The Rise and Fall of Modern Medicine (3 page)

The success of modern medicine should make it a particularly satisfying career, which indeed it is, but recent surveys reveal the proportion of doctors ‘with regrets' about their chosen career increased steadily from 14 per cent of the 1966 cohort to 26 per cent of the 1976 cohort to 44 per cent of the 1981 cohort and to 58 per cent of the 1986 cohort.
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These findings should not be taken at face value, as spasms of self-doubt may become commoner for any number of reasons. Nonetheless, they would seem to be symptomatic of a genuine – and serious – trend. Until very recently – and in marked contrast to the experience of the other liberal professions – virtually all medical graduates went on to practise medicine. But no more. In 1996 one-quarter had no plans to work in the National Health Service,
accounting for both the progressive decline in the numbers entering general practice and many hospitals reporting difficulties in recruiting junior doctors. Why should it be that today's young doctors are so much less content than those who qualified thirty or more years ago?

The benefits of modern medicine in alleviating the fear of illness and untimely death should have meant that people are now less worried about their health than in the past. But once again, the trend is the reverse of that anticipated. The proportion of the population claiming to be ‘concerned about their health' over the last thirty years has also increased in direct parallel to the rise in the number of ‘regretful' doctors – from one in ten to one in two.
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And the most curious thing about this phenomenon of the ‘worried well' who are ‘well' but ‘worried' (that they might not be) is that it is not simply symptomatic of privileged life in the West, where ‘people don't know when they are well-off', but that it is medically inspired. The ‘well' are ‘worried' because they have been led to believe their lives are threatened by hidden hazards. The simple admonition of thirty years ago – ‘Don't smoke, and eat sensibly' – has metamorphosed into an all-embracing condemnation of not just tobacco but every sensuous pleasure, including food, alcohol, sunbathing and sex. Further, every year brings a new wave of ‘dangers', posed by low-fat milk and margarine, computer screens, head-lice shampoo, mobile phones and much else besides, with Britain's Chief Medical Officer warning that eating three lamb chops a day or its equivalent increased the risk of cancer.
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This is ‘Healthism' – a medically inspired obsession with trivial or non-existent
threats to health whose assertions would in the past, quite rightly, have been dismissed as quackery.
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The demonstrable success and effectiveness of modern medicine should have marginalised alternatives such as homeopathy and naturopathy into oblivion. Not so. In the United States there are more visits to providers of ‘unconventional therapy' (425 million) than to ‘primary care physicians' (388 million annually). As the efficacy of alternative therapies is not routinely tested in clinical trials (which does not mean they do not work), it is only natural to ask why the public should appear to have so much faith in them.
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The more that medicine ‘can do', the higher will be its cost, which will be further compounded by the continuing rise in the numbers with the greatest need – the elderly. Neither of these two factors, however, can begin to account for the massive escalation in the resources allocated to health care. Thus the budget of Britain's famously ‘cheap and cheerful' National Health Service doubled from
£
23.5 billion in 1988 to
£
45 billion in 1998. This financial largesse suggests that the almost universal belief that the problems of the Health Service would simply be solved by more generous funding, must be incorrect.
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In summary, then, the four-layered paradox of modern medicine is why its spectacular success over the past fifty years
has had such apparently perverse consequences, leaving doctors less professionally fulfilled, the public more neurotic about its health, alternative medicine in the ascendancy and an unaccounted-for explosion in Health Service costs.

It is important to keep a sense of proportion about all this. In general, doctors do find fulfilment in their work, and in general people appreciate the benefits of modern medicine, as anyone whose mobility has been restored by a hip replacement or whose spirits have been lifted by an antidepressant will testify. But the same point could be put the other way. It is precisely because medicine
does
work so well that the discontents reflected by these paradoxes are worthy of explanation.

These are complex matters and there are many reasons for each of these paradoxes. But ‘History is a high point of advantage from which alone men can see the age in which they are living' (G. K. Chesterton), and from the high point of advantage of a historical perspective on medicine's last fifty years it is possible to perceive there might also be a unifying explanation that can be inferred from the chronology of Definitive Moments – with the massive concentration of important innovations from the 1940s through to the 1970s followed by a marked decline. There has been, as suggested in the title of this book, a ‘Rise and Fall', which provides the key to understanding the paradoxical discontents of modern times.

But when this historical account opens, such matters are still a long way off. Imagine, rather, that Europe is in the throes of war, children are still dying from whooping cough and polio, the inmates of mental asylums are lucky to see a doctor from one year's end to the next, and curing cancer or transplanting organs seem like unattainable fantasies. And yet there is a terrific sense of optimism in the air. Medicine's greatest epoch has already begun, and the possibilities of science seem limitless.

A LENGTHY PROLOGUE

Twelve Definitive Moments

The history of modern medicine starts sometime in the 1830s, when a few courageous physicians acknowledged that virtually everything they did – bleeding, purging, prescribing complicated diets – was useless. The distinguished medical commentator Lewis Thomas elaborates:

By the time this history begins, doctors had become very skilled at diagnosing what was wrong – deploying the simple skills of taking a history, conducting an examination and doing a few simple tests on blood and urine – but, the ‘therapeutic ritual' having been jettisoned, the cupboard of specific remedies was virtually bare. The efficacy of some of the traditional remedies derived from plants – such as the heart drug digoxin from the foxglove and aspirin from the bark of the willow tree – had been vindicated. Several forms of immunisation of varying effectiveness had been developed for the treatment of the infectious diseases, and the chemical salvarsan had been found to be specifically successful against syphilis. The only other two
significant therapeutic developments had been the discovery of vitamins (though vitamin-deficiency diseases were rare enough) and the isolation of hormones such as thyroxine and insulin for the treatment of diseases caused by their deficiency, hypothyroidism and diabetes respectively.
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But that was about it. The pattern of human disease had changed little over the previous 2,000 years. The problems of infectious disease – both acute and chronic – dominated medical practice, culling the young either early in infancy or later from the lethal childhood illnesses such as whooping cough and measles. The causes of the diseases that emerged from adolescence onwards – schizophrenia, rheumatoid arthritis, multiple sclerosis – were unknown and had no specific remedies. Those who survived into old age were vulnerable to the chronic degenerative diseases of ageing – cataracts clouded their sight, arthritic hips limited their mobility – and succumbed to the age-determined illnesses of the circulatory disorders and cancer.

In general the nation's health had been gradually improving over the previous 100 years, infant mortality rates were in decline and the average lifespan was, albeit modestly, slowly increasing, trends that could plausibly be attributed to social improvements in housing and diet. There were, however, three ‘new' diseases that had recently emerged to become major causes of untimely death in middle age: peptic ulcers, heart attacks and cancer of the lung. Their cause was not known and, as ever, there were no effective treatments. The purpose of this book is to describe what happened next, starting with an account of the ‘twelve definitive moments' – the ‘canon' – of modern medicine.

T
he 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 beneficent 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:

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 it. ‘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.
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