Tag Archives: Medicine

Fatal Flaws – Jay Ingram ****

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There is no doubt that Jay Ingram knows how to make a story dramatic, and he does so with all guns blazing in Fatal Flaws, the story of the discovery of the (probable) causes of Screenshot_21_04_2013_11_21prion-based diseases kuru, scrapie, CJD and BSE.

The first half or more of this book reads wonderfully well at a good pace, exploring the detective story behind the suspicions that these diseases were some how transmittable despite not appearing to involve bacteria or virus – in fact any sign of conventional infection. Ingram focuses on two fascinating areas: what prions are and how they could cause such terrible diseases, and the nature of scientific discovery, warts and all. He profitably spends plenty of time on the less salubrious aspects of academic rivalry and the vastly different approaches of some grandstanding scientists and other solid, behind the scenes workers.

From the offset I thought this was a great book. I have a low tolerance for medical matters, but prions and the nature of their means of attack and transmission are so fascinating that this pushed any medical squeamishness out of the way, as did the biographical detail. After all these appear to be proteins with no DNA component that somehow manage to reproduce, running contrary to what could be regarded as a dogmatic aspect of biology. In a horrible way, prions and their ability to interfere with the way other proteins fold are things of wonder.

Only one thing grated – Ingram insists on telling us over and over again what he is doing and how he is going about it. This is mildly irritating. Also the later part of the book, where he looks at the deer equivalent of BSE and goes through a whole set on chapters on brain diseases that are like prion-based diseases with no obvious prion contribution gets a little tedious and lacks all the storytelling and drive of the earlier section.

All in all, despite these minor failings it’s a gripping read on prions, kuru and BSE, and really gives food for thought on the way we go about science. Recommended.

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Review by Brian Clegg

Plagues Pox and Pestilence – Richard Platt ****

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This large format hardback has all the gusto of a Horrible Science title in taking on disease – specifically the illnesses caused by protists, bacteria and viruses - and making it rather fun. The layout is very much Dorling Kindersley style with large two page spreads, busy with information, but John Kelly’s detailed (if occasionally murky) illustrations bring out much more of a fun side you might think there would be a struggle to incorporate in a title like this.

On the whole it’s hard to argue about the detailed and interesting contents. As well as meeting plenty of individual bugs we take in the way they travel and the  great pandemics, ways of stopping them, theories of disease and more. Sometimes we’re presented with quite a high level overview, like ‘Death in the air’ on diseases carried by mosquitos and the like – at others we dive in to quite a lot of detail, with a spread on John Snow and the Broad Street pump and its deadly dose of cholera.

I think the book’s biggest weakness is the lack of structure – it seems to dart from one thing to another with very little idea of ordered progression. I was also a little disappointed with its dealing with viruses. We are told, for example, that viruses ‘are not alive. To reproduce, they invade tiny body cells…’ but hang on there. How can something not alive do something like ‘invade’ or ‘reproduce’? Richard Platt could have taken a step back and given us a rather less pat view of what a virus is and how it works.

However these are relatively minor concerns in what is a very enjoyable read with lots of detail to discover on every page. Excellent pestilent fun.

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Review by Brian Clegg

The Little Book of Medical Breakthroughs – Naomi Craft ***

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Naomi Craft’s small book is a handy reference guide to the development of medicine over the years. She takes us through some of the most significant advances in chronological order, with each entry being one or two pages long, and also covering the main people behind the discoveries and breakthroughs, the time of the breakthroughs, and the places the advances originated.

We have big theoretical breakthroughs in science, which advanced our general understanding of how to practice medicine, like the outcome of Mendel’s experiments on peas and Watson and Crick’s discovery of the structure of DNA. We look at the emergence of operational techniques, like key hole surgery and tele-surgery (where the doctor and patient can be separated by thousands of miles). We have small practical advances, like the idea that hand washing can prevent the spread of disease. And we look at ideas that have changed the culture within which medicine is done – evidence-based medicine (including randomised-controlled trials) is covered, for instance, with this now being seen as just as important as the authority of individual doctors.

There are some interesting facts along the way. It is said, for instance, that the Roman philosopher Seneca used to read books through a bowl filled with water, using it as a primitive lens. And there are quite a few unpleasant medical practices covered – one of these, which isn’t the worst example in the book, is doctors drinking their patients’ urine to measure the sweetness of it. They were testing for what we now know as diabetes.

There is enough context and surrounding information in each short article for the book not to feel too much like a dictionary and, as everything is in chorological order, it is something you could read to get a general feel for the history of medicine. Being the kind of book that it is, there’s nothing to get too excited about – but it does the job it aims to do well.

