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A hair in the mouth
THE LANCET
~IVERTleU~6~ 'The conjunction "and" commonly serves to indicate that the writer's mind still functions even when no signs of the phenomenom are noticeable." --Rudolf Virchow [ 1821-1902]
A hair in the mouth I once discovered a wire hook in a tinned sardine, and was grateful for t h e sentinel function of m y oral cavity. In this case, the detection of the aberrant material was by the teeth, which are very alert to any resistance to complete occlusion. Yet m o s t o f us will m u n c h t h r o u g h a t o u g h steak without questioning its freedom from adulteration; let u s detect a piece o f steak gristle in a bowl o f bread a n d milk, and we get a warning. It seems that in formation o f the first bolus we m e m o r i s e the prototype of its physical composition, to which subseq.uent m o u t h f u l s m u s t conform. Remarkably, the prototype accommodates t h e varied constitution of, say, a s a l a d - - w i t h i n w h i c h we would, I think, detect a small length of string or a very little grit. Evidently, the sensory e q u i p m e n t o f our m o u t h is an elaborate system for discriminating t h e physical constitution o f what we c o n s u m e and monitoring its uniformity. W h a t is accepted by the p h a r y n x for deglutition has come to it with a certification of consistency. T h e rapid coordination of such data is a neurological function that vies with visual image analysis or the interpretation of speech in complexity; b u t these have identifiable organisation centres in the brain. Olfaction, too, has the rhinencephalon almost to itself; yet bolus analysis appears to have no n a m e d centre in the brain. Continual surveillance o f the m o u t h goes o n between meals; food fragm e n t s released from dental crevices are ignored, b u t a short length o f hair is instantly recognised as an intruder. T h e wonder is that the presence o f a o n e - i n c h long hair in the m o u t h is detectable or identifiable: its total weight is only a fraction of a milligram, a n d its area of contact with t h e m u c o s a is far less t h a n the area of a pin-head. T h e question invited by these reflections is: w h y is the p h a r y n x , which is a c c o m m o dating e n o u g h to pass the blade o f a swallower's sword, so insistent on a bill of lading for every bolus it accepts? It r e m a i n s a m y s t e r y w h y we are equipped with s u c h a delicate and elaborate sensory apparatus for e n s u r i n g the conformity o f boluses to a standard w h i c h varies with t h e food eaten, and w h y (since our species is not subject to obstruction by hair balls) we are distracted by the astonishingly sensitive detection of a hair in the m o u t h . Readers m a y test their aptitude for research by a t t e m p t i n g to set d o w n a line o f enquiry for e x a m i n i n g the problem. I ' m well o n the way: I ask what limited the survival o f those of o u r evolutionary ancestors w h o sdoffed their food?
Harold Hewitt
1566
Rickmanswo~h, UK
The limpet Here I was, with m y wife, back in E d i n b u r g h , fifty-seven years since I enrolled in medical school. W e were staying with m y n e p h e w , who offered to take m e to his wife's estate on the banks of L o c h T u m m e l l . W e set off well supplied with sandwiches and cans of good Scottish beer: A 100 miles per h o u r later we reached the s o u t h e r n shore of L o c h T u m m e l l , a n d the family holiday home. I was horrified w h e n I saw that the land m a r c h e d to t h e horizon at an an angle o f forty degrees, a n d told m y n e p h e w that at 77 I could n o t possibly a t t e m p t s u c h a climb. He laughed and said that I w a s n ' t to worry because we would be ascending in his limpet, a n d disappeared into one of the outhouses.
well. T h e r e was no answer to that, so back down we went. L o o k i n g across t h e L o c h on o u r way back to E d i n b u r g h , I saw a h u d d l e of tourists admiring the Q u e e n ' s view. I t h o u g h t to m y s e l f t h a t they were welcome to their v i e w - - m i n e had been that of the gods.
