- Email: [email protected]
Daniel Mason
Perspectives
Historical keywords Trial
Lunch with The Lancet Daniel Mason
The therapeutic trial is as old as medicine itself, but our understanding of its nature and purpose has changed. The earliest uses of “trial” include the determination of guilt or innocence in a law court; a test of endurance, competence, or fitness; and doing something to see what happens. Up to the 18th century, this last definition prevailed. Humoral theories led physicians to regard a patient’s disease as unique, requiring unique therapy. Thus, a trial involved giving a remedy to an individual and observing the outcome. Classification of diseases in the 17th and 18th centuries was followed by a shift in notions of illness. Disease was no longer a unique experience, but a process essentially similar in all patients. Our current understanding of the therapeutic trial was born: giving the same remedy to many patients to judge its effect. This is a more legalistic definition in which the remedy itself is on trial, rather than an individual therapeutic experiment. From the beginning of the 18th century, some UK physicians began to use measurement and systematic observation. The naval surgeon James Lind published a trial of remedies for scurvy in 12 patients in 1753. Although his results supported citrus fruit, his own theories led him to recommend different treatment, and it was some 50 years before the British navy routinely adopted fruit. Another naval surgeon, David Macbride, did a trial of wort (mash from unfermented malt) in ten sailors with scurvy in 1764, and the physician William Withering published observations of the effect of foxglove on patients with “dropsy” in 1785. The “arithmetical method” was popular in prophylactic therapy; practitioners used it to assess the worth of smallpox inoculation, notably James Jurin’s large-scale observations in the 1720s, and Charles Maitland’s 1721 trial on six condemned prisoners. Some scholars attempted to introduce probabilistic statistical theory to therapeutic observations in the 19th century, and by the early 20th, large trials were common. Investigators used a rag-bag of methods until the Medical Research Council’s 1948 trial of streptomycin for tuberculosis codified the randomised controlled trial, which has defined a proper therapeutic trial ever since. The older notion of a trial as seeing what happens to an individual patient nevertheless persists in physicians’ daily parlance, and has recently been dignified as an “n of 1” trial.
Martin Edwards
When Daniel Mason’s first novel The Piano Tuner was published in 2002, it was greeted with lustrous reviews from some of the world’s most influential publications. The New York Times called his tale of a 19th-century Englishman who travels to Burma on a mission to tune a piano “seductive and lyrical”. In the UK, The Guardian said its images “linger like a haunting tune”. These reviews are remarkable enough for any first-time novelist. The achievement is more striking when you consider the book was written while he was in medical school, and published when he was only 26. I met up with Mason on a rainy afternoon in autumn; he was in London helping to promote a new opera based on his novel. He had been subjected to a morning of interviews at the BBC, so we took refuge at the Royal Institute of British Architects’ restaurant, just up the road. He’s a modest, low-key kind of man; elongated-looking and dressed casually in the way you might expect of a writer. Over squid, aubergine pasta, and chilli pannacotta, he explained that the book was inspired by a year spent studying malaria in Thailand. The writing process began in earnest when he returned to the USA to start medical school. “It was when I came back and had started school and was very disoriented that I began writing. It was a reaction to being back in school, the absence of the other experiences.” Facing disease at close quarters for the first time was also a factor, he said. “I think a lot of people write in medical school. A lot of it comes from that need to express what you’re seeing.” It seemed to me that medicine and writing had some kind of symbiotic relationship for Mason, one feeding off the other. Maybe that’s true, he said, “except for the lack of time and sleep, and the risk of forgetting what I need to know about medicine—that worries me”. He’s obviously aware of the challenges he faces in juggling medicine and writing, nevertheless, he’s planning a future that includes both. He graduated only a few months ago, but a couple of weeks after we talked he was already jetting off to Brazil to write his next book. He’s taking a year or two off medicine to get it written, but plans to come back to clinical practice afterwards, he says, possibly working part time in a hospital. Reviews of The Piano Tuner have made much of its structural relationship to the fugue—a musical composition constructed of one or more themes, which are harmonised according to the laws of counterpoint and reintroduced from time to time. Mason managed this balance beautifully in his novel—it would be a great achievement to make it work for his career, too.
