The Rise and Fall of Modern Medicine

James Le Fanu contributes a twice-weekly column on medicine, science and social policy to the Sunday and Daily Telegraph. His articles and reviews have also appeared in the New Statesman, Spectator, GQ, the British Medical Journal and the Journal of the Royal Society of Medicine. He has also made original contributions to controversies concerning experiments on human embryos, environmentalism and the causes of disease. The Rise and Fall of Modern Medicine won the Los Angeles Times Book Prize in 2001. His most recent book Why Us? How Science Rediscovered the Mystery of Ourselves was published jointly by HarperCollins in the UK and Random House in the United States in 2009. He is married to the publisher Juliet Annan and they live with their two children in South London.

Praise for The Rise and Fall of Modern Medicine

‘Excellent . . . As Le Fanu explains in a telling phrase, the human hip joint is more slippery than a skate sliding on ice. How could such a thing be made artificially? This is one of the fascinating “twelve definitive moments” that make up the first part of the book. Le Fanu describes them – from penicillin to heart surgery and the treatment of infertility – with just the right mixture of science, history and anecdote. The struggles, disappointments and fatal errors of these early pioneers are described with zest, authority and a special brand of wry humour . . . An endlessly fascinating read’

MAX WILKINSON in the Financial Times

‘Le Fanu [is] one of today’s leading writers on medicine to the informed public. The Rise and Fall of Modern Medicine is a substantial work (and very good value) for those with a fairly serious interest in health matters’

HUGH FREEMAN in the Daily Telegraph

‘Stand by for a brilliant read. James Le Fanu’s massive book, bulging with juicy medical history and anecdotes, will set your heart palpitating and your blood pressure rising from the start. It is an absolute must-read for all people interested in medical matters, and particularly for those (like me) whom Le Fanu dubs The Worried Well, i.e. the ones who are “well” but “worried” we might not be . . . By reading Le Fanu’s book we will be made aware of the thrilling power of the scientific method and the manner in which it pushes the boundaries of knowledge, to thank our lucky stars for the leaps forward in medicine and to acknowledge the enormous limitations imposed by the inscrutable mysteries of biology’

VAL HENNESSY in the Daily Mail

‘Recently writing a history of medicine from the Stone Age to New Age, I deeply regretted that there was no up-to-the-minute account of modern medicine which I could pillage. That book has now arrived . . . Its author, the distinguished medical journalist Dr James Le Fanu, writes with clarity and authority, and has the great knack of making even the most complex technical developments in immunology or embryology exciting and intelligible . . . You’ll find nowhere a better crafted and more expert account of how modern medicine helps ensure that the great majority of us live to a ripe old age . . . Erudite [and] absorbing’

ROY PORTER in the Observer

‘[A] well written, fascinating and informative book, which should be read by anyone with an interest in contemporary medicine . . . Everyone will finish the book knowing much that he did not know before, and stimulated into thought about the future of medicine. At the very least, the reader will have a more realistic appreciation of the powers and limitations of medicine; and in an age of hysteria about the subject, that is no mean achievement’

ANTHONY DANIELS in the Sunday Telegraph

‘This book is a major achievement. It will be a test of the state of modern medicine to see whether that achievement is acknowledged and The Rise and Fall of Modern Medicine accorded the widespread discussion it deserves. It is a book that desperately needed to be written. And it is an indictment of the universities and medical schools that the job had to wait for the attentions of one of the country’s most gifted freelance intellectuals. The book succeeds at two levels. It is at the same time a thorough, scholarly and well-referenced text, and a clear, vivid and compelling narrative, accessible to the interested lay person’

BRUCE CHARLTON in The Tablet

‘In this invaluable amalgam of human drama, vivid history, cutting-edge nous and old-fashioned polemic, Le Fanu issues an appeal to reason and calls for medicine to recover its sense of what it is for . . . The ambition of this, the first historical account of this period, is admirably justified throughout. Le Fanu communicates complex material in a clear and straightforward fashion while taking care, wearing his journalistic cap atop his white coat, never to let the scientific facts stand in the way of what is a rattling good story’

