Informed Consent in California: Latent Liability Without `Negligence'

Informed consent is a legal obligation due from a physician to his patient, an obligation which may not be met by the physician''s skillful treatment of his patient. It may only be met by the treating physician obtaining from his patient knowing authorization for carrying out the intended medical procedure. The physician is required to disclose whatever would be material to his patient''s decision, including the nature and purpose of the procedure, and the risks and alternatives. The disclosures should be made by the physician to his patient, and not through use of consent forms which are not particular to individual patients. To minimize any subsequent claim by the patient that there was a lack of adequate disclosures, the physician should record in the patient''s chart the circumstances of the patient''s consent, and should not rely on the patient''s unreliable ability to recall those circumstances.     

McMaster's pioneer in evidence-based medicine now spreading his message in England.

Dr. David Sackett, formerly of McMaster University and now at Oxford University in England, is considered one of the pioneers of the evidence-based medicine movement. This article looks at his colleagues'' assessment of Sackett''s contributions to medicine and at Sackett''s own views on his lengthy career.     

Movement in the normal visual hemifield induces a percept in the 'blind' hemifield of a human hemianope.

We have investigated visual responses to moving stimuli presented to the normal hemifield of a hemianope, GY, who exhibits residual visual function in his right, ''blind'' hemifield. Preliminary experiments established that his perception of moving stimuli localized in his ''blind'' hemifield is retained when a similar stimulus is presented simultaneously in the normal hemifield. In response to a grating stimulus moving horizontally towards fixation in the non-foveal region of the normal, left hemifield, he perceives in addition to a normal motion percept in the left hemifield, a sensation of movement localized in the right hemifield. Qualitatively, this latter is indistinguishable from responses elicited by direct stimulation localized within his ''blind'' hemifield by moving stimuli. We have investigated the characteristics of the mechanisms which induce the ''blind'' field component of GY''s responses to stimulation of the normal hemifield. We show that GY''s sensitivity for detection of movement localized within his ''blind'' hemifield is dependent on the direction of movement, the contrast and the velocity of a grating presented to the normal hemifield. No induced effects were recorded in response to colour or to non-moving, flickering stimuli. We examine the possible contribution of scattered light to our observations, and eliminate this factor by consideration of our experimental results. We discuss the neural mechanisms which may be involved in this response.     

An appreciation of A.E. Malloch,MB, MD (1844-1919): a forgotten surgical pioneer

Dr. Archibald Edward Malloch was a surgeon whose life and work were greatly influenced by Joseph Lister and his revolutionary system of antiseptic surgery. This paper describes how a young Canadian medical man came to introduce Lister''s system to North America in 1869 and studies his career in the light of Lister''s surgical epoch.     

Remembering Malcolm J. Casadaban

Malcolm J. Casadaban died on 13 September 2009 from an infection and was found to have a weakened strain of the bacterium Yersinia pestis in his blood. This tragic event took the life of one of the most creative and influential geneticists of our time. In the late 1970s and ''80s, Malcolm invented novel approaches which changed the way many of us did science. Jon Beckwith, Tom Silhavy, and Olaf Schneewind have chronicled his scientific life from graduate school to his death and give us insight into Malcolm''s genius.Philip Matsumura Editor in Chief, Journal of Bacteriology     

THE HIGH SCHOOL FOOTBALL TEAM PHYSICIAN

Mutual confidence is necessary between the football coach and the team physician. The physician''s decision in the matter of a boy''s condition must always be final. The coach should also consider the physician''s advice in shaping his psychological appeals to the players in before-game and between-halves talks. The physician should be on his way to a man injured on the field as soon as the play is ended. It is up to him and not the trainer or coach to make the diagnosis. The physician must have the ability to make an immediate evaluation of the extent of injury and use appropriate measures to get the player off the field. To see a semi-conscious man with dangling head being half dragged off the field is far worse from the patient''s standpoint and from the spectator''s standpoint than removal by stretcher.     

Dr. Max King: the sad life and early death of Mackenzie King's physician brother

While researching her best-selling biography, Mrs. King: The Life and Times of Isabel Mackenzie King, CMAJ contributing editor Charlotte Gray discovered a wealth of information about Dr. Dougal Macdougall (Max) King. Although he never became as famous as his older brother Mackenzie, Gray presents a convincing argument that Dr. Max King''s life and early death speak volumes about medicine and the medical profession at the turn of the century. She also argues that Mackenzie King''s own life would have been much different had his brother not died at the too young age of 42. Gray''s book was nominated for the Viacom Award, which honours the best nonfiction book published annually in Canada.     

