Saint Bartholomew’s Peanuts - Addendum

I have given the crux of what I wanted to say about the inhalation of peanuts. It showed that accepted explanations are not always explanations as such and that one must continue to think critically for oneself. Even about what is an accepted opinion.

The erroneous explanation is something else that has appeared in textbooks and was accepted uncritically. I read it in the same book that gave the incorrect description of what happens to the thyroid cornu during strangulation. (See: Prof Simpson and Textbook Strangulation.)

There is one further brief comment to add. That is about writing style. The authors needed to write their paper in a style that suited the requirements of an academic journal.

I first read about this study in New Scientist, a popular science magazine. It caters for a broad readership and must have an appropriate style. It was some years before I read the original paper. The contrast in writing styles was striking. There was a considerable difference between the academic journal and popular magazine writing styles. A description of the same study can have a very different feel.

I was excited by the New Scientist article. It was brief and to the point and written in a style that was easy to read. The study fascinated me. I referred to it in my lectures for many years after. The dryness of the original academic paper did not enthuse me. The study did not fascinate me when described that way. That was due to no fault of the writers. They had to follow the accepted writing style. Academic journals often prescribe what these should be.

Thousands of books are read every day for pleasure or interest. Academics are no exception. They do not confine their reading to academic literature alone. I have known many academics to be voracious readers of non-academic writing. Their reading is for pleasure.

There is little or no pleasure associated with reading academic papers. I do not recall hearing a colleague get excited about something read in an academic paper. I have heard plenty of criticisms. I have also heard - and experienced - how difficult it can be to write in the required style. The academic style of writing is neither simple nor is it natural. Journal editors sometimes comment on how laborious editing can be.

There is perhaps only one thing pleasurable about academic papers. That is seeing one’s name in print. However, that is only a transitory pleasure. It soon passes. Published works soon recede into the past. Only the most recent work gets read. Older works are not. The paper by Lowe and Ross Russell demonstrates this. The year 1984 was a long time ago. Were it read, the erroneous explanation of why peanuts find their way into the right main bronchus might be no more.

Reductionism

 

Can the human body be reduced to a set of clinical specialities?

(From:
Pearson, Vaughan & Fitzgerald (1996) - Nursing Models for Practice)

Reductionism

Can the human body be reduced to a set of parts?

(From:
Pearson, Vaughan & Fitzgerald (1996) - Nursing Models for Practice)

Biomedicine

Having mentioned [here] the numerical expansion in courses entitled Health Science and Health Studies, another word commonly appearing in course titles is Biomedicine. Alternatively, one may find the adjective Biomedical used - as in Biomedical Science or the like.

These courses are primarily science-based. The addition of Science in the course title is somewhat redundant. However, calling a course simply Biomedicine does not distinguish it sufficiently from medicine. Biomedical Science is the academic study of health-related topics. Medicine is about training to become a doctor.

Health Science and Biomedical Science are synonymous. The inclusion of the phrase medical provides extra cache.

The term biomedical will appear again. The medical model of the body - and disease and health - to which Western medicine adheres is also called the biomedical model. The two phrases are synonymous.

Nobel Prize Thinking

I found the following comments by Nobel Laureates on the role of conceptual/theoretical thinking in biology some time ago. I cannot remember the original source.

Biological understanding is the combined end product of two types of effort: the collection of observations (or facts) and the formation of relationships between observations. Scientists produce observations in the laboratory or clinic, and form relationships between observations in their mind (while in the lab, office, shower...) Both endeavours are essential. However, many practising biologists tend to dismiss the significance of conceptual or theoretical thinking in biology. In contrast, many Nobel Laureates recognise and emphasize the importance of such thinking, as follows...

