Episode 37: Let It Bleed (PopMed #1)

 in Podcasts  tagged bloodletting / epidemiology / epistemology / history / nosology / pierre louis / sydenham by

For thousands of years, bloodletting was the standard of care for any number of medical conditions, but at the turn of the nineteenth century, often acrimonious debates about the practice would lead to a new method of medical knowledge. The first of a multipart series on the birth of population medicine, this episode visits the controversies surrounding the death of George Washington and Benjamin Rush’s bleeding of Philadelphia during the 1793 yellow fever epidemic and asks the big question — how do doctors truly “know” what actually helps their patients? Plus, a brand new #AdamAnswers about military metaphors in medicine. All this and more on Episode 37 of Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine!

 

Sources:

  • Brickell J, Observations on the Medical Treatment of General Washington in His Illness, retrieved from https://books.google.com/books?id=YXA3AQAAMAAJ&pg=PA90&lpg=PA90&dq=craik+dick+washington+medical+repository&source=bl&ots=IZB72sSdaS&sig=kUY0JZHft1HbRrarR9RE4r-2w_A&hl=en&sa=X&ved=2ahUKEwju3PT439TcAhVOxVkKHZPHBVQQ6AEwA3oECAcQAQ#v=onepage&q&f=false
  • Cohen B, The death of George Washington (1732-99) and the history of cynanche. J Med Biogr. 2005 Nov;13(4):225-31.
  • Craik J and Dick E, The Medical Repository and Review of American Publications on
    Surgery, Third Quarter, 1805.
  • Fuks A, “The Miliary Metaphors of Modern Medicine,” 2009.
  • Harington J, Regimen Sanitatis Salernitanum (ca. 11th c.), retrieved from https://faculty.humanities.uci.edu/bjbecker/PlaguesandPeople/week3f.html
  • Kopperman P, “Venerate the Lancet”: Benjamin Rush’s Yellow Fever Therapy
    in Context. Bulletin of the History of Medicine, Volume 78, Number 3, Fall 2004, pp.
    539-574
  • Lane HP et al, “The war against dementia: are we battle weary yet?” Age and Ageing, Volume 42, Issue 3, 1 May 2013, Pages 281–283.
  • Moed et al, “Cantharidin Revisited: A Blistering Defense of an Ancient Medicine,” JAMA Dermatology, October 2001.
  • Morens DM, Death of a President, NEJM Dec 9, 1999
  • Niehyl PH. The English bloodletting revolution, or modem medicine before 1950. Bull Hist Med 1977; 51, pp. 464-483.  
  • North RL, “Benjamin Rush, MD: assassin or beloved healer?” Proc (Bayl Univ Med Cent). 2000 Jan; 13(1): 45–49.
  • Parapia LA, History of bloodletting by phlebotomy. British Journal of Haematology Volume 143, Issue 4
  • Rush, Benjamin. Observations Upon the Origin of the Malignant Bilious, or Yellow Fever in Philadelphia, and Upon the Means of Preventing It: Addressed to the Citizens of Philadelphia. Philadelphia: Printed by Budd and Bartram, for Thomas Dobson, at the Stone House, No. 41, South Second Street., 1799, retrieved from: https://iiif.lib.harvard.edu/manifests/view/drs:6483213$1i
  • Wallenborn WM, George Washington’s Terminal Illness: A Modern Medical Analysis of the Last Illness and Death of George Washington, retrieved from: http://gwpapers.virginia.edu/history/articles/illness/

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. I’m starting a multipart series on the birth of arguably the most influential and controversial medical idea of all time — population medicine, that we can better learn how to treat individuals from looking at large groups of people. This is part one, called “Let it Bleed,” and it’s about the acrimonious 19th century debates in North America about massive bloodletting — George Washington’s final illness, and Benjamin Rush’s bleeding of Philadelphia during the 1793 yellow fever epidemic. These controversies, along with a parallel controversy in revolutionary France, would lead to a fundamental reassessment of how doctors know things. Well, we have a lot to talk about — so let’s get started!

