The Inflammatory Response

“It’s truly amazing the progress we have made in our understanding of the disease process and how to treat it—all through basic cellular research. I have witnessed it all over the course of my career.”

I sat next to the Chinese woman and stared out of the salt-streaked window at the white-capped waves, conscious of the slight pitch and roll of the ferryboat. She was a Ph.D. biologist who headed a lab devoted to pharmacological research for treatment of dermatological disease.

“Thirty years ago,” she continued, “we treated the pain of rheumatoid arthritis with almost no thought to attacking the disease at the root of the problem—autoimmune inflammation. Now we have mapped the biochemical cascade of the inflammatory response—cytokines, prostaglandins, interleukins, components of complement—and we are in the process of designing drugs to block these agents to prevent tissue destruction. It is all so fascinating.”

We were returning to Hyannis from a weekend medical conference devoted to soft science on Nantucket Island. Ironically, here we sat discussing the benefits of basic medical research. There is always more than one perspective when it comes to the practice of medicine.

How much of what we experience as disease is in reality the result of the human body’s response to certain agents, such as viruses, bacteria, and other toxic agents?

A recent article in the New York Times spoke to this very idea.

A new insight in cold science: the symptoms are caused not by the virus but by its host — by the body’s inflammatory response. Chemical agents manufactured by our immune system inflame our cells and tissues, causing our nose to run and our throat to swell. The enemy is us.

The inflammatory response: a potent cocktail of the so-called inflammatory mediators that the body makes itself — among them, cytokines, kinins, prostaglandins and interleukins, powerful little chemical messengers that cause the blood vessels in the nose to dilate and leak, stimulate the secretion of mucus, activate sneeze and cough reflexes and set off pain in our nerve fibers.

Listening to my colleague speak, I thought back to a patient I had recently evaluated, someone diagnosed with bipolar disorder, a different kind of inflammatory response, where labile emotions flare in the limbic system of the human brain.

Perhaps one day basic medical research will enable us to delineate specific biochemical pathways that trigger such responses; and, in turn, help us to formulate pharmaceutical agents to block the cascade that results in the downward spiral of major depression.

With our current state of basic medical research we stand poised to micromanage these medical maladies.

What’s good for the cell is ultimately good for the soul.

The Naïve Narrative

In his recent column In Defense of Naïve Reading, Professor Robert Pippin speaks to the state of literary criticism as it is taught on university campuses. His contention is that, although the current trend is to scrutinize the literary arts through the lens of the natural scientific research model — with the ultimate end of developing a “science of meaning” — creative works themselves were never crafted to serve research. Rather, their authors penned them as works of art, works meant to speak to us at the deepest level of our being.

In Pippin’s words: “Literature and the arts have a dimension unique in the academy, not shared by the objects studied, or ‘researched’ by our scientific brethren. They invite or invoke, at a kind of ‘first level,’ an aesthetic experience that is by its nature resistant to restatement in more formalized, theoretical or generalizing language.”

Pippin goes on to say: “Likewise ─ and this is a much more controversial thesis ─ such works also can directly deliver a kind of practical knowledge and self-understanding not available from a third person or more general formulation of such knowledge.”

I was reminded of these words during small group discussion at our recent Cell2Soul gathering on Nantucket. One of the presenters, a young physician, published author and director of a narrative medicine course, put forth his observations on illness. Illness, he maintained, separates us from our bodies. Illness diminishes us physically and morally. Illness alters the way we perceive the world and our place in it. Illness threatens us at the core of our being.

This young physician examined illness in various spheres of influence: illness and the self, illness in the doctor-patient relationship, illness and the family unit, illness and the community. He is working to formulate a theory of illness and its impact on the individual, the family, the community and society, in part to provide a framework for and justification of the study of narrative medicine in the medical school curriculum.

I applaud his efforts. In academic settings it is always necessary to justify what students need to learn to become competent in their chosen careers. A well-developed theory lends credence to academic study — and ultimately, acceptance of the particular discipline. In Pippin’s words: “We certainly need a theory about how artistic works mean anything at all, why or in what sense, reading a novel, say, is different than reading a detailed case history.”

When I engaged him in further discussion, the young physician maintained that the illness narrative could not stand alone by itself. It is too soft a subject to garner academic recognition.

Personally, I believe that narrative, like art, whether in written, cinematic, poetic or visual format, is sufficient to speak by itself. Although narrative understandably deals with the particular, it encompasses the universal, and so becomes relevant on a profound level.

Simple vignettes, simple narratives, in the hands of a skilled teacher, can be used to impart universal truths — scientific or moral — which every clinician needs to learn.

