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August 31, 2006

"Anyone with an involvement with medicine - and that means anyone with a body and a brain - should read this brilliant, bracing and erudite book" - Seamus Sweeney on Bad Medicine: Doctors Doing Harm Since Hippocrates - David Wootton

Posted by Seamus Sweeney

Bad Medicine: Doctors Doing Harm Since Hippocrates
by David Wootton
Pp. 304. Oxford: Oxford University Press, 2006
Hardback, 16.99

Not only were the Ancient Greeks influential, in many fields they are still directly influential today. Whitehead famously remarked that all Western philosophy is footnotes to Plato. Euclidean geometry is still central to mathematics. Aeschylus, Sophocles, Euripides and Aristophanes are still performed. While the practice of history today is very different from that of Thucydides (and more different still from that of Herodotus), the tradition is recognisable. Aristotle's Poetics is the explicit ancestor of many how-to-write-fiction books today.

One of the most durable "big names" of the Ancient Greek world is that of Hippocrates. Yet modern medical practice is nothing like that of Hippocrates. The Hippocratic Oath is deeply enough embedded in our cultural consciousness to be referenced in The Simpsons.

Surprisingly, only recently have formal ceremonies involving the Oath (which, Wootton writes, was written by Hippocrates of Kos after all and is not a later invention) been incorporated into medical school graduations. It became part of a graduation ceremony in Montpellier in 1804; in 1928 only 19 per cent of American medical schools administered the oath, and:

it is only after the Second World War that the oath (in its various modernized forms) began to be administered almost universally.
Almost universally indeed - in University College Dublin in 2002 it wasn't administered, and a straw poll of other graduates of Irish medical schools in the Oughties reveals none of them formally took the oath, either. The Oath in various "updated" forms is often administered, but not "almost universally".

While the Hippocratic Oath looms large in discussions of medical ethics, Hippocrates' various treatments have barely any relevance to modern practice. Hippocratic remedies could not even be dignified with the name of placebo:

Hippocratic remedies were far from inert. Bloodletting, purging, and emetics acted powerfully and, in so far as they acted on the body, they were bad for patients.
Not only that, but the key idea of David Wootton's book is that hardly any treatments had any relevance to health or recovery until 1865. And until the invention of antibiotics in the 1940s, most of what doctors did for their patients caused more harm than good. At first sight this history of medicine -
the first general history of medicine to acknowledge the frequency with which doctors have harmed their patients throughout the ages
according to the back cover - could be an Ivan Illich-style demolition of the pretensions of the medical profession to do any good whatsoever.

In fact it is very far from this. It is a catalogue of the medical profession's vanity, resistance to innovation, protectionism and frank stupidity at times. Yet it is not a depressing read for a medic. In fact, it could almost be called triumphalist, except that it is too honest about the many follies and vanities of medicine and medical practitioners. It is not a Foucault-style text which sees the relation of doctors to their patients as a power relation in which treatment is at best irrelevant.

The book is studded with impatience at the failure of medicine throughout the years. Indeed, reading the early chapters, one felt Wootton was being rather harsh. We are all wise through the retrospectroscope. But as the book goes on, Wootton's case becomes more and more convincing.

What separated medicine that did harm from medicine that did some good? The answer is very simple, and very complicated. Counting. When doctors began to compare the number of patients that recovered on a certain treatment with another, or no active treatment, medicine began. The concept of evidence based medicine is central to modern practice, to an extent that the general public are unaware.

Evidence based medicine - essentially the championing of data from properly conducted studies over clinical experience or intuition - has been linked with some dreadful jargon and waffle, but the clarity and rightness of the basic principle shine brightly. Of course, evidence based medicine does not mean that clinical experience or intuition are to be ignored or cast aside, as zealots sometimes make it sound, but that in the hierarchy of evidence the randomised controlled trial (or, to be more accurate, the systematic review of double-blind placebo-controlled randomised trial) is king. If it served no other purpose, Wootton's book would be useful as a corrective to the presumption that doctors and trainee doctors often fall into - wearied, understandably, by having to study all these frankly dull statistics - that things were better in the old days.

