Then came the Hoover
- Allergy: The History of a Modern Malady by Mark Jackson
Reaktion, 288 pp, £25.00, May 2006, ISBN 1 86189 271 3
The term ‘allergy’ was coined in 1906 by the Viennese paediatrician Clemens von Pirquet to denote any kind of biological reactivity, including asthma, hay fever, reactions to insect bites and stings, and the immunological effects of vaccines and natural infections. Some influential contemporary specialists thought the new term to be both wrong and unnecessary. Wrong, because the evidence linking the different manifestations of the condition was weak; and unnecessary, because there were other neologisms with much the same meaning: ‘hypersensitivity’, introduced by Emil von Behring in 1894, and ‘anaphylaxis’, invented by Charles Richet and Paul Portier in 1902. Von Pirquet won. The linking evidence has turned out to be very strong. And although Nobel Prizes were awarded to Behring (in 1901) and Richet (in 1913) for their immunological researches, their terms, unlike ‘allergy’, remained scientific and technical.
What makes a malady modern? Some define themselves as such because they are caused by novel microbes, germs that did not exist in antiquity. The first sound evidence of an infection with the human immunodeficiency virus (HIV) comes from a blood sample taken in Leopoldville in the Congo in 1959, and Aids was first seen in New York, Los Angeles and San Francisco in 1981. The spread of HIV/Aids was affected by modern lifestyles and technology: there is no doubt that it was helped by male flight attendants having sex with many men when they were away from home. But there is nothing particularly modern about the worldwide spread of a sexually transmitted microbe by chronically infected long distance travellers. The hypothesis that the sailors on Columbus’s ships spread syphilis from the New World to the Old is still a sound one.
Other maladies are modern because their causes relate to modern technology. Asbestos was used in antiquity: the wicks of the lamps of the vestal virgins were described as ‘asbesta’ – inconsumable – and those who weaved the wicks wore masks for protection. But its use two thousand years ago was trivial, and remained so until the end of the 19th century. In 1880, world production was 500 tons. In 1967, it was 3,500,000 tons. Airborne asbestos causes pulmonary fibrosis – asbestosis – and malignant mesothelioma. Forty to 50 per cent of smokers with asbestosis die from lung cancer. Malignant mesothelioma is a tumour of the membranes lining the chest. It kills more than a thousand people in the UK every year, mostly older men who worked in industries such as shipbuilding. Mortality rates are predicted to go on rising because significant reductions in exposure to asbestos didn’t happen until the mid-1970s; malignant mesothelioma is a disease of our time because it takes four decades and more to develop.
A subset of maladies that are modern because they relate to new technologies are the iatrogenic: those caused by medical innovations. X-rays were introduced into clinical practice extraordinarily quickly. Wilhelm Röntgen discovered them in November 1895. On 22 December he X-rayed his wife’s hand, and six days later he gave a paper on the subject to the Würtzburg Physical-Medical Society. Within two weeks newspapers had carried the story round the world. Crookes vacuum tubes, Röntgen’s X-ray source, were easy to get; their clinical use began in January 1896. A common claim in hospital histories, particularly those of the celebratory kind, is that the institution being written about was one of the first, if not the first, to use X-rays for diagnostic purposes. All these histories are nearly correct in the sense that the introduction happened in many places simultaneously. The early workers paid a heavy price for their enthusiastic use of unshielded tubes and long exposures. Painful progressive destructive dermatitis was followed by malignant skin cancers. Anaemia killed others. A definitive list of the radiologists, technical assistants and Crookes-tube assemblers (who tested them on their own skin) killed by X-rays doesn’t exist, but hundreds are known to have died directly from radiation-induced disease.
The 1890s was also the decade when surgeons first entered the abdomen routinely and on a grand scale. The laparotomy rates at St Bart’s and St Thomas’s hospitals increased more than tenfold. Appendicitis became fashionable. In these same years scientific research led for the first time to the introduction of a successful treatment for an infectious disease. It had been shown in the 1880s that tetanus and diphtheria kill by producing powerful toxins. In 1890 in Berlin, Behring and Shibasaburo Kitasato published proof that the serum of animals immunised against these toxins protected against disease. Popular accounts have it that the first time such a serum was used to treat a child with diphtheria was on Christmas Eve 1891. The dying child is said to have made a miraculous recovery. This is best regarded as a myth. According to his own account, Behring did not test his serum on humans until 1893.
Behring needed more funding to continue his work. He got it from industry, in the form of Farbwerke Hoechst. Nevertheless, his basic facilities remained modest; much of his early development work was done in a laboratory under a Berlin railway arch. And after serum treatment became routine there were many arguments in Germany and elsewhere about who should pay for it. This was an early example of one important side effect of the impact of science on medicine: increased costs.
