Wednesday, December 19, 2012

Alexander Fleming : surgeon manque ?

It is not well known that Alexander Fleming the bacteriologist actually trained to be a surgeon but never practised and apparently didn't mind the missed opportunity.

Or did he ?

I think he did, in fact, long to use a surgeon's lancet - albeit on a tiny/micro scale.

 But if so, that would be perfectly consistent with his equally tiny/micro bacteriological techniques - it reflected his basic personality.

I think his surgeon manque nature is evident in his lifelong focus on antiseptics used in local applications.

I am defining local illnesses as situation where the germs and their damages are limited to just a part of the body and that part is 'somewhat' directly approachable by external means.

(If I seem vague in my definition, blame the doctors. Treating meningitis by injecting through the skin directly into the spinal cavity is local, but injecting directly through the skin into the kidneys is usually considered not to be local.)

And his "local" desire so distorted the fate of penicillin , that it didn't come into "general" (systemic) use until 15 years after its discovery.

If this interest in matters surgical were not immediately apparent to people who knew Fleming, there is an explanation.

Fleming, by all accounts, was effective enough in face to face conservations : his comments were terse, pithy and somewhat 'in your face'.

But as a public speaker, he was truly dreadful.

The volume of his voice was inadequate because he not only didn't project over and into the crowd, he also totally failed to modulate and shade his voice : to pitch his key points more strongly.

His flat low monotone left his listeners unable to make sense of whatever it was he was saying: to separate his wheat from his chaff.

But if his lecture was later printed and read, it surprisingly revealed a lucid and limpid writer.

His prose is brisk and confident , never diffident, scarcely bothering to conceal the man's considerable ego.

It is thus quite different from his adversary Henry Dawson, whose articles are delivered in a tone that is one part scientifically objective and one part cautiously diffident.

By way of further contrast, Dawson was seemingly an effective public speaker, combining earnest humility with earnest conviction.

If we examine Fleming's little known Campbell Lecture (Oration), delivered in mid-1944 in Belfast, just after he had been knighted and just when he is starting to believe that he is about to become very, very famous indeed, we see something of Fleming we aren't normally permitted to see.

He is dismissive of systemic medication as being easy ( a nurse can give sulfa pills - a resident or intern the penicillin needles) but says local applications (real local applications - not just a dab on the skin near the lesion) is a job requiring real skill : real surgical skill.

He is thus separating local from topical - the two are often confused, with good cause, because they frequently shade into each other.

The outermost layer of most of our skin are tough dead cells : an extremely toxic chemical dabbed on them (topically) can still be medically useful.

If carefully enough done, it will kill any germs there that might migrate into the open would right next to that skin but won't itself migrate far enough to kill any living cells inside the open wound.

But dropping an antiseptic into the eye socket to cure an eye infection is both topical ( on the surface) and local (the disease is restrained to the eye socket area).

But because the skin of the eye socket is much more delicate than that on the bottom of our feet (more membrane like) the antiseptic must be much more non-toxic.

Fleming, in his campbell lecture, says that even the most diffusible chemical agents have their limits in diffusion ( this is a harsh dig at systemics which diffuse throughout the body from the blood supply).

No, to get the microbes killed for sure,  he feels that the chemical must be brought right to where the microbes are, particularly if they are luring in areas far from a good blood supply.

Bring the drug in directly, one kills the bugs cleanly and quickly ---AND --- one uses as little medication as possible.

By contrast, general systemics (casting their charms all over the body when only the left ear bone is infected) are so wasteful, so very un-Scottishly un-thrifty.

He then proceeds to give a very active -interventionist sounding -micro surgical history of the cases he has treated.

Clearly the big Harley Street consulting surgeons who long ignored him from 1922 to 1942, had to stand back (helpless - oh sweet !) while he demonstrated how a real precise scalpel-like needle could reach into just the right place in a bone or spinal cavity to kill the germ without killing the patient.

It brings up a question never asked about Fleming as far as I recall : why did he train as a surgeon and then never practise ?

I have no doubt that Fleming would eventally made a perfectly adequate living as a surgeon in some larger mining or engineering works sort of town, somewhere in Wales or Northern England.

But he very much wanted to stay close to his tightly knit family of transplanted Scots - in London.

And London, capital to an empire, the world's largest or second largest city, was home to some very skilled surgeons.

Surgeons skilled with the knife and more importantly skilled with social graces and social connections and possessing a big self-confident physical presence and charisma.

Fleming had none of this : in fact, he felt awkward even around other Scots, as his was an extremely rural childhood with his family living all alone on top of a big isolated moor, miles from even the nearest small village.

But Fleming always felt he had the physical chops for the surgeon's job, at least a certain kind of surgeon's job.

His needle skills in administrating the easily-fatal Salvarsan (VD ) shots had made him wealthy and admired before the Great War.

Fleming wanted to be a surgeon - hence his life long interest in local (surface wound) infections and antiseptics, not the pill pushing systemics sought by your average busy garden-variety GP.

But he was wrong - dead wrong.

Because penicillin, for its first 35 or so years, couldn't be delivered as a pill.

Now the ordinary GP could reach into his black bag at the rural farm cottage and give a needleful of penicillin G himself, arresting a fatal case of spinal meningitis before the patient even reached all those big shot specialists at the big city hospital.

GP Power Rules ! Over life and death !  Oh sweet !

The phallic symbolism of the frequently reproduced image of the needle held high up in the air at a 45 degree angle, just before the GP plunged into the patient below to save a life is almost too obvious to mention - but there you go - I said it.

Systemics like Penicillin G that must be delivered by needle, not by pill, would have given the short, homely and shy Mitty'esque Fleming all the glory he so obviously craved - if only he had  been the first to use the needle with gusto in 1928, not among the last to use it avidly in 1943......

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