There will be blood
Authors: Theodore Dalrymple
Journal: BMJ (2008)

Staying recently at a country house with an intact library from the late 18th and early 19th centuries, I found myself leafing through leatherbound volumes of sermons and essays by divines. At one time I would have dismissed such volumes as being inherently without interest, but now I found them pleasant reading (perhaps it is my age).

I started to read the Winter Evenings or Lucubrations on Life and Letters of the Reverend Vicesimus Knox DD (third edition, 1795). Who, indeed, could resist an essay entitled “On the imprudence of urging incorrigible dunces to a learned profession,” although it made me slightly uncomfortable to read it. Was I merely one of what the Reverend Knox called the “mediocrists,” that is to say one whose “understandings are not bright and shining,” or one of the true dunces, who “ought to be passed over with tacit connivance, or the gentlest reproof, ridiculous as their blunders appear”?

There is much of medical interest in the Lucubrations, including a letter received by the Reverend Knox from a man calling himself “an ethico-chirurgical operator” on the subject of “moral phlebotomy, a mode of discipline among the Romans.” The ancient Romans, he said, practised phlebotomy on delinquents in the army, on the grounds that all who misbehaved were ill. Most of the serious human failings, the author of the letter maintained, were caused by a surfeit of blood, which led him to conclude that “all poets, religious enthusiasts, balloonists, lottery adventurers, ambitious statesmen, and choleric orators in the British or Irish parliament, may . . . receive great benefit from the phlebotomizing system of morality.” If he had been living today, the author, I think, would have added senior staff at the Department of Health as suitable subjects for phlebotomy.

One of Knox’s lucubrations was “on the rashness of young and adventurous writers in medicine.” Here we learn that things have not changed quite as much in the intervening couple of centuries as we might have supposed. “Whoever takes a retrospective view of medicines,” says Knox, “which a few years ago were highly extolled, and generally used, will find many of them at present in total disrepute.” This is because “if poison can be administered, in any form, without certain and immediate death, it is soon advanced to the rank of a panacea.”

What drug do you think of when you read the following? “Many fall victims [to the new drug] before the full discovery of its ill effects, or the danger of relying upon it because of its inutility, in extreme or difficult cases.”

As for the pitfalls of the availability of the internet to the sick person, they are nothing new:

In these times, every man and woman reads a book, in which they think themselves interested; and the sanguine pamphlet of a young physician, who is able to dress his fancies in a language tolerably agreeable and perspicuous, falls into the hands of those, who are totally ignorant of medicine, both practical and theoretic, and who, imagining their own case to be exactly described in the book, take the medicine . . . Constitutions are thus ruined by those who speciously pretend to have discovered their preservative.”

Every man, says Knox, attempts everything for himself, guided only by books; and “the professor is called at the last, and finds much more employment, than if his assistance had been sought before the bungling efforts of ignorance had rashly interposed.”

At last I understand why so many of my patients failed to improve.

If he had been living today, the author, I think, would have added senior staff at the Department of Health as suitable subjects for phlebotomy