This is a book about progress. The popularity in the 1970s of the attacks on the idea of medical progress and indeed medicine itself as an agent of social good by Foucault, Ivan Illich and Thomas McKeown (who argued that the improvements in life expectancy of the Twentieth Century owed nothing to medicine - more recent work has shown that this is not correct, but that the contribution of medicine is nothing as great as what we doctors would like to believe) still has some influence. The final words of the book are:

Of those three authors, Illich and McKeown no longer have the influence they once had; only Foucault remains a major obstacle. The idea of progress now needs to be rescued from the condescension of [Herbert] Butterfield [whose 1932 "The Whig Interpretation of History" attacked the idea of progress in history] and of Foucault.
So this is a history of progress, but without the cheering implications that phrase may have. A real history of progress will be also be a history of why there wasn't progress.

In considering this issue, great medical reputations do not emerge unchanged. Much of this change is for the worse. James Lind, the ship's surgeon who - the textbooks say, and I up to now believed - carried out the first randomised trial of citrus fruit for the prevention of scurvy in 1763. He did, but he didn't, or rather while he did carry out a trial he drew the wrong conclusions and didn't follow through on the implications, becoming just as dogmatic in his own way as other medical authorities. Captain James Cook is the real hero of the conquest of scurvy. Alexander Fleming's reputation takes even more of a hit. His accidental discovery of penicillin mould in 1928 was not followed up. Fleming's major interest was in profitable "vaccines" that were little more than quack cures, and he made no effort to find a clinical use for penicillin. Two lowly assistants - Ridley and Craddock - working in obscurity managed to produce purer penicillin. It took the work during World War Two of the much less well known Chain and Florey, who shared the Nobel Prize with Fleming but never achieved his fame, to develop clinically useful antibiotics. And yet, there was no reason why Fleming could not have done so. Why didn't he? Readers may find Wootton's judgement somewhat harsh when he writes that:

Had he done this experiment [injecting mice with penicillin, which would have been feasible with the supply created by Ridley and Craddock] in 1929 literally millions of lives could have been saved, lives that were lost without an adequate broad-spectrum antibiotic .. If Fleming deserves the credit for recognising the action of penicillin on his contaminated dish, he also carries the responsibility for this delay.
This delay is at the heart of the book. There has been a delay, throughout the history of medicine, between the technical knowledge that permitted a therapeutic advance to be made and that advance actually occurring. An example is the fifty year delay between the discovery in 1795 that nitrous oxide killed pain and its general adoption as an anaesthetic agent. Wootton invites the reader to:
Think for a moment what surgery was like before the invention of anaesthesia in 1842. Imagine amputating the limb of a patient who is screaming and struggling. Imagine training yourself to be indifferent to the patient's suffering, to be deaf to their screams. Imagine developing the strength to pin down the patient's trashing body.
One would like to imagine that surgeons would seize the opportunity to make surgery painless, even if only to make their lives easier. And yet:
The use of anaesthetics was pioneered not by surgeons but by humble dentists, not in London, or Paris, or Berlin, the centres of medical research, but first in Rochester, NY, and then in Boston. One of the first practitioners of painless dentistry, Horace Wells, was driven to suicide by the hostility of the medical profession. When anaesthesia was first employed in Europe, in London in 1846, it was called a "Yankee dodge". In other words, practising anaesthesia felt like cheating.
This example is bad enough, but worse is the story of the germ theory of disease. For Wootton, the application of the germ theory to medical practice in 1865 was the birth of modern medicine. He is contra Foucault in this regard; in The Birth of the Clinic Foucault dates modern medicine to 1816, with Francois Broussais' pathological anatomy; in other words with a particular way of relating to and looking at patients' bodies. This reflects Foucault's own preoccupations, and for Wootton the story told in The Birth of the Clinic is the story of ancient medicine's collapse rather than modern medicine's birth. For these fifty years or so of the Nineteenth Century were a sort of interregnum in medical history.

