Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and our Difficulty Swallowing It

by Burch, Druin

  This is not the impression given by standard medical histories. Roy Porter’s 1997 The Greatest Benefit to Mankind puts it this way: ‘. . . after much pooh-poohing of “primitive medicine”, pharmacologists studying ethnobotany now acknowledge that such lore provided healers with effective analgesics, anaesthetics, emetics, purgatives, diuretics, narcotics, cathartics, febrifuges, contraceptives and abortifacients’. Porter’s list is generally accurate, yet his effect is to mislead. What, for example, did Galen possess? Emetics worked in that they made people vomit, but what conditions benefit from vomiting? Purgatives are useful for constipation but little else. In infections they serve a similar role to bleeding and emetics – helping to dehydrate and weaken patients who are already dehydrated and weak. Diuretics, drugs that make you urinate out extra fluid, are useful in heart failure – in small, predictable doses and to a minimal degree. Commonly they were used instead for acute illnesses, like trauma or infection. Like bleeding or purgatives, they worsened a situation that was already bad. Drugs that made people sweat were used, since people believed that poisons came out of the body with sweat. They were wrong. What came out in sweat was salt and fluid – both vital for anyone already ill.

  Drugs to bring on abortions or to prevent conception are old. The ancient Egyptian use of crocodile dung as a vaginal pessary actually did work – to an extent, and arguably as much by damping sexual attraction as being directly spermicidal. A very few ancient treatments actually did some good. Mercury, despite being very toxic, could help against syphilis: but not much, and often not enough to counteract its own harms. Another chemical element, antimony, has a limited ability to fight off a disease called schistosomiasis, a parasite that can be acquired from swimming in infected water in Africa. Colchicine, from the crocus, was used with some benefit to treat gout – as well as with a lot of harm to induce vomiting and diarrhoea. So these treatments were biologically active, and did some good as a result. It is likely that these benefits were heavily outweighed by the harms that came with them.

  Trepanation in ancient Egypt is often held up as an example of how advanced ancient surgery was. Surgeons were able to drill holes in people’s skulls, to lift out pieces of bone. Skulls have been found where the wounds have healed over, showing that some people survived. The ancient Egyptians were advanced enough to sometimes remove a portion of someone’s skull without killing the patient – but that does not mean they understood when doing so might be of help. They used the technique to save some of those suffering from certain types of fractured skulls. They used it to harm many whose problems were actually psychiatric, neurological or infective, and incapable of benefiting from the pain and danger of trepanation.

  The inclusion of a potentially helpful ingredient in a long list of others is no indication of real knowledge or any actual healing powers. In the twentieth century, for example, knowing that something in penicillin could kill bacteria, doctors still struggled to get any practical benefits from it. With exactly the right species of mould and advanced chemical techniques to extract concentrated amounts of its juice, they still found it exceedingly difficult to make it do anything useful. Getting a therapeutic effect from the Penicillium fungus was that hard. This tells us something important about how to interpret the fact that some Egyptian wound dressings included mouldy bread.

  So something else matters, beyond the pharmacological properties of a drug: people’s ability to harness it. Were the Greeks and the Romans able to use opium to reliably or even usually bring an end to pain? Did they make operations comfortable, death easy, illnesses mild? No. Even by the nineteenth century doctors were unable to do these things, remaining too confused about doses and preparations, too uncertain of effects, and too frightened of side effects.

  2 Sophistry and Laudanum

  AN EARLY STEP forwards in the history of science came with a philosophical argument amongst the ancient Greeks. Five hundred years before the birth of Christ, a group of Greeks made their living from their skills in argument. Athens was a litigious society, and success or failure in lawsuits often depended on such skills. This group of men were called sophists, initially as a compliment to their wisdom and, later, as something of an insult to their morals. (‘Sophistry’ came to mean arguing for something not honestly or because it was true, but with lies and confusions and because doing so served your own selfish interests.) The sophists rejected the widespread belief that the best way to understand the world was to reason it out. They argued that experience, rather than pure reason, gave you more accurate information about the way the world actually was.

  One of the greatest opponents of the sophists was Plato. His belief was that experience of the world was misleading. The ground that we walked on and the buildings and people and shapes around us were only versions – imitations – of what was most real. That deeper truth was hidden. The mind could attempt to figure out, through the power of thought, the pure forms of this underlying reality. Experience only got distracted and confused by the jumbled reflections of it. Experiments could tell you only about these illusions and superficialities, not about anything more important. Those who believed in such barbarically practical methods as experiments were called ‘empirics’. It was a term of contempt.

  Aristotle argued against this belief in the value of speculation. Reason had to be founded on experience, he suggested. Philosophy was not enough to tell you about how a bee managed to fly or the number of teeth in a person’s head. Instead you needed to study the bee, or to open up someone’s mouth and start counting what you saw. The words ‘experiment’ and ‘experience’ still meant pretty much the same to Aristotle, but at least he felt that something important was hidden away in them. It was an idea that rumbled away in the human mind, not emerging into anything that saved lives or eased pains, but packed, all the same, with promise.