William C Clark
The pestilence " W h e n there was a m o s t cruel pestilence at Montpelier, in the year 1630, w h e n they were infected with the plague, t h e y sent for me to know what they s h o u l d do. I, r e m e m b e r i n g that the pickle o f t h o s e little fish called anchovies h a d helped s o m e o f the plague, I advised t h e m to take thereof. O n e patient drank a porringerful by itself, another took it mingled with u r i n e a n d both were cured, for there followed v e h e m e n t evacuation by vomit and stool." (Rivere L. F o u r books of that learned a n d r e n o w n e d doctor, Lazarus Riverius, containing 513 observations or histories o f f a m o u s a n d rare cures. Translated by Nicholas Culpeper. L o n d o n : George Sawbridge. 1678) I suppose we've all been to cocktail parties like that.
John L Barton
The limpet
(DougalMaefarlane)
Shortly afterwards there was a great clatter, a n d in a cloud o f blue s m o k e he appeared driving a collection o f g r o w n - u p Meccano, with large p n e u m a t i c wheels at each corner. T h e r e was a seat for t h e driver, a n d b e h i n d h i m a contraption looking like m i n i a t u r e goal posts w h i c h was for the passenger to h a n g on to. W e set off u p the m o u n t a i n slope, t h r o u g h , over, a n d almost u n d e r m o u n t a i n streams, ever higher, with m y n e p h e w ' s labrador, Basher, quartering in front. W e soon left the bracken a n d birch a n d staggered our way t h r o u g h a sea of purple heather. U p and u p we went, the view all r o u n d swelling magnificently in the crystal-clear air, and I spotted a h e r d o f a b o u t fifty red deer s t r e a m i n g u p a corrie a n d disappearing over the horizon, h a v i n g decided that the nasty s m o k i n g t h i n g c o m i n g u p into their d o m a i n was best left to its o w n devices. Anticipating our picnic I looked at m y watch to see that it was one o'clock; at the same time Basher began j u m p i n g into the limpet, licking m y n e p h e w ' s face a n d w h e n p u s h e d off coming a n d m a k i n g even m o r e fuss t h a n before. W h e n I asked m y n e p h e w what was the trouble he said it was time for the dog's daily meal, a n d we would have to go back d o w n to the house. W h e n I w o n d e r e d w h y we h a d to go all the way back just to feed t h e dog, he said that as a m a t t e r of fact he h a d left our l u n c h at t h e h o u s e as
Leamington Spa, UK
Bristol, UK
Needs Balint recognised a quarter o f a c e n t u r y ago that the physician/patient interaction h a s the capacity to meet t h e n e e d s o f both parties to it. M o r e recently, M a t t h e w s , S u c h m a n a n d Branch (Ann Intern Med 1993; 118: 973) maintain that t h e m e e t i n g o f s u c h needs " . . . is m o s t readily recognised in occasional m o m e n t s o f particular closeness d u r i n g medical e n c o u n t e r s . . . and by a lingering feeling of joy, peacefulness or awe". T h e risks include c o m p l e m e n t a r y wishes for d e p e n d e n c e o n t h e patient's part, for power on t h e p h y s i c i a n ' s , and sexual attraction. I s u b m i t that excessive self-satisfaction is a f u r t h e r threat as suggested by the aforementioned feelings of joy and peacefulness, as w h e n a good diagnosis is m a d e or a paper accepted. Its inverse is the d i s a p p o i n t m e n t s e n s e d w h e n an otherwise flawless diagnosis of, say, multiple m y e l o m a is not s u p p o r t e d by t h e bone m a r r o w findings. At s u c h a t i m e , t h e patient's escape from an almost invariably fatal disease m a y be overlooked as t h e physician experiences an access of chagrin. Yes, we should be cognisant o f t h e needs we b r i n g into the consulting r o o m , b u t we m u s t be careful to avoid t h e s t r o n g e s t sexual attraction of all--falling in love with ourselves!
