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Understanding Evolution and Being a Good Doctor - Comments

Schrodinger's Cat's Avatar Comment 1 by Schrodinger's Cat

I'm not sure I'd want to be in a hospital with a doctor who believed that a woman might spring from my ribs at any moment.

Sat, 26 May 2012 02:20:57 UTC | #943605

Sample's Avatar Comment 2 by Sample

What's on the horizon in your particular field, doctor?

I find that healthcare providers often love this question. It produces meaningful small talk. For instance, my ophthalmologist remarked about the eventual cure of lenticular sclerosis (hardening of the lens) which is a reason why we require glasses as we age (and, he continued, how 99% of eye doctors will go out of business).

I used his response as a segue into evolutionary medicine and aging by bringing up the concept of antagonistic pleiotropy. What I'm saying is, evolutionary medicine may benefit from its own Out Campaign. Let's get some lapel pins manufactured, shall we? I'm envisioning a Darwin fish/caduceus combination.

Oh, and then, don't forget, when the lovely small talk is over and you deduce that your doctor is a Catholic, conclude your exam by asking him or her, do you really believe the wafer turns into the body of a 1st century Jew? Do you really believe that? *

Mike

*Dawkins

Sat, 26 May 2012 03:22:52 UTC | #943611

Neodarwinian's Avatar Comment 3 by Neodarwinian

" One commenter even said he thought oncologists “have precisely and exactly zero need to understand evolutionary theory.”

Oncologists don't take second semester lower division biology? They better understand it then!

" compartmentalize. " I can not see how there would not be leaking between the compartments. One compartment studying and taking tests on evolution and the theory that explains it and the other compartment, which must be ill built by the contents it holds, having ridiculous creationist beliefs.

Sat, 26 May 2012 03:34:25 UTC | #943612

drumdaddy's Avatar Comment 4 by drumdaddy

Peace to Steve, a great teacher.

Sat, 26 May 2012 13:16:51 UTC | #943643

Sue Blue's Avatar Comment 5 by Sue Blue

I consider an understanding of evolution to be a requirement for medicine; it's foundational to biology! I'm a registered nurse, and I had to take four years of organic chemistry, microbiology, anatomy and physiology before even being accepted into the nursing program - and in all these courses evolution was key (especially in microbiology) to understanding the pathophysiology of disease, from how bacteria and viruses reproduce, mutate, share genes and infect human cells, to the inheritance patterns of genetic disorders, to antibiotic resistance. In order to understand basic human metabolism, it was necessary to learn about the role of mitochondria - and understand how they became part of eukaryotic cells. I can't think of a time when the roles of evolution and natural selection didn't play a part in my medical education. Besides, I found the concepts fascinating, and I can't imagine anyone with the slightest curiosity about functioning of the human body NOT being interested in how we got this way. How can a doctor or nurse be so blinkered and narrow-minded and incurious? My field would be so boring to me if I wasn't constantly seeing wonderful (sometimes scary) evidence of evolution.

Sat, 26 May 2012 14:03:17 UTC | #943651

aquilacane's Avatar Comment 6 by aquilacane

Knowing how and from where our various organs and body parts sprung is an advantage. Learning the building blocks of our own eye and the various stages of its evolution could lead to new ways in which to treat eye problems or engineer superior ones. You have to have no understanding of evolution to think it can't be beneficial.

Sat, 26 May 2012 14:31:36 UTC | #943655

Starcrash's Avatar Comment 7 by Starcrash

The claim here, as usual in this debate, is an equivocation of "medicine" when saying "evolution is useful to medicine". The average doctor checking a patient for signs of illness does not apply evolutionary knowledge, but is implied to be the subject of the field of "medicine". However, the application of evolution is invariably linked to medical researchers. Researchers need to understand evolution? No kidding! But the average doctor can diagnose and prescribe medicine without once resorting to knowledge of evolution.

Sat, 26 May 2012 15:37:21 UTC | #943661

mordacious1's Avatar Comment 8 by mordacious1

One reason evolutionary medicine is important for family doctors is in explaining the reasons for the development of antibiotic resistance and it also has the potential to explain cancer pathogenesis.

