Aphorisms About Alcohol

Alcoholism is a trap for the unwary physician. I do not mean overt, flagrant, persistent, disgracing drunkenness. It is covert, concealed alcohol addiction which corrupts diagnosis, wasting time, and money, while creating the risks of inappropriate or unnecessary investigation and treatment.

So I offer these aphorisms: if you think I am cynical, take it as a confession that I missed occult alcoholism too often.

1. Alcohol drives out honesty.

As a newly appointed physician a respected senior colleague advised me thus.

"Don't waste your time asking people about their drinking habits: you can't believe a word they say."

I have many times been made aware of the truth he spoke, and of the shameless, facile lying which alcoholics use, attempting to deceive themselves and the physician.

A middle-aged businessman was in hospital with severe alcoholic hepatitis. He recovered and returned to the clinic after 6 weeks for review. He assured me he had heeded my warnings: "Not a drop has passed my lips since I left hospital". His speech was slurred, he was unsteady on his feet; his blood alcohol was 85 mg%; and it was 1015 on Monday morning.

2. Husbands deny their wives' drinking; wives declare their husbands' drinking.

A 32 years old woman had blackouts at home, then was brought home by a friend after falling in a supermarket. The friend told the doctor she was drunk, her husband denied this. Her sister came with her to a second clinic visit, to tell me privately she was drinking at least a bottle of vodka a day. Still husband and wife denied an alcohol problem. They told me she had fits as a child; the blackouts were epileptic. Eventually she fell again and was brought to casualty, obviously drunk - her blood alcohol was more than 300mg%.

On a number of occasions a wife became restless as her husband assured me his drinking was modest - a glass of wine with dinner, perhaps, sometimes a nightcap. Then she would interrupt forcefully, something like this.

"That's not right; you tell the doctor the truth. It's a bottle of wine every evening, and a lot of gin. And he's in the pub every lunchtime. He buys the drink - but I put out the bottles for the dustman."

3. Wives divorce alcoholic husbands; husbands shelter alcoholic wives.

Alcohol unmasks crude, immature sexual characteristics: men tend to aggression and violence, women to provocation and flirting. Women will put up with violence to themselves, sometimes to a surprising degree, but violence to their children they will not tolerate. Conversely the behaviour of a drunken wife is likely to engender primitive male responses of protection and possession; and an alcoholic wife shames a man, hinting he is inadequate.

4. Suspect alcohol if something is hard to explain.

An elderly lady had a stroke, with left sided weakness. After 3 weeks her strength had returned but she was still unsteady and couldn't walk. She lived with two sisters, who visited most days, bringing a large plastic lemonade bottle. A student nurse became suspicious, checked the bottle and found it contained vodka. That patient was drinking vodka like lemonade, in hospital, and I had failed to spot it.

5. Alcoholism may explain social failure.

Failure to be promoted, unexpected bankruptcy, divorce not for adultery, loss of the driving licence: all such should arouse suspicion. Of course these personal failures have various causes; alcoholism is likely to be denied or concealed.

6. Alcohol preys on success and wealth.

George Best is an obvious example. 25 years ago in England, compared to the general population, doctors, lawyers and army officers had 3 times the risk of alcoholic cirrhosis; for barristers, judges and journalists the risk was increased 9 times; for company directors it was into double figures. For the modern profession of celebrity the risk probably goes higher still.

Finally - look critically at 'routine' blood tests. Three values may suggest alcoholism, singly or together. They are useful only if abnormal: normal values do not rule out alcoholism.

Automatic blood counters calculate the average size of the red cells in the blood - the mean corpuscular volume, MCV. A moderately increased MCV, say 100-105, suggests alcoholism.

The cause of this is interesting. The normal red blood cell is a disc with two concave faces. Alcohol causes some red cells to develop with four concavities, creating cells shaped as a regular tetrahedron. From above these cells appear triangular, and are called triangulocytes. They are bigger than normal red cells, so increasing the MCV.