 

I’ve talked about bloodletting quite a bit on the show, and with good reason. For thousands of years, bloodletting — also called phlebotomy and venesection in English — was probably the most recognized treatments that physicians could offer. The classic way to perform bloodletting is by using a lancet to make an incision in a large vein — usually the antecubital vein in the crook of the arm, or the popliteal vein in the back of the knee, and then allowing several ounces to flow out. Cupping, called Hijama in Arabic medicine, was used as well to draw off blood from superficial knicks. The intellectual basis was from balancing the four humors, the four constituent body fluids whose balance make up human health and illness. But we should also be careful when we talk about bloodletting monolithically — the indications and methods of phlebotomy varied quite a bit over the millennia.  It has been used for headaches, analgesia, fevers, childbirth, and plethora. It is still used today for polycythemia and hemochromatosis. It crosses cultures — not only is it in the Western-Arabic medical traditions, but used in a variety of different societies across the world including Uganda, Australia and Tasmania, Fiji, and Patagonia. 

 

By the time the modern era in Europe rolled around, bloodletting was used for just about everything. I want to read you an excerpt from a poem called the “Regimen Sanitatis Salernitanum,” or the school of Salerno. It’s an apocryphal Latin poem of medical knowledge, supposedly attributed to a John of Milano in the 11th century, and translated into English in 1608. A large part of it is about bloodletting, which:

It maketh cleane your braine, releeves your eie,

It mends your appetite, restorathe sleepe,

Correcting humors that do waking keep:

All inward parts and sences also clearing,

It mends the voice, touch, smell, and taste, and hearing

 

So it’s basically a panacea. In the late 18th century in Europe, bloodletting was the standard of care for many diseases, including mostly notably fever, or ague. Remember that this is a very early period in nosology, and fever was considered a disease in and off itself, though some forward-looking physicians had begun to attempt to classify disease. By this time, the intellectual justification for bloodletting had largely shifted — though the four humors still held sway, the past few centuries had convinced many doctors (though certainly not most people), that all of human health was not influenced by four discrete body fluids. Now disease was thought to be caused by a concept called “inflammation,” which depending on where it was located could cause different symptoms. Bloodletting worked by removing the inflamed blood, thereby relieving the illness. While there were plenty of debates about it — whether you should be bled locally or globally, the method used, how much blood should be removed — no one seriously doubted the utility of bloodletting. 

 

That is, until several well-publicized scandals on both sides of the Atlantic. So let’s first start by talking about the final illness of the first American president, George Washington. Apparently I love talking about the death of American Presidents on this show — if you want more dead presidents, you should listen to episode 22, called the assassination, which was the controversy and innovation surrounding the assassination of James Garfield.

 

Fortunately, we have a wealth of knowledge of Washington’s medical care in his last days, thanks to Tobias Lear, his secretary, who left two detailed journal entries written days after Washington’s death, and from the medical notes of the doctors who treated him. So let’s go back to Thursday, December 12, 1799 — just a few weeks shy of the end of the century. The General, as pretty much everyone respectfully calls him in their correspondence (Mr. President was still reserved for the sitting president) rode out on a cold morning to inspect his farms on his expansive Mt. Vernon estate in northern Virginia, and also to swing by the post office to mail some letters, his link to the outside world. The weather turned unexpectedly bad, with rain, then hail and snow. The General returned that evening and sat down for dinner without changing much to the consternation of Lear, who chided that his hair was caked in snow, and his neck was wet, but Washington insisted that he wore his great coat throughout, and to stop being a bother. The light snow turned heavy, the Washington and Martha turned in for the night. There was no sign anything was wrong The next morning Washington “took cold”, which Lear blamed on his wet clothes the day before. But the General still seemed to be in excellent health, though retired to his bed chambers at 9 PM with his papers from the mail to read up on the news and correspondence from his old friends.

