The Rise and Fall of Modern Medicine

by James Le Fanu

  The Slow Death of Psychoanalysis

  John Cade, in giving his patient Mr W. B. his first dose of lithium salts, signed the death warrant of psychoanalysis, though he would scarcely have appreciated it at the time. Clearly the fact that a naturally occurring salt can, within a couple of weeks, terminate a manic illness is incompatible with Freudian analysis, which lasts for several years and does not work.

  The question of how psychiatry and indeed many doctors were mesmerised for the best part of fifty years by the bogus theories of Freudianism is one of the most extraordinary events of the intellectual history of the twentieth century. Its humiliation is exemplified by the case of Rafael Osheroff, as described by Edward Shorter:

  In 1979, Osheroff, a 42-year-old physician from Alexandria was admitted to Chestnut Lodge Hospital with the symptoms of psychotic depression. In the course of his seven-month stay he was treated with four sessions in intensive psychotherapy a week and denied medication, despite his own requests, on the grounds that his clinicians wanted him to regress back to the point in childhood at which the initial trauma occurred and then ‘build from there’. Dr Osheroff, by contrast, merely wanted to get better and finally obtained a transfer to another private clinic where he was treated with chlorpromazine and antidepressants. Within three months he was discharged and able to return to a normal life. On returning home, Osheroff found that his world had disintegrated, his wife having left him and his partner – who had driven him to Chestnut Lodge – having ousted him from their joint practice. In 1982 Osheroff sued Chestnut Lodge for malpractice on the grounds that he should have been given state-of-the-art treatment with medication of demonstrated efficacy rather than left to vegetate for seven months. In 1987 the case was settled out of court for an undisclosed sum. Did psychoanalysis meet ‘accepted standards of care’? Gerald Clareman, an influential psychiatrist who had testified on Osheroff’s behalf, made the point that the efficacy of intensive psychoanalysis had never been established. The case left a strong impression that treating major psychiatric illness with psychoanalysis alone constituted malpractice.16

  The collapse of Freudianism is now well documented. Its major fault was that beneath the veneer of rationalism (psychoanalysis as a ‘science of the mind’) it was profoundly irrational, in that it located the source of mental illness in conflicts in early childhood that were inaccessible to human reason. But it was not just the drugs that killed off psychoanalysis.17 Rather its claims to offer an explanation for the neuroses was undermined by the dramatic success of its antithesis, cognitive therapy, in the 1980s and 1990s. In contrast to psychoanalysis, cognitive therapy is simple, straightforward, lasts weeks rather than years, but above all permits the patients to make sense of, and thus control, their psychological problems. It also works – for generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, agoraphobia and depression.18

  Post-war psychiatry has indeed been a ‘smashing success’, but it is also deeply enigmatic. The ‘triumph’ of human reason in understanding the neuroses epitomised by psychoanalysis has been shown to be a sham, while the accidental discoveries of the drugs ‘that really made a difference’ were made completely independently of any intellectual understanding of mental illness.

  REFERENCES

  ABBREVIATIONS

  AJM American Journal of Medicine

  AJOG American Journal of Obstetrics and Gynaecology

  BJHH Bulletin of the Johns Hopkins Hospital

  BMJ British Medical Journal

  JAMA Journal of the American Medical Association

  JRSM Journal of the Royal Society of Medicine

  MRC Medical Research Council

  NEJM New England Journal of Medicine

  OUP Oxford University Press

  PSMMC Proceedings of the Staff Meetings of the Mayo Clinic

  The place of publication is London unless otherwise stated.

  Introduction

  1.Richard Horton, ‘A Manifesto for Reading Medicine’, The Lancet, 1997, Vol. 349, pp. 872–4.

  2.Isobel Allen, Doctors and Their Careers (Policy Studies Institute, 1988); Isobel Allen, Doctors and Their Careers: A New Generation (Policy Studies Institute, 1994).

  3.Anthony King, Daily Telegraph, 3 June 1996.

  4.Nigel Hawkes, The Times, 4 February 1998.

  5.Peter Skrabanek, The Death of Humane Medicine and the Rise of Coercive Healthism (Social Affairs Unit, 1994).

  6.David Eisenberg, ‘Unconventional Medicine in the United States: Prevalence Costs and Patterns of Use’, NEJM, 1993, Vol. 328, pp. 246–52.

