Ways we think about medical care

kw: book reviews, nonfiction, medicine

Considering the number of times I have had to be my own doctor, one might expect me to be quite skeptical and resistant to doctors' advice. So when I saw Your Medical Mind: How to Decide What is Right for You by Jerome Groopman and Pamela Hartzband (both MD's), I hoped two things. Firstly, that they would refrain from telling me what I think, and secondly, that I would find how rare or common my experience and medical thinking style is. I was pleasantly gratified on both counts.

In the second chapter, both Jerry and Pam (who are husband and wife, but they play it down) present their own histories. In their own ways, both were strong "believers" in medicine who became more skeptical as time passed. They have learned to think about a suggested treatment: sometimes they will go along, and at other times ignore the recommendation or modify it. It quite much parallels my own path. Because of a few instances, I am very, very glad to benefit from 21^st Century medicine. Yet I have learned just how fallible doctors are (about as fallible as I am, and that has grown on me also!).

Some people by nature and perhaps upbringing are very much believers in medicine and not only take all their doctor's recommendations, they may be quite proactive and push for more care. Others are doubters and push back if they push at all, but more frequently ignore most medical advice and only partake of medical care in the most dire circumstances. I don't know if the split is 50-50 or skewed. But I think of my grandmother. She had her first child in a hospital, in 1918. She was not at all pleased and vowed not to enter a hospital again. She had her second and third children (my Mom was #2) at home on the kitchen table, assisted by her husband. At age 81, she hosted me for a couple of months when I moved to her town and was apartment hunting. She was strong and witty. The next year she had a stroke and died a day later without regaining consciousness. My mother said, "It is a good thing she didn't wake up in the hospital. She would have died anyway, of fear or rage, I am not sure which."

The book's chapters center on stories, of a patient wrestling with the decision whether to take a statin for moderately high cholesterol (a twin of my wife's dilemma); of Jerry regretting allowing a back operation and Pam deciding to skip an MRI for a sprained ankle because it was prescribed earlier than usual; of a man brought back from death's door by the transplant of a nearly discarded liver; of treatments that didn't work, and those that did.

One amazing chapter shows how people's thinking evolves once they fall ill. In a typical case, a healthy person in middle or late-middle age might write a Living Will or Advance Directive. I have helped my father do so, not in late-middle age, but at the age of 89. One frequently hears, "Oh, I don't want any heroics. I wouldn't want to live with (horrible disease of your choice) anyway." Then when (horrible disease) arises, many people change their mind. They find that, if you live with a condition for a while, you adjust, and can still find much to enjoy. Only in cases of chronic agony do we find people demanding a "Kevorkian remedy". The authors state several times that a person in good health simply cannot imagine what he or she might think once major illness occurs. I liken it to the way we tell our kids, "Just wait until you have kids." We know they can't imagine it; they can only live it.

I found it no surprise that the authors recommend a balanced attitude: take everything with a grain of salt, but be wise and don't reject your doctor's advice out of hand (what did you see the doctor for, otherwise?). My own attitude is that of a contract foreman. My doctor is hired help. He (my current doc is male) has knowledge I don't have, and knows a gaggle of experts who have more specialized knowledge, and can do things he and I cannot do. I seek their advice, but make them talk me into any treatment they think I need. When you need a doctor, you really need one!

I am sure glad for the surgeon I was directed to in 2000, for my cancer surgery. He brought me back from death's door. He was a "contractor" to whom I trusted my life, and whom I empowered to make decisions when I could not (because I was anesthetized). He faithfully discharged his task (it took him 5 hours). Surgery is the prime example of our occasional need to empower another to temporarily control our life.

But in the more usual cases, I find myself in long-term negotiations with my doctor over blood pressure—to medicate or not—and my weight and level of exercise. In such things, I am more comfortable being able to have a say in how I am treated. Absent a life-or-death scenario, continued negotiation is a great kind of relationship to have with a doctor. You just need to have one who is comfortable with that. If your doctor is a "My way or the highway!" sort, take the hint and take the highway. Get a doctor who will negotiate, but also knows when to say, "Hold on, there, this one can kill you quick. Let's do something NOW!"