Other markers of alcohol include an increased plasma value for the enzyme gamma-glutamyl transpeptidase - gamma-GT. This enzyme is important in the metabolism of folic acid.

Another marker is a low value for the blood urea. This can be attributed to poor protein nutrition: alcohol is rich in energy, and is expensive. It may also reflect chronic liver injury and reduced urea synthesis.

The old truisms are true. Alcohol is a good friend, but an evil master. It increases the desire, but impairs the performance. Enjoy a drink with friends, but shun the disgrace of drunkenness.

Alcohol in strict moderation is healthy, especially red wine, giving some protection against coronary thrombosis, for example. I advised one glass of red wine every evening for my coronary patients; that was my only prescription where compliance approached 100%.

And there is the old Arabic proverb, taught me by an eminent Egyptian scholar:

wa qalil min al khamr yasla' al ma'ida

[and a little alcohol awakens the stomach.
Or, maybe:
and a little wine puts fire in the belly.]

Oaths and Aphorisms

Laudator Temporis Acti, master blogger, has posted the full Hippocratic Oath, in Greek and in translation.

Few new medical graduates of my generation swore an oath, Hippocratic or otherwise. I seem to remember new fellows of the Royal Colleges must affirm consent to the college laws, but otherwise I have never met a physician who has sworn to obey a code of practice.

There was talk that the graduates of the new 'Omani medical school should take an oath, but I don't think anything came of it.

The Hippocratic Oath demands that all patient contact and information be strictly confidential and professionally responsible. That is perhaps the most important and enduring of its provisions.

Senior physicians no doubt approve the the duties owed to them by their pupils, but there is a whiff of secret society about some of its provisions.

Physicians should leave surgery to those skilled in the art - amen to that.

More controversially today, physicians should not give a pessary to procure an abortion - although I don't know of any material available for this purpose in Hippocrates' time. But amen to that too, save in exceptional circumstances.

For this elderly English physician, the Hippocratic text which resonates most strongly is the first aphorism. Remember this is the opening of one of the earliest textbooks of medicine; a remarkable summary of the physician's dilemma. It would serve well to open the introductory lecture in any syllabus of medicine.

Ὁ βίος βραχύς, ἡ δὲ τέχνη μακρή,

ὁ δὲ καιρὸς ὀξὺς, ἡ δὲ πεῖρα σφαλερὴ, ἡ δὲ κρίσις χαλεπή

[ ho bios brakhys, hi de tekhni makri,

  ho de kairos oksys, hi de peira sphaleri, hi de krisis khalepi ]

Which may be translated thus.

Life is short, but the skill is great;

opportunity is fleeting, experience fallacious, and judgement difficult.

Opportunity fleeting: miss the early signs of meningitis and a child dies or is crippled for life.

Experience fallacious: prescribe a drug safely used many times, and a patient reacts fatally.

Judgement difficult, but may be needed urgently and on insufficient information.

Any physician who denies bad mistakes is a fool or a liar. We can only learn and do our best to minimise error and the consequences of error. And hope for understanding - and mercy - when we get it wrong.

A Remarkable Insight

Atomic theory began in Greece almost 2-1/2 millennia ago,in the 5th century BCE. Leukippos is credited with the first proposal of the theory, which was developed and publicised by Demokritos, his pupil and successor.

The logic of the theory is beautifully simple. Nothing comes from nothing - there is no spontaneous generation of matter, and matter is indestructible, as we say now.

But everything changes. Matter is constantly redistributed into different forms.

Therefore matter must be composed of invisible particles, ultimately indivisible [atomos]. There must be different types of atoms, to account for the manifold varieties of matter. Atoms must link together in different ways: rigidly, in solids; loosely, in liquids.

It is a remarkable insight, probably unique: a theory which had to wait more than 2300 years for experimental proof.

Demokritos does not appear to have asked a question which now seems obvious. Are there substances which consist of just one type of atom? In modern terms, are there elements?

