NEJM 24 May 2007 Vol 356

The trouble with medical research is that it involves so much boring hard work. First carry out 2,446,431 person-years of follow-up involving questionnaires on aspirin use every two years. Having picked up 636 incident colorectal cancers, get all the paraffin-embedded histology specimens of these cancers and test them for the expression of cyclo-oxygenase-2 activity. Then analyse the data to determine the preventive effect of aspirin on colon cancers with and without COX-2 expression. You write up and rewrite the thing for the New England Journal and, hey, with luck you may be able to move yourself and your family to another ill-paid but more prestigious job in a distant university. Thank God there are people willing to do it. Now we know that the protective effect of aspirin against colon cancer is indeed specific for the kinds that over-express COX-2 activity.

By the time we turn 45, Evolution has largely lost interest in us, despite all the arguments about survival advantage from the extended family, altruism, and so forth. The human urinary tract is a good example. The Universe cares little whether older women leak when they cough, or older men get big prostates. Burch cared more, and invented colposuspension for women with stress incontinence. Then someone invented the fascial sling procedure, which involves creating a sling from the rectus abdominis fascia and slotting it under the urethra. This results in less stress incontinence but more voiding difficulty and urinary infections, according to this study. The editorial also mentions “blind” mesh insertion, now popular with British gynaecologists, only to dismiss it with a certain disdain.

In fifteen Canadian cities, paramedics were trained to perform intubation and to give intravenous drugs, in the hope that this might reduce deaths from out-of-hospital respiratory distress. In fact they performed very few intubations, gave a fair amount of intravenous furosemide, and used nebulised medication on more than half the patients, so reducing the death rate from 14.3% to 12.4%.

Not long after antiseptic surgery had made it possible to open the abdomen without killing the patient, the Prussian-born surgeon Christian Billroth devised a series of astonishing procedures on the stomach which still remain in the modern surgical repertoire. I was put in mind of these looking at the illustrations in this review of bariatric surgery for morbid obesity. They are really quite ingenious, and in practice it must be quite a challenge even to get the laparoscope through the abdominal wall of someone with a BMI of 55. The procedures all work, but at the cost of considerable malabsorption and unknown long-term sequelae. After operating, the surgeon can relax like Billroth, going off to play chamber music with Brahms and Joachim.