I sure love it when doctors are not only good physicians, but can also write so well. Kudos to this couple.

Ten legs and a hard shell

kw: book reviews, nonfiction, natural history, crabs, arthropods

Meeting a crab this size would take the edge off my desire for crab cakes. What must it be like for this fascinating creature to live in the depths of the sea, without enemies (except humans, of course)? The Japanese Spider Crab, Macrocheira kaempferi, can get 12 feet (3.7m) from claw to claw and weigh 20 lbs (9 kg) or more. There is a crab species that can weigh twice as much, but is nowhere near as spectacular as the 9-footer (2.7m) "Big Daddy", seen here in Blackpool, England (image from FoodBeast.com). You can see from the small size of the claws that Big Daddy has little to fear in his native habitat.

At the other end of the scale, little, semiparasitic Pea Crabs grow up to measure about 2cm (females) or 0.8cm (males). They live in the gill chambers of mussels and other shellfish, mainly in the northern hemisphere (Image of a species found in California, Fabia subquadrata, from the RaceRocks website).

With almost 6,800 known species, the crabs number about a tenth of crustacean species. As a child I was surprised to find out that the little pill bugs in the garden are more closely related to crabs than to millipedes. They are formally called woodlice, and are also crustaceans.

Not all crabs walk sideways, but the familiar ones do, so Walking Sideways: The Remarkable World of Crabs is an apt title for a new book by Judith S. Weis. The ten chapters present the full range of crab knowledge and lore, and 23 vignettes scattered throughout add associated subjects, such as lobsters, festivals related to crabs (mainly as food), their use in medicine, and as pets.

Presenting crabs and inducing us to sympathize with them is a harder sell than telling us what life is like for birds (see this review from last month). Crabs are just too strange. Compared to ours, their internal body plan is upside-down: The main nerve bundle, comparable to our spinal cord, runs down their front, while the digestive organs are in back. Our skeleton is internal, theirs is external, and needs to be replaced frequently. Hmm, I'd sure like to replace my skeleton, with some of its creaky joints! We have two jaws; they have two or three pairs of claw-like mouth parts, and can taste their food before it gets into the mouth. Their eyes are usually on stalks, and are more closely related to the eye of a dragonfly with its wonderful geodesic-dome shape, than to our liquid cameras. They have gills, that take up at least as much of their body cavity as our lungs do of ours. Their blood is blue, and they have arteries but no veins: the blood just leaks out of capillaries and sloshes back toward the heart.

For all that, they are intensely fascinating. Many years ago, when it was allowed to visit tide pools in California, I got the biggest kick out of finding some crabs and watching them. Starfish and snails are cool enough, but they move slowly. Crabs scuttle right along, and aren't afraid to challenge an intruding human child, ready to give a sharp nip if needed. I wasn't afraid of a nip from a crab up to perhaps an inch across the shell, but any bigger, and they could Hurt!

The author packs so much information into the book's 214 pages that it has to be read rather slowly. It is dense reading, and I hope it does not put people off. The author would clearly like to tell us everything about crabs, but had to limit herself. There are so many, which occupy so many different habitats, that a large encyclopedia would not suffice. And new things are being
learned constantly. At the current rate of a new species found every few months, they ought soon to surpass 6,800 known species. It is thought that we have found only a tenth of them. This purple crab from the Philippines (image from Mother Nature Network) is one of four new, purple crab species discovered just a year ago.

Another ambiguous whack at the origin of J.C.

kw: book reviews, science fiction, political fiction, moon, apollo program, conspiracies

After reading The Cassandra Project by Jack McDevitt and Mike Resnick, two writers whose work I admire greatly, I gave myself a while to think. Then I did something I haven't done before: took a look at other reviews. I wanted to see who, if any, shared my concern about yet another "ancient alien" explanation for the Christian religion. Didn't find anyone, as expected. Very few Christians read science fiction anyway. Sorry if that's a spoiler, guys.

