Image courtesy of Alex Wild, click image for link

Not all hallucinations are disturbing, but most probably are.  They can be categorized by which sense is involved or by cause.  Schizophrenics often experience auditory hallucinations, hearing voices that are not actually present.  Many people can experience olfactory hallucinations, usually smelling foul odors that no one else can detect.  These are often caused by specific problems in the brain or nose.  A classic cause is seizure in the temporal lobe of the brain.

Visual hallucinations aren’t that common and usually aren’t associated directly with mental illness as auditory ones are.  Most of the time, visual hallucinations are caused by chemicals such as drugs, or by withdrawal from drugs.  Sometimes they are caused by specific brain disorders.  A classic cause of visual hallucination is delirium tremens, or acute alcohol withdrawal.  Victims often have disturbing visual hallucinations (one of my favorites being skeletons fighting with swords on the IV pole, although in that case, the patient wasn’t all that disturbed by it).

As if that weren’t enough, alcohol withdrawal is often accompanied by an additional type of hallucination called formication (from Latin formica ant). This is a tactile hallucination usually described as a feeling of bugs crawling on the skin.  It’s rarely pleasant.

Delusions differ from hallucinations.  Rather than being a sensory problem, they are a thought problem.  People with delusions believe something that is demonstrably false and cannot be convinced otherwise.

Which brings us to what is surely not the end of the story of “morgellons syndrome”.  Over the last few years, patient advocacy groups have militated for further investigation of this putative skin disease.  The disease is characterized by a variety of symptoms, most of which are cutaneous and include itching, sores, and foreign substances arising out of wounds.  Most physicians view this as a variant of delusional parasitosis, an illness where people believe they are infested but no proof of infestation can be found.

Patients typically have a pattern of skin lesions indistinguishable from damage done by scratching, and the fibers and other substances, when analyzed, have been found to be common substances such as clothing fibers.  Even a brief perusal of morgellons advocacy websites will demonstrate the hostility with which this analysis is viewed. Sufferers believe they are truly stricken—and they are. But the enemy is within rather than without. Their brains have convinced them that their skin is crawling with various sorts of things and they cannot be convinced otherwise.

A few years ago, the CDC decided to investigate what they have labelled “unexplained dermatopathy”.  This week, the results of their study were published in PLoS ONE.

The investigators focused on Northern California, where there seemed to be many case reports.  They sifted through charts and invited those who described the syndrome to join the study.  What they found was that cases were rare, but were associated with significant disruption in quality of life.  They also found a significant incidence of neuropsychiatric disorders.  A remarkably large percentage of patients had hair samples testing positive for drug use, but the specific drugs are not reported, nor is the validity of the hair sampling technique.

In sum, there was a set of patients who reported disturbing skin sensations and wounds, who were disproportionately unhappy and may have been using drugs.  But which way does the arrow of causation go?  Does a mystery disease cause people to become depressed and use drugs, or does psychiatric disease and/or drug use cause a delusional syndrome? Delusions and hallucinations caused by psychiatric disease and substance use are well-documented.  The other way ’round is a bit murkier.

Some clues are found in the study.  Many cases began around the same time the internet picked up on morgellons suggesting a folie a deux/plusiers —a shared delusion (this also suffers from a correlation vs. causation problem).  Also, the skin changes among patients were diverse, too diverse to be easily explained by a single non-psychiatric cause. Pathology findings most commonly showed skin changes due to sun exposure and trauma such as scratching.  Finally, the “fibers” and other objects emerging from the skin were found to be common substances like threads from clothing and were not emerging from the skin but rather were enmeshed with skin debris.

This will not be the last word on this particular variant of delusional parasitosis.  The definition of a delusion is a fixed, false belief, one that is not dislodged by data or knowledge.  The inability to accept the diagnosis is part of the illness itself.  The challenge to clinicians will be to treat these patients delicately, with respect, acknowledging their real distress and attempting to guide them toward proper treatment.

References

Pearson, M., Selby, J., Katz, K., Cantrell, V., Braden, C., Parise, M., Paddock, C., Lewin-Smith, M., Kalasinsky, V., Goldstein, F., Hightower, A., Papier, A., Lewis, B., Motipara, S., Eberhard, M., & , . (2012). Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy PLoS ONE, 7 (1) DOI: 10.1371/journal.pone.0029908

In Part I we discussed the history of medicine as a science. In Part II we addressed the role of compassion. This is the third part of the series.

Meridians of so-called Traditional Chinese Medicine

In 1994, I first put my hands on a human cadaver.  When we first received it, the head and hands were wrapped.  The rumor was that this would help us to adjust to the humanity of the thing more gradually.  When we did uncover the hands, the nails were painted, giving the meat a sudden, undeniable humanity.

