Book Review: Unwell Women

This review was written for and first published by Bookmunch.

I read my way through Unwell Women in a prolonged and barely suppressed rage. Women and girls the world over know we are routinely demeaned – effectively silenced – and this account of historical treatment lays bare the toll it has taken on our health, mental and physical. The author presents the facts clearly, maintaining engagement and never shying away from topics rarely discussed openly – ‘women’s problems’ and how we are expected to go through life quietly, grinning and bearing. I pondered if male readers would have any interest or dismiss this well researched and presented account as a rant, females still being regarded as overly emotional – hysterical – and in need of calming down, by whatever means.

Divided into three main sections, the first of these explores how medical knowledge developed from the time of the Ancient Greeks to the nineteenth century. Throughout most of this period, women’s bodies remained a mystery. Each month they would bleed. They grew babies. They complained of pains men didn’t experience so were probably imagined. As their father’s and then their husband’s property, it mattered that females remained amenable, attractive, modest and faithful. They were vessels for men’s sexual satisfaction and, most importantly, procreation.

“They were seen as weaker, slower, smaller versions of the male ideal, deficient and defective precisely because of their difference to men … in writings that would become the foundations of scientific medical discourse and practise, unwell women emerged as a mass of pathological wombs.”

The required modesty cost lives. Women were made to feel ashamed of their bodies – sinful temptresses. In the powerful Christian world it was, after all, the first woman, Eve, who ‘ruined everything because of her desirous and disobedient ways.’ Girls and women were expected to remain covered even when seeking medical treatment, untouched by the always male physician. Ingrained shame and ignorance in medical matters led to them being regarded as unreliable narrators of their own bodily suffering. An early pamphlet written in the thirteenth or fourteenth century stated ‘the female body is inherently flawed and defective in many of its functions.’

Female healers and midwives existed. Educated women worked tirelessly throughout history to improve care but were routinely dismissed by men who retained the power to effect change.

“the male writers espousing this nonsense understood only too well that women had to be exempted from the hallowed halls of medicine if they themselves were to maintain their stranglehold.”

A great many aspects are covered in this comprehensive and gripping history, much of it disturbing and, at times, horrifying. When physicians were eventually permitted to examine women (their reproductive physiology was considered an inverted version of men’s) treatments offered for a plethora of misunderstood problems included operations to cut off clitorises and crush ovaries. Alongside the need to suppress female excitability – bad for the nerves in already nervy creatures – the ideologies of eugenics were emerging in medical aims and practice.

The second section of the book, covering the late nineteenth century to the 1940s, saw the slow emergence of hard fought for advances in women’s rights as well as medical knowledge. Doctors still regarded women as sexual objects and child bearing machines. Birth control was frowned upon, abortions illegal and therefore carried out in secret. Women reporting gynaecological pain were regarded as overly sensitive – neurotic and requiring rest away from any form of stimulation. Typical treatments offered for common ailments such as uterine fibroids, and cancers in reproductive areas, were often as dangerous as the problems they claimed to cure. Doctors were keen to further their reputations – for financial reasons as well as ego. Women – particularly those not valued, such as sex workers and the criminalised – were useful subjects for experimental procedures. Troublesome wives and daughters were readily presented for surgical interventions.

The final section covers 1945 to the present day. Although much more was now understood about how a woman’s body functioned, many female complaints still couldn’t be explained and were dismissed as psychosomatic.

“In an era when a mentally healthy woman was a serene wife and mother, almost any behaviour or emotion that disrupted domestic harmony could be interpreted as justification for a lobotomy … And the success of the lobotomy was measured according to how obligingly she resumed her household duties.”

Although much of the book focuses on the way privileged, often white, women were treated by the medical establishment over the centuries, chapters also cover attitudes towards Black and ethnically diverse women. There are accounts of how slaves were believed to have higher pain thresholds, and how entire communities in economically deprived regions were enrolled in clinical trials without being informed of potential side-effects. There may have been a need for family planning to improve maternal health, but birth control was regarded as a means of limiting procreation amongst those deemed eugenically undesirable.

