Who is the greater, Alexander the Great or Fleming? | A K Sinha

Today, when war in some part of the world or the other has become a constant and we are researching space medicines, we take this opportunity to discuss two greats in war and medicine, the two Alexanders. One is the Macedonian king, conqueror of the West’s then-known world, Alexander III (21 July 356 BC – 11 June 323 BC), commonly known as Alexander the Great. The other is the Scottish microbiologist, Sir Alexander Fleming (6 August 1881 – 11 March 1955). What is the connection one might wonder. There is a connection. Wars have often proved to be a great place for testing medical efficacy. In fact, often, outcome of wars in history, those lost or won, have been dependent on how efficacious the medical support system was and is, of warring factions. A comparison of the exploits of the two provides a baffling story in the history of mankind and argues for a change in the way History is read and a reconsideration of the way History has been written so far. The comparison, perforce, has to be of the two Alexander’s contributions in the service of humanity in real terms and not as perceived in History.

HUMAN HISTORY, THOUGH interesting, is a selective text, in real terms. It always gets attracted by dazzles of Empires, Kingdoms, Glorious Victories and Mass Defeats but never describes the subtle truth beneath. The cost involved in wars and tragedies incurred by societies, countries and humanity as a whole, is never discussed. In contrast, medicine has always come in situations of wars, peace, calamities or disasters as a saviour to help all human beings in an attempt to wipe out their tears and relieve their sufferings without any discrimination, as is so well said by the great Louis Pasteur: I do not ask for your opinion or religion but what is your suffering.

The basic purpose of history writing should be to ascertain the effect of wars on the involved people and their effect in totality on mankind and the world rather than glorification of kings, races, countries and the transient bravery of individuals associated with destruction of human existence and widespread devastation.

Not so long ago, there was a time when it was impossible to find History analysing either the effects of great wars on economies, or the magnitude of human miseries, disabilities, deaths and losses of life and wealth of all the people involved or affected directly or indirectly in wars. Nor was there any account of how much time it takes to erase the tears and grief of people and communities, inflicted by so-called great wars. Usually, it takes a long, long time, even decades and centuries, to wipe out the ill effects of war but quite often, it may not get wiped out at all. In fact, scars, so created, are too heavy to be removed or repaired as is the sociological impact. Unfortunately, everyone has to bear the brunt of this man-made calamity called ‘war’. The women, the children, the old and socially and economically underprivileged are the worst sufferers of such disasters but nobody cares for them since they do not have a common voice of their own to reject wars. The decision to wage war is even now not in the hands of the common man, but peace and the healing touch is.

Quite often, wars have been followed by devastating catastrophe and spread of diseases. A great example is the Spanish Flu after the First World War. It spread globally (affecting 33 per cent of the global population) with a high mortality (about 50 million people were estimated to have been killed by this influenza virus; 6.75 lakh in the US alone in 1918-19). Soldiers contracted the flu while they were fighting in the war. When they returned home afterwards, they spread the illness among native population, especially in Africa and Asia including India, where it was called the Bombay Fever.

Alexander III of Macedonia was called ‘The Great’ because he was not only a superbly active warrior, a super hero, a great tactical manipulator and meticulous war planner; he outmaneuvered everyone around in this art of fighting. He became so invincible that he planned for himself to be the victor of the whole world. But 330 years before the Christian era, this was just an unfulfilled imagination, one big dream. In those days, scientific development was meagre, lifestyle was too primitive to bear the brunt of such an extensive and exhaustive journey. Human logistical support systems like transportation, food for a huge army, its availability and preservation etc were very poor. Medical advancement, treatment and understanding of diseases were limited and primitive in nature.

Wars need a very efficient medical support system. Wars have been lost and won – human tragedies avoided and minimised, and happiness preserved and multiplied – depending on the healthcare support for the moving armies and existing societies but, unfortunately, these are less described and poorly acknowledged in historical literature. History itself is witness to the fact that whosoever has tried to capture the whole of the world, even centuries later in the era of scientific development and momentous achievement, has ultimately failed miserably. Poor humanity has to pay a very, very heavy price for such random wars (classic examples are the two World Wars).

Like Alexander, many historical Greats thought that they were invincible, but the truth is nobody has ever been. In case of Alexander the Great too, unfortunately, prevailing circumstances ultimately forced him to give up his conquest, when he reached the western Indian bank of the Indus River. His own army revolted, which had obeyed him tooth-and-nail throughout his victorious journey, starting from Greece eastwards for thirteen long years. This is too long a period for soldiers of that era to stay away from their homeland and it is a mark of poor human management; by the time he reached the shore of the Indus, Alexander’s army was plagued by desertions and seventy-five per cent filled with foreign soldiers.

Everyone, not only the Greeks, were exhausted, became ill and psychologically torn. The soldiers became too fearful regarding their own fates and missed the support of their families. The Greeks, especially, became very anxious about whether they would ever go back alive to Macedonia. After all, the fact remains, soldiering was at first just a paid profession. Ultimately, human sufferings and behavioural aberrations in his army became too heavy a burden for Alexander’s ambition to bear.