Gold would be an immediate candidate for a substance composed of one element only. Silver, copper and tin would be familiar to Demokritos; he might have identified bronze as an example of a new substance formed by mixing two elements, a simple demonstration of the theory.

A bolder step would be to identify carbon as an element -  charcoal the residue after other elements are driven off by heat.

Had Demokritos identified elements, he might then have considered how they mix and combine. He would now be called the father of chemistry.

If by some miracle he had recognized charcoal and diamond as different forms of the same element he might have founded an alternative alchemy.

Unfortunately atomic theory became a topic for philosophers, not experimenters.

It is so easy with 20:20 hindsight.

In 1869 Mendeleev presented the Periodic Table of the Elements; arguably the most significant of all advances in human knowledge.

And Demokritos' logic was finally shown to be correct.

   

To Emulate Merlin

I passed my 70th. birthday just over a year ago.

Since then I have thought long and hard about the inevitabilities of life after 70, and I don't like what I see. I have had ample opportunities to visit the land of 70+: I have no wish to go there.

Accordingly, I have made an important decision.

I will go no further forward in time. From now on I am living in reverse time. My recent birthday was my 69th., not my 71st. And next year I shall be 68.

I plan to continue life in reverse time until I am 32, when I shall switch to forward time again.

By so doing I am emulating Merlin, the great wizard, tutor of the young King Arthur [the reference is to The Sword in the Stone by TH White - a great book].

Merlin also lived backwards in time. He was apt to be confused, because he remembered the future well, but had difficulty foretelling the past.

So, I send this message to family, friends and all whom it may concern. Mark well my new life trajectory, and adjust your expectations of me as necessary.

There is just one problem. How do I explain this to my pension providers?

Libel Most Foul

The Independent newspaper today carries an article by Yasmin Alibhai-Brown, which includes what may be the worst libel I have ever seen in a contemporary British publication.

The article is a tirade of muslim grievances, including the Prime Minister's evidence to the Chilcot inquiry into the Iraq War. I have written before about Iraq and Afghanistan, expressing criticism, doubts and anger. But Yasmin Alibhai-Brown's accusations cause me outrage.

This paragraph in particular; it is offensive and ill-informed in the extreme. She is speaking of the Prime Minister's evidence.

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Not a word about the countless Iraqis killed when we bombed indiscriminately in civilian areas, no word of sorrow, however hollow or feigned, about the dead children or those now born in that blighted land with two heads and other grotesque abnormalities. John Simpson's recent BBC report described the rising number of such births in Fallujah, picked for the cruelest collective punishment by America.

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Allied forces did not bomb indiscriminately in civilian areas: that was the work of insurgents - muslims attacking different muslims. Allied soldiers know civilian casualties do great damage to their progress; insurgents often deliberately or recklessly cause civilian casualties, knowing that the allies will be blamed, in the muslim world and in the western media.

That accusation is bad enough, but much worse follows.

She accuses the Americans of responsibility for the alarming prevalence of congenital abnormality in Fallujah, and implies this is a deliberate policy of collective punishment.

That is a foul libel.

John Simpson was careful to stress there are no figures for the prevalence of congenital malformations and disease in Fallujah before the war.

The most significant fact in the BBC report is the new hospital built in the town by the Americans. No doubt that new, modern hospital is keeping good medical records and statistics.

No doubt too, many local women are for the first time receiving proper obstetric services and care.

The BBC report is a revelation of the alarming frequency of still-birth and congenital disease in such deeply in-bred communities. Cousin marriage is the custom, approved by the mullahs. Centuries of endogamy have damaged the genetic pools of such communities, with bitter consequences for their children.

I know of one hospital in Arabia which has a discreet 'bad-baby ward': it is there, but not admitted publicly. I heard of others.

  

In-breeding increases the risk of the following:

still-birth;

congenital malformation;

inherited disease, often metabolic;

childhood leukaemia and other malignancies.

These conditions are prevalent wherever endogamy is practised, including immigrant communities in Britain.