Wellcome Trust Centre for the History of Medicine at UCL [email protected]
Stephen Pincock [email protected]
www.thelancet.com Vol 364 November 6, 2004
1659
Historical keywords Trial
Lunch with The Lancet Daniel Mason
The therapeutic trial is as old as medicine itself, but our understanding of its nature and purpose has changed. The earliest uses of “trial” include the determination of guilt or innocence in a law court; a test of endurance, competence, or fitness; and doing something to see what happens. Up to the 18th century, this last definition prevailed. Humoral theories led physicians to regard a patient’s disease as unique, requiring unique therapy. Thus, a trial involved giving a remedy to an individual and observing the outcome. Classification of diseases in the 17th and 18th centuries was followed by a shift in notions of illness. Disease was no longer a unique experience, but a process essentially similar in all patients. Our current understanding of the therapeutic trial was born: giving the same remedy to many patients to judge its effect. This is a more legalistic definition in which the remedy itself is on trial, rather than an individual therapeutic experiment. From the beginning of the 18th century, some UK physicians began to use measurement and systematic observation. The naval surgeon James Lind published a trial of remedies for scurvy in 12 patients in 1753. Although his results supported citrus fruit, his own theories led him to recommend different treatment, and it was some 50 years before the British navy routinely adopted fruit. Another naval surgeon, David Macbride, did a trial of wort (mash from unfermented malt) in ten sailors with scurvy in 1764, and the physician William Withering published observations of the effect of foxglove on patients with “dropsy” in 1785. The “arithmetical method” was popular in prophylactic therapy; practitioners used it to assess the worth of smallpox inoculation, notably James Jurin’s large-scale observations in the 1720s, and Charles Maitland’s 1721 trial on six condemned prisoners. Some scholars attempted to introduce probabilistic statistical theory to therapeutic observations in the 19th century, and by the early 20th, large trials were common. Investigators used a rag-bag of methods until the Medical Research Council’s 1948 trial of streptomycin for tuberculosis codified the randomised controlled trial, which has defined a proper therapeutic trial ever since. The older notion of a trial as seeing what happens to an individual patient nevertheless persists in physicians’ daily parlance, and has recently been dignified as an “n of 1” trial.
Martin Edwards
When Daniel Mason’s first novel The Piano Tuner was published in 2002, it was greeted with lustrous reviews from some of the world’s most influential publications. The New York Times called his tale of a 19th-century Englishman who travels to Burma on a mission to tune a piano “seductive and lyrical”. In the UK, The Guardian said its images “linger like a haunting tune”. These reviews are remarkable enough for any first-time novelist. The achievement is more striking when you consider the book was written while he was in medical school, and published when he was only 26. I met up with Mason on a rainy afternoon in autumn; he was in London helping to promote a new opera based on his novel. He had been subjected to a morning of interviews at the BBC, so we took refuge at the Royal Institute of British Architects’ restaurant, just up the road. He’s a modest, low-key kind of man; elongated-looking and dressed casually in the way you might expect of a writer. Over squid, aubergine pasta, and chilli pannacotta, he explained that the book was inspired by a year spent studying malaria in Thailand. The writing process began in earnest when he returned to the USA to start medical school. “It was when I came back and had started school and was very disoriented that I began writing. It was a reaction to being back in school, the absence of the other experiences.” Facing disease at close quarters for the first time was also a factor, he said. “I think a lot of people write in medical school. A lot of it comes from that need to express what you’re seeing.” It seemed to me that medicine and writing had some kind of symbiotic relationship for Mason, one feeding off the other. Maybe that’s true, he said, “except for the lack of time and sleep, and the risk of forgetting what I need to know about medicine—that worries me”. He’s obviously aware of the challenges he faces in juggling medicine and writing, nevertheless, he’s planning a future that includes both. He graduated only a few months ago, but a couple of weeks after we talked he was already jetting off to Brazil to write his next book. He’s taking a year or two off medicine to get it written, but plans to come back to clinical practice afterwards, he says, possibly working part time in a hospital. Reviews of The Piano Tuner have made much of its structural relationship to the fugue—a musical composition constructed of one or more themes, which are harmonised according to the laws of counterpoint and reintroduced from time to time. Mason managed this balance beautifully in his novel—it would be a great achievement to make it work for his career, too.
Wellcome Trust Centre for the History of Medicine at UCL [email protected]
Stephen Pincock [email protected]
www.thelancet.com Vol 364 November 6, 2004
1659