Cover image for The rise and fall of modern medicine
Title:
The rise and fall of modern medicine
Author:
Le Fanu, James.
Personal Author:
Publication Information:
New York : Carroll & Graf Publishers, 2000.

©1999
Physical Description:
xxi, 426 pages, 16 unnumbered pages of plates : illustrations ; 24 cm
General Note:
Originally published in Great Britain 1999.
Language:
English
ISBN:
9780786707324
Format :
Book

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Status
Central Library R149 .L45 1999 Adult Non-Fiction Non-Fiction Area
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Summary

Summary

This penetrating study of medicine in our times addresses one of its most baffling paradoxes as it explores the widening gulf between achievement and advancement. Dr. Le Fanu takes a clear-sighted look into the darkening future of public health and medicine at the end of the 20th century. of photos.


Reviews 3

Booklist Review

The post^-World War II rise of modern medicine is widely deemed a glory of our times. But Le Fanu, medical columnist and M.D., focuses instead on its fall--that is, he makes a cogent case that it has happened and continues. Modern medicine often benefited from fortuitous events and discoveries, and not solely from the much touted triumph of science and rationalism. Le Fanu demonstrates the substantial advances made during its rise and also the problems that brought about its ongoing fall. Those resulted in part from emphasizing and highly esteeming "clinical science" --the practice of looking at the patient as a case rather than as a person. More problems arose from promoting the social theory of medicine that most difficulties can be overcome by lifestyle changes--which leads to blaming the patient--and from the new genetics' search for simple answers and neglect of careful reasoning, especially in the application of statistics. Modern medicine faces a bleak, unimaginative future, Le Fanu portends in this tightly reasoned, well-documented wake-up call. --William Beatty


Publisher's Weekly Review

"Much current medical advice is quackery," cautions Le Fanu in this remarkably engrossing scholarly study of medical progressÄand the recent lack thereofÄin the 20th century. Le Fanu (a medical columnist for London's Daily and Sunday Telegraph) contemplates what he sees as the unhappy situation of contemporary health care. The decades from the 1940s to the 1980s saw some of the most critically important advances Western medicine has seen, from penicillin to the heart pump that made open-heart surgery possible. Yet doctors are disillusioned, and patients are turning in droves to alternative forms of medicine. How has this dilemma come about? Le Fanu first details the astonishing breakthroughs of the earlier part of the 20th century (he describes, for instance, the progress made by the first patient ever administered penicillin). But, more controversially, he argues that since the 1980s medical progress has been crippled by two developments, which he terms "Social Theory" and "New Genetics," respectively: according to the author, misguided epidemiologists promote a lifestyle changes (low-cholesterol diet, etc.) as a means of preventing heart disease; and geneticists have misled us into thinking that their research breakthroughs can eliminate genetic diseases. Both cases have been overstated, Le Fanu contends, drawing on a wealth of scientific data to attempt to show that dietary changes have done little to prevent heart disease and that genetic experiments, despite "millions of hours of research," have had "scarcely detectable" practical results. He concludes with a plea to return to the traditional in the practice of medicineÄthe relationship between doctor and patientÄand to a renewal of faith in the diagnostic skill and judgment of one's personal physician. B&w photos. Agent, Caroline Dawnay. (July) (c) Copyright PWxyz, LLC. All rights reserved


Choice Review

Le Fanu's marvelously written, meticulously researched book is one of the most thought-provoking and important works to appear in recent years. His introduction includes the list "The Ten Definitive Moments of Modern Medicine"--only one, the discovery of "Helicobacter as the cause of peptic ulcer" dates later than the 1970s (1984). The 1940s-70s are clearly the years of "The Rise of Modern Medicine" and the great age of medical optimism. Penicillin, cortisone, streptomycin, chlorpromazine, e.g., are discoveries of that era. Viagra is the drug of the '90s; in drugs the shift has been from proven life savers to life style enhancers. "The Fall of Modern Medicine" reflects the frustration felt because medicine has not found many major cures since the 1970s. Improvements of therapies certainly, cures no. The emphasis in medicine, faced with a seeming brick wall, has shifted from biology to prevention. The twin agents of the fall, Le Fanu argues, are social theory and new genetics. The first centers around the concept that eating right can prevent at least 70 percent of diseases. Similarly, will "new genetics" cure or prevent diseases of aging? The answers may surprise readers. A must read for professionals, policy makers, and educated readers. All levels. I. Richman; Pennsylvania State University, Harrisburg