Yasmin Alibhai-Brown's virulence disgraces the Independent newspaper; the editor deserves severe censure.

The Abana and Pharpar Syndrome

[This syndrome was recognized in 1973 by Kelsey.]

In the Old Testament, in the Second Book of Kings, Chapter 5, you may read the story of Naaman, a Syrian General. Naaman had leprosy, and was sent to Israel, to Elisha, to be cured. But Elisha did not come himself, to pray and to lay on hands. Instead he sent a servant to advise Naaman to bathe seven times in the Jordan river.

Naaman at first rejected the advice: "Are not Abana and Pharpar, waters of Damascus, better than all the waters of Israel?"

However he was prevailed upon to do as Elisha said, and his leprosy was cured.

So now we may speak of the 'Abana and Pharpar Syndrome': the angry rejection of a physician's advice, because it contradicts a patient's expectations, or is not delivered in a manner considered appropriate.

All physicians know the syndrome, avoiding it is in the art of medical practice, but it is more difficult in the age of information. The internet and TV are rich sources of erroneous, inapplicable or impracticable opinion and advice. Patients come to the clinic knowing what they need: woe betide the physician who demurs.

But the story of Naaman is a good yarn: here it is in full, in the glorious English of the King James' version. 

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1. Now Naaman, captain of the host of the king of Syria, was a great man with his master, and honourable, because by him the Lord had given deliverance unto Syria: he was also a mighty man in valour, but he was a leper.

2. And the Syrians had gone out by companies, and had brought away captive out of the land of Israel a little maid; and she waited on Naaman's wife.

3. And she said unto her mistress, Would God my lord were with the prophet that is in Samaria! For he would recover him of his leprosy.

4. And one went in, and told his lord, saying, Thus and thus said the maid that is of the land of Israel.

5. And the king of Syria said, Go to, go, and I will send a letter unto the king of Israel. And he departed, and took with him ten talents of silver, and six thousand pieces of gold, and ten changes of raiment.

6. And he brought the letter to the king of Israel, saying, Now when this letter is come unto thee, behold, I have therewith sent Naaman my servant to thee, that thou mayest recover him of his leprosy.

7. And it came to pass, when the king of Israel had read the letter, that he rent his clothes, and said, Am I God, to kill and to make alive, that this man doth send unto me to recover a man of his leprosy? Wherefore consider, I pray you, and see how he seeketh a quarrel against me.

8. And it was so, when Elisha the man of God had heard that the king of Israel had rent his clothes, that he sent to the king, saying, Wherefore hast thou rent thy clothes? Let him come now to me, and he shall know that there is a prophet in Israel.

9. So Naaman came with his horses and with his chariot, and stood at the door of the house of Elisha.

10. And Elisha sent a messenger unto him, saying, Go and wash in Jordan seven times, and thy flesh shall come again to thee, and thou shalt be clean.

11. But Naaman was wroth, and went away, and said, Behold, I thought, He will surely come out to me, and stand, and call on the name of the Lord his God, and strike his hand over the place, and recover the leper.

12. Are not Abana and Pharpar, rivers of Damascus, better than all the waters of Israel? May I not wash in them, and be clean? So he turned and went away in a rage.

13. And his servants came near, and spake unto him, and said, My father, if the prophet had bid thee do some great thing, wouldest thou not have done it? How much rather then, when he saith to thee, wash, and be clean?

14. Then went he down, and dipped himself seven times in Jordan, according to the saying of the man of God: and his flesh came again like unto the flesh of a little child, and he was clean.

15. And he returned to the man of God, he and all his company, and came, and stood before him: and he said, Behold, now I know that there is no God in all the earth, but in Israel: now therefore, I pray thee, take a blessing of thy servant.

16. But he said, As the Lord liveth, before whom I stand, I will receive none. And he urged him to take it; but he refused.

