Andrew Scull is Distinguished Professor of Sociology and Science Studies at the University of California, San Diego.  His newest book, Hysteria: The Biography, is a volume in our series Biographies of Disease which we will be looking at for the next few week (read previous posts in this series here).  Each volume in the series tells the story of a disease in its historical and cultural context – the varying attitudes of society to its sufferers, the growing understanding of its causes, and the changing approaches to its treatment. In the excerpt below Scull looks at the spectacle hysteria patients provided, specifically the displays by Jean-Martin Charcot.

It was Jean-Martin Charcot (1825-93), the august Professor of Pathological Anatomy and later of Diseases of the Nervous System of the Paris Medical Faculty, the leading international neurologist of the nineteenth century, who made hysteria a spectacle and a circus.  It was a scandalous circus that attracted the attention of  tout Paris, one that regularly featured scantily clad women disporting themselves in unmistakably erotic cataleptic poses, or writhing and moaning in ways that mimicked orgasms on a public stage, before an understandably rapt audience – an audience soon drawn not just from the highest ranks of French society, but also from those attracted to Paris by news of these extraordinary Leçons du Mardi.  The photographs of these occasions, captured in carefully staged arrangements before the supposedly objective lens of the camera and thus transmuted into indelible visual representations for a vastly greater virtual audience, have survived for later generations to inspect, and have become iconic images of a disorder seen as at once sexual and feminine.

Yet Charcot thought of himself, and was acknowledged by his contemporaries, to be no nineteenth-century Mesmer, no marginal charlatan catering to depraved appetites (among patients and audience alike), but on the contrary a sober scientists, a man of genius, one of the leading contributors to the newly emerging science of the brain.  His accomplishments first in internal medicine and then as a neurologist were legion, and had brought him czars and princes, great merchants and bankers, as his clients, in the process making him a very rich man.  And, while his most famous patients were women, he personally insisted…that hysteria was not solely a female malady, but, on the contrary, could be diagnosed and detected among the male of the species.  Hysteria was, he confidently declared, a disorder of the nervous system, not of the female reproductive organs.  It was, moreover, as real and as somatic a disease as any of the other neurological catastrophes he had earlier elucidated….

…Charcot had his favorites, those who returned time and again to put on multiple, often increasingly elaborate, performances.  None was more famous than Blanche Wittman, the queen of hysterics, a performer who luxuriated in her role.  Perhaps the most famous single image of a hysterical patient is an 1887 painting by André Brouillet that captures Charcot presenting Blanche, his pet hysteric, to members of his neurological service.  She swoons over the outstretched arm of his assistant, Joseph Babinski, her pelvis thrust forward, her breasts barely covered by her blouse and pointing suggestively toward the professor, her head twisted to the side and her face contorted in what looks like the throes of orgasm.  (Freud kept a copy of this painting, which dates from 1887, in his study in Vienna, and again in London.)

Wittman was admitted to the Salpêtrière in 1878, and remained there for some sixteen years, performing on command.  After her discharge, she became Marie Curie’s laboratory assistant, and eventually was poisoned by the radium she was working with. In consequence, both legs and her left arm had to be amputated…

The Iconographies, the collections of photographs of the performers who made up the circus, circulated widely and disseminated the Charcotian vision of hysteria to an audience who could only virtually witness the Parisian scene.  They did much to fix the image of hysteria in the public mind, and perhaps to spread suggestively what purported to be neutral, naturalistic recording of a neuropathic disorder.  The photograph (at least before the age of digital manipulation) carried the illusion of providing the truth, a direct and unmediated portrait or even a mirror of nature, the instantaneous representation of what passed before the lens of the camera.  But the limitations of lighting, and the technical requirements of picture-taking with wet collodion plates, or even the later silver gelatino-bromide coating, made for long exposures, sometimes as long as twenty minutes per plate.  Perhaps appropriately, given that Charcot’s posthumous critics…viewed his clinical demonstrations as fraudulent, the “objective” photographs that recorded the pathologies were themselves necessarily staged, posed, and manufactured constructions whose status as “facts” is as slippery as the live demonstrations they purport to record.

Charcot was not alone in exploiting his patients, in treating them as so many specimens rather than as suffering human beings.  The disdain and the callousness were a feature of the whole clinico-pathological tradition, something that American medical students visiting Paris for instruction viewed with dismay as early as the 1830s.  As feminist historians focused their attentions on hysteria as a female complaint, and perhaps the product, as some them speculated, of an inchoate, inarticulate protest against the roles in which Victorian women were imprisoned, Charcot’s serial exploitations of these poor creatures, his willingness to expose them repeatedly to the prurient gaze of his audience at whatever cost to their emotional well-being drew fierce criticism and reproof.  But those same moral failings were visible to Charcot’s contemporaries, and were the subject of bitter commentary, even from the literary figures such as Tolstoy and de Maupassant.  A Madame Renooz, in the pages of the Revue scientifique des femmes, protested about his “sort of vivisection of women under the pretext of studying a disease for which he knows neither the cause nor the treatment.”…

…And yet Charcot, as the feminist historian Elaine Showalter acknowledges, cannot be easily typecast as a crude misogynist, for he adopted liberal positions by the standards of his time on women’s rights, and his students and externs included women training for the medical profession.  Moreover, one of Charcot’s more striking departures from the conventional wisdom of his time had been his insistence that hysteria was not just a female disease…

Elvin Lim is Assistant Professor of Government at Wesleyan University and author of The Anti-intellectual Presidency, which draws on interviews with more than 40 presidential speechwriters to investigate this relentless qualitative decline, over the course of 200 years, in our presidents’ ability to communicate with the public. He also blogs at www.elvinlim.com. In the article below he looks at the health-care reform bill that the House passed. See his previous OUPblogs here.