I remember explaining to my physician why humans are prone to lower back pain. I cited Randolf Nesse and explained how the human ancestors walked on all fours and that the spine and hips evolved under this circumstance. When it became advantageous to go bipedal, our skeleton and supporting structures didn't evolve enough to completely handle this change in moving about, therefore lower back pain. I suppose you could state that god designed us this way because he is an incompetent fool.

As an aside, I got an email the other day offering an online nursing degree from Liberty University (fully accredited, according to the email). Does anyone want someone from this diploma mill giving them medical care? I'm hoping California has rules in place to keep these people from working in this state, it's scary.

Sat, 26 May 2012 15:55:49 UTC | #943663

alphcat's Avatar Comment 9 by alphcat

There is one very simple reason why a doctor needs to understand and accept evolution and that is that a doctor needs to have an understanding of scientific method, reaearch and what constitutes evidence over rubbish. A doctor may not need to know the detailed ins and outs of every new fossil but if they cannot distinguish between genuine peer reviewed scientific research carried out by experts in their fields and the inane garbage spewed out by so called creation 'science' how on Earth can they be trusted to distinguish between serious clinical trials and mystic megs new magic beans cure for cancer? The practicalities are perhaps less pertinent on a day to day basis than the requirement to have your critical faculties in place and an understanding of what is science and what is not. Evolution is not even contentious new science, it is well established fact. And at the end of the day evolution is essential to learning biology and an in depth understanding of biology is essential to medicine.

I personally would not let a creationist doctor or nurse or pharmacist treat me or my family because the critical faculties required for the job have been disabled. Their religious beliefs are in direct conflict with the specific skills required for the job. In the same way I would not get onto a bus or plane driven by someone clearly drunk - as the critical faculties required for that job would also have been disabled.

I think it is high time evolution was given a bigger role in science education in general and in medical education. Students should be able to prove they understand its importance and the sheer weight of evidence underpinning it. After all it's role in medicine will only increase as we learn more about it. Hopefully that should weed out creationists and encourage them into roles where an understanding of science and logical thinking are less important.

Sat, 26 May 2012 17:47:54 UTC | #943670

Stafford Gordon's Avatar Comment 10 by Stafford Gordon

You can't be a Doctor if you don't understand where all the superfluous residual bits and pieces came from; pure and simple.

As always, I stand to be corrected; I'm only here to learn.

Sat, 26 May 2012 18:10:46 UTC | #943674

Stafford Gordon's Avatar Comment 11 by Stafford Gordon

You can't be a Doctor if you don't understand where all the superfluous residual bits and pieces came from; pure and simple.

As always, I stand to be corrected; I'm only here to learn.

Sat, 26 May 2012 18:19:52 UTC | #943675

ridelo's Avatar Comment 12 by ridelo

Quote: Nothing in Biology Makes Sense Except in the Light of Evolution" is a 1973 essay by the evolutionary biologist and Russian Orthodox Christian Theodosius Dobzhansky

Sat, 26 May 2012 20:31:27 UTC | #943692

Starcrash's Avatar Comment 13 by Starcrash

I was going to defend my position, but I take it back -- despite speaking to reasonable people, bias ruins a lot of these arguments. And frankly, I don't want to defend creationists any more than you guys do.

Sat, 26 May 2012 22:10:35 UTC | #943707

LaurieB's Avatar Comment 14 by LaurieB

Harvard University has a winter lecture series called Evolution Matters. The March 29th lecture was on Evolutionary Medicine, given by Randolph Nesse. Here's the video:

http://vimeo.com/41358588

It was very interesting and I am currently reading the book by Nesse and Williams, Why We Get Sick. Looks like it was published in 1995 and I'll probably look around for something more current when I'm done. I'm just on chapter 6 right now titled, Toxins: New, Old, and Everywhere. He's talking about adaptations that neutralize toxins that we encounter in the environment and that we intake through food. Here's an interesting section from chapter 6, page 84-85 paperback edition:

"Human diets expanded after fire was domesticated. Because heat detoxifies many of the most potent plant poisons, cooking makes it possible for us to eat foods that would otherwise poison us. The cyanogenetic glycosides in arum leaves and roots are destroyed by heat, so that arum could be cooked and eaten by the early Europeans. Unfortunately, some toxins are stable at high temperatures, while other new toxins are actually produced by cooking. That tasty char on barbecued chicken contains enough toxic nitrosamines for several authorities to recommend restricting our intake of grilled meat to prevent stomach cancer. Have we been cooking meat long enough to have developed specific defenses against the char toxins? Cooking may have been invented hundreds of thousands of years ago, and it must have started with barbecues on open fires. It would be interesting to know if we are more resistant to heat-produced toxins than our closest primate relatives are."

