Civilization in the United States: An inquiry by thirty Americans

by Unknown

MEDICINE

From time immemorial the doctor has been the object of respect and awe by the generality of mankind. It is true that he has occasionally been made the butt of the satirical humour of such dramatists as Molière and Shaw, but the majority of people have regarded these jests as amiable buffooneries, and not as penetrating criticisms. In ancient days the veneration of the medico was based upon his supposed association with gods and devils, and upon the belief that he could cure disease by wheedling propitiation of deus, or by the exorcism of diabolus. In modern times he holds sway by his supposed possession of the secrets of science.

In spite of his pretension to scientific attainment, many vestiges of his former priesthood remain, and this mélange of scientist and priest has produced curious contradictions and absurdities. But these absurdities must by an inexorable law remain concealed from all save a few, and the general failure to recognize them has led to a great increase in the importance and prosperity of the medical cult. In America, of all civilized nations, medical magnificence has reached its most formidable proportions. This exaggeration, characteristic of all social phenomena in the new world, makes the real importance of the doctor to society easy to inspect and to analyze.

A friend not long ago asked me to explain the co-existence, in the same city, of the elaborate installation of the Harvard Medical School and the magnificent temple of the religion of Mrs. Eddy. “What is it in our culture,” said he, “that permits the symbol of such obvious quackery as that of Mrs. Eddy to flourish within a stone’s throw of such an embodiment of scientific enlightenment as the medical college?”

I replied that the reason for this must be sought in the gullibility of our citizens, who are capable of entertaining most incompatible and contradictory credos. Thus, the average American can believe firmly and simultaneously in the therapeutic excellence of yeast, the salubrious cathartic effects of a famous mineral oil, the healing powers of chiropractors, and in the merits of the regimen of the Corrective Eating Society. His catholicity of belief permits him to consider such palpable frauds seriously, and at the same time to admire and respect authentic medical education and even the scientific study of disease. But the teachers, students, and alumni of medical colleges are drawn from our excessively credulous populace. So it is dangerous to consider the votaries of the profession of medicine as sceptical and open-minded savants, in contrast to the promulgators of the afore-mentioned imbecilities and to Homo sapiens americanus, who is the unconscious victim of such charlatanry. In reality the great majority of the medical profession is credulous and must always remain so, even in matters of health and disease.

The tendency to consider physicians in general as men of science is fostered by the doctors themselves. Even the most eminent among them are guilty in this respect. Thus the Director of the Hospital of the Rockefeller Institute maintains that medicine must be considered not as an applied science but as an independent science (R. Cole, Science, N. S., Vol. LI, p. 329). And an eminent ex-President of the American Medical Association holds a similar view, at the same time preposterously asserting that “medicine has done more for the growth of science than any other profession, and that its best representatives have been among the leaders in the advancement of knowledge....” (V. C. Vaughan, Journal, A. M. A., 1914, Vol. LXII, p. 2003.)

Such pronunciamentoes rest upon the almost universal confusion of the art of the practice of medicine with the science of the study of disease. Science, in its modern definition, is concerned with the quantitative relationship of the factors governing natural phenomena. No favourites are to be played among these factors. They are to be weighed and measured meticulously and coldly, without enthusiasm for one, or disdain and enmity toward another. Now, in the case of relationship of doctor to patient, it is clear that such emotions must enter. The physician must entertain enthusiasm for the defensive powers of his patient, John Smith, and at the same time hate virulently the pneumococcus that attacks him. This emotional state of the soldier of health prevents the employment of what is known in the language of the laboratory as the “control.” For example, a doctor wishes to test the efficacy of a serum against pneumonia. In America it is practically unknown for him to divide his cases of pneumonia into two groups of equal size, to administer his serum to group A and to leave group B untreated. He almost invariably has a parti-pris that the serum will work, and he reflects with horror that if he holds his remedy from group B, some members of this group will die, who might otherwise have been saved. So he injects his serum into all of his patients (A and B), and if the mortality in the entire group appears to him to be lower by statistics than that observed in previous series of cases, he concludes that the value of his nostrum is proved. This is an illustration of the fallacy of the notion that medicine is a science in the modern sense.

