P. Charlier

A new definition of health? An open letter of autochthonous peoples and medical anthropologists to the WHO

Currently, for many practitioners (hospital and liberals) and researchers (including public health), the WHO definition of health is outdated: first it seems more utopian than pragmatic; then, it proves unsuitable for a large part of the world population. There is clearly a need to refine this definition or propose additional criteria to be more relevant or discriminating. In this perspective, what can indigenous people offer in the elaboration of a new definition of health? In this article, leaders or representatives of autochthonous peoples, anthropologists and physicians from many cultural origins (Amazonia, Patagonia, Papua New-Guinea, Inuit, North-American Indian, sub-Saharan Africa, India, China, Melanesia and Polynesia) have tried to identify and explain several key concepts that WHO should reintegrate into its new definition of health: human equilibrium in nature, accepted spirituality and adaptation. On the sidelines of the application of COP21 decisions that should give back to man his place into the environment, autochthonous people leaders, anthropologists and MDs explain why these three concepts are fundamental and universal health determinants, and need to be included in a new WHO definition of health.

The “Ulysses syndrome”: An eponym identifies a psychosomatic disorder in modern migrants

Due to civil wars, violence and persecutions, between 2015 and 2016, more than 1.4 million people, from the Middle East and Africa, fled their counties and migrated to Europe. The vast majority of migrants, who have already experienced enormous level of stressors, are faced with dangerous, often lethal, migratory journeys. Those who survive are exposed to adaptation stressors such as different languages, isolation, lack of work opportunities, diminished social status and a sense of failure in the new countries of residence. These are stressors that go far beyond the usual adaptation stresses to new cultures and migrants experience permanent crises with an imminent risk of developing the Ulysses syndrome. As a consequence, many individuals often develop symptoms such as irritability, nervousness, migraine, tension headache, insomnia, tiredness, fear, loss of appetite and generalized ill-defined discomfort. If left untreated these symptoms, originally described by Hofer in the 17th century, may degenerate into a severe psychosomatic disorder leading to reactive depression. Here we expand the concept of Ulysses syndrome and illustrate new initiatives aimed at reducing the level of stressors in migrants and at promoting their successful integration in their new countries.

What do cranial bones of LB1 tell us about Homo floresiensis

Cranial vault thickness (CVT) of Liang Bua 1, the specimen that is proposed to be the holotype of Homo floresiensis, has not yet been described in detail and compared with samples of fossil hominins, anatomically modern humans or microcephalic skulls. In addition, a complete description from a forensic and pathological point of view has not yet been carried out. It is important to evaluate scientifically if features related to CVT bring new information concerning the possible pathological status of LB1, and if it helps to recognize affinities with any hominin species and particularly if the specimen could belong to the species Homo sapiens. Medical examination of the skull based on a micro-CT examination clearly brings to light the presence of a sincipital T (a non-metrical variant of normal anatomy), a scar from an old frontal trauma without any evident functional consequence, and a severe bilateral hyperostosis frontalis interna that may have modified the anterior morphology of the endocranium of LB1. We also show that LB1 displays characteristics, related to the distribution of bone thickness and arrangements of cranial structures, that are plesiomorphic traits for hominins, at least for Homo erectus s.l. relative to Homo neanderthalensis and H.xa0sapiens. All the microcephalic skulls analyzed here share the derived condition of anatomically modern H.xa0sapiens. Cranial vault thickness does not help to clarify the definition of the species H.xa0floresiensis but it also does not support an attribution of LB1 to H.xa0sapiens. We conclude that there is no support for the attribution of LB1 to H.xa0sapiens as there is no evidence of systemic pathology and because it does not have any of the apomorphic traits of our species.