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Review by Matt Chorley

Diagnosis [Every Patient Tells a Story] – Lisa Sanders ****

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In the class system of popular science books, Diagnosis has all the marks of good breeding. It is authored by an experienced medical professional, is based on a popular New York Times column, is backed by a hugely successful TV series (House, M. D.), and bears a cover endorsement from a household name in the UK and US (Hugh Laurie). With such a background, what could possibly go wrong? The answer, not surprisingly, is “not much.” Lisa Sanders — the technical adviser to House – gives a frank and engaging tour of the modern diagnostic process, packed with real-life case studies.

The brevity and variety of the case studies means it is hard to get bored with this book; even if one loses track of the argument, there is always another medical mystery to latch on to. Some of these mysteries are bizarre, from the patient who has turned highlighter yellow to the computer programmer who suddenly loses his memory. Others are less colourful but no less difficult or telling: the patient with a tell-tale rash that has been overlooked among his more dramatic symptoms; the enlarged prostate gland, incapacitating an old man’s kidneys, that is discovered by chance in the rush to get him to surgery. All cases are chosen to make a point about medical diagnoses.

Saunder’s main points are: doctors should listen to everything the patient tells them, not just the bare facts; doctors should translate medical diagnoses into a language patients can understand; high-tech testing procedures are no substitute for a sensitive physical exam using at least three of the doctor’s five senses; an uncertain diagnosis is better than a false one; and doctors are not immune to cognitive errors.

In and around these key ideas, Sanders weaves a narrative about modern medical education, drawing from research studies and her own experience. In this regard it is especially interesting to read about the informality of the learning process, with interns thrust unsupervised into physical exams, medical lore passed from doctor to doctor in the corridors, and senior doctors drawing regularly on more experienced staff for help on tough cases. Sanders brings to life the awkwardness of her first physical exam, conducted on a topless patient-trainer; the embarrassment of making basic errors in a field where mishaps can be fatal; the eeriness of her first autopsy and various other medical rites of passage. Another recurring theme is the reasoning process that is involved in making a diagnosis. In this respect, a highlight is Sander’s fond portrayal of a “stump the professor” meeting in which student medics challenge a guest professor with a difficult case, the point being less to get the right answer than to learn from the professor’s approach to the problem. There is also a too-brief section on the cognitive science of medical decision-making, where Sanders does little more than distinguish between intuitive and analytical thought processes.

Occasionally the broader argument of the book gets lost in the details of the case studies. Or rather, it is not clear what the overall argument is meant to be. Over half of the book is devoted to aspects of the physical exam – seeing, hearing, and touching the patient to make a diagnosis – and Sanders clearly wishes to argue for a reversal of the trend towards hands-off medical training and practice. But if that is her argument it is not stated in the introduction or in the non-existent conclusion. And other parts of the book, though interesting in themselves, do not obviously fit into the back-to-basics theme. These include sections on attempts to automate diagnosis with computers, the use of Google as a diagnostic tool, and the curious and unsettling case of the phantom illness “chronic Lyme disease.” This ambiguity of aim is not helped by the book’s odd structure: it is divided into three parts of wildly different lengths.

Diagnosis could have been more carefully planned, but it holds the reader’s attention all the way through and gives colour to some pressing issues in modern medicine.

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Review by Michael Bycroft

The Emperor’s New Drugs – Irving Kirsch ****

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They say that the Origin of Species is “one long argument.” Irving Kirsch may not share Darwin’s eloquence, but in The Emperor’s New Drugs he shares his passion for persuasion. Thanks to its wide scope, smooth delivery, and mastery of the data, this book is about as persuasive as a popular science book can be.

“The belief that antidepressants can cure depression chemically is simply wrong.” So Kirsch claims. A claim like this raises a host of questions. Some are easy to answer: why would drug companies exaggerate the value of their pills in an anti-depressant market worth $19 billion a year? Why would regulatory agencies that are partly funded by drug companies play along with these exaggerations? Other questions are harder: if antidepressants do not cure depression chemically, how do they do so? And if the answer is “the placebo effect”, how can the placebo effect be so strong as to convince millions of patients, thousands of doctors, and dozens of editors, that antidepressants are more than just glorified sugar pills?

Some of the tough questions turn out to have simple answers. The reason everyone was duped by the chemical-imbalance theory of depression, says Kirsch, is that the theory itself was based mainly on the (supposed) effectiveness of chemicals in treating depression. Some answers rely on clever reasoning. Clinical trials show that antidepressants are actually more effective, by a small but significant amount, than placebos. Kirsch explains this deftly as an “enhanced placebo effect”: patients who detect the side-effects of antidepressants know that they are on active drugs, raising their expectations about the treatment and enhancing the placebo effect.

