Science Times - Paleolithic disability, mental illness and guns, some humor, and some fossils
DISABLED Almost all the other skeletons at the Man Bac site, south of Hanoi, are straight. But the man now called Burial 9 was laid to rest curled in a fetal position that suggests lifelong paralysis.
Ancient Bones That Tell a Story of Compassion
By JAMES GORMAN, The New York Times, December 17, 2012
While it is a painful truism that brutality and violence are at least as old as humanity, so, it seems, is caring for the sick and disabled.
And some archaeologists are suggesting a closer, more systematic look at how prehistoric people - who may have left only their bones - treated illness, injury and incapacitation. Call it the archaeology of health care.
The case that led Lorna Tilley and Marc Oxenham of Australian National University in Canberra to this idea is that of a profoundly ill young man who lived 4,000 years ago in what is now northern Vietnam and was buried, as were others in his culture, at a site known as Man Bac.
Almost all the other skeletons at the site, south of Hanoi and about 15 miles from the coast, lie straight. Burial 9, as both the remains and the once living person are known, was laid to rest curled in the fetal position. When Ms. Tilley, a graduate student in archaeology, and Dr. Oxenham, a professor, excavated and examined the skeleton in 2007 it became clear why. His fused vertebrae, weak bones and other evidence suggested that he lies in death as he did in life, bent and crippled by disease.
They gathered that he became paralyzed from the waist down before adolescence, the result of a congenital disease known as Klippel-Feil syndrome. He had little, if any, use of his arms and could not have fed himself or kept himself clean. But he lived another 10 years or so.
They concluded that the people around him who had no metal and lived by fishing, hunting and raising barely domesticated pigs, took the time and care to tend to his every need.
“There’s an emotional experience in excavating any human being, a feeling of awe,” Ms. Tilley said, and a responsibility “to tell the story with as much accuracy and humanity as we can.”
This case, and other similar, if less extreme examples of illness and disability, have prompted Ms. Tilley and Dr. Oxenham to ask what the dimensions of such a story are, what care for the sick and injured says about the culture that provided it.
The archaeologists described the extent of Burial 9’s disability in a paper in Anthropological Science in 2009. Two years later, they returned to the case to address the issue of health care head on. “The provision and receipt of health care may therefore reflect some of the most fundamental aspects of a culture,” the two archaeologists wrote in The International Journal of Paleopathology.
And earlier this year, in proposing what she calls a “bioarchaeology of care,” Ms. Tilley wrote that this field of study “has the potential to provide important - and possibly unique - insights into the lives of those under study.” In the case of Burial 9, she says, not only does his care indicate tolerance and cooperation in his culture, but suggests that he himself had a sense of his own worth and a strong will to live. Without that, she says, he could not have stayed alive.
“I’m obviously not the first archaeologist” to notice evidence of people who needed help to survive in stone age or other early cultures, she said. Nor does her method “come out of the blue.” It is based on and extends previous work.
Among archaeological finds, she said, she knows “about 30 cases in which the disease or pathology was so severe, they must have had care in order to survive.” And she said there are certainly more such cases to be described. “I am totally confident that there are almost any number of case studies where direct support or accommodation was necessary.”
Such cases include at least one Neanderthal, Shanidar 1, from a site in Iraq, dating to 45,000 years ago, who died around age 50 with one arm amputated, loss of vision in one eye and other injuries. Another is Windover boy from about 7,500 years ago, found in Florida, who had a severe congenital spinal malformation known as spina bifida, and lived to around age 15. D. N. Dickel and G. H. Doran, from Florida State University wrote the original paper on the case in 1989, and they concluded that contrary to popular stereotypes of prehistoric people, “under some conditions life 7,500 years ago included an ability and willingness to help and sustain the chronically ill and handicapped.”
In another well-known case, the skeleton of a teenage boy, Romito 2, found at a site in Italy in the 1980s, and dating to 10,000 years ago, showed a form of severe dwarfism that left the boy with very short arms. His people were nomadic and they lived by hunting and gathering. He didn’t need nursing care, but the group would have had to accept that he couldn’t run at the same pace or participate in hunting in the same way others did.
Ms. Tilley gained her undergraduate degree in psychology in 1982 and worked in the health care industry studying treatment outcomes before coming to the study of archaeology. She said her experience influenced her interest in ancient health care.
What she proposes, in papers with Dr. Oxenham and in a dissertation in progress, is a standard four-stage method for studying ancient remains of disabled or ill individuals with an eye to understanding their societies. She sets up several stages of investigation: first, establishing what was wrong with a person; second, describing the impact of the illness or disability given the way of life followed in that culture; and third, concluding what level of care would have needed.