Prison became second home for psychiatrist (George Scott).

Retired prison psychiatrist George Scott recalls his career working in Canada''s penal system, including his peacemaking role in a hostage-taking incident and his work with Steven Truscott. Life "inside" is dangerous for guards, inmates, staff and psychiatrists, he says, but he never regretted his decision to devote his career to studying criminal behaviour.     

Addison,pernicious anemia and adrenal insufficiency

In 1849 Thomas Addison described the clinical entity now known as pernicious anemia. In 1855 he reported several cases of adrenal insufficiency, or Addison''s disease. Considering the importance of these works, there remains a great deal of confusion about them. Contrary to what many historians have written, a review of Addison''s original publications demonstrates a firm appreciation of the distinction between pernicious anemia and adrenal insufficiency, based particularly on the discoloration of the skin in these conditions. Three major sources of possible confusion for historians who are attempting to understand Addison''s views include Addison''s early attempts to link pernicious anemia with disease of the supra-renal capsules, Addison''s redefinition of pernicious anemia in his monograph on adrenal disease, and several confusing statements made by Wilks and Daldy in the first reprint of Addison''s monograph.     

Do you have any regrets about entering medicine?

Do today''s students have any second thoughts about their decision to pursue a career in medicine? Gabriel Leung, who graduates in June from the University of Western Ontario, considers the problems and dilemmas that have confronted him and his classmates during their short careers and muses on the uncertain future today''s physicians face.     

Sir William Osler revisited.

The basis of Sir William Osler''s fame is elusive to almost all and the appropriateness of such recognition is questioned by many. His many contributions as a practitioner, teacher, writer, and scientist in medicine do not adequately explain his prominence 60 years following his death. It was his participation in the covenant of medicine and the special components of that relationship that may account for his hold on his followers today.     

Raymond Gosling: the man who crystallized genes

On April 25th 1953, three publications in Nature forever changed the face of the life sciences in reporting the structure of DNA. Sixty years later, Raymond Gosling shares his memories of the race to the double helix.It has not escaped our attention that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.James D Watson and Francis HC Crick [1]By including this statement in their April 25th 1953 Nature article describing a model for the structure of DNA, Watson and Crick made one of the great understatements in history. In that moment, the seeds for the double helix''s infamy - alongside the names ''Watson'' and Crick'' - were sown. Lesser known outside scientific circles is that this article did not include one iota of experimental data: Watson and Crick, who were based at the University of Cambridge''s Cavendish laboratory, contributed deductive reasoning alone to the double helix model, albeit reasoning of an undoubtedly Nobel Prize-worthy standard. Instead, as has now been described many times, the model relied on X-ray diffraction data obtained by others, at King''s College, and these data did not reach Watson and Crick by entirely wholesome means [2]. To add to the insult, Watson and Crick''s report of the double helix did not fully credit the work of King''s as being essential to the construction of their model, although the King''s team did enjoy co-publication of their data alongside the double helix article, in the form of two articles in the same issue of Nature [3,4]. One of these articles described the X-ray diffraction work performed by senior researcher Rosalind E Franklin, together with PhD student Raymond G Gosling, and contained the highest quality diffraction patterns yet achieved for DNA [3]. It was these data that had proved invaluable in Watson and Crick''s quest for the double helix.Earlier still, before Franklin arrived at King''s, Gosling had achieved a major breakthrough in the search for DNA''s structure when he became the first person to crystallize genes, under the guidance of Maurice Wilkins, who was the lead author of the other King''s article to accompany Watson and Crick''s model [4].Watson published his controversial memoir of the discovery, aptly named ''The Double Helix'', in the 1960s [5], and in doing so propelled the story to worldwide fame, establishing DNA''s structure as an icon of science in the popular imagination. However, events were relayed in Watson''s book very much from his own point of view and at times, it has been argued, even verged on the fictitious.Aside from Watson, Ray Gosling is the only surviving member of the select group of seven scientists to feature as an author on one of the three Nature articles. Gosling and his wife, Mary, were kind enough to welcome Genome Biology into their home, where he shared with us his perspective of the events of 60 years ago.Elsewhere, Genome Biology has marked the anniversary by canvassing our Editorial Board for their opinions on the most important advances in the field since 1953 [6].     

