Bad Medicine: Doctors Doing Harm since Hippocrates
This book is not burdened with numerous footnotes and a lengthy bibliography, though I know it will be read by students and scholars as well as by others with an interest in the subject. For those who wish to pursue this further, at www.badmedicine.co.uk you will find detailed bibliographies and notes, along with links to other web sites. You will also find updates: corrections, clarifications, responses to critics, and references to literature that has appeared since this book was written. The very short bibliography you will find at the end is intended only as an indication of the most important sources on which I have drawn and the most significant works that have influenced my thinking.
We all have bodies, and all our bodies function in much the same way. Each of us originates in a fertilized egg; we all breathe and maintain a heartbeat; we all eat, digest, and excrete. If we cannot perform these basic functions for ourselves, then our life depends on medical machinery doing them for us. In these respects we are all alike, and like, too, not only all the generations of human beings before us, but all mammals, birds, and reptiles. Bodies, you could say, have no history because they have been much the same since the first human beings came into existence.
But our bodies do have a history. I am tall, over six feet. The vast majority of people over six feet tall have been born in the last century, perhaps in the last thirty years. In the mid-eighteenth century Frederick the Great of Prussia searched across Europe to assemble a regiment of men over six foot tall: the enterprise took its point from the rarity of such giants. Anybody inspecting my body for a post mortem would find that on my upper arm there is the scar of a vaccination against smallpox, which must have occurred after 1796, when Jenner invented vaccination, and before 1980, when smallpox was officially declared eradicated. They would also find evidence of my surviving an appendix operation and a compound fracture of the tibia: this, as we shall see, implies medical care received after 1865. Before that date an appendectomy was almost certain to be fatal, while the only hope for someone with a compound fracture (where the bone sticks through the skin) was amputation. The amalgams used to repair my teeth, and my varifocal lenses, without which I would be half blind, set a terminus post quem in the late twentieth century. My life expectancy is quite different from that of someone born a hundred or a thousand years ago. Put two dead bodies, one from the eleventh century and one from any industrialized society in the twenty-first, on to a mortuary slab, and you would not need to be an expert to tell them apart.
To have a body is to experience, at least on occasion, pain: every infant suffers from wind and teething. Every child encounters disease. And part of the process of growing up is discovering that death awaits us all. All societies seek to alleviate pain, ward off disease, and postpone death; to fail to do these things would be inhuman. In Western society, we turn above all to the medical profession for help, and the doctors who treat us belong to a profession that dates back to Hippocrates, the ancient Greek who, some 2,500 years ago, founded a tradition of medical education that continues uninterrupted to the present day. Yet the striking thing about the Hippocratic tradition of medicine is that, for all but the last hundred years, the therapies it relied on must have done (in so far as they acted on the body, not the mind) more harm than good. For some two thousand years, from the first century BC until the mid-nineteenth century, the main therapy used by doctors was bloodletting (usually opening a vein in the arm with a special knife called a lancet, a process called phlebotomy or venesection; but also sometimes cupping and leeching), which weakened and even killed patients.
Moreover medicine became more not less dangerous over time: nineteenth-century hospitals killed mothers in childbirth because doctors (trained to consider themselves scientists) unwittingly spread infections from mother to mother on their hands. Mothers and infants had been much safer in previous centuries when their care had been entrusted to informally trained midwives. For 2,400 years patients have believed that doctors were doing them good; for 2,300 years they were wrong.
I think it is fair to say that historians of medicine have had difficulty facing up to this fact. Historians of medicine are a diverse group, with widely differing views, but in general they no longer write about progress, and so they no longer seek to distinguish good medicine from bad. Indeed they try to avoid what they think of as anachronistic evaluations: ‘only the most dyed-in-the-wool Whig history still polarizes the past in terms of confrontations between saints and sinners, heroes and villains’, wrote Roy Porter (1946–2002, the greatest medical historian of his generation) in 1989. This book, on the other hand, is directly concerned with progress in medicine: what made it possible, and why it was so long postponed. To talk about progress is to talk about discoveries and innovation, and about obstacles and resistance: it is inevitably to talk about heroes and villains, if not about saints and sinners. This book, therefore, is written against the grain of contemporary historical writing.
There is a particular reason for writing about progress in medicine now. In recent years the medical profession has discovered what it calls ‘evidence-based medicine’—that is, medicine that can be shown to work. This is the first history of medicine properly to acknowledge that most medicine, even into the present day, has not been evidence-based, and indeed that it did not work. If the story I tell in this book is very often one of failure not success that is because we have begun to redefine success, which means we are now in a position to rethink the history of medicine.
Recognizing how late and limited medical progress has been makes the progress that has taken place even more remarkable. So this book is also about the process whereby we have at long last learnt to preserve life and health. Here I have tried to concentrate on the big picture: the first successful operation on appendicitis took place, as best we can tell, in 1737; in Britain the first successful caesarean section, in which both mother and baby survived, had been performed by the end of the eighteenth century; but until 1865, when Joseph Lister, working in a Glasgow hospital, first demonstrated the principles of antiseptic surgery on a young boy with a compound fracture of the tibia, such operations were bound to be almost always fatal. With Lister there begins a new era in medicine, made possible by the triumph of germ theory, and the third part of this book examines the incredible revolution in medicine that began in 1865.
When I use phrases like ‘until 1865’ or ‘a new era’ I am using a sort of shorthand. There was considerable resistance to Lister’s innovations, and they were slow to win acceptance. Despite the fact that antiseptic surgery helped consolidate a germ theory of disease, it was to be thirty years before a cure was found for any major infectious disease. The new era is separated from the old by a lengthy period of transition, from antiseptic surgery to penicillin, from 1865 to 1941, not by a single event, Lister’s first antiseptic operation.
Moreover Lister’s innovations made possible new types of bad medicine. For the first time it was possible to operate on the abdomen, and some surgeons proceeded to happily chop out bits and pieces (an appendix here, a colon there) not because they were infected, but because they might one day become infected—the historian Ann Dally has called this ‘fantasy surgery’. These operations never became the norm, but tonsillectomies did, and we now know they did more harm than good. Worse still, the decision as to whose tonsils should be removed was not remotely rational. Of 1,000 11-year-old children in New York in 1934, 61 per cent had had tonsillectomies.
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