Joseph Herman
Jerusalem, Israel
Vo1342 • December 18/25, 1993
~IVERTleU~6~ 'The conjunction "and" commonly serves to indicate that the writer's mind still functions even when no signs of the phenomenom are noticeable." --Rudolf Virchow [ 1821-1902]
A hair in the mouth I once discovered a wire hook in a tinned sardine, and was grateful for t h e sentinel function of m y oral cavity. In this case, the detection of the aberrant material was by the teeth, which are very alert to any resistance to complete occlusion. Yet m o s t o f us will m u n c h t h r o u g h a t o u g h steak without questioning its freedom from adulteration; let u s detect a piece o f steak gristle in a bowl o f bread a n d milk, and we get a warning. It seems that in formation o f the first bolus we m e m o r i s e the prototype of its physical composition, to which subseq.uent m o u t h f u l s m u s t conform. Remarkably, the prototype accommodates t h e varied constitution of, say, a s a l a d - - w i t h i n w h i c h we would, I think, detect a small length of string or a very little grit. Evidently, the sensory e q u i p m e n t o f our m o u t h is an elaborate system for discriminating t h e physical constitution o f what we c o n s u m e and monitoring its uniformity. W h a t is accepted by the p h a r y n x for deglutition has come to it with a certification of consistency. T h e rapid coordination of such data is a neurological function that vies with visual image analysis or the interpretation of speech in complexity; b u t these have identifiable organisation centres in the brain. Olfaction, too, has the rhinencephalon almost to itself; yet bolus analysis appears to have no n a m e d centre in the brain. Continual surveillance o f the m o u t h goes o n between meals; food fragm e n t s released from dental crevices are ignored, b u t a short length o f hair is instantly recognised as an intruder. T h e wonder is that the presence o f a o n e - i n c h long hair in the m o u t h is detectable or identifiable: its total weight is only a fraction of a milligram, a n d its area of contact with t h e m u c o s a is far less t h a n the area of a pin-head. T h e question invited by these reflections is: w h y is the p h a r y n x , which is a c c o m m o dating e n o u g h to pass the blade o f a swallower's sword, so insistent on a bill of lading for every bolus it accepts? It r e m a i n s a m y s t e r y w h y we are equipped with s u c h a delicate and elaborate sensory apparatus for e n s u r i n g the conformity o f boluses to a standard w h i c h varies with t h e food eaten, and w h y (since our species is not subject to obstruction by hair balls) we are distracted by the astonishingly sensitive detection of a hair in the m o u t h . Readers m a y test their aptitude for research by a t t e m p t i n g to set d o w n a line o f enquiry for e x a m i n i n g the problem. I ' m well o n the way: I ask what limited the survival o f those of o u r evolutionary ancestors w h o sdoffed their food?
Harold Hewitt
1566
Rickmanswo~h, UK
The limpet Here I was, with m y wife, back in E d i n b u r g h , fifty-seven years since I enrolled in medical school. W e were staying with m y n e p h e w , who offered to take m e to his wife's estate on the banks of L o c h T u m m e l l . W e set off well supplied with sandwiches and cans of good Scottish beer: A 100 miles per h o u r later we reached the s o u t h e r n shore of L o c h T u m m e l l , a n d the family holiday home. I was horrified w h e n I saw that the land m a r c h e d to t h e horizon at an an angle o f forty degrees, a n d told m y n e p h e w that at 77 I could n o t possibly a t t e m p t s u c h a climb. He laughed and said that I w a s n ' t to worry because we would be ascending in his limpet, a n d disappeared into one of the outhouses.
well. T h e r e was no answer to that, so back down we went. L o o k i n g across t h e L o c h on o u r way back to E d i n b u r g h , I saw a h u d d l e of tourists admiring the Q u e e n ' s view. I t h o u g h t to m y s e l f t h a t they were welcome to their v i e w - - m i n e had been that of the gods.