17. And Naaman said, Shall there not then, I pray thee, be given to thy servant two mules' burden of earth? For thy servant will henceforth offer neither burnt offering nor sacrifice unto other gods, but unto the Lord.

18. In this thing the Lord pardon thy servant, that when my master goeth into the house of Rimmon to worship there, and he leaneth on my hand, and I bow myself in the house of Rimmon: when I bow down myself in the house of Rimmon, the Lord pardon thy servant in this thing.

19. And he said unto him, Go in peace. So he departed from him a little way.

20. But Gehazi, the servant of Elisha the man of God, said, Behold, my master hath spared Naaman this Syrian, in not receiving at his hands that which he brought: but, as the Lord liveth, I will run after him, and take somewhat of him.

21. So Gehazi followed after Naaman. And when Naaman saw him running after him, he lighted down from the chariot to meet him, and said, Is all well? 

22. And he said, All is well. My master hath sent me, saying, Behold, even now there be come to me from Mount Ephraim two young men of the sons of the prophets: give them, I pray thee, a talent of silver, and two changes of garments.

23. And Naaman said, Be content, take two talents. And he urged him, and bound two talents of silver in two bags, with two changes of garments, and laid them upon two of his servants; and they bare them before him. 

24. And when he came to the tower, he took them from their hand, and bestowed them in the house: and he let the men go, and they departed.

25. But he went in, and stood before his master. And Elisha said unto him, Whence comest thou, Gehazi? And he said, Thy servant went no whither.

26. And he said unto him, Went not mine heart with thee, when the man turned again from his chariot to meet thee? Is it a time to receive money, and to receive garments, and oliveyards, and vineyards, and sheep, and oxen, and menservants, and maidservants?

27. The leprosy therefore of Naaman shall cleave unto thee, and unto thy seed for ever. And he went out from his presence a leper as white as snow.

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Gehazi did wrong, but his punishment was cruel and excessive - no mercy, no appeal, and inflicted on innocent descendants; barbaric, a stain on Elisha's reputation.

As for Jordan water in the treatment of leprosy, this appears to be anecdotal evidence of  a single case: I have seen no controlled trials.

Rifampicin, clofazimine and dapsone work by science, not miracle; but for many lepers their benefit is little short of miraculous. 

Orthodox or Complementary Medicine?

I have been asked often for my views on this or that unorthodox - 'complementary' - medical system. There are a lot of them - and the list continues to grow.

The simple reality is that any therapy promptly becomes regular medical practice, if and when it is shown to work. Thus, by definition, 'complementary' medicine comprises theories and therapies which fail critical evaluation.

Nevertheless, unorthodox practitioners flourish and prosper. That is a telling commentary on human nature.

Any physician quickly learns that placebo, suggestion, and faith are wonderfully potent in symptom control - especially if they are exotic and expensive. In itself, an air of authority tempered by patience and kindness is seriously therapeutic, doubly so when backed by impeccable tailoring, and [shhh!] a hefty fee: "He must be good - look at his charges". [As a whole-time health servant I had to do without the vis medicatrix pecuniae.]

What is the placebo effect of surgery? Double-blind controlled trials are difficult or impossible in that specialty. In one famous example a popular procedure for angina pectoris was discredited when operated and sham-operated patients reported approximately equal benefits. No modern ethical committee would sanction such a trial.

As a physician I was often struck how patients are willing, sometimes eager, to submit to surgery.

A frequent problem for the physician is the persistent patient with multiple symptoms but no significant disease. The Germans call it 'Undhier Syndrome". ["O Doctor I have pain here, und hier, und hier, und hier."]

Patients with such problems are often best managed by an unorthodox practitioner. I found I was so advising more often as I grew older.

I confess on many occasions I have prescribed an injection of vitamin B12 as a deliberate placebo. Vitamin B12 is a perfect placebo. A powerful vitamin, essential for life, it is beautifully red, safe and cheap, and must be injected. I instructed nurses to draw up the dose in full view of the patient.

Unfortunately most patients so treated came back for more. Many were grateful and complimentary, which was embarrassing.

