgeon. It started to be “40 years a surgeon” but I decided to include the rest and changed to 50. In June 2016, it will 50 years since I graduated from Medical School and that seemed a appropriate.

I enjoyed my time with students and I am quitting only because of frustrations with the Electronic Medical Record, about which I used to be enthusiastic, and with changes in the County Hospital which used to be a wonderful teaching institution. The Electronic Medical Record, now more often called The Electronic Health Record, probably because much of it is not about medicine, is a big problem.

The EHR, as it is called, has acquired a bad reputation.

(more…)

The Medical History of the American Civil War III

Friday, September 4th, 2015

This continues the series from a lecture I have given a few times.

Slide23

William W Keen was a student when he first served as an Army surgeon at Bull Run. That experience changed the Army medical services and gave a great deal of power to the volunteer organizations.

Slide24

William Hammond quickly replaced the incompetent surgeons who had been in place when the war began. He was competent but argumentative and clashed with Stanton who became Secretary of War.

Hammond met Jonathan Letterman. Hammond worked with Letterman and Rosecrans on the design of a new ambulance wagon.

The atmosphere in the upper levels of medical services was then one of internal strife and personal conflicts. Hammond—a tall and imposing young man[12]—was no man of intrigue, nor even, according to all accounts, a very flexible person. However, the situation offered him the possibility for advancement. When Finley, the 10th Surgeon General, was fired after an argument with Secretary of War Edwin M. Stanton, Abraham Lincoln, against Stanton’s advice and the normal rules of promotion, named the 34-year-old Hammond to succeed him with the rank of brigadier general. Hammond became Surgeon General of the Army on 25 April 1862, less than a year after rejoining the army.

Lincoln liked “Men who fight” and defended his choices but Hammond was just too hard headed.

On his initiative, Letterman’s ambulance system was thoroughly tested before being extended to the whole Union. Mortality decreased significantly. Efficiency increased, as Hammond promoted people on the basis of competence, not rank or connections, and his initiatives were positive and timely.

On 4 May 1863 Hammond banned the mercury compound calomel from army supplies, as he believed it to be neither safe nor effective (he was later proved correct). He thought it dangerous to make an already debilitated patient vomit. A “Calomel Rebellion” ensued, as many of his colleagues had no alternative treatments and resented the move as an infringement on their liberty of practice. Hammond’s arrogant nature did not help him solve the problem, and his relations with Secretary of War Stanton became strained. On 3 September 1863 he was sent on a protracted “inspection tour” to the South, which effectively removed him from office. Joseph Barnes, a friend of Stanton’s and his personal physician, became acting Surgeon General

Stanton later died of an asthma attack so his “personal physician” was important to him. Calomel was “The Blue Pill” that had been advocated by Benjamin Rush. It was an ancient remedy based on the success of mercury in the treatment of syphilis dating back to Paracelsus in the 14th century. Medicine until the 20th century was quite primitive and many remedies were tried for wildly inappropriate indications.

van gogh

For example, a Van Gogh painting of his doctor shows evidence of digitalis intoxication which might have caused his death. Yellow vision is one indication of overdose of digitalis (sudden death is another) and a Van Gogh painting, Portrait of Dr. Gachet shows the characteristic yellow tint plus an example of the plant held by the doctor.

Anyway, Hammond was replaced after some of his innovations including evacuating the wounded from the Peninsula Campaign of McClellan. They were taken by ship back to large hospitals near DC.

Slide25

Slide26

Treatment of the wounded early in the war was primitive and would soon improve under Hammond’s reforms.

Slide27

The volunteer organizations began to make their influence felt and the Army was unable to resist the reforms.

Slide28

Tripler, for whom the great Army hospital in Hawaii is named, was chosen by McClellan to be the chief surgeon for the Army of the Potomac. His great innovation was the “Ambulance Corps.”

Slide29

The “Ambulance Corps” restored the invention of Baron Larrey and began the reforms of the Union

To be continued

The Medical History of the American Civil War II

Friday, September 4th, 2015

This continues the story of medicine in the Civil War. Samuel Gross, a Professor of Surgery at Pennsylvania Hospital in 1860, realized that no textbook of military medicine and surgery existed so he wrote his own in 60 days. It is shown in this exhibit at the Warren Collection at Harvard’s medical library.

manaual of mil surg

The Confederate Army also had no manual so the Gross manual was used by both sides in the war. It was quickly copied for Confederate Military surgeons. A copy of the manual, which was identical to the Union Army manual is preserved at Jefferson Medical College in digital form.

Slide16

The first battle, famously, was at Fort Sumpter where the commanding office during the battle was actually the medical officer, Samuel Crawford.

Slide17

The woeful state of the army medical department was recognized immediately and a volunteer organization quickly organized. The first was the US Sanitary Commission. It was rebuffed by the Army but quickly became very powerful. This was a people’s war and the Army was incompetent, as everyone knew.

Slide18

Here is the cover of Gross’s book. It was used throughout the war, which had enormous influence on American and world Medicine. The book from which this lecture is taken was used by Theodore von Billroth to design the Prussian Army medical corps for the Franco-Prussian War in 1870. The French had forgotten Baron Larrey’s lessons and suffered terribly.

