SGEM#200: Dr. Alexander Hamilton and Bloodletting for Camp Fever

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Date: December 19th, 2017

Reference: Lesassier Hamilton A. Dissertatio Medica lnauguralis De Synocho Castrensi [Inaugural medical dissertation on camp fever]. Edinburgh: J Ballantyne, 1816.

Guest Skeptic: Dr. Robert Leeper is an assistant professor of surgery at Western University and the London Health Sciences Centre. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation.

This is the 200^th episode of the SGEM and it is the 2017 holiday edition. The idea for this episode came after seeing a twitter photo on Halloween of Dr. Leeper (@Rob_Leeper) doing rounds dressed up as Alexander Hamilton.

To be clear, Dr. Alexander Lesassier Hamilton was a Scottish physician who lived around the early 1800s. He is a completely different person than one of the founding fathers of the United States.

The American Alexander Hamilton family was Scottish but he was born out of wedlock in Charlestown, Nevis. He was abandoned by his father and became an orphan when his mother died.

Hamilton vs. Burr Duel

Despite his challenging start to his life, Alexander Hamilton became the first Secretary of the Treasury, established a national bank and contributed greatly to the early years of the United States of America.

However, he was a very controversial figure for a number of reasons. One reason was his embroilment in the first major sex scandal involving an American politician. He was also mortally wounded in a duel with Aaron Burr. Many people know about the American Alexander Hamilton because of the amazing Broadway musical written by Lin-Manuel Miranda.

Dr. Alexander Hamilton will be the focus of this SGEM holiday episode. He too was a controversial figure. Dr. Hamilton was reported to have been self-absorbed, shameless opportunist, scoundrel, seducer and at times a failed physician.

Inagural Medical Dissertation on Camp Fever

Dr. Hamilton published his medical thesis in 1816 called Inaugural Medical Dissertation on Camp Fever. It is a study that highlights the importance of randomization. A copy of the paper was retrieved from the achieves at McGill University with the help of a librarian at Western University. It was a 90 page document written in Latin.

Google Translate was not able to convert the Latin to English. Western University Assistant Professor of Classics and Graduate Chair Kyle Gervais said it would take a graduate student about three months working on it full time to translate the document.

The James Lind Library were very helpful. They had English copies of Dr. Hamilton’s papers. One of them was thought to have been the document given to a Latinist to produce the Latin version required by Edinburgh University for Dr. Hamilton’s medical thesis. It was this hand-written document that was relied upon for this special holiday edition of the SGEM.

Case: 23-year-old soldier presents to the medical tent with camp fever. On examination, “the pulse is frequently, full and soft. Respirations somewhat affected. Heat increased. Anorexia. Thirst. Tongue furred. Urine high coloured. Constipation.”

Peninsular War

Background: The Peninsular War was between the Napoleon Empire and the allied powers of the Spanish Empire from 1807 to 1814. The allies consisted of Spain, Great Britain, Ireland and Portugal. They were fighting for control of the Iberian Peninsula.

It was the Peninsular War that popularized the term guerilla warfare. Guerilla is a Spanish word that is usually translated as “little war”. This is not to be confused with gorilla, the largest living primate. Guerilla warfare typically centers around a small, mobile force going up against a larger professional army.

During the Peninsular War, there was an outbreak of camp fever. Camp fever is a form of typhus called Epidemic typhus. It is caused by the Rickettsia prowazekii, and often results in epidemics following wars, hence the name. Camp fever is transmitted by the human body louse.

Typhus is an infection that causes high fever, rash, cough, myalgia, headache, hypotension, delirium and if untreated, death. So basically, it causes sepsis, septic shock and often death.

Modern treatment of typhus includes antibiotics and supportive management. We have covered sepsis many times on the SGEM (44, 69, 90, 92, 113, 168 and 174). In none of those episodes did we recommend bloodletting in the management of sepsis.

During Dr. Alexander Hamilton’s time the treatment for camp fever included aromatics (camphor), essential oils, tonics, opium and ether. External measures of sponging the body with warm water and spirits were also employed.