Once again in Africa the issues are simpler and starker. Physicians in rural clinics often have a good mutual relationship to the local witch doctors. The witch doctors know a patient losing weight and spitting blood must go to the clinic; the physicians learn the witch doctor is best able to manage hysterical symptoms, such as unexplained paralysis of an arm.

Physicians must admit that reliable medical knowledge and practice is less than two centuries old. Before that we were all 'complementary', to some extent. Evidence-based medicine is the gold smelted by science from a vast accumulation of stories, legends, myths, theories, doctrines and dogmas.

I understand one hundred years ago leeches were still in the British Pharmacopeia, and medical students had to learn materia medica - how to recognize various herbal and other natural products used in practice.

We must also recognise that herbal and folk remedies have on occasion yielded important medical knowledge. 

In the 17th. century Jesuit missionaries in South America learned from Inca herbalists the value of the bark of the "Fever Tree". The tree is now called Cinchona officinalis. Its bark is an important source of quinine, still perhaps the most reliable treatment for malaria.

The English physicians Morton and Sydenham recognized that "Jesuits' bark", as it was called, worked only in intermittent fevers, which are distinctive of malaria.

Pure quinine was isolated from Cinchona in 1820, by Pelletier and Caventou in Paris. A specific chemotherapy for malaria was available 60 years before the parasite was identified.

Digitalis and morphine are valuable drugs originating in folk medicine. Coca yielded cocaine, starting the development of local anesthetics. Chinese herbal practice led to the recent discovery of Artemesia annua,  which yielded Artemesinine, a new potent anti-malarial.

Vaccination is perhaps the greatest contribution of folk medicine to human health. Edward Jenner heard country people in Gloucester say that after cow-pox no-one caught small-pox. He saw local people deliberately infecting their families with cow-pox. In 1796 Jenner inoculated an 8 years old boy, and the rest is history. [The word vaccination is from the Latin vacca, a cow.]

An old farmer once assured me he took 'blue stone of vitriol', a sovereign remedy for rheumatism, " what we give to the 'orses".

Blue stone of vitriol must be copper sulphate, a known toxin. I didn't try it myself. 

Other complementary medicines have added little to the practice of evidence-based medicine. For most of them the theoretical base ranges from unlikely to absurd.

The number and variety of 'complementaries' should further erode faith in them.

It is said that 'complementaries' have no side effects, and do no harm. Well, I have seen an outbreak of Hepatitis B caused by an acupuncturist. I was sent to talk to him. He had beautiful Chinese acupuncture charts, and finely made sets of needles. He assured me he sterilized his needles carefully, every evening. I admired his expensive car.

I have also seen cases of chemical hepatitis traced to a fashionable remedy containing mistletoe.

'Complementaries' would not work with me: I don't believe in magic, I lack the faith. 

The Cost of a Brain

Homo is the product of at least a billion years of biological evolution on planet earth. To be sure not much happened until maybe 600,000 years ago, but when multicellular eukaryotic life appeared the pace of evolution increased dramatically.

No single organism achieved global domination before Homo. A big brain delivers biological success;  beating size, strength, speed and fecundity.

Or does it? Monkeys and apes have big brains, and many of the attributes of Homo, but it is hard to claim they achieved spectacular biological success.

I suspect that language, so far unique to Homo, is the most important element in the success of Homo.

Language is the operating system of the brain, permitting thought and creativity, disseminating information, and enabling complicated social structures.

The corollary to this is that personality will be influenced by the qualities of the language learned in childhood.

A brain capable of language distinguishes humanity.

But brains are biologically very expensive. The demands of a big brain dominate the anatomy, physiology and behavior of Homo, with consequences which are often surprising.

Consider the anatomy of Homo. Intelligence needs a means to manipulate objects, to examine and to use. The human hand is a remarkable multi-purpose tool, the peripheral essential for thought and intelligence. Its fine control attests remarkable co-ordination between hand, eyes and nervous system.