A 1842 skull from Dupuytren’s museum of Paris: an original artifact of Joseph Gensoul first maxillectomy technique

Joseph Gensoul was a pioneer of ENT surgery. In 1827, he performed the first total maxillectomy on 17-year-old boy. His work inspired many surgeons, who were previously unwilling to remove maxillary tumours. A paleopathological study performed in the Dupuytren museum allowed us to identify a skull from the early 19th century, with a large maxillar tumour. There were indications that this skull was operated according to Gensoul’s technique. The aim of this study is to confirm that this patient had, in fact, received this surgical treatment. This is a historical and descriptive paleopathological study of a skull of the early 19th century of Dupuytren Museum in Paris. The historical research was conducted in collaboration with the French Academy of Medicine and the Museum of Medicine History (Paris). Bones mark cut studies allowed us to confirm that the patient was operated according to the method described by Gensoul in his “Surgical letter” in 1833. Our historical research has allowed us to understand the perspectives of surgeons in the 19th century and the intellectual processes that led to this discovery. At a time when the robotization and industrialization dominate our art, it is interesting to look to our past, our origins, and our history. The study of ancient humans remains and allows us to understand the origin of our specialty and pay tribute to these pioneering surgeons. Their intellectual approach and boldness should be acknowledged and applauded, especially as it is also the key to our success.

What new life for the Parisian (and European) anatomical and pathological collections? Struggle for medical education.

Why do French medical schools seem to have abandoned medical museums? France can boast of great contributions to the development of medical and surgical practice during recent centuries (Hollande, 2016). Consequently, Paris has a very rich medical history and conserves priceless collections of pathological specimens. Nevertheless, two major institutions have closed within the past few years. Several others have been subjected to restructuring, transfers, or closure (temporary or permanent? This is not yet known). They include the Delmas-Orfila-Rouvière Museum, the Museum of Public Health and the Hospitals of Paris, and, most recently (April 2016), the Dupuytren-Dejerine Museum. The lastnamed, founded in 1835, conserved almost 6,000 anatomical preparations, skeletons, and pathological waxes, including some exceptional cases such as the brain of Tan, the patient who led Broca to make the first-ever diagnosis of aphasia (Berker et al., 1986). These institutions have not closed because of lack of interest on the part of the curators (universities and health authorities) or of the general public, but for legal reasons: the way in which the material was presented had become incompatible with current safety standards so they could not remain open to the public. Why should we care about the history of medical practice? The presentation of anatomical and pathological collections such as those in the DupuytrenMuseum is interesting formany practical reasons: heritage (priceless collections that need to be preserved and bequeathed to future generations), scientific (useful for biomedical research and the study of how diseases have evolved), educational (access to education and training for health professionals), extension (awareness of general public health challenges, promoting public debate about matters related to the status of the body and medical practice in the context of health democracy), and ethics (reflections on the status and the feelings of patients and caregivers). There is no “science of death,” but there is a scientific discipline that enables the dead to speak and teach to the living (mortui dicent viventes): forensics, which deals with traumatized life and with standards relating to justice and civil society as well as with death. Forensics experts and pathologists now practice far fewer autopsies, but their duty is to be interested in dead bodies whatever their condition; and they have been excluded from research for too long. But how can “dead museums” be revived? Anatomy museums can no longer be regarded as mere collections and accumulations of specimens but as places for research, adumbrating real life situations. That is to say, museums must become dynamic and must transcend simple academic presentation. New models for anatomical and pathological museums are possible and must be implemented. They must be dedicated not to the pursuit of rigid academic presentation, as in the 19th or even the 20th century, but to a modern vision of service to the scientific community. Research laboratories must be at the heart of scientific endeavor: interdisciplinary studies of the collections should be funded so the research programs encompass almost every field of fundamental research and clinical medicine. Some older institutions have managed this shift in the status of museums and academic establishments, ensuring their sustainability for several generations despite financial cuts. They have foregone the mere accumulation of curiosities, which has sometimes been unhealthy, and have become useful again; that is to say, totally integrated into national and international scientific life. For example, London, our neighbor, exemplified this opening of anatomical collections to scholars and to the general public with the Wellcome Institute, the Hunterian Museum (Royal College of Surgeons) (Williams and Farrell, 2013), the Gordon Museum of Pathology (King’s College); and at greater distances, there are (for instance) the M€ utter Museum (Philadelphia, USA) and the Federal Pathologic-Anatomical Museum (Vienna, Austria), where both the attendance and the vitality are exceptional. These institutions have celebrated the interest that the dead can hold for the living: education, transmission of medical and surgical knowledge, time capsules of infectious agents so the genetic evolution of microbes can be studied (thus predicting trends for future generations), etc. (Benmoussa et al., 2015, in press). Such successes must become our models for institutional and scientific development, so that the specificity of French nosology and medical practice will not be lost.