What all Kirsch’s answers have in common is thorough attention to the relevant data (published and unpublished) and a keen nose for interpretation. Kirsch marshals an impressive range of evidence to back his case: the bibliography runs to 25 pages and consists mainly in articles from top medical and psychology journals. If he does not have a study or meta-analysis to back up a claim, he says so. And he knows that a striking anecdote is just a striking anecdote, even if it punches for his own team.

The book a good first course in scientific method, and a key lesson in the Kirsch curriculum is that data alone does not put a hypothesis to the test. Data, plus a dose of careful interpretation, is the only real medicine in science. Drug companies did not falsify the reports of individual patients or doctors. Nor did they (usually) fudge individual studies. The devil was not in the details but in the grand design, the way they selected out negative studies and re-hashed positive ones. In lifting the lid on the cover-up, Kirsch gives a running response to those say that meta-analysis, as a scientific technique, is indefensible; nay, says Kirsch, it is indispensible.

The question every reader will have is partly an ethical question: given that antidepressants would no longer be effective if everyone knew they were only placebos, should the “dirty little secret” be made public? Kirsch, true to form, answers this question with a patient summary of studies and meta-studies. In doing this, he does not ignore the ethical core of the question. The aim is to cut through the empirical flesh to make the core issue as clear as possible. Kirsch shows that if you cut deftly enough, the core issue might not be ethical at all. This book asks: if we can show that psychotherapy is cheaper, safer, and more effective in the long run than anti-depressants, what ethical argument could possibly warrant the continued prescription of anti-depressants? Good question.

When it comes to writing clear prose, it is not always advantageous to be a scientist. But for Kirsch, it is so. He is no wordsmith (or doesn’t want to be), and if you are looking for blazing rhetoric then this not the book for you. But if you want to understand what a balanced-placebo test is and why it works, how neurotransmitters are meant to explain depression, and the difference between “response-rate” and “average improvement” in clinical trials, Kirsch is a lucid guide. His prose might read dryly for some. But the result is that if you can understand a bar graph, you can understand this book.

What Kirsch lacks in verbal charisma, he makes up for in arresting content. His chapters on the placebo effect make for fascinating reading. My favourite is the man who swallowed all his pills and collapsed in a heap on his GP’s floor – only to find, when he came round, that he had overdosed on fake pills. Equally striking are the basketball-players whose knee problems were fixed using placebo surgery, and the angina, dermatitis, and electro-shock victims who were all cured or assuaged by the power of belief. Kirsch describes lots of experiments designed to tease out the details of the placebo effect. The methods are clever, and the results run a skewer through our intuitions about physiological cause and effect. The results seem like voodoo, but the methods do not. As this book reminds us, implicitly but forcefully, it is the methods that matter.

Kirsch is sometimes not as methodical as he might be. One defence of anti-depressants is that they have both a placebo effect and a real chemical effect, but that these two effects are not additive. Kirsch describes how this hypothesis might be tested, but admits that no such tests have been done. He tells us that drug companies, who would otherwise sponsor such tests, are running scared. Fair enough; but the fact remains that the tests have not been done. Also, a bullet-point summary would be useful to tie up the threads of evidence against anti-depressants; sometimes the same thread turns up in widely separated chapters, making it hard to keep track.

Kirsch could do better to explain the weirdness of the placebo effect. How can the mind restore the cartilage in a bad knee just by expecting the knee to be cured? Kirsch suggests that this is easily explained as a purely physical causation, the brain acting on the knee. But it seems just as weird for the brain to cure cartilage as for the mind to do it. It also seems weird to say that the brain “expects” something. Lastly, it seems weird for positive expectations to have a positive effect. Why don’t positive expectations just make the brain more complacent, and therefore idle? Kirsch seems complacent about explaining the placebo effect, even if (or because) the evidence for its existence is overwhelming.

These quibbles do not threaten Kirsch’s argument. In the epilogue Kirsch says he enjoys “rocking the boat.” And the evidence suggests he has knocked antidepressants into the water. He reports a recent survey of UK clinicians showing that almost half will (or have) changed their practices because of Kirsch’s work. He has also made waves in the murky waters of drug regulation, helping to bring about proper tracking of drug trials. But he is a placid revolutionary, and his easy prose and wide knowledge make for a smooth ride – and a persuasive one.

