The Pharmaceutical Journal
Vol 269 No 7229 p899-900
21/28 December 2002

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Death at the hands of doctors

Any field of human endeavour is a catalogue of mistakes. If, in the past, errors in the field of medicine seem more unwarranted and bizarre than in other disciplines it is because the victims were helpless individuals, usually ill and defenceless.

When the pope and church decided to make it a heinous crime to believe that the earth orbits the sun there was only one victim, Galileo, since Copernicus was already dead. Ignorance in medical matters affected whole populations for generations, even millennia.

For 2,000 years, the main medical treatment was bleeding, a procedure that weakened every patient on whom it was inflicted and caused the deaths of innumerable innocent sufferers. Purging, a well established practice by the time of the great Egyptian civilisations, remained a mainstay of medicine until the 19th century, and although not as dangerous as bleeding, the two used together, as they often were, constituted a dangerous and often lethal combination.

Medicine is perhaps the only field where, in the bad old days, the rich and powerful came off worst. In the 17th to 19th centuries, the era of heroic medicine when blood-letting and purging were being pushed to ever more violent lengths, the higher up the social scale and the more prestigious one's physicians, the more heroic their approach and the more the patient suffered. The young Louis XIV just survived the ministrations of his doctors. George Washington, older and less resilient, was finished off by his. Louis XIV may have been the most glorious monarch of his age, but to his physicians he was just another body to purge and bleed. The Sun King was a mere 20-year-old when the court doctors had their first chance to treat him with the full complement of medical indignities befitting his station.

The scene opens on Saturday 29 June 1658 with Louis leading a campaign in Flanders and, exhausted after his exertions at the sieges of Dunkirk and Bergues, starting with a fever and a searing headache. Vallot, the king's personal physician, was away tending to one of the king's generals and Louis did not reveal his symptoms to the physicians in camp. But by the Sunday night Louis felt worse and turned to his man for all seasons, Cardinal Mazarin, who immediately arranged for the king to be moved to Calais, where "proper" medical facilities were available. Mazarin dispatched a messenger to recall Vallot, and the doctor arrived the following night, diagnosed typhoid fever and, being of the heroic school, ordered a purging enema and a drastic bleed.

Not surprisingly, Louis's condition deteriorated and over the next few days he suffered a raging fever, convulsions, agonising pain and, no doubt mercifully, delirium. A contemporary account describes the king's swollen throat, thickened and blackened tongue and hideously bloated body. Mazarin had in the meantime assembled a medical team consisting of Du Saussoy, a local physician, together with Dr Genault, the personal physician of Louis's mother, Anne of Austria, sent by her from Paris, with his colleague d'Aquin. All three, believing that desperate diseases require desperate measures, continued the assault on the king's body with enemas and bleedings. After several days there was no improvement in the king, which left the doctors with just one decision — whether or not to try antimony.

Antimony wine for Louis XIV

All four doctors attending Louis XIV in Calais were devotees of antimony therapy, but did they dare use such a controversial remedy on the monarch? The matter was resolved by a further deterioration in the king's condition and Vallot decided that antimony must be tried. The others, well aware of antimony's risks, were not persuaded, and Vallot had to pull rank and use Mazarin's influence to quash their reservations. The form in which Vallot administered the drug was antimony wine, prepared by allowing wine to stand in a vessel made of antimony, when it gradually absorbed the metal. The resulting antimony content was variable, depending on the type of wine and the purity of the antimony, and Louis may have been fortunate that the fluid ounce he was given — a low dose by heroic standards — was not too heavily laced. It will also have helped that he vomited twice after taking the wine, but even so he underwent a series of purgings, over 20 evacuations being recorded. Whether by antimony or coincidence, the fever abated and within a few days Louis was safe.

Throughout the history of medicine, new drugs with any merits at all have always been overprescribed and "too much, too often" applied as much to antimony in the 17th century as it did to the over-use of penicillin in the 1950s and '60s, and to excesses with the prescribing of Prozac and Viagra in more recent times. The Sun King's good fortune led to plenty of misery for his unwell subjects. What had cured Louis, reasoned the doctors of the time, could cure anyone of almost anything, and rivers of antimony wine were poured down the throats of innumerable sufferers, until, as happens with all drug crazes, interest faded and was transferred to the next wonder drug.

Blood-letting promoted

The reasoning behind the widespread adoption of blood-letting is easy to understand. Blood loss through injury lowers the blood pressure and can ease the pain of swollen and inflamed tissues, and this observation led early physicians to try deliberate blood-letting from a vein for the relief of pain. Hippocrates and his school (from about 400BC) were the first known advocates of bleeding and Galen, round about 200AD, promoted a more aggressive blood-letting policy. Galen's teachings dominated medicine for a millennium and a half and even when science began making its gradual and cautious intrusions into medicine in the 17th century, the devotion of doctors to blood-letting hardly wavered.