Modern study of disease, conducted in the laboratory upon experimental animals, has furnished medical practitioners with a few therapeutic and prophylactic weapons. In the use of these the American medico has not lagged behind his European colleague. But the great majority of the malaises that plague us are not amenable to cure, and it is with these that the doctor has since the beginning of time played his most important rôle, i.e., that of a “professional sympathizer.” The encouraging conversation with the family of the sufferer; the mumbling of recondite Latin phrases; the reassuring hopeful hand on the patient’s shoulder; the grave use of complicated gimcracks; the prescription of ineffective but also innocuous drugs or of water tinted to pleasing hues; all these are of incalculable value to the ménage stricken by disease. It is my lamentable duty to point out the danger of the decline of this essential rôle among the doctors of America. The general practitioner of the ancien régime was sincere in his performance of his quasi-religious function. He was unsparing of his energies, stern in his devotion to duty, deeply altruistic in sentiment, and charmingly negligent in economic matters.

But at the present time this adorable figure is disappearing from the land, to be replaced by another, more sinister type, actually less learned in the important folklore of the bedside, pseudo-scientific, given to rigidly defined office hours, and painfully exact in the extortion of his emolument. What are the factors that give rise to the appearance of this new figure on the American scene? The most important of these is to be found in the high development of the craft of surgery in the United States. Of all the dread afflictions that plague us, a few may be cured or ameliorated by the administration of remedies, and an equally small number improved or abolished by surgical interference. But in spite of the relatively few diseases to which surgery is beneficial, the number of surgeons that flourish in the land is enormous. The fundamental discoveries of Pasteur and their brilliant application by Lister were quickly seized upon in America. The names of Bull, Halstead, Murphy, the brothers Mayo, Cushing, and Finney are to be ranked with those of the best surgeons of any nation. In fact, we may be said to lead the world—to use an apt Americanism—in the production of surgeons, just as we do in that of automobiles, baby carriages, and antique furniture.

The success of these protagonists in the higher carpentry at once attracted a horde of smaller fry, imitators, men of inferior ability. The rapid advances made by the leaders resulted in the development of a diversified and complicated technic, which the ordinary surgeon was able to master in sections but not in toto. From this, specialization in surgery has developed rapidly and naturally, so that now certain men devote their lives exclusively to the enthusiastic and indiscriminate removal of tonsils, others are death on gall bladders, some the foes of the vermiform appendix, and yet others practise exclusively the radical cure of phimosis. It is obvious that such narrow specialization, practised in isolation, would lead to most amusing results, which may best be left to the imagination. But these absurdities were finally apparent even to the surgeons themselves, with the resulting development of what is now known as “group medicine.”

In brief, surgeons with special penchants for the removal of various organs, form partnerships, calling to their aid the internist for the diagnosis of their prospective victims. The internist gathers about him, in turn, a group of less important fry, known as radiographers, bacteriologists, pathologists, and serologists. Frequently a dentist is added to the coterie. The entire organization is welded into a business partnership of typically American efficiency. These groups are forming over the entire nation, are appearing even in the tank-towns of the hinterland. They occupy elegant suites in important office buildings, their members are generally considered the arbiters of the medical opinion of the community. Their more or less intelligent use of the paraphernalia of pathology, bacteriology, et cetera, gives them an enormous advantage over their more humble brother, the general practitioner. This last, indeed, is being rapidly routed in his battle with such associations of “best minds,” equipped with the armamentarium of modern science.

The remuneration required by the “super-docs” of group medicine is naturally far in excess of that demanded by the general practitioner. It is right that this should be so, if not for the results obtained, then by reason of the elaborate organization and expensive equipment that the group system demands. This increase in reward has made the profession of medicine in America what it never was before, a paying proposition—again to use an apt Americanism. The result of this entry of crass materialism into a previously free-and-easy, altruistic, anything but business-like profession is, once more, better left to the imagination than described. The brigandage of many of these medical banditti is too painful even to think about. It will be apparent that relatively few of our citizens are able to pay for group medicine. So, it is interesting to observe that the best in medical treatment and advice is accessible only to the highest and lowest castes of our plutocracy. The rich receive this at the elegant offices and private hospitals of the groups, the miserably poor at the teaching hospitals of medical colleges.