Four Humours

One other treatment often used was bloodletting. This therapy goes all the way back to 5^th century BCE with Hippocrates. There were four humours (blood, phlegm, black bile and yellow bile) and was associated with the four fundamental elements of air, water, earth and fire. The hypothesis was that fever could be treated with bloodletting and that would balance the humours.

There is the famous story of George Washington the first president of the United States. He developed some kind of throat infection. Part of his treatment was bloodletting. They removed 3.75 liters of blood over about ten hours before he died of the infection in 1799.

Barber Pole

The practice of bloodletting was continued by surgeons even after the humoral system fell into disuse. Bloodletting would be recommended by physicians but it was the surgeons who carried out the tasks usually in barber shops. The red-and-white-striped pole of the barbershop came from this practice. The pole advertised bloodletting with the white symbolizing the bandage and the red symbolizing the blood.

Bloodletting was used to treat almost every disease. One British medical text recommended bloodletting for acne, asthma, cancer, cholera, coma, convulsions, diabetes, epilepsy, gangrene, gout, herpes, indigestion, insanity, jaundice, leprosy, ophthalmia, plague, pneumonia, scurvy, smallpox, stroke, tetanus, tuberculosis, and for approximately one hundred other diseases.

The Burns Archive – Burns Archive via Newsweek

The practice of bloodletting persisted well into the 20th century with Dr. William Osler being a prominent supporter. It was recommended by him in his 1923 textbook called The Principles and Practice of Medicine.

This is an excellent example of the knowledge translation problem. There was evidence that bloodletting did not provide a benefit. Dr. John Hughes Bennet from Edinburgh opposed bloodletting and supported a more science-based approach in the late 1800’s. Despite the evidence of harm, bloodletting persisted for another 100 years.

There are a few conditions that bloodletting (now called phlebotomy) is still used for and include polycythemia and hemochromatosis.

Clinical Question: Does bloodletting a soldier with camp fever increase chances of survival?

Reference: Lesassier Hamilton A. Dissertatio Medica lnauguralis De Synocho Castrensi [Inaugural medical dissertation on camp fever]. Edinburgh: J Ballantyne, 1816.

Population: Soldiers with camp fever
Intervention: Usual care plus bloodletting
Comparison: Usual care
Outcome:
- Primary: Death
- Secondary: None

Author’s Conclusions: “The hypothetical part of this essay will, no doubt, appear objectionable to many, even at present, shortly hence, probably to all. In this it will be shared the fate, which is common to every visionary opinion that pleases us for a time; but which struggles through its ephemeral existence of a day, and is forgotten.

The practical part, however, at least what relates more immediately to the care and management of the soldiers, is deduced from experience, and founded on reason.

Those who served in the late Peninsular War, under the distinguished individual who presides over the medical department of the army will not have forgotten, with what solicitude he taught us how vastly more important it is to prevent, than to cure disease.

They will ever remember Sir James McGregor with admiration and gratitude, for the ready protection and assistance his suavity of manners rendered doubly pleasing, and for the luminous information his eminent talents so well fit him to afford.”

Quality Checklist for Randomized Clinical Trials:

The study population included or focused on those in the emergency department. No. These were soldiers presenting for medical attention in with camp fever during the Peninsular War.
The patients were adequately randomized. Yes. “It had been so arranged, that this number was admitted, alternately, in such a manner that each of us had one third of the whole.”
The randomization process was concealed. No
The patients were analyzed in the groups to which they were randomized. Yes
The study patients were recruited consecutively (i.e. no selection bias). Yes. “The sick were indiscriminately received.”
The patients in both groups were similar with respect to prognostic factors. Unsure
All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
All groups were treated equally except for the intervention. Yes. “were attended as nearly as possible with the same care and accommodated with the same comforts.”
Follow-up was complete (i.e. at least 80% for both groups). Yes
All patient-important outcomes were considered. Yes
The treatment effect was large enough and precise enough to be clinically significant. Yes

Key Results: 366 soldiers with camp fever were enrolled in the study (122 bloodletting and 244 no bloodletting).

Significant increase in death with bloodletting – NNH of 4

This gives an absolute difference of 26.2% or an Number Needed to Harm (NNH) of 4.