  Aristotle complained that Plato relied too much on his own thoughts, his own ability to reason from nothing about how the world worked. That was not, suspected Aristotle, quite good enough. Why should the world work the way you expected it to? It seemed better to him to start by observing what was around you, and then to move on to trying to think through what you saw. Fitting your thoughts to the world rather than the world to your thoughts held more promise of getting things right. Aristotle’s belief was in what he called ‘natural philosophy’, in basing your knowledge on your experiences. Thomas Aquinas rephrased this belief seventeen centuries later: Nihil est in intellectu quod non prius in sensu, ‘Nothing is in the intellect which was not first in the senses.’ Experience, both men believed, was more reliable than innate wisdom, at least when it came to understanding the truth about the natural world.

  A lot of thought and effort went into working out what it was about experience that was helpful. Certain forms of experience seemed more useful than others. Organising observations made them more reliable; the notion that experiments were vital grew in people’s minds.

  Roughly a thousand years after the birth of Christ, Ibn al-Haytham was born in Basra, in the south of modern Iraq. His book on optics explored the nature of vision and included the most developed statement yet of scientific method. Observations, said al-Haytham, gave rise in people’s minds to problems, which they then developed theories to explain. Those theories then needed experimental examination. Both al-Haytham’s approach and his optical knowledge greatly impressed Roger Bacon, the thirteenth-century English philosopher friar. Bacon stressed that observation, theorising and experimentation provided the means for finding out about the reality of the world. He documented his experiments in detail, precisely so that others could repeat them and check on his results.

  Bacon’s emphasis on verification contained an acknowledgement of his fallibility. Never before had anyone so seriously tried to build in safeguards against their own aptitude for errors and confusions. The decline of mental arrogance, the dissolution of people’s instinctive belief in the accuracy of their intuition, was ever so gradually progressing.

  In t
he late sixteenth century the unrelated Francis Bacon helped to popularise this view of scientific method. ‘Men have sought to make a world from their own conception’, he wrote, ‘and to draw from their own minds all the material which they employed, but if, instead of doing so, they had consulted experience and observation, they would have the facts and not opinions to reason about, and might have ultimately arrived at the knowledge of the laws which govern the material world.’

  Francis Bacon (his eyes like those of a viper, according to the contemporary physician William Harvey) died in the manner of a true scientist. A winter coach-ride in the company of the king’s physician, Dr Witherborne, prompted him to wonder if the snow, lying round about, might preserve meat. Consumed with curiosity, the two men plunged out of their coach and into the nearest house, persuading the woman who lived there to sell them a live chicken. They had her kill and gut the creature, and Bacon, full of enthusiasm, grabbed handfuls of snow to help stuff it with. ‘The Snow so chilled him that he immediately fell so extremely ill, that he could not returne to his Lodging,’ wrote the gossipy biographer John Aubrey towards the end of the seventeenth century, some fifty years after the events he confidently recounted. ‘2 or 3 dayes’ after, probably having been bled by his travelling companion, he died of pneumonia. Later opinion on his life was mixed. ‘If parts allure thee, think how Bacon shined,’ wrote Alexander Pope in the eighteenth century, ‘The wisest, brightest, meanest of mankind.’

  These advances in thinking about the need to experiment were important scientifically but not medically. They changed nothing about the way patients were treated. Seeing a doctor for professional advice remained a bad choice. This is not to say that doctors were universally awful, or even that they did not occasionally do good, only that their overall impact on the human race was to diminish it – to shorten lives and extend disease. Surgeons could set simple fractures and perform basic operations, often to the benefit of their patients. But without the idea of infection the wounds they created frequently went bad, and even the shallowest scratch of a doctor’s needle let in the possibility of death. In the seventeenth century the Norfolk doctor Thomas Browne was greatly taken with Bacon’s methods, as well as with another great find of the time: William Harvey’s discovery of the circulation of the blood. ‘Be sure’, he wrote, ‘you make yourself master of Dr Harvey’s piece De Circul. Sang.; which discovery I prefer to that of Columbus.’ After thousands of years of ignorance, Harvey showed in the seventeenth century that the heart pumped blood in a circuit around the body. It was a terrific insight, more impressive to Browne than the discovery of the Americas, but it led to not a single change in the way doctors treated their patients. It did not even prompt them to reconsider their enthusiasm for bleeding and leeches.

  *

  These new ways of thinking played a central part in the life of Theophrastus Phillipus Aureolus Bombastus von Hohenheim – or, as he took to calling himself, Paracelsus. He was born in Switzerland in 1493 and the name he chose signified his sense of superiority to the Roman medical authority Celsus. It was a superiority that Paracelsus declared for himself. His career took him across the known European world, searching out knowledge and its mad relations. Paracelsus took a florid interest in the theories, intuitions and products of his own genius, combining them with armfuls of the occult, of alchemy and of more straightforward natural philosophy. ‘When I saw that nothing resulted from [medical] practice but killing and laming, I determined to abandon such a miserable art and seek truth elsewhere.’ His low opinion of contemporary medicine was accurate. Like many of those who held it over the centuries, his consequent belief that he could do very much better was wildly off the mark.