The service of the “super-doc” to such of our citizens as can afford him cannot at this time be properly estimated. It is true that he is progressive, that he leans heavily upon the subsidiary sciences of pathology, et cetera, that he publishes papers in medical periodicals, that he visits medical libraries, frequents medical congresses. It has just been insisted that the doctor has benefitted himself to a great extent economically by forming the group; it is for the future to divulge whether his ministrations have resulted in a perceptible reduction of human suffering or in a prolongation of human life. Certainly he has perpetrated some astounding hoaxes, the kind-hearted will say unwittingly. Probably the most interesting of these is to be observed in the focal infection mania just now subsiding.

Focal infection came into prominence as the theory, so called, of a group of eminent physicians in Chicago. It is, in brief, the doctrine that many of our aches and pains whose direct etiology it is impossible to demonstrate are due to the presence in the body of foci of harmful microbes, at the roots of the teeth, in the tonsils, accessory sinuses, or the appendix. Discover the focus, remove it, and presto!—the ache disappears like the card up the sleeve of the expert American poker player. The advantages of this theory to the various specialists of a group will be obvious. To illustrate. Henry Doolittle is plagued by a persistent and annoying pain over his left shoulder-blade. He goes to the office of a group of “super-docs,” is referred to the diagnostician, who makes a careful record of his status præsens, then orders his satellites to perform the Wassermann reaction, make the luetin test, do differential blood counts, perform the determination of his blood urea, and carry out a thorough chemical study of his basal metabolism. If the results of these tests show no departure from the normal, or if they seriously contradict each other, the cause of the pain is probably focal infection. The patient is then subjected to examination by X-ray, his teeth are pulled by the dentist, his tonsils excised by the otolaryngolist, who also takes a swipe, in passing, at his accessory sinuses, and should these mutilations fail to relieve him, his appendix is removed by the abdominal surgeon. If relief still fails to occur, the theory is not given up, but the focus is presumed to exist elsewhere. If Mr. Doolittle’s patience is equal to the test, and if his purse is not by this time completely empty, additional operations are advised. These continue until all organs and appendages not actually necessary to mere existence have been removed. Henry then returns to his former mode of life, depleted and deformed, it is true, but occasionally minus his original pain. It is not the intention to deny that infected teeth and tonsils have no significance in pathology. But it is certain that their importance has been greatly exaggerated by many physicians. The question needs more investigation, with fewer preconceived ideas. The “science” underlying this astounding practice is admirably outlined in the book of Billings called “Focal Infection.” It is the most striking example of medical Ga-Ga-ism that has appeared in our country. It is, as its author himself admits, a triumph of the new idea of team-work and co-operative research in medicine. The factors giving rise to this lamentable Ga-Ga are the gullibility of patient and doctor, the emotional element entering into the interpretation of all of the phenomena observed by the physician, commercialism, and, finally, the self-limiting nature of most disease.

So much for the Art of Healing as practised by the physicians of America. What of our activities in the second aim of medicine, that is, the prevention of disease? While superficial examination is enough to lay bare the many hollow pretensions of the practice of medicine, it would appear a priori that the work of disease prevention might at least approach the category of the applied sciences. This would seem to be so, since the greater part of this field must of necessity concern itself with infectious disease. Now the etiologic agents of the majority of infectious diseases are known. It is easy to see that the labour of their prevention rests upon an exact knowledge of the nature of the disease-producing microbes, the analysis of the delicate balance between the virulence of the microbic invader and the resistance of the human host, and, most important of all, upon the exact path by which the germ in question travels from one individual to another.

