A diplomat has been described as a person sent abroad by his government to lie for his country; the mission of a political doctor is very closely related. By political doctor I mean a physician charged with the care of a government official or a group of them. Dr Brian Monahan is the capital physician. Accordingly, he was sent before the press to comment on the medical condition of Senator Mitch McConnell who has “frozen” twice before cameras during public appearances.

Senator McConnell underwent a triple cardiac bypass in 2003 and has had two serious falls. In 2019 he fractured his shoulder. In March of this year he fell again and suffered a concussion. On July 26, 2023, he froze, unspeaking, for around 20 seconds while addressing a press conference. He was escorted away by aides, but later returned and said he was “fine”. On August 30, 2023, he again froze during a press conference in Covington, Kentucky and was eventually led away by staff.

When Dr Monahan appeared before the press to comment on the medical condition of Senator McConnell he said: “Occasional lightheadedness is not uncommon in concussion recovery and can also be expected as a result of dehydration.” Dr. Monahan also stated he had conferred with Mr. McConnell’s neurology team and that Senator McConnell can still do the work and has no need to step down as minority leader.

Dr Monahan has had a distinguished career as an internist and hematologist/oncologist. But like many physicians is sometimes challenged by the distinction between dehydration and volume contraction.

Let’s start with dehydration. It’s a simple concept. It’s what its name states the loss of water without solute. Since two-thirds of total body water is inside cells, they are the most affected by the loss of water or by the inability to drink or receive sufficient amounts of water. In the absence of diabetes and its consequent hypergylcemia (high blood sugar) dehydration is almost invariably associated with a high blood serum sodium concentration. If water is denied a subject the serum sodium rises and water moves from the cell to extracellular fluid down the osmolar gradient that the high sodium concentration causes – hence intracellular dehydration.

Volume contraction is predominantly an extracellular event. It can be associated with intracellular over or underhydration. An example of the former is volume contraction secondary to diuretic therapy which causes hyponatremia and extracellular volume contraction. The hyponatremia results in an osmolar gradient that moves water into the cell. The infusion of large amounts of hypertonic saline will expand extracellular volume but the movement of water out of the cell will simultaneously cause intracellular dehydration. Volume contraction results from the loss of both water and solute. Examples are blood loss, vomiting, diarrhea, and disease states in which extracellular volume is increased, but its distribution is such that “effective” volume is reduced. Congestive heart failure is a prime example of expanded extracellular volume (the patient has edema), but effective volume (ie, organ perfusion) is reduced. In other words, extracellular volume though increased is distributed such that the circulation is inefficient and impaired organ blood flow causes these organs (especially the kidney) to respond as if volume were contracted.

Even the Mayo Clinic is confused about the distinction between dehydration and volume contraction. “The most common cause of dehydration in young children is severe diarrhea and vomiting.” The quotation is from the Clinic’s article on dehydration. These children have lost both water and solute and are volume contracted. The difference is important because they need more than water replacement – they need salt and water and typically potassium as well. Dehydrated patients need water alone.

Well, what’s this prolix detour got to do with Dr Monahan’s depiction of Senator McConnell’s medical condition? Lightheadedness is a symptom not a diagnosis. It has many causes ranging from trivial to serious. It does not cause people to freeze up and remain rigid and mute for 30 seconds or more. We’ve hit dehydration with a bat and it should be obvious that a person who lives in an air-conditioned environment and has unlimited access to water has no reason to be dehydrated. And dehydration does not cause the episodes Senator McConnell has experienced. Given that he has had two of these “freezes” on camera it is highly likely that he had identical events off camera. The smoothness and alacrity with which his staff handled the second episode suggest that they have experience with the condition. All one can say with certainty is that the senator’s disorder is neurological in origin and that it requires expert medical care.

When doctors are asked to comment on the medical condition of active politicians who are important members of the species they commonly freeze themselves and are capable of nothing more informative than boilerplate. The most insightful comment on the reporting covering the medical analysis of Senator McConnell’s medical problem along with those of other Senators with cognitive issues (not to mention the executive branch) comes predictably from The Babylon Bee. Capitol Physician Medically Clears Bowl Of Jell-O To Serve In Senate