But it is no spoiler to guess, without opening the book, that a novel by McDevitt and Resnick is going to bring in aliens in some way. I do wonder about the title, though. Other than connecting the plot with ancient Greece, it makes little demand on the reader, and actually seems irrelevant.

For the record: In the Iliad, Cassandra was a prophetess who spurned the advances of Zeus (he had more conquests than Wilt the Stilt). He angrily cursed her to be always right and never believed. Turns out to be a big factor in the demise of Troy. I never figured out how it connected with the 50-year-old alleged conspiracy in the book. I guess they had to name it something.

There is one bit of nonsense that I didn't expect from writers who are known for hardheaded science. During the return trip from the Moon:

"It's raining out."
"Raining?"
"Meteors."
Bucky looked out the window and watched a cloud of rocks sweep past.

Now, that's a bit of supreme silliness. Any "rocks" sweeping by will be going about 30 km/s, with respect to the spacecraft, which is moving something like 7 km/s toward Earth. A piece the size of a golf ball would be in sight no more than a millisecond or two; if you knew exactly where to look, you'd still miss it. Bucky, by the way, is a billionaire (he claims $3B) who is funding a commercial venture to return to the Moon. He must have some powerful aces up his sleeve; in 1969 dollars, each visit to the Moon cost about $4B; multiply by 8 for current dollars.

All that aside, the book is a great read. While it is pretty clear quite early that the "conspiracy" is going to be validated, precisely what it is, and why, are kept just out of reach until very late. That's a prime piece of plot management. The writers make a reader care about, not just the "hero", Jerry, but his erstwhile antagonist and then employer, Bucky, and several others. While I had to suspend more disbelief than usual, I enjoyed the novel.

The early evolutionists

kw: book reviews, nonfiction, evolution, evolutionary theory, short biographies, history of science

The fundamental divide between the facts of evolution and the theory of evolution has been at the root of both the scientific and theological debates about "transformation of species" for centuries. In Charles Darwin's correspondence he once referred to "us transformationists", using the word derived from ancient speculations about species change. As Rebecca Stott brings out in Darwin's Ghosts: The Secret History of Evolution, some early attacks upon On the Origin of Species were accusations of plagiarism!

Poor Darwin was assailed from all sides. The religious censured him for impiety (as many still do), and most scientists either decried his theory of natural selection or denied his priority. Claimants to priority put forward by various "correspondents" included Aristotle, nearly 2,200 years earlier, and Jahiz of Basra "only" 1,000 years before Darwin's publication. As Professor Stott shows, these first two at least are bogus claims. Anything that either man may have written about mutability of species served only as a foil to clear statements on their eternal fixity. Aristotle in particular may have been curious about the apparent ambiguity of sponges, but seems to have concluded that they were rather peculiar plants. It was not until the 1820s that the motile larvae of sponges were observed, giving the first clue to their animal nature.

However, numbers of earlier students of natural history did speculate about species change. Such speculations were based on observations that the boundaries of "kinds" were not as fixed as one might like. Certain hybrids were known, for example, some sterile and others not. In the 16^th to the early 19^th Centuries, however, just to speculate in print could get you in serious trouble with the theocratic governments of Europe. There were notions that all species might have somehow been derived from a "primordial filament". Those who published such views were at great risk.

Prior to Jean-Baptiste Lamarck in 1800, though, nobody put forward a theoretical explanation for a mechanism of species change. His theory is called "Inheritance of Acquired Characteristics", and the best-known example is the giraffe, which is imagined to have arisen as ancestral forms stretched their necks to reach the leaves of trees; those which could stretch the best passed on longer necks to their descendants. Charles Lyell effectively demolished this view before Darwin had developed his own theory.

As the mini-biographies in Darwin's Ghosts show, those who published "transformationist" views prior to 1840—including Erasmus Darwin—and thus risked censure, persecution and death, laid the groundwork for Darwin to publish Origin and survive with his skin intact. The only person who clearly enunciated a theory of Natural Selection, independently of Darwin, was Alfred Wallace. The gentlemanly way both Darwin and Wallace and the scientists Darwin consulted handled the priority question is a highlight of scientific history.

