France,the fundament,and the rise of surgery

This article describes events in 17th and 18th century France that resulted in the elevation of surgery from a lowly status to one of parity with medicine. Changes in the education and organization of surgeons are described, and the nature and significance of the successful operation for fistula-in-ano on Louis XIV is considered in some detail.     

Medicine, the novel, and the passage of time

Doctors and patients move together through time, humble in the face of its dictates. Novelists allow their characters to enter time, revealing in the characters' particular, ongoing lives some universal truths about living. Both the medical chart and the novel capture individual human lives as they change and as they age, finding some meaning in the random events that happen in them. Literary critics who write about the novel provide useful frameworks for doctors who reflect on their practice. In this essay, I examine the medical charts of two of my patients in detail and describe the experiences I shared with them. As a repository of detail not only about the patients but about the doctors and nurses who cared for them, the charts provide rich and powerful evidence about the insides of practice and the meanings that clinical relationships accrue. Doctors might discover underlying meaning in their practices that would otherwise elude them by reading their patients' charts as if they were novels, looking for patterns and movements throughout a patient's life, and recognizing the deep connections woven between their patients and themselves. By placing great novels-by Henry James, Virginia Woolf, and Thomas Mann-side by side with actual medical charts, I suggest the usefulness of close readings of medicine's texts. The juxtaposition suggests the utility of brooding about the seasons of our relationships with patients. Perhaps not a luxury but a necessity for effective care, reflection such as this on our patients may restore to medicine some of its passion, its meaning, and its joy.     

Freedom, dependency, and the care of the very old

Difficulties exist in making treatment decisions for the very old and dependent patient. In the years to come, these difficulties will increase. It is argued that such persons should not be abandoned to their "rights" as autonomous persons; yet quality of life judgments should also be avoided except in limited circumstances. Since aging is a process of becoming more dependent, the author proposes a dependency rule, by which greater responsibility for treatment decisions falls on care-givers as a person's dependency increases. In place of quality of life judgments he suggests a medical indications policy, if the latter includes restoration of some affective function. Five kinds of freedom are proposed, of which only some are lost in chronic illness and old age. Finally, it is suggested that life itself involves greater interdependence than the autonomy criterion itself can allow. The author focuses on the problem of dependency in the aged and the role an increase in this dependency plays, with corresponding loss of personal autonomy, in quality of life judgments. These, in turn, form the basis for treatment decisions.     

Abstinence, abstinence-only, faith-based, and the psychology of stigma

If abstinence is 100% effective in preventing sexual transmission, why does abstinence-only not work well? And what is the personal psychology of the stigma that prevents individuals, communities, and nations from protecting themselves against the epidemic? We offer some fairly obvious analysis that has been largely overlooked in the public discussion.     

Race,ethnicity, and the risk of sudden death,

Sudden cardiac death (SCD) is a major cause of death worldwide, with an estimated U.S. annual incidence of 350,000 [1]. This review will examine the influence of race and ethnicity on SCD burden and risk factors, and review the available literature on resuscitation outcomes and primary prevention of SCD. An improved understanding of associations between race, ethnicity, and SCD may provide clues to mechanisms, lead to improved prevention of SCD, and ultimately reduce racial and ethnic disparities in the burden of SCD.     

Detection of Met-enkephalin and Leu-enkephalin in the brain of the hagfish, Eptatretus stouti, and the lamprey, Petromyzon marinus

Acid extracts of the brain of the pacific hagfish, Eptatretus stouti, and the marine lamprey, Petromyzon marinus, were each fractionated by gel filtration chromatography and aliquots of column fractions were screened with radioimmunoassays (RIAs) specific for pro-dynorphin-related end products and for pro-enkephalin-related end products. Only pro-enkephalin-related immunoreactive forms were detected. The enkephalin-sized immunoreactive material, isolated for each species, was separately fractionated by reverse-phase high-performance liquid chromatography (HPLC). Aliquots of column fractions were screened with RIAs specific for Met-enkephalin, Leu-enkephalin, Met-enkephalin-Arg-Phe, and Met-enkephalin-Arg-Gly-Leu. In the hagfish brain, immunoreactive forms with the same retention times as synthetic Met-enkephalin and Leu-enkephalin were detected in a ratio of approximately 2:1. In addition, an immunoreactive form was detected with the Met-enkephalin-Arg-Phe-specific RIA. This form had the same chromatographic properties as synthetic Met-enkephalin-Arg-Phe. Analyses with the Met-enkephalin-Arg-Gly-Leu RIA were negative. HPLC analysis of the lamprey enkephalin-related material revealed the presence of authentic Met-enkaphalin and Leu-enkephalin in a molar ratio of 3:1. C-terminally extended forms of Met-enkaphalin were not detected in the lamprey extracts. Collectively these observations indicate that pro-enkephalin-related opioid peptides are present in the brain of cyclostomes.