Remember the trope: exceptions prove the rule. Well, in biology, it is mutants that are often informative. Not so much proving the rule, but hinting at what form any rule must take. In medicine, and maybe other subject domains, the best we can do is look for how things work at the periphery of a subject. At the centre, the causal pathways are so dense that understanding how things work is often beyond us. As we move away form the centre the density of causal arrows, and the pure weight of facts, diminish. It is easier to sort out the wood from the trees: our mental regression analyses have been pruned.
The example that always impressed me was Jan Vandenbroucke’s editorial in the Lancer in 1995, ‘Homoeopathy trials: going nowhere.’ I have no idea how often it has been cited but to me it was the most important paper published in that decade. And unusually for medicine (sadly), it owed more to imagination, rather than ‘data collection’. The argument was as follows.
- Published metaanalyses or trials apparently showed that homeopathy ‘worked’.
- It is self-evident that if there are no molecules present in a therapeutic agent, then it cannot work.
- Therefore, if your experimental methods show it works, then your methods are flawed.
What Vandenbroucke had elegantly shown in a few hundred words was that the edifice of much EBM was flawed.
The practical lesson, for me, was how important it is to have people scavenging around the unpopular bits of a subject domain, looking for data and arguments that are uncomfortable to those at the centre. I think if you want to look at much of modern medicine critically, you should look hard at psychiatry. I started many decades ago, when I was keen on psychiatry as a career, with Anthony Clare’s ‘Psychiatry in Dissent’, and David Ingleby’s ‘Critical Psychiatry (I read the first edition). Years later I discovered David Healy’s work (I started with the Pyschopharmacologists), Healy is somebody who thinks more deeply about medicine that almost anybody else I know.
This is all by way of introduction to a few quotes from a review of Neurotribes: The Legacy of Autism and the Future of Neurodiversity. By Steve Silberman. Avery; 544 pages; Allen & Unwin.
“The American Psychiatric Association, which determines what ailments American insurance companies will pay to treat, classifies it [autism] as a disorder.”
“America’s Centres for Disease Control and Prevention thinks that one in 68 children in the country have at least a touch of autism, which if true means there are more autistic Americans than Jewish ones. “
“He traces the prehistory of autism, which he argues persuasively was around long before it was given a name in the 1940s, and explains how a condition that now seems common is the product of ego-driven scientists and of the unusual circumstances in which they worked.”
“German eugenicists, inspired by work in America, referred to such children as “useless eaters” and said the kindest thing would be to kill them. Asperger lost this argument, but continued his work in a place that made it impossible. One haunting image in the book is of his head nurse buried alive in Vienna by an Allied bomb, her arms wrapped protectively around a young patient.”
“Kanner was so keen to make a brilliant breakthrough that he insisted that his discovery was new and rare, when it was neither. That bit of vanity might have been more forgivable had he not also speculated, on flimsy evidence, that the parents of autistic children were unusually cold. Time magazine ran a story headlined “Frosted Children” about these “Diaper-Age Schizoids”. The slur on refrigerator mothers took decades to fade.”
“Perhaps the grimmest case Mr Silberman cites is of a child who would not stop crying being subjected to electroconvulsive therapy, after which he never spoke again. This sort of stuff is, thankfully, now largely forbidden. But most treatments for autism still inhabit the realm of chelation, supplements, strange diets and other junky science.”
On a slightly lighter note, since my fear is that world will not end in fire, famine or pestilence but one giant bloody spreadsheet written by Human Resources, this anecdote about the great physicist Paul Dirac (who may have been part of the autistic spectrum) made me laugh. I will not be following his advice, however.
Faced with some marital tension over his tendency to ignore his wife (and everybody else, really), Dirac constructed a spreadsheet where he could insert her queries and make sure he answered them properly, an arrangement that seems to have worked rather well for the Diracs.