1) External Validity – These were not emergency department patients but rather soldiers presenting with camp fever. We do not see much typhus these days. However, we do see many people with sepsis. Removing circulator volume in the form of bloodletting would not be recommended today for our patient population.

2) Baseline Characteristics – We are unsure if the patients’ baseline characteristics were equal between both groups. It was probably a fairly homogenous group of young men who were fighting in the Peninsular War. There was no documentation on basic demographics or past medical history, which could have influenced the results.

3) Usual Care – There appears to be a protocol in Dr. Hamilton’s thesis as to “usual care”. Treatment for camp fever, besides bloodletting, included aromatics, essential oils, tonics, opium and ether. External measures of sponging the body with warm water and spirits were also employed. Some of our current usual care for septic patients would include source control, IV fluids and early broad-spectrum antibiotics. The Surviving Sepsis Campaign has guidelines and bundles that contain all the details of current septic management.

4) Blinding – No one was blinded to group allocation in this study. The patients knew if bloodletting was being performed. The practitioners also knew group assignment and the outcome evaluator, Alexander Hamilton, would also know. That being said, you would think the bias should have been in favour of bloodletting because that was the standard care.

An observational study could have rationalized any deaths with bloodletting as the patient did not have enough blood removed, it was not started soon enough, it was not done long enough, it was doing with the wrong frequency, it should have been done on the right arm instead of the left arm, etc. That is why it is so important to have a randomized study with a no bloodletting group to remove some of the biases.

Even if the bias was towards not bloodletting, it would be hard to fudge the outcome (alive or dead). It is not one of those Princess Bride outcomes where they are only “mostly dead”.

By Professor Lisa Rosner

5) The Man: Dr. Alexander Hamilton is reported to have been a self-absorbed, shameless opportunist, scoundrel, seducer and failed physician. People are flawed and some are seriously flawed individuals. Physicians and researchers are no exception. There are many scandalous stories about scientists behaving badly in their professional and private life. While Hamilton’s short comings do not falsify his research on bloodletting, it does make us more skeptical.

Lisa Rosner is a Distinguished Professor of History from Stockton University in New Jersey. She wrote a book about Dr. Alexander Hamilton called: The Most Beautiful Man in Existence: The Scandalous Life of Alexander Lesassier. I reached out to her as a historian and asked her expert opinion about Dr. Hamilton’s early life, the bloodletting trial and what kind of man he was. Professor Rosner was kind enough to send a 15 minute recording summarizing the life of Dr. Hamilton. Listen to the podcast and if you are further intrigued, consider buying her book like I did.

Comment on Author’s Conclusion Compared to SGEM Conclusion: We generally agree with the Dr. Alexander Hamilton’s conclusion, especially the part about preventing disease being more important than curing disease.

SGEM Bottom Line: Bloodletting is harmful for soldiers with camp fever and cannot be recommended.

Case Resolution: The solider is provided with the usual care but does not have bloodletting performed. He recovers and goes on to fight another day.

Dr. Rob Leeper

Clinical Application: Given the mounting evidence of the potential harm of bloodletting for febrile illnesses, the lance should not be employed any longer to treat patients with camp fever or other febrile illnesses.

What Do I Tell My Patient? It looks like you have camp fever. We are going to treat you with the best medical care possible. This used to involve bloodletting but we have found this to hasten death. Therefore, we will not be employing the lance at this time.

Keener Kontest: Last weeks’ winner was Carl Preiksaitis a MS4 student from NYU. Carl knew the first description of an epileptic seizure appears in a text from 2000 B.C. written in the Akkadian language, used in the region of Mesopotamia.

Listen to the podcast on iTunes for this weeks’ keener question. If you think you know the answer then send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

References/Resources:

The James Lind Library
Dr. Alexander Hamilton: Translation of an Inaugural Dissertation
Milne and Chalmers: Alexander Lesassier Hamilton’s 1816 report of a controlled trial of bloodletting
Lisa Rosner: The Most Beautiful Man in Existence: The Scandalous Life of Alexander Lesassier.