There was another side effect. As with the insulating power of asbestos and the diagnostic gaze of X-rays, the serum treatment of diphtheria brought big benefits. When used early on in the development of the disease its preventive effect was great. Even using it after the toxin had caused serious damage reduced mortality rates. But like asbestos and X-rays it also caused a new disease. The first case of serum sickness was described in 1894. A child with diphtheria was given serum from an immunised horse. Ten days after the first injection the joints in his feet became red and swollen, and this was followed by a general skin rash with fever and severe pains in his other joints. The illness lasted a week; recovery was complete. Serum sickness was a very common complication of treatment with diphtheria antiserum. The more serum given to a patient the greater the likelihood of its appearance: on average, nearly half of patients developed it. But unlike untreated diphtheria, it was very rarely fatal. Serum sickness became common because, in the early 20th century, diphtheria was common. Von Pirquet became a serum sickness specialist, and with Béla Schick he wrote a standard text on it, published in 1905. It led to his work on allergy.
So ‘allergy’ has its roots in a brand new disease. But those who criticised von Pirquet for creating the concept were right when they pointed out that most of its victims suffered from diseases that were neither new nor rare. As an English word ‘asthma’ goes back to the 16th century. And when Sherlock Holmes in the ‘Adventure of the Norwood Builder’ (1903) greets John Hector McFarlane, who has just burst unceremoniously into 221b Baker Street, with the words ‘you mentioned your name, as if I should recognise it, but I assure you that, beyond the obvious facts that you are a bachelor, a solicitor, a Freemason, and an asthmatic, I know nothing whatever about you,’ Dr Watson felt no need to explain beyond saying ‘the breathing’. Von Pirquet was not even the first to link asthma, hay fever and other allergic conditions like urticaria. One popular medical textbook in the late 19th century was The Theory and Practice of Medicine by J.S. Bristowe, which went through seven editions from 1876 to 1890. My own copy (a second edition of 1878) used to belong to a successful general practitioner in Norwich. He obviously found its 1202 pages daunting – he had stopped cutting them at page 429, in the middle of Bristowe’s account of liver cirrhosis – but the later section on asthma and hay fever, which Bristowe calls ‘hay-asthma’, had been opened up.
Bristowe speculated that the mechanisms responsible for an asthmatic attack and urticaria might be the same. He said that asthma was due to a ‘spasmodic contraction of the muscular tissue of the bronchial tubes, and consequent narrowing of their calibre’, an ‘urticaria-like swelling of the bronchial tubes’. It is instructive to compare his account with that in the most recent edition of The Oxford Textbook of Medicine (2004), which summarises the asthmatic as having bronchial ‘mucous gland hypertrophy and hypersecretion, smooth muscle hypertrophy and hyper-reactivity’. After stripping out the jargon there is little difference between these 19th and 21st century descriptions. Of course, much research has been done since 1878. In Bristowe’s time, nothing was known about the cells and chemicals that act in asthma and hay fever. For instance, the ‘prominent eosinophilic inflammation’ and ‘T-lymphocyte infiltrations’ that the Oxford Textbook highlights were unknown to him. Eosinophils – white cells containing granules that are stained strongly by the red dye eosin – were not described until 1880.
But the biggest difference between Bristowe’s allergies and those in the Oxford Textbook is not the modern understanding of the cells and chemicals that act during an asthmatic attack, but the recent massive increase in the number of people reported to be allergic. The proportion of the population of England and Wales consulting general practitioners for asthma increased from 8.5 per 1000 in 1955-56 to 17.8 in 1981-82. Similar rises have been recorded in other developed countries. Describing, discussing and explaining this phenomenon occupies much of Mark Jackson’s book. He makes a convincing argument that to look on his subject in a straightforward technical/scientific way will not do, and that it’s impossible to understand allergy without placing it in the context of modern medicine: where specialist doctors see themselves not just as consultants but as boosters for their field, where advocacy groups have great influence, where industry drives practice and policy, and where an insatiable public demand for therapy creates superb opportunities for quacks and charlatans.
Jackson’s account is underpinned by Ulrich Beck’s Risk Society (1986). Beck describes a new modernity, one no longer coextensive with industrial society. These days, the risks created by industry and science are of a new kind, ‘somehow universal and unspecific’; those who worry about them ‘are mostly well educated and informed but they are afraid and feel threatened’. Mary Douglas and Aaron Wildavsky put it well in Risk and Culture (1982):
What are Americans afraid of? Nothing much, really, except the food they eat, the water they drink, the air they breathe, the land they live on, and the energy they use. In the amazingly short space of fifteen to twenty years, confidence about the physical world has turned into doubt. Once the sources of safety, science and technology have become sources of risk.
It is a widely held view that the products of science, particularly chemicals, industrial pollutants and the modern Western lifestyle itself, must have something to do with the increase in the number of allergies, which itself reinforces the belief that we do indeed live in a ‘risk society’. Jackson writes about the fertile imaginations of those looking for connections. Paradoxes abound. Dust was demonised early. US patent 889,823, of 2 June 1908, described J.M. Spangler’s ‘Carpet Sweeper and Cleaner’ (Spangler was a department store janitor whose asthma was exacerbated when he brushed rugs). The patent was bought and exploited by William H. Hoover, whose product revolutionised domestic cleaning. But three-quarters of a century later the ‘hygiene hypothesis’ was suggesting that things had gone too far: infections in early life mean fewer allergies later and a little bit of dirt is a good thing.