In the early days of preventive medicine, following shortly upon the fundamental researches of Pasteur, several important contributions were made by Americans. These include the brilliant investigations of Theobald Smith on the etiology and mode of transmission of the Texas fever of cattle, and, later on, the differentiation of bovine and human tuberculosis. America had again reason to be proud when, in 1901, Reed, Carroll, Agramonte, and Lazear demonstrated that yellow fever was spread exclusively by the mosquito, Ædes calopus. These investigators showed a beautiful spirit of self-sacrifice and devotion to their science. The construction of the Panama Canal was made possible by the application of these researches by Gorgas. Again, the American Russell was the first to show that vaccination against typhoid and allied infections is feasible. In the New York Board of Health, Park, Krumwiede, and their associates have made careful and valuable studies on the prevention of diphtheria. These constitute the high lights of American achievement in preventive medicine. It must be admitted that the majority of these examples are to be placed in the category of the science of the study of disease, rather than in that of its application—preventive medicine.

It is noticeable even by cursory survey of recent American work that such striking achievements have become distinctly fewer in recent years, despite an enormous increase in personnel, equipment, and money devoted to the prevention of disease. Along with this decrease in solid contributions there has been an augmentation of fatuous propaganda and windy theory. All of the judicious must view this tendency with alarm and sadness, since it seemed for a time that science was really about to remove the vestigia of witchcraft and high-priesthood from this branch of medicine at least.

What is the cause of this retrogression? It must be laid at the door of Religio Sanitatis, the Crusade of Health. This is one of the most striking examples of the delusion of most Americans that they are the Heaven-appointed uplifters of the human race. Just as all Baptists, Presbyterians, and Methodists deprecate the heathen happiness of the benighted Oriental, so the International Health Board seeks to mitigate his contented squalour and to eradicate his fatalistically born disease. Just as Billy Sunday rages against John Barleycorn and the Dionysians who worship him, so the Great Hygienists seek to point out the multiform malaises arising from such worship. Just as the now extinct Wilson strove to show the world that it was horrid and wrong to fight, so the Public Health Service seeks to propagate the notion that chastity and adherence to marital vows are the sole alternatives to a universal syphilization.

Thus we observe with horror the gradual replacement of those Nestors of preventive medicine who had the dispassionate view of science, and who applied its methods of cold analysis, by a group of dubious Messiahs who combine the zealous fanaticism of the missionary with the Jesuitical cynicism of the politician. For most of the organizations for the promotion of health are closely dependent upon state and municipal politics, and must become contaminated with the obscenity of political practice. Finally, it is apparent that the great privately endowed foundations are animated by the spirit of proselytism common to the majority of religions, but especially to Baptists. It will be objected that such charges are vague generalizations. It is necessary, therefore, to bring forward one or two specific instances in support of these contentions.

The soldiers of the recent successful campaign for national prohibition were supported by battalions of noted hygienists who made excellent practice with a heavy artillery of so-called scientific evidence upon the confused ranks of brewers, distillers, and their customers, the American bibuli. What is the value of their “scientific evidence”? Two charges are made against the use of alcohol as a beverage. Primo, that its moderate or excessive use is the direct cause of various maladies. Secondo, that the children of alcoholic parents are often deformed, degenerates, or imbeciles, and that such lamentable stigmata are the direct results of the imbibitions of their parents.

Now it is vain to argue that alcohol, taken in great excess, is not injurious. Mania a potu (Korsakow’s disease) is without doubt its direct result, at least in some instances. On the other hand, excessive indulgence in water is also not without its harmful effects, and I, for one, would predict evil days for our Great Commoner, should he so far lose control of himself as to imbibe a gallon of grape juice per diem. Many enthusiastic hygienists advance the opinion that alcohol is filling our insane asylums! This generalization is a gorgeous example of post hoc propter hoc reasoning, and is based upon the idiotic statistical research which forms so large a part of the activity of the minions of public health. The recent careful work of Clouston and others tends more and more to indicate that chronic alcoholics do not go crazy because they drink, but become alcoholics because they already were crazy, or had the inherited tendency toward insanity. This embarrassing fact is carefully suppressed by the medico-hygienic heavy artillerists of the prohibition army. What is more, diseases with definite pathologic pictures, such as cirrhosis of the liver, have by no means been definitely proved to be caused by alcohol. Indeed, the researches of Friedenwald, who endeavoured to produce such effects by direct experiment, have led to negative results.