'There is now a crisis developing in biology, that completely unstructured information does not enhance. What people want is to understand which means you must have a theoretical framework in which to embed this.'
Sydney Brenner (1927-2019)

'We've got to start thinking. We have all these individual components behaving in different ways, that interact in different ways, and we've got to somehow extract the general principles from that behaviour.'
Paul Nurse (1949-)

'All of the disciplines will benefit from this tremendous amount of information which is coming. But now we need people who can digest this information and can distil it into new concepts.'
Gunter Blobel (1936-2018)

'Conceptually driven research as opposed to end-use driven research, is what is likely to yield some of the biggest benefits ... Real curiosity-led work cannot be confined by a short time-horizon.'
Peter C. Doherty (1940-)

'The good scientist is not a drudge who collects facts like stamps and then searches these for a lucky conclusion: the good scientist chooses a problem of Nature, imagines an answer, and then tests to see whether imagination has been right. In science, imagination leads the way. Without imagination, without intellectual daring, science is dead.'
J. Michael Bishop (1936-)

'The rate of accumulation of knowledge or information is so vast, none of us can take it. But knowledge just adds, and you might think all this knowledge will make progress. But progress isn't based on knowledge, it's based on ideas.'
Sir James W. Black (1924-2010) 

A Particular Interest

In the UK, in the 1990s, there was a considerable expansion in higher education. More students than ever before were able to study on degree courses. As a result, there was an increase in the number and range of courses taught. Instead of the word degree, the phrase degree programme became common. A degree programme consisted of a series of credit-bearing modules of study. Success at each step through the programme depended on acquiring a prescribed number of credits.

As part of the higher education expansion, there was a considerable increase in the number of courses associated with health on offer. That reflected an extensive interest in health-related subjects. Most of these were non-vocational qualifications. Particularly numerous were students who did not want to follow a clinical or paramedical career. Training courses for such professions continued to be available. These were upgraded separately to degree status.

Courses titles like Health Science and Health Studies proliferated. New departments became established to cater for this, and existing ones expanded. In addition, departments of biological science and social studies were often called upon to provide teaching as appropriate. Noticeably, departments of medicine were not involved. Whether a degree programme merited a science (BSc) or arts (BA) degree was a product of the modules completed. Some modules were compulsory, others optional. Often, modules in a science-based subject were available to arts-based students and vice versa. Courses often took on a multi- or inter-disciplinary character as a result. That added to the appeal of these programmes.

Of shared interest to all students was the human body. A sound understanding of its structure and workings is fundamental. Modules on this topic were, therefore, usually compulsory. The phrase human body often implies just its physical makeup or anatomy. That overlooks its physiology. Anatomy and physiology teaching can be as separate subjects. Whether they can or should be separated is a moot point. Anatomy and physiology are intricately related. (The question of which has precedence is probably best left open.)

Medical schools typically teach anatomy and physiology as separate subjects. Teaching is by specialists from each discipline. (Sometimes even specialists from a sub-discipline.) Health-related degree programmes typically teach them as a single combined subject. That is to their credit. Where taught separately, the problem of how the two can be (re-)integrated arises. In short, they have a form of Humpty Dumpty problem. In addition, a biological scientist usually teaches modules on the human body. That means a somewhat reductionist approach is typically adopted. Opportunities for innovative approaches to studying the human body remained largely unexplored.

I used to teach students on health-related programmes. Anatomy, physiology and pathology were the areas I was required to teach. Wanting to find new ways into established subjects was a particular challenge. That was particularly so when adhering to a prescribed syllabus written in a reductionist way. There are plenty of facts to teach. There are plenty of books to recommend to aid the process. However, to do that does not educate fully. Teaching should not be merely a matter of transferring information from teacher to student. One must make the subject make sense and help others make sense of it. Maybe a student will go on to make better sense of it. That does not come from mere statements of facts.

Why there continues to be such an interest in health-based subjects is unclear. When I was an undergraduate, to suggest that it is because these topics are interesting in their own right would have been sufficient. I knew many students at university who were doing their subjects simply out of interest. Their careers after graduation were independent of what they had studied. Now, employment has much greater emphasis. It can begin in Freshers’ Week.

