Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and our Difficulty Swallowing It Read online

  Around this time we were introduced to something called ‘evidence-based medicine’. Truth, it suggested, was not something that could be divined by the mysterious insight of experts. You developed a theory and then you tested it, and only certain types of tests were reliable.

  A lot of things that seemed confusing started becoming clear. I began to understand about the leeches, and the textbooks and the professors. If someone senior and wise believed that something worked, it was not necessarily true. Even though sincere and educated and intelligent people thought a treatment was helpful, it could still be toxic.

  Down by the river, things also changed. Formerly my coaches had seemed like gods, gifted with perfect understanding and total power. Any time I failed, it was clear to me that it was my fault: some limitation in myself. The coaches shared these views. No matter how certain I was of their wisdom and understanding, they were more certain still.

  ‘I want you to keep your heart rates at 85 per cent of max. for the next hour and a half,’ they said. It was the kind of thing they said quite often.

  ‘Why?’ I began to ask.

  There was usually a short pause.

  ‘Because it’s the best way to improve your fitness.’

  ‘How do you know?’

  There was a longer pause.

  ‘Because I’ve done it before and it worked. Because that’s what the people who win the Olympics do. I know, I’ve trained some of them.’

  ‘But,’ I asked, ‘has anyone actually done an experiment?’

  Another short pause, but this time a little more threatening.

  ‘What on earth are you talking about?’

  This book is my answer.

  1 Early Medicine and Opium

  WHEN OUR ANCESTORS ceased to gather and hunt some ten to fifteen thousand years ago, they were making a curious choice, not least because it made them less healthy. Their diet became more restricted, and more vulnerable to a bad season affecting one or two main crops. Domestic animals brought with them lice and worms and diseases that hadn’t had a crack at Homo sapiens until that point. Hygiene became more of a problem. You don’t need to be too scrupulous about where you defecate if you are likely to move on the next day. That changed. Average lifespan, at least for a little while, went down.

  What agriculture did provide (other than a steady supply of beer, which some people have seriously argued was what made it attractive to begin with) was the opportunity for acquiring wealth. Grain could be stored, workers could specialise, chiefs could rise to the top and get fat and lazy. Healers, for the first time, could really concentrate on their craft. With large agriculturally minded populations, specialised professional doctors first appeared.

  The Sumerians, the earliest agricultural society we know much about, lived around six thousand years ago in what is now Iraq. They had faith in their medics. ‘My son, pay attention to everything medical! . . . pay attention to everything medical!’ were the words of a Sumerian matron who, in the manner of many mothers since, felt her offspring paid so little attention that she needed to repeat herself. The Sumerians worried about ‘the anxiety and intestinal disease which pursue mankind’, as well as afflictions beyond the power of medicine (‘A malicious wife living in the house is worse than all disease,’ ran one proverb). They wrote of potions, of a doctor ‘who keeps people alive, and brings them to birth’ and of making ‘perfect the divine powers of medicine’.

  To get an idea of Sumerian medicine, we have to turn to the Egyptians. The clay tablets we have from the Sumerians contain poems, proverbs, history, religion and even a novel, but they are short on medical details. One does list a few medical ingredients – the shells of turtles, skins of snakes, thyme and milk and figs and dates – but gives no clue as to their preparation or intended uses. The Egyptians, however, inherited a great deal from the civilisation of Sumer, and we also have a better record of the specifics they offered to their sick. They were not, generally speaking, up to much.

  Edwin Smith, a middle-aged adventurer from Connecticut, spent £12 in January of 1862 for two papyri. They were around three and a half thousand years old, and included knowledge handed down from long before that. They list around 160 different remedies, of which modern scholars have translated a small portion. So we know that the medical armouries of the Egyptians contained onions and watermelons and celery, as well as almonds and aniseed, dates and dill, juniper and cinnamon.

  A recent historian of aspirin, Diarmuid Jeffreys, grew excited about the inclusion in this Egyptian list, as well as in that of the Sumerians, of willow. It is from willow that we originally get aspirin. It would be nice to think that this meant the Sumerians and the Egyptians were using willow in a medically effective way. They drew no distinction, however, between willow and their other ingredients. As far as they were concerned, willow was no more effective than onions or celery.

