My Early Ecologic Thinking

Majid Ali, M.D.

My own ecologic thinking, as I recall it, began one day in 1969. As a pathology resident, I received a large basin brimming with a messy inflamed and distended colon with copious bloody fecal matter spilling out of some tears in its wall. It was not much fun to clean that bowel and take tissue samples for preparing microscopic slides. The next day I examined the slides and observed the expected microscopic features of ulcerative colitis: acute and chronic inflammation, dead and dying immune and other types of cells, ulceration of the lining mucosa, disruption of the general architecture of the colon wall, and pockets of pus. After finishing my study, I took the case to one of my professors. He examined the slides and agreed that it was a case of ulcerative colitis.

The next day, something unexpected happened. Without purpose, I picked another slide of that colon, looked at it, and chanced upon a cluster of large, pale cells forming a discrete round structure. Such a formation is called a granuloma and is considered diagnostic of Crohn’s colitis. “Look at that!” I said to myself in surprise. “Now, that granuloma makes it Crohn’s colitis, doesn’t it? Yesterday it was ulcerative colitis. Today it seems to be Crohn’s colitis. Interesting!” I marked the microscopic field with ink and took the slides to a second professor, since the first one was out of the department. He looked at the case and readily diagnosed Crohn’s colitis.

The next day as I prepared to carry the slides to one of the secretaries for filing, I picked another slide from the same case and started gazing at an area that showed discrete layers of tissue debris covering small patches of the inner surface of the bowel wall. Those are the features of another common type of colitis called pseudomembranous colitis. “Aha! Another diagnosis!” I exclaimed. “Let’s see if I can get someone also to agree with me.” That time I purposefully looked for a third professor and decided not to tell him about the diagnoses made by the other two. I pointed out to him the membrane-like structures and he agreed that we had a case of pseudomembranous colitis. I returned to my desk triumphantly. I knew I had a story to tell. Sometime after that Choua said, “Can you make more slides from that colon and see if you can get another professor to diagnose yet another type of colitis from the same colon?” he challenged. I smiled. Worth a try, I murmured to myself.

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