Over the months, my friends and I slowly dissected this person, finding nerves, veins, arteries, muscles.  At the same time we learned the microscopic anatomy.  We learned how chemistry drove the smallest units of muscles, causing the whole to contract and lift an arm. We learned how specialized channels in the gut could be poisoned, causing cholera patients to dehydrate and die in hours.

We learned how the immune system could be taught to fight influenza; the mechanism by which common antibiotics poisoned cell wall formation in bacteria; the horridly complicated function of the smallest functional unit of the kidney called the nephron.  We stood on the shoulders of giants. I loved it.

The first two years of medical school is an intimate visit with the inanimate.  Living patients are scarce; the knowledge the human machine is the focus.  We stayed in the labs until the middle of the night examining our cadaver, looking into microscopes and comparing what we saw to pictures in books.  We traced out biochemical pathways on chalkboards.  Never did we see anything corresponding to a meridian or to the four humors, or any other pre-scientific medical ideas. They were clearly a fiction, one dreamed up by our ancestors to explain something insanely complicated.

In the third year, when we did finally see patients regularly, it all came together—slowly.  It’s a medical aphorism that patients don’t always read the textbooks.  Their diseases may not follow expected patterns.  And the addition of real human desires and fears complicates everything.

It takes years to learn how to use medical knowledge to help real people, but you can tell immediately how comforting a word or gesture can be.  During that period of perceived incompetence, while you learn how put book knowledge into practice, we reach for things we already—hopefully—know: how to comfort people.

So-called alternative medicine seems attractive at this point because it purports to focus on the compassion, the relief of symptoms. Let’s look into why this is a false compassion.

During my third year internal medicine rotation, some of the nurses were practicing “therapeutic touch” on our patients. Since none of us knew what this was, we asked them to stop doing things to patients without an order.  Soon after, a remarkable article showed up in the Journal of the American Medical Association.  A young girl, with the help of her parents and a well-respected physician, conducted a study on therapeutic touch showing its underlying theory to be fictitious.  The alleged energy fields being manipulated by practitioners could not be found to exist.

This was a revelation for me.  It brought it all together: the lack of alternative medicine findings in biology or anatomy, the mystical nature of altmed, the claims that the effects could not be measured by “traditional, scientific means”.  I came to realize that there was no such thing as alternative medicine.  There was only medicine shown to work, and everything else.

I did go through my “shruggie” phase—after all, if acupuncture makes my patient feels better, than what’s the harm? (In the case of acupuncture, one of the harms may be hepatitis C.)

What I found, though, is whatever good may have come from some altmed practices, it didn’t even compare to the harm. Patients were taking buckets of supplements, undergoing potentially harmful procedures, and turning away from medicine proven to work.

This whole process took me years.  The rhetoric of alternative medicine is seductive; the truth of real medicine beautiful but messy. How can we teach people to sort out real medicine from everything else?  For a layperson, there is no sure way, but here are some hints for laypeople and for doctors who haven’t thought much about it.

• If a claim goes against the basic rules of nature, it’s probably bunk. Homeopathy, where substances are diluted beyond existence, claims to treat all manner of problems, but for this to be true, we would have to overturn our basic understanding of the universe.  Unless the data are close to unrefutable, I’ll stick with the model of the universe we already have.
• If a treatment relies on an energy or pathway in the body that cannot be seen in the anatomy lab or detected in some other way, it doesn’t exist.  So-called energy fields purported to run through the body have never been detected.  Meridians of qi have never been detected.  Subluxation complexes of chiropractic have never been detected.  Therefore, they are unlikely to exist.
• If someone claims that their healing method can’t be measured by modern science, they are wrong.  It is nonsense on its face.  If someone claims an effect, then it is measurable. For example, if someone says that reiki treats a disease, then it should be easy enough to create a study where one group gets fake reiki and the other gets “real” reiki.  There.  You’ve measured it. There is no medical intervention that cannot be measured in some way.
• If someone is charging you an exorbitant price for something seemingly simple, it’s probably a rip-off.  Energy bracelets, crystals, special supplements, sea salts—none of these things contain anything special, nor should they cost a lot of money.  Most real doctors prescribe medicines and interventions that they don’t directly profit from (directly being the key word).  Some specialties, such as dermatology and ophthalmology may sell items directly related to their practice, but most other specialties do not.  As an internist, there is nothing I can think of that I could ethically sell to my patients.
• If a practitioner tells you not to go to regular doctors, then they are trying to kill you, whether they know it or not.
• If a practitioner claims to have special tests that no one else has access to, such as mouth swabs for toxins or special tests for Lyme disease, something is fishy.
• If a practitioner claims there is a grand plot by pharmacy companies or “mainstream medicine” to hide a cure, they are either criminal or crazy.  Real doctors want to help people, and real cures are very, very profitable.
• If a practitioner is a “brave maverick”, bucking the stodgy power structure of traditional medicine then he is more likely a dangerous rogue and believes his intuition is smarter than science.
• Older is not better.  Just because something is ancient doesn’t make it good. In fact, the opposite is usually true, as ancient medical beliefs are usually pre-scientific and fictitious.
• If it sounds too good to be true, it probably is.  This is an old rule, but useful.  If some drug or procedure really makes you live longer, or cures a horrible disease, it will eventually be available everywhere.  Patients and doctors will demand it.  But most of these claims never pan out.

