- Email: [email protected]
Clustered together
DISSECTING ROOM
Clustered together Cluster headache and related conditions Jes Olesen, Peter J Goadsby, eds. Oxford: Oxford University Press, 1999. Pp 309. £85·00. ISBN 0192630733. luster headache, also called suicide headache, is thought to be one of the most severe forms of head pain. The pain is always one-sided, around the eye, and is accompanied by symptoms such as ipsilateral red eye, tearing, or Horner’s syndrome. The attacks last 15 min to 3 h and in most patients, occur in episodes, generally with a regular time pattern—“alarmclock headache”. Although it should be easy to diagnose, the diagnosis is often missed because the disease is rare. Sometimes referred to as an “orphan disease” since no one “takes care” of it, there has been little research into cluster headache. Scientific attention was mainly focused on migraine, which is more common, and cluster headache had to do with “left overs”. For example, one of the most potent drugs for the treatment of cluster-headache attacks, sumatriptan, was designed as a treatment for migraine and, as happens with most migraine medication, was tried in patients with cluster headache—with good results. In the past few years, fortunately, cluster headache has caught the attention of some good researchers and Cluster Headache and Related Conditions gives an overview of their
C
recent research, making it an important book for anyone interested in headache. Notably, there is only one other book solely dedicated to cluster headache: a monograph by O Sjaastad (Cluster Headache Syndrome. London: W B Saunders Company, 1992). Based on the proceedings of the Ninth International Headache Research Seminar, held in Copenhagen in 1998, Cluster headache and related conditions contains contributions from many authors and consequently, the chapters differ much in quality. Fortunately, the editors—both at the forefront of headache research—have chosen a mixture of up-to-date reviews and original contributions. The first category will be of interest for all who are interested in headache, whereas the latter is of more specific interest to clusterheadache researchers. The 50 chapters are grouped into six sessions, each of which starts with some overviews, and ends with a discussion summary. Session 1 (“The clinical picture”) starts with a fascinating description of molecular mechanisms of circadian biology—perhaps a useful starting point for further research in cluster headache, especially for genetic studies. The patho-
physiology and epidemiology of cluster headache are also reviewed, followed by several original clinical studies. Session 2 describes the so-called “Trigeminalautonomic cephalagias”, a number of rare “cluster headache like syndromes”. The pathophysiology of cluster headache is discussed in two sessions and includes evidence from animal studies, and from endocrinological and genetic investigations. Chapter 28 is particularly important since it addresses studies about functional imaging and their implications on the theories about the pathophysiology of cluster headache: whether it is a disease of the central nervous system rather than a vascular disease, as was previously thought. Session 5 gives an overview of the acute treatment of cluster headache, and session 6 deals with prophylaxis. The importance of the book lies in its focus on an, until recently, largely neglected headache syndrome. The weakness of Cluster headache and related conditions lies in the rather artificial subdivision into sessions, the differences in quality of the chapters, and the many non-peer-reviewed studies described. As a whole, however, this book is a welcome addition to the headache library. Joost Haan Department of Neurology, Leiden University Medical Centre and Rijnland Hospital Leiderdorp, Netherlands [email protected]
Statistics: a moral and an engaging history Statistics on the table: the history of statistical concepts and methods Stephen M Stigler, Cambridge, MA: Harvard University Press, 1999. Pp 488. £27·95. ISBN 0674836014. n 1998, the British Medical Association sponsored a conference on the randomised clinical trial, commemorating an influential study of streptomycin undertaken half a century earlier. For most medical researchers, this is about where the history of statistics in medicine begins. Or perhaps they go back a decade further, to 1937, when Austin Bradford Hill first published his Principles of medical statistics. A few years earlier still, the work of the statistician R A Fisher began to reshape experimental design and analysis in many disciplines, including psychology and the social sciences as well as medical therapeutics. Stephen Stigler proposes 1933 as the birth year of mathematical statistics, when many of the institutions and mathematical tools of modern statistics were finally set in place. This is not, however, when the history of statistics begins, and indeed his essay on “The history of statistics in 1933” is one of the most nearly contemporary in this collection. In others he goes back to the 17th
