Trick or Treatment (2 page)

THIS BOOK IS ABOUT ESTABLISHING THE TRUTH IN RELATION TO
alternative medicine. Which therapies work and which ones are useless? Which therapies are safe and which ones are dangerous?

These are questions that doctors have asked themselves for millennia in relation to all forms of medicine, and yet it is only comparatively recently that they have developed an approach that allows them to separate the effective from the ineffective, and the safe from the dangerous. This approach, known as
evidence-based medicine
, has revolutionized medical practice, transforming it from an industry of charlatans and incompetents into a system of healthcare that can deliver such miracles as transplanting kidneys, removing cataracts, combating childhood diseases, eradicating smallpox and saving literally millions of lives each year.

We will employ the principles of evidence-based medicine to test alternative therapies, so it is crucial that we properly explain what it is and how it works. Rather than introducing it in a modern context, we will go back in time to see how it emerged and evolved, which will provide a deeper appreciation of its inherent strengths. In particular, we will look back at how this approach was used to test
bloodletting
, a bizarre and previously common treatment that involved cutting skin and severing blood vessels in order to cure every ailment.

The boom in bloodletting started in Ancient Greece, where it fitted in naturally with the widespread view that diseases were caused by an imbalance of four bodily fluids, otherwise known as the four
humours
: blood, yellow bile, black bile and phlegm. As well as affecting health, imbalances in these humours resulted in particular temperaments. Blood was associated with being optimistic, yellow bile with being irascible, black bile with being depressed and phlegm with being unemotional. We can still hear the echo of humourism in words such as sanguine, choleric, melancholic and phlegmatic.

Unaware of how blood circulates around the body, Greek physicians believed that it could become stagnant and thereby cause ill-health. Hence, they advocated the removal of this stagnant blood, prescribing specific procedures for different illnesses. For example, liver problems were treated by tapping a vein in the right hand, whereas ailments relating to the spleen required tapping a vein in the left hand.

The Greek medical tradition was held in such reverence that bloodletting grew to be a popular method for treating patients throughout Europe in the centuries that followed. Those who could afford it would often receive bloodletting from monks in the early Middle Ages, but then in 1163 Pope Alexander III banned them from practising this gory medical procedure. Thereafter it became common for barbers to take on the responsibility of being the local bleeder. They took their role very seriously, carefully refining their techniques and adopting new technologies. Alongside the simple blade, there was the
phleam
, a spring-loaded blade that cut to a particular depth. In later years this was followed by the
scarificator
, which consisted of a dozen or more spring-loaded blades that simultaneously lacerated the skin.

For those barbers who preferred a less technological and more natural approach, there was the option of using medicinal leeches. The business end of these bloodsucking parasitic worms has three separate jaws, each one of them carrying about 100 delicate teeth. They offered an ideal method for bloodletting from a patient’s gums, lips or nose. Moreover, the leech delivers an anaesthetic to reduce pain, an anticoagulant to prevent the blood from clotting, and a vasodilator to expand its victim’s blood vessels and increase flow. To enable major bloodsucking sessions, doctors would perform
bdellatomy
, which involved slicing into the leech so that blood entered its sucker end and then leaked out of the cut. This prevented the leech from becoming full and encouraged it to continue sucking.

It is often said that today’s red-and-white barbershop pole is emblematic of the barber’s earlier role as surgeon, but it is really associated with his position as bleeder. The red represents the blood, the white is the tourniquet, the ball at the end symbolizes the brass leech basin and the pole itself represents the stick that was squeezed by the patient to increase blood flow.

Meanwhile, bloodletting was also practised and studied by the most senior medical figures in Europe, such as Ambroise Paré, who was the official royal surgeon to four French kings during the sixteenth century. He wrote extensively on the subject, offering lots of useful hints and tips:

When Europeans colonized the New World, they took the practice of bloodletting with them. American physicians saw no reason to question the techniques taught by the great European hospitals and universities, so they also considered bloodletting to be a mainstream medical procedure that could be used in a variety of circumstances. However, when it was administered to the nation’s most important patient in 1799, its use suddenly became a controversial issue. Was bloodletting really a life-saving medical intervention, or was it draining the life out of patients?

The controversy began on the morning of 13 December 1799, the day that George Washington awoke with the symptoms of a cold. When his personal secretary suggested that he take some medicine, Washington replied, ‘You know I never take anything for a cold. I’ll let it go just as it came.’

The sixty-seven-year-old former president did not think that a sniffle and a sore throat were anything to worry about, particularly as he had previously suffered and survived far more severe sicknesses. He had contracted smallpox as a teenager, which was followed by a bout of tuberculosis. Next, when he was a young surveyor, he caught malaria while working in the mosquito-infested swamps of Virginia. Then, in 1755, he miraculously survived the Battle of Monongahela, even though two horses were killed beneath him and four musket balls pierced his uniform. He also suffered from pneumonia, was repeatedly afflicted by further bouts of malaria, and developed ‘a malignant carbuncle’ on his hip that incapacitated him for six weeks. Perversely, having survived bloody battlefields and dangerous diseases, this apparently minor cold contracted on Friday 13th would prove to be the greatest threat to Washington’s life.

