Doctor in charge

The Rise and Fall of Modern Medicine

James Le Fanu<em> Little, Brown, 490pp, £20</em>

ISBN 03166

It is the privilege of historians, sporting and medical no less than conventionally academic, to choose their period and the spectacles through which to view it. A book on my shelves declares that the "golden age of cricket" ended, as did so much, in 1914, ignoring any era we might construct around the likes of Hammond, Bradman and the three Ws. James Le Fanu's rose-tinted years, containing his 12 definitive moments of modern medicine, span almost half a century, between the clinical rediscovery of penicillin in 1941 and the identification of a microbe as the cause of peptic ulcers. To disagree with some of his candidates - in reproductive medicine the oral contraceptive still has a far greater impact than the test- tube baby - is to miss the point of his list, which is to illustrate a triumphalism from which, Le Fanu argues, medicine has fallen.

The Le Fanu thesis is that the resulting vacuum - abhorrent to nature and to thinking man - is filled by two theories, on the social origin of disease and the promise of the "new genetics". No good, either of them, he says; the former is flawed, the other hyped. He wants a return to a bygone age when, to exaggerate just a little, silver-haired physicians with reassuring bedside manners relied on history-taking and judgement. Though by no means Luddites, they make sparing and sceptical use of technology and they rarely want to alter your bad habits. Some hope. Time was when masterly inactivity was an admired quality in medicine, but in 1999 it would be easier to restore the game of Kipling's flannelled fools to the age when the amateur strode through one gate and the rude professional another and when the Lord's pavilion had no need for ladies' toilets.

Le Fanu's dozen vignettes are excellently done, though the table alone might have served the purpose. Perhaps the details are too familiar to this reviewer, but there is a long wait for the meat, and when it arrives the author's diagnoses seem incomplete and overconfident. Le Fanu rightly observes that continuous progress is not inevitable, though for medicine a plateau rather than a decline seems a fairer verdict. It is far easier to halve a high infant-mortality rate than a rate already lowered, and the first therapy will always impress where previously there had been nothing.

Le Fanu might also have given greater attention to the restraints under which research has to operate. In May of this year research at the Duke University Medical Center in North Carolina was shut down for a few days by a US government office charged with overseeing informed-consent procedures. That would not have happened 50 years ago. The author too briefly describes the exposure by Dr Maurice Pappworth, in his book Human Guinea Pigs, of what used to be done in the name of science back in the Le Fanu golden years. Thanks largely to thalidomide, a golden-age drug disaster one might say, drug research, too, is now tightly regulated. These changes cannot be reversed.

Le Fanu does not like health busybodies. Epidemiologists, especially those of the low-cholesterol school, come in for a lot of criticism. One of them, the late Geoffrey Rose, still much admired as a scientist and mentor, contributed to public health the controversial notion that whole-population patterns of, say, blood pressure or table-salt consumption should be tackled, even though few people stand to benefit. The author is spot on here: as a source of sound advice to the not-yet-sick, epidemiology often disappoints. It is better as a research tool than as fuel for public policy.

The other vacuum-replacing discipline is molecular biology, which we can date from 1953, when the genetic language of DNA was decoded. Newspaper and television reports certainly abuse the word "breakthrough", and researchers are learning that a public profile does no harm to funding, but the truth is that the clinical promise of DNA is not yet fulfilled. Even so, Le Fanu seems impatient here. Of course progress was easier with the rarer, single-gene-defect illnesses (the old genetics). But DNA dictates what all cells do. The attempt to explain the disinhibited behaviour of a cell that frees itself from these controls and turns nasty seems a reasonable, if difficult, objective for cancer research, for example.

Le Fanu, a part-time general practitioner, sounds just the sort of physician we would like to consult. Those bewitched by a first read of The Rise and Fall of Modern Medicine (as I was) might, however, be more critical of his arguments the second time round. Medicine - already assaulted by self-doubt, by highly publicised mistakes, by the behaviour of its bad apples, by the assaults of bureaucrats and by patients and lawyers seeking someone to blame - now has to survive this challenge to any residual complacency.

After a tangled metaphor involving express trains pole-vaulting over brick walls, Le Fanu urges us to "accept at face value" his version of events. What - trust me, I'm a writer? Le Fanu cites with approval one Nobel prize-winner's aphorism that research is "the art of the soluble". Peter Medawar, too, urged us not to "deride the hope of progress".

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