Ill-health
Anthony Storr
The Diseases of Civilization Brian Inglis (Hodder & Stoughton pp.371, £.10.95) Brian Inglis has long been recognised as a well-informed historian and critic of orthodox medicine and a supporter of unorthodox, 'fringe' methods of treatment. In this book, he returns to the attack, armed with a detailed bibliography, and a formidable range of information. Although, in a limited number of instances, his knowledge can be faulted, or his reporting deemed to be biased, most of his criticisms of medical practice are just and very few doctors can claim as wide familiarity with so many different aspects of their professional concerns. Moreover, Brian Inglis's tone is moderate. He entirely lacks the shrill querulousness which so disfigured Ian Kennedy's Reith lectures.
At a time when the N.H.S. is attracting much criticism, it is encouraging to find that Brian Inglis supports it as 'easily the most cost-effective system.' In the U.S.A., in spite of increasing sums poured into medical insurance, it is estimated that a quarter of bunkruptcies are due to the cost of serious illness. There is little check to prevent surgeons performing unnecessary, but lucrative, operations and medicine is regarded primarily as a money-making profession. In Britain, we are largely protected from this deplorable state of affairs by the fact that the majority of the best doctors choose to remain within the N.H.S.
Nevertheless, as Mr Inglis demonstrates, there is something sadly wrong with the practice of medicine. Part of the trouble springs from the training of medical students, which, although better than it was in my day, still leaves much to be desired. Medical education is largely in the hands of specialists in hospitals, and not sufficiently geared to the needs of the GP who gets little training in the recognition and treatment of the common complaints and personal and family problems which will constitute the bulk of his practice. Social factors in illhealth are still underplayed; I am glad that Brian Inglis quotes with approval the seminal work of George Brown in defining the social origins of depression in the women of Camberwell.
Doctors are far too ready to accept the effectiveness of new methods of treatment of disease, especially when these are dramatic. In my own professional lifetime as a psychiatrist, I have seen the discrediting of insulin coma in the treatment of schizophrenia, the waxing and waning of enthusiasm for psychosurgery, and the over-enthusiastic acceptance of a variety of drugs which have been found to be either ineffective or dangerous. Heart disease is one of the major killers in our time, at least in the West. Yet, as Brian Inglis demonstrates, by-pass surgery for coronary disease, though widely performed, is doubtfully effective; expensive coronary care units, as opposed to treatment at home, may not reduce the death-rate from coronary thrombosis; and we all know that heart transplants, whilst providing dramatic publicity for both surgeons and patients, have not been sufficiently successful to warrant the resources of skill and money which they require.
Over many years, thousands of women have been subjected to the dreadfully mutilating operation of radical mastectomy for breast cancer; yet, today, serious doubts have been raised as to whether this operation prolongs survival beyond that secured by local removal of the tumour. Indeed, treatment of any form of established cancer may be little more than palliative, although, in types of cancer where external irritants like tobacco are known to be involved, more could be done by way of prevention. It is probable, as Brian Inglis points out, that everyone past middle age is developing various cancers which the body's defensive system is able to abort. Research, therefore, ought to be directed more towards understanding the workings of the defensive system and how it comes to fail than towards understanding the 'cause' of cancer and its cure once established. Brian Inglis produces evidence to show that, in spite of the claims of cancer specialists, the incidence of, and death-rate from, cancer has declined very little in the last 30 years.
Brian Inglis believes, with reason, that the role of psychological factors in physical disease has been underestimated. For example, he quotes the impressive work of Professor Lynch in the U.S.A. showing that the mortality rate of males dying from heart disease is related to whether they are married, single, widowed, or divorced. Heart disease and absence of affectionate relationships may well be related: but, even if cardiologists neglect emotional factors in their patients, it is hard to see how recognition of their importance can be used effectively in prevention. Are doctors to say to their patients (before they even become patients) 'Avoid psychological stress, especially unhappiness in marriage, divorce, and bereavement, and you will probably not die of coronary thrombosis?' Such advice may be soundly-based, but is not likely to reduce mortality, since it is impossible to follow. The same goes for 'psychosomatic' factors in cancer and other diseases. Brian Inglis is naive in believing that understanding the emotional factors in physical disease does much to help. Moreover, he fails to draw attention to one mysterious aspect of stress; the fact that, as we know from studies of people who have been confined in concentration camps and prison camps, the effects of stress may not be manifested until years after the time of stress has passed. And he entirely neglects to consider the role of genetics. Asthma, for example, is often thought to be partly a stress disease; but the genetic aspect is so important that a huge proportion of the inhabitants of Tristan da Cunha, an island far removed both from allergens and the stresses of civilisation, gave a history of asthma because the orginal settlers of the island included three asthmatics.
Doctors are geared to `do something' for those who are already ill; and although it may be desirable for them to become preachers, advising healthy people how to remain so, it is unlikely that they will or can abandon their traditional rOle. However, the more criticism which doctors bring to bear upon their own assumptions and traditional attitudes the better. Brian Inglis's indictment of our gullibility, our neglect of the side-effects of the drugs which we too lightly prescribe, and our undervaluation of emotional factors in disease, is salutary. Every doctor should read this book. It will make him re-consider much of what he takes for granted.
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