nostalgic after all…

Posted on Wednesday 23 July 2014

    He who knows syphilis knows medicine
    Sir William Osler, the Father of Modern Medicine
some of the research subjects

Some years back, I saw a play, Miss Evers’ Boys, about the Tuskegee syphilis study. In 1932. 600 black men were recruited into a Public Healtrh Service study that went on for forty years. In return for participating, they were given free medical care and burial insurance. The back story was that this was a study about the natural course of syphilis and 399 of these men had the disease, but weren’t told. They were only told they had the bad blood [a colloquialism with many meanings]. When penicillin came along in the 1940s, the definitive treatment for the disease, it was neither used nor discussed. The play centered on the study nurse, the Miss Evers of the play, who "saw after" the participants all those years knowing they weren’t being treated. The study was finally leaked in 1972, and the aftermath brought many changes in the safeguards for human experimentation [see Wikipedia’s Tuskegee syphilis experiment].
By the end of the study in 1972, only 74 of the test subjects were alive. Of the original 399 men, 28 had died of syphilis, 100 were dead of related complications, 40 of their wives had been infected and 19 of their children were born with congenital syphilis.
It’s a story of epidemiology; of racism; and of the origin of Informed Consent and Institutional Review Boards. The entire 1997 HBO Movie of Miss Evers’ Boys is available on-line [1:57:59]…

Eunice Rivers (the real nurse)

Osler’s famous pronouncement came at the turn of the century [twentieth century] attesting to the many manifestations of syphilitic pathology. At the time, CNS Syphilis was the main disease found in the patients in our large mental hospitals. Osler was still quoted in the days of my Internal Medicine residency [for good reason]. Some snippets:
    [1964] I paid my room and board in early medical school by being the house manager for a medical fraternity house. That essentially entailed keeping up with the elderly black man who had actually run the place since the dawn of time. One day I returned from a lecture where I’d heard for the first time about Tabes Dorsalis [tertiary syphilis of the spine], and I noticed that his walk looked a lot like the film I’d seen in class that day. I asked him about it and he said he was just "getting old." I engaged an upper classman who went to the hospital and got his chart. Sure enough, he’d been treated with heavy metal injections as a young man [for bad blood], but nothing since. We escorted him to the neurology clinic where he was treated with Penicillin [and became a Grand Rounds case].
    [1967] The first patient I had as an Intern was an elderly man admitted after abruptly losing his voice. The next day, we got an emergency page and found him in extremis coughing up blood and he quickly arrested and died. That afternoon, his VDRL [lab test for syphilis] came back positive. At autopsy, he had a syphilitic aortic aneurism that had ruptured into his trachea. The hoarseness was from the compromised recurrent laryngeal nerve [that wraps under the aorta on its way to the vocal cord].
    [1973] When I was an Air Force Doctor overseas, an older civilian administrator was admitted with jaundice and delirium from liver failure. He had the physical findings of chronic cirrhosis though he was not a drinker. But he also had fever and signs of some acute process. He had a history of hepatitis in the South Pacific in World War II and we speculated he had Chronic Active Hepatitis. But then on the second hospital day, he developed a generalized rash, present on his hands and feet [a characteristic sign of secondary syphilis]. Scrapings of the rash revealed those little corkscrew Treponema pallidum organisms bending in the middle that I’d only seen in pictures [the organisms that cause Syphilis]. In spite of our starting him on a very low dose of penicillin, he had a Jarisch–Herxheimer reaction [toxicity from the sudden death of the organisms] requiring high doses of steroids. He had been infected by a dalliance with the wife of a ranking officer at a base in another European country [a delicate and touchy point]. He recovered nicely, but unfortunately we were right the first time. On a subsequent liver biopsy, he also had Chronic Active Hepatitis that had been complicated by the Syphilis infection.
So what’s with a Syphilis retrospective out of nowhere all of a sudden? I got to thinking about Miss Evers’ Boys and what Dr. Osler said after writing about Adolescent Depression [its origin…], about the Mild Neurocognitive Disorders [needs looking into…], about the Attenuated Psychosis Syndrome that was being considered for the DSM-5 – or the current front burner issue of the Statins. It’s all about prevention – preventing suicide, preventing Alzheimer’s, preventing psychosis, preventing heart attacks and strokes – in each case, requiring a precise baseline knowledge of the course of a disease, and identifying the early signs of coming trouble that may become irreversible.