The priority question arose only because the theocratic risk had induced Darwin to spend some twenty years gathering added examples and refining his arguments, so there would be no refuting his theory (so greatly did he underestimate the persistence of Pharisaical creationists!). Had he published his theory soon after he had confirmed it, Wallace would likely have known about it, and possibly had the book in hand during his expeditions in the Malay Archipelago. Think what a different route his collecting activities might have taken were he searching for further confirmation of the theory! However, his independent derivation of Natural Selection, based on Malthusian theory for both him and Darwin, strengthened Darwin's supporters when the debates heated up in the decades after 1860.

The debates continue, sad to say. While proponents of Judaism don't seem to care much, both Christian and Muslim apologists decry all aspects of evolutionary theory, from the great spans of time it needs to the notion that human dignity is denigrated (We're apes, folks. Get used to it). Now that millions of fossils and their stratigraphic relations have shown that extinction and evolution are factual, many are forced by the evidence to admit that "life has changed through time", which is how evolution is defined. But the Theory of evolution! Now, that's where the Shinola "hits the fan". The Theory is Natural Selection. Its outline is simple:

• Most individuals of all species die young and thus do not reproduce.
• There is variation among the members of any species.
• Certain variations tend to help an individual survive and reproduce, while others tend to hinder or prevent survival and reproduction.
• There is a mechanism that leads to increased variation within a species, nowadays called mutation.
• Over long periods of time, variations that promote survival and reproduction increase, even as others decrease.

All this together is also called Descent with Modification, a term Darwin first used. By contrast, in the prior theory, Lamarckian evolution,  modification precedes descent.

The matter of mutation was unknown to Darwin and his contemporaries. So was the digital nature of inheritance. When I was young, "mutation" in popular culture was thought to be some sudden, monumental change, such as the radioactive spider biting Peter Parker to turn him into Spider Man. Actual mutations are tiny, tiny variations in DNA. Every one of us contains between 50 and 100 such mutations that make each person genetically different from being exact replicas of the parental mix that produced the egg and sperm that fused to form the embryo that became him or her. Even "identical" twins are different in this way. Most mutations have no effect. Of the very few that do, some cause the embryo to die very early, some lead to birth defects or other debilities, while a few may be beneficial. These last are most likely to help us or our descendants survive better.

In a later edition of Origin, Darwin was persuaded to add a Historical Sketch, to outline the ideas of his predecessors. This Sketch is included as the last chapter of Darwin's Ghosts. So what is the secret of this Secret History? That Darwin and Wallace really did produce an entirely original theory. Natural Selection has been called the most successful scientific theory (proponents of quantum electrodynamics or the general theory of relativity notwithstanding). It has been said that without Natural Selection, none of biology makes any sense, but with it, everything does.

For me, the book placed a solid stamp on the originality of the theory of Natural Selection. Those who accused Darwin of plagiarism were mistaken. No theory of descent with modification preceded Darwin and Wallace. No substantial variant theory has stood the test of time. Subscripts such as "punctuated equilibrium" add details that explain the effect of sudden shifts of environment, for example, without changing the essential nature of Darwinism.

A face for all occasions

kw: book reviews, nonfiction, typography, type faces, fonts

I have a few methods of locating new books of interest, but I missed this one when it came out a couple of years ago: Just My Type: A Book About Fonts by Simon Garfield. Take a brief look at the book title. Why is slanty type called "Italic"? And why is the text typeface called "Roman" (though a growing number of publications use "Swiss" typefaces)? You'll find answers in Garfield's romp through the history of typeface design.

And what a romp it is! Helpfully, it starts in the middle and runs both ways through time. It would be a bit boring to just plod along the timeline from Gutenberg's Fraktur faces, what my parents called "Old German", through serifed faces based on Roman inscriptions of the Imperial period (particularly Trajan's Column, still the standard-bearer), to sans-serif faces that were more "modern" some 100 years ago. Instead, he starts by discussing what makes a typeface more or less likeable and useful.