Finally, Alexander the Great had to surrender to the wish of his own army, who convinced him that Great Generals are those who not only win wars but are also shrewd enough to know when to retreat. The Greek army was thus ordered to retreat and marched for Greece. Little is known about the true story of the army and its poor soldiers, while in retreat. How much sufferings they faced and at what cost is not really known. [Alexander died young. His ruled for just about a decade. We have ancient narratives of Alexander’s life, written between 30 BCE and the third century CE – hundreds of years after his death. The earliest known account is by the Greek historian Diodorus, but we also have accounts by other historians, including Roman historians; these writers are called the ‘Alexander historians’ and much of it is propaganda by rulers of the time when these were written; they used his fame for their own pursuits. Some of these historians interpreted written accounts from shortly after Alexander’s death, penned by those who fought alongside Alexander on his campaigns. Many chroniclers in other part of Alexander’s extensive empire too have left sketchy records of his time but there is no reliable or authoritative account of what was life like in Alexander’s army.]

What happened ultimately to the great Alexander is a pathetic story and has great lessons for societies, nation and the world at large. While going back home – to Macedonia – Alexander became ill in June of 323 BC in Babylon (now Iraq), where he had planned to make his grand capital. He remained ill for twelve days, after which he died. His symptoms and his condition in those twelve days were described in detail by contemporaries but cause is not mentioned.

Alexander’s tomb or burial site has not yet been found and conclusions cannot be drawn by modern technologies. He developed excruciating abdominal pain during a party, followed by rising fever, rigors, sweating, convulsion, delirium and coma before the final journey. The cause of death is under debate by historians, epidemiologists, microbiologists, toxicologists and physicians for centuries but no unanimity has been achieved till date. It could be Typhoid, Malaria, Acute pancreatitis, Poisoning, Septicemia, Guillain Barre Syndrome or any other infections.

A map showing the route that Alexander the Great took to conquer Egypt, Mesopotamia, Persia, and Bactria. Image credit: US Military Academy, uploaded by Jan van der Crabben, on 20 December 2011, public domain.

Wars, Wars and more Wars, that is what he waged for the last twelve years of his life. Wars had taken their toll on Alexander, both physically and mentally. Analysts have found lots of aberration in the accounts of his persona in the late years of his life. Injuries and exhaustion sustained during various wars in different terrains were detrimental to his overall health, which cut his life too short, to just 32 years. His son was yet to be born. Sensing his impending death, the great and the brilliant warrior ordered some measures to be followed during his last journey. They are great sermons for future generations, including today’s.

• The best physicians must accompany his coffin to tell the people that even great physicians couldn’t save Alexander the Great.

• All of his wealth must be spread on the road, to tell the people that wealth became useless at the end for him.

• His hands must be kept out of the coffin to show that they were empty, when he left for his heavenly abode.

This was in keeping with the Greek belief system led by Aristotle, alexander’s teacher and to distinguish him from the Egyptians, who believed in afterlife. Alexander’s last wishes was a great lesson indeed from a non-religious man, to one and all. Salute the man and the warrior and his spirit, but don’t forget the human sufferings, miseries and havoc created by his bravery, wars and ruthless destructions of human settlements to attain his unachievable goal at any cost. Unfortunately, people become philosophical about the futility of conquests, victories and wealth at the fag end of their life’s journey, not before. That is the greatest tragedy of human history.

Now let us compare Alexander the Great with Alexander Fleming, more than two thousand years later and his effects on human survival and relief from miseries and sufferings. His scientific contribution proved to be a great boon for humanity. Alexander Fleming proved to be such a genius that one can easily divide medical therapeutics (treatment) into two eras – one before and the other after Fleming. Before Fleming, ordinary life was full of agony for patients, society and doctors, all at the same time, since no definitive and curative treatment was available for a large number of diseases like Cholera, Plague, complicated Influenza etc (epidemics) and Pneumonia, Syphilis, Gonorrhea, Septicaemia, Rheumatic fever, Gangrene etc (endemics). Hospitals, in those days, were full of patients suffering from Septicemia and Toxemia, resulting from even minor infections, cuts and scratches. Often, they culminated in the death of a large number of such patients globally, due to paucity of any effective treatment.

A chance observation has always proved to be a great development in various fields of Science. Nature is full of such happenings but they lay the foundation of great achievements in the service of humanity, only when they are carefully observed, analysed, experimented with, and results deduced and utilised for larger benefits of science and humanity. The real Big Bang Explosion in the service of humanity came from Alexander Fleming and Fleming alone. Even today, billions of people owe their survival to Fleming and his torch-bearing research. Fleming did wonders with an accidental observation. In 1928, September 3 proved to be such a day, when Alexander Fleming returned home from a long holiday. He found that petri-dishes, containing Staphylococci bacteria, which he had left in his lab were as they were left originally, except for one dish.

The exception contained a special area, where blob of a mold had grown, and no Staphylococci had grown around it. The mould was found to be a rare fungus, Penicillium Notatum.

Fleming deduced that something from the mold had inhibited growth of the bacteria and could have huge therapeutic implications. He initially called it, the Mold Juice. Later, he named it ‘Penicillin’, which became the first man-made antibiotic saving the lives of millions. In fact, Fleming started the new era of manufactured antibiotics, which is regarded as the greatest discovery in the history of medicine – the greatest saviour of mankind since human existence.

