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Evidence-Based Surgery

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reviews
BOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS • MINERVA
Demon Drink: George
Cruikshank’s “The Worship
of Bacchus” in Focus
Tate Britain, Millbank, London SW1,
until 2 December 2001
F
irstly, we are told that one or two
glasses of red wine a day are good for
you, and then researchers claim that
there are no health benefits whatsoever,
even from moderate drinking. To the 19th
century artist George Cruikshank it seemed
quite clear: all alcohol was evil, and
moderate drinking invariably led to addic-
tion and moral, social, and financial ruin.
Cruikshank was a prolific illustrator and
social satirist who produced the famous
original plates for Sketches by Boz and Oliver
Twist. His father, Isaac, had drunk himself to
death, and George’s own consumption of
alcohol was phenomenal until he gave up
drinking at the age of 55 and became a lead-
A manifesto for teetotalism: George Cruikshank’s The Worship of Bacchus
1494
ing figure in the Temperance movement. He
went on to live for another 30 years in good
health, which he attributed to abstinence.
Works produced during this time
summed up his passionately held beliefs
about the perils of alcohol and his wish to
turn others away from the bottle. Chief
among them is The Worship of Bacchus
(1860-62), the focus of this small exhibition
of prints and artefacts extolling the virtues
of temperance.
The Worship of Bacchus is as much an
essay or manifesto as a work of art. Its multi-
ple vignettes teem with tipplers and
revellers—at a wedding, a birthday celebra-
tion, even a funeral—all destined for the
same sort of ignoble fate: the reformatory,
the ragged school, the house of correction,
the hospital, the workhouse, the jail, and the
lunatic asylum. And there is no escape, not
even for the bereaved elderly woman in the
bottom right hand corner who is handed a
drink for comfort. All await the descent (or
rather ascent, as the narrative reads from
bottom to top) into violence, ruin, and
premature death. Presiding over this meticu-
lous catalogue of horror is the statue of
Bacchus, Roman god of wine. This is a hell-
ish landscape strongly reminiscent of some-
thing by Bosch or Breughel the Elder’s The
Triumph of Death.
Also on show is Cruikshank’s The Bottle,
a series of eight prints portraying the
progressive decline through alcohol of a
once prosperous Victorian mechanic and
his family. The Bottle was a hit with Victorian
society—where pollution meant it was safer
to drink beer and wine than water, and
where alcoholism was rife—and sold
100 000 copies in just a few weeks.
Despite Cruikshank’s popularity in Vic-
torian Britain, The Worship of Bacchus has not
been shown in public for nearly 100 years. It
languished in the stores of various galleries
until the Tate began restoration on the vast
canvas last year. Its re-emergence now could
be seen as a timely corrective to the “little is
good for you” message. Recent research
indicates only a marginal protective cardiac
effect for men aged over 55 and women over
65 (Journal of Epidemiology and Community
Health 2001;55:383-8), and some suggests
not even that (BMJ 1999;318:1725). How-
ever, a final bequest of fine wines by
Cruikshank suggests that his final three dec-
ades may not have been completely teetotal.
Trevor Jackson BMJ
BMJ VOLUME 322 16 JUNE 2001 bmj.com

Lies we Live by: The Art of
Self-Deception
Eduardo Giannetti (translated by
John Gledson)
Bloomsbury, £7.99, pp 320
ISBN 0 7475 5294 0
Rating: ★★★
W
hen people tell lies we think we
understand what they are doing.
They know the truth themselves
but instead of telling “the truth” to their vic-
tim they intend to create a false belief in that
person’s mind. Alternatively, deceivers might
choose not actively to tell a lie but instead to
dissimulate: in this scenario they withhold
vital information. In the way of politicians,
they are being “economical with the truth.”
But what of self deception? Do we
understand what is happening here? Cer-
tainly we use and hear the term commonly
enough and there are philosophical tomes
devoted to it. But can it really happen? How
might one really lie to oneself? Classically,
there have been two problems. The first is
the dynamic paradox: how might I set out
now to convince myself to believe in the
future something that I already know to be
false? Am I not bound to fail? Secondly,
there is the static paradox: how can I believe
two opposing “truths” at the same time, the
one that I “know” is really true and the false
one that I “want” to be true?