  7.Office of Health Economics, Compendium of Health Statistics, 1998.

  A LENGTHY PROLOGUE: TWELVE DEFINITIVE MOMENTS

  1.Lewis Thomas, ‘Biomedical Science and Human Health’, Yale Journal of Biology and Medicine, 1978, Vol. 51, pp. 133–42.

  2.H. H. Dale, ‘Advances in Medicinal Therapeutics’, BMJ, 7 January 1950, pp. 1–7.

  1: 1941: Penicillin

  GENERAL READING

  R. Hare, The Birth of Penicillin (Allen & Unwin, 1970).

  G. Macfarlane, Howard Florey: The Making of a Great Scientist (Oxford: OUP, 1979).

  ——, Alexander Fleming: The Man and the Myth (Chatto & Windus,1984).

  John C. Sheehan, The Enchanted Ring (Cambridge, MA: MIT Press,1982).

  Wesley W. Spink, Infectious Diseases: Prevention and Treatment in the Nineteenth and Twentieth Centuries (Folkestone: Dawson, 1979).

  Milton Wainwright, Miracle Cure (Oxford: Blackwell, 1990).

  REFERENCES

  1.Charles Fletcher, ‘First Clinical Use of Penicillin’, BMJ, 1984, Vol. 289, pp. 1721–3.

  2.E. P. Abraham, E. Chain, H. W. Florey et al., ‘Further Observations on Penicillin’, The Lancet, 16 August 1941, pp. 177–88.

  3.Ronald Hare, The Birth of Penicillin. See also John Henderson, ‘The Yellow Brick Road to Penicillin: A Story of Serendipity’, PSMMC, 1997, Vol. 72, pp. 683–7; Alexander Fleming, ‘Discovery of Penicillin’, British Medical Bulletin, 1944, Vol. 2, pp. 4–5.

  4.Alexander Fleming, ‘On the Antibacterial Action of Cultures of a Penicillium, With Special Reference to Their Use in the Isolation of B. Influenzae’, British Journal of Experimental Pathology, 1929, Vol. 10, pp. 226–36.

  5.E. Chain, ‘Thirty Years of Penicillin Therapy’, Proceedings of the Royal Society of London: Series B, 1971, Vol. 179, pp. 293–319.

  6.E. Chain, H. W. Florey et al., ‘Penicillin as a Chemotherapeutic Agent’, The Lancet, 24 August 1940, pp. 226–8.

  7.G. Macfarlane, Alexander Fleming: The Man and the Myth.

  8.G. Macfarlane, Howard Florey: The Making of a Great Scientist.

  9.H. W. Florey, ‘Penicillin’, Nobel Lectures: Physiology or Medicine, 1940–62 (New York: Elsevier, 1964).

  10.E. F. Gale et al., The Molecular Basis of Antibiotic Action (Chichester: John Wiley & Sons, 1981). E. F. Gale et al., The Molecular Basis of Antibiotic Action (Chichester: John Wiley & Sons, 1981).

  11.John C. Sheehan, The Enchanted Ring.

  12.Lawrence Garrod and Francis O’Grady, Antibiotics and Chemotherapy (E & S Livingstone, 1971).

  13.S. A. Waksman, ‘The Soil as a Source of Micro-organisms Antagonistic to Disease-producing Bacteria’, Journal of Bacteriology, 1940, Vol. 40, pp. 581–600.

  14.S. A. Waksman, ‘The Role of Antibiotics in Nature’, Perspectives in Biology and Medicine, Spring 1961, pp. 271–87.

  15.L. C. Vining, ‘Role of Secondary Metabolites from Microbes’, Secondary Metabolites: Their Function and Evolution, ed. D. Chadwick and J. Whelan, Ciba Foundation Symposium 171 (Chichester: John Wiley & Sons, 1992).

  2: 1949: Cortisone

  GENERAL READING

  E. G. L. Bywaters, ‘The History of Paediatric Rheumatology’, Arthritis and Rheumatism, 1977, Vol. 20, pp. 145–52.

  David Canton, ‘Cortisone and the Politics of Drama, 1949–55’, Medical Innovations in Historical Perspective, ed. John V. Pickstone (Macmillan, 1992).

  G
eorge D. Kersley and John Glyn, A Concise International History of Rheumatology and Rehabilitation (Royal Society of Medicine Press, 1992).