A paralyzed person, for example, would need “direct support” similar to nursing care while someone like Romito 2 would need “accommodation,” that is to say tolerance of his limitations and some assistance.
Debra L. Martin, associate professor of biological anthropology at the University of Nevada, Las Vegas, invited Ms. Tilley to write “The Bioarchaeology of Care” for a special report on new directions in bioarchaeology published this year in the Archaeological Record, the magazine of the Society for American Archaeology.
She said in an e-mail that what Ms. Tilley proposes “is a very nicely integrated approach” to using all the available evidence. “Lorna’s innovative approach,” she said, “has provided a way to move from the bones of individuals to thinking about the community as a whole.”
The fourth stage in the proposed method is where the gathered facts form the basis for interpretation. Extrapolating from hard evidence drawn from human remains to conclusions about how people lived is at the heart of bioarchaeology, a word coined in the 1970s by Jane E. Buikstra at Arizona State University to describe using the methods of physical anthropology, which concentrates on the bones, and those of archaeology, which concentrates on the culture and its artifacts, to try to “people the past,” as she phrases it, to put ancient people into a cultural context.
Dr. Buikstra, director of the Center for Bioarchaeological Research, who currently concentrates on the co-evolution of humans and their diseases, said that “People have from time to time across the years tried to attribute caring and caring for” to ancient humans. But, she said, “getting into the minds of ancient people” is always difficult. Ms. Tilley’s methods for how and when to make that kind of leap would base such attempts on standards used today for evaluating health care needs for severely disabled people.
Dr. Martin, who studies violence and illness as well, gave an example from her own work of the sort of case that can benefit from Ms. Tilley’s approach. The case is described in a coming book, “The Bioarchaeology of Individuals.” A skeleton of a young woman about 18 years old from a site on the Arabian Peninsula more than 4,000 years old indicated that the woman had a neuromuscular disease, perhaps polio.
“Her condition likely made it difficult for her to walk,” Dr. Martin wrote in an e-mail. “She had exceedingly thin arm and leg bones with very little buildup of normal muscle attachments.” She probably received round-the-clock care, Dr. Martin concluded.
But one problem that she had was apparently not a result of the disease. The teeth that she had were full of cavities, and she was “missing teeth from abscesses and periodontal disease.”
Those who cared for the young woman may have been too kind, Dr. Martin said. Her people grew dates, and, “Perhaps to make her happy, they fed her a lot of sticky, gummy dates, which eventually just rotted her teeth out, unusual for someone so young.”
In Gun Debate, a Misguided Focus on Mental Illness
By RICHARD A. FRIEDMAN, M.D., The New York Times, December 17, 2012
In the wake of the terrible shooting at an elementary school in Newtown, Conn., national attention has turned again to the complex links between violence, mental illness and gun control.
The gunman, Adam Lanza, 20, has been described as a loner who was intelligent and socially awkward. And while no official diagnosis has been made public, armchair diagnosticians have been quick to assert that keeping guns from getting into the hands of people with mental illness would help solve the problem of gun homicides.
Arguing against stricter gun-control measures, Representative Mike Rogers, Republican of Michigan and a former F.B.I. agent, said, “What the more realistic discussion is, ‘How do we target people with mental illness who use firearms?’ ”
Robert A. Levy, chairman of the Cato Institute, told The New York Times: “To reduce the risk of multivictim violence, we would be better advised to focus on early detection and treatment of mental illness.”
But there is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness.
This does not mean that mental illness is not a risk factor for violence. It is, but the risk is actually small. Only certain serious psychiatric illnesses are linked to an increased risk of violence.
One of the largest studies, the National Institute of Mental Health’s Epidemiologic Catchment Area study, which followed nearly 18,000 subjects, found that the lifetime prevalence of violence among people with serious mental illness - like schizophrenia and bipolar disorder - was 16 percent, compared with 7 percent among people without any mental disorder. Anxiety disorders, in contrast, do not seem to increase the risk at all.
Alcohol and drug abuse are far more likely to result in violent behavior than mental illness by itself. In the National Institute of Mental Health’s E.C.A. study, for example, people with no mental disorder who abused alcohol or drugs were nearly seven times as likely as those without substance abuse to commit violent acts.