Slide19

The cover of the Confederate version of Gross’s textbook.

Slide20

Joseph Woodward was an academic surgeon, such as it was known at the time.

“Woodward was the first scientist to establish photomicrography as a tool for both scientific and medical investigations.” According to an article in the Archives of Pathology and Laboratory Medicine:[2] “In addition to collecting specimens for the museum’s archive, he co-authored the definitive medical history of the Civil War in the 6-volume 1870 publication of the MSHWR.4 Woodward’s technique using aniline dyes for staining thin sections of tissue, along with his pioneering work in photomicroscopy, helped prepare the groundwork for modern surgical pathology.”

The “History” is “The Medical and Surgery History of the War of the Rebellion” of which there are six existing full copies. I found one copy in the USC Medical Library and asked the library staff, who had no idea of its value, to place it in a locked collection room. It would be like finding a copy of “De Revolutionibus” on the shelves of an open university library.

Slide21

The design of Union Army Hospitals was entrusted to Frederick Olmsted, who had designed New York City’s Central Park. He was, after the war, very involved in establishing The National Park Service.

Slide22

The first battle of the war illustrated the appalling condition of the medical services of both sides. There were no ambulances and the wounded and to walk back to Washington City, as DC was known then.

A famous American surgeon, who would write one of the world’s great medical textbooks, William W Keen acted as a young army surgeon at the battle.

He studied at Brown University, where he graduated in 1859. He graduated in medicine from Jefferson Medical College in 1862. During the American Civil War, he worked for the U.S. Army as a surgeon. After the war, he spent two years studying in Paris and Berlin.

His “An American Textbook of Surgery” was a hugely influential text and the 1905 edition had a chapter on brain surgery by Harvey Cushing and a chapter on “Appendicitis,” the first use of the term in medical literature, written by John B Murphy, who was the first advocate of early appendectomy for appendicitis.

To be continued.

The Medical History of the American Civil War.

Wednesday, September 2nd, 2015

Slide01

This is a lecture I have given a few times and am converting to a long blog post. The American Civil War was the first major war since a number of major advances of medicine had occurred. Sanitation had been studied by John Snow and Florence Nightingale. Anesthesia had been discovered by two Americans, Morton and

Unfortunately, antisepsis would not be described until, 1867, after the war. Infection than was the great scourge of the wounded.

Slide02

The state of medical art before the war was limited.

Slide03

Baron Larrey was the greatest army surgeon of the Napoleonic Wars. He invented the ambulance and pioneered some sanitary advances but the cause of infection was still obscure.

Slide04

Benjamin Rush was a famous American physician but little of what he knew or advocated was of use.

Slide05

The discovery of Ether anesthesia was momentous but it did add the factor that more operations would be attempted before infection was understood.

Slide06

Semmelweiss was tragic figure who realized that infection was transmissible from physicians’ hands to patients but he was unable to convince his colleagues. His discovery of the uses of hand washing were ignored.

Slide07

Florence Nightingale discovered the use of hand washing in caring for the wounded but she did not know why it worked. She is a great hero of the British Army and her apartment in Scutari Barracks in Istanbul is preserved in a shrine.

Slide08

The Scutari Barracks from across the Bosphorus.

Slide09

I visited the museum about ten years ago and visited her quarters which the Turkish Army preserves.

Slide13

The history of Military Medicine really begins with Ambrose Pare’ who served several French Kings and who invented the hemostat.

200px-Ambroise_Paré

His methods were a huge improvement on the Greeks but not much else can be said for their efficacy.

Slide14

The American Army in 1860 was tiny and the medical establishment was a joke.

Slide15

The war resulted in many of the army surgeons resigning to join the Confederacy. The lack of military medical texts resulted in Samuel D Gross, professor of surgery at Jefferson Medical College, writing his own textbook.

To be continued.

The fate of babies in medieval Italy.

Saturday, July 4th, 2015

Sienna babies ladder

This painting is on the wall of a medieval hospital in Sienna, Italy which depicts babies climbing a ladder to heaven. This probably represents the fate of many babies in those times. A figure, probably the Blessed Virgin, is seen helping them once they reach to top.

This photo was taken on a trip to Italy with a medical history group in 2003.

Obamacare Lives !

Thursday, June 25th, 2015

UPDATE: The decision is analyzed at Powerline today with quotes for the decision.

The Affordable Care Act contains more than a few examples of inartful drafting. (To cite just one, the Act creates three separate Section 1563s. See 124 Stat. 270, 911, 912.) Several features of the Act’s passage contributed to that unfortunate reality. Congress wrote key parts of the Act behind closed doors, rather than through “the traditional legislative process.” Cannan, A Legislative History of the Affordable Care Act: How Legislative Procedure Shapes Legislative History, 105 L. Lib. J. 131, 163 (2013). And Congress passed much of the Act using a complicated budgetary procedure known as “reconciliation,” which limited opportunities for debate and amendment, and bypassed the Senate’s normal 60-vote filibuster requirement. Id., at 159–167.