ANDREW MACKENZIE in Scotland on Sunday

‘[Le Fanu’s] book, in many ways a history of medicine since 1935, is as lucid as it is comprehensive. In it, he comments that few doctors are intellectuals. He is an exception, but, even so, it is an easy and fascinating read, studded with little-known facts . . . His arguments develop slowly and clearly . . . I would recommend The Rise and Fall of Modern Medicine. I found it informative and intriguing’

THOMAS STUTTAFORD in the Literary Review

‘The skill [of medical journalism] is to write with humanity and objectivity, a dual responsibility brilliantly fulfilled by the author . . . This book is well worth reading just for the brilliant pen portraits of Le Fanu’s twelve definitive moments of medical advance. Some, like the discovery of penicillin, are well known, but even here the author has a way of encapsulation that is full of insights and unusual detail . . . It would be possible to close the book here, just over halfway through, and still feel you had had your money’s worth. But the challenge is in the second half, where three much hyped hopes for the future are brought down to earth . . . This excellent book has challenged many of my views’

DAVID OWEN in the Spectator

‘[The first] part of the book makes a jolly good yarn. The tales are well told, and should be read by all [junior doctors] to give them some feeling of the excitement felt by their grandparents as major diseases that had seemed totally untreatable came under control. Seniors should read it too: they will be reminded of the great men who taught them . . . The second half of the book, concerning the fall of medicine, is more contentious though no less enjoyable for that’

J. R. HAMPTON in the Journal of the Royal Society of Medicine

‘Le Fanu’s dozen vignettes [of the definitive moments of modern medicine] are excellently done . . . Le Fanu, a part-time practitioner, sounds just the sort of physician we would like to consult’

DAVID SHARP in the New Statesman

‘Close on 500 pages of passionate criticism . . . Le Fanu’s accounts of the success stories of medical care are lively and well worth reading’

D. J. WEATHERALL in the Times Higher Education Supplement

‘This well written, extremely readable, and thought-provoking book deserves to be widely read, especially by those in the establishment who would say he is wrong’

ROB HENDRY in the British Journal of Medical Practice

‘Le Fanu’s The Rise and Fall of Modern Medicine is the best book on the history of medicine I have ever read. Thoroughly fascinating, immensely readable. Deserves wide public attention’

NORMAN F. CANTOR, Emeritus Professor of History, New York University

‘A compelling insider account that tries to determine, from the vantage point of the United Kingdom, why so few people are happy with the institution of medicine’

IAIN BAMFORTH in the Times Literary Supplement

‘I enjoyed The Rise and Fall of Modern Medicine, and I expect most doctors will also, possibly dipping into it (topics are well indexed), rather than reading from start to finish. Le Fanu’s “twelve definitive moments” are a particular pleasure to read. Having practised through most of the years he covers, and having participated in or observed first-hand many of the events he recounts, his accounts of the serendipity, imagination, and luck that led to each are intriguing and informative . . . Le Fanu is a keen observer of the changing medical scene. He presents a wealth of interesting material and offers interpretations that, whether or not they agree, readers will find thought-provoking and well worth reading’

JOHN BUNKER in the British Medical Journal

ACKNOWLEDGEMENTS

The arduousness of writing has been more than compensated for by the privilege of meeting so many of those who participated in the great events recorded in this book. To them; to the sympathetic souls whose interest has been more important than they realise; to the librarians at the Royal Society of Medicine and the Wellcome Institute for the History of Medicine; to my wife Juliet; to my agent Caroline Dawnay, publishers Philippa Harrison and Richard Beswick and editors Andrew Gordon and Victoria Pepe; and to Vanessa Adams and Caroline Sherbrooke for their prodigious secretarial skills: my thanks.