William C Clark
The pestilence " W h e n there was a m o s t cruel pestilence at Montpelier, in the year 1630, w h e n they were infected with the plague, t h e y sent for me to know what they s h o u l d do. I, r e m e m b e r i n g that the pickle o f t h o s e little fish called anchovies h a d helped s o m e o f the plague, I advised t h e m to take thereof. O n e patient drank a porringerful by itself, another took it mingled with u r i n e a n d both were cured, for there followed v e h e m e n t evacuation by vomit and stool." (Rivere L. F o u r books of that learned a n d r e n o w n e d doctor, Lazarus Riverius, containing 513 observations or histories o f f a m o u s a n d rare cures. Translated by Nicholas Culpeper. L o n d o n : George Sawbridge. 1678) I suppose we've all been to cocktail parties like that.
John L Barton
The limpet
(DougalMaefarlane)
Shortly afterwards there was a great clatter, a n d in a cloud o f blue s m o k e he appeared driving a collection o f g r o w n - u p Meccano, with large p n e u m a t i c wheels at each corner. T h e r e was a seat for t h e driver, a n d b e h i n d h i m a contraption looking like m i n i a t u r e goal posts w h i c h was for the passenger to h a n g on to. W e set off u p the m o u n t a i n slope, t h r o u g h , over, a n d almost u n d e r m o u n t a i n streams, ever higher, with m y n e p h e w ' s labrador, Basher, quartering in front. W e soon left the bracken a n d birch a n d staggered our way t h r o u g h a sea of purple heather. U p and u p we went, the view all r o u n d swelling magnificently in the crystal-clear air, and I spotted a h e r d o f a b o u t fifty red deer s t r e a m i n g u p a corrie a n d disappearing over the horizon, h a v i n g decided that the nasty s m o k i n g t h i n g c o m i n g u p into their d o m a i n was best left to its o w n devices. Anticipating our picnic I looked at m y watch to see that it was one o'clock; at the same time Basher began j u m p i n g into the limpet, licking m y n e p h e w ' s face a n d w h e n p u s h e d off coming a n d m a k i n g even m o r e fuss t h a n before. W h e n I asked m y n e p h e w what was the trouble he said it was time for the dog's daily meal, a n d we would have to go back d o w n to the house. W h e n I w o n d e r e d w h y we h a d to go all the way back just to feed t h e dog, he said that as a m a t t e r of fact he h a d left our l u n c h at t h e h o u s e as
Leamington Spa, UK
Bristol, UK
Needs Balint recognised a quarter o f a c e n t u r y ago that the physician/patient interaction h a s the capacity to meet t h e n e e d s o f both parties to it. M o r e recently, M a t t h e w s , S u c h m a n a n d Branch (Ann Intern Med 1993; 118: 973) maintain that t h e m e e t i n g o f s u c h needs " . . . is m o s t readily recognised in occasional m o m e n t s o f particular closeness d u r i n g medical e n c o u n t e r s . . . and by a lingering feeling of joy, peacefulness or awe". T h e risks include c o m p l e m e n t a r y wishes for d e p e n d e n c e o n t h e patient's part, for power on t h e p h y s i c i a n ' s , and sexual attraction. I s u b m i t that excessive self-satisfaction is a f u r t h e r threat as suggested by the aforementioned feelings of joy and peacefulness, as w h e n a good diagnosis is m a d e or a paper accepted. Its inverse is the d i s a p p o i n t m e n t s e n s e d w h e n an otherwise flawless diagnosis of, say, multiple m y e l o m a is not s u p p o r t e d by t h e bone m a r r o w findings. At s u c h a t i m e , t h e patient's escape from an almost invariably fatal disease m a y be overlooked as t h e physician experiences an access of chagrin. Yes, we should be cognisant o f t h e needs we b r i n g into the consulting r o o m , b u t we m u s t be careful to avoid t h e s t r o n g e s t sexual attraction of all--falling in love with ourselves!
Joseph Herman
Jerusalem, Israel
Vo1342 • December 18/25, 1993