Therefore, Roberts rewrote it. Nice !

Today, the Supreme Court upheld the Obamacare state exchange subsidies.

The Supreme Court has justified the contempt held for the American people by Jonathan Gruber. He was widely quoted as saying that the “stupidity of the American people “ was a feature of the Obamacare debate. This does not bother the left one whit.

Like my counterparts, I have relied heavily on Gruber’s expertise over the years and have come to know him very well. He’s served as an explainer of basic economic concepts, he’s delivered data at my request, and he’s even published articles here at the New Republic. My feelings about Gruber, in other words, are not that of a distant observer. They are, for better or worse, the views of somebody who holds him and his work in high esteem.

The New Republic is fine with him and his concepts.

It’s possible that Gruber offered informal advice along the way, particularly when it came to positions he held strongly—like his well-known and sometimes controversial preference for a strong individual mandate. Paul Starr, the Princeton sociologist and highly regarded policy expert, once called the mandate Gruber’s “baby.” He didn’t mean it charitably.

(more…)

Psychiatry and the “deinstitutionalism” movement.

Tuesday, November 4th, 2014

There is a piece in the City Journal this quarter about the New York state experience with psychotic citizens and the prison system. Years ago, I wrote a book about my experiences in medical school and still have some thoughts of publishing it as an e-baook. Chapter One included my own experience working in a psychiatric hospital before the changes took place that put the mentally ill on the streets.

In June of 1962 I was released from active duty. A place in the 1962 first year medical school class had been held for me, but I needed a job for the summer until classes resumed in September. I came across an ad in a Los Angeles paper for medical students to work at the Veteran’s Administration Hospital in West Los Angeles. I was a medical student, albeit one with only a month of medical school under my belt, and I responded to the ad. I got the job, which consisted of performing annual physical examinations on patients in the closed psychiatric ward of the VA Hospital in West Los Angeles. My first experience with patients then was with chronic schizophrenics in a VA hospital.

As I entered upon my new duties at the VA hospital I had more experience than one would expect of a one-month medical student because I had been a corpsman for three years (only one on active duty). Nonetheless, performing annual physicals on 200 psychotic adult men was a daunting task. The psychiatry attending staff and residents decided that they would not do these required physicals because they thought physical contact would interfere with their relationship with the patients. These were the days of Psychoanalysis in psychiatry and examining or even touching patients was considered harmful. They chose medical students to do the task, and I was hired along with a few others. I reported to Building 206 on the Sawtelle Veteran’s Administration Hospital campus about the 15th of June to start my job. Building 206 housed 200 patients, all but a few of whom were chronic schizophrenics. There was one elderly black gentleman who suffered from tertiary syphilis (also called “General Paresis of the Insane” in the old days) contracted during the First World War. He had been a Veteran’s Administration Hospital patient since about 1928. The remainder was from World War II and Korea. The second floor of the building was a locked ward where patients were not allowed out on the grounds without being accompanied by a staff member. There was even a locked room on that floor where patients were confined in strait jackets if they were too agitated to be free on the locked ward. The first floor patients were in an “open ward” where they were allowed to go to the canteen and to go about the grounds of the hospital but were not allowed off the hospital grounds without a pass. If someone left without a pass he had “eloped.” There was one building on the hospital campus with a higher level of security than Building 206, but these patients of mine were chronically psychotic and not allowed to wander about freely except when they were on pass. It was an interesting experience for a first year medical student.

The VA Psych hospital was called The Sawtelle Veterans Home at one time.

The VA Psych hospital was north of Wilshire and evidence of the psych hospital is not easy to find.

(more…)

New developments at Mission Hospital

Wednesday, October 15th, 2014

A few months ago, I described the hospital where I used to practice and what was happening there recently.

Now, we have some new developments.

A couple more years went by and I learned that the hospital had laid off the low wage “environmental services” workers who cleaned the operating rooms between cases. Nurses, who made three or four times the hourly wage of the cleaning staff were now expected to clean rooms between cases in addition to their other duties.

That practice continued and now has caused severe problems. Last week, I learned that the Joint Commission on Accreditation of Hospitals had visited the hospital and had withdrawn the accreditation from Surgery, Labor and Delivery and Cardiology services. These are the heart of the acute care hospital. The reason ? Let’s read the paper.

From todays Orange County Register.

All elective surgeries at Mission Hospital, the third-largest hospital in Orange County, are on hold after four patients who underwent orthopedic operations developed infections.

The hospital opted to close its 14 operating rooms in Mission Viejo and Laguna Beach last week after a major accrediting agency, The Joint Commission, intervened and found, among other problems, high temperatures and humidity in some of the rooms, according to Chief Medical Officer Dr. Linda Sieglen.

If those infections were in patients undergoing total joint replacements, they are disasters for those patients. The cost of laying off those room cleaners has finally come home.

The scandal, and that is what it should be, is deeper than that story suggests. Surgeries are being shifted to other hospitals and doctors are going to have to make changes in their practices. Relationships may change permanently.

It is frustrating and infuriating to see the great hospital we built up in the 1970s, reduced to a news story about poor care as the result of ignorant and corrupt administrators.