 

Then at 3 AM, he awoke, gasping for breath, and a few hours later was overcome with, in Lear’s  words, ague, shaking fevers and chills. Lear immediately sent for the local physician, James Craik. Craik was a respected local doctor, and an old war buddy of Washington’s to boot. He arrived around 7:30 in the morning and brought with him George Rawlins, an experienced bloodletter, with his blood pan and lancet. Craik considered the old man in front of him, shaking with fever and struggling to breathe, and he prescribed the standard of care at the time, bloodletting. Rawlins removed 12-14 ounces of blood into his pan, at Craik’s direction. We know that Martha became nervous about the amount of blood that was being removed. Wasn’t the General too old, too weak? But Washington reassured his wife and asked for the bleeding to be continued. 

 

Next Craik prepared various mixtures — of molasses, vinegar and butter, as well as garlic sage tea, and instructed his patient to gargle. But the patient started to gag and choke. Craik then decided that he’d have to locally treat Washington’s swollen throat, and applied “blister of cantharides” directly inside of his throat. 

 

So a brief aside on cantharides — you’ve probably never heard of it, but it has quite a juicy history. It is an irritant and poison made directly from an insect called the Spanish fly. After contact with the skin, it causes severe blistering. It’s been used in traditional forms of medicine for thousands of years — Hippocrates describes it as a treatment for dropsy, or swelling, and it is used in a variety of conditions in Chinese medicine. But its infamous reputation comes because of its use as an aphrodisiac. It can cause priapism in men and pelvic congestion in women, and the Maquis de Sade — you know, the guy sadism is named after — apparently poisoned prostitutes with it to increase their sexual pleasure. And there are a few cases in the medical literature of modern people attempting to use cantharides in the same manner. I’ll just quote from a review of a 1952 BMJ article here, “In England, a man gave coconut ice laced with cantharidin to 2 women, hoping to facilitate a sexual interaction. Both women died of the poisoning.”

 

All of this is to say, these ground up beetle secretions that Craik was directly applying to Washington’s throat were nasty stuff. It must not have worked well, because at 11 AM Craik ordered Rawlins to remove 18 more ounces of blood — and then another 18! At 3PM another local doctor, Dr. Dick, arrived, and apparently felt quite strongly against bleeding the General any further. He suggested performing a brand new surgical procedure that had only been described the past year — a tracheostomy, or making an artificial opening below the obstruction in Washington’s throat, and allowing him to breathe through a tube. Craik initially considered this and sent Dick to get his surgical tools. However, by the time he returned, Craik had changed his mind and ordered a fourth bleeding, this time of 32 ounces of blood. Apparently the blood flowed slowly and thick — signs of volume depletion. But Washington said he felt better, and his slow bleeding was sanguinely interpreted as a lessening of his inflammation.

 

It didn’t last, and as the patient worsened throughout the afternoon the doctors became more desperate. They applied cantharides too his feet, arms, and legs, and placed a poultice directly in his throat. By 10 PM, the president knew he would soon die, and gave burial instructions. A man of the Enlightenment, he lay back and took his own pulse to try and divine when the end was coming. He was surrounded by his doctors, his secretary Lear, his wife, and by his slaves — Caroline Branham, Charlotte, Molly, all housemaids, and Christopher Sheels, his valet. His doctors noted the time of death — 1020 PM according to Lear, 1130 PM according to the doctors — when Washington’s fingers went limp and fell off his own wrist. 

 

Washington had only wanted one thing from doctors: “to enable him to die easy.” But not even death would stop his doctors’ ministrations. Concerned with inflammation affecting the whole household, the doctors recommended putting Washington’s body outside, where it froze. The next day another doctor, Thornton arrived. Like Dick, he also suggested performing a tracheotomy — but on Washington’s corpse. His plan to to gradually thaw Washington’s body, first in cool water, and then by rubbing him with warm blankets. He would then perform the tracheotomy and breathe through a pipe directly into Washington’s lungs. Finally, he would transfuse warm lamb’s blood directly into his veins.

 

Martha Washington politely declined. 