It’s possible that preventing people with schizophrenia, bipolar disorder and other serious mental illnesses from getting guns might decrease the risk of mass killings. Even the Supreme Court, which in 2008 strongly affirmed a broad right to bear arms, at the same time endorsed prohibitions on gun ownership “by felons and the mentally ill.”
But mass killings are very rare events, and because people with mental illness contribute so little to overall violence, these measures would have little impact on everyday firearm-related killings. Consider that between 2001 and 2010, there were nearly 120,000 gun-related homicides, according to the National Center for Health Statistics. Few were perpetrated by people with mental illness.
Perhaps more significant, we are not very good at predicting who is likely to be dangerous in the future. According to Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, “Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”
Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.
Jeffery Swanson, a professor of psychiatry at Duke University and a leading expert in the epidemiology of violence, said in an e-mail, “Can we reliably predict violence? ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”
It would be even harder to predict a mass shooting, Dr. Swanson said, “You can profile the perpetrators after the fact and you’ll get a description of troubled young men, which also matches the description of thousands of other troubled young men who would never do something like this.”
Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the states have submitted more than a tiny proportion of their mental health records.
How effective are laws that prohibit people with mental illness from obtaining guns? According to Dr. Swanson’s recent research, these measures may prevent some violent crime. But, he added, “there are a lot of people who are undeterred by these laws.”
Adam Lanza was prohibited from purchasing a gun, because he was too young. Yet he managed to get his hands on guns - his mother’s - anyway. If we really want to stop young men like him from becoming mass murderers, and prevent the small amount of violence attributable to mental illness, we should invest our resources in better screening for, and treatment of, psychiatric illness in young people.
All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.
Journal Offers Dose of Fun for Holiday
By LAWRENCE K. ALTMAN, M.D., The New York Times, December 17, 2012
LONDON - Dutch and Norwegian scientists say they have solved a glowing mystery: why Rudolph the reindeer’s nose is red.
By traveling to the Arctic and using video-microscope and thermal imaging technology, the scientists showed that the glow is from tiny blood vessels that are more abundant in the noses of reindeer than in humans’. Yes, seriously. The findings are being reported next week in BMJ, formerly known as The British Medical Journal, a publication with a quirky holiday tradition.
For the past 30 years, BMJ has devoted its Christmas-week issue to a lighter and sometimes brighter side of medicine, publishing unusual articles that vary from simply amusing to bizarre to creative or potentially important. All are based on methodologically sound science.
Alongside Rudolph on the cover of this year’s holiday issue is Cliff, a 2-year-old beagle who was trained by another Dutch team to accurately sniff out the sometimes fatal bacterial bowel infection Clostridium difficile and make the diagnosis in minutes - days faster than standard laboratory tests. The Christmas tradition began in 1982, originally intended as a one-time effort to give readers a break from stodgy scientific reports written in technical jargon. The editor then, Dr. Stephen P. Lock, recalled in an interview that he wanted to present “another side of medicine” by offering lighter reading: research oddities, bizarre stories and history. But this was no April fools’ issue: Dr. Lock insisted that the articles meet the same rigorous criteria as research published in regular issues.
Indeed, some articles in the holiday issue are also suitable for regular issues, said Dr. Tony Delamothe, the BMJ deputy editor who has overseen the last eight Christmas issues. “We are on an incessant search for novelty,” he said.
Over the years, BMJ Christmas reports have demolished myths, including a Danish one that people could get drunk by absorbing alcohol through the feet. After soaking their feet for three hours in a basin containing three bottles of vodka and measuring their blood alcohol levels, three Danish scientists found no such absorption.
The first Christmas issue included an account of a resuscitation from 1650 that still astounds today. An unwed 22-year-old mother in Oxford was condemned to death after being accused of murdering her premature, stillborn son and concealing his body. She was executed by hanging by the neck for half an hour while people present jerked her up and down.
At the time, the bodies of executed prisoners were given to doctors for anatomical dissection. Two doctors who opened the woman’s coffin were startled to hear raspy breaths. They revived her, and she went on to recover her memory and live another 15 years, marrying and giving birth to three children. The 17th-century doctors’ report met the criteria for a modern case report, wrote J. Trevor Hughes, the author of the 1982 article.
Dr. Lock, the editor, also encouraged historical back stories. In 1984, Dr. Charles Fletcher wrote about how he tested ways to safely administer the first precious batches of penicillin in 1941. The initial full test was on a 43-year-old British policeman who developed the widespread bacterial infection septicemia. He showed striking improvement from small doses of the antibiotic, but he died after the scarce supply - much of it recycled from his urine - ran out.
