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134 British Journal of General Practice, February 2008

A patient’s diary:
episode 14 — Dr Teacher’s dream

Evening surgery is over. In his consulting
room, Dr Teacher relaxes for a few minutes
with a favourite Jane Austen novel. But his
eyelids are heavy. He sleeps. He dreams …

Sally Greengage, good-looking, clever
and ambitious, with a comfortable flat in a
fashionable part of town and a happy
disposition seemed to unite some of the
best blessings of existence; and had lived
nearly 28 years in the world with very little to
distress or vex her. Wishing to qualify herself
in the medical profession, she had recently
engaged herself as apprentice to Mr Gerald
Teacher, a reputable local apothecary. She
soon proved herself an apt pupil, rapidly
acquiring a skillful consultation manner and
a good knowledge of medicinal herbs; much
admired and respected by her many grateful
patients, she seemed to have a brilliant
professional future ahead of her.
If she had any fault at all it was perhaps

the power of having rather too much her own
way and a disposition to think too well of
herself. She would sometimes alight on an
interesting diagnosis without sufficient resort
to the evidence base, or indeed the counsel
of her master. She would also delight in
giving injudicious advice to the apothecary’s
female servants concerning their personal
lives and matrimonial aspirations. However,
these disadvantages of her character, if they
can be so described, were at present
unperceived by Sally and so did not by any
means rank as misfortunes with her.
Now there lived in the pleasant little village

of Glanders Magna in the County of Surry, a
very civil and respectable gentleman of
middle years called Norman Gland. He and
his wife, Hilda, had a very pleasant house
enclosed before and behind by small, yet
well-tended gardens. Although an amiable
man, with an enquiring mind and a friendly
disposition, it was universally acknowledged
that Mr Gland’s thoughts were excessively
occupied by the state of his health. For many
years he had fretted over the condition of his
liver and other internal organs; and his
conversation revolved almost entirely round
the remedies he had sought for them. All

manner of herbs were sent for from London;
leeches had many times been applied in vain
and even the drawing of three of his teeth
wherein lay, he was convinced, the source of
the disorder, appeased his suffering for only
a few days. And now, being once again
sorely distressed, he had sent for his
favourite apothecary, Mr Teacher, who
practised but a few miles away.
So it was that Mr Teacher and Miss

Greengage were proceeding in the doctor’s
new carriage along the country lane which
led to Glanders Magna. As the carriage
moved along they talked of an affair which
had of late been exciting the interest of
both of them. There was a young health
care assistant in the practice, not above
17 years, who was very taken with Mr
Martin, the local podiatrist and had hopes
of an offer of marriage from him. ‘Pray, Dr
Teacher,’ said Sally, ‘do not you think that
Harriet should aim higher than Mr Martin
who is a man of limited education. In truth
he is a very agreeable young man but in no
way is he Harriet’s equal. You may as well
know that she shewed me his letter, and I
am glad to say that I was able to guide her
to pen to refuse his offer. For I have it in
mind to make a match for Harriet with Dr
Elton!’
‘Oh, Sally’ returned her mentor, ‘I have

always thought your intimacy with Harriet a
foolish one, though I have kept my
thoughts to myself. But now I perceive that
it has been very unfortunate for Harriet.
You will puff her up with such ideas about
herself that she will lose all chances of
matrimony with a man of her station in life.
Do not forget the mystery of her parentage
which in our society is bound to count
against her.’
It was not long before the carriage drew

up under the pleasant chestnut trees that
sheltered the home of Mr and Mrs Gland.
Mrs Gland welcomed them courteously for
indeed she was relieved to see them. ‘Oh,
Miss Greengage, it is so obliging of you to
come and bring Mr Teacher because
Norman has been so ill lately, I do not know
what to do with him. He lies on the couch

in his dressing room, groaning constantly
and refusing all food except for a thin gruel
which is the only nourishment his poor liver
can tolerate. Do tell me, Miss Greengage,
have you brought the leeches? Or will you
do scarification and cupping today. Please
do not draw any more of his teeth or he will
never chuse to eat the apple dumplings
that I made him, when a week ago I was in
high hope of his recovery. Do not you think
that the air here might be too full of
impurity? We were considering a visit to
the sea at South End, but Mr Gland says he
is now much too weak. Oh dear, am I
talking too much, dear Miss Greengage?’
Sally was tempted to make a tart remark

to the effect that Mrs Gland’s volubility was
entirely within her expectations.
Sometimes her youthful high spirits made
her tongue run ahead of her kinder
sensibilities; and Mr Teacher had had
occasion to remonstrate with her about it,
to her considerable shame. This time she
restrained herself and merely said, ‘not at
all, Mrs Gland, you are understandably
upset. Now shall you conduct us to your
patient?’
So they climbed the stairs and entered

the dressing room, where Mr Gland lay
groaning. A bowl of gruel lay untouched on
the small table by his couch.
‘It is good to see you, Teacher,’ said the

invalid, on perceiving his old friend. ‘And
your fair apprentice too. But I fear your visit
is too late. I fear that the consumption has
destroyed my liver entirely and spread to
my other vital organs. If only you had a
magic glass with which to see inside me
you would be amazed at the terrible
destruction.’ ‘Now, now, my dear Gland,’
replied the good doctor. ‘Pray do not
distress yourself in this way. Let me
examine this specimen of your urine that I
see Mrs Gland has thoughtfully placed on
the sideboard for us. Now, I declare, it is
perfectly clear and the colour is most
satisfactory. If I may say so, your
melancholy temperament has again led
you to experience a lowering of the spirits
as a physical suffering. This is not



