Biochemistry 101
Sept. 13, 2005

Presentation: Edward Tenner, “Why Things Bite Back,” chapter 2
Sources: UK National Health Service / FBI / Univ. of Illinois at Urbana-Champaign

I. Introduction

-       Medicine has made great strides over time. People are more healthy but also more anxious – about their health.

-       “Revenge effect” – unforeseen consequences that often accompany technological advances

-       - Solves one problem, but often creates a new one in the process

-       - Broadly speaking, medical technology has brought more effective cures and treatments, but they’re more difficult to accurately perform. 

In this chapter, Tenner looks at:

-       Advances of medicine over the past few centuries

-       Examples of what brought about new treatments

-       Some of the “revenge effects” brought on by these new developments

-       Tenner doesn’t claim to be against technology – but he does warn against relying too heavily on it, as well as blind acceptance of a new idea without weighing its risks.

II. Interaction With Class – Laparoscopy / Laparoscopic Surgery

-       Ask: Does anyone know what it is? Do you know anyone who has had it?

-       Explain:

o     Laparoscopy is a diagnostic procedure.

o     A laparoscope is a very small, thin fiber optic tube. It has a light and a microscopic lens at one end that projects images back to a camera. On the other end of the tube is an eyepiece.

o     Doctors use the instrument to examine the abdomen and identify various conditions, such as appendicitis.

o     Surgeons can “insert miniaturized instruments into the body through a few small incisions.”

o     The use of laparoscopy to carry out such small operations is called laparoscopic surgery.

-       Class discussion: Potential advantages and disadvantages


-       Keyhole surgery / “minimally invasive” surgery

-       Requires only small cuts

-       Recovery in days, not weeks

-       Small incisions rather than large ones

-       Less pain and scarring

-       Generally less expensive

-       Reduced rate / likelihood of infection

-       Avoids some of the side effects often caused by traditional surgery (“invasive” surgery)


-       Patients can be up to 10 times more likely to have complications from surgery

-       Imaging comes from TV monitor rather than regular open surgery – image is grainy, flat and narrow (easier to see things in traditional surgery)

-       Surgeons can’t feel internal organs directly with their fingers

-       Requires different and greater skill

-       Accidental damage to intestines or certain blood vessels can occur

-       Incision could become infected (and require antibiotics)

-       Requires expensive equipment

- Transition: What we did was, in a sense, what Tenner is doing – analyzing a development in technology. Weighing both the advantages and the risks of a solution or proposed solution allows people to see both sides of the topic and to more responsibly incorporate it into our society.

III. Summary of Sections 

A. Health Without Medicine

Developing countries can reach a “remarkably high level of public health even before building an industrial base.” Improvement of public health is due to economic growth just as much as it is due to scientific medicine. It’s not clear which of the benefits of economic growth have the most impact on health. We do know that sickness and mortality rates rise when living standards deteriorate.

Tenner says that Physician Thomas McKeown points to a number of instances throughout history in which mortality rates from a disease or epidemic began declining before an effective treatment or vaccine became available -- so “what has been responsible for declining mortality?” McKeown’s explanation is that it’s due to nutritional / dietary changes.

Leonard A. Sagan & Donald S. Kenkel both challenge McKeown’s theory. Recent studies indicate a relationship between a person’s health and various factors – including their education, their level of confidence about their future / feeling of control, and even their financial situation. Tenner says that “for all the contributions of medical technology,” these other factors have meant more, but they’re so entangled and interconnected that we’re not sure what the answer is.

B. The Power of Localizing

Medicine’s contribution to health and longevity is very significant, even if it is hard to measure. Prior to the 19th century, medicine viewed and treated patients as a “whole person,” rather than focusing on finding the specific area and cause of illness. Purges, bloodlettings and other “cures” revolved around balancing the body’s humors (black bile, yellow bile, blood and phlegm) – a general approach to treatments that did much more harm than good. Relatively modern is the concept of localized treatment (a “focused attack on the site of a problem”). And while the idea of diseases as distinctive entities has long existed, only recently has technology been strong enough to put this notion to into practical application.