I'll bet Richard Wrangham has something to say about this. His book is Catching Fire How Cooking Made us Human. I have that book too but read it quite a while back.

Sat, 26 May 2012 22:40:32 UTC | #943715

Odalrich's Avatar Comment 15 by Odalrich

How can some people say that a good doctor doesn't need knowledge of Darwinian evolution when viruses are constantly evolving? Evolution cannot be detected in real time; however, scientists and doctors can see the evolutionary process in the HIV virus (the virus that causes AIDS). This virus can evolve within hours to become resistant to drugs and doctors need to know how these processes are carried out in order to struggle against AIDS more efficiently and with less risk for patients. Evolution should be a compulsory subject in Medicine.

Sat, 26 May 2012 23:55:40 UTC | #943730

sciencemd68's Avatar Comment 16 by sciencemd68

As a physician, I think I understand why physicians may be less than comfortable with natural selection. We see the human body at its worst. We see superflous and dangerous organs that don't seem to have a purpose that should have been eliminated under natural selection. We see things like senescence, shock and congestive heart failure that don't seem to have an explanation from a survival of the fittest perspective. For example, as the heart starts to fail, blood pressure rises, kidneys hold onto more salt and fluid, and lungs fill up with that excess fluid all of which makes it harder on the failing heart. As physicians get further and further from biology class they don't recall (or were never taught) the evolutionary explanation for these conundrums they face every day. But it is critically important to understand why we age, why we get sick and more importantly why we die if we are going to be able to converse intelligently and realistically with our patients faced things like hernias, appendicitis or cancer. To give into religious explanations (it's God's plan) or to forgo intellectual curiousity over these issues is a diservice to our patients afflicted with these ailments. I have seen papers trying to explain from an evolutionary perspective,the persistance of the appendix or the explanation of the prevalence of autoimmune disease. These articles fail to realize that perhaps these entities persist because at one time in our evolution, it was beneficial for your progeny if not everyone lived forever. Another surgeon wrote about this in a curious book called The Ju-jitsu of the Peahen. It's an interesting perspective of evolution from a physician and should be mandatory reading for all medical students.

Sun, 27 May 2012 02:28:47 UTC | #943749

Nietzsche's_Moustache's Avatar Comment 17 by Nietzsche's_Moustache

LaurieB:

I'll bet Richard Wrangham has something to say about this. His book is Catching Fire How Cooking Made us Human. I have that book too but read it quite a while back.

I just finished that book yesterday! Fascinating. It's a pity there isn't more evidence to more accuratelly pinpoint when our ancestors started cooking. Homo Erectus definitely and probably a lot earlier according to Wrangham. It may go back several million years (?) although that is merely speculation.

Sun, 27 May 2012 03:46:40 UTC | #943757

SnowyDoc's Avatar Comment 18 by SnowyDoc

Saying a doctor doesn't need to fully understand or apply the principles of evolution by natural selection in order to practice competently could be reasonably argued (as some have commented above), however such an approach leaves us in "stamp collecting" territory; learning by rote, and relying on recalling and applying purely descriptive knowledge without the understanding of how and why things are the way they are. And, more importantly, how they are likely to change in the future.

It would be a bit like a 17th century biologist dutifully discovering, cataloging and classifying species phenotypically, devoid of the underlying principle that would later allow molecular/genetic cladists to probe those relationships in an entirely more refined, complete, and intellectually satisfying way. Indeed, it's something like the difference between knowing that stuff falls to the ground (and even measuring how fast stuff falls, quite accurately) and having an understanding of Newtonian mechanics and Kepler's laws. An entirely new vista of knowledge and understanding and, importantly, predictive power, is revealed. Working out pretty well how you can expect a cannonball to fly based on trial and error is a very different kettle of fish to accurately and confidently putting space probes into precise orbit around distant celestial bodies.

The obvious see-evolution-happening-before-your-very-eyes case is the development of antimicrobial resistance in bacteria (and I highly recommend anyone curious and with a cellular biology bent to read up a little bit on the myriad ways in which the sneaky little buggers do it... it is fascinating). But beyond this most overt, and now almost culturally bland, example of the importance of evolutionary principles to the practice of medicine, there is a panoply of applications of immediate relevance to our efficacy as physicians.