 

So what actually killed George Washington in the end?  Let’s start with what the doctors thought. Craik and his col leagues most certainly knew that they would be scrutinized deeply no matter what they did. After all, that had ministered to the death of the most famous man in the new United States. They quickly published their notes where they concluded that he died of “cynanche trachealis,” which they describe as “inflammatory affliction of the upper part of the windpipe.” It’s a great name — cynanche refers to a dog’s collar, that its sufferers are strangled like when your dog really wants to eat the chicken bone on the ground, but you’d really rather not deal with canine gastroenteritis for the next 12 hours, so you give him a tug. You can tell I have experience in this matter.Cynanche is sometimes translated as “dog strangulation,” though that a little intense of a translation. It’s still a wonderfully descriptive term — but it doesn’t exactly fit with a modern nosolgy. Cynanche trachealis appears to have described a variety of conditions, including diphtheria, croup, Ludwig’s angina, and probably the actually disease that killed him, acute epiglottitis, a bacterial infection of the epiglottis, the small flap of tissue that covers the windpipe when we swallow. 

 

But the public had their own ideas — and a lot of them blamed the doctors. The immediate focus was on the bloodletting — especially the aggressive amount of blood removed from such an old and sick man. 80 ounces of blood — that is 2.4 liters — were removed in total. That was likely half of Washington’s entire circulating blood volume. We have a letter by a Dr. John Brickell essentially arguing this point, and even Dr. Dick, who had wanted to perform the initial, not-reanimated-from-a-frozen-state tracheotomy, later wrote that he wanted to “put away his lancet forever” and then become a nurse based on this experience with bloodletting.

 

Washington’s death was just fuel to the fire of public anger against copious bloodletting, because of a very public controversy that was dramatically winding its way through the court system and newspapers — and that’s the libel suit against William Cobbett by the famous physician and signer of the Declaration of Independence Benjamin Rush, whom Rush Medical School in Chicago is named after.

 

In 1793, a massive outbreak of yellow fever struck the city of Philadelphia. This was the first real epidemic in the new United States, and has achieved almost legendary stature, despite later, even more deadly epidemics. Yellow fever,  we now know, is caused by a virus spread usually by the Aedes aegypti mosquito. Most people get a flu-like illness, but in about a fifth, the disease enters in its so-called toxic phase. Rapid viral replication in the liver leads to liver failure, causing the jaundice that gives the disease its name. With the ability to clot the blood now impaired, victims will start to ooze blood from their mucosal surfaces, especially in the eyes and the gut, leading to the second name for the disease — the black vomit. Of course, in 1793, it was thought that yellow fever was caused by miasma, by toxic odors coming from the docks. So panicked citizens fled the city, including many of the doctors. Over 5,000 people died, out of a total population of 45,000, and another 17,000 fled, including the new nation’s government. The nation’s capital ground to a screeching halt. 

 

Only a small number of doctors — at one point there were only three left — stayed to treat the sick and the dying. And chief among them was Benjamin Rush. Rush was already a celebrity at this point. He trained in Edinborough under William Cullen, and had signed the Declaration of Independence as a representative from Pennsylvania, the only doctor to sign. Rush was an early convert of Cullen’s nolosgy, influenced by Sydenham, and Linnaeus — all disease was divided into four classes (pyrexiae, neuroses, cachexiae, and locale) — or fevers, nervous issues, wasting diseases, or local diseaess — and then further subdivided into nineteen orders and 132 genera. This was a groundbreaking idea at the time — but not particularly useful for treating patients, and by the time yellow fever struck the city, Rush had determined that any attempts to subdivide disease were fruitless. 

 

Fruitless might be an understatement, because if Rush was anything, he was opinionated. He wrote: “the multiplication of diseases … [is] as repugnant to truth in medicine, as polytheism is to truth in religion. The physician who considers every different affection of the different systems of the body … as distinct diseases when they arise from one cause, resembles the Indian or African savage, who considers water, dew, ice, frost and snow as distinct essences”

 

Instead, Rush proposed that there “is but one fever in the world,” caused by a “convulsive” vascular system. So what was the treatment for this unitary fever caused by a convulsive vascular system? The answer, unsurprisingly, was bloodletting, which he reasoned relaxed the entire vascular system. 

 

As yellow fever victims started to pour into his clinic, Rush initially treated them with what was basically the standard of care at the time — small amounts of bloodletting, mild purgatives, and bland foods. Many of his patients died, and Rush started to search for a better way to treat them. He reviewed an old medical case from 1741 given to him by Benjamin Franklin which basically argued that “bigger is better.” Within a month, he was removing ever larger amounts of blood, as much as 80 ounces, or 2.4 liters, over five days. 