  One of the papyri that Smith bought suggested mixing willow with figs, dates and beer to ‘cause the heart to receive bread’. (The Egyptians used ‘bread’ as a synonym for all sorts of fine things. Their daily greeting for each other was a cheerful wish for ‘Bread and beer!’ meaning pretty much everything in life that was good.) The historian of aspirin commented that ‘many of their superstitions, reasoning and treatments are based on concepts that are alien to us’. That is true, but it is not what really matters. The Egyptians considered their doctors and their medicines as being potent and effective. Records of their practices show something different. These papyri, the oldest proper medical instructions of our species, contained potions and salves and drugs whose effectiveness was a fantasy. Traditional knowledge of healing was not reliable. The first doctors in the world were frauds. This was a remarkable beginning for any profession, even more so for one that has always delighted in a special trust. For the next three and a half thousand years, little changed.

  Despite it all, the world grew more populated. People began living longer. They became healthier. By the start of the twentieth century, someone lucky enough to be born in the developed part of the world could expect to live for almost three times the lifespan of their gatherer-hunter ancestor. This huge change came from having more food, better shelter and richer environments. Medicine took away more than it added.

  The idea of science – the notion that theories must be tested, and that those that cannot or have not been tested are something other than facts – did not occur to the Sumerians. They had one drug, however, that worked so immediately and so obviously that they understood its effects. That drug came from the poppy, and it has stayed popular to this day.

  The poppy is of the genus Papaver, family Papaveraceae, order Ranunculales, class Magnoliopsida, division Magnoliophyta, kingdom Plantae and the domain of the eukaryotes. It prefers soil that has been disturbed, by war or by the plough, and is a common sight in the Oxfordshire fields that surround my home. Papaver rhoeas is an annual plant, springing up in the midst of the small irregular fields of wheat and barley. It has the hairy stalk and drooping green flower bud of the Papaver genus, rearing up its head to the sun when its twin sepals fall and the scarlet and black petals beneath burst out for a few bright days. Other poppies have other colours: the oranges of the Californian poppy, Platystemon californicus, the clear yellow of the Welsh or the host of shades in which the large Iceland poppy appears.

  With warm summer days the poppy’s ovary swells. A fruit is formed, an upturned bell, the stigma forming a cap where the clapper should be. For a time this fruit is obviously lactiferous. Scratch it, and a white substance oozes slowly from the seed-head. Eventually, though, it dries, and the breezes blow the seeds through the capsule’s pores, the plants of another year.

  Growing up in the later part of the twentieth century, the poppy seemed to me to symbolise happiness. You saw them when idling in the countryside in good weather, or glimpsed them from the window of a train or a car, flashes of bright scarlet. Even the perpetual image of the Flanders fields heightened the sense of the poppy’s cheerfu
l nature. It was partly this contrast with the mud and the death all around that made it appeal so much to the troops: the way it crept into their minds like the promise of the pastoral home for which so many believed they were fighting, their memories of rural joy.

  That was what the Sumerians called it: the joy plant. Their writing was cuneiform, a clumsier form of symbolism than our generally phonetic alphabet, and many of the clay tablets they used have survived. One from south of Baghdad describes how to extract the joy from the plant. You score the ripening seed-heads, and the bitter-tasting, drug-filled latex emerges. Leave it to dry and oxidise in the sun, then return and collect the brown sticky paste that results. What you have is opium.

  Opium itself – the dried sap of the poppy – is a mixture of different chemicals, the most important of which we today call morphine. It is one of a class of compounds called alkaloids, many of which have pharmacological effects. Why they should do so is not fully clear, but it appears at least in part to be because many alkaloids are produced by plants specifically to have an effect on the species around them. Many make a plant (or a portion of it) unappetising to whatever insect or herbivore might be otherwise tempted to eat it. Some of these defences can occasionally become attractions, as when people seek out chilli peppers for the heat that is meant to make mammals avoid them. In a similar way the production of morphine has proved to be a successful evolutionary adaptation for the poppy. The drug binds to neurons throughout our brain and spinal cord, subduing pain and producing happiness, as well as damping down both our drive to breathe and the normal movement of our bowels. For this, as well as for the delights of its flower, people have been moved to propagate and protect the plant.