The 22 main chapters are interspersed with 12 short chapters on individual typefaces, or groups of them (or, in one case, a very particular symbol). The first of these is the much-used but much-hated Gill Sans. Loved because it is legible, hated because Eric Gill offended nearly everybody, primarily by his Satyric tendencies.

To any who don't now, a "serif" typeface is one like Georgia, which I chose for this review. A serif is the little blip or hook such as the hangy-downs on the capital T or the feet of a capital A or small n. Fonts without these, such as Verdana, a very common Web font, are called "sans-serif", "sans" being French for "without". Also, Fraktur is a lot like Old English (look both up in Google Images; the differences appear minor until you really look), but with the extra letters needed for German typesetting. Both are also called Black Letter; they use a lot of ink on the page. Finally, a font was originally a specific style and size of a particular type face, such as "Georgia Regular 12 point" or "Headline Bold 48 point". These days, with TrueType and OpenType standards for re-sizable glyphs, a font file contains the glyph definitions for a specific style, and several files are needed to make full use of a particular typeface. Thus "Georgia" refers to a typeface, while "Georgia Bold" refers to its boldface variant. Many typefaces intended for text have four variants: Regular, Italic, Bold and Bold Italic. But many commercial fonts have 20 or 30 variants, including light, heavy, and hollow versions, plus condensed or extra-wide, even "fat".

Certain typefaces have become so widespread they seem part of the furniture. In England, for example, most road signs used a typeface named Transport, a sans-serif face using both upper and lower case. Its promoters established that a sign reading Watling 4 km is easier to comprehend at a glance than WATLING 4 KM. The Transport face is found on English language road signs around the world. This bears on a point Garfield makes repeatedly. Numerous typeface standard-bearers have stated that if you notice the typeface, it interferes with the message. Thus fancier or prettier faces are to be reserved for special uses.

Still, the number of very useful typefaces is large. This clip from Camdon Wilde's Periodic Table of Typefaces shows just a few of the 100 most popular types (at this point in time). If you're curious, #2 is Futura, also sans-serif, and #3 is Bodoni, a hugely popular serif font.

I have collected font files for my own use for many years. Though I am discriminating, still the collection numbers 1,840 files. For convenience I have them in 9 categories and 54 sub-categories. Text fonts make up a large part of the collection, with serif and sans-serif faces categorized along a wide-narrow continuum, from ultra-condensed to ultra-wide.

I also have a careful selection of decorative faces, including 200 specifically useful for initial capitals (drop caps), that I like to use to spruce up a text document.

Here is a glimpse at just a few of the 200:

Among those seen here, Goldstone and Genzsch are the most useful. The frilly ones are easier to comprehend in larger sizes. A 3-line drop cap in 12-point text is about 40 points, depending on the ledding (now spelled leading, but pronounced with a short "e", not the "ee" sound), which refers to the extra space between lines of type that improve readability.

Type design went through several stages of mechanical production, but computer design is now ubiquitous. Punch cutting is practiced only by a few gluttons for punishment. A multitude of typeface design programs makes the craft accessible to all, and the existence of more than 100,000 electronic typefaces testifies that it isn't that hard. Making a face that will last, though, that's hard. Someone I expect to make a lasting mark on typeface design is Ray Larabie, who has designed hundreds of typefaces. I have obtained several that I like very much. There are others designers who are equally prolific, something quite impossible in the days of punch cutting in metal.

The book just scratches the surface of the wonders of typefaces and their design. I seldom mention a book's bibliography, but I recommend it for those interested in the subject. There is also a fine list of useful web resources. And by all means, if you've a hankering for type design, there is plenty of freeware available. I am partial to FCP, which has a free version, but the "good" version is not too costly. Try your hand at type design. Of course your first effort will be junk, but you'll learn something. And you'll learn a lot from the book!