I
THE LANCET • Vol 355 • April 22, 2000
century, or even earlier, as in his essay on medieval tests of English coinage, called “trials of the pyx”.The basic mathematics of probability derives from a correspondence between Pascal and Fermat in 1654. The early history of probability and statistics, like its modern history, ranges over the intellectual landscape, from charting the stars to measuring inflation to fixing the metre. Almost from the beginning, medicine was prominent among the objects of statistical study. As a science in which certainty remained elusive, medicine was particularly suited to analysis in terms of probabilities. From the beginning, however, there were doubters. Physicians had other traditions for dealing with the complexities of their craft: a practiced eye, a sensitive touch, and skill in eliciting case histories. One might detect satirical intent in a title like Apollo mathematicus, or the art of curing disease by the mathematicks (1695), and this would be correct. The object of its mockery was Dr Archibald Pitcairn, who held the body to
be a machine, and who was a pioneering advocate of quantitative medicine. He supposed that if: “Excretion by Stool be as 4, That by urine is as 16, and That thro’ the Pores of the Skin as 40, or more.” Based on his understanding of the earliest treatise on probability, a booklet published in 1657 by Christiaan Huygens, Pitcairn argued that the chances of cures must be in like proportions. Thus he endorsed the efficacy of sweating. His critic, one Dr Edward Eizat, recommended acidly that the new methods should be tried first of all on Pitcairn himself. The clockwork of the human body, after all, is not readily reassembled once it has been taken to pieces. Stigler deals benignly with quirky efforts such as Pitcairn’s, encouraging our sympathy for the pioneers of a difficult but eminently worthwhile enterprise. It is surely important enough to deserve the attention of historians, and Stigler’s writing on the history of statis-
1469
Clustered together Cluster headache and related conditions Jes Olesen, Peter J Goadsby, eds. Oxford: Oxford University Press, 1999. Pp 309. £85·00. ISBN 0192630733. luster headache, also called suicide headache, is thought to be one of the most severe forms of head pain. The pain is always one-sided, around the eye, and is accompanied by symptoms such as ipsilateral red eye, tearing, or Horner’s syndrome. The attacks last 15 min to 3 h and in most patients, occur in episodes, generally with a regular time pattern—“alarmclock headache”. Although it should be easy to diagnose, the diagnosis is often missed because the disease is rare. Sometimes referred to as an “orphan disease” since no one “takes care” of it, there has been little research into cluster headache. Scientific attention was mainly focused on migraine, which is more common, and cluster headache had to do with “left overs”. For example, one of the most potent drugs for the treatment of cluster-headache attacks, sumatriptan, was designed as a treatment for migraine and, as happens with most migraine medication, was tried in patients with cluster headache—with good results. In the past few years, fortunately, cluster headache has caught the attention of some good researchers and Cluster Headache and Related Conditions gives an overview of their
C
recent research, making it an important book for anyone interested in headache. Notably, there is only one other book solely dedicated to cluster headache: a monograph by O Sjaastad (Cluster Headache Syndrome. London: W B Saunders Company, 1992). Based on the proceedings of the Ninth International Headache Research Seminar, held in Copenhagen in 1998, Cluster headache and related conditions contains contributions from many authors and consequently, the chapters differ much in quality. Fortunately, the editors—both at the forefront of headache research—have chosen a mixture of up-to-date reviews and original contributions. The first category will be of interest for all who are interested in headache, whereas the latter is of more specific interest to clusterheadache researchers. The 50 chapters are grouped into six sessions, each of which starts with some overviews, and ends with a discussion summary. Session 1 (“The clinical picture”) starts with a fascinating description of molecular mechanisms of circadian biology—perhaps a useful starting point for further research in cluster headache, especially for genetic studies. The patho-
