Tuesday, August 17, 2010


Medical Meanderings 21 May 2008


“[John R. Brinkley and Mrs. Brinkley are] two of the finest people and the greatest benefactors to mankind on earth…I wear goat glands and am proud of it.”
U.S. Senator Wesley Staley (D - CO), 1922

By 1930, John Brinkley was the millionaire founder of the Brinkley Institute of Health (containing the Brinkley-Jones Hospital, Brinkley-Jones Associates, the Brinkley Research Laboratories and the Brinkley Training School for Nurses) in Milford, Kansas, and host of the “Medical Question Box” on KFKB, the most popular radio station in the United States. He had powerful friends, including the Vice President of the United States, and was considering a run for governor of Kansas.

He was also the most dangerous charlatan in America. Brinkley, born in 1885, had at first attempted to go to medical school in Chicago in 1908. At the time, the idea of standardized medical training was far from widely accepted. Although experimentally-based, “allopathic” physicians were dominant in America, there were dozens of other schools teaching the gospels of osteopathy, chiropractic, homeopathy, herbs and more. Brinkley settled on the Bennett Eclectic Medical College. Eclectic medicine relied largely on herbs and taught several ideas ahead of their time, but also included a lot of pseudoscientific guesswork. After dropping out due to excessive drinking and leaving his first wife, Brinkley had several false starts including a stint as an “electro-medic” in South Carolina and as a general practitioner in Arkansas (after buying a medical diploma from the Eclectic Medical University of Kansas City). Finally, his big break came in 1917.

One strong trend of American quackery in the early 20th century was “gland therapy” for that most perennial of human afflictions—sexual inadequacy. The thinking ran thus: animals like chimpanzees and goats are sexually…vital. If we can take the animal’s testicle and get it into the human body, it will make its recipient similarly vital. I am not kidding. So, people who would not buy a second-hand Model A Ford without skeptical evaluation were gullibly risking their health ingesting and injecting goat glands. Brinkley saw an opportunity. A farmer named Stittsworth complained of “no pep.” Brinkley surgically implanted goat testicles in Mr. Stittsworth’s scrotum. The farmer paid and went home. Two weeks later, the farmer returned with a smile and new vigor, and word spread. Dr. John Brinkley’s goat-gland practice was born.

Author Pope Brock tells Brinkley’s full, incredible story in his excellent new book, Charlatan: America’s Most Dangerous Huckster, the Man Who Pursued Him, and the Age of Flimflam. Brinkley’s dubious career was paralleled by that of Dr. Morris Fishbein, associate editor of the Journal of the American Medical Association, who determinedly crusaded to bring Brinkley down and in so doing became the most famous “quack-buster” of his day.

Brinkley’s career ended on March 30, 1939, when he lost a lawsuit against Fishbein during which his scams and hokum were fully exposed. When he died in 1942, Brinkley had killed 42 patients at his hospital, not to mention those who were discharged and died later, nor those harmed or killed by his bad advice and fake remedies sold on the radio. He was still one of the most popular men in the United States. In our age of weight-loss remedies, sexual tonics, various gurus pushing supposed cures “your doctor won’t tell you about,” and other nonsense, Brinkley’s story should be cautionary for all of us.


Medical Meanderings 9 January 2008

Snip, Snip

This was the most unkindest cut of all.
William Shakespeare, “Julius Caesar,” Act III, scene ii

Vasectomy is a safe, permanent method of birth control for men. It is also one of the few suggestions that will send the most macho, grizzled tough guy running for the door. Still, it’s not uncommon: one in five American men over age 35 have had vasectomies, and about four million are performed each year worldwide.

But before we get into details, a quick anatomy review. Sperm are made in the testicles, which hang out (literally) in the scrotum. New sperm move into the epididymis, a convoluted network of tubes on top and behind the testicle. In the epididymis, the sperm are mixed with fluid from the seminal vesicles to make semen. During ejaculation, the semen is pushed out of the epididymis, up the vas deferens, through the prostate and out. The vas deferens (or “vas,” but never “the v.d.”!) is a long, thin tube, about the size and consistency of a piece of half-cooked spaghetti. It runs from the epididymis, into the pelvis, behind the bladder, through the prostate and, finally, into the urethra and out. Long trip, but the section through the scrotum without exits or U-turns gives us a great spot to put in a roadblock.

During a vasectomy, a small amount of anesthetic is injected with a tiny needle into part of the skin of the scrotum. When the skin’s numb, the doctor finds the vas and holds it steady with one hand while making a tiny incision in the skin over the vas. A loop of the spaghetti-like vas is brought up through this tiny hole and a section clipped out. The ends are then either clipped with small staples or burned with electrical current (which doesn’t hurt). Then, the vas is put back and the skin closed up if needed (sometimes a stitch isn’t even necessary). It all takes about 30-45 minutes. The man is then sent home wearing a jock strap to hold his equipment steady (and to help his sense of manliness). Most guys can go back to work the next day with some limits, and are back to normal in a week.

Now for the weird part. In the eight weeks following the procedure there are still some sperm in the plumbing. So, another form of birth control has to be used. To clean out the pipes, the fellow has to ejaculate about 20 times before his follow-up visit. Then, he goes to the doctor where he gives a semen sample to make sure no sperm are left.

Once the plumbing is clear, vasectomy is a highly effective form of birth control—the failure rate (that is, pregnancy rate) is less than one in a thousand. For those guys not persuaded by statistics, how about money? Vasectomy costs half as much as tying a woman’s tubes (not to mention being a safer procedure), and is about the same cost as a two-year supply of birth control pills.