Nantucket Bound

How Melville’s Ishmael got from Manhattan to New Bedford is unclear; but for the record I drove to Hyannis, taking the Bourne Bridge across the Cape Cod Canal and pulling into the Yarmouth lot shortly before eleven o’clock on a crisp clear Friday autumn morning. The shuttle driver dropped me off at the dock just in time for me to purchase my ticket for the high-speed ferry to Nantucket.

Onboard the M/V Iyanough I stowed my bag and elbowed my way through the mass of humanity in the main cabin to the upper deck, where I found an open spot on the fantail. I stood at the head of the port ladder and surveyed the harbor as the boat’s engines kicked in. Slowly we backed out of our berth and turned toward the channel that led to the open sea.

“At last, passage paid, and luggage safe, we stood onboard the schooner,” Ishmael tells us. “Gaining more open water, the bracing breeze waxed fresh, the little Moss tossed the quick foam from her bows, as a young colt his snortings.”

As we slid into open water, the helmsman eased open the throttle. When we approached 35 knots, a roostertail of fine white spray spewed from the stern. Through this mist in the midday sun, ephemeral rainbows skirted the air.

“Rainbows to do not visit the clear air; they only irradiate vapor,” Ishmael observes. “And so, through all the thick mists of the dim doubts in my mind, divine intuitions now and then shoot, enkindling my fog with a heavenly ray.”

The long dark ribbon of cape stretched across the horizon, dotted here and there with fixed white pixels: tiny man-made structures resting on this spit of land. Below the ribbon lay the grey-green white-capped sea. You could tell where the sea ended and the land began from the way the distant whitecaps faded and formed against the backdrop of the fixed white houses.

My glasses fogged with salt spray. I licked my lips and tasted the salty sharpness. I turned my collar up against the wind and felt the dampness of the sea on my back.

“How I snuffed that Tartar air!” Ishmael exclaims. “On, on we flew; and our offing gained, the Moss did homage to the blast, ducked and dived her brows as a slave before the Sultan. Sideways leaning, we sideways darted; every rope yarn tingling like a wire…”

As we dipped and rolled through the waves, I surveyed the cast of humanity sprawled before my eyes: older men, grey-haired, baseball caps pulled down low on their foreheads to brace their eyes against the sun and spray; newspapers roughly folded and stuffed into back pockets of faded blue jeans; spotless tennis shoes. Young men sporting close-cropped reddish-brown hair, wrap-around sunglasses, hooded fleeces, pressed white Bermuda shorts, moccasins on sockless tanned feet.

“Methinks I have hugely mistaken this matter of Life and Death,” Ishmael muses. “Methinks that what they call my shadow here on earth is my true substance. Methinks that in looking at things spiritual, we are too much like oysters observing the sun through the water, and thinking that thick water the thinnest of air. Methinks that my body is but the lees of my better being.”

Older women, thin, with sparkling eyes and salt-and-pepper hair, close-cropped; bandanas wrapped round their necks; cardigans, slacks. Young women, hair billowing like auburn sails in the wind, peacoats buttoned down over striped sailor’s jerseys, each one clutching an iPhone or equivalent. One bald-headed man hung by the railing off to port, coughing into the wind. A little curly-haired girl wearing a pink baseball cap and jersey to match held her mother’s hand.

As we approached the island, the ferry slipped between the red and green nuns and cans that marked the channel; while on either side a string of underwater rocks rose to form parallel jetties. Suddenly off to starboard a stunted lighthouse hove into view. We rolled past sloops and ketches reefed at their moorings. All along the wharf tiny houses stood in a row, grey-shakes with white trim. Up on the hill the golden dome of a church mushroomed above the roofs and widow walks.

“Nothing more happened on the passage worthy the mentioning: so, after a fine run, we safely arrived in Nantucket.”

Cormorants watched in silence while we slipped into our berth. The ferry shuddered as it struck the fenders at the dock, then stood still. The gangway dropped with a metallic clang, and we stepped onto solid ground once again.

I collected my bag and found my way into the cobblestone street. After a brief walk I retired to a raised concrete curb. As I took stock of my next steps, a white van with the words “Nantucket Inn” stenciled on its door crept by. I flagged down the driver and caught a ride to what would be my lodging for our weekend gam.

Humane Medicine — Out of Season

Shy birds, hermit thrushes generally keep to themselves. Here in New England I often hear one calling in the woods near our house in the late winter or early spring. A migratory bird like his cousin the robin, the hermit thrush is seldom seen this time of year, when the foliage has fallen and the days grow short.  >>more

Interested readers can now access my latest Humane Medicine columnOut of Season — recently published in the Journal of the American Academy of Physician Assistants.

Thought to Thought

Energy transfer.

Carbohydrates, digested and absorbed through the gastrointestinal tract, broken down to glucose, fuel for the human body.  Only glucose powers the human brain—food for thought, as it were.

