Book Review

Cures out of Chaos: How unexpected discoveries led to breakthroughs in medicine and health

N Engl J Med 1999; 340:659-660February 25, 1999

Article

Cures out of Chaos: How unexpected discoveries led to breakthroughs in medicine and health
By M. Lawrence Podolsky. 430 pp. Amsterdam, Harwood Academic, 1997. $32.95. ISBN: 90-5702-556-6

In his lecture to first-year medical students entitled, “The Internist as Sherlock Holmes,” Stanford hematologist William Creger described the “crimes” (illnesses) that strike patients and the “clues” (the patient's medical history and the results of physical examinations, laboratory tests, and other tests) with which physicians have to work. He went on to demonstrate that the clues are not always in sequence. Data can be incomplete or misleading; physical evidence can disappear. Too many sleuths can spoil the plot; reasoning can be faulty. The payoff — finding the solution by using a systematic approach — is exhilarating. What could be better than making a correct diagnosis and designing appropriate treatment? The thrill of the chase caught the imagination of his audience.

Cures out of Chaos reports a darker path to discovery, reflecting Podolsky's assertion: “Chaos . . . precedes the formation of an original paradigm and reappears when the paradigm is compelled to change.” The book, written for the general public but of interest to physicians, leaves the reader with the sense that bright new information is often found by sheer accident. Hubris, pessimism, obstruction by entrenched forces, and misconduct can make finding the light even more difficult.

Podolsky's view could discourage a lay audience that may be unfamiliar with the scores of scientific advances that are made by investigators who move steadily ahead with intelligence, integrity, perseverance, and even financial support. The benefit of good luck must be acknowledged, but a reader could wonder why Congress increased the 1999 budget of the National Institutes of Health by $2 billion over that of fiscal year 1998 and the budget of the Centers for Disease Control and Prevention by $226 million instead of investing in Ouija boards. Nonetheless, the book adds value by describing the tortuous routes to the understanding of a variety of physiologic mysteries, such as the relation of iodine to the function of the thyroid gland, and Dr. Rose Payne's work on tissue typing. The first was far from elementary; the second is still a fertile field for investigation. The convoluted paths to such miracle cures as streptomycin and penicillin are also laid out.

The descriptions of accidental contamination, such as cattle food mixed with polybrominated biphenyls (PBBs) and cooking oil mixed with polychlorinated biphenyls (PCBs), in the chapter “Elegy for a Planet” seem out of character with the rest of the book. The topic is primarily environmental and the journalism borders on yellow, with the use of terms such as “scariest” and descriptions of “gruesome events” that were called “the four horsemen of the apocalypse.” A person could be left with the impression that contamination with PBBs or PCBs at a concentration of one part per trillion would be as damaging as such contamination at a concentration of one part per hundred and that we will all become sick from irreversible damage after our inevitable exposure to these substances.

The book does have appealing features in addition to some fascinating and underappreciated tales. Sections entitled “Paradigm Pointers,” and “Post Script,” at the end of each chapter highlight, respectively, basic points that the reader may have missed in the detail of the stories and directions for future thinking and research. In addition, some chapters also feature a section called “Personae,” which provides biographical information about selected notables. Another pleasure is the liberal use of quotations from observers ranging from Euripides to Joseph Priestly, Claude Bernard, and Julius Comroe.

Making medical discoveries ranks high on the list of worthwhile endeavors. “Worthwhile” is not the same as “easy.” This book documents the perennial challenges of medical research: discrimination against women and scientists from minority groups, the intrusion of corporate interests into research and publication, inadequate equipment and space, and the inability to see patterns, cause, and effect. Fortunately, cures come, knowledge grows, and authors have the curiosity and diligence to look back at history and to describe the past so we can learn from it.

Linda Hawes Clever, M.D.
University of California at San Francisco, San Francisco, CA 94143