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1,600 Years of Medical Hubris
Humorism, Miasmism, and More
Painting: “In the Valley,” by Alanna S. Graboyes, asgraboyesart.com.
NOTE: In the coming months, I’m posting excerpts from my not-yet-published book manuscript, Fifty-Million-Dollar Baby: Economics, Ethics, and Health. The goal is to edit the manuscript in plain view, and to ask for your comments, corrections, suggestions, and criticisms.
Over its long history, the field of medicine has been at its best when it was rife with questions and at its worst when it was brimming with answers. The physicians whose ignorance killed George Washington and James A. Garfield would probably have nodded approvingly at the “We Believe Science Is Real” signs planted today in the front yards of America’s tonier precincts. Medical science has a long history of slavish devotion to orthodoxy and stasis and virulent opposition to heterodoxy and change. Physicist Max Planck famously said, “Science progresses one funeral at a time.” In medical science, I would argue that, “Science progresses millions of funerals at a time.” Unwarranted stasis can kill in large numbers.
Since 1962, people have debated the meaning and value of philosopher Thomas Kuhn’s The Structure of Scientific Revolutions. Kuhn challenged the perception that the accumulation of scientific data leads us closer and closer to “truth.” Rather, in his paradigm, science is more of a metaphor for reality—an imperfect lens with which we examine a universe whose complexities are and will always be well beyond our grasp. In Kuhn’s formulation, any scientific theory, no matter how useful and imposing, will ultimately be overturned by successor theories when new evidence batters the old metaphor sufficiently. Newton’s formulation of gravity, for example, served mankind exceedingly well for centuries (and still does in certain settings). But by the early 20th century, the shortcomings of that model were becoming obvious, and Einstein devised a new metaphor—relativity. In some ways, medicine has always been especially resistant to the process that Kuhn enunciated.
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In 1799, doctors with answers knew that it was wise to drain sick patients’ blood into a bowl. The practice, they knew, had a proven record of success that dated back over many centuries. By 1799, however, doctors with questions challenged this logic, but they were met with powerful disapproval by the doctors with answers.
Lewis Thomas was an essayist and poet—a 20th century bard. Aside from those roles, he also served as dean of the New York University School of Medicine (1966-69) and Yale School of Medicine (1972-73), and also as President of Memorial Sloan-Kettering Institute (1973-83). In his elegiac The Fragile Species, Thomas recounted the 1,600 years in which Western medicine was mired in the answers inherited from the Greek-Roman physician Galen (129 – 216 CE). Galen was an undoubted genius who helped define the fields of anatomy, neurology, pathology, physiology, and pharmacology. However, as Thomas noted:
Galen … had guessed wildly, and wrongly, in no less than five hundred treatises on medicine and philosophy, that everything about human disease could be explained by the misdistribution of “humors” in the body. Congestion of the various organs was the trouble to be treated, according to Galen, and by the eighteenth century, the notion had been elevated to a routine cure-all, or anyway treat-all: remove the excess fluid, one way or another. The ways were direct and forthright: open a vein and take away a pint or more of blood at a sitting, enough to produce faintness and a bluish pallor, place suction cups on the skin to draw out lymph, administer huge doses of mercury of various plant extracts to cause purging, and if all else failed, induce vomiting.
Galen’s unfounded belief in the four bodily humors—known as “humorism”— became the central credo of Western medicine till the early 1800s.
Thomas noted that George Washington, a “hale and hearty” 66-year old, likely died from bloodletting after contracting a fever and sore throat. Researchers still debate whether doctors drained enough of Washington’s blood to have killed him. But we do know that in the years leading up to 1799, the practice itself was already coming under intense criticism. In particular, Benjamin Rush, signer of the Declaration of Independence and the most celebrated American doctor of his time, was undergoing years of withering criticism of his management of a 1793 yellow fever epidemic in Philadelphia.
In a paper on that episode, “Benjamin Rush, MD: Assassin or Beloved Healer?” Robert L. North, MD, describes Rush as, “unshakable in his convictions, as well as self-righteous, caustic, satirical, humorless, and polemical.” He had decided in 1789 that:
there was only 1 fever in the world. He held that all fevers were a single entity, just as fire is a single entity: “Thus fire is a unit whether it be produced by friction, percussion, electricity, fermentation, or by a piece of wood or coal in a state of inflammation.”
And so, just as the streets of Paris were running red with blood unleashed by the guillotine, the streets of Philadelphia were running red with blood unleashed by Benjamin Rush’s medical instruments. From North’s paper:
Rush entered a frenzied state, personally seeing as many as 100 patients a day. His home became a clinic and a sort of pharmaceutical factory staffed by 5 of his students and apprentices, 3 of whom died of yellow fever. So much blood was spilled in the front yard that the site became malodorous and buzzed with flies. He prescribed repeated doses of pills and powders consisting of 10 grains of calomel and 10 grains (later 15) of jalap, at least 10 times the customary dose. These produced copious black stools and often provoked gastrointestinal bleeding before finally yielding only a few shreds of mucus. Rush estimated that the average person contained 25 pounds of blood and recommended that up to 80% be removed.
As such practices finally fell from favor, Lewis Thomas the era of “therapeutic nihilism” that settled in during the 1830s:
Groups of doctors in Boston, Paris, and Edinburgh raised new questions, regarded as heretical by most of their colleagues, concerning the real efficacy of the standard treatments of the day. … The great illumination from this, the first revolution in medical practice in centuries, was the news that there were many diseases that are essentially self-limited. … The new lesson was that treating [patients] made the outcome worse rather than better.