Evidence-Based Surgery
Eds Toby Gordon, John Cameron
B C Decker, £99.95, pp 688,
with CD
ISBN 1 55009 116 6
Rating: ★★★
I
was intrigued when I was asked to
review Evidence-Based Surgery because
precious little surgery is evidence based.
Contrary to the expected short book I was
confronted by a 688 page tome from the
Items reviewed are rated on a 4 star scale
(4=excellent)
BMJ VOLUME 322 16 JUNE 2001 bmj.com
Eduardo Giannetti has written an essay
in four parts attempting to place self decep-
tion in an evolutionary context. He begins
by describing the widespread occurrence of
“deception” in nature. Here are accounts of
fauna and flora in disguise, of birds that
replace each other’s eggs, of organisms that
send false signals. This is fine as far as it goes,
but how much of it really constitutes decep-
tion? For the most part we do not know if
animals are consciously aware of their
survival strategies. How much of this behav-
iour is implicit or hard wired?
Moving on, the author assays the great
minds of philosophy and creative literature,
and of those scientists from the past who
thought deeply about their own motives.
This book is worth reading if only for the
thoughts of the “mighty dead”—Plato,
Aristotle, Bacon, Diderot, the young Darwin,
and here, the cold realism of Dostoevsky: “In
every man’s remembrances there are things
he will not reveal to everybody, but only to
his friends. There are things he will not
reveal even to his friends, but only to
himself, and then only under a pledge of
E & D HOSKING/FLPA
When a cuckoo usurps a nest, is it consciously
aware of its survival strategy?
prestigious Johns Hopkins Hospital.
Intended as an introduction, it is not a set of
clinical guidelines, but an explanation of
how sifting and using the available scientific
research can influence the art of surgery.
What, for example, is the value of colos-
tomy in the management of colonic injuries?
During the second world war all colonic
injuries were managed with a stoma and the
results were much better than during previ-
ous wars. A paper in 1979 challenged the
view that colostomy improved the outcome
in all these injuries. It was then understood
that the decrease in mortality was due to
improved general care of the critically
injured and criteria were suggested for
selective primary repair of colonic injuries.
The first part of this book delves into the
principles of the subject, with a look at the
history of surgery, including Johns Hopkins’
contribution to early evidence based sur-
gery, followed by discussion about the stake-
holder, legal, and ethical perspectives. Lord
McColl contributes an interesting chapter
reviews
MARTIN WITHERS/FLPA
Flap-necked chameleon: a master of disguise
secrecy. Finally, there are some things that a
man is afraid to reveal even to himself, and
any honest man accumulates a pretty fair
number of such things.”
Sadly, Giannetti does not quite succeed
in explaining how self deception occurs. But
he does have some interesting things to say
about the vagaries of belief. We avow beliefs
and decide upon a great many actions, the
ultimate truth or success of which we cannot
know at the outset. Life is a gamble. Was it
madness or genius that drove a middle aged
man to give up a comfortable bourgeois life
in Europe and travel to Tahiti to paint
pictures? Could Gaugin have “known” that
he would be successful? Was he deceiving
himself? Had he failed we might have said
so, but knowing of his success we might say
that he believed in himself.
Giannetti’s conclusion is that we cannot
live an authentic life without beliefs but that
the strength of those beliefs is not an indica-
tion of their truth content. As we know from
delusions and dictatorships, so often cer-
tainty precedes catastrophe.
Sean A Spence senior clinical lecturer in
psychiatry, University of Sheffield
on evidence based surgery in the United
Kingdom, illustrated by a discussion on
making the diagnosis of appendicitis with
computed tomography. Various contribu-
tors describe how to design studies and
interpret the results, discussing clinical and
economic outcome measures.
The second part considers the practice of
evidence based surgery, with 25 chapters on
the various specialties and areas of surgery, as
well as anaesthesia and pathology.
I enjoyed reading about the impact of
the internet on modern surgery, allowing
the patient access to unlimited information
(with its benefits and dangers) and making
research results more readily available to
surgeons.
The book’s strength is how it discusses
particular clinical situations, weighing the
evidence and structuring advice on patient
care. This is a useful introduction to what is
set to become an important topic.
