Christmas myth exploded

January 17, 1997

THE CAMBRIDGE ILLUSTRATED HISTORY OF MEDICINE Edited by Roy Porter Cambridge University Press 400pp, Pounds 24.95 ISBN - 0 521 4412117

When I was a medical student in the 1950s a distinguished professor of medicine told me that Christmas disease, the bleeding disorder related to haemophilia, was so named because it was described at Christmas time. Years later when I read the original description of this condition I realised that I had been misinformed. Christmas, it turned out, was the name of the patient in whom the disease was first identified. However, in partial vindication of the great man, the paper appeared in the Christmas edition of the British Medical Journal in 1952!

Although I doubt this piece of misinformation had a major impact on my clinical career, it reminds me of the blissful ignorance of the history of our field which has characterised most British medical graduates (and their teachers) over the past 30 years. We all recognise many diseases and syndromes by their eponymous titles but we do not have the foggiest idea about who their discoverers were or, more importantly, how the kind of medicine that we practise has evolved. In short, medical history has not been thought to be of enough importance to be included in an increasingly crowded curriculum, mainly I suspect because it has been seen as having little relevance to the work of doctors or other health-care providers.

Things are changing, albeit slowly. Over recent years there has been a gradual realisation that many of the current problems of medical practice might be better appreciated in the light of how this extraordinarily complex field has evolved. Anybody who still doubts the value of this way of thinking should read the chapter "What is disease?" by Roy Porter, the editor of the new Cambridge Illustrated History of Medicine. After a fascinating account of the changing attitudes to disease on the part of both doctors and society over the centuries, Porter ventures into the extremely difficult field of psychosomatic illness, where he considers the modern ills that go under the term somatisation, myalgic encephalomyelitis (ME), repetitive strain injury (RSI), and the rest. After placing these ill-defined complaints into the context of similar conditions that were rife in the 19th and early parts of the 20th century, and pointing out that they do not appear to have a physical basis, he goes on to suggest that, in our secular society, illness of this kind is one of the relatively few ways of expressing social complaints and the ambiguities of self. "Yet it is riven with ambiguity, publicly distrusted, freighted with stigma, and often mocked by the very professionals who massage it."

Perhaps it is no coincidence that Porter decided to follow this section with an equally balanced account of the pros and cons of alternative medicine. In future, while warning them to keep an open mind about the possibility that at least some of these puzzling ailments may turn out to have a physical basis, I shall certainly advise people coming into medicine to read this extremely fine summary of the changing view of disease; if nothing more it should endow them with a little more humility and understanding of the complexities of their trade.

Compiling a bird's eye view of the history of medicine that will be of interest not only to doctors but to the world at large is no mean task. This beautifully illustrated new book from Cambridge is, in my opinion, the best effort to date. By dint of good organisation and tight writing it manages to encompass the history of disease, the rise of medicine, primary care, medical science, the development of modern hospital medicine, therapeutics, and mental illness. The story ends with a lively account of the interaction between medicine, society and the state, and a chapter by the presenter of the BBC's excellent Medicine Now, on what medicine may offer in the future.

It is inevitable that, in an effort to compress this vast amount of material into a short space, a few ambiguities and mistakes are introduced. After perusing the inset entitled "protection against malaria" it seems unlikely that a general reader would end up much the wiser about the biology behind the extraordinary example of balanced polymorphism that has turned the inherited anaemia, sickle cell disease, into a major killer in Africa; at the same time, those who know the field reasonably will be irritated to read that a "less costly" mechanism of protection against malaria is exemplified by the thalassaemia trait alone and in combination with the sickle trait. In fact, thalassaemia does not occur "most frequently among Africans" but is responsible for millions of deaths all over Southeast Asia and elsewhere and is the prime example of how the genetic make-up of populations has been changed by infectious agents.

And nonmedical readers may be confused by a table entitled "major human diseases" which, with the exception of two deficiency disorders, consists entirely of infections, some of which are not world health problems. As pointed out in the 1993 World Bank Report the demography of disease is changing dramatically. A table of this kind, aimed at a general audience, should provide some hint of the increasing role of noninfectious disease in the health of the nations during the 20th century.

But these are small niggles. Overall, the History is remarkably free of errors of fact and is extremely successful in presenting the remarkable story of how medical practice has developed into a scientific discipline, and how at each stage of its evolution it has reflected a complex interaction between its practitioners, the needs and perceptions of society, and the social changes which shape our health.

As a complete outsider to the world of medical history I have only one real difficulty with the way the subject is presented in this book, and it is something which seems to pervade much of current historical writing in this field. While the authors provide a very clear account of the background to how modern medicine has developed and, certainly in this work, give a balanced view of both the advances and problems that have accompanied them to produce the complex and uncertain scene that typifies our health-care systems, for the general reader there appears to be a break in continuity somewhere about the middle of the 20th century.

For example, we learn about how the clinical science of cardiology evolved at the beginning of this century, and about some of its great practitioners such as Thomas Lewis, but there is a disconcerting gap between the work of these pioneers and the remarkable technology of modern cardiology. Who made it all happen? How did these early discoveries generate the remarkable and diverse science that underlies the investigation and treatment of heart disease today? Cardiology is only one and arguably not the most spectacular example of the development of the biomedical sciences. How did modern immunology or haematology reach such a level of sophistication that they were able to pave the way towards molecular medicine and the application of the remarkable advances in molecular and cell biology to the study of disease? And how were the insights of the early pioneers of epidemiology transformed into current preventive and "evidence-based" medicine?

The final chapter tells us how some of these new fields might develop in the future, but how did they reach as far as they have, given their humble origins? Is it simply the sheer volume and rate of change of the biomedical sciences that make life so difficult for historians who wish to present a general survey of the development of medicine in the 20th century? Perhaps we are still too close to put it into any kind of historical perspective. While the evolution of scientific medicine has been extremely rapid in the past 50 years, it is still far from clear whether all the triumphs of the therapeutic scene reflect completely new ideas, or whether many of them are the fruits of remarkable technical advances based on pathophysiological principles that were defined much earlier this century.

Certainly the effects of the fallout for clinical care and preventive medicine from the extraordinary new insights into human pathology that are stemming from molecular biology, will not be felt for some time to come.

It is also possible that these problems are accentuated by the rather limited amount of cross-communication between medical historians and those who are involved in day-to-day medical research or clinical practice.

With that one caveat, this is an excellent overview of the history of medicine. It is beautifully written and argued and will be an invaluable way in to the field for medical students and practitioners, as well as providing the world at large with a lively account of a remarkably complex story, aspects of which affect all of us and our futures. The editor and Cambridge University Press should be congratulated on a fine volume.

Sir David Weatherall is regius professor of medicine, University of Oxford.

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