Article Outline

• Copyright

For 2,400 years patients have believed that doctors are doing them good; for 2,300 years they have been wrong (p. 2).

David Wootton is an historian with a non-ordinary account of medical history. The context for Wootton's history is the relatively recent medical commitment to evidence-based practice. Bad Medicine shows us what happens when there is a schism between Theory/Evidence/Practice as there was for most of medical history. An ordinary history of medicine is a triumphant account of brilliant insights and advancing medical care. In an ordinary history, medicine takes credit for advances in the health of populations even when it has been improved diet, sanitation and household cleanliness that have been shown to be the major contributors to health. Wootton began the project of writing Bad Medicine by wondering why doctors took so long to adopt new knowledge and to change old practices that were damaging and killing patients. In Bad Medicine he sets out a history to support his central thesis: that from the 5th century until the widespread introduction of antibiotics in the 1940s doctors have done more harm than good. The British Medical Journal calls this book “Explosive” and for the general reader it is indeed. I will share with you a sample of the type of history you can expect if you read this book.

Hippocrates lived on the Greek island, Cos, around 460–375 b.c. Hippocrates believed that when health was disrupted then balance needed to be restored by manipulating diet, exercise, rest and fluids. The original medical therapies were emetics, purgatives and blood letting; either using a lancet or by ‘cupping’ after cutting the skin. Later leeches and cautery were added and these ‘therapies’, together made up the fundamental medical interventions for the next 2000 years. Wooton argues that Hippocratic ideas, so strongly influenced doctors that they resisted adapting their therapies when new and better knowledge came along. Instead of improving, modern medicine became more dangerous over time. Nineteenth century hospitals killed mothers in childbirth because doctors, unwittingly, spread infection. Women and babies had been much safer in previous centuries when their care had been provided by midwives.

There was much development of medical knowledge after Hippocrates, the medical paradigm, however, did not shift until the germ theory was established. The establishment of the germ theory happened only slowly after Lister's experiments with antiseptics in surgery (1865). The fact that the premier medical journal, even today, is called ‘The Lancet’ is Wootton claims, indicative of how doctors loved this instrument. Further, owning and using a lancet was intrinsically bound up with individual and collective medical identity. Equally a surgeon's identity was bound up in being emotionally tough enough to withstand a patient's screaming and struggling. This clinging to identity was a major reason surgeons resisted anaesthetics when they were first discovered. These are examples of medical resistance that show the way that knowledge translation into practice was prevented or delayed.

The beginning of modern medicine can be traced back to 1536 when Vesalius stole some body parts and commenced the tradition of creating knowledge out of dissecting human bodies. William Harvey published his manuscript on the heart and circulation in 1628. The microscope was invented about 1610 and allowed the internal structures of body organs to be seen for the first time. By 1692 the serious study of the microscope had all be been abandoned. It was not until the 1830s that the use of microscopes become established in scientific research. This long period of non-development was not because the microscopes of the 1830s were so much more powerful: indeed the early microscopes were comparable in power. The period between these two dates is, says Wooton, “a story of squandered opportunities, of wasted effort, of intellectual dead ends. It is a history of failure” (1, p. 116). The examples he gives to make this point are very convincing.

The Birth of the Clinic (hospital) in France in 1749, combined with developments in statistics allowed doctors to compare treatments and to see the limits of their powers. Sir James Simpson, the British discoverer of chloroform memorably wrote that “a man laid out on the operating table in one of our surgical hospitals has more chances of death than an English soldier on the fields of Waterloo” (p. 180). Using Hippocratic thinking the dangers of hospital were linked to ‘bad air’ and the answer was though to be cleanliness. Florence Nightingale was a great exponent of ventilation and cleanliness; but that was not enough to stop the spread of infection. This is because the principles of asepsis and the importance of hand washing were not known. By the mid-1800s many people were arguing that patients should be treated at home for their own safety. The new awareness of the harm caused by hospitals and medical bloodletting, coupled with the ineffectiveness of other medical treatments led to the coining of the phrase ‘primum non nocere’ meaning ‘first do no harm’. These famous words were uttered, not by Hippocrates, but by Thomas Inman in 1860.

Wootton tells the story of the slow development and medical acceptance of germ theory and considers the way that this could have been developed earlier. He argues that there was no satisfactory intellectual development of medicine between 1677 and 1867. In final chapters of Bad Medicine Wootton answers the questions he posed in earlier chapters including the following two. “How is it that traditional medicine survived when it did no good”? (p. 295). “What psychological, cultural and institutional factors represented an obstacle to medicine developing as it might have”? (p. 241). These factors are related to the way doctors thought and to the way institutions have mechanisms for protecting their survival even against mounting evidence of their need to change. All this history pre-dates the contemporary commitment to evidence-based practice. In a sense evidence-based medicine is a necessary corrective to ensure that that new knowledge is translated to improvements in practice; even against opposition. Bad Medicine is a strong argument against ‘group think’ and a call to push on with practice development based on knowledge and research. I recommend Bad Medicine to all health professionals and the interested general reader.