Hogben on speed, paradoxes and strain*

Abstract

Reflections’ section in this issue. 3 The patient studied had previously undergone surgery for thyrotoxicosis and was now suffering from symptoms of tiredness and weakness that might have either a physical or psychological cause. The study design involved creating a ‘chaotic’ sequential administration of placebo, prostigmine and amphetamine over several 3-day cycles of treatment with careful patient self-reports of experience across 10 outcomes, including mood, appetite and physical activity. Hogben had thyroid surgery in 1943 1 and from the small clues he gives in the paper [e.g. ‘his previous retrosternal goitre had been labelled as functional until he himself persuaded a surgeon to explore the affected area’; ‘the subject (H)’], it is apparent that he was the patient in the study. James Tabery considers that this study stems from Hogben’s interests in statistical inference and causal mechanisms at the individual level—the ‘tyranny of averages’. 4 Paul Glasziou notes that the earliest description of the N-of-1 design pre-dates Hogben and Sim’s by over 150 years, 5 but their approach was methodologically sophisticated and aimed to remove multiple sources of bias. The clinical relevance of the N-of-1 design, mirroring careful clinical practice, is so obvious that it is surprising that it has not become more widely used as a means of finding suitable treatments for patients with chronic conditions. The findings of the study are not commented upon but Hogben certainly felt much better on amphetamines. I wonder if he continued to take them as so many people did (British Prime Minister Anthony Eden allegedly relied on them during the Suez Canal crisis of 1956); they could be bought over the counter in a chemist shop without a prescription at that time. Alun Evans provides a diversion with a historical account of the French paradox of low levels of coronary heart disease despite high levels of fat intake first described in 1981. He traces the paradox to a comparison of the prevalence of angina between Ireland and France published in 1819. 6 He notes that the clin