Pollutants undetectable by the human senses, such as minute particles from motor car exhausts, microwaves from phone masts and insecticides in food, have caused particular concern since the publication of Rachel Carson’s Silent Spring. But Carson was building on a long-standing tradition. Miasmas – invisible emanations from the environment – were feared just as much in the 19th century as pollutants are today, and memorials of the debates about them are easy to find. When, in the early 1860s, St Thomas’s had to find a new home because of railway developments at its site in Borough, near London Bridge, Florence Nightingale, a fanatical miasmatist, wanted the new hospital to be built in the unpolluted leafy suburbs of Camberwell, Norwood or Lewisham. Her opponent was John Simon, head of the government’s Medical Department, who favoured a site on the Albert Embankment (opposite the Houses of Parliament) that was being created by Joseph Bazalgette’s construction of a new sewer system. Simon’s campaign against Nightingale was masterly: he got John Delane, the editor of the Times, on his side; and commissioned Bristowe, who was yet to write his textbook but was already a physician at St Thomas’s, to survey the sanitary circumstances and results of British hospitals. With the surgeon Timothy Holmes, Bristowe visited all the bigger ones and concluded that location had no effect on outcomes. Nightingale was furious. She rubbished the report. But the hospital was built on the Embankment.
The ideas of the miasmatists nevertheless live on. The notion that natural disasters are commonly followed by disease and that corpses cause epidemics is held not only by journalists and TV reporters. In 2004 the World Health Organisation said that epidemic outbreaks were a ‘major concern’ after the Bam earthquake and ‘could occur at any moment’ after the Boxing Day tsunami. There were no epidemics. A study by Nathalie Floret and others of the 516 earthquakes, 89 volcanic eruptions and 16 tidal waves and tsunamis listed in the Emergency Disasters Database as occurring between 1985 and 2004 found that only three were followed by outbreaks of disease: one of malaria after an earthquake in Costa Rica in 1991, one of coccidioidomycosis (a fungal infection) after an earthquake in California in 1994, and one of measles after the eruption of Mount Pinatubo in 1991.
A loss of trust in experts is the hallmark of the risk society. Whatever scientists may say, miasmas are still thought to assault and pollutants to poison. But pinning them down as allergens has not been easy. Research results have been counterintuitive. Studies of allergy incidences in the two parts of Germany soon after the fall of the Berlin Wall, for example, found them to be lower in the heavily polluted East. Nevertheless, the risk society provides many opportunities for practitioners eager to exploit its fears.
Jackson’s excellent account of clinical ecologists who battled with the allergy establishment, such as Theron G. Randolph of Chicago and his British disciple Richard Mackarness, shows how they expanded von Pirquet’s broad concept and rejected the tightly drawn definitions of Behring and Richet. They claimed that biological sensitivities to foods, natural inhalants and chemicals in the environment often at levels much lower than those deemed to be harmful by toxicologists cause not only asthma and hay fever but headaches, depression, bowel problems, fatigue and anxiety. Their supporting evidence came from anecdote rather than clinical trials; the jargon of science was freely used but its results were rejected. This widening of the meaning of allergy has played well with the public. But by all the generally accepted criteria people overestimate the role that immunology plays in their intolerances, particularly to foods; double blind tests in an English town showed that only 5 per cent of those claiming to have food allergies had made an accurate diagnosis. All this gets in the way of finding out with any precision how many people are allergic, and whether the increase in the number of allergies is real, rather than a product of increased awareness or enhanced diagnostic assiduity.
But allergy is real. Every year in Britain it kills about as many people as does malignant mesothelioma. And there can be no doubt that modernity has a hand in its causes. Syphilis wasn’t the only South American export of Columbus’s time. Peanuts were another. Anaphylaxis caused by peanuts and peanut products has marched alongside the big increase in their popularity in Britain over the last fifty years. Serum sickness may have disappeared along with diphtheria, but iatrogenic allergy remains; penicillin is the commonest cause of anaphylaxis in adults. Science has provided uncontroversial explanations of these phenomena and effective treatments for them. They are at the end of the spectrum of allergic disorders where there are no arguments about definitions. The total allergy syndrome resides at the other end. It has no scientific basis and nothing to do with immunology. So von Pirquet’s concept is not without problems. That some who practise under its rubric have an uneasy relationship with science isn’t surprising; it’s typical of medicine across the board. As Jackson says towards the end of his book, allergic diseases are ‘existential realities intimately related to the material processes of modern civilisation which are vulnerable to scientific dissection, epidemiological investigation and biochemical manipulation’ and at the same time ‘an index of cultural anxiety’, a set of pathological concepts ‘closely shaped by the imaginative forces of radical environmentalist critiques of modern commercial civilisation and spiritual yearnings for individual solace’.