  Albert Q. Maisel, The Hormone Quest (New York: Random House,1965).

  Harry M. Marks, ‘Cortisone, 1949: A Year in the Political Life of a Drug’, Bulletin of the History of Medicine, 1992, Vol. 66, pp. 419–39.

  REFERENCES

  1.Philip S. Hench et al., ‘The Effect of a Hormone of the Adrenal Cortex on Rheumatoid Arthritis’, PSMMC, 1949, Vol. 24, pp. 181–97.

  2.Albert Maisel, The Hormone Quest.

  3.Philip S. Hench, ‘Analgesia Accompanying Hepatitis and Jaundice in Cases of Chronic Arthritis’, PSMMC, 1933, Vol. 8, pp. 430–37.

  4.Philip S. Hench, ‘Effect of Spontaneous Jaundice on Rheumatoid Arthritis: Attempts to Reproduce the Phenomenon’, BMJ, 1938, Vol. 2, pp. 394–8.

  5.Philip S. Hench, ‘The Reversibility of Certain Rheumatic and Non-rheumatic Conditions by the Use of Cortisone’, Nobel Lectures: Physiology or Medicine, 1942–62 (New York: Elsevier, 1964).

  6.F. A. Hartman et al., ‘The Hormone of the Adrenal Cortex’, Science, 1930, Vol. 72, p. 76.

  7.H. L. Mason et al., ‘The Chemistry of Crystalline Substances Isolated from the Suprarenal Gland’, Journal of Biological Chemistry, 1936, Vol. 114, pp. 613–31.

  8.H. Selye, ‘Thymus and Adrenals in the Response of the Organism to Injuries and Intoxications’, British Journal of Experimental Pathology, 1936, Vol. 17, p. 234.

  9.See Note 2. See also Edward Kendall, ‘The Development of Cortisone as a Therapeutic Agent’, Nobel Lectures: Physiology or Medicine, 1942–62 (New York: Elsevier, 1964).

  10.J. H. H. Glyn, Cortisone Therapy (Heinemann, 1957).

  11.The Times, 5 July 1949.

  12.Philip S. Hench, ‘A Reminiscence of Certain Events Before, During and After the Discovery of Cortisone’, Minnesota Medicine, July 1953, pp. 705–10.

  13.W. S. C. Copeman (ed.), Cortisone and ACTH in Clinical Practice (Butterworth, 1953).

  14.The initial reaction to Hench’s paper had been very enthusiastic. See ‘A New Treatment for Rheumatoid Arthritis’, BMJ, 7 May 1949, p. 812, and ‘Cortisone in the Treatment of Rheumatism’, BMJ, 2 July 1949, p. 24. Hench’s results were replicated in Britain in a trial reported in the BMJ the following year: ‘A Study of Cortisone and Other Steroids in Rheumatoid Arthritis’, 14 October 1950, pp. 847–55: ‘the dramatic clinical effects of cortisone were immediately obvious’.

  15.Harvey A. McGhee et al., ‘Introduction to a Series of Papers on Studies on ACTH and Cortisone’, BJHH, 1950, Vol. 87, pp. 349–507.

  16.The main papers describing the effect of cortisone in diseases other than rheumatoid arthritis include: Philip S. Hench et al., PSMMC, 1949, Vol. 24, pp. 277–97 (rheumatic fever); L. A. Brunsting et al., PSMMC, 1950, Vol. 25, pp. 479–82 (lupus erythematosis); R. A. Carey, BJHH, 1950, Vol. 87, pp. 425–60 (polyarteritis nodosa); T.W. Oppel, Annals of Internal Medicine, 1950, Vol. 32, pp. 318–24 (dermatomyositis); R. R. Kierland et al., Archives of Dermatology and Syphilology, 1951, Vol. 64, pp. 549–54 (scleroderma); R. A. Carey et al., BJHH, 1950, Vol. 87, pp. 354–414 (drug hypersensitivity and asthma); A. C. Woods, American Journal of Ophthalmology, 1950, Vol. 33, pp. 1325–49 (ocular inflammatory disease); B. J. Kennedy et al., AJM, 1951, Vol. 10, pp. 134–55 (silicosis); M. Gladstone et al., AJM, 1951, Vol. 10, pp. 166–81 (pulmonary fibrosis); L. E. Shulman, BJHH, 1952, Vol. 91, pp. 371–415 (sarcoidosis); W. H. Deering et al., PSMMC, 1950, Vol. 25, pp. 486–8 (ulcerative colitis); T. E. Machella et al., AJM, 1951, Vol. 221, pp. 501–7 (Crohn’s); E. R. Sulzberg et al., JAMA, 1953, Vol. 151, pp. 468–72 (dermatological disease); E. P. Farnsworth, Proceedings of the Society for Experimental Biology and Medicine, 1950, Vol. 74, pp. 60–2 (nephrotic syndrome);M. M. Wintrobe et al., AMA Archives of Internal Medicine, 1951, Vol. 88, pp. 310–36 (haematological disorders); H. Ducchi et al., Gastroenterology, 1952, Vol. 21, pp. 357–74 (hepatitis).