Excerpts

Excerpts

Chapter One 1941: PENICILLIN The discovery of penicillin is, predictably, both the first of the twelve definitive moments of the modern therapeutic revolution and the most important. Penicillin and the other antibiotics that followed rapidly in its wake cured not only the acute lethal infections such as septicaemia, meningitis and pneumonia, but also the chronic and disabling ones such as chronic infections of the sinuses, joints and bones. This in turn liberated medicine to shift its attention in the coming decades to a completely different and up till then neglected source of human misfortune: the chronic diseases associated with ageing such as arthritic hips and furred-up arteries.     Antibiotics transformed doctors' and indeed the public's perceptions of medicine's possibilities. If a naturally occurring non-toxic chemical compound produced by a species of fungus such as penicillin could make the difference between whether a child with meningitis should live or die, it was only natural to wonder whether other ghastly and baffling illnesses might not yield to similar simple solutions. Perhaps cancer might be curable, or schizophrenia might be treatable?     In the public imagination antibiotics came to symbolise the almost limitless beneficient possibilities of science. Yet, this is not entirely merited for, as will be seen, the discovery of penicillin was not the product of scientific reasoning but rather an accident -- much more improbable than is commonly appreciated. Further, at the core of antibiotics lies an unresolved mystery: why should just a few species of micro-organisms produce these complex chemical compounds with the capacity to destroy the full range of bacteria that cause infectious disease in humans? On 12 February 1941, a 43-year-old policeman, Albert Alexander, became the first person to be treated with penicillin. Two months earlier Mr Alexander had scratched his face on a rose bush, a trivial enough injury perhaps, but the scratches had turned septic. Soon his face was studded with abscesses draining pus, his left eye had had to be surgically removed because of the infection and now his right eye was endangered in a similar way. His right arm drained pus from an infection deep in the bone and he was coughing up copious amounts of phlegm from cavities in his lungs. He was, as Charles Fletcher, the doctor who was to administer the penicillin, recalls, `in great pain, desperately and pathetically ill'. Dr Fletcher subsequently described what happened: Penicillin therapy was started every three hours. All Mr Alexander's urine was collected and each morning I took it over to the pathology laboratory on my bicycle so the excreted penicillin could be extracted to be used again. There I was always eagerly met by the members of the penicillin team. On the first day I was able to report that for the first time throughout his illness Mr Alexander was beginning to feel a little better. Four days later there was a striking improvement ... he was vastly better, with a normal temperature and eating well and there was obvious resolution of the abscesses on his face and scalp and right orbit [eye].     But on the fifth day, 17 February, the supply of penicillin was exhausted. Inevitably, his condition deteriorated and he died a month later. It would, of course, have been much better for Mr Alexander had more penicillin been available, but in a way his death has a metaphorical significance -- a reminder to future generations of the crucial transitional moment between human susceptibility to the purposeless malevolence of bacteria (and there can be nothing more purposeless than dying from a scratch from a rose bush) and the ability, thanks to science, to defeat them. `It is difficult to convey the excitement of witnessing the amazing power of penicillin,' comments Professor Fletcher. Over the next few years he observed `the disappearance of the "chambers of horrors" -- which seemed the best way to describe the old septic wards' in which Albert Alexander and thousands like him had spent their last days. When more supplies of penicillin became available four more patients were treated, including a 48-year-old labourer with a vast carbuncle on his back 4 inches in diameter that vanished `leaving no scar' and a fourteen-year-old boy `extremely ill' with a bone infection -- osteomyelitis -- of the left hip complicated by septicaemia.     More than fifty years later this first description of the use of penicillin has lost none of its power to amaze. Reading it one has the impression of witnessing a miracle, whose origins, as is well known, lay in the chance observation made by Alexander Fleming in his laboratory at London's St Mary's Hospital over ten years earlier. As a microbiologist Fleming's research work involved growing colonies of bacteria on special plates called petri dishes and observing their behaviour in different circumstances. He had, for example, recently shown that a chemical called lysozyme present in tears could inhibit the growth of several types of harmless bacteria. In 1928, returning from his summer holidays, Fleming picked up a petri dish standing in a pile waiting to be washed and noticed how a contaminating mould (later identified as penicillium notatum ) had inhibited the growth of a colony of staphylococcal bacteria. He then extracted the juice from the mould (which he called penicillin) and showed it was capable of inhibiting the growth of a whole range of micro-organisms. Curiously, however, when other scientists tried to replicate the accidental method by which he had made his discovery -- by dropping some penicillium mould on to a plate of staphylococci -- they were quite unable to do so.     