Transcript
MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. Today I’ve got the pleasure of chatting to two fellow podcasters. The Adelaine-based hosts of This Medical Life. It’s described as a show about the “stories of medicine” so it’s a natural sibling to Pomegranate. So thankyou Dr Travis Brown and Steve Davis for joining me.
TRAVIS BROWN: Thank you very much for having us.
STEPHEN DAVIS: Yes, thank you.
MIC CAVAZZINI: If we want to find a neuroanatomical analogy, I feel like Travis is the neurons of the show, and Steve is the glia that keeps him alive and ticking. Travis was this history of medicine always a pet interest? Or were there certain experiences in your pathology career that sent you down that rabbit hole?
TRAVIS BROWN: I've always enjoyed stories. But when I was going through medical school, I found that there was doctors or presenters—it didn't matter what specialty they were in—but if they started with a story, often historical story, telling us about the context of what we're about to learn—they would say, here, here is an unusual hook—and that would key in my interest if they had a story to start with, that would capture my imagination. And then I would start to find, in my mind, where to actually put that information. So that is actually the premise for what was initially This Pathological life that moved on to This Medical Life. And so we have stories and that's what we sort of base everything on. And then we learn around that. What is important to know about this condition?
MIC CAVAZZINI: I’ve studied synaptic plasticity and learning and, of course, emotional cues are help information encoding. So like you said, the landmarks of learning. Can you remember any of those particular stories from way back?
TRAVIS BROWN: There was one story that got me. An ENT surgeon came in and he said, “Did you know that—"you know, in literature, they talk about Oscar Wilde. And Oscar Wilde was, a fantastic character, amazing author, but he died, people say—You know, there’s a whole bunch of theories about how he died; that he had a tumour in his in his ear that cause his problems. One was even always the historical defamer, syphilis is always there. And then the other one was, “no, I think he died of a fracture of the skull”. Because he was imprisoned due to homosexuality at the time, and he had a large fall. And they talk about that fall, sort of hitting his head. And they talked about he had some symptoms of fluid coming out of his ear. Was it ear or nose? Because you’re an Oscar Wilde fan. What do you remember?
STEPHEN DAVIS: It's only vague. I just finished listening to this beautiful new biography of his life. Vaguely I thought it was the ear but…
MIC CAVAZZINI: It was not included by the biographer?
STEPHEN DAVIS: Strangely enough in the 1000 odd pages…
TRAVIS BROWN: Well that’s actually… this is a future podcast I'm wanting to do with Steve, that historical autopsy. But they talk about that fluid coming out of the year as being significant and saying, look, this may not have been a tumour. This may have been a base of skull fracture, therefore leading to meningitis, and that's why he died. He had you know, this headache. What was his statement? There was a there's a statement that he said of, “I have a headache that is beyond…”
STEPHEN DAVIS: I can't remember the head. I know that on his deathbed, he was in a room with hideous wallpaper. And he said, “the wallpaper and I are in a fight to the death, only one of us is going to win” .
TRAVIS BROWN: So that was a hook. And for I forever remembered that. And I don't think I remember the facts after, unfortunately for the ENT surgeon. But the story had me and that's where it sort of led to from there.
MIC CAVAZZINI: And that was an unplanned segue. But Steve, you're a seasoned radio presenter in Adelaide and you run Talked About Marketing. Explain that Oscar Wilde reference and why you admire the man.
STEPHEN DAVIS: Well, that saying of his—that witticism from one of his plays The Picture of Dorian Gray, actually—that “there's only one thing worse than being talked about, and that's not being talked about”. When I reflected I think it's entwined in my DNA. If I look back, I used comedy, humour to survive in primary school and high school. And it's woven into my being. I've started doing stand-up comedy in the last five years. But from a marketing perspective, yes, we do want to be talked about. And I find that Oscar has a quote—all my newsletters finished with a quote from him, all my presentations begin with a relevant quote, in fact, I just noticed that he's got one here, perfect for your podcast. He says, “illness of any kind is hardly a thing to be encouraged in others. Health is the primary duty of life”.