Democrats must be thinking: what happened to the halcyon days of 2008? It is almost difficult to believe that after the string of Democratic electoral victories in 2006 and 2008, the vast momentum for progressive “change” has fizzled out to a mere five vote margin over one of the most major campaign issues of 2008, a health-care bill passed in the House this weekend. If you raise hopes, you get votes; but if you dash hopes you lose votes. That’s the karma of elections, and we saw it move last Tuesday.

Democratic Party leaders scrambled, in response, to keep the momentum of “Yes, we can” going, by passing a health-care reform bill in the House this weekend. But despite claims of victory, Democratic party leaders probably wished that their first victory on the health-care reform road came from the Senate and not from the House. President Obama and Speaker Nancy Pelosi have always hoped to let the Senate pass its health-care reform bill first, initiating a bandwagon effect so that passage in the House would follow quickly and more easily, and a final bill could be delivered to the president’s desk.

Instead, the order of bill passage has been reversed, making a final bill less likely than if things had gone according to plan. If even the House, which is not subject to supermajority decision-making rules, barely squeaked by with a 220-215 vote, then it has now set the upper limit of what health-care reform will ultimately look like. Potentially dissenting Democratic Senators see this, and there might now be a reverse band-wagoning effect. Already, we are hearing talk from the Senate about the timeline for a final bill possibly being pushed past Christmas into 2010. This is just what Nancy Pelosi and Barack Obama were hoping against, by pushing the Senate to pass a bill first. Unfortunately for them, the Senate took so long that to keep the momentum going (and amidst the electoral losses in NJ and VA last week), they felt compelled to pass something in the House to signal a token show of progress.

But the danger is that the move to regain control may initiate a further loss of control. The less than plenary “victory” in the House bill has only made it clearer than ever that if a final bill is to find its way to the President’s desk, it will have to be relieved of its more ambitiously liberal bells and whistles. Even though the House Bill, estimated at a trillion dollars, is more expensive than the Senate version being considered, and it has added controversial tax provisions for wealthier Americans earning more than $500,000, what the House passed was already a compromise to Blue Dogs. On Friday night, a block of Democratic members of Congress threatened to withhold their support unless House leaders agreed to take up an amendment preventing anyone who gets a government tax credit to buy insurance from enrolling in a plan that covers abortion. If even the House had to cave in some, there will have to be many more compromises to be made in the Senate, especially on the “public option.”

Sequencing matters in drama as it does in politics. It is at the heart of the Obama narrative, the soul and animating force behind the (now unraveling) Democratic majority in 2009. “Yes, we can” generates and benefits from a self-reinforcing bandwagon effect that begins with a whisper of audacious hope. From the State House of Illinois to the US Senate, from Iowa to Virginia – the story of Barack Obama is a narrative of crescendo. “They said this day would never come” is a story of improbable beginnings and spectacular conclusions. The structural underpinnings of the Obama narrative are now straining under the pressure of events. To regain control of events, the President must first regain control of his story.

Mark Jackson is Professor of the History of Medicine and Director of the Centre for Medical History at the University of Exeter. His newest work, Asthma: The Biography, is a volume in our series Biographies of Disease which we will be looking at for the next few week (read previous posts in this series here).  Each volume in the series tells the story of a disease in its historical and cultural context – the varying attitudes of society to its sufferers, the growing understanding of its causes, and the changing approaches to its treatment. In the excerpt below Jackson relays the story of Carlill v. Carbolic Smoke Ball Company.

On 7 December 1889, an American inventor, Frederick Augustus Roe, obtained a patent for a device that was designed both to cure and to prevent not only the deadly strain of influenza that was sweeping across Europe from Russia, but also a wide range of other respiratory complaints, including catarrh, bronchitis, coughs and colds, croup, whooping cough, hay fever and asthma. Sold from offices in Hanover Square in London for ten shillings, the Carbolic Smoke Ball comprised a hollow ball of India rubber containing carbolic acid powder. When the ball was compressed, a cloud of particles was forced through a fine muslin or silk diaphragm to be inhaled by the consumer. Boosted by testimonials from satisfied customers and endorsements from prominent doctors, Roe was sufficiently confident that the contraption would prevent influenza that, in several advertisements placed in the Illustrated London News and the Paul Mall Gazette during the winter of 1891, he offered to pay £100 to any person who contracted influenza ‘after having used the ball 3 times daily for two weeks according to the printed descriptions supplied with each ball’. As if to demonstrate the sincerity of his offer, Roe claimed to have deposited £1,000 with the Alliance Bank in Regent Street.

In November 1891, Louisa Elizabeth Carlill, the wife of a lawyer, purchased a Carbolic Smoke Ball in London and carefully followed the instructions for use. When Mrs Carlill contracted influenza the following January, her husband wrote to Roe claiming the ‘reward’ offered in the advertisements. Suggesting that the claim was fraudulent, Roe refused to pay and provided Mr Carlill with the names of his solicitors. In the resulting legal case, initially heard in the court of Queen’s Bench and subsequently reviewed by Appeal Court, the dispute did not revolve primarily around whether the plaintiff had used the device correctly or indeed whether or not she had contacted influenza; these issues were accepted largely as fact. Rather, legal arguments focused on whether the advertisement constituted a valid offer, rather than ‘a mere puff’, as Lord Justice Bowen neatly put it, and whether Mrs Carlill’s use of the smoke ball constituted acceptance of that offer. By deciding unanimously in Mrs Carlill’s favour, the English courts set a precedent regarding unilateral contracts that continued to inform the legal doctrines of offer and acceptance, consideration, misrepresentation, and wagering throughout the twentieth century.