British Journal of General Practice, February 2008 135

Serial

One of the many areas of clinical practice
in which GPs are accused of failing to
keep up with modern methods is in the
management of allergies. It seems that
every couple of years some elite medical
body documents the woeful state of
standards in primary care and insists on
the urgent need for more training for GPs
as well as demanding the provision of
more specialist services.
So when patients ask for a referral for

skin tests or other forms of expert
investigation and treatment, I duly oblige.
It is always something of an anticlimax
when they return with a recommendation
for a prescription for some combination of
an antihistamine, a steroid cream, inhaler
or nasal spray, and sodium cromoglycate
eye drops. I used to think — ‘I could have
done that’ — in fact, I already had. But
now, I’m just grateful that by the time they
have discovered the uselessness of patch
testing and the limitations of all these
medications, their symptoms have usually
passed (at least until next time).
It is reassuring to discover, from Mark

Jackson’s excellent Allergy: the history of
a modern malady, that doctors and
patients have been engaged in a
frustrating waltz around the problem of
allergy for more than a century, indeed
since 1906 when the Austrian
paediatrician Clemens von Pirquet coined
the term. Like most such neologisms, this
one was not well received by his peers
and it took a while to catch on.
Yet in time it proved a potent and

enduring metaphor for the ‘pathologies of
progress’ in the 20th century, its
associated conditions expressing a
‘symbolic aversion to the diverse horrors
of modern life’.1 Jackson notes the
pioneering allergists’ difficulties in
establishing a firm scientific foundation for
their emergent clinical speciality.
Nor could science resolve the long-

running turf war between mainstream
allergists who insisted on a strict definition
of allergic conditions in terms of
hypersensitivity reactions and clinical
ecologists who sought to include a wide
range of disorders attributed to diverse
environmental factors and associated
with a vast range of non-specific
symptoms.

This battle was once characterised by
the paediatric immunologist John Soothill
as a conflict between ‘the blimps’,
predominantly respectable physicians,
and ‘the nuts’, sometimes renegade
doctors or psychiatrists, joined by a range
of alternative therapists and nutritionists.
For the blimps, allergy meant simply hay
fever, asthma, urticaria, and eczema, for
the nuts, however, allergy signified the full
diversity of human responses to the toxic
hazards of modern life.
Over the past two decades a growing

environmentalist consciousness has
provided a ready resonance for the notion
of an epidemic of allergic disorders
resulting from atmospheric pollution and
from chemicals in the workplace, in the
home, and in foods and drugs. The blimps
have baulked at nutty notions such as
‘multiple chemical sensitivity’, and have
rejected many nutty (though lucrative)
tests. However, they have pragmatically
relabelled ‘food allergy’ as ‘food
intolerance’ and have entered the
flourishing market in elimination diets and
nutritional supplements.
While the blimps have always been

quick to accuse the nuts of quackery and
profiteering, ever since Big Pharma (in the
shape of Parke Davis & Co) financed Sir
Almoth Wright’s pioneering Department of
Therapeutic Inoculation at St Mary’s in the
1920s, the boundaries in allergy between
science and pseudoscience, and
between evidence-based practice and
commercially-driven practice, have
always been blurred.
It is heartening to see that, 20 years

after GPs were effectively banned from
giving courses of desensitising injections
for hay fever after a series of anaphylactic
fatalities, immunotherapy is now making a
comeback (at least in hospital outpatient
departments). A century on, allergy has
come full circle. As Jackson observes,
‘perhaps more than any other condition,
allergy embodies the biological, political,
and spiritual challenges faced by
inhabitants of the post-modern world’.1

REFERENCES
1. Jackson M. Allergy: the history of a modern

malady. London: Reaktion, 2006.

DOI: 10.3399/bjgp08X277159

The problem of allergy
Mike Fitzpatrick

uncommon in country gentlemen; we see
many such cases and some have even
been described in the learned journals. You
may recollect, Sally,’ he said, turning to his
young apprentice, ‘that I placed the
volume on your desk only yesterday in the
hope that you would read it. But alas,’ he
went on shaking his head solemnly, ‘you
did not.’ ‘I meant to read it’ said Sally. To
which her master replied, ‘I have seen a
great many lists of books and journal
articles that Sally has meant to read. And
very good lists they were too, But
somehow she cannot find the time, but
must be always exchanging the latest
intelligence with her young friends, or
buying new clothes. I have given up
expecting any course of serious reading
from Sally.’
On receiving this rather affectionate

admonition, Sally pouted a little but made
no reply other than a toss of her fair head.
Changing the subject, she reminded her
master that they had brought some fresh
herbs from the physic garden especially for
Mr Gland and that a good result might be
anticipated by applying them in a poultice
to his liver. She then proceeded to do this
with utmost skill and competence ... Mr
Gland thanked them in a low voice for their
trouble and said that he would make sure
that Mr Teacher’s fee was sent to him by
his widow, even if, as he feared, he did not
live to see the sun rise on another day. Mr
Teacher, patted him fondly on the shoulder
and said that he looked forward to
attending on him for many a year. And with
a word of thanks to Mrs Gland for the apple
dumplings that she had stuffed into his
bag, he turned and descended the stair,
followed by the resourceful Miss
Greengage.

From the diary of Dr Teacher.

DOI: 10.3399/bjgp08X277140