MIC CAVAZZINI: I like that.
STEPHEN DAVIS: So look, that flamboyance of his to want to be out front and to grab attention. He had many flaws, as we all do. But his peaks, his triumphs, I think outweigh them.
MIC CAVAZZINI: I didn't realize the show was a pandemic baby but then you've kept it running.
STEPHEN DAVIS: I must say Travis funds This Medial Life directly. He’ll probably be all bashful that I'm saying this, but this is a man with a mission to keep his peers at the forefront, just out of his own beneficence.
MIC CAVAZZINI: That's wonderful. And you've published almost a hundred episodes since July 2020. You've told some stories listeners would be familiar with; the 1906 typhoid outbreak in New York, whose spread was linked to a cook called Mary, Typhoid Mary. And there are many, there are many, many other stories that I've never heard before. How Alexander the Great probably died from sepsis, or how coeliac disease was described by the ancient Greeks. And like you said, the stories that stick. So a couple of years ago I was preparing an episode of Pomegranate Health on opioid prescribing and deprescribing. And I went down a few historic rabbit holes that that sort of overtook me. Just to explain to listeners—I'll be actually able to finally tell those stories on a cross pollination exercise with your show. And it was particularly a story about how bad ideas persist in medicine—in this case, it was a weird potion that survived for 1700 years. And today, we're going on a parallel sort of trip. You know, what we think of as the gold standards of experimentation today took hundreds of years to evolve but we still get plenty of wacky ideas. And if the pandemic is anything to go by, they are gaining more traction; so COVID vaccines, Bill Gates and 5G. Travis, you've brought an example of this from a pandemic that struck the world 100 years before COVID. Take it away.
TRAVIS BROWN: That's right. One of the things that was frustrating through COVID was the amount of misinformation was so prevalent, it almost eclipsed—well, it did eclipse the real information that was coming out and we were still learning. And I think this was the first time that the public had probably seen in recent memory of the medical community learning in real time. And you know, one time people tell you, “you do need masks”, “you don't need masks” and medical advisories were a bit disordered, in that instance, and then they’d say, “Oh, well, that's evidence of lying”. And it's just like, “it's not lying, it’s learning”. But if we look into history, misinformation has actually always been with us. And if you look at the vast majority of history, it's probably all almost all been misinformation because evidence-based medicine is only recent, But health is particularly prone to misinformation. Health emergencies, absolutely. And this is this is where it comes into rumours and false information, then you have to start to understand there's a whole bunch of motives in this. And there is a quote from an article Facing Down the Infodemic, about misinformation, and in particular about the COVID pandemic.
STEPHEN DAVIS: “Most conspiracy theories coalesce around an underlying belief in a secretive power of immense capabilities and nefarious intent that manipulates circumstances to suit its will.”
TRAVIS BROWN: So this actually goes into human psychology, almost, that we're actually far more comfortable believing that something evil is working against us than just random events occurring and creates this circumstances which we have no control of. I think people will far more prefer to feel in control than a random act just impacting the world. And the useful example is from 1918, the influenza pandemic. Now this is known as the Spanish Influenza or the Spanish flu. That in itself is a piece of misinformation because, actually, it seems to have originated out of the United States. But this was a during wartime, and so the problem with wartime is all the countries that were in war had censorship and they didn't want that information to go out that they were experiencing the flu because they didn't want morale to drop. And the one country that was not involved was Spain, and they were actively reporting about it. So everyone thought, well, this came from Spain, this is the Spanish flu. And so that's the oddity about all of this and no one actually knew the cause of influenza—it wasn't until the 1930s that we actually identify the virus. But they knew about bacteria at this time and a lot of the autopsies of people who had died had, what we would know now as, secondary infection, a bacterial infection soon on top of the virus. And so they started assuming that this secondary infection was the actual cause, And rumours began to circulate that a cure for this was a mix of whiskey and water
MIC CAVAZZINI: Worth a shot.