While Carlill v. Carbolic Smoke Ball Company became a celebrated moment in legal history, it also reveals several dimensions of contemporary approaches to respiratory diseases, including asthma. In the first instance, it demonstrated the growing popularity of inhalation as a treatment. Ancient Greek, Egyptian, and Indian doctors had certainly recommended burning and inhaling smoke from a variety of plants to relieve asthma and catarrh, but this therapeutic approach blossomed from the mid-eighteenth century with the invention of several patent inhalers, such as those introduced in the 1760s and 1770s by the English physicians Philip Stern and John Mudge (1721-93). These devices allowed effective delivery of hot vapours from menthol, camphor, eucalyptus, and balsam directly to the lungs. Indeed, according to the author of a short tract entitled Instant Relief to the Asthmatic, published in 1774, the inhalation of medications for asthma was greatly superior to ‘inward applications’, which resulted in the drugs being ‘separated and subtilized by the body’ before reaching the lungs. In this instance, inhalation of vaporized acid salts, or ‘aetherial essence’, supposedly operated by loosening phlegm, increasing expectoration, and easing respiration.

Robert Tattersall is an internationally recognized authority on diabetes.  He received specialist training at King’s College Hospital, London and the University of Michigan in Ann Arbor.  He moved to Nottingham in 1975 where he became Professor of Clinical Diabetes.  His most recent book, Diabetes: The Biography, is part of the series Biographies of Disease which we will be looking at in the upcoming weeks.  Each volume in the series tells the story of a disease in its historical and cultural context – the varying attitudes of society to its sufferers, the growing understanding of its causes, and the changing approaches to its treatment.  In the excerpt below we learn about the discovery of insulin- a moment that changed the lives of diabetics forever.

After war service in Europe, Frederick Grant Banting (1891-1941) failed to get a surgical job at the prestigious Toronto Hospital for Sick Children and so set up as a doctor in London, Ontario. This was not a success, and to make ends meet he got a part-time job at the University of Toronto. In October 1920 he had to lecture the students on carbohydrate metabolism, about which he knew little. While preparing, he read an article about a man in whom a stone had blocked the pancreatic duct leading to atrophy of the digestive-enzyme-producing part of the gland but leaving the islets intact. This was hardly new, since it had been known for thirty years that this was what happened when the duct was tied in animals, but in his notebook Banting wrote:

Diabetus [sic]
Ligate pancreatic ducts of dog. Keeping dogs alive until ancini degenerate leaving Isletes.
Try to isolate the internal secretion of these to relieve glycosurea [sic]

Against the background of the fruitless attempts described in the previous chapter, it is not surprising that Macleod did not take Banting seriously. Macleod wrote: ‘I found that Dr Banting had only a superficial textbook knowledge of the work that had been done and no familiarity with the methods by which such a problem could be investigated in the laboratory.’ Quite apart from Banting’s ignorance, Macleod had lost interest in diabetes and was researching acid-base balance. Banting later said that during the first interview Macleod was so disinterested that he started reading letters on his desk. Nevertheless, he offered Banting a disused lab and two students, Charles Best (1899-1978) and Clark Noble (1900-78), who were to do alternate months. They tossed a coin to decide who should to the first month. Best ‘won’, but was so involved at the end of the first month that Noble agreed that he should continue.

Banting need an assistant, because he did not know how to measure blood sugar, and Macleod had wisely insisted on this as the end point of their experiments. During his research on the blood sugar of the turtle, Best had learned the new Lewis-Benedict method, which needed as little as 0.2 ml blood, whereas other methods needed 25 ml. Another stumbling block was that Banting had never done a pancreatectomy, an operation that at the time was used only in animal research. Macleod assisted at the first operation, but Banting and Best then worked alone, writing from time to time to Macleod, who replied with advice. In August 1921they depancreatized two dogs and treated one with pancreatic extract leaving the other as a control. The untreated dog died in four days which the treated one remained well. Macleod was encouraged by their results but felt that the falls in blood sugar might be due to dilution or even normal fluctuations. He suggested further experiments, to which Banting objected violently and accused Macleod of trying to steal their thunder. Nevertheless, the experiments were done. When Macleod returned in October, he had a stormy interview with Banting, who threatened to go elsewhere if better facilities were not provided. At a departmental meeting on 14 November 1921 Banting and Best gave a preliminary presentation of their work. One important suggestion at this meeting was that the best of showing that the extract worked would be if regular injections could prolong the life of diabetic dogs.

This was a logistic problem, because the duct-ligation method needed many dogs and a wait of seven weeks while the exocrine tissue degenerated. Banting’s solution was to use foetal calf pancreas, which Best got from the local abattoir. The rationale, as Sobolev had suggested twenty years before, was that it contained a high proportion of islets in relation to exocrine tissue. An important breakthrough came in December, when Banting decided to use alcohol in making extract (an idea Macleod had suggested some months before). It worked well and led them to wonder whether they could get a similar result with the more easily available adult beef pancreas. That they did must have been a surprise, because the original rationale for duct ligation was that the internal secretion would be destroyed by pancreatic enzymes. In fact, although Macleod and others believed this, it had been known since 1875 that fresh pancreas did not break down proteins. The intact gland contains an inactive precursor trypsinogen, which is converted into the protein-dissolving enzyme trypsin only by contact with duodenal juice. Around this time Banting and Best were joined by a biochemist, Bert Collip (1892-1965)-more accurately, he was foisted on them by Macleod, who regarded him as a proper scientist. Collip had come on a Rockefeller fellowship and was studying the effect of pH on blood sugar. Later he was asked to help with the purification of insulin and made rapid progress, although afterwards he downplayed his role, suggesting that any biochemist could have done the same.