Neurotransmitters diffuse across synaptic gaps, completing circuits—biochemical thoughts.

Thoughts: ideas, concepts, questions, solutions, formed in cerebral grey matter, transmitted through the pons to the spinal cord, anterior horn cell, nerve root, peripheral nerve, neuromotor junction, muscle—twitch, and twitch again.

Fingertips fly, propelled by kinetic energy, punching buttons on a keyboard, stringing symbols in rows of lines—symbolic thoughts, electromagnetic energy transmitted instantaneously at the speed of light.

In a galaxy far, far way—Arizona, perhaps; Pennsylvania, Massachusetts, Spain, or South Korea—photons fly across a flat screen, producing light symbols, the same symbols in rows of lines, the same symbolic thoughts.

Photons fly and strike the rods and cones of another human retina, triggering biochemical impulses transferred via the optic nerve to the occipital lobe of another human brain—reception of thoughts, ideas, concepts, emotions, problems, solutions—the stuff of life.

Energy transfer; lickety-split—thought to thought—via biochemical and electromagnetic channels.

Cosmic communication: the stuff of electrons.

“Notes from a Healer” — Great and Noble Tasks

“Some things just stay with you, I guess,” our receptionist told me, as she gathered the pile of finished charts from my desk. “Sometimes it’s the little things that turn out to be the most significant.”

My latest installment of Notes from a HealerGreat and Noble Tasks — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.

Holistic Solutions

“Wow, they’ve certainly been busy!”

My neighbor and I stood side by side with our necks careened back, staring up at the south face of my house.  Scattered throughout the cedar shakes along the periphery there appeared a string of holes expertly drilled into the wood—the work of a woodpecker, most certainly.

“You said you heard him drumming on the side of the house?”

I nodded my head.  “Sometimes it’s so loud I have to stop working in the upstairs office—I can’t concentrate.  Do you have any idea why a woodpecker would attack a house?”

“Could be searching for bugs,” my neighbor mumbled, as he scraped away the sandy soil at the foundation.  “Don’t see any evidence of that here.  Then too, woodpeckers are territorial—they mark their territory by drilling holes, the same way that dogs urinate.”

“What can I do about it?”

My neighbor, formerly a pest control specialist, shrugged his shoulders.  “You could hang up a few aluminum pie pans with some string.  They make a racket when the wind blows and keep the birds away.  Trouble is, that doesn’t always work.

“You could shoot them with a pellet gun.  Technically, that’s illegal—you’d have to get a federal permit to do that.  One big headache, let me tell you.

“You could also go up to the hardware store and buy a spring-loaded rat trap.  Bait it with suet and nail it to the side of the house.  When the bird comes to peck at the suet—bingo!  Adios, problem.”

“Wouldn’t I need a permit to do that as well?”

“There’s no law against setting out rat traps,” my neighbor said with a wink.

My neighbor had stopped by to borrow my Have-A-Heart trap so he could capture a stray cat.  I handed it down to him from the shelf in my garage before retiring to my rocking chair to consider my options.

That afternoon from my front porch perch I watched the season change. The fire bushes along the driveway had begun to blush.  Tall maples on our street were turning orange and gold.  Blackbirds gathered in the tops of the old ash trees.  Overhead, hawks sailed high on the air currents along the eastern flyway.

I went to bed uneasy that night, wrestling with a decision.

I remembered when my third grade teacher used to read us from a chapter book entitled Rabbit Hill, by Robert Lawson.  The narrative was told from the perspective of the animals that inhabited the grounds of an abandoned Connecticut country estate.  At some point new folks move into the house on the hill.  Animal lovers at heart, they put out food for the birds, squirrels and rabbits.  When the moles tunnel beneath the expanse of lawn, the owner instructs his hired man to roll the mounds flat instead of killing the tiny creatures.  But none of these animals did damage to the old foursquare house.

The next day I wandered out into the yard and looked up at the damaged shakes.  I knew what I had to do.

The following Wednesday afternoon I drove to the hardware store and browsed the aisles, looking for the paraphernalia I would need.  I paid cash at the checkout counter and threw the brown paper bag into the back of my station wagon.

Back home, I pulled up the garage door and found the aluminum extension ladder buried beneath the workbench.  I manhandled it across the yard and leaned it up against the south side of the house.  I ratcheted up the extension, gathered my tools and ascended the ladder to the top of the second story to begin my work.

It didn’t take as long as I had imagined.  Satisfied, I dropped the ladder down and stowed it back in the garage.  I returned the tools to their place above the workbench in the basement and strode into the kitchen to wash up.

“So, you made your decision?” my wife asked.

I nodded my head.

“What now?”

“There will be plenty of time to prime and paint the putty,” I said.  “If that doesn’t fix things, I suppose I can always hang out some aluminum pie pans.”