Ordering the right laboratory investigations and making the correct diagnosis can hinge on an informed understanding of the pre-test probabilites of potential underlying conditions... the genetic differences (small though they are) between peoples who have evolved (quite recently on the timescales we usually bandy about when discussing evolutionary change) in different parts of the world can crucially alter our ability to get a diagnosis right (or even consider it in the first place), and can mean the difference between an optimal outcome, and unnecessary (and potentially harmful) investigations and incorrect treatment.

Knowing how microbes have co-evolved with our immune system is at least as important as simply knowing that "antibiotic resistance happens". For example, the fact we know the mechanisms that have evolved in encapsulated organisms (Strep.pneumonia, N.meninigitidis ("meningococcus"), etc...) to enable them to evade most of our usually highly effective immune response means that as well as knowing what drugs I need to kill these bugs, I can also pretty confidently predict that in 10 years' time if I have a patient who needs his spleen removed after a bad motorcycle accident, I will need to immunise him with a vaccine for the newly discovered encapsulated pathogen (that I don't even know exists yet) that started making the rounds in humans say 5 years from now.... because whether by sharing genes with older strains of bug, or by convergent evolution, the new bug will very likely be difficult to opsonise with antibodies and without a fully functional splenic reticuloendothelial system, my patient will be particularly susceptible to such an infection.

It allows us to offer useful advice to people who may, or do, carry certain genetic traits regarding antenatal screening for specific conditions, or it may even affect whether they have children at all.

It helps us understand our own mortality. We fall apart after a certain age because our selfish genes have little practical use for us after we've passed them on, and maybe hung around long enough to be helpful and effective grandparents beyond that.

It guides our decision-making about where our research funding should most fruitfully go, and informs our interpretation of new research findings and our application of those findings to our practice.

If nothing else, it enables us to do what... for the longest time... was the only real service a doctor could offer a patient; provide a prognosis, and explain... truthfully... why this ailment has happened to them, and how and why it would either progress, or improve.

Evolution by natural selection is the central explanatory and predictive principle of all biology as we know it and, by extension, all medical science, upon which we base our medical practice. A fellow by the name of William Osler once said: “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” I would humbly suggest that practicing medicine without embracing and understanding evolution is, perhaps, a bit like heading out onto those same seas, but without an understanding of plate tectonics, oceanography and meteorology. Knowing roughly what the coastlines look like is very helpful and necessary, but a deeper understanding of why they are where, and how, gives us a much better grasp of what we are likely to find when we get there, as well as an improved ability to both predict and adapt to problems we might encounter along the way.

Sun, 27 May 2012 04:04:48 UTC | #943759

Anonymous's Avatar Comment 19 by Anonymous

Comment Removed by Moderator

Sun, 27 May 2012 05:36:23 UTC | #943766

LaurieB's Avatar Comment 20 by LaurieB

Nietzsche's_Moustache

I tried to find the video of Wrangham's presentation at Harvard but couldn't. It's probably there someplace if you search for it. I saw the lecture there just after his book came out. Some aspects of that book annoy me to no end but I love the whole topic in general.

If you like Wrangham's book then you may want to consider reading Evolution of the Human Head by Daniel Lieberman. I read this book after I finished Wrangham's book and was blown away by Human Head. A good familiarity with A&P would be advised for this book and I'm very sure that the Docs on this site would find it to be gripping. Unfortunately I missed Lieberman's lecture on the subject at Harvard but here's the video:

http://www.hmnh.harvard.edu/lectures-classes-events/evolution-matters-lecture-series-videos-2011.html

As I've mentioned before, this Harvard Lecture series is a fantastic gift to the general public. The lectures go all winter and are free to the public. Sometimes they open the Museum of Natural History for us to wander through after the lecture and serve free wine and food. The lecturer is there mingling (not to mention various other Harvard Proffs) and answering questions. This type of event, like the internet, has the effect of bringing the public more closely into the domain of our most accomplished academics. I think this is a valuable way to introduce ideas to the general public and hopefully inspire them to read further on topics that capture their imagination. Boston has a history of public lectures as educational devices and I wish this would be expanded for the purpose of instructing people on various current issues.