Many Christmas issue accounts would have upset earlier BMJ editors “like mad,” Dr. Lock said. “But so what?” he added. “It was fun.” Now there is so much competition for a spot in the issue that some authors submit papers early in the year and request publication at Christmastime.
Some articles poke fun at hoary traditions, such as diagnosing ailments in historical figures despite the lack of medical evidence. Mozart is a special favorite of armchair diagnosticians, Dr. Lucien R. Karhausen wrote in 2010 after tabulating articles reporting 140 possible causes of death and 27 mental disorders in the composer. Many, he said, were based on shoddy medical interpretations, undocumented “eyewitness accounts” or the ignoring of criteria that separate normal and abnormal behavior.
“Some causes are plausible,” Dr. Karhausen wrote, “only a few - maybe one, or maybe none of them - can be true, so most if not all are false.”
In 2006, BMJ reported on the results of a questionnaire sent to 110 members of the Sword Swallowers’ Association International. Forty-six members responded; they reported having swallowed more than 2,000 swords in the three preceding months. Sore throats (“sword throats”) were common during the learning phase, and after frequent repeated performances. Swallowers rarely sought medical advice. Of six who perforated their pharynx or esophagus, three needed surgery. No deaths were reported.
Still other articles play on the vanity of doctors, many of whose names are attached to instruments and syndromes. An article in 2010 extended the list to food products developed by doctors, including Kellogg’s Corn Flakes, various cookies, and Penfolds and Lindeman’s, the Australian wines.
As for the animals featured in this year’s holiday issue: The story of the infection-sniffing beagle began with a report from a nurse in the Netherlands, who mentioned that a patient’s stool had the distinctive odor of C. difficile - a bacterium that is causing serious and growing public-health problems in many countries, including the United States.
A team led by Dr. Marije K. Bomers at the VU University Medical Center in Amsterdam reasoned that it might be possible to train dogs to detect the infection, and Cliff the beagle did just that.
Cliff was trained to sit or lie down when he smelled C. difficile in the air walking by a patient’s bedside, and he also quickly and accurately identified all 50 stool samples with C. difficile and 25 of 30 infected patients - along with 50 stool samples free of the bacteria and 265 of 270 uninfected patients.
And the Dutch team that studied reindeer, working with researchers at the University of Tromso in the Norwegian Arctic, used a hand-held video microscope to observe the deer’s nasal capillaries as they ran on a treadmill.
The capillaries are arranged in circular clusters at different locations through the nose. Those in reindeer noses are 25 percent thicker than those observed in the human nose and are believed to perform critical roles like heating, delivering oxygen and humidifying inhaled air to keep the animal’s nose from freezing. (The leader of the team, Can Ince, a physiologist at Erasmus University Medical Center in Rotterdam, says he has a financial interest in the company that manufactures the technology, which is used to monitor reactions to various drugs and therapies among critically ill human patients.)
By showing that a large number of red blood cells flowed through the small nasal vessels, the scientists said they had unlocked the mystery of Rudolph’s red nose. May it long glow.
A view of Pauline avibella, a shrmplike marine creature, from a computer-generated model.
Fossils of New Species Discovered in England
By SINDYA N. BHANOO, The New York Times, December 17, 2012
A tiny, fossilized crustacean that lived 425 million years ago has been discovered, remarkably intact, in a rock formation in Herefordshire, England. Paleontologists say it represents a new genus and species, belonging to a class of shrimplike marine creatures called ostracods.
Despite their age, the two specimens were well preserved. They included the shell and the soft parts of the animal, including its body, limbs, eyes, gills and alimentary system.
“It gives us a really special insight into the biology of these animals,” said David Siveter of the University of Leicester in England. He and colleagues from the University of Oxford, Imperial College and Yale discuss the findings in the journal Proceedings of the Royal Society B.
The researchers determined that the animal had large eyes and seven pairs of limbs, with the front two pairs adapted for swimming.
It probably used these limbs to swim near the water’s bottom rather than in the water column, Dr. Siveter said.
Analyzing the fragile fossil posed a challenge. “We couldn’t grab it from the rock because it’s so delicate and small,” Dr. Siveter said. “And we couldn’t X-ray it because there wasn’t enough density contrast between the rock and the fossil.”
So the researchers used physical tomography, grinding minute slices off the fossils and capturing an image of each new section. The process, permitted by international guidelines for establishing new species, destroys the fossils themselves but yields detailed data to produce a computer-generated model.
The crustacean is named Pauline avibella, after Dr. Siveter’s deceased wife, Pauline.