 

Rush worked at a frenetic pace. He barely slept, maybe a couple hours a night. He saw hundreds of patient’s at his clinic each day, and had to turn others away. Blood oozed from the place, the front yard sticky dark red with rancid blood and flies.  Three times Rush fell ill with a fever — and he had himself bled, 20 ounces of it. Rush would later use almost religious tones to talk about blood letting. 

 

“I cannot dismiss this subject without calling upon you to Venerate the Lancet. It is the Magna gratia coeli, the great gift of Heaven.”

 

The medical community at large did not heed Rush’s advice to “venerate the Lancet”. They were not against mild amounts of bloodletting, with exceptions for the elderly and the frail. But what Rush was doing was far from the standard of care. He was publicly accused of murder, and there were rumors of criminal charges. The journalist William Cobbett reviewed the 1793 Bills of Mortality for Philadelphia, and wrote that Dr. Rush had found “one of those great discoveries which have contributed to the depopulation of the earth.” Rush had liked to refer to his treatments as the “Samson of medicine.” Cobbett agreed, and wrote:

 

“In his hands and those of his partisans it may indeed be justly compared to Samson: for I verily believe they have slain more Americans with it than ever Samson slew of the Philistines. The Israelite slew his thousands, but the Rushites have slain their tens of thousands “

 

Insults were better in the 18th century. Rush, however, sued Cobbett for libel. The case was decided on December 14, 1799 — just says before Washington’s fatal illness. Even though Rush won the libel case — and the award money was huge, the largest in the US at that time — the public had turned against Rush and his copious, “murderous” bloodletting. So to hear that the beloved first president had been bled similarly was scandalous.

 

Rush does not come across well in these stories — he is self-righteous, convinced that he is right despite being so obviously wrong from a modern perspective. And neither do Washington’s doctors. But let’s take a step back from our point of view and seriously ask, how could Benjamin Rush realistically have known that his strategy was killing people? How could George Washington’s doctors have known that their treatments would only make the old man suffer more?

 

Now we’re getting to the good stuff. So let’s leave Bedside Rounds for a for minutes and go back to Philosophy 101 and talk about epistemology — how we, as human beings — and more specifically, as doctors — know things.

 

The oldest still-extant form of medical knowledge, stretching back to the beginnings of civilization, is what is generally called “empiricism,” coming from the word “to experience.” Doctors would observe their patients, their diseases, and the treatments they offered, and make careful notes of what happened. Based on this personal experience, they would offer the best treatments to their patients. Empirics realized, of course, that no individual human would ever have enough experience to fully practice medicine. Therefore, they promoted a system of medical education — recording cases, such as they could be referenced by future generations. When you read ancient medical texts — think the Edward Smith papyrus, an Egyptian surgical text, or the Epidemics, a medical text from the Hippocratics, this is essentially what is going on. Doctors are sharing their careful observations on human disease with other physicians with the intent of helping future generations. By the time of Galen, a formal school of Empirics was influential, and took this reliance on experience to its logical conclusion. Medical knowledge could only come from pragmatic, personal experience; they had no time for explanatory models like the Four Humors, or the study of anatomy. Their Tripod of Medicine — observation of individual patients, recording and reading histories of other patients, and using analogy to describe new diseases — would basically define the Western intellectual approach to medicine for over a millennium. In Benjamin Rush, we can see the influence of this Empiric school. His copious bleeding was based not only on his own personal experience, but also on reviewing an old case report he had received from Benjamin Franklin.

 

You can see some of the problems with the empiric school from the get go. Now now know there are any number of “cognitive distortions” and biases that can stymie individual observation. And despite the Empiric claims otherwise, it’s impossible to separate individual observations from theory. Rush, for example, would likely have acted differently if he had realized that yellow fever was a mosquito-borne illness with a variety of systemic effects, rather than a manifestation of a single unitary fever.