London after Tomlinson. Clinical research.

Sir Bernard Tomlinson''s report focuses on London''s health services, but his proposals have major implications for the future of clinical research--not just in London but in the United Kingdom as a whole. They must be seen in the context of a widely perceived decline in British research and development which also threatens clinical research. This article examines the implications of Tomlinson''s proposals and related strategies and recommends the construction of a research market for the patient costs of clinical research to complement the NHS market for patient services introduced in 1991. These arrangements would help sustain the clinical research base and guarantee excellence.     

Darwin and Dostoyevsky: twins

The Russian poet Fyodor Dostoyevsky published an insightful treatise on human nature in his novel ‘The Brothers Karamazov'' in 1880. His account of humanity may offer as much insight into human nature for scientists as Darwin''s The Descent of Man.Late in the nineteenth century, Charles Darwin (1809–1882) and Fyodor Dostoyevsky (1821–1881) published accounts of their investigation of humankind. Darwin did so in 1871 in his book The Descent of Man, Dostoyevsky in 1880 in the parable of The Grand Inquisitor in his book The Brothers Karamazov. Last year we celebrated Darwin''s anniversary; for biologists, 2010—the 130th anniversary of Dostoyevsky''s book—might have been the year of Dostoyevsky.Dostoyevsky was familiar with Darwin''s doctrine and he was willing to admit “man''s descent from the ape”. An orthodox Christian, he put this sentiment in religious terms: “It does not really matter what man''s origins are, the Bible does not explain how God moulded him out of clay or carved him out of stone. Yet, he saw a difference between humans and animals: humans have a soul.The philosopher Nikolay Berdyayev noticed: “[Dostoyevsky] concealed nothing, and that''s why he could make astonishing discoveries. In the fate of his heroes he relates his own destiny, in their doubts he reveals his vacillations, in their ambiguity his self-splitting, in their criminal experience the secret crimes of his spirit.”The Grand Inquisitor can be read as Dostoyevsky''s treatise on human nature. In the tale, Jesus Christ revisits Earth during the period of the Inquisition and is arrested by the Church and sentenced to death. The Grand Inquisitor comes to visit Jesus in his prison cell to argue with him about their conceptions of human nature. He explains that humankind needs to be ruled to be happy and that the true freedom Jesus offered doomed humanity to suffering and unhappiness. Dostoyevsky''s superposition of these two points of view on humankind reminds us of the principle of complementarity, by which the physicist Niels Bohr attempted to account for the particle-wave duality of quantum physics.Dostoyevsky conceives of humans as complex, contradictory and inconsistent creatures. Humans perceive personal liberty as a burden and are willing to barter for it, as the Grand Inquisitor explained to Christ, for “miracle, mystery, and authority”. In addition, “the mystery of human being does not only rest in the desire to live, but in the problem: for what should one live at all?” We might say that these faculties make Homo sapiens a religious species. Not in the sense of believing in gods or a god, but in the sense of the Latin word religare, which means to bind, connect or enfold. Humans are mythophilic animals, driven by a need to find a complete explanation for events in terms of intentions and purposes.Research into the neurological bases of imagination, transcendence, metaphorability, art and religion, as well as moral behaviour and judgement (Trimble, 2007) is consistent with Dostoyevsky''s views. It has identified areas of the brain that have been labelled as the ‘god module'' or ‘god spot'' (Alper, 2001). These areas represent a new stratum of evolutionary complexity, an emergence specific to the human species. Their mental translations might be tentatively designated as the Darwinian soul, anchored in the material substrate and neither immortal nor cosmic. As consciousness and volition have become legitimate subjects of neuroscience (Baars, 2003), the Darwinian soul, and with it spirituality, seems to be ripe for scientific inquiry: the quest for meaning, creation and perception of metaphors, the experience of the trinity of Truth, Good and Beauty, the capacity for complex feelings that Immanuel Kant called sublimity, the thrill of humour and play, the power of empathy and the follies of boundless love or hate. Secularization does not erase the superstructure of spirituality: it is reflected, however queer it might seem, in the hypertrophy of the entertainment industry and also, more gloomily, in spiritual conflicts on a global scale.Dostoyevsky''s views on the human soul might be closer to those of Alfred Russel Wallace, who believed that an unknown force directed evolution towards an advanced organization. We can identify this ‘force'' as the second law of thermodynamics (Sharma & Annila, 2007). By moving evolving systems ever farther away from equilibrium, the second law eventually became the Creator of the ‘Neuronal God''.Christ, in the parable of the Grand Inquisitor, might be conceived of as a symbol of the truth outside the human world. Christ was listening to the assertions and questions of his interlocutor, but did not say a single word. His silence is essential to the parable.Similarly, the cosmos, to which humanity has been addressing its questions and predications, remains silent. By science, we increase knowledge only by tiny increments. The ‘god modules'' of our brains, unsatisfied and impatient, have hastily provided the full truth, deposited in the Holy Scripture. There are at least three books claiming to contain the revealed and hence unquestionable truth: the Judaic Torah, Christian Bible and Muslim Qur''an. A dogma of genocentrism in biology might offer an additional Scripture: the sequence of DNA in the genomes.Dostoyevsky''s legacy may suggest an amendment to the UN Charter. We, united humankind, solemnly declare: No truth has ever been revealed to us; we respect and tolerate each other in our independent searching and erring.     

The road to Wisconsin

In this article Lynne Sears Williams of Calgary describes her family''s decision to leave for the US, where her husband, Dr. Jim Williams, will pursue his career in family medicine. The decision was not made easily, she writes, but eventually a love for Canada was outweighed by her husband''s desire to practise medicine without the financial and other constraints facing physicians in Canada.     

Warwick Hillier: a tribute

Warwick Hillier (October 18, 1967–January 10, 2014) made seminal contributions to our understanding of photosynthetic water oxidation employing membrane inlet mass spectrometry and FTIR spectroscopy. This article offers a collection of historical perspectives on the scientific impact of Warwick Hillier’s work and tributes to the personal impact his life and ideas had on his collaborators and colleagues.     

Revisiting Metchnikoff's work in light of the COVID-19 pandemic

Revisiting Metchnikoff''s work in light of the COVID-19 pandemic illustrates how much this amazing scientist was a polymath, and one could speculate how much he would have been fascinated and most interested in following the course of the pandemic. Since he coined the word “gerontology”, he would have been intrigued by the high mortality among the elderly, and by the concepts of immunosenescence and inflammaging that characterize the SARS-CoV-2 infection. While Metchnikoff''s work is mainly associated with the discovery of the phagocytes and the birth of cellular innate immunity, he regularly invited his closest collaborators to investigate humoral immunity, and it was in his laboratory that Jules Bordet made his major discovery of the complement system. While Metchnikoff and his team investigated many infectious diseases, he also contributed to studies linked to vaccination, such as those on typhoid fever performed in chimpanzees, illustrating that non-human primates can provide animal models which are potentially helpful for understanding the pathophysiology of the COVID-19 virus. In the present review, we illustrate how much his own work and the investigations of his trainees were pertinent to this new disease.     

Historical roots of centrosome research: discovery of Boveri's microscope slides in Würzburg

Boveri''s visionary monograph ‘Ueber die Natur der Centrosomen’ (On the nature of centrosomes) in 1900 was founded primarily on microscopic observations of cleaving eggs of sea urchins and the roundworm parasite Ascaris. As Boveri wrote in the introductory paragraph, his interests were less about morphological aspects of centrosomes, but rather aimed at an understanding of their physiological role during cell division. The remarkable transition from observations of tiny dot-like structures in fixed and sectioned material to a unified theory of centrosome function (which in essence still holds true today) cannot be fully appreciated without examining Boveri''s starting material, the histological specimens. It was generally assumed that the microscope slides were lost during the bombing of the Zoological Institute in Würzburg at the end of WWII. Here, I describe the discovery of a number of Boveri''s original microscope slides with serial sections of early sea urchin and Ascaris embryos, stained by Heidenhain''s iron haematoxylin method. Some slides bear handwritten notes and sketches by Boveri. Evidence is presented that the newly discovered slides are part of the original material used by Boveri for his seminal centrosome monograph.