Gordon Caruana-Dingli surgeon, St Luke’s
Teaching Hospital, Malta
1495
reviews

The $2m (£1.4m) advertising campaign

A choice image
Gavin Yamey previews a US advertising
campaign for mifepristone, the early
pregnancy abortion pill
has been funded by the National Abortion
Federation, which is the largest professional
group of abortion providers in the United
States. The federation says that the advert
will reach over 70% of women aged
between 18 and 49 years.
The advert conveys a sense of empower-
ment, which is what the federation hoped to
achieve. “We chose a picture of a woman
rather than a pill,” said Vicki Saporta, the
federation’s executive director, “and shot the
image ourselves, as we wanted to convey an
openness that would say to women, ‘Come

D
ead fetuses. Weeping mothers. Doc- in and get the information.’ ”
tors portrayed as murderers. In the So far, drug adverts in the United States
United States, we are force fed a aimed at consumers have had nothing to do
steady stream of graphic advertisements
with educating people or promoting their
funded by opponents of abortion. Their lat-
health, and they have led to a huge increase
est target is mifepristone (RU-486), which
in drug prescribing (BMJ 2000;321:783).
was approved by the Food and Drug
Isn’t this just another direct-to-consumer

NAF
Administration in September 2000.
advert that will serve mainly to profit the Empowering: the mifepristone ad
Operation Rescue, an antiabortion
drug manufacturer? No, says Saporta. “This
group that believes in “taking the battle to
is a public service education campaign,
the streets” (www.operationrescue.org), is
driving its “Truth Truck” across the United responding to women’s need for infor- and effective experience. We want women to
States. The truck carries a billboard showing mation. We received no funding from the have accurate medical information.”
a fetus on the gloved palm of a doctor’s manufacturer, but raised the money from Operation Rescue is, not surprisingly,
hand, supposedly representing a pregnancy private foundations.” And, unlike a direct-to- opposed to the advert. Troy Newman, direc-
terminated by mifepristone. Next to it is a consumer advert, there is no mention of the tor of the Las Vegas based Operation
mother in anguish. The caption reads, “One drug’s trade name or of the manufacturer. Rescue West, said that it merely showed how
dead. One wounded.” Two of largest pro-choice groups in “women have been empowered to kill their
In its “battle” to impede women from America, Planned Parenthood and the own pre-born [sic] children.”
choosing to have an abortion, the antiabor- National Abortion and Reproductive Rights But it is not just the antiabortion activists
tion lobby has used advertising as a weapon. Action League (NARAL), told me that anti- who are opposing the mifepristone advert.
It makes sense, therefore, that supporters of abortion activists had prevented women One high profile women’s magazine, Red-
mifepristone are using a national advertis- from finding out about the drug. book, which is owned by the Hearst
ing campaign to fight back. An advert for the Saporta agrees. “The antiabortionists Corporation and which has a circulation of
drug is set to appear in the July issues of 14 are trying to frighten women with medical 2.2 million, is refusing to run it. Redbook’s
glossy women’s magazines, including Cosmo- misinformation,” she said. “They have been editor in chief, Lesley Jane Seymour,
politan, Glamour, and Marie Claire, and it will talking about how dangerous RU-486 is declined to speak to the BMJ but passed me
run until November. when, in fact, the trials show 12 years of safe on to her corporate communications
spokesman, Paul Luthringer. “Redbook has
the right not to run this ad,” he said, “based
on the publisher’s wishes.”
AIDS: the global challenge With 23 million people dead and 36 million HIV Redbook is the only magazine that has
positive, the need to do more to tackle AIDS is painfully clear. This week’s BMJ turned down the advert, possibly because it
(pp 1440, 1451, 1475) draws attention to the catastrophe. To get a comprehensive does not want to upset its socially conserva-
internet update on AIDS, the best website to visit is www.aegis.com. This is the tive readership, but its refusal may well back-
largest HIV/AIDS site and it contains a vast amount of information, useful links, fire. Its editor, said Saporta, “is believed to be
pro-choice, and the fact that she has refused
WEBSITE and an impressive news archive, which is updated hourly.
to run it has caused an even bigger story.”