  3: 1950: Streptomycin, Smoking and Sir Austin Bradford Hill

  GENERAL READING

  Sir Austin Bradford Hill, Statistical Method in Clinical and Preventive Medicine (E & S Livingstone, 1962) – a collection of his important papers.

  Richard Doll, ‘Sir Austin Bradford Hill and the Progress of Medical Science’, BMJ, 1992, Vol. 305, pp. 1521–6.

  Edmund A. Gehan and Noreen Lemak, Statistics in Medical Research: Developments in Clinical Trials (New York: Plenum, 1994).

  International Agency for Research on Cancer (IARC), Statistical Methods in Cancer Research, Vol. 1: The Analysis of Case-Control Studies (IARC, 1987).

  ——, Statistical Methods in Cancer Research, Vol. 2: The Design and Analysis of Cohort Studies (IARC, 1987).

  David E. Lillienfeld and Abraham M. Lillienfeld, ‘Epidemiology: A Retrospective Study’, American Journal of Epidemiology, 1977, Vol. 106, pp. 445–59.

  J. Rosser Matthews, Quantification and the Quest for Medical Certainty (Princeton, NJ: Princeton University Press, 1995).

  Theodore M. Porter, The Rise of Statistical Thinking, 1820–1900 (Princeton, NJ: Princeton University Press, 1986).

  ——, Trust in numbers: The Pursuit of Objectivity in Science and Public Life (Princeton, NJ: Princeton University Press, 1995).

  Statistics in Medicine, 1982, Vol. 1, pp. 1–375 – a series of essays exploring different aspects of Bradford Hill’s life.

  Mervyn Susser, ‘Epidemiology in the United States After World War II: The Evolution of Technique’, Epidemiologic Reviews, 1985, Vol. 7, pp. 147–77.

  Peter Taylor, Smoke Ring: The Politics of Tobacco (Bodley Head, 1986).

  Lisa Wilkinson, ‘Sir Austin Bradford Hill: Medical Statistics and the Quantitative Approach to Prevention of Disease’, Addiction, 1997, Vol. 92, pp. 657–66.

  REFERENCES

  1.Sir Henry Dale, ‘Advances in Medicinal Therapeutics’, BMJ, 7 January 1950, pp. 1–7.

  2.A. Bradford Hill, ‘The Life of Sir Leonard Erskine-Hill FRS, 1866–1952’, Proceedings of the Royal Society of Medicine, 1968, Vol. 61, pp. 307–16. See also I. D. Hill, ‘Austin Bradford Hill: Ancestry and Early Life’, Statistics in Medicine, 1982, Vol. 1, pp. 297–300.

  3.A. Bradford Hill, ‘A Pilot in the First World War’, BMJ, 1983, Vol. 287, pp. 1947–8.

  4.Major Greenwood, ‘Medical Statistics’, The Lancet, 1921, Vol. 1, pp. 985–8. See also Major Greenwood, Some British Pioneers of Social Medicine (Oxford: OUP, 1948).

  5.Edmund A. Gehan and Noreen Lemak, Statistics in Medical Research: Developments in Clinical Trials.

  6.A. Bradford Hill, ‘Memories of the British Streptomycin Trial’, Controlled Clinical Trials, 1990, Vol. 11, pp. 77–9.

  7.Linda Bryder, Below the Magic Mountain (Oxford: Clarendon Press, 1988). See also John R. Bumgarner, ‘Phthisis: My Case History’, North Carolina Medical Journal, 1993, Vol. 54, pp. 288–90.