  There are other ways of extracting opiates from Papaver, some of them simpler. Eating a poppy-seed bagel is sufficient to fail a drugs test; the stuff is in there, even if the doses are too low for you to feel. A botanist at the United States Department of Agriculture has suggested that there are significant quantities of opiates in all poppies, and that an unripe seed-head steeped in a glass of vodka could produce enough for a more than decent dose. Less than a century ago the same government department was advising farmers on planting drug poppies as a good cash crop.

  If we take a drug in order to bring joy, is it a medicine? Using a drug to produce a sense of well-being does not seem ‘medical’ to most of us. Yet unhappiness, at least according to some, is a form of illness. So says the World Health Organisation, whose definition of health is stridently positive. Health, declares the WHO, ‘is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. From that perspective anything that brings happiness brings health. Opium has been used since ancient times as an antidepressant drug. Sometimes we still use it medically in similar ways. I have injected people with morphine and seen their fear, their misery and terror dissolve. Was it just that they were in pain, and the pain loosened their worst feelings? Perhaps. But sometimes pain and terror and unhappiness are not separate things. Opium can treat them all.

  Papaver rhoeas, the poppy of the Flanders fields, is a poor producer of useful drugs. For potency you need a poppy like Papaver setigerum or, even better, Papaver somniferum. If a field of poppies reminds most of us of summer or of war, in days gone by poppies evoked sleep and rest and forgetfulness. Poetry was rich with it. Homer sang of Helen, daughter of Zeus, preparing a draught by which Odysseus’s son Telemachus might forget the pang of his absence. She ‘cast a drug into the wine of which they drank to lull all pain and anger and bring forgetfulness of every sorrow’. That certainly sounds like opium, the drug that a Victorian poet described as making him feel his soul were being rubbed down with silk. Dioscorides, who wrote a five-volume textbook of pharmacology in the first century AD, thought Helen had used henbane. That is an altogether less predictable and less beatific drug and it seems unlikely, although Dioscorides, who travelled with the Roman military and almost certainly collected opium as he went, had some authority. More modern writers believe that Helen used opium, and an article in the Bulletin of Narcotics in 1967 even suggested that Telemachus avoided any ill-effects by virtue of being a regular user. It is not clear where in the Odyssey they found the authority for such a belief, but the Bulletin of Narcotics, perhaps, has some lingering worries about the effect of Homer on impressionable minds.

  English poetry, especially in the nineteenth and twentieth centuries, was rich with the poppy. It bloomed with connotations of sleep, oblivion and mock-death – blessings all. Francis Thompson’s ‘The Poppy’, written around 1887, today seems rather unintentionally soporific and forgettable. In 1919, though, it was regarded highly enough to make it into the Oxford Book of English Verse. There the poppy also hangs sleepily from Tennyson’s craggy ridge, and blows in the Flanders fields of John McCrae. Isaac Rosenberg knew how a poet should keep a poppy safe, especially at break of day in the trenches:

  Poppies whose roots are in man’s veins

  Drop, and are ever dropping;

  But mine in my ear is safe,

  Just a little white with the dust.

  Private Rosenberg was killed at dawn on 1 April 1918, having just completed a night patrol. Oscar Wilde, in tune with his occasional declarations that he reserved his best genius for his life rather than his work, preferred wearing poppies to writing about them. The homoerotic symbolism of the poppy, particularly a floppy-petalled purple one, helped prepare the ground for war poets who needed images to describe the red wounds of fresh young men. After McCrae’s ‘In Flanders Fields’, the poppy became the symbol of the War to End All Wars – and then of the wars after it. The symbol of oblivion became that of remembrance.