The second indictment, i.e., that alcoholism in parents causes degenerate offspring, rests upon still more dubious scientific foundations. The most important animal experimentation in this field is that of Stockard, who used guinea-pigs as his subjects, and of Pearl, who had recourse to chickens. Both of these researches are sound in scientific method. Unfortunately for hygienists, they lead to completely contradictory conclusions. Stockard and his collaborators found the offspring of alcoholic guinea-pigs to be fewer in number than those of his normal controls. What is more, the children of the alcoholics were frequently smaller, had a higher post-natal mortality, and were prone to suffer from epileptiform convulsions. These results brought forth banzais from the hygienists and were extensively quoted, though their application by analogy to the problems of human heredity is not to be made too hastily.

Pearl, on the other hand, discovered that while the number of offspring from his inebriated chickens was distinctly fewer, yet these were unquestionably superior to normal chickens in eight of the twelve hereditary characters amenable to quantitative measurement. Now if one can generalize Stockard’s results to human beings, then it is equally permissible to do the same with Pearl’s. Of the two, the latter generalization would be preferable, and of greater benefit to the human race, were the analogy valid. For who will not whoop for “fewer children, but better ones”? Do the votaries of preventive medicine place the results of Pearl along side of those of Stockard? Indeed, who even mentions Pearl’s results at all? If satisfactory evidence is adduced that this has been done, I hereby promise to contribute one hundred dollars in cash toward the foundation of a home for inebriated prohibition agents. Again, while much is heard of the results of Bezzola in regard to the Rauschkinder resulting from the Swiss bacchanalia, the negative findings of Ireland in similar investigations of the seasonal debauches of Scotland are carefully avoided. Once more, Elderton and Karl Pearson have failed utterly to find increase in the stigmata of degeneracy among the children of alcoholic parents as compared with those of non-alcoholics. This research, published in a monograph of the Francis Galton Laboratory of London, is the one really careful one that has been made in the case of human beings. It was directed by Pearson, admittedly a master of biometrical science. Yet, turning to Rosenau’s “Preventive Medicine and Hygiene,” the bible of this branch, I find the Elderton-Pearson report relegated to a footnote in the edition of 1913, and omitted completely from the 1920 edition.

A discussion of the fatuity to which American preventive medicine descends cannot be terminated without touching upon the current propaganda of the syphilophobes. For just as practitioners of medicine exploit human credulity, so the preventers of disease play upon the equally universal instinct of fear. There is no intention of minimizing the seriousness of syphilis. Along with cancer, pneumonia, and tuberculosis, it is one of the major afflictions of humanity. It causes thousands of deaths yearly; it leads to great misery. Paresis, one of the important psychoses, is definitely known to be one of its manifestations. It is obvious, therefore, that its eradication is one of the major tasks of social hygiene.

But by what means? Let one of the most noted of our American syphilophobes give the answer! This gentleman, a professor of pathology in one of the most important medical schools of the Middle West, yearly lectures over the length and breadth of the land on the venereal peril. He begins his expostulation with reduction of his audiences to a state of terror by a lantern-slide display of the more loathsome manifestations of the disease. He does not state that modern treatment makes these more and more rare. He insists upon the utter impossibility of its cure, a fact by no means established. He advocates early marriage to a non-syphilitic maiden as the best means of prevention, and failing that, advises that chastity is both possible and salubrious. Then follows a master stroke of advice by innuendo—the current belief that masturbation causes insanity is probably untrue. Finally he denies the value of venereal prophylaxis, which was first experimentally demonstrated by Metchnikoff and Roux, and which the medical department of the Army and Navy know to be of almost perfect efficacy when applied early and thoroughly.