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Review by Michael Bycroft

Living with Enza – Mark Honigsbaum ****

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There was something chilling about reading Mark Honigsbaum’s account of the 1918 flu pandemic at a time when the world is threatened with another pandemic, of a similar type of influenza (at the time of writing, the 2009 swine flu outbreak has recently been declared a pandemic). There are distinct parallels – in 1918 there was a mild early outbreak before a crushing attack in the winter that killed millions worldwide.

What’s fascinating in Honigsbaum’s account is the way he intertwines the story of the flu pandemic with the story of the First World War, an era in history that for my generation was largely forgotten (we studied the Second World War in school, but not the first). It’s essential to make this link as it has, at least in part, to explain why the flu pandemic was given such scant regard at the time – there is very little written up about it – and it also adds pathos as we see these two terrible killers side by side. It also seems to be the case that, despite being called Spanish Flu back then, that the outbreak may well have come to Europe from the USA along with troops fighting in the war.

There is now a certain amount of irony about the last part of the book, which looks at how things might develop with a future pandemic, basing it on the bird flu scare that was prevalent when the book was written. Oddly, one thing Honigsbaum didn’t foresee was that we would have a mild outbreak first, paralleling the 1918 situation, and so giving the authorities more breathing space than he thought we would get.

Even so, the book, with its vivid descriptions of the impact of flu and the associated bacterial infections that tend to piggy-back on it makes grim and worrying reading. If the book has a fault, it’s a touch dry and does perhaps labour some of the details, but it is, nonetheless, a timely warning of what could be around the corner. It’s difficult to encourage people to buy books that are going to depress them – but this should be the exception to the rule.

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Review by Brian Clegg

Polio: An American Story – David M. Oshinsky *****

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Author David Oshinsky has done a masterful job of bringing to life the struggles to develop a vaccine against polio. I used the word struggles because it is not just a story of virus versus man. The story he weaves is exciting and compelling; it is so much more than the history of growing viruses and testing vaccines. The book is comprised of three intertwining storylines: the efforts of the March of Dimes campaign and the National Foundation for Infantile Paralysis to raise money for research and patient care, the development of the killed vaccine by Jonas Salk, and the competition between the supporters of the killed vaccine and the supporters of a live, weakened vaccine, represented most vividly by Albert Sabin.

The story was extremely well-written and easy to follow. When I picked up the book, I thought that this will be a chauvinistic attempt by the author to demonstrate how the mighty United States was able to conquer a deadly disease all by itself. But I’ve always found the story of the polio vaccine very interesting and I even remember my mother saying how happy she was that the vaccine had became available when I was a child. Oshinsky does clearly prove that it is truly an American story: an American fund-raising campaign, an American president (Franklin Delano Roosevelt) afflicted with the disease, and the American scientists striving to develop the first vaccine. But to Oshinsky’s credit, it is a very unbiased report. He points out the scare tactics used by the National Foundation and its then-novel method of fund-raising. He is also critical of the method of vaccine distribution and attributes vaccine shortages to industry and physicians’ desire to keep government out of medicine. He even contrasts this to Canada’s more successful policy of centralized distribution. And he is clear when there is a non-American connection, that is when studies of the live-weakened vaccine take place in the Soviet Union.

Oshinsky gives just the right amount of biographical information so that the reader understands why the main characters acted the way they did. He delves not only into the salient facts but also places events in the context of the personalities and the clashes that can occur among people of strong personalities. In order to understand the development of the vaccine, some understanding of the science is required and Oshinsky carefully leads the reader along. The politics of the development of the vaccine is also discussed. There wasn’t much that I didn’t like about the book and I would have no suggestions about how it could be improved. Indeed this book led me to another book about polio that I look forward to reading, The Cutter Incident: How America’s First Polio Vaccine Led to the Growing Vaccine Crisis, by P.A. Offit.

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Review by Stephen Goldberg

Trick or Treatment – Simon Singh & Edzard Ernst *****

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It’s typical, isn’t it. You wait for years for a good book on bad medicine, and then two come out close together – Ben Goldacre’s Bad Science and this. Don’t worry, though, about choosing between them – every sensible person ought to get both.

Although Ben Goldacre comes from a medical background he takes a wider viewpoint than just bad medical science, where this book looks specifically at alternative medicine. The outcome is electrifying to everyone who thinks and has used or considered using anything like homeopathy or acupuncture. Singh and Ernst don’t set out with any malice – Ernst has worked for many years in alternative medicine – but they show devastatingly how proper trials have shown these alternative treatments to rarely be better than a placebo, and often to have negative or even life-threatening consequences.