So, guys…think about it. It’s quick, cheap, effective and not all that painful. It won’t make you sing soprano, hurt your sex drive or make you more likely to ask for directions. Real men get vasectomies.


Medical Meanderings 12 September 2007

Testosteroni: The Elderly Man’s Treat?

I think age is a very high price to pay for maturity.
- Tom Stoppard (1937 - )

It’s likely that anyone reading a weekly medical column has heard of menopause, or “the change” as many women call it. Menopause is the normal, age-related process of decreasing estrogen levels in the woman’s body, causing classic symptoms like hot flashes (or flushes), thinning of the bones, and lack of menstrual periods. Recently, however, there has been talk in some medical circles of an “andropause,” or male menopause, caused by declining testosterone levels in older men. Is there anything to this idea of “andropause”?

As men age, the level of testosterone in their blood normally decreases to some extent. Unlike menopause, however, there’s not a huge drop in hormone levels and, so far, the symptoms caused by this change aren’t clearly defined. Nevertheless, believers in “andropause” seem to think backward. They reason as follows: since many symptoms of aging in men are similar to symptoms of low testosterone in young men (called hypogonadism), it is reasonable to assume that low testosterone may cause many of the symptoms of aging. This is a tricky bit of flawed reasoning (called “argument by analogy,” for you logic buffs), and the link has not been supported by scientific evidence so far. Just because low testosterone and aging have similar results does not mean one causes the other.

Then the question arises: Even if it’s not an obvious disease, if we can, shouldn’t we fix problems such as age-related loss of bone, loss of sexual function and loss of muscle mass and strength? If an older man has declining testosterone and these problems, shouldn’t giving him some testosterone help get back his strength and mojo? Not necessarily. The available medical studies (and there aren’t that many) on testosterone treatment show that making the hormone level normal does NOT improve bone density, sexual function, quality of life, muscle strength or physical function.

Not only is aggressive testosterone replacement in older men apparently ineffective, it may be harmful. Both prostate enlargement and prostate cancer depend on testosterone, so giving more can worsen these problems. Testosterone treatment also worsens sleep apnea, increases the percentage of red cells in the blood (which may increase risk of heart attack) and lowers good cholesterol. It’s no magic elixir of youthful manliness.

Just as recent studies have made us doctors seriously question whether we should be trying to undo the changes that women experience as they go through menopause, it may be time to reconsider testosterone replacement in older men. It should probably be reserved only for those patients with severe, proven hormone problems, not for those older men who would just like more pep (or a younger girlfriend). In fact, it may be time for us all to reconsider the common view that aging is a disease that needs to be cured. Just as we don’t try to stop the changing of the seasons or the falling of the leaves, perhaps we shouldn’t stubbornly try to reverse those inevitable signs that our bodies have been around for awhile.

Lesch-Nyhan Syndrome

Medical Meanderings 15 August 2007


“I take you where you want to go / I give you all you need to know / I drag you down, I use you up / Mr. Self-Destruct…” - Nine Inch Nails, “Self Destruction”

In 1964, a pediatrician named Dr. William Nyhan and his medical student assistant, Michael Lesch, published a report bearing the esoteric title: “A familial disorder of uric acid metabolism and central nervous system function.” In it, they described a horrifying disease affecting little boys that caused them, around 6 months of age, to move spastically, twitching and involuntarily jerking their limbs. Then, as the disease progressed, these little boys would develop self-mutilating behaviors. Their hands would fly to their mouths, where they would bite off parts of their fingers, all the while screaming for help, unable to stop. They would bang their heads into walls, stab themselves, burn themselves, unable to stop.

In earlier times, such horrifying behavior would have doubtlessly been attributed to demonic possession or witchcraft. But Lesch-Nyhan syndrome, as it is now known, is due to the buildup of a simple chemical in the areas of the brain that control movement, the basal ganglia. The culprit is uric acid, a byproduct of the metabolism of DNA in our diet. Uric acid is familiar to anyone with gout—it is this chemical that builds up and crystallizes in the joints, causing inflammation and pain.

When Drs. Nyhan and Lesch discovered the uric acid was the cause of the bizarre syndrome, they attempted to treat affected children with allopurinol, a medication used to lower uric acid levels in gout patients. However, this medication, and no medication so far, has been able to change the course of the disease. As it turned out, the high uric acid levels and the self-mutilating behavior are both symptoms of a separate underlying problem.

That problem is a misspelling. Patients with Lesch-Nyhan syndrome are born with one letter misplaced in one gene in their entire genetic program. That gene, which is carried on the X chromosome, codes for an enzyme, hypoxanthine-guanine phosphoribosyltransferase (HPRT). Since boys have only one X chromosome, while girls have two copies, this abnormal gene and thereby the disease, shows up predominantly in boys.

What does it mean that a single gene can cause a person to chew off his own fingers against his will? How can any of us believe in “free will” (whatever that means) if a random, simple DNA misspelling can make someone destroy his own life if left unrestrained? Lesch-Nyhan syndrome raises interesting questions, not just about the brain and our body’s complex chemistry, but also about our easy assumptions about our behaviors and choices. Do we control our brains, or do our brains control us? Does that question even mean anything?

Dr. Nyhan, now 81 years old, still works with patients affected with the disease at the University of California – San Diego. His younger colleague, Dr. Lesch, is now Chairman of the Department of Medicine at New York’s St. Luke’s-Roosevelt Hospital. The disease named for them is fortunately rare, affecting only a few dozen people worldwide. But the questions about human nature it raises affect us all.