Friday, September 06, 2013


In his book, Bad Medicine, David Wootton makes an interesting remark about the symbolism of the stethoscope. It was invented in 1816 by René Laennec out of a problem in gender politics: the norm for female patients of the all male doctor fraternity was to be examined with their clothes on. Thus, the doctor could not lay his head against the chest of the patient and listen to the sound of what was going on inside. Laennec was concerned with phthisis, a nosological category that has now been subsumed as tuberculosis. The stethoscope was a true advance: doctors became much better at diagnosing phthisis. But therein lies the historical burden of Wootton’s book:

“Phthisis no longer exists as a disease: we now call it tuberculosis because we think of it as an infectious
disease caused by a specific micro-organism. The same sounds in  a stethoscope that would once have led to a diagnosis of phthisis now leads to tests to confirm tuberculosis. But there is an important difference between our diagnosis of tuberculosis and Laennec’s diagnosis of phthisis: we can cure tuberculosis (most of the time), while his patients died of phthisis––he died of it himself. Until 1865 (when
Lister introduced antiseptic surgery) virtually all medical progress was of this sort. It enabled doctors to get better and better at prognosis, at predicting who would die, but it made no difference at all to
therapeutics. It was a progress in science but not in technology.”     

The gap between the ability to diagnose and the ability to cure, or even to understand the cause of a disease, or its etiology, is easy to forget. I often edit articles about medicine, or public health, in the pre-twentieth century period. Some of these articles concern the medical culture of native peoples. And even with the best anti-colonialist will in the world, often the authors simply assume that there is a contrast between a rational and curative Western medicine and a ritualistic and non-curative folk medicine. In fact, folk medicine was medicine up into the twentieth century, and often continues to be today. Western medicine as therapy was largely either fraudulent or depended on the placebo effect. The latter is a real effect, of course.

But the fact that there was no progress––far too little to have any systematic impact on life expectancy––and the fact that medical intervention did more harm than good, does not mean that doctors
did not cure patients. Modern studies of the placebo effect show that it is a mistake to think that there are some therapies that are effective and others which though ineffective work on those who respond
to the placebo effect. Even effective medicine works partly by mobilizing the body’s own resources, by invoking the placebo effect: one estimate is that a third of the good done by modern medicine is
attributable to the placebo effect.

When patients believe that a therapy will work, their belief is capable of rendering it surprisingly efficacious; when doctors believe a therapy will work their confidence is consistently transferred
to the patient. There are all sorts of studies that show this in practice. Thus if a new and better drug comes out, the drug it replaces begins to perform consistently less well in tests, merely
because doctors have lost confidence in it.”

Ah, transference! Surely this is a fact about human nature that goes beyond pharmacopeia.