In history, ‘Antibiosis’ is a term known and utilised by mankind for long at various places. It means a process, where one organism produces a substance, which inhibits growth of another organism. Egyptians used this phenomenon to treat wounds by applying mold on it. Fleming’s observation initially got a lukewarm response from the scientific world. Penicillin was difficult to extract and make available for wider use. It was a daunting task. Penicillin, itself from the mold, was found to be quite unstable, meagre and fragile in action. The viable extraction needed help from others.

Howard Florey and Ernst Chain et al, chemists at Oxford University, extracted and tried to make Penicillin. Penicillin had to be taken out from the laboratory and made available to the man in the street globally. The journey was very very difficult indeed. It needed meticulous planning, untiring effort and large-scale collaboration from enormous number of people and organisations from various walks of life and countries, for the product to be finally brought to the market and within reach of the common man. This turned out to be an unique effort and never seen before. In fact, it was a mammoth and colossal task.

It needed huge amount of Penicillin for animal experimentation and clinical trials to make Penicillin available for commercial use. As much as 500 liters of mold secretion was made available for such trials in a week. Whole of Oxford was literally converted into a factory. All small and big things and all manner of containers were used as vessels to keep such a huge amount of liquid in storage and immediately available for experimentations. Such tools can make us laugh today, but that was the truth and became vehicles for a great achievement. Gradually, Penicillin established itself as an effective antibiotic. The progress was slow but sustained and steady. By this time, it was 1939 and World War II started. By 1941, in this war penicillin found its true calling and proved to be an effective antibiotic.

Albert Alexander, another Alexander in the service of humanity, became the first recipient of Penicillin (1941) for his severe facial infection. He responded well initially but died because of lack of sufficient amount of the drug he needed to really help him. Subsequently, several patients were treated successfully. The second was Arthur Jones, a 15-year-old boy with a streptococcal infection. He was given 100 mg every three hours for five days and recovered. Here evolved the concept of sustained treatment with calculated doses for several days. By 1941, it became clear that large-scale penicillin production was not possible in Britain, since all the chemical industry there was involved in the war effort. Everybody worth his salt in the world was involved in inflicting human injury during World War II and no one was interested in alleviating the human miseries and sufferings this war caused.

With this realisation, the center of gravity for penicillin production shifted from Europe to the USA. In America, the Penicillin project got a huge support from various sectors including the government and many American and British pharmaceutical companies. Still, the yield from existing mold was meagre. Hence, a global search was made for a better-yielding mold and interestingly, a better-yielding mold was found in a fruit market at Peoria (Illinois).

The Penicillin journey is full of substantial number of such stories, a culmination of huge effort, unending enthusiasm and tireless endeavor from a large group of people. Penicillin was gradually acknowledged as an effective treatment for various Gram (+ve) bacterias in military and civil patients, which were so difficult to treat in those days and proved lethal many a times. By the end of World War II in1944, a huge amount of Penicillin was available to treat the war affected casualties and civilian infections alike. With huge pile-up of the drug among competitors, the price fell drastically and it became available at every nook and corner of the world at a reasonable price. It was a huge collective and global effort started by Alexander Fleming and supported by myriad of people e.g. chemists, chemical engineers, mycologist, microbiologists, chemical and pharmaceutical industry, government agencies and clinicians at large.

Large number of deaths, just from regular infections is not an issue today, as it was a hundred years ago. No one has yet calculated the economic gain for humanity that occurred due to the introduction of penicillin in medicare? Even today, penicillin remains the main-stay for treatment of infections all over the world in one form or the other. Penicillin and its offsprings and cousins, the Cephalosporins-Carbopenoms and their sisters, still rule the world of antibiotic today. We have not added any new antibiotic in the treatment portfolio for decades. The World Health Organisation and most medical administrations across countries continue their research for more evolved antibiotics so that the world never returns to a pre-WWII era of medicare but penicillin remains the staple.

No sociological study has been done on the impact of Alexander the Great’s wars on a vast stretch of land, what today we call the Middle east, right up to the Indian subcontinent. No economist or statistician has calculated the cost of Alexander’s great expedition to find the ocean, that the Greeks believed, existed at the eastern-most edge of their world. He actually was never interested in occupying kingdoms, unlike the Romans. He was on an adventure. To reach that great vast ocean at the edge of a flat world. In the process, he not only razed innumerable human habitations, he left Greece’s mark on local populations, cultures and communities.

In comparison, Alexander Fleming’s legacy left a global impact in a spherical world that is home to eight billion people and his penicillin is now a part of space medicine study, though its use is discouraged in space conditions. And, surely, if penicillin was used on the ill Alexander the Great, he would have lived longer. Nevertheless, if we were to ever decide which Alexander is greater, undoubtedly Fleming would win by popular vote hands down.

(Author: Dr A K Sinha is a physician)

Reference:

https://asm.org/Press-Releases/2019/January/Study-Shines-Light-on-Antibiotic-Use-in-Space