Some time in December 1921 Collip began making extracts from whole pancreas and, at Macleods suggestion, tested them on rabbits. The extracts reduced the rabbit’s blood sugar, and how far it fell was a useful and cheap way of telling how potent the extract was.

The first use of insulin (an extract made by Charles Best) on a human being was on 11 January 1922. The pancreatic extracts were relatively impure, and the house physician at Toronto General Hospital described what he injected into the buttocks of 14-year-old Leonard Thompson as ‘15 cc of thick brown muck’. Thompson has been on the Allen diet since 1919 and weighed only 65 lb (29.5 kg). After the injection, his blood sugar fell from 440 to 320 mg/dl (24.4 to 18.3 mmol/l), but no clinical benefit was seen. The experiment was resumed on 23 January, when he was given Collip’s extract, and now his blood sugar fell during one day from 520 mg/dl (29 mmol/l) to 120 mg/dl (6.7 mmol/l). He continued treatment for ten days with marked clinical improvement and complete elimination of glucose and ketones from his urine. Subsequently he lived a relatively normal life, although reliant on insulin injections, before dying of pneumonia in 1935.

The first clinical results were published in the March 1922 Canadian Medical Association Journal, where the authors reported that they had treated seven cases…

Rosemarie Garland-Thomson is Professor in the Department of Women’s Studies at Emory University.  She was recently named one of 2009’s “50 Visionaries Who Are Changing Your World” by UTNE Reader. Her most recent book, Staring: How We Look captures the stimulating combination of symbolic, material and emotional factors that make staring so irresistible while endeavoring to shift the usual response to staring, shame, into an engaged self-consideration.  In the original post below she looks at end-of-life issues and the health care debate.

Democracy thrives on polarized debates, theatrical performances that try to convince citizens about how to spend their dollars and place their votes. Statements get especially extravagant when we are discussing important policy issues that affect such sensitive personal issues as how we take care of each other when we are sick, vulnerable, hurt, or dying. Our recent debate about health care has flared especially intensely about end-of-life and life ending issues. That the inevitable outcome of life is death is a hard pill for us all to swallow. Health maintenance is a more comfortable and cheerful topic for us ever optimistic Americans than the uncompromising truth of our impending mortality.

One of the more vivid concepts to emerge from the health care debate is the provocative concept of pulling the plug on granny. The image of our granny shorn from life-sustaining sustenance, care, and support cuts both ways, calling up tender sympathy in some and tough pragmatism in others. A forlorn granny is code for the larger issue of how to make difficult decisions about not just distributing resources but who we think deserves those resources. In other words, the figure of granny lets us consider who we think of as deserving and valued fellow citizens, of who we want to be in our human community.

One way we frame this is through a cost-benefit analysis about what we imagine to be high or low quality of life. One reason we might pull the plug on granny is that the quality of her life seems low to those of us who are not old sick, or disabled. Moreover, we understand Granny to be using up more resources than she is contributing to society. People on both sides of the healthcare debate have brought forward the most extravagant example from history of where evaluating the quality of other people’s lives can lead. Between 1939 and 1942, the Nazi regime undertook an official euthanasia program. More recently questions of life quality and resource distribution sprang forward with the revelation that a number of grannies and other significantly disabled people at a hospital in New Orleans might have been euthanized during the Katrina disaster. These troubling occurrences, one then and the other now, remind us of the continuing communal struggle to decide what the Democratic premise of equality among citizens might actually mean.

The contemporary British version of our American granny is the physicist Stephen Hawking, whose imagined low quality of life based on his significant disability starkly contrasts with the value of his contribution as a brilliant scientist. Hawking is an exception, of course, to the usual way we consider the grannies of the world. Those who offered up Hawking has an example of a person whose plug might be pulled by a reformed healthcare system were surprised when Hawking claimed that the British healthcare system have provided him with the plugs he needed for a quality life through which he made his important contributions.

The late Harriet McBryde Johnson, who was a civil rights attorney and advocate for disability rights, made public a discussion about plug pulling with the Princeton ethicist Peter Singer, who has advocated euthanizing disabled newborns as a form of moral pragmatism when parents get a child they would prefer not to have. Johnson, who like Hawking lives with significant disabilities, put herself forward in the pages of the New York Times Magazine in 2003 to present the public with the story of how someone we imagine us having a very low quality of life in fact has a very high quality of life. In doing so, she offered us an opportunity to think through how we distribute resources and what a valuable life might be.

People like Stephen Hawking and Harriet McBryde Johnson–as well as our frail grannies, Katrina victims, and disabled German citizens under fascism– remind us that the conversation about who should and should not be in the world– to use Hannah Arendt’s phrase– is an urgent and confusing one today.

Today’s healthcare debate and it’s polarizing icons points to a less dramatic and often unnoticed contradiction between two opposing currents in American culture today. On the one hand is the endeavor to integrate people with disabilities into the public world by creating an accessible, barrier free material environment. On the other hand, is the medical mission to eliminate people with disabilities from the human community. What we might call the “integration initiative” arises from a rights-based understanding of disability and occurs through legislative and policy mandates such as the Americans with Disabilities Act of 1990 and 2009. In contrast, the “elimination initiative” arises from the idea that social improvement requires elimination of devalued human qualities and cons of people in the interest of reducing human suffering and increasing life quality and building a more desirable citizenry.