Philip II of Spain suffered perhaps worst of any, in 1598 undergoing a purging and bleeding assault for two months, lying in his own excrement because he was in too much pain to be moved, until released by death. George Washington was unlucky, happening to fall ill late in life when heroic medicine in America was at its most drastic peak, largely due to the influence of one man.

Benjamin Rush, born in Philadelphia in 1745, was a charismatic figure who blazed trails in several different fields. A signatory to the Declaration of Independence, he campaigned zealously for national universities, the education of women and the abolition of slavery. Sound on most issues, he was to go astray only when it came to medicine, his chosen career. After graduating from Princeton University at the age of 15, Rush studied medicine at Edinburgh, absorbed its moderately heroic principles and refined them further, deciding that to classify diseases into different categories was nonsense. Between 20 and 30 medicines would suffice as a complete materia medica and in the great majority of cases all that was required — the reader may be ahead here — was blood-letting and purging by calomel (mercurous chloride). Rush spurned the idea that bleeding could be dangerous. "'Tis a very hard matter to bleed a patient to death," he assured his students when he became professor of medicine at Philadelphia University in his late 20s.

Normally such reckless advice would have influenced only a minority of medical students but Rush's influence on the medical scene was unparalleled. Pennsylvania was one of four medical schools in America at that time, but during the 44 years of Rush's tenure there, it produced three-quarters of all doctors who qualified, all indoctrinated with the belief that purging and bleeding were the paramount treatments.

Rush elevated bleeding to new and lethal heights, his recommendation for pneumonia being the drawing off of 140 fluid ounces (4 litres) of blood during the treatment period, an amount not far short of the average total blood volume (160 fluid ounces/4.94 litres). Rush employed huge doses of calomel, and when copious salivation and other symptoms of mercury poisoning resulted, he welcomed them as signs of "mercurial fever", which he believed was a prelude to recovery. When the patient died, as frequently happened, the death was conveniently attributed to the original disease.

Fatefully for Washington,he began to feel unwell in the early hours of Friday 13 December 1799 with a sore throat, probably resulting from a thorough soaking the day before. He developed a fever and when his breathing became laboured, Washington thought that he needed treatment and sent for a local bleeder who drew a pint or so of blood from his arm. Washington slept fitfully and being no better in the morning he sent for his personal physician, Dr James Craik, who arrived at 11am. Seeing the seriousness of Washington's condition, Craik sent for two of his colleagues and pending their arrival he pursued the obligatory heroic procedures, carrying out two more copious bleedings, administering two purging doses of calomel and a purging enema. All these measures, as the report on Washington's death put it, were "to no avail".

The colleagues Craik had called in were Dr John Brown and Dr Elisha Dick, and Craik told them that he favoured another blood-letting. Brown supported him but Dick, more sensible and humane, opposed the idea, pointing out that three pints of blood had already been taken from a seriously ill patient. "He needs all his strength," Dick cautioned, "and bleeding will diminish it." But Dick was the junior of the three and was overruled. A further pint and a half of blood being drawn off, although the senior pro-bleeding doctors later had the honesty to admit that the procedure was "... without the smallest apparent alleviation of the disease".

Washington, now suffering from a serious loss of blood as well as from the infection, might have benefited from a quiet regimen of rest and the administration of light nutrient foods, but heroic medicine demanded action, and so the tortures went on. The patient was given a dose of calomel — 10 grains (0.6g) — that would have been testing for a fit man, and several doses of tartar emetic, a nauseous antimony compound, in spite of the fact that there can have been nothing left in his stomach to vomit. He had already been subjected to blistering of the throat, another form of heroic assault where a drastic irritant was applied to the skin to create a blister, the idea being that as the blister swelled it drew off harmful elements from within. A vinegar poultice was now applied on top of the throat blister and blistering agents were strapped to the soles of his feet. Washington tried several times to speak through the encumbrances at his throat, and when eventually he could make himself heard, the message was clear. He wanted to be left to die in peace.

George Washington died late on the Saturday night, less than 24 hours after being taken ill, a sufferer at the hands of heroic medicine and entirely a victim of it.

Medicine moves forward

Medicine has moved on since heroic times and we should be grateful. Unfortunately man's degree of expectation is greater than his sense of gratitude. When one of us has a painful knee, we are more concerned with getting to the top of the waiting list for knee replacement operations than with marvelling that such a procedure, unheard of a generation ago, is available. If the history of heroic medicine teaches us anything, it is perhaps that waiting lists are not quite the affront we have been led to believe.