I mentioned the rage I felt reading this book. Despite the impressive progress in medical treatment and knowledge, so many of the attitudes detailed here are still recognisable and widespread. They manifest as: banter, mansplaining, paternalistic teasing, bafflement when women do not appreciate a well meant gesture, anger when men feel underappreciated or disrespected. Women want to be treated as fully human, not simply a vessel available for sex and procreation.

I pondered the choices parents around the world make when offered the chance to gender select an unborn child. Boys are still widely chosen more often than girls. Biomedical research funding focuses on finding treatments for ailments suffered by men. Clinical trial subjects have, over decades, mostly been white and male. Unexplained chronic pain reported by women – even that with testable biological markers – is often dismissed with ‘withering glances, eye-rolls, smirks and heavy sighs.’ It can take years of suffering before tests are offered and treatment made available.

The medical histories detailed here are mainly USA and UK based. In these supposedly forward thinking countries, women still struggle to maintain autonomy over their bodies. Access to abortion requires a doctor’s permission and is not available in certain places, such as Northern Ireland. Many of women’s illnesses remain a mystery and are not taken seriously.

The first step in finding a solution is recognising there is a problem, making this an important work. What we need though are advocates who will be heard, not silenced as shrill and hysterical. If history tells us anything it is that the treatment of unwell women is of little interest to men while their needs continue to be met.

Any Cop?: Read this book and be aware of how ingrained and widespread the prejudices are – then learn to listen when unwell women speak.

Jackie Law

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Book Review: Cure

This review was written for and first published by Bookmunch.

Medical research scientists are required to be rigorous in their investigations but also open minded to the lessons that can be learned, both positive and negative, from the results of clinical trials. Drugs that show early promise may not be as effective when tested over the long term on a wide variety of subjects. Side effects of treatments and surgical interventions can be as harmful as the problems they attempt to resolve.

While doctors may be eager to find more effective treatments, particularly for the growing number of chronic conditions, there are deep seated biases against certain alternatives: homeopathic remedies, mindfulness and meditation, distraction techniques, hypnotism, religious belief. What Cure sets out to do is to look at the trials that have been undertaken around such so called woo woo treatments and scientifically question their efficacy.

The book opens with an investigation into the placebo – pills given to patients that are known to contain no active ingredient, or treatment that has been shown not to work after accounting for the placebo effect in test results. Time and again trials show that many patients’ outcomes improve when given a placebo. The author asks why such a cheap and easy alternative is not offered when it could have clinical value. It is now known that the body is capable of producing its own powerful drugs, e.g. endorphins. The brain is a natural pharmacy.

“If someone takes a placebo and feels their pain melt away, it isn’t trickery, wishful thinking, or all in the mind. It is a physical mechanism, as concrete as the effects of any drug.”

There are important limitations in the placebo as treatment; it is limited to the natural tools that the body has available.

“Placebos are good at influencing how we feel but there’s little evidence that they affect measures we’re not consciously aware of”
“Feeling great isn’t everything. We also want to be kept alive.”

Yet for those who do not feel great, placebos could offer a welcome improvement in the way they live. Certain patient groups, especially those with chronic conditions such as CFS / ME, reject that the mind can have such an important impact as they then feel they are being blamed for their illness. This separation of the mind and the body, and the biases such thinking uncovers, may be one reason why the treatments looked at in this book are often dismissed.

Another reason is the difficulty of obtaining funding for large scale clinical trials. Drugs companies are unlikely to support investigations into treatments that will lead to fewer expensive drugs being administered.

Living with long term stress has been shown to create physiological damage and to rewire the brain.

“people in a threat state take longer to recover to baseline once a task is over […] Over time, the extra strain on the heart can lead to hypertension. And as we’ve seen, repeated activation of cortisol can damage the immune system.”

