Quacks over the ages

David Wootton
BAD MEDICINE
Doctors doing harm since Hippocrates
304pp. Oxford University Press. £16.99.
0 19 280355 7
Katrina S. Firlik
BRAIN MATTERS
Adventures of a brain surgeon
290pp. Weidenfeld and Nicolson. £16.99.
0 297 84807 0

Expert opinion is treacherous. Consider a paper from last year’s British Medical Journal, looking at four decades of trials on new cancer treatments. The theory behind each treatment was excellent, the understanding of the molecular processes was first-rate, and initial small studies had shown some evidence of benefit. Doctors thought the new treatments would work; but the trials showed that they harmed as often as they helped. That is to say, without the benefit of large-scale, randomized, double-blind controlled trials, doctors were unable to pick out the treatments that worked from those that were total failures.

To an extent, the dangers of expert opinion explain why doctors have spent most of human history killing their patients. Women giving birth in hospitals frequently paid for the privilege with their lives, while physicians, apothecaries and surgeons all doled out bad advice and poisonous drugs. Therapeutic nihilists were the best the medical profession had to offer, like the seventeenth-century Italian who defended himself by saying, “I take the money not for my services as a doctor but as a guard, to prevent some young man who believes everything he reads in books from coming along and stuffing something down the patients which kills them”. Thomas McKeown first pointed out that the vast twentieth-century improvements in health came about before doctors developed much that was an effective therapy. We know that most medicines were worse than useless. It is truly odd that some discoveries were not made much sooner.

In Bad Medicine, David Wootton puts all these things together to create a genuinely thrilling adventure out of the abysmal failings of doctors over the past 2,000 years.
Wootton’s is a concise cry of appalled rage. He takes an unsparing interest in why doctors made bad decisions, ignored screamingly obvious discoveries and consistently refused to adopt therapies that stood to be of the greatest benefit to mankind. “We can only think about medical progress if we start with the long tradition of medical failure . . . . We know how to write histories of discovery and progress, but not how to write histories of stasis, of delay, of digression.” A sound knowledge of anatomy, the discovery of the microscope and the stethoscope, the birth of the great charity hospitals and most of the great nineteenth-century innovations in chemistry, pharmacology, pathology and therapeutics: all of these, Wootton insists angrily, are wrongly portrayed as medical successes. They were scientific advances, often held back for centuries by doctors uncomfortable with change, but they extended nobody’s life and healed no one’s disease. As medical innovations they were failures, and traditional histories of medicine overlook this basic fact. To read them is to think doctors were the powerfully effective health-givers they mistakenly believed themselves to be.

Wootton lavishes most fury on those who are normally praised for achievements that they never really made – achievements they actually often delayed or prevented. James Lind, for example, is usually credited with saving millions of lives by eradicating scurvy. He randomly allocated three pairs of sailors to different treatments, noting that the two given citrus juice stayed healthy while the others sickened. Doctors worship Lind not only for the lives he saved as a result, but also for the technical innovation of this first randomized controlled trial. Wootton points out that Lind’s trial was small, inconclusive and inconsequential, and that Lind was so incapable of perceiving its importance that he prevented anybody else from being persuaded of it. Lind’s study wasn’t interpreted correctly until the second half of the twentieth century, when the utility of randomized controlled trials was fully understood. The realization that fresh fruit – especially citrus – cured scurvy was very gradual. It had been suggested before Lind’s study, and the Navy did not start to issue limes as standard until some fifty years after this. It wasn’t until the early twentieth century that the effects of vitamin C were fully understood. For Wootton, “Lind had no clear understanding of exactly what it was that he had discovered in 1747, and no grasp of the importance of the clinical trial as a procedure, and his failure to repeat and extend it, means that he actually deserves to be left in obscurity”. The suggestion is damning enough, but Wootton believes Lind deserves infamy even more than obscurity: those blessed with the ability to see the truth clearly must take the most blame for remaining blind. In the words of Luke 11:52: “Woe unto you . . . for ye have taken away the key of knowledge: ye entered not in yourselves, and them that were entering in ye hindered”.

For Wootton, the past is full of men like Lind, men whose disastrous ignorance has been transformed by historians into the appearance of heroic innovation. Thomas Sydenham is normally regarded as the founder of clinically astute medicine in Britain, a man who made generations think more clearly about the evidence of their senses. Wootton paints him as a fool who made an arrogant mistake that held medicine back for 200 years. “I am passing judgement on Sydenham for failing to understand the potential of the microscope”, he writes, suggesting that truthfulness in medicine can be so objective that honest commentators must take sides. Hippocratic therapies are not perfectly valid within the context of their own culture: they are just plain wrong. Leeches are not a cure-all, lettuce is not an effective therapeutic drug and homoeopathy cannot be viewed as a medical therapy when all the trial evidence shows it to be useless. We should refuse to praise medical ideas for their intellectual coherence or emotional satisfactions, says Wootton, and insist on looking only at their ability to extend our lives and make us healthier. The ability to dispense cures and comforts defines a doctor, not the possession of a white coat and a diploma. “Why do historians prefer to focus on the birth of the clinic”, he asks, “rather than the germ theory of disease or the clinical trial?” Foucault’s emphasis on the doctor-led hospital clinic mistakes the basic business of medicine. Results, not rituals, are what count.

