Author: James Le Fanu
This book depicts ‘…one of the most impressive epochs of human achievement’, the medical progress made following the 2nd world war. The author, a medical doctor and newspaper columnist, highlights twelve ‘definitive moments’ of this period. He recounts, in thrilling narrative, the re-discovery of Penicillin by Howard Florey and Ernst Chain following on the chance detection by Alexander Fleming; the discovery of Streptomycin by Selman Waksman; and the discovery of Cortisone by Philip Hench. He recounts Henri Laborit’s observation of the psychiatric benefits of Phenothiazines, and Bjorn Ibsen’s insights that laid the foundations of intensive care therapy. He recounts the competitiveness of Walton Lillehei and John Kirklin, the pioneers of open heart surgery, and the role John Gibbon’s heart-lung bypass pump which made it all possible. He tells of the tribulations of John Charnley, the forerunner of artificial hip replacement, and we learn of the collaborative efforts of Peter Medawar, Joseph Murray, George Hitchings, and Gertrude Elion to establish the foundations of renal transplantation. He relates the discoveries of Propranolol and Chlorothiazide by James Black and William Schwartz respectively, and the role of these anti-hypertensives in stroke prevention. We learn of the efforts of Robert Edwards and Patrick Steptoe to establish in-vitro fertilisation, and of Barry Marshall to show that helicobacter pylori causes peptic ulcer disease. Donald Pinkel‘s development of combination chemotherapy to treat childhood leukaemia rounds off the twelve.
Serendipity and luck are prominent themes that run through these discoveries. Of Penicillin, for instance, he says ‘…the discovery…was not the product of scientific reasoning but rather an accident’ (page 5) and ‘…the crucial decision that led to its mass production…is a triumph of will over reason’ (page 16). Of the Phenothiazines and other antipsychotics the author says ‘…their discovery was not based on the scientific knowledge of brain chemicals, which was at the time extremely primitive. Rather the drugs came first, being discovered for the most part by chance…’ (page 60). The pioneers however had the insight and aptitude to recognise and develop these chance discoveries. Waksman observation, for example, that there were no disease-causing bacteria in soil even though this was teeming with microorganisms eventually led to the discovery of Streptomycin (page 37).
The book highlights a major challenge the innovators faced-how to overcome the prevailing scientific orthodoxy. Of Ibsen for instance the author says ‘…the revolutionary solution he proposed required him to first challenge the fundamental tenets of contemporary medical understanding of the precise cause of death in polio’(page 75). Marshall had to ‘think the unthinkable that peptic ulcer might be an infectious disease’ (page 186) while Steptoe and Edwards had to debunk several false ideas about fertilization (page 165). The discoverers also faced initial failures and the ‘…open hostility of colleagues’ (page 231). Edwards for example ‘…experienced first nine years, and then eight years, of bitter disappointment that would have convinced any lesser person to give up in despair’ (page 158). Charnley on the other hand ‘…needed phenomenal willpower and determination-both of which he possessed in abundance’ (page 113). The innovators all demonstrated sheer determination and commitment to their objectives.
The proverbial ‘fall’ of Medicine is the decline of innovation which started in the late 1970s. This was partly because stringent research regulations made ‘unexpected’ discoveries unlikely. The author argues that ‘…over-regulation had, if not exactly killed the golden goose, certainly reduced her production of golden eggs’ (page 247). He makes the point that the hypothesis-driven approach to research and innovation would have made the discoveries of Penicillin and Hydrocortisone impossible (page 249). The result of the ‘fall’ is what he calls ‘the four layered paradox of modern medicine’: disillusioned doctors, the worried well, the popularity of alternative medicine, and the rising costs of health care. These are associated with the overuse of investigative and monitoring technologies and the fruitless pursuit of marginal benefits from therapeutic agents (page 396). He rounds off with a critique of ‘the new genetics’ and the ‘social theory of disease’, both of which have not lived up to their promise to eradicate disease.
This is a thought-provoking account of Medicine’s recent history and it is masterfully told. It places medical discoveries in proper historical context, and flavours them with inspiring stories. The book has excellent lessons for doctors on how medical innovation happens, the personal characteristics that drive it, and the antagonism that inevitably follows it. It is a thrilling account of the foibles and successes of medicine with no boring parts whatsoever. The hardships endured by the protagonists, the professional rivalries of the pacesetters, and the triumphs and failures along the way are all graphically described. The author’s arguments against the social theory of disease and the new genetics are contentious but nevertheless well-argued. The book is a great introduction to the excellent personalities that drove medicine forward and the author has done a great job of putting it all together.
This is an excellent book and I thoroughly enjoyed reading it. I recommend it to all doctors .
The author discussing his book
- Publisher, place and year: Abacus, London, 1999
- Other edition: Revised and updated
- Number of chapters: 26
- Pages: 490
- ISBN: 0-349-11280-0
- Price: £26.49
- Rating: 5 stars