Sunday, January 13, 2008

Review: "Bad Medicine: Doctors Doing Harm Since Hippocrates", David Wootton

How did a set of medical techniques and institutional styles with absolutely no therapeutic value survive for 2,500 years from ancient Greece to the early 20th century - even though the scientific knowledge required to demolish them had been available since the 1600s? This is the question David Wootton's "Bad Medicine: Doctors Doing Harm since Hippocrates" sets out to answer.

Writing the history of failure is an interesting project; even more so when the activity concerned isn't adversarial. Wootton's main thesis is, in effect, that the germ theory was the all-decisive factor in the great breakout from disease in the mid-19th century, and that resistance to it or failure to grasp the consequences was the main reason why scientific medicine took so long to arrive.

Van Leeuwenhoek, the inventor of the microscope, was the first man to see a bacterium, in the 1650s in Leiden; soon there was a wave of interest across Europe in the new technology of microscopy and the astonishing discovery of microorganisms. This gave rise to an intellectual ferment about the nature of, well, fermentation among other things; the centre of the debate was the notion of spontaneous generation. Although, with hindsight, the fact that microbes were already everywhere should have blown the gaff and made clear that the experiments that supposedly displayed it were actually examples of experimental error, there were still believers as late as the 1870s.

Whether germs were spontaneously generated or not seems a slightly odd preoccupation; surely it was more important that they were there? However, it was a major ideological roadblock to accepting that germs were responsible for wound infections; strangely, none of van Leeuwenhoek's peers seems to have thought of turning their microscope on a patient. Even more strangely, microscopes went out of fashion; medicine simply ignored microscopy up to the 1830s. The opportunity was passed up. This sort of thing kept on happening; even John Locke, who called on van Leeuwenhoek in exile and looked down the microscope, wrote that it was absurd to imagine it had any clinical use.

What was going on was a major disjuncture between the value medicine placed on different forms of knowledge; practical, technical knowledge was undervalued, and canonical, scholastic knowledge overvalued. As Wootton pointed out, a hypothetical early-18th century pupil in Leiden could have observed an infected wound with a microscope; they could have experimented on an animal; they could have tried, as Schwann eventually did in 1837, to kill the germs with heat or salt or perhaps alcohol (Holland was where the gin came from, after all), and this would have given us antiseptic surgery a hundred and fifty years before Lister.

Something similar happened with regard to infection control; Alexander Gordon had recognised that puerperal fever and erysipelas were the same disease, and that they were spread through the hospital by doctors, in the 1790s. He was even able to predict who would get it next, having worked out which staff members were carriers - including himself. But the only part of his research anyone was interested in were some suggestions about bloodletting, the canonical medical treatment pre-Lister. It was the kind of knowledge that was authorised. Oliver Wendell Holmes made the same discoveries fifty years later and collected a similar budget of abuse. Ignaz Semmelweis did, too, but fatally missed the link with other diseases, which would have given us antiseptic surgery thirty years before Lister.

In the 17th century, it had been routine for ships to carry lemon juice as a precaution against scurvy, but although it actually worked the medical establishment was able to persuade the navy that they were wrong to use it for almost a hundred years. Again and again, bad knowledge actually triumphed over good; it kept doing so until its failure was both glaringly apparent and its replacement obvious.

A leitmotif in the book is the microscope; not only because of its role in microbiology, but I think also because it was a form of subversive technology. Unlike medical degrees and Galenic textbooks, anyone could possess a microscope; even the skills required to make them were not incredibly rare. The user was able to observe the new nature without anyone's intermediation; a genuinely Protestant product. No wonder they were scared. Similarly, the beginning of statistics made it increasingly impossible to conceal the uselessness of medicine. John Snow could plot cholera cases on a map; so could the priest Henry Whitehead, who set out to conduct his own research in order to refute Snow but ended up convincing himself. Counting, like microscopy, was fatal to the closed system of knowledge.

None of this guarantees success; Snow had to convince William Farr, a top government official and a sort of David Kane figure who theorised that cholera was caused by living too close to sea level. Farr had identified a correlation between altitude and cases, and derived a formula; unfortunately it predicted that at sea level everyone would already be dead, but this didn't stop him. He argued that people at sea level actually lived 13 feet above it because of buildings, and predicted that the race would degenerate unless the government forced everyone to build on higher ground.

It's hard not to wonder what other scientific revolutions didn't happen; it's more profitable to wonder what our systems of knowledge are denying now. Wootton points out that medicine didn't have to be converted; it would have been quite possible for the traditional doctors to stagger on, competing for patients with newly emerging Lister Institutes, perhaps perpetuating the divide between surgery and medicine. As late as the 1970s, he says, it was possible to find "Ionian" - i.e. Galenic - doctors practising in Iraq.

The climate change deniers are an obvious example, but I suspect they are well on the way out; I can't help but suspect there are a lot of Galenic economists out there.

In a special note, by the way, Wootton does suggest that Daniel Davies's manifesto may be flawed. Daniel argues that middle-class progressives' schemes to nudge the poor this way and that are always and everywhere stupid, ineffective, and destructive of freedom. There is much to be said for this view; however, Wootton presents a strong case for the view that a canonical example of such schemes, the health visitor and the Fabians' keenness on telling the poor how to cook, may have saved many lives in Edwardian London. Specifically, although London had the Bazalgette sewerage system and clean water by then, the death rate from infantile diarrohea was the same in houses with flush toilets and without; the explanation of the paradox was that children shat in the street, and then didn't wash their little hands. The answer was apparently a good finger-wagging, and maybe a thrashing or six; by the 1930s the rate was effectively zero.


Anonymous said...

Hmmmm, yeah, good point - I probably ought to read the book. I seem to remember that the Fabians (among others) took the opportunity to bring along a number of other progressive schemes for the improvement of the working class as they went along though (specifically, quite a bit of eugenics wasn't it)?

Anonymous said...

Ever hear of the London Statistical Society? Not to be confused with the Statistical Society of London (tr. arr. T. Malthus, later to come over all Royal, etc), this was a 2-men +dog outfit which emerged from the late 1810s radical scene, on a mission to count the extent of Old Corruption. And a lot of other things, including: 'the territorial extent and population, rental, taxation, finances, commerce, consumption, insolvency, pauperism, and crime, of the British Empire'.

Then the utilitarians stuck their oar in, and that was that. Powerful juj^h^H discourse, numbers.

Chris Williams

ejh said...

Was it like the Nine Billion Names of God, i.e. once they'd counted all of it, it would begin to disappear?

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