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Excerpt from "Trick or Treatment"

How Do You Determine the Truth?

‘Truth exists - only lies are invented.' - Georges Braque

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:

If the leeches be handled with the bare hand, they are angered, and
become so stomachfull as that they will not bite; wherefore you shall
hold them in a white and clean linen cloth, and apply them to the skin
being first lightly scarified, or besmeared with the blood of some other
creature, for thus they will take hold of the flesh, together with the skin
more greedily and fully. To cause them to fall off, you shall put some
powder of Aloes, salt or ashes upon their heads. If any desire to know
how much blood they have drawn, let him sprinkle them with salt made
into powder, as soon as they are come off, for thus they will vomit up
what blood soever they have sucked.

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

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:
As the night advanced it became evident that he was sinking, and he
seemed fully aware that ‘his hour was nigh'. He inquired the time, and
was answered a few minutes to ten. He spoke no more - the hand of
death was upon him, and he was conscious that ‘his hour was come'.
With surprising self-possession he prepared to die. Composing his form
at length and folding his arms on his bosom, without a sigh, without a
groan, the Father of his Country died. No pang or struggle told when the
noble spirit took its noiseless flight; while so tranquil appeared
the manly features in the repose of death, that some moments had
passed ere those around could believe that the patriarch was no more.

George Washington, a giant man of 6 feet 31⁄2 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 threequarters
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.
For example, the trial called just three witnesses, who were all
doctors sympathetic to Dr Rush's approach to medicine. Also, the case
was argued by seven lawyers, which suggests that powers of
persuasion were more influential than evidence. Rush, with his wealth
and reputation, had the best lawyers in town arguing his case, so
Cobbett was always fighting an uphill battle. On top of all this, the jury
was probably also swayed by the fact that Cobbett was not a doctor,
whereas Rush was one of the fathers of American medicine, so it
would have seemed natural to back Rush's claim.

Not surprisingly, Rush won the case. Cobbett was ordered to pay
$5,000 to Rush in compensation, which was the largest award ever paid
out in Pennsylvania. So, at exactly the same time that George
Washington was dying after a series of bloodletting procedures, a court
was deciding that it was a perfectly satisfactory medical treatment.
We cannot, however, rely on an eighteenth-century court to decide
whether or not the medical benefits of bloodletting outweigh any
damaging side-effects. After all, the judgement was probably heavily
biased by all the factors already mentioned. It is also worth remembering
that Cobbett was a foreigner, whereas Rush was a national hero,
so a judgement against Rush was almost unthinkable.

In order to decide the true value of bloodletting, the medical profession
would require a more rigorous procedure, something even less
biased than the fairest court imaginable. In fact, while Rush and
Cobbett were debating medical matters in a court of law, they were
unaware that exactly the right sort of procedure for establishing the
truth about medical matters had already been discovered on the other
side of the Atlantic and was being used to great effect. Initially it was
used to test a radically new treatment for a disease that afflicted only
sailors, but it would soon be used to evaluate bloodletting, and in time
this approach would be brought to bear on a whole range of medical
interventions, including alternative therapies.

Reprinted from Trick or Treatment: The Undeniable Facts About Alternative Medicine by Simon Singh and Edzard Ernst. With permission of the publisher, W.W. Norton & Company, Inc.

This program aired on September 9, 2008. The audio for this program is not available.

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