STEPHEN DAVIS: That's my doctor.
TRAVIS BROWN: Yeah well, doctors began prescribing in the United States, whiskey to patients. And now this was not isolated. This was widespread throughout the United States. There was no evidence, everyone just started thinking that whiskey would be the cure for this. But the problem at the time was that over half the states had prohibition laws. And so, alcohol and whiskey was in short supply.
MIC CAVAZZINI: That's ironic, isn’t it, that during the COVID pandemic, when there was the rush on hand sanitizer, we actually had gin distilleries making hand sanitizer instead.
TRAVIS BROWN: It's basic sort of demand and supply and everyone starts to move into that area and newspapers began reporting that military doctors were treating army personnel with whiskey. This newspaper report caused a run, and so this started creating a political undercurrent because pro prohibitionists started claiming the stories were exaggerated. And some even said that it was German propaganda trying to get the soldiers at risk of deadly alcohol. A diabolical Hun plot trying to encouraged US people to drink.
MIC CAVAZZINI: It reminds me of something known as Hanlon’s razor which is, “Never attribute to malice that which can adequately be explained by stupidity.” Supposedly named after Robert Hanlon, who was a philosopher or something.
TRAVIS BROWN: A cynical philosopher. Again, looking back this actually set a run like the IRS, the Internal Revenue Service ordered agents of North Carolina to distribute a whole bunch of confiscated whiskey to hospitals around the state. And there's examples of cities Alexandria in Virginia was a dry city. Well the police supplied the pharmacy with whiskey from seized bootleggers. Not only that, rumours began to circulate the police were hoarding bootleg whiskey and so there were seizures, and people descending on police stations for them to actually release the whiskey. A hospital in Omaha, Nebraska received 500 gallons of seized bootleg whiskey from the local sheriff for treatment for patients.
MIC CAVAZZINI: Do you think this this theory of the whiskey cure emerged out of guesswork or superstition or just the desperate motivations to try anything? I mean, can we parallel that to the ancient potions and herbal remedies of old? Or, you know, was there a seed that led to this?
TRAVIS BROWN: Yeah, I believe there was a seed. And alcohol is actually an excellent cleaning agent and kills viruses and bacteria. Now they didn't know so much about the virus then but alcohol itself as we use it today, excellent cleaning agent. So then this takes it to the next step. Okay, well, if alcohol can kill, then whiskey will kill. And I think that that was the next step. It may have been logical, but it wasn't scientifically based.
MIC CAVAZZINI: Just like bleach can clean your kitchen, why not drink it to clean the bugs out of your system?
TRAVIS BROWN: Exactly, the same kind of stepwise procedure. But even when we look at doctors at this point, they were divided on their opinion whether this helped or not. [Despite warnings from the AMA that “the use of alcohol as a therapeutic agent should be discouraged”] They had 51 percent of physicians at the time who were surveyed said, “Oh, yes, it does help. We think that it helps heart and respiratory can symptoms in patients who are weakened by the illness,” and some even said it had a sedative effect on patients who were affected and in quite a bit of discomfort, which probably wouldn't be right you would think. But the problem is again, all these prohibition states had laws that stopped them from going there. And Colorado had to issue prescriber script pads that were numbered for doctors who could prescribe up to four ounces of whiskey to their patients, which was, which was half a cup of whiskey. If you went to Michigan, doctors could prescribe up to eight ounces, which was one cup of whiskey. If you go to Burlington, Vermont, whiskey prescriptions were free of charge under the epidemic emergency fund, so you could get your whiskey through the emergency fund. If you went to Nashville, they actually prescribed over 10,000 half pints to residents. And Pittsburgh, doctors would earn $1 per prescription for their whiskey, and pharmacists could charge $5 A bottle of whiskey. And the interesting part about that is it was so cheap that the bootleggers had to reduce their price to be able to compete with the authorities. And so states that didn't have prohibition they could freely buy whiskey, and there was a president of a Baltimore roofing company was so concerned for his 200 workers that he bought a huge bottle of rye whiskey and told the his 200 workers to help themselves, and he happily reported that none of his workers fell ill.
