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.