Schistosomiasis in the mummified viscera of Saint-Louis (1270 AD).

Louis IX, King of France from 1226 to 1270 AD, died at the age of 56 during an epidemic episode of ‘‘plague’’ in the city of Tunis, Northern Africa. In order to transport his body back to the basilica of Saint-Denis (necropolis of the French Kings), it was eviscerated and boiled in wine and spices. Although his bones were entombed in the basilica of Saint-Denis, the embalmed viscera were deposed in the abbey of Monreale (close to Palermo, Sicily) which was then ruled by the young brother of the defunct, Charles of Anjou [1]. A sample of these viscera was given for the consecration of the cathedral of Tunis in 1894, and transferred to the cathedral of Versailles in 1985, as the king was officially canonized in 1297 and recognized as ‘‘SaintLouis.’’ On the occasion of a scientific identification of the relics for the 800th anniversary of the birth of Saint-Louis, we recently sampled 2 g of these viscera (Fig. 1) for a full medical and forensic anthropological analysis, including a SEM examination (Zeiss Supra 55 vp with an energydispersive X-ray spectrometer Bruker SDD detector). Microscopic analyses revealed several parasitic formations (Fig. 2) whose morphology (semicircular adult worms with a gynecophoral canal) and size (maximal length of 28 mm) clearly allow them to be identified as adult male Schistosoma [2]. These results show that the French King was infected by schistosomiasis. This parasitic disease, also known as snail fever, is now widespread in Africa [3], but has also been described on archeological material such as a ninth century AD individual from France [4]. According to the historical context, it seems very probable that Louis IX contracted this disease during the 8th Crusade, when he was imprisoned by the Egyptians in Damietta (delta of the Nile) in 1250, and/or during the following 4 years when he was present in the Near East (mainly in Accra, Cesarea, and Jaffa). An infestation around the time of his death (9th Crusade) appears very unlikely, as the King, who landed on Northern Africa on the 17th of July, died only 4 weeks later on the 25th of August 1270 [1], and the time needed for a Schistosoma to reach maturity is at least 7 weeks after trans-cutaneous infestation. The exact species should therefore be Schistosoma haematobium, the only species originating in the Mediterranean basin, Africa, and Near East. No other parasites have been identified on the viscera yet, including those of alimentary origin (roundworm, whipworm, fish tapeworm, or liver fluke) [5], but secondary optical and immunological analyses are being undertaken in order to complete the pathological record of the patient. Reasonably, Schistosoma did not play a direct role in the mechanism of death for Saint-Louis, whose exact cause of death remains unknown. From the point of view of forensic anthropology this historical case highlights the fact that SEM examination of altered remains may constitute a key element in the reconstitution of a pathological background. & Philippe Charlier philippe.charlier@uvsq.fr

Anonymous biomedical publications for security reason? An open letter to the ICJME

Can we publish anonymously in a biomedical journal for security reasons? We have recently been alerted by an international scientist who wanted to denounce the lack of informed consent and freedomof choice regarding blood donation in a Middle East country, but was prevented to publish his article by fear of physical and professional retaliation. The anonymization of scientific articles could be a solution, but is it technically and morally possible? Of course, some publications are signed by multi-author groups (a kind of global anonymization) for which a corresponding author should always be clearly identified [1]. Authorship is slightly different with editorials from major scientific journals: no specific name, but a specific team of employees and some regular authors whose identification is easy on the journals website. A direct interaction should be established between the readers and author(s) after the publication in the form of criticism, opinions, and confrontation of data sources and results. ICJME rules stipulate that the author must be clearly identifiable and reachable: [2] but only by the editorial team (the only ones aware of the true identity of the author). The key is to ensure the traceability of data and statements (including conflict of interest), the guarantor of scientific integrity. Are we not deprived of basic biomedical and unpublished data (including health policy) because of the risk of publication in hot geopolitical contexts (Syria, USA, Russia, North Korea, China, etc.)? Can there be anonymous whistleblowers in the field of biomedical sciences at the service of the fight against bio-terrorism, political and religious abuses, and disrespect for human rights [3]? Wewould like to know theposition of the ICJMEabout it, and anyproposals for action and improvement at the service of themost objective information possible, within the limits of respect for public safety [4].

'There will be blood'. Differences in the pictorial representation of the arterial spurt of blood in Caravaggio and followers.