  The mental techniques with which Paracelsus armed himself were weak and treacherous. The ‘doctrine of signatures’, which pre-dated written histories, was one of his favourites. It held that inner powers could be determined by superficial appearances. When it came to medicine, this meant that similarities between a plant and a disease were taken to be proof of a therapeutic link. Gold cured jaundice since both were yellow, flowers that looked like testicles cured sexual diseases, the prickles of thistles mended prickly internal pains. It is an idea found in many societies, and neither its long heritage nor its attractive simplicity moves it any closer to being truthful. Other men trusted their intuitions and came up with therapies that were harmful. Paracelsus mocked them for it, then made up some of his own. More usefully, perhaps, he also equipped himself with a large sword. It was handy in itself, for a wandering and pugnacious soul in the medieval world, but within its hilt was something even better. He stuffed his sword with riches. ‘I possess a secret remedy,’ he declared, ‘which I call laudanum and which is superior to all other heroic remedies.’

  This pioneer of a new medicine talked a good revolution. ‘If I want to prove anything,’ he said, ‘I shall not do so by quoting authorities but by experiment and by reasoning thereupon. I do not believe in the ancient doctrine of complexions and humours which has been falsely supposed to account for all diseases. It is because of these doctrines that so few physicians have correct views of disease, its origins and its course.’ His ‘experiments’, however, were extensions of his own faith and intuition, their results folded up into theories so curdled and capacious that they contained all possible outcomes. Paracelsus talked like a scientist but his ‘truths’ were often fabulously complex delusions. He used the scientific jargon of the day, adopted the words and the traditions of emerging chemistry, and applied them in a manner as misleading as that of the mistaken Greeks, Romans and Arabs he viciously scorned. ‘I tell you, one hair on my neck knows more than all you authors, and my shoe-buckles contain more wisdom than both Galen and Avicenna.’ So much for his boasts. What, however, was this laudanum in the pommel of his sword?

  The miracle cure that Paracelsus carried around with him certainly looked strange. It consisted of what he called ‘Stones of Immortality’, which looked a bit like the droppings of an odd and furtive animal. Citrus juice, gold and other more unlikely ingredients were combined with opium. In fact, the only part of them that had a real effect was the opium. And it was an effect that people rather liked.

  They liked it not least because it really could increase their chances of living. So long as doctors like Paracelsus believed that it could cure them, they set aside their more dangerous alternative remedies. And while laudanum, like any form of opium, could be dangerous in overdose, compared to the rest of what the doctors used it was often safer than water.

  What Paracelsus discovered was a more potent form of opium, a way of concentrating it. He dissolved the poppy’s dried latex in alcohol rather than water. That added an extra dose of spirits to the medicine itself. It also meant, since the active compounds within the poppy dissolved far more easily in alcohol, that the pharmacological kick per pint was considerably greater.

  Paracelsus died in 1541. Eighty-three years later, in the summer of 1624, a baby was born in the English county of Dorset. Thomas Sydenham grew up in a world whose medicine as well as its school teaching remained heavily Greek and Roman. Subsequent advances in anatomy and in scientific method continued to be of little use to those who sought help from physicians, apothecaries or surgeons. Still, with an Oxford education and much natural sense (the more useful of the two, given the quality of England’s universities at the time), Sydenham was able to recognise a good thing. The poppy impressed him. He declared that ‘among the remedies which it has pleased the Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium’.

  Not that anyone yet understood how opium worked. Molière’s mockery in Le Malade imaginaire of 1673 made fun of the pompous jargon with which doctors hid their ignorance.

  ‘I have been asked by a learned doctor what is the cause and reason why opium induces sleep,’ says a medical student, hoping to be granted a licence to practise as a fully qualified doctor. ‘To which I reply it is because there is in it a dormitiv
e virtue, the nature of which is to sedate the senses.’ His examiners are delighted with his excellent response.

  Thomas Sydenham’s commitment to fresher ways of looking at the world bit deep into his life. His first session of study at Oxford ended when the Civil War broke out in 1642, and Sydenham went off to fight for the cause of Parliament and democracy against the Divine Right of the kings. He returned, having lost two brothers and a great quantity of his own blood, and finished his studies. But, he wrote, ‘I became convinced that the physician who earnestly studies, with his own eyes – and not through the medium of books . . . must necessarily excel.’ His Oxford education was entirely based on books; for a physician to study anything else was seen as being beneath such highly qualified men. Sydenham believed otherwise, and did his best to persuade others. A junior colleague asked for advice about the most useful books to study. ‘Read Don Quixote,’ he was told, ‘. . . a very good book; I read it still.’ It was not only the uselessness of contemporary textbooks that he was highlighting, but his own reputation for Quixotic eccentricity. It seemed more than a little mad for a doctor not to put his whole faith in the teaching of his elders.

  Robert Boyle, the Royal Society chemist, described Sydenham to a mutual friend as a ‘ripe scholar, a good botanist, and a skilled anatomist’. The friend repeated the praise, only for Sydenham to surprise him by responding: