When I was working in Africa I read a paper that proved that intravenous corticosteroids were of no benefit in cerebral malaria. Soon afterwards I had a patient with that foul disease whom I had treated according to the scientific evidence, but who failed to respond, at least as far as his mental condition was concerned — which, after all, was quite important. To save the body without the mind is of doubtful value.
I gave the patient an injection of corticosteroid and he responded as if by miracle. What was I supposed to conclude? That, according to the evidence, it was mere coincidence? This I could not do: and I have retained a healthy (or is it unhealthy?) skepticism of large, controlled trials ever since. For in the large numbers of patients who take part in such trials there may be patients who react idiosyncratically, that is to say, differently from the rest.
A paper in a recent edition of the New England Journal of Medicine brought back my experience with cerebral malaria. Animal experimentation had shown that progesterone, one of the class of steroids produced naturally by females, protected against the harmful effects of severe brain injury. The paper does not specify what exactly it was necessary to do to experimental animals to reach this conclusion, but it does say that it has been proven in several species. What is not said is often as eloquent as what is said.
The investigators decided to try the experiment in humans, though they could not, of course, actually give human subjects standardized head injuries as presumably they could with experimental animals: they had to wait until “normal” circumstances (in 21 countries) produced a sufficient “crop” of such injuries. They experimented with more than 1,000 such injuries, allocating them randomly to progesterone treatment or placebo.
As seems now to be almost customary in trials the results of which are published in the August journal, the results were entirely negative (even though a couple of smaller previous trials have been encouraging). On no measure did those given progesterone do better than those given placebo. The drug was useless. The only good news was that it did not cause active harm to the patients, and therefore complied with the most important injunction of medical ethics: first to do no harm.
There were some interesting figures in the paper. For example, slightly more than 78 percent of the participants in the trial were male. Surely in an age of equality, this is an outrage? Some effort must be made either to reduce the rate of head injury among men, or perhaps more controversially, to increase it among women, so that equality may be established.
Then there was the terrible toll taken by sports injuries, amounting to nearly fifteen percent of the total. If the causes of the head injuries of the participants in the trial were representative of the people as a whole who suffer head injuries, then (on the figures given in the paper) there are more than 250,000 head injuries a year in the United States alone caused by sporting activities. Is there any other activity that caused such easily avoided carnage that would be permitted to continue?
As to the cost of sporting injuries to the United States, it is far from negligible. The paper estimates the annual cost of head injuries to be $76 billion. Of course, such estimates are always approximate, but it can hardly be doubted that, with 1.7 million cases a year, the cost must be considerable. The cost of sporting head injuries would be in the region of $10 billion, to say nothing of those to knees, shoulders etc.
It must be time to call a halt to the pluri-millennial human foolishness known as sport.