It was not until 1964, when Fleming's former assistant, Ronald Hare, investigated the matter in detail, that the reason emerged. Hare found that this failure to replicate Fleming's original observation was because the growth of the penicillium mould occurred at a different temperature (20 degrees Celsius) than the staphylococcus, which grows best at a temperature of around 35 degrees Celsius. So what had happened?     Firstly, the penicillium mould that had `floated through the window' was not a commonly occurring strain but rather a rare one that had wafted up from the laboratory below, where a fellow scientist and fungus expert, C.J. LaTouche, was working. Fortuitously this rare strain just happened to produce large amounts of penicillin. Some spores, it must be presumed, contaminated a petri dish on which Fleming had been growing some colonies of staphylococci. Inexplicably, but essential for his subsequent discovery, Fleming did not, prior to going on holiday, place the dish in the incubator but left it out on the laboratory bench. Consulting the meteorological records for London at the end of July in 1928, Ronald Hare discovered that while Fleming was away there had been an exceptionally cool nine-day period -- which would have favoured the growth of the penicillium mould -- after which the temperature rose, which would have stimulated the growth of the staphylococcus. The penicillium mould was by now producing sufficient quantities of penicillin, and on his return Fleming noted that the pinhead-sized yellow spots on the plate, each of which represented a colony of the staphylococcus, had an unusual appearance. `For some considerable distance around the mould growth the colonies were obviously undergoing lysis [dissolution].' Thus, without the `nine cool days' in London in the summer of 1928, Fleming would never have discovered penicillin.     Fleming was much luckier than he realised, but he was then remarkably indolent in exploring the therapeutic potential of his findings. He used juice extracted from the penicillium mould to treat a colleague's conjunctivitis and found an obscure application in culturing a species of bacteria in the laboratory that was notoriously difficult to grow, but by the following year he had abandoned any formal research into its further clinical use, because of the prevailing view that chemicals were likely to be too toxic to be used to treat infectious diseases. Fleming did not take the matter further because he did not think it worth pursuing, `a good example of how preconceived ideas in medicine can stifle the imagination and impede progress'.     So the miraculous properties of penicillin had to be rediscovered all over again ten years later by Howard Florey and Ernst Chain in Oxford, which was preceded, interestingly enough, by recapitulation of Fleming's work on the antibacterial properties of lysozymes in tears. Howard Florey had arrived in Britain from his home country of Australia in 1922 and after obtaining a degree from Oxford rapidly ascended the academic ladder. He was prodigiously industrious, very good with his hands and had the knack of attracting others as, or more, talented than himself to work as his collaborators. In 1935 when still only thirty-seven he became Professor of Pathology at Oxford and promptly recruited Ernst Chain, a young German Jewish chemist refugee from Nazi Germany. As Florey's scientific interests included the study of the chemistry of the body's natural secretions, he initially hoped that Chain's chemical talents would be able to elucidate their biochemical structure. `When Florey and I in our first meeting discussed the future research programme in the department, Florey drew my attention to a very startling phenomenon,' Chain recalled. This was Fleming's observation, made back in 1921, that lysozymes in tears and nasal secretions were capable of dissolving thick suspensions of bacteria, though how they attacked the cell wall of bacteria was unknown. It took only a year for Chain to show that lysozyme was a complex enzyme. While writing up this work for publication, he looked around for other instances of compounds that might destroy bacteria and inevitably came across Fleming's original paper describing the effects of penicillin. By now it should be clear why Chain and Florey were to succeed where Fleming had failed. The skills of a microbiologist like Fleming lay in the observation and interpretation of experiments with bacteria; the skills of a biochemist like Chain lie at a deeper level, in identifying the biochemical mechanisms that underpin the microbiologist's observations. And so just as Chain had so rapidly solved the question of the biochemistry of lysozyme, it was only a matter of time before he would unravel the mechanisms of the action of penicillin and appreciate its real significance.     