Bipedalism with the spine erect is an anatomical necessity for an intelligent brain, demanding sophisticated neuromuscular control: brain and brawn mutually dependent. Bipedalism frees the fore-limb: locomotion becomes a function of the hind-limbs only.

Bipedalism imposes penalties. The hind-limbs must carry the body weight, generate power for locomotion, and cope with the loads generated. Human leg joints must be among the most stressed in nature: abnormally tall individuals suffer arthritis from an early age.

Bipedalism developed in dinosaurs and birds, but with the spine horizontal. In birds this permitted the evolution of wings; in most bipedal dinosaurs problems of balance mean head, mouth and fore-limbs must be light and small, and the tail big and heavy. In later dinosaurs better posture -  semi-erect - made this problem less severe, so more versatile fore-limbs are found.

Does this mean that dinosaurs might have evolved big brains, even speech and intelligence, but for the extinction event?

Probably not - they lacked the tight control of the internal environment necessary for advanced brain function.

Sense organs must provide precise information: stereoscopic colour vision, acute hearing, and finely discriminating touch, especially on the fingers. Scent and taste are less important, so the muzzle is reduced.

Perception is further improved by the balance of the head, high on a mobile neck - more joints severely stressed in Homo, as the prevalence of cervical osteo-arthritis testifies.

Human physiology supplies the brain, disposes of its wastes, maintains its precise temperature and chemical environments, and delivers its high energy demand.

As a rough guide, in average conditions, a whole day's human energy may be divided three ways: one part for the brain, one to maintain body temperature, and one for all the rest.

Homo needs a lot of food. This is a serious biological penalty incurred to have a brain capable of language.

The brain takes priority in human nutrition, especially during development. If malnutrition or placental insufficiency retards foetal growth, the baby is born with a near normal head, but a short and stunted body.

But Homo's biggest biological penalty is the long growth and maturation of the brain: at least 10 years infancy.

The human baby is a biological absurdity: helpless, exceptionally vulnerable and slow growing. It demands unprecedented care and commitment, from mother and father, bonded intensely and durably. Some say the survival of grand-parents beyond their reproductive years evolved because their additional support helped more grand-children reach maturity.

Social behavior is essential for human survival.

Sex is intense in Homo. It is the primary bonding between reproductive male and female. It is reinforced by powerful emotional responses, the stuff of so much human artistry.

The human female trades sex and guaranteed paternity for commitment, support and security - that is the big deal done at the dawn of man. In chimpanzees sex strengthens clan bonding, but in human evolution the bargain became more intense and more specific.

Essential to this bonding function is loss of the usual mammalian oestrous cycle, in which the female ovulates and becomes receptive to males for short periods only, in due season and time after pregnancies. Instead the human female has the menstrual cycle, in effect continual oestrous, cycle following cycle without intermission, receptive to a chosen male for most of the time.

So menstruation is an adaptation to the biological demands of a big brain!

Too frequent pregnancy is a complication of this behavior, threatening bonding and the future of children. In 'natural' human societies female fertility is suppressed after pregnancy, especially by lactation, which may go on for years.

In well fed modern societies such suppression seems to be lost, and a hard lesson must be learned. Limited numbers of intensively reared children are essential for civilization.

The importance of sex is shown by the strict regulation of sexuality in most human societies. Custom, law and religion focus powerfully on this issue, prescribing severe and sometimes savage penalties for disobedience.

Religion an adaptation promoting the survival of a big-brained species? Hmm. I'll have to think about that.

Homo is a very high maintenance organism. This is the root of the territorial imperative, the need to own resources for the kindred / cultural social unit, excluding competitors. This behavior is  seen already in chimpanzees.

War is another unforeseen consequence of the demands of a big brain.

Indeed the costs of a big brain are exacting, extensive, exigent, and often unexpected. But so far the benefits have amply justified the investment. And even a brief contemplation prompts another important conclusion:  

E biologia semper aliquid novi.