This is just a few hints, not a comprehensive list.  And certainly, these don’t work all the time.  A cancer specialty center will probably have new tests that aren’t available everywhere, but this is the exception.  Web sites like What’s the Harm, Quack Watch, and Science-based Medicine have lists of questionable practices and make useful references.  But the easiest thing to do is to find a doctor you trust and run things by them.  Patient come to me all the time with ads from the paper or printouts from websites.  I explain to them what the context is and whether it’s worth while to follow up on them.

Medicine has spent the last century-and-a-half maturing into a real science.  We know that human body is part of the same universe as everything else, made of the same “star stuff”.  Understanding and improving medicine requires a scientific approach to a real, physical problem. The practice of medicine requires a thorough dedication to science and a deep well of compassion.  With either missing, we do our patients a disservice.

In Part I we discussed the history of medicine as a science. This is Part II in a series.

It is during a surgery rotation when a medical student perhaps feels least competent. Not only is there an enormous amount of book learning, there are the physical skills that take years to develop.  Most of the time you pull on a retractor and answer questions, record vitals and pull out drains. My instructor, who in the OR hurled Spanish invectives like scalpels and called every med student, “Pullgoddamyou”, was gentle as a kitten with conscious patients. When I was in his office an elderly woman came in for a superficial biopsy. He had treated her for years and she trusted him.  After spending time talking to her and calming her, he numbed up the area and went to work. But the patient was tearful, from the pain and also from the knowledge that the biopsy was not going to give her good news.  I reached up an took her hand, then quickly released it, uncomfortable with my spontaneous act of intimacy.  Dr. Gruff looked at me and said, “No!  Hold her hand!  That is compassion, that is being a doctor!”

Compassion can be learned, or at least a simulacrum of it. Hopefully it comes naturally to most doctors, but for those who is does not, and cannot be taught, there are specialties that don’t involve much patient care.  Radiology, pathology, and a few others involve very little patient interaction, but are essential to the modern practice of medicine.  While the surgeon waits, hands folded in the OR, the pathologist quickly prepares slides and calls up with an answer that can be the difference between a small biopsy or a radical cancer surgery.  Sitting in the barber’s chair one day, the barber asked me to take a bottle of wine to a radiologist.  His wife had gone in for minor surgery and the radiologist had discovered an early cancer on a routine x-ray, saving the woman’s life.

I’d guess that most people, when thinking of a doctor, think of their own doctor, a primary care physician or an OB/GYN.  Hopefully this is someone they’ve come to trust, someone who can give them the tools to stay as healthy as possible and to treat them with compassion when they fall ill.  This part of medicine: this rapport, this compassion, is essential to good patient care.  A patient who likes you, and who you in turn like, is more likely to trust in and benefit from your advice.

But compassion is not enough.   In medicine, compassion unguided by science can be dangerous.  When you have strep throat, do you seek out a compassionate clergy or friend with no medical knowledge, or a doctor?  The doctor knows that untreated, strep can lead to abscesses, rheumatic fever, and can (but does not usually) cause permanent damage.  She knows that strep is easily killed by certain antibiotics and not by others.  She knows when the sore throat is more likely to be a virus and should be treated with hot tea and chicken soup rather than drugs.

Physicians are daily witnesses to the power of compassion, and like any power, compassion can corrupt. A compassionate act often has immediate and satisfying results. Treating hypertension gives neither the physician nor the patient immediate satisfaction.  It is the reduction of the risk of heart attack and stroke, a benefit that accrues over time, that makes treatment worthwhile.  But doctors like anyone else would love to see an immediate reaction, something unlikely in a patient with a disease without symptoms.  Patients are rightly skeptical about treating a disease which causes no discomfort.  It is up to the physician to work with the patient to help them understand the importance of treatment, to use their rapport to help the patient understand the benefit.

