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How Sick Is Modern Medicine?

1.

As Marcus Aurelius gathered his forces against German tribes in the second century AD, he summoned Claudius Galenus, an up-and-coming physician from Pergamum, to ride with him. Galen declined, politely and imaginatively, claiming a higher loyalty to “the contrary instructions of his personal patron god Asclepius.”1 This early instance of conscientious objection was accepted, it seems graciously. But in exchange for his indulgence, Marcus Aurelius ordered Galen to await his return and attend the health of his neophyte emperor son, the soon to be deranged Commodus.

Galen did his job rather too well, curing Commodus of an illness around 174 AD and unwittingly laying the ground for a murderous period of political instability some ten years or so later. Rome’s long-term loss was medicine’s great gain, for, as Galen later wrote,

During this time I collected and brought into a coherent shape all that I had learned from my teachers or discovered for myself. I was still engaged in research on some topics, and I wrote a lot in connection with these researches, training myself in the solution of all sorts of medical and philosophical problems.

In addition to being a fine scholar and a wise court physician, Galen was also the supreme polemicist of his day. The aggressive tendencies of his mother—“so bad-tempered that she would sometimes bite her maids”—provided a valuable store of endurance for Galen to draw on as he quarreled with his contemporaries. Indeed, his passion for conflict led him, at the age of twenty-eight, into the unusual role of physician to the gladiatorial school of Pergamum, a position, amid the flayed limbs, punctured chests, and eviscerated abdomens, that gave him a perfect vantage point for firsthand anatomical observation.

One of Galen’s philosophical preoccupations was to understand how doctors came to know what they did about healing. He lived at a time when there was no consensus about how doctors should acquire knowledge. Empiricists relied entirely on experience, while Rationalists depended on reason from a prespecified theory of causation. A third group, the Methodists, rejected both experience and causal theory, putting all illnesses down to a tension between the flow of bodily discharges and their constipation. Galen was a deft eclectic. He scrutinized opposing arguments, identified their flaws, erased erroneous logic, and combined what remained into a practicable clinical method. He wished to assert the primacy of clinical observation and to bind an integrated (Hippocratic, Platonic, Alexandrian) theory of medical knowledge with its practice. But Galen wanted to achieve his unique synthesis neither as a remote theoretician nor as someone who had a reputation for being merely a “word doctor”: “Rather, my practice of the art alone would suffice to indicate the level of my understanding.”

In The Rise and Fall of Modern Medicine James Le Fanu, a practicing London doctor, a prominent medical controversialist in the English press, and a person wholly dissatisfied with the huge power exerted by modern medical sects, has surveyed and systematized, processed and picked apart the past fifty years of medical discovery. Like Galen, he is frustrated by what he sees as the misleading ideologies of today’s widely accepted and lavishly praised medical epistemologists.

So just what has medicine achieved? If one believes the mainstream view of Western white male medical progress, it has been an astonishing success. The year 1999 saw many efforts to sum up what the editors of The New England Journal of Medicine have called “the astounding course of medical history over the past thousand years.”2 Medicine deserves such glorification, they said, because it “is one of the few spheres of human activity in which the purposes are unambiguously altruistic.” Well, quite possibly, provided that academic tenure is speedily secured, research grants are generously awarded, salaries stay ahead of inflation, teaching loads are progressively lightened, managed care organizations try harder to be respectfully flexible, and patients keep their lawyers at a distance.

Is it also true to say, as the prolific British historian Roy Porter has done, that Western medicine is “preoccupied with the self”? The narcissistic obsession with the body’s personal cosmos has produced, Porter insists, a compulsion to celebrate historical winners. He defends this constant reverence for success:

I do not think that “winners” should automatically be privileged by historians…but there is a good reason for bringing the winners to the foreground—not because they are “best” or “right” but because they are powerful.3

Other critics are less respectful of medicine’s traditions. Richard Gordon, the British author of Doctor in the House and fourteen amusing sequels, is an agreeably arch cynic. He prefers the view that

the history of medicine is not the testament of idealistic seekers after health and life…. The history of medicine is largely the substitution of ignorance by fallacies…. Medicine has persistently decked itself out in fashion’s shamming achievements, while staying miserably bare on masterly discoveries.4

Despite his witty debunking, Gordon’s personal résumé of pre-modern “masterly discoveries” largely conforms to the accepted medical canon. He includes William Harvey’s discovery of the circulation of the blood (1628), Edward Jenner’s exploitation of vaccination (1796), the discovery of anesthesia (in the 1840s), the elucidation of endocrine function by Claude Bernard (1850s), Charles Darwin’s theory of evolution (1859), Lord Lister’s invention of surgical antisepsis with carbolic acid (1865), the launch of bacteriology in the 1880s by Louis Pasteur and Robert Koch, the discovery of X-rays by Wilhelm Roentgen (1895), and Freud’s early forays into psychiatry. Great achievements, every one of them, even if we might quibble about Freud’s staying power.

To which, after consulting antiquarian medical book dealers, physician-collectors of historical memorabilia, and doctors working at two well-established West Coast medical schools, the respected clinicians Meyer Friedman and Gerald Friedland added Andreas Vesalius’s anatomic sketches (1543) and Antony Leeuwenhoek’s visualization of bacteria (1676).5 Friedman and Friedland also single out the work of William Harvey for special honor since it was he who “introduced the principle of experimentation for the first time in medicine.”