William Osler was "the Father of Modern Medicine" in part because he exemplified the era of the grand clinician – physicians who spent their lives carefully mapping the signs and symptoms, the clinical course, the family and environmental histories of diseases. They collected detailed case histories extracting patterns that became syndromes, many of which still carry their names. Their treatment options were limited, but hard won advances informed by their clinical precision. As monstrous as it was to withhold the diagnosis in the Tuskegee Study early on, and even worse, to withhold treatment when it became available, the idea of gathering precise epidemiological data was consistent with the way medicine operated in the latter nineteenth and early twentieth century.

In our current era, there is a race to treatment based on small differences and speculation, both measured and hypothesized. Each evening, we expect our evening news to be accompanied by an announcement of some medical advance or breakthrough, punctuated by direct to consumer ads with their mumbled warnings. We’ve become used to questionnaires, rating scales, laboratory examinations, and loud whirring machines replacing the classic history and physical examinations of the past. My point here is not simply nostalgia for former days, it’s about the hurried pace with which we race into action, to treatment. The current Tamiflu debacle is an exempler. Billions have been spent on a medication to stave off a hypothesized global epidemic. Now it appears that that medication, while not inert, is hardly suited to the task. We’ve defined Mild Neurocognitive Disorder and the Attenuated Psychosis Syndrome without having a solid anchor that tells us that they are, indeed, the precursors we seek. We are subjected to recurrent studies that try to convince us to use SSRIs in teens with little evidence that they even treat adolescent depression itself, much less prevent anything, and with that come accusations of withholding treatment.

The Tuskegee Study is a genuine example of withholding treatment – epidemiology run amok. But the Black Box Warning with antidepressants in youth, the push-back against the current recommendations about Statins, the bruhaha about Tamiflu, and urging caution about diagnoses like Mild Neurocognitive Disorder, Attenuated Psychosis Syndrome, or Disruptive Mood Dysregulation Disorder may well be the wise voice of Dr. Osler’s generation cautioning us across time to beware of therapeutic zeal, to be careful with our epidemiology, and to be conservative with treatments until we’re sure of what we’re doing. Maybe I am nostalgic after all…
    Steve Lucas
    July 23, 2014 | 7:35 PM

    I can think of a couple of doctor bloggers who would agree with this post. Amazing what a little time and a little thought will do in getting to the root of a patients problem, not to mention the cost savings to all involved.

    Steve Lucas

    July 23, 2014 | 11:36 PM

    Off the cuff, this reminds me of the American conscientious objectors who volunteered for a study of starvation during WW II. They volunteered, and I’m thinking it took all their conviction to bear it.

    Tuskegee is inexcusable.

    The lack of informed consent with all these “preventive” treatments and the tendency to push for treatment for increasingly small risks is cynical beyond reason.

    It’s reassuring to see the risks of statins covered here and in an increasing number of searches. The elderly are currently being used much like blacks in the Tuskegee experiments. I’m guessing the death tolls are much higher, though.

    July 24, 2014 | 12:15 AM

    Re “the American conscientious objectors who volunteered for a study of starvation during WW II” – see “The Depths: The Evolutionary Origins of the Depression Epidemic” for fabulous accounts of their experiences – and the author’s blog here

    Steve Lucas
    July 24, 2014 | 7:43 AM

    We need to be aware of a continuation of this pattern in today’s hospitals and private practices. A 55 year old male goes to the ER with severe lower abdominal pain. First it is gas. Then it is an inflamed bowel. Then they do a complete cardiac workup. Finally on the fourth day they say there may be something on the CT scan taken on admission and take out his appendix.

    Four days of pain and expense. My question is; was this done because they did not know or was it an attempt to run up the bill?

    This is a hospital that has been sued in some high profile case for unethical business practices. Do the means justify the ends when the end is to maximize revenue and where is the review of this situation to assure patients are diagnosed in a timely manner, not when their insurance is about to run out.

    Steve Lucas

    James O'Brien, M.D.
    July 24, 2014 | 11:34 AM

    The Tuskegee experiment was conducted by the USPHS. Not a corporation. Just thought I’d point that out.

    There is zero moral equivalence between Tuskegee and using cognitive enhancers in the elderly with MCI. As much as I question the purpose of the latter.

    Bradley Evans
    July 24, 2014 | 7:21 PM

    I think there was a medical committee convened to determine what to do about the Tuskegee syphilis study, and the vote was to continue the study. It was only after a journalist broke the story that the USPHS ended the study, and treated the patients.

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