OF THE As we went to press it was heartening to be signposted to an article in the
Despite abortion being legal in the
Washington Post suggesting that the new Global Health Fund to tackle AIDS,
WEEK tuberculosis, and malaria is gathering momentum. France has joined the
United States, there are huge barriers facing
women who want one. In 86% of counties
United States and United Kingdom in making a formal pledge ($127m; £89m).
there is no physician to provide abortions
The first corporate donation ($1m) has just been made by a subsidiary of
because antiabortionists have harassed,
Credit Suisse. The sums are paltry compared with the $10bn target, but these
injured, and even killed health professionals.
donations may spur other governments and private institutions to follow suit at However, if the mifepristone campaign is
the United Nations General Assembly session on HIV/AIDS next week. successful it should go some way towards
At this meeting, recent data will be aired showing that the HIV/AIDS redressing the balance and supporting
epidemic is worsening, not only in Africa but also in parts of Asia and Latin women’s reproductive freedom and choices.
America. Most of those affected live in Africa and although www.safaids.org and In case you’re in any doubt about what
www.gnpplus.net are African AIDS sites, neither approaches the quality or the National Abortion Federation is up
topicality of www.thebody.com—a global network that aims to improve the against, just listen to Troy Newman’s chilling
quality of life of people with HIV/AIDS. Comprehensive news updates and words to the BMJ about Operation Rescue’s
useful links complement a wealth of practical information. next campaign: “When we find out where
Tessa
Jumping off to www.avert.org/news/htm reminded me that, despite the RU-486 is being distributed, we are going to
Richards
pledge to donate 0.7% of GNP to development assistance, the UK still donates expose the doctors who provide it as the
BMJ
trichards@ only 0.31%. Most Scandinavian countries do much better. By contrast, the US is murderers that they are.”
bmj.com bottom of the list, contributing a miserly 0.1%.
Gavin Yamey deputy editor, wjm—Western Journal
of Medicine

1496 BMJ VOLUME 322 16 JUNE 2001 bmj.com


PERSONAL VIEW
Lament for missing an A award
I
used to support the merit award system
because I believed that, despite its flaws, meetings saw the curricula vitae of col-
it encouraged people to stretch them-
selves beyond their daily chores. From
doubting its fairness for myself, I realised my
specialty had a poor share of awards and this
has been true for at least 35 years.
In the dozen years since a medical chair-
man of the Advisory Committee for Distinc-
tion Awards tried to channel more awards
towards service specialties, there has been
little increase in the number of awards for
anaesthetists, pathologists, or radiologists.
Compared with local colleagues in other
specialties and other anaesthetists elsewhere
I think that I deserved an A award, but I
never received one.
I first heard of merit awards soon after I solicited about who should get a B award.
became a senior house officer in the early
1960s. A surgical registrar engaged me in
conversation over the blood-brain barrier. He
asked me why I had taken up anaesthesia,
and then he said: “Anaes-
thetists are sucking on the
hind tit as far as merit It was worrying
awards are concerned, but that awards
they’re either young or
ex-general practitioners.” seemed to be
I had no idea what he based on
was talking about. By the
time I became a consultant Buggins’s turn
in 1972 I knew that C
awards were for local merit, B awards for
regional or national merit, and A awards for
national or international merit. This was
confirmed in the 1990s by the now lay chair-
man of the advisory committee. In the late
1970s, in my 40s and a (minor) national fig-
ure in anaesthesia, I thought I ought to get a
C award. I had no idea what happened so I
asked a senior colleague. He told me simply
that I would get one.
By 1982 I was fed up and thinking of
writing a vitriolic piece for World Medicine.
Early in 1983, however, a kind colleague on
the regional C awards committee rang up
and said: “Adrian, open the champagne.”
There had been an extra award for
anaesthetists that year so I and a much older
colleague got one.
It was worrying that awards seemed to
be based on Buggins’s turn and, as I learnt
more about the processes, this impression
was reinforced. In 1990 a nobody from else-
where, who had been put on the regional
higher awards committee, rang to ask me
about someone’s eligibility for an award. At
the end of his call I plaintively asked, “What
about me?” Not long after, in early 1991, I
received a letter saying that I had received a
B award starting in April 1990. I was
pleased, but I wondered why nonentities in
the region had got B awards before me.