  Papaver somniferum has been found in human settlements dating back six or seven thousand years. It grew widely across Europe and Asia, perhaps being domesticated in the western Mediterranean. Burials in the Murciélagos Cave in Spain, dating to around 4200 BC, were accompanied by bags of poppy seed-capsules.

  The ancient Egyptians, after the fashion of the Sumerians, cultivated the poppy. They used it for many purposes, but they were clear about its medical power. In their pantheon the god Isis gave opium to Ra, the sun god, to clear up his headache. In their long list of medical treatments, the poppy was important, in some ways unique.

  In Roman days, Nero was fond of the poppy. Pliny reported that the emperor used it as a way of getting rid of his enemies. Coleridge, two thousand years later, found it enthralling. ‘How divine that repose is,’ he said, of the dreams it brought, ‘what a spot of enchantment, a green spot of fountains and flowers and trees in the very heart of a waste of sands.’ His London lectures, popular enough that the world’s first one-way system was created outside to handle the traffic, were based on his belief that he could only be at his most interesting to his audience if he was also at his most interesting to himself. So he stepped up to speak with no fixed ideas of his script, and opened his mouth to hear what ideas came out. Into a glass of water on the podium he poured a little laudanum, opium in alcohol, and a few drops of it were enough to colour the whole glass. As he spoke he added more, and as the talk progressed the glass grew darker.

  Here was something that was unmistakably a drug. The poppy caused sleep and happiness, it relieved depression, shortness of breath and – remarkably – diarrhoea. Above all it could take away pain. Oscar Wilde, dying in the shabbiness that overtook his last years, was given morphine and opium to take away the pain of what the doctors believed to be a fatal meningitis. Towards the end, in November of 1900, they took the strange step of only pretending to give him the injections. Wilde, his mind half gone with disease, was reduced to shoving his hand into his mouth to keep from screaming. That his doctors withheld morphine was undoubtedly cruel, but it may have prolonged Wilde’s life a fraction. The poppy’s ability to deliver people from a feeling of suffocation is not because it helps them breathe. It does the opposite, taking away their awareness of being short of breath. That eases away people’s suf
fering. Potentially it eases away their lives too.

  Appreciation of a drug’s effects does not mean that the theories used to explain them are correct. Opium, said Galen, ‘is the strongest of the drugs which numb the senses and induce a deadening sleep’. Galen was a Greek living in Rome during the second century after Christ. He is the most influential doctor ever to have lived. His writings summed up the classical knowledge of the time, with a few of his own innovations thrown in. For over a thousand years after he died his beliefs were accepted as absolute truth. Despite Galen’s proclaimed belief in experimentation, the bulk of his knowledge was based on insight. Galen recommended soaking opium in boiling water, then using it on a woollen sponge either up past the anus or into the nose. Both methods work, the blood supply to the rectum and the nostrils being rich, and the mucous membranes lining those body parts being thin and easily permeable. Galen possessed opium. He had other drugs that gave people diarrhoea – senna and castor oil are still used today – and ones that made them vomit or sweat. Such effects were within the capability of primitive people to discover.

  Anthropologists have sworn off using the word ‘primitive’, worried that it implies that others have cultures that are less complex or rich than our own. They may be correct. When it comes to objective knowledge, however, the word is truthful. Galen’s understanding of medicine really was primitive compared to ours, just as ours will hopefully be compared to that of our grandchildren.

  What was it about these early drugs that enabled people to discover them? If something, relatively quickly, made someone vomit, sweat, hallucinate or become unconscious then you could see it. If the person’s bowels or bladder behaved differently, he or she was able to tell someone about it the next day. Drugs with these effects could be pinned down by the same processes that helped people discover what was good to eat. Subtler effects, and longer time-scales, were not so easy. Many poisons which worked slowly were missed. The Romans sweetened their wine with lead. It was not obvious that the painful and lingering deaths that resulted – decades afterwards – were caused by the metal dissolved in the wine. Beneficial effects were overlooked too, if they were not immediate, dramatic and unmistakable. From the food they ate to the plants in their gardens, people were surrounded by substances containing active drugs – but they lacked the means to notice them.