## Metadata - Author: [[James Le Fanu]] - Full Title: The Rise and Fall of Modern Medicine - Category: #books ## Highlights - ‘History is a high point of advantage from which alone men can see the age in which they are living’ (G. K. Chesterton), ([Location 309](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=309)) - 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. ([Location 331](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=331)) - despite the complexity and diverse mechanisms by which antibiotics work, the process of their discovery turned out to be astonishingly simple. All that was required, as Florey pointed out in his Nobel Prize speech, was the screening of micro-organisms to identify the handful that could destroy other bacteria, and then identification of the active antibiotic ingredient. Thus, though antibiotics are commonly perceived as a triumph of modern science, scientists alone could never have invented or created them from first principles. They are, rather, ‘a gift from nature’, which raises the question of what their role in nature might be. ([Location 501](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=501)) - It would seem obvious that a proper understanding of disease would be indispensable to developing an effective treatment, but the discovery of steroids permitted doctors to pole-vault the hurdles of their own ignorance, or, mixing metaphors, the inscrutable complexity of disease was dissolved away in the acid bath of steroid therapy where, in practical terms (at least for the patient), the only really important question – ‘What will make this better?’ – was resolved by the simple expedient of writing a prescription for cortisone. ([Location 666](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=666)) - It is only necessary to add that, fifty years later, the means by which cortisone controls the inflammatory response are still not clear. It influences the changes in the local blood supply, the attraction of cells to clear the injured tissue and the proliferation of healing tissue, but there is as yet no unifying hypothesis of how these powerful effects work together. ([Location 705](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=705)) - The crucial point to inspire twentieth-century epidemiologists was that statistical enquiry, by determining the underlying causes of ill health such as poor sanitation, provided the means for the prevention of disease on a massive scale, so ‘statisticians’ potentially had an infinitely greater effect in improving the health of the nation than white-coated doctors with their airs and graces. ([Location 784](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=784)) - It had been unnecessary to formally test whether or not penicillin worked in humans because the results were immediate and dramatic. But the efficacy of streptomycin in tuberculosis was not quite so straightforward because the tubercle bacillus, in its waxy shell, is very resilient and the damage it causes the lungs and other organs is more chronic. Accordingly, streptomycin had to be given for several months before there was any obvious improvement. ([Location 812](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=812)) - the hip joint has to fulfil the apparently incompatible tasks of both sustaining the weight of the body while at the same time being fully mobile. ([Location 1891](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=1891)) - The word ‘stroke’, which for the young carries the gentle resonance of affection and physical comfort, acquires by middle age the much gloomier connotation of its other meaning – a devastating blow. ([Location 2280](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=2280)) - the greatest mental peace is obtained by the realisation that a group of doctors and nurses are doing everything that can be done in the light of available knowledge. The needs of the family are met by a policy of complete truth and the only promise that is made is based upon the hope that the next step forward may come in time. [When] the atmosphere is one of guarded optimism based upon actual achievement, fear is more easy to dispel and to be replaced by a courageous handling of problems. ([Location 2606](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=2606)) - Thus the therapeutic revolution of the post-war years was not ignited by a major scientific insight, rather the reverse: it was the realisation by doctors and scientists that it was not necessary to understand in any detail what was wrong, but that synthetic chemistry blindly and randomly would deliver the remedies that had eluded doctors for centuries. ([Location 3531](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=3531)) - The potential of synthesising new chemical compounds seemed virtually limitless, and the whole process was best achieved by placing it on an industrial footing. This was a high-risk venture with no guarantee of return on the investment – as there was no predicting where the next discovery might come from – but ‘risk’ is what capitalism is all about. The dynamics of the therapeutic revolution owed more to a synergy between the creative forces of capitalism and chemistry than to the science of medicine and biology. ([Location 3625](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=3625)) - Technology, along with drug discovery, shares the prize for the massive expansion of medicine in the post-war years. They are similar, in that both provided empirical solutions to the problems of disease without the necessity for a profound understanding of its nature or causes. They differ, however, in that the manner of technological innovation is almost the precise opposite of drug discovery for, whereas most drugs were discovered by ‘accident’, technological solutions are, by definition, highly intentional, specific answers to well-defined problems. ([Location 3652](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=3652)) - Many medical problems proved highly amenable to technological solutions, which subdivide into three categories: Life-sustaining, Diagnostic and Surgical ([Location 3657](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=3657)) - On the surface of the cell we would see millions of openings, like the portholes of a vast space ship, opening and closing to allow a continuing stream of materials to flow in and out. If we were to enter one of these openings we would find ourselves in a world of supreme technology and bewildering complexity. We would see endless corridors branching in every direction away from the perimeter of the cell, some leading to the central memory bank in the nucleus and others to assembly plant units. The nucleus itself would be a vast spherical dome inside of which we would see, all neatly stacked together, the miles of coiled chains of the DNA molecules. A huge range of products and raw materials would shuffle along the corridors in a highly ordered fashion to and from all the various assembly plants in the outer regions of the cell. We would wonder at the level of control implicit in the movement of so many objects, all in perfect unison. We would see that nearly every feature of our own advanced machines has its analogue in the cell: artificial languages and their decoding systems, memory banks for information storage and retrieval, elegant control systems regulating the automated assembly of parts and components, proof-reading devices utilised for quality control, assembly processes involving the principle of prefabrication and modular construction. What we would be witnessing would be an object resembling an immense automated factory carrying out almost as many unique functions as all the manufacturing activities of man on Earth. However, it would be a factory which would have one capacity not equalled in any of our most advanced machines, for it would be capable of replicating its entire structure within a matter of a few hours. ([Location 3934](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=3934)) - First, the cortisone molecule must pass through one of the millions of portholes on the external surface of the cell, where it finds and docks with another molecule, its receptor. Together they pass down one of the avenues or conduits leading to the nucleus, into which they pass and somehow, inexplicably, find among the closely packed coils of DNA the gene that codes for one or other of the many proteins involved in the control of inflammation. The cortisone molecule, with its receptor, somehow stimulates the relevant section of DNA to produce a replica of itself called messenger RNA (mRNA), which then passes back out of the nucleus into the main part of the cell. The mRNA finds a protein factory called a ribosome, into which it feeds itself like a tickertape, providing the instructions to construct the relevant anti-inflammatory protein, which is then conveyed to the outer wall of the cell and expelled to enter the general circulation. ([Location 3956](https://readwise.io/to_kindle?action=open&asin=B005ZTC1W6&location=3956))