Dr Digby Anderson, Lord Annan, Bryan Appleyard, Mr John Ballantyne FRCS, Sir Douglas Black, Professor Nicholas Black, Sir Christopher Booth, Dr Thomas Boulton, Professor John Bunker, Dr Bruce Charlton, Mr Bill Cleland FRCS, Sir John Dacie, Dr Ann Dally, Dr Anthony Daniels, Professor Norman Dennis, Professor C. J. Dickinson, Sir Richard Doll, Professor Deborah Doniach, Professor Israel Doniach, Professor R. S. Downie, Sir John Ellis, Professor Peter Ellwood, Professor Renée Fox, Mr Michael Freeman FRCS, Professor David Galton, Dr John Glyn, Mr James Gow FRCS, Dr C. W. Haigh, Professor John Hampton, Dr Myles Harris, Sir Donald Harrison, Dr I. D. Hill, Professor A. V. Hoffbrand, Dr Arthur Holman, Mr John Hopewell FRCS, Dr David Horrobin, Professor Bryan Jennett, Professor Trevor Jones, Dr Michael Joseph, Dr Leo Kinlen, Dr Ghislaine Lawrence, Professor John Marshall, Dr William Marshall, Dr Robert Matthews, Professor James McCormick, Professor Kenneth Minogue, Dr G. Misiewicz, Professor John Moorehead, Mr E. P. O’Donoghue FRCS, Professor Peter Openshaw, Mr Nicholas Parkhouse FRCS, Professor Michael Patton, Sir Stanley Peart, Mr Elliot Philipp FRCS, Mr Michael Powell FRCS, Dr David Pyke, Mr Gordon Rees FRCS, Professor Jonathan Rees, Professor Lesley Rees, Dr Henry Rollin, Dr Jack Scannell, Dr Rupert Sheldrake, Professor Peter Skrabanek, Professor Alexander Spiers, Professor Gordon Stewart, Mr John Studd FRCOG, Professor Raymond Tallis, Dr Tilli Tansey, Dr Wendy Taylor, Professor Tom Treasure FRCS, Mr Patrick Trevor-Roper FRCS, Dr John Wade, Sir David Weatherall, Dr Mark Weatherall, Professor Simon Wesseley, Mr Adrian While FRCS, Dr Elizabeth Whipp, Mr John Wickham FRCS, Sir Michael Woodruff, Dr Nigel Yeatman.

PREFACE TO THE REVISED EDITION

Over the past fifty years medicine has metamorphosed from a modest pursuit of limited effectiveness into a massive global phenomenon employing millions and costing (hundreds of) billions. Now, in the vast shiny palace the modern hospital has become, the previously unimaginable goals of transplanting organs and curing childhood cancer have become unexceptional, while every year tens of thousands previously doomed to blindness from cataracts or to immobility from crippling arthritis have their sight and mobility restored. Medicine has become the most visible symbol of the fulfilment of the great Enlightenment Project where scientific progress would vanquish the twin perils of ignorance and disease to the benefit of all.

And yet the more powerful and prestigious medicine has become, the greater the impetus to extend its influence yet further, resulting in the progressive ‘medicalisation’ of people’s lives, to no good purpose and potentially harmful consequences. This takes many forms, from the overinvestigation and over treatment of minor symptoms to the inappropriate use of life-sustaining technologies, anxiety mongering about trivial (or non-existent) threats to health in people’s everyday lives, and the propagation of unreasonable expectations about what the current state of medical research can reasonably expect to achieve.

These are no trivial matters. They warrant clear analysis and, if possible, remedial action; yet their significance has for the most part been concealed from view by the common perception, profoundly influenced by medicine’s historic achievements, of it being on a continuous and upward curve of knowledge. Here the unknown is merely waiting to be known with, in principle, no limits to its further beneficent advance.

Yet it is not so, for as I proposed a decade ago in the first edition of The Rise and Fall of Modern Medicine, the current difficulties and discontents of medicine are ultimately linked to the changing fortune of the three forces that forged the therapeutic revolution of the post-war years – clinical science, pharmaceutical innovation and technical progress. This, in turn, has created an intellectual vacuum within which faulty and unrealistic assumptions of medicine’s ‘tasks and goals’ have flourished. Now, ten years on, the ‘massive global enterprise’ of medicine remains as powerful as ever – if not more so, and as suggested by the continued exponential increase in National Health Service expenditure and the revenues of the pharmaceutical industry.