physiology and epidemiology of cluster headache are also reviewed, followed by several original clinical studies. Session 2 describes the so-called “Trigeminalautonomic cephalagias”, a number of rare “cluster headache like syndromes”. The pathophysiology of cluster headache is discussed in two sessions and includes evidence from animal studies, and from endocrinological and genetic investigations. Chapter 28 is particularly important since it addresses studies about functional imaging and their implications on the theories about the pathophysiology of cluster headache: whether it is a disease of the central nervous system rather than a vascular disease, as was previously thought. Session 5 gives an overview of the acute treatment of cluster headache, and session 6 deals with prophylaxis. The importance of the book lies in its focus on an, until recently, largely neglected headache syndrome. The weakness of Cluster headache and related conditions lies in the rather artificial subdivision into sessions, the differences in quality of the chapters, and the many non-peer-reviewed studies described. As a whole, however, this book is a welcome addition to the headache library. Joost Haan Department of Neurology, Leiden University Medical Centre and Rijnland Hospital Leiderdorp, Netherlands [email protected]
Statistics: a moral and an engaging history Statistics on the table: the history of statistical concepts and methods Stephen M Stigler, Cambridge, MA: Harvard University Press, 1999. Pp 488. £27·95. ISBN 0674836014. n 1998, the British Medical Association sponsored a conference on the randomised clinical trial, commemorating an influential study of streptomycin undertaken half a century earlier. For most medical researchers, this is about where the history of statistics in medicine begins. Or perhaps they go back a decade further, to 1937, when Austin Bradford Hill first published his Principles of medical statistics. A few years earlier still, the work of the statistician R A Fisher began to reshape experimental design and analysis in many disciplines, including psychology and the social sciences as well as medical therapeutics. Stephen Stigler proposes 1933 as the birth year of mathematical statistics, when many of the institutions and mathematical tools of modern statistics were finally set in place. This is not, however, when the history of statistics begins, and indeed his essay on “The history of statistics in 1933” is one of the most nearly contemporary in this collection. In others he goes back to the 17th
I
THE LANCET • Vol 355 • April 22, 2000
century, or even earlier, as in his essay on medieval tests of English coinage, called “trials of the pyx”.The basic mathematics of probability derives from a correspondence between Pascal and Fermat in 1654. The early history of probability and statistics, like its modern history, ranges over the intellectual landscape, from charting the stars to measuring inflation to fixing the metre. Almost from the beginning, medicine was prominent among the objects of statistical study. As a science in which certainty remained elusive, medicine was particularly suited to analysis in terms of probabilities. From the beginning, however, there were doubters. Physicians had other traditions for dealing with the complexities of their craft: a practiced eye, a sensitive touch, and skill in eliciting case histories. One might detect satirical intent in a title like Apollo mathematicus, or the art of curing disease by the mathematicks (1695), and this would be correct. The object of its mockery was Dr Archibald Pitcairn, who held the body to
be a machine, and who was a pioneering advocate of quantitative medicine. He supposed that if: “Excretion by Stool be as 4, That by urine is as 16, and That thro’ the Pores of the Skin as 40, or more.” Based on his understanding of the earliest treatise on probability, a booklet published in 1657 by Christiaan Huygens, Pitcairn argued that the chances of cures must be in like proportions. Thus he endorsed the efficacy of sweating. His critic, one Dr Edward Eizat, recommended acidly that the new methods should be tried first of all on Pitcairn himself. The clockwork of the human body, after all, is not readily reassembled once it has been taken to pieces. Stigler deals benignly with quirky efforts such as Pitcairn’s, encouraging our sympathy for the pioneers of a difficult but eminently worthwhile enterprise. It is surely important enough to deserve the attention of historians, and Stigler’s writing on the history of statis-
1469