C. Instruments of Localization

From the stethoscope to the ophthalmoscope, and x-radiation to the electrocardiogram, Tenner talks about the advent of new medical instruments and diagnostic tools that have helped pinpoint and identify conditions – and provide a means to look at the body, inside and out, in much greater detail. The advancements of medical technology, Tenner says, “revolutionized the ways doctors saw, heard and thought – and in turn changed the attitude of patients toward their physicians as well as their own bodies.”

One example of a “revenge effect” Tenner sees in this enthusiasm about new technology came about when x-rays were relatively new. People who had a foreign object trapped somewhere often insisted on its removal, even if the object’s presence was harmless and painless. Such extractions sometimes ended in fatal complications.

D. Localizing Surgery

In the 1840s, two dentists showed how nitrous oxide and ether could be used as surgical anesthetics. Anesthesia makes surgeries much less painful and more practical to perform on people who need them. Localized surgeries in general are much less invasive, and with the advent of imaging, surgery is sometimes not necessary at all. Open surgery can take weeks or months to fully recover from; minimally invasive surgery can see a person in and out of the hospital in as little as half a day.

Some revenge effects can arise from anesthesia and localized surgery, including a possible increase in “the sum of medically induced pain,” as well as the potential for adverse reactions to the anesthesia itself.

E. Localizing Pharmacy

The germ theory of disease (states that infections, contagious diseases and various other conditions result from the action of microorganisms) brought about the design of drugs targeted for specific ailments, and as Tenner says, chemical synthesis is what first made specific medicine possible. In the 1800s and before, tonics were what predated specific drugs, because tonics were supposed to balance the body’s humors.

Revenge effect: Tenner says that in modern times, people want precise remedies – sometimes a request for unnecessary treatment. Are people so worried about health that they are suffering from hypochondriasis and becoming dependent on treatment by its very nature?

F. Mastering the Urgent

“One of the happiest unexpected benefits of technology: how military carnage came to the aid of civilian surgery.” In wars, technology made weapons more and more dangerous. But “the new intensity of casualties inspired impressive gains in treatment” – the increased severity of medical situations brought about increased intensity and skill of response.

Tenner talks about this “positive revenge effect” in the development of surgery. It used to be that a person in war was more likely to die under a military hospital’s treatment than from the wound itself. In WWI and WWII, medical technology was forced to rise to the challenge of improved treatments, and at a faster rate, too.

G. The Emergence of Emergency: Civilian Accidents and Epidemics

The 19th and 20th centuries, Tenner says, have been times of technological development, especially in transportation and industry. Along with new technology are new risks, though (such as car crashes and industrial explosions), and so emergency medicine has been forced to improve as a result. “Faster evacuation and better life-support systems rise to the occasion,” he says. Louis Pasteur was a success because he provided “a specific response to an urgent situation.”

Revenge effect: For one example, Tenner says that an attempt to get rid of prairie dog colonies -- by introducing sick animals -- instead helped the resurgence of the plague Bacillus. More species of rodents and fleas became plague carriers.

H. Paradoxes of Vigilance and Craft

Tenner talks about the problem of iatrogenic diseases, or diseases inadvertently brought about by a physician. Malpractice, which can include an incorrectly prescribed drug or treatment, can often make a person’s disease worse -- or cause additional illnesses to form. But are iatrogenic diseases a real revenge effect? Tenner says the notion of side effects is based in the modern ideals of “targeted, localized, measured interventions with effects that can be verified with controls” – whereas premodern medicine essentially said that pain was a sign of an effective treatment.

I. Medical Technology and Its Discontents

According to physician and medical historian Stanley Reiser, there is a “hierarchy of medical evidence” with doctors. The most important thing to them, he says, is tests and imaging results; second in importance is the doctor’s direct visual and aural examination; least important is the patient’s account of his illness. The problem is that doctors rely too much on computer-generated data, facts and test results. The doctors forget the importance of personal observations, common sense and, among other things, not acting aloof and impersonal when dealing with patients.