This contradiction in beliefs has filled the contemporary American public landscape with both fewer and more people with disabilities. For instance, wheelchair users now enter public spaces, transportation, employment, and commercial culture on a scale impossible before the legal mandates of the 1970s began to change the built environment. At the same time, medical technologies increasingly identify and eliminate through selective reproductive procedures potential wheelchair users born with traits such as spina bifida, which often requires wheelchair use for effective mobility. In another example, people with developmental and cognitive disabilities are now educated in integrated, mainstream educational settings which accommodate their educational needs rather than in segregated institutions. Simultaneously, medical technology routinely selects fetuses with Down syndrome or trisomy 21 in pregnancies to evaluate for termination.

The point is that not just what we do with granny’s plugs but how we imagine granny’s life reaches out beyond the nursing home room and into our shared world, affecting who we are and want to be as a human community.

Joanna, Intern

In The Thought that Counts: A Firsthand Account of One Teenager’s Experience with Obsessive-Compulsive Disorder, Jared Douglas Kant tells the story of how he was diagnosed with OCD at the age of 11 and dealt with the disease as an adolescent. Kant is a Clinical Research Assistant at the Massachusetts General Hospital Obsessive-Compulsive Disorder Clinic and Research Unit. Written alongside psychologist Martin Franklin Ph.D., Associate Professor of Clinical Psychology in Psychiatry, Department of Psychiatry, University of Pennsylvania School of Medicine, & Clinical Director, Center for the Treatment and Study of Anxiety, and science writer Linda Wasmer Andrews, a freelance health and psychology writer, The Thought that Counts serves as a guide for teenagers struggling with OCD and is part of the Adolescent Mental Health Initiative series created through a partnership with The Annenberg Foundation Trust at Sunnylands. In the following excerpt, Kant describes his new understanding of obsession in light of his struggles with OCD.

When I was younger, the word “obsession” made me think of infatuation. If a boy fell head over heels for a girl, spending an extraordinary amount of time and energy daydreaming about her and hanging on her every word, people would say, “He’s obsessed with that girl.” Naturally, it didn’t occur to me to use the same word to describe the peculiar thoughts I was having. But as I later realized, there’s a big difference between the everyday meaning of obsession and the scientific definition.

In scientific terms, an obsession is a recurring thought or mental image that seems intrusive and inappropriate, and that causes anxiety and distress. It’s different from simply being preoccupied with a cute classmate or a favorite hobby, because even after obsessive thoughts start causing serious problems, the person feels powerless to stop thinking them. At some point, the person realizes that the thoughts are controlling him or her instead of the other way around.

Obsessive thoughts aren’t just exaggerated worries about real-life concerns. Instead, they’re overblown fears and anxieties with little basis in reality. Yet once these thoughts push their way into someone’s mind, they refuse to leave no matter how hard the person tries to push them out.

Consider my obsession with images of disease, for instance. Flipping through magazines as a boy, I sometimes came across disturbing images of plague and pestilence, such as flies buzzing over open sores. When I saw such pictures, I carefully avoided touching them. Occasionally, though, I would make a mistake. My finger would drag across the ink on the page until it hit one of the infected people. Whenever this happened, I screamed inside. I ran to the bathroom, slathered myself in soap, and turned the hot water up to boil. I was steaming, and I must have looked like a lobster by the time I emerged from the bathroom.

My reaction to touching the images illustrates another critical point: Obsessive thoughts lead to intense anxiety about something bad or harmful that the person fears will occur. The anxiety is so strong that the person feels compelled to do something – anything – to get relief and ward off the feared consequence. That’s how compulsions, such as my excessive hand-washing, are born. From a scientific standpoint, then, a compulsion is a repeated act, either behavioral or mental, that a person feels driven to perform in response to an obsession, to keep something bad from happening or to reduce the associated distress.

Mark Griep is a chemistry professor at the University of Nebraska-Lincoln who is searching for new antibiotics and who recently received a College Distinguished Teaching Award.  Along with Marjorie Mikasen he wrote ReAction!: Chemistry in the Movies, which focuses on chemistry’s role in the narrative of films.  The focus is on contemporary Hollywood feature films, but also include a sampling of documentaries, shorts, silents and international films.  In the original article below, Griep looks at the new film, The Informant!.

The Informant! was directed by Steven Soderbergh, who directed Julia Roberts’ Oscar-winning performance in Erin Brockovich (2000). In this latest movie, Matt Damon plays a corporate executive turned whistleblower with a twist; he proves to be an unreliable witness. Damon is so effective in this role that he has already received Oscar speculation in the September issue of Entertainment Weekly. Since both movies are based on true stories that involve real chemistry, I was curious to know whether Soderbergh got the real chemistry right again.

In Erin Brockovich, Brockovich (Julia Roberts) is an unemployed young mother of three children, perhaps the ultimate underdog. She hustles herself into a legal case against Pacific Gas & Electric. The company allowed hexavalent chromium to leak into a small town’s water supply and then covered it up. Brockovich makes a case that it caused many diseases in the townsfolk and wins the biggest corporate settlement to date. From the movie, the audience learns that hexavalent chromium is toxic but not much else. In our book, we identify the family of compounds meant by “hexavalent chromium”, the reason they were used by PG&E, and the nature of their toxicity.

In The Informant!, Mark Whitacre (Matt Damon) has a PhD in Biochemistry, meaning he’s not much of an underdog. Instead, he is an enthusiastic booster of his company’s products. The movie opens with him quizzing his son about the contents of orange juice, maple syrup, and plastic bags. The answer every time is “corn”. Then, as narrator, he introduces himself and says: “most people haven’t heard of us [ADM] but everyone has eaten our products. We turn dextrose into the amino acid lysine. We put corn in one end and profit comes out the other.”