But the central thesis of The Rise and Fall . . . still holds, and so for this second edition I have revised but made no substantial changes to the original text. To this I have added an epilogue examining the three most significant factors in the continuing expansion of the medical enterprise over the past decade: the technical innovations that have extended the benefits of medical intervention to an ever ageing population; the ascendancy of The New Genetics in the aftermath of the completion of the Human Genome Project to become the dominant form of medical research; and, most importantly of all, how an ever wealthier pharmaceutical industry has successfully subverted the proper aims of medicine to its own very profitable advantage.

INTRODUCTION

The history of medicine in the fifty years since the end of the Second World War ranks as one of the most impressive epochs of human achievement. So dramatically successful has been the assault on disease that it is now almost impossible to imagine what life must have been like back in 1945, when death in childhood from polio, diphtheria and whooping cough were commonplace; when there were no drugs for tuberculosis, or schizophrenia, or rheumatoid arthritis, or indeed for virtually every disease the doctor encountered; a time before open-heart surgery, transplantation and test-tube babies. These, and a multitude of other developments, have been of immeasurable benefit, freeing people from the fear of illness and untimely death, and significantly ameliorating the chronic disabilities of ageing.

This post-war medical achievement is well recognised, but much less appreciated is the means by which it was brought about. For the previous 2,000 years doctors had sought in vain for the ‘magic bullets’ that would alleviate their patients’ suffering and then, quite suddenly and without warning, they came cascading out of the research laboratories just as if medicinal chemists had hit the jackpot (as they had). Or again, in 1945, desirable objectives such as transplanting organs or curing cancer were rightly perceived as being unattainable, as there was simply no way of overcoming the biological problems of the rejection of foreign tissue or the selective destruction of cancer cells. But these and many other obstacles were surmounted. The past fifty years have been a unique period of prodigious intellectual ferment that, quite naturally, invite investigation.

There is a problem, however, in knowing where to start. The scale of the therapeutic revolution has been so vast that any comprehensive history would necessarily run to several volumes. Decisions had to be made about not only what to include and what, regretfully, to leave out, but also how to go beyond a simple chronological account to illuminate themes of more general significance. The compromise I have chosen is illustrated opposite. This list of the major events of this period identifies twelve ‘definitive moments’ which are considered in depth in a prologue that is necessarily longer than is customary. The rationale of this selection is not of immediate concern but several themes are easy enough to identify, including the decline of infectious disease (sulphonamides, penicillin and childhood immunisation); the widening scope of surgery (the operating microscope, transplantation and hip replacements); major developments in the treatment of cancer, mental illness, heart disease and infertility; and improvements in diagnostic techniques (the endoscope and the CT scanner).

Each of these events is a remarkable story of human endeavour in its own right, but when they are assembled together then, as with the dots of the pointillist, a coherent picture should begin to emerge. The value of such an historical perspective is not necessarily obvious. ‘Medicine pays almost exclusive homage to the shock of the new,’ writes the editor of The Lancet, Richard Horton. ‘We place constant emphasis on novelty . . . this is an era of the instantaneous and the immediate.’¹ This preoccupation with ‘the new’ leaves little room for history, and indeed medicine has got by well enough with no sense of its immediate past at all. Perhaps the history of twentieth-century medicine is solely of academic interest, an intellectual pastime for retired doctors but of little practical importance?

The Twelve Definitive Moments of Modern Medicine

Needless to say, I do not share this view, but rather, taking my cue from T. S. Eliot – ‘the historical sense involves the perception not only of the pastness of the past, but of its presence’ – maintain it is not possible to understand the present, and in particular present discontents, outside of the context of this recent past. And what is the nature of these ‘present discontents’? Any account of modern medicine has to come to terms with a most perplexing four-layered paradox that at first sight seems quite incompatible with its prodigious and indubitable success.

Paradox 1: Disillusioned Doctors

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.² 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?

Paradox 2: The Worried Well

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.³ 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.⁴ 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.⁵

Paradox 3: The Soaring Popularity of Alternative Medicine

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.⁶

Paradox 4: The Spiralling Costs of Health Care