Matters became interesting. I was invited
to discuss awards for other anaesthetic
colleagues at Sheffield and regional meet-
BMJ VOLUME 322 16 JUNE 2001 bmj.com
View publication stats
ings. Only the chairman at the regional
leagues put forward from the different
hospitals. I suggested that all members
should see them if we were to discuss
comparative merits, but this reasonable idea
was refused. The Royal College of Anaes-
thetists received our recommendations. Per-
haps that was why my academic colleagues
were given awards when they were younger
than other doctors. Curiously, I was never
put on the regional C awards nor the
regional higher awards committees. Was the
playing field level in the region, I wondered?
Meetings for all consultants with at least a
B award in North Trent were convened by an
A award holder each year. Opinions were
After that the B award holders left so that the
holders of A and A plus awards could discuss
them. One year when I could not attend I
telephoned the convenor with recommenda-
tions. I remarked that few
anaesthetists had awards.
“Ah,” said the professor (a
physician), “there are a lot of
young anaesthetists about.”
I pointed out as politely
as I could that this comment
has been made for at least 35
years. It seems that physi-
cians believe this is true,
however illogical; after all, there are also a lot
of surgeons but they are divided up into spe-
cialties. Analogously, a medical professor
thinks that the low number of awards for doc-
tors from ethnic minorities will improve as
they get older (BMJ 1998;317:475).
What about surgical backing for anaes-
thetists? When I spoke to the medical dean
some years ago about my chance of an A
award, he asked which surgeons supported
me. I was almost speechless but depressed. I
worked with surgeons who were younger
than me or juniors.
In December 1993 I got the question-
naire from the advisory committee as part of
its five year review to see if I had done
enough to retain my B award. I thought that
it was an opportunity not a threat; I would
be able to show that I was still worthy and
perhaps more meritorious—I’ve always been
naive. After I had returned the form, one of
my colleagues accused me of sending my
curriculum vitae to the advisory committee
in pursuit of an A award. This shows just
how deeply people care about these things.
Nothing will change unless there is a
radical shake up of the system or it is
abolished. If I were in a specialty with a high
percentage of awards I would not like my
share of the cake reduced for the benefit of
other specialties, would I?
Adrian Padfield retired consultant anaesthetist,
Sheffield
reviews
SOUNDINGS
The old and the new
In a crowded lift in a fairly important
building in London’s political village
there was a momentary drama. The
doors closed, the lift lurched upwards,
then dropped a few inches. Assorted
apparatchiks and policy wonks glanced
at each other nervously. A squat, square
middle-aged man looked upwards, shook
his head and murmured, “Bloody
winding engineers.” I laughed, but no
one else did.
He was vaguely familiar—an MP and
former miner—and definitely old Labour.
I remembered where I’d met him first. We
were both at work in an unwinnable
constituency in what turned out to be an
unwinnable election, that of 1979. The
candidate was a novice—pale and intense,
committed and convincing—and a lot of
people turned out to help.
I had never been as close to real
politics before and found it all very
interesting. Campaign headquarters was
an abandoned butcher’s shop in the
middle of a shabby housing estate.
Everyone else seemed to know what they
were doing. I watched a bit, asked
sometimes, and learned the basics. In the
run-up we stuffed envelopes and knocked
on doors. Late on the day itself, as the
owner of a respectable, safe and fully
insured car, I was sent out with the former
miner, who was then a trade union official,
to round up the last of the vote.
He was forceful and persuasive.
Memorably, he marched into a busy,
scruffy pub, called for silence, then asked,
“Any o’ ye here no’ voted . . .? Right. Intae
the car. We’ve got 10 minutes.” I drove
three bewildered youths and their captor
to the polling station, suddenly convinced
that our candidate would take the seat, by
a majority of just one or two votes.
He didn’t. He knew he wouldn’t.
After the polls closed, and amid the meat
hooks and white tiles of his campaign
HQ, he led us—students, pensioners,
miners, friends—as we sang: “The
people’s flag is deepest red . . .” Tears
flowed and life-long allegiances were
reaffirmed.
An election or two later the trade
union official was in parliament,
representing a nearby constituency. He
served the people of its former mining
towns and villages faithfully and stood
down just a few weeks ago, one of the
last of an old tradition.
And the pale, young candidate? He
tried again in a more promising seat,
entered parliament, did well in
opposition, and is now, I believe, quite
highly regarded for his work as
chancellor of the Exchequer.
Colin Douglas doctor and novelist, Edinburgh
1497