The author investigates a variety of alternative treatments that attempt to train the body to deal with challenges and decrease the harm caused.

“Just as with physical exercise, if we put our bodies under a manageable amount of stress, then go home and rest, this eventually makes us stronger and more resilient.”

The effects of meditation and mindfulness are studied and compared to the effects of antidepressants. Once again, certain patients enjoy benefits yet many medical practitioners dismiss such treatments as nonsense, the proponents delusional. Prejudices are strong.

One problem with alternative and holistic treatments is the way modern medicine is practiced. In the UK an initial consultation typically involves a ten minute GP appointment with the expectation at the end that there will be a prescription or potential for surgical intervention. There may not be a pill for every ill but there could be minimally invasive and effective treatment if the patient is willing.

Drugs for stress, depression and chronic pain are costly with damaging side effects such as risk of addiction. Trials have shown time and again that mind-body techniques can work better on many. Despite the evidence, stigma remains.

Religion is shown to have a placebo effect although only if compassionate and accepting rather than threatening. A sense of belonging – the importance of community and damage caused by loneliness – are also investigated. There is a beneficial effect on health when a patient feels they are a part of something bigger.

“the prolonged impact of having the opportunity to live your life in a way that you find meaningful”

The author is asking: if an alternative treatment works for a patient then why mock and dismiss it? It is clearly stated that a patient may not simply wish themselves better yet there are ways in which the conscious mind can influence outcomes and deal better with painful situations. There is also the argument that keeping alternative medicine within the NHS allows for regulation and the ability to offer conventional treatments as needed. The potential for harm is acknowledged, such as when proven beneficial medications such as vaccines are withheld for spurious reasons.

Each chapter contains details of a variety of patients’ experiences alongside interviews with clinicians and references to papers and journals in which studies are detailed. Throughout, the writing is warm and accessible, the tone clear and inquiring rather than dogmatic. The reader may decide for themselves if improvements in health are worthwhile even if treatment cannot always be fully, scientifically explained in the traditionally accepted way.

Any Cop?: This is a fascinating approach to a controversial subject. The author offers due diligence and a willingness to look for facts without prejudice. The workings of the mind may not yet be fully understood by doctors but this doesn’t mean it cannot be harnessed for innovative and effective treatments. The book offers a compelling and persuasive contribution to a wider conversation. It may change the way rational and informed readers view alternative medicine.

 

Jackie Law

Book Review: Chicken Unga Fever

There have been a plethora of books written in recent years by doctors and other health professionals about the cases they treat and how they cope with the challenges of a job involving potentially life and death decisions. Chicken Unga Fever, by Dr Phil Whitaker, provides a series of snapshots of the working life of a GP. It is a collection of the author’s ‘Health Matters’ columns from the New Statesman magazine, where they have appeared fortnightly for the past five years. Each entry is short – typically a couple of pages in length – and the book is best dipped into rather than read in a sitting. What emerges is a gentle and humane view of the nation’s health from the perspective of a front line doctor who is expected to recognise every ill within a ten minute consultation and offer effective treatment.

Doctors are human and will sometimes make mistakes – an increasingly litigious culture can thus detrimentally affect outcomes as they strive to protect themselves professionally. When rare disorders are encountered they may take some time to diagnose – no doctor can remember every possible symptom and illness. In Britain they work within a system that demands ever more time and cost savings, encountering patients who will already have consulted Dr Google without understanding background and context. With the recent marked increase in obesity, patients are not always able or willing to help themselves.

Some of the cases included are heartbreaking to read – not so much in the experiences of the dying but rather their treatment of those who love and support them when confronted by their imminent mortality. There are interesting musings on medical myths – how science may not always provide the sought after cure. I found it surprising that a doctor would have faith in chiropractors or acupuncture but psychosomatic illnesses are becoming more widespread so perhaps such treatments can prove beneficial for those who believe in them. It was no surprise to learn that a balanced diet, adequate rest and regular exercise can be effective as longer term solutions for many ills.