The perspectives of the Docs who commented here is very interesting but it's not just Docs who need to understand these matters. Parents would do well to have a basic grasp of these ideas too. Novella's question stated above is, "How does understanding the science of medicine impact the practice of medicine?" In the book by Nesse, Why We Get Sick, which I am reading now, he brings up the simple question of to what extent should we treat things like runny noses, fever, diarrhea? If fever exists as the body's way of frying the pathogens that have invaded then isn't it a better idea to let the moderate fever run it's course? When I think back to when my kids were small, I wish I'd had a better understanding of this particular issue. I was much too quick to run for the tylenol and give them a dose of it just to bring the fever down. I definitely viewed fever as a frightening threat to the health of my child. I see now that I may have tripped up a very effective natural defense strategy that exists in them and in fact lengthened the recovery time in general.

Here's another interesting paragraph from Why We Get Sick by Nesse, from Chapter 3 page 36.

"The defenses at each body opening can be quickly increased if danger threatens. Irritation of the nose by a viral infection provokes the discharge of such copious mucus that one can go through a whole box of tissues in a day. Millions of people use nasal sprays each year to block this useful response, but there are remarkably few studies that have investigated whether the use of such devices delays recovery from a cold. If they do not demonstrably delay recovery, as seems to be the case from the limited data, it would be evidence that a runny nose is not a defense but an example of a pathogen manipulating the defensive adaptation, but not every sneeze need be adaptive for the sneezer. Some sneezing may possibly be an adaptation that viruses use to disperse themselves."

Isn't this an interesting quandary? Are diarrhea, sneezing, runny nose, etc., defensive devices that kick in to do battle against invasive pathogens by casting them out in short order or are these just ways that these microscopic invaders are manipulating us for their own benefit? There's nothing like diarrhea, sneezing and runny nose to effectively disperse microbes far and wide. (except maybe sexual behavior!) To what degree should we treat these?

Sun, 27 May 2012 12:23:45 UTC | #943812

Alan4discussion's Avatar Comment 21 by Alan4discussion

Comment 7 by Starcrash

The claim here, as usual in this debate, is an equivocation of "medicine" when saying "evolution is useful to medicine". The average doctor checking a patient for signs of illness does not apply evolutionary knowledge, but is implied to be the subject of the field of "medicine". However, the application of evolution is invariably linked to medical researchers. Researchers need to understand evolution? No kidding! But the average doctor can diagnose and prescribe medicine without once resorting to knowledge of evolution.

Comment 18 by SnowyDoc

Saying a doctor doesn't need to fully understand or apply the principles of evolution by natural selection in order to practice competently could be reasonably argued (as some have commented above), however such an approach leaves us in "stamp collecting" territory; learning by rote, and relying on recalling and applying purely descriptive knowledge without the understanding of how and why things are the way they are.

It is possible to reach a degree of success by following rote-learned diagnostic manuals and pharmaceutical company guidance on medication and dosages for particular medical conditions.

Many doctors in general practice cover a huge range of topics, while specialist surgeons are almost like engineer/technicians in very narrow fields.

I would suspect that educated supporting medical staff and pharmacists could "carry" a lame duck evolution denying doctor, even though this is far from satisfactory.

Mon, 28 May 2012 13:47:35 UTC | #943972

Roy72's Avatar Comment 22 by Roy72

Working for a drug company we frequently discuss data from clinical trials run on human volunteers, but also occasionally discuss the phase I animal studies where physicians want the background info.

As an example several highly useful and established drugs are actually toxic or carcinogenic to rats and mice (the most frequently used animals) in early trials but when tested on primates (usually monkeys) have not had the same negative effects. Using a test subject closer to us in evolutionary terms allowed the drug to be developed to eventually benefit patients.

Working in the UK I am comfortable that about 99% of doctors would understand the basic evolutionary logic of this but I would hesitate if I thought the doctor was a creationist. In fact wouldn't a creationist presumably have to believe all animal studies are irrelevant to humans?

Mon, 28 May 2012 22:18:19 UTC | #944087

Nietzsche's_Moustache's Avatar Comment 23 by Nietzsche's_Moustache

Thanks LaurieB, I'll check those suggestions out.

Tue, 29 May 2012 11:10:52 UTC | #944201

Enlightenme..'s Avatar Comment 24 by Enlightenme..

