Book Review: Moments of Truth: Four Creators of Modern Medicine
Authors: Richard Carter
Journal: Journal of the Royal Society of Medicine (2004)

Dr Dormandy's choice for his creators of modern medicine—Laennec, Semmelweis, Lister, Reed—is `not entirely arbitrary'. They were all medically qualified, all active in the 19th century, and their discoveries all changed clinical practice within their own lifetime—a telling point given that three died young between the ages of 45 and 51. Three were concerned with microbial infections (puerperal fever, `hospital sepsis' and yellow fever) and the fourth, Laennec, used his stethoscope pre-eminently to describe the evolution of pulmonary tuberculosis. Only Lister would ever have seen the relevant microorganisms under the microscope. Dormandy's choices neatly draw on four nationalities and four branches of medicine, and they provide the basis for an enjoyable book.

Biographical details for his four subjects are already extensively documented, and a particular merit of this book is the attention given to the wider historical, social and cultural contexts in which the four men lived and worked. What could be more diverse than post-revolutionary Paris, the mid-century Habsburg empire, Victorian England and Scotland and the Southern-based US Army Corps?

`No great medical discovery is entirely without antecedents and, however tentative, they deserve to be remembered' (p. 167). Leopold Auenbrugger's introduction of percussion is a perfectly valid forerunner to Laennec's `tightly-rolled sheets of paper' which formed his first stethoscope. Both represent a new way of `listening to patients'. Dormandy quotes about a dozen historical references to puerperal sepsis, published in English in textbooks and papers between 1773 and the 1840s. These accounts admittedly tell an incomplete story but it is doubtful whether Semmelweis in Vienna knew of their existence. His studies led him to conclude that puerperal sepsis was spread by attendants contaminated by previous contact with infected material from autopsies or living patients. Obligatory washing of hands in a solution of chlorinated lime had spectacular consequences.

Lister became aware of Pasteur's microbiological studies in areas far removed from clinical medicine. But could Pasteur's living `germs' be responsible for `hospital sepsis', and could they be controlled by antiseptic agents? Carbolic acid, poured into wounds or used as atmospheric sprays, virtually solved the problem. Antisepsis was replaced by asepsis, but the two approaches had the common objective of preventing microbial infection. Modest evidence that mosquitoes might transmit yellow fever was available when Reed began his investigations among US army personnel in Cuba. Contemporary opinion, however, favoured a bacterial aetiology: several `yellow fever bacilli' had been described, and the disease was widely believed to be transmitted by fomites. Both these fallacies had to be disproved and, to establish the role of the mosquito vector (the female Aedes aegypti), Reed set up some controversial studies in which volunteers were bitten by A. aegypti in controlled conditions. It was many years later that the causative agent, an RNA flavivirus, was identified, but anti-mosquito measures provided an immediate and successful means of controlling the disease.

The ways by which `creators' disseminated their results are interesting. National and foreign visitors were attracted to the hospitals where Laennec, Semmelweis and Lister worked; Laennec, Lister and Reed wrote extensively; Lister travelled widely abroad. Semmelweis, by contrast, never left Austro-Hungary and did not publish his results until 1860, ten years after completing his investigations. Equally interesting are the different responses from the four men to contemporary criticism of their work, Semmelweis and Lister representing the sharpest contrasts.

Several new `creators' can be identified in the 20th century, but Dormandy argues that the conditions under which more recent discoveries are made have changed radically. The operation of large research groups may blur the individual contributions of its members; and simple questions about who did what turn out not to be simple at all.