“If someone is in poor health then there are likely to be myriad contributors. Some, like genes or age, we can do little about. But what we eat, how much rest and recreation we grant ourselves, what exercise we take, our sense of security and autonomy, and our levels of deprivation, are all important determinants that can be addressed – some at a personal level, others socio-politically. The success of scientific medicine has led to the belief that there’s a pill to solve every ill. Our medical forebears would be astounded by the efficacy of our drugs, but equally bemused by our inability to take care of ourselves.”

There is discussion of many issues – from well meaning but ultimately nagging government health promotions that put patients off consulting doctors, to unnecessary testing as a means of reassuring the patient that all possible avenues are being explored but which can lead to false positives that end up doing more harm than good. These false positives also occur when private companies become involved in screening programmes – the more tests they do the more money they make. Modern tests such as MRI and CT scans can spot potentially scary lumps and bumps that the body may successfully cope with given time. Not all precancerous cells become malignant, or develop quickly. Interventions are not always in the patient’s best interests.

The details of the various consultations are presented in calm and measured language. Patients are treated with compassion and respect. Doctors may be best placed to know how to most effectively allocate scarce resources but patients will not always appreciate decisions made that do not provide them with the care they seek. The over prescribing of antibiotics is a case in point, and one that will likely cause future problems for the patient.

The author talks of his more personal experiences as a doctor – such as when called to treat a patient on a holiday flight, or at a child’s school event. He also comments on the equipment and therefore treatments offered in other countries, comparing Zambia and then the USA with Britain’s facilities.

“I want our health service to be as good as it can be, but the juxtaposition with what I was witnessing in Zambia felt raw. UK medical students undertake electives abroad to gain valuable perspectives on healthcare elsewhere in the world. Perhaps it’s time our politicians did likewise.”

Although garnering the occasional mention this is not a political book. The short entries offer an overview of the day to day life of a GP in today’s NHS – the importance of trust and teamwork. It makes for sobering but also comforting reading. The media may love to paint a bleak picture of current UK healthcare, mostly still available to all despite the current government’s endeavours. With continual medical advances I would posit that this is one area that few would wish to revert to ‘the good old days’.

My copy of this book was provided gratis by the publisher, Salt. 

Book Review: Under the Knife

Under the Knife: The History of Surgery in 28 Remarkable Operations, by Arnold van de Laar, offers an eye watering, riveting, always accessible account of surgical techniques and development from biblical times through to the present day. The operations detailed focus on well known names – figureheads, tyrants and celebrities – as well as the medical practitioners who pioneered new practices, mostly without anaesthetic. Along the way technical terms commonly used by doctors are explained.

With the benefit of hindsight the unhygienic conditions that prevailed for so long may horrify, as will recurring treatments such as blood letting. For centuries surgeons and doctors were regarded separately, each developing their skills but rarely working together. Progress was sometimes accidental with a key observation or new practice ridiculed by peers until accepted by a high profile patient.

“in the Middle Ages common sense was obscured by tradition. Rather than looking at the results of their actions, our medieval forefathers would follow what some great predecessor had written in an ancient book.”

The Hippocratic Oath, historically taken by medical students as a step towards qualifying as a doctor, used to contain the line ‘I will not cut for stone’, implying that such dangerous practices as lithotomy – stone cutting – should be left to experts. The first operation detailed in the book involves a Dutch man who ignored this advice and, in desperation, cut out his own bladder stone at home. It was larger than a chicken’s egg and somehow he survived. The formation of such stones is explained as is the more standard operation to remove them and how this has changed over the years. Bladder stones are caused by bacteria. What was once an everyday complaint is now rare.

Treatment for asphyxia – problems with breathing – is then explored by detailing treatment of a very famous patient following a shooting – President John F. Kennedy. As we know he did not survive, following in the footsteps of the first president of the United States, George Washington, who suffocated after his doctors refused to perform a tracheotomy – a cut into the windpipe to allow air into the lungs. This and similar treatments are described along with when and why they may be needed.