 

Starting in the 18th century, a new approach medical knowledge started to appear in Europe, but especially localized around Paris. This new field was experimental physiology, influenced by developments in science in other fields like physics and chemistry, and was focused on doing actual experiments, both on animals and on real patients. This is the “scientific method” you were taught in grade school — come up with a hypothesis, perform an experiment to test it, and then either accept or reject it. Doctors like Magendie and later Claude Bernard performed detailed (and horrific) experiments on animals to figure out how the human body actually worked. I usually don’t talk about this basic science on Bedside Rounds — not because it’s not important, but because I’m not really a “science guy.” That being said, think about  William Beaumont’s detailed experiments on Alexis St. Martin’s gastrocutaneous fistula from episode 33. You can see this approach with Dr. Dick, Washington’s doctor who was against extreme bloodletting. He advocated a tracheostomy to allow the president to breathe — based on physiological experiments on animals that had only been described a year before. Experimental physiology turned “Empiric” into a dirty word that meant quack. By the late 19th century, experimental physiology was dominant, and was weaponized in the 20th century as it was folded in with the new fields of microbiology, biochemistry, and pharmacology. 

 

Yet there are still weaknesses to this model. You can imagine experiments on, say, a horse, taking off large versus small amounts of blood and monitoring effects on the animal. And there’s evidence that some experiments of this nature were performed in the 1790s by a Dr. Thompson. 

 

These bloodletting controversies were pushing up against a cognitive barrier. I know it seems pretty obscure to talk about the appropriate volume of bloodletting in 2018. I certainly never thought I’d dedicate an entire episode to it. But these acrimonious debates would directly lead to a paradigm shift in how we know things in medicine — a third way of knowing that we’re still arguing about today. So we’re going to head across the Atlantic to post-Revolutionary Paris, where this same bleeding debate spurred a doctor named Pierre Louis to develop his “numerical method,” or what we today call population medicine. But of course, that journey will have to wait for next month, for Part 2, tentatively titled “Blood on the Tracks.”

 

Okay, that’s it for the show! But wait — it’s time for a #AdamAnswers.

 

#AdamAnswers is the segment on the show where I answer any question sent in by my listeners — and that means you, dear podcast listener — no matter how profound, or how silly. So this month’s question comes from Dr. Eileen Barrett, who asks, “Why do we use so many military metaphors in medicine, like ‘in the trenches,’ ‘rank and file,’ new treatments in ‘our armamentarium’?”

 

What a great question! Because military medicine terms are so prevalent in medicine, you probably don’t even notice them. Like Dr. Barrett points out, we have “in the trenches”, ‘rank and file”, “armamentarium”. The War on Cancer, or whatever, is a pretty easy one. But we also have “a silver bullet”, “the body’s defenses,” or, hey, even “doctor’s orders”. And how about that cohort study that you read? “Cohort” of course, is a military term dating back to the Romans.

 

So my first thought was that military metaphors date from the period of heroic medicine in the nineteenth century — from Benjamin Rush, for example — the idea that only through harsh treatments could we restore health. Think of that famous art deco sculpture on Grady Hospital  in Atlanta of the physician with his caduceus — and yes, caduceus, not the rod of asclepius — warding off the skeletal figure of death like Gandalf warded off  the Balrog. I’ll post it to Twitter so you can see what I’m talking about. And yes, I realize how nerdy I sound right now.

 

But military metaphors in medicine actually appear to be quite older, and have a fascinating parallel to the development of modern nosology and modern medicine. I think it’s super appropriate that the scholar Abraham Fuchs first dated them to the 17th century, starting with Thomas Sydenham. Sydenham, who I mentioned earlier in the episode, is called the “English Hippocrates,” and is the first person in history to attempt to try and develop a way to classify diseases. William Cullen, whose ideas deflated Benjamin Rush, was a followed of him. And through classifying and naming diseases, his natural metaphor was violence — he wrote, “A murderous array of disease has to be fou ght against, and the battle is not a battle for the sluggard.” And the work of a physician was war: “In eradicating a chronic disease therefore, whoever is possessed of a medicine, powerful enough to destroy the species of it, justly deserves the appellation of a physician.”