What an excellent introduction to corn syrup. To make it, the kernels are ground into a powder, the water-soluble starch (a large molecule composed of many glucose molecules connected together by chemical bonds) is separated from the other material, and the resulting mush is treated with the enzyme amylase to break the long glucose chain into smaller ones. The shortest is maltose with only two glucose molecules connected together by one strong chemical bond. The final step is to treat this mixture with another enzyme called glucoamylase to break some of it to the desired amount of glucose monomer, a sweet-tasting sugar. Corn syrup is a thickener, a sweetener, and a humectant (water-retainer) all rolled into one. This “corn syrup” is also the raw material used to create high-fructose corn syrup and the four molecules mentioned in the movie: lysine (see structure below), citric acid, gluconate, and threonine.

As journalist Kurt Eichenwald explains in his 2000 book titled The Informant, the real Whitacre was hired in the 1989 to lead Archer Daniels Midland’s new lysine production facility. His facility fermented the corn syrup with a soil bacterium called Corynebacterium glutamicum and it excreted lysine as its waste product. As long as the price of starch is low, lysine produced in this way costs much less than by synthetic chemical methods. After Whitacre discovered the company had set up agreements to control worldwide lysine supply in 1992 (they managed to raise the price by 70% over nine months), his wife prompted him to inform the FBI. He then helped them gather evidence for two and a half years. In the end, three company executives were jailed for the scheme and ADM paid the largest antitrust fine for such a crime. Whitacre was also jailed because he embezzled millions of dollars from ADM during the same period. In the movie, Whitacre’s unreliability increases as the movie progresses to give actor Matt Damon a juicy part to play.

When pigs and poultry are fed soybeans, they grow fast because they obtain a sufficient complement of amino acids from the soybean proteins. When they are fed corn, they don’t. Corn proteins are low in the amino acid lysine and many studies have shown lysine is the most important growth-limiting nutrient for these two animals. As Whitacre explains after only 3 minutes of movie time: “When you feed chicken corn plus lysine, it goes to market in six weeks rather than eight.” As an aside, you may recall the dinosaurs in Jurassic Park (1993) were genetically engineered to require lysine in their diets. If they escaped the island, they would die in seven days because they wouldn’t receive their lysine-supplemented food. The demand for lysine as a feedstock supplement has been growing since the 1960s. Until ADM began fermenting corn syrup into lysine in 1989, the world’s lysine supply was produced by two companies in Japan and one in South Korea. The international lysine price-fixing conspiracy involved all four of these companies.

I would say The Informant! has just as much screen chemistry as Erin Brockovich. Both feature engaging characters fighting the forces of unethical companies with plots involving chemicals. The difference is that The Informant! provides a little bit more information about the chemical and why it is important. While it was amusing to see a dial reading “Lysine Levels Abnormal”, it would have been even better if they had shown the chemical structure of lysine. Now that would have given me a real reaction!

William R. Clark is Professor and Chair Emeritus of Immunology at the University of California, Los Angeles.  His new book, Bracing For Armageddon?: The Science and Politics of Bioterrorism in America, provides a reassuring overview of what we really need to worry about – and what we don’t.  In the excerpt below we learn about one early bioterrorism attack in America.

In 1981, the Rajneesh cult, founded by a displaced Indian mystic named Bhagwan Shree Rajneesh, purchased a 60,000-plus-acre ranch in north central Oregon, not far from the city of The Dalles (population 11,000).  The Rajneesh commune soon grew to several thousand souls, who enjoyed various degrees of success in their search for peace and enlightenment, in an atmosphere of easy drugs and sex.  But the Bhagwan clearly flourished.  He accumulated ninety Rolls Royces, five private jets, and a helicopter.

Not content with having built a thriving community on their own land, cult members gained electoral control of the nearby small (population 75) town of Antelope in Wasco County.  They named their new town Rajneesh and quickly converted it to their own needs and ends, to the utter disgust of the mostly retired locals.  Soon, perhaps growing weary of life in such a small town, Rajneeshees began vying for seats on Wasco County boards and commissions.  Reaction at the county level was mixed, but mostly negative.  A few saw potential downstream benefits from the influx of money and reasonably educated people, but most shared the views of their compatriots in Antelope.

In mid-September 1984, a dozen people who worked in or had recently eaten in several restaurants in The Dalles became ill from food poisoning.  One of the restaurants, a Shakey’s Pizza franchise, was co-owned by a member of the Wasco County land-use board, but this raised no particular flags at the time.  The number of victims grew over the following week, and the biological culprit behind it was soon identified by public health officials: Salmonella enterica typhimurium, a bacterium commonly causing food poisoning.  Everyone was treated with appropriate antibiotics, no one died, and the incident seemed to have subsided.

But a week later it was back.  This time ten restaurants were involved.  Local health services, including medical laboratories, were overwhelmed.  The only hospital in The Dalles quickly ran out of beds.  The number of persons who became ill soon exceeded 700, considerably beyond what might be expected in a community of this size for a normal outbreak of salmonella poisoning.  The city called the Centers for Disease Control and Prevention (the CDC) in Atlanta for help.  By the time help arrived, local health officials determined that most or all of the affected people had eaten at salad bars, and restaurants were immediately advised to stop serving salad.  They did.