The theme of the beheading of Holofernes by Judith is one of the most frequently painted biblical scenes [1]. Famous painters such as Mantegna (1431–1506), Michelangelo (1475–1564), Botticelli (1445–1510) and Klimt (1862–1918) depicted the same scene. Nevertheless, only few artists, namely, Caravaggio (1571–1610), Artemisia Gentileschi (1593–1693), Louis Finson (1580–1617) and an unknown artist, whose canvas was recently discovered in Toulouse, painted the actual action of beheading.

Ethical limits to biomedical publications

Out of the political implications of the recent editorial signed by editors (not scholars!) in the Lancet about the Israelo-Palestinian conflict, one may ask if some ethical limits exist to biomedical publication [1]. In other words, should some basic or fundamental research, or case reports, not be published for security and/or political reasons? In a recent French book (not yet translated into English), professor Patrick Berche (head of the Pasteur Institute, Lille, France) stated that any viral and/or bacteriological data related to dangerous species should not be published, especially in open access sources, in order to prevent misuse by bio-terrorists [2]. To present an example of political (and/or ethical?) limit of biomedical publication, one of us (P.C.) was prevented from publishing an extremely interesting case report of bone lesions from the skeleton of an early 19th c. individual conserved in a Parisian museum because this “patient” was of Syrian origin and killed by the French Army (his body is considered, by some, as stolen by scientists); curators and officials were concerned about strong diplomatic problems between these two countries, and had already faced two bomb alerts directly related to the conservation of this historical skeleton. We have to discuss the balance between a (fatal?) course to publication by scholars, and the special requirements related to protection of international interests, i.e. current research versus health politics. The problem is directly related to the status of medicine in itself. Can medicine, which was nourished – as philosophy during the past centuries – by other disciplines, carry within itself other subjects? Indeed, since its origins, medicine has been considered as being protective of human beings. What if it goes out of the roads?When medicine crosses the boundaries of its disciplinary field, does it not become objectionable? And if it remains in its specific field, is it legitimate to give a platform to publications that might attract some kind of violence? Even within its methodological limitations and objects, should the medicine publish on everything? For example, presenting plans of anti-terrorism policies [3], or publishing in open access journals precise characteristics of potential bioterrorist agents? [4] Were not sure at all. The main problem, as we see it, is the status of the disciplines. This is stressed by a global reflexion on publications arising within an inter-disciplinary system. Do we – editors in chief, authors, editorial staff, etc. – have to think about the legitimacy of our articles prior to their publications? Competency in the humanities now seems to benecessary, in addition to «classical» fundamental scientific advances that are the primordial object of articles.

Variations in the thickness of the cranial vault in a deformed skull from pre-Hispanic Ancón (Peru)

A medical tomodensitometric study (TDM) was performed on a dry skull from the necropolis of Ancón in Peru. The skull, housed at the Muséum national d’histoire naturelle in Paris, displays an anteroposterior, brachycephalic, oblique, asymmetric, and bilobar deformation. TDM permitted 3-D reconstructions of the skull, endocranium, and vault thickness. The external surface displayed deformation and asymmetry in the bone structures and the endocranium demonstrated deformation and asymmetry in the brain lobes and superficial structures. The TDM demonstration of abnormal variations and pronounced asymmetry in the thickness of the vault strongly suggested that the deformation was ante mortem. The 3-D TDM reconstructions also helped to reconstruct the device used to deform the head.RésuméUne étude tomodensitométrique (TDM) médicale a été réalisée sur un crâne sec de la nécropole d’Ancón au Pérou. Le crâne est conservé au Muséum national d’histoire naturelle à Paris. Il présente une déformation antéropostérieure, brachycéphale, oblique, asymétrique et bilobée. La TDM a permis la réalisation de reconstructions 3D du crâne, de l’endocrâne et de l’épaisseur de voûte. La surface externe montrait la déformation et l’asymétrie des structures osseuses. L’endocrâne montrait la déformation et l’asymétrie des lobes cérébraux, et les structures superficielles. La mise en évidence par TDM de variations anormales et d’une asymétrie marquée de l’épaisseur de voûte suggérait fortement que la déformation était ante mortem. De plus, les reconstructions 3D ont pu aider à la reconstitution de l’appareil déformateur.