The next century—straight through Thomas’s own medical education at Harvard in the 1930s, was one not of answers, but of questions. The questioners, we might say, drained the medical field of its centuries-old hubris as surely as its cocksure physicians had drained their patients of bodily fluids.
This is not to say that medicine was devoid of destructive certainty after the 1830s. As Galenism faded in the 19th century, miasma theory, which had been around for a long while, had its day. Miasmists perceptively noticed that outbreaks of disease often occurred where there was stench in the air. They concluded, however, that the stench itself—“bad air”—was the cause of disease. (The word “malaria,” for example, literally means “bad air.”) For many or most, that was all one needed to know. Miasmism had profound effects on popular culture. People of the Victorian Era became obsessed with ventilation. In the mid-19th century, miasmists conjectured that disease-causing air gathered in the right angles of houses. This set off a brief craze for octagonal houses, popularized by the vegetarian phrenologist pundit Orson Squire Fowler.
Researchers who suspected that microorganisms (germs) or genetics might be at work were excoriated. The great showdown between miasmists and “contagionists” (some of whom were germ theorists) came in 1854, when a cholera epidemic broke out in London. Miasmists correctly noted the presence of stench in the affected areas. But physician John Snow—arguably the first modern epidemiologist—traced the outbreak to sewage flowing beneath the affected neighborhoods. The history of Snow’s triumph is told in Steven Johnson’s riveting The Ghost Map: The Story of London’s Most Terrifying Epidemic—and How It Changed Science, Cities, and the Modern World (2006).
Miasmism wasn’t quite done yet, however. Most famously, this anti-germ obstinacy destroyed and likely killed Hungarian physician, Dr. Ignaz Semmelweis (1818-1865). He had demonstrated that hand-washing resulted in massive reduction in childbirth deaths. Semmelweis could not explain his miraculous results, and many practitioners were offended by the suggestions that they were filthy transmitters of disease. They mocked Semmelweiss, and some fabricated contradictory data. Semmelweiss was institutionalized after a mental breakdown and quickly died of an infected wound likely sustained in a beating by guards. Decades later, Semmelwiss’s theories became medical orthodoxy through the work of Louis Pasteur, Joseph Lister, and others.
If the humorists killed one U.S. president (George Washington), then miasmists likely killed another, eight decades later. In Destiny of the Republic: A Tale of Madness, Medicine and the Murder of a President (2011), author Candice Millard tells the gripping history of Garfield’s assassination. Garfield was shot in a Washington, DC, railway station and died an excruciating two-and-a-half month descent into death. An autopsy instantly revealed that the bullet had not killed Garfield. Left alone, he would probably have recovered quickly and survived. But Garfield’s physicians were old-school faces from the miasma era of medicine. Throughout what should have been Garfield’s convalescence, they poked and prodded his wound with unwashed fingers. Thus was the result of obsession with one particular theory of health and resistance to evidence to the contrary. Ironically, national outrage over the autopsy did much to bring germ theory to the forefront of American medicine.
Hubris and disdain for heterodoxy did not vanish from medicine with the conclusion of the 19th century. Eugenics became The Answer in the late-19th and early-20th century. Late in the 20th century, Stanley Prusiner and others asked whether misfolded proteins might cause diseases such as bovine spongiform encephalopathy (mad cow disease) or its human equivalent, Creutzfeldt-Jakob Disease. He was pilloried as a heretic — a pejorative that didn’t entirely vanish when he received a Nobel Prize for his pathbreaking discoveries. When the underqualified pop figure Bruno Bettelheim suggested that autism resulted from emotional deprivation caused by “refrigerator mothers,” one questioned his ideas at one’s peril.
In a classic Saturday Night Live skit, Steve Martin (humorist in the entertainment sense) portrays Theodoric of York, Medieval Barber (humorist in the medical sense). Barbers in medieval times often acted as doctors, too, and Theodoric is a practitioner who exuberantly drains every incoming patient’s blood—sometimes with fatal result.
With a cheerful, philosophic bent, Theodoric tells the mother of one patient:
Why, just fifty years ago, we would have thought your daughter's illness was brought on by demonic possession or witchcraft. … But nowadays we know that Isabelle is suffering from an imbalance of bodily humors, perhaps caused by a toad or a small dwarf living in her stomach.
After the exsanguinated daughter dies, the mother is distraught, and Theodoric suggests that draining some of the mother’s blood might make her feel better. The mother calls him a charlatan, and he breaks the fourth wall, sharing his inner doubts with the audience.
Wait a minute. Perhaps she’s right. Perhaps I’ve been wrong to blindly follow the medical traditions and superstitions of past centuries. Maybe we barbers should test these assumptions analytically, through experimentation and a “scientific method.” Maybe this scientific method could be extended to other fields of learning: the natural sciences, art, architecture, navigation. Perhaps I could lead the way to a new age, an age of rebirth, a Renaissance!
After a pregnant pause, he grimaces and exhales a loud “Naaaaaaaaah!” For 16 centuries, “Naaaaaaaaah!” was the predominant response to anyone who questioned Galen or his theories.
“Naaaaaaaaah!” resides with us still.
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