There followed an exhaustive investigation of all suppliers of salad vegetables and dressings to local restaurants.  Everything came up clean; even the local water.  Preliminary reports from state and federal health investigators stated that the poisonings were most likely caused by accidental incursions of salmonella into the food supply of the restaurants involved.  Even the CDC felt that the food handlers were the most likely source for introduction of the bacteria into the salad bars.  Some locals, in particular another member of the Wasco County land committee, believed the Rajneesh cult was somehow involved, but lacking any hard evidence or direction from health authorities, investigations into this possibility eventually fizzled out.

The involvement of the Rajneeshees became clear only as the result, a year or so later, of internal squabbles within the cult. The Bhagwan himself implicated some of his lieutenants in the affair, and called for a government investigation, after which he beat a hasty retreat to India.  Authorities found abundant evidence at the commune of not only S. enterica typhimurium but a fairly sophisticated medical research laboratory and evidence that the cult had considered employing other deadly pathogens, including HIV – the AIDS virus.  They had purchased salmonella essentially over the counter, from a Seattle scientific supply house.  Among their intended victims, in addition to various county officials, was U.S. Attorney Charles Turner, the top federal prosecutor in Oregon.  He was to be spared infection with salmonella.  Cult members planned to shoot him.  They failed.  But they also intended to use their cultured salmonella to poison the Dalles water supply in the days before an upcoming election.  The grand plan, as it turned out, was to reduce the number of Wasco County citizens able to vote, thereby increasing the influence of Rajneeshees.  For various reasons, this never came about.

Probably no more than a dozen Rajneeshee leaders were fully aware of our involved in the salmonella poisonings.  Seven cult members were ultimately indicted in various murder or attempted conspiracies.  The cases against the conspirators came to a close only in 2005, when the last of these returned from self-imposed exile in Germany and surrendered to authorities.

While the Rajneesh incident gained national and international attention among those who had been predicting bioterrorism in America, it could be argued that what happened in Oregon was not so much a form of bioterrorism as a simple criminal attempt to manipulate a specific civilian population and its various civil agencies through malicious intimidation – a biocrime.  There was no discernible political aim beyond an attempt by a few members to influence a single election and to expand their power and influence within the cult, and perhaps the intimidation or possible elimination of some individuals.  Still, many of the features of bioterrorism were there: preparation and crude weaponization of a human pathogen, delivery of the pathogen to intended victims, and serious social and psychological disruptions in the targeted population.

Professor Alan Whiteside is an AIDS researcher and author. He is Professor of Economics and Director of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal, South Africa, and is a member of the Governing Council of the International AIDS Society. He has written several books on HIV and AIDS, including HIV/AIDS: A Very Short Introduction. In this original post below, Professor Whiteside discusses the recent encouraging results of HIV vaccine trials in Thailand.

The human immunodeficiency virus the cause of AIDS, is fortunately not easily transmitted. When it first appeared in 1981, there were fears of a global epidemic, some thought it would be on the scale of the impending Swine flu (H1N1) outbreak. This has not and will not happened. However those who are infected will eventually develop AIDS and in the absence of treatment will die.

There are an estimated 33 million people living with HIV in the world. The majority are in sub-Saharan Africa and more women than men infected. Most HIV transmission takes place through unprotected sexual intercourse. Some people are infected through drug abuse – sharing contaminated needles. If a woman is HIV positive and pregnant then there is a chance that her child will be born with the virus or infected while breast feeding (vertical transmission).

HIV transmission can be prevented. In injecting drug using populations provision of clean needles will halt the epidemic – as was done in a number of western cities. It is rare for vertical transmission to occur in the rich world, pregnant women will be given drugs and babies formula feed, in the poor world one dose of nevirapine will greatly reduce risk. New interventions are being developed and tried and it is likely that this form of transmission can be further reduced.

Preventing sexual transmission requires behavior change. Clearly not being sexually active will ensure a person remains HIV negative. This is not an option for humankind or most individuals. Having only one partner (who is faithful) will be effective but again, human nature being what it is, this is not a realistic goal despite what many faith-based organizations would have us believe. Condoms are generally effective provided they are used consistently and correctly. Unfortunately this too is not always an option. In some settings they are not available or are discouraged by religious leaders. Women may not be empowered to insist or even ask their partners to use them. And of course there are many who just don’t like them.

I believe that halting the HIV epidemic requires a mix of behaviour change and science. With regard to behaviour the key is developing respect. People should not enter sexual relations without respecting each other. If they do then they will either be faithful or they will want to protect their partner(s) by knowing their HIV status and/or using condoms.

Science has brought us drugs that keep people alive albeit at price. It is too science that we look in the area of prevention, here there are a few possibilities. Male circumcision provides a degree of protection for men. A microbicide, a substance that could be inserted into the vagina prior to intercourse that would kill viruses and bacteria would be female controlled and highly beneficial. A number are being tried. But the first prize would be an effective vaccine.

In 1983 when the virus was first isolated the then US Secretary of Health and Human Services announced confidently that a vaccine was imminent. This proved to be widely optimistic and in my book I said: “Despite rapid scientific advances there are no simple solutions. There will almost certainly not be a vaccine available by 2015 the date the Millennium Development Goals were to be met”. At the time of writing there were just four pharmaceutical companies with vaccines in trials; only one candidate had gone through all trials and it was not effective.

The news over the past week of developments in Thailand is extremely significant. The US Military HIV Research Programme and Thai Ministry of Health announced that a ‘combination of two vaccine candidates’ is at least partially effective in preventing HIV transmission. It was reported that the combination is 31% effective at preventing infection with HIV. Clearly this is not were we need to be but it is a breakthrough. More information will be given on 20th October this year at an AIDS vaccine meeting in Paris.