Revenge effects also come from doctors’ overly skeptical attitude toward new means of treatment and therapy. The trouble with contemporary medicine is that we think that as technology advances, fewer problems can arise and fewer workers with craft knowledge will be needed. It is not true; the more complex medicine and technology get, the more interacting systems there are, and so more things can go wrong.

J. Burdens of Craft

I used laparoscopy as an example before I even got to reading this section. Tenner repeats some of the points from earlier: for example, laparoscopy has a greater risk of complications, and because of the technology involved in it, there may well be a greater risk of something, somewhere, going awry. And the fact that a surgeon is doing his work remotely, rather than directly with his own two hands through open surgery, means that he is doing something not unlike a game in virtual reality. Tenner wonders if surgeons in the future will be so involved in “virtual” operations that they’ll forget how to do things the traditional way when it is necessary. All this new technology has great potential, but the learning curve is high, the risks are also great, and all it could take is a single glitch, incompetent technician or unforeseen complication to turn progress into catastrophe.

K. Burdens of Vigilance

What is one of the most fundamental things doctors should do -- but sometimes don’t -- to control the spreading of disease? Sanitize. The progress of science and technology multiplies the possibilities of infection, meaning that it is even more important to keep things as clean and sterilized as possible. Equally important is the need for doctors and others to be able to correctly interpret test results.

Tenner concludes that our discontent with medicine isn’t just a self-deceptive, psychosomatic trick of the mind. Nor is it us reacting to a medically induced illness. Technology can be great, but over-reliance on it is dangerous, as we can’t expect it to work flawlessly. Great strides were made in medicine before modern machinations and calculating computers came onto the scene. We’ve already heard about some of the most significant advances, including localization of treatment. Are the real revenge effects in failed procedures and unexpected side effects of a medicine?

Tenner says no, that it’s the practice of medicine itself that suffers, because we think that these new innovations will require our attention less and take the place of old-fashioned skill. Not so! If I have a 20-year-old computer and a brand-new one, which can I do more on? The new one, of course – the same one that requires more competency to operate, and the same one that can now break in two thousand different ways instead of two dozen!

IV. Extra Participation + Conclusion

What really is this so-called revenge effect that Tenner keeps talking about? It seems that the book could just as well be titled “Murphy’s Law Meets the Law of Unintended Consequences.” Murphy’s Law says, “If there’s more than one way to do a job, and one of those ways will result in disaster, then somebody will do it that way.” Unintended Circumstances says that nearly all human actions have at least one unintended circumstance -- each cause has more than one effect, including those unforeseen. This is sort of what “revenge effect” means -- technological fixes can give rise to other, sometimes worse, troubles than the one they were intended to solve. One Publishers Weekly reviewer said, “Revenge effects demand ingenuity and brainpower as technology continues to replace life-threatening problems with slower-acting, more persistent ones.” 

Just a few of the hundreds of proposed / in-progress new technologies that hold both great possibilities and great risks…

There are many proposed new ideas, on the forefront of science and technology, that may sound great but that will require careful consideration. Take the concept of “designer children,” which proposes the ability to pre-choose children’s physical and personality traits by manipulating the genes of human embryos.

What other innovations can you think of that could have both great potential and significant risks?

-       Human cloning

-       Holographic environments (interactive simulated environments)

-       Robotic surgery

-       Exoskeleton suit (a wearable machine that would give soldiers amplified strength and speed)

-       Nanotechnology

-       “Smart structures” (buildings / bridges that automatically react to seismic activity to limit damage)

I think we’ve begun to see that it is important to look at and think carefully about new technologies as they are proposed. Tenner might say that it’s important to take an attitude that is neither a blind acceptance nor knee-jerk-reaction refusal of new ideas. As with essentially anything else, technological advancements and solutions should not come at the cost of a new or greater problem that comes about as a result.