My training as an electrician did not need Faraday & Maxwell !

Tue, 29 May 2012 18:23:48 UTC | #944275

Ignorant Amos's Avatar Comment 25 by Ignorant Amos

Comment 24 by Enlightenme..

My training as an electrician did not need Faraday & Maxwell !

Perhaps not....but it needed Faraday's Law of Induction....and that's just for starters.

Well....mine did in any case.

Tue, 29 May 2012 19:34:44 UTC | #944298

ozkrenske's Avatar Comment 26 by ozkrenske

The electrician idea is interesting.

You are effectively doing rote work to a plan without needing to know the design principals. I guess as has been mentioned a doctor could work that way 90% of the time and unload the work on a different/specialist doctor for the other stuff.

But for actual design and modification work to complex electrical designs we use electrical engineers. People who have studied Faraday and Maxwell. Even then though many of those engineers have simply learnt equations and when to apply them.

Applied electrical research is effectively a static or set field, the equations are determined and they work, other branches of physics show why. So very little work is done on finding alternatives but if there was a valid falsification of those theories and ideas, then you would see massive research efforts into why they fail (see the discovery of exceptions and the research boom around super conductors).

Medicine though is not a set or static field, we still know very little about the interactions of many of the basic elements of medicine. As such the engineer level of medicine (I speculate that is the specialist) doesn't have set formulas and so needs to know more of the research side. Similarly the Medical researcher needs to know huge amounts about related Biology to determine functions and carry out their research.

I guess it is the simplicity of Physics and the fact that much of it, is actually near complete for our normal realms of comprehension, that makes the rote level of worker useful. If the whole of electrical theory was up in the air and no formulas existed and it was more of an art form then I would expect common electrical workers to need a lot more knowledge of current theory and research to be competent. That was the case for early electricians and mechanical workers, many of which made the jump to engineer/designer and researcher.

Just my musings on the idea. Not particularly insightful.

Wed, 30 May 2012 03:00:10 UTC | #944363

Ignorant Amos's Avatar Comment 27 by Ignorant Amos

Comment 26 by ozkrenske

The electrician idea is interesting.

You are effectively doing rote work to a plan without needing to know the design principals. I guess as has been mentioned a doctor could work that way 90% of the time and unload the work on a different/specialist doctor for the other stuff.

I can only speak from my own perspective.

Training as an Electrician R.E., a lot of the course was theory. Kirchoff's Law, Ohm's Law, Wheatstone Bridge, Faraday's Law, etc., etc. A lot of math's also, transformation of formula, vectors, etc., etc.,. Installation regulations are also continuously changing...the U.K. is on the 17th Edition. One has to keep up with ever changing developments in the field and the materials used. It is not a static field.

None of the theory learned is used to wire a house, but a competent understanding along with taking and passing of exams in such, was required before moving on to the 'hands on' part. Certainly, trust in Ohm's Law being right is not a requirement to be able to erect and dress a high voltage pylon, synchronise generators, join an underground cable, install an airfield ring circuit or wire a house, but I don't know of any electrician that doubts the validation of such Law's and as you say, to progress to greater things in the discipline, one must accept the basics. Medicine seems to be the only area outside woo woo where woo woo can trump the science of "the shoulders of giants" on which a doctor is standing.

The rudiments of any discipline can be rote learnt with the right intellectual capacity and manual dexterity, but like everything else, an electrician that has been out of the game for any length of time will have their eyes widened if they returned, say having not practised for 30 years. As would anyone who is an out-of-touch professional, doctor included, heck even soldiering is not what it was when I was there.

A modern doctor's working environment has been impacted by our changing developments and understanding of the details in evolution. It makes no difference if an individual doctor has no support for the theory....their job would be impossible without it whether they like it or not.

Wed, 30 May 2012 11:24:00 UTC | #944448

Tyler Durden's Avatar Comment 28 by Tyler Durden

Comment 27 by Ignorant Amos :

It is not a static field.

Very droll :)

Wed, 30 May 2012 11:52:49 UTC | #944464

Ignorant Amos's Avatar Comment 29 by Ignorant Amos

Comment 28 by Tyler Durden

Insulation is the name of the game Tyler....great for the rubber fetishist. Anti-static matting everywhere.

Wed, 30 May 2012 12:57:03 UTC | #944478