Primum non nocere is a relatively recent precept, coined in 1860. It dates from the age of "therapeutic nihilism". If counting began in 1800, then the realisation that counting brought - that the treatments administered by doctors were useless - lead not to instant improvements in therapy but a crisis of confidence. Sir James Simpson, the discoverer of chloroform, found that forty per cent of amputations carried out in hospitals were fatal, while only ten per cent of those performed outside hospitals were. He dolefully concluded:
A man laid on an operating table in one of our surgical hospitals is exposed to more chance of death than was the English soldier on the field of Waterloo.
Unsurprisingly, for many doctors, trying to minimise the harm they did became an imperative, hence primum non nocere. And then came Joseph Lister. If other reputations are damaged by Wootton's account, Lister's is enhanced:
Modern medical science began in March 1865, when Joseph Lister, a 37 year-old professor of surgery in Glasgow, tried (unsuccessfully) to tackle a compound fracture of the leg by applying the principles of what he called "the germ theory of putrefaction".
The key sections of the book consider this question - why there was such a delay between Leeuwenhoek seeing germs through his microscope in 1677 and Lister's breakthrough. In some ways it is a history of what didn't happen. Lister, incredibly, later downgraded his role, presenting himself as simply following in the footsteps of the venerated Pasteur. Wootton carefully analyses Lister's contemporary lectures and concludes that Lister denigrates himself. The somewhat controversial - and earlier - work of Theodore Schwann influenced Lister's thinking, rather than that of Pasteur. This point does not simply glorify Lister - it actually leads to further indictment of the medical profession. For:
Does it matter whether Pasteur's research was crucial to Lister's innovation in surgery? It matters a great deal. If it was, Lister can be safely accommodated within the relay-race model of medical progress. Pasteur, Lister, Koch, Pasteur, Wright - the baton was passed from one to the other without being dropped. In this list, Lister seems the least important, because he merely found a new practical application for Pasteur's work on spontaneous generation. But if Schwann's work could have equally inspired Lister, then a yawning gap opens up. Schwann's work has been published in 1837 ... and Lister did not publish until 1867. For thirty years the intellectual principles required for antiseptic surgery has been widely known and much discussed, but no one grasped their possible application.
Again the story of medical progress is not a serene relay race but a story of unaccountable delay. This is considered at some length and is difficult to summarise. There are many reasons, but Wootton concludes:
The primary obstacle to progress, as I have argued, was not practical (Leeuwenhoek's microscopes worked well), nor theoretical (the germ theory of putrefaction was not difficult to formulate), but psychological and cultural. It lay in doctors' sense of themselves, their awareness of their own traditions, their habit of conferring authority on an established canon and upon established therapies.
It should be noted that the book is succinct and narrowly focused. This is not a book about quackery or charlatanry, or rather it is not about recognised quackery or recognised charlatanry. It is not about outright fraudulent research. It is not about alternative or complementary or herbal or whatever-you-want-to-call-it medicine. Wootton specifically excludes mental illness from his study, observing succinctly that:
The story of bad psychiatry would require at least a volume to itself.
Wootton's focus is narrow in another sense. Throughout, good medicine reduces death, bad medicine does not. The triumph of germ theory means that less people die from influenza, pneumonia and tuberculosis. More therefore die of heart disease and cancer. The medical enterprise is surely not - and never has been - purely about the avoidance of death, or prolongation of life, but palliation of symptoms as well.

And yet it is not narrow at all. In this review I have only touched on the range of topics covered. There is much fascinating material on the development of anatomical knowledge, the reality behind Doll and Hill's work on smoking and lung cancer (which Wootton dubs "at last, good medicine" - but he also writes of Richard Doll's deliberate self-mythologising), the history of the microscope, physicians of the past reticence about actually physically examining their patients - especially female - and the story of vivisection. Again, technical and scientific knowledge advanced while clinical application stagnated. Many of us have no problem with animal experimentation or vivisection if it is for the sake of medical science. And yet, as Wootton writes, the amazingly cruel experiments of anatomists and physiologists did not lead to any advance in therapeutics - at least not at the time, and it is hard to determine just what advances are owed to them.

This short, brilliant bracing book is written with a combination of erudition and narrative drive. Wootton has a gift for making the often-recondite story of medicine alive. He manages to convey a controlled sorrow at the enormous waste of effort that the overwhelming majority of medical practice has been throughout history. For much of that history, one could possibly say that it could not have been otherwise. The real tragedy is that for a not inconsiderable part of it, it could have. Anyone with an involvement with medicine - and that means anyone with a body and a brain - should read this book.

Seamus Sweeney is a medical graduate and freelance writer.

To read Richard D. North's rather different take on Bad Medicine, see: "Wootton is so at sixes and sevens as to his own purposes that he sets up a defiance in at least this reader" - Richard D. North on Bad Medicine: Doctors Doing Harm Since Hippocrates.

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