A history of haematology : from Herodotus to HIV

247 Pages·2016·7.334 MB·English

by  McCann, Shaun R

A History of Haematology
Oxford Medical Histories Series
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What do you think?
Christopher Gardner-Thorpe, MD, FRCP, FACP
Series Advisor, Oxford Medical Histories
A History
of Haematology
From Herodotus to HIV
Shaun R. McCann, Hon. FTCD
Professor Emeritus of Haematology and Academic Medicine,
St James’ Hospital and Trinity College, Dublin,
Ireland
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This book is dedicated to my wife, Brenda Moore-McCann, without
whom it would never have seen the light of day. Her faith in me and her
continuing support has been immeasurably helpful and I hope she
enjoys reading the finished product.
‘Patients want to know how much you care before they want
to know how much you know’.
Professor Aidan Halligan (1957–2015)

Foreword
I like the dreams of the future better than the history of
the past
Thomas Jefferson, third president of the United States
of America (1743–1826), in a letter to John Adams,
dated 1 August 1816
When I was asked to submit a proposal for this book by Dr Christopher
Gardner-Thorpe, the series editor, I immediately agreed. I knew that Maxwell
M. Wintrobe had written two famous books about the history of haematology
in the 1980s, Blood, Pure and Eloquent, and Hematology, The Blossoming of a
Science: A Story of Inspiration and Effort. Both are excellent, with contributions
from many famous haematologists. Unfortunately, both books are now out of
print. Nonetheless, I have not repeated the ground covered by Wintrobe but
instead concentrated, with a few exceptions, on events in the last 25 years.
When I started as a ‘Fellow’ in haematology at the University of Minnesota
in the mid-1970s, haematology was still preoccupied with the physiology of
blood and concentrated mainly on benign blood diseases. There was effective
treatment for childhood acute lymphoblastic leukaemia and Hodgkin lym-
phoma, or Hodgkin’s disease, as it was then called. Acute myeloid leukaemia,
although treated with combination chemotherapy, was almost universally
fatal, and non-Hodgkin lymphoma included a bewildering number of diseases
and classifications. Therapy consisted of a combination of radiation and chem-
otherapeutic agents and rarely, if ever, resulted in cure. Chronic myeloid leu-
kaemia and multiple myeloma were depressing diseases to treat, with inevitable
mortality a few years after diagnosis. The term ‘myelodysplasia’ had not yet
been invented.
Widespread population migration had not yet taken place, with the exception
of the United States of America, and many red cell diseases such as sickle cell
disease and the thalassaemic syndromes were scarcely seen in European coun-
tries. Although treatment for haemophilia was available, support care for the
treatment of haematological malignancies was relatively underdeveloped. The
study of thrombosis, bleeding, and transfusion medicine had begun to separate
from ‘general haematology’, and this split became more obvious with the suc-
cessful use of chemotherapy and haemopoietic stem cell transplantation.
viii FoREwoRD
The successful treatment of acute myeloid leukaemia and the advent of haema-
topoietic stem cell transplantation were associated with a surge in the develop-
ment of support care, with improved venous access, treatment of infections, and
platelet transfusions on demand. Haematopoietic stem cell transplantation was
becoming available in most major haematology units by the mid-1980s.
Progress seemed to be in a linear direction until the epidemic of HIV/AIDS
struck in the 1980s. There was a lack of interest among the general population
and politicians, initially, as the disease appeared to be confined to prisoners and
gay men. When it became clear that HIV/AIDS could affect the heterosexual
population and that the disease was clearly spread by blood and blood product
transfusion (before the virus was identified), the world sat up and reacted. Un-
fortunately, the reaction was not always helpful, and the disease became stigma-
tized. The transfusion services were severely stressed and, unfortunately, many
people with haemophilia succumbed to HIV/AIDS.
At around the same time, genetics and molecular biology were beginning to
undergo a revolution. In a strange way, the deaths of so many from HIV/AIDS
provided a stimulus for the development of accurate testing of blood products
for infectious agents, or antibodies to infectious agents. As a result, it is prob-
ably accurate to say that transfusion of blood and blood products has never
been safer, from an infectious disease point of view, than they are today.
The development of automated cell counting and the widespread use of flow
cytometry changed the diagnostic landscape for haematologists. The profusion
of molecular techniques provided new investigations, new drugs, and a new
understanding of the molecular basis of a number of both malignant and be-
nign haematological diseases.
As always, changes in society occurred and these influenced the practice of
medicine and haematology. Old ‘paternalistic’ attitudes began to change and
patients gradually became more involved with their own disease/health. The
training of medical students changed to accommodate this development and, at
the same time, the number of women entering medical schools increased dra-
matically. Guidelines and new management styles of health services began to
appear, augmented by European Union directives.
As outlined in the book, there were also changes in drug therapy. The major
success story was the development of imatinib for the treatment of chronic
myeloid leukaemia. This is a remarkable story and many of us know patients
with chronic myeloid leukaemia who are alive and well 15 or more years from
the time of their diagnosis. The use of monoclonal antibodies has been hugely
beneficial, especially in the treatment of non-Hodgkin lymphoma.
On the downside, what has happened? Medical practice had undoubtedly
become more bureaucratic, and doctors have, to some extent, lost the trust of
FoREwoRD ix
the public. Doctors are losing the art of history taking and performing a thor-
ough physical examination. There is an over-reliance on ‘tests’, and the costs of
medicine to the state and to the individual are becoming unsustainable. In hae-
matology, a careful examination of a well-made blood film is becoming a ‘dying
art’, and morphological expertise has become compromised.
The culmination of the above is the idea of ‘personalized’ medicine. This phe-
nomenon will certainly change the relationship between doctor and patient.
Will doctors become less ‘caring’? Will we create a cadre of the ‘worried well’?
Doctors must, of course, keep up with the latest developments but not at the
cost of losing their ability to treat a patient humanely. The holistic management
of patients, rather than the treatment of diseases, should be our goal. We must
treat patients with respect and take adequate time to listen carefully to their
story.
The outlook for patients with haematological diseases has never been better,
but we as doctors, and not primarily scientists, must remember the words of the
great Canadian physician and teacher, William Osler: ‘The good physician
treats the disease. The great physician treats the patient’. As a female colleague
said to me recently, ‘Perhaps a little bit of paternalism is not necessarily a bad
thing!’
At a personal level, I am deeply indebted to my ‘Chief of Hematology’, Harry
S. Jacob at the University of Minnesota, as he started me on a wonderful journey
which culminated in my recent retirement as Professor of Haematology in St
James’ Hospital and Trinity College, Dublin.
Shaun R. McCann, Hon. FTCD
March 2015