Lack of space prevents the display of further examples of the new phenomenon of the entrance of religion and morals into medicine. It is not my intention for a moment to adopt a nihilistic attitude toward the achievement of preventive medicine. But it is necessary to point out that its contamination by moralism, Puritanism, proselytism, in brief, by religion, threatens to reduce it to absurdity, and to shake its authority in instances where its functions are of unmistakable value to our republic. At present the medical profession plays a minor rôle in the more important functions of this branch. These are performed in the first place by bacteriologists who need not be doctors at all, and in the second by sanitary engineers, whose splendid achievements in water supply and sewage disposal lead those of all other nations.

It has been remarked above that one of the chief causes of the unscientific nature of medicine and the anti-scientific character of doctors lies in their innate credulity and inability to think independently. This contention is supported by the report on the intelligence of physicians recently published by the National Research Council. They are found by more or less trustworthy psychologic tests to be the lowest in intelligence of all of the professional men excepting only dentists and horse doctors. Dentists and horse doctors are ten per cent. less intelligent. But since the quantitative methods employed certainly carry an experimental error of ten per cent. or even higher, it is not certain that the members of the two more humble professions have not equal or even greater intellectual ability. It is significant that engineers head the list in intelligence.

In fact, they are rated sixty per cent. higher than doctors. This wide disparity leads to a temptation to interesting psychological probings. Is not the lamentable lack of intelligence of the doctor due to lack of necessity for rigid intellectual discipline? Many conditions conspire to make him an intellectual cheat. Fortunately for us, most diseases are self-limiting. But it is natural for the physician to turn this dispensation of nature to his advantage and to intimate that he has cured John Smith, when actually nature has done the trick. On the contrary, should Smith die, the good doctor can assume a pious expression and suggest that, despite his own incredible skill and tremendous effort, it was God’s (or Nature’s) will that John should pass beyond. Now the engineer is open to no such temptation. He builds a bridge or erects a building, and disaster is sure to follow any mis-step in calculation or fault in construction. Should such a calamity occur, he is presently discredited and disappears from view. Thus he is held up to a high mark of intellectual rigour and discipline that is utterly unknown in the world the doctor inhabits.

A survey of the present condition of American medical education offers little hope for a higher intellectual status of the medical profession or of any fundamental tendency to turn medicine as a whole from a mélange of religious ritual, more or less accurate folk-lore, and commercial cunning, toward the rarer heights of the applied sciences.

Such a reform depends absolutely upon the recognition that the bodies of all the fauna of the earth (including Homo sapiens) are essentially physico-chemical mechanisms; that disease is a derangement of one sort or another of this mechanism; and that real progress in knowledge of disease can only come from quantitatively exact investigation of such derangements.

Up to the present, the number of professors in any branch of medicine who are aware of this fact is pitifully few. The men, who, being aware of it, have the training in physics and chemistry to put their convictions into practice are less in number. So, it is vain to hope that medical students are being educated from this point of view.

This casual glance at American medicine may be thought to be an unduly pessimistic one. It has not been my intention to be pessimistic or to be impertinently critical. Indeed, turning from the art of the practice of medicine, and the religion and folk-lore of sanitation, to the science of the study of disease, we have much of which to be proud. American biochemists of the type of Van Slyke and Folin are actually in the lead of their European brothers. Their precise quantitative methods furnish invaluable tools in the exact study of the ills that afflict us.

Finally, the greatest figure of all, Jacques Loeb, working in an institution that declares its purpose to be the dubious one of medical research, has in the last three years published investigations which throw a flood of light upon the dark problems of the chemistry of proteins. His work is of most fundamental significance, will have far-reaching results, and is measurably in advance of that of any European in the same field. Loeb, like all men of the first rank, has no spirit of propaganda or proselytism. His exact quantitative experiments rob biology of much of its confused romantic glamour. The comprehension of his researches demands thorough knowledge of physical chemistry. However, it is encouraging to note that among a few younger investigators his point of view is being accepted with fervour and enthusiasm. But it is time to stop. We are straying from our subject which was, if I remember, American medicine.

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