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The American Journal of Psychiatry, VOL. 160, No. 3

Book Forum: Historical, Philosophical, and Religious Perspectives | March 01, 2003

The Rise and Fall of Modern Medicine

TRUCE T. ORDOÑA, M.D.

Am J Psychiatry 2003;160:608-609. 10.1176/appi.ajp.160.3.608

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By James Le Fanu, M.D. New York, Carroll & Graf, 1999, 426 pp., $26.00.

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Cicero, before his head and hands were unceremoniously dismembered from his body and displayed before the Roman Senate, said that gratitude is the greatest of all virtues and that, in fact, it is the father of all virtues, upon which all virtues are based. As I enter the third decade of my private practice of medicine, I realize how Plutarch’s Moralia (or Lives and Essays) and George Santayana’s admonitions to study history can indeed suffuse my sometimes disaffected heart with gratitude as I listen to Longfellow’s call to virtue:

Lives of great men all remind us we can make our lives sublime, and despairing, leave behind us footprints on the sands of time.

Footprints, that perhaps another, sailing o’er life’s solemn main, a forlorn & shipwrecked brother, seeing, shall take heart again.

The biggest hindrance for psychiatrists in private practice is not only the fear of what Pascal referred to as "the eternal silence of these infinite spaces" but an epidemic disease that has insidiously infected us all in these litigious times: eisoptrophobia, a morbid fear of mirrors.

As with Plutarch’s desire to jump-start the flagging spirits of his fellow Romans, Dr. Le Fanu, an evocative raconteur, weaves a riveting tapestry of stories spanning the years 1935 to 1998 and highlights in bold, colorful—sometimes brash—brush-strokes 10 of 46 definitive moments of modern medicine. Le Fanu succeeds in keeping the reader’s interest throughout with an uncanny fiction-author-like manipulation of story, character, plot, and action. He "shows" rather than "tells." He dexterously uses "hooks" and "leads" that leave those among us old enough to have met or known the many protagonists of his play walking away shaking our heads saying, "I’ll be damned if I saw that one coming!" and marveling at some description or insight.

Le Fanu, a Londoner, is a medical columnist for both The Daily Telegraph and The Sunday Telegraph and a writer for the Times, The Spectator, and GQ magazine. His writing is bold and his wit biting. For example, he says,

The only sound verdict, hard as it might be to accept, is that The Social Theory [regarding dietary control of diseases, water and air pollution as causing diseases] is in error in its entirety. It is possible to assess this without qualification because each of its four components either ignore or are contradicted by the inescapable laws of biology. The dietary theory of heart disease and strokes is invalidated by the biological superlative of maintaining the milieu interieur so the important physiological functions such as the levels of cholesterol and blood pressure are kept in a steady state! The dietary theory of cancer is invalidated by the contribution of biologically inevitable aging to this age-determined disease. The environmentalist theory is invalidated by the biological necessity that the human organism be resilient and not readily injured by miniscule levels of pollutants in air and water!

An analysis in 1997 of nine MRFIT-type studies involving over 125,000 participants confirmed that admonishing people to adopt a healthy lifestyle—no matter how desirable and whatever benefits it might confer from promoting exercise and stopping smoking—had absolutely no effect on stopping them from dying from heart disease!

He calls the cholesterol studies of Ancel Keys and Jeremiah Stamler "the great cholesterol deception." I asked my cardiologists their reactions to Le Fanu’s ideas. Their responses are not fit to be printed in this publication.

In 1928 Alexander Fleming did not take the matter of discovering penicillin farther because he did not think it worth pursuing, a good example of how preconceived ideas in medicine can stifle the imagination and impede progress. It was not until February 12, 1941, that a 43-year-old British policeman (Albert Alexander) became the first person treated with penicillin, thanks to the combined efforts of Florey and Chain in Oxford (1935).

The same thing seems to have happened in psychiatry. Although Freud died in 1939 at age 82, his oppressive, phantasmagorical influence on the therapeutic nihilism of psychiatrists worldwide was still felt in 1960–1972, when I was in medical school and postgraduate training for adult and child psychiatry. Psychiatric psychoanalysts still ruled over academia and specialty boards. So it was no small miracle that, according to Le Fanu, a French naval surgeon named Henri Laborit, while laboring in a maritime hospital in Tunisia in 1949, by sheer inquisitiveness

claimed in an article published that year—remarkable for its complete absence of any data—that with this combination [the antihistamine promethazine, among others] we have been able to distinctly influence the development of post-operative problems.

Laborit noted that promethazine produced a "euphoric quietude"—a "calm, with a restful and relaxed face." In 1950, the drug company Rhone-Poulenc, picking up on the hunch that it might be useful for psychiatric patients, initiated a major research into phenothiazines, the group of drugs promethazine belongs to. In 1952, when health maintenance organizations and pharmacopoeia oversight boards, which would have vetoed such an "unproven venture," were unheard of, two Parisian psychiatrists, Jean Delay and Pierre Deniker, treated a 57-year-old laborer, Giovanni A., who was diagnosed as having schizophrenia. After 3 weeks of treatment with chlorpromazine, a phenothiazine, Giovanni was discharged "able to have a normal conversation."

It was not until 1963 that chlorpromazine was shown to interfere with the action of the neurotransmitter dopamine. Le Fanu says, "This goes to show that to treat a problem does not necessarily require absolute knowledge of the causation or the mechanism or the explanation of what is wrong in a particular illness."

And so, on and on, Le Fanu goes in a pace that never lets your interest wane or wander, recounting how 10 definitive moments in medicine—including the discovery of penicillin, open-heart surgery, in vitro fertilization, kidney transplantation, the cure of childhood cancer, the discovery of Helicobacter pylori by Barry Marshall—brought on watershed, sometimes tsunami-like changes in the way medicine began to conceptualize and deliver its services. As in the dispirited days of Rome, when Plutarch’s Moralia fanned the hopes of the spent Romans by reintroducing them to the unheeded advice on gratitude by the beheaded Cicero, Le Fanu fans the dying embers of growing disillusionment among medical professionals.

In The 1001 Arabian Nights of Scheherazade, there is a story of three princes from Serendip who were so learned, astute, and intrepid that when ordinary people saw an accidental occurrence or an event of no significance, these three found opportunity and fortune. It is no coincidence that the Chinese words for "crisis" are "way" (risk or danger) and "gee" (opportunity). The medical pioneers whom Le Fanu describes follow a consistent pattern, which mirrors the studies on resiliency and "Emotional Intelligence" by Daniel Goleman (1): zeal, impulse control, persistence, perseverance, self-awareness, self-motivation, empathy, and social deftness.

References

Goleman D: Emotional Intelligence. New York, Bantam Books, 1995

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TRUCE T. ORDOÑA; The Rise and Fall of Modern Medicine. American Journal of Psychiatry. 2003 Mar;160(3):608-609.

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