STEPHEN DAVIS: Or fell off the roof.
MIC CAVAZZINI: I wonder if—you know, today we talk about Big Pharma, nefarious Big Pharma conspiracies. Was there any influence of Big Whiskey?
TRAVIS BROWN: Big alcohol!
MIC CAVAZZINI: And that reminds me of a similar story I heard during the COVID pandemic. A friend of mine, a bit of a hippie trippy, nuts and berries kind of friend who was insistent that—again, it's a story that goes back to the World War I internment camps on the Isle of Man when the Spanish Influenza was going around, and one of the internees was none other than Joseph Pilates. A German-born migrant to the UK locked up just in case in case he had sympathies with Kaiser Wilhelm. Pilates firm father had been a gymnast and his mother and naturopath. So he'd been brought up in this turn of the century culture of medical gymnastics and the body beautiful.
So, while in detention, Joseph Pilates developed the routine and machines that now bear his name on every street corner. You know the Pilates workout. And lo and behold, neither he nor any of his, presumably lycra-clad followers, contracted the Spanish flu. So my friend was telling this story to say that, of course, Pilates and natural remedies would protect you against COVID rather than all these nefarious Big Pharma drugs. Ignoring perhaps the fact that by being on an isolated island in open air they might have also had a head start in prevention.
TRAVIS BROWN: And that's the thing, misinformation. And what we're what we're finding is coincidence is misinterpreted as causality. Look, a good example again is—no one was immune. There was a whole bunch of what we call now snake oil salesmen who were who were peddling a whole bunch of stuff and, and look, Australia wasn't immune to that. There was a food manufacturer who came out with their, their own cure for the flu around this time.
STEPHEN DAVIS: After the “Flu” or any other disease, it’s impossible for the digestive organs to get enough nourishment out of your food to make you strong. That’s why people linger after having the epidemic “Flu”. That’s why so many apparently recover from the “Flu” and then die of sheer weakness and other complications ensuing.
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MIC CAVAZZINI: Jee, the spin hasn't really changed in all these years, has it?
TRAVIS BROWN: It’s amazing when you look at some of the information comes out, and yes, we believe a lot. I think what people are bottling though is hope, something that you can do. And that’s where this goes down. And that's why misinformation, will be with us, it will always be with us. I think in the medical community, we spend a lot of time trying to educate. And you have to have a critical mind, it doesn't actually take a doctor, it just takes someone who has a little bit of critical thinking, to be able to sort of sweep away a lot of this this sort of misinformation. And look, this podcast, your podcast, in regards to actually trying to help doctors keep up to date is also part of patient information. It's trying to disseminate what is true, what we know. And I mean, that goes into a philosophical discussion; what is true today may not be true tomorrow, but we're at least honest about that. And this is why today we're talking to you. This is about sharing information. And this is part of why we do what we do and we hope to entertain as well.
MIC CAVAZZINI: I agree. I mean, Pomegranate Health, yes, it's aimed at our physicians, but I hope that lay people who have an interest in health would be listening to and that somehow lifts the bonnet on the medical system on the scientific methods so that it helps build trust in the health system. And even by admitting where there are limits to knowledge and degrees of uncertainty. So yeah, let's hope let's hope it makes some small impact.
STEPHEN DAVIS: We'll be back in just a moment after this word from our sponsor. Bonox, pre-digested fluid be food, which never sounded so tasty.
MIC CAVAZZINI: Wonderful, thank you so much for sharing that with us. And I really hope our listeners will take the punt and subscribe. See you again.
