Friday, May 7, 2010
Does phlebotomy 'work'?
By Ken Weiss
There's a discussion in a nice book about the history of Islamic science (Ehsan Masood, Science and Islam: A History) of a man named al-Razi, who in about AD 900 was said to have done a carefully controlled experiment to test whether phlebotomy (blood-letting) worked as a treatment for meningitis. Some patients were given the treatment and others were untreated 'controls'. Al-Razi found that the bloodletting worked, in that more of the treated patients than controls recovered.
This therapy was part of the ancient and revered view of life upon which the classical medical approach codified by Galen was based. The humoral theory, that existence and hence life and health are based on balance of four basic properties (earth, air, fire, water), that in humans corresponded to blood, black bile, yellow bile, and phlegm.
Everything could be explained in terms of disease as the state in which these are out of balance. Blood-letting was done when the patient was deemed to have an imbalance by an excess of blood. Galenic medicine lasted for many centuries and it was verboten even to question it. And why question it? It worked! That is, some patients got better and the belief in the system led everyone to accept its sometime success as supportive evidence (and indeed, it's possible that even when assessed by modern scientific standards, bloodletting may sometimes have done some good, as this story describes).
Why don't we accept it today? In fact, even al-Razi himself wrote a book casting doubt about the degree to which Galenic medicine was true. After all, we accept modern medicine even though it fails to cure everyone. We have to ask what causation really is. After all, placebos work. If you know people are praying for you, it apparently works -- although prayer doesn't work if you don't know people are praying for you.
We dismiss that as 'only' psychological, even if that is purely physical and molecular, by involving neurotransmitters that affect other cell behavior, such as by the immune system and who knows what else, eventually leading to improvement in the disease. Blood-letting apparently has a measurable, replicable physiological rebound effect that makes people feel better a few hours later. We say these things don't really cure the disease, or if they're just psychosomatic, somehow that doesn't count. But if the brain is a material rather than immaterial structure, and the effect is thus material, why doesn't it count?
We want higher percentages of success. We want therapy to be direct, rather than indirect. If the treatment is believed by the patient, it boosts his immune system in some way, etc. Somehow, targeting the true pathology indirectly, rather than by targeting the proximate molecular cause, is not considered 'real'.
But that's our own culturally derived way to define medicine and its efficacy. It's similar with diseases like AIDS and HIV. As the South Africans said for a decade or more, poverty is the true 'cause' of AIDS, not the virus. Unfortunately, many thousands died as a result. Yet poverty is still causally associated with HIV infection. South Africa has finally accepted that HIV is also a cause of AIDS, and thousands or millions of lives may now be saved as a result.
Empirically, the desired explanation can be chosen to be some net result -- 'cure' in the case of disease. Science in the west, at present, wants reductionist molecular explanations, about proximate cause. Causes higher up the material chain -- like poverty and poor education cause poor neighborhoods with no good grocery stores cause reliance on McFastFood causes obesity causes high blood pressure or glucose causes retinal and peripheral neuropathy causes blindness and loss of extremeties. So what causes blindness? Even in our molecular, reductionist, technical age, diabetics still become blind.
There is no one answer. If removing poverty greatly reduced blindness, isn't poverty a cause? Or McBurgers? The prevailing view is that if we identify some ultimate cause -- the preferred target for many in science these days is your 'personalized' genome -- we will get to the 'real' cause and will then live forever. But the focus on genes is part and parcel of the structure of our current society.
Whether one approach to causation will ever, by itself, lead to miraculously high levels of efficacy nobody can say. Galenic physicians thought they had the ultimate answer. Collinsian medicine (Francis Collins, Director of NIH and the chief spokesperson for personalized genomic medicine) is having its day today. What about tomorrow?
The same kinds of questions arise in evolutionary and developmental biology. We've recently posted on phenogenetic drift-- the idea that essentially the same trait can come to be due to different genetic bases even while being conserved by natural selection -- which suggests that genes contribute but are not 'the' cause of the trait. This is related to the entire concept of complex causation.
So was al-Razi right that phlebotomy cured meningitis? Perhaps it is inappropriate to ask whether Galenic medicine 'works'. It is more interesting, to us at least, to ask what we mean by 'works'.
[p.s., al-Razi, known in the west as Rhazi, wrote critically about Galenic medicine in a book Doubts About Galen]