At this point those of us working in the field of HIV/AIDS are encouraged. It is in the words of the International AIDS Vaccine Initiative’s Chief Executive “a significant scientific achievement. It is the first demonstration that a candidate AIDS vaccine provides benefits in humans”. It will lead to new investment and energy in the development of vaccines.

Although an effective vaccine is still some years off, there is at last good news on this front.

Robert Veatch is Professor of Medical Ethics at the Kennedy Institute of Ethics, Georgetown University. He received the career distinguished achievement award from Georgetown University in 2005 and has received honorary doctorates from Creighton and Union College. His new book, Patient, Heal Thyself: How the “New Medicine” Puts the Patient in Charge, he sheds light on a fundamental change sweeping through the American health care system, a change that puts the patient in charge of treatment to an unprecedented extent. In the original article below, Veatch looks at how the empowerment effected Michael Jackson’s medical decisions and the responsibility of his doctor.

Dr. Conrad Murray is the doctor who apparently administered a fatal dose of the anesthetic, propofol, to Michael Jackson in a desperate attempt to respond to his cries for help in getting some sleep. He has received rough treatment from the media. Jackson’s death has been ruled a homicide and the media are reporting that he will be charged with manslaughter. I think that judgment is too quick and want to come to the doctor’s defense.

The case is, of course, being tried in the press before we have all the details, but the likely scenario is emerging. Making some plausible assumptions, I think a case can be made for the doctor’s decisions. Let me assume, for purposes of discussion, that the doctor did not intend to kill Michael (He was reportedly being paid $150,000 a month to be Michael’s full time physician. Even if he had completely abandoned his duty to serve the patient, he would be a fool to intend the death.) Let me assume that the lethal effects were foreseeable, but not inevitable side effects of a very potent drug. Let me also assume that Michael had been informed by Dr. Murray how dangerous the drug was and how unusual it was to use it for this purpose. Possibly, he had even told Michael that the drug’s labeling did not include the use of propofol outside of a hospital and that almost all physicians would refuse to use it this way.

With these assumptions, a prosecutor will have a difficult time accusing the doctor of a crime. It is not even clear to me that “homicide” is the right term for the death. First, it is important to realize that “off-label” uses of drugs by doctors is not illegal. It is done all the time when a physician becomes convinced that it in the patient’s interest. Second, it is critical to understand that medical choices about what is in a patient’s interest are directly dependent on the patient’s goals and values. They cannot simply be read out of a textbook as if medical science can prove what is in a particular patient’s interest. (Think about whether aggressive chemotherapy is in a terminal cancer patient’s interest or whether an abortion is in the interest of a pregnant woman.) The patient’s interest is necessarily a subjective matter about which only the patient can have direct knowledge.

It seems clear that Michael was in the advanced stages of insomnia and was in excruciating agony from persistent lack of sleep. That is an awful situation about which patients often have to make desperate choices. None of us can know what was in Michael’s head that caused the insomnia or led him to plea for pharmacological intervention. We do know that other drugs had been used even that fateful night (benzodiazepines that are often used to reduce anxiety and induce sleep). These other drugs had failed to solve the problem and made the use of the propofol even more dangerous, something Dr. Murray surely knew and presumably had told Michael.

Now the question for Dr. Murray and for Michael Jackson is, given his desperate situation, is the only drug that will give him some sleep worth the very great risk of side effects, even death? Surely, for most of us the answer would be negative, but that doesn’t mean it was Michael’s answer. Given that he had apparently received the drug many previous times without side effects, I don’t see how we can claim that Michael would be wrong to decide that the risk would be worth it in his case. Deciding whether the drug is “worth it” is a value judgment, not a scientific fact that the doctor can look up in a book. Even if almost everyone else would have decided not to try the desperate off-label use, I don’t know how we can say Michael’s gamble was wrong for him.

But, you might say, even if Michael’s judgment was understandable, surely Dr. Murray was wrong to go along with his patient’s demand. Surely, other physicians would not have agreed. A physician is supposed to be a responsible professional who has the right not to go along with a patient’s very unusual and risky demand. Most physicians would have refused to provide the propofol (at least outside of a hospital) and that is understandable, but this does not prove that Michael’s value judgment about the risk was wrong or that Dr. Murray was wrong to comply. Some medical issues are appropriately judged by what is called a “standard of care.” The correctness of the physician’s behavior is judged by what his colleagues similarly situated would have done. This, however, is not a decision that should be judged by that standard. If it is possible that Michael had made a rationally defensible decision that the risk was worth it for him, then a physician is within his rights to decide to cooperate in a legal behavior if he so chooses. He surely would have had the right not to provide the dangerous drug for off-label use, but he also has the right to decide it is a tolerable risk. If he does so after the patient is adequately informed, I don’t see how we can fault him assuming that the lethal effect was not intended.

This turns out to be crucial for the rest of us if we are to get high-quality, rational medical care. We have for many years recognized that most powerful, valuable drugs have anticipated side effects. If we choose to take the risk and the side effect occurs, we don’t say that the choice was a mistake. If the side effect is death, we don’t say it was a homicide. Provided the intended beneficial effects are good enough, we say that the side effect is tolerable even if it is foreseen. That, in fact, is precisely the justification for doctors’ use of narcotics to control severe pain in cancer patients even though they know that the side effect can be respiratory depression and even death. Most ethical systems have long acknowledged that such “unintended, but foreseen” deaths are tolerable. Normally, such a death is not deemed a “homicide.” Just may be, if we put ourselves in Michael’s shoes and plug in the value judgments he made, we can understand why Dr. Murray, apparently with great reluctance, was willing to go along. I can’t fault him if that was what he did.