Nonetheless, at the outset neither Chain nor Florey believed penicillin would have any `clinical applications' in the treatment of infectious diseases, so the precise sequence of events that persuaded them to change their minds is of some interest. Firstly it seems that Chain was intrigued to find that penicillin was `a very unusual substance'. It was not, as he had imagined it would be, an enzyme like lysozyme, but rather it turned out to be `a low molecular substance with great chemical instability'. In brief, he had no idea what it was so `it was of obvious interest to continue the work'. Secondly, he had the biochemical skills to extract and purify (though not to a very great extent) penicillin, which when tested against bacteria grown in culture proved to be twenty times more potent than any other substance. Thirdly, when penicillin was injected into mice it was apparently `non-toxic'. This last point was very important, for, as already pointed out, probably the most important reason why Fleming had failed to pursue the possibilities of penicillin was the common belief that any compound capable of destroying bacteria would necessarily harm the person to whom it was given. Finally, in a classic experiment Chain and Florey demonstrated that penicillin could cure infections in mice: ten mice infected with the bacterium streptococcus were divided into two groups, with five to be given penicillin and five to receive a placebo. The `placebo' mice died, the `penicillin' mice survived.     After the publication of the results of this experiment in The Lancet on 24 August 1940, Florey hoped that one of the pharmaceutical companies would become sufficiently interested to produce penicillin on a large scale for, as he pointed out, a man, being 3,000 times bigger than a mouse, would need a large amount of penicillin if the results in mice were to be replicated in humans. But these were difficult times. The mice experiment had been conducted just as the British Expeditionary Force of 350,000 men had been driven on to the beaches of Dunkirk to be evacuated by an improvised armada of ships that somehow survived the repeated attacks of the German dive-bombers. This shattering defeat, in which Britain lost the equivalent of an entire army, made the prospect of a German invasion almost inevitable and heralded the Luftwaffe's daily assaults on London in the Battle of Britain.     At this desperate moment, when the future of Britain lay in the balance, Florey decided to commit the puny resources of his laboratory in Oxford to making enough penicillin to test in humans. `The decision to turn an academic university department into a factory was a courageous one for which Florey took full responsibility ... if his venture had failed it would have been seen as an outrageous misuse of property, staff, equipment and time, and Florey would have been severely censured.'     The hallmark of Florey's university laboratory-turned-penicillin factory was improvisation, the penicillium moulds being grown on hospital bedpans and the precious fluid extracted and stored in milk jugs: [In] the `practical' classroom, the washed and sterilised bedpans were charged with medium and then inoculated with penicillin spores by spray guns. They were then wheeled on trolleys to what had been the students' `preparation' room, now converted into a huge incubator kept at 24° Centigrade. After several days of growth, the penicillin-containing fluid was drawn off from beneath its mould by suction ... The air was full of a mixture of fumes: amyl acetate, chloroform, ether. These dangerous liquids were pumped through temporary piping along corridors and up and down stairwells. There was a real danger to the health of everyone involved and a risk of fire or explosion that no one cared to contemplate.     By the beginning of 1941 there was just enough penicillin for the first trial in humans. On 12 February Charles Fletcher administered the first injection directly into the policeman Albert Alexander's vein, and, as already described, a further four patients were treated over the next few months. Seven university graduates, including two professors and ten technical assistants, had worked every day of the week and most nights for several months to achieve these results. If the work on penicillin were to go forward then much larger quantities were going to be needed. In June Florey travelled to America where eventually four major drug companies took up the challenge of the mass production of penicillin.     At the end of the war, in 1945, Florey and Chain shared, along with Fleming, the Nobel Prize. Their achievement was not just the development of penicillin but rather the clarification of the principles by which all antibiotics were subsequently to be discovered. In his acceptance speech Florey spelled out what those principles were: the screening of microbes to identify those which produced an antibacterial substance; the determination of how to extract the substance; testing it for toxicity; investigating its effect in animal experiments; and finally tests in humans.     