Further chapters cover other common complaints: wound healing, including reasons for circumcision; shock, which in medical terms means a failure of the blood’s circulatory system; obesity and its complications, recurrent amongst popes over the years; fracture; varicose veins and other problems caused when our ancestors decided to walk on two legs; peritonitis, which killed Harry Houdini; narcosis and the introduction of anaesthetics for which Queen Victoria was thankful; gangrene; aneurysm; castration; hernia; stroke and more.

Bob Marley died because his religion forbade him from accepting required treatment. Alan Shepard became the fifth man to walk on the moon thanks to a placebo. Lenin suffered multiple strokes throughout his life, the causes and effects of which likely contributed to making him the tyrant he became, although he may have been felled due to lead poisoning from a bullet that remained in his body following a shooting years previously.

As well as detailing key operations, methods of diagnosis are discussed along with complications that can arise due to surgical error. Successful surgeons can become much sought after, especially by those willing and able to pay. Michael DeBakey was one such man in the twentieth century. Described as a maestro by his famous patients he enjoyed to the full his reputation and fame. Nevertheless he dismissed an assistant’s concern during an operation and did not follow through when the patient, the deposed Shah of Iran, developed worrying post operative symptoms which ultimately led to the former leader’s death.

“great surgeons can sometimes make a mistake. Complications are, after all, part and parcel of operations and the risk of problems can never be counted out, no matter how great you are.”

Each of the twenty-eight chapters offers a fascinating insight into surgical developments and subsequent treatment. They are written with sympathy and wit in a style that enables lay readers to understand and learn more about doctor’s reasoning, vernacular and limitations.

For anyone interested in little known medical issues suffered by the famous over the centuries, in how their own body functions and the work of those who may be called upon to keep it going, this is a well structured, digestible, recommended read.

My copy of this book was provided gratis by the publisher, John Murray, via Bookbridgr

Book Review: Complications

“No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.”

Unlike other medical themed books I have recently reviewed, Complications, by Atul Gawande, is set in the USA with its insurance based system of healthcare. I can only assume that payment was not an issue for the patients treated as there is never any question, in any of the cases detailed, of the cost of the complex care provided. Indeed, when cost has already been taken care of, the tests and treatments offered are perhaps more complex than may actually be required.

Written when the author was a surgical resident, he explores in this book the myriad reasons why sometimes fatal mistakes can and are being made. These serve not to lessen the reader’s confidence in doctors but rather to remind us that they are human, and that they must learn a craft that is constantly changing due to welcome advances in surgical techniques, equipment and medication.

The first section of the book, Fallibility, explores the need to teach doctors for the future good of all. They must practice on patients if they are to adequately learn, and as they progress will not always be under close supervision. In the USA doctors become specialists in very particular areas leading to better statistical outcomes as the surgery and subsequent treatment is familiar to the clinical team. Nevertheless, individual patients will not always react in a uniform way. They bring their differing health issues, and sometimes doctors will diagnose incorrectly. With a growing culture of litigation, professional honesty may prove inadvisable. There is discussion of reliance on machines, rote learning and the improvements achieved through practice. One chapter looks at what happens when previously good doctors repeatedly fail to achieve satisfactory outcomes. It can be a challenge to kill the career of a once respected colleague, even when their actions are inadvertently killing patients.

The second section looks at the mysteries encountered in medicine, the diagnosis and results that remain inexplicable. One chapter touches on pain and the role of the brain, the reluctance to accept psychosomatic causes of physical issues. There is a chapter on prenatal nausea, another on blushing. The limited effectiveness of medical interventions alongside the lack of drugs for certain problems is acknowledged. The chapter on obesity suggests this problem is a particular challenge where there is no clear solution.

