by Burch, Druin
Contents
About the Book
About the Author
Also by Druin Burch
Dedication
Title Page
Prologue
1. Early Medicine and Opium
2. Sophistry and Laudanum
3. Self-confidence and Quinine
4. Learning to Experiment
5. The Taste of Trees
6. Beetroots, Mesmerism and Organic Chemistry
7. New England and New Ways of Thinking
8. Dyes, Stains and Antibiotics
9. Medical Missionaries
10. Aspirin and Drug Development
11. Cough Medicine Called Heroin
12. Francis Galton Almost Reforms Medicine
13. Antibiotics and Nazi Nobels
14. Penicillin and Streptomycin
15. ‘Sickness in Salonica: my first, worst and most successful clinical trial’
16. Captain of the Men of Death
17. Ethics and a Glimpse of the Future
18. Thalidomide’s Ongoing Catastrophe
19. Syphilis, Leprosy and Head Injuries
20. Aspirin and the Heart
21. Large Trials and Grand Designs
22. The Battle for Hearts and Minds
23. The Risks of Opinion
24. Revolutionary Confidence
25. The Beauty of Doubts
Index
Acknowledgments
Bibliography
Copyright
About the Book
Doctors and patients alike trust the medical profession and its therapeutic powers; yet this trust has often been misplaced. Whether prescribing opium or thalidomide, aspirin or antidepressants, doctors have persistently failed to test their favourite ideas – often with catastrophic results. From revolutionary America to Nazi Germany and modern big-pharmaceuticals, this is the unexpected story of just how bad medicine has been, and of its remarkably recent effort to improve. It is the history of well-meaning doctors misled by intuition, of the startling human cost of their mistakes and of the exceptional individuals who have helped make things better. Alarming and optimistic, Taking the Medicine is essential reading for anyone interested in how and why to trust the pills they swallow.
About the Author
Druin Burch works as a hospital doctor in Oxford, and is the author of Digging up the Dead, a biography of the Victorian surgeon Astley Paston Cooper.
ALSO BY DRUIN BURCH
Digging up the Dead
To Theodore John Burch, who didn’t help at all
Taking the Medicine
A Short History of Medicine’s Beautiful Idea and our Difficulty Swallowing It
Druin Burch
Prologue
Few things are more frightening than standing over someone with a very large needle, the intention of plunging it into their neck for their own benefit, and no previous experience of success.
I am not talking about the little needles you use to give drugs, or the slightly bigger ones for blood transfusions. I mean the large and long pieces of sharpened steel that are used for making entry holes into people’s bodies.
The process is meant to be straightforward. You lie the patient flat, or tilt the bed backwards so that the head is below the feet and the blood vessels of the head and neck engorge. You clean the skin, put sterile drapes all around the neck (which means covering over the face) and inject some local anaesthetic around the jugular vein. Then, gloved and gowned, with a mask on your face and a cap on your head, you feel in the neck for a pulse. The heat of all the extra clothes makes you sweat. You find a pulse, then pause for a second to make sure it is not your own. Under your fingers, now, is the patient’s carotid artery, each pulse taking a beat’s worth of blood towards the brain. In most people the vein you need lies just to the outside of this pulsation.
Keeping your fingers on the pulse, you grab a very large needle attached to a small syringe. The vein you are after is deep beneath the skin. You cannot see it or feel it. The needle might pass through it or miss it entirely. It can pierce the artery, where the blood squirts along under high pressure, or it can pass through and puncture the top of a lung. It can make a hole in the windpipe or cut through important nerves.
You grab the syringe in one hand and, carefully, put the end of the needle on the skin of the patient’s neck, next to your fingers. The tip is bevelled and sharp, not a round ‘O’ but, seen in profile as you are seeing it now, a piercing ‘V’. If you are lucky the patient is not moving their head, or twitching, and you are not nervously aware of how easy it is to plunge the needle through the thin protection of your surgical gloves and into your own hand.
‘You may feel some slight pushing now,’ you say, hoping it sounds more convincing to the patient.
My education in placing these needles began on a ward that was unusually organised about monitoring it. That was because two months before my arrival, a doctor tried the procedure and failed. He put his needle into the carotid artery. When he took the syringe off the end of the needle, just to make sure, the blood spurted out with enough force to spatter its way across the length of the room. Hitting the carotid is reasonably common. You press hard enough for long enough and the bleeding usually stops.
The doctor then tried on the other side of the patient’s neck, where he made the same mistake. Withdrawing, he pressed again to encourage the bleeding to stop.
The patient’s neck swelled. Over each side there was a bulge of blood. It was contained within her flesh, not pouring uncontrollably onto the floor. The pressure grew in her neck, the two tomato-like swellings squashing the structures around them. The patient began to struggle for breath. The two internal bleeds, not much more than big bruises, pressed on her windpipe. They crushed it. She died.
Medical interventions are dangerous. Things sometimes go wrong, no matter how careful you are. It is easy to understand when looking at a large needle, somehow harder when it comes to a pill. Sharp edges are not required to make something dangerous. I have given clot-busting drugs to people having heart attacks, then seen them bleed so rapidly into their tongue that it has swollen and choked them. Others have collapsed with strokes, the drugs saving their hearts at the same time as making them bleed torrentially into their own brains. Even when the deaths are not so dramatic, they are as real. Drugs can do their damage unobtrusively, scarcely noticed. A little more confusion than someone normally suffers, a slight step forwards in the crumbling of old age. Someone with cancer beginning to bleed internally, vomiting up their own blood. When you have been expecting something bad to happen, it is easy to overlook the fact that a pill may have hurried it along.
There are also the errors of omission. A doctor, remembering that two of his patients have bled to death from aspirin over the last month, becomes wary of giving it to others. The bleeds stick in his memory, nagging at him. The purpose of the aspirin is to fend off strokes and heart attacks, yet the patients carry on having them whether they are on the drug or not. Those few people who die spectacularly from blood loss are memorable. The many others whose heart attacks and strokes happen a little bit later, a little less often: they are less vivid. So the doctor slips in his habits, and the errors of omission happen in obscurity. When an old man clutches his chest and collapses, as all his family knew he one day might, it is easy to ignore the drugs that he was not on. Yet these deaths, too, are side effects of medical dangers.
You would think that doctors, aware of thes
e dangers, know what they are doing and that seeking medical advice is a good thing. Most of the time you’d be right, but only recently. Doctors, for most of human history, have killed their patients far more often than they have saved them. Their drugs and their advice have been poisonous. They have been sincere, well-meaning and murderous. This book is about medicine’s bleak past, and the methods it learnt in order to improve.
Using a handful of common drugs – opium, aspirin, quinine and a few others – I want to show how the way in which people have thought about medicine has determined their success. Different treatments tell different tales. Those collected together here share a common theme. Their story is about the importance of how you try to answer questions about the human body, about what makes it healthy or sick, and how surprisingly difficult it can be to tell the difference.
Most histories of medicine are strikingly odd. They treat their subject as though it was a matter of perspective, of judgement, of opinion. Roy Porter’s The Greatest Benefit to Mankind is the best of the comprehensive modern histories. In his introduction Porter apologises for focusing on the people who made advances, disliking the idea of a ‘“great docs” history which celebrated the triumphal progress of medicine from ignorance through error to science’. Porter was abashed about the extent to which he concentrated on the West. He did so, he explained, only because Western approaches became so culturally successful. ‘Its dominance’, he says, meaning that of Western medicine, ‘has increased because it is perceived, by societies and the sick, to “work” uniquely well, at least for many major classes of disorders.’
Why should Porter put the word work in quotation marks?
Historians treat medicine the way they do politics and society and art. The Egyptians used ostrich egg poultices for open skull fractures, just as they mummified their dead and built pyramids for them. All these activities, for historians, fit into the system of beliefs that defined what it was to be an ancient Egyptian. And to the extent that another culture’s medicine is as much a part of who people are as their religion, these historians are right. Porter’s brilliantly written history contains thrilling accounts of the remedies used by the Egyptians, the Greeks, the Romans, the Victorian English.
Did their medicines save lives, cure ills, and offer comfort to them in their distress? Here the historians are less helpful. They will not tell you. Their interest is in the way the therapies reflect the beliefs of particular cultures. Porter’s interest, like that of most historians, is in the cultural relativity of medicine. What may be a cure to my eyes could be a poison to yours. Each society’s ‘diagnostic arts and therapeutic interventions’, Porter says, are as valid as any others. He focuses on Western ones because of their worldwide popularity. This is the traditional view of medical history, in which medical systems war with each other like religions, battling it out for the hearts of the faithful.
Yet medicines are not like poems, the different virtues of pills and potions as capable of endless debate as odes and sonnets. Our bodies are the bodies of the Egyptians that came before us, and the Sumerians that came before them. We have the same organs and the same construction. The cancers and infectious diseases and hazards of accident and age have changed a little over the millennia, but not a great deal. Histories of medicine give readers a rich feeling for the vast array of drugs that the Greeks and Romans, the Chinese and Indians and eighteenth-century French, possessed. They provide a clear account of what people believed they were doing, but almost none at all of whether they were right.
Suffering from cancer, did a patient get better treatment under medieval French physicians than under the Egyptian doctor Imhotep? Struck down with pneumonia, was someone better off being bled for it by the Greeks, the Romans, the Renaissance Italians, the Revolutionary Americans or the best minds of nineteenth-century medicine from Harvard to Heidelberg? The answer is that it made no difference. The rationales varied, but not the effects. The Greeks had an explanation for why taking 4 pints of blood away would help someone with a chest infection. George Washington’s doctors had their own explanations. In terms of understanding the cultures of the two civilisations who held those views, the differences between their explanations are interesting. Relative to the effects of blood loss on a sick human being they matter not at all.
The Egyptians had complicated ideas about how the body worked and they believed that lettuce was a drug that caused lust. What happened a thousand years later, in the classical civilisations of Athens and Rome? Thomas Dormandy’s recent history of pain is long and entertaining. When he gets to the Greeks and the Romans he comments that ‘the garden lettuce gathered when young and tender had an established reputation as a mollifier of grief. But it could also encourage frenzy.’ Could the lettuce have changed from the days of Egypt? Could human physiology? Should we be wary of salads?
On the last day of 1664, Samuel Pepys wrote in his diary of his unusually good health over the previous months. ‘I am at a great loss to know whether it be my Hare’s fote, or taking every morning a pill of Turpentine, or my having left off the wearing of a gowne.’ Whatever the cause, it was none of those three. We are still at a loss for many things, frequently including physical explanations, but we have progressed since 1664. Medical progress is real, and it comes from realising that some medical theories are more useful than others. Pepys’s beliefs were sincere, but they were wrong.
The United Nations Children’s Fund started monitoring global child deaths in 1960. In 2007 they reported that for the first time deaths dropped below 10 million a year. Over the same period the number of children in the world rose. In 1960 20 million died each year. In 2007 the number was 9.7 million. The reason for the success was that some poor countries became a little less poor, meaning better food and housing and sanitation, while vaccinations and vitamins and mosquito nets helped save millions of children’s lives. Progress relies on understanding that some medical treatments really do ‘work’.
I never intended to save any lives. It was sort of an accident, arranged chiefly with a view to extending my sporting life. A time spent in genetic research failed – I found the pipette too dull a companion and the statistics too frightening – yet the outside world was not attractive. I could not understand the rush of my colleagues towards the City of London. That meant suits and rigid working lives, not to mention very little opportunity to do any sport. The thought of a ‘proper job’ was equivalent in my mind with middle age. My mental world was divided up into sport and non-sport, and it was the first that I wished to live in.
So with these hidden motives, I applied for medical school. My interview preparation was largely non-existent. ‘What if they ask you why you want to be a doctor?’ suggested a friend. ‘They won’t ask me that,’ I explained. ‘Why would anyone ask such a dull question? They’ll only get identical answers about liking science and wanting to help people.’
‘Why do you want to be a doctor?’ they asked me.
Whatever I said has long passed from my memory. Probably the examiners were not even listening. To this day I think it was a bad question. Medicine seemed reasonably interesting and reasonably honourable, but I did not have the first idea how I might one day feel practising it. How can you, other than by giving it a go?
Medical school went smoothly. My surgical tutor wrote me the kindest of possible reports. ‘I have not met this student,’ he recorded, some months after I was allocated to his weekly tutorials. ‘But I understand his rowing has improved enormously.’ It had. I never did turn up to any of my surgical teaching and the surgeon, whom I later discovered to be eminent, passed me without problems.
One summer I needed an excuse to stay on during the vacation and train. A helpful tutor, hoping my plans might represent some academic enthusiasm, helped me win a small grant to pursue medical history during the summer. So, after mornings going up and down the Thames, I spent the bulk of each sunny day sitting in an old library. I sat there reading until the heat of the day softened into gentle warmth,
and then I went out rowing again. It was perfect. I read about the practice of medicine during the nineteenth and early twentieth centuries. It seemed very civilised, in many ways, except that the treatments were laughable. Leeches were popular, along with a range of other interventions that also shortened people’s lives. I found it remarkable that no one at the time noticed.
When the summer was over (and winter training properly begun) we learnt about heart attacks. One of my books told me that you used a drug called lignocaine, but it wasn’t mentioned in the lectures. I put my hand up and asked about it.
‘We don’t use that these days,’ I was told.
‘But my book says it saves lives.’
‘Not any more. Nowadays it kills people.’
The lecturer was echoing a famous exchange from Molière, often quoted in medical journals:
GÉRONTE: It seems to me you are locating them wrongly: the heart is on the left and the liver is on the right.
SGANARELLE: Yes, in the old days that was so, but we have changed all that, and we now practise medicine by a completely new method.
How could something save lives one year and cost them the next? The days of leeches began to seem not so very far away. Now I noticed other contradictions in my textbooks. One said that amphetamines were good for helping students to concentrate, and that family doctors were happy to prescribe them. Another explained that antidepressants made people commit suicide. A third said that pregnant women should drink Guinness. The fourth stated that bed-rest saved lives, while the fifth was confident it cost them. On the wards, senior doctors in the mornings told you to avoid certain things at all costs, while others in the afternoon declared the same treatments to be essential. Professors disagreed over whether people had infections, heart attacks, cancers and strokes – and then argued that their opponent’s treatments were likely to be disastrous.
