Molasses in the tropics
Websites in brief
Diagnosis and treatment Keith Birrell and Ginny Birrell. Oxford: MacMillan Education, 2000. Pp 264. £9·90. ISBN 0333722116. his manual for VSO primary health-care workers and the people they are attempting to train is a puzzle of simplicity. I couldn’t decide whether it was refreshingly direct, a welcome contrast to the ever-increasing obfuscation of medical textbooks, or just dangerously dogmatic. Textbooks in all fields have become larger, spreading their ungainly tentacles over more feet of shelving, dripping and puddling into extra volumes, and the prose has become more and more sticky, molasses cooling. Every sentence is qualified, contradicted, reiterated, and footnoted. After many years of studious application, one comes to develop a grudging affection for this stilted, gooey, selfreferential prose. Here, the pool of molasses has been snap-frozen, dealt a sharp blow with a heavy object, and the splinters swept up and reassembled in this collection of often practical, sometimes baffling, aphorisms. The difficulty in reconciling first world medical training with third world practice is a feat that all volunteers must attempt, and reading this manual gives some indication of the scope of the task. Designers of complex resuscitation mannequins would be aghast to have the “student pretend he has a broken arm, and the others practise straightening it in turn”. If it is not bent, how can you tell if it is broken? By rubbing the ends of bone together, of course. I don’t believe anyone has advocated eliciting fracture crepitus for over 50 years. Even Hamilton Bailey’s 14th edition (1967) is firm on the matter: “First the injured part must be exposed: severing overlying garments with scissors or slitting a seam with a scalpel is often necessary. This must be carried out with the utmost care and gentleness. Even so, the modicum of movement thus entailed is sometimes sufficient, inadvertently, to call attention to two unfailing signs of complete fracture—abnormal movement and crepitus—the deliberate elicitation of either of which, for fear of inflicting further damage as well as excruciating pain, is forbidden absolutely.” Such unfortunate slips are almost redeemed by delightful teaching tips, including how to demonstrate intussuisception with a sock. The manual has a series of 15 practical workshops on common difficulties, from rational prescribing, to leprosy, psychiatric emergencies, anaemia, &c, with set dialogues for practising patient communication,
THE LANCET • Vol 357 • March 17, 2001
and answers that students should give to questions, presumably verbatim. It reads like a board game: ask the patient, “have you had any convulsions?” The box then says, “convulsions are a general danger sign. Treat the patient for a very severe febrile disease and send her to the hospital”. In case things are not crystal clear, one is referred to a helpful glossary. Some of the descriptions beggar belief, however, and would not encompass even developing world experience; abortion: the unborn baby dies inside the uterus before the woman has been pregnant for 6 months; bloody diarrhoea: dysentery. The manual also has sweeping mandates such as universal breastfeeding until 2 years of age; although this statement is eventually qualified in case of available solid food, it is not in the same chapter, or cross-referenced. Whether these simplifications are seen as appropriately clear, or risky and erroneous, depends on whether the context in which one practises can afford a degree of complexity. One could argue that there is no point in attempting to differentiate causes of fever, when only one drug is available to treat it. Indeed, the book is endorsed by the director of WHO’s essential drug programme, but perhaps he did not read it. An appendix lists a selection of essential drugs, with indications but almost no contraindications, and no note of adverse reactions. “If the patient insists that you give them medicine, give them multivitamins . . . paracetamol is a symptomatic drug . . . oral rehydration salts: to treat shock on the way to the hospital.” On one level, Diagnosis and treatment is an entertaining book; nosological, existential, and pathological dilemmas are all blithely resolved; “Consciousness: the patient is awake or asleep but can be woken . . . oxygen: a gas in air that the body needs to live . . . symptom: something the patient tells you about, or which you can see, which helps you to decide which disease a patient has.” Readers are left to decide if this novel approach to the dissemination of medical knowledge will be more useful than the odd piles of smelly old texts that often find their way to impoverished locations—they are out of date, but at least they had the virtue of proclaiming, rather than obscuring, the small things that are more or less established. Laragh Gollogly The Lancet, London, UK
C elegans explained Caenorhabditis elegans is arguably the quintessential model organism for medical research, and this site from molecular biologist Farhang Payvar explains why. Payvar, whose own work deals with hormonal signalling in mammalian systems and new drug discovery, has created a compendium of links to top-notch web resources on C elegans; topics range from the origins of the nematode’s name to its anatomy, role in the understanding of human disease gene interactions, and overall value for medicine. Also posted are links to such diverse resources as functional genomics and bioinformatics databases, meeting abstracts, and the Worm breeder’s gazette. peds.mc.vanderbilt.edu/c_elegans/c_ elegans_Introduction_Value_to_Biology_ Medicine.htm Linus Pauling lauded In honour of the 100th anniversary of molecular biologist and Nobel laureate Linus Pauling’s birth in Portland, Oregon State University (Pauling’s alma mater) has created a centenary site celebrating the scientist’s many achievements. I found the audio/video presentations especially intriguing—for example, snippets of Pauling’s crystal structure lecture (1957), excerpts from a peace lecture (1961), personal reminiscences, commentary on the responsibility of scientists in the nuclear age, and the story behind his discovery of the alpha-helix. Also of interest are the molecular model photo gallery (Pauling created the models but did not name them, according to a museum source) and timeline. pauling.library.orst.edu Britain’s wars recalled The website of London’s Imperial War Museum is simply fascinating. I started with the virtual tour of the cabinet war rooms (Quicktime VR lets you use your mouse to explore the nooks and crannies) and moved on from there. Online multimedia exhibitions include the illustrated diary of wartime artist Edward Ardizzone, a Holocaust photo gallery, background on the Battle of Britain, Korean War recollections, and much more. The site is a must-see (in multiple visits). www.iwm.org.uk Marilynn Larkin [email protected]
For personal use only. Reproduce with permission from The Lancet Publishing Group.