The Rise and Fall of Modern Medicine (29 page)

The development of IVF illustrates in a more complex form this interconnectedness, where four quite independent lines of research combined to culminate in the birth of the first test-tube baby: embryology, the study of human fertilisation in the early stages of foetal development; endocrinology, the elucidation of the mechanism of action of the female reproductive hormones; radioimmunoassay, the technique that allows minute quantities of hormones in the blood to be measured accurately; and optics, essential for the design of Patrick Steptoe's laparoscope, through which he aspirated eggs from the ovary. When the definitive moments of post-war medicine are viewed separately they seem diverse and independent of each other, but their interconnectedness lies at the heart of the cumulative progressive nature of medical advance.

This Olympian view may seem to provide reason enough for the rise of medicine in the post-war years. But it is not, for as soon as one starts to scrutinise these events in greater detail, a whole new level of explanation becomes apparent. The first was the displacement of the traditional philosophy of medical practice with the revolutionary new creed of ‘clinical science', where the best interests of the patient become – in the name of progress – secondary to the scientific scrutiny of his illness. The second, and without doubt much the most powerful single factor of all, was the stunning success of the exploitation by the pharmaceutical industry of medicinal chemistry, which increased within a few years the number of useful drugs from a handful to several thousand. The third, predictably enough, was the
liberating power of technology – the pump, dialysis and endoscopy – in ‘opening up' new territories to medical intervention. Finally, however, we are left with the curious phenomenon that the origins of several of the most significant achievements remain to this day inscrutable biological mysteries that lie beyond the range of rational explanation.

O
n 13 January 1935, King George V visited the Hammersmith Hospital in West London, formerly known as the Workhouse Infirmary, situated next door to one of Britain's largest prisons, Wormwood Scrubs. This location had been chosen as the site for the British Postgraduate Medical School, the first institution in the country committed to ‘training specialists and the promotion of medical research in the advance of medical knowledge'. It was a ‘glittering gathering'. The King was met by the chairman of the board of governors, Austen Chamberlain, brother of the future Prime Minister, Neville, as well as ‘the most distinguished medical men of the day resplendent in their academic regalia'. The King expressed the wish ‘that the school with its happy union of ward and laboratory, joining students and teachers alike from all parts of our Empire . . . may prosper under God's blessing'.
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But no sooner had the School become established than the outbreak of war threatened to close it. ‘The advance of medical knowledge' had to give way to more urgent priorities. Most of
the medical personnel of the School were seconded elsewhere, leaving behind a ‘skeleton staff' to run the hospital, whose responsibilities now extended to looking after civilian casualties from the Blitz. And yet the research conducted in these straitened circumstances by the ‘skeleton staff' that remained behind, John (later Sir John) McMichael, Sheila (later Dame Sheila) Sherlock and Eric (later Professor Eric) Bywaters, ensured the style of medicine epitomised by the School – ‘clinical science' – would in the following twenty-five years revolutionise the practice and philosophy of medicine, for reasons that will be become clear enough.

Eric Bywaters, writing in the
British Medical Journal
in March 1941, described ‘a specific and hitherto unreported syndrome' in civilian air-raid casualties who had been dug out of their homes with crush injuries to their limbs. He described this syndrome as follows:

The patient's urine output starts to fall, the kidneys fail resulting in coma and ‘death occurs suddenly usually within a week'. Bywaters suggested this ‘hitherto unreported syndrome' be called ‘crush syndrome', which he correctly inferred resulted from the crushed muscle clogging up the kidneys, and for which, as there was no treatment for kidney failure, there was
nothing to be done. The most striking aspect of Bywaters's paper is the manner in which this new syndrome is reported – the meticulous day-by-day recording of the patient's steady deterioration in which the blood pressure, haemoglobin, urine volume, level of urea and other biochemical measurements are all noted. Indeed, Bywaters's paper is the most detailed scientific monitoring of the biochemical changes prior to death from kidney failure ever to be reported.
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Sheila Sherlock's research addressed another problem thrown up by the war: the difficulty in identifying the cause of jaundice in servicemen, and particularly distinguishing between the three main causes, infective hepatitis (now known to result from the hepatitis A virus), blood transfusion hepatitis (now known to be caused by the hepatitis B virus) and hepatitis arising as a complication of the treatment of venereal disease with arsenic. This too, as with Bywaters's research, was in a sense ‘academic' as there was no treatment for any form of hepatitis, but perhaps if specimens of liver were removed by a sharp needle through the abdominal wall (liver aspiration, now known as liver biopsy) and were examined under the microscope, this might reveal some valuable information? Sherlock performed liver aspiration on 126 patients, of whom two died following the procedure, including one who was ‘already moribund from subacute liver necrosis, general paralysis of the insane and rectal carcinoma'. She found three patterns of pathological change – ‘diffuse' (generalised), ‘zonal' (confined to one area) and ‘residual fibrosis' (replacement of the liver with fibrous tissue), but there was no correlation between any of these specific patterns and the underlying cause of the hepatitis.
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Lastly, John McMichael investigated another military-related medical problem, the haemodynamic changes in the heart following severe blood loss. Here a group of volunteers agreed to
have a catheter inserted into a vein in the arm and manoeuvred into the right side of the heart. They were then bled of 1 litre of blood, while the pressure within the heart was measured through the catheter.
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Through modern eyes these three research projects might seem straightforward, if of rather limited practical application. Their significance rather lies in the circumstances in which they were carried out. Research of any sort is never easy, but for these doctors to undertake these studies alongside their primary responsibility of looking after patients suggested a certain zeal and desire for knowledge. This zeal is the defining characteristic of the new ideology – clinical science – that was to transform medicine. It is difficult to describe how this philosophy of medicine differed from that of the pre-war years which it supplanted, but some idea can be gleaned from a comparison between two dominant medical figures of the pre-war years in Britain, Lord ‘Tommy' Horder of London's St Bartholomew's Hospital and Sir Thomas Lewis of University College Hospital.