Sometimes the doctor and the patient unconsciously conspire to gain immediate satisfaction where none should medically exist.  Of the two, the physician should know better.  When doctors recommend unproven or implausible treatments with the idea that it may make the patient feel better they enter a folie a deux. We know how to treat high blood pressure with diet, exercise, and medication.  It might not make you feel better immediately but it will save your life.  Compassion will help bring the patient around. But how about adding on some hypnosis or acupuncture?  These feel more “real” to the doctor and the patient, but are no more real than a sugar pill.  If there is any benefit to these, it is through the same mechanism the doctor uses in the exam room: a hand on the shoulder, a cocked ear, a smile.  It is compassion without the benefit of actually treating the disease.

There is nothing wrong with compassion. In fact it is necessary to get the most benefit out of the patient-doctor collaboration.  But it is not, in itself, powerful enough to cure infection, to prevent strokes and heart attacks.  Compassion plus medical science is good doctoring.  Compassion plus no science is charlatanism.

In Part III, how to spot the difference.

Remarkably accurate anatomical sketch by Vesalius

For nearly five years, I’ve been writing about medicine.  One of the questions I hear the most is, “when it comes to my health, who do I believe?”

Anyone who’s read my writing knows I’m critical of so-called alternative medical practices.  I’m also critical of the abuse of mainstream medical practices.  I’ve had years of education devoted to studying human medicine.  How is a layperson to know what works and what doesn’t, what is real medicine and what is hucksterism disguised as medicine?  Let’s explore how a non-physician can think critically and skeptically about health and medicine to make good decisions for themselves and their family.  In my mind, I’ve subtitled this series, “An Introduction to Medical Skepticism.”

The study of human medicine goes back, presumably, to the beginning.  Gods, spirits, ill-winds have always been invoked to explain illness.  ”Malaria” means “bad airs”, even though we now know it’s caused by a small organism transmitted by mosquitoes.  As humanity became literate, human illness was studied and observations recorded systematically.  Hippocrates of Cos, who probably lived and practiced around the 4th century BCE, wrote excellent observations on the natural history of many common illnesses, descriptions that modern doctors easily recognize.

In the 15th century, Andreas Vesalius dissected cadavers, recording his findings in beautiful and mostly accurate drawings.  While human anatomy was probably well known to agrarians who slaughtered animals, and warriors, who slaughtered people, Vesalius’ writings and pictures provided one of the most accurate catalogs to date of gross (non-microscopic) human anatomy.  A century later, William Harvey gave the first complete description of the circulation of blood through the human body (probably; Ibn al-Nafis gave a partial description a couple of centuries earlier, while Europe was still immersed in the Dark Ages).

Through this time, as the anatomy and some basic physiology of the body was being described, real understanding of how the body works still eluded physicians.  Doctors, such as they were, still held to ancient beliefs on cause and effect, mostly described using the “humors” or “temperaments” model, attributing disease to imbalances of “black bile”, “blood” or other important substances.  A disease believe to be caused by excess blood could be treated by bleeding, for example.

It wasn’t until the 19th century that any real understanding of what we now call physiology began to appear.  This is when medicine began to become more frankly materialistic (in the sense of “not supernatural”).  At the time, it was widely believed that life was fundamentally different than non-life in that it was imbued with some sort of vital principle.  In 1828, chemist Friedrich Wohler synthesized urea, the first documented synthesis of an organic compound—compounds found in living things—from inorganic materials.  This was thought to be impossible, as organic chemicals were supposedly fundamentally different from inorganic ones, imbued somehow with a “life force”.

Wohler and his contemporaries showed that life is made of the same chemicals as everything else.  Scientists began to believe that the human body must act by the same laws and processes as everything else in nature (though many still held on to an idea of a “soul” or something like it).  Once it was realized that human beings were no different from any other part of the natural world, they could be studied without referencing ill humors or vital principles.  Scientists and doctors began to study the function of the human body and how we might use this new understanding to help people.

The 20th century birthed the practice of scientific medicine.  The Flexner report attempted to standardize medical education, something that could be done because of the shared understanding that medicine was now a science rather than a branch of religion. Deborah Blum’s The Poisoner’s Handbook follows doctors and chemists who use this new knowledge. Her narrative takes place in the early 20th century when doctors and chemists struggled to understand illness and death caused by poison.  Without an understanding of biology, chemistry, and physiology, these breakthroughs could never have taken place.  There was nothing easy and nothing supernatural about the discovery of how poisons worked and could be detected.  It took hard work and a thorough understanding of science.  From studying the damage done by poisons, they helped advance the science of how the human machine works.

Every advance we have made in preventing and treating disease is based on our understanding of the science of the human body. This combined with the use of statistical analysis has allowed us to live longer and healthier than our ancestors could have imagined.

In Part II, the piece that makes medical practice whole.