  8.P. d’Arcy Hart, ‘Chemotherapy of Tuberculosis Research During the Past 100 Years’, BMJ, 1946, Vol. 30, pp. 805–11; Part 2, 7 December 1946, pp. 849–55.

  9.S. A. Waksman, My Life With the Microbes (Robert Hale, 1958).

  10.Frank Ryan, Tuberculosis: The Greatest Story Never Told (Bath: Swift Books, 1992).

  11.Julius Comroe, ‘Pay Dirt: The Story of Streptomycin’, American Review of Respiratory Disease, 1978, Vol. 117, pp. 773–81; Part 2, pp. 957–68.

  12.Albert Schatz and Selman Waksman, ‘Effect of Streptomycin upon Mycobacterium Tuberculosis and Related Organisms’, Proceedings of the Society for Experimental Biology and Medicine, 1944, Vol. 57, pp. 244–8.

  13.H. C. Hinshaw and W. H. Feldman, ‘Streptomycin and the Treatment of Clinical Tuberculosis: A Preliminary Report’, PSMMC, 1945, Vol. 18, pp. 313–18.

  14.Frederick Bernheim, ‘The Effect of Salicylate on the Oxygen Uptake of the Tubercle Bacillus’, Science, 1940, Vol. 92, p. 204.

  15.See Note 10.

  16.Jorgen Lehmann, ‘Para-amino Salicylic Acid in the Treatment of Tuberculosis’, The Lancet, 1946, Vol. 1, pp
. 15–16.

  17.F. H. K. Green, ‘The Clinical Evaluation of Remedies’, The Lancet, 1954, Vol. 2, pp. 1085–91. See also J. P. Bull, ‘The Historical Development of Clinical Therapeutic Trials’, Journal of Chronic Diseases, 1959, Vol. 10, pp. 218–48.

  18.Peter M. Dunn, ‘James Lind of Edinburgh and the Treatment of Scurvy’, Archives of Disease in Childhood, 1997, Vol. 76, pp. 64–5. See also Duncan P. Thomas, ‘Sailors, Scurvy and Science’, JRSM, 1997, Vol. 90, pp. 50–4.

  19.A. Bradford Hill, ‘The Clinical Trial’, NEJM, 1952, Vol. 247, pp. 113–19.

  20.John Crofton and D. A. Mitchison, ‘Streptomycin Resistance in Pulmonary Tuberculosis’, BMJ, 11 December 1948, pp. 1009–15.

  21.M. E. Florey, The Clinical Application of Antibiotics, Vol. 2: Streptomycin (Oxford: OUP, 1961), p. 133.

  22.MRC, ‘Treatment of Pulmonary Tuberculosis With PAS and Streptomycin: Preliminary Report’, BMJ, 31 December 1949, p. 1521.

  23.MRC, ‘Treatment of Pulmonary Tuberculosis With Streptomycin and Para-amino-salycylic Acid’, BMJ, 11 November 1950, pp. 1074–85.

  24.MRC, ‘The Prevention of Streptomycin Resistance by Combined Chemotherapy’, BMJ, 31 May 1952, pp. 1157–64.

  25.MRC, ‘Isoniazid in the Treatment of Pulmonary Tuberculosis’, BMJ, 7 March 1953, pp. 551–63.

  26.Bernard Crick, George Orwell: A Life (Secker & Warburg, 1980).

  27.Richard Doll, ‘Clinical Trials Retrospect and Prospect’, Statistics in Medicine, 1982, Vol. 1, pp. 337–44.

  28.W. Grant Waugh, ‘A Blast of the Trumpet Against the Monstrous Regiment of Mathematics’, BMJ, 3 November 1951, p. 1088.

  29.Andrew Wilson et al., Clinical Trials: Symposium, 5 April 1962 (Pharmaceutical Press, 1962).

  30.Joan Austoker, History of the Imperial Cancer Research Fund, 1902–86 (Oxford: OUP, 1988).

  31.J. R. Bignell, ‘Bronchial Carcinoma: Survey of 317 Patients’, The Lancet, 1955, Vol. 1, pp. 786–8.

  32.Conversation with Sir Richard Doll, British Journal of Addiction, 1991, Vol. 86, pp. 365–77. See also A. Bradford Hill, ‘Mortality from a Malignant Disease’, The Practitioner, 1945, Vol. 155, pp. 27–34.