Several suggestions exist for the popularity of health-related courses. The implications are perhaps more pertinent. It means that problems in understanding health-related issues now have a much broader, well-educated set of contributors. Problems once confined to medicine are no longer so. What the doctor ordered/orders is now open to scrutiny. Issues in understanding health, illness, and disease are not limited to the medical arena. That is likely to influence how those problems are appreciated societally. A distinctively non-professional, non-vocational interest in health has now emerged. Now, issues in the philosophy of medicine have a wider ownership. The medical profession seeks to cure. From their respective perspectives, Health Science and Health Studies graduates each seek to understand. The study of clinical phenomena is no longer limited to a purely clinical context. In effect, issues in medicine are no longer the sole intellectual preserve of the medical or allied professions.

Saint Bartholomew’s Peanuts

Children sometimes inhale foreign objects which lodge in the airways leading to the lungs. All accident and emergency departments have seen cases where worried parents have brought in a child to whom this has happened. It also happens to adults who toss up a peanut in an attempt to catch it in the month. Although this may apply to any object of the right size, peanuts are the main culprits in Britain.

When inhaled, it is the right main bronchus (the airway leading to the right lung) that the peanut seems to favour. But why? (Of course, peanuts do not exhibit choice.) The answer usually given is that the right main bronchus is straighter, more vertical, and broader than the left. This reason continues to be accepted. It was even the response from ChatGPT (when asked in January 2024).

This reasoning lacks experimental evidence. It is based entirely on clinical observation and what is known anatomically about the arrangement of the central airway (the trachea) and its two branches (the left and right main bronchi). A moment’s critical thinking should cast doubt over the reason given.

The right main bronchus may be straighter, more vertical and broader than the left, but none influence whether a peanut ends up on the left or right. The characteristics of the airway AFTER the peanut has entered it can have no bearing on a choice made before entry. The reasoning is flawed. Whether this qualifies as reasoning is a moot point. It takes what we know about the airways and concocts an explanation without testing it. In so doing, it fails to be an explanation as such. It does not follow that what we know about the airways is complete enough to make a judgment. Clinical experience leads us to suspect that an inhaled peanut will more likely lodge in the right main bronchus. Chest radiography is necessary to confirm this. Only then can extraction be attempted. Anatomical knowledge without critical thought does not provide an accurate explanation. Here, critical thinking has been lacking.

Little known is that experimental work on this problem has been performed and published in 1984. (Some 40 years before ChatGPT gave the stock answer.)

It appeared as:

Tracheobronical foreign bodies - The position of the carina

Lowe, D. and Ross Russell, R.I.

The Journal of Laryngology and Otology. May 1984, Vol. 98. pp499-501

A brief, popular science report of this paper also appeared in New Scientist:

Why peanuts prefer the right lung

New Scientist 7th June 1984 - p25

Volume 102 Issue 1413

In a laboratory at St. Bartholomew’s Hospital in London, Lowe and Ross Russell suspended dissected tracheas and bronchi and placed a funnel in the top. They then lobbed peanuts into the funnel to simulate their inhalation. These found their way into the right main bronchus four times more often than the left. Thus, they corroborated clinical experience. They then cut these specimens into front and back halves and photocopied them. Using these, they analysed the geometry of the airways. The key finding was that the position of the carina was typically slightly to the left of the axis of the trachea.

Carina is Latin for the keel of a boat. The anatomical carina is the ridge that points upwards where the main bronchi divide. (Imagine the boat upturned on the seashore.) The carina is slightly to the left of the mid-line of the trachea. As a result, it deflects peanuts to the right when inhaled. (Imagine now a pinball machine.)

As I suggested above, this was an elegant piece of work. By this, I mean that it was clear and concise. What the authors set out to test and how they did it left little or no room for doubt. In that sense, there was something ideal about it. Unfortunately, experiments are rarely like that. Therefore, it was refreshing to find one. So, I can recommend reading it.

Note:

An omission from all accounts of why inhaled peanuts favour the right main bronchus is our upright posture. Gravity has a bearing. However, the role played by gravity is missing. It is not just to do with inhalation of air carrying a peanut. It is much less likely that any quadrupedal animals experience such a problem. Of course, giraffes may inhale things while browsing the treetops. Any such nuts or berries fall a long way and gain considerable momentum as they do so. Gravity may play a role in those cases. But this is conjecture.