The third section looks at the uncertainty doctors face in diagnosing problems without opening patients up in surgery. There is a chapter on a patient’s right to decide on treatment, focusing on their lack of specialist knowledge and the pressure of being unwell and, perhaps, fearful. One case cited involved a young woman who the author treated, his recommended procedure invasive when there was a possibility it may simply have required antibiotics. Such choices are made on instinct, an imprecise use of science and learning. This is an ongoing issue – how much can be prescribed and made routine when dealing with the variations of people and their circumstances.

Although a fascinating account of actual cases, with a number of strong arguments and commentaries from the author, I found this book lacked the warmth, occasional humour, and undercurrent of emotion found in other medical themed books I have read. It is factual and interesting but perhaps less engaging to a casual reader. My medical student daughter was glowing in her praise.

Book Review: Histories

“Only this morning, brushing her teeth, she’d listened to a young woman on the radio announcing that her father was being denied treatment, then an interview with a minister about rationing and resources and so on. As though every drug, every penny, has to be made available for every treatment. All the while printers breaking, then nurses, then doctors.”

Histories, by Sam Guglani, is a set of interlinked stories – histories – of the nurses, doctors, patients, porters and cleaners who populate the oncology department of an NHS hospital during the course of one week in October. It is a humane, devastating exploration of the effect of sickness on those who suffer, observe and treat it. Beautifully written it offers an empathetic observance of the many types of people encountered and their coping strategies when dealing with death.

Unlike other books written by doctors this one does not emphasise the stresses caused by the long hours worked. Rather it looks at the relationships between medical staff at all levels, their expectations, and those of patients. Doctors are not homogeneous; they each cope differently with a job that demands they save lives when what they are doing on a daily basis is trying to postpone death.

The consultants featured are at different stages in their careers. One is wealthy and arrogant, believing that patients want their doctors to appear confident and professional, even on days when they may feel crumpled and rushed. He is growing his private practice, the status conferred by the cost of treatment making certain patients consider him the best.

“It’s no big secret. The more elusive or expensive or glamorous a medical opinion, the more hope a patient invests in it, the more trust. He’s convinced of it. Desire and trust are so perfectly aligned in the practice of medicine.”

He talks of the need for self-care, that he always ensures he takes breaks. He is accused of not caring for those requiring consultations, of finding time for his private patients when those coming through the NHS must wait.

“Look. I get that you’re clever. Busy, capable. All that

And so?

I know you can do it all, Nathan. But you give nothing.

What do you want me to give?

It’s just a set of tasks for you, isn’t it? Medicine. While you stay intact.

You want us – what? You want us to break?”

Another consultant becomes frustrated when patients demand tests and treatments that she does not consider necessary. They accuse her of withholding due to their age. They ask for a second opinion from someone more senior. She feels relief and then guilt when she signs them over to someone else.

The junior doctors are still finding their way, struggling to deal with the daily experiences and fear of missing signs of illness progression, or of being blamed for unnecessary escalation. The nurses and other staff members at times resent the doctors with their sometimes acerbic discussions of patients in their care. Yet all are affected by the age and demeanour of the never ending stream of patients.

“We’re drawn to the young and the beautiful in hospitals. We flock to them. We meet them differently to the elderly, say, or the obese, the vast majority of mentally and physically fraying persons that fill these buildings. […] As though, at some level, we really do believe that beauty renders us invulnerable to suffering.”

Patients’ loved ones talk of the unfairness of this suffering, asking why them? as if illness should be deserved. The medical staff have learned what is almost a script in order to deal with the human pain that daily surrounds them. They may care but cannot survive the job if they care too deeply.

In spare yet emotionally unsparing prose the author presents a cast who are at moments of medical crisis. Their stories are told with sympathy but also realism in an environment where patients are demanding miracles. This is a powerfully understated, beautifully written portrayal of life in a hospital, from many perspectives. A recommended read for anyone who may one day require medical treatment.

My copy of this book was provided gratis by the publisher, riverrun.