STEPHEN DAVIS: Thanks for having us.
TRAVIS BROWN: Thankyou.
MIC CAVAZZINI: That was Travis Brown and Stephen Davis. If you want to hear more strange tales from the archives of medicine, search for This Medical Life in your pod catcher or your browser. I’ve binged about half the episodes and every one has raised my eyebrows. And if you’re not sick of hearing my voice, in the episode published March 26th, I lead a journey through the history of opiate prescribing. Specifically, a wacky potion with scores of ingredients called the theriac, which started in ancient Turkey and was still being prescribed up to the 19th Century.
When I joined Travis and Steve in their virtual studio, they asked me a question I often hear. Why is this podcast called Pomegranate Health? But it’s only recently that I pieced together the full story behind this. The pomegranate that you see in our podcast tile is in fact copied straight from the coat of arms of the RACP. It appears there on a shield is held aloft by an emu and a kiwi, the legendary flightless birds of Australia and Aotearoa-New Zealand.
The Australasian College was founded in 1938, but prior to that our physicians had been members of the Royal College of Physicians, London. The RCP shield design is meticulously described in its official Grant of Arms as “A black border with golden half fleur de lis, in the top a flesh coloured arm with an ermine cuff out of a silver and blue cloud, with the rays of the golden sun. The hand feeling the pulse of a flesh coloured arm, on top of a golden pomegranate.”
All these colours and motifs have a recognised symbolism in heraldry, but there's no explanation as to why the pomegranate was chosen. We can presume, however, that it was an homage to the College’s founder, King Henry the VIII. That’s right, the College was created by a Royal Charter in 1518, after Henry was petitioned by his personal physician Thomas Linacre to do something about rampant malpractice and quackery.
But surprisingly enough, pomegranates don’t grow in England, and had never been represented in English heraldry before then. It actually made its entry through Henry’s marriage to Katherine of Aragon in 1510. Her personal crest was a crowned pomegranate and it infiltrated the palaces in many forms, often entwined with the red and white Tudor rose. Just last year an amateur metal detectorist in Warwickshire uncovered a unique gold pendant in the shape of a heart decorated with these botanical symbols and the letters H and K.
But the pomegranate isn’t typical of Aragon either, flanked as it is by the Pyrenees mountains. In fact, it’s known as the Apple of Granada, the capital of Andalucia on the mediterranean. The fruit is seen everywhere throughout the city, in reliefs and fountains and mosaics and today even bollards and manhole covers. That’s because pomegranate trees thrived down there after they were brought over by the Muslim sultans from North Africa.
But their rule of several hundred years was coming to an end with the reconquista. The last stronghold of the Moor’s was Granada, under the Nasrid Sultan, Muhammad XII, known to the Europeans as Boabdil. Katherine’s parents, Queen Isabella of Castile and King Fernando of Aragon, had demanded its surrender, and when Boabdil refused, their forces besieged the city. Months later, he capitulated, and handed over the keys to the city at huge ceremony in January 1492. Interestingly, the scene was described by Christopher Columbus who set out on his little adventure in the same year, bankrolled by the royal couple.
There’s some debate as to whether the name of the city itself is a nod to the fruit. So pomegranate comes to us from Latin, pomum granatum. That’s an apple with grains or seeds. But some suggest it’s a corruption of garnatum, which is where we get the name of the deep red gemstone garnet. The city of Granada was, in fact, known by the Moors as Medina Garnata, or originally Garnata al Yahud, given the population of Jews living there when they took over. But I’ve also read that in Arabic, Gar-anat means “hill of pilgrims” so it’s possible that this is all just an elaborate linguistic coincidence.
What we can say more confidently is that the pomegranate was absorbed by the house of Aragon as a symbol of its conquest but also of Katherine’s own personal connection to the city. She was only 6 years old when Granada was handed over, but she received her extensive education there before being sent off to England at age 15. That was marry Henry’s older brother Arthur, who died five months later of a respiratory infection. By the time Katherine married Henry at age 23, she was already a seasoned diplomat.