We now know, though Florey did not When he gave his speech, that penicillin was not just `a lucky break'. Rather the screening of tens of thousands of species of micro-organisms over the next few years revealed a handful that produced a whole further range of antibiotics (see page 13). Their impact on medicine has already been mentioned, but three further points are worth noting. Firstly, it is necessary to appreciate the comprehensiveness of the antibiotic revolution. There are many different types of infectious illness, from the trivial sore throat to life-threatening meningitis. The bacteria involved behave in different ways, both in how they spread themselves around and how they damage the body's tissues. An attack of meningitis can kill within twelve hours while tuberculosis may take ten years or more. And yet there is not one of the hundreds of different species of bacteria that cause disease in humans that is not treatable with one or other antibiotic.     Secondly, the antibiotic-producing bacteria might seem simple but the mechanism of action of the antibiotics they produce are both very diverse and highly complex. They can interfere with the enzymes and peptides that make the cell wall, blow holes in the lining of the cell, disturb the transport of chemicals across the lining, interfere with the synthesis of the nucleotides that make up the bacteria's DNA or inhibit the manufacture of proteins in the cell.     Thirdly, despite the complexity and diverse mechanisms by which antibiotics work, the process of their discovery turned out to be astonishingly simple. All that was required, as Florey pointed out in his Nobel Prize speech, was the screening of micro-organisms to identify the handful that could destroy other bacteria and then the identification of the active antibiotic ingredient. Thus, though antibiotics are commonly perceived as a triumph of modern science, scientists alone could never have invented or created them from first principles. They are, rather, `a gift from nature', which raises the question of what their role in nature might be.     The most obvious and commonly accepted explanation is that antibiotics are `chemical weapons' produced by bacteria to maximise their own chances of survival against other organisms in the atmosphere and the soil. This was certainly the view of Selman Waksman, the discoverer of streptomycin for the treatment of tuberculosis. Waksman was, by training, a soil microbiologist and knew more about the ways in which bacteria in the soil interacted with each other than anyone else in the world.     Waksman received the Nobel Prize in 1952 for his discovery of streptomycin, and yet in the following years he came to realise that his original perception of antibiotics as `chemical-warfare' weapons deployed by bacteria in the soil must be mistaken. He noted the ability to make antibiotics was limited to a very few species and so could not play an important role in the ecology of microbial life. Further, the ability of microorganisms to produce antibiotics turned out to be highly dependent on the quality of the soil, and indeed they were only reliably produced in the artificial environment of the laboratory. Next, there was no evidence that antibiotics could be found or accumulated where there are many organisms present. And so, if antibiotics did not act as bacterial `chemical weapons' in the struggle for survival in the soil what did Selman Waksman believe their role to be? They are, he said, a `purely fortuitous phenomenon ... there is no purposeness behind them ... the only conclusion that can be drawn from these facts is that these microbiological products are accidental'.     This is a very difficult concept to accept. It seems inconceivable that bacteria, the simplest of organisms, should have the ability to produce such complex molecules but which then serve no purpose in their survival, but as Leo Vining, a biologist from Dalhousie in Canada observed at a conference in London in 1992, even `accepting these products [antibiotics] have a role, does not mean that we can readily agree upon or perceive what that role might be'.     The story of penicillin and the other antibiotics that followed is thus very different from that so often presented -- and usually perceived -- as the triumph of science and rationalism in the conquest of illness. The unusual climatic circumstances that led to Fleming's discovery of the antibacterial properties of the penicillium mould were quite staggeringly fortuitous. The crucial decision that led to its mass production -- Florey's resolve to turn his university laboratory into a penicillin factory when a German invasion was imminent -- is a triumph of will over reason. Lastly the questions of how, and more particularly why, a handful of the simplest of micro-organisms should have the ability to create these complex chemicals, and of why they should exist at all, is simply not known. This, the mystery of mysteries of modern medicine, will be revisited. Copyright © 1999 James Le Fanu. All rights reserved.

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