Bernard Lown, MD
Not so long ago, doctors bled, purged, cupped, and performed all sorts of mayhem to cure diseases about which they had not a clue. With the advent of scientific medicine in the late 19th and early 20th centuries, evidence increasingly guided medical practice. This was particularly true for acute illness. Science, though, remained a porous veneer overlaying the treatment of chronic diseases , especially those afflicting the elderly. With the best of intentions, doctors over-treated their patients with unproven procedures and polypharmacy. These exacted an inordinate toll in suffering, morbidity, and death.
The advent of scientific medicine did not stop doctors from breaching the hallowed moral injunction of their profession, Primum nihil nocere (“first do no harm”). Early in my medical career I became keenly aware of how doctors — though committed to benefiting their patients — unwittingly harmed them. The insight derived from a transformative experience. It occurred sixty years ago, shortly after I began a cardiovascular fellowship under the mentorship of Dr. Samuel A. Levine at the Peter Bent Brigham Hospital (now the Brigham and Women’s Hospital) in Boston. Dr. Levine was a clinician without peer — astute in diagnosis, innovative in managing intractable clinical problems — and a riveting teacher.
At the time, the major challenge in hospital-based cardiology was dealing with the steady inflow of patients with acute heart attacks. Care was largely palliative: to relieve chest pain, to prevent blood clots, to ease the breathlessness and edema provoked by a failing heart muscle. Patients were confined to strict bed rest for four to six weeks. Sitting in a chair was prohibited. They were not allowed to turn from side to side without assistance. During the first week, they were fed. Moving their bowels and urinating required a bedpan. For the constipated, which included nearly every patient, precariously balancing on a bedpan was agonizing as well as embarrassing.