It really is striking – the vast majority of alternative medical treatments are proved to be on a par with snake oil. Apart from anything else, this ought to be required reading for doctors -a surprising number encourage alternative treatment – for celebrities who endorse this kind of medication and particularly the media which all too often is wide-eyed and idiotic on the subject of alternative treatments. In the UK, Prince Charles who has bumbled on about the subject for many years, ought to be forced to copy this book out by hand until he gets the point.

All in all, one of the most important popular science books of the year, and what’s more it’s very readable too. By combining Ernst’s expertise on the subject and Singh’s superb science writing we have a book that is as entertaining as it is informative, and the emphasis on real testing will be a delight to anyone who enjoys the saying ‘data is not the plural of anecdote.’ More than recommended – essential.

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Review by Brian Clegg

The Living End – Guy Brown ***

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Take a glance at the cover of Guy Brown’s book and what does it seem to be about? I have to confess I thought it was fishermen, and with a title like that, the collapse of the fishing industry. I don’t say this to complain about the book design, though I will be doing that shortly, but to highlight the way the true topic doesn’t really encourage the reader in, which is presumably why the cover doesn’t feature graves or something similar. It’s about death, ageing and immortality, but mostly death.

Let’s get that design moan out of the way. Apart from the misleading cover design, this little hardback doesn’t look unattractive, but open it up and there’s horror inside. The text is plastered across the page in a largish sans serif font, heading way into the gutters at the side with very small paragraph indentations. The result is such a big, undistinguished block of text that it’s very uncomfortable to read. I’ve seen (much) better page layout in books on Lulu.

There’s no doubt that there some interesting stuff in here. I was particularly fascinated that the ‘people only lived until their thirties in the middle ages’ myth was in fact a double inverted myth. People used to assume the fact that the average lifespan of an adult was (say) 35 meant that people mostly lived to 35. More educated books (like, I admit, a couple of mine) spot that this is not really a meaningful number, because there was so much child mortality. We also see quite a few well known individuals live to their 50s, 60s, and 70s. So the assumption is that lifespans weren’t vast different from now, if you survived to be an adult.

However Brown shows that, though child mortality was hugely dominant in (say) the 17th century, the commonest life expectancy of those surviving childhood was mid-thirties. Even this, however proves an over-simplification, because as many people died in their 50s 60s and 70s as died in their 30s and 40s. The reality was that the spread was a lot bigger than now, but it’s too simple to say that most people who survived adulthood reached at least 60.

Towards the end of the book, Brown treats the ideas of life extension, though I found this rather stodgy and miserable for such an interesting subject. And in the end, that’s the fatal (?!) flaw of this book. It’s just a miserable topic. I didn’t want to start it, and as I read it didn’t get any more encouraging. I know everything we read can’t be cheerful and upbeat, but I find it hard to recommend taking on what is clearly an important topic, but nonetheless is one that dampens the soul so thoroughly.

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Review by Brian Clegg

The Surgeons – Charles R. Morris ****

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Seeing a still-warm human heart, beating just minutes ago, sliced up takes some getting used to. For journalist Charles Morris as he observes a heart transplant, this is just another shock in his year-long stay with a team of top heart surgeons at a New York hospital.

His admiration for the medics is clear. Their skill, training and concentration have saved thousands of lives. And yet there is something eerie about this book, a hint of a horror movie. The physicians perform near miracles as they work on patients suspended between life and death by machines and clever tricks. But the cultural value of the heart is such that, fleetingly, there is the impression that surgeons are removing more than just flesh.

Morris’ descriptions convey the urgency and precision of heat surgery. He also reveals the contrasts: the delicate manipulation of tiny vessels around the heart during a by-pass operation and the sheer physical effort required to saw through the chest bone and later ratchet the rib cage back together. The endurance and stamina of the operating team – eight hours bent over a patient without a drink, food or toilet break while maintaining absolute concentration – is to be marvelled at.

The mixed emotions stimulated by the macabre runs to ‘harvest’ organs from the recently deceased are hard to deal with. Across New York state, teams gently remove organs – heart, lung, kidney and liver – from the dead, still pink from the life-support machines needed to keep the organs in top condition. The tragedy of an early death balanced against the priceless gift of life for four or five others.

The Surgeons is thought-provoking, gripping and occasionally desperately sad. It is an uneasy read, raising issues of mortality and who should receive precious donor organs. Morris’ almost blind devotion to the operating team contrasts with his swipe at the influence of the pharmaceutical industry. Technical terms, hard to avoid when describing open-heart surgery, can make procedures hard to follow, and the Americanisms – gurney (trolley), OR (operating theatre), for example — take some getting used to. Overall it’s a fast-moving book that holds the reader. Though written to mark the triumph of science, the feeling of witnessing a horror movie was hard to shake.

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Review by Maria Hodges