His condition deteriorated during Friday night, so much so that he awoke in the early hours gasping for air. When Mr Albin Rawlins, Washington’s estate overseer, concocted a mixture of molasses, vinegar and butter, he found that his patient could hardly swallow it. Rawlins, who was also an accomplished bloodletter, decided that further action was required. Anxious to alleviate his master’s symptoms, he used a surgical knife known as a lancet to create a small incision in the General’s arm and removed one-third of a litre of blood into a porcelain bowl.

By the morning of 14 December there was still no sign of any improvement, so Martha Washington was relieved when three doctors arrived at the house to take care of her husband. Dr James Craik, the General’s personal physician, was accompanied by Dr Gustavus Richard Brown and Dr Elisha Cullen Dick. They correctly diagnosed
cynanche trachealis
(‘dog strangulation’), which we would today interpret as a swelling and inflammation of the epiglottis. This would have obstructed Washington’s throat and led to his difficulty in breathing.

Dr Craik applied some cantharides (a preparation of dried beetles) to his throat. When this did not have any effect, he opted to bleed the General and removed another half a litre of blood. At 11 a.m. he removed a similar amount again. The average human body contains only 5 litres of blood, so a significant fraction was being bled from Washington at each session. Dr Craik did not seem concerned. He performed venesection again in the afternoon, removing a further whole litre of blood.

Over the next few hours, it appeared that the bloodletting was helping. Washington seemed to recover and for a while he was able to sit upright. This was, however, merely a temporary remission. When his condition deteriorated again later that day, the doctors conducted yet another session of bloodletting. This time the blood appeared viscous and flowed slowly. From a modern perspective this reflects dehydration and a general loss of bodily fluid caused by excessive blood loss.

As the evening passed, the doctors could only watch grimly as their numerous bloodlettings and various poultices failed to deliver any signs of recovery. Dr Craick and Dr Dick would later write: ‘The powers of life seemed now manifestly yielding to the force of the disorder. Blisters were applied to the extremities, together with a cataplasm of bran and vinegar to the throat.’

George Washington Custis, the dying man’s step-grandson, documented the final moments of America’s first President:

George Washington, a giant man of 6 feet 3
¹
/2 inches, had been drained of half his blood in less than a day. The doctors responsible for treating Washington claimed that such drastic measures had been necessary as a last-ditch resort to save the patient’s life, and most of their colleagues supported the decision. However, there were also voices of dissent from within the medical community. Although bloodletting had been an accepted practice in medicine for centuries, a minority of doctors were now beginning to question its value. Indeed, they argued that bloodletting was a hazard to patients, regardless of where on the body it took place and irrespective of whether it was half a litre or 2 litres that was being taken. According to these doctors, Dr Craik, Dr Brown and Dr Dick had effectively killed the former President by needlessly bleeding him to death.

But who was right – the most eminent doctors in the land who had done their best to save Washington, or the maverick medics who saw bloodletting as a crazy and dangerous legacy of Ancient Greece?

Coincidentally, on the day that Washington died, 14 December 1799, there was effectively a legal judgement on whether bloodletting was harming or healing patients. The judgement arose as the result of an article written by the renowned English journalist William Cobbett, who was living in Philadelphia and who had taken an interest in the activities of a physician by the name of Dr Benjamin Rush, America’s most vociferous and famous advocate of bloodletting.

Dr Rush was admired throughout America for his brilliant medical, scientific and political career. He had written eighty-five significant publications, including the first American chemistry textbook; he had been surgeon general of the Continental Army; and, most important of all, he had been a signatory to the Declaration of Independence. Perhaps his achievements were to be expected, bearing in mind that he graduated at the age of just fourteen from the College of New Jersey, which later became Princeton University.

Rush practised at the Pennsylvania Hospital in Philadelphia and taught at its medical school, which was responsible for training three-quarters of American doctors during his tenure. He was so respected that he was known as ‘the Pennsylvania Hippocrates’ and is still the only physician to have had a statue erected in his honour in Washington DC by the American Medical Association. His prolific career had allowed him to persuade an entire generation of doctors of the benefits of bloodletting, including the three doctors who had attended General Washington. For Rush had served with Dr Craik in the Revolutionary War, he had studied medicine with Dr Brown in Edinburgh, and he had taught Dr Dick in Pennsylvania.

Dr Rush certainly practised what he preached. His best-documented bloodletting sprees took place during the Philadelphia yellow fever epidemics of 1794 and 1797. He sometimes bled 100 patients in a single day, which meant that his clinic had the stench of stale blood and attracted swarms of flies. However, William Cobbett, who had a particular interest in reporting on medical scandals, was convinced that Rush was inadvertently killing many of his patients. Cobbett began examining the local bills of mortality and, sure enough, noticed an increase in death rates after Rush’s colleagues followed his recommendations for bloodletting. This prompted him to declare that Rush’s methods had ‘contributed to the depopulation of the Earth’.

Dr Rush’s response to this allegation of malpractice was to sue Cobbett for libel in Philadelphia in 1797. Delays and distractions meant that the case dragged on for over two years, but by the end of 1799 the jury was ready to make a decision. The key issue was whether Cobbett was correct in claiming that Rush was killing his patients through bloodletting, or whether his accusation was unfounded and malicious. While Cobbett could point to the bills of mortality to back up his case, this was hardly a rigorous analysis of the impact of bloodletting. Moreover, everything else was stacked against him.