Wootton spends much time puzzling over why scientific knowledge failed to advance. He tries to work out why Harvey should have discovered the circulation of the blood when Galen did not (an innovation that he accurately identifies as being of no therapeutic benefit to anyone, failing even to make doctors realize that bleeding their patients to unconsciousness was a bad idea). “There is no way of identifying a difference of method or of intellectual equipment that distinguishes Harvey from Galen . . . . The experimental method, comparative anatomy, mechanical models, quantification, and vivisection are familiar to Galen just as they are to Harvey.”

Wootton frequently raises questions that he feels unable to answer. It makes a wonderful contrast with the generations of doctors whose inability to tolerate uncertainty betrayed their thinking and their patients. The philosophy of “Often wrong, never in doubt” has killed too many people. It is one of Wootton’s charms that he repeatedly applies the lessons learnt from the mistakes of doctors, questioning his own assumptions, distrusting his own answers and dosing himself repeatedly with a fertile and winning humility. Instead of a steady march of progress, Wootton finds medical history to be full of pauses and regressions, with inexplicable gulfs separating haphazardly timed accidents of inspiration and discovery. This belief in chance and punctuated development is reminiscent of Stephen Jay Gould’s take on evolution, but here it has even more appeal.

Outrageous fortune is far more interesting, after all, when it stems from personalities rather than random mutations, and Wootton has a knack for sketching the relationships between character and history. The nineteenth-century physician John Snow’s teetotal vegetarianism made him easily suspicious of London’s water supply when investigating the causes of cholera, we are told, since he knew it was contaminated with microscopic bits of half-digested meat from human faeces. Richard Doll mentally revised his discovery of a link between smoking and cancer, blurring the truth in a manner that Wootton suggests was characteristic of the medical profession at the time. This is a book of credit and blame, genius and stupidity, fear and insight, and its revisions of accepted history make for an emotionally and intellectually gripping drama. The historical catastrophe of medicine has never been so excitingly and stirringly told.

Excusably, since he is caught up in pointing out that everyone has generally got everything upside down, Wootton fails to make some important connections. It is true that doctors have been criminally intolerant of doubt, and that their resulting incompetence has been compounded by their innumerate complacency. But these are not exclusively medical traits, and societies get the doctors they deserve. Wootton suggests that homoeopathy should be available on the NHS as a harmless placebo, ignoring the fact that colluding with mental laziness is a guarantee of intellectual ill health. If you allow people to avoid the trouble of thinking, you lose the right to complain when their children become doctors and do the same. And there is a wider point about the way in which the randomized double-blind controlled trial (RCT) has transformed the medical world. Doctors now accept that the human body is so complex that, while they can come up with good theories, only RCTs can eliminate prejudices, separate associations from causal links, and provide reliable answers. Yet economics, politics and social policy continue to rely on the sort of expert opinion and low-quality studies that have proven so disastrous for medicine. Attention must be paid.

Katrina S. Firlik’s Brain Matters makes a stimulating change from all this compelling originality and provocative thoughtfulness. If you have ever suspected that pushing a finger into the soft goo of another person’s brain leads to fresh and startling conclusions about human life, this is the book to disillusion you. Firlik is full of breathless enthusiasm; so full of it, unfortunately, that other qualities are kept at bay. She wants to tell you about her life as a neurosurgeon, and her best point is her infectious eagerness. The style is reminiscent of a teenage essay on “what I did during my neurosurgical training”, and the insights are at roughly the same level. She reveals that sick patients are people too, “not just a collection of clinical data”; she lets us into the fact that “life is not a dress rehearsal”, and that “you can’t judge a person’s intelligence by his outward appearance”.
Initially it’s hard to pin down exactly why her thoughtless and clichéd anecdotes are so insufferable. Blind adoration is appealing in its way, but Firlik seems to worship even the most stupid and destructive aspects of the American hospital system. Teaching by humiliation, pointlessly long hours and the infliction of needless operations on damaged patients are all held up for praise. But the source of the real chill gradually becomes apparent. It is Firlik’s conviction of her own superiority, and her misguided overestimation of her dull, workplace thoughts. At the end of Brain Matters, she invites us to marvel with her at the superlative intelligence of a group of her colleagues. “What might be accomplished”, she asks, awed at the qualities of people like herself, “if the same group lent some of their collective brain power to, say, improving public education or homeland security?” Both books demonstrate the dangers of doctors who think too much of themselves.