Miasmatics

Out of the night that covers me, Black as the pit from pole to pole, I thank whatever gods may be, For my unconquerable soul.  This may be how we choose to think about ourselves as we screw our courage to the sticking place. And yet, much as we hate to admit it, there is something a little frightening about things that surround us which we cannot see. Clouds that, had we not been made aware of them, would have drifted as unseen and unregarded as smoke on a moonless night.

Bacteria, at least in popular culture, have usually been associated with filth, contamination, and especially, illness. The Germ Theory, which postulates that some diseases are caused by agents (microorganisms), was first proposed in the mid-1500s and later substantiated with the advent of microscopes and public sanitation advances. The recognition of microorganisms as causes of disease supplanted the previously held disease theory of Miasma –bad air- as propounded by Galen, a Greek physician and philosopher in the mid second century CE Roman empire.

As counter intuitive as it might sound nowadays, new discoveries have lately suggested that he may well have been on to something: http://www.bbc.com/news/health-34314065. I suppose this shouldn’t come as a complete surprise, though. As the news article observes: ‘Studies have already shown that our microbiome – the collection of bacteria, viruses and fungi that live on our skin and in our bodies – outnumbers our own cells 10 to one. These can be spread through direct contact, airborne emissions and shed skin cells in dust.’ Or, perhaps more disturbing, ‘Walk through someone else’s cloud, and it will “rain” bacteria on your skin and be breathed into your lungs.’ The study, from scientists at the University of Oregon, was published in the Sept. 2015 edition of Peer J: https://peerj.com/articles/1258/ -a fascinating read, to be sure.

I suppose I found this article a timely reminder that we all approach the idea of ‘cleanliness’ in different ways, and to different degrees. Not everybody who pays attention to it has OCD.

Lisa was a good example, I think. A beautifully coiffed, tall woman in an almost obsessively ironed white, frilly blouse and perfectly pleated black skirt, she sat primly, but in isolation in the fully packed waiting room. Trying not to seem rude, she had managed to negotiate the chaos of hyperactive children and their large-tummied mothers, by contracting herself into the smallest possible dimensions in a corner. She wasn’t obvious about it, nor did she seem at all uncomfortable –just careful to avoid undue and unnecessary contact. As if everyone around her had the flu –or something else of which they might not even be aware. Yet.

As I led her down the corridor to my office I noticed she stopped at the front desk for a quick dab of alcohol hand rub from the dispenser the secretaries had placed there, probably for their own protection. Good, I thought, she’s getting her hands ready so she won’t contaminate me when we shake. Then it occurred to me in kind of uncomfortable shiver, that we had already shaken hands. So, to make her feel that it was indeed an appropriate thing to do after touching, I helped myself to a dollop from the same container. I don’t think she noticed; she was too engaged in straightening the sleeves of her blouse and then making sure no hair was out of place to ruin the effect. I put it down to nervousness.

Once she had settled into the chair across from my desk and examined my office with what seemed like polite curiosity, I asked her why she had been sent to see me in consultation. Her expression immediately changed. Her initially benign and neutral face suddenly wrinkled suspiciously, and her eyes wandered over my face for a moment searching for a safe place to stand. Or were they looking for reasons –any excuse- to terminate the visit and seek help elsewhere?

I thought I’d make it easier for her. “Well, your family doctor seems to feel you have… issues in the vaginal area that he can’t resolve. Would you like to tell me about them..?”

Her face gradually hardened. “I told him I wanted to see a female gynaecologist! But he never listens. He’s too busy to listen, I think.” She stared at a painting on the wall beside her, for a moment. “And your waiting room looks even fuller than his, I have to say.” Her eyes migrated slowly around the room stopping to feed on the eclectic tidbits I had scattered almost randomly throughout: the wooden statue of an Ethiopian woman holding a child and seeming to hide behind a plant on my desk; the terracotta woman sitting on a flimsy oak table holding a begging bowel filled with shiny coins that require constant vigilance from every mother who visits with her children; the jade apple on my desk; the multicoloured painting of a peasant woman leading a horse…

Interestingly, it was to the painting that her eyes continually returned. “But he never had pictures on his wall. Nothing at all interesting about his office except a window with a tree right outside it…” She lowered her eyes for a moment and then they flew back to my face and settled there. “So, what did you want me to tell you?”

“Dr. Grossac seemed concerned about your vaginal issues, as he put it.” I couldn’t suppress a smile at his turn of phrase and she noticed it.

“He just got fed up with not finding anything. He seemed to be a one-trick-pony: if his swabs and cultures didn’t show anything abnormal, then of course nothing was abnormal. A standoff.

“There is an odour, however –but like describing the taste of wine, words sometimes fail to capture it -or validate it… I don’t expect most family doctors will have a gas chromatograph in their offices, but I do think most noses are able to detect differences, don’t you? I mean, isn’t that what they’re for?”

She had a point.

She hesitated a moment, and then continued with a guilty expression. “I don’t mean to imply that Dr. Grossac doesn’t know his medicine -he told me he could smell something, but he didn’t know what. I guess he thought you would…”

“What have you tried so far?”

“I’ve tried scented oils in the bathwater; I’ve tried different laundry soaps, different personal products, but they only seem to help for an hour or two…”

“How long has this been going on, Lisa?”

She shrugged. “I don’t know –maybe a couple of weeks now.”

“And has this ever happened to you before?”

She shook her head, thought better of it, and then looked at me with caged eyes. “I suppose maybe something similar when I was a teenager…” She stopped, no doubt hoping I wouldn’t demand a fuller description. Sometimes you’re just not supposed to ask.

I smiled expectantly. “Oh, and what did your doctor find then?”

She blushed and looked at the horse painting once again. “Actually, I found it…”

I pretended to look at something on my desk. “And what did you find?” Sometimes I’m merciless.

She looked down at her lap, embarrassed beyond words. “I… I left something inside.” Her head snapped back upright and she unleashed her eyes on my face, daring me to pursue it. “I mean I was really young –just starting my periods, really…” Her voice trailed off in distress. This was a woman’s issue after all; she didn’t really expect me to understand.

“And this time?”

“Nope,” she mumbled to her knees. “Couldn’t find anything…”

“And your doctor?

“He never really looked in there…”

I tried not to show surprise. “Do you mind if I look?”

She shook her head –with relief, I think.

After I’d examined her and dealt with the issue, she came back into the office with an awkward smile on her face. “So,” she said, “Where there’s smoke there’s fire, eh?”

I had to smile again. “Ever heard of the Miasma Theory?”

She returned my smile. “Galen?”

I nodded. “He wasn’t entirely wrong was he?”

The Human Microbiome

 

 

I have always been excited by a new paradigm. Captivated by its novelty. Intrigued by the realization that what we had previously considered to be self evident and true was not sacrosanct. Immutable. Of course I have to confess that it is often the perspective that interests me: that it sometimes okay to question the consensual adherence to a theory -to question what we have all come to believe is correct. To re-interpret the data.  Consensus establishes nothing; it only demonstrates that that we have been swayed by it. It merely lionizes a viewpoint; it does not validate it. And yet that’s Science: always open to refutation, reassessment. Change. According to Karl Popper -the great philosopher of science- a theory should only be considered scientific if it allows the possibility of being proven false.

I’ve just read a fascinating new book on the microbiome (microbiological contents) of the gut and its influence on our health (Missing Microbes, by Dr. Martin Blaser). Admittedly it’s a topic that is all the rage nowadays, but its previous neglect seems, in retrospect, to defy belief. Of course, since the Germ Theory was proposed in the mid sixteenth century, and since microbes were first observed by Anton Van Leeuwenhoek through his primitive microscope the following century, we have been at odds with them, to say the least. They seemed to be hostile to us. Alien. Their presence caused diseases, suffering, and death. We called them germs. That they could be other than enemies was inconceivable. The only good germ was a dead germ; it was obviously in our best interest to eliminate them. All of them…

And yet if they are so menacing, so evil,  why do our bodies tolerate such a large number of them? Seventy to ninety percent of all the cells in our bodies are not ours -an estimated 100 trillion enemy soldiers hidden in a Trojan horse. And inside our gates… If microbes are bad, why is our large bowel packed with them? Why would we carry around our own sources of disease? How could evolution be so stupid?

It seems blindingly obvious, in retrospect, that they must help us in some fashion. And indeed, the bowel micro-organisms are now being increasingly recognized as extremely useful; so useful in fact that one might be well advised to consider them to be another organ –as important for our health as the liver or the kidneys. It’s becoming clear that they seem to serve as co-directors of many bodily processes – immune functions most importantly perhaps, but also for digestion and production of important nutrients, suppressors of other less-friendly bacterial and viral invaders, and even regulators of energy resources -changes in gut flora may be important in obesity and diabetes, for example. We’re only beginning to understand what role they play in our health, and how altering them can alter us.

But I’m an obstetrician, un accoucheur; I deliver babies; I take care of moms and their foetuses through their pregnancies. I lay no claim to much bacteriological expertise, let alone a privileged view of its cutting edges. But as I mentioned, I was absolutely fascinated by Dr. Blaser’s book -especially the chapters about how we get the first dose of bacteria in our bowels, and how the method of delivery might alter that for good or ill. Obviously at this stage, much of this is speculation -interesting, but as yet largely unproven. But think about it: foetuses in the womb are pretty well bacteria free before they are born. They acquire bacteria only after (or during) birth. On their way down their mother’s vagina they acquire their first micro-organisms: they swallow the lactobacilli which dominate the vaginal bacteria. This helps the baby to break down lactose -the major sugar in its mother’s milk. And given the proximity of the vagina to the anus, the baby also gets its first dose of bowel bacteria -the area is not clean no matter how hard we pretend.

So what happens to the baby’s bowel flora if it never passes through the vagina and is delivered instead by Caesarian Section? Is it different? Is it deficient? And if so, does this have any long lasting effects -either good or bad? I mean, the babies seem to turn out okay…

And what about the customary prophylactic dose of antibiotics that are given preoperatively to prevent maternal infection, or the penicillin (or other antibiotic substitute) that is given to mothers who are intending to have a normal vaginal birth but are positive for Group B Streptococcus (GBS) and in labour? Some of this enters the baby, too; does it alter their bowel bacteria? Is this bad, or do the bacteria recover eventually? Does the interim bacterial alteration, come at a crucial time in the immature but rapidly developing immune system just as the baby is learning to adapt to life and its challenges outside the womb?

The difference is obviously an area that needs more study, but some of the early data are truly intriguing. Researchers have even wondered whether the mode of delivery may alter conditions in the growing child -but later (and so less easily attributable to method of delivery). Things such as asthma, or allergies are exaggerated immune responses -maybe ones not dampened by early modulation by the microbiome. And inflammatory bowel disease, autoimmune dysfunction, and even diabetes may be types of genetic epiphenomena -existing genes turned on or off, dimmed or augmented- altered from an early age and possibly -maybe probably- influenced by the bacteria in the gut …

So, am I recommending we stop doing Caesarian Sections? Stop giving antibiotics? Stop wiping off babies to dry them and help their thermoregulation but also -almost a bonus- to clean them after delivery? Should we abandon all that we’ve accomplished, all that we’ve learned in the last 50 years? No, of course not. But sometimes there are options. Choices. If nothing else, it behooves us to discuss these issues with our patients  -early in their pregnancies, preferably, so that rational conversations, untainted by fear and stress, can provoke dialogue and exploration. There are consequences to every decision. So if an elective Caesarian section is chosen for reasons other than absolute necessity we -patient and doctor- must be apprised of the risks -even the potential, unproven risks of suboptimal microbiomal acquisition…

We are naturally engrossed in the prevailing paradigms -they have served us well and reduced mortality rates; we no longer fear death each time we fall ill. But we have entered an age when an increasing cohort of bacteria are becoming resistant to even the most powerful antibiotics. We need a different appreciation of micro-organisms -a paradigm shift- one that acknowledges that not all of them are malevolent; one that appreciates that they probably do more for us than they do to us. An approach that acknowledges there are far more of them than us and so we should try to use their strength to our advantage. It seems to me that, as members of the current paradigm flock, we’ve almost exhausted the meadow where we’ve successfully grazed for such a long time; we have been so happy with the pasture, so complacently wandering with the herd that we didn’t even notice a gate in the fence to an area where the grass is truly greener and more abundant.

We progress incrementally, but only when our minds are open to new ideas. New perspectives. Truth, it seems, is ever changing, and not always what we want it to be. It can be messy and unbelievable at first -uncomfortable even. But as Einstein once remarked: If you are out to describe the truth, leave elegance to the tailor.