Lord Horder symbolised the pinnacle of achievement to which every consultant in London aspired. He was wealthy and stylish, arriving for his ward rounds at Bart's in his Rolls-Royce and sporting a top hat. ‘Tommy [Horder] was certainly the greatest clinician of his day, based on vast experience and shrewd judgement. His short squat figure exuded wisdom and humanity.'
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Born the son of a Dorset draper, his reward for winning every prize at medical school was to be appointed for his first job as the house doctor to Samuel Gee, physician to the Royal Household, whose patronage rapidly propelled the young Horder into the most influential circles.

Horder's private practice read like a
Who's Who
of the times. It included three prime ministers: Andrew Bonar Law, Ramsay MacDonald and Neville Chamberlain; writers: Sir James
Barrie, Somerset Maugham, Rebecca West and H. G. Wells; and musicians: Sir Thomas Beecham, Sir Malcolm Sargeant, Sir Henry Wood. And in time he succeeded Samuel Gee as physician to the Royal Household, becoming medical adviser to first King Edward VII, then George V, Edward VIII, George VI and finally Queen Elizabeth II.
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Tommy Horder's success was well deserved. He was very good at what he did, which, in the era before sophisticated medical investigations, was making an accurate diagnosis, relying almost exclusively on what are known as ‘clinical methods', the ability to infer what is amiss from the patient's history and physical signs elicited at examination. This was traditional doctoring, unencumbered by the trappings of technology, and its essential feature was the human relationship between doctor and patient.

While Lord Horder was attending to the rich and famous, Sir Thomas Lewis, the son of a Welsh mining engineer, was hard at work in the basement at University College Hospital investigating the many different types of irregularity of the heartbeat with the help of the newly invented electrocardiogram. This was extremely arduous and complex work, involving thousands of recordings of the heart, which Lewis then investigated further by conducting experiments on dogs, placing electrodes into their hearts to identify the precise manner in which the electrical impulses spread. The distinguished cardiologist Paul White subsequently recalled what it was like:

This work culminated in ‘a truly magnificent volume',
The Mechanisms and Graphic Registration of the Heartbeat
, 529 pages long with 400 figures and more than 1,000 references.

As a young man Lewis had come under the influence of the leading physiologists of the day, one of whom, E. H. Starling, summed up what was to become the main difference between the Lewis and Horder methods of practising medicine: ‘This is what I regard as the University spirit, not simply diagnosing a patient and deciding what to do for him in order to earn our fee, but what we can get out of his case in order to do better next time.' Lewis's biographer, Arthur Holman, elaborates:

The science in question was essentially the application of the methods of physiological investigation to man. For two hundred
years physiologists had been cutting up animals, investigating how their hearts beat and their nerves worked. Now, in the form of clinical science, precisely the same approach was to be applied to patients. Its appeal was obvious. Horder's medicine of ‘clinical methods' could not progress. It could be refined and added to, but essentially its knowledge base was grounded in the autopsy room of the late nineteenth century. Clinical science, by contrast, appeared to have apparently limitless possibilities of investigating, as Lewis did, the abnormal rhythms of the heart, or, as among his youthful protégés such as McMichael, what precisely happened to the circulatory system following a substantial loss of blood. This was ‘new' knowledge, out of which might come ‘better' understanding of disease and perhaps even ‘better' treatments. This at least was the view that had inspired Thomas Lewis and a handful of others and had culminated in 1935 in the opening of the Postgraduate Medical School at the Hammersmith.

But John McMichael was to take Lewis's concept of clinical science one small but definitive step further, which probably more than anything else explains what a truly radical departure it was to become. In December 1943, at a meeting at London's University College Hospital chaired by Thomas Lewis, McMichael presented the research he had been conducting, where catheters were inserted into the heart to measure the fall in pressure following blood loss. At the end of the presentation Lewis described his work as ‘startling' and strongly hinted that he should abandon it. ‘The study sent shock waves through medical London, as many physicians regarded the technique as unethical, even immoral.'
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