 

Military language increased into the 19th century, especially with the development of germ theory which expanded nosology even further. Now many conditions that had seemed mysterious had ever more specific causes that could be fought. The twentieth century saw this expanded even further, to cancer, to heart disease, and even to Alzheimer’s dementia. 

 

So why did this focus on military language happen? I have a few theories. Traditional Western medical views would have seen disease as coming from imbalances in the body’s natural humors. There is nothing to fight — treating disease is about achieving balance. Sydenham and his successors slowly chipped away at this model (mostly unintentionally) by naming diseases — and by naming them, making them real. Disease was now something foreign to be eliminated, not something within us to be balanced.

 

Theory number two — this same period consists of “the loss of the sick man from the medical cosmology;” the idea that as medical knowledge, and especially medical diagnostics expanded, the patient’s experience no longer mattered — disease was an objective finding on their body (and in the 21st century, in their imaging and laboratory results).  This is fertile ground for physicians to “wage war” in their patient’s bodies; the patient themselves comes second.

 

And my theory number three — the job of a modern physician does actually bear some resemblance to that of a general — both in an organizational capacity, and also in our ability to cause harm.

 

So are military metaphors helpful? Good? Bad? Some positives first — wars bring a great amount of public attention. The War on Cancer has done lots of destigmatize breast cancer. And metaphors are effective ways to communicate, and for some patients, especially say, facing a cancer with multiple treatment modalities, a battlefield with a competent general is 

enticing imagery. 

 

But our military speech has plenty of negatives. If you don’t follow a general’s orders, you are insubordinate; maybe even a deserter. If you don’t follow a doctor’s orders to take a chemotherapy regimen? Well, maybe it’s because the suffering you get compared to your expected life expectancy isn’t worth it. Maybe there are less toxic regimens. But if you unconsciously view yourself as “insubordinate” because cancer is a war, you’re far less likely to discuss this with your physician. 

 

And it’s important to point out that while some diseases lend themselves to war — a bacterial infection, for example, many don’t. How do military metaphors help with diabetes, a chronic condition that can be managed and treated, but still takes constant vigilance and can have bad effects regardless of how well it is managed? That is no war that no one would ever want to fight. 

 

And holistically, for many of these chronic disease, the military metaphor puts the focus on the disease — the enemy — and not on the patient, who we really should be paying attention too. Seeing disease as a war leads to polypharmacy (that is, overprescribing), and not viewing the patient as a whole — and not just as their diseases.

 

So what do we do instead? What metaphors work better? For this one, I’m not really sure. There’s actually something enticing about the premodern way of describing symptoms in terms of balance. But I don’t think that works with a modern understanding of disease, despite how often you might see that particular analogy pop up. So I’m at a loss. But we need better metaphors, so if you’re aware of any, please let me know!

 

Okay Dr. Barrett — thank you so much for that excellent question! And you, dear listeners, if you have any burning questions you want to submit to #AdamAnswers, please Tweet at me @AdamRodmanMD!

 

That’s really it for the episode! This episode grew out of my attempt to discuss and contextualize Pierre Louis’ famous bloodletting trial, and slowly grew into a behemoth that was going to be, well, let’s just say, very, very long. I actually conducted a Twitterpoll a few days ago about how long an ideal episode should be, and it seems that you guys think a Bedside Rounds sweet spot is 30-45 minutes or so — but DEFINITELY not more than an hour. I’m inclined to agree with that, though my natural tendency is to always jump to the next source, the next study, and to write a novel. So thank you to everyone for that feedback. 

 

And speaking of Twitter — come say hi! I’m at @AdamRodmanMD, and I’ve been working on some fun histmed Tweetorials — I’ll have one of the death of George Washington soon that will complement this episode. And if you have no idea what a Tweetorial is — well, definitely come and check it up. They’re my new favorite way to learn about medical education. I’m also on facebook at /BedsideRounds. All of the episodes are on the website at www.bedside-rounds.org, or on Apple Podcasts, Spotify, Stitcher, or the podcast retrieval method of your preference. The sources are in the shownotes.

 

And finally, while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.