In the twentieth century, medicine underwent something of a bifurcation. The physician Kerr White, a decisive figure in the study of American public health, has identified 1916 as the crucial point of separation between a medicine concerned with the health of individuals and one concerned with the health of populations.6 It was in 1916 that the Rockefeller Foundation decided to create schools of public health independent of schools of med-icine. The result was an abandonment of the social impulse within American medical education. This division contributed to the origination of two distinct histories of Western medicine, histories that had until then been indivisible.

By the end of the century, the separation of public health from clinical science was complete and officially recognized to be so. The “ten great public health achievements” of the twentieth century, according to the US Centers for Disease Control and Prevention, are vaccination, motor-vehicle safety, safer workplaces, control of infectious diseases, declines in deaths from coronary heart disease and stroke, safer and healthier foods, healthier mothers and babies, family planning, fluoridation of drinking water, and recognition of tobacco as a health hazard.7 Compare these simple social milestones with those feats of technical discovery celebrated annually since 1901 in the Nobel Prize in Physiology or Medicine. All but a few distinguished laureates have come from the laboratory rather than the clinic, and few prize winners reflect the tradition of public health.

This leaning of the Nobel committee to basic science has caused consternation among many in medicine. For some years, unsuccessfully, an annual letter-writing campaign has taken place to persuade the reluctant Swedes to give their prize to Richard Doll, the man who, among other achievements, codiscovered the link between smoking and lung cancer. He is eighty-seven years old and time is ebbing away. Will 2000 be his year?

Le Fanu’s thesis takes in this strange parallel evolution of laboratory science and public health, and he engagingly refuses to submit to convention about who should be applauded for their contributions to each. About Doll, for example, whom he agrees is “one of the world’s most eminent cancer epidemiologists,” Le Fanu is scathing. Doll’s 1981 treatise, The Causes of Cancer, is found badly wanting: it “may look impressive, but appearances can be deceptive…. Intellectual rigor…is conspicuous only by its absence.”

I hope that Professor Ralf Pettersson, who chairs this year’s Nobel committee, does not read The Rise and Fall of Modern Medicine.

2.

In the fifty years after World War II, Le Fanu argues, the Western world has undergone a “unique period of pro-digious intellectual ferment.” Drawing mainly on British and US experience, he goes on to select his personal ten definitive moments of discovery, arbitrarily he admits, from this half-century. But he also begins with a warning. Although there has been startling progress, medicine is now facing an era of perplexing stagnation. Doctors are disillusioned by their profession; they increasingly have to deal with “the worried well” rather than the genuinely sick; they have to contend with the puzzling and, for many physicians, irritating popularity of alternative medicine; and the costs of diagnosis and treatment are escalating at a rate that is not matched by advances in knowledge. From the 1970s onward, there has been “a marked decline” in innovation. And, worst of all, doctors have experienced a “subversion, by authoritarian managers and litigious patients, of the authority and dignity of the profession.”

The purpose of retelling standard histories of drug development (penicillin), physiology (cortisone), dramatic treatments (open-heart surgery), and identification of major causes of disease (the bacterium that causes peptic ulcers), as Le Fanu does in his “Lengthy Prologue,” is to find common patterns in the social conditions that delivered these discoveries. Four characteristics appear time and time again, none of which support the notion that medical progress is a rational enterprise. Le Fanu’s reading of the postwar history of medicine marks him, in Galenic terms, as an extreme and unforgiving empiricist.

First, medicine must pay a great debt to chance. In cancer treatment, for example, “virtually all [drugs] owe their origins to chance observation or luck.” They were mostly “stumbled upon,” often by “accident.” “The common theme,” Le Fanu concludes, “running through the discovery of these cancer drugs was that there was no common theme.” With respect to treatment of the childhood cancer acute lymphoblastic leukemia (ALL), “the most impressive achievement of the post-war years,”

the cure of ALL is proof of the power of science to solve the apparently insoluble. But science can certainly not claim all the credit, for many aspects of the cure of ALL remain frankly inexplicable.

Second, straightforward observation rather than intricate experimentation often produced the significant step forward when an impediment presented itself. Alexander Fleming’s fortuitous scrutiny of a discarded specimen plate, which showed a contaminating mold inhibiting bacterial growth—thus preparing the way for the discovery of penicillin and other antibiotics—required only an alert eye. Third, insight, not technological wizardry, can open hidden doors to understanding. In 1949, while studying ways to treat shock, Henri Laborit, a French naval surgeon, gave his patients promethazine, an antihistamine. He noticed that the drug produced not only sleep but also pain relief, so much so that a shot of morphine was unnecessary. He noted that “antihistamines produce a euphoric quietude… our patients are calm, with a restful and relaxed face.” From this careful description came the realization that promethazine and similar agents might treat disordered and agitated states of mind. The use of chlorpromazine as a treatment for schizophrenia soon followed.

  1. 1

    Galen, “My Own Books,” in Selected Works, translated by P.N. Singer (Oxford University Press, 1997), p. 8.

  2. 2

    The Editors, “Looking Back on the Millennium in Medicine,” The New England Journal of Medicine, January 6, 2000, p. 42.

  3. 3

    Roy Porter, The Greatest Benefit to Mankind (HarperCollins, 1997), p. 12.

  4. 4

    Richard Gordon, The Alarming History of Medicine (Mandarin, 1993), pp. 1-2.

  5. 5

    Meyer Friedman and Gerald Friedland, Medicine’s 10 Greatest Discoveries (Yale University Press, 1998), pp. 1, 37.

  6. 6

    Kerr L. White, Healing the Schism: Epidemiology, Medicine, and the Public’s Health (Springer-Verlag, 1991), p. xi.

  7. 7

    See Morbidity and Mortality Weekly Report, April 2, 1999, pp. 241-243.

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