The pomegranate motif also has a long tradition in religious art that would have made it an appropriate symbol for the Catholic princess. There’s a famous Botticelli painting from this period called Madonna of the Pomegranate, with the Virgin Mary holding the fruit alongside the baby Jesus. An article in the British Medical Journal explains how the motif is understood to evoke the resurrection, life everlasting, and also motherhood and fertility.
Similarly, in the 10th Century Persian epic Shah-nameh, the divine prince Esfandiyār attains becomes invincible by eating a pomegranate, and then goes on to complete heroic labours that allow the prophet Zoroaster to spread his faith. In Judaism too there are references to the pomegranate’s power; in particular that it has 613 seeds, one for each of the commandments in the Talmud.
And all this probably goes back to the Greek myth of Hades and Persephone. When she was abducted by the lord of the underworld, her mother, Demeter despaired. Being as she was the goddess of harvest, this brought an endless winter to the land and she appealed to Zeus for intervention. Hades told Zeus he would only allow Persephone to leave if she’d not eaten any of the enticing food of the underworld. As it happened, Persephone had cracked and eaten just six pomegranate seeds. So Hades agreed to release her for half the year, a month for each seed, and this was manifest through the arrival of spring and summer. Hence the ideas of fertility and reincarnation.
Whatever the origin story, by the 1600s there was a popular encyclopedia of heraldry produced “by the study and industry of John Guillam, late pursuant at armes.” In its entry for the pomegranate as associated with the city of Granada it is written, “This fruit is holden to be of profitable use in Physick, for the qualifying and allaying of the scorching heat of burning Agues, for which end the juice thereof is reckoned to have a very sovereign virtue”. And there may be a grain of truth in all this too, given more recent evidence that polyphenols within the pomegranate are associated with improved cardiovascular and metabolic health, as well as antioxidant, anti-inflammatory and even anticarcinogenic activity.
So that’s the roundabout story of how this fruit made its way from ancient myth into English heraldry and then onto this podcast. But there’s still one more twist to the story. I said that the Royal College of Physicians was likely honouring its founder Henry VIII. The problem is that the RCP only filed its blazon with the Royal College of Arms in 1546, which is after Henry’s somewhat turbulent divorce from Katherine in 1533. Remember all that fuss with the pope and the six wives? Awkward.
So how could this have come about? One editor of RCP’s journal made this speculation, “As the physicians of 1546 would not have been so rash as to purposely remind the irascible Henry VIII of his first wife, the choice of the pomegranate as a compliment to royalty could only have been made when the physicians first received their charter in 1518.” So it sounds like the crest sat in someone’s drawer for two decades before being submitted to the College of Arms. Now that’s not something that could ever happen at the RACP.
Thanks for staying with me this far. You can find heaps more digital resources for your professional development at elearning.racp.edu.au. There are reading lists called Curated Collections, there are lectures just for Trainees under the College Learning Series. There are bespoke eLearning courses and a library of other relevant videos under the banner Medflix. You can even make your own suggestions for inclusion via the Resourceful Physician link.
You know that time spent reading and watching and listening all count towards Category 1 CPD. What you might not know is that it doesn’t take much to "level up" these activities to earn Category 2 credit as well, which is described as reviewing performance. So for example, you could organise peers into a sort of journal club to discuss an episode of the podcast. Specifically, how aspects of the story might relate to your own practice and how this could be improved. It doesn’t matter if you have these conversations in person, by telecall, or even through the RACP Online Community forum, as long as you’ve got some record of the reflection you’ve undergone. Please explore the MyCPD Handbook for further guidance and templates.
I hope that helps. You can get in touch any